SYSTEM OF MEDICINE. 
EDITED BY 
J. RUSSELL REYNOLDS, M.D., F.R.S., 
FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS OF LONDON ; 
FELLOW OF THE IMPERIAL LEOPOLD-CAROLINA ACADEMY OF GERMANY ; 
FELLOW OF UNIVERSITY COLLEGE, LOND. J 
PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE IN UNIVERSITY COLLEGE ; 
PHYSICIAN TO UNIVERSITY COLLEGE HOSPITAL ; 
EXAMINER IN MEDICINE TO THE UNIVERSITY OF LONDON. 
WITH NUMEROUS ADDITIONS AND ILLUSTRATIONS, 
BY 
HENRY HARTSHORNE, A.M., M.D., 
FELLOW OP THE COLLEGE OF PHYSICIANS OF PHILADELPHIA J FORMERLY PROFESSOR OF PRACTICE OF 
MEDICINE IN MEDICAL DEPARTMENT OF PENNSYLVANIA COLLEGE, AND PHYSICIAN TO THE 
EPISCOPAL HOSPITAL OF PHILADELPHIA 5 LATELY PROFESSOR OF HYGIENE 
IN THE UNIVERSITY OF PENNSYLVANIA, AND PROFESSOR OF 
HYGIENE AND DISEASES OF CHILDREN IN THE 
WOMAN'S MEDICAL COLLEGE OF 
Pennsylvania; etc. 
IN THREE VOLUMES. 
VOL. I. 
GENERAL DISEASES AND DISEASES OF THE NERVOUS SYSTEM. 
PHILADELPHIA: 
HENRY C. LEAS SON & CO." 
1880. Entered according to Act of Congress, in the year 1879, by 
HENRY C. LEA, 
in the Office of the Librarian of Congress. All rights reserved. 
COLLINS, PKINTEB. PREFACE TO THE AMERICAN EDITION. 
Of the eminent authority of the contributors to this System of 
Medicine, and the excellence of their work, there can be but one opinion 
on either side of the Atlantic. If the present republication were made 
only in the interest of medical literature, in the historical sense, it would 
be an unwarrantable presumption to attempt any additions to it. But the 
purpose of such a work, cyclopaedic in character, is, obviously, to render 
the greatest possible advantage to students and practitioners ; for which 
end, it is desirable that the most important recent advances in clinical 
observation, pathology, diagnosis, and therapeutics should be supplied in 
connection with essays, some of which were written several years ago. 
This remark applies especially to the articles contained in the first 
Volume of the present edition, upon General Diseases and the Affections 
of the Nervous System. Moreover, the practical aspect of some subjects is 
different in this country from that which they present abroad, and the 
American physician may reasonably expect that the results of American 
experience should be concisely laid before him. So far as comments are 
made, and opinions occasionally expressed in this edition, more or less 
divergent from those of the authors of the work, it is, of course, at the 
option of every reader to estimate them at their proper value. If such 
comments appear at times obtrusive, the excuse of the American Editor 
is, his conscientious desire, sustained by the request of the Publisher, 
that he should omit nothing which seemed likely to prove serviceable to 
those concerned in, or preparing for, the responsible and arduous labors 
of medical practice. 
The text of the articles in the English edition has nowhere been 
altered, except in correction of typographical or other oversights ; and 
in the omission or abridgment of several extremely elaborate and com- 
plex Tables, which, it is believed, very few readers would follow in 
detail, as the inferences deduced from them are fully developed in the 
text. In two or three instances, the order of succession of articles has 
III IV 
PREFACE. 
been changed ; not, however, without conformity to the general plan of 
arrangement. 
The most considerable additions are upon the following subjects: the 
question of Blood-letting (Introduction); Rdthcln, or German Measles; 
Apyretic measures in Typhoid Fever; Prophylaxis of Yellow Fever; 
recent history of Plague; Typho-malarial Fever; Pernicious Fever; 
Pathology and Treatment of Cholera; Chlorosis; Scrofula ; Salicylic 
Acid in Rheumatism ; Hysterical Hemianaesthesia ; Hystero-epilepsy ; 
Methomania; Athetosis ; Puerperal Convulsions ; Pseudo-hypertrophic 
Muscular Paralysis; Tubercular Meningitis; Ophthalmoscopic Appear- 
ances in Brain Disease ; Cerebral Localization ; Spinal and Cerebro-spinal 
Sclerosis; Symptomatology of Locomotor Ataxy; Reflex Paralysis; 
Croup; Communicability of Phthisis ; Treatment of Pneumonia; Para- 
centesis Pericardii; Cardiac Exhaustion; Haemophilia; Cholera Infantum; 
Trichina; Progressive Pernicious Anaemia. 
All additions are marked by brackets, and signed [II.]. 
HENRY HARTSHORNE. 
Phh.adelphia, November, 1879. ENGLISH PREFACES. 
PREFACE TO THE FIRST EDITION OF VOL. I. 
The object proposed to himself by the Editor of this System of Medicine 
is to present, within as small a compass as is consistent with its practical 
utility, such an account of all that constitutes both the natural history 
of disease and the science of pathology as shall be of service in either 
preventing the occurrence, or detecting the presence, and guiding the 
treatment of special forms of illness. 
As the science and art of Medicine have within the last few years 
increased very greatly, in regard to both facts and principles, it is held 
to be desirable-and indeed almost imperative-in order to secure the 
ends that have been mentioned, to divide the large field of growing 
knowledge into such comparatively small sections as should be enriched 
by the results of individual and special culture. The Editor feels con- 
fident that these results have been obtained ; and, in order to secure the 
like confidence of others, has simply to refer to the names of the many 
distinguished men who have kindly contributed to this volume. 
The general scope of the System of Medicine, and the mode in which it 
has been carried out, render unnecessary any discussion of the so-called 
" Principles" of Medicine ; and the Editor has preferred, by the omission 
of articles on " general" subjects, to incur the risk of occasional repeti- 
tion, rather than that of such apparent contradiction as might arise 
from the treatment of some matters " in the general" by one contributor, 
and " in detail" by many others. 
He has, further, only to express his most grateful thanks to those who 
have rendered him their invaluable aid; and to submit these results of 
their toil to the Profession of which they are the distinguished orna- 
ments. 
March 21st, 1866. 
V VI 
ENGLISH PREFACES. 
PREFACE TO THE SECOND EDITION OF VOL. I. 
In this Second Edition, the articles have been submitted for revision 
to their respective authors. That on Purpura, by the late Dr. Thomas 
Hillier, has been revised by Dr. Tilbury Fox. 
The Editor has introduced into this volume the article on Epidemic 
Cerebro-Spinal Meningitis, which in the First Edition was placed among 
the diseases of the Nervous System. 
38 Grosvenor Street, Grosvenor Square, 
January 18(A, 1870. 
PREFACE TO VOLUME III 
In dealing with so large a series of subjects as those which make up 
the section on " Diseases of the Respiratory System," some repetition of 
statement and occasional divergence of opinion have been found inevita- 
ble. The Editor has, however, thought it desirable to allow the occur- 
rence of the former, in order to give completeness to separate articles, 
and has taken pleasure in the representation of the latter, inasmuch as, 
in his opinion, such divergence expresses, with the greatest faithfulness, 
the present state of scientific knowledge on many unsettled problems of 
pathology, and by so doing will prove more useful than would any 
attempt at enforced uniformity of teaching. 
The general doctrine of Tubercle; the relation which that material 
bears to local and general diseases ; the precise meaning of certain morbid 
conditions, the characters of which are matters of familiar recognition ; 
and the inter-relations of many well-known words, are each and all of 
them susceptible of various interpretations: and the Editor is grateful 
and glad to be able to bring together in a connected form, under the 
notice of his professional brethren, the views that are severally enter- 
tained by those distinguished authors who have already shed much light 
upon these obscure regions, and have furnished many of the results of 
their finest labors in the present work. 
J. RUSSELL REYNOLDS. 
38 Grosvenor Street, 
August Sth, 1871. ENGLISH PREFACES. 
VII 
PREFACE TO VOLUME IV. 
The Articles on Position and Malposition of the Heart, on Angina 
Pectoris, on Pericarditis, and Endocarditis, were begun by their respective 
authors some years ago, and several distinct portions of each of those 
articles were at once committed to the press. But both Dr. Gairdner 
and the late Dr. Sibson held that much new matter must be introduced 
into them; and by far the largest contributor to this volume, the late 
Dr. Sibson, found a mass of facts at his disposal, the analysis and repre- 
sentation of which occupied an amount of time and space that far 
exceeded his anticipation. The entire originality of his work, the sub- 
tlety of thought which it displayed, the carefulness of the observations 
upon which it was based, the catholicity of the views which it expressed, 
the honest, kind, although keen criticism that it contained of the opin- 
ions of other workers, and the intimate and important relations of all its 
parts, decided me not to reduce its magnitude beyond that which it now 
presents, and to wait for its completion. Those who know what it is to 
give a concise account of facts derived from their personal observation, 
and represented by the statistical method, will appreciate the years of 
labor that have been bestowed upon the articles, Position and Malposi- 
tion of the Heart, upon Pericarditis and Endocarditis. Their Author, 
when he left England during this past autumn, had left one table uncor- 
rected, and three pages on Carditis unwritten; I have endeavored to 
correct the table, and Dr. Gowers has written the article on Carditis. 
We have, in this volume, the results of many years of Dr. Sibson's 
ardent toil, and the last, and, as I think, the best production of that 
earnest, industrious, enthusiastic worker, and most kind and genial 
friend. 
Another of the contributors to this volume has also passed away since 
his papers were printed, and happily in the main corrected by himself; 
I refer to the late Dr. Warburton Begbie, whose work was as good as 
his heart was large, and who never spared any pains to carry to the 
highest point of his ability even the smallest fragment of labor that he 
undertook to perform. 
J. RUSSELL REYNOLDS. 
38 Grosvenor Street, 
December, 1876. VIII 
ENGLISH PREFACES. 
PREFACE TO VOLUME V. 
The fifth and concluding volume of this System of Medicine will, I 
believe, be as instructive and interesting as any of those which have 
preceded it. It contains information upon a very wide range of diseases, 
and the manner in which the authors of the respective articles which fill 
its pages have dealt with them throughout, has been such as to justify 
my belief. To those who have contributed to this volume, and to whom 
I can now address myself, I offer my heartiest thanks, both for the readi- 
ness with which they have done their work, and for the industry, learn- 
ing, and critical faculty which they have displayed. 
One of the contributors, Dr. Basham, was removed by death before he 
had completed his work, but I was most kindly and ably assisted by Dr. 
Frederick Roberts, in the anxious work of editing MSS., ■which in some 
cases proved to be but half completed. To Dr. Gowers, I am deeply 
grateful, not only for the very able papers which he has written, but also 
for his kindness in rendering me very great assistance in the preparation 
of this volume for the press. 
It is not a matter for much surprise that a work, which has taken so 
long a time to produce, by men who had already become eminent in our 
profession-the longevity of which is less than that of most-should not 
be completed until many of its contributors had passed beyond the reach 
of either our praise or our blame, and that they should not have seen the 
work, which they had done so carefully, placed in its proper niche in the 
edifice that they had helped to raise. To two of these, Drs. Warburton 
Begbie and Sibson, I have made some allusion in my note of introduction 
to the fourth volume; of the others, from whom I had expected further 
help, I must say something here. 
Dr. Anstie-whose loss the profession has never ceased to feel, and 
about whom, every one who had the privilege of his friendship can 
scarcely speak in terms that shall do justice to the memory of his earnest, 
loving soul, and of that devotion to duty and science which led to his 
early death-was one of my most helpful and considerate coadjutors in 
the production of the second volume, not only by contributing his papers 
to the System of Medicine, but by the great assistance which he rendered 
me in the preparation of the second volume for the press. From him, I 
had hoped for much more help, but, for him " there was nobler work 
to do." ENGLISH PREFACES. 
IX 
Dr. Basham entered most heartily into the scheme of this book, but 
the publication of his papers was long delayed in consequence of circum- 
stances which I explained in my note to the fourth volume. Those 
which he has left behind him, nearly completed, and which have been 
finished by Dr. Frederick Roberts, will show, as bis other works have 
done, the simple and scientific character of his writing, and the thorough 
practicality of all his teaching. 
The death of Dr. Warburton Begbie, to whom I have already alluded, 
occasioned another of the great losses which this System has sustained. 
There are few, if any, who have surpassed him in the scientific ability, 
scholarship, and high moral tone of his work. 
Dr. Hughes Bennett, whose strong personal views on pathological 
questions gave an interest to the subjects with which he dealt, con- 
tributed the article on Phthisis, containing much original matter and 
thought, which will be useful to all interested in the history of tuber- 
culosis. 
The death of Dr. Thomas Hillier, the whole of whose published works 
afforded such rich promise of still more useful labors, occasioned another 
loss which the profession could ill sustain, a loss also to myself as a 
friend, colleague, and, as I hoped, future fellow-worker. 
To Dr. Parkes, it is absolutely impossible for me to express my obliga- 
tion. From the first day that I planned the construction of these 
volumes, until the last day but one before his death, he was my faithful 
counsellor and friend. His direct contribution to the System of Medicine 
was comparatively small, but the help that he gave me, indirectly, was 
immeasurably large. He was punctual to an hour, and precise to a three- 
place decimal. High above all his scientific work, great as it was, rose 
his grand moral character, for which all who have known him well must 
be profoundly grateful, in feeling that they are " better men, and are 
conscious that they may be better still." 
Dr. Hyde Salter contributed a valuable paper on Asthma, condensing 
for this System the result of a great many years of good, scientific work. 
His well-known and recorded personal sufferings from the malady, upon 
which he wrote so ably, supply an interest and instruction that could 
perhaps have not been otherwise obtained. 
To Dr. Sibson, the profession is much indebted for some most carefully 
elaborated papers, which appeared in the fourth volume, and to which in 
its introductory preface I have already alluded, so that I can here do no X 
ENGLISH PREFACES. 
more than reiterate my regret for the loss which medical science and 
literature have sustained in his unexpected death. 
Dr. Edward Smith, a highly distinguished member of our profession, 
who had contributed much to the advance of medical science, and espe- 
cially in some of its more practical bearings upon daily life, took a warm 
interest in the volumes which I have edited, and, until his work was 
prematurely arrested by death, he had hoped to render still further 
assistance in their production. 
Dr. Squarey, a worker of great earnestness and promise, contributed 
several articles on Diseases of the Mouth and Throat to the third volume, 
but his life was cut short in the midst of his devoted labor. 
The value of this work is greatly enhanced by the Indices to each 
separate volume, and also to the five volumes collectively. For the 
production of these, I have to thank, and I do so most heartily, Mr. 
Marcus Beck, the late Dr. Loy, and Dr. J. W. Langmore, the last of 
whom has furnished the Indices to the fourth and to the fifth volume. 
To the dead and to the living, I again express my thanks, and feel 
most grateful that I have been able to put into the hands of the medical 
profession a series of admirable original contributions to the medical 
literature of our country, of which I think any country might be proud. 
38 Grosvenor Street, 
November, 1878. 
J. RUSSELL REYNOLDS. CONTENTS OF VOL. I. 
INTRODUCTION, by the Editor. 
Page 
Definition of Disease ; and Names 
of Diseases 17 
Structural and Functional Disease . 19 
Natural History of Disease . . 21 
Causes of Disease ... 21 
Predisposing Causes ... 21 
Exciting Causes ... 23 
Symptoms of Disease ... 23 
Symptoms and Signs . . 23 
Objective and Subjective Symp- 
toms 24 
PASS 
Natural History of Disease- 
Course of Disease ... 25 
Duration of Disease . . .25 
Termination of Disease . . 26 
Diagnosis of Disease ... 26 
Pathology 27 
Pathological Anatomy ... 28 
Prognosis 29 
Therapeutics and Hygienics . . 30 
Classification of Diseases . . 32 
PART I. 
GENERAL DISEASES, OR AFFECTIONS OF THE WHOLE SYSTEM. 
§ I. Those determined by Agents operating from without. 
INFLUENZA, by Edmund A. Parkes, M.D., F.R.S. 
Definition 33 
Synonyms 33 
History of Influenza ... 34 
Spread of the Disease ... 34 
Etiology 34 
Symptoms 41 
Consideration of the Special Symp- 
toms 41 
Varieties 43 
Mortality 43 
Diagnosis 43 
Pathology 43 
Morbid Anatomy .... 44 
Prognosis 44 
Treatment 45 
Definition of Hooping-Cough . . 48 
History . . . ... .48 
Causes 48 
Symptoms 49 
Diagnosis 52 
HOOPING-COUGH, by Edward Smith, M.D., F.R.S. 
Pathology 52 
Morbid Anatomy .... 52 
Prognosis 53 
Treatment 53 
DIPHTHERIA, by William Squire, L.R.C.P., Lond. 
Definition 57 
Synonyms 57 
Name 58 
History 58 
Etiology 61 
Symptoms 65 
Diagnosis 70 
Pathology 72 
Morbid Anatomy . . . .74 
Prognosis 77 
Therapeutics 78 
XI XII 
CONTENTS of VOL. I. 
SCARLET FEVER, by Samuel Jones Gee, M.D., Lond. 
PAGE 
Definition 83 
Causes 84 
Symptoms 84 
Symptoms of Ordinary Scarlet Fever 85 
Symptoms of Malignant Scarlet Fe- 
ver 88 
Symptoms of Latent Scarlet Fever 89 
PAGE 
Sequelfe 89 
Diagnosis 93 
Morbid Anatomy .... 94 
Prognosis 94 
Prophylaxis 95 
Treatment 95 
DENGUE, or DANDY FEVER, by William Aitken, M.D. 
Definition 98 
Synonyms 98 
History 98 
Symptoms 99 
Etiology and Propagation . . 103 
Diagnosis 103 
Treatment 103 
ROSEOLA, by Hermann Beigel, M.D. 
Definition 104 
Cause 105 
Course 105 
Diagnosis 106 
Prognosis 106 
Treatment 106 
MEASLES, by Sydney Ringer, M.D. 
Definition 106 
Synonyms 106 
Symptoms 106 
Varieties 107 
Complications and Sequela; . . Ill 
Diagnosis 113 
Prognosis 114 
Treatment 114 
[ROTIIELN (German Measles), by Henry Hartshorne, M.D. 
Symptoms 117 
Diagnosis 117 
Treatment 117] 
PAROTITIS, by Sydney Ringer, M.D. 
Definition 118 
Synonyms 118 
Symptoms 118 
Pathology 119 
Diagnosis 120 
Treatment 120 
SUDAMINA and MILIARIA, by Sydney Ringer, M.D. 
Sudamina 122 
Miliaria 123 
Treatment 124 
VARICELLA, by Samuel Jones Gee, M.D. 
Definition 124 
Causes 125 
Description of the Disease . . 125 
Diagnosis 126 
Prognosis 127 
Treatment 127 
Varieties and Synonyms . . . 127 
SMALLPOX, by J. F. Marson. 
Definition 127 
Synonyms 127 
History 127 
Description of Smallpox . . . 128 
Varieties 129 
Primary Fever .... 132 
Secondary Fever .... 132 
Diagnosis 135 CONTENTS OE VOL. I. 
XIII 
PAGE 
Prognosis 136 
Susceptibility to Smallpox . . 138 
Infectious Nature of Smallpox . 138 
Treatment 140 
Mortality from Smallpox . . 145 
Morbid Appearances . . . 146 
PAGE 
Anatomical Characters of the Vari- 
olous Pock 147 
Smallpox after Vaccination.-Vari- 
celloid, and modified Smallpox . 149 
Epidemic Diffusion of Smallpox . 156 
Inoculation from Smallpox . . 156 
VACCINATION, by Edward Cator Seaton, M.D. 
Phenomena of Cow-pox in the Hu- 
man Subject .... 159 
Phenomena of Revaccination . . 161 
Method of Vaccinating . . . 161 
Protection afforded by Vaccination 
against Smallpox .... 166 
Revaccination 174 
Relations of Variola and Vaccinia 176 
Alleged Dangers of Vaccination . 177 
GLANDERS-EQUINIA, by Arthur Gamgee, M.D., and John Gamgee. 
Definition 182 
Nomenclature and History . . 182 
Glanders and its Varieties in the 
Horse, Ass, and Mule . . .183 
Chronic Glanders .... 183 
Acute Glanders .... 183 
Chronic Farcy 184 
Acute Farcy 184 
History of the Disease in Man . 185 
Etiology of the Disease in Man . 188 
Semeiology ..... 189 
Diagnosis 191 
Morbid Anatomy .... 191 
Prognosis 192 
Therapeutics 192 
HYDROPHOBIA, by John Gamgee and Arthur Gamgee, M.D. 
Definition ..... 192 
Synonyms ..... 192 
History 192 
Causes 195 
Hydrophobia in Man . . . 197 
Symptoms of Hydrophobia in man 197 
Diagnosis 199 
Morbid Anatomy .... 199 
Prognosis ..... 200 
Therapeutics 200 
ENTERIC or TYPHOID FEVER, by John Harvey, M.D., F.L.S. 
Definitive Description . . . 201 
Synonyms 201 
Preliminary Observations . . 202 
Clinical History of the Disease . 202 
Morbid Anatomy .... 209 
Pathology 218 
Associated Pathology of Enteric 
Fever 221 
Varieties 232 
Distribution 234 
Causes 235 
Diagnosis ..... 244 
Prognosis ..... 246 
Treatment ..... 247 
TYPHUS FEVER, by George Buchanan, M.D. 
Definition 251 
Etiology ...... 252 
Symptomatology .... 254 
Duration 261 
Termination and Sequelte . . 261 
Diagnosis 262 
Pathology 263 
Morbid Anatomy .... 264 
Prognosis and Mortality . . . 265 
Therapeutics 266 
Varieties 269 
Definition 269 
History, Nomenclature, and Bibli- 
ography 269 
Geographical Distribution . . 273 
RELAPSING FEVER, by J. Warburton Begbie, M.D. 
Etiology 274 
Symptomatology .... 277 
Therapeutics 280 contents of vol. i. 
XIV 
YELLOW FEVER, by J. Denis Macdonald, M.D., F.R.S. 
PAGE 
Definition 281 
Synonyms . . • , • • 281 
History 281 
Altitudinal and Horizontal Ranges 284 
Symptoms ..... 284 
Diagnosis . . . ... 285 
PAGE 
Pathology 286 
Morbid Anatomy .... 290 
Prognosis 292 
Therapeutics 293 
Varieties and their Classification . 294 
EPIDEMIC CEREBRO-SPINAL MENINGITIS 
by John Netten Radcliffe. 
Definition 296 
Synonyms 296 
Description of the Disease . . 297 
Special Symptoms .... 299 
Complications 303 
Duration 303 
Termination 304 
Mode of Death .... 304 
Diagnosis 304 
Prognosis 305 
Morbid Anatomy .... 305 
History and Geographical Distribu- 
tion 306 
Etiology 308 
Nature . . . • . . . 311 
Treatment 312 
Bibliography 314 
THE PLAGUE, by G^vin Milroy, M.D, 
Definition 314 
Synonyms 314 
Symptoms 314 
Diagnosis 315 
Morbid Anatomy .... 316 
Curative Treatment . . . 311 
Natural History . . . .311 
Causation 311 
Prophylaxis, &c 311 
[Recent History .... 320[ 
ERYSIPELAS, by J. Russell Reynolds, M.D., F.R.S. 
Definition 321 
Synonyms 321 
Natural History .... 321 
Causes 321 
Symptoms 322 
Diagnosis 325 
Pathology 325 
Morbid Anatomy .... 325 
Prognosis 326 
Treatment 327 
Varieties 329 
PY2EMIA, by John Syer Bristowe, M.D. 
Etymology 330 
Definition 330 
Pathology 330 
Morbid Anatomy . . 331 
General Pathology . . . 338 
Symptoms 344 
Considered collectively . . 344 
Considered in relation to the vari- 
ous Organs .... 345 
Symptoms- 
Considered further in regard to 
Pyaemia 347 
Diagnosis 347 
Treatment 348 
Prophylactic .... 348 
Medical ..... 350 
MALARIAL FEVERS, by W. C. Maclean, M.D. 
1NTERMITTENT FEVER . . 352 
Definition 354 
Synonyms 354 
History and modes of Commence- 
ment 354 
Causes . . . . • . . 356 
Symptoms ..... 356 
Diagnosis 358 
Morbid Anatomy .... 358 
Prognosis 359 
Treatment ..... 360 
Remittent Fever . . . 365 
Definition 365 
Synonyms 365 
History 365 
Symptoms 366 
Diagnosis 368 
Pathology 368 
Prognosis 368 
Treatment . 369 XV 
CONTENTS OF VOL. I. 
DYSENTERY, by W. C. Maclean, M.D. 
PAGE 
Definition 372 
Terminology 372 
History 372 
Modes of Commencement . . 373 
Causes 373 
Symptoms 375 
Acute 376 
Chronic 376 
Malarious 377 
PAGE 
Symptoms- 
Malignant 377 
Scorbutic 377 
Diagnosis 378 
Pathology 378 
Morbid Anatomy .... 378 
Prognosis 380 
Treatment 380 
EPIDEMIC CHOLERA, 
by Edward Goodeve, M.B. 
Definition 384 
Synonyms \ 384 
History 385 
Etiology ...... 386 
Symptoms 398 
Varieties 406 
Duration 408 
Mortality 408 
Diagnosis 409 
Pathology 410 
Morbid Anatomy .... 410 
Considered during life . . . 412 
Prognosis 415 
Treatment 415 
Treatment of Choleraic Diarrhoea . 420 
Prophylaxis 421 
CONSTITUTIONAL SYPHILIS, by Jonathan Hutchinson, F.R.C.S. 
Stages of Syphilis .... 424 
Conditions interfering with their 
Evolution 426 
Modes of Communication . . 429 
Tertiary Symptoms .... 431 
Treatment 435 
Diagnosis 438 
Diagnosis when consequent upon in- 
herited Taint .... 440 
Contrast between acquired and in- 
herited Syphilis .... 443 
§ II. General Diseases determined by Conditions existing within the Human Body. 
SCORBUTUS, or SCURVY, by Thomas Buzzard, M.D. 
Definition 445 
Synonyms 445 
Etiology 445 
Symptoms 451 
Diagnosis 454 
Pathology 455 
Morbid Anatomy .... 456 
Prognosis 457 
Therapeutics 458 
PURPURA, by Thomas Hillier, M.D., revised by Tilbury Fox, M.D. 
Description of different Forms . 460 
Anatomical Characters . . . 460 
Symptoms 460 
Varieties 461 
Causes 463 
Pathological Anatomy . . . 463 
Nature 465 
Prognosis 466 
Diagnosis 466 
Treatment 467 
[CHLOROSIS, by Henry Hartshorne, M.D. 
History 468 
Symptoms 468 
Causation 469 
Pathology 469 
Prognosis 470 
Treatment 470] XVI 
CONTENTS of VOL. I. 
RICKETS, by W. Aitken, M.D. 
PAGE 
Definition 472 
Synonyms 472 
Causes 473 
Symptoms 475 
Diagnosis 484 
PAGE 
Pathology 485 
Morbid Anatomy .... 487 
Prognosis 494 
Therapeutics 495 
[SCROFULA, by Henry Hartshorne, M .D. 
Ilistory 497 
Symptomatology .... 498 
Anatomy 503 
Pathology 503 
Causation 507 
Treatment 509] 
GOUT, by Alfred Baring Garrod, M.D., F.R.S. 
Definition 512 
Synonyms 512 
Ilistory 512 
Description of an attack of Acute 
Gout, and progress of the Dis- 
ease 512 
Gout in a Chronic form . . 516 
Irregular Gout; effects on differ- 
ent forms of Gout . . . 518 
State of the Urine in different 
forms of Gout .... 522 
Morbid Anatomy .... 523 
Causes dependent on the Individual 526 
Causes independent of the Indi- 
vidual 527 
Pathology 531 
Diagnosis 536 
Prognosis 537 
Treatment 538 
Diet and Regimen in different forms 
of Gout 548 
RHEUMATOID ARTHRITIS, 
by A. B. Garrod, M.D., F.R.S 
Definition 550 
Synonyms 550 
Ilistory 550 
Description of Rheumatoid Arthritis 551 
Morbid Anatomy .... 553 
Causes 554 
Pathology 554 
Diagnosis 555 
Prognosis 556 
Treatment 556 
Diet and Regimen .... 558 
RHEUMATISM, by A. B. Garrod, M.D., F.R.S. 
Articular Rheumatism . . . 559 
Definition 559 
Synonyms 559 
History 559 
Description of Acute and Sub- 
acute Rheumatism . . 559 
Consideration of the different 
Phenomena .... 561 
Condition of the Blood in Acute 
Articular Rheumatism . . 562 
Urine in Acute Articular Rheu- 
matism 562 
Cardiac and other Inflammatory 
Affections . . . > 563 
Morbid Anatomv .... 563 
Causes 564 
Articular Rheumatism- 
Effects of Climate, Seasons, and 
Weather .... 565 
Pathology 565 
Diagnosis 566 
Prognosis and Treatment . . 567 
Muscular Rheumatism . . .573 
Definition 573 
Synonyms 573 
History 573 
Description 573 
Causes 574 
Pathology 575 
Diagnosis 575 
Prognosis 575 
Treatment 575 
GONORRHCEAL RHEUMATISM, by B. E. Brodiiurst, F.R.C.S. 
History 576 
Symptoms 576 
Treatment 579 XVII 
CONTENTS OF VOL. I. 
PART IL 
LOCAL DISEASES. 
INTRODUCTION, by The Editor. . . . ^81 
GENERAL DISEASES OF THE NERVOUS SYSTEM, List of . . . 584 
INSANITY, by Henry Maudsley, M.D., F.R.C.P. 
PAGE 
Synonyms 584 
Definition 584 
Classification . . . . 585 
Causes . . . * . . . 587 
Forms of Insanity and their Symp- 
tomatology .... 591 
Melancholia 592 
Mania 595 
Monomania 599 
Dementia 600 
Forms of Insanity and theii' Symp- 
tomatology- 
Moral Insanity .... 601 
Idiocy 603 
General Paralysis.... 605 
Diagnosis 607 
Pathology 610 
Morbid Anatomy .... 614 
Prognosis 616 
Therapeutics . . . ... 618 
HYPOCHONDRIASIS, by Sir William Withey Gull, Bart., M.D., 
D.C.L., F.R.S., and Francis Edmund Anstie, M.D., F.R.C.P. 
Definition 623 
Nomenclature 623 
History 624 
Symptoms 624 
Diagnosis 626 
Prognosis 628 
Etiology 628 
Treatment 629 
HYSTERIA, by J. Russell Reynolds, M.D., F.R.S. 
Natural History .... 631 
Causes 631 
Symptoms 634 
Pathology 640 
Diagnosis 642 
Prognosis 643 
Treatment 644 
ECSTASY, by Thomas King Chambers, M.D., F.R.C.P. . 646 
[HYSTERO-EPILEPSY, by Henry Hartshorne, M.D. . 649] 
CATALEPSY, by Thomas King Chambers, M.D., F.R.C.P. 
Name ...... 652 
Definition 652 
Description 652 
Causes 654 
Treatment 658 
SOMNAMBULISM AND ALLIED STATES, by Tuomas King 
Chambers, M.D., F.R.C.P. 
Description 658 
Treatment 660 
Definition 661 
Synonyms 661 
History 661 
Etiology 664 
Symptoms 666 
Diagnosis 667 
Pathology 667 
SUN-STROKE, by W. 0. Maclean, M.D. 
Morbid Anatomy .... 668 
Mortality 668 
Prognosis 668 
Prophylaxis 668 
Treatment 669 
Treatment of the Sequelae . . 670 XVIII 
CONTENTS OF VOL. I. 
ALCOHOLISM, by Francis Edmund Anstie, M.D., F.R.C.P 
PAGE 
Definition 670 
Synonyms 670 
History 670 
Etiology 671 
Symptoms . . . . 675 
Chronic Alcoholism . . .675 
Acute Alcoholism . . . 678 
PAGE 
Diagnosis. . . . . . 681 
Prognosis 682 
Complications 683 
Pathology 684 
Treatment 684 
Definition 690 
Description 690 
Prognosis 691 
Etiology 691 
Varieties 691 
VERTIGO, by J. Spence Ramskill, M.D. 
Stomachal Vertigo .... 691 
Vertigo of the Aged . . . 693 
Essential Vertigo .... 693 
Vertigo from Overwork . . . 694 
Treatment 695 
CHOREA, by C. B. Radcliffe, M.D., F.R.C.P. 
Diagnosis 710 
Prognosis 711 
Treatment 711 
Symptoms 696 
Exceptional Forms of Chorea . 700 
Pathology 704 
Causes 709 
PARALYSIS AGITANS, by W. Rutherford Sanders, M.D., F.R.C.P. 
Synonyms 718 
Definition 718 
Historical Notice .... 719 
Description 720 
Causes 725 
Diagnosis 726 
Complications 727 
Pathology and Morbid Anatomy . 727 
Treatment ... . . . 729 
Bibiography 730 
[ATHETOSIS, by Henry Hartshorne, M.D. . . 731] 
WRITER'S CRAMP, by J. Russell Reynolds, M.D., F.R.S. 
Definition 732 
Synonyms 733 
Symptoms 733 
Etiology 734 
Diagnosis 734 
Prognosis 735 
Pathology 735 
Treatment 737 
CONVULSIONS, by J. Hughlings Jackson, M.D., F.R.C.P. 
Convulsions in Children . . . 738 
The Paroxysm . . ... 740 
Premonitory Symptoms . .740 
Sequelae 744 
The Causes of Convulsions . . 745 
Prognosis 749 
Convulsions in Children- 
Treatment 749 
Convulsions in Adults . . . 752 
The Convulsion begins unilaterally 752 
Causation 754 
Death 761 
Treatment 761 
EPILEPSY, by J. Russell Reynolds, M.D., F.R.S. 
Definition 762 
Synonyms 763 
Natural History . . . .763 
General Prevalence of the Disease 763 
Causes 763 
Symptoms 767 
Relations between the Symptoms 775 
Natural History- 
Complications .... 776 
Pathology 777 
Diagnosis 778 
Prognosis 779 
Treatment 780 CONTENTS OF VOL. I. 
XIX 
MUSCULAR ANAESTHESIA, by J. Russell Reynolds, M.D., F.R.S. 
PAGE 
Definition 783 
Nomenclature 783 
Symptoms 783 
Causes 784 
PAGE 
Diagnosis 784 
Pathology 785 
Prognosis 785 
Treatment 786 
WASTING PALSY, by William Roberts, M.D., F.R.C.P. 
Definition 786 
Synonyms . . . . . 786 
History 786 
Etiology 786 
Symptoms 788 
Course and Duration . . . 789 
Diagnosis 790 
Morbid Anatomy . . . .790 
Pathology 793 
Prognosis 796 
Therapeutics 798 
METALLIC TREMOR, TREMBLEMENT M^TALLIQUE, 
by W. Rutherford Sanders, M.D., F.R.C.P. 
Synonyms ..... 801 
Definition 801 
Mercurial Tremor or Shaking Palsy 801 
Causes 801 
Description 802 
Symptoms 802 
Course and Prognosis . . . 804 
Diagnosis 805 
Pathology and Morbid Anatomy . 805 
Lead Tremors 806 
Symptoms 807 
Causes 807 
Course 807 
Prognosis 807 
Pathology and Morbid Anatomy 807 
Diagnosis 807 
Treatment 807 
PARTIAL DISEASES OE THE NERVOUS SYSTEM, List of . . . 808 
SIMPLE MENINGITIS, by J. Spence Ramskill, M.D. 
Definition ...... 808 
Acute Meningitis .... 808 
Symptoms 808 
Inflammation of the Dura Mater 813 
Progress, Duration, and Termina- 
tion 813 
Pathological Anatomy . . 814 
Acute Meningitis- 
Etiology 814 
Diagnosis 815 
Treatment 815 
Chronic Meningitis .... 816 
History and Description . . 816 
Treatment 817 
TUBERCULAR MENINGITIS, by Samuel Jones Gee, M.D., E.R.C.P. 
Causes 817 
Symptoms 818 
Primary Tubercular Meningitis in 
the Child 818 
Symptoms 818 
Invasion 819 
The Established Disease . . 820 
(a) Meningitis of the Base . . 820 
Primary Tubercular Meningitis in 
the Child- 
(6) Meningitis of the Convexity . 827 
Secondary Tubercular Meningitis in 
the Child 828 
Tubercular Meningitis in the Adult 829 
Diagnosis 829 
Morbid Anatomy .... 832 
Prognosis and Treatment . . 835 
CHRONIC HYDROCEPHALUS, by J. Spence Ramskill, M.D. 
Anatomical Characters . . . 836 
Symptoms 837 
Diagnosis 839 
Treatment 839 XX 
CONTENTS OF VOL. I. 
MENINGEAL HEMORRHAGE, by J. Spence Ramskill, M.D. 
PAGE 
Symptoms 841 
Treatment 842 
Adventitious Products in the 
Meninges 843 
PAGE 
Congenital Malformations of 
the Meninges .... 844 
CONGESTION OF THE BRAIN, by J. Russell Reynolds, M.D., F.R.S., 
and H. Charlton Bastian, M.D., F.R.S. 
Symptoms 845 
Causes 848 
Diagnosis 848 
Pathology 849 
Morbid Anatomy .... 851 
Prognosis 853 
Treatment .... 853 
CEREBRITIS, by J. Russell Reynolds, M.D., F.R.S., and II. Ciiarlton 
Bastian, M.D., F.R.S. 
Causes 855 
Symptoms 855 
Diagnosis 855 
Pathology 855 
Prognosis 856 
Treatment 856 
SOFTENING OF TIIE BRAIN, by J. Russell Reynolds, M.D., F.R.S., 
and II. Charlton Bastian, M.D., F.R.S. 
Definition 856 
Causes 857 
Symptoms 857 
Acute Softening of the Brain . . 857 
Chronic Softening of the Brain . 864 
Pathology 865 
Morbid Anatomy .... 873 
Diagnosis 880 
Prognosis 882 
Treatment 882 
ADVENTITIOUS PRODUCTS OF THE BRAIN, by J. Russell 
Reynolds, M.D., F.R.S., and II. Charlton Bastian, M.D., F.R.S. 
Symptoms 883 
Diagnosis 886 
Morbid Anatomy .... 889 
| Prognosis 901 
Treatment 901 
CEREBRAL HEMORRHAGE AND APOPLEXY, by J. Hughlings 
Jackson, M.D., F.R.C.P. 
Morbid Anatomy .... 902 
Etiology and Pathology . . . 905 
Constitutional State prior to Cere- 
bral Hemorrhage .... 906 
Hemorrhage from Aneurism of the 
larger Cerebral Vessels . . 910 
Localization of Lesions . . . 910 
Cerebral Hemisphere . . . 910 
Lateral Ventricles . . .911 
Corpus Striatum . . . .911 
Thalamus Opticus . . . 913 
Crus Cerebri .... 913 
Localization of Lesions- 
Pons Variolii .... 914 
Medulla Oblongata . . . 915 
Cerebellum 915 
The Apoplectic Condition . . 920 
Diagnosis 922 
Premonitory Symptoms . . 923 
Mode of Onset of Cerebral Hemor- 
rhage 925 
Special Diagnosis .... 927 
Prognosis 931 
Treatment 932 XXI 
CONTENTS OF VOL. I. 
ABSCESS OF THE BRAIN, by Sir William W. Gull, Bart., M.D., 
F.R.S., and Henry G. Sutton, M.B., F.R.C.P. 
PAGE 
History 934 
Morbid Anatomy .... 936 
Symptoms 937 
PAGE 
Pathology 938 
Diagnosis 940 
Treatment 941 
DISEASES OF THE SPINAL COLUMN, List of 942 
DISEASES OF THE SPINAL CORD, by C. B. Radcliffe, 
M.D., F.R.C.P. 
Preliminary Remarks . . . 942 
Meningitis 951 
Symptoms ..... 951 
Post-mortem Appearances . . 955 
Causes 955 
Diagnosis 955 
Prognosis 955 
Treatment 956 
Myelitis 956 
Symptoms 956 
Post-mortem Appearances . . 962 
Causes 963 
Diagnosis 963 
Prognosis 964 
Treatment 964 
Congestion 965 
Symptoms 965 
Post-mortem Appearances . . 968 
Causes 968 
Diagnosis 968 
Prognosis 968 
Treatment 968 
Tetanus 968 
Symptoms 969 
Post-mortem Appearances . .976 
Causes 977 
Diagnosis ..... 978 
Prognosis 979 
Treatment . . . . .979 
Locomotor Ataxy . . . 980 
Symptoms 981 
Causes 989 
Locomotor Ataxy- 
Prognosis 989 
Diagnosis 989 
Treatment 990 
Spin at Irritation . . . 991 
Symptoms 991 
Post-mortem Appearances . . 997 
Causes 997 
Diagnosis 997 
Prognosis 998 
Treatment 998 
General Spinal Paralysis . 999 
Hysterical Paraplegia . . 1000 
Reflex Paraplegia . . . 1001 
Infantile Paralysis . . . 1004 
Spinal Hemorrhage . . . 1007 
Non-inflammatory Spinal Soft- 
ening 1008 
Induration of the Spinal Cord 1008 
Atrophy and Hypertrophy of 
the Spinal Cord . . . 1015 
Tumor of the Spinal Cord . 1016 
Concussion of the Spine . . 1016 
Compression of the Spinal Cord 1017 
Caries of the Vertebral Col- 
umn 1017 
Spina Bifida 1018 
DISEASES OF THE NERVES, List of 1020 
NEURITIS AND NEUROMA, by J. Warburton Begbie, 
M.D., F.R.C.P.E. 
Neuroma 1022 | 
Traumatic Neuroma . . . 1025 
NEURALGIA, by Francis E. Anstie, M.D., F.R.C.P. 
Definition 1026 
Synonyms 1026 
Clinical History and Symptoms . 1027 
Varieties ...... 1027 
Complications 1037 
Diagnosis 1040 
Prognosis 1040 
Pathology and Etiology . . . 1041 
Treatment . . . . 1042 XXII 
CONTENTS of VOL. I. 
LOCAL PARALYSIS FROM NERVE DISEASE, by J. Warburton 
Begbie, M.D., F.R.C.P.E. 
PAGE 
General History .... 1048 
Varieties • 1050 
PAGE 
Prognosis 1053 
LOCAL SPASMS, by J. Warburton Begbie, M.D., F.R.C.P.E. 
1055 
TORTICOLLIS, by J. Russell Reynolds, M.D., F.R.S. 
Definition 1060 
Synonyms 1060 
Causes 1061 
Symptoms 1061 
Diagnosis 10G2 
Pathology 1062 
Prognosis 1063 
Treatment 1063 
LOCAL ANJESTIIESIA5, by J. Warburton Begbie, M.D., F.R.C.P.E. 
1064 
Index 1067 
List of Chief Authors referred to in Each Article .... 1109 LIST OF CONTRIBUTORS TO VOL. I. 
William Aitken, M.D., L.R.C.S. Edinburgh ; Professor of Pathology in the Army 
Medical School, Netley. 
Francis Edmund Anstie, M.D., F.R.C.P. ; Senior Assistant Physician to the 
Westminster Hospital, and Lecturer on Medicine in the Westminster Hospital 
Medical School. 
Henry Charlton Bastian, M. A., M.D., F.B.S., F.L.S.; Professor of Pathological 
Anatomy in University College ; Physician to University College Hospital. 
J. Warburton Begbie, M.D., F.R.C.P. Edinburgh; Physician to the Royal In- 
firmary of Edinburgh. 
Hermann Beigel, M.D. Berlin; M.R.C.P. Lond.; Fellow of the Imperial Leopold- 
Carolina Academy of Germany ; Physician to the Metropolitan Free Hospital. 
John Syer Bristowe, M.D., F.R.C.P. Loud.; Physician to St. Thomas's Hospital. 
Bernard Edward Brodhurst, F.R.C.S., F.L.S., Surgeon to, and Lecturer on 
Orthopsedic Surgery at, St. George's Hospital. 
George Buchanan, M.D., F.R.C.P. Lond.; Fellow of University College; formerly 
Physician to the Lond. Fever Hospital, and to the Hospital for Sick Children ; 
Inspector of Public Health in Medical Department of II.M. Privy Council. 
Thomas Buzzard, M.D., M.R.C.P. Lond., University Medical Scholar ; Physician 
to the National Hospital for the Paralyzed and Epileptic ; formerly on the Staff 
of II. II. Omar Pacha. 
Thomas King Chambers,M.D. Oxon., F.R.C.P. Lond.; Hon. Physician to H.R.H. 
the Prince of Wales; Consulting Physician and Lecturer on Medicine in St. Mary's 
Hospital. 
Tilbury Fox, M.D. Lond., M.R.C.P.; University Medical Scholar; Physician to 
the Department for Skin Diseases in University College Hospital. 
Arthur Gamgee, M.D. Edinburgh, late Resident Physician to the Royal Infirmary 
of Edinburgh. 
John Gamgee, Principal of the Albert Veterinary College. 
Alfred Baring Garrod, M.D., F.R.S., F.R.C.P. Lond.; Physician to King's 
College Hospital, and Professor of Materia Medica and Therapeutics in King's 
College. 
Samuel Jones Gee, M.D., F.R.C.P. Lond., University Medical Scholar, Assistant 
Physician to St. Bartholomew's Hospital and to the Hospital for Sick Children. 
Edward Goodeve, M.B., Deputy Inspector-General of Hospitals II.M. Bengal 
Army ; Hon. Physician to the Queen ; late Professor of Medicine in the Medical 
College, and First Physician to the Medical College Hospital, Calcutta ; Member 
of the Senate of the University of Calcutta. 
Sir William Withey Gull, Bart., M.D., F.R.S., F.R.C.P. Lond., D.C.L. Oxon.; 
late Physician to Guy's Hospital. 
XXIII XXIV 
LIST OF CONTRIBUTORS TO VOL. I. 
John Harley, M.D., F.R.C.P. Lond., F.L.S.; lion. Fellow of King's College, Lon- 
don ; Assistant Physician to the London Fever Hospital. 
Henry Hartshorne, M.D., lately Professor of Hygiene in the University of Penn- 
sylvania, &c. 
Thomas Hillier, M.D., F.R.C.P. Lond.; Fellow of University College ; late Phy- 
sician to the Hospital for Sick Children, and to the Department for Skin Diseases 
in University College Hospital. 
Jonathan Hutchinson, F.R.C.S. Lond.; Surgeon to the London Hospital, and to 
the Metropolitan Free Hospital. 
J. Hugiilings Jackson, M.D., F.R.C.P., Physician to the National Hospital for the 
Paralyzed and Epileptic ; Physician to the London Hospital. 
John Denis Macdonald, R.N., M.D., F.ILS., Staff-Surgeon to H.M.S. Victory. 
William Campbell Maclean, M.D. Edin.; Member of the Senate of the University 
of Madras ; Deputy Inspector-General of Hospitals ; Professor of Clinical and 
Military Medicine in the Army Medical School, Netley. 
James Furness Marson, F.R.C.S. Lond.; Corresponding Fellow of the Royal 
Academy of Surgeons of Madrid; Resident Surgeon to the Smallpox and Vac- 
cination Hospital. 
Henry Maudsley, M.D. Lond., F.R.C.P., Physician to the West of London Hos- 
pital ; Professor of Medical Jurisprudence in University College, London. 
Gavin Milroy, M.D. Edinburgh, F.R.C.P. Lond.; Superintendent Medical In- 
spector to the General Board of Health. 
Edmund A. Parkes, M.D., F.R.S., F.R.C.P. Lond.; Emeritus Professor of Clinical 
Medicine in University College; Member of the General Council of Medical Edu- 
cation ; Professor of Hygiene in the Army Medical School, Netley. 
Charles Bland Radcliffe, M.D., F.R.C.P. Lond.; Physician to the Westminster 
Hospital, and to the National Hospital for the Paralyzed and Epileptic. 
John Netten Radcliffe, Hon. Secretary of the Epidemiological Society; Inspector 
of Public Health in Medical Department of II. M. Privy Council. 
J. Spence Ramskill, M.D. Lond.; Physician to the London Hospital, and to the 
National Hospital for the Paralyzed and Epileptic. 
J. Russell Reynolds, M.D., F.R.S., F.R.C.P. Lond., Examiner in Medicine to the 
University of London ; Professor of the Principles and Practice of Medicine in 
University College ; Physician to University College Hospital. 
Sydney Ringer, M.D., M.R.C.P. Lond.; Professor of Materia Medica and Thera- 
peutics in University College ; Physician to University College Hospital, and to 
the Hospital for Sick Children. 
William Roberts, M.D., F.R.C.P. Lond.; Physician to the Manchester Royal 
Infirmary ; Lecturer on Medicine in the Manchester School of Medicine. 
William Rutherford Sanders, M.D., F.R.C.P. Edinburgh; Physician to the 
■ Royal Infirmary, and Lecturer on the Institutes of Medicine, Edinburgh. 
Edward Cator Seaton, M.D. Edin., M.R.C.P. Lond., Medical Department of 
II.M. Privy Council. 
Edward Smith, M.D., F.R.S., F.R.C.P. Lond.; Inspector to the Poor Law Board; 
late Assistant-Physician to the Hospital for Consumption, Brompton. 
William Squire, I.R.C.P., M.R.C.S. Lond.; late Senior Surgeon to the St. Maryle- 
bone Infirmary. 
Henry G. Sutton, M.B. Lond., F.R.C.P., Assistant Physician to the London Hos- 
pital and to the City of London Hospital for Diseases of the Chest. A SYSTEM OF MEDICINE. 
INTRODUCTION. 
THE EDITOR. 
Definition of Disease ; and Names 
of Disease.-The attempt to define " dis- 
ease" must be a failure until we are 
possessed of a satisfactory definition of 
"health and we are not likely to arrive 
at this possession until we are able to define 
the idea that we entertain of the still more 
fundamental fact of " life. " Yet some at- 
tempt at definition is not only important, 
but even essential, for the work set before 
us in these volumes ; inasmuch as the gen- 
eral ideas entertained about disease vary 
as the years pass on, and the position 01 
"medicine" in the "system of the sci- 
ences" is not only expressed by the ap- 
proximative definition that we frame of 
disease, but is actually determined by the 
principle or idea which such definition is 
constructed to convey. 
If we regard disease in the " abstract," 
we have to deal with that which changes, 
fetters, renders painful, shortens, or puts 
an end to life ; and, from this point of view, 
disease may be defined to be any condition 
of the organism which limits life in either 
its powers, enjoyments, or duration. We 
need not stop to discuss the many futile 
essays that have been made to define that 
which transcends definition, but which we 
all, more or less accurately, understand by 
" life." We accept it as a fact, of which 
we all know much, but of which we are all 
assured, by w'hat we do know, that there 
is much more that we do not know ; for it 
goes beyond our observation, not only at 
its beginning, and at its end, but in its 
middle term, when it is the most-but 
even then only partially-exposed to both 
our senses and our consciousness. 
Disease is a condition of the individual 
man ; it is always something more than 
the changes that we yet can recognize and 
describe in any particular organ or its func- 
tion. It is the man who is ill; and, under 
all circumstances of illness, he has a di- 
minished life. Some organs may be over- 
active ; but their excess of work is needed 
either because work elsewhere has been 
left undone, or because it has been done 
so roughly that parts of organs have been 
killed before their time, and their wasted 
materials have to be changed and got rid 
of with all haste ; or because that which 
held their activity in check has been dam- 
aged or destroyed. At all times such over- 
work is fatiguing and hazardous ; often it 
is directly dangerous, and sometimes it is 
destructive. Disease is that which limits 
life-in its usefulness, enjoyments, or du- 
ration ; and although the body is so con- 
structed that it can often regain its bal- 
ance when the disturbance has been slight, 
yet disease, under all circumstances and. 
to all degrees, is the lowering of life, and, 
even in its most trivial forms, is the 
"shadow of death." 
This mode of regarding disease furnishes 
us with the measures of its importance. A 
man is ill, or diseased, in degree exactly 
corresponding with this limitation of his 
life. A morbid idea may make life miser- 
able and useless ; a fatty tumor may be an 
unfelt excrescence. Many lives are spoiled 
by diseases that the anatomist cannot 
name ; many lives are but little altered by 
growths or lesions which may be weighed 
and demonstrated before a crowd. 
If we consider disease from another 
point, and deal with it as a " fact" of daily 
experience, we come to regard it as any 
departure from the structure or functions 
of the body as these are shown to us in 
health ; and thus we may define it to be 
an abnormal condition of function, or 
structure, or both. 
But if we contemplate disease in its re- 
lation to the many "names" by which its 
various forms are recognized, we have a 
complicated problem with which to deal, 
and can only solve it by endeavoring to 
separate that which is common to all 
phases of ill-health, from that which is pe- 
VOL. I.-2 
17 18 
INTRODUCTION. 
culiar to the various names by which those 
phases may be known, but by which they 
are only imperfectly expressed. And in 
order to do this we must recall some typi- 
cal examples of these names. A patient 
may be described as suffering from, or he 
may be said to be an example of, the dis- 
ease called inflammation of the lung, hoop- 
ing-cough, tuberculosis, anaemia, typhoid 
fever, hysteria, or of some other malady, 
which would or would not readily fall into 
one or the other of these categories. And 
be it observed that by this term " inflam- 
mation of the lung," is expressed a par- 
ticular kind of change in one organ of the 
body; by "hooping-cough" is meant a 
special and characteristic variety of a 
symptom common to many very different 
affections ; by "tuberculosis" is intended 
some general change in the whole body, 
distinguished from other general changes 
by its association with the appearance in 
one, two, or many organs of a particular 
material known as tubercle; by "anae- 
mia" is understood literally only an ab- 
sence or deficiency of blood, but generally 
an alteration of quality rather than of 
quantity ; by " typhoid fever" is conveyed 
the idea of a change, of a particular type, 
in the whole organism, and one which is 
produced by the introduction into the body 
of a poison from without; while by "hys- 
teria," and similar phrases, is conveyed 
some meaning or none at all, and, when 
the former, a meaning as various in cha- 
racter as are the individuals who use the 
word. There are other principles upon 
which disease has been named, and by 
which it is now described, but these ex- 
amples are sufficient to show by their very 
existence the varying prevalence, at dif- 
ferent periods, of diverse theories about 
disease ; about the relation of the one or- 
gan to the whole system of organs; the 
nature of the changes which different or- 
gans may undergo ; the value of particular 
functional alterations, and of special symp- 
toms ; the relation of the blood to life, and 
to the tissues of the body; the lien be- 
tween certain materials we can see, and 
some general conditions we can appre- 
ciate by their effect on life ; the position 
in which life-functions stand to the vari- 
ous poisonous agencies around them, and 
the concealment, by patent facts of little 
moment, of important conditions which 
may be inferred to be their cause. Thus 
the history of a science might be shown 
to be written in the names by which the 
objects about which it is concerned have 
been described and recognized : but such 
is not the end now in view ; it is to show 
that the principles upon which diseases 
have been named have varied widely, not 
only at different periods, but at the same ; 
and that so great is the diversity among 
them, and so strangely aberrant are the 
forms which disease sometimes assumes, 
that, hitherto, no self-consistent and at 
the same time practical nosology has been 
devised. English physicians have there- 
fore thought it better to retain old names 
that were well understood, although based 
upon doubtful, if not erroneous pathology, 
rather than to invent new terms which 
could not possess the advantages of their 
predecessors, although they might very 
probably share their faults. We have 
therefore gradually accepted a nosology of 
most complex composition with the tacit 
or expressed admission on all hands, that 
by "pneumonia" is intended much be- 
yond the particular condition of the lung; 
that it implies changes antecedent to itself 
in the general nutrition of the body, and 
alterations in all the tissues and in their 
processes when the disease itself appears ; 
that the words " hooping-cough" convey 
more than is included in a particular va- 
riety of cough which is characterized by a 
hooping sound, viz., the well-known his- 
tory and social relationships of a disease 
altogether distinct from the paroxysmal 
cough and hooping sounds not rarely met 
with in cases of chronic bronchitis and 
emphysema; that by "tuberculosis" is 
intended a condition as well marked by 
general as by local changes, and probably 
dependent upon some constitutional vice 
which determines, and is not determined 
by, the special form of local change ; that 
by "anaemia" is meant much more than 
the mere etymology of the word can con- 
vey ; that by "typhoid fever" is intended 
the description of a disease having rela- 
tionships only very inadequately expressed 
by the words in common usage to denote 
it; and that by " hysteria" and similar 
expressions are understood more than the 
present state of medical science will ex- 
plain, and much more than the words 
themselves accurately define. 
In this state of medical nomenclature, 
and of medical science as represented by 
the names it sanctions, it is difficult to ar- 
rive at any other definition of " disease," 
than that it is the sum total of morbid 
changes in both function and structure; 
and we must further admit that the names 
by which diseases are recognized are some- 
what arbitrary terms used for the purpose 
of recognition without any constant value 
as to the meaning of those words in a sys- 
tem of pathology. Sometimes the name 
expresses what is believed to be the essen- 
tial or most important fact; sometimes 
the first link in a long chain of causes and 
effects ; sometimes a characteristic symp- 
tom or group of symptoms ; sometimes an 
idea as to the mode of origin of the dis- 
ease; and sometimes such a negation of all 
theory as contents itself with words which 
shall be understood to mean certain things 
to which they bear no more pathological 
relation, although they may have more 
seeming scientific value, than the common STRUCTURAL AND FUNCTIONAL DISEASE. 
19 
algebraical expressions for "unknown 
qualities,"-x, y, z. 
But there is, underlying all our nosol- 
ogy, an idea of something special or indi- 
vidual in the diseases that we name. This 
notion is distinctly expressed with regard 
to some, hinted at in relation to others, 
and unsuccessfully concealed in respect of 
the rest. In spite of opinions to the con- 
trary, the physician knows that there is, 
in his mind, an ideal type of disease, which 
he cannot define, and cannot find realized 
in actual practice, but yet to which type 
he refers the examples that come before 
him. Disease to him is something more 
than a group of symptoms, it is that which 
makes the group ; and he is-as indeed he 
ought to be-like the naturalist in his pro- 
cess of nomenclature, striving to express, 
by the names he uses, that which occa- 
sions the inner relation between essential 
facts, and not merely that which will de- 
note the outer and often quite superficial 
assemblage of phenomena. 
As, however, the idea above alluded to 
is very different in different minds, and 
pathology is, as yet, in such a condition 
that it cannot furnish a complete scheme 
of nosology, based upon the attempt to 
express, by name, the fundamental fact of 
all the many maladies with which we are 
acquainted, disease is defined to be the 
sum total of changes from a condition of 
health which may be recognized in either 
function or structure, or both; and the 
names of diseases are held to be merely 
convenient expressions for their recog- 
nition. 
Structural and Functional Dis- 
ease.-In describing the elements of what 
we call disease, two terms have been fre- 
quently used, "structure" and "func- 
tion ;" and we know that the two phrases 
"structural disease" and "functional 
disease" have passed into common usage. 
Recently it has become somewhat the 
fashion to object to the latter, and to deny 
the existence of any such condition. It is 
necessary therefore to state the grounds 
upon which the phrase "functional dis- 
ease" has been retained in this "System 
of Medicine," and the precise sense in 
which it is employed. 
For this purpose three classes of facts 
have to be remembered. 1st. That there 
are some structural alterations, such for 
example as atheroma in the vessels, which 
may, if an individual has been killed by 
an accident, be found extensively distrib- 
uted throughout the body, the existence 
of which had been neither known nor sus- 
pected by the presentation of any func- 
tional change, or symptom, during life. 
On the other hand, a man may have suf- 
fered for many years from discomfort, or 
marked derangement of the functions of 
the brain, heart, or lungs, and yet the 
most practised anatomist, with all means 
and appliances to help him, may fail to dis- 
cover, post-mortem^ any organic change 
which is sufficient to have accounted for 
them. 2d. Another class of facts, con- 
stantly lost sight of by those who deny the 
existence of functional disease, is to be 
found in the relations between structure 
and function in health. At the end of a 
day's work, and after a night's repose, we 
might find the two extreme conditions of 
the organism as regards function. For 
twelve hours every muscle, nerve, and 
organ has been doing its utmost, and, as 
we know, has been wearing out: during 
the hours of sleep, many organs have been 
doing little, and some nothing, whereas 
others have, as it seems, to work on with- 
out repose; but in all repair has been 
going on. By an examination of the body, 
killed suddenly at the end of one or the 
other of these periods, it might be possible 
to infer which had been the condition 
immediately preceding death. But this 
inference would be based upon the relation 
exhibited between the products of func- 
tional activity, such as the nature, quan- 
tity, and quality of the secretions in their 
several receptacles ; and the raw materials 
upon which the organs have to work, such 
as the nature, quantity, and quality of the 
chyle, lymph, and blood. It would not be 
formed upon regard directed only to the 
condition of organs which had been either 
in activity or repose. It could not be so 
based, because the process of repair in the 
living, healthy body is one that is simulta- 
neous and commensurate with waste. The 
muscles are not mended up as we mend a 
damaged wall, by patching up a hole here, 
and binding on an iron brace or girder 
yonder; but the process is interstitial; 
new material is brought in, and brought 
everywhere; the existing organ is worn 
down, and the waste matter is carried 
away; but, with all this change, there is 
a persistent textural result. Looking at 
this question still more closely, we see that 
function is related to structure, not only 
in the sense that it is what the organ does, 
but in the much more important meaning 
that it is at once the expression of the 
wear and also of the repair of tissues ; or 
in other words the outcome of their life. 
In the present state of physiology, it is 
impossible to conceive of a living organ 
without believing in the nutritive, mole- 
cular changes it is undergoing ; and these 
are the essential conditions of its func- 
tional activity : it is equally impossible to 
imagine the function of any living tissue 
being called into exercise without recog- 
nizing the dependence of this functional 
operation upon interstitial movements of 
repair and waste. But we should be 
wrong on the other side were we to con- 
found function with the nutritive changes 
which constitute, not the function itself, INTRODUCTION. 
20 
but the conditions of its exercise. It is, 
for example, the peculiar function of a 
muscle to shorten itself, of a nerve to con- 
vey an impulse either of motion or sensa- 
tion, and of a nerve-centre to convert one 
of these impulses into the other ; the or- 
gans referred to, in exercising these func- 
tions, undergo certain nutrition-changes ; 
but these molecular changes are not the 
functions of the organs, but the conditions 
essential for their performance. This prin- 
ciple, which it seems almost unnecessary 
to state, in regard of the particular organs 
or tissues now referred to, is, however, 
not unfrequently lost sight of in respect of 
secreting organs. It is the function of the 
salivary gland to secrete a fluid having 
special characters ; of the liver to do this, 
and to effect changes in the blood which 
comes to it; and so of other secreting or- 
gans : they receive blood into them, and 
from all of them it passes away, changed ; 
and the organ, as part-product of this 
change, gives up its secreted matter. 
These functions, be its observed, depend 
for their performance upon nutrition- 
changes in the cells and tissues of the or- 
gans ; but those fine processes of change 
are the conditions of functional activity, 
and are not to be confounded with the 
thing itself. The secreting cell has to 
live, to waste, and be repaired; audit lives 
at a degree of pressure, and is wasted and 
repaired at a rate, directly proportioned 
to the amount of work that it accomplishes; 
and thus it is conditioned precisely as are 
the ultimate elements of the muscle or the 
nerve. But minute aS is our knowledge 
of much that goes on in the secreting or- 
gans, and of the chemical nature of the 
results or products of their work, we know 
no more of the physical conditions which 
determine that one set of cells shall sepa- 
rate urea, another set saliva, and a third 
bile acids from the blood, than we do of 
those which enable one nerve-fibre to con- 
vey impressions of light, another of sound, 
and another those of motion. These are, 
at present, ultimate facts of physiological 
science ; the function is the expression of 
the life of the structure ; it is what the 
latter was constructed for the purpose of 
doing ; in doing it, the structure under- 
goes change ; it is wasted and repaired, 
but these processes are carried on without 
any breach in the integrity of tissue. 
Function is to nutrition, as electricity is 
to the chemic changes in the galvanic 
battery, a "correlated force." We do 
not say that the one is the other, but that 
it is converted into it; and, as in the in- 
organic world, the arrangement and na- 
ture of the particular materials with 
which different forces come into contact, 
determine whether chemic action shall 
appear as heat or magnetism, whether 
heat shall be shown in motion, light, or 
electricity, so do the different materials of 
the living organs, and their arrangement, 
determine the nature of the functions 
they perform: how they do this, we do 
not know, but the facts of physiological 
science are well known, viz., that the 
nerve cell exhibits one class of powers, 
the muscular cell another class, and the 
secreting organs a third. 3d. A third 
class of facts to be remembered is, that in 
many diseases, the only symptoms to be 
recognized are changes in the degree of 
activity with which certain organs per- 
form their functions. No new element is 
introduced by some diseases into the cate- 
gory of vital actions; such affections as 
chorea, hysteria, epilepsy, might be shown 
to consist of mere modifications in the de- 
gree, time of occurrence, and combina- 
tions of functions, each of which, taken 
per se, is consistent with health. The 
sudden loss of consciousness in epilepsy, 
for example, is not more mysterious than 
is the sudden but every-day recurring 
passage from wakefulness to sleep; the 
arrested respiration is similar in kind to 
that seen when the chest is fixed in the 
performance of any great muscular exer- 
tion involving the upper limbs ; and still 
more similar to that which can scarcely 
be called morbid, the prolonged apnoea of 
a screaming child, whether the scream be 
the expression of terror, temper, or pain : 
the convulsive movements are neither 
more nor less than nerve and muscular 
functions, any of which might separately, 
and many of which might in combination, 
be the expression of healthy vital activity. 
From these three classes of facts, there- 
fore, we are compelled to admit that, in the 
present state of science, the onus probandi 
lies with those who assert the constant 
presence of structural in association with 
functional change; and we affirm that 
those who make the assertion have never 
proved their point. Further, that as a 
matter of inference from what we know 
of the relation subsisting between struc- 
ture and function in health, we should not 
even expect to find solutions of continuity 
or coarse changes of texture in those dis- 
eases, the essential elements of which are 
functions altered, not in kind, but only in 
degree and mode of association ; and that, 
on the other hand, when we do find mate- 
rial changes in association with functional 
disturbances, we should refer many of the 
latter only indirectly to what we see of 
the former, the more numerous and more 
important of them being dependent upon 
what we do not see, viz. the finer changes 
in the interstitial processes of nutrition. 
A scirrhous tumor of the stomach, for ex- 
ample, may produce certain symptoms 
easy explicable by its mechanical effects ; 
it may be so situated as to prevent the in- 
gress or egress of food ; but vomiting may 
occur when the orifices are free, or when 
the tumor is situated in some organ in the NATURAL HISTORY OF DISEASE. 
21 
pelvis : the supposed tumor may cut off 
the supply of food, and so explain some of 
the changes we see in color and general 
nutrition ; but, on the other hand, the ex- 
treme of wasting and of cancerous tinting 
may be seen when there is no such enforced 
abstinence from food, but when indeed a 
large quantity is not only taken, but is di- 
gested and enjoyed. So again a clot of 
blood in the corpus striatum may sever the 
nerve-fibres, and so explain the severance 
between the will and certain muscles of 
the extremities ; but it will not so explain 
the presence of convulsions, or of spasms 
in those palsied limbs. 
For these reasons we retain the words 
"functional disease;" understanding by 
them such changes as have no recognized 
morbid anatomy, but such as depend upon 
corresponding changes in the finer pro- 
cesses of nutrition. We do not believe 
that there is any altered function without 
a correlated change in the nutrition of the 
organ ; but what we assert is that such a 
change, as a matter of fact, is of such kind 
as to be undiscoverable by our senses, and 
as a matter of inference, from what we 
know of the relation between nutrition 
and function, is of such nature that it may 
always be beyond the reach of observa- 
tion. No healthy function is performed 
without nutrition-change; no morbid func- 
tion can exist without altered nutrition- 
change ; but the relation between the two 
elements, "structure" and "function," 
is the same in the two conditions. 
Nothing is more erroneous than the 
common notion that " functional " means 
trivial, and that "structural" means se- 
vere. Many diseases, designated by the 
former word, are long-continued, obsti- 
nate, or destructive ; many known by the 
latter are of short duration, are amenable 
to treatment, or are harmless. Diseases 
which spoil or shorten life are not trivial 
because they depend upon such fine 
changes as may escape our observation ; 
but they are the more serious wrhen they 
thus elude our notice, just because they 
have their place in the very centre-the 
most ultimate process and fact-of life, 
the conduct of nutrition. 
Natural History of Disease.-Un- 
der this phrase are recorded the symptoms 
or phenomena of disease, their causes, the 
manner of their development, their dura- 
tion, and the different mode of their termi- 
nation, whether the termination be in 
death, or in a return to health. In the 
natural history of disease no theory is in- 
volved ; we have to deal only with facts. 
Causes.-Commencing with that which 
precedes the appearance of symptoms, viz. 
the "causes" of disease, there are some 
principles which it is important to lay 
down ; inasmuch as our ideas of the caus- 
ation of disease are determined, in great 
measure, by our conceptions of what dis- 
ease itself is. Nothing is more easy some- 
times than the discovery of a cause, and 
its distinct separation from a particular 
and well-known malady. For example, a 
healthy child is brought into a room where 
some one is suffering from scarlet-fever, 
and after a certain period it exhibits symp- 
toms of the same malady, and passes 
through all its stages. Here we say there 
was direct communication of the malady; 
but we must not forget two facts, first that 
some children so exposed do not take the 
fever, although they have not previously 
had the disease ; and secondly, that those 
who have suffered from it once rarely take 
it again, although they may be exposed to 
infection. We suppose a constitutional 
disposition in one case, an indisposition in 
a second, and assert the existence of the 
latter in a third. Still, when the cause 
has operated we feel that we tread on safe 
ground when asserting broadly that the 
cause is "'infection." 
Nothing, however, is more difficult in 
some cases than to say what the cause of 
a disease has been. For example, six 
people take an indigestible meal, and one 
of them suffers nothing, a second is trou- 
bled with dyspepsia, a third with asthma, 
a fourth has an epileptic fit, a fifth an at- 
tack of gout, and a sixth is disturbed with 
diarrhoea. One element in the causation 
of all these maladies is the same, viz. an 
indigestible meal, but the results vary 
widely; and we say that this is owing to 
constitutional conditions which "predis- 
pose" to these particular affections. These 
have been called "predisposing causes ;" 
but we must inquire what they are, and 
how they are related to these diseases, if 
we would understand the latter. Among 
the predisposing causes are reckoned he- 
reditary taint, sex, age, and constitutional 
peculiarities, either congenital or acquired; 
and with regard to two of these, heredi- 
tary taint and constitutional peculiarity, 
we must admit that they are, in reality, 
disease. When we allow the existence of 
either, we but throw back a few steps fur- 
ther the line and widen the circle which 
includes all that we mean by the disease 
itself: we include in the malady more 
than its name expresses ; we partially ac- 
count for its occurrence, but do not ex- 
plain its "cause." It is quite true that 
we may sometimes draw a line between 
certain so-called causes and effects; we 
may say, for example, this man, of tuber- 
culous family and with latent tubercle, 
was yesterday apparently well, but he was 
exposed to cold, and to-day he has tuber- 
cular pneumonia ; his constitutional state 
"predisposed" him to the evil, which the 
exposure "excited" into activity ; but re- 
garding him from a pathological point of 
view in his present position, that of a suf- 
ferer from tubercular pneumonia, we can- INTRODUCTION. 
22 
not separate the elements of his disease so 
easily, for it was not a cause of his malady 
which was there before, but an integral 
part of the affection under which he is now 
laboring. A similar difficulty is to be 
encountered on almost every "hand; the 
worry of the Stock Exchange is borne by 
some men bravely, others succumb, but va- 
riously, one goes mad, another is "broken 
down," a third becomes epileptic, and so 
on; and we fly to the resource of "pre- 
disposition," some weakness somewhere, 
which this wear and tear has pointed out, 
and urged into morbid activity; but in 
that very weakness, if there was not the 
whole of the disease called A, B, or C, 
there was some important element of 
it, and not its remote or predisposing 
"cause." If disease be, and we believe 
it must be, defined to be the sum total of 
changes in either structure or function, or 
both, then almost all of these so-called 
"predisposing causes" are part of the 
disease itself. 
But those other conditions, sex and age, 
it may be asked, are they integral ele- 
ments of disease, or are they its cause ? 
Sex cannot be said, accurately, to be a 
cause of disease any more than the same 
can be affirmed of life, but yet, in all 
modern treatises on medicine, it figures in 
the chapter on etiology. Be it observed, 
however, that the word " sex" when thus 
used, has reference to many conditions of 
difference beyond those which exist in the 
reproductive organs. The male sex, as a 
rule, exhibits the masculine frame of body 
and of mind, while the female sex dis- 
plays the opposite, and their respective 
" predispositions" to disease have relation 
to these characters as well as to the phys- 
ical structure of the apparatus of repro- 
duction. The existence of an organ is 
the necessary condition of its becoming 
diseased-a man cannot suffer from ova- 
rian tumor, nor a woman from orchitis- 
but there are some organs common to the 
two sexes, and equally developed in each 
until the sexual distinctions of puberty 
are seen; then in the one they become 
rudimentary and inactive, whereas in the 
other they take on new and important 
functions. In these instances sex may be 
said to be a predisposing condition of dis- 
ease, but it is so only in this sense, that 
it exposes certain organs to some of the 
causes of disease by the simple fact of 
their functional activity. It must not be 
supposed that the healthy action of any 
organ predisposes it to morbid change ; on 
the contrary, it exerts rather a strength- 
ening and protective influence ; but such 
activity simply lays it open to the opera- 
tion of influences which cannot be brought 
to bear upon its counterpart which re- 
mains in a rudimentary condition in the 
other sex. But besides these essential dif- 
ferences there are others which are acci- 
dental, and winch depend upon education, 
practice, and habits of life, as these are 
determined by the customs, fashions, or 
peculiarities of the people and their times. 
And, further, there are many facts with 
regard to the relative proclivity of the 
sexes to special diseases which have not 
yet been explained by any known relation 
of these maladies to the reproductive or- 
gans. Simple ulcer of the stomach and 
carcinoma of the same organ afford exam- 
ples of this difference of proclivity, and 
we at present have to regard them as ulti- 
mate facts of pathology. 
Among the conditions which deter- 
mine, therefore, the differences of sexual 
predisposition to disease we reckon (1) the 
actual presence or absence of the organs ; 
(2) the action or almost absolute inaction 
of the organs ; (3) the relation between the 
amount of activity of some functions of cer- 
tain systems of organs, and other functions 
of the same systems, where differences ex- 
ist ab initio; and (4) the effects of habit, 
education, and fashion, in either produc- 
ing or lessening functional activity, with 
all its correlated structural conditions. 
In a similar manner must we regard 
the influence of age in the production of 
disease. It is not per se a predisposing 
cause, but it carries with it certain things 
which may be. If we can conceive of a 
perfectly healthy organism, placed in ab- 
solutely healthy conditions, then we may 
believe that it would pass through the 
stages of growth, dentition, puberty^ adult 
life, and decline ; and that it would per- 
form all the functions of self-preservation 
and reproduction without either hurt or 
hindrance ; sometimes, nay, very often, 
we do actually see some of these stages 
passed through with as entire a freedom 
from discomfort as any ideal being placed 
in the most Utopian circumstances could 
wish for; but at some point or another in 
the long course of life, the chain of good 
succession is broken by a faulty link or an 
unexpectedly heavy blow, and then follow 
one or another of the many ills that make 
up the miseries of common life, and ave- 
rage health. On the other hand, we see 
cases in which nothing seems to be capa- 
ble of going -well; every epoch, every 
change, every organ, seems, as it were, 
pounced upon at every turn by all the 
evil agencies that surround it; action or 
inaction, growth or decay-it matters not 
which-seems exaggerated into a condi- 
tion of disease, and life is a lifelong mis- 
ery. It is clear that no one period of life 
is in itself a cause of disease, or of exemp- 
tion from its occurrence, since all periods 
may be passed through without any dis- 
turbance of the health, and no period pos- 
sesses absolute immunity from its attack. 
But it is also evident that the changes 
which take place at certain periods, render 
some individuals liable to the operation SYMPTOMS OF DISEASE. 
23 
of other causes, and that this operation 
may be very effectual in the production of 
disease. Such periods are those of rapid 
structural development, and the com- 
mencement of new functional activities, 
or the decline of structure and the arrest 
of action. That which would seem to be 
the condition tending to morbid develop- 
ment is the disturbance of the balance of 
activity and growth between different or- 
gans, or systems of organs, so that for a 
time at least an undue preponderance is 
^iven to a certain set. Thus during the 
first dentition, although there is general 
growth, there is particular activity of cer- 
tain organs; and, in like manner, at the 
commencement of puberty, there is, as it 
were, undue prominence given to the or- 
gans effecting reproduction ; and although 
the particular structures involved in these 
developmental changes may not be se- 
lected as the localities for morbid action, 
the very fact of their disproportionate ac- 
tivity-by a disturbing balance of general 
nutritive progression - may become a 
cause of derangement in other systems of 
organs, such as the vascular or nervous. 
In like manner, at the climacteric period, 
the repression of certain functions, to the 
operation of which the whole body has 
become habituated through a long series 
of years, may prove itself the starting- 
point of morbid changes in the functions 
of other organs which are, by this repres- 
sion, placed in new and trying circum- 
stances. By these considerations we may, 
for the most part, explain the influence, 
where it is marked to the highest degree, 
of age as a so-called " predisposing cause" 
of disease. 
But there are some maladies which ap- 
pear to have a definite relation to age, 
and which are not explicable upon these 
principles ; and with regard to these we 
must admit that certain periods of life are 
associated with proclivity to disturbances 
of particular kinds, the nature of the rela- 
tion between the two classes of conditions 
being at present unrecognized by medical 
science. At the same time the history of 
all science is such that it teaches us to 
believe that these relations will be here- 
after discovered and found to be analogous 
to those which we already understand and 
appreciate. 
The term "exciting cause" of disease 
has been applied to another class of con- 
dition altogether, and one with regard to 
which there is much less difficulty. That 
which is involved in the term is the ope- 
ration of some influence from without, be 
that such as to act upon mind, emotion, 
sensation, nutrition, vascular conditions, 
temperature, or any other function or 
property of the living body. A great sur- 
prise, or an overwork, may affect the 
mind ; a domestic calamity, or the worry 
of business, may disturb the emotional 
centres; a physical injury may set up 
changes in sensation; a forced rest may 
weaken muscular nutrition ; a tight band- 
age, or an altered position, may influence 
the vascular supply ; cold or heat may di- 
minish or increase the temperature of 
parts ; and in like manner other agencies 
may affect the organism, and become the 
exciting causes of disease. The form 
the latter take is determined partly by the 
nature of the exciting cause, and its rela- 
tion to this or that system of organs ; and 
partly by the condition of the organism, 
in regard of hereditarily received or con- 
genitally acquired morbid state, the pecu- 
liarities of sex, and the period of life. 
Two things therefore concur to make 
up what we term the causes of disease, 
but they are essentially distinct, and it 
would be better to denote them by differ- 
ent names, than by one name differently 
qualified. The one, the so-called "pre- 
disposing cause," is a "diseased condi- 
tion, ' ' and is therefore a part of the disease 
itself; the other has no necessary relation 
to the individual or his constitution, and 
is in reality a " cause" of the disease from 
which he is suffering. 
Symptoms of Disease.-The meaning 
which now we must assign to the word 
"symptom" or "sign" of disease, is very 
different from that which some time ago 
would be conveyed by those terms. So 
long as disease was regarded as some- 
thing put into, added to, or engrafted 
upon the body; a material, or other en- 
tity,-having even a more or less substan- 
tive existence,-these words described the 
means by which we might recognize the 
presence of such an entity : but so soon 
as disease is recognized to be, as we have 
defined it, the sum of changes in function 
and structure presented by the living be- 
ing, the words "symptom" and "sign" 
have another meaning, and describe only 
those parts of the disease which are ap- 
preciable by others. Disease is a complex 
state of a complicated organism, and al- 
though the name which we may give it 
may be intended to express its primary or 
most important fact, we cannot separate 
this one fact from others with which it is 
associated, but must regard them as inte- 
gral parts of the malady we have either 
to study or to treat. They may differ, 
from an outside point of view, in proximity 
of relationship ; but the heat of skin, the 
altered pulse-respiration ratio, the nature 
of the expectoration, the changes in the 
secretions, in the nervous system, and in 
the prospects of life, together with the al- 
tered resonance, breath and voice-sounds, 
are as much parts of the disease called 
"pneumonia" as are the structural condi- 
tion of the lung. Some of them may be 
signs by which we recognize its presence ; 
but they are also essential elements of the 
malady itself. In like manner it might 24 
INTRODUCTION. 
be shown with regard to those other dis- 
eases, the nomenclature of which differs 
as we have already described, that a pre- 
cisely similar relation exists between what 
we have denominated "symptoms" and 
what we understand by "disease." We 
cannot know of the existence, during life, 
of any disease except by its symptoms; 
we cannot conceive of disease apart from 
some recognizable changes in either func- 
tion or structure ; and these changes con- 
stitute the disease : nor can we, on the 
other hand, imagine the existence of what 
we call "symptoms" apart from the cor- 
relative idea of what we conceive to be 
"disease." The two classes of notion 
have been, of necessity, distinct in their 
development; but the maintenance of the 
distinction between them has been a hin- 
drance to true progress in pathology ; and 
it will be well for us to try and remove 
that hindrance. So long as "disease" is 
thought of as a something-it matters not 
what-distinct from the "phenomena," 
or "symptoms," by which it makes itself 
known, so long are we in danger of mis- 
taking its real meaning, and of overlook- 
ing those true guides towards the removal 
or alleviation of its evil, an end to which 
all medical science ultimately points. 
"Disease," we have said, is a change 
of structure, or of function, or of both; 
"symptoms" are those changes in struc- 
ture or function, or both, which we can 
recognize. The latter, the symptoms, are 
not separate from, but are parts of the 
disease, and their only characteristic is 
that they are such parts as are apprecia- 
ble during life. But they differ in kind 
and in value among themselves, and have 
been known by different names, so that 
we meet with such distinctions as those 
between "signs" and "symptoms," be- 
tween "objective" and "subjective" 
symptoms; and between "general" and 
" local" symptoms. These terms almost 
explain themselves, and are retained be- 
cause they possess a certain amount of 
utility ; but it is more easy to make use 
of them in practice than to define their 
exact meaning in the abstract. The idea 
underlying the word "sign" is that it is 
some physical change which can be ob- 
served directly ; and thus we speak of dul- 
ness on percussion, tubular breathing, 
augmented vocal fremitus, and broncho- 
phony, as "physical signs" of condensa- 
tion of the lung ; whereas we speak of 
dyspnoea, expectoration, and fever as 
"symptoms" of pneumonia, or tubercu- 
losis. But heat of skin, an eruption on 
its surface, the wasting of a muscle, or 
the fact and quality of a secretion, are as 
much " physical signs" of a disease as are 
the particular phenomena we have men- 
tioned. Yet it is almost unknown, it is 
certainly very unusual, to hoar the term 
"physical sign" applied to any of them. 
It is easy to trace the origin of this dis- 
tinction between symptoms and signs to 
the period when the physical examination 
of the chest arrived at its due position. 
It was felt that an amount of precision in 
diagnosis was arrived at by percussion 
and auscultation, such as w'as never 
dreamed of in the times before such 
modes of exploration were employed ; and 
therefore the conditions revealed by their 
aid were expressed in terms differing from 
those which had been previously em- 
ployed, to describe such changes as short- 
breathing, pain, expectoration, and the 
like. But it is impossible to maintain the 
distinction ; the number of respirations 
per minute is as much a " sign" as is the 
dulness on percussion, and both of them 
may be " symptoms" of disease. Every- 
thing that may be observed is both the 
one and the other, and the reason why the 
distinction has been maintained is~ be- 
cause with regard to the former-the 
" sign"-there may be but one means for 
its recognition, namely, observation from 
without; whereas with regard to the 
latter-the "symptom"-there is a pos- 
sibility of confounding two things essen- 
tially distinct, namely, the sensations of 
the patient, and the phenomena he pre- 
sents. Deficiency of resonance is dis- 
covered only by percussion; but short- 
breathing is a sensation of which the 
patient complains, as well as a pheno- 
menon which may be appreciated and 
measured by the physician ; and in like 
manner wasting of a limb may make itself 
at once evident to the observer, whereas 
paralysis is a condition which the patient 
may assume. 
The really valuable element of distinc- 
tion between these two classes of pheno- 
mena is therefore that which exists be- 
tween "objective" and "subjective" 
symptoms ; meaning, by the former word, 
all those elements of disease which can be 
appreciated by the senses of the observer, 
and by the latter, those which can only be 
known through the statements of the pa- 
tient. Whatever of disease comes to us 
only through the mind or feelings of the 
patient, as expressed by language, either 
of gesture or words, is a "subjective" 
symptom. Its form and its degree of in- 
tensity are subjected to the conditions of 
the machinery-mental, emotional, and 
sensational-through which it passes, and 
it is liable therefore to be changed, either 
in character or degree. Whatever of dis- 
ease comes to us through our own senses 
alone escapes this danger of addition, 
alteration, or subtraction, and is pro tanto 
of higher value. In one class the patient 
gives his version of his case ; the symp- 
toms are such as we can only get at 
through his mind, and they are termed 
"subjective in the other, we make our 
own observations-the'feelings or ideas of 25 
COURSE AND DURATION OF DISEASE. 
the sufferer have nothing to do with them 
-simply, physical facts are the objects we 
recognize, and such symptoms are called 
"objective." 
As a general rule the objective are much 
more valuable than the subjective symp- 
toms ; but let it be remembered that the 
importance of the latter is very widely 
variable, and that sometimes it may far 
exceed anything that can be derived from 
direct observation. In the early stages of 
some serious diseases of the heart or brain, 
nothing may be presented to the practised 
ear or eye; and yet the patient tells us of 
a deep unrest, or sudden horror, which, 
although it has no objective sign, may be 
the herald of a sudden or lingering disease ; 
as true and as important - although to 
others the mind seems clear, and the 
heart's beat healthy-as any murmur we 
might hear with the stethoscope, or any 
palsy we might measure by the hand. We 
have to deal with man as a whole ; and to 
ignore or undervalue what he tells us of 
his ideas, emotions, or sensations, because 
they may be termed "subjective symp- 
toms," and be held to be therefore unre- 
liable, would be to shut out from ourselves 
that which-egotistic and fearful, preju- 
diced and ignorant as man may be-yet 
forms an integral part of his life, and 
therefore of his disease. We must be 
careful to give to both groups of symp- 
toms their true value, and our danger in 
the present day is to underrate the im- 
portance of those which, a few years ago, 
constituted almost the total symptoma- 
tology of disease. 
The distinction between "general"and 
"local" symptoms need not detain us, 
since the terms are obvious in their mean- 
ing, and the difference between them is 
gradually dying out by the recognition of 
the fact, that no one organ can have its 
functions or its structure changed without 
the existence of some relative change in 
all the rest. 
Course.-In describing some few dis- 
eases we have little more to do than to 
detail the phenomena present at any one 
given time ; whereas in furnishing the 
natural history of others we are compelled 
to speak of premonitory symptoms, or 
prodromata, of the modes of commence- 
ment of the illnesses, their forms of attack 
or their debut, and of the different stages 
-two, three, or more-through which 
they pass. Between these two extremes 
we have every amount of variation : the 
natural history of one disease may be 
compressed into a sentence; that of an- 
other may expand into a book ; but more 
commonly we have to deal with histories 
intermediate in duration, and perhaps 
less emphatic in their interest. 
It often happens, however, that the 
mode in which one event follows another 
is of great importance in the diagnosis of 
disease. For example, the decumbency 
in pleurisy has different meanings at the 
commencement of the malady, and at its 
later stages ; and in like manner rigid 
muscles teach one thing at the onset of a 
paralytic seizure, another when the im- 
mediate effects are passing off and the pa- 
tient is regaining power ; and still a third 
when without such restoration it makes 
its appearance at a yet later period, and 
in a well-known order. 
Not merely the mode of sequence, but 
the actual time of sequence, is of diagnos- 
tic and therapeutic value; and this we 
know full well in the study and recogni- 
tion of the acute specific diseases, of mala- 
rial fevers, and the like; and with equal 
significance, though with less accuracy of 
measurement, can we use the element of 
time in the diagnosis of many chronic 
diseases; and such element may some- 
times be sufficient to determine a question 
left wholly in the dark by other elements 
which we have had before us. In this 
manner time enters occasionally into the 
diagnosis of tubercle, of cancer, of hemor- 
rhage, and of other maladies; and it 
would be difficult to overrate its value in 
those special cases which are left in obscu- 
rity by the absence of special or pathogno- 
monic symptoms. 
Again, the relative intensity of symp- 
toms is a point to which attention must 
be frequently directed, for by this alone a 
diagnosis may be possible. If we regarded 
the relative intensity of pain, dyspnoea, 
fever, cough, and general nutrition- 
change, each of which might be present 
in bronchitis, pneumonia, pleurisy, phthi- 
sis, or asthma, it might be possible to say 
which disease existed, and this without 
the aid of auscultation or percussion. 
And in like manner by regarding the 
relative amount of coma, paralysis, spasm, 
and rigidity, it would be possible to dis- 
tinguish, in some cases, between cerebral 
hemorrhage, acute softening of the brain, 
congestion of the brain, or urinsemia. 
All these particulars have to be de- 
scribed under the head " course" of symp- 
toms ; and they form an essential part of 
the natural history of disease. 
Duration.-The importance of a consid- 
eration of time in the diagnosis of some 
classes of disease has already been referred 
to ; it is of no less importance when, diag- 
nosis being determined, a knowledge of 
the natural history of disease gives us 
power to foretell, with some approxima- 
tion to accuracy, its probable results. 
We know approximately the duration 
of herpes zoster, of vaccine, or variolous 
pustules, of typhus, or scarlet fever ; and 
we know also, approximately, the dura- 
tion of phthisis pulmonalis, of carcinoma 
ventriculi, and of other maladies. With 
regard to the latter-the chronic class- 
our knowledge is much less definite, or 26 
INTRODUCTION. 
rather it lies within a larger range, and is 
of less practical utility. It may, regarded 
from a pathological point of view, be even 
more accurate than that which we boast 
of in respect of the acute diseases; for the 
relative range of variation is not greater, 
although in the one case we deal with 
days or even hours, and in the other with 
months or years. But life is on one side 
of the balance, and death is on the other, 
and the balance is struck between these 
two, whether the beam be long or short; 
and so we congratulate ourselves upon a 
readily used and readily appreciated fore- 
casting of the immediate, present evil, 
and perhaps underrate our sounder knowl- 
edge, with regard to that which may not 
happen for ten, twenty, or a hundred 
months. 
The duration of symptoms, therefore, 
though of variable social value, is of vast 
interest in the natural history of disease 
Termination.-A disease may end in 
various ways: (1) The patient may 
gradually get rid of it altogether. (2) lie 
may lose all the urgent symptoms-all 
that at one time seemed to constitute the 
malady-and yet retain some less urgent 
symptoms ; or some which are not recog- 
nized at all; or some which-so far as the 
patient's own feelings are concerned-are 
not, even after recovery, recognizable, but 
■which may be discovered by a physical 
examination of the organs instituted by 
the physician. (3) He may continue to 
present all the local disturbances, while 
the general or constitutional changes pass 
away, and thus the disease persists, but 
in an altered and what is called a " chro- 
nic" form ; or (4) the disease may become 
worse, pass from one stage of weakness to 
another, and end by the destruction of 
the patient, which may be brought about 
in various ways. Now, all these points 
in the natural history of disease, are of 
much interest in regard of prognosis and 
of treatment. The recognition of early 
signs of recovery is a great help towards 
the choice between therapeutic means, 
and is a good ground for employing one 
of the strongest of these means of cure, 
viz., hope. The search for and discovery 
of the effects of an acute illness-although 
in that acute form it has passed away- 
are of great importance to the life, pros- 
pects, work and career of the unconscious 
sufferer. We must know these probable 
consequences if we would perform our du- 
ties as the advisers of those who place 
themselves under our care. It is not 
enough to guide a disease to an apparently 
successful issue; we must know what 
weak point it may have left behind, and 
we must guard this with the utmost cau- 
tion. Again, the tendency to pass into a 
chronic form often reveals the existence 
of some constitutional vice we had not 
before suspected, and thus renders itself 
available for a more effective direction of 
our therapeutic agencies. And, lastly, 
the perception of the early indications of 
a fatal issue may be of great social or in- 
dividual value; whereas the recognition 
of the mode in which death threatens to 
approach, may be the means of teaching 
us to select such measures as shall tem- 
porarily, or even indefinitely, postpone 
the evil. Thus the "terminations" of 
disease, whether they be in health, in im- 
paired health, or in death, are not only of 
interest to the natural historian and the i 
pathologist, but are full of teaching to him 
whose aim is to render natural history 
and pathology subservient to the great 
work of healing diseases, of relieving them, 
or of measuring their duration, and lessen- 
ing the pain with which they do their 
work. 
Diagnosis of Disease.-In the earlier 
days of medical science, the problem of 
diagnosis might have been stated thus: 
"given the symptoms, to find the dis- 
ease but, in these days, such problem 
must be translated into the following 
terms: "given some of the elements of 
disease, to discover the others." We do 
not now regard eruptions on the skin, pe- 
culiar changes in the mucous membrane 
of the throat, an elevated temperature, 
and a disturbed innervation as the signs 
by which some morbid "entity" in the 
body reveals its presence ; but as parts of 
the morbid condition of the organism, 
from which we may infer the existence 
of simultaneous changes in stomach, in- 
testines, liver, spleen, or kidneys. The 
rose rash of typhoid is as much a part of 
the disease as is the ulceration of Peyer's 
glands; the dulness on percussion, the 
altered condition of the urine, the changed 
nervous power, are as truly elements of 
the disease called pneumonia as are the 
minute alterations which constitute in- 
flammation of the lung. Some of the ele- 
ments of disease escape our observation 
during life; some are directly perceived 
by us ; and others are appreciated in- 
directly by such processes as percus- 
sion, chemical examination, laryngoscopy, 
spirometry, and the like: but the only 
difference between these is their relation 
to the observer; they occupy precisely the 
same position in regard to the disease 
itself. The process of diagnosis therefore 
is the passage, not from effects to causes, 
not from phenomena to noumena, for, 
strictly speaking, we do not at all know 
what are either the causes or the noumena 
of disease; but diagnosis is the process 
by which, perceiving some particulars, we 
infer the existence of others, which we 
know to be commonly associated with 
them. This is however the pathologic or 
scientific side of diagnosis ; and the ques- 
tion may still be asked, What is it practi- PATHOLOGY. 
27 
cally ? Practically, diagnosis is the pro- 
cess by which to a certain set of symptoms 
we affix a more or less familiar name; 
and become able to say that such a one is 
suffering from typhoid fever, meningitis, 
hooping-cough, epilepsy, or gout. And 
when we have given some names to dis- 
eases, we have, more or less intentionally 
and with differing degrees of accuracy, 
conveyed some theory into the process of 
diagnosis. Remembering what was said 
with regard to "names of disease," we 
shall find that, in this practical sense, 
diagnosis is sometimes the discovery of 
and the calling of a disease by what we 
conceive to be the most important struc- 
tural change by which it is accompanied, 
such as pneumonia ; at other times diag- 
nosis stops short at the recognition of a 
pathognomonic symptom, such as hooping- 
cough ; again, it may mean to express the 
starting-point or principal fact in a group 
of symptoms ; or some general condition 
but imperfectly understood, or some con- 
dition which is not understood at all. In 
all of these instances we notice two things: 
first, that diagnosis-looked at from its 
scientific side-is the step from particulars 
to particulars, from those which are ob- 
served to those which during life can only 
be inferred ; the step from the one or the 
one hundred to the whole; second, that 
diagnosis - regarded practically - is the 
giving of a name to the disease from which 
an individual suffers ; the ticketing, and 
as it were placing of that malady in some 
niche with others that resemble it, so that 
it may be known and brought out when 
required. But let it be remembered that 
the principles upon which names are con- 
structed are so various that no expression 
can be framed to convey their meaning, 
in so far forth as that it should carry 
further what is meant by diagnosis. 
Pathology.-When a patient presents 
himself for examination or for treatment, 
he tells us of certain things that he feels 
or sees, which are wrong, and which we 
call "symptoms we ask him questions, 
and learn additional facts of a similar 
class ; wre observe him, and notice other 
facts which he can neither feel nor know 
by independent means, and these we call 
"signs, " or "objectivesymptoms. " From 
what we are informed, and from what we 
observe, we pass on to the inference of 
other facts : we believe, when some three, 
four, or more changes from the healthy 
state are present, that other alterations 
exist; and this belief is more or less 
strong, and its character more or less defi- 
nite, according to the state of medical sci- 
ence, and our knowledge of it, at the time 
that the patient presents himself. We 
infer certain things, certain conditions 
which we cannot see, but which we may, 
in some measure, classify, and therefore 
call by distinctive names. Thus heat of 
skin is a symptom from which we infer a 
number of ulterior conditions. The reason 
for this heat of skin may-other symptoms 
being regarded-be conjectured by us to 
be an altered blood-state,, such as typhoid 
fever, tuberculosis, or the like : it may, on 
other symptomatic evidence, be referred 
to a change in some particular organ, such 
as inflammation of the lung, or destruction 
of a portion of the spinal cord : and we 
may give names to the general conditions, 
part of which we have observed, part of 
which we have inferred. This is what we 
call " diagnosis" in its practical sense ; but 
that which makes diagnosis possible is the 
existence of a certain amount of informa- 
tion about the relations subsisting between 
different organs, and about the modes in 
which particular organs may become al- 
tered in function or in structure. We ob- 
serve a change in the quantity, color, or 
other qualities of a certain secretion, and 
we infer from this that there is diminished, 
increased, or perverted action of a certain 
organ. We examine further, we discover 
other changes, and we infer the nature of 
the disease which that organ has under- 
gone, or through which it is now passing. 
What in this sense is true of one organ is, 
more or less, true of all, and of the organ- 
ism as a whole, so that we are able to give 
some general expression to its general 
state; and thus we speak of paralysis, 
fever, amemia, suppression of urine, weak- 
ness, etc. etc., and so advance from symp- 
toms-by diagnosis-to pathology. This 
is what we do in particular cases ; finding 
certain symptoms, and knowing certain 
principles, we place the individual who 
presents those symptoms in a particular 
category, and call his disease by a name 
that is understood: and in this way the 
process of thought which we call 4'diag- 
nosis" is a bridge across from "symp- 
toms" to "pathology." Diagnosis is, 
then, the practical application of what we 
know about pathology; and its accuracy 
will be in proportion to the amount of 
our information, and to the keenness and 
readiness of our observing power. Path- 
ology, therefore, is the foundation, the 
essential condition of diagnosis; for it 
would be simply impossible to advance, 
from the observation of symptoms, one 
step towards the recognition of the nature 
of disease, unless that step were based 
upon pathology ; i. e., upon a knowledge 
of the conditions under which morbid 
changes occur in structure and in func- 
tion, and also of the inodes in which such 
changes may so affect organs as to render 
themselves appreciable during life. Prac- 
tically, as cases come before us, we ob- 
serve symptoms and we diagnosticate 
pathological conditions; but we could 
form no diagnosis without pathologic 
knowledge, and diagnosis is in reality but 28 
INTRODUCTION. 
a portion of, or the practical application 
of pathology. Theoretically, however, 
pathology is the groundwork of diagnosis ; 
and not only so, but of all valuable and 
correct observation: and thus the one is 
seen to be but the necessary complement 
of the other in the practice of physic. 
The one is a science, the other is an art: 
the latter could not exist without the 
former; the former grows daily by the 
application of the latter. 
By Pathology, then, we mean the gene- 
ral doctrine of disease, the knowledge of 
the conditions under which it occurs, and 
of the kind of change which it expresses 
in the functions of the body. We mean 
also the inter-relations of different organs, 
or systems of organs, whether these may 
be compensative, or sympathetic, or an- 
tagonistic of one another. By the pathol- 
ogy of a disease we mean the scientific 
classification and nomenclature of its 
phenomena, and the interpretation of the 
conditions under which they have arisen. 
Pathology is to the body, under diseased 
conditions, what physiology is to the 
healthy organism, viz. the law of its 
being, or rather the best expression that 
we can give to what we believe that law 
to be. In its detail it must embrace all 
changes in either structure or in function ; 
but in its common and general accepta- 
tion it is used to express the idea that is 
entertained of the primary or essential 
or most important change in both; and 
the bearing that this has directly upon 
life as a whole is, in its statement, the 
unravelling of the problem of what we 
ordinarily mean by "Pathology." 
Pathological Anatomy.-Structu- 
ral changes in some organs are so con- 
stantly and definitely related to functional 
alterations observed during life that " Pa- 
thological Anatomy" in some maladies 
constitutes the most important, if not the 
major, part of their pathology. There 
are other cases in which structure-changes 
cannot be shown so to account for all the 
detail of symptoms ; and in these, patho- 
logical anatomy has its interest, but is of 
less immediate value. And further, there 
are diseases with regard to which patho- 
logical anatomy has hitherto taught no- 
thing that is worth our knowing ; while, 
on the other hand, it has not seldom ex- 
hibited the existence of disease, never 
suspected during life, and yet dire enough 
to be the cause of death, and thus to show 
that our diagnostic powers are not such, 
that we may boast of them. 
Unquestioned as is the value of Patho- 
logical Anatomy, it is no less unquestion- 
able that this value may be overrated and 
misapplied; and it is possible that such 
mistake may exist at the present day. 
Let us, therefore, remember what Patho- 
logical Anatomy is, and what it teaches. 
It is the condition of an organ after death, 
when tissues are cold, ordinary chemic 
changes have begun, secretion and living 
motion have ceased, circulation has stop- 
ped, and all that we know to be unex- 
plained by ordinary , physical conditions, 
and that we call "vital," has gone, and 
gone we know not whither, and know not 
how. Pathology, on the other hand, re- 
fers to the conditions and modes of action 
of the organs when they are warm ; when 
chemic changes seem to be directed by a 
power that cannot yet be explained by 
chemic force ; when sensation and motion 
are constantly placing the organ in new 
positions, in regard to other organs, and 
in new conditions, in so far as relates to 
their own integral parts ; when the blood 
is constantly flowing, and affecting, as it 
does so, both the tissues and itself, not 
leaving them as it found them, not leaving 
them as it came ; when all that we under- 
stand, and all that we dimly guess at about 
that complex force or principle, combina- 
tion of forces, condition or what-not, that 
we call "life," is the director or harmo- 
nizer of all we see, or is engaged in what 
seems a fierce struggle with powers it has 
long directed, but which, having now risen 
in defiance of its authority, seem likely to 
accomplish its dethronement. 
Everything that we can see is altered 
by that change from life to death ; and 
Pathological Anatomy has to do directly 
with physical conditions, which may be 
partially causes, partially effects, partially 
conditions of, and partially unrelated to 
the disease of which they are but a part, 
although an important one. If everything 
that we can see is thus altered in the step 
that all bodies make before they come 
under the scalpel or the microscope of the 
pathologist, still more altered is almost 
everything that we cannot see, but which 
we have inferred to exist from our laborious 
physiological investigations. It would 
seem therefore that Pathological Anatomy 
is about as capable of furnishing, per se, a 
notion of disease as dissection would be 
of teaching physiology ; and if we are to 
exalt into such undue prominence-as it 
has been the fashion of late years to do- 
this branch of science, which is yet only a 
branch and not the science itself, it would 
be nothing more than consistent to attempt 
to write biographies from post-mortem ex- 
amination and to construct the history of 
a nation by exhuming the bodies from its 
graveyards. 
Pathological Anatomy has reference to 
one element of disease-structural or tis- 
sue change-and that only under condi- 
tions very different from those which exist 
during life, and when only disease can be 
said to exist. Further, we get the mate- 
rials for examination when disease has 
passed through all its stages, and through 
that final one which cannot be said to PROGNOSIS. 
29 
form a part of either life or of disease. It 
is only when, by accident or intercurrent 
malady, a patient is struck down in the 
earlier stages of morbid change, that we 
have the opportunity for observing the 
kind of alteration which exists at such 
most important periods; and even to 
them is added all that we have already 
described, and probably much more than 
we can even guess at, by the great fact of 
death. Disease, being a complex of change 
in function and in structure, is represented 
anatomically only by the latter : disease, 
having a history, and passing through 
stages, is shown to us only in one stage, 
and with infinite predominance of fre- 
quency in the last stage : disease, being a 
change in the conditions of life, is shown 
to us anatomically only in the condition of 
death: while General Pathology, there- 
fore, may embrace all that we know or 
can know of the mechanism of human suf- 
fering. Pathological Anatomy but touches 
the human body when the period of suffer- 
ing has passed. 
But the facts revealed by a study of 
Pathological Anatomy have a peculiar 
kind and a high degree of value, which we 
would most unwillingly underrate. There 
is an intimate and constant relation be- 
tween function and structure (see p. 19); 
and we believe that, although certain 
structural conditions have yet escaped our 
observation, they may hereafter be ren- 
dered patent to the senses of the observer ; 
and on the other hand, we hold that there 
are some structural changes which may 
always transcend our powers for their im- 
mediate recognition; but, notwithstand- 
ing these facts and principles, we must 
remember that where anatomical changes 
have been discovered and verified, they 
have thrown unexpected light upon pre- 
viously dark and complicated problems ; 
and that they have possessed-in them- 
selves and by their very nature-a definite- 
ness, or precision, and have been suscepti- 
ble of description and measurement to a 
degree that is quite unattainable by our 
present modes of research in regard of 
functional change. In Pathological Ana- 
tomy, what we have, however little it may 
be, is definite, describable, demonstrable, 
and measurable. These characters con- 
stitute its great value ; and it is against its 
undue exaltation-and not its proper use 
-that we raise our protest. Let us be 
as exact in our inferences from its facts as 
we may be in our observation and de- 
scription of them, and then Pathological 
Anatomy will take its proper place, and we 
shall learn from it its most useful lessons. 
Prognosis.- The practical test of a 
true science is the power which it confers 
of " prevision," or of knowing now what 
will follow hereafter. Some sciences have 
attained to this point, as we see daily 
illustrated by physics and chemistry ; but 
as yet medical science has arrived at only 
very partial security of forecast. And yet 
the fore-knowledge of the consequences of 
a present disease is that for which patients 
and their friends often seek from the phy- 
sician with the greatest eagerness. When 
we can prognosticate with certainty, 
medicine will have become a "science." 
At present we only, with different degrees 
of nearness, approach this end. We may 
describe the " probabilities" of a given 
disease ; we may even measure them ; we 
may accept or reject lives at insurance 
offices ; or we may affix a numerical value 
to their duration ;* but we deal with 
doubts, and not with certainties. Life is 
too subtle for us to know or measure all its 
possible contingencies ; and our informa- 
tion is too scanty to render us thoroughly 
satisfactory interpreters of the outcome of 
any malady. But, with all this doubt, 
much may be accomplished for the safety 
of society, and the relief of individual 
anxiety or care. 
In prognosis we have almost always 
two ends to be considered : the immediate 
effects of the present illness, and its re- 
mote consequences upon life. We have 
also two main elements by which we are 
guided in judging of these ends, viz. : the 
local changes which we may directly ap- 
preciate, and the general conditions which 
we may infer to underlie them, or to be, in 
some way, their consequence. 
Prognosis with regard to the immediate 
effects of a present malady is guided 
mainly by the degree to which it inter- 
feres with any or all of the great vital 
functions, the circulation, respiration, in- 
nervation, or nutrition of the body. Prog- 
nosis in regard of the ultimate issue of a 
malady is based upon all these, but still 
more frequently upon the recognition of 
changes, often minute, in either function 
or structure, which our knowledge of 
pathology leads us to interpret for either 
good or evil. For example, a man is suf- 
fering from pneumonia, and we may- 
finding his general functions performed 
with an amount of ease consistent with 
life-infer that he will recover from the 
attack which to other eyes may appear 
most threatening ; but we may discover 
physical signs of tubercular disease- 
slight, even unnoticed previously-and 
these teach us that the ultimate prognosis 
is unfavorable. In like manner, a child 
may be taken with convulsions which ap- 
pear as frightful as only convulsions can 
do, and yet we may give a favorable 
opinion as to the present illness; while, 
on the other hand, some much slighter 
convulsive movement accompanied by 
heat of skin, a variable pulse, an obstinate 
1 See pp. 25, 26, on the duration and ter- 
mination of diseases. 30 
INTRODUCTION. 
vomiting and constipation, and a history 
of failing health, or of hereditary tuber- 
cular taint, may lead us, in the midst of 
what seems a trifling malady, to augur the 
worst results from what we believe to be 
the onset of tubercular meningitis. 
In prognosis, therefore, we must bear 
in mind the two objects we have set be- 
fore us, and the two classes of means by 
which we may advance towards them. 
The immediate prognosis turns upon the 
degree to which great vital functions are 
interfered with : the remote depends upon 
the nature of slighter changes, of which 
pathology teaches us the meaning. 
Therapeutics and Hygienics.-In 
the prevention or treatment of a disease 
our science culminates and becomes an 
art. Unless it can accomplish one or the 
other of these ends, the world would do 
as well without as with our aid. It is of 
some value to know the probabilities of 
our state, but it is of comparatively small 
value to have this knowledge if we can do 
nothing either to ward off, alleviate, or 
cure disease. We may prepare some peo- 
ple for the worst, we may dispel some 
groundless fears ; but our mission is to do 
more than this : we have to try to "cure 
the curable, and comfort the incurable." 
In the prevention of disease regard is 
had to the condition in which the indi- 
vidual is placed, to his hereditary or ac- 
quired constitutional peculiarities, and to 
the minute physical or functional depart- 
ures from health which we may discover. 
In the treatment of disease no one of 
these can be lost sight of with impunity, 
but we are guided principally by the ac- 
tual symptoms present at the time. These 
symptoms, however, it must be remem- 
bered, are of two orders: from the one 
set we learn the actual physical condition 
of an organ, or group of organs, such as 
inflammation of a lung, congestion of the 
liver, or paralysis of one side of the body; 
while from the other series we become ac- 
quainted with the state of the system 
generally, whether this be antecedent to 
the local change, its cause, its effect, or a 
mere coincidence of its existence ; and 
from such a group of symptoms we infer 
the existence of dyscrasiae ; such as tuber- 
culosis, carcinoma, or the like, and appre- 
ciate the presence of vigor, or of asthenia, 
of sound constitution, or of impaired 
health and wasted strength. 
To the most superficial observer it must 
be obvious that therapeutics has under- 
gone great and important changes, that 
the mode of treatment now adopted for 
many diseases is just the opposite of that 
which was in vogue a generation ago, and 
which lingers even in recent editions of 
standard books, although their authors 
have long since ceased to follow the direc- 
tions which they still give to others. A 
few years ago the treatment of inflamma- 
tion of an important organ was laid down 
definitely ; such and such things were to 
be done, and no questions were to be 
asked as to whether the case was of this, 
that, or the other type. Inflammation 
was there, and blood was to be taken; 
low diet was to be enjoined, and lowering 
medicines were to be exhibited ; and sup- 
posing the inflammation did not yield, 
the forces of attack were to be again 
placed in action : but here evidently there 
crept in some distrust of the theory at the 
bottom of the practice; for, instead of 
general bleeding, leeches or cupping were 
to be employed, and then only to a mild 
degree. Somehow or another the inflam- 
mation was to be put down, and it not 
rarely happened that the process urged 
against the bugbear "inflammation" 
proved fatal or highly injurious to the 
patient. If we can, by bleeding, and by 
it alone, save the eyesight which may be 
threatened by iritis, or if we can by de- 
pletion save a life which is endangered by 
laryngitis, we are quite justified in adopt- 
ing that measure, although it may entail 
some injurious consequences. It would, 
however, be as unkind as it would be un- 
philosophical to relieve the pain of a sim- 
ple pleurisy by abstracting blood, in such 
amount as should damage the individual 
in after years, when equal relief might be 
obtained by poultices and patience. We 
still find it written, if these conditions are 
found - a hard, full, strong, frequent 
pulse, with great heat of skin, no prostra- 
tion, impending evil from this condition 
being patent as the phenomena them- 
selves- then bleeding, antiphlogistics, 
and the like must be employed. But, as 
a matter of fact, we do not find these 
cases, and the more common on dit of 
medical practice is to the effect that as 
the inflammation seemed extending, the 
quantity of wine has been doubled, the 
supplies of beef-tea increased, and bark 
and ammonia given more frequently. 
Partly to account for, and partly to jus- 
tify, so material a change in our modes of 
dealing with disease, it has been assumed 
that the vis vita? of the British constitution 
has been lessened, or that the so-called 
"type" of its maladies has altered ; an 
assumption which has little to be said in 
its defence, and still less that can be re- 
garded as its establishment. A more 
simple, and we believe accurate, explana- 
tion of the change is to be found in this, 
that previously theory was the ground- 
work of therapeutics, and that now fact 
is the basis of treatment: that, years ago, 
diseases were treated by their names, and 
that now they are treated by their known 
conditions: that local changes were the 
main guides in times gone by, but that 
the general state of the patient is that 
which in these days the physician esteems THERAPEUTICS AND HYGIENICS. 
31 
as his therapeutical informant. When 
pathology scarcely existed, medical prac- 
tice was an empirical art; and had, with 
the few advantages of that position, all 
its evils: whereas, with the growth of 
pathology, therapeutics, still an art, has 
become, or is becoming, a science ; and, 
knowing more accurately the limits of its 
powers, is content to attempt less heroic 
measures, being convinced that it does 
less harm. Much is done by medical 
treatment now, more real good than ever 
was done before, but it is done in a dif- 
ferent way, and with another aim. Dis- 
ease is detected in its earlier stages, and 
often arrested there ; and when developed 
the patient is guided through it, if he can 
be, and is not sacrificed to some wild at- 
tempt at its destruction. 
What we now believe and act upon is 
no set theory regarding the nature of par- 
ticular diseases, or disease in general- 
modern times have not been devoid of 
theories upon which the fathers of medi- 
cine would justly have turned their backs 
in derision ; but such notions, although 
they may have misguided a few individ- 
uals, have soon found their proper place, 
or no place at all, in the science of the 
day-what we do believe and act upon is 
a better knowledge of the laws and rela- 
tions of morbid change : when we see that 
the man is greater than his maladies ; 
that his general condition is of more im- 
portance than his local ailments; that 
disease is a change in him rather than in 
some part of him ; and that no treatment 
can be of any real service which sacrifices 
the greater to the less. In all treatment, 
therefore, what is general is to be dealt 
with upon the basis of a true appreciation 
of the general pathological condition, and 
this in spite of all theories in regard of 
local changes, however they may be 
termed, whether they come to us with 
names hoary with age, or scarcely intelli- 
gible, and even sometimes ludicrous from 
their novelty. If the general condition be 
one of weakness, it matters not that the 
brain, the heart, or the lungs may be in a 
state of so-called "inflammation;" the 
weakness is the one thing that demands 
immediate treatment, and to neglect its 
treatment is to run the risk of sacrificing 
the patient to a theory of a compound 
state even now but imperfectly under- 
stood. This is the starting-point, the es- 
sential element in therapeutics; but the 
mode in which the treatment should be 
applied will often be determined by the 
nature and position and origin of the spe- 
cial lesion; and these conditions of the 
latter will direct the management of those 
means and appliances which, employed 
locally, will prove of service to the injured 
organ. 
garded as corresponding with the actual 
practice of a large number of physicians 
at the present time, in Great Britain and 
Ireland, on the European continent, and 
in America, there is reason to believe that 
more practitioners will partially dissent 
from it now (1879) than would have been 
the case ten or twelve years ago. Cer- 
tainly it is a sound principle, not only to 
disregard, but to annul, in practical books 
and teaching, all merely traditional or 
"theoretical" precepts, which either im- 
proved pathology or extended experience 
has shown to have been erroneous. But, 
was it only, or chiefly, local changes, that 
were the guides of Sydenham, Cullen, 
Rush, and others in the old days of the 
lancet and other "antiphlogistic" meas- 
ures ? The pulse, the skin, the period of 
the attack, and the absence of evidence of 
exhaustion of the recuperative energy of 
the system; these, rather than merely 
organic conditions, determined, with 
them, ■whether or not depletion should be 
resorted to. It would seem to be a change 
in the interpretation of general indications, 
and a different theory of therapeutics, that 
have introduced, instead of the somewhat 
overdone antiphlogistic measures of our 
predecessors, the expectancy with some, 
and the stimulism with others, that have 
chiefly characterized the middle portion of 
the present century, in general practice. 
That some important qualification of 
the view set forth in the above paragraphs 
would now be approved by a considerable 
number of the most eminent practitioners, 
might be shown by many citations. It is 
illustrated by some examples in the work 
to which this essay furnishes so able and 
fitting an Introduction. Thus, W. Squire, 
L.R.C.P., advises, in croup, under cer- 
tain circumstances, "a free abstraction 
of blood." J. Hughlings-Jackson, M.D., 
in the instance of repeated convulsions, 
thinks that "we neglect to bleed as often 
as we ought to do, on the principle Mark- 
ham has laid down." J. Spence Rams- 
kill, M.D., in regard to the treatment of 
simple meningitis, refers to three great 
remedial measures, of which the first is 
bloodletting. Dr. J. S. Bristowe speaks 
well of the same remedy in certain cases 
of enteritis ; and Dr. J. S. Wardell desig- 
nates it as our best ally in sthenic acute 
peritonitis. 
The intention of these remarks is not to 
antagonize, but to qualify, the summary 
conclusion which the language of Dr. 
Reynolds appears to convey, that vene- 
section and kindred measures of treatment 
may be with advantage dismissed as ob- 
solete procedures. Of names not yet 
antiquated, in favor of the occasional and 
moderate use of the lancet, in the early 
stage of acute inflammatory disorders, it 
may suffice to add here as examples those 
of Aitken and B. W. Richardson in Eng- 
[While the view above given of the 
therapeutics of inflammation may be re- INTRODUCTION. 
32 
land ; Niemeyer and Wunderlich in Ger- 
many ; Jaccoud, Ilerard, and Cornil in 
France ; S. D. Gross and Fordyce Barker 
in America. 
The most important qualification of the 
expressions upon which these comments 
are made is, in regard to "weakness" 
being the "one thing that demands im- 
mediate treatment;" this being " the 
starting-point, the essential element in 
therapeutics." Few, if any, pathologists 
will hesitate to admit that a difference, 
often momentous, exists, between the ex- 
haustion of a system weakened by the 
continuance for some time of severe dis- 
ease, and that oppressive debility with 
which the most robust person may be tem- 
porarily affected, under the influence of 
an acute malady, such as pneumonia, 
meningitis, or croup. 
Those physicians who (like the present 
writer) were trained under the "anti- 
phlogistic " regime, and had the opportu- 
nity of seeing something of its clinical re- 
sults, which they may compare with those 
of the last two decades under a different 
prevailing practice, will hardly be able to 
insist, from their own observation, that 
the general effect of the abandonment of 
the lancet and of local depletion in private 
practice has proved advantageous. The 
mortality of pneumonia in Philadelphia 
has, for some reason, certainly increased ; 
not in the hospitals, where the average 
character of the patients has always made 
them unfavorable subjects for depletion ; 
but in private practice. It is not too bold 
an assertion, indeed, for one who, without 
partisanship, maintains his conviction of 
the occasional importance of venesection 
and local depletion as remedies,-that, 
while acute, uncomplicated pneumonia 
under moderate depletory treatment was, 
thirty years ago, rarely fatal outside of 
hospitals, and not at all frequently so 
within them, the indiscriminately stimu- 
lating method, now often applied to all 
classes of cases, has increased very con- 
siderably the fatality of this and other 
inflammatory diseases in private prac- 
tice.-II.] 
Classification of Diseases.-A cor- 
rect classification is a condition of the 
existence of a science, and an essential for 
its teaching ; but we do not think that 
"medicine" has yet arrived at this high 
position. That it will advance to it, that 
it is making progress towards it, we have 
no doubt; but, at the present time, we 
must admit that imperfections abound in 
every system that has been propounded. 
The problem is too vast and too compli- 
cated for solution now, and we have there- 
fore to adopt that which appears to pos- 
sess the greatest amount of practical ad- 
vantage. 
It would be useless here to spend time 
upon criticism of the various schemes 
which have been proposed; we prefer 
rather to state briefly the very simple plan 
upon which this book will be constructed. 
It is proposed to make the first division 
of diseases into their two great groups; 
1st. Those in which the whole organism 
appears primarily and prominently de- 
ranged, and 2d, those in which special or- 
gans or systems of organs are, in like 
manner, affected. Subdividing the first 
group we have two classes ; A, those in 
which the disease appears to be developed 
by causes operating from outside the body ; 
and B, those in which the malady seems to 
depend upon some internal change. Thus 
in the first subdivision we find the acute 
specific diseases, and their analogous affec- 
tions ; in the second, gout, rheumatism, 
scorbutus, and the like. Subdividing the 
second group we have many classes, con- 
sisting of diseases of systems of organs, 
such as : A, diseases of the nervous sys- 
tem ; B, diseases of the digestive system 
and its appendages; C, diseases of the 
circulatory system ; D, diseases of the 
respiratory system ; E, diseases of the uri- 
nary system ; F, diseases of the repro- 
ductive system ; G, diseases of the loco- 
motive system; and H, diseases of the 
cutaneous system. 
Each of these is, in its turn, again sub- 
divided, upon the primary principle of 
general or partial change, so that, in re- 
gard of the nervous system, for example, 
we have 1st, those of general or undeter- 
mined seat, and 2d, those depending upon 
distinct local change in its parts, anatomi- 
cally considered : and this leads to further 
reduction into affection of parts, such as, 
a, brain ; 6, spine ; c, nerves : whereas the 
final division is based upon the nature of 
the changes which these portions of sys- 
tems undergo. 
If this mode of arranging diseases has 
no other merit, it has that of simplicity ; 
and it will, we believe, bring, as a general 
rule, into closer proximity than some more 
ambitious systems would allow, those 
diseases which have the most intimate 
clinical association. It involves little 
theory in any case, none in many, and 
may therefore commend itself to those 
who realize, amid the great progressive 
science of medicine, the difficulties and 
dangers which attend upon all nosologies 
which, based on theories, partly right and 
partly wrong, carry with them, and only 
with great effort disentangle themselves 
from, what is erroneous in their ground- 
work, and a fortiori luxuriant in their 
after-growth. 
J. BUSSELL REYNOLDS. PART I. 
In the First Part of this System of (Medicine are included those diseases in which the 
whole organism is primarily and prominently deranged. We have therefore to deal with:- 
General Diseases, or Affections of the Whole System ; and dividing these 
into two sections, we have to consider first:- 
? I.-Those determined by agents operating from without, such as malarial diseases, the 
exanthemata, and their allies. 
Influenza. 
Hooping-Cough. 
Diphtheria. 
Scarlet Fever. 
Dengue. 
Roseola. 
Measles. 
Mumps. 
SUDAMINA AND MlLIARIA. 
Varicella. 
Variola. 
Vaccination. 
Glanders. 
Hydrophobia. 
Enteric Fever. 
Typhus Fever. 
Relapsing Fever. 
Yellow Fever. 
Epidemic Cerebro-Spinal 
Meningitis. 
Plague. 
Erysipelas. 
Pyaemia. 
Malarial Fevers 
Dysentery. 
Cholera. 
Syphilis. 
INFLUENZA. 
By Edmund A. Parkes, M.D.,F.R.S. 
Definition. - An epidemic specific 
fever, with special and early implication of 
the naso-laryngo-bronchial mucous mem- 
brane ; duration definite of from four to 
eight days; one attack not preservative 
in future epidemics. 
Synonyms.- Scientific Names. - Peri- 
pneumonia Notha (Sydenham, Boerhaave). 
Peripneumonia Catarrhalis (Huwham). 
Pleuritis Humida (Stoll). Febris Catar- 
rhalis (F. Hoffman, Sauvages). Catarrhe 
Pulmonaire (Pinel). Catarrhus a Contagio 
(Cullen). Defluxio Catarrhalis. Cepha- 
lalgia Contagiosa. Rheuma Epidemicum. 
Popular Names.-Pose (in old English 
writings, from the Anglo-Saxon gepose, 
heaviness). Tac or Horion (in France in 
1411). Coqueluche (in France in 1414, 
and in subsequent epidemics, because the 
sick wore a cap over their heads.) La 
Dando, or Ladendo (in France, 1427). 
Quinte (in France in 1578, because the 
paroxysms of cough returned every five 
hours). Follette (in France in several 
epidemics). Ziep (in Germany in 1580, 
probably from zieppen, to pipe or chirp). 
Schaff husten and Schaffkrankheit (in Ger- 
many in 1580, because the cough was like 
the cough of a sheep, or because the verti- 
go -was like the sudden giddiness of sheep). 
Iliihner-weh (in Germany in 1580, because 
the cough was like the crowing of a cock). 
Blitz-katarrh (from the suddenness of the 
attack). Mal del Castrone (in Italy in 
1580, because the giddiness was like the 
common disease " turnsick, " of the sheep). 
In the seventeenth century it was first 
called Influenza, in Italy, because it was 
attributed to the " influence" of the stars, 
and this term has passed into medical use. 
In 1743, it was called La Grippe in 
VOL. I.-3 
33 34 
INFLUENZA. 
France, from the Polish Grypka(Raucedo), 
a term which, like Influenza, has passed 
into medical writings. 
It has been called in Russia " Chinese 
Catarrh;" in Germany and Italy, "the 
Russian disease;" in France, "Italian 
Fever," &c. 
A great number of other popular names 
have been given to it: Petite poste ; Petit 
courier ; Follette ; Coquette ; Cocote ; Al- 
lure ; Baraquette ; Generale, &c. 
History.-Supposed to be referred to 
by Hippocrates, who yet gives no perfect 
description. The epidemic among the 
Athenian army in Sicily (415 before 
Christ), recorded by Diodorus Siculus 
(lib. xiii.), has been supposed to have 
been Influenza. In A. D. 827 an attack 
of cough, which spread like the plague, 
was recorded. Again, in 876, Italy, and 
then the whole of Europe,' was attacked, 
and the army of Charlemagne, returning 
from Italy, suffered greatly ;2 dogs and 
birds were both attacked by this disease. 
In 976 the whole of France and Germany 
was attacked by a fever, whose principal 
symptom was a cough. In 1173 another 
catarrhal epidemic was widely spread; 
and in 1239 and 1299 other slighter epi- 
demics are noticed. 
It is not, however, till the 14th century 
that the records became numerous and 
precise :- 
In the 14th century 6 epidemics are re- 
corded. 
15th " 7 " 
16th " 11 " 
17th " 16 " 
18th " 18 " 
19th (firsthalf) 10 " 
In some cases, however, the same epi- 
demics may have been recorded twice, 
though I have excluded several that ap- 
pear to have been so. Probably, also, 
among the lesser epidemics are some of 
hooping-cough wrongly diagnosed as In- 
fluenza. 
There is little doubt that the apparent 
increase of prevalence in the last centuries 
is merely due to more accurate recording 
of minor epidemics. 
Of these epidemics, some have been very 
widely spread over a great part of the 
known world, as in 1311,1557,1580,1590, 
1729, 1762,1775,1780-2,1830-2,1847. In 
other epidemics the disease has either been 
partial, or not recorded in many places ; 
in some instances it has spread only over 
comparatively small tracts of country. 
The first epidemic which was carefully 
described was that in 1557, by Riverius. 
The great epidemic of 1580 was described 
by Sennert. 
In England the following epidemics have 
been recorded,1 many of them with great 
care : 1510 and 1557 by Thomas Short; 
1658 by Willis ; 1675 by Sydenham ; 1729- 
1743 by Huxham ; 1732-3 by Arbuthnot; 
1758 by Whytt; 1762 by Baker and Butty ; 
1767 by Heberden; 1775 by Fothergill, 
who collected observations from many 
physicians ; 1782 by Gray, Haygath, and 
Carmichael Smith ; 1803 by Pearson and 
Falconer, and a great number of others ; 
1833 by Hingeston and others; 1837 by 
Streeten, Graves, and Bryson, &c. ; 1S47 
by Peacock,2 Laycock, and many others.3 
Spread of the Disease.-Etiology.- 
Before entering on the consideration of the 
external nature of the causes, it is neces- 
sary to state the facts which have been 
ascertained in respect of the spread of In- 
fluenza. 
It has prevailed in most places of the 
habitable globe : in the whole of Europe ; 
in China, Tartary, Egypt, India, and other 
parts of Asia ; in Australia, Polynesia ; 
in North and South America, and in the 
West Indies ; that is to say, in both hemi- 
spheres and in all latitudes. It has occa- 
sionally occurred in both hemispheres at 
the same time, but more usually has ap- 
peared successively in different places, and 
has been seen at some point or other of 
the earth's surface for two to four years, 
after which it has disappeared. In some 
years, as in 1580, 1730,1762,1775, its pre- 
valence has been so great, that almost all 
parts of the known world have been at- 
tacked ; at other times it has been more 
partial, affecting only a part of a conti- 
nent, or even a single country.4 It has 
been supposed, indeed, occasionally to 
prevail in quite a limited area, in a single 
city for example,5 but it is possible that 
local catarrhal fevers of this kind are not 
identical with the true influenza. 
When it has been pandemic, i. e., when 
it has invaded a large portion of the earth's 
surface, its progress lias usually been ra- 
1 Annals of Influenza, by Theophilus 
Thomson (Sydenham Society, 1852). I have 
only quoted the principal works. 
2 The Influenza, or Epidemic Catarrhal 
Fever of 1847-8. ByG. T. B. Peacock, M.D. 
London,1848. 
3 Since 1847 there has been no pandemic 
Influenza, but several minor outbreaks, the 
widest diffusion of which was in 1857-8. In 
Paris in 1867 (February and March) there 
was a severe outbreak, characterized as usual 
by great prostration. There was also an out- 
break almost at the same time at Strasburg. 
4 See Hirsch, Hist. Geog. Pathol, vol. i. p. 
286, for twenty-four examples of this fact. 
6 Hirsch has collected seventeen examples. 
1 Schnurrer. Chronik der Seuchen, Band 
i. p. 175. 
2 Schnurrer states that measles followed, 
and appeared indeed to be developed out of 
this epidemic, but the records are necessarily 
very imperfect. 35 
HISTORY. 
pid, yet not to such an extent as is com- 
monly supposed, and sometimes it has 
travelled slowly. It is said to have over- 
spread Europe in six weeks, and at an- 
other time to have taken six months or 
more to do so. In any particular country 
its progress may also be comparatively 
slow ; thus, between the invasion of Lon- 
don, and of provincial towns, or of Scot- 
land, weeks, and even sometimes months, 
have elapsed. Thus in 1762 it appeared 
in London in the beginning of April; at 
Edinburgh in the beginning of May; in 
some parts of Cumberland in June. In 
1782 it attacked London in the middle of 
May; Exeter at the end of May; and 
Newcastle-upon-Tyne and Edinburgh in 
the beginning of June. 
In 1830-31-32, it prevailed in Moscow 
and St. Petersburg, and from thence took 
no less than eight months to spread over 
the whole of Germany. In Europe it has 
sometimes prevailed simultaneously at 
several points, as in 1847, when it was 
raging at the same time in Copenhagen, 
London, and Marseilles. In spreading 
over a large tract of country, it has often 
been supposed to follow a regular course ; 
which has been believed to be from the 
high north or northeast to the south and 
west. Thus it has been supposed to pass 
from Chinese Tartary to Russia, Germany, 
Holland, England, Scotland, France, and 
then to Italy and the Mediterranean, or 
to America in succession, and certainly in 
some epidemics there has been a course of 
this kind. But this is by no means inva- 
riable, and may indeed have been acci- 
dental, or our knowledge of the successive 
steps of the spread may have been inaccu- 
rate. Thus the epidemic of 1762 was said 
to follow this course,1 and to reach Ame- 
rica in October, 1762, having affected Ger- 
many in February and March, London in 
April, and France in July. But Influenza 
prevailed in America the year before 
(1761) and thence passed into Europe,2 
taking thus the exact contrary of the tract 
assigned to it, unless indeed it passed 
round by the icy regions of North British 
and Russian America, of which there is 
no evidence. So again it has sometimes 
(1775) passed from the south to the north 
of Europe, or from the south or west of a 
particular country to the north or east. 
Gluge,3 indeed, from an examination of 
the epidemics of the last 300 years, be- 
lieved he had discovered that its course is 
from west to east. It is obvious that, in 
former times, the want of reliable infor- 
mation, and of intercourse between na- 
tions, must have rendered all evidence of 
dates very uncertain. The next epidemic 
will give more reliable information than 
any of the former. 
When it has entered any large town, it 
remains there for from six weeks to two 
months as a rule, but occasionally longer, 
as at Paris in 1831, when it was more or 
less prevalent for nine or ten months. It 
has never, however, failed entirely to dis- 
appear eventually, and sporadic cases are 
not seen in the intervals of the epidemics. 
In its course it appears to pass over seas, 
and it is said to have attacked the crews 
of ships far from land, who had not sailed 
from an infected port.1 
The exact spot on the earth's surface 
where an epidemic commences has not yet 
been made out, and two opinions prevail. 
One is, that every epidemic owns one un- 
known source, whence it spreads ; each 
nation, in turn, attributing to its neighbor 
from whom it derived the disease, the un- 
1 The statement that Influenza will thus 
break out in mid-sea, without there being 
any possibility of the disease having been in- 
troduced on board, is a most important piece 
of evidence, as it would prove that the atmo- 
sphere can not only carry the poison, but 
that no degree of dilution can destroy it. 
Without denying the occurrence of such out- 
breaks, I cannot but consider we require bet- 
ter evidence of ships being attacked in mid- 
ocean. In some of the quoted instances, the 
ship had been at a port either known to be 
infected, or in which Influenza was really 
present, though it had not become epidemic. 
As we are ignorant of the exact period of in- 
cubation, some men may have been infected 
before sailing. In other cases the examples 
are of old date, and it is impossible to feel 
quite sure that the evidence is correct. Such 
for example as the celebrated case of the Atlas 
East Indiaman, which was attacked with In- 
fluenza, on a voyage from Malacca to Canton ; 
Malacca being healthy at the time, but Can- 
ton being affected at the same time as the 
ship. (Robert Williams : On Morbid Poisons, 
vol. ii. p. 667.) In 1782, Admiral Kempen- 
feldt's and Lord Howe's squadron, cruising 
at different parts of the Channel, were each 
attacked, although, it is said, they had been 
at least twenty-two to twenty-seven days at 
sea. 
There is better evidence that ships near the 
land have suffered. In 1833 the iStag frigate 
was coming up Channel, and when off Beechy 
Head, in Devonshire, the wind was easterly 
and off the shore at two o'clock, the crew 
being then quite healthy (and it is presumed 
no communication having taken place, but 
this is not stated)-40 men were, at half-past 
two, suddenly attacked with Influenza ; at six 
o'clock 60 men were down, and by the next 
day 160. (Watson : Principles and Practice 
of Medicine, 4th Edition, vol. ii. p. 44.) If it 
were certain that there had been no commu- 
nication with the shore, the cause must have 
drifted over the sea. 
1 Robert Williams. On Morbid Poisons 
(1841), vol. ii. p. 663. 
2 Noah Webster. A Brief History of Epi- 
demic and Pestilential Diseases (London, 
1800), vol. ii. p. 44. 
3 Quoted by Hirsch, op. cit. p. 287, footnote. INFLUENZA. 
36 
enviable honor of originating it. Thus 
the Italians have termed it the German 
disease ; the Germans, the Russian pest; 
the Russians, the Chinese Catarrh; and 
these names are indeed some evidence of 
its usual track. Noah Webster attributed 
its origin to America in 1698, 1757, 1761, 
and 1781, while in 1788 he believed it 
arose in Europe, and several writers have 
fixed it in Chinese Tartary, or in India. 
The other opinion is, that it has no special 
place of origin, but may arise anywhere ; 
and some,1 indeed, have questioned whe- 
ther such " autochthonic" developments 
are not the rule, and whether we are right 
in believing in a "genetic connection" of 
the various local outbreaks. But surely 
no one can doubt the connection of the 
various attacks in the great epidemics of 
Influenza with some general and pandemic 
infltlence. 
If it may arise thus spontaneously in 
various places, no one has yet precisely in- 
dicated its first origin. 
It has been also supposed to have acyc- 
lical course, and to return pretty regu- 
larly in periods of years. The older writers 
thought it had a cycle of about 100 years, 
but it has returned much more frequently 
than this; about every twenty-five to 
thirty-five years it has been pandemic, and 
lesser outbreaks have occurred more fre- 
quently. But no regular period can be at 
present perceived. 
In passing through a country it does 
not attack all parts of it; it more usually 
spares the country places, but sometimes 
even large towns escape. 
When the disease enters a town, it has 
occasionally attacked numbers of the inha- 
bitants almost simultaneously. But more 
frequently its course is somewhat slower ; 
it attacks a few families first, and then in 
a few days rapidly spreads ; the accounts 
of thousands of persons being at once at- 
tacked at the onset of the disease are 
chiefly taken from the older records, in 
which the suddenness of the outbreak is 
exaggerated. Frequently, perhaps always, 
in a great city the outbreak is made up 
by a number of localized attacks, certain 
streets or districts being more affected than 
others, or being for a time solely affected, 
and in this way it successively passes to 
different parts of the city. It has gene- 
rally occurred in a great city before ap- 
pearing in the smaller towns and villages 
round it, and sometimes these towns, 
though in the neighborhood, have not been 
invaded for some weeks. 
In some cases, and perhaps a large num- 
ber, it breaks out after persons ill with In- 
fluenza have arrived from infected places. 
The decline in any great town is less 
rapid than its rise, and usually occupies 
from four to six weeks, or sometimes 
longer. 
In every epidemic the symptoms so 
closely resemble each other, that there is 
no difficulty in recognizing it from the de- 
scriptions even of ancient and unlearned 
writers ; yet there are said to be certain 
slight differences in symptoms between 
different epidemics, to which reference will 
be hereafter made. 
Different epidemics have varied some- 
what in the number of persons they affect, 
but on the whole a large number suffer. 
In London in the last epidemic (1847) it 
has been calculated that at least 250,000 
persons suffered ; in Paris, between one- 
fourth and one-half of the population suf- 
fered, and in Geneva not less than one- 
third.1 
When the different telluric and atmo- 
spheric conditions which are coincident 
with the attacks are considered, the fol- 
lowing are the conclusions :- 
Soil.-It prevails on every soil and geo- 
logical formation, and apparently equally 
on all. It has been supposed to be worst 
on marshy soils, and some have even be- 
lieved it to arise in very malarious re- 
gions, as Lower Bengal, or the plains of 
China, yet very malarious countries, as 
Holland, do not suffer more than others ; 
Holland, indeed, has escaped some epi- 
demics which have traversed Europe. 
Lowlands have been sometimes affected 
more than the adjacent hills, as in the 
lowlands in Jamaica, in 1802, and in 
several epidemics in the Lombard plains, 
as compared with the Blue Mountains 
and the Alps. 
Volcanic Eruptions.- Telluric Emana- 
tions.- Noah Webster2 and Schnurrer3 
have collected the available evidence on 
this point, but it is entirely negative. 
There have been constant volcanic erup- 
tions without Influenza, and epidemics of 
Influenza -without great volcanic erup- 
tions. It has been thought that emana- 
tions of seleniuretted hydrogen from vol- 
canoes might excite Influenza, but no 
proof has ever been given of the existence 
of this substance in the atmosphere. 
Electrical Conditions.-No evidence has 
been collected which shows any connec- 
tion with conditions of telluric magnetism 
or atmospheric electricity; and indeed 
the peculiar spread and frequent localiza- 
tion of Influenza seem inconsistent with 
general magnetic conditions. 
Seasons.-The disease appears at all 
times of the year ;4 nor is there any reason 
1 Peacock on Influenza, p. 13, Introduction. 
2 A Brief History of Epidemic and Pestilen- 
tial Diseases. 1800. Vols. i. and ii. 
3 Chronik der Seuchen. 1825. 
4 See Hirsch, op. cit. p. 287, for evidence 
on this point, but almost all writers have 
noticed it. 
1 Biermer, in Virchow's Handbuch der Path, 
und Then, vol v. p. 607. (1865.) 37 
SPREAD OF THE DISEASE. 
for considering it an affection of the late 
summer, autumn, and winter, as has been 
stated. 
Temperature of the Air.-Owing to the 
confusion in the popular mind between 
Influenza and common catarrhs or catar- 
rhal fevers, it has been always a common 
opinion that Influenza depends either on 
a low temperature, or a sudden variation 
of temperature. This error has taken a 
long time to kill; but almost every writer, 
since the epidemic of 1580, has examined 
this point,1 and has decided that there is 
no connection between either low tempe- 
rature, or variations in temperature, and 
Influenza. As respects high temperature, 
it has prevailed in the West Indies at a 
temperature of 72°-82° ;2 on the hot sea- 
coast of Java ; in South India ; in Egypt; 
at the Cape of Good Hope, in the most 
genial season ; in the south of Europe in 
summer. So also there is abundant evi- 
dence to show that the changes of weather, 
which may appear to have accompanied 
or preceded its outbreak, were mere coin- 
cidences.3 
Moisture of the Air.-It has prevailed in 
the dry air of Upper Egypt; in the moist 
air of sea-coasts, and on the sea itself, 
without being apparently in any way in- 
fluenced. 
Barometrical Condition.-No coincident 
alteration can be traced. 
Ozone.-Although ozone was known be- 
fore 1847, the observations during that 
year led to no result, and since that time 
there has been no epidemic of Influenza. 
But the observations hitherto made on the 
effect of ozone on other diseases4 seem to 
render it improbable that any connection 
will be traced between the development 
of ozone and Influenza. The statements 
of Schbnbein are based merely on the 
effect of large quantities of ozone artifi- 
cially produced, on the mucous membrane 
of the nose. Applied in large quantities, 
ozone is irritating, and may produce sim- 
pie catarrh, but nothing like the specific 
symptoms of Influenza. 
Fogs and Mists.-In some cases, as in 
Paris in 1675, France in 1733 and 1775, 
England in 1782, a thick and acrid fog has 
shortly preceded, or has immediately ush- 
ered in, the Influenza ; but so many out- 
breaks have occurred without such a coin- 
cidence, that it is impossible to attach 
any weight to it. 
Wind.-Its main spread is not influ- 
enced by the wind ; it does not move with 
the same velocity ; it often moves against 
it. Yet it appears to be sometimes car- 
ried by the wind for a short distance. (See 
case of the Stag frigate, previously quoted.) 
In fine, if there is any special atmo- 
spheric condition which invariably attends 
epidemics of Influenza, it has yet to be 
discovered, and the words of Pearson are 
still true :- 
"Between the epidemic and the condi- 
tion of the atmosphere, there appears to 
be a connection different from that which 
depends on a mere alteration of tempera- 
ture, or of dryness or moisture, but what 
that peculiar connection is we shall not 
attempt to explain."1 
Fungi in Atmosphere. - Abundance of 
flies, caterpillars, etc.-Attempts have been 
made to show that during epidemics there 
are indications of an unusual development 
of animal or vegetable life, and that 
"bloody or red snow," "blood rain," 
"flights of locusts, or insects," &c., are 
more common in Influenza years. These 
speculations have, at present, even more 
than usual interest, and certainly should 
be brought to the test of close inquiry. 
At present, all that can be said is that no 
facts of any moment exist which connect 
an unusual fungoid development with the 
spread of Influenza. 
We must now pass on to a different or- 
der of facts. 
Human Intercourse.2-The rapidity of 
the spread would seem at once to negative 
any connection between human inter- 
course and the propagation of the disease ; 
yet there is some affirmative evidence. It 
does not appear to follow the great lines 
of commerce; but when it has entered 
towns and villages in which the investiga- 
tion can be carried on, it is curious how 
1 Salius Diversus (1580) ; Molineux (1693); 
Whytt (1757); Baker (1762); Ilaygarth 
(1775-1782) ; Fothergill (1775) ; Metzger 
(1800) ; Lombard (1831), &c. 
2 Observations relative to the West India 
Islands, by John Williamson, M.D. 1817. 
Vol. ii p. 110. 
3 In his late work (Catarrh and Influenza, 
1865), Seitz attributes more influence to the 
effect of vicissitudes of weather in causing 
epidemic Influenza than appears to me to be 
warranted by the facts. 
4 Especially those of Shiefferdecker : Sit- 
zungsbericht der Math. Naturw. Classe der 
Wien. Akad. July 1855, Band xvii. Seite 
191. The ozonic results had no connection 
with any malady, and were in all cases pro- 
portionate to a numerical range, derived from 
a consideration of the strength of the wind 
and of the moisture of the air. See also Seitz 
(Catarrh and Influenza, 1865, p. 360). 
1 Observations on the present Catarrhal 
Fever, or Influenza, by Richard. Pearson, M.D. 
London, 1803. P. 3, footnote. 
2 The presumed importation of Influenza 
into Iceland and the Faroe Islands, as de- 
scribed, especially recently, by Schleissner 
and Panum, as well as by older writers, is 
doubtful. It would seem probable that the 
endemic catarrh of these islands, said to fol- 
low each year the arrival of the first ship, is 
different from the true Influenza, which comes 
more rarely, and only when it is prevailing 
elsewhere in Europe. 38 
INFLUENZA. 
frequently the first cases have been intro- 
duced, and how often the townspeople 
nearest the invalids have been first affect- 
ed In this country especially, Haygarth 
in 1775 and 1782, and Falconer in 1802, 
collected so many instances of this that 
they became convinced that its propaga- 
tion was due entirely to human inter- 
course.1 So also, when it passes through 
a house, it occasionally attacks one person 
after another. But if it is introduced in 
this way, it afterwards develops with mar- 
vellous rapidity, for we cannot discredit 
the accounts of many thousand persons be- 
ing attacked within a day or two, which 
is quite different from the comparatively 
slow spread of the contagious diseases. 
This sudden invasion of a community 
makes it, to many persons, appear highly 
improbable that any effluvia passing off 
from the sick should thus so rapidly con- 
taminate the atmosphere of a whole town. 
Still, we must remember how singu- 
larly, of late years, the knowledge of the 
introduction of cholera by persons coming 
from infected districts has increased, and 
how very striking are the instances of this 
kind already recorded in several works on 
Influenza.2 
In some cases, again, isolation or seclu- 
sion of a community, as in prisons, have 
given immunity ; or at least that commu- 
nity has not been attacked. 
Inoculability.-The disease is not inocu- 
lable; at least, when horses are attacked, 
it cannot be transferred from one horse to 
another. (Hertwig.) 
Incubative Period.-All the contagions 
have one remarkable property ; there is a 
time when they are said to lie dormant, 
and to be undergoing or inducing in parts 
of the body those changes which lead at 
last to the symptoms of the declared dis- 
ease. During this period there are either 
no symptoms, or, what is more probable, 
they have not been determined. 
Such a period has been supposed not to 
exist in Influenza,1 which has been said 
to strike down persons in perfect health, 
as with a stroke of lightning. But the 
suddenness does not exclude an incubative 
period without subjective symptoms. It 
is also certain that the incubative period 
sometimes exists. It is sometimes very 
short ;2 sometimes of many days' dura- 
tion. 
Preservation from Second Attack.-There 
is some discrepancy of evidence; but, on 
the whole, it seems clear that, while per- 
sons seldom have a second attack in the 
same epidemic (though even this may oc- 
cur), an attack in one does not protect 
against a subsequent epidemic. Indeed, 
it has been supposed rather to render the 
body more liable. 
Relation of other Epidemic Diseases of 
Man.- It has been attempted to trace out 
a connection between Influenza and mea- 
sles, the plague, yellow fever,3 and cynan- 
che maligna (diphtheria). It has been 
1 Biermer, op. cit.: " The disease seems to 
come on without an incubative stage ; the 
causes of Influenza do not work after many 
days, as a contagion; but rapidly, like a 
poison."-P. 604. 
2 In the Transactions of the College of Phy- 
sicians (vol. iii.), it is stated that in the epi- 
demic of 1782, seventeen persons came to 
London to an hotel, and on the following day 
three were attacked with Influenza. Hay- 
garth (On the Manner in which the Influenza 
of 1775 and 1782 spead by Contagion in Ches- 
ter and its Neighborhood, by John Haygarth, 
M.D., F.R.S.) says that a gentleman came to 
Chester from London, on the 24th of May, 
1782, ill of Influenza; a lady, into whose 
family he came, was seized on the 26th, and 
was the first case in the town. Haygarth 
states, evidently with the wish to point out 
the possibility of a direct contagion, that the 
gentleman was engaged to be, and was after- 
wards, married to this lady. In this case the 
longest possible incubative period was two 
days. In 1782 a family landed at Harwich, 
from Portugal, and came to London directly ; 
the day after arrival, the lady, two servants, 
and two children were all seized. Two men- 
of-war arrived at Gravesend from the West 
Indies ; three Custom-house officers went on 
board ; a few hours afterwards the crews of 
both vessels were attacked. (Robert Wil- 
liams, on Morbid Poisons, vol. ii.) gome other 
cases are on record where the incubative 
period, if it existed, could not have been 
more than a single day. On the other hand, 
some cases are on record in which the incu- 
bative period must have been two or three 
weeks. (Ibid. vol. ii. p. 674.) 
3 Noah Webster, op. cit. vol. ii. p. 48. To 
some extent Schnurrer held that there is 
some connection between measles and Influ- 
enza. 
1 Sir Thomas Watson, M.D., whose care 
and accuracy inspire such faith, says also on 
this point: ' ' The instances are very numer- 
ous, too numerous to be attributed to mere 
chance, in which the complaint has first 
broken out in those particular houses of a 
town at which travellers have arrived from 
infected places." (Principlesand Practice of 
Medicine, vol. ii. p. 43. 4th Edition.) 
Sir George Baker was one of the first who 
noticed this fact. (Opuscula Medica; Edi- 
tion of 1814, p. 27.) 
Cullen's term, "Catarrhus 11 Contagio," 
seems to me to imply, however, merely the 
idea of origin from a special virus. 
[2 May not this analogy, however, be, with 
equal facility, used in the reverse manner as 
an argument ? As the general history of In- 
fluenza seems so cogently to negative any 
connection between human intercourse and 
its propagation, therefore the occurrence of 
some apparent instances of the introduction 
of cholera by persons should be regarded as 
most probably explicable otherwise than by 
contagion.-H. ] SPREAD OF THE DISEASE. 
39 
supposed also to precede and herald chol- 
era. On the other hand, it has been stated 
that epidemic scarlet fever disappeared 
when Influenza prevailed, and reappeared 
when this ceased. The same fact has 
been affirmed of smallpox.1 During its 
prevalence other severe inflammatory dis- 
eases have been supposed to lessen. With 
regard to all these supposed relations, the 
evidence is most unsatisfactory. Coinci- 
dences between the prevalence of different 
epidemic diseases must be expected, but it 
would require repeated instances to prove 
any connection. Measles constantly pre- 
vail without Influenza ; and if an epidemic 
has occasionally followed an Influenza epi- 
demic, this really proves nothing. The 
utter want of connection between cholera 
and Influenza is evident at a glance. 
So also the very imperfect knowledge 
we have of the relative prevalence of the 
acute inflammatory affections, makes it 
quite uncertain whether cases of simple 
bronchitis, rheumatism, and pneumonia 
really lessen in number during influenza. 
According to Graves (Clinical Med., vol. 
i. p. 425), during acute diseases persons 
are less liable, but they may be attacked 
at convalescence. 
It has not been shown to prevail espe- 
cially in years when intermittents have 
been more common, yet there may be 
some connection between the diseases 
(see Symptoms). Instances have been 
given in which intermittents seemed to 
disappear, and others in which the Influ- 
enza seemed to cause intermittents. 
Relation to the Diseases of Brutes.-In 
some epidemics of Influenza, dogs,2 horses, 
cats, and, it is said, birds, have been af- 
fected simultaneously with an epidemic 
catarrh. Horses are subject to an epi- 
demic catarrhal disease (18273) even when 
no Influenza prevails among men, and this 
disease, to which veterinary surgeons now 
give the name of Influenza, appears closely 
to resemble human Influenza. Its conta- 
giousness has been warmly debated, and 
it certainly appears incapable of inocula- 
tion, but yet some believe it to pass from 
horse to horse. It appears to be now' gene- 
rally thought an epizootic affection, and 
dependent on a specific cause.4 
After this statement of the facts con- 
nected with the spread of Influenza, we 
proceed to notice the speculative subject 
of the 
Nature of the Excit ing or External Causes. 
-So enigmatical are the phenomena con- 
nected with Influenza, that caution is 
necessary in attempting to form some idea 
of what the nature of the exciting cause 
may be. 
It must be a specific agent of some kind. 
From the earliest times authors have 
come to this conclusion ; the similarity of 
the symptoms in different epidemics show 
that this agent is the same in its successive 
invasions. If it be connected with an 
unusual meteorological or atmospheric 
condition, this has not been detected, and 
cannot be at present even guessed at. 
At the same time this agent must be in 
the air ; the diffusion is too rapid to sup- 
pose it to be conveyed by water ; besides, 
water-poisoning is usually localized. It 
cannot be attributable to food. There 
remains only the air as a medium of com- 
munication ; and that this is so, seems 
also shown by the way in which it can at- 
tack vessels at some distance at sea. 
There is, then, some special agent in 
the air. But this cannot be a gas ; no gas 
could spread in this way without utter 
dispersion and destruction. Besides, the 
manner in which it is located in a part of 
a town, a street, even one side of a street, 
for a time, or affects a town without 
touching a village a mile or two off, is 
quite conclusive against the hypothesis of 
seleniuretted hydrogen, allotropic oxygen, 
or any other gas being the cause. Nor 
can it be any molecular matter driven 
through the air, arising from some un- 
known telluric source, for this would be 
equally diluted and dispersed. The agent 
evidently cannot own one single and pri- 
mary origin; it may, indeed,"issue from 
one spot, but all the phenomena of its 
spread show that it must, in its transit, 
reproduce itself. Otherwise, if a gas, it 
must be rendered innocuous by dilution ; 
if an organic matter, by oxidation ; if a 
suspended mineral matter, by subsidence. 
It must increase, and the more the sub- 
ject is gone into, the more firmly will the 
idea gain upon the mind, that there must 
be a continual reproduction of the agent, to 
a greater or less extent, in different places. 
Now this reproduction must either be 
in the air or in the bodies of the sick, in 
which latter case the agent would be a 
true contagion. If it grows in the air, the 
only conceptions we can form are, either 
that some force changes successively the 
atmospheric elements in some way, or 
that the increase is a vital one, and con- 
sists of microscopic plants or animals. 
The first idea is supported by no evidence ; 
and as to the second, we find ourselves 
in the presence of the so-called fungoid 
1 See Biermer, op. cit. p. 619, for references 
on these points. 
2 In the great epidemic in Australia, in 
1851-52, dogs were affected in great numbers. 
3 In this Influenza of horses which spread 
over almost all Europe, no cause could be 
found in the weather, food, or work of the 
horses; transfusion of blood of a diseased 
horse did not communicate it to another; 
many veterinary surgeons considered it to be 
contagious ; others did not hold this opinion. 
Influenza prevailed among men in North 
America, Mexico, and Siberia, but not in 
Europe. 
* Turpentine has been used beneficially in 
the so-called Influenza of horses. 40 
INFLUENZA. 
theory of Influenza. There are many 
phenomena consistent with the hypothesis 
of a vital and growing cause : the occa- 
sional introduction of the disease by per- 
sons about whose bodies or clothes the 
fungi may cling; its passage at times 
with the wind, contrasted with the occa- 
sional passage against it when other modes 
of conveyance may be presumed to come 
into play ; the gradual development of the 
disease to a climax, and then its decline, 
contrasted with its occasional persistence 
when the conditions of growth may be 
supposed to be more persistently in the 
same place; the entire disappearance of 
the disease, and its extremely rapid resus- 
citation when it again appears ; its birth, 
apparent in various parts of the world, 
and yet its evident incapability of origi- 
nating in some countries, as France and 
England (whither it has always passed 
from other lands), are all easily explicable 
if we assume a fungoid origin, and re- 
member the different conditions which 
can effect the development of fungi. The 
remarkable powers which have lately been 
ascribed (with what justice time must 
show) to those lower forms of life increase 
the interest with which this question must 
be regarded. 
But, on the other hand, there is a com- 
plete want of direct evidence, without 
which the argument in favor of a special 
living agency is worth little. It is im- 
possible to make a certain and assured 
step without some tangible evidence. 
Moreover, for the rapid increase of fungi 
we should suppose certain meteorological 
conditions to be necessary-a certain tem- 
perature, moisture, organic effluvia ; but 
the spread of Influenza has little, if any, 
connection with these conditions. 
If the cause be a fungus, or some allied 
organism, it may increase in the body as 
well as out of it, and if so would be found 
in the secretions, especially in the nasal, 
buccal, and bronchial mucus. In this 
way human intercourse would spread it. 
A thorough microscopic examination of 
these discharges is yet wanting, but pos- 
sibly the next epidemic may supply this 
link. 
If the agent is not a fungus, the only 
other ready explanation which presents 
itself is that of a true contagion ; namely, 
that particles of the sick body being 
thrown off are in some special condition, 
or are undergoing certain putrefactive or 
other chemical changes, which can excite 
a similar action on particular parts of 
other human bodies. And in this case, to 
account for the spread of Influenza, we 
must believe that these particles pass off 
in myriads from each sick person, are ex- 
cessively small and light, perhaps become 
dried up, and floating through the air, to 
greater or less distances, are breathed or 
swallowed by other persons, and then set 
up in their bodies the same series of 
changes which the particles themselves 
are undergoing. This view seems to me 
to involve greater difficulties than the 
fungoid theory, i. e., it accounts less satis- 
factorily for the spread of Influenza. 
If neither of these views be correct, 
then the cause of Influenza is something 
of which we have no conception whatever. 
It seems to me to be impossible at present 
to come to any conclusion as to the nature 
of the cause. [Two alternatives seem to 
remain for further investigation, in con- 
nection with the etiology of Influenza, as 
well as of several other epidemic diseases; 
especially Yellow Fever and Cholera. One 
of these is an expansion of the idea pro- 
posed and elaborated especially in regard 
tc Cholera, by the late Dr. Snow, of Lon- 
don; designated by him as the theory of 
" continuous molecular change;" supposed 
by him rather to extend than to substitute 
the common notion of contagion. The 
other, very probable, view is, that the 
"disease germs" of many epidemics, al- 
though really organic in nature, are ziltra- 
microscopic in minuteness, and therefore 
not demonstrable except by their effects.- 
IL] 
Predisposing or Internal Causes.-Race 
has no influence, sex probably none, or, if 
at all, women are slightly more affected; 
age has only a slight effect; young chil- 
dren are, it is said, rather less affected 
than old persons. If any special bodily 
predisposition is necessary, it is common 
to the whole human race, and apparently 
to horses, dogs, cats, &c., herein differing 
greatly from several of the true conta- 
gions. 
Persons in overcrowded habitations 
have, particularly in some epidemics, es- 
pecially suffered, and several instances are 
on record of a large school or a barrack 
for soldiers being first attacked, and of the 
disease prevailing there for some days be- 
fore it began to prevail in the town 
around. Sometimes, on the other hand, 
schools and prisons have escaped. 
A low, damp, ill-ventilated and un- 
healthy situation appears to predispose to 
it,' and in some instances, in hospital pa- 
tients, it has assumed a malignant cha- 
racter (Sir George Baker, Gray). In other 
cases again, hospital patients have es- 
caped ; for example, the old people in the 
Salpetriere in 1837, when the younger at- 
tendants were attacked. 
It has been supposed that persons with 
chronic lung diseases, especially emphy- 
sema, and chronic heart affections, are 
particularly liable, but this seems uncer- 
tain ; it is probable that the Influenza 
being more serious in such persons, cre- 
ates the impression that they are as a 
1 Pearson noticed this in both 1762 and 
1782. INFLUENZA. 
41 
class more liable. The Registrar-General 
has shown that in 1847 the increase of 
deaths by Influenza was much greater in 
the districts in which ordinarily there is 
a high mortality than in healthier places; 
this must indicate either greater preva- 
lence or greater severity of the disease. 
Symptoms.-General Course of the Dis- 
ease.- The symptoms of Influenza are 
compounded of two conditions-a gene- 
ral fever of determinate duration, and a 
marked and evidently specific affection of 
the mucous membrane of the nose, mouth, 
throat, and respiratory tract, which has 
also a determinate course. 
Individual cases differ in the propor- 
tion of these two conditions, and in ad- 
dition there may be superventions of true 
inflammation of the lungs or pleura, or 
implication of other mucous membranes, 
those of the stomach and intestines in 
particular, and less frequently of the blad- 
der and kidneys. 
It would appear that the fever has the 
priority, and that shivering or coldness 
down the spine, with heat and flushing 
and dry skin, quick pulse, thirst, and se- 
vere headache, very frequently usher in 
the attack. These symptoms precede any 
local signs. But it would be very desira- 
ble to re-investigate this point. The fe- 
brile symptoms sometimes come on quite 
suddenly, sometimes develop slowly, in 
from twelve to thirty-six hours, or even 
to four days. When they commence sud- 
denly, the first symptom is often an ex- 
treme frontal headache, with pain and 
aching in the eyes. 
They last for four or five days usually, 
or sometimes a few days longer, and then 
disappear gradually, or occasionally rather 
rapidly, with profuse perspirations, or 
spontaneous diarrhoea. Sometimes they 
continue ten or twelve days, but this is 
generally when pneumonic complication 
supervenes. 
The specific catarrhal affection usually 
follows the early symptoms of fever; 
sometimes occurs at the same time, per- 
haps sometimes precedes them. It ap- 
pears to commence in extreme hypersemic 
swelling and dryness of the mucous mem- 
brane of the frontal sinuses, the nose, and, 
in a less degree, of the conjunctivae, caus- 
ing intense pain across the brows, great 
sneezing, sometimes epistaxis and thin 
acrid discharges from the nose and eyes; 
the same condition then occurs in the 
pharyngeal, the laryngeal, tracheal, and 
pulmonary mucous membrane to the mi- 
nutest ramifications. Usually, perhaps, 
the affection commences above and passes 
rapidly down, but sometimes the whole 
tract is attacked at once. The inside of 
the mouth and the tongue are also, but 
less, affected, and the pharynx is also not 
so marked by hypereemia as the other 
parts. A punctiform redness of the mu- 
cous membrane of the palate, something 
like the eruption of measles, has been 
lately described by Tigri, and considered 
to be pathognomonic. The discharge from 
these membranes, when it occurs, is first 
thin and acrid, and sometimes bloody, it 
becomes afterwards thicker, more tena- 
cious, and at length purulent; great sneez- 
ing, sore throat, difficulty in smelling, vio- 
lent paroxysmal cough, pains in the chest; 
occasionally very sharp stitches in the 
side, which are apparently often nervous, 
and not pleuritic, accompany the specific 
condition of the respiratory tracts. Great 
dyspnoea and the stethoscopic examina- 
tion show that there is immense conges- 
tion of the lungs, and often the face and 
lips show very considerable impairment in 
the aeration of the blood. In pure cases the 
catarrh is at its height on the second and 
third, or fourth day, and declines about 
the fifth to the seventh ; but cough expec- 
torations often remain for some time. In 
severe cases the disease lasts with great 
severity even to the tenth or twelfth day. 
Attendant upon these symptoms, and 
in proportion, it is usually supposed, to 
the fever, though some have thought it 
to be in more direct ratio to the extent 
and violence of the membranous catarrh, 
is a peculiar state of the nervous sys- 
tem. Very early in the disease there is 
a remarkable nervous depression, loss of 
strength, and lowness of spirits, com- 
bined often with great aching in the mus- 
cles, and severe nerve pains in different 
parts, which certainly give one the impres- 
sion that both muscles and nerves are 
undergoing some profound nutritional al- 
teration. " The mind, too, becomes weak, 
and sometimes there is even stupor or de- 
lirium. In some epidemics, indeed, the 
early sopor or cerebral heaviness is very 
remarkable. 
These nervous symptoms often last 
longer than either the fever or catarrh; 
hence convalescence is tedious and mental 
activity slowly regained. 
In pure cases, when the disease is over, 
the nasal and respiratory mucous mem- 
branes do not for some short time entirely 
recover their structure, at least if it be 
true that there is increased liability to 
common catarrh. Also if it be true that 
there is a greater liability in future epi- 
demics of Influenza, it is possible that 
some structural change may permanently 
remain. The severity of the cases differs 
greatly, and sometimes the affection is 
very slight, sometimes very severe. 
Consideration of the Special 
Symptoms.-1. Temperature of the Tody. 
-No observations have yet been made 
with the thermometer. In some epi- 
demics (1580, Salius Diversus) there has 
been intense heat of skin ; in others (1775, 42 
INFLUENZA. 
Fothergill) the skin has not been particu- 
larly hot. But perhaps this might depend 
upon individual cases; for in the same 
epidemic some have great, others have 
slight, fever. 
2. Condition of the Skin.-Sweating at 
first is usually absent or partial. If it is 
profuse in the early stages, the disease is 
sometimes arrested. The perspiration is 
often sour smelling, and is said to be very 
acid. In the epidemic of 1782 in London, 
the sweating was so profuse as to cause 
the name of sweating sickness to be given 
to the Influenza. Sudamina are sometimes 
seen in great numbers, so that the case 
looks like miliaria. A pustular or herpetic 
(Peacock) eruption about the mouth some- 
times occurs. There is no decided erup- 
tion peculiar to Influenza, but occasion- 
ally it is said rose-colored little blotches, 
and sometimes urticaria are seen. There 
is sometimes most decided hypersesthesia 
of the skin of the neck and head ; this is 
usually coincident with severe headache. 
3. Nervous and Muscular Symptoms.- 
The headache is often excruciating ; fron- 
tal most usually; limited to the region 
of the frontal sinuses, or extending more 
or less over the head, or over the face, 
(Antrim of Highmore) ; there is often 
great heaviness, sometimes torpor, and 
occasionally delirium. In some epidemics 
high delirium has been considered a mor- 
tal symptom (Huxham in 1737). Severe 
vertigo is a common symptom. There is 
a general lowering in the acuteness of all 
the special senses. The spirits are low, 
mind weak ; the nights restless, and this 
loss of sleep is not in relation to the fever ; 
it is seen often in patients without fever.1 
Meningitis occasionally occurs, and 
sometimes otitis, and there is often severe 
pain in the region of the Eustachian tube. 
There are also neuralgic or rheumatic-like 
pains of many parts of the body, especially 
of the muscles of the neck, loins, legs, and 
the intercostals. 
The extreme prostration of muscular 
strength has been already noticed; it is 
often a very early symptom, and in some 
epidemics has given almost a special char- 
acter to the disease ; the complete return 
of strength does not occur till after conva- 
lescence is far advanced. 
4. Respiratory System.-The paroxys- 
mal cough is one of the most distressing 
symptoms, and sometimes causes hernia, 
or abortion in pregnant women. At first 
dry, the cough is soon attended with 
stringy, often bloody sputa ; as soon as 
the sputa get more consistent, thicker, 
more opaque, and purulent, the cough 
lessens. In different epidemics the 
amount of cough has varied, but this, may 
be, in part depends on erroneous observa- 
tions, as formerly no doubt epidemic 
hooping-cough was confounded with In- 
tluenza. Dyspnoea is often considerable, 
and is dependent either on the great 
congestion of the respiratory tract, or on 
pneumonic complications, or possibly, as 
suggested by Graves, on some special im- 
plication (paralysis ?) of the vagus. 
There are often remissions in the dyspnoea 
not accounted for by stethoscopic signs. 
Occasionally there are orthopnoea and suf- 
focative attacks. Sometimes there is in- 
tense and oppressive feeling across the 
chest. The number of respirations is 
often great, and the pulse-respiration 
ratio becomes one to two-and-a-half or 
one to three. In bad lung cases the 
voice is often very weak as well as hoarse. 
At first the stethoscopic signs are almost 
wanting ; the vesicular murmur is feeble, 
even though the percussion note be clear ; 
if there be dulness, it is equal and indecti- 
ble. Afterwards when oedema of the lung 
occurs they are fine moist rales, and sono- 
rous and sibilant rhonchi are present in 
some cases. 
Capillary bronchitis, pneumonia (which 
is usually combined with pleurisy), and 
pleurisy are present in some cases, though 
it is impossible to state in how many. It 
has been supposed that pneumonia occurs 
in from five to ten per cent.1 In some epi- 
demics pneumonic complication is sup- 
posed to be more common, as in 1837 ; 
the pneumonia is said to be of the catar- 
rhal variety when it occurs during the 
attack (about the fourth to the sixth day), 
and of the croupous kind when it occurs, 
as it sometimes does, in convalescence 
(Lombard). The supervention of pneu- 
monia is not easily detected by stetho- 
scopic signs before consolidation, in con- 
sequence of the oedema. The same rea- 
son makes it sometimes difficult to detect 
true capillary bronchitis unless one lung 
is more affected than the other. Pleurisy 
is easily detected. 
Sometimes it is supposed that a sort of 
paralysis of the lungs occurs with great 
oedema (Graves), possibly from affection 
of the vagus. Collapse of some portion 
of the lungs often occurs. That during 
the height of the disease aeration is most 
imperfect, is evident from the dark lips, 
congested cheeks, and great distress, 
which are often seen. 
As sequelse to the chest affection, chro- 
nic laryngitis, chronic bronchitis, emphy- 
sema, and tuberculosis are sometimes seen. 
Yet it is well known that some phthisical 
patients pass well through Influenza with- 
out increase of their disease. 
5. Circulatory System.-At first strong 
and quick, the pulse soon becomes soft, 
1 The epidemic of 1712 was attended in 
Tubingen by great drowsiness, and in that 
outbreak the brain symptoms appear to have 
been unusually heavy. 
1 Biermer, op cit. p. 624. INFLUENZA. 
43 
and in the latter stages feeble, and even 
slow. It is often singularly changeable 
within a few hours. Heart affections are 
not common, yet pericarditis will occur, 
and is then usually complicated with pleu- 
risy. 
The blood is buffed and cupped in pneu- 
monic complications, perhaps in all cases. 
(Vigia.) 
6. Digestive System.-Nausea and vom- 
iting are sometimes seen in the commence- 
ment ; diarrhoea is much less frequent till 
towards the end, when there arc often 
rather profuse discharges; thirst and 
complete anorexia are very usual. There 
is sometimes pain in the right hypochon- 
drium, and a yellowish tint of eye and 
skin. (Peacock.) In some cases there is 
a decided icteric state of the skin. The 
great depression and languor is very simi- 
lar to that which accompanies some cases 
of jaundice when the bile is accumulating 
rapidly in the blood. Sometimes the 
bilious vomiting, fever, and oppression of 
the brain cause the case to resemble the 
bilious fever described by authors. There 
is no evidence of any splenic affection. 
In some epidemics these gastro-enteric 
symptoms have been, it is said, more pro- 
nounced than in others, but there is no 
doubt that cases of typhoid fever compli- 
cated with or following Influenza have 
often been described As a rule, in pure 
cases, the symptoms of stomach and 
bowel implications are not marked, or are 
caused by medicine or food. 
Urinary System.-The urine is at first 
scanty and high colored ; at a later period 
it becomes sedimentous from lithates, 
which are often pink ; it is believed there 
is no albumen nor bile, but good observa- 
tions fail on these points, as well as on 
the composition of the urine in twenty- 
four hours. Occasionally there is almost 
complete or entire ischuria. 
Genital System.-The catamenia are 
sometimes induced, and amenorrhoea has 
been thus cured. Abortions are frequent, 
especially in some epidemics, probably 
from the violence of the cough. 
Lymphatic System.-Swellings of the 
parotid, the submaxillary, and sometimes 
the cervical glands are observed, and oc- 
casionally, but rarely, severe parotitis fol- 
lows. 
It is somewhat curious that either an 
intermittent fever has been united to In- 
fluenza in some epidemics, or that the 
Influenza has had an intermittent charac- 
ter. Thus in 1580 Sennert mentions that 
the quartan fever was joined to the epi- 
demic ; in 1658 Willis states that the 
epidemical catarrhal fever often had an 
intermitting character, usually tertian, 
rarely quotidian. In 1762 Baker says that 
Influenza appeared under the form of an 
intermittent with tertian periods. Tn 
1767 Donald Monro also saw an intermit- 
tent character, but not so marked as in 
the epidemic at Bremen in 1762. In 1775 
he says that few persons had such distinct 
paroxysms as to resemble those of an 
ague ; but Fothergill (1775) states that 
" in many instances the disease assumed 
the type of an intermittent towards its 
decline." In 1803 Pearson noticed that 
the lassitude and depression which con- 
tinued after the fever had gone had an 
intermittent character, and were worse 
every other day. The histories of the 
recent epidemics show no character of this 
kind, and it is possible that in former cen- 
turies the far greater prevalence of malaria 
impressed on other diseases a periodical 
character which was not in their own na- 
ture. But the observations are curious in 
connection with the opinions of those who 
have connected Influenza with malaria. 
Varieties of Influenza.-The va- 
rieties in different epidemics have been 
already referred to. In the same epidemic 
Influenza differs in intensity in different 
people. In some persons it is an extremely 
slight disease; in others, a very severe 
one; this is especially the case if there 
are pulmonic or gastric complications. 
So also in some cases an unusual nervous 
depression prolongs a case which might 
be otherwise a mild one, or paroxsymal 
cough and expectoration, or flying neural- 
gia, or rheumatic-like pains continue for 
some time during convalescence. 
Mortality.-This seems to vary great- 
ly in different epidemics (1837 and 1847 
were more fatal than 1833-4; Graves), 
and is also partly, perhaps, dependent on 
treatment. Wierus says that the great 
mortality in Italy in 1580 was owing to 
the promptitude with which the Italians 
bled ; the mortality in London has some- 
times been severe, while it has been slight 
in Germany. In 1837 the rate of mortal- 
ity was calculated at two per cent., but it 
was considered that this was a very severe 
epidemic. 
There appears no doubt that mortality 
increases greatly with age. It is also 
higher in persons with chronic bronchitis, 
emphysema, and chronic heart-diseases, 
especially dilated and fatty hearts. Mere 
valvular disease, without loss of power, 
has little influence. During the preva- 
lence of Influenza, other causes of death 
show an increase, especially pulmonary 
complaints, and typhoid, and typhus. 
This depends probably on the superven- 
tion of Influenza upon those affections. 
Diagnosis.-If the term Influenza is 
restricted to the truly epidemic disease 
which spreads over large tracts of country, 
there is no difficulty in the diagnosis. 
Although there is no special eruption as 
in the exanthemata, or peculiar cough as 44 
INFLUENZA. 
in pertussis, or membranous pellicle as in 
diphtheria, the collection of symptoms is 
peculiar. 
Nor can there be any confusion between 
cases of epidemic cough and isolated cases 
of catarrh, arising usually from marked 
meteorological conditions. However com- 
mon such attacks, however severe and 
influenzoid they may be in certain cases, 
they do not constitute an epidemic ; there 
is no disease spreading over the country. 
Moreover, the symptoms are really dis- 
similar in ^their mode of connection and 
succession. Far more difficult is the di- 
agnosis between true Influenza and ca- 
tarrhal fevers invading a town or district. 
That there are such local or endemic at- 
tacks of catarrhal fever seems certain, 
and it is doubtful whether or not they 
should be classed with Influenza. They 
want the power of travelling ; they attack 
more slowly, and are far less common 
among the population. There is for the 
most part less of the overwhelming pros- 
tration, and fewer mucous membranes are 
attacked. They appear usually to be 
merely the common catarrh developed 
into unusual proportions by changeable 
or severe weather, and possibly this may 
be the simple explanation of their occur- 
rence. If by the use of the thermometer a 
typical course of temperature is discovered 
in Influenza, or if the examination of the 
excretions detects any special characters, 
the diagnosis will be easy. Till these 
points are determined some doubt must 
exist, nor does it seem to me possible to 
lay down any precise rules of diagnosis. 
There are few points more deserving care- 
ful study than the precise characters and 
causes of catarrhal fevers, localized in a 
town or district, and not forming part of 
a general epidemic. 
There is no other disease with which 
Influenza can be confounded, but during 
its prevalence many other diseases-bron- 
chitis, typhoid fever, etc.-are often called 
Influenza, and this probably has given 
rise to the opinion that during epidemics 
of Influenza such diseases lessen, to reap- 
pear at its close. 
Pathology.-We are not yet in a po- 
sition to discuss the pathology of this dis- 
ease. Does the agent enter the blood, 
act on the nervous system, and then by 
election seize upon and irritate the mucous 
membrane of the respiratory tract ? Or 
is it really a membranous local disease, 
acting very promptly (just as simple an- 
gina will act on the system at large) in the 
secondary constitutional effects ? At pres- 
ent the sequence of symptoms seems to 
show the first view to be more probable, 
viz., that it is a general disease, with a 
special secondary localization. 
What is the exact nature of the general 
disease ? The blood is buffed and cupped ; 
i. e., there is increase in the fibrine; that 
is all that is known of the blood ; the pe- 
culiar changes in the nervous system and 
the muscles are quite unknown. 
What is the exact nature of the respira- 
tory affection ? If -we reply, it is a gen- 
eral hypersemia, this is a mere translation 
of terms. Of the exact cause of that hy- 
persemia we have no idea. Is there a 
partial coagulation of blood in the venous 
system, or some affection of the vaso-mo- 
tor nerves leading to general dilatation ; 
and is the altered mucous discharge due 
to such change, or to some special condi- 
tion of the nutrient plasma as it comes 
from the vessels, which strikes deeply at 
their growth and nutrition ? The inflam- 
mation, if we are to give it that term, is 
evidently specific; in what the specific 
character consists it seems at present vain 
to inquire. 
Morbid Anatomy.-Fatal cases of 
pure Influenza are rare ; they occur chiefly 
in old persons, with old lung or heart dis- 
ease, or in consequence of recent inflam- 
matory pulmonic or cardiac complications. 
The results of simple Influenza seem to 
be general congestion of the respiratory 
tract, amounting sometimes to enormous 
congestion of the lungs, oedema of the 
lungs, with more or less collapse. The 
collapsed portion is smooth, non-crepitat- 
ing, and is said to be sometimes softer 
than usual, like gangrene, but without 
fetor.1 Sometimes membranous exuda- 
tions are found in the bronchi, not unlike 
those ofcroup. 
If pleurisy and pneumonia have oc- 
curred, the usual post-mortem appear- 
ances of those diseases are present. The 
pneumonia is sometimes lobular (or possi- 
bly this statement has arisen from lobular 
collapse not being identified) or lobar, and 
is often double. 
Prognosis.-The very young and the 
very old bear Influenza badly, especially 
the latter. Persons with chronic bron- 
chitis, emphysema, and fatty heart, are 
bad subjects. 
In persons without such complaints the 
danger is chiefly connected with the state 
of the lungs. Great dyspnoea, very weak 
voice, impossibility of coughing up the 
tough sputa, and duskiness of the face, 
are unfavorable signs. If the pulse be- 
comes early very feeble and slow, and 
then unequal and intermittent, it shows 
that the heart is not receiving its due sup- 
ply of blood on account of the lung-con- 
gestion. 
The fever and the nervous symptoms 
seldom kill, yet in some epidemics there 
have been frequent delirium, convulsions, 
1 Especially in very aged persons : Greene, 
in Graves's Clin. Med. vol. i. p. 438. INFLUENZA. 
45 
and fainting, and these have always been 
found to be very bad symptoms. 
As favorable signs may be noted, copious 
warm sweats, loose so-called concocted 
sputa, spontaneous diarrhoea, and urine 
with copious red lithates. 
In the case of pregnant women there is 
danger of abortion and subsequent hemor- 
rhage. 
Treatment.-Preventive Treatment. - 
No means are yet known by which In- 
fluenza can be prevented. Unfavorable 
hygienic conditions, and especially over- 
crowding, heighten its prevalence and 
its severity ; but persons in the most favor- 
able circumstances may be attacked. Per- 
haps persons in well-warmed and yet 
ventilated houses escape best. It has 
sometimes been noticed that persons ex- 
posed by work to the weather suffer most: 
hence it may be a rule that those persons 
who can do so, should be more within the 
house during an epidemic ; but as bed- 
ridden persons are not infrequently at- 
tacked, this is no guarantee. 
Treatment of the declared Disease.-Re- 
gimen.-It is of great importance to have 
the room cool and well ventilated. Pear- 
son, whose little work on Influenza is one 
of the most practical which has ever been 
written, pointed out, in 1803, the differ- 
ence in this respect between common 
catarrh and Influenza. In the former 
case the patient is better in bed in a warm 
room ; in the latter case, if the patient is 
not too ill, it is better to get him out of 
bed after the third day, and to place him 
on a sofa.1 Draughts or chills must be, 
however, most carefully avoided, on ac- 
count of the risk of pneumonia. 
As there is usually almost complete 
anorexia, it is difficult to give much food. 
The common custom of giving hot beef- 
tea is an extremely bad one ; it invariably 
increases the headache and languor, and, 
as Pearson pointed out, any warm food 
which forces sweating appears not only to 
be useless, but to do harm. Solid meat 
also should be abstained from for two or 
three days in bad cases. Several writers 
recommend vegetable food for four or five 
days. Plenty of cold drinks, especially sub- 
acid fruits, oranges, lemon-juice, cream- 
of-tartar water, raspberry vinegar, weak 
citrate of potash, and citric acid flavored 
with sugar, barley-water with lemon juice, 
infusion of mallows or althea, and drinks 
of the like kind, should be given ad libi- 
tum, and when there is fever they should 
be iced. Very weak cold white-wine whey 
is a very grateful drink. Some good 
writers speak strongly against the prac- 
lice of stimulants early in the disease, in 
all young persons ; the great languor and 
weakness often lead to their use, but it 
seems probable that they do harm. If 
stimulants seem indispensable, claret or 
hock, with seltzer water, is the best. In 
old persons it may be necessary to use 
stimulants earlier and more freely. 
Stimulants must however be given, and 
often given largely, in the later stages, if 
the heart fails, and especially if there are 
symptoms of intense lung congestion and 
asphyxia. Brandy, with ammonia, must 
then be freely used. 
As soon as the severity of the fever is 
passing away, patients should be made to 
eat; the appetite is still bad, but they 
will generally take food. Care should be 
taken not to derange the stomach by too 
great quantity or variety of food, of which 
there is some danger. 
No experiments have yet been made, 
to my knowledge, on the effects cf cold 
affusion in the stage of fever ; but possibly 
it might be useful. The wet sheet has 
been used, and apparently with some 
benefit. For old people, Schdnbein used 
to order warm baths or warm fomenta- 
tions. 
Keeping the air of the room moist, by 
conducting the steam from a boiling kettle 
into it by means of a tube, or by putting 
boiling water into flat shallow vessels, 
appears to ease the cough. Also, as in 
common catarrh and bronchitis, the inha- 
lation several times daily of hot steam is 
most useful. The old inhaler of Mudge, 
with the hollow handle, and the valve in 
the cover, or any of the new inhalers, 
may be used. If they cannot be obtained, 
breathing through a sponge dipped in hot 
water is the best way. 
Drugs. - Slight cases require almost 
nothing ; a little cooling saline medicine, 
citrate and acetate of potash, nitrate of 
potash, &c. 
In severer cases treatment must be more 
active. 
Blood-letting seems always hurtful, and 
this was noticed so long ago as in the 
epidemics of 1580. Hardly a writer of 
any note has failed to make the same re- 
mark. The fever is not relieved, the 
nervous depression is increased, and the 
risk of the lung congestion and paralysis 
is augmented. Even with supervening 
pneumonia, in the old days of bleeding, 
blood was very seldom taken more than 
once. If cupping or pneumonia come on 
with severe pain, a few leeches or a pleu- 
risy glass to the painful part are often 
useful, but depletion should hardly go be- 
yond this. 
A dose of calomel, one to three grains, 
according to circumstance, repeated once, 
but not oftener, should be given at first, 
and may be followed by a saline purgative. 
Pearson strongly recommended this, and 
1 In some of the older epidemics the prac- 
tice in England was to keep the patient ex- 
tremely hot in bed, and to give calefacients. 
1801. INFLUENZA. 
46 
various writers have endorsed the prac- 
tice. The calomel generally brings away 
copious dark-colored motions, after which 
the patient is much better in spirits, and 
the fever abates. But neither mercurial 
nor other purgatives should be too freely 
or repeatedly given, as the intestinal mu- 
cous membrane is irritable. Repeated 
catharsis is sometimes most injurious. 
The substitutes for mercury, podophyllin, 
jalapine, &c., have not yet been tried in 
Influenza, and it is impossible to say 
whether they will be more or less useful. 
In children, gray powder must be sub- 
stituted for calomel, or, what seems better 
for them, clysters of warm water, with a 
little castor-oil, may be used. 
From the good effects of one or two 
doses of mercury some have proposed to 
continue to give mercury, stopping just 
short of salivation. But this is bad prac- 
tice ; there is no evidence that these small 
repeated doses of mercury are useful, and 
it is impossible to be sure that salivation 
will not come on before we are aware, 
with all its evils. 
Emetics, at the onset, have been very 
strongly recommended, and in the older 
epidemics an emetic of antimony and ipe- 
cacuanha was invariably given, when the 
patient was first seen. If there is much 
nausea an emetic is useful, and perhaps 
may be so in all cases; but there is one 
disadvantage, it occasionally produces 
great and permanent irritability of the 
stomach, so that it is afterwards difficult 
to check the constant vomiting. Tartar 
emetic has been chiefly used, but it causes 
much depression. On the whole it seems 
undesirable, as a rule, to give emetics. 
After the bowels have been well acted 
upon, the best remedies to give in com- 
mon cases seems to be nitrate of potash 
mixed with lemon-juice and sugar. It 
seems most useful to give it highly diluted, 
so that it may be taken as drink. From 
60 to 120 grains, in twenty-four hours, 
may be given to an adult. 
Supposing the chest symptoms are not 
urgent, nothing else need be done ; but if 
the hmg congestion is considerable and the 
cough very hard, some expectorants must 
be used. Of these ipecacuanha seems on 
the whole the best, and can be combined 
with conium or henbane, or with the 
etherial tincture of lobelia. (Blakiston.) 
Tartar emetic, as an expectorant, has 
been strongly recommended, but it ap- 
pears to be too lowering in many cases. 
In the epidemic of 1847 I found it to be 
of little service, and sometimes to cause 
irritation and congestion of the intestinal 
mucous membrane. It is, I believe, better 
avoided altogether. 
Opium requires to be used in bad cases 
with the greatest caution. There has 
been much discrepant evidence as to its 
employment, but on the whole it seems, 
as Pearson pointed out, best to defer its 
use till the later stages. If given early it 
increases the tightness across the chest 
and the difficulty of breathing. At a late 
stage, when the expectoration is coughed 
up easily, and all danger of great lung 
congestion seems passing off, opium with 
ipecacuanha quiets the paroxysms of 
cough, and gives great ease. 
Sometimes, however, when the cough is 
extremely violent, and conium and hen- 
bane do no good, opium must be given. 
In fact the cough itself, simply as a me- 
chanical agent, excites an unfavorable 
effect on the congested lung, and must be 
stopped. Then Dover's powder, with 
nitre and lobelia, should be given ; if this 
does not answer, the liquor morphise mu- 
riatis or the bimeconate of morphia with 
ipecacuanha, in large doses, must be used. 
Squills seem decidedly hurtful till quite 
the latter stages. 
If there is great tightness across the 
chest, sinapisms and warm bran poultices 
or warm water fomentations must be con- 
stantly used. Sharp stitches in the side, 
if pleuritic, must be treated with sina- 
pisms and warm poultices, or, if very 
severe, with a few leeches, followed assi- 
duously by warm fomentations. If no 
friction-sound can be detected, they are 
intercostal neuralgic pains, and are soon 
relieved by warmth, opium, and chloro- 
form, applied externally. 
In the latter stages, if the expectoration 
is profuse, the cough still violent, and the 
strength failing, senega and serpentaria, 
mixed with light wines, seem to be very 
useful. Ammonia must also be used. If 
the expectoration continue extremely pro- 
fuse, the acetate of lead, with a little 
opium is useful. 
Some of the older writers thought that 
cinchona bark was hurtful in the earlier 
stages, but in some of the late epidemics 
quinine appears to have been found useful 
throughout. Whether this be the case or 
not, it seems clear that immediately the 
acute stage is passing off quinine should 
be freely given. It does good service 
against the neuralgic pains which are of- 
ten troublesome at the commencement of 
improvement. [The employment of qui- 
nine in Influenza has now become ex- 
tremely common in America, even in non- 
malarious districts. Beginning with it 
upon the occurrence of the first symp- 
toms, doses of from three to five grains 
every two or three hours, until ten or 
twelve grains have been taken, will, if not 
abort, at'least mitigate the violence of an 
attack. Should this, with other palliative 
treatment, not avert or arrest the disorder 
at the beginning, quinine will, throughout 
its course, do the most good in small or 
moderate doses; not more than eight or 
ten grains in a day. The early abortive 
practice, however, with quinine seems to TREATMENT. 
47 
be well worthy of general trial, not only 
in epidemic Influenza, but in those spora- 
dic catarrhal attacks, which, under the 
name of "catching cold," are common 
everywhere.-H.] 
Warm plasters between the shoulders 
have been much praised by some writers 
(Legendre). Blisters do no good, and 
add to the patient's sufferings. 
Inhalations have been tried both for the 
cough, sore throat, and nasal soreness. 
Pearson used the vapor of ether, which 
he had found very useful in common 
catarrh ; it was not so good in Influenza. 
Chloroform, in small quantities, may re- 
lieve the tightness and the violence of the 
cough. Inhalation of steam has been al- 
ready noticed. In future epidemics it 
would seem very desirable to try various 
inhalations to act on the membranes of 
the nose, pharynx, and lungs. It is im- 
possible a priori to say whether they could 
be of any use, but small quantities of 
chlorine, iodine, carburetted hydrogen, 
even perhaps sulphurous acid, might be 
tried. The naso-bronchial mucous mem- 
brane is very accessible to such influences, 
much more so than to medicines intro- 
duced into the blood. 
It may be a question also whether some 
local applications could not be made to 
the membranes of the nose and throat, 
such as solutions of iron, catechu, or al- 
terative substances of that kind. Possi- 
bly the local disease might be thus partly 
checked. 
The use of sulphites of potash and soda 
may also be suggested as a local applica- 
tion to the throat and nose. 
Complications. - It is very doubtful 
whether pneumonia is benefited by bleed- 
ing ; the pneumonia has itself a course, 
and cannot be cut short; it is probably 
better to persevere with ipecacuanha and 
nitre, and to apply only a few leeches or 
a cupping-glass if pleuritic pain be intense. 
In double capillary bronchitis bleeding 
is hurtful; the great danger is suffoca- 
tion ; brandy and ammonia, with vale- 
rian, and lobelia inflata, must be freely 
used. Sometimes, even in cases of ex- 
haustion, it is necessary to give an emetic, 
as the thick secretion blocks up the tubes ; 
sulphate of zinc and ipecacuanha is then 
the best emetic. 
In obstinate vomiting, hydrocyanic 
acid, and very small doses of morphia, 
with effervescing draughts, will generally 
suffice. 
Excessive diarrhoea must be checked, 
but moderate diarrhoea does good, and is 
indeed a favorable sign, especially on the 
third or fourth day. 
In suppression of urine, a very hot bath 
and copious draughts of linseed-tea, with 
a little liquor potassse, or chlorate of pot- 
ash, must be given. 
If there be intense headache and stupor, 
purgatives, cold applications to the head 
and a few leeches, either to the temples or 
the Schneiderian membrane, will often 
give relief. 
If there be much coryza and great pain 
in the nose and frontal sinuses, a few 
drops of solution of muriate of morphia in 
a little water, sniffed or injected up the 
nostrils, will give relief. 
If rheumatic symptoms come on, col- 
chicum is said to be useful (Peacock) in 
small doses (4 or 5 minims of the tincture 
of the seed), given every 3, 4, or 6 hours, 
with ammonia and opium. Iodide of po- 
tassium with colchicum is also sometimes 
useful. 
Convalescence.-Iron and quinine must 
be given for some time in, small doses. 
A very nutritious diet, beer, and wine, 
must be employed. Milk in large quanti- 
ties is very usef ul. Milk and seltzer water 
is a favorite German remedy. 
The skin must be very warmly clothed, 
as it is very sensitive. 
If there is much dyspnoea left behind, 
the alcoholic or etherial tincture of lobelia 
should be used. Flying pains of the chest 
are best treated by opiate fomentations, 
or a liniment of acetic acid and oil of tur- 
pentine, recommended by Dr. Stokes. 
If a paroxysmal cough is left behind, 
with copious and rather viscid expectora- 
tion, ammoniacum and opium should be 
given. 48 
HOOPING-COUGH. 
HOOPING-COUGH. 
By Edward Smith, M.D., F.R.S. 
Definition.-A convulsive cough con- 
sisting of a series of forcible expirations, 
followed by a deep, loud, sonorous inspira- 
tion, and repeated more or less frequently 
during each paroxysm ; occurring usually 
in childhood, and once only during life, 
and continuing several weeks. Cullen's 
definition is, " Morbus contagiosus, tussis 
convulsiva, strangulans, cum inspiratione 
sonora,, iterata, scope vomitus." 
It is popularly known in England as 
Whooping-cough, Kink-cough, Chin- 
cough ; in France, Coqueluche, and in 
Germany, Keuch-husten and Kik-husten; 
from the sonorous inspiration which marks 
it; and technically, as Tussis convulsiva 
(Willis and Sauvages) and Pertusis (Sy- 
denham and Cullen). 
History.-It is difficult to believe that 
a disease having characters so well and 
easily defined could have been known to 
the ancients without a description having 
been recorded by which we might now 
recognize it; and, as no writer before the 
middle of the seventeenth century has de- 
scribed it, we are led to the conclusion 
that the disease was unknown to the 
fathers of medicine, or that it has acquired 
one of its chief characteristics since their 
day. Diseases having a contagious or epi- 
demic character, and resembling Hooping- 
cough in its catarrhal symptoms, were 
known to Hippocrates and others before 
the Christian era, and have been described 
by Arabian, Italian, and French authori- 
ties down to the sixteenth century; but, 
lacking the distinctive character of the 
Hoop, they more nearly resembled influ- 
enza than any other disease now known 
to us. Hence the history of the disease 
cannot be clearly traced back to a period 
earlier than that of Willis, from whom we 
have received not only the first description 
of it, but one which in all respects is ap- 
plicable to the disease as it exists at this 
day; yet, as from his definition "Tussis 
puerorum convulsiva sen suffocativa, et 
nostro idiomate, chincough vulgo dicta," 
it is probable that the disease was then 
commonly known to the people, we may 
infer that it had existed in England some 
time before he described it. Dr. Gibb 
avers, but without citing authorities, that 
it has been known traditionally among the 
French Canadians for more than three 
centuries; and, as they are. pyesuined to 
have received it from France, he affirms 
that the disease to which Mezeray gave 
the name Coqueluche in the fifteenth cen- 
tury, was truly Hooping-cough notwith- 
standing the absence of the distinctive 
Hoop in that author's description of it. 
Causes.-There is no known specific 
cause to which it can be attributed; but 
that atmospheric influences are its chief 
exciting causes may be inferred from the 
facts that it has often occurred as an epi- 
demic, and is most prevalent at certain 
seasons of the year. The imperfection of 
our knowledge in reference to atmospheric 
influences, other than temperature, and 
the absence of registration of the preva- 
lence of diseases which do not end fatally, 
prevent a more minute inquiry into this 
relation. The fact that Hooping-cough 
is, without reasonable doubt, a contagious 
disease, implies that a materies morbi gene- 
rated, or at least acting, within the body, 
is communicated from one to another per- 
son, and that the atmosphere is also the 
vehicle for its transmission; but as we 
know nothing of the nature of this mate- 
ries morbi within the body, so are we 
equally ignorant of its characters when 
existing without it. Further, we do not 
know with any precision the period of in- 
cubation during which the communicated 
poison is imperceptibly acting within the 
body, but it probably does not exceed ten 
days. 
The influence of childhood in the causa- 
tion of the disease must also be cited. In 
our analysis of the deaths from Hooping- 
cough, published in the Medico-Chirurgi- 
cal Transactions for 1854, it was shown 
that Hooping-cough was the most mortal 
of all diseases of children underset, lyear; 
that 68 per cent, of all the deaths from 
Hooping-cough occurred under set. 2 
years ; and that only 6 per cent, of the 
deaths were recorded after set. 5 years. 
But here again our knowledge is most 
limited and vague when we attempt to 
analyze the conditions attending early life 
which may be presumed to lead to the 
occurrence of the disease. It is summed 
up in the phrase "great excitability or 
impressionability of childhood," by which 
all influences are asserted to exert special 
power at that period. But it applies with 
equal force to the occurrence of other dis- 
eases -in childhood which have but little SYMPTOMS. 
49 
affinity with Hooping-cough in its leading 
characteristics. Yet it accords well with 
the generally adopted views as to the im- 
mediate cause of the cough, to which we 
shall presently refer, and is further sup- 
ported by the fact proved in the paper 
just quoted, that the disease when fatal 
prevailed more in females than in males 
- in the sex in which this special char- 
acter of childhood is the most marked. 
Nature and Seat.-The intimate cause, 
or the nature and seat, of Hooping-cough 
is variously regarded, as one of the two 
leading characters of the disease-the ca- 
tarrhal or the convulsive-is the more 
urgent; but with literature rich in authori- 
ties the preponderance of opinion is in 
favor of the essentially nervous nature of 
the disease. This opinion has been held 
by Hoffmann, Hufeland, Lobenstein, 
Lobel, Paldame, Wendt, Jahn, Cullen, 
Leroy, Guibert, Webster, Pinel, Todd, 
Gibb, and Copland. The immediate seat 
of this nervous irritation has been very 
variously ascribed to the stomach (Cham- 
bon and Broussais); to the lungs (Wendt 
and Paldame); to the diaphragm (Millot); 
to the pneumogastric nerves (Hufeland 
and Hoffmann); to the phrenic nerve 
(Jahn); to the medulla oblongata (Cop- 
land); to the brain and its membranes 
(Webster); and to the general nervous 
system (Guibert); but several of these 
authorities included more than one seat 
in their description. 
The most characteristic views of recent 
date are perhaps those of Guibert and Cop- 
land, to be found in the renowned Dic- 
tionary of Medicine of the latter. Guibert 
"considers that a common cough may 
pass into this affection by having the spas- 
modic state of the muscles of the larynx 
and of the diaphragm superadded to it; 
and, therefore, that spasm superadded to 
cough constitutes the disease-the state 
of spasm resulting from the high nervous 
susceptibility and particular disposition 
to it existing in children, and from indi- 
vidual idiosyncrasy." "The increased 
secretion of mucus he refers to an excited 
state of the mucous membrane of the air 
passages . . . existing independently of 
any inflammatory action . . . the nervous 
symptoms being the result of the spasm, 
which he considers the chief agent of the 
morbid phenomena. " Dr. Copland writes: 
"I believe that the disease is chiefly ner- 
vous in the simple cases; that it preserves 
this character more or less throughout, 
even when inflammatory complications 
ensue; and that in the uncomplicated 
state the nervous affection never proceeds 
beyond irritation. . . . The inflamma- 
tory appearances in the medulla oblongata 
and base of the brain may be owing to 
the functional relation of these parts to 
the respiratory order of nerves which re- 
ceive the first impression of disease. 
The writers of high repute who give 
greater prominence to the catarrhal or 
even inflammatory nature than to the 
nervous character of the disease, are 
Laennec, De wees, Guersant, Watt, and 
Badham. Dawson believed that the in- 
flammation was restricted to the glottis, 
whilst Desruelles, with many others, re- 
garded Hooping-cough as beginning with 
bronchial inflammation and advancing to 
cerebral irritation. Many writers, with 
Guersant, believe that the inflammation 
is of a specific kind; but the chief distinc- 
tion which they draw between this and 
ordinary bronchitis is the marked char- 
acter of the spasm, and the other evi- 
dences of nervous irritation-evidences 
which coincide more with the views of 
those who believe in the nervous nature 
of the disease, than with those who con- 
sider the disease to be essentially inflam- 
matory. 
In a disease in which these two main 
characteristics exist, there are doubtless 
grounds for difference of opinion as to 
their relative importance, and particularly 
when their respective influences vary in 
different cases and in different epidemics, 
and when observers, by their special 
studies, are led to regard cases from dif- 
ferent aspects, as the nervous, inflamma- 
tory, and pathological. Those who adopt 
the opinion that Hooping-cough is essen- 
tially a disease of the blood, and is due to 
a morbid poison existing in that fluid, 
regard both the nervous and the catarrhal 
evidences as of equal importance, but 
with this difference in their aim-that the 
former are direct evidence of the action of 
the poison, whilst the latter are the throes 
of the system to rid itself of the poison 
by secretion from the mucous membrane. 
Without denying the existence of a spe- 
cific poison, and without admitting that 
the supposed poison is eliminated by the 
mucous membrane of the bronchi, we do 
not doubt that that feature which gives 
character and importance to the disease 
is the nervous or spasmodic one, and that 
in any uncomplicated case, when this has 
been abated, the disease is shorn of its 
specific characters and dangers. 
Symptoms.-On proceeding to state the 
symptoms of the disease, it becomes neces- 
sary to divide them into two classes : those 
of the simple and those of the complicated 
form of the disease. 
Simple Hooping-Cough.-The early evi- 
dences are those of simple catarrh without 
any, or with scarcely any, febrile compli- 
cation. They are coryza, secretion from 
the nose, cough, more or less severe, but 
not at this stage spasmodic, with frothy 
and watery secretion from the bronchi, 
lassitude, restlessness, and some diminu- 
tion of appetite. After a period varying 
Worn OTre-toAwo weeks the cough becomes. 
VOL. I.-4 50 
HOOPING-COUGH. 
a more marked symptom-is louder and 
more prolonged than an ordinary cough, 
and generally assumes a spasmodic cha- 
racter. When the nature of the disease 
has become quite clear, the cough is found 
to occur in paroxysms, during which the 
body is bent forward, and a series of short, 
very rapid, and violent expirations occur, 
and are continued until the face is ex- 
tremely suffused and the respiration seems 
almost to have ceased, when a deep, pro- 
longed, loud, and crowing inspiration 
takes place. This alternation occurs two, 
three, or more times in each paroxysm. 
The attack terminates with the emission 
of a somewhat large quantity of semi- 
transparent glairy and very tenacious 
mucus, which hangs about the mouth and 
lips, and not unfrequently with vomiting. 
At a yet later period the pertinacity of 
the expiratory effort is diminished and 
inspiration occurs more frequently, whilst 
the secretion, although still abundant, is 
more opaque and less tenacious, and 
vomiting less rarely occurs. 
During this period the peculiar charac- 
ter of the sounds with the cough somewhat 
subsides, and in progress of time it is 
omitted from some of the attacks-the 
relative frequency gradually diminishing 
until it altogether disappears, and the 
cough has no longer any special cha- 
racters. In mild cases the disease may 
soon end ; but in more severe cases there 
remains much exhaustion and emaciation, 
with defective appetite and increased sen- 
sibility of the stomach, which leads to 
vomiting from trivial causes. The rate of 
pulsation is increased in a most marked 
manner during the attack, so that in very 
severe paroxysms it is too great to be 
counted ; yet it is not due to any inflam- 
matory or febrile condition, but to the 
mechanical interference with respiration. 
In the intervals it assumes a normal state, 
except when the system has become much 
enfeebled. The force of the heart's action 
is the greatest at the commencement of 
each paroxysm, and diminishes sensibly 
when the rapidity of pulsation is the great- 
est ; and it is also lessened when the dis- 
ease has been prolonged and the system 
much exhausted. 
The skin is usually soft, and at the end 
of a paroxysm is bathed in perspiration. 
It is also usually cool and highly sensitive 
to low temperature. 
Bleeding from the nose is a very fre- 
quent attendant upon a severe attack of 
Hooping-cough ; and whilst it shows how 
great is the interference with the circula- 
tion, it is often a most valuable remedy. 
The period of the occurrence of a par- 
oxysm is uncertain, but it is particularly 
liable after a meal, when the stomach is 
full and the action of the diaphragm is 
impeded, and when food of slow digesti- 
bility has been eaten. If the child be 
very young, the cough is excited when 
the nurse throws it about; and if older, 
crying or seeing another in a paroxysm 
will bring on an attack. The paroxysms 
are more frequent in the day than in the 
night. Hence there is usually much in- 
terference with nutrition, and consequent 
loss of flesh, whilst the lassitude extends 
to exhaustion and prostration of the sys- 
tem. 
In ordinary cases the child regains 
much of its spirits and healthful appear- 
ance between the paroxysms, and runs 
about, plays, and eats almost as in health; 
but when the paroxysms are severe, the 
face remains suffused, the eyes injected, 
and the surrounding parts swollen during 
the intervals ; whilst loss of strength is 
proportionate to the constitutional feeble- 
ness and the early age of the child, the 
vomiting, and the duration and violence 
of the disease. 
In a typical case the catarrhal symp- 
toms, without spasmodic cough, continue 
about two or three weeks, and the spas- 
modic cough three to four weeks ; whilst 
after the spasm has ceased and the cough 
has become again catarrhal, the duration 
may be short, if the child have not been 
too much enfeebled, and prolonged for 
some weeks, if otherwise. 
Complicated Hooping-cough.-The com- 
plications are of two classes, viz. : when 
Hooping-cough supervenes upon another 
disease and complicates it; and when, the 
Hooping-cough being primary, other dis- 
eases arise in its course. The former 
class is a somewhat extensive one, and is 
for the most part limited to diseases which 
involve bronchial affections in their 
course; but the latter only will be con- 
sidered here. 
The complications are of four kinds, 
viz.: disease of the lungs, disease of the 
brain, infantile remittent fever, and vital 
exhaustion. The last may by some be 
regarded as one of the sequels of uncom- 
plicated Hooping-cough ; but when it is 
considered that the almost infinite pro- 
portion of the cases of simple Hooping- 
cough end favorably, with only a moder- 
ate state of exhaustion, it will be thought 
better to regard the very exceptional 
occurrence of fatal exhaustion as a com- 
plication rather than as a sequel to the 
simple form. The pulmonary complica- 
tions are, congestion of the lungs, emphy- 
sema, atrophy, bronchitis, and broncho- 
pneumonia. 
A certain amount of congestion of the 
lungs is found in all severe cases of Hoop- 
ing-cough. It is due perhaps exclusively 
to interference, through the respiration, 
with the pulmonary circulation, and it is 
one of the sources of danger attending the 
disease; but in the degree in which it 
becomes a complication, the dyspnoea and 
frequency of respiration are increased and SYMPTOMS. 
51 
continue during the intervals, the dis- 
coloration and suffusion of the face are 
more marked, the pulse is feeble and 
rapid, and the exhaustion of the system is 
greatly increased. Haemoptysis of a more 
or less severe kind sometimes occurs and 
yields temporary or permanent relief. 
Physical examination of the chest shows 
that the respiratory sounds are somewhat 
more feeble than in simple Hooping-cough, 
and there may be a shade of dulness on 
percussion; but unless effusion occurs 
into the lung-parenchyma, the physical 
signs are not very marked. There are 
not any marked signs of fever. 
Emphysema, although usually regarded 
as a sequel of the disease, is a frequent 
concomitant of the severe forms, and par- 
ticularly in the children of parents who 
have been afflicted with chronic bronchi- 
tis. Its production is mechanical, as in 
the case of adults, and occurs from the 
forcible compression of the air in the lungs, 
which is effected by the diaphragm and 
other expiratory muscles, whilst an obsta- 
cle is opposed to the egress of the air. 
This obstacle is most commonly only the 
ordinary one which exists in the larynx 
and pharynx, and is a necessary part of 
the act of coughing, as shown in my 
paper on the "Closure of the Larynx at its 
Upper Orifice," in the Journal (le Physio- 
logie, and as seen at the RimaGlottidis by 
the laryngoscope ; but it may also be pro- 
duced by the plugging up of a large bron- 
chus after the part of the lung to which it 
leads has been distended with air. The 
result of this condition is to increase the 
dyspnoea and to render it permanent in 
proportion to its extent, and if it exist in 
any considerable degree the respiratory 
sounds will be lessened and the resonance 
on percussion increased. 
Atrophy of a part of the lungs is a not 
unfrequent complication of Hooping- 
cough. It results from closure of one or 
more divisions of the bronchi, by which 
the ingress of air to a part of the lung is 
prevented, and the space thus left unoc- 
cupied is filled up by the undue expansion 
of the adjoining cells. When the part 
thus rendered useless is considerable, the 
gravity of the complication is great, and 
it may be detected by the diminished ex- 
pansion of the intercostal space, and by 
the absence of respiratory sounds over the 
part atrophied ; but when it is small, the 
encroachment of the adjoining structure 
prevents the occurrence of distinct physi- 
cal signs. 
Bronchitis and broncho-pneumonia are, 
however, the more frequent and fatal 
lung-complications of this disease. In 
the paper already quoted from the Medico- 
Chi rurgical Transactions it was shown 
clearly that deaths from Hooping-cou"h 
were almost exclusively due to these dis- 
eases, and that they did not correspond at 
all with the rate of mortality from zymo- 
tic or nervous diseases. In both there are 
evidences of fever in the varying degrees 
of heat and dryness of the skin, and in 
the rapid pulse both during the paroxysms 
and in the intervals. The cough is more 
frequent and not always spasmodic, and 
the dyspnoea is more permanent. Dis- 
coloration of the face, enlargement of the 
opening of the ake nasi, difficulty in 
speaking, and panting respiration are 
more perceptible as the complication is 
severe. The only change in the physical 
signs is an increase in the moist rales, 
whilst with broncho-pneumonia there is 
a more or less persistently localized state 
of this sign accompanied by some amount 
of dulness on percussion and lessened re- 
spiratory sounds. The general exhaus- 
tion and loss of appetite are more appa- 
rent. 
The brain complications are convul- 
sions and hydrocephalus. It has already 
been shown that, in the opinion of very 
able physicians, irritation of the brain 
and its membranes, and particularly of 
the medulla oblongata, is so common as 
to be an integral part of the disease. 
Usually, however, there are no signs of 
this state other than the reflex condition 
which excites the spasm of the glottis ; 
but in no inconsiderable number of com- 
plicated cases convulsions occur with or 
without hydrocephalus. 
The occurrence of convulsions cannot 
usually be predicted; but if the child be 
teething or suffering from derangement of 
the bowels, if during the spasm the thumbs 
be drawn inwards, and during the inter- 
vals the discoloration of the face continue 
without lung-complication, and if there be 
a marked degree of exhaustion or oppres- 
sion following the paroxysm, or the eyes 
be intolerant of light, this complication 
may be imminent. They are in some 
cases due to irritation of the membranes 
of the brain and medulla oblongata, and 
in others to congestion of the brain, due 
mainly to interference with the pulmonary 
circulation. 
Hydrocephalus is so frequently a con- 
stitutional affection that the relation of 
Hooping-cough to it is rather that of an 
excitant of a pre-existent predisposition. 
The signs are often obscure at first, but in 
many cases the occurrence of drowsiness, 
headache and starting during sleep, con- 
vulsions, increased heat of skin and 
rapidity of pulsation, intolerance of light 
and lessened mobility of the pupils; and 
in others the persistent disposition to 
vomiting on being moved, will indicate 
the advent of this most important compli- 
cation. The breathing is more irregular 
and accompanied by sighs, than it is in 
simple Hooping-cough ; and if there be no 
lung-complication existing at the same 
time, the diagnosis will not long remain 52 
HOOPING-COUGH. 
doubtful. When the convulsions are 
restricted to one side of the body, or when 
paralysis of one side occurs either with or 
without simultaneous convulsions on the 
other, the evidences are still clearer. 
[Occasionally, even in children, apoplexy 
occurs, under the violent disturbance of 
the circulation of the head during the 
paroxysms of Hooping-cough. Such a 
case occurred in the neighborhood of Phil- 
adelphia, a few years since, in a child not 
more than eight years of age, with a fatal 
result in less than twenty-four hours, the 
symptoms not having been previously un- 
favorable.-H.] 
The complication with infantile remit- 
tent fever is most generally found when 
the latter disease prevails, and when there 
have been evidences for some weeks of a 
disordered state of the bowels. The 
tongue is coated, the breath foul, the 
evacuations unhealthy, and the bowels 
are tender on pressure and tumefied. The 
patient does not recover health and 
strength, but, with or without introduc- 
tory rigors, slowly exhibits signs of fever, 
having the exacerbations and remissions 
distinctive of remittent fever, and want- 
ing all the diagnostic signs of bronchitis. 
Such cases are usually protracted in their 
recovery, and demand very careful and 
able supervision. 
The complication of excessive exhaus- 
tion is most frequent in children of very 
weak constitutions, or in those which 
have been enfeebled by previous disease. 
In such, prostration is a marked feature 
even during the catarrhal period, but 
when the spasm has fairly set in it is ex- 
treme after every paroxysm. Careful ex- 
amination into the state of the hmgs, 
brain, and bowels fails to offer any satis- 
factory reason ; and this, with the absence 
of fever, suffices to indicate the complica- 
tion to which we refer. Moreover the 
skin is unusually soft, cool and liable to 
perspiration, and the appetite is inade- 
quate to the nourishment of the system. 
Diagnosis.-The distinguishing feature 
which marks Hooping-cough is undoubt- 
edly the paroxysm of spasmodic cough, 
whether the sound accompanying it 
amount to a distinct whoop or not; whilst 
the accidental (as opposed to essential) 
symptoms are the preliminary catarrh, the 
glairy tenacious secretion from the bron- 
chi, the early age of the patients, and the 
general course of the increase and decline 
in the severity of the paroxysms. In the 
early catarrhal stage, it cannot be distin- 
guished from a common cold. 
Pathology.-The pathology of this 
disease has been already hinted at in our 
account of its history. In reference to 
simple Hooping-cough the aim has been 
to determine the cause of the spasm of 
the glottis and the closure of the larynx, 
with the prolonged expiratory action of 
the diaphragm, which are the prominent 
features of the disease. All writers have 
regarded the nervous system as the source 
of this influence, and have speculated 
upon the part which was principally in- 
volved. Thus the recurrent laryngeal 
nerve as affecting the larynx, the phrenic 
as controlling the diaphragm, the medulla 
oblongata as controlling all the respiratory 
movements by the pneumogastric nerve, 
and the whole brain and its membranes, 
have each in their turn been cited as the 
seat of this disease. The blood has by 
others been assumed to contain a zymotic 
poison which, acting upon the nervous 
system, excites spasm, and upon the mu- 
cous membrane of the bronchi, causes 
cough, with a secretion whereby it is to 
be ultimately cast out. We cannot yet, 
however, arrive at a sound conclusion 
upon this question, although there are 
many points of striking similarity between 
Hooping-cough and some recognized forms 
of zymotic disease.1 
The interference with the circulation of 
the blood which occurs when the respira- 
tion is so greatly impeded and the lungs 
so largely emptied of the residual air as 
in severe cases of Hooping-cough, is doubt- 
less the cause of the complications both in 
the head and the lungs to which we have 
referred; whilst the exhaustion which 
follows each paroxysm, and the inter- 
ference with nutrition, are the causes of 
the remaining complications. The me- 
chanical act of coughing whilst the larynx 
and some of the bronchi are closed pro- 
duces emphysema of the lungs and dila- 
tation of the bronchi; and closure of the 
tubes by secretion may lead to atrophy. 
Morbid Anatomy.-In nearly all fatal 
cases death occurs not from the Hooping- 
cough, but from its complications; and 
the morbid signs will therefore be those 
of the supervening diseases, and must be 
sought for in other parts of this work. 
Dr. Copland believes that in all cases 
there are inflammatory appearances about 
the medulla oblongata; and it cannot be 
denied that congestion of the bronchial, 
laryngeal, and faucial mucous membrane 
is always present. From what has been 
already stated, it may be affirmed that 
there are evidences of bronchitis or of 
1 [The analogy to Hydrophobia is not un- 
important ; in the combination of a nervous 
disorder with a respiratory affection; the 
length of duration in Hooping-cough corre- 
sponding, also, in some manner to the pro- 
tracted incubation in Hydrophobia. Instead 
of the cough, in Hydrophobia, we have spas- 
modic, gasping inhalations, produced by any 
sudden impression made upon the senses.- 
H.] PROGNOSIS - TREATMENT. 
53 
broncho-pneumonia, with atrophy or col- 
lapse of lung, in by far the greater number 
of fatal cases 
Prognosis.- The prognosis depends 
upon the age and strength of the patient, 
the severity of the spasm, and the presence 
of particular complications. In simple 
Hooping-cough occurring in childhood, 
with moderate spasm and with an average 
state of health, it may almost always be 
regarded as favorable, and the disease 
may be expected to leave no ill effects be- 
hind. When it occurs in an infant under 
4 months old it is very liable to induce 
head symptoms, unless the attack be a 
very mild one; and when occurring in 
adult life, it is more likely to lead to chest 
complications and to leave permanent 
changes in the structure of the lungs. 
When the paroxysms are unusually 
prolonged and the spasm very severe, 
complications are almost sure to arise ; 
and if the child be feeble, the prognosis 
must be given with caution. 
The complication of bronchitis renders 
the prognosis unfavorable only in propor- 
tion to its severity. When it occurs in a 
moderate degree and without inducing 
much dyspnoea in the intervals between 
the paroxysms, and at a season of the 
year when the temperature is not very 
low (the deaths from both Hooping-cough 
and bronchitis are inversely as the tempe- 
rature), the gravity of the case is not 
seriously increased ; but when it involves 
both lungs, and is attended by much dys- 
pnoea and increased lividity of the counte- 
nance, the prognosis becomes unfavorable. 
Extension of the inflammatory condition 
to the substance of the lung adds much to 
the danger, from the fact that broncho- 
pneumonia is usually less amenable to 
treatment than bronchitis alone. 
When emphysema and enlarged bron- 
chi have already occurred, or when it is 
probable from the severity of the spasm 
that they will occur, permanent dyspnoea 
to a greater or less extent may be appre- 
hended. 
The occurrence of head symptoms at- 
tended by convulsions or paralysis must 
always render the prognosis unfavorable ; 
but with convulsions not due to hydro- 
cephalus, many cases recover. 
The cases in which disordered secre- 
tions and intermittent fever occur will 
certainly be protracted, and may leave an 
enfeebled state of system from which the 
patient will not entirely recover, although 
life may be continued for many years. It 
is probably a less fatal complication than 
the others referred to, but causes much 
anxiety both to the physician and the 
friends of the patient. 
When extreme exhaustion is present 
without evident cause, the prognosis 
should be a guarded one. 
It is a fact which is not sufficiently ap- 
preciated, that whilst so very large a pro- 
portion of cases of Hooping-cough recover, 
only six other diseases in the London dis- 
trict during the ten years from 1844 to 
1853 inclusive, were more fatal than 
Hooping-cough; viz., phthisis, pneumo- 
nia, bronchitis, typhus, convulsions, and 
scarlatina.1 Hence at the commencement 
of any attack of the disease it is well to 
speak of the future with caution. 
Treatment.-There are but few dis- 
eases in which so many remedies have 
been employed as in Hooping-cough, and 
still fewer in which so much has been 
confidently asserted of remedies which 
differ much from each other. This is 
owing probably to the fact that the dis- 
ease, running a more or less clearly de- 
fined course, usually subsides either with 
or without medical treatment, and with 
or in spite of whatever remedies may have 
been employed, and also that many reme- 
dies diverse in name and appearance are 
closely allied in their modes of action upon 
the system. 
It is highly probable that many have 
been recommended on empirical grounds 
only ; but others have been intended to 
effect one of the following objects: 
namely, to abate inflammatory action, to 
promote expectoration, and the elimina- 
tion of the supposed morbid poison, to 
diminish the bronchial secretion, and to 
allay the spasm, directly or indirectly, 
through the invigoration of the general 
system. 
Those to abate inflammatory action 
have been leeches and antimony ; to pro- 
mote expectoration, antimony, ipecacu- 
anha, squills, and other emetics ; to lessen 
secretion, alum and zinc; and to allay 
spasm directly, hydrocyanic acid, conium, 
hyoscyamus, belladonna, opium and mor- 
phia, musk, valerian, ether, and chloric 
ether, with various liniments supplied to 
the chest and back, and a strong solution 
of nitrate of silver to the throat; to allay 
spasm indirectly, iron, zinc, copper, sil- 
ver, and other metallic salts, mineral 
acids, with quinine, and other vegetable 
tonics, and change of air. Some were 
probably expected to have a specific ac- 
tion, as tar-water and tar inhalations, the 
air in the neighborhood of gas-works, salts 
of lead and cantharides. 
Simple Hooping-cough. - In the treat- 
ment of an uncomplicated case of Hoop- 
ing-cough, the chief, if not the sole, aim 
should be to allay the spasm, and thus to 
prevent complications which result from 
it, and reduce the disease to a common 
cough. 
As a preliminary step it is needful to 
1 Medico-Chirurgical Transactions, 1854, p. 
230. 54 
HOOPING-COUGH. 
regulate the functions of the chylopoietic 
viscera, to prevent or remove fecal accu- 
mulation, to promote a proper secretion 
of bile, to prevent the occurrence of an 
excess of acid in the secretions of the 
stomach and oesophagus, and to prohibit 
the use of indigestible or irritating food. 
For these purposes, castor oil, or carbo- 
nate of magnesia, or Dinneford's or Mur- 
ray's soluble magnesia, should be given 
daily or every second day, until the neces- 
sity for their use has ceased; and an 
occasional dose of one or two grains of 
hydrarg. c. creta may be given at bed- 
time. The state of the nurse's milk should 
be examined in the case of suckling in- 
fants, and at a later period the food should 
be restricted as far as possible to cooked 
milk, and given alone or in puddings. 
Two or three pints of milk may be taken 
daily, but in such a manner that the 
quantity given at a time shall not exceed 
one-quarter of a pint, and the intervals 
between the supplies be short. Bread 
should be rarely if ever given, except 
when cooked with milk. The use of vege- 
tables should be greatly restricted. Meat 
in small quantities, and cut into very 
small pieces, may be given to a child of 
three years of age and upwards ; and eggs 
made into puddings, and beef-tea, may be 
allowed at any age if there be a deficiency 
in the supply of milk. 
In the general management of the child 
the body should be kept properly warm 
by clothing, and the atmospheric air 
should not have a lower temperature than 
64° either by night or day ; and so long as 
the aim is to allay the spasm, the patient 
should be kept absolutely quiet both in 
mind and body, or as quiet as may be pos- 
sible. [When the general symptoms are 
mild, fever and inflammatory bronchial 
disorder being absent, there is advantage 
in the child being taken into the open air, 
in good weather, every day. Often, the 
paroxysms will be very few and moderate 
while the patient is out of doors, becoming 
more frequent and severe under confine- 
ment in the house.-II.] 
Such being premised, the next step de- 
pends upon the view which is taken as to 
the possibility of shortening the course of 
the disease. Some of the most eminent 
physicians of the present day are of opinion 
that it will run its course, and that the 
duty of the physician is to conduct it 
evenly and safely to the end.1 With this 
view it is only possible to use palliative 
remedies, such as small doses of ipeca- 
cuanha, with or without rhubarb ; but if 
a belief is entertained that the progress of 
the disease is amenable to treatment, the 
proper course is to select that sedative, 
narcotic, or antispasmodic agent, the ac- 
tion of which is the most uniform, and the 
dose capable of proper regulation ; and the 
aim should be to administer it with the 
frequency and dose which will allay the 
spasm and keep it under control without in- 
terfering materially with any vital action. 
[In American practice, assafoetida is 
used, probably, in mild or moderate cases, 
as largely as any other antispasmodic 
medicine. It may be given as soon as 
the paroxysmal character of the disorder 
is shown, in combination with ipecacu- 
anha or squills. For children, a much 
employed preparation is the "milk" of 
assafoetida, in teaspoonful doses. It is a 
mild remedy, less powerful as an anti- 
spasmodic than musk, belladonna, &c., 
but, in ordinary cases, it seems to be often 
serviceable.-H.] 
Hydrocyanic acid has been strongly 
recommended by, amongst others, Drs. 
Granville, Hamilton Roe, Atlee, Elliot- 
son, and West; and of these Dr. Roe has 
given the most detailed and judicious 
directions. He prescribes three-quarters 
of a minim of Scheele's strength to an 
infant, 1 111 to a child aged three years, 
and 1| to 21T[ to one aged ten or twelve 
years, to be given every three or four 
hours, or even more frequently when the 
effect of the previous dose has abated. He 
has given 1^1T[ every quarter of an hour 
for twelve hours to a girl aged ten years. 
He attaches great value to its action in 
reducing fever-a state of system which 
in simple cases rarely exists ; but he also 
affirms that it will cure simple Hooping- 
cough quickly, or at any rate abridge its 
duration. Laurel-water, which contains 
hydrocyanic acid, has been given in doses 
of 6TT[ to children and 30 Hl to adults 
every two or three hours. Belladonna 
has been strongly recommended by Boer- 
haave, Hufeland, Guersant, Trousseau, 
Williams, Jackson, Churchill, G. A. Rees, 
and others. The dose of the extract re- 
commended varies from to 5 grain for 
a child aged two years, and 1£ grain for a 
child aged four years and upwards ; and 
Dr. Williams, bearing in mind its action 
upon the iris, and the desirability of di- 
minishing the irritability of the bronchial 
and laryngeal muscles, regards the action 
upon the former as the measure of the 
action upon the latter, and takes it as his 
guide. 
Conium was introduced as a specific 
remedy for this disease, and has received 
the support of many distinguished physi- 
cians. The dose of the extract most com- 
monly employed is of a grain for a child 
aged four months, to 1,6 for one aged 
one year, and to 1 grain for older chil- 
dren, repeated every six hours. In the 
use of this drug, as in that of hyoscyamus 
and belladonna, it is customary to add 
small doses of ipecacuanha, and some 
physicians, as Guersant, combine it with 
the oxide of zinc or other metallic salts. 
1 Sir Thomas Watson's Lectures. TREATMENT 
55 
[The succus hyoscyami, in doses of a few 
drops at a time, will sometimes act very 
well in quieting the paroxysms of cough- 
ing, especially at night.-H.] 
Tincture of lobelia is now given by Dr. 
Sidney Ringer with very good effect. The 
dose is 5 IT[ for a child set. one or two 
years, increasing to 10HL as the age ad- 
vances to ten years, and is repeated every 
hour. 
The preparations of opium which have 
been most generally used are the tincture 
of opium and salts of morphia ; but Bat- 
tley's sedative solution and codeia have 
also been much commended. In a paper 
published in the Edinburgh Medical Jour- 
nal, May 1856, we took occasion to ex- 
press the opinion that morphia was the 
best remedy in this disease, since it is 
more certain and uniform in its action 
than belladonna, conium, hyoscyamus, 
and digitalis, and exerts a less injurious 
effect upon the sensorium and the bowels 
than the tincture of opium. It has already 
been pointed out that Drs. Roe and Wil- 
liams, when administering hydrocyanic 
acid and belladonna, understood the im- 
portance of giving them in doses sufficient 
to allay the spasm ; but in the paper re- 
ferred to we endeavored to explain that 
an essential part of the treatment was to 
carry this influence just so far as to be 
evident to an observer, and to maintain it 
during the period of treatment. With 
the view that the essential character of 
Hooping-cough, and that which leads to 
dangerous complications, is the spasm, 
and that the removal of the spasm should 
be the object of the physician, our aim 
was to cause the slightest oppression of 
the sensorium as a measure of the required 
effect of the drug, and to maintain it from 
three to six days. With children under 
one year of age the dose of the hydro- 
chlorate or the acetate of morphia should 
be 6'5 of a grain repeated every four hours ; 
with children between one and three years 
of age, to 3'e of a grain ; and with those 
yet older to of a grain. The dose 
selected should be repeated three or four 
times; and if no perceptible drowsiness 
should be induced, it should be increased 
a step and repeated in like manner, and 
again increased if necessary until the dose 
has been ascertained which produces a 
very slight oppression of the sensorium. 
The aim must then be to maintain this 
effect by repeating the same dose, or by 
further increasing it from time to time. 
The cases of simple Hooping-cough are. 
extremely few in which slight drowsiness 
has been produced and uniformly main- 
tained for three or four days without the 
spasm having subsided, and the cough 
nearly reduced to that of a common cough. 
The plan, when intelligently carried out, 
has been most successful in our hands, 
and in those of Dr. Muller in Germany, 
as well as in the practice of many in Eng- 
land. It is rarely necessary to add any 
other remedy; but in certain cases the 
exhibition of carbonate of soda in addition 
to the morphia has further lessened the 
irritability of the larynx and promoted 
expectoration. 
A very favorite combination is that re- 
commended by Dr. Pearson, consisting of 
one drop of tinct. opii, five drops of vin. 
ipecac., and two grains of carbonate of 
soda, to be given every four hours after 
the operation of an emetic. 
Dr. Eben Watson has proposed an ad- 
mirable plan of treatment in the applica- 
tion of a strong solution of nitrate of silver 
to the larynx, by which the spasm is 
quickly relieved. "The strength should be 
twenty grains to the ounce, and the solu- 
tion applied not only to the tonsils and 
uvula but to the back part of the fauces, 
and if possible to the seat of the epiglottis. 
This is more difficult to effect in very 
young children, but in children of eight 
years of age and in adults it may be readily 
performed by depressing the back of the 
tongue until the free edge of the epiglottis 
is seen, and sweeping the pharynx with 
the camel's-hair brush or the mop charged 
with the solution. The application should 
be repeated every second day, and the 
spasm may be expected to subside in less 
than a week. 
The external application, to the chest 
and between the shoulders, of belladonna 
plasters and of liniments containing bella- 
donna, opium, or oil of amber, has been 
much employed with advantage ; but the 
effects of belladonna must be watched, 
and dilatation of the pupil restrained 
within very moderate limits. 
The inhalation of ether and chloroform, 
when diluted with air with the aid of a 
proper instrument, is often of great ad- 
vantage in cases where the spasm is very 
severe and the patient not very young. It 
should never be carried so far as to induce 
anaesthesia. 
The employment of metallic salts in the 
treatment of this disease has been very 
general and extensive, and those of ar- 
senic, copper, and silver have been re- 
garded as specifics. The proper dose of 
liq. arsenicalis is one drop daily, divided 
into four doses, for an infant, and one 
drop twice or thrice a day for a child of 
five years of age and upwards, and it may 
be given with water or decoction of cin- 
chona. Carbonate of iron is prescribed by 
Dr. Graves after recovery from inflamma- 
tory symptoms : but others give the sul- 
phate, and employ it in the early stage of 
the disease. In Dr. Rees's opinion it is 
particularly adapted to those of a stru- 
mous diathesis. Zinc has been given 
both to lessen the secretion from the mu- 
cous membrane and to allay the spasm. 
The proper dose of the oxide is one grain 56 
HOOPING-COUGH. 
three or four times daily for a child aged 
one year, and two grains four to six times 
daily for those of live years of age and up- 
wards. Acetate of lead has been particu- 
larly recommended by Dr. Rees, and he 
affirms that | grain given every six hours 
removes the spasm on the first day of its 
exhibition. 
Sulphuric, hydrochloric, and nitric acids 
have all been given in this disease with 
advantage when no inflammatory compli- 
cation existed. Of these, nitric acid has 
received the most recent support, and has 
been given in remarkably large doses. To 
a tumblerful of thin syrup as much dilute 
nitric acid is added as will render it as 
sour as lemon-juice, and of this a child 
under one year of age may take a dessert- 
spoonful every hour, and an adult the 
whole tumblerful in three or four hours. 
So much as ^ij to 3j of the dilute acid is 
given to a patient ten years of age and up- 
wards, and 101T[ to a very young infant, 
when well sweetened with honey or sugar. 
No evil results are said to have followed, 
and the beneficial effect has been, it is af- 
firmed, proportioned to the dose. Injury 
to the teeth is averted by using a gargle 
with carbonate of soda after each dose. 
This plan of treatment has received the 
approbation of Dr. Gibb, and its mode of 
action is presumed to be that of a tonic, 
sedative, and antiseptic. 
Change of air is a very popular remedy, 
and it is affirmed that it matters little 
whether it be to a purer or to a less pure 
atmosphere, but above all others the air 
in the vicinity of gas-works and lime-kilns 
has been, even very recently, commended. 
Except upon empirical grounds, and in 
the absence of sufficient proof of the bene- 
fit alleged, we can advise only that change 
which country air may offer to children 
living in towns; and even this exerts no 
marked influence in otherwise healthy 
children until the period of recovery from 
the exhaustion which follows the disease. 
Alum and tannin have been much com- 
mended with a view to restrain the secre- 
tions and allay spasm. The former, when 
given in the nervous stage of the disease, 
was exceedingly efficient in the hands of 
Dr. Golding Bird. His prescription was, 
alum twenty-five grains, extract of conium 
twelve grains, with syrup and dill-water 
to make a three-ounce mixture, of which 
a dessert-spoonful was given for a dose to 
a child two or three years of age. Tannin 
is given in doses of one-sixth to three- 
fourths of a grain, and even to three 
grains, combined with hyoscyamic or ben- 
zoic acid every two hours. 
Alkalies, as carbonate of potash or soda, 
sulphuret of potass, liquor potassse and 
liquor ammonite, are oftentimes of value, 
when conjoined with other remedies, in 
rendering the bronchial secretion less tena- 
cious, and in relieving disordered bowels. 
Nux vomica and strychnine have been 
given with advantage in the stage of 
spasm. Certain antispasmodics, as musk, 
valerian, and ether, are of value, but they 
do not so immediately and certainly relieve 
the spasm as narcotics and sedatives ad- 
ministered so as to slightly affect the sen- 
sori um. They are more particularly suited 
to the stage of recovery from the spasm. 
[Some physicians, however, have found 
musk the most potent of all remedies for the 
violence of the cough in severe cases.-II.] 
Emetics may be employed with advan- 
tage in those simple cases of Hooping- 
cough in which there is unusual difficulty 
in removing the secretion from the bron- 
chi, whilst at the same time it is excessive 
in quantity and impedes respiration. But 
with the view which we entertain of the 
nature and treatment of this disease we 
do not think that emetics should be the 
chief remedies employed. 
Such are the remedies which have been 
and may be properly employed in simple 
cases of Hooping-cough - hydrocyanic 
acid, belladonna, conium, morphia, ar- 
senic, zinc, alum, nitrate of silver, hydro- 
chloric and nitric acids,-all affirmed at 
different periods to be specifies, or, at the 
least, sure and speedy remedies for this 
disease. With the weight of testimony in 
their favor we cannot deny that they have 
been and are very valuable agents; and 
if we have given the preference to one of 
them, it is because by it we may the most 
readily and safely induce that gentle im- 
pression of the sensorium by which the 
spasm subsides. The mode of adminis- 
tration is as essential a part of the treat- 
ment as the drug itself, and the plan will 
succeed only in intelligent and careful 
hands. 
Complicated Hooping-cough. - As the 
most frequent complication is that of 
bronchitis, care should be taken to watch 
the earliest indications of its approach. 
When it exists, the use of metallic, vege- 
table, and mineral tonics and astringents 
should be discontinued, and antimony or 
ipecacuanha in small doses should be 
added to the narcotic or sedative in use. If 
there be much febrile action, the patient 
should be placed in a warm-water bath 
up to the neck every night or every second 
night, and spt. eth. nit. with liq. ammon. 
acet, added to the medicine. With much 
oppression of the respiration and difficulty 
in removing the secretion, the occasional 
use of an emetic and the constant use of 
alkalies will be proper, and counter-irrita- 
tion of the chest by blisters, turpentine, 
or mustard should be effected. If there 
are evidences of the extension of the dis- 
ease to the parenchyma of the lung or to 
the pleura, the application of leeches and 
cupping at the root of the lung or over a 
painful part may be of service ; but the diphtheria: definition-SYNONYMS. 
57 
use of mustard or other rubefacients be- 
tween the shoulderswill usually afford the 
greatest relief. Even during this period 
it will also be needful to sustain the vital 
powers by good beef-tea, and as far as 
possible by milk, given in very small quan- 
tities at a time ; and great care should be 
taken not to carry the antiphlogistic treat- 
ment so far as to lower the vital powers 
and induce disgust for food. 
When convulsions occur, the first duty 
should be to ascertain if the teeth cause 
irritation, or if there be irritating matters 
accumulated within the stomach and bow- 
els. If the former, the gums, when tender, 
should be lanced; and if the latter, the 
bowels should be freely evacuated and the 
character of the evacuations carefully 
watched. At the same time the patient 
should be supplied with beef-tea and milk. 
When hydrocephalus occurs, with or with- 
out convulsions, the treatment of the case 
must centre in that complication, and be 
such as will be elsewhere advised in this 
work. With heat of skin and head it will 
be proper to apply cooling lotions and 
even ice ; and should the disease be active, 
leeches to the base of the head should be 
early used. The free exhibition of mer- 
cury in the form of calomel in small doses, 
or of hyd. c. creta, must be persisted in 
when effusion has been diagnosed. As 
the bowels are usually constipated in this 
condition, mercurials do not readily purge, 
and care should be taken to induce a suffi- 
cient action. Moreover, a state of inani- 
tion from want of food must not be per- 
mitted. 
In the complication with remittent 
fever, care should be taken to evacuate 
the bowels and to correct the secretions, 
in addition to the use of those remedies 
referred to under that disease in another 
part of this work. The cough, which is 
also then unusually distressing, will re- 
quire the frequent exhibition of morphia, 
syrup of poppies, and of tolu. As soon as 
possible the patient should have a change 
of air. 
When extreme exhaustion is the chief 
complication, it will become necessary to 
administer nitric acid with bark, or some 
of the metallic tonics with quassia, and to 
supply wine-and-water in small doses 
every three hours. Much care should 
also be taken to induce the patient to take 
food, in small quantities, made from milk, 
eggs, jelly, and meat every two hours; 
and if neither the exhaustion be extreme 
nor the atmospheric temperature low, to 
obtain change of air and a moderate de- 
gree of exposure to it. 
The recovery from Hooping-cough al- 
ways demands the use of tonics [quinine 
in tonic doses, iron and cod-liver oil.-H.], 
of abundant animal food, and of change 
of air, and possibly also of wine adminis- 
tered in small doses. Sea-voyaging is 
then of great service. 
DIPHTHERIA. 
By William Squire, L.R.C.P. Lond. 
Definition.-An acute specific dis- 
ease, both epidemic and contagious, cha- 
racterized by a special inflammation of 
the mucous membrane, chiefly of the 
pharynx and first air-passages, attended 
with enlargement of the lymphatic glands, 
a rapid exudation either of fibrine or non- 
organizable lymph, and its deposit within 
and upon the surfaces affected. Other 
parts of the mucous membrane and the 
skin sometimes suffer at the same time, 
and changes often take place simultane- 
ously in the spleen or kidneys, albumi- 
nuria frequently occurring at an early 
period. The disease is accompanied by 
great prostration of the vital powers, and 
is followed by a remarkable series of local 
lesions of innervation ; the tendency to 
death is by asthenia, either coincident 
with the disease or gradually induced, or 
by apnoea from implication of the air- 
passages, which may happen as early as 
the second day, or as late as the second 
week of the disease. 
Synonyms.-Cynanche ; Angina, Cel- 
sus; Synanche, Aetius Aurelianus; Ul- 
cera Egyptica vel Syriaca, Aretseus; 
Crustosa et Pestilentia Tonsillarum Ul- 
cera, Aetius Amidenus ; Ulcera Pestifera 
in Tonsillus, Paulus yEgineta; Morbus 
Suffocans, Villa Real; Angina Exulcerata 
Maligna, Nunes ; Faucium Ulcera Angi- 
nosa, Mercatus ; Angina Maligna, Here- 
dia ; Carbunculus Faucium Anginosus, 
Riolan; Morbus Strangulatorius, Aetius 
Cletus ; Morbus Guise ; Apbthse Malignse ; 
Angina Puerorum Epidemica, Bartholin : 58 
DIP1ITHERIA. 
Prunella Alba, R. James; The Sore- 
Throat attended with Ulcers, Fothergill; 
Malignant Ulcerous Sore-Throat, Hux- 
ham ; Angina Infantum, Wilcke ; Angina 
Polyposa sive Membranacea, Michaelis ; 
Cynanehe Pharyngea Epidemica, and Epi- 
demic Croup, Rosen ; Angina Suffocativa, 
or Sore-Throat Distemper, Bard ; Mal de 
Gorge Gangreneux, Chomel; Angine 
Couenneuse Pharyngienne, and Croup in 
the Adult, Louis; Pellicular Angina, 
Diphtheritic Angina, Diphtherite, and 
Diphtheric, Bretonneau; Pharyngite 
Pseudo-membraneuse, Rilliet and Bar- 
thez ; Cynanehe Membranacea; Cy- 
nanche Maligna, Putrid Sore-Throat, 
Malignant Quinsy, England; Garotillo, 
Spain ; Strypsiucka, Sweden ; Rachen- 
Croup, Germany. 
Name.-Diphtheria is derived from 
5i$0spa, a skin, or covering of leather. 
The multiplicity of synonyms has been 
occasioned by the undetermined nature 
of the disease, and its appearance at 
times and places removed from each 
other, either by considerable intervals or 
by imperfect communication. Fothergill 
has the merit of setting forth, during its 
prevalence in the last century, the iden- 
tity of the epidemic with that of the pre- 
ceding century; while the Spanish and 
Italian physicians had already recognized 
its correspondence with the accounts de- 
rived from antiquity. Diphtherite, as 
signifying the special product of a specific 
disease, was proposed by Bretonneau. 
To him we owe not only the name but 
that energetic inquiry into the disease, 
as it showed itself in France during the 
present century, which has led to a more 
perfect definition of its character, and a 
better comprehension of its relation, than 
was previously possible. He at first 
applied the term to the whole disease, as 
well as to its characteristic morbid pro- 
duct, so soon visible in the fauces of those 
attacked; but further observation, prov- 
ing that the local appearance was only 
one of the manifestations of the more 
important general affection, induced him, 
while retaining diphtherite in its more 
restricted sense, to speak of the general 
disease itself as diphtheric. We are in- 
debted to Dr. W. Farr for the introduc- 
tion of Diphtheria into our nomenclature 
as soon as the epidemic spread of the dis- 
ease among us rendered it important that 
it should be designated by one general 
term. 
History.-There is little doubt that 
Diphtheria, like the other acute specific 
diseases, has existed as long as the his- 
tory of man extends. We have traces of 
it two thousand years ago, and the de- 
scription given of it more than a thousand 
years since applies equally to its appear- 
ance in our own day. Its individuality is 
not difficult to recognize during its epi- 
demic prevalence, at other times its dis- 
tinctive characters have been merged with 
those of scarlet fever and erysipelas; 
these two diseases, though specifically 
different, approach at many points the 
nearest to it: they were not discriminated 
even in Sydenham's time ; and though 
scarlet fever then began to be separated 
and to receive an increasing share of 
attention, the intimate connection always 
observed between it and Diphtheria pre- 
cludes our astonishment at finding them 
sometimes confounded. 
Unmistakable evidence of the exist- 
ence of this special form of disease is 
found wherever medical science has at- 
tained any degree of exactness. Hippo- 
crates describes it, and gives us the name 
of probably its first recorded victim.1 It 
attracted the attention of Asclepiades and 
Uelsus.2 Aretseus3 is the founder both of 
our knowledge of and treatment of the 
disease ; and Aetius of Amida showed an 
equally familiar acquaintance with it. It 
is impossible to say which of the many 
plagues of the dark ages of history may 
claim this disease as its agent. After the 
time of Paulus H^gineta only the writings 
of the Arabian physicians can be appealed 
to, and it is not until the intellectual re- 
vival of the sixteenth century that we 
again find its traces recorded ;-as by 
Forrestus, in Holland, in 1557 ; Weir, in 
Basle, in 1567 ; by Baillou, in Paris, in 
1576 ; and by Spanish writers from 1581 
to the close of the century, whence is 
dated the first clear account of its epi- 
demic prevalence in modern times. The 
numerous and graphic accounts of many 
and able Spanish medical writers of the 
seventeenth century afford valuable mate- 
rials for the comparative study of the dis- 
ease ; and though the Sicilian'and Italian 
writings of the same time are less original, 
we gather from them many important 
particulars. The epidemic attracted at- 
tention in the kingdom of Naples in the 
year 1618, and is described by Sgambatus, 
Carnevale, and Nola. The writings of 
Cortesius, in 1625, and of Alaymus, in 
1632, speak of its ravages in Sicily; at 
the same time it had extended into Cen- 
tral Italy, as witnessed by Aetius Cletus ; 
Severinus and Bartoline speak of its con- 
tinuance. The disease, if not epidemic, 
continued to be extremely prevalent in 
Spain ; and, besides the special works of 
Fonteccha, Villa Real, Herera, Tamayo, 
and Nunes, was treated of systematically 
by the royal physicians, Mercatus and 
Heredia. Scattered notices of its occur- 
1 Hippoc. Epid. lib. v. tex. 37. 
2 Celsus, lib. iv. cap. 4. 
3 Aretaeus, De Causis et Signis Aoutorum 
Morborum, lib. i. cap. 9. HISTORY. 
59 
rence elsewhere appear in subsequent 
publications, but it is not until near the 
middle of the next century that we find 
it extensively epidemic, appearing simul- 
taneously in Italy, France, and England, 
as evidenced by the independent observa- 
tions of Ghizi, in Cremona, 1747; Ar- 
nault, in Orleans, 1748; and Starr,1 in 
Cornwall, 1749: it also called forth the 
noble essay of Fothergill,2 published in 
1748 ; the epidemic had then hardly at- 
tained its height in England, though cases 
had been observed as early as 1739. It 
existed at Rouen at the same time, and 
appeared more extensively in 1748,3 when 
the epidemic was at its height in France. 
Sweden suffered from it in 1755, and occa- 
sional outbreaks occurred there till 1778, 
as we learn from Michaelis. The pres- 
ence of the disease in North America at 
this time is described by Dr. Samuel Bard, 
who having been trained in the University 
of Edinburgh to the study of medicine, re- 
turned to its practice in his native coun- 
try, and furnished, by his careful observa- 
tion of the cases under his care, the 
foundation upon which our knowledge of 
the disease was to be much further ad- 
vanced. 
That each of these epidemics preserved 
the essential characteristics of the disease 
as now observed, two quotations will suf- 
^ce to show. Of the first, in Italy, Aetius 
Cletus, in the introductory chapter to his 
work,4 the only part of interest, says, 
" Morbi facies hsec est. In faucibus rubor 
apparere incipit, cum dolore, et febre ; 
paulo post prsebet se conspiciendam pus- 
tula, quam subsequitur cum crusta ulcus 
cinerei coloris, quod frequentius accidit, 
subalbicantis nonnunquam, vel nigrantis 
coloris. Stepius sine pustula crustosum 
ulcus ; . . . . et in ipsis faucibus sunt, 
quibus ex ulcere itur in gangrenam, et 
sphacelum, qui ex oesophago porrigitur ad 
ventriculum, vel ex aspera arteria ad pul- 
monem ; et hi difflculter respirant, et non 
nisi recta cervice, illi deglutire nequeunt 
.... ex his nonnulli profundiori somno 
oppress! moriuntur; alii copiosa cum 
narium hsemorrhagia vita finiunt, alii 
absque his symptomatibus exanimantur. 
Morbus impuberes precipue invadit, tanta 
custrage, ut familiarum multarum omnes 
emori visi sint. Nulla moriendi est certa 
dies . . . die quarto decimo elapso non 
absque delicto quis emoritur-ex iis, qui 
pristinam valetudinem consequuntur anni, 
plus minusve spatio, omnes fere mussitant, 
et verba difflculter efferunt. " Of the next, 
Dr. Starr1 writes in 1749 : "The morbus 
strangulatorius, with great propriety and 
justice thus denominated, has within a 
few years raged in .several parts of Corn- 
wall with great severity. Many parishes 
have felt its cruelty, and whole families 
of children, whence its contagious nature 
is but too evident, have, by its successive 
attacks, been swept off. Few, very few, 
have escaped." "Many in the first at- 
tacks have complained of swelling of the 
glands, as tonsils, parotids, submaxillary 
and sublingual glands, but frequently of 
no great importance. A few, from an 
internal tumor, have had a large external 
oedematous swelling of the subcutaneous 
and cellular tunic, from the chin down to 
the thyroid gland, and up the side of the 
face. Not a few early in the disorder 
have had gangrenous sloughs formed in 
their mouths, and perhaps so early in 
some, that the disorder was scarce com- 
plained of till the slough was formed, so 
quick has it been in its progress. " And 
again, "I have not mentioned a fcetor 
oris, because, though some have had it, 
others have had it not." The symptoms 
of its extension to the larynx are then 
given, and he goes on to say: "I have 
frequently examined the matter these 
patients have at times spit; the greatest 
part was of a jelly-like nature, glairy, and 
somewhat transparent, mixed with a 
white opaque thready matter, sometimes 
more, sometimes less, resembling a rotten 
membranous body, or slough. Such a 
slough I have seen generated on the skin 
of one of these patients in the neck and 
arm, where blisters had been before ap- 
plied This white surface had the 
aspect of an oversoaked membrane, which, 
being oversoaked, had become absolutely 
rotten. The part blistered, if not quite, 
was in effect dry, and the flux from the 
slough was incredibly great I 
scratched the slough with my nail; it 
separated with ease, and without being 
felt by the child. What my nail took off 
afforded the same appearance with the 
matter of the spittle before mentioned. 
Hence I thought I saw sufficient reason 
to convince me that the disorder in the 
larynx and aspera arteria was similar to 
this, generating in the same manner, and 
arising from the same external cause ; . . 
and it is likely, had the anatomical knife 
been employed, that what was seen on 
the back of one, might have been dis- 
covered in the arteria aspera of the other. 
There is a circumstance which adds to 
the probability of this opinion, viz., in 
one or more instances these different dis- 
orders appeared in different subjects in 
the same family at the same time." 
A century again elapsed before the 
disease attained to epidemic intensity; 
1 Phil. Transactions, vol. xlvi. p. 435. 
2 An Account of the Sore-Throat attended 
with Ulcers, by John Fothergill, M.D. 8vo. 
Lond. 1748. 2d Edition: 
3 Phil. Transactions, vol. xlix. pt. 1. 
4 De Morbo Strangulatorio Opus, JEtii Cleti, 
Signini. 8vo. Rome, 1636. 
1 Loc. cit. DIPHTHERIA. 
60 
during the interval, outbreaks of more or 
less extent and severity occurred in vari- 
ous parts of France, Germany, North 
America, and in England, Scotland, and 
Ireland; sometimes sufficiently serious 
to receive full comment in the medical 
periodicals, sometimes so isolated and 
rare as almost to escape notice. 
Paris, at the beginning of the present 
century, was a frequent seat of its appear- 
ance, and the death from this cause of a 
promising member of the Imperial family 
of France in that city, in the year 1807, 
was the occasion of a large share of medi- 
cal attention being directed to its elucida- 
tion. No real progress however was made 
towards that object until the epidemic at 
Tours, in 1818, received a thorough inves- 
tigation under Bretonneau. From this 
time the Archives Generales de Medecine 
contain frequent reports of its appearance 
in various parts of France, and, by re- 
cording its period of greater or less preva- 
lence in Paris, and the details observed in 
the Hopital des Entants Malades, afford 
valuable contributions to the study of the 
disease : most of these notices are to be 
found under the heads of Croup and Epi- 
demic Croup. 
The records of the disease in this country 
become less frequent after the close of the 
last century. 
Dr. Mackenzie, of Glasgow, describes 
two cases that came under his notice in 
1813, of throat-disease ending in Croup, 
and says that this kind of disease was 
very prevalent in Glasgow in 1819; he 
gives a careful description of it, agreeing 
very closely with the results arrived at by 
Bretonneau : these, made known in Eng- 
land by the publication of his work in 
1826,' rendered the differentiation of the 
two diseases possible, and henceforth they 
are described apart. Dr. Abercrombie2 
alludes to cases of this kind in Dublin ; he 
says, though not a common affection in 
Scotland, yet that it was very frequent 
and fatal among children in Edinburgh in 
the year 1826, and that "it is evidently 
an affection quite distinct from the idio- 
pathic inHammation of the membrane of 
the larynx, to which we commonly apply 
the name of Croup." Dr. Webster, of 
Dulwich,3 records the deaths of two chil- 
dren in one family, in a house near Lon- 
don, in 1824, and of four other cases of 
ulcerated sore-throat, involving the lar- 
ynx, coming under his observation shortly 
after: they "all had," he says, "an as- 
semblage of similar symptoms, and the 
common point of danger was the wind- 
pipe." Mr. Ryland' describes cases of the 
kind as epidemic in Birmingham, in the 
year 1837. Dr. Humphry, of Cambridge, 
observed a case in the Norwich Hospital 
in the same year, and Sir William Jenner2 
remarks, in his Lectures on Diphtheria, 
"I have seen cases of it every now and 
then as long as 1 have practised medi- 
cine." 
Though isolated cases were from time to 
time observed, any memory of its epidemic 
violence in this country had almost passed 
away when its appearance in South Wales 
was announced by Mr. J. I). Brown,3 of 
Haverfordwest; about two hundred cases 
occurred there in 1849-50, of which forty 
were fatal. Some general conditions, 
which at present we are unable suffi- 
ciently to appreciate, including the effects 
of the two cold winters of 1853 and 1854, 
and the intense cold of January, 1855, 
seem at this time to have checked its epi- 
demic progress, and also to have stayed 
the ravages of cholera in this country. 
Traces of it meanwhile are to be found in 
other countries: Denmark,4 Germany, 
France, the North of Africa, Madeira, 
Teneriffe, America, and Hindostan. Dr. 
Jackson5 reports two cases occurring in 
Calcutta in 1853, one at a later period, 
and also thirteen cases at the Martiniere 
school, five of which died. We have ac- 
counts of it at Lyons in 1851, at Avignon6 
in 1853, of its great increase in Paris7 in 
1852-53, and of its reigning simulta- 
neously there and in many parts of 
France from 1855 to 1857, as a most fatal 
epidemic. In Boulogne alone it was the 
cause of 3668 deaths in that period. It 
was present, though not extensively, in 
the armies in the Crimea9 in 1855, and 
also at Moscow10 in the same year, and in 
1 Treatise on the Diseases and Injuries of 
the Larynx and Trachea, by Fredk. Ryland. 
8vo. Lond. 1837. 
2 Jenner, Sir W., M.D., F.R.S. Diph- 
theria, its Symptoms and Treatment. Lond. 
1861. P. 3. 
3 Med. Times and Gazette, 1850, vol. i. p. 
670. 
4 Beck in Oppenheim's Zeitschrift, b. xliv. 
s. 200. 
5 British Medical Journal, 1859, p. 373. 
6 Archives Generates de Medecine, s. 5, t. 
viii. p. 338. 
7 Ibid. s. 5, t. v. p. 260. 
8 On Diphtheria, by E. H. Greenhow, M.D. 
Lond. 1860. P. 68. 
9 Haspel, Gazette M^dicale, 1855, p. 829. 
10 Tarassenkoff, Diphtheritic Epidemica, 
Med. Zeit. Russlands, p. 92. 
1 Des Inflammations Speciales du Tissu 
Muqueux, et en particulier de la Diphth^rite, 
on Inflammation pelliculaire, connue sous le 
nom de Croup, d'Angine Maligne, d'Angine 
Gangreneuse, &c. 8vo. Paris, 1826. 
2 Abercrombie, John, M.D. Pathological 
and Practical Researches on Diseases of the 
Stomach, Intestinal Canal, Liver, and other 
Viscera of the Abdomen. 8vo. Edin. 1828. 
Pp. 53-56. 
3 The Institute, vol. i. p. 100. These cases 
were published in an Appendix to Mr. Hig- 
ginbottom's Essay on the Use of Nitrate of 
Silver. 8vo. Lond. 1829. Pp. 185-196. ETIOLOGY. 
61 
Algeria1 the year following. It was epi- 
demic in California2 in 1856-7, and some- 
what later in the Northern States of 
America.3 
The epidemic attained its height in 
England in the year 1858 and 1859, and 
during these two years we may estimate 
that 20,000 deaths were occasioned by it. 
In 1860 the number of deaths had fallen 
from near 10,000 to 5202, and though they 
have not since reached the latter figure, 
yet the mortality from this cause in Lon- 
don was almost as great, and in the 
northwestern counties quite as great, in 
1862 as in 1859. 
In Scotland, where the disease pre- 
vailed at the same time as in England, the 
mortality from this cause did not reach 
its highest until 1861. It is somewhat re- 
markable that though Diphtheria existed 
both in India and California, we have 
no history of any outbreak of it in Aus- 
tralia until 1859, when Mr. James Moore4 
records nine deaths from this cause, and 
the occurrence of 275 cases at the same 
time in New Norfolk, Tasmania. This 
part of the world is perhaps more exclu- 
sively in communication with England 
than any other. The appearance of the 
disease there is not until after it had at- 
tained in this country to its full epidemic 
development: moreover, though epidemic 
in North America, both in California and 
the United States, as early as 1857, it was 
not till 1859 that it made its appearance 
in Nova Scotia, the part of that continent in 
closest communication with this country. 
The severity of the outbreak at Bou- 
logne, the constant communication from 
our own shores to that place, and the 
number of English visitors and residents 
there, many of whom fell victims to the 
epidemic, excited reasonable alarm, not 
only of the advance of the disease, but of 
its direct introduction into this country 
through the medium of those affected. 
Individual cases were imported, both at 
Folkestone5 and Dover, without the dis- 
ease spreading in those localities; its 
independent appearance in Wales, Lin- 
colnshire, Cornwall, and Staffordshire pre- 
cludes Boulogne from being considered its 
origin ; yet sources of infection imported 
thence may have afforded new centres for 
the propagation of the disease, and have 
contributed in some degree to the deter- 
mination of its type. 
Etiology.-The records of the first half 
of the epidemic in England are imperfect; 
many deaths from this cause were included 
in the registration under the heads of scar- 
let fever, croup, and cynanche maligna. A 
table,1 published by Dr. Farr, in his let- 
ter to the Registrar-General, shows that, 
while in 1855-57 there are 1846 deaths 
registered as cynanche maligna, and only 
725 as Diphtheria, in the year 1858, upon 
the first introduction of the new general 
term,2 the numbers are 1770 as cynanche 
maligna, and 4836 as Diphtheria ; and 
that in the year following, when not only 
the name, but also the nature of the dis- 
ease was more generally understood, 9587 
deaths are registered as Diphtheria, and 
only 597 as cynanche maligna. In look- 
ing through the returns under croup and 
scarlet fever, the two diseases most likely 
to be mistaken for Diphtheria, it is not 
difficult to infer, both from the unprece- 
dented numbers returned under these 
heads, as well as from the usual number 
of deaths of the two sexes from these 
causes being reversed, that some other 
disease has been included, and this varia- 
tion occurs in the very districts in which 
we have other evidence of Diphtheria 
being present: thus in Wales, while the 
deaths from croup in 1853 were 207 males 
and 197 females, total 404; for the year 
1854 they were 215 males and 298 females, 
total 513 ; they then continue at or near 
500, till Diphtheria is introduced into the 
registration nomenclature, when they sud- 
denly fall to 424. The same exceptional 
proportion is first noticed in the Cornwall 
district in 1854; in the three following 
years the whole number is doubled, and 
in 1859 undergoes the same sudden dimi- 
nution. The west-midland, north-mid- 
land, and eastern districts, from which at 
this time we have the most frequent ac- 
counts of Diphtheria, show the same 
gradual increase, and the same sudden 
fall; and it cannot be doubted that of the 
6220 deaths returned as croup in the year 
1858, at least 1000 were Diphtheria. In 
scarlet fever this is still more conspicuous; 
the number of deaths mounts up from 
14,229 in 1857 to 30,317 in 1858 ; and in 
the latter year, for the only time that I 
am aware of, the number of deaths of fe- 
males from that cause exceeds the num- 
ber of deaths of males. An epidemic of 
scarlet fever certairdy accompanied that 
of Diphtheria, and culminated in the 
following year, when the deaths from 
it, Diphtheria being excluded, reached 
19,907 ; so that we may reasonably sup- 
pose that of the 30,317 deaths registered 
under this head in 1858, near upon 10,000 
were really owing to Diphtheria. The 
probability is that some deaths from this 
cause in previous years were so regis- 
1 Notes sur la Diphtherite. Recueil de Me- 
moires de Medecine Militaires, s. 2, t. xvii. p. 
392. 
5 Fourgeaud, Diphtheria. 8vo. Sacra- 
mento, 1858. 
3 Boston Medical Journal, vol. lix. p. 252. 
4 Australian Medical Journal, July, 1859. 
5 E. H. Greenhow, M.D., op. cit. p. 69. 
1 Twenty-fifth Annual Report, p. 178. 
2 This was in the first Quarterly Report of 
the Registrar-General, No. 37. 62 
DIPHTHERIA. 
tered : on turning to South Wales in 1857, 
we find that of 267 deaths from croup, 
177 were of females ; and of 349 from scar- 
let fever, 185 were of females ; so that in 
600 deaths, chiefly of children, the ma- 
jority of which ought to be among males, 
we find an excess of 40 among females. 
In the second half of the epidemic, 
taking the four years 1859-62, the number 
of deaths registered from Diphtheria is 
24,219; of these 11,229 are of males, 
12,990 of females. Half these occur in 
the first five years of childhood, and show 
a nearly uniform fatality in each of these 
years, the first year only being somewhat 
below 10 per cent, of the whole number ; 
half the remaining number, or 25 per 
cent, of the whole, take place between 
the ages of five and ten years, and about 
10 per cent, during the next five years; 
in the next ten years, that is, from the 
ages of fifteen to twenty-five, the propor- 
tion of deaths does not exceed 6 per cent, 
of the whole ; from twenty-five to thirty- 
five it hardly reaches 2 per cent, and is 
below 1 per cent, in decreasing ratio for 
each succeeding decade. The propor- 
tional mortality from Diphtheria for each 
age, to the deaths from all causes, is :- 
1st 
Year. 
2d 
Year. 
3d 
Year. 
4th 
Year. 
5th 
Year. 
5-10 
Years. 
10-15 
Years. 
15-25 
Years. 
25-35 
Years. 
Both Sexes 
•5 
2- 
3-7 
6- 
8- 
9- 
6-3 
2-5 
•32 
Females . . . . . . 
•5 
2-1 
4- 
6-4 
8-8 
10-4 
7-3 
1-8 
•45 
Males 
•5 
1-9 
3-4 
5-6 
7-3 
7-7 
5-3 
1-2 
•2 
These results are opposed to some state- 
ments with respect to the liability of sex, 
but fully bear out Fothergill's remarks on 
this subject. He says:1 "Children and 
young people are more exposed to it than 
adults ; a greater number of girls have it 
than boys ; more women than men ; and 
the infirm of either sex are more likely to 
have the disease and suffer from it than 
the healthy and vigorous. If it break out 
in a family, all the children are commonly 
affected by it, if the healthy are not kept 
apart from the sick ; and such adults as 
are frequently with them, and receive their 
breath near at hand, often undergo the 
same disease." He also remarks that 
" this disease has now been with us several 
years, and has consequently survived the 
different seasons and all the variety of 
weather to which we are subject." 
Climate and season do not influence the 
nature of the disease; it presents the 
same features in Sweden as in Spain ; nor 
is any difference observable in its appear- 
ance in our own humid climate from that 
which it presented to Aretaeus, when he 
attributed its causation to the peculiarly 
dry air of Egypt. Hot and dry climates 
or seasons, the germ being present, seem 
to favor its development. Yet difference 
of season has no marked effect on the 
course of the disease, nor on its preva- 
lence2 over limited areas ; nor has a sud- 
den change of weather any effect in 
originating or arresting its epidemic ap- 
pearance.3 
The London Quarterly Reports illus- 
trate, not the influence of season upon 
the disease, but the variableness of its 
prevalence in the metropolis. On the 
commencement of the registration of 
Diphtheria in the second quarter of 1859, 
the number of deaths from this cause was 
173, in the third quarter 190, and in the 
winter quarter 141. In the next year the 
third quarter shows the lowest, and the 
winter quarter the highest mortality. 
For 1861 the numbers are : 1st quarter 
139 ; 2d, 159 ; 3d, 168; 4th, 231'-a pro- 
gressive increase rarely met with even in 
other epidemic diseases. The extreme 
degree of cold reached in the winter of 
1860 had no inlluence in cheeking the 
second advance of the disease in London : 
that it was not the occasion of the in- 
crease is shown by the comparatively low 
number for the first quarter of 1861, and 
the very high return for the last quarter 
of that year, when the season was usually 
mild. 
The influence of contagion is estab- 
lished ; not the exact mode in which it 
operates. The matter of infection would 
seem not to be capable of any wide diffu- 
sion in the air, but to cling to particular 
places, houses, and even chambers ; hence 
it not only becomes endemic, but might 
also be distinguished as hypodemic, as 
well as epidemic. When epidemic, no 
kind of soil or situation influences its oc- 
currence ; of places in close proximity 
some escape, while others suffer, and tht h 
frequently some direct communication is 
to be traced with the districts previously 
affected : isolated cases are, however, fre- 
quently met with without any widely- 
spread consequences. The earlier part of 
any local epidemic is generally attended 
with the largest proportion of fatal re- 
sults : during the period of greatest epi- 
1 Op. cit. p. 30. 
2 Boudet, Arch. G6n. de MSdecine, 1842, s. 
3, t. xiii. pp. 144, 446. 
3 Gazette Medicale de Paris, 1848. 
1 Some deaths from this cause are included 
under Croup. Vide Vol. III. ETIOLOGY. 
63 
demic prevalence the disease is found to 
be subsiding in one district while advanc- 
ing in another ; the height of the epidemic 
coincides with the greatest number of 
local outbreaks. No general atmospheric 
condition can then be its cause, and what- 
ever the unknown assemblage of circum- 
stances that favor the progress of the dis- 
ease, they would not occasion it without 
the presence of its own special reproduc- 
tive gem ; so that the idea of the epidemic 
constitution must always include that of 
contagion. 
The theory of direct contagion, as set 
forth by Bretonneau, requires considerable 
modification ; the possibility even of in- 
oculation is rendered doubtful by the ex- 
periments of Trousseau upon himself, and 
of Dr. Harley1 upon animals ; noris there 
reason to suppose that greater power of 
propagation attaches itself to the fibrinous 
exudation, or special product of the dis- 
ease, than to some of the secretions and 
exhalations from the sick. I know of no 
instance of the disease being carried from 
one house to another by the passage to 
and fro of those who were themselves 
unaffected : the presence of one sick per- 
son in a house is sufficient for its commu- 
nication to the susceptible, however care- 
fully kept apart, so that the infectious 
matter must, to some extent, be diffusible 
in the air, and the danger of infection has 
seemed to me to be greater from this 
source than from direct contagion. Most 
of our brethren can speak of having come 
into disagreeable contact with* the secre- 
tion from the throat of sufferers, no bad 
effects following: very many can refer to 
dangerous illness in themselves as the 
result of too long or too close attendance 
in the sick-room. It is probably to this 
influence rather than to direct inocula- 
tion that is to be attributed the death of 
Valleix, and of Dr. Adams of Boston, U. 
S.2 The case of M. Herpin, adduced by 
Bretonneau, admits of the same explana- 
tion ; it is not clear that a very limited 
denudation of the skin, or of the mucous 
membrane, renders the system more ex- 
posed to the contagion ; but the disease 
once contracted, those parts of the mucous 
membrane exposed to the air are specially 
liable to be affected by the disease; or if 
there be any abrasion of the skin, it is 
likely to suffer.3 The existence of ex- 
coriation, as at the edge of the nostril, of 
unhealthy gums, of enlarged tonsils, pos- 
sibly of catarrh, may determine the local 
manifestation of the disease without these 
lesions having been the channel of its ad- 
mission. 
It has been noticed that the more abun- 
dant the secretion in particular cases of 
Diphtheria, the greater has been the con- 
sequent extension of the disease, especially 
where the greatest care has not been given 
to cleanliness; even where this has re- 
ceived every attention infection will some- 
times cling with surprising tenacity to 
particular Imuses or apartments. A sin- 
gle case, in itself not severe, occurring in 
a house, is sufficient to originate the 
severer form of the disease in the sus- 
ceptible. It is not necessary that there 
should be much secretion from the mouth 
and nares to originate infection ; a man 
named Sheppard, under Dr. Reynolds's 
care in University College Hospital, 1865, 
for paralysis subsequent to Diphtheria, 
contracted the disease from his child whom 
he held constantly in his arms during a 
short illness, the nature of which was not 
evident until after the child's death from 
asphyxia. A very short time suffices for 
the development of the disease after ex- 
posure to infection ; the boy in the Hos- 
pital for Sick Children whose case is re- 
ported by Sir W. Jenner,1 was observed 
to have advanced symptoms of Diphtheria 
within thirty hours of the commencement 
of the affection in a child occupying the 
next bed, and it is probable that a time 
considerably shorter is sufficient. 
Evidence of infection is not always 
shown immediately after exposure; of 
two children removed from an infected 
house to a village where no case of Diph- 
theria had occurred, the elder showed the 
first symptoms of the disease on the third 
day, having been very cheerful and well 
the whole of the two intervening days. A 
young lady going from this village to 
nurse her sister in the infected house, 
became ill four days after her arrival. 
Eight days is the longest interval that has 
been known to occur before the disease 
has shown itself where prompt removal 
from the source of infection has been car- 
ried out.2 Mr. W. Adams, of Harrington 
Square, has kindly furnished me with the 
clearest particulars of the case in point, 
mentioned at page 46 of Sir W. Jenner's 
book. A much longer interval may occur 
where the cause of infection is acting 
more continuously. Dr. Hughes,3 of 
Denbigh, records a case where a servant 
was taken ill twenty-two days after the 
occurrence of Diphtheria in the house 
1 Transactions of Path. Soc. of London, 
vol. x. p. 315. 
2 Med. Times and Gazette, 1861, vol. i. p. 
375. 
3 Mr. Lister, while House Surgeon at Uni- 
versity College, received a scratch on the fin- 
ger while performing tracheotomy in a case 
of diphtheria. Signs of the disease subse- 
quently appeared in the injured part. 
1 Loc. cit. p. 83. 
2 Exactly this interval has been observed 
under the same circumstances in scarlet 
fever, as the longest that has come under my 
notice. 
3 British Medical Journal, 1859, p. 80. 64 
DIPHTHERIA. 
where she was residing. In a vicarage in 
the country a servant was ill with Diph- 
theria, and remained one month in the 
house till convalescence enabled her to be 
removed ; an interval of ten days was 
then allowed for cleansing and ventilating 
the houso, when the family, consisting of 
mother, a weaned infant, and two other 
children, the eldest under four years of 
age, who had left the house on the first 
appearance of the disease, returned home ; 
three weeks afterwards the infant had 
symptoms of Diphtheria, and before the 
death of this child, which took place on 
the tenth day, the mother who had been 
constantly in attendance was taken ill, 
and subsequently the two other children. 
Infection may be disseminated for an 
uncertain time by those convalescent 
from Diphtheria; a girl ten years of age 
was removed from home at the outbreak 
of Diphtheria, from which three children, 
two younger and one older than herself, 
afterwards died ; two other sisters conva- 
lescent from the disease went to the sea- 
side, the one five weeks from the com- 
mencement of her illness, the other only 
three weeks, but from whom the last 
trace of deposit had cleared away ; they 
left together and seemed to be equally 
well: they were joined by other members 
of the family, and at the end of the week 
by the little girl, set. 10 ; early in the 
following week symptoms of the disease 
appeared in her,' and became rapidly fatal. 
She was the only one of the family that 
had been isolated during the whole period 
of the illness. Sir W. Jenner1 gives two 
similar instances : in the first, only a fort- 
night elapsed from the commencement of 
the disease to the removal into the coun- 
try, and within a fortnight from the date 
of arrival, another member of the family, 
some time resident there, was attacked; 
in the second a little boy, aftei' three 
weeks' separation from his family, joined 
his sisters, convalescent from Diphtheria, 
at a country residence to which on their 
recovery they had been removed. "Ten 
days after his arrival there, the boy 
sickened with Diphtheria. In this case, 
either the poison was in the child's sys- 
tem when he left London, and remained 
latent for a month, a supposition highly 
improbable, or he caught the disease from 
his sister, after they met in the coun- 
try."2 
Constitutional predisposition has a great 
influence in increasing the liability of 
families and individuals to receive the dis- 
ease: of two families residing in the same 
house several members of the one have 
suffered, while all of the other have es- 
caped ; a difference of susceptibility is 
also observed in members of the same 
family, and this not always in favor of the 
seemingly more robust. Allowing for the 
effects of similarity of diet, occupation, 
general management and hygiene, and 
chiefly for the degree of exposure to the 
same sources of infection, it is yet impos- 
sible to contest the effect of family consti- 
tution, both in fa voring the occurrence of 
the disease and in disposing to its fatal 
termination. 
Great mental activity, and a high de- 
gree of nervous susceptibility, would seem 
to increase the liability to become affected; 
bodily fatigue, and exhaustion from any 
causes, predispose. There appears to be 
but little difference in the liability of the 
different classes of society. 
The presence of other diseases, as of ty- 
phoid fever, pneumonia, measles, erysipe- 
las, and scarlet fever, has a great effect in 
exposing the system to the attacks of this 
one. The special poison of this disease 
sometimes produces effects short of gene- 
ral Diphtheria, which, however, predis- 
pose to the occurrence of the fully-devel- 
oped disease, either from the first local 
evidence of it being unchecked, or upon 
some accidental source of weakness aris- 
ing, as from the effects of aperient medi- 
cine, or of menstruation. The disease is 
especially likely to be established, if there 
be repeated or continual exposure to the 
exciting cause. 
The recurrence of Diphtheria more than 
once in the same subject is not settled so 
conclusively in the affirmative as has been 
supposed. That the same person may re- 
peatedly suffer from the slighter forms of 
the malady, and that some do so upon the 
slightest exposure, is frequently observed; 
but when the fully-formed disease has 
been undergone, though relapses are to be 
feared in convalescence, even during the 
whole of the subsequent period of debility, 
w hich may be prolonged for twro or three 
months, independent recurrence is rare. 
Of the children that recovered from the 
disease at the commencement of the epi- 
demic, and who have been constantly un- 
der my observation since, no instance of 
a second visitation has occurred. Such 
instances are recorded, one by Dr. Gull, 
eleven months after the first attack, and 
three others by Dr. Greenhow,1 one of 
which was fatal, but no particulars are 
given in this case as to the intensity of the 
first attack. The development of Diph- 
theria agrees more closely with that of 
erysipelas than of scarlet fever ; the close- 
ness with which many of its pathological 
effects coincide with those of the latter 
disease makes it necessary to remark here, 
that the occurrence of scarlet fever offers 
no protection against the attacks of Diph- 
theria.2 So with respect to croup: twro 
1 Loc. cit. p. 111. 
2 Dr. Ballard, in Medical Times and Ga- 
zette, 1859, vol. ii. p. 78. 
1 Loc. cit. p. 52. 2 Loc. cit. p. 53. SYMPTOMS. 
65 
instances have occurred to me, wherein 
children that had suffered severe attacks 
of croup, fell victims to Diphtheria after 
intervals of four and six years. Hygienic 
conditions influence the frequency, and 
even the fatality of Diphtheria, less di- 
rectly than they do the permanence and 
diffusion of the infectious principle ; want 
of cleanliness allows the infectious parti- 
cles to accumulate ; the presence of de- 
composing organic matters shields them 
from destructive oxidation in the atmo- 
sphere ; thus they linger in districts natu- 
rally malarious, and in those artificially 
so from an improper drain system, as well 
as in the close, dark, and dirty districts of 
large towns, and evils thus matured rest 
not in their cradles, but come forth and 
often exert their most fatal effects in 
homes the most unlike those where negli- 
gence had allowed them to lurk. [The 
influence of unsanitary local conditions in 
promoting the occurrence and mortality 
of Diphtheria has been marked of late 
years in many places in America; amongst 
others, in certain quarters of the city of 
New York. Tenement houses, contain- 
ing an excessively crowded population, 
have often been subjected to great loss of 
life from this as well as other " enthetic" 
diseases. Foul privies, badly drained cel- 
lars and streets, and leaky connections of 
dwelling houses with sewers, favor Diph- 
theria very positively, notwithstanding 
the specific nature of its immediate cau- 
sation.-H.J 
Symptoms. - Some general constitu- 
tional symptoms precede those occasioned 
by the concomitant local changes; both 
may co-exist in every degree of severity, 
sometimes the one, sometimes the other 
attaining a deceptive prominence; at 
ether times both are so obscure as to 
make the inroad of the disease remarka- 
bly insidious. Among the earlier symp- 
toms are yawning or sighing, shallow and 
infrequent respiration, great lassitude and 
debility, some aching of the back and legs, 
either a distinct rigor, or chilliness, pal- 
lor, a sense of nausea or rising in the 
throat, anorexia, sometimes vomiting, or 
diarrhoea, and in children convulsions, a 
sense of constriction across the forehead, 
or intense headache, vertigo, extreme 
muscular weakness, some anomalous fixed 
pain, an altered mental state, slowness of 
recollection, an indifference of manner, 
and an obtuseness of the mental faculties; 
this latter gives place to a short period 
of excitement, during which it may be 
thought that no illness is impending. 
There is, however, a marked elevation of 
temperature, which is increased at night, 
when wakefulness or restlessness always 
occurs. The pulse is accelerated, and in 
children or young persons may rise to 130 
or even to 140 in the minute: this fre- 
quency soon subsides, generally before the 
end of the second day ; and though the 
pulse continues to be quick, it is either 
feeble or easily compressible. The respi- 
ration is never proportionately accelerated 
at this period. The tongue is moist, with 
a thin creamy fur; the urine is pale in 
color, at first free, soon rather less in 
quantity, with scanty deposit of lithates, 
but still pale, and at this time it may be 
albuminous. The lymphatic glands at 
the angle of the jaw are already precepti- 
ble ; there is always some enlargement of 
the cervical glands, and redness with a 
little swelling of the posterior part of the 
soft palate, of the fauces, of the back of 
the pharynx, and of the tonsils. The 
throat is sore, deglutition is difficult if not 
painful, sometimes the pain is felt in the 
ear, and there is frequently stiffness of the 
neck; very little external swelling is at 
this time noticeable, and there is no dif- 
fused redness of the skin; sometimes little 
isolated red spots are found in different 
parts of the surface, as over the neck or 
behind the ears; there maybe suffusion of 
the eyes and slight injection of the con- 
junctival vessels, and a little obstruction 
to the nasal passage from a similar vascu- 
lar state of its lining membrane. Some- 
times this is seen at the nares to be sim- 
ply red, sometimes an opaque white spot 
may be noticed beneath the epithelium, 
or one nostril may be completely ob- 
structed, and some fibrinous exudation al- 
ready observable; sometimes the back of 
the pharynx will show the first indication 
of this in lines of opaque tenacious secre- 
tion, or commencing deposit is seen there, 
in the apices of its enlarged follicles. The 
earliest evidence of the disease is, how- 
ever, most frequently found within the 
follicles of the tonsils or deposited on its 
inflamed and turgid surface. 
The first general symptoms are transient, 
and may be so trifling in degree as to es- 
cape notice, until they are intensified by 
the progress of the local lesion ; this will 
give rise to pain, heat, and soreness of the 
throat, with impeded function: it also 
excites some sympathetic febrile disturb- 
ances of its own, and always increases 
that proper to the general disease ; where 
both are severe, the throat, though covered 
with exudation, is often the least part of 
the patient's complaint; where both are 
slight, there may be an interval in which 
little complaint is made. During this in- 
terval, two days, there may be no visible 
exudation in the fauces ; the tonsils con- 
tinue to be enlarged and their surfaces 
irregular, and they, in common with the 
whole of the pharynx, the arches of the 
palate, the velum, and the uvula, are of a 
deep-red color and unequally turgid ; one 
side is generally the most affected, the 
uvula is enlarged, red, and glistening, and 
a mottled redness extends forwards from 
VOL. I.-5 66 
DIPHTHERIA. 
it over the soft palate, but the rest of the 
buccal membrane is pale. Some of these 
parts soon appear more tumid and glisten- 
ing than others, and spots at first semi- 
transparent and afterwards opaque, rapid- 
ly form and coalesce, so that in a few 
hours a large surface may be covered with 
a continuous layer of exudation; or the 
exudation is limited to one or more cen- 
tres, the mucous membrane around being 
elevated and of a violet tinge of redness, 
until it is invaded by the same change. 
The raised edge is then extended, the 
centre being occupied by a flattened, 
yellowish-white, leather-like deposit, in- 
creasing in thickness by additions to its 
under-surface ; this is accompanied by the 
pouring out of a considerable amount of a 
more fluid secretion, while that from the 
surrounding mucous follicles is also in- 
creased and altered in quality, so that a 
tenacious fibrinous matter is mingled with 
the mucus. The cervical glands increase 
in volume, the submaxillary lymphatic 
glands especially; a large amount of 
serous infiltration takes place in the sur- 
rounding cellular tissue, and the whole of 
the front of the neck becomes greatly 
swollen ; deglutition is involuntarily sus- 
pended, secretions escape in some quantity 
from the mouth, and even from the nos- 
trils, by which the lips are excoriated. 
The superficial layers of the localized de- 
posit, partially separated and exposed to 
the passage and re-passage of the air and 
the warmth and moisture of the mouth, 
undergo decomposition and give rise to 
great fetor; extravasated blood mingles 
with the decomposing exudation, or es- 
capes freely from its under-surface, or 
occasions epistaxis. The voice is muffled 
or nasal in tone; impeded respiration 
may occur from the physical obstacles in 
the fauces without laryngeal symptoms 
arising; or these being slightly marked, 
symptoms of pulmonary obstruction come 
on insidiously. These processes may be 
■gone through with great rapidity, and are 
accompanied by the most marked adyna- 
mia ; the pain in the head is intense, the 
restlessness and agitation extreme, vomit- 
ing or diarrhoea may occur, the lips and 
tongue become dry and brown, the pulse 
very rapid, feeble, and irregular ; the skin 
becomes cold, the face pallid, the whole 
attitude is indicative of powerless exhaus- 
tion ; there is impaired consciousness,- 
slight delirium, or deep somnolency, and 
some repeated attack of syncope termi- 
nates life. 
The elevation of temperature is always 
marked, and characteristic ; it may be as 
high as 103° very early in the disease ; it 
will generally reach this point by the end 
of the third day, and is highest at night, 
when it may amount to 104°, then prob- 
ably with delirium. This temperature has 
not been exceeded in uncomplicated cases. 
The clays of highest temperature observed 
from the commencement of the illness 
have been from the third to the ninth or 
tenth. Free exudation is attended with 
temporary depression of temperature. De- 
fervescence in the severer cases recovered 
from has been on the twelfth and four- 
teenth days ; in the milder cases this has 
not occurred before the sixth day, though 
some precedent subsidence of temperature 
may have been noticed. In fatal cases an 
earlier decline of temperature has some- 
times been met with. A girl, aged 8, had 
a surface temperature of 103° on the third 
day, 101° on the fourth, then barely 100°, 
with swelling of glands, foetorosis, and 
haemorrhagic tendency,death on the eighth 
day ; the day before the temperature in 
the axilla was below the normal. In cases 
markedly asthenic the temperature of the 
surface falls, while that of the interior of 
the body continues to be high : in a boy, 
aged 2, with a temperature of 103° in the 
rectum on the fifth, sixth, and seventh 
days of the disease, only 100° could be ob- 
tained in the axilla, and sometimes only 
994°; the temperature after subsiding to 
100° was suddenly raised to 102° by acute 
kidney complication ; continued there two 
days, and was again below 100° the day 
before death. Another boy, aged 4, with 
nasal diphtheria and slight tracheal im- 
plication, had a temperature of 103° in 
the rectum on the sixth day, suddenly 
falling to 99-5° on the seventh, then con- 
tinuing at or near 100° until death on the 
fifteenth day. In the apparent interval 
between the first illness and the distress 
occasioned by the throat symptoms, the 
high temperature is an indication of value : 
a child has been taken out for a walk on 
the fifth day with a temperature in recto 
of 103-7°. A young man was found 
dressed and walking about on the ninth 
day of illness, with a surface temperature 
of 102°; on being kept in bed the tem- 
perature fell 2° in two days ; the exuda- 
tion then ceased to extend, but the tonsil 
last affected had become turgid and more 
inflamed coincidently with the fall of tem- 
perature : albuminuria appearing here 
during defervescence was considered to 
be rather hsemic than renal. 
During convalescence the temperature 
is low, and readily depressed : but any 
intercurrent affection may keep up the 
temperature indefinitely. 
The advancing asthenia is always ac- 
companied by a considerable increase of 
exudation ; it- continues while the process 
of exudation is going on, and is at its 
greatest when the separation of the dis- 
eased products is being accomplished ; this 
may be completed by the ninth or tenth 
day of the disease. The exhaustion at 
this period, if not fatal, is often so great 
as to suspend for some days the hope of 
recovery, to delay the process of repair, SYMPTOMS. 
67 
and to prolong the diseased action, so that 
there may be a reappearance of exudation 
in the fauces, or it may at this time in- 
vade the larynx. If there be any injury 
of the skin, the diphtheritic action, pro- 
bably already established there, will be 
continued so as to become an additional 
source of exhaustion. Besides the hemor- 
rhagic tendency at any affected surface, 
spots of purpura sometimes make their 
appearance either widely distributed or 
grouped together : sometimes an earthy 
pallor pervades the whole surface of the 
skin. Where there are none of these un- 
favorable complications it is not rare to 
find that, when the exudation is clearing 
off from the fauces, a remarkable increase 
of albumen occurs in the urine. Noc- 
turnal delirium may occur, not only at 
the commencement, but at the height of 
the disease, when the asthenia is consi- 
derable. A more violent symptomatic 
disturbance at the commencement of the 
disease, occasioned either by local or by 
constitutional reaction, may mask the 
tendency to asthenia without making it 
less ; and should the course of the disease 
not be interrupted by the implication of 
the air-tubes, asthenia becomes the pre- 
vailing condition throughout all the sub- 
sequent illness, and may bring on a fatal 
result, not only at the end of the second 
week, but during any of the subsequent 
weeks of convalescence, even to the fifth 
or sixth from the commencement of the 
disease. 
Extension of the disease to the larynx 
and trachea may be the cause of death at 
a much earlier period ; the air-passages 
are specially liable to become the seat of 
the peculiar exudation of Diphtheria ; it 
may commence there either by indepen- 
dent centres of deposit, or by the spread 
of exudation from the pharynx to the epi- 
glottis, over the arytteno-epiglottidean 
fold, and thence downwards, even to the 
remotest bronchi, and be fatal, with symp- 
toms of sudden or of slow suffocation, in 
the earliest stages of the disease, or at the 
period of greatest exudation, towards the 
end of the first or commencement of the 
second week. This extension often pro- 
ceeds insidiously when the general symp- 
toms are of great intensity, and is only 
indicated by hoarseness, or weakness of 
the voice, and by some laryngeal quality 
in the breath sounds, faintly audible dur- 
ing both inspiration and expiration, by 
signs of impeded respiration, evidenced in 
the oedema of the face and livid hue of the 
lips, sometimes only by pallor, and gradu- 
ally deepening unconsciousness, and by 
the retraction of the softer parts of the 
thoracic parietes. In other cases the first 
invasion of the mucous membrane of the 
upper part of the air-tube is announced 
by highly characteristic phenomena, simi- 
lar to those produced by acute laryngitis 
in adults, or by idiopathic croup in chil- 
dren, differing only in the less sharp and 
sonorous clang of the cough, in the more 
husky tone of the voice, and in the ante- 
cedent and concomitant symptoms. Be- 
sides the appearance in the fauces, and 
the dysphagia, the sudden change from 
the asthenic character of the prevalent 
symptoms to the excitement, arterial and 
general, now occasioned is very striking. 
In other cases, chiefly among children, 
the disease may have set in with no great 
severity, the power of swallowing and 
even the desire for food may be returning, 
and the child, no longer confined to bed, 
is resuming its amusements, when a 
hoarseness of voice and a noise in breath- 
ing are the only precursors of paroxysmal 
dyspnoea, differing only from that of croup 
in the time of the day in which the first 
attack may occur, and in the readiness 
with which the child will return to play 
on its subsidence, but soon becoming more 
terrible in the unintermitting violence 
which it rapidly assumes, or in the sud- 
denness of the fatal result. 
The mortality from this complication 
alone is very great; it has been estimated 
that one-half of the fatal cases of Diph- 
theria die from this accident; nor is this 
estimate excessive when children are the 
sufferers ; an extension to the air-tubes, 
necessarily fatal to children, will some- 
times be survived by adults ; in the man 
Sheppard a cough of unequalled violence 
with expectoration of false membrane 
continued into the third week of illness. 
In a small proportion of cases the larynx 
or trachea has been the first seat of the 
disease ; in these cases and in those where 
the faucial deposit is small or already dis- 
appearing, the urine is more frequently 
found to contain albumen at an early pe- 
riod than in those cases attended with 
abundant exudation on the pharynx. In 
a female, aged 35, named Bowra, under 
Dr. Hare's care in University College 
Hospital for Diphtheria, in April 1865, 
who died of pneumonia, coincident with 
slight deposit in the larynx and fauces, 
there was a considerable amount of albu- 
men in the urine on her admission, the 
second day of her illness; the next day 
the temperature of the surface rose to 
104°, pulse 144, respiration 36 ; the albu- 
men increased to one-sixth, and the re- 
spiration to 57; death took place on the 
sixth day. The first evidence of deposit 
was in the larynx, and there was no ex- 
tension of it into the bronchi. Soreness 
in the front of the neck, and pain or sense 
of tightness over the sternum, are fre- 
quently complained of in these cases, and 
sometimes slight oedema is noticeable in 
front of the trachea. 
Albumen is found in the urine in the 
great majority of cases; its presence 
either in large or small quantity does not 68 
DIPHTHERIA. 
necessarily affect the excretion of urea : 
this is always increased during the whole 
period of illness, and when the disease is 
at its height is frequently double. In 
one case (J. B., a young man, aged 18), 
on the seventh day of illness, 606 grains 
of urea were excreted, or more than treble 
the normal quantity : the urine has an 
acid reaction, a high specific gravity, and 
deposits a furfuraceous sediment in which 
uric acid, urates, oxalates, and sometimes 
phosphates, are detected by the micro- 
scope, and not infrequently casts of the 
renal tubules, either waxy or granular; 
blood-corpuscles are rarely found, and 
never in large quantity. Albuminuria 
generally occurs early in the illness; it 
may be absent and reappear more than 
once in its course. In a man named 
Walker, aged 42, admitted to University 
College Hospital, under Sir W. Jenner's 
care, Nov. 14th, 1864, for Diphtheria, at 
the end of the first week of illness, there 
was no albumen found till the end of the 
third week ; it then continued till death, 
which took place in the fifth week of the 
disease. In the case of J. B., albumen 
was present throughout the illness; on 
the twelfth day it had increased to one- 
third, on the twenty-fourth day it was 
one-eighth, and then gradually lessened 
during the ingress of paralytic symptoms, 
and finally disappeared at the end of the 
fifth week, while the nervous disorder 
was at its greatest, and three weeks be- 
fore convalescence was established. Al- 
buminuria is not persistent after recovery, 
and does not often result in anasarca. 
Hemorrhage is not infrequent, and may 
be so profuse as to cause sudden exhaus- 
tion, either on the separation of some 
morbid deposit of unusual depth, or from 
some dyscrasia of the blood favoring its 
ready transudation. Vomiting and diar- 
rhoea, generally absent after the first in- 
gress of the disease, may set in with gas- 
tralgia and great depression. Exhaustion 
may come on gradually without these 
symptoms, the pulse increases in rapidity 
and feebleness, and death takes place 
without distress of breathing or impair- 
ment of the mental faculties. In some 
of these cases, and of those yet to be de- 
scribed, fibrinous coagula form before 
death in the cavities of the heart. 
The liability of other mucous mem- 
branes and of the skin, especially when 
denuded, to become the seat of the 
changes characteristic of Diphtheria, has 
often a great influence on the progress 
of the disease ; eczema behind the ears, 
or in any fold of integument, abrasions or 
fissures at the juncture of skin and mucous 
membrane, leech-bites, blistered surfaces, 
and even those irritated by a mere rube- 
facient application, may become affected, 
and add greatly to the amount of disease 
against which the patient has to contend ; 
a cutaneons eruption, occasioned by the 
disease itself, is sometimes, though rarely, 
the seat of these ulterior changes ; the 
cuticle is raised, a white surface is ex- 
posed-this is identified with the upper 
layer of the cutis and does not implicate 
its whole depth-the skin immediately 
around is red and tumid ; new vesicles, 
sometimes sanious, are raised upon it, 
they burst and coalesce ; the white layer 
extends its surface, which is still some- 
what below the level of the surrounding 
skin ; it increases in thickness by addi- 
tions from below, and the upper layers 
soften, decay, and disintegrate; it is 
accompanied by an irritant fluid secre- 
tion, both increase proportionally, and the 
extension of false membrane takes place 
most readily in the direction where the 
secretion is most in contact with the skin ; 
where these changes take place in some 
portions of the skin, towards the end of 
the disease, there is but little secretion 
formed, and no great extension occurs. 
At the height of the disease the extension 
is sometimes very rapid; but this is less 
remarkable, because less constant, than 
the tendency then observed to repetition. 
Not only will every abraded or irritated 
surface take on this action, but isolated 
patches of deposit may occur on the edge 
of the lip, on the eyelid, in the meatus 
auditorius, and elsewhere. Open wounds 
undergo a similar change, the superficial 
granulations are converted into this 
pseudo-membranous layer, cicatrization 
stops, the wound becomes painful, and a 
copious ichorous secretion is poured out ; 
a fissured nipple has been the starting- 
point of the morbid process, and much of 
the surface of the breast has suffered ; the 
disease readily establishes itself in the 
vagina, where layer upon layer of false 
membrane may accumulate. An abraded 
surface of integument is sometimes 
covered with a granular or pulpy exuda- 
tion only, attended with but little fluid 
secretion ; the affected surfaces then con- 
tinue to be irritable, but do not always 
extend. Diphtheria has generally first 
appeared in the fauces, and made some 
progress, before other parts of the mucous 
membrane, or of the exposed skin, have 
been attacked ; instances are not, how- 
ever, wanting of the disease commencing 
elsewhere, and inducing in the pharynx, 
larynx, and trachea, the characteristic 
changes that soon become fatal. 
A remarkable train of symptoms often 
make their appearance after the disease 
has reached its height, and become a new 
source of danger. These are the limited 
and varying series of paralyses, which are 
some of the characteristic effects of the 
special diphtheritic poison. An altered 
tone of voice and the regurgitation of 
fluids through the nose are frequent evi- 
dences of this, and have long attracted SYMPTOMS. 
69 
notice; an inability to swallow, first 
pointed out by Ghizi, was noticed by M. 
Guersant to occur about the ninth day of 
the disease, and to become an embarrass- 
ing obstacle to recovery in cases where 
tracheotomy had been performed. This is 
frequently observed only with respect to 
fluids ; there is at this time, as shown by 
M. Trousseau, a loss of sensibility in the 
velum pendulum palati, and probably in 
the pharynx and glottis. Complete in- 
ability to swallow from loss of power in 
the muscles of deglutition seldom occurs 
before the third or fourth week of the ill- 
ness ; at this time on inspection of the 
throat, the uvula is often found to be lax, 
and neither it nor the pillars of the fauces 
act upon stimulation ; difficulty in the in- 
gestion of sufficient nutriment adds to the 
dangers of this period ; vomiting, more- 
over, is possible when the power of swal- 
lowing is gone. Loss of power and of 
sensibility in the parts supplied by the 
par vagum occur at a somewhat earlier 
period than the paralytic affections of 
other parts of the body, and hence arise 
special sources of danger ; the slow weak 
pulse observed in the second and third 
weeks of illness is from this cause, and is 
frequently a fatal symptom. The pulse 
may be reduced in children to sixty or 
even forty beats in the minute, and the 
child seeming otherwise well, death by 
syncope has occurred suddenly, on some 
undue exertion ; or the heart's pulsations 
have gradually failed to thirty or, shortly 
before death, even to sixteen beats in the 
minute.1 I have seen a similar failure 
of respiration occur to a boy, aged 9, in 
the second week of illness, where no ex- 
tension of the disease to the larynx had 
taken place ; inspiratory efforts had to be 
artificially excited at frequent intervals 
during many hours; every few minutes 
the respiratory movements became more 
and more shallow and inefficient, until 
they were again stimulated into action, 
and even then the ribs were not always 
elevated ; at the end of twenty-four hours 
respiration was more satisfactorily per- 
formed ; during the second day the voice 
regained its clearness and force, the intel- 
lectual activity seemed to be more than 
usually quickened, the respiratory mur- 
mur was perfect in every part of the hmg, 
both food and stimulant were swallowed, 
but the action of the heart became at first 
slow and weak, afterwards very feeble and 
rapid, and death took place on the third 
day from the commencement of these 
symptoms. Paralysis of the muscles of 
respiration occurring at a later period, in 
an adult, threatened to be fatal but for the 
stimulus of galvanism. Dr. Gull reports 
the case of a boy, aged 11, who, five weeks 
from the commencement of Diphtheria, 
was unable to prevent the head falling for- 
ward, or to either side, owing to paralysis 
of the muscles of the neck; he suffered 
from dysphagia, aphonia, and paroxysmal 
dyspnoea; a few days afterwards " the 
breathing became entirely thoracic. The 
diaphragm was unmoved in inspiration 
and depressed in expiration, indicating a 
loss of power in the phrenic nerves."1 
Death approached rapidly by apnoea. 
Loss of power and irregular action of 
the pharyngeal muscles is not only the 
ea rliest, but the most frequent form of dis- 
ordered innervation. It sometimes rapidly 
disappears, and is not followed by other 
symptoms of this kind ; in other cases the 
power of swallowing may continue to be 
impaired for three or four weeks ; at first 
the difficulty is with liquids, afterwards it 
is now and then found that solids cannot 
be passed down, and are in danger of re- 
maining in the lower part of the pharynx, 
or of being forced up towards the pos- 
terior nares, while liquids find their way 
into the stomach, and these conditions 
may alternate. At this time articulation 
is sometimes defective from imperfect 
movement of the tongue ; tingling sensa- 
tions in the tongue and lips are also felt, 
and may continue during the fifth and 
sixth weeks. Paralysis of the nerves of 
the special senses was first observed as a 
consequence of Diphtheria by J. F. Hoff- 
man.2 Taste is sometimes lost, more 
rarely hearing ; defective vision is not in- 
frequent ; it begins with an immovable 
and sluggish pupil, and an inability to 
read or "to distinguish near objects; soon 
more distant objects become indistinct, 
double vision or strabismus may occur; 
sometimes one eye only is affected ; these 
changes of vision take place from the fourth 
to the seventh week, and when sight is 
perfect the pupils again act freely. As 
these alterations of sense improve, numb- 
ness and tingling commence in the fin- 
gers and toes, extending gradually to the 
hands and arms, and to the feet and back 
of the legs, or even to the hips. Some 
degree of these sensations, with formica- 
tion or a sense of coldness in the extremi- 
ties, various degrees of anaesthesia, or 
even some hyperaesthesia, may occur 
earlier, and before any great loss of mus- 
cular power. These conditions vary very 
much, disappearing at some parts, in- 
creasing and extending at others. They 
may pass off for a time, and reappear with 
the increasing muscular debility; the 
sense of touch may continue to be im- 
paired ; anaesthesia is seldom complete 
except in the severest cases. The lower 
1 Sir W. Jenner, op. cit. p. 44. Mr. Adams 
has given valuable details of a case of this 
kind in the Second Report of the Medical Offi- 
cer of the Privv Council, p. 327. 
* Lancet, 1858, vol. ii. p. 5. 
2 Rust's Magazin, 1831, b. xxxiii. s. 241. 70 
DIPHTHERIA. 
extremities suffer most; it may be impos- 
sible not only to stand but to move the 
legs in bed. When this degree of paralysis 
is not reached, the gait is often unsteady, 
and walking may be impossible from a 
loss of the muscular sense ; this sometimes 
interferes with the use of the hands, and 
the power of co-ordinating muscular move- 
ments. Loss of power is not to the same 
degree or so persistent in the upper ex- 
tremity as in the lower, though here also 
remarkable alternations are observed, one 
limb or one set of muscles being free to 
act on one day, and powerless on another; 
when power is regained, one muscle, or 
part of a muscle, may remain for a time 
the subject of inaction or of spasm. Re- 
flex action is often diminished, but not 
increased. Paralysis of the bladder has 
occurred, not of the rectum. Constipa- 
tion, from paralysis of the abdominal 
muscles, is a frequent condition, demand- 
ing attention. The first symptoms of 
paralysis will almost always appear before 
the end of the fourth week ; they generally 
attain their greatest degree of intensity 
by the seventh or eighth week ; they may 
not do so until the tenth or twelfth, as in 
Sheppard's case ; all traces of the affection 
may not have entirely disappeared after 
five or six months. Lesions of innervation 
are not in proportion to the extent and 
persistence of the local lesions, nor always 
the consequences of the more severe and 
prolonged attacks of Diphtheria only, 
though it is after these that they are most 
likely to occur; they may conduce not 
only indirectly, but directly, to a fatal re- 
sult, from progressive loss of nervous 
power, apart from muscular weakness ; in 
these cases the period most dangerous to 
life is reached in the seventh or eighth 
week. Trousseau1 has detailed a case 
where delirium and convulsions at this 
time appeared, with ultimate recovery. 
More frequently death by asthenia, unat- 
tended by symptoms of other disease, 
occurs within this period. A peculiar 
pallor and opacity of the skin is often a 
concomitant of even the more slightly 
marked cases of paralysis consequent on 
Diphtheria. In the more prolonged cases 
there is always some evidence of anaemia. 
Diagnosis.-A careful inspection of the 
fauces will, in the majority of cases, be 
conclusive as to the presence of the dis- 
ease : where a yellowish patch of exuda- 
tion moulded to the surface it has invaded 
is thus brought into view, the nature of 
the serious illness, which may have been 
obscure, is at once revealed : where this 
anatomical character of Diphtheria is 
not obvious, the appearances in the fauces, 
taken in conjunction with the associated 
phenomena, will still be of primary diag- 
nostic value. It is important that the 
earliest stages of Diphtheria should be 
distinguished from catarrhal affections. 
The redness of the fauces in Diphtheria is 
more intense but less uniformly diffused 
than in catarrhal inflammation ; the ton- 
sils are more tumid, and one side is more 
affected than the other; the lymphatic 
glands at the angle of the jaw and beneath 
the sterno-mastoid are always enlarged : 
in children coryza may be present, the 
vascularity of the conjunctiva is then 
more like that observed in measles, but 
there is less secretion; afterwards, the 
defluxion from the nares becomes more 
considerable, it is not simply mucous, but 
sero-purulent or sanious ; or the nares not 
being so much affected, a quantity of un- 
equally opaque and tenacious mucus bub- 
bles in the gullet, and prevents the view 
of the posterior part of the pharynx ; there 
will be pain in deglutition, as shown by 
the infrequency of the effort, or the 
grimace that accompanies it; in either 
case the exudation soon extends to the 
larynx, and the cough, hitherto infrequent 
and moist, becomes frequent, dry, and 
croupy, and the disease is set down as 
catarrhal croup. For the further diag- 
nosis of croup from Diphtheria, see the 
article on Croup. 
Tonsillitis resembles Diphtheria in the 
two sides of the throat being unequally 
affected, and in the occurrence of external 
swelling at the angle of the jaw ; the con- 
stitutional symptoms are, however, symp- 
tomatic, dependent on, and in proportion 
to, the local complaint; the lymphatic 
glands are not enlarged at the commence- 
ment of the attack, nor those beneath the 
sterno-mastoid at any time. A yellowish 
soft secretion appears at the orifices of the 
tonsil ; the mucous surface preserves a 
smooth, glistening appearance, and any 
exudation of lymph upon it is semi-trans- 
parent, very thin, and limited in extent; 
the tendency of the inflammation is to 
resolution or suppuration, the other tonsil 
often becomes affected in the same way, 
but without any similar change taking 
place in the intermediate mucous mem- 
brane. 
In Herpetic sore throat the highest 
temperature is on the second day, when 
it may rise to 102°, and then rapidly sub- 
side. 
In scarlet fever, the throat affection is 
always preceded by symptoms of severe 
febrile, disturbance, which are persistent, 
and in proportion, not to the throat affec- 
tion, but to the severity of the attack of 
fever which follows; the chilliness and 
headache may not be so marked, but the 
heat of skin is greater, and the pulse at 
once attains a high degree of frequency 
which it maintains during the first days 
of the illness, and until after the appear- 
ance of the rash, or the condition of the 
1 Gazette des Hdpitaux, 1860. DIAGNOSIS. 
71 
throat, has removed all doubt as to the 
nature of the disease. The premonitory 
symptoms in Diphtheria are sometimes 
not noticed in the severer cases, and when 
well marked do not always indicate the 
approach of the graver symptoms ; should 
these follow, the frequency of the pulse 
during the first few days is not maintained, 
the respiration is shallow and not propor- 
tionally accelerated, and there is neither 
the continued high temperature nor the 
same pungent heat of skin. The dimin- 
ished frequency and fulness of respiration 
at the outset of Diphtheria is often an in- 
dication of value when the disease is not 
yet fully developed. The cervical lym- 
phatic glands are enlarged in both dis- 
eases. The redness of the throat in 
scarlet fever is uniformly diffused ; on the 
second or third day it becomes very in- 
tense, appearing simultaneously upon all 
parts of the throat and palate, and affect- 
ing the papillae of the tongue ; both ton- 
sils are equally enlarged. In Diphtheria 
the redness and turgescence are greatest 
in certain parts about to become the seat 
of exudation, and at the edges of the ex- 
udation already formed, so that it and the 
surrounding redness gradually advance 
upon the contiguous portions of the mu- 
cous membrane ; the papillae of the tongue 
are neither red nor enlarged, and the ton- 
sils are unequally affected. In scarlet 
fever exudation, both tonsils are covered 
with a milk-white layer applied equally to 
the surfaces of both, and the soft palate 
and tongue may be covered with a similar 
layer; this undergoes no great increase 
in substance, and at a certain period is 
detached in shreds; it is not capable of 
absorption, and on its separation leaves a 
red and sensitive surface. In Diphtheria 
the process of exudation continues to be 
active for some time ; on its cessation, 
there is a separation of membranous 
layers of considerable density and extent, 
which may represent a cast of the surface 
on which they formed ; a re-absorption is 
now possible of some of the products still 
imbedded in the mucous tissue ; this is 
accomplished either without loss of sub- 
stance, or with superficial ulceration only, 
and the sensibility of the surface is dimin- 
ished. In scarlet fever there may be 
sloughing of the tonsil, and there is a 
tendency to suppuration of the cervical 
glands. There is no tendency in the in- 
flammation of the throat in scarlet fever 
to be propagated to the air passages ; the 
nasal tone of voice, and the regurgitation 
of fluid through the nose, cease on the 
subsidence of the swelling cf the tonsils 
and lymphatic glands. In Diphtheria 
these symptoms often undergo a remark- 
able increase subsequently, from the para- 
lytic sequels of the disease. Scarlet fever 
has a definite course, modified only in de- 
gree of severity ; Diphtheria may either 
be arrested or modified in its course, so 
that the period of its duration is less 
definite. In scarlet fever there is a greater 
liability to inflammations of the serous 
membranes than in Diphtheria. Albu- 
minuria, as a sequel to scarlet fever, 
interferes with the excreting power of the 
kidneys, is attended with hsematuria, and 
more frequently results in dropsy and 
anasarca: it is an early symptom in 
Diphtheria, is rarely attended with hema- 
turia, seldom interferes with the excretion 
of urea, and does not result in dropsy. 
Both diseases are contagious, but while 
the contagion of Diphtheria has not been 
shown to give rise to scarlet fever, that of 
scarlet fever has apparently been followed 
by Diphtheria. They are not prophy- 
lactic of each other: in the late epidemic 
of Diphtheria, children who had gone 
through scarlet fever were equally liable 
to sufferand though in some cases a se- 
vere attack of Diphtheria has seemed to 
give an immunity from scarlet fever, yet 
instances are not wanting of those who 
have recovered from Diphtheria being at- 
tacked with scarlet fever. Dr. Buchanan,2 
of Glasgow, records the appearance of 
scarlet fever in a boy six years old, four 
days after the performance of tracheo- 
tomy, and in the second week of his ill- 
ness from Diphtheria ; anasarca appeared 
in the third week ; in the sixth week con- 
valescence was complete. A patient suf- 
fering from paralytic symptoms, conse- 
quent upon Diphtheria, while under the 
care of Dr. Stewart, in the Middlesex 
Hospital, contracted scarlet fever, during 
the febrile stage of which, and the full 
appearance of the rash, the paralytic 
symptoms cleared away. This modifica- 
tion of a symptom peculiar to the one dis- 
ease upon the establishment of a condition 
peculiar to the other, though an instance 
of the distinct nature of the two, does not 
show any necessary antagonism between 
them ; not only may the one succeed to 
the other at very short intervals, but it 
would seem to be possible for them to co- 
exist. The appearance in the throat 
characteristic of Diphtheria may com- 
mence after the subsidence of the redness 
occasioned by scarlet fever, and the dis- 
appearance of the rash ; they may, how- 
ever, come on at any period of its course, 
and more rarely the two diseases may 
seem to be coincident, so that the aspect 
of the throat on the first day may be indi- 
cative of Diphtheria, and with the charac- 
teristic rash of scarlatina appearing on the 
second or third day there may be a fall in 
the frequency of the pulse. In some epi- 
demics of scarlet fever undoubted cases of 
the disease occur without the character- 
1 Dr. Ballard, loo. cit. p. 78. 
2 British Medical Journal, September 1864, 
p. 324. DIPHTHERIA. 
72 
istic rash. A redness of the skin, and 
more or less marked rash or eruption, 
readily distinguishable from that of scarlet 
fever, has sometimes accompanied the 
early stages of Diphtheria. Mercatus1 
mentions a rash like flea-bites in some of 
the Spanish epidemics, and a redness of 
the whole face and neck, with loss of voice 
and dyspnoea. Fothergill describes a rash, 
in the first edition of his treatise, which 
he says, in a foot-note2 in the second edi- 
tion, did not regularly accompany the dis- 
ease, and which is certainly not that of 
scarlet fever ; it agrees more nearly with 
that lately observed, and described by Dr. 
Babington, as rubeola notha, which was 
sometimes, though rarely, seen in cases 
of Diphtheria, appearing on the first day. 
Dr. Fuller3 communicated to the Ilarveian 
Medical Society, February 1858, the case 
of a child ill with sore throat and a rash, 
like scarlet fever, from the commence- 
ment ; on the third day there were great 
dyspnoea and excitement with an increase 
of the rash and of the redness of the face ; 
by night a membranous cast of the pha- 
rynx was expelled, with immediate relief 
to the dyspnoea and a rapid subsidence of 
the redness and rash, so that by the next 
day no trace of either remained ; recovery 
■was rapid, there were none of the sequelie 
of scarlet fever, and no desquamation. 
Desquamation of the cuticle from the 
hands and feet has occurred after pro- 
longed illness from Diphtheria, when there 
has been no preceding rash. 
Erysipelas comes on with rigors, or 
chills, and headache ; there is pain in de- 
glutition, often extreme, and some en- 
largement of the cervical glands; the 
throat redness, though intense, is diffused ; 
there is no secretion, and none of the fibri- 
nous exudation characteristic of Diph- 
theria : this form of sore throat may occur 
either before or after the appearance of 
the erysipelas on the face or head. Ery- 
sipelas, smallpox, and measles are liable 
to be followed or complicated by Diph- 
theria. 
Diphtheria may follow upon typhoid 
fever or any prolonged and exhausting 
disease ; it is important, therefore, to dis- 
tinguish the sordes that collect in the 
fauces, and the special product of thrush, 
or muguet, to which such cases arc liable, 
from the exudation of Diphtheria. The 
matter of thrush is closely attached to the 
mucous membrane when it is first exuded, 
but it becomes more and more easily sepa- 
rable ; it occurs in little rounded masses, 
is whitish, and soon projects beyond the 
level of the surface : if artificially removed, 
the membrane beneath looks slightly hol- 
lowed, and either red or gray, but it is 
neither completely abraded nor ulcerated ; 
the buccal membrane and not the throat 
is specially the seat of this formation ; it 
acquires no great extent, nor considerable 
tenacity. Chemically, it has an acid re- 
action, is not acted upon either by acetic 
acid or by alkalies, and is only dissolved 
or destroyed by sulphuric acid ; these 
qualities are owing to the large parasitic 
vegetable growth of Oidium aIbicans, which 
also give to it special microscopical cha- 
racters. Sordes occur in patches of un- 
equal thickness, very little coherence, and 
no great extent, and are removable with- 
out injury to the subjacent tissue, however 
red and tender it may be ; they chiefly 
accumulate in front of the arch of the 
palate, acquire an acid reaction, and then 
also become the seat of the Oidium albi- 
cans. It is only when the diphtheritic 
exudation approaches to these local and 
chemical conditions that it becomes the 
seat of similar parasitic growths. 
Pathology.-The general disease and 
the local lesions that arise during its con- 
tinuance have an interdependence and mu- 
tual reaction. The latter are not confined^ 
to one period of the disease only; they oc- 
cur throughout its course, sometimes 
proving fatal by the vital importance of 
their site, at others adding to its force, 
and prolonging its continuance. The gen- 
eral disease impresses a special character, 
not only upon the local lesions which it 
occasions, but upon any concomitant mor- 
bid action: it is marked throughout by an 
elevation of the normal temperature of 
the body, by enlargement of the lymphatic 
glands and the spleen, by a varying amount 
of congestive action of the liver and kid- 
neys, and of various parts of the mucous 
surfaces, as well as that of the fauces and 
first air-passages, where the speciality of 
the diseased action is most marked, and 
where it sometimes expends its whole vio- 
lence. 
The local lesion peculiar to Diphtheria 
is most readily induced in surfaces ex- 
posed to the free access of air, and though 
not restricted to them, it is there that it 
assumes its most characteristic develop- 
ment; there is a state, of blood in the ca- 
pillaries, a destruction of the red corpus- 
cles, and a formation of fibrin, as shown 
by the spontaneous coagulation of part of 
the exudation. These changes take place 
in close contact with the bloodvessels, and 
commence in the mucous membrane be- 
neath the epithelium, transforming the 
cells of the sub-epithelial layer or of the 
epithelium itself, or altogether replacing 
1 Consultationes, p. 136. 
2 Op. cit. 2d edition, pp. 32, 33. It is not 
until the publication of the fifth edition, 
twenty years after this, that an error in the 
alteration of this foot-note, and an added 
paragraph to the preface, led to the confusion 
that has since existed between Fothergill's 
sore throat and scarlet fever. 
3 British Medical Journal, 1858, p. 173. PATHOLOGY. 
73 
them by the fibrinous exudation or false 
membrane. The false membrane cannot 
be detached without leaving a bleeding 
surface, which is rapidly covered with a 
new layer: it neither assists the cicatriza- 
tion of the surface on which it forms, nor 
ever becomes itself organized. Super- 
ficial ulceration results from the inter- 
stitial necrosis of some parts of the tissue 
invaded by it, but there is no gangrene or 
mortification of its substance. Changes 
of decomposition rapidly take place in the 
deposit itself, with injurious consequences, 
both to the lymphatic glands near, and to 
the system at large, from the absorption 
of effete matters; the site of these changes 
may occasion other ill effects, by contami- 
nating the air of respiration on its passage 
to the lungs. The disappearance of the 
false membrane is effected partly by this 
superficial destruction, and partly by ab- 
sorption from its under surface and edges, 
and by return to healthy action in the 
vessels below. It is seldom entirely sepa- 
rated in this way; a thin layer is often 
left, through which pink points gradually 
appear; soon only isolated spots of exuda- 
tion remain, which are finally removed by 
absorption, gradually effected as the pro- 
cess of reparation proceeds. This is some- 
times much retarded by the constitutional 
debility induced by the disease; and is 
sometimes interfered with by a retrograde 
process of ulceration. 
The extension of false membrane pro- 
ceeds, primarily, from the wide dissemi- 
nation of original centres of its deposit; 
secondarily, from the invasion of contigu- 
ous surfaces; the morbid action may thus 
extend gradually in every direction, or 
advance with great rapidity on the parts 
irritated by the accompanying serous exu- 
dation. This may be -one cause of im- 
plication of the air tubes,1 and of that 
progress of the disease from above down- 
wards which Louis was induced to con- 
sider as almost the law of its extension. 
An illustration of the opposite mode of 
extension is sometimes seen when Diph- 
theria extends from the nose to the lachry- 
mal duct, and thence to the conjunctiva; 
or in its progress from the lower edge of 
the palatine arch to the uvula; the tur- 
gescence preceding the exudation causes 
the uvula to be recurved upon the side 
already affected; soon the false membrane 
has not only invested the whole uvula, 
but extends upwards behind the velum. 
Wherever false membrane is formed, some 
degree of inflammatory action is excited; 
this may either approach very nearly, 
both in its products and symptoms, to the 
type of ordinary inflammation, or be en- 
tirely subordinated to the influence of the 
general disease, in which case this pecu- 
liarity is remarked-that the less marked 
the inflammatory condition, the more ex- 
tensive is the pseudo-membranous forma- 
tion. 
The evidence of the general disease 
next in importance is the existence of al- 
bumen in the urine. Dr. Copland, in his 
Dictionary, first mentions "albuminous 
urine" in his account of the pathology of 
croup, which is framed to include the 
croupal complications of this disease. We 
are indebted to Dr. Wade, of Birming- 
ham, for demonstrating the dependence 
of this system upon Diphtheria. Bouchut 
and Empis1 soon after called attention to 
its importance, and Dr. Sanderson2 con- 
siderably advanced our knowledge of its 
relation to the general course of the dis- 
ease, by showing that the presence of a 
considerable amount of albumen did not 
interfere with the large excretion of urea, 
which accompanies the progress of the 
general disease. I possess notes of three 
cases confirmatory of his observation; in 
that of J. B. before referred to, thirty-one 
determinations of the quantities of urea 
and albumen were made from the sixth to 
the thirty-seventh day of the disease, by 
Mr. W. Dunnett Spanton, now of the 
North Staffordshire Infirmary, at that 
time (1861) residing with me. On the 
tenth day of the disease, when the albu- 
men was estimated at one-third, the quan- 
tity of urea was twice as much as is nor- 
mally excreted, the specific gravity being 
1016; it was not until the thirty-seventh 
day that the urea fell to its normal quan- 
tity, and albumen was then for the first 
time absent; the specific gravity had fallen 
from 1015 to 1010. Subsequent observa- 
tions on the forty-seventh, fifty-fourth, 
and sixty-second days, agreed very closely 
with the last result. The albuminuria is 
not to be considered as solely dependent 
on an original change in the blood, but 
chiefly upon a morbid process in the kid- 
ney, which is one of the disseminated le- 
sions of structure occasioned by the gene- 
ral disease. Congestion of the Malpighian 
tufts is an early lesion, followed by further 
change in the tubular structure of the 
kidney; a relation is found between these 
changes and the amount of albumen, but 
no constant relation between the albumen 
and the amount of blood change. In the 
case of Walker, where albumen did not 
occur till late in the disease, the blood 
change was extreme, as evinced by hemor- 
rhagic oozing from the palate, petechise, 
and purpura; there was no hsematuria at 
1 Not only may noxious matters thus reach 
the trachea, but detached shreds of secretion 
from it may be drawn into the smaller bron- 
chi, and mechanically block up, by a kind of 
embolism, some lobules of the lung, as pointed 
out by Sir W. Jenner. 
1 L'Union Medicale, No. 132, 1858. 
2 Brit, and For. Med.-Chirurg. Review, 
January 1860, p. 196. 74 
diphtheria. 
any period, and recent disease of the kid- 
ney was found post mortem. That the 
function of the kidney may be seriously 
interfered with, and even suppressed, is 
shown by a case mentioned by Dr. Gull,1 
and by one reported at the Pathological 
Society, February, 1865, by Dr. Green- 
how.2 Dr. Humphry gives one instance 
of the occurrence of anasarca,3 but these 
cases are rare: albuminuria does not per- 
sist after convalescence. Blood changes 
may be concerned in these symptoms; 
that these changes are considerable during 
the progress of the disease is shown by 
the hemorrhagic tendency, by the occur- 
rence of fibrinous coagula in the heart and 
great vessels after death, by the remark- 
able pallor during the illness, and the anae- 
mia of convalescence, while the frequent 
affection of the spleen would point to a 
cause of this aglobulosis of the blood. 
Whether the lesions of innervation are 
owing to this cause, to a failure of nutri- 
tion in the nerve textures, or to a more 
special effect of the diphtheritic poison, is 
doubtful; from the instability of the dis- 
ordered innervation, and the variety of 
conditions which it assumes, we may con- 
clude with M. Trousseau, "that the le- 
sion of the nervous centres is not of a very 
grave character." The impairment of 
vision is generally, as remarked by Mr. 
Dixon,4 due to loss of adjusting power, 
and there is inaction of the ciliary mus- 
cles; he has not found any important 
change in the retina. Some of the more 
serious and persistent muscular paralyses 
are owing to wasting or degeneration of 
the muscular tissue itself. There are no 
good reasons for supposing that either 
special deterioration of the blood, or alte- 
ration of its quality, precedes the devel- 
opment of Diphtheria; a state of hyperi- 
uosis, if it were possible, is not that 
induced by many of the diseases to which 
Diphtheria readily succeeds; the altera- 
tions in the properties of the blood, physi- 
cal, vital, or chemical, are rather the con- 
sequences than the cause of the disease; 
and it would seem that the first influence 
of the disease, as well as its later effects, 
are exerted upon the nervous system. 
Morbid Anatomy.-The special pro- 
duct of Diphtheria has affinities with some 
deposits formed in other diseases, with 
the products of some forms of inflamma- 
tion, and with the huffy coat of the blood, 
which it often closely resembles in appear- 
ance and some of its physical properties. 
It has an alkaline reaction, swells, and 
becomes transparent in strong acetic acid, 
and is disintegrated or dissolved by caus- 
tic alkalies. It is unaltered by maceration 
in water, and yields no gelatine to it, as 
tested by tannin ; in this respect it differs 
from the bully coat, and from coagulable 
lymph, and also in giving no evidence of 
albumen on being boiled ; it is stained 
brown by tincture of iodine, and assumes 
entirely the character of pure fibrin. It 
is possible to obtain solution of some speci- 
mens in the same way that Denis1 dis- 
solved recent fibrin, and to find them un- 
mixed with other protein matters ; other 
specimens less fibrillated, or less recent, 
are not acted upon in this way. The 
tubes of exudation found in the bronchi 
will often lose their coherence on macera- 
tion in water only, and afford evidence of 
albumen on boiling, which will not always 
be the case with the denser membrane 
from the trachea. 
Microscopically the superficial part of 
the exudation is made up of the epithe- 
lium of the membrane on which it occurs, 
entangled in the upper layers of a trans- 
parent homogeneous substance, through- 
out which are found some altered epi- 
thelium cells, granular corpuscles, and 
nucleolar bodies, in varying proportion; 
they become less numerous in the lower 
layer of the exudation, in which blood- 
corpuscles and pus cells frequently occur. 
Fibrillation, similar to that of other 
fibrinons exudations, is sometimes ob- 
served on the under-surface of the diph- 
theritic false membrane, from the fauces. 
The false membrane from the trachea is 
corpuscular throughout, as is also the 
pulpy and granular deposit which is some- 
times found in the fauces, and is more 
frequent in the larynx; these deposits 
rapidly pass into-granular degeneration. 
In the bronchial exudation the corpuscu- 
lar element differs little from that observed 
in the product of ordinary inflammation 
there ; sometimes little flakes of fibrin are 
found attached to the bronchial mem- 
brane, but the only other evidence of its 
presence is the coherence of the bronchial 
casts. The laminated, or fibrillar, the 
pultaceous and the granular, or corpuscu- 
lar, are the leading forms of this exuda- 
tion ; they may present themselves in any 
combination under the same morbid influ- 
ence ; in the trachea they are always as- 
sociated. and either may predominate; 
the fibrillated may be deposited in the 
mucous and submucous tissue of the 
larynx,2 and the granular may be seen in 
1 Arch. Gen. de Med. s. 3, tom. i. p. 171. 
Half a drachm of nitre to an ounce of water 
will effect this at a mean temperature. The 
solution is imperfect, viscid, coagulates in 
flakes at 1630 Fahr., and is strongly precipi- 
tated by acetic acid. 
2 Dr. Bristowe, Trans. Path. Soc. Lond. 
vol. x. p. 323. 
1 Second Report of the Medical Officer of the 
Privy Council, p. 304. 
2 Transactions of the Pathological Society 
of London, vol. xvi. p. 47. 
3 British Medical Journal, July, 1863, p. 4. 
4 Holmes, System of Surgery, vol. ii. Dis- 
eases of the Eye, p. 766. MORBID ANATOMY. 
75 
the fauces together with the laminated, 
the less coherent deposit, misnominated 
croupous, being as truly diphtheritic as 
the more tough, leather-like formation. 
The one point common to both is their 
intimate relation to the structure of the 
membrane on which they are formed. In 
the case of Bowra I saw deposit in the 
contiguous edges of the true and false vo- 
cal cords, the sacculus laryngis being free, 
and the commencing granular deposit in 
the trachea firmly imbedded in the mu- 
cous membrane. Dr. Wilson Fox has 
demonstrated, in all stages of tracheal 
exudations, lesions of the membrane some- 
times exposing the fibrous tissue beneath, 
both in adults and in children. M. Hache 
observes' the resistance to the separation 
of the false membrane from the trachea 
at a certain stage, and calls attention2 to 
the sanguineous points found imbedded 
in its under-surface when removed. 
The condition of the tissue in which the 
morbid action is exerted, though of less 
importance than the general course of the 
disease, affords better means of character- 
izing it than the exudation to which it 
gives rise : the unsatisfactory nature of a 
distinction founded upon the two forms 
of exudation in this disease is thus ad- 
mitted by the most advanced pathologists 
of Germany :3-" The difference which I 
formerly established between the croupous 
and diphtheritic forms, is often lost in 
particular cases, so that the true croup of 
the larynx and trachea invades the tissue 
of the mucous membrane, ay, very often 
coexists with Diphtherite at the back of 
the pharynx and of the fauces; and not 
till the deeper bronchi are reached, or the 
pulmonary cells, does it become a free 
exudation. This is found not only in the 
epidemic croup of children, but also in 
Diphtherite occurring in typhoid condi- 
tions, and in hospital gangrene ; or simul- 
taneously with diphtheritic necrosis of the 
vaginal and intestinal mucous surfaces." 
This interstitial necrosis, or ulceration of 
the surfaces in relation with the exuda- 
tion, is the anatomical character on which 
the distinction between the diseases here 
mentioned and Croup, in our acceptation 
of the term, must be based. 
The diphtheritic deposit may occur in 
isolated patches, or extend continuously 
from the nares to the bronchi ; it may be 
moulded on to any anfractuosity of the 
nasal passages ; it may line the whole 
pharyngeal cavity, adhere to both surfaces 
of the epiglottis, cover the interior of the 
larynx, form a cylindrical cast of the 
trachea, and may thus be removable from 
even the smaller.bronchi. More rarely it 
is found to extend in this manner through- 
out the oesophagus ; in one of the two cases 
reported by Bretonneau,1 it was strongly 
adherent to the upper part of the tube. 
In two of seventy-four cases tabulated in 
the British Medical Journal,2 the oesopha- 
gus was partially affected, one with, one 
without extension to the air-passages. In 
a case reported by Dr. Morley Harrison, 
of Manchester,3 the false membrane ex- 
tended forwards to the mouth, and a 
patch existed upon the fraenum linguae. 
Dr. Bristowe gives an instance of the 
upper part of the oesophagus being cov- 
ered. Virchow alludes to one case ; he 
has seen the occurrence of false membrane 
in the gall-bladder.4 
The tonsils are frequently the seat of 
this formation ; it is often detached early, 
but may accumulate to a surprising thick- 
ness, the outer surface retaining for a 
time the exact appearance of the enlarged 
tonsils, and marked with the opening of 
its follicles. I have met with one speci- 
men, which it was difficult to believe was 
not the organ itself under examination ; 
every part of it was soluble in Denis' 
solution, and no trace of organized tissue 
occurred throughout its substance ; this 
exudation has attained to the thickness of 
two-thirds of an inch.5 The decomposi- 
tion of such concrete deposits, their varied 
color from admixture of altered blood, and 
their detachment in offensive shreds, has 
often given a false idea of the gangrene of 
the tissue beneath, which really remains 
almost intact. Bretonneau called atten- 
tion to the importance of this fact, but 
while he correctly described the " ecchy- 
moses of no great extent, as well as the 
slight erosion of the surfaces on which the 
disease had existed longest,"6insisted too 
much upon the integrity of the mucous 
membrane being always preserved ; but 
though much may be repaired before 
death, it is rare not to find some evidence 
of lesion of the mucous membrane. Some- 
times the submucous layer is bare and 
granular, without defined ulceration ;7 at 
other times a defined ulcer exists, exposing 
the muscular fibres.8 M. Louis noticed 
erosion of cartilage at the posterior nares. 
The uvula and part of the soft palate have 
1 These cases, and two others occurring in 
children with implications of the larynx, are 
mentioned by Barthez and Rilliet, tome i. p. 
322. 
2 Brit. Med. Journ. 1859, pp. 305-6. 
3 Ibid. 1863, vol. i. p. 306. A complete 
cast of the tube was ejected. 
4 Op. cit. vol. i. p. 292. 
5 Memoirs on Diphtheria. New Sydenham 
Society, 1859, p. 98. 
6 Traite de la Diphtherite, p. 33. 
7 Dr. J. R. Hughes, Brit. Med. Journal, 
1859, p. 80. 
8 Barthez et Rilliet, tome i. pp. 259 and 287. 
1 Barthez and Rilliet, tome i. p. 318. 
2 Ibid. p. 319. 
3 Virchow, Path, und Therapie, vol. i. p. 
292. 76 
DIPHTHERIA. 
been lost by ulceration.1 Dr. Sanderson2 
mentions the division of the left half of 
the soft palate by a penetrating ulcer. 
Mr. Simon3 describes a circular ulcer of 
the pharynx and other signs of ulceration. 
Dr. Ashley4 observed phagedama com- 
mence at one tonsil and extend to the 
carotid. Ulcerations on either surface of 
the epiglottis, and on the mucous mem- 
brane of the larynx and trachea, are fre- 
quently met with. The submucous tissue 
may be infiltrated with blood, with serum, 
or with inflammatory products. Dr. New- 
man5 reports the formation of an abscess 
in the palate soon after the disappearance 
of the superficial exudation. In the case 
described by Sir T. Watson,6 pus was 
found in one tonsil, and this has since 
been not infrequently observed. Mr. 
Pound,7 of Odiham, reports a case of ab- 
scess in the pharynx, and Greenhow8 
gives one of post-pharyngeal abscess. 
Suppuration rarely, if ever, occurs in the 
cervical glands ; they are large and red, or 
paler, and brittle, and sometimes present 
a spleniform disorganization ; the swelling 
around them is from infiltration of serum 
in the cellular tissue. Dr. Bristowe9 re- 
ports a remarkable effusion of blood among 
all the tissues of the neck. Various forms 
of petechise, purpura and superficial es- 
chars are found upon the skin, and spots 
of purpura, petechise, and ecchymotic 
staining are frequent in other parts of the 
body, as in the muscular tissue and under 
the serous membranes, as on the lung, 
upon or within the heart and the perito- 
neum. I have met with no instance of 
inflammation of the serous membrane. 
Fatty degeneration of the muscular tissue 
of the heart occurred in the case reported 
by Dr. Bristowe. 
Fibrinous coagula are very frequently 
met with in the cavities of the heart, ex- 
tending into the great vessels. This oc- 
currence is not limited to cases where 
there has been obstruction of the air-pas- 
sages, though they are at least as frequent 
in the right cavities as in the left. Dr. 
Barry,0 of Tunbridge Wells, reports three 
cases, all in the right side of the heart; 
the coagulum existed in the right auricle 
only in one case, and in another extended 
into the pulmonary artery. Dr. Rollo' 
gives the case of a soldier where, with 
the characteristic exudation of Diphthe- 
ria, fibrous polypi were found in the right 
ventricle. The lungs are frequently con- 
gested, and the seat of lobular hepatiza- 
tion in various stages, often sufficiently 
extensive to be the cause of death, even 
where no exudation has occurred in the 
air-passages. Pulmonary apoplexy is 
sometimes found. Where the air-pas- 
sages are the seat of the exudation, lobar 
and lobular pneumonia, the latter often 
secondary to embolism of the smaller 
bronchi, with collapse of lung tissue, and 
acute vesicular emphysema, have gener- 
ally been induced. The vessels of the 
brain or of the pia mater have presented 
fine injection in some cases ; in others 
there has been fulness of the sinuses, and 
even transudation of blood ; and Dr. Gull 
reports2 suppurative inflammation of the 
membranes of the brain and cord, with 
soft, purulent lymph in the sub-arachnoid 
space. Dr. Humphry3 has met with a 
small spot of suppuration on the under- 
surface of the left cerebral hemisphere, 
with softening of the adjacent brain sub- 
stance, attributed to Diphtheria. The 
liver is frequently found full, sometimes 
greatly congested, but is seldom the seat 
of disease. The stomach often presents 
serious changes, its mucous membrane 
being softened, unequally thickened, and 
red from small patches of deep-colored 
congestion, or from extravasated blood ; 
sometimes these changes are found in 
connection with isolated patches of opaque 
deposit at its cardiac end, and the oeso- 
phagus presents abrasions of its mucous 
membrane when it has been the seat of 
deposit. Vascular injection and minute 
ecchymoses have been found in the small 
intestines, the follicular orifices are often 
conspicuous, more rarely Peyer's patches 
in the lower part of the ileum are very 
distinct and prominent; sometimes de- 
posit and ulceration occur in the large 
intestines, hardly distinguishable from 
that of dysentery. The spleen is gener- 
ally found full and soft, more frequently 
paler in color than redder, and often pre- 
senting a cloudy or opaque appearance on 
section. 
The kidneys may often appear healthy 
to the naked eye, but are very rarely 
found so under microscopic investigation; 
they generally present well-marked, and 
semetimes extreme evidence of special 
change : this is chiefly in the intra-tubu- 
lar structure, and though congestion of 
the Malpighian tufts is often very conspi- 
1 Greenhow, op. cit. p. 201. 
2 Log. cit. p. 191. 
3 Trans. Path. Soc. Lond. vol. x. p. 317. 
4 Brit. Med. Journ. 1859, p. 490, case 60. 
5 Ibid. 1863, vol. i. p. 215. 
6 Lectures on the Practice of Physic, vol. i. 
p. 865. 4th edit. 
7 Brit. Med. Journal, 1858, p. 750. Report 
of Reading Path. Soc. 
8 Op. cit. p. 237. 
9 Trans. Path. Soc. of London, vol. x. p. 
328. 
10 British Medical Journal, 1858, p. 623. 
1 Essay on Cynanche Trachealis, by John 
Cheyne, M.D. 4to. Edin. 1801. P. 68. 
2 Loc. cit. p. 299. 
3 Brit. Med. Journal, July, 1863, p. 4. PROGNOSIS 
77 
cuous, the general aspect, sometimes mot- 
tled from an irregular blending of anaemia 
and congestion, is more often of a pale 
than of a deep color ; they have not been 
found in the extreme state of disorgani- 
zation sometimes seen after scarlet fever. 
The tubules appear opaque, from the 
epithelial cells being numerous, easily 
detached, and filled with an unusual 
amount of finely-granular material, in 
which oily globules are sometimes abund- 
ant. Some tubes are devoid of epithe- 
lium, and present transparent, fibrinous 
casts, or these are found separated from 
the tubes to which they correspond in 
diameter; occasionally blood-corpuscles 
are found in the tubules ; more frequently 
they are filled with masses of epithelial 
cells and fibrinous exudation. These 
changes are as noticeable in the medul- 
lary as in the cortical structure ; granular 
exudation is also found between the Mal- 
pighian capillaries and their capsule. 
The supra-renal capsules have been found 
intensely vascular. 
Prognosis.-No case of Diphtheria is 
to be regarded without anxiety; every 
danger incident to the disease may re- 
sult, though the early symptoms are but 
slightly marked. The successive appear- 
ance of fresh patches of deposit, of albu- 
minuria, or of other signs of the disease, 
excites alarm, lest its next local manifes- 
tation should be in the larynx : the simul- 
taneous occurrence of many of these signs, 
and the increase of any of them, as of the 
enlargement of the lymphatic glands, and 
of the amount of exudation, indicate an 
intensity of the general disease which the 
young or enfeebled will hardly withstand1' 
and which, with implication of the larynx, 
will be rapidly fatal. The least laryngeal 
quality of the voice or cough, and espe- 
cially of the respiration, is a sign of the 
greatest danger ; it may, in the strongest 
person, soon end in fatal obstruction of 
the glottis from the occurrence of exuda- 
tion there, or it may be the first indica- 
tion of the equally fatal and more insidious 
extension of it to the bronchi. Much 
exudation in the nasal passage is unfavor- 
able. If both nares are occluded, respi- 
ration must be carried on by the mouth 
with great discomfort; this may be a 
cause of death in young children, as they 
are thus unable to suck. The occur- 
rence of hemorrhages is a bad and dan- 
gerous symptom ; so is repeated vomiting 
and purging at the commencement of the 
attack. These symptoms occurring some- 
what later, bring on death by exhaustion, 
and indicate either serious alteration in 
the blood, or that the stomach has be- 
come the seat of the disease. A very 
rapid pulse, except at the commencement, 
is indicative of danger; so also if the 
pulse fall below the normal frequency. 
Albuminuria, if unattended by any rise 
in temperature, is in itself not serious as 
long as the urine is in normal quantity, 
without blood corpuscles or casts of tubes, 
and while the specific gravity continues 
to be high. Any increase of the tempe- 
rature of the body after the first five days, 
or a persistence of high temperature after 
the first ten days, is unfavorable ; a sud- 
den rise may indicate danger from some 
intercurrent disease. There is also the 
danger of relapses from the slightest debili- 
tating causes, either in the earliest or at 
the latest periods of the illness. The 
liability to laryngeal obstruction is great- 
est towards the end of the first week; it 
begins with the commencement of the 
disease, and probably continues through- 
out ; this complication has happened as 
late as the fourteenth day,1 and possibly 
later.2 These dangers are especially 
treacherous, as they may occur in cases 
where there has been but little exudation 
on the larynx, and as a period of compara- 
tive convalescence may intervene between 
either the first symptoms and the laryn- 
geal complication, or between those of the 
more advanced disease and its asthenic 
accidents. The first impression of the 
general disease may be so profound as to 
make recovery impossible ; on the other 
hand, cases commencing with marked 
constitutional reaction, and with symp- 
toms generally unfavorable, such as vom- 
iting, epistaxis, or nocturnal delirium, 
may recover without experiencing the 
more serious consequences of the disease. 
Certain epidemics and certain periods 
of them are marked by a great fatality, 
and instances have occurred in which all 
or nearly all of those seized have died. 
Age and family constitution have the 
greatest influence ; where one member of 
a family has suffered severely from this 
disease, there is the more reason to dread 
its effects upon the younger members of 
the same family. The proportion of deaths 
to seizures in 1,321 cases reported in the 
British Medical Journal for 1858-59, is one 
in seven ; among the severer cases, and at 
the height of any local epidemic outbreak, 
it was as high as one in three ; in other 
cases it was less than one in ten. Of the 
seventy-four cases collected by the British 
.Medical Journal,3 twenty-six died,-four- 
1 Etude de la Diphtherite, par G. S. Empis* 
Arch. Gen. de M6d., 1850, s. 4, tome xxii. p. 
298. 
2 Cases of Diphtheria, by G. M. Humphry, 
M.D. Case 7. Brit. Med. Journal, July 4, 
1863. Dr. Ballard tabulates one case, loc. 
cit. p. 55. 
3 Brit. Med. Journal, 1859, p. 498. Of 
eighty fatal cases occurring in Islington in 
1858-59, Dr. Ballard found that in fifty-eight 78 
DIPIIT1IERIA. 
teen from asthenia, eight from implication 
of the larynx, three from syncope, and 
one from subsequent bronchitis. These 
cases were mostly severe, and seldom 
under treatment at their commencement. 
One of the most important conditions of a 
favorable result is the early recognition 
and treatment of the disease. 
Therapeutics.-In Diphtheria both 
local and general means of treatment are 
required ; the cure of particular cases may 
sometimes be attributable to the one, 
sometimes to the other, but in no case can 
either be safely disregarded. The general 
therapeutical indications are of primary 
importance throughout; they consist 
neither in attempts to nullify a poison by 
specifics, nor to expel it by elimination, 
but in withstanding the encroachment of 
the disease, and in sustaining the vital 
powers. 
Complete rest and purity of air are es- 
<Tsential. Alcoholic stimulants are required 
throughoutthey are often as service- 
able early in the disease as in that part of 
k its course when they become indispensa- 
IJole. A rapid pulse indicates their em- 
ployment, and heat of skin is no counter- 
indication. The limit to their adminis- 
tration should be calculated according to 
the age of the patient and the amount of 
bland liquid representing water that can 
be taken at the same time. In certain 
cases one or two full doses of quinine may 
be given, often with good effect when there 
is either vertigo, headache, or vomiting ; 
soon afterwards beef-tea, eggs, or even 
more solid food, can be taken, as well as 
the brandy or wine ; milk, in any form, is 
always suitable. The night must not pass 
without either nourishment or stimulant 
being given; wakefulness or nocturnal 
delirium is often thus obviated ; some- 
times a dose of morphia or opium has to 
be combined with the stimulant, after the 
second or third night, if restlessness then 
persist. 
The condition of the fauces must be al- 
leviated by the free use of ice sucked or 
swallowed, and by any of the soothing 
means hereafter mentioned internally, 
and by moderately warm applications ex- 
ternally. [One of the most comfortable 
and often really serviceable applications is 
ice, taken into the mouth in small pieces 
and swallowed slowly. Some practitioners 
assert this to have a more beneficial effect 
than any other local remedy.-II. ] When 
the patient first comes under observation, 
a patch of exudation may be apparent, 
such as to require energetic topical mea- 
sures. For this purpose a solution of 
nitrate of silver should be applied so as 
thoroughly to come into contact both with 
the patch and the turgid mucous mem- 
brane surrounding it. The strength of 
the solution should not exceed the propor- 
tion of one part of nitrate of silver to 
three of distilled water; the superficial 
whiteness left by it will clear off in twenty- 
four hours, and is easily distinguishable 
from the points of exudation. A mixture 
of hydrochloric acid and honey in equal 
proportions, or with one or two parts of 
water, is as effectual in checking the pro- 
gress of the exudation, but leaves a more 
persistent white mark. These applica- 
tions, when seen to be efficient, need not 
be repeated ; care is to be taken that no 
excess of them reach beyond where they 
are required. The strong acid and solid 
nitrate of silver are both objectionable.1 
Where there is much redness and pain a 
weaker solution of nitrate of silver, one 
part to eight or twelve of water, pencilled 
over the whole surface, tends to prevent 
further exudation, and affords relief to 
the local discomfort. Hydrochloric acid, 
diluted with five parts of water, may be ap- 
plied in the same way with the same effect. 
As soon as nourishment, however light, 
can be retained by the stomach, five to ten 
grains of the perchloride of iron, the equi- 
valent of twenty or forty minims of the 
tincture, should be given, with not less 
than half an ounce of water and half a 
drachm of glycerin ; this should be re- 
peated every three or four hours, or still 
more frequently, so that as much as a 
drachm of the iron, or half an ounce of 
the tincture, be taken in the course of 
twenty-four hours. This quantity may 
be reached even in children, during severe 
attacks. It should be commenced on the 
first day of the illness, or as soon as the 
deaths twenty-seven were from laryngeal affection, and twenty-three from exhaustion; thus 
distributed as to age and period of illness :- 
Under 
5 Years. 
Under 
10 Years. 
10 Years 
and 
upwards. 
1st Week. 
2d Week. 
3d Week. 
4 th Week. 
Laryngeal affection . . 
17 
7 
3 
18 
8 
1 
Exhaustion .... 
13 
5 
5 
8 
8 
3 
4 
1 [Not, however, in every case.-H.] 
1 Extreme dysphagia has at once subsided 
on the use of solid nitrate to a foul or irritable 
ulcer consequent upon Diphtheria. •THERAPEUTICS 
79 
patient comes under notice, and continued 
till the tongue becomes red and the throat 
improves ; when deposit has already taken 
place, the good effect of the remedy will 
be shown, not by any alteration in the 
dimensions of the patch, but by a dimi- 
nution in the accompanying secretion, and 
by an improvement of the general symp- 
toms ; it is not to be discontinued for 
some days, and may require energetic 
repetition if improvement is slow in ap- 
pearing. Dr. Druitt1 reports a case where 
great benefit followed upon the quantity 
of the tincture of the muriate of iron, ad- 
ministered under the direction of one of 
the physicians of the Middlesex Hospital, 
amounting to one ounce and a half in the 
twelve hours. Mr. Hamilton Bell,2 of 
Edinburgh, first proved the utility of iron 
in this form and quantity in erysipelas, 
and his brother, Dr. C. Bell, advocated 
its employment in analogous diseases; 
hence its application in Diphtheria. Dr. 
Godfrey,3 of Enfield, used it in this way, 
and its use was further recommended by 
Dr. Heslop, of Birmingham; it was em- 
ployed with advantage in the Boulogne 
epidemic, and M. Aubrun4 gives the re- 
sult of three years' favorable experience. 
The solutions of the pernitrate of iron, or 
of the acetate, answer equally well when 
given in proportionate doses, the latter 
being stronger, the former of less strength, 
than the tincture of the perchloride. A 
local as well as a general influence is 
exerted by these agents; they have a 
constringing effect on the vessels, and 
their action on the decomposing exuda- 
tion is antiseptic ; their general effect is 
as much owing to a topical action on the 
whole gastro-intestinal canal, as to ab- 
sorption, for when the prescribed quantity 
of the persalt of iron is reduced by soda in 
the presence of citric acid, and so admin- 
istered in a soluble form little liable to 
decomposition, and readily available for 
absorption, no favorable effect is produced ; 
indeed, none of the protosalts of iron are 
equally efficacious at the outset of the dis- 
ease. [Chlorate of potassium (mentioned 
further on) is regarded by many physicians 
in America as the most valuable of medi- 
cines in Diphtheria. It may be used early 
and freely; with adults, twenty grains 
every three hours; with children five 
years old, five grains, every two or three 
hours, will not be excessive.-II.] 
The local action upon the surfaces af- 
fected is certainly important; and when 
the nasal passages are implicated, syring- 
ing them with perchloride in a solution 
slightly weaker than that prescribed for a 
draught, is essential; half a drachm each 
of the tincture of the perchloride of iron 
and glycerine with six or seven drachms 
of water, may be injected into the nares 
by an ordinary glass syringe, the point of 
which is shielded by a piece of india- 
rubber tubing, or into the upper part of 
the pharynx by means of the laryngeal 
syringe directed upwards. These parts 
may be gently and efficiently irrigated by 
placing a vessel of any fit liquid at an ele- 
vation, and inserting an india-rubber tube 
from it into either nostril. When the 
patch is already formed, and the secretion 
in the fauces considerable, it is well to 
apply a stronger solution of the perchlo- 
ride, not exceeding the strength of the 
tincture, by means of a full-sized camel's- 
hair brush, both to the patch and to the 
adjacent surfaces. A patch of consider- 
able thickness, and intimately adherent 
to the membrane, may be touched with a 
preparation twice the strength of the tinc- 
ture, made by mixing equal parts of the 
liquor ferri perchloridi and of glycerine ; 
this application is strongly styptic, and 
should be confined to the surface of the 
exudation, which it readily penetrates : 
and exerts its influence upon the vessels 
beneath. Where the use of the persalts 
of iron is commenced early, and persisted 
in, the necessity for local application to 
the throat is often obviated, and it is better 
to encounter a little difficulty in the ad- 
ministration of the medicine, which may 
be given in any degree of dilution, than to 
be obliged to resort to the always dis- 
agreeable, though often indispensable, 
performance of topical medication. The 
medicine is better given at the time of 
taking nourishment, the pain of swallow- 
ing diminishes under its use, and its ap- 
plication in any way to the whole pharynx 
affords relief. 
Difficulty of deglutition is often a seri- 
ous aggravation of the illness. Much 
benefit is derived from the application of 
the perchloride of iron diluted with water 
to the strength of the tincture, but with a 
further addition of glycerine, to the pha- 
rynx by means of a camel's-hair brush 
two or three times in the first twenty-four 
hours. Pure glycerine1 applied in this 
way is very soothing, and the frequent 
use of more simple means conduces to re- 
lief. A lotion of acetate of lead, gr. ij ad 
§j, relieves. A weak solution of tannin, 
with a little chlorinated soda, is useful. 
Lime water as a wash, or gargle if the 
effort be not too painful, alleviates; so 
does the injection of cold water into the 
pharynx. The most grateful, and in all 
cases one of the most useful appliances, is 
ice in small pieces, dissolving in the 
mouth. Weak solutions of borax, or qf 
1 Brit. Med. Journ. 1861, vol. i. p. 208. 
2 Edin. Monthly Journal, June 1851. 
3 Lancet, October 17, 1857. 
4 Gazette Med. de Paris, December 8, I860, 
f. 764. 
1 Dr. Mayer, American Journal of Med. 
Sciences, April 1858. 80 
DIPHTHERIA 
alum, with honey or glycerine, or a strong 
solution of chlorate of potash, are useful 
where there is much tenacious secretion ; 
the latter salt in coarse powder, or small 
crystals of it, may be taken into the mouth 
from time to time with benefit. Any of 
these may be used either cold or tepid as 
may be most grateful to the patient, and 
when there is fetor, or the glands are 
much swollen, Condy's fluid (permanga- 
nate of potash), largely diluted, or chlori- 
nated soda, one part of the strong solution 
to twelve or fifteen parts of water, is to be 
used so as to wash away any detached 
exudation, and this by means of a syringe 
if not otherwise easily manageable. The 
strong solution of chlorinated soda may be 
directly applied to any foul surface not 
yet detached, or to any foul ulceration 
when there is induration of the external 
glands. The Pharmacopoeial glycerine of 
carbolic acid is a convenient local remedy 
when decomposing matters are tainting 
the breath. The similar glycerine of 
gallic acid checks hemorrhage from parts 
whence the slough is separating. The 
glycerine of tannin is most useful in the 
earlier stages of the disease, and is a 
necessary application to the fauces where 
bark with a mineral acid in the place of 
iron and quinine is the general medication 
adopted. Semi-detached shreds of de- 
composing matter are to be carefully re- 
moved ; such matters cannot be allowed 
to remain with safety where they are ; 
they must be reduced to the smallest 
amount possible, and antiseptics employed 
until they disappear. When exudation 
ceases, the necessity for local application 
has passed ; some portions of deposit will 
be slow in clearing away, and may remain 
without interference ; abrasions or ulcera- 
tions of the mucous membrane heal most 
quickly when left alone. A tender sur- 
face is never to be exposed by the forcible 
removal of any adherent exudation.1 
All the remedies of special utility in 
Diphtheria are antiseptic: the stronger 
forms above indicated are limited in their 
application to parts that can be brought 
within the range of sight or touch. This 
range may in some states of the disease 
be extended by the use of the laryngo- 
scope not only in the direction of the 
larynx, but also towards the posterior 
nares. 
Many of these agents can be most advan- 
tageously used in all stages of the treat- 
ment by atomizing their dilute aqueous 
solutions in the manner first suggested by 
M. de Sales Giron. Any of the spray- 
producers now in use will effect this, and 
supply a ready means of diffusing the rem- 
edies over every part of the mucous sur- 
faces obnoxious to the disease. Dr. De- 
war, of Kirkcaldy, has shown that the 
strong sulphurous acid of the Pharmaco- 
poeia may be used at short intervals with 
benefit, and has devised a portable instru- 
ment with a vulcanite tube for the pur- 
pose. In one case where this was used 
without resort to the iron treatment in a 
child, no laryngeal extension of the dis- 
ease occurred. A mixture of sulphurous 
acid and honey for frequent deglutition 
was useful in clearing the posterior nares; 
the fauces required an occasional applica- 
tion of glycerine of tannin ; on the four- 
teenth day acute kidney complication 
began, and terminated fatally on the 
eighteenth day. When the tincture of 
perchloride of iron is given (generally 
combined with quinine), very little local 
treatment other than the spray is resorted 
to. Besides the weak Condy's fluid, a 
still weaker solution of carbolic acid, a 
teaspoonful to a pint of water, may be 
used in this way ; a few spoonfuls of the 
latter solution is advantageously given oc- 
casionally as a drink. Both these liquids 
should be kept in the sick-room in a 
stronger form, both for diffusion into the 
air of the room by means of the vaporizer, 
and ready for disinfecting any secretions 
or soiled clothes. 
There are other remedies that some- 
times are necessary in checking the spread 
of Diphtherite, or in modifying its charac- 
ter. The salts of copper, as used by Are- 
tseus, are very effective, but their use is 
not free from danger. Alum in powder 
(the poudre croupale of Pommier) is as ef- 
fective, and both safe and simple in use ; 
it may either be used alone, or mixed 
with one-third of its bulk of finely-pow- 
dered nitrate or chlorate of potash, or 
with a less proportion of sugar or gum ; it 
may be applied to the throat by insuffla- 
tion, as practised by Bretonneau,1 or by 
making it into a paste with a drop of wa- 
ter, and carrying it to the part by means 
of a rod or spatula, or on the handle of a 
tablespoon. When required in the upper 
or lower part of the pharynx, or indeed 
1 2Etii Amid, tetrab. 2, serm. 8, cap. 46 : 
"Nam inscii ad quos in rebus dubiis praeci- 
pue homines confugiunt, vehementius illi- 
niunt, simulque inflammatum locum compri- 
munt, simulque crustam detrahunt; quod 
minime facere convenit, priusquam elevatam 
et vix innitentem crustam conspiciamus; 
quod si enim adhaerentem adhuc crustam 
avellere aggrediamur ulcerationes magis in 
profundum procedunt et inflammationes con- 
sequuntur, augentur dolores, et in ulcera 
serpentia proficiunt: itaque sicca remedia in- 
sufflare oportet, liquida vero cum pinnula 
illinito, ita ut quantum licuerit, pinnulam 
penitissime immittamus." "Ex quo prae- 
cepto docent medici, quod cbm pueri nequeunt 
gargarismatis uti, injiciantur cum siring^ 
medicamenta liquida." (Heredia op. Med. 
tom. iii. sec. 3, cap. xii.) 
1 Archiv. Gen. de M6d. tome xiii. p. 5, and 
tome xvii. p. 508. THERAPEUTICS. 
81 
on any part from the gums to the glottis, 
that best and safest of all instruments, the 
end of the finger, may be used for this 
purpose ; in the same way, with the pro- 
tection of a little cotton-wool wrapped 
around it, the other local remedies can be 
carried to any spot determined upon, with- 
out at the moment requiring the aid of 
sight. Calomel has an undoubtedly use- 
ful topical effect, as is seen in its applica- 
tion to cutaneous Diphtherite. Any sore 
on the skin should receive careful atten- 
tion, as, however trivial at first, it may 
seriously compromise the prospect of re- 
covery, either by spreading or by deepen- 
ing so as to lay bare the subjacent struc- 
tures. In addition to the requisite escha- 
rotics, cotton-wool should be used as a 
dressing; greasy applications are inju- 
rious. 
The care given to the local treatment 
will fail of success, the diseased action 
checked at one part will reappear, or 
again extend rapidly, if the general con- 
dition necessary for a safe conduct 
through the illness be disregarded. Chil- 
dren, when improving, must continue in 
bed ; it is the only place where they get 
rest of limb. There must also be pre- 
cautions against fatigue from over-amuse- 
ment or excitement. The period during 
which rest is to be enjoined is not merely 
while exudation remains, but while any 
symptom of the disease continues, such as 
slightly elevated temperature, excess in 
the excretion of urea or urates, or albu- 
men in the urine ; care is still more neces- 
sary in providing against any undue ex- 
penditure of strength during some of the 
after effects of the disease. 
As long as solid food cannot be taken, 
it is to be noted with the greatest exacti- 
tude that the quantity of the liquid nour- 
ishment and of stimulant administered in 
the twenty-four hours is equal to the esti- 
mated requirement of the patient; the 
less the quantity of nourishment, the 
greater must be the dependence upon the 
stimulant. The youngest children may 
require a teaspoonful of brandy every two 
hours ; a child of three years old two tea- 
spoonfuls. This may be given diluted in 
any way and in very small quantities fre- 
quently repeated. Older children take it 
best mixed with iced water or soda-water. 
Champagne is often a good substitute; 
port wine requires dilution, except for 
adults, who also find good claret, red 
hock, or some of the stronger Hungarian 
wines, suitable. The quantity of stimu- 
lant ordered must be considered in rela- 
tion not only to the immediate necessity 
that may exist for its employment, but 
also to the probable course of the disease 
and the strength of the patient; a mode- 
rate quantity, repeated at regular inter- 
vals, is of most service in maintaining the 
strength of the patient where all the 
symptoms are well marked ana likely to 
go through their full stages; at certain 
crises of the disease, or where some symp- 
toms only have attained great promi- 
nence, the benefit that results from a bold 
resort to stimulants is surprising, and the 
effect is the more marked, if their use had 
up to that time been neglected. Where 
the exudation is checked and is first sepa- 
rating, I have known the determined 
deglutition of four pints of beef tea and 
nearly two pints of port wine, in little 
more than twelve hours, by a temperate 
young man, teacher in a school, put a 
stop to further illness. Mr. M'Donald,1 
of Bristol, relates a case where bottled 
bitter-beer being the stimulant ordered, 
nearly eight pints were taken (twelve 
pint bottles were emptied) in the course 
of one night, with a like good effect. At 
a further period of the disease, when the 
separation of the deposit is completed, 
extra stimulants are required to combat 
the restlessness and depression then some- 
times extreme. Sleep, at all times neces- 
sary, is at this latter period of the illness 
to be carefully conciliated. Opiates are 
well borne, and are now more likely to 
procure sleep than when the first symp- 
toms in the throat are most troublesome ; 
their use for several nights, when the 
diminished exudation reveals injury of 
the mucous membrane, may do much to 
prevent the exhaustion at this time so 
dangerous, and upon which stimulants, 
beyond what is necessary for support, 
seem to have but little power. Quinine 
and bark are particularly serviceable ; the1 
former may be combined with iron if its 
use be still indicated, the latter with the 
mineral acids. Quinine can be given to 
children in powder, and in solution is 
often advantageously added to the nu- 
trient eneinata that must so frequently 
supplement the inadequate amount of 
support otherwise received. Brandy is 
occasionally to be administered in this 
way, care being taken not to set up an 
irritability of bowel that might interfere 
with the continued employment of a 
means of sustaining life that so often be- 
comes a necessity in the treatment of this 
disease. 
Aperients are seldom required at the 
commencement of the illness, and during 
the earlier stages their effects are injuri- 
ous ; for then the waste of tissue is most 
active, and the impediment to the recep- 
tion of nutrition the greatest. It has been 
a matter of frequent remark that exuda- 
tion in the throat, already stationary, or 
even diminishing, has at once extended 
after the moderate action of aperient medi- 
cine. The only indication for their em- 
ployment would be occasioned by inter- 
current disease, which would give rise to 
1 Lancet, 1858, vol. ii. p. 539. 
VOL. I.-6 82 
DIPHTHERIA 
a greater elevation of temperature than 
usually obtains in uncomplicated Diphthe- 
ria; otherwise several days maybe allowed 
to pass without action of the bowels.1 The 
appearance of albuminuria does not call 
for their administration. Mr. Spanton 
found an increased excretion of urea fol- 
low the action of a purgative. Diarrhoea 
frequently demands attention ; opiate in- 
jections, or small doses of opium with bis- 
muth, will generally suffice; alum in bo- 
luses is mentioned by Bretonneau; small 
doses of sulphate of copper with opium 
are best in severe cases. The constipa- 
tion of the latter stages of the illness re- 
quires stimulating enemata, friction to the 
abdomen, and galvanism. 
Salines are contra-indicated. I have 
seen no good result from the administra- 
tion of the alkaline remedies recommended 
by some French authors in the earlier 
stages, nor from the use of the iodides or 
bromides in the later. Ammonia, in con- 
tinued doses, is injurious;2 as a stimulant 
it is useless. The diaphoretic action of 
salines is not required, and their diuretic 
action has an unfavorable influence upon 
the specific irritation of the kidney. 
Diluents and acid drinks should be con- 
tinued while albuminuria persists; and 
though stimulants are then not always to 
be withdrawn, they are not to be inju- 
diciously augmented. The hot air bath 
applied to the body only, without removal 
from bed, or warm packing to the loins, is 
serviceable in this complication; the ap- 
pearance of blood-corpuscles or of tube 
casts in the urine indicates the adminis- 
tration of iron with the mineral acids, and 
the addition of cod-liver oil. 
Mercurials, if continued till their gene- 
ral effect upon the system is produced, are 
productive of much mischief; Breton- 
neau's second memoir gives evidence of 
this. The carefully regulated action of 
them may be usefully opposed, when de- 
sirable, to some of the inflammatory com- 
plications of the disease. Salivation rather 
favors than checks the rapid extension of 
■the special exudation.3 
Bleeding is specially to be avoided; the 
worse effects of the disease seem to have 
!been more extensively developed in many 
of the cases where this was practised.4 
Antimony also is prejudicial. 
When the progress of the disease under 
the influence of appropriate general treat- 
ment seems most encouraging, death may 
suddenly threaten from impeded access of 
air to the lungs ; relief then depends upon 
energetic local treatment, the same gene- 
ral means not being neglected. Symp- 
toms that, did we not know their cause, 
would suggest the free employment of 
bleeding or antimony for their relief, may, 
if their cause is patent upon inspection of 
the throat, be efficiently obviated by a 
styptic application to the extending exu- 
dation, or to the orifice of the glottis itself, 
and their increase or return prevented by 
the free use of iron and wine. Nor are 
these to be entirely suspended if the mis- 
chief be altogether within the glottis. 
Where this is the case the symptoms are 
more gradual in their appearance, and 
may sometimes be alleviated by giving 
chlorate of potash, four grains,1 to a des- 
sertspoonful of water, by the insufflation 
of alum, or by the application of it to 
either surface of the epiglottis, or of gly- 
cerine to the edge of the glottis: the diffu- 
sion into the throat of a strong solution of 
chlorate of potash, or of sulphurous acid, 
by means of a vaporizer, may also be use- 
ful. It will depend upon the type of the 
general disease whether one or more doses 
of calomel are to be administered; the 
laryngeal symptoms once established, the 
resort to an aperient may be advisable, 
and calomel is the best that can be em- 
ployed; where calomel will bear repetition 
emetics are also admissible. Senega may 
be used with this object. If ipecacuanha 
is chosen, ten grains of sulphate of zinc 
should be added. When secretion is 
abundant, alum, as elsewhere directed,2 or 
sulphate of copper (five grains to the 
ounce of water), given in divided doses (a 
teaspoonful only for young children), is 
the best and most effectual. Emesis is not 
to be frequently repeated, and it is only 
when readily induced that it can be other- 
wise than prejudicial. Real and obvious 
relief, with increasing fulness of the chest 
expansion, is not only the encouragement 
forgiving these means a trial, but the sole 
warrant for trusting to them for the relief 
of the temporary exacerbations. They 
must not be trusted to implicitly, as at 
any moment it may be evident that ths 
obstruction is beyond their influence. 
Tracheotomy should be performed when- 
ever the increasing recession of the softer 
parts of the thoracic parietes shows that 
the cause of obstruction to the entrance 
of air is increasing. In the greater num- 
ber of cases, if the local medication of the 
glottis and larynx do not suffice to obviate 
the danger, tracheotomy, performed early, 
1 Nunes gives a caution against aperients 
at the latter stages of the illness, lest the 
death of the patient should be attributed to 
their use. Heredia, tom. iii. s. 3, cap. xi. 
2 See also Huxham's " Dissertation on the 
Malignant Ulcerous Sore Throat." Lond. 
8vo. 1759, p. 53 et seq. 
3 See Lancet, 1838-39, vol. i. pp. 726, 728, 
for two cases illustrative of this. 
4 Memoirs on Diphtheria, pp. 50, 97. Arch. 
G6n. de Med., tome xvii. pp. 494-7. 
1 [Twenty grains, in a tablespoonful of 
water, every three hours, will be better.-H.] 
2 Vide Treatment of Secondary Croup, Vol. 
III. scarlet fever: definition. 
83 
is much more likely to be successful than 
after the use of remedies that in any way 
impair the vital powers. A delay that 
admits of secretions accumulating in the 
bronchi is dangerous, and extension of the 
disease to the lung is the one insurmount- 
able obstacle to success. Where the ef- 
fects of the obstruction are more suddenly 
induced, tracheotomy, performed at the 
very last moment of apparent life, may 
save it. No degree of severity in the gen- 
eral disease should interfere with this 
means of averting threatened death from 
asphyxia, unless the presence of some 
other complication, necessarily fatal, can 
be demonstrated. I recently saw a case 
in consultation with Mr. Adams, in which, 
had it occurred at the commencement of 
the epidemic instead of towards the end, 
I should have decided against tracheoto- 
my, concluding that it must end fatally; 
although unconsciousness had set in be- 
fore commencing to operate, the child, six 
years old, recovered. At some periods of 
an epidemic, success less frequently at- 
tends this operation than at others; at 
the Hopital des Enfants Malades,1 in 
1851, there were twelve recoveries in 
thirty-one operations; in 1853 only seven 
recovered in sixty-one cases; in 1856 tra- 
cheotomy was performed there fifty-four 
times, with success in fifteen cases.2 Of 
466 operations at this hospital in eight 
years there were 126 recoveries; these 
were generally operated upon as soon as 
the laryngeal symptoms were decided.3 
The result of M. Trousseau's 200 opera- 
tions gives a similar success of more than 
one in four, while in the cases operated on 
by him in private practice one-half have 
recovered;4 of nine such cases in 1854 seven 
were cured.1 Of forty-two cases reported 
by Professor Rosen of Tubingen,2 nine- 
teen recovered. In six of the cases as- 
phyxia had advanced too far before the 
operation; and of the subsequent deaths, 
one took place from pneumonia, fifteen 
days after, and one from albuminuria in 
the third week.3 Dr. Buchanan writes, 
"I have performed tracheotomy twenty- 
one times with the result of seven recove- 
ries; and if it be remembered that the pa- 
tients were all on the point of death from 
suffocation, it cannot but be regarded as 
an encouragement to the surgeon to en- 
deavor to save life by operative interfer- 
ence in the later stages of this most fatal 
disease." After the operation the chief 
condition of success is efficient support. 
The tube must remain in the trachea for 
at least a week; liquids are to be given in 
the form of sop; and nutrient enemata 
with brandy will generally be required. 
A little steam should be diffused in the 
apartment, and the tube lightly covered 
with gauze or porous woollen material. 
In adults, laryngotomy is often sufficient; 
in one case that occurred to me, the ad- 
mission of air in this way sufficed to expel 
the exudation so speedily, that no tube 
was required. 
The after-treatment of Diphtheria re- 
quires great care in proportioning the 
amount of exertion to the degree of 
strength existing. Good food, good air, 
and tonics are necessary. Galvanism may 
be required when an important function is 
impeded from muscular inaction. [Strych- 
nia, used with proper caution, will be as 
likely to be beneficial in post-diphtherial 
paralysis as in any other form of paralytic 
disease.-H.] 
SCARLET FEVER. 
By Samlel Jones Gee, M.D. Bond. 
Definition.-An acute pyretic dis- 
ease, specific in its cause and course, and 
best characterized by a peculiar exanthem 
hereafter to be described. 
The earliest record which we possess of 
the existence of Scarlet Fever bears no 
more ancient date than a.d. 1556, the 
year wherein Ph. Ingrassfas published a 
description of a malady which had been 
previously recognized by the common peo- 
ple, and named by them Rossalia. It is 
1 Trousseau, De la Tracheotomie dans la 
Periode extreme du Croup, &c. Arch. G5n. 
de MM., s. 5, tome v. p. 360. 
2 Sydenham Society's Year-book, 1863, p. 
278. 
3 On Tracheotomy in Diphtheria. By 
George Buchanan, A.M., M.D. Glasgow, 1865. 
1 Arch. Gen. de Med., s. 5, tome v. p. 360. 
2 M. Andre. See art. Croup, Vol. III. 
3 Edin. Med. Journal, vol. v. p. 417. 
4 Clinique Medicale. Paris, 1861, p. 414. 84 
SCARLET FEVER. 
possible that examples of a severer type 
of the same disease formed part of the 
famous epidemic of malignant angina 
which raged, sixty years later, in the 
south of Europe ; in Germany, about this 
time, Scnnertus witnessed what he con- 
sidered to be the rossalia of the Italians, 
and what we may readily admit to have 
been our Scarlet Fever. I n 1676 appeared 
Sydenham's short chapter on "Febris 
Scarlatina," and by the end of that cen- 
tury the disease had been described in 
every part of civilized Europe. 
Causes.-I. Contagion is the only 
known cause of Scarlet Fever. In de- 
gree of contagiousness, the disease takes a 
place between measles and hooping-cough 
above, and typhus fever below ; diphthe- 
ria being very far below. The contagious 
material may be taken up by clothes, and 
retained by them for a great length of 
time. Sir Thomas Watson narrates an 
instance in which a strip of flannel re- 
mained contagious for at least a year ; and 
Ilildenbrand was infected by a cloak 
which, after exposure to the disease, had 
been put aside for eighteen months; 
hence we may assume that the morbific 
principle of Scarlet Fever is anything but 
volatile or unstable. Which being so, 
affords an answer to the important ques- 
tion : When does a person who has re- 
covered from an attack of the disease 
cease to be contagious ? To speak strictly, 
not until those natural fomites, the epithe- 
lial scales, which were existing at the time 
of the fever, have been removed ; or, what 
is nearly the same, not until desquamation 
has ceased. And in the fact that, under 
ordinary circumstances, these epithelial 
scales are all but permanently contagious 
we have an explanation of the tenacity 
with which danger clings to materials of 
any but the closest texture. Uncovering 
a scarlet fever patient in the direct rays of 
the sun, a cloud of fine dust may be seen 
to rise from the body ; contagious dust, 
which, no doubt, subsides into every cre- 
vice near the bed. The distance at which 
the disease may be communicated is com- 
monly said to be not more than a few feet; 
yet considering the slight volatility of the 
poison, one is quite prepared to admit 
the possibility of what is said to have 
occurred,-namely, of the contagion hav- 
ing been conveyed hundreds of miles by 
letter, or similar means. In like manner 
a person, himself not liable to the disease, 
may become a travelling disseminator of 
contagion : a trite observation, the appli- 
cation of which to practice is easily over- 
strained. 
[The contagion clings long to rooms 
and houses ; sometimes even for many 
months.-H.] 
II. Such being the exciting cause, it is 
required that the subject be apt or predis- 
posed. 1. This aptitude does not exist, 
as a rule, in those who have passed 
through one attack of the disease ; still 
the possibility of recurrence and relapse 
is admitted on all hands. 2. Of persons 
not protected by a previous attack, 
whether the liability to contract the dis- 
ease diminishes with increase of years or 
not, is not easy to say. The affirmative is 
probably true, yet no age is exempt. The 
percentage of deaths at different ages, 
according to Dr. Richardson, is,- 
From 
40 and 
Under 5. 
5 to 10. 
10 to 20. 
.20 to 40. upwards. 
67'63 
24-43 
5-52 
1-73 0-66 
Indeed all experience goes to prove that 
the majority of scarlet fever patients are 
of an age between eighteen months and 
six years. The relative proportion of 
cases of Scarlet Fever to all cases of illness, 
is greatest from four to nine years inclu- 
sive, and is, moreover, withinthose years, 
nearly stationary. 3. The two sexes are 
equally liable to Scarlet Fever; women 
after puberty suffer more frequently than 
men, because more exposed to contagion. 
Scarlet Fever appears at any season; 
but in England especially prevails, as Sy- 
denham says, at the end of summer ; or, 
more strictly speaking, from the middle of 
September to the middle of November. 
Incubation Period.-The duration of the 
incubation period partakes of that irregu- 
larity which attends most of the points 
which go to make up the history of Scarlet 
Fever. Trousseau relates a case which 
seems to prove that the incubation occa- 
sionally lasts no longer than twenty-four 
hours; this we may accept as a mini- 
mum. Positively to fix the maximum is 
impossible : probably seven days are rarely 
exceeded ; but I have myself been witness 
to facts which did not admit of explana- 
tion otherwise than by presuming that 
the incubation period may sometimes last 
three weeks. Rilliet and Barthez are of 
the same opinion. 
Symptoms.-Scarlet Fever is some- 
times so mild as to escape the observation 
of both patient and physician, or, again, 
is sometimes so severe as to kill inevitably 
within twelve hours : another illustration 
of the wonted irregularity of the disease. 
Between these extremes lies a mean or 
typical form (here first to be described), 
in which all the characteristic symptoms 
are well developed, and none excessively: 
a description of the abnormal forms will 
follow. In the last place will be noticed 
the complications and sequelce which may 
supervene upon any form of the disease. ORDINARY scarlet fever. 
85 
Ordinary Scarlet Fever. 
I. Invasion Period.-That stage which 
precedes the eruption of the rash. 
The onset (except in mild cases) is sud- 
den, so that it is often easy to fix the 
hour, almost the very minute, at which 
the disease began. 
The symptoms are : 1. Sore throat (the 
first symptom noticed by most adults) ; 
tenderness at the angles of the lower jaw 
and stiffness of the neck soon follow. 2. 
Vomiting, the warning children give, but 
not so common with adults; it may be 
repeated many times, becoming ultimately 
bilious, yet not prognosticate, as a neces- 
sity, severity of the ensuing disease : ac- 
tive diarrhoea sometimes concurs. 3. 
Pyrexia. The first febrile symptom is 
often, not always, a sensation ofchilliness ; 
never a rigor ; the face is pale. Flushing 
of the face and great heat rapidly succeed ; 
a temperature of 104-75° may be reached 
on the first day. Pulse remarkably fre- 
quent, and frequent out of proportion to 
the height of the fever ; for the pulse of a 
child to reach 160, or even more, on the 
first day of the disease, in prognosis, sig- 
nifies nothing; in diagnosis, Trousseau 
thinks the symptom might be of some 
value. Respiration in proportion to pulse ; 
no cough ; no lachrymation : coryza before 
the appearance of the rash is very un- 
usual. The tongue, mostly covered with 
a light white fur, except at the tip and 
edges, which are red, in some cases re- 
mains quite pale, clean, and moist; there 
are loss of appetite and thirst in marked 
instances of the disease. Skin hot, not 
necessarily dry. 4. Nervous symptoms 
are present, languor, sleepiness by day 
(especially in children), disturbed sleep at 
night, nocturnal delirium ; headache, not 
severe, frontal; aching of the limbs. 
Convulsions even may precede the rash 
in non-malignant Scarlet Fever; coma, 
according to Valleix, is a frequent pre- 
cursor of the rash of the normal disease, 
and Sydenham makes a similar observa- 
tion. Lastly, in mild cases, mere poorli- 
ness the day before the eruption is often 
the only premonitory symptom. 
The duration of this stage is, as a rule, 
from twelve to thirty hours. In trivial 
cases the rash is sometimes the first symp- 
tom of the disease. Not rarely the dura- 
tion seems to be longer than the maximum 
given above ; but proof is difficult; and 
the difficulty lies in fixing the time of oc- 
currence, not of the first invasion symp- 
tom, but of the eruption ; sometimes the 
rash recedes for a short time, and then 
conies out again. In a case observed by 
Trousseau, the rash did not appear before 
the eighth day, upon the cessation of most 
unusual prodromata, squinting, infrequent 
pulse and stupor, with headache, and 
vomiting. 
II. Eruptive Period. - 1. The Pash. 
The normal exanthem consists of small 
dots, in color bright scarlet, most intense 
at the centre of the dot, fading towards 
the periphery; confluent by their mar- 
gins, so as not to leave any skin of normal 
appearance between ; not elevated to the 
touch; completely disappearing under 
pressure, and rapidly reappearing when 
the pressure is removed. The rash some- 
times comes out over the whole body at 
once, but is mostly at first limited to a 
much smaller area, especially to the sides 
of the neck and the upper part of the 
chest. Occasionally the eruption appears 
first on the legs. The most common de- 
partures from the type are the following : 
The color may be deep, purplish, dusky 
(this being, alone, no sign of malignancy): 
in such a case add numerous flea-bites, 
and the disease may be (and has been) 
mistaken for typhus fever. On the other 
hand, the color may be very pale. The 
puncta are sometimes set so closely as to 
produce a uniform blush, in larger or 
smaller patches: this condition is con- 
stant indeed on the cheeks, and often seen 
on other parts of the face, and below the 
knees. Again the puncta may be per- 
fectly discrete. Wherever there is hyper- 
semia there must be swelling of the cutis, 
not commonly perceptible, however, sim- 
ply because the spots are confluent, but 
when they are discrete, it is not impossi- 
ble to feel their elevation (sc. papulosa); 
in the latter case, should the color be at 
the same time more purple than usual, 
the rash of measles will be closely simu- 
lated. This swelling of the cutis must 
not be confounded with other occasional 
accompaniments of the rash,-namely, a 
cutis anserina, and a subcutaneous swell- 
ing, which is sometimes present to a 
notable degree in the eyelids, hands, and 
feet, and which may persist for a day or 
two after the rash has gone. 
The eruption reaches its maximum ex- 
tent and intensity on the third or fourth 
day of the illness (occasionally as early as 
the second) ; begins to fade on the fourth, 
fifth, or sixth day ; and lasts altogether 
from five to ten days. 
When the nail is firmly drawn over the 
skin in which the rash is present (over the 
belly or thigh is best) a white streak soon 
follows, lasts a minute, and then disap- 
pears ; a very firm stroke brings out a 
middle red mark, and two lateral white 
streaks. The phenomena have been 
thought to be pathognomonic. But are 
they really peculiar to scarlet fever? 
Does the " white streak" show more than 
that the skin is injected, whereby the 
((fleet of a contraction of the small vessels 
in the cutis is heightened, and of a dilata- 
tion, obscured ? 
Miliaria are frequently, but far from 
constantly present. They are most com- SCARLET FEVER. 
86 
monly met with about the sides of the 
neck and upper part of the chest, but may 
be nearly universal. Occasionally they 
are so thickly set that the epidermis is de- 
tached by a rough touch. They are not 
connected with unusual sweating, but 
rather with the age of the patient and the 
amount of eruptive swelling of the cutis; 
the rash rarely being intense in an adult 
without the presence of miliaria. They 
dry up in a day or two and desquamate. 
Sc. pemphigoidea seu pustulosa is de- 
scribed by continental writers. Large 
patches of urticaria sometimes come out 
while the proper rash is still present. 
When the skin is pulled upon, the rash 
does not always altogether disappear ; a 
yellow stain may be left, or all grades be- 
tween this condition and actual petechise. 
Like a dusky rash, petechise alone do not 
indicate malignity. 
2. The Sore-throat is always present to 
some degree. In a typical case, exami- 
nation of the throat detects increased red- 
ness of the soft palate, uvula, and tonsils, 
sometimes of the posterior wall of the 
pharynx, and of the tip of the epiglottis. 
These parts are swelled also, but the 
amount of redness and swelling is often 
disproportionate ; the latter may be so 
great that the tonsils meet in the middle 
line, and thrust the uvula forwards. Such 
great swelling is due to causes over and 
above the hypersemia, namely, (1) 
(Edema; this is most notable in the 
uvula, which from gravitation of the se- 
rosity becomes club-shaped. (2) Excess 
of secretion : this enlarges the tonsils; 
post mortem they are found to be sur- 
charged with thick yellow matter; during 
life the same secretion often appears at 
the mouths of the tonsillar crypts, or is 
exuded so as to cover the surface with a 
uniform layer. Superficial ulceration of 
the tonsil sometimes coincides. More 
rarely the matter does not escape, and, 
liquefying, causes an abscess in the tonsil, 
as early, it may be, as the sixth day. The 
mucous membrane is either dry and shin- 
ing, or coated with thick mucus, which 
clogs the fauces. Ulceration of any part 
of the throat, other than the tonsils, be- 
fore the fifth day, is very uncommon in 
cases which are not, for other reasons, 
classed under the gravest forms of the 
disease. There can be no question that 
the majority of "ulcers" and "sloughs" 
observed during the first four or five days 
of Scarlet Fever are nothing but excess of 
the secretion of the part smeared over the 
surface ; and likewise no question that 
the dire sloughing and gangrene described 
so well by the older writers (e. g. IIux- 
ham, Heberden), and on their authority 
still attributed at times to Scarlet Fever, 
appertain altogether to diphtheria. To 
quote the words of Armstrong: "The 
first four or five days there will be seldom 
either sloughs or specks about the tonsils; 
but merely an increased secretion of mu- 
cus, some of which often adheres to the 
part and looks like an ulcer. But when 
the fever continues longer, or runs higher, 
specks generally form about the tonsils, 
which are finally converted into super- 
ficial ash-colored sloughs." Ulcerative 
angina, then, either occurs in cases con- 
spicuous far more by the symptoms called 
malignant, or is a sequela, an epiphenome- 
non, supervening after the cessation of 
the specific disease. 
The lymphatic glands at the angles of 
the lower jaw become enlarged and ten- 
der; in fact, inflamed. In severe cases the 
connective tissue around is involved, and 
puffy; but neither brawniness nor suppu- 
ration occurs before the rash has begun to 
fade. 
Difficult deglutition, snoring, and alter- 
ation of the quality of the voice (it is 
thick and nasal), are results of the swell- 
ing of the throat. Kennedy once saw a 
child carried off by oedema glottidis within 
thirty hours from the onset of the dis- 
ease. 
In favorable cases the angina will re- 
cede with the eruption, and have disap- 
peared by the seventh day, the tonsils 
perhaps being left rather swollen, but 
pale. The lymphatic glands often remain 
large for some time. , 
3. The Pyrexia.-The height attained 
by the fever has been subject to singular 
exaggeration; the fiery hue of the erup- 
tion. and the great dryness of skin often 
present, conspiring to mislead the ob- 
server. The mercury of a thermometer 
placed in the axilla never rises above 106° 
Fahr., rarely above 105°. The fever cer- 
tainly runs higher than in measles, and 
very much higher than in diphtheria, but 
on the other hand does not reach the de- 
grees which are often observed in ague, 
typhoid fever, rheumatic fever, and py- 
aemia. On the day when the eruption 
begins to fade the fever frequently sub- 
mits to a complete crisis, as indicated by 
the temperature not rising above the nor- 
mal for twenty-four hours; should this 
crisis not occur, the pyrexia is prolonged 
for an indefinite period. (The tempera- 
ture of a healthy child may reach, but 
does not rise above, 99°.) In two cases 
the thermometric crisis occurred on the 
fourth day, in four on the fifth, and in 
three on the seventh. So, out of the cases 
observed by Dr. Ringer, the temperature 
of two became normal on the fourth day, 
of seven on the fifth day, and of one on 
the sixth day. In the rest the pyrexia 
was prolonged beyond the eruptive pe- 
riod. "The pyrexia slightly remits in 
the morning, and, rising in the course of 
the day, reaches its highest point about 
bedtime." (Armstrong.) A similar fore- 
noon remission and afternoon exacerba- ORDINARY SCARLET FEVER. 
87 
tion takes place in health. Yet the Scar- 
latinal Fever is continual; the remission 
is not at any time complete until (in un- 
complicated cases) the final crisis. The 
severer the fever the more tritling the re- 
mission. 
4. The Alimentary Canal.-(1) Tongue. 
The fur present during the invasion pe- 
riod becomes thicker on the second and 
third days, and then begins to clear off 
from before backwards, so as to leave the 
tongue deep-red, broad, smooth-looking, 
and dotted over with elevated papilla?; a 
condition sometimes met with in other 
diseases (especially those attended with 
suppuration), when a thick fur clears off 
quickly. Both the earlier furred and later 
papillated condition are often absent. (2) 
Vomiting during the eruptive period is 
rare, except in the severer forms of the 
disease. Constipation, easily overcome, 
is the rule, but diarrhoea a not infrequent 
exception. Tympanites is sometimes 
present. Thirst and anorexia occur in 
well-marked cases. 
5. The Respiratory Organs.-(1) Coryza, 
thin or mucopurulent, may supervene at 
any period of this stage, and is not neces- 
sarily a grave symptom. (2) It is rare to 
detect the physical signs of bronchitis 
or pneumonia before the rash begins to 
fade. Cough due to the condition of the 
fauces is common. The frequency of the 
respirations is proportionate to the py- 
rexia. 
6. The Pulse maintains the frequency 
of the invasion period, and may reach 144 
in an adult, 100 in a child, or even more, 
without any serious import. The fre- 
quency does not increase as the disease 
progresses, and it falls with the tempera- 
ture. 
7. The Urine.-(1) The water is dimin- 
ished in quantity. (2) Urea. In an in- 
dividual case of Scarlet Fever the most 
trustworthy standard of the amount of 
urea excreted by the person in health is 
derived from estimations made while he 
is kept in bed. and upon unaltered diet, 
for a week or ten days after the crisis. 
We must exclude all observations made 
upon cases in which the crisis of the 
pyrexia did not occur within the first 
week ; and hence, in order to obtain suf- 
ficient data, the observations should be 
begun upon the urine of the third day at 
the latest. The following cases fulfilled 
these conditions :- 
Sex, 
Age. 
Weight. 
Kilog.ams. 
Days inclusive. 
Water, 
cub. cents. 
Urea, 
grammes. 
Chi. 9od. 
grammes. 
Boy 
7 yrs. 
22} { 
1st to 4th 
5th to 12th 
pyrexia 
apyrexia 
377 
450 
14-28 
15-02 
2-21 
4-59 
Boy 
5 yrs. 
16} { 
2d to 4th 
5 th to 9 th 
pyrexia 
apyrexia 
551 
709 
18-83 
13-33 
0-97 
4-69 
Girl 
10} yrs. 
27} J 
2d to 5 th 
6th to 13th 
pyrexia 
apyrexia 
316 
567 
16-17 
19-64 
0-67 
4-38 
(minus 1 day) 
per 24 hours. 
These figures suffice to show that there is 
no necessary increase in the quantity of 
urea excreted during the pyrexia. (3) 
Chloride of sodium is more or less dimin- 
ished, sometimes very much, sometimes 
very little. This diminution cannot be 
connected with any known concurrent 
condition. The salt is not subsequently 
passed in abnormal quantity. The dimi- 
nution mostly ceases suddenly on the 
fourth, fifth, or sixth day. (4) Phosphoric 
acid undergoes very decided changes in 
quantity, which, normal, or a little more 
than normal, during the first three or four 
days of the disease, on the fourth or fifth 
day is notably diminished, for the four 
subsequent days remains at a half or a 
third of the normal, and then assumes the 
standard of health.1 These changes bear 
no relation to the temperature or any 
other condition yet discovered ; the same 
phenomenon of diminished excretion of 
phosphoric acid at the climax of the 
pyrexia, or soon after, appears in ague, 
measles, and probably in other febrile 
diseases. (5) Uric acid. The only suit- 
able case in which I was able to make a 
daily estimation by weight of the uric 
acid manifested a great diminution (al- 
most a suppression) in the quantity of the 
acid on the second and third days, a re- 
turn to the normal on the fourth, and a 
great excess on the fifth day (the last day 
of pyrexia); after this the normal was re- 
sumed. It is highly probable that similar 
changes always occur in Scarlet Fever of 
any severity, as is judged from less exact 
observations upon several other cases. 
Sediments of uric acid and of urate of 
soda are common. (6) Pigment is not 
necessarily increased in quantity. (7) 
The occurrence of albumen during this 
period is considered under the head of 
Renal Dropsy. 
8. The Skin.-Dryness is a frequent 
but by no means a constant condition : 
the patient may sweat; but for a sweat 
to follow a trivial exertion, say the move- 
i These remarks are based upon daily ob- 
servations by Neubauer's process in eight 
eases of Scarlet Fever. 88 
SCARLET FEVER. 
ments of delirium, is a bad sign. Dry- 
ness signifies, not that the secretion of 
the skin is diminished, but that it is 
rapidly evaporated. 
9. Yellowness of the conjunctivae, ten- 
derness over the liver, and evidences of 
bile in the urine, are occasionally present; 
and when present, devoid of prognostic 
value. It is rare that the spleen can be 
felt enlarged. 
10. Nervous System.-An agitated man- 
ner, moderate frontal headache, and de- 
lirium, are common enough in ordinary 
Scarlet Fever. The delirium ("■ noctibus 
aliena loqui") which occurs during the 
evening exacerbation is not a grave prog- 
nostic, yet delirium is a prominent symp- 
tom of some of the worst cases of the 
disease. 
The duration of Scarlet Fever is said by 
Valleix to be from ten to forty days. But 
what is the necessary duration of the spe- 
cific disease, the Scarlet Fever, as distin- 
guished from the possible duration of the 
illness, common sequelae included ? If we 
bear in mind that, in regular cases, the 
pyrexia often wholly ceases while the 
eruption still stands out well, I think we 
may agree with Heberden that the disease 
rapidly recedes after the seventh day, 
nay, I would add, that the specific disease 
even ceases then. The sore-throat may 
abate with the eruption, or be prolonged 
beyond, just as the catarrh of measles 
may increase on the eighth day of that 
disease. 
III. Desquamation Period.- After the 
rash has receded, certain deviations from 
health are observed in all but the mildest 
cases. 
1. If the pyrexia cease by the seventh 
day, the pulse falls in frequency often to 
below the normal: irregularity is common 
when the nervous symptoms of the prior 
periods have been well marked. The 
temperature often remains for a week or 
ten days below the point which it reaches 
subsequently. The urine is dilute, defi- 
cient in phosphoric acid, and often defi- 
cient in acidity; earthy phosphates pre- 
cipitate, and vibriones form. All these 
conditions of pulse, animal heat, and 
urine, indicate an exhaustion of the vital 
energy. The tongue, if it have been cha- 
racteristic (as is said), becomes, in the 
second week, more natural, and often as- 
sumes a delicately furred, silvery appear- 
ance. 
2. Desquamation.-With the disappear- 
ance of the rash, the skin does not regain 
the characters of health ; the epidermis is 
dry and shining, has lost its pliability, 
and is easily thrown into fine wrinkles. 
Desquamation begins in a day or two: 
the chin, sides of the neck, and upper part 
of the chest are mostly the parts first to 
desquamate. Where the cuticle is deli- 
cate, it becomes everywhere scurfy, and 
is so thrown off: where thicker, it is raised 
and removed in small isolated patches, 
which increase in size by a continuous des- 
quamation of their margin, until they 
meet, and so leave the whole surface des- 
quamated ; and lastly, where the epider- 
mis is very thick, it is undermined in large 
flakes before it is cast off. The amount 
of the desquamation depends very much 
upon the previous intensity of the rash : 
where the latter has been slight, there the 
former may be almost absent. Miliaria 
cause an abundant and early desquama- 
tion. The duration of desquamation is 
from a few days to a month or two. 
3. The throat, in favorable cases, loses 
its redness ; but the tonsils may remain 
swelled for some time : in like manner the 
lymphatic glands cease to be tender, and 
gradually diminish in size. 
Such is normal or regular Scarlet Fever ; 
it remains to trace the disease to its ex- 
tremes, of severity on the one hand, and 
of mildness on the other. And first of 
Scarlet Fever of abnormal severity, com- 
monly called 
Malignant Scarlet Fever. 
But before going further I must enter 
my protest against the manner in which 
the epithet " malignant" is used, or rather 
abused, with regard especially to Scarlet 
Fever, but also more or less to many other 
diseases. Malignity has almost ceased to 
have any real meaning, and all that some 
of the greatest physicians have written 
upon the subject seems to have been 
written in vain. This is not the place for 
me to discuss what malignity really in- 
tends, however much I may feel inclined 
to do so : in what follows I shall simply 
strive not to misapply the term in the 
case of Scarlet Fever. 
The severer forms of Ordinary Scarlet 
Fever merge into a type of malignity 
characterized by excitement, followed by 
exhaustion. There are all grades of se- 
verity between this, the least grave form 
of malignity, and that which places Scar- 
let Fever almost on a footing with Asiatic 
cholera and the plague, that form in which 
a preliminary period of excitement is 
hardly to be perceived, so rapidly does 
collapse follow upon the onset of the dis- 
ease. 
Tape I.-The malignity is deutero- 
pathic, secondary to a state of ataxia or 
excessive disorder of the functions of the 
nervous system ; in the nomenclature of 
Armstrong the malignity is inflammatory. 
The invasion symptoms are all well 
marked, yet even from the first, those 
which are to be referred to a disturbance 
of the nervous system predominate,- 
delirium, agitation, sleeplessness. The LATENT SCARLET FEVER-SEQUELS. 
89 
premonitory stage over, the rash comes 
out well, the sore throat is considerable, 
the fever runs high. Delirium remains, 
exists at all times, and is active ; the pa- 
tient throws himself about, gets out of 
bed, sings loudly; his mind is confused ; 
his eyes bloodshot; pulse frequent, full 
and soft; extremities warm ; vomiting 
after food is a prominent symptom ; there 
may be diarrhoea or coryza. But depres- 
sion follows in a day or two, the delirium 
is much less active, the person lies mut- 
tering, the pulse becomes small, weak, and 
still more frequent, the face gets dusky, 
the cutaneous circulation is remarkably 
sluggish, swallowing is imperfectly per- 
formed, vomiting may persist, the belly is 
tympanitic. Lastly, stupor supersedes 
delirium, and death ensues. Sometimes 
the fatal issue is accelerated by a sudden 
attack of convulsions, the pulse ceases to 
be perceptible, the whole surface is blue, 
coma follows. 
Type IL-'The malignity is protopathic 
(congestive, in the phrase of Armstrong), 
the vital debility is primary and sponta- 
neous, the disease goes straight to the 
source of life. The patient becomes sud- 
denly pale and faint, vomits ; the vomit- 
ing is repeated with short intervals, the 
bowels are relaxed, the hands twitch, 
there are great anxiety and feeble deli- 
rium. In a very few hours the depression 
is extreme, the whole exposed surface 
feels cold, yet the temperature of the arm- 
pit is febrile ; the pulse is very small and 
frequent. Perhaps, for a time, the pa- 
tient seems to rally ; he sits up in bed, 
but his pulse remains very frequent, and 
his feet cold; a faint rash may appear. 
Depression returns, the face becomes pale 
livid, and perfect stupor (interrupted by 
convulsions) supervenes; pulse is exces- 
sively weak and frequent, respiration re- 
markably irregular, sweats break out, 
the skin is cold and mottled ; these symp- 
toms precede death. The duration of 
the whole illness may be less than twenty- 
four or even less than twelve hours. 
The temperature of the body in the rec- 
tum and axilla is maintained at a tolera- 
bly high fever standard, but I have not 
yet observed that extreme elevation of 
temperature which is to be found in some 
cases of rheumatic fever, tubercular men- 
ingitis, sun-stroke, and injury to the 
brain. It is not given to any physician 
to observe with sufficient closeness many 
cases of protopathic malignity in Scarlet 
Fever ; by far the most uncommon form 
of the disease. A child who died in this 
manner twenty hours from the onset of 
illness, afforded a temperature in the 
axilla of only 104° an hour and a quarter 
before death. Half an hour previously 
the temperature had been 105° : this was 
the highest degree observed, though the 
temperature was taken at intervals of 
about two hours. It is manifestly untrue 
to say that the vital debility is due to 
hyperpyrexia ; they would be merely con- 
comitant conditions in any case in which 
they should both occur. 
Excluding the examples of these well- 
marked types of truly malignant Scarlet 
Fever from the whole medley of cases 
which are loosely called malignant, there 
is left a large and heterogeneous caput 
mortuum which consists in part of cases 
attended by unusual or unusually severe 
local lesions, and in part of cases which 
certainly may lay a sort of claim to be re- 
garded as instances of a prolonged malig- 
nity. The latter class of cases runs a 
course more or less of the following kind. 
For the first day or two the attack does 
not seem to be unusually grave ; but about 
the third day the patient is alternately 
restless and heavy, pulse frequent and 
feeble, expression vacant, face pale and 
thick-looking, mouth very tender, sweats 
follow a slight exertion ; coryza, diarrhoea, 
tympanites, ulceration of the tonsils, and 
dysphagia, supervene, some or all; deli- 
rium is frequent, emaciation proceeds 
rapidly, and the patient dies exhausted, 
it may be during the first week, or not 
till far on in the third ; the prolongation 
being due partly to the local processes set 
up and partly to inability to rally. 
The rash in Malignant Scarlet Fever is 
of small prognostic value; it is often 
abundant and of a bright color; in the 
worst cases no rash appears, but none 
would be expected, death occurring before 
the second day. The tonsils mostly ulcer- 
ate early, even on the first day. The py- 
rexia lasts to the very end. 
Latent Scarlet Fever. 
The symptoms are so ill-developed as to 
be not characteristic or not observed. Ex- 
amples of Sydenham's Scarlet Fever- 
disease by name alone-hold a mid place 
between this latent and the regular forms. 
How mild soever the primary disease, the 
gravest sequelae may ensue. 
[Popularly, scarlatina is, in some places, 
supposed to be the proper name for an 
unusually mild form of Scarlet Fever. It 
is important for physicians to correct this 
error, as it induces a want of care, not 
only in regard to the patient, but as to 
exposure of others to the contagion. 
There seems to be no doubt that the 
mildest cases may, by contagion, give rise 
to others of the greatest severity ; and, 
also, that very light cases may be followed 
by considerable dropsical effusions.-II.] 
Sequelae. 
As symptoms of the desquamation pe- 
riod, I have described sundry sequelae of SCARLET FEVER. 
90 
Ordinary Scarlet Fever which are con- 
stant, and the necessary results of normal 
precedent conditions : there remains for 
consideration a long list of sequelre which 
are inconstant in their occurrence, and 
therefore mostly looked upon as complica- 
tions of the disease. The distinction may 
be somewhat artificial, but it is in the 
present state of knowledge convenient. 
I. Seme-throat.-Any sore-throat which 
may be present during the decline of the 
rash, or after it, is due either to a simple 
persistence of the ulcerated condition of 
the tonsils, which has been described as 
an occasional symptom of the eruptive 
period, or to the establishment of a new 
form of lesion. In the former kind of sore- 
throat, the ulceration tends to progress 
deeply rather than widely, and bubo is a 
frequent concomitant. The latter kind 
supervenes most frequently on the sixth 
day, sometimes a day or two later, but 
never after the end of the second week : 
in very many cases the fauces have pre- 
viously escaped grave implications ; then, 
at the time specified, one or several small 
grayish patches, surrounded by a vivid 
red margin, appear on the tonsils, uvula, 
or arches of the soft palate, sometimes on 
the hard palate or the tip of the epiglottis. 
At the same time the fauces are swelled 
and reddened, deglutition gives pain, the 
lymphatic glands at the angles of the jaw 
become larger and tender, the connective 
tissue is puffy. The epithelium of the 
tongue is sometimes raised in patches. 
The excoriations go on to heal or to ulcer- 
ate. If to heal, the pellicle becomes 
thicker, so as to look like a false mem- 
brane, the surrounding redness abates, 
and in a short time, when the scab is 
thrown oft', the mucous membrane is left 
uniform in surface. In the other alterna- 
tive, when the pellicle is removed, the 
deeper layer of the mucous membrane is 
left exposed, ulceration ensues at this spot, 
and thence may spread far and wide ; in 
the worst cases the tonsils are destroyed, 
the cartilage and bone in the vicinity are 
laid bare, dysphagia ensues, the fluids re- 
turn through the nose. The state of the 
sides of the neck corresponds: in the 
favorable cases the swelling gradually dis- 
appears ; in the severe, all distinction be- 
tween gland and connective tissue becomes 
lost, a "collar of brawn" extends around 
the neck (scarlatinal bubo), softening en- 
sues at places, and here the skin will 
slough in order to give exit to a shreddy 
sero-pus; yet the swelling is not dimin- 
ished until large sloughs of the connective 
tissue come away, and the skin (it may be 
of the whole neck) is left floating over the 
parts beneath, and perforated in numerous 
holes. The suppuration reaches down- 
wards into the mediastinum, or, spread- 
ing upwards, invades the parotid glands, 
passing along the interstitial connective 
membrane, and dissecting out the salivary 
lobules. Hemorrhage from the large ves • 
seis of the neck sometimes occurs to in 
crease the complication. The rapidity 
with which the hard brawny swelling will 
establish itself is remarkable: a neck 
which was only putty one day may be hard 
the next; a semi-comatose condition is 
often produced : the veins of the eyelids 
are turgid. The majority of cases of ex- 
tensive sloughing of the connective tissue 
die; symptoms not directly connected 
with the throat are apt to supervene, par- 
ticularly vomiting and diarrhoea. Simple 
suppuration is a much less grave result; 
and indeed a very considerable amount of 
firm swelling of the neck may be resolved 
without suppuration. 
II. Coryza.- Coryza, which persists into 
or supervenes during the second week, is 
an important symptom, indicative of a 
morbid state of the mucous membranes in 
general. The direct consequences of 
coryza are often serious, and especially 
the extension of disease along the Eusta- 
chian trumpet into the tympanum ; when 
this cavity is filled with pus, the mem- 
brane bursts or sloughs, and an obstinate 
otorrhoea results. Fistula lacrymalis is 
much less common. Worst of all is the 
coryza, which is indicative of nasal diph- 
theria, a complication comparatively in- 
frequent. 
III. Otorrhoea. - Otorrhoea is of two 
kinds. The first is that otorrhoea which 
begins in the external meatus ; the dis- 
charge, which is whitish at the onset, soon 
becomes purulent, while the lining mem- 
brane everywhere thickens. The second 
kind of otorrhoea is that which follows 
coryza; ulceration of the lining meml rane 
of the tympanum, necrosis of the bone, 
facial paralysis, incurable deafness, and 
abscess of the brain, these are conse- 
quences not uncommon : the discharge is 
purulent from the first; when injections are 
used, they pass from the nose out at the 
ears, and the reverse. Hemorrhage from 
the internal carotid artery is a rare sequel. 
IV. Diarrhoea.-This sometimes coin- 
cides with the decline of the rash. Bloody 
stools and excoriations of the anus and 
buttocks may be the consequence of this, 
as of other kinds of diarrhoea. 
V. Bronchitis and Pneumonia.-Com- 
plications more common in the second 
than the first week, and mostly preceded 
by coryza. Severe bronchitis is not neces- 
sarily fatal; when it is fatal, we always 
find lobular pneumonia superadded. Pri- 
mary lobar pneumonia sometimes o curs. 
VI. Tlbscesses.-Convalescence is often 
put back by the formation of one or more 
abscesses ; if they are very large or numer- 
ous, they may be the immediate cause of 
death, and even when they are small and 
solitary the local results are sometimes 
grave. For example, on the back of the SEQUELS. 
91 
hand, an abscess as it closes leaves the 
tendons glued to the neighboring parts. 
Or again, behind the pharynx, an abscess 
may cause death, especially in infants. 
The symptoms of post-pharyngeal abscess 
are dysphagia, return of fluids through 
the nose, some stiffness of the neck, one 
side of which may be fuller than natural, 
and dyspnoea. Any one, or even all of 
these symptoms, may be so slight as not 
to attract attention. The finger passed 
into the pharynx feels a soft tumor pro- 
jecting in the middle line or somewhat to 
one side. Should the abscess burst spon- 
taneously, sudden suffocation may ensue. 
Abscesses about the neck are nearly 
always, if not always, the result of in- 
ternal ulceration. 
VII. liheumatism.-Towards the end 
of the second or beginning of the third 
week, we occasionally observe a consider- 
able increase or a re-establishment of the 
pyrexia, and at the same time an affection 
of the joints; the latter consisting in great 
tenderness and elastic swelling (more 
around than in the joint), with or without 
redness of the skin; the patient sweats at 
times, perhaps profusely; the serous mem- 
branes are prone to inflammation. There 
are all grades of severity between transi- 
tory pain in a single joint and painful 
swelling of nearly all the joints of the 
body. A similar complication may attend 
the eruptive period, but is less common; 
it is common enough for adults to com- 
plain of great tenderness of the muscles 
while the rash is present. The swellings 
are mostly resolved, and then the patient 
recovers; but sometimes suppuration oc- 
curs around and in the joint. Suppura- 
tive rheumatism is fatal. The nature of 
this complication must, at present, be left 
an open question, whether the disease be 
really rheumatic, or whether it be pyse- 
mial. 
VIII. lienal Dropsy.-Scarlet Fever is 
very often followed by albuminuria, drop- 
sy, and a form of nephritis; three acci- 
dents which it is convenient to group to- 
gether and to view as collateral symptoms 
of a more general condition. 
1. Condition of the Urine.-The propor- 
tion of cases of albuminuria seems to dif- 
fer with different epidemics: albumen was 
at no time present in the urine of six out of 
twelve children, the whole of whose urine 
was saved and examined daily by myself, 
from the decline of the rash to the fourth 
week; Abeille found albuminuria in one- 
third of the cases examined by him; in 
the experience of Begbie, Newbigging, 
and Holder, the occurrence of albuminu- 
ria was a rule without an exception. In 
twelve cases I tested the urine daily 
throughout the fever and the convales- 
cence; in one, albumen appeared on the 
fourth day, in one on the eighth, and in 
none was albumen detected for the first 
time after the twenty-first day; four cases 
occurred during the second week, seven 
during the third. In eight out of twenty- 
one cases observed by Abeille, the urine 
became albuminous before the sixth day; 
Jaccoud has noticed albuminuria as early 
as the second day. In the two above- 
mentioned instances of the occurrence of 
albuminuria on the fourth and eighth 
days, the abnormal condition of the urine 
was present for one day only; in the ten 
other cases the duration of the albuminu- 
ria was at least a week. In most of the 
examples of the more enduring form of 
the disease it is easy to distinguish three 
stages, each characterized by a peculiar 
condition of the urine. 
Stage 1.-The quantity is diminished 
(total suppression for several days has 
been observed by others now and then), 
the specific gravity is increased in propor- 
tion to the concentration, urate of soda is 
precipitated, the color is unchanged, and, 
when any saline deposit is dissolved, how- 
ever turbid the urine be with organic 
matters, it is not at all smoky: the urea 
is diminished in quantity beyond the pro- 
portion of the diminution of the water; 
the relative lack of chloride of sodium is 
greater still; albumen is present; when 
the diminution in the quantity of urine is 
considerable, the microscope discovers 
casts, some clear and perfectly free from 
granules or epithelium, some finely gran- 
ular, but hardly any blood disks or renal 
epithelium ; when the disease is less se- 
vere (and in all cases as this stage is pass- 
ing away), there are renal epithelium and 
epitheliated casts, with a few blood disks. 
The amount and the duration of the di- 
minution of the quantity of the urine in 
this stage are to a great extent prognostic 
of the future course of the disease. 
Stage 2.-The quantity of urine regains 
the normal, and soon exceeds it; there is 
a perfect diuresis; the specific gravity foils 
low; the urea and chlorides return to the 
standard, or nearly so; the urine becomes 
bloody (from slight smokiness up to the 
deepest brown); the amount of albumen 
is relatively less, though it may be abso- 
lutely greater than in the earlier stage, 
and is not proportionate to the depth of 
the color of the urine ; the microscope 
shows blood disks, hsematoidin crys- 
tals(P), renal epithelium, epitheliated and 
granulated casts. As this stage passes 
off the urine becomes clearer, less red, and 
more yellow (passing through brown and 
green); the albumen lessens. 
Stage 3.-The diuresis continues, but 
the smokiness disappears; though dull 
with excess of organic flocculence, the 
urine is normal in color; the albumen 
gradually disappears. Even after albu- 
men has ceased to be present, it mostly 
happens that for some time the quantity 
of urine secreted is above the normal. 92 
SCARLET FEVER. 
Tn mild cases the distinctions of the 
stages are necessarily ill-marked ; some- 
times the urine is at no time diminished 
in quantity; sometimes, although the first 
stage is well marked, the urine is hardly 
at any time smoky; sometimes the third 
stage never comes to an end, or in other 
words the urine remains permanently al- 
buminous; a sudden increase in the depth 
of the bloody color of the second stage 
often occurs, without the quantity of albu- 
men in the urine being proportionally in- 
creased; the urine returns to its prior con- 
dition in two or three days. A class of 
cases, by far the worst of any in a prog- 
nostic point of view, has been exemplified 
by several children who, when first they 
came under observation, brought a his- 
tory to the effect that two or three months 
previously they had had Scarlet Fever 
(perhaps so mildly that the nature of the 
illness was ignored at the time) and that 
after the lapse of several weeks dropsy 
had supervened, not suddenly, but gradu- 
ally, increasing from day to day. The 
urine is normal in color and specific 
gravity, clear or with some excess of 
flocculence, not necessarily diminished in 
quantity ; but the amount of albumen 
present is very large; very little is to be 
seen by the microscope, and that little is 
not characteristic. The steps by which 
this stage is reached have not yet been 
observed ; so far as the writer has seen 
the condition is permanent and resists all 
treatment.' 
2. The Dropsy.-Dropsy or luematuria 
is the first symptom which arrests the at- 
tention of the inexpert. The former is 
very uncertain in occurrence, and is often 
almost wholly absent from first to last; 
when it is the first symptom noticed, it 
supervenes rather suddenly in the third 
week, and especially towards the end of 
that week. Dropsy is mostly preceded by 
albuminuria for a day or two ; occasion- 
ally the dropsy precedes the albuminuria 
very rarely, when both symptoms have 
been present, the albuminuria nearly 
wholly (possibly wholly) ceases and yet 
the dropsy remains. In some epidemics, 
dropsy without albuminuria at any period 
is common. Philippe of Berlin did not 
once find the urine albuminous in more 
than sixty cases of scarlatinal anasarca 
(quoted by Jaccoud). The dropsy as- 
sumes the forms of-(1) Anasarca, which 
may be general or limited to the eyelids, 
backs of hands, and bottom of back: 
oedema glottidis is a very rare result of 
scarlatinal dropsy. (2) Serous dropsies, 
which occasionally precede the anasarca : 
when peritoneal, the effusion is of no 
great practical moment: the diagnosis of 
pericardial effusion depends upon physi- 
cal examination ; dyspnoea, intermitting 
lividity, indistinctness of the pulse, and a 
tendency to syncope, may or may not be 
present: pleural dropsy, hydrothorax, is 
a more common and formidable complica- 
tion. A child whose anamia and ana- 
sarca have shown a tendency to increase, 
and who has a slight cough and some 
sonorous rhonchi over the lungs, suddenly 
becomes much worse, vomits repeatedly, 
dyspnoea and lividity ensue and rapidly 
increase, very little urine is passed; the 
distress is painful to behold ; and death 
rapidly follows, mostly within twenty- 
four, sometimes within six hours from the 
first exacerbation of symptoms. Post 
mortem both the pleural cavities are found 
to contain a great excess of serum, which 
is perfectly clear, or floats the network of 
a delicate coagulum ; sometimes lymph is 
present, the evidence of pleurisy hen after 
to be described. The lungs are collapsed 
but oedematous also, dark iron-gray on 
section, and capable of imperfect insuffla- 
tion. 
3. General Symptoms.-(1) Pyrexia ac- 
companies the onset of renal dropsy, and 
is high in proportion to the severity of the 
symptoms; in mild cases pyrexia is almost 
absent: it is rarely prolonged into the 
second stage of albuminuria. All the 
more chronic cases of renal dropsy are, 
when uncomplicated, a pyretic. The 
attendant symptoms are heaviness, dry 
skin, troublesome vomiting, parched lips, 
and constipated bowels. (2) Anemia is 
mostly a marked symptom after the py- 
rexia has passed off. Children who are 
dropsical look more pale than those who 
are not. (3) Uraemia: convulsions and 
(oma supervening upon scarlatinal 
dropsy are more often symptomatic of the 
onset of some local inflammation, than 
indicative of uraemia. Indeed true urae- 
mic convulsions are not very common ; 
when they do occur they induce a fatal 
issue in a minority of cases : on the other 
hand the prognosis is most unfavorable 
when the convulsions merely assume the 
place of a rigor. 
The cause of renal dropsy is unknown : 
that exposure to changes of temperature 
will insure dropsy when the urine is albu- 
minous (or rather, perhaps, when that 
condition which tends to produce albumi- 
nuria is present) has been admitted by 
most observers ; but that a chill is a fre- 
quent cause of albuminuria is a dogma 
much more disputable, and apparently 
disproved by the fact that albuminuria is 
a sequela almost constantly present in 
some epidemics and almost constantly ab- 
sent in others. 
IX. Serous Inflammations. - They 
mostly, not always, are accompaniments 
1 Soon after the first edition of this volume 
was published, Dr. Weber read a paper upon 
some cases of this kind before the Medical and 
Chirurgical Society. Transactions vol. xlix. 
p. 199. DIAGNOSIS. 
93 
either of albuminuria or of the rheumatic 
state. 1. In the latter, the pericardium 
is especially prone to inflame, a complica- 
tion which, by itself, does not render a 
prognosis unfavorable. 2. In albumi- 
nuria, pleurisy is the most common. 
One or both pleurae are inflamed, the 
lymph effused rapidly breaks up into pus, 
and in most cases, death ensues in a few 
days; yet occasionally a chronic em- 
pyema is the result. States intermediate 
between pure hydrothorax and pleurisy 
are sometimes met with. Pneumonia is 
frequently combined with the pleurisy. 
In the pericarditis and peritonitis likewise 
the lymph has a great tendency to become 
puriform. It is not rare to find all the 
serous membranes inflamed at once. 3. 
Occasionally pleuro-pneumonia, pericar- 
ditis, or peritonitis supervenes, and there 
are neither dropsical nor rheumatic symp- 
toms present. Yet such sequelae are 
especially apt to occur in what may be 
termed the rheumatic period ; that is, the 
second week. 4. Systolic cardiac mur- 
murs sometimes spring up during the ill- 
ness : they are heard with greatest inten- 
sity at the apex or the second left inter- 
space. Neither albuminuria nor rheuma- 
tic symptoms necessarily accompany the 
development of the apex murmur: nay 
more, it can hardly be said to be proved 
that the occurrence of a systolic murmur 
at the apex of the heart is always due, in 
these cases, to endocarditis. These apex 
murmurs in my own experience persist 
for a month or two at least,-persist as 
long as the patient is under observation. 
Sometimes possibly dilatation of the heart 
originates in an attack of Scarlet Fever. 
X. Other Sequelae and Complications.- 
(1) Sloughing of the cornea is an accident 
of which the occurrence may probably be 
always prevented. (2) Hemorrhage in 
consequence of a sloughing bubo, of de- 
struction of the pars petrosa, or in the 
form of hsematuria, has already been 
described. Epistaxis is an occasional 
phenomenon. Here may be mentioned 
that variety of Scarlet Fever which many 
writers, probably somewhat biased by the 
analogy of smallpox and measles, have 
been very ready to admit into their noso- 
logy, I mean Sc. hsemorrhagica ; a form of 
the disease which must be very rare (ex- 
cept, perhaps, in certain epidemics),-so 
rare that the occurrence of a passive 
hemorrhage from several mucous mem- 
branes at once might make one with jus- 
tice suspend a diagnosis of Scarlet Fever 
until the notion of possibly having to do 
with variolous roseola was discarded. I 
have known Variola hsemorrhagica to be 
mistaken for Sc. hsemorrhagica, and the 
truth not appear until, in course of time, 
those who had dealings with the case 
were themselves attacked by smallpox. 
(3) Gangrene. Cancrum oris is a very 
uncommon sequela of Scarlet Fever. 
Gangrene of the pharynx is said to have 
occasionally supervened. Sloughing of the 
skin over a bubo is much more common ; 
so also is gangrene of blistered or ulce- 
rated parts of the skin. Here may be 
classed such sequelae as necrosis of parts 
of the jaw-bones, and hip-disease. (4) 
Tubercle. Scarlet Fever by no means 
tends to develop tubercle even in a sub- 
ject predisposed. (5) Other acute specific 
diseases. The eruptions of Scarlet Fever 
and measles may appear at the same time 
upon the same patient (Rilliet et Barthez, 
iii. 281). Smallpox has been known by 
the same writers to complicate Scarlet 
Fever. I myself ha ve made this observa- 
tion ; a girl of three had hooping-cough ; 
about a week after she began to whoop 
she became very feverish,-this was on 
April 5th ; on the 6th and 7th she vomited 
beyond what the cough would account 
for; on the 8th an indubitable varioloid 
eruption appeared upon her, and on the 
9th, a rash which possessed in every re- 
spect the scarlatinal character. In an- 
other girl of two and a half I saw the 
eruptions of Scarlet Fever and varicella 
appear upon the same day. I have 
known the long course of typhoid fever to 
be broken asunder, as it were, by an 
attack of Scarlet Fever. Diphtheria is a 
comparatively frequent sequela : the pa- 
tient seems to be in a fair way of recovery, 
when an acrid discharge from the nostrils 
is noticed, the neck swells again, the py- 
rexia returns : death is inevitable (Graves, 
Clin. Med. i. 318 ; Trousseau, i. 15); this 
complication may ensue as early as the 
fifth day (Rilliet et Barthez, iii. 168). 
The writer has seen diphtheria supervene 
upon the chronic dropsical cachexia, the 
new disease here also inducing rapid death. 
Lastly, Scarlet Fever may be intercurrent 
during the acute period of rheumatic 
fever, and neither disease be perceptibly 
modified. 
[Although much more rarely than is 
the case with diphtheria, Scarlet Fever 
may be followed by partial paralysis; es- 
pecially of the lower limbs. This is sel- 
dom of a very severe grade, but it may 
require weeks, or sometimes months, to 
pass away.-H.] 
Diagnosis.-During the invasion pe- 
riod the diagnosis depends upon the pre- 
sence of vomiting or angina, and the ab- 
sence of sneezing, lachrymation, or pain 
in the back, in a person who has been 
taken ill suddenly, and has not previously 
suffered from Scarlet Fever. The fre- 
quency of the pulse, and severity of the 
nervous symptoms from the first, are 
sometimes valuable aids to diagnosis. 
The rash may be confounded with the 
eruption of measles, smallpox, typhus, 
roseola, miliaria, or urticaria. Measles 94 
SCARLET FEVER. 
may be wrongly suspected when a Scarlet 
Fever rash is of a darker color than usual, 
and especially when it is discrete also. 
And, contrariwise, in several eases of 
measles I have been perplexed by the ex- 
istence of a scarlatiniform rash upon the 
body several hours before the proper erup- 
tion of measles appeared. The roseola 
which precedes smallpox occasionally 
causes an error in diagnosis. The resem- 
blance which the rash of Scarlet Fever 
occasionally bears to that of typhus has 
been alluded to previously. To know that 
the minute vesicles of miliaria and the 
confluent wheals of urticaria are not un- 
frequently mistaken at first sight for 
Scarlet Fever rash, will suffice in most 
cases for the diagnosis. Reviewing some 
of these statements, and bearing in mind 
how closely the rash of Scarlet Fever and 
of measles may simulate each other, that 
the two diseases may concur, and that 
symptomatic roseola is not always easily 
distinguished from Scarlet Fever on the 
one hand or measles on the other, it is 
fair to conclude that at least some sup- 
posed cases of a disease which has been 
called rubeola (rotheln, roseola febrilis) 
are attributed to an impossibility in the 
diagnosis.1 
Scarlatinal angina is indistinguishable 
per se from ordinary simple erythematous 
sore throat, or from pellicular angina 
(pharyngeal herpes) which forms so large 
a proportion of the sore throats popularly 
styled diphtheritic. 
The swelling which occurs about the 
joints during the first two or three days 
of the disease is sometimes very consider- 
able, while the rash is pale or absent; such 
Scarlet Fever has been mistaken for rheu- 
matic fever. 
Surgical Scarlet Fever. - It has been 
doubted by some whether the scarlatini- 
form rash which sometimes follows opera- 
tions is really scarlatinal. The eruption 
appears from the second to the sixth day 
after the operation, and, in the cases 
which have caused the doubt, is very 
fugitive, the first and only symptom. 
Yet, that the disease really is Scarlet Fe- 
ver, would seem to be proved by the fol- 
lowing observations: first, that the dis- 
ease occurs in epidemics ; secondly, that 
in a given epidemic a severe case occa- 
sionally relieves the monotonous recur- 
rence of the very mild form ; thirdly, that 
a precisely similar scarlatinilla attacks, in 
the same epidemic, patients who have not 
been subjected to operation, and who 
have no open sore ; and lastly, by way of 
a veritable experimentum crucis, that, how- 
ever freely these patients are exposed to 
Ordinary Scarlet Fever contagion after- 
wards, they do not contract that disease. 
Morbid Anatomy. - Scarlet Fever 
does not possess any distinctive anatom- 
ical character which persists after death: 
the alterations of texture found post mor- 
tem are common to other pyrexiae. 
The furred tongue indicates a condi- 
tion, similar in kind, if not in degree, of 
the mucous membrane of the whole ali- 
mentary canal; there is an excessive for- 
mation of epithelium and concomitant 
hypertemia of the sub-epithelial layers; 
casts of the gastric tubuli are to be de- 
tected by the microscope in the vomit. 
(Fenwick.) From the frequency of co- 
ryza, pulmonary catarrh, and pneumonia, 
we infer that the respiratory mucous 
membrane does not escape. 
A peculiar change in the muscular tis- 
sue has been described by Zenker; a 
change more constant, as it would seem, 
in typhoid than in Scarlet Fever. 
The puffy swelling which sometimes 
precedes the rash or coincides with it, 
may indicate a direct implication of the 
connective tissue. 
The spleen, the lymphatic glands, the 
tonsils, and the lymphoid (solitary or 
agminated) glands of the stomach and 
intestines are swollen and injected ; the 
tonsils and the gastro-intestinal glands 
sometimes go on to ulcerate. In this 
place may be just mentioned the leuchee- 
mic deposits which have been detected 
here and there. 
The liver and the kidneys are involved 
to a slight degree; a little cloudiness of 
the cortex of the kidneys by no means 
indicates the existence of albuminuria. 
The kidneys of renal dropsy will be de- 
scribed under the head of Kidney Dis- 
eases. 
The cerebral symptoms are, so far as is 
known at present, unaccompanied by 
anatomical change. 
Prognosis.-I. Prognostics derivedfrom 
pre-existing conditions.-1. The social posi- 
tion of the person attacked has no influ- 
ence upon the course of the disease, which 
is quite as fatal among the rich as among 
the poor. 2. Family constitution seems 
to influence Scarlet Fever to a degree 
which can be hardly overrated ; that one 
or more members of a given family have 
succumbed, renders the prognosis in the 
case of any other persons in that family 
who may chance to be attacked, very 
grave. 3. Pregnant women are said to 
be peculiarly exempt from the liability to 
contract Scarlet Fever ; but the puerperal 
state predisposes to the occurrence of not 
only Scarlet Fever, but Scarlet Fever of a 
very fatal form. The rate of mortality 
seems to differ in different epidemics ; but 
whether of thirty-six patients attacked all 
die (Trousseau), or the mortality be twenty- 
live per cent. (MaeClintock), or all of nine 
1 [See article on "Rotheln."-H.] PROPHYLAXIS-TREATMENT. 
95 
patients recover (Blakely Brown), the 
prognosis cannot be too guarded. 4. A 
scrofulous vulnerability of the mucous 
membranes or the lymphatic glands 
greatly adds to the gravity of the prog- 
nosis. 5. A previously feeble state of 
health by no means predisposes to a bad 
type of Scarlet Fever-almost the reverse ; 
certainly the majority of cases of Sc. 
maligna are in persons of previously 
robust health. 6. Age and sex have no 
effect. The epidemic constitution does 
not always afford trustworthy aid in a 
particular case. 
II. Prognostics derived from the actual 
disease.-The number and the gravity of 
the possible complications and sequelae of 
Scarlet Fever should render the prognosis 
very wary even in the mildest cases. 
Excluding the malignant forms, we fudge 
of the severity of the disease more from 
the number and severity of the local 
lesions, than from the height of the py- 
rexia or the color of the rash ; each addi- 
tional local lesion, complication, or se- 
quela, being an addition to the gravity of 
the prognosis. Bubo and coryza are the 
most formidable symptoms of the first ten 
days, rheumatism and albuminuria of the 
next ten days. There are no guides to 
prognosticating the probability of the 
occurrence of bad sore-throat, rheuma- 
tism, or renal dropsy. If on the first day 
of deflorescence of the rash the fever still 
keeps up, we must attribute it to a new 
or an increased local lesion, and this will 
mostly be found to be anginal. The 
gravity of a brawny bubo is always great. 
A tendency to relaxed sore-throat does 
not predispose to bad angina. In most 
cases in which coryza has appeared on the 
fourth or fifth day, the secondary sore- 
throat will ensue to a certain extent. Of 
the patients seen by MM. Rilliet and 
Barthez, all who during the first fifteen 
days of the disease exhibited convulsions, 
convulsive movements, rigidities, in other 
words, symptoms referable to the locomo- 
tive apparatus, have died ; according to 
my own experience, the prognosis which 
might be derived from this statement 
would be too unfavorable. The nocturnal 
talkative delirium (noctibus aliena loqui) 
is, no doubt, as Heberden says, an unim- 
portant symptom. But when delirium 
becomes more active than this, more con- 
stant, more independent of surrounding 
things; when attended by restlessness, 
sleeplessness, drowsiness, or by vomiting 
and diarrhoea, it is impossible to dissemble 
the grave significance of the symptom. 
Suppurative arthritis is a most serious 
accident; multiple abscesses are much 
less grave. In the renal dropsy, moderate 
oedema puhnonum and pleural effusion 
may be recovered from. The reader will 
find many other prognostics under the 
heads of the sundry symptoms. 
Prophylaxis. - Removal from all 
sources of contagion is the most obvious, 
the surest, and probably the only means 
of preventing Scarlet Fever. The pro- 
phylactic virtue of an infinite number of 
fumigations and drugs has been vaunted 
from time to time, but fruitlessly, with 
one exception, namely, belladonna; yet 
even of that remedy the reputation, not 
wanting the support of hundreds of obser- 
vations tabulated, has in the present day 
sunk very low. Inoculation by means 
of the blood, the fluid of the miliaria, or 
the secretions of the fauces, has been 
practised in a few cases, and so far, appa- 
rently, not without favorably modifying 
the disease thereby communicated. 
With reference to the purification of 
materials which have been exposed to 
Scarlet Fever, it may be here remarked 
that the morbific principle is destroyed by 
a heat considerably below the boiling- 
point of water. 
Treatment.-In the following pages 
I shall endeavor to trace an outline of the 
plan of treatment ordinarily adopted at 
the present day. It will be impossible 
not to omit mention of many curative 
means which may be of real value ; in a 
common disease, not very powerfully con- 
trolled by any therapeutic method, the 
remedies which have been and which are 
employed must be innumerable. 
To know the natural course of Scarlet 
Fever is a great guide to the appropriate 
treatment; for, although we cannot abridge 
that course, we can be prepared for the 
occurrence of different accidents at differ- 
ent stages, and so be able to meet those 
accidents from the very first. Provided 
that no complications occur, Scarlet Fever 
will terminate favorably within a week 
from the onset of the disease. Among 
the complications we must place the 
malignant form of the disease, and also 
any unfavorable pre-existing condition, 
such as the puerperal state. 
The regimen of acute diseases must be 
put in force. The patient should be kept 
in bed, as a rule to which there is no ex- 
ception ; the bed-clothes should be those 
to which he has been accustomed in 
health, and no more; carpets, curtains, 
and porous materials must be removed ; 
the bed-room should be carefully venti- 
lated (in part by an open fire), bearing in 
mind that there is no special reason to 
fear cold during the first week ; the whole 
surface of the body should be sponged 
with tepid water once or twice a day, and 
subsequently to grease the skin with mut- 
ton suet often brings comfort to the pa- 
tient. The diet is to be unstimulating, 
consisting of milk, broths, the farinacea, 
an egg, light puddings; drink should be 
freely supplied. Purgation is to be 
avoided. 96 
SCARLET FEVER. 
In many cases a consideration of the 
previous and the present condition of the 
patient will indicate the administration 
of wine: the child seems low, the pulse is 
not only frequent but soft and feeble, there 
is possibly coryza present. At the same 
time full doses of carbonate of ammonia 
should be given, in milk, every four hours. 
And it must be conceded that no great 
harm comes from the moderate employ- 
ment of stimuli, even when they are not 
absolutely necessary. 
When the throat is much inflamed, 
great relief may be afforded by either of 
the following methods of treatment. The 
first is to cause the patient to use ice 
freely; he is to allow lumps of it to dis- 
solve in his mouth. Under this treatment 
tenderness of the submaxillary glands 
sometimes passes away in a few hours, an 
improvement which is an index of that 
which has taken place within. Ice can 
be easily given to patients above five or 
six years of age ; but the second remedy 
is one which is inapplicable in the case of 
children; I mean the inhalation of the 
steam of hot water. Puffy swelling of the 
neck may often be removed by external 
applications of spongio-piline wrung out 
from hot water, or of hot linseed-meal 
poultices, frequently renewed. 
In like manner coryza is a symptom 
which, when treated early, may thereby 
cease to be of evil omen. To check the 
coryza is to check, in the majority of 
cases, that worst form of otorrhoea which 
proceeds from the destruction of the tym- 
panum. In patients above eight years of 
age, the valuable method of washing out 
the nostrils introduced by Dr. Thudichum 
may be employed. An ounce of salt is 
dissolved in a pint of warm water, and 
this solution, contained in a vessel a little 
raised above the head of the patient, is 
conveyed by means of a flexible caoutchouc 
tube into one nostril; respiration being 
carried on through the mouth, and all at- 
tempts at swallowing forbidden, the fluid 
passes out freely by the other nostril.1 
In young children we are reduced to the 
expedient of syringing the nasal fossa; 
with a weak solution of nitrate of silver 
(gr. v. to §j) once a day when the coryza 
is troublesome. 
Of the remedies employed in the treat- 
ment of the malignant form of Scarlet Fe- 
ver, there is one which stands out from 
among the rest, the cold affusion. Yet it 
is not of equal value in all cases; from 
the days of Currie downwards the ataxic 
form of the disease, characterized by de- 
lirium, diarrhcea, vomiting, full pulse, 
and great heat of skin, has been recog- 
nized as the special indication for this 
active treatment. The patient is to be 
seated naked in a bath, two or three buck- 
etfuls of water at 70° F. are poured over 
him quickly, so that the allusion does 
not last longer than half a minute ; he is 
then returned undried into bed, and laid 
between blankets. The first affusion hav- 
ing had a markedly beneficial effect, 
should the indication symptoms return in 
the course of the same day or the next, 
the water treatment may be repeated, and 
this even two or three times if necessary. 
When this treatment has been objected 
to, or has seemed too bold, I have seen 
very good results follow from packing the 
patient in a wet sheet for an hour. A 
still milder method remains to be men- 
tioned, that of occasional cold sponging. 
Ammonia and brandy are nearly always 
needed, sooner or later, by these patients. 
[Cold sponging is often very useful in 
non-malignant, open cases, with high tem- 
perature and inflammatory eruption. It 
may be practised more than once a day ; 
but is especially serviceable for the pro- 
motion of sleep at night. Some practi- 
tioners prefer inunction with lard, or the 
application of glycerin, when the irritation 
of the skin is great.-H.] 
In the primary adynamic form all treat- 
ment will be baffled. The cold affusion 
is the only means which has seemed to 
me to be of even momentary benefit. Hot 
mustard baths, which would at first sight 
appear to fulfil the indication better, may 
be tried; strong tea or coffee, brandy, 
ether, camphor, are to be given internally. 
The treatment is much the same, and 
also, unhappily, the prognosis, in adyna- 
mia, sequential to an excited state. A 
full description of the treatment formerly 
adopted (and not, perhaps, without suc- 
cess) in cases such as these, will be found 
in the pages of Armstrong. 
[Certain cases of a dangerous kind, at- 
tended by stupor, without reduction of 
temperature or marked feebleness of pulse, 
are best treated with purgatives and diu- 
retics. A good combination for this pur- 
pose is that of jalap, digitalis, and squills. 
In the more prolonged adynamia, qui- 
nine is a useful addition to the remedies 
just mentioned. A most nutritious diet 
and a rather liberal allowance of wine 
will often enable such patients to recover. 
The Hippocratic remedy of warm affu- 
sion to the head is most soothing in the 
nocturnal delirium and sleeplessness. 
However favorable an attack of Scarlet 
Fever, the patient should be kept in bed 
for three weeks from the commencement 
of the disease; he may then get up, but 
he should not leave his room for another 
week. Even after four weeks have elapsed 
he is not free (if we are to believe some 
observers) from all danger of albuminuria. 
If on the morning of the fifth or sixth 
day any ulcerous appearance that the 
1 For fuller particulars refer to Dr. Thudi- 
chum's paper. Lancet, Nov. 26, 1864. TREATMENT. 
97 
fauces may have previously presented 
does not show signs of yielding, it is well 
to cauterize the morbid surface. For the 
tonsils undiluted hydrochloric acid is to 
be used ; for any other part of the soft 
palate, solid nitrate of silver. The latter 
caustic is to be applied to those excoria- 
tions which are apt to appear about this 
time or later. It need hardly be added 
that these potent escharotics are, as a rule, 
to be used once for all; if repeated four 
or five days at least should have elapsed 
since the previous application. The ex- 
ternal swelling should be assiduously fo- 
mented while in the puffy stage, for as 
soon as brawniness sets in, anything that 
may be done will be of very small service ; 
poultices are to be continued, but the oc- 
currence of suppuration will hardly be 
thereby hastened. As soon as suppura- 
tion has occurred, however small the spot 
to which the process is limited, an incision 
should be made to let out the pus; the 
poultices being afterwards resumed. The 
abscess should never be allowed to open 
itself. In the worst cases of Scarlatina 
anginosa, openings and counter-openings 
will be required; a free discharge of 
sloughs and ichor affords the patient his 
sole chance. Should hemorrhage occur, 
the wound is to be stuffed with lint 
soaked in the solution of the perchloride 
of iron ; this moderate pressure will stop 
the bleeding, which is more often venous 
than arterial. 
All cases of otorrhoea are to be treated 
by syringing the meatus gently with warm 
water three or four times a day. Should 
a discharge either from the ear or from 
the nose become chronic, quinine and sul- 
phuric acid are the drugs indicated. 
The suppurative tendency likewise is 
an indication for quinine, and an abun- 
dance of fresh air and substantial food. 
All abscesses are to be opened early. A 
post-pharyngeal abscess should be evacu- 
ated if possible (and it mostly is possible) 
through the neck; should this be im- 
practicable, a cut must be made with a 
guarded bistoury through the posterior 
wall of the pharynx upon the vertebral 
column-an operation devoid of risk, if 
performed with ordinary care. The mat- 
ting together of tendons is remediable to 
a great extent by fomentations, friction, 
and passive motion. 
The treatment of the rheumatism is 
that of its symptoms : Dover's powder for 
the pains, diluents for concentrated urine, 
aperients if necessary, cotton - wool or 
poultices round the affected joints. Alka- 
lies are not of any special value. The 
treatment of intercurrent pericarditis is 
often difficult ; whether local blood-let- 
ting is admissible, and when counter- 
irritation more or less severe should be 
used, depend entirely upon circumstances 
beyond the local inflammation. 
The remedies to be employed at the on- 
set of renal dropsy may be thus arranged 
in order of importance. First come active 
purgatives; elaterium is good, but the 
uncertainty of the ordinary drug often 
causes the loss of much valuable time; 
compound jalap powder in doses of not 
less than a scruple to a child of six or 
eight years of age, repeated at intervals of 
eight hours, until the bowels act freely, is 
altogether more trustworthy. The hot- 
air bath, preceded by a hot-water bath 
and a dose of antimonial wine, may be 
used every night so long as the quantity 
of the urine is much diminished. After 
four or five such baths the strength of the 
patient should be carefully estimated, and 
the baths continued or not accordingly. 
Dry-cupping, not practicable in the case 
of children, would no doubt deserve trial 
in older patients. Vomiting is an inter- 
current symptom which will perplex the 
practitioner ; not the least valuable rem- 
edy will be found to consist of ice swal- 
lowed in the lump. Diluents should be 
given as much as possible. It may as 
well be observed that there is a concen- 
tration of the urine which is due to insuf- 
ficient ingestion of liquids or to excessive 
sweating ; to drink water freely is all that 
is needed in such cases to increase the 
quantity of urine. 
[Lemonade is not only an agreeable, but 
a useful diluent in such cases. Among 
diuretics, digitalis is most valued by some 
practitioners. The late Dr. L. Gebhard, 
of Philadelphia, after a very extended ex- 
perience, considered it one of the best of 
remedies in Scarlet Fever. Several prac- 
titioners have reported well of the use of 
quinine in considerable doses, in scarlati- 
nal dropsy.-H.] 
The less acute stage of albuminuria 
(called the second in the previous pages) 
requires an altogether different plan of 
treatment. The bowels must not be con- 
fined, but purgation is no longer neces- 
sary. Hot-air baths have little or no 
beneficial effect upon the condition of the 
urine. When there is much hsematuria, 
gallic acid in sufficient doses may be 
tried ; it should be discontinued if it does 
not bring about a decided improvement in 
four or five days; to diminish the quan- 
tity of albumen as such, gallic acid has 
little if any power. Quinine has at times 
a remarkably good effect in these chronic 
cases. But upon the whole no remedy is 
equal in value to the perchloride of iron. 
Counter-irritation to the loins will be use- 
ful, and generous diet necessary. In the 
great majority of cases the disease tends 
to wear itself out in time. When exten- 
sive anasarca is present, the whole condi- 
tion is more grave; should the dropsy 
tend to the lungs and pleural sacs, the 
danger can hardly be exaggerated. We 
must try laxatives and diuretics so tong 
VOL. I.-7 98 
DENGUE, OR DANDY FEVER. 
as the anasarca remains simple. The hot- 
air bath may be used cautiously, but there 
comes a time when it will increase the 
anasarca rather than diminish it. When 
acute hydrothorax or pleurisy with effu- 
sion occurs, the question of paracentesis 
presents itself, but is rejected not only by 
experience, but also on a priori grounds ; 
both sides are involved at once,"and the 
lungs mostly suffer as much as the pleura?. 
Sloughing of the cornea would probably 
be preventable in many cases by the sim- 
ple expedient of keeping the eyes shut, as 
recommended first by Trousseau. 
DENGUE, OR DANDY FEVER. 
By William Aitken, M.D. 
Definition.-A febrile affection, sui I 
generis, commencing suddenly, and asso- 
ciated from the commencement with se- i 
vere pains in the large and small joints. 
About the third day a peculiar cutaneous 
eruption or efflorescence appears upon the 
palms of the hands, rapidly spreads over 
the whole body, and rarely continues visi- 
ble beyond twenty-four hours. A distinct 
remission succeeds, but relapses are nu- 
merous, and the disease may thus persist 
about two months marked by prostration 
and cachexia, its course being character- 
ized by intervals, or remissions, and the 
exacerbations marked by rheumatic or 
neuralgic-like phenomena. 
Synonyms. - Scarlatina Rheumatica, 
Cock ; Exanthesis Rosalia Arthrodynia, 
Cock ; Dandy Fever, Natives of West In- 
dies; Dunga*Bouquet; Bucket; Epidemic 
Inflammatory Fever of Calcutta, Meilis ; 
Eruptive Epidemic Fever of India ; Too- 
hutia, Natives of East Indies ; Three-day 
Fever, Natives of East Indies; Rheu- 
matic Fever with Gastric Irritation and 
Eruption, Furlonge; Eruptive Articular 
Fever; Eruptive Rheumatic Fever; Plan- 
taria ; Febris Exanthematica Articularis; 
Giraffe, on account of the stiff holding of 
the neck ; Epidemic Anomalous Disease, 
Stedman ; Peculiar Epidemic Fever; Colo- 
rado, on account of the red spots ; Exan- 
thesis Arthrosia; Stiff-necked Fever; 
Broken-wing Fever ; Break-bone Fever. 
History.-During many months pre- 1 
vious to October, 1824, there prevailed in 
Calcutta an epidemic fever so impartial in 
its attack that few remained untouched by 
the distemper in a population of nearly 
half a million of beings. Passing from 
the East Indies the disease was next heard 
of in 1827-8, amongst the islands of the 
Archipelago and in the Southern States 
of North America. 
Between the months of September and 
January of these years it prevailed in the 
islands of St. Thomas and Santa Cruz. 
Almost every individual in a population 
of 12,000 persons is reported to have suf- 
fered. (Stedman, Ed. Med. and Surg. 
Journ. Oct. 1828.) With few exceptions 
the disease spared no one of either sex, of 
any age, or complexion, or caste. The 
new-born infant, the young child, the 
aged, the weak, the robust, the rich, the 
poor, all were alike the objects of attack. 
Physicians too, invariably became pa- 
tients, and hence perhaps the details of 
symptoms in the epidemics of this disease 
are so extremely minute ; and although 
the disease was a very painful one, it was 
not one dangerous to life. The attacks 
were invariably sudden. In families of 
ten or twelve persons (including servants), 
a half or even eight members would lie 
down at once (Furlonge, loc. cit. vol. 
xxxvii. 1832). Attention was therefore 
immediately arrested by epidemics of such 
a disease, and the general public, not less 
than medical men, were curious to learn 
the natural history of a disease with fe- 
brile characters so peculiar, and in results 
so unlike the epidemic or endemic fevers 
of tropical regions with which the physi- 
cians of the East and West Indies had 
been familiar. When the disease first at- 
tracted attention in Calcutta, it was gene- 
rally believed that nothing of precisely the 
same nature had ever existed there before, 
unless the disease known to the native 
"conductors" of India by the name of 
" the Three-day Fever" were of the same 
nature. (Cavell, Trans. Phys. Soc. of 
Calcutta, vols. i. and ii.) 
For the earliest accounts of this disease 
we are indebted to the physicians of the 
East Indies, and especially to Drs. James 
Meilis, Kennedy, Twining, Cavell, and J. 
Mouat; and the natural history of the 
fever given by them was subsequently cor- 
roborated, in all essential particulars, by 
the physicians of the Southern States of SYMPTOMS. 
99 
North America and those of the West In- 
dian islands, more especially by Drs. Sted- 
man, Cock, and Furlonge, in these islands, 
and by Dr. Dickson, of Charleston, in 
America. [Dr. Benjamin Rush first de- 
scribed it as occurring in Philadelphia in 
1780.-H.] When the disease was first 
described by Dr. Meilis, he was disposed 
to regard it as "inflammatory fever;" 
but he found that such a name did not 
fully indicate the peculiar characters of 
the fever ; nor could it be identified as ex- 
actly similar to the fever described by 
Cuhen under the name of Synocha; nor 
to the fever described by Good under the 
name of Cauma ; nor to the Febris acuta 
sanguinea of Hoffman. Many different 
opinions have accordingly been enter- 
tained regarding the nature of Dengue. 
By some it was considered as a rheumatic 
fever; by others as a remittent. Some 
regarded the complaint as measles ; others 
as scarlatina. Some considered the fever 
synocha, with gastric irritation and an 
eruption associated with it, similar to that 
which in some constitutions follows fish- 
poisoning. Treatment therefore varied, 
alike in principle and in detail. But 
rather than subscribe to a definite name 
in any then existing nosology, the physi- 
cians who first described Dengue preferred 
comparing the phenomena of the peculiar 
cases they saw, as regarded their symp- 
toms and sequelfe, with diseases of a simi- 
lar kind ; and so the first records of the 
history of this disease are peculiarly valu- 
able when the speculations with which 
they abound are eliminated. 
Symptoms. - Commencement. Develop- 
ment^ Duration, Termination.-The inva- 
sion of this disease as a rule was very 
sudden, and the progress of successive 
phenomena was rapid. Lassitude, drowsi- 
ness, heavy sensations in the eyes, fre- 
quent yawning, slight vertigo, a sense of 
coldness creeping down the back, or of 
numbness in the extremities which be- 
came cold, occasional rigors, pains in the 
head in most cases confined to the fore- 
part, or most severe there, acute pain in 
different parts of the body, sometimes in 
the larger muscles and joints, and occa- 
sionally in the smaller ones, such as the 
fingers and toes, are among the pheno- 
mena, one or other of which, or several 
combined together, suddenly expressed 
the commencement of the disease; and 
in the several epidemics whose histories 
have been recorded, some of these pheno- 
mena were more prominently marked than 
others. As a rule, however, the attacks 
were so sudden that no sensation of any 
deviation from the usual health indicated 
the approach of the malady. It often 
happened that people had a most violent 
attack, wi h severe headache and burning 
pains in the temples, within three hours 
after having boasted of their escape from 
the disorder. (Twining.) In general the 
patients woke out of their sleep with great 
pain in the head, loins, shoulders, arms, 
wrists, hips, thighs, and ankles, fingers or 
toes. (Mouat.) Acute pains in one or 
both knees, in the ankles, the wrists, or 
in all of these joints at once (though in 
general only one was at first affected), 
marked so suddenly the invasion of the 
disease, that the symptoms would first 
express themselves as the person walked 
along the street. (Stedman.) The motion 
of the joint was at first arrested, partly 
by stiffness, and partly from the pain 
caused by movement; and in cases where 
the symptoms commenced in the lower 
limbs the patient fell to the ground. The 
most usual mode of attack in the West 
Indian epidemics was expressed by a sud- 
den stiffness, amounting to pain, in one of 
the fingers-generally the little finger. 
The stiffness increased, spreading rapidly 
over the whole hand and up the arm to 
the shoulder, so that in a few hours the 
fingers of both hands became so swollen, 
so stiff, and so painful, that all attempts 
to bend the joints were useless. At later 
periods in the various epidemics the ap- 
proach of the fever was indicated at least 
a day before by anorexia, languor, listless- 
ness, and a white tongue. A dry heat at 
the scrobiculus cordis was among the 
earliest symptoms noticed by Twining. 
The face was soon flushed-a phenomenon 
often observed by others before it attracted 
the attention of the patient. Intense 
headache followed upon the burning sen- 
sation in the forehead. The eyes became 
watery and the conjunctiva suffused. The 
whole countenance appeared bloated and 
swollen, the face assumed a scarlet hue, 
and the surface of the skin was every- 
where flushed. The signs which then 
predominated were a chilliness extending 
over the whole frame, quickly followed by 
pain and weariness in the limbs, a general 
sensation of stiffness or soreness, with a 
heaviness over the eyes so excessive as to 
render the effort to open them painfully 
oppressive, and a headache so severe as 
to be beyond description. (Cavell.) Pres- 
sure over the eyes increased the pain, but 
light did not affect them. The eye-balls 
appear to the patient as too large for their 
sockets, as if ready to start from the head, 
and the pain in them so intense as to cause 
extreme distress. The expression of the 
eyes was ferrety. The lobes of the ears 
were likewise greatly pained. (Cock.) 
The rapidity of the pulse, the aspect of 
the tongue, and the condition of the skin, 
each of which at first might not seem to 
be much influenced, yet rapidly passed 
from their normal condition. 
The pulse, soon after the accession of 
the fever, was in most instances above 
one hundred per minute, becoming more 100 
DENGUE, OR DANDY FEVER. 
frequent, full, hard, and strong, till it 
averaged about thirty or forty beats per 
minute above its normal rate, within six 
hours after the fever became expressed. 
Twining once observed it 140 in an adult 
whose usual pulse in health was eighty 
beats per minute. In some instances its 
force was so greatly increased that the 
temporal arteries were felt and seen to 
beat with violence. In children it was 
often so extremely rapid as to be indis- 
tinct and weak. Respiration was rela- 
tively extremely hurried ; while determi- 
nation of blood to the head was consider- 
ably increased, as indicated by bleeding 
at the nose, increasing redness of the face 
and eyes, confusion of thought, and some- 
times delirium. 
The tongue soon became of a scarlet 
color, at the sides, furred with a white or 
brown coat in the centre, so that in a few 
hours it appeared as if covered with a 
dense white paste, or with a thick dirty- 
white coating, always moist, and asso- 
ciated with a disagreeably bitter taste in 
the mouth. The bowels were generally 
confined at first, while oppression at the 
prsecordia, nausea, vomiting of viscid mu- 
cus and of bile were present from the 
commencement, and continued for some 
time. Irritability of the stomach was 
often indeed so very great that it retained 
anything with difficulty. The desire for 
food was inconstant. In some cases ap- 
petite was entirely gone ; but not infre- 
quently in children, the desire for food 
was increased. Thirst was not commen- 
surate with the distress from other symp- 
toms. Extreme prostration of strength 
became apparent at a very early period of 
the disease, and with rapid increase of 
pain in the loins, with not less severe 
pains in the muscles of the limbs, espe- 
cially the legs, attended with a remark- 
able degree of anxiety and jactitation. 
The febrile anguish was extreme, with 
aching in the back of the neck. In short, 
suffering from pain was a leading feature 
in the accession and course of the attack 
of Dengue. The debility, the restlessness, 
and the general soreness rendered every 
position alike uneasy and intolerable, not 
less distressing to the patient than alarm- 
ing to the spectator. (Twining.) Such 
was the excruciating nature of the pains, 
that few had fortitude sufficient to sup- 
port them without complaint. (Cock.) 
These pains have been known to shift from 
one part of the extremities to another; 
sometimes attacking the patient in his 
knees, or in his toes, sometimes in one 
knee or toe, and sometimes in another; 
each new invasion of a part being accom- 
panied with twitchings of the muscles of 
the part affected. So sudden were the 
attacks of pain in a fresh place, that a 
person might be calmly conversing writh 
you when he would suddenly scream out 
from the severity of returning pain. 
(Cock.) In some cases the headache and 
the pain in the back and loins were the 
most distressing symptoms, although not 
at all times equally severe during the first 
twenty-four hours. These pains would 
frequently subside a little to return in 
paroxysms with redoubled violence. It 
was, indeed, a disease of extreme severity 
as far as relates to the sufferings of the 
patient; but having regard to the result 
of the disease, as affecting life, and com- 
pared with its universal prevalence, it 
was a fever of unexampled benignity. 
Such were the phenomena which, more 
or less severely expressed, marked the ac- 
cession of an attack of Dengue ; but to- 
wards the end of the first twenty-four 
hours the symptoms, which had gradually 
increased in severity, began to abate. 
The headache and flushing of the face 
somewhat subsided. The heat became 
more general and burning all over the ex- 
tremities, to the relief of the head in 
some degree. With this remission of the 
pyrexia, the headache after the second 
day became still less, and the pains in the 
loins and other parts were attended with 
less jactitation ; the character of the pain 
was changed to that of a dull aching kind, 
gradually leaving the fingers and ankles, 
and the toes last of all. During the first 
two nights there was little or no sleep, in 
consequence of the pain and febrile an- 
guish ; and although for several succeed- 
ing nights sleep was in most cases still 
interrupted by thirst and pains in the 
loins and legs, extending down to the 
toes and fingers, yet there was little or no 
disturbance of the intellect. Great pros- 
tration of strength; general debility of the 
whole system ; weakness of the stomach, 
of the loins, of the limbs, of the knees, 
and of the joints generally; continued 
pain in several joints, large and small, 
sometimes limited to a finger only ; oede- 
matous swelling of the extremities ; and 
general cachexia-denoted the exhaust- 
ing and debilitating nature of the malady. 
The debility was so great that sudden 
death during the period of remission or of 
spurious convalescence was known to 
occur in some instances during the epi- 
demic in Calcutta. The debility was not 
diminished by the sudden occurrence of 
perspiration, which during the early 
hours of the febrile accession had been 
suppressed, and, although this return of 
perspiration was accompanied by warmth 
of the feet and a remission of all the more 
distressing symptoms, yet the prostration 
of strength was all the more apparent. 
The urine was now copious and pale- 
colored ; and the evacuations from the 
bowels, even if freely moved by remedies, 
were of a dark green color, or even black, 
glutinous, scanty, and always offensive. 
During the three days following this re- SYMPTOMS 
101 
mission, the patient, in the more severe 
cases, lay in a state of extreme languor, 
but irritable and restless ; but as there are 
no records of temperature in this disease, 
it is not known if fever wTas entirely 
absent during the remission, although it 
is sometimes stated to have been so. It 
is rather to be presumed that the tem- 
perature did not fall to the standard of 
health; for although there was no acute 
suffering yet the feelings were said to be 
very different from those of health. 
Thirst continued to prevail in some, and 
the desire for food did not return. The 
sense of taste seemed entirely lost; while 
in some cases little aphthous sores, on the 
inside of the lips and on the edge of the 
tongue, rendered attempts at eating pain- 
ful in the extreme. (Stedman.) About 
the end of the third day the febrile phe- 
nomena again expressed themselves with 
even increased severity, compelling the 
patient to return to bed if he had ventured 
to leave it, deceived by the apparent but 
treacherous and spurious convalescence. 
With this febrile exacerbation, the cuta- 
neous system exhibited remarkable and 
peculiar phenomena. With great turgid- 
ity of the skin an eruption or rash ap- 
peared on different parts of the body. 
The appearance of this rash has been 
variously described : 
(a) As an efflorescence, beginning at 
the palms of the hand, and gradually 
spreading over the whole body. In gene- 
ral appearance this efflorescence differed 
considerably in different cases. In some 
it consisted of Blotches of red-colored skin, 
resembling in appearance, something be- 
tween measles and scarlatina. In some 
it was raised perceptibly above the sur- 
face of the skin, imparting a distinct feel- 
ing of roughness and elevation to the 
fingers passed over the eruption. In 
severer cases more obvious local swell- 
ings accompanied the efflorescence, and a 
distressing tingling of the skin resolved 
itself into an itching so intense, while the 
eruption disappeared, that the sufferers 
were almost driven to distraction. As a 
rule this efflorescent eruption remained 
only for about a single day, beginning to 
fade on the second day, and before the 
third morning it was generally entirely 
gone. Some degree of desquamation fol- 
lowed, generally in proportion to the 
intensity of the eruption. One instance 
is on record, in which a man eighty years 
of age had the eruption in so severe a 
form that the cuticle came off in flakes 
like pieces of parchment, leaving the sur- 
face of the body quite red. (Stedman.) 
The itching was extremely distressing, 
and the patient was in the utmost misery. 
In old men, the desquamation from the 
scrotum was attended with most intolera- 
ble itching, and in some of them the tes- 
ticle became swollen to a great degree. In 
others, extensive abscesses formed beneath 
the skin, probably of the nature of the 
pyogenic fever of Tessier and Jenner, and 
popularly regarded as " the dregs of the 
fever." In the epidemic at St. Thomas's, 
two children, each about five or six 
months old, died from the irritation at- 
tending the desquamation of the cuticle. 
The true skin, so exposed, was red, raw, 
and exceedingly painful from the inflam- 
mation of its texture. 
(6) About the third or fourth day an 
erythematous eruption appeared on the 
hands and feet (Cock), accompanied with 
swelling of those parts. This eruption 
gradually extended over the rest of the 
body, continuing for about thirty-six 
hours, when it faded, and the cuticle 
peeled off as in scarlet fever, leaving a 
considerable degree of soreness. The 
soles of the feet were sometimes rendered 
so sore, that walking, for many days after 
restoration to health, was attended with 
pain. The pains were apt to remain after 
the eruption had completely disappeared, 
and to become fixed in one or more of the 
joints, where they would remain for 
several months w'ith morning and evening 
exacerbations ; the pains then were most 
severe. Sometimes the glands in the 
groins were swollen and painful. (Cock.) 
(c) Dr. Furlonge regarded the eruption 
as altogether symptomatic of the gastric 
disturbance. lie observed that its inten- 
sity and extent were proportional to that 
disturbance; that those who were " known 
dyspeptics" had the eruption more exten- 
sively than others; that literary or seden- 
tary people and those whose occupations 
were such as to derange the chylopoetic 
organs, suffered most from nausea and 
other symptoms of gastric disorder, and in 
them the eruption was always more ex- 
tensive and marked. This eruption, he 
thought, resembled measles elevated with 
papulse and wheals; a sort of hybrid be- 
tween urticaria and rubeola, and of its 
nature similar to that which is known to 
attend the gastric disturbance from fish- 
poisoning. (Ed. Med. and Surg. Journ., 
p. 52, 1830.) 
(d) Dr. Meilis regarded the eruption as 
similar to roseola or to the lichen simplex 
ofWilian. 
(e) Dr. Twining regarded it as resem- 
bling rubeola; while in some instances it 
resembled patches of an inflammatory ap- 
pearance, in others a papillary, and in one 
or two instances that of a vesicular erup- 
tion. In many instances little more than 
a flush attended the febrile excitement. 
(/) Mouat says of the eruption, that it 
is like erythema papulatum, or purpura 
simplex not disappearing on pressure, and 
resembling roseola miliaris or lichen tro- 
picus. 
(g) In some cases there was said to 
have been no eruption (Cavell); but when 102 
DENGUE, OR DANDY FEVER. 
the short persistence of the eruption is 
taken into account, it is not improbable 
that it may have been overlooked in such 
cases. In most cases indeed discolora- 
tion of the skin was evident from the first; 
and it seems to have been characteristic 
of Dengue that the eruption which at- 
tended it assumed many characters. In 
one case the eruption might be referred 
to the class papula, in a second to exan- 
themata, in a third to vesicula, in a fourth 
to bullae, and in a fifth to that of wheal. 
But whatever the form of the eruption, 
all the cases were attended during its con- 
tinuance with very high excitement of the 
vascular system, which at last suddenly 
subsided, leaving the patient convales- 
cent. The eruption came on suddenly 
and vanished suddenly, hence it may have 
been very often overlooked, or its charac- 
ters might not have been observed, for it 
does not seem to have gone through any 
definite changes or marked stages. In 
some cases it appeared simultaneously 
with the febrile symptoms, in others not 
till twenty-four or thirty hours after- 
wards, and in two or three instances after 
all fever had apparently subsided. When- 
ever it appeared the color of the eruption 
was similar, and the amount of the sur- 
face covered by the rash of various extent. 
In proportion to its early appearance it 
generally portended a further mitigation 
of the more distressing symptoms, and 
more especially if the efflorescence uni- 
formly covered the whole body and the 
extremities. When the eruption was only 
partial on the body and less on the ex- 
tremities, but increased about the chest, 
neck, and face, there was, for the most 
part, some increase of feverishness, more 
uneasiness and anxiety, with aggravation 
of headache. It remained persistent for 
a comparatively short time, and had for 
the most part considerably faded at the 
end of twenty-four hours after its first ap- 
pearance, although it might continue ob- 
vious for two days. It was always at- 
tended with some degree of heat or 
itchiness, particularly when the minute 
exfoliations of the cuticle began to sepa- 
rate during the period of desquamation. 
It seemed to be chiefly in cases where the 
eruption remained persistent beyond two 
days that it assumed the aspect of urtica- 
ria, affecting more particularly the extre- 
mities; the fingers and toes, hands and feet 
being swollen, red, and affected with dis- 
tressing itching and burning, combined 
with febrile exacerbations and extreme de- 
bility for twenty-four or thirty-six hours. 
Associated with the eruption, some pa- 
tients had boils; others had small acumi- 
nated vesicles with hardened bases. Chil- 
dren suffered most from urticaria, and in 
them large watery vesicles sometimes led 
to the formation of ulcers. In one case the 
sloughing was so deep, the ulcers so foul, 
and the fever so high, that, convulsions 
supervening, the case terminated by death. 
In most instances, if not in all, as in the 
epidemic at Suzuratte, the throat and 
fauces were so affected as to make deglu- 
tition painful. The secretions from the 
lungs and salivary glands were very co- 
pious, unhealthy in appearance, and dis- 
tressing to the patients. The saliva rv 
glands were in some much swollen (the 
parotid as early as the fourth day), and 
the discharge of saliva in some instances 
amounted to ptyalism, although mercury 
had not been taken. It was also observed 
(Mouat) that very small doses of calom 1 
frequently induced disagreeable ptyalism, 
The disease was not considered to leave 
the patient fill he had suffered from a 
second and even a third relapse or parox- 
ysm of fever. The relapses were each at 
one time considered as separate attacks of 
fever; but the history of subsequent epi- 
demics showed that these several parox- 
ysms, each nearly equal in severity (al- 
though it was not noted where the 
eruption repeated itself), combined to con- 
stitute one and the same attack of a fever 
marked by such peculiar remissions and 
exacerbations. There were also dailv re- 
missions observed by Dr. Mouat, there 
being two or even three paroxysms in 
twenty-four hours. Few recovered, under 
three months, from the debilitating effects 
of the attendant fever and the aching 
pains in the wrists, fingers, toes, and an- 
kles. Tardy recovery, and the tendency 
to repeated relapses, were .characteristic 
phenomena. In these periods of exacer- 
bation the third days were decidedly 
"critical" (Kennedy); the pains in the 
limbs would abate, and the capability of 
taking food would return; but the furred 
tongue, the foul taste, and the disordered 
stomach generally continued for ten or 
twelve days after the final remission. The 
secondary prostration of strength evinced 
itself in proportion to the constitutional 
powers of the patient. Females in vari- 
ous periods of pregnancy went through 
the severer forms of the fever without any 
tendency to abortion. 
Although the actual temperature of the 
body in cases of Dengue has not yet been 
recorded, there is reason to believe that 
the fever reaches its fastigium at a very 
early period-probably within three days ; 
and during this period the surface of the 
body is subject to an irregular distribution 
of the blood, so that while the hands and 
feet are cold, the rest of the body, and 
particularly the head, may be intensely 
hot. During the height of the fever the 
head and eyes seem to indicate the great- 
est suffering, but the whole body is racked 
with pain, especially in the joints. Not 
an inch of the body from head to foot 
seems to have been exempt from suffer- 
ing ; hence the American name of " break- ETIOLOGY AND PROPAGATION-TREATMENT. 
103 
bone fever." In some cases the features, 
especially the eyelids, were swollen and 
distorted, associated in one or two in- 
stances with profuse ptyalism. But al- 
though the skin in cases of Dengue felt 
intensely hot to the touch of the observer, 
yet the patient experienced feelings of 
intense cold during all the different stages 
of the disease. When it prevailed as an 
epidemic at St. Thomas's, although the 
weather was extremely sultry, yet the pa- 
tient felt the warmest coverings (of two 
oi' three blankets) scarcely enough. 
Etiology and Propagation.-The 
origin of Dengue is unknown. The dis- 
ease is said to have been first noticed in 
Rangoon about the end of May or begin- 
ning of June, 1824; and on the 10th of 
June a large portion of the troops em- 
ployed on the expedition under Sir Archi- 
bald Campbell, then at Rangoon, had 
been ordered out to attack the Burmese, 
and were thus exposed to incessant heavy 
rains for four-and-twenty hours. 
The disease extended in various direc- 
tions, not only to Calcutta, but to Chitta- 
gong in the southeastern extremity of the 
Province of Bengal, and to Guzerat, in 
the Presidency of Madras. It was par- 
ticularly severe in the large and populous 
towns of Benares, Patna, and Chunarghur, 
and prevailed generally from Buxar to 
Benares, Churnar, and Mirzapore. 
In all of these places it seems to have 
become epidemic during or subsequent to 
the existence of heavy rains, associated 
with tlie close cloudy heat of sultry 
weather. Heat, moisture, and stagna- 
tion of air seem to have been always as- 
sociated with the origin and transmission 
of the disease. 
Stedman implies that the disease was 
imported into the free port of St. Thom- 
as's, and the accounts of the disease gen- 
erally show that it was propagated from 
place to place in the course or route of 
human intercourse. It travelled from 
Barbadoes to Jamaica. It raged in 
America and the East Indies. No dis- 
ease, indeed, with the exception of influ- 
enza, ever had so wide a diffusion. From 
St. Thomas's it proceeded upwards to 
Barbadoes. It seemed by the mode of 
attack as if something were applied which 
in a moment had the power of destroying 
the balance of health, and of producing a 
disease, the symptoms of which were so 
appalling at first sight. 
Protracted debility, with long-continued 
pains in the limbs, were the invariable 
sequelae of the fever. In several instances, 
tedious visceral disease, mainly of a sub- 
acute form, especially of the liver, with 
jaundice, were associated with the pro- 
tracted duration of fever. Hemorrhoidal 
affections sometimes preceded an attack 
of subacute hepatitis with slight jaun- 
dice. Returns of pains in the extreme 
joints of the fingers, distension of the ab- 
domen, anorexia, slight tenderness of the 
belly, and thirst, betokened the advent of 
incipient visceral disease. 
In a few cases the eyes were affected 
with ophthalmia. (Mouat.) 
Partial anchylosis is known to have oc- 
curred in the fingers of the hand. (Cock.) 
Diagnosis.-While the severe pains, 
on the one hand, caused the disease in 
some instances to be regarded as rheu- 
matic, the paroxysms of the febrile attack 
and the intercurrent remissions, on the 
other hand, caused the disease to be con- 
sidered as one of a malarious nature. 
But there was to be noticed the peculiar 
eruption already described, which, com- 
bined with the other characteristic phe- 
nomena, at once stamped the disease as 
one sui generis. The suddenness of the 
attack, the redness and the watering of 
the eyes, the acute pain in all the joints,. 
rendered excruciating on the slightest 
touch, the scarlet or crimson efflorescence 
on the surface, its ephemeral duration, 
the disease sparing neither age, sex, nor 
habit of body, its seizing the acclimatized 
as well as those recently arrived, stamp 
Dengue at once as a disease different from 
the endemic remittent fevers of the coun- 
tries where it has prevailed. The diag- 
nostic differences from measles and scar- 
latina must be studied in connection with 
the natural history of those diseases. 
Dengue attacked indiscriminately those 
who had suffered from scarlatina and 
those who had not. (Cavell.) 
Treatment.-Amongst the natives of 
India, Dr. Mouat had convincing proof 
that the disease was protracted and se- 
vere when no remedies were used. Pros- 
tration and severity were evinced in the 
great emaciation, the more extreme de- 
bility, the severer pains and the swollen 
extremities and the longer duration of the 
disease, in those cases left to run their 
own course. 
Experience has proved that emetics and 
free eliminative remedies (especially pur- 
gation) insure an early freedom from fever. 
Time is no doubt an essential element in 
relation to the cure of the disease, which 
seems to run a specific course, and may 
be aided or retarded by remedies. 
These remedies have been on the one 
hand (1) bleeding, on the other hand (2) 
purgation and eliminative medicines. 
Twining did not resort to general blood- 
letting, but in several of the earlier cases 
in which the head was much effected, he 
sometimes applied a considerable number 
of leeches to the temples. A further ob- 
servation of the progress of the epidemic 
and nature of the fever convinced him, 
however, that even leeches were by no 104 
ROSEOLA. 
means necessary, "as other cases with 
symptoms parallel in nature and severity 
were as speedily remedied without leech- 
es. '' lie Considered that general bleeding 
was not adapted to the treatment of this 
fever. Cold affusion he also considered a 
hazardous remedy. The experience of 
Cavell also proved that depletion did not 
afford the relief expected of it. So also, 
Mouat records that bleeding did not cut 
short the disease, nor mitigate the symp- 
toms. It added to the exhaustion of the 
patient; it impaired the powers of diges- 
tion ; it induced vertigo during convales- 
cence, with a tendency to fainting, dis- 
tressing dreams, and bad nights. It was 
only of use in cases of local affection of 
the lungs, liver, or intestines. 
With reference to purgation, Twin- 
ning's experience showed that a moderate 
dose of calomel, combined with an active 
dose of colocynth and scammony, and re- 
peated every twenty-four hours, till the 
evacuations were free, and of a more natural 
and healthy color, were the remedial 
agents he observed to be followed by the 
best effects. The use of purgatives in 
this way was indicated by the stools being 
of a dark-green color; and with the dis- 
appearance of greenness from the stools, 
the symptoms were ameliorated. Calo- 
mel is never to be given alone. It is 
probable that calumba, rhubarb, and 
soda, combined in equal proportions, will 
equally answer as an alterative remedy. 
The eliminative action of purgation is to 
be obtained without the result of watery 
purgation ; and so far as the use of purga- 
tives is concerned, the only objection that 
is urged against them is the aggravation 
of the pain which they cause by the mo- 
tion which their action entails. But the 
skill of the nurse and the physician must 
be combined to obviate this very second- 
ary consideration. Eliminative remedies 
in an opposite direction were also shown 
to be of use. Emetics of tartar emetic 
and of ipecacuanha discharged large 
quantities of bile, relieving the pains of 
the head and of the limbs almost immedi- 
ately. An emetic given at first always 
relieved the head and eased the pains; 
and this evacuation, followed by purga- 
tion, or even an open state of the bowels, 
tended greatly to facilitate recovery. A 
free, open state of the bowels is then best 
preserved by a dose (every two hours) of 
tartar emetic and sulphate of magnesia ; 
or a compound of jalap powder or of sul- 
phate of magnesia with infusion of senna. 
(Mouat.) 
In thirty-six hours after the action of 
such remedies was obtained the fever was 
subdued with less prostration of strength 
than by any other treatment; but if no 
bile followed the emetic, the symptoms 
were not relieved, and it was necessary to 
repeat it till the bile was discharged. 
In the cases where ophthalmia was a 
consequence, leeches applied to the inner 
membrane of the eyelids sufficed for the 
cure, with free and repeated purgation. 
After the bowels were freely opened, a 
light febrifuge mixture of sweet spirits of 
nitre, nitrate of potass, tartarized anti- 
mony, and colchicum, was attended with 
benefit, given every two hours, with an 
occasional effervescing draught, a pedilu- 
vium at bedtime, and ten to fifteen grains 
of Dover's powder. After all the acute 
symptoms had subsided, forty to sixty 
drops of' the wine of colchicum, with 
twenty-five drops of laudanum, always 
insured a good night's rest, and thirty 
drops of antimonial wine were now and 
then added to the draught. (Furlonge.) 
Tonics (such as infusion of calumba, qui- 
nine, iron, or strychnia) ought to follow 
the free action of the bowels. Cordials, 
stimulants, and good diet, consistent with 
the habits of the individual patient, must 
also be thought of, and remedies of a local 
kind to allay the itchiness of the skin may 
also be of service ; such as emulsions of 
almonds, with hydrochlorate of ammonia 
and corrosive sublimate judiciously com- 
bined and carefully applied. 
ROSEOLA. 
By Hermann Beigel, M.D., L.R.C.P. Bond. 
Definition.--Roseola is a disease cha- 
racterized by the appearance on the skin 
of spots, separate from each other, of a 
roseate, scarlet, or dusky red hue; of 
minute size, like marks made by the point 
of a pin ; but which may exist in such 
large numbers and so close together as to 
form large patches, of most varied shapes. 
These are not raised above the surface of 
the skin ; are not communicated by con- CAUSE-COURSE. 
105 
tagion; and are generally unaccompanied 
by fever. 
Willan is known to have described seven 
forms of Roseola, which number has been 
raised to twelve by Bateman, Rayer, and 
Wilson. Whoever wishes to take the 
form and hue of an irritation of the skin 
or any other part of the organism as a 
basis for classification, can, with great 
facility, introduce hundreds of new species 
into medical science. But whether science 
would gain anything by our calling a 
pneumonia, in which the inflamed part of 
the lung is round, pneumonia circularis, 
or if triangular, pneumonia triangularis, 
is another question. Quite the same may 
be said in reference to roseola annulata 
and punctata; and if the words sestiva 
and autumnalis express anything, which 
may be taken as a basis for division, we 
might just as well find in the 365 days of 
the year material for a division into the 
same number of forms, not only of Roseola, 
but of any other disease. Classifications 
of this kind, which neither define correctly 
nor are of any utility, ought to be banished 
from medical science. Those who know 
the former unpractical, incorrect, and cir- 
cumstantial classification of ulcers, and 
compare it with that of the present time, 
simplified and based upon correct observa- 
tions-admitting what influence nomen- 
clature has on treatment-will acknow- 
ledge the necessity of a judicious division 
in other spheres of medical science, and 
particularly in dermatology. 
We may observe Roseola in the course 
of different, mostly feverish, diseases (Ro- 
seola symptomatica), or independent of 
diseases (Roseola idiopathica). The Symp- 
tomatic Roseola is a part of the disease in 
the course of which it occurs, and is there- 
fore excluded from our consideration. We 
have now only to speak of Idiopathic Ro- 
seola, which rarely requires medical inter- 
ference, but which gives us an important 
hint in reference to the pathology of skin- 
diseases in general. 
Cause.-Anything which weakens or 
lowers the action of the nervous system, 
and this for a long time, may cause Ro- 
seola. Severe illnesses-such as typhus 
or syphilis-which change the vitality of 
the blood and nerves; bad nourishment, 
and general debility, are the common 
causes of R. symptomatica. 
Idiopathic Roseola is brought about in 
a similar manner, but the action of the 
nervous system is weakened for a short 
time only. Not only errors of diet, but 
some particular kinds of food may produce 
Roseola. I know a lady who has a regular 
attack of Roseola, of seven to eight hours' 
duration, after eating strawberries, and 
this without any other disturbance ; an- 
other lady who can voluntarily produce 
Roseola by getting hot through dancing 
or other exertion and by drinking water 
afterwards. The eruption constantly ap- 
pears in about half an hour, causes no 
other disturbance, and disappears after 
several hours. I attended a child who 
was troubled by hooping-cough. The 
milder attacks passed as usual, but the 
violent ones, during which the whole body 
of the little patient took a dusky hue, al- 
ways brought on Roseola, which after a 
few minutes disappeared. 
That sudden changes of temperature 
may produce Roseola is well known ; and 
its appearance during dentition is remark- 
able. Sometimes it comes and goes so 
quickly, that a child, while teething, may 
exhibit five or six attacks during the 
course of one day. These attacks are 
usually unaccompanied by any pain. At 
the first appearance of the eruption, an 
anxious mother may send for the physi- 
cian ; but, so transient is its duration, 
that often, when the doctor comes, there 
is nothing to be seen. I am attending a 
family of two little boys and two daugh- 
ters, and both of the boys have exhibited 
the phenomena of Roseola to a very high 
degree. The boys, who are strong and 
healthy, exhibit it at the commencement 
of every trifling indisposition, and this 
quite independently of dentition. The 
girls, who are twin-sisters, have not suf- 
fered. It is not rare, however, for Ro- 
seola, in some women, to precede every 
menstrual period. 
It would appear, therefore, that Roseola 
depends immediately upon changes in the 
vitality of the blood and nerves ; and we 
may be tolerably sure that if another 
Willan-endowed with Jussieu's capacity 
for observing nature-should appear, we 
should find Roseola, and many other skin 
diseases, ranging among the diseases of 
the nervous system. 
Course.- Idiopathic Roseola appears 
almost feverless; yet feverish symptoms 
may exist, although they never reach a 
high degree. Headache, excited pulse, 
constipation, want of appetite, disturbed 
sleep, itching may occur, but their occur- 
rence is rather the exception than the 
rule. In the majority of cases Roseola 
idiopathica occurs suddenly, over a large 
surface, and without marked forerunners ; 
it remains a few hours or days, and either 
disappears as suddenly as it came on, or 
turns into a more dusky hue, becomes at 
length pale, and a fortnight may expire 
before the last spots vanish. But it may 
happen that the rash disappears on one 
part of the body while new spots make 
their appearance on another. 
In other cases a few little red dots may 
occasionally be discovered and increase in 
number until the body is partially or to- 
tally covered with them. I never saw 
slowly developed Roseola disappear sud- 106 
MEASLES. 
denly; but slowly as it came. The mu- 
cous membranes may participate in the 
eruption, but this is mostly observed in 
dentition, when these membranes are al- 
ready affected. 
That the same individual may repeat- 
edly be subject to the eruption, is evident 
from the above statement. 
Diagnosis.-Roseola bears the greatest 
resemblance to flea-bites, and to those 
partial inflammations of the skin which 
are caused by the stings of other insects. 
But bites and stings are distinguished 
from Roseola by the black central spot 
which, in an early stage, is clearly seen 
in almost all of them. Erythema Roseola 
differs in the fact that its confluent spots 
are raised above the level of the healthy 
skin. With measles and scarlet fever Ro- 
seola cannot be easily confounded; for be- 
side the symptoms proper to those exan- 
themata, the skin, in the latter, is in a 
state of turgescence, and forms a red basis 
for the eruption, whereas in Roseola the 
skin between the spots is healthy. Its ex- 
tremely mild course, independence of epi- 
demic influences and character, and the 
absence of catarrhal phenomena, are suffi- 
cient to distinguish Roseola from measles. 
Prognosis.-Idiopathic Roseola is a 
slight affection which never reaches a de- 
gree causing anxiety. Even in those 
cases where Roseola occurring during 
dentition is accompanied with fever, we 
scarcely have a right to refer the latter 
to the eruption, as it forms a symptom, 
which often occurs in dentition without 
being followed by Roseola or any other 
eruption. 
Treatment.-Cases in which Roseola 
idiopathica requires medical interference 
seldom occur. The eruption comes and dis- 
appears without any disturbance of the 
general health. But if there exists a local 
irritation which keeps up the eruption or 
causes its recurrence, then, of course, it 
must be removed. Ascarides, which often 
cause Roseola, must be expelled ; gentle 
laxatives will be applied against constipa- 
tion, and impaired appetite improved by 
carbonized water, soda, seltzer water, and 
by dilute mineral acids, particularly phos- 
phoric acid. If during dentition the ne- 
cessity arises to lance the gums, it ■will 
not be Roseola which necessitates this 
proceeding. 
MEASLES.1 
By Sydney Ringer, M.D. 
Definition.-An acute febrile conta- 
gious disease, mostly occurring in epi- 
demics. It generally attacks the patient 
but once, but sometimes again occurs 
after the interval of a few months, or 
many years. Relapses are very rarely 
met with. They may commence imme- 
diately or three or four days after the fe- 
ver of the first attack has declined. 
Generally coexisting with epidemics of i 
other diseases, it is especially related to 
hooping-cough. The one disease appa- 
rently predisposes to the other. Thus 
often an epidemic of Measles precedes one 
of hooping-cough, or vice versd. In the 
latter case, the paroxysmal cough may 
continue, or temporarily disappear during 
the existence of the Measles. It is stated 
that persons with pulmonary disease, such 
as bronchitis, are especially apt to catch 
the disease. 
The period of incubation, in those cases 
in which the disease was produced by in- ' 
oculation, was seven days. 
Synonyms.-Measles; Flecken; Ma- 
seru ; Morbilli; Rubeola ; Rougeole. 
Symptoms.-Measles is generally ab- 
rupt in its commencement, and is then 
ushered in by chilliness which may amount 
to rigors, or not uncommonly, in children, 
to convulsions; or, on the contrary, the 
invasion is so insidious that it is impossi- 
ble to determine with accuracy the first 
day of attack. The disease, when estab- 
lished, is accompanied with a variable 
amount of prostration, but which is usu- 
* For much of the information contained in 
this article, the author is indebted to Wil- 
lan's Miscellaneous Works, Dr. Armstrong's 
Practical Illustrations of Scarlet Fever, Mea- 
sles, &c. ; Trousseau's Clinical Lectures, 
Graves's Clinical Lectures, Hebra, Rilliet et 
Barthez's Maladies des Enfants, Journal fiir 
Kinderkrankheiten, Schmidt's Jahrbiicher, 
Canstatt's Jahresbericht, Aitken's Practice of 
Medicine, Parkes on the Urine. 107 
VARIETIES 
ally not extreme, and sometimes amounts 
only to a feeling of lassitude. The pa- 
tients take voluntarily to bed, and are in- 
disposed to either physical or mental 
exertion. They are fretful and irritable, 
in some cases only when disturbed ; in 
others they are constantly restless, whin- 
ing, and peevish-differences dependent 
on peculiarities inherited, or developed 
by bad education. The expression is va- 
cant, and the powers of perception and 
reflection are much impaired. Delirium 
is in some cases present, always slight and 
usually limited to the night. The skin is 
hot and dry; the lips are parched, and in 
severe cases covered with sordes; the 
tongue, thickly coated, is mostly moist, 
and a few red papillae may be often ob- 
served to project through the thick coating 
of fur. The appetite is much impaired, 
and the thirst often extreme. Vomiting 
not infrequent at the commencement, 
may be repeated and persistent, and then 
indicates a severe attack of the disease. 
. The bowels, in some cases confined 
throughout, are often relaxed, and are 
generally easily influenced by medicine. 
Diarrhoea not unfrequently first occurs at 
the period of the eruption. Usually from 
the very commencement the mucous mem- 
brane of eyes, nose, mouth, and respira- 
tory tract suffers changes. The conjunc- 
tivae are injected, and the eyes suffused 
with tears. There is generally some in- 
tolerance of light, and occasionally the 
patient complains of a sensation as of 
sand beneath the lids; the eyelids are 
swollen and red at the edges ; there is 
often repeated sneezing, with at first a 
thin watery discharge from the nose; 
epistaxis not infrequently accompanies 
the coryza at its commencement. The 
mucous membrane of the mouth and 
throat is mottled with redness, and a feel- 
ing of weight and tension over the frontal 
sinuses may be complained of. There is 
generally some soreness of the throat, but 
without much swelling of that part. The 
cough is dry, hacking, and frequent, and 
there is a feeling of weight and oppression 
at the chest, at which part wheezing and 
rhonchal fremitus may often be felt. The. 
voice is often hoarse ; the respirations are 
hurried and shallow: the pulse is in- 
creased in frequency, but loses in force. 
The urine is scanty, and deposits an 
abundance of lithates on cooling. In rare 
instances severe pain in the abdomen has 
been noticed, with or without diarrhoea ; 
pain and tenderness have been sufficient 
to lead to the idea of peritonitis, but they 
entirely disappear on the resolution of the 
rash. 
Usually on the fourth day from the 
commencement of the disease the charac- 
teristic rash appears. First noticed on 
the forehead close to the scalp and on the 
chin, it from thence spreads over the face, 
trunk, and extremities, in the accomplish- 
ment of which it occupies a period vary- 
ing from a few hours to two days. On 
the appearance of the rash the fever is 
stated to increase ; it certainly does not 
diminish. The lachrymation of the eyes 
and injection of the conjunctiva} become 
more marked. There is slight swelling of 
the whole surface of the body (if the rash 
be abundant and general) ; this is especi- 
ally noticeable in the face, and causes a 
variable amount of alteration of the fea- 
tures, so that in some cases the patient 
can scarcely be recognized. The feet and 
hands at the same time feel full and tense ; 
deafness may be present, being due to the 
swelling of the mucous membrane of the 
Eustachian tube. 
The cough at this time generally in- 
creases in severity, and is occasionally 
rather paroxysmal. 
Examination of the lungs reveals so- 
norous, sibilant, and even a small amount 
of submucous rhonchus, the latter being 
most abundant at the bases of the lungs. 
After the second or third day of the 
eruption the fever disappears, the tempe- 
rature becomes normal, the pulse much 
less frequent, and the patient at once 
enters on the period of convalescence. 
The period elapsing before perfect 
health is restored varies greatly ; in some 
cases the recovery being rapid, in others 
prolonged to an indefinite period, this 
diversity being dependent on the previous 
state of health of the patient. Thus, if 
the health has been impaired by excesses 
of any kind, or by bad hygienic conditions 
of life ; or if the patient be the subject of 
tuberculosis, scrofulosis, or syphilis, the 
recovery is often very greatly retarded, 
and more or less serious sequelae often 
result. Further, other conditions being 
the same, recovery is more speedy in the 
young than in the old. 
Varieties.-The severity of the dis- 
ease varies greatly, and has thus led to 
its division into Morbilli mitiores and 
Morbilli graviores. Occasionally the dis- 
ease is unaccompanied by any catarrhal 
symptoms, and is then termed Morbilli 
sine catarrho. This latter form is said 
not to protect the patient against another 
attack. Morbilli mitiores has already 
been described. 
Morbilli graviores, Malignant Measles, 
or Black Measles, appears to have been 
far more common formerly than at pres- 
ent ; still, cases do now and again present 
themselves. 
Due either to individual peculiarity, or 
more commonly to a previously depraved 
state of health, or to epidemic causes, it 
may begin mildly, or the symptoms may 
be at once violent and severe. Usually 
the rash is but imperfectly developed, and 
partial in its distribution, of a livid, pur- 108 
MEASLES 
plish, or even black color, apt to disappear 
and again appear. There are marked 
prostration, great tremulousness, twitch- 
ing of the muscles, delirium low and 
muttering in character, stupor or partial 
coma. The lips and teeth are covered 
with sordes, the tongue becomes dry and 
brown, the pulse is rapid and feeble, the 
respirations are hurried, and often the 
symptoms of congestion of the lungs are 
present. The extremities are cold, and 
petechial spots appear on various parts of 
the body.1 The urine may contain blood, 
and bloody effusions are found in the vari- 
ous cavities and organs of the body. 
Death usually occurs early ; should the 
patient rally, convalescence is much pro- 
longed, and death not infrequently results 
from diarrhoea, bronchitis, or other of the 
sequelse. 
Hash.-Usually appearing on the fourth 
day, in some instances it is noticed as 
early as the first, or may be postponed to 
the seventh or eighth day of the disease.2 
Earliest seen on the forehead, close to the 
scalp, it from thence rapidly spreads to 
the rest of the face, then to the trunk and 
lastly to the extremities, in the accom- 
plishment of which it occupies, in some 
cases but a few hours, but more commonly 
three days. On the first day chiefly limited 
to the face, it increases greatly in quantity 
over the trunk on the second and is most 
abundant on the extremities on the third 
day of the eruption. 
The development of the rash is best 
observed on the trunk. There are earliest 
seen minute red, not elevated points, 
probably the papillae of the skin reddened, 
and but little, if at all, enlarged. These 
rapidly develop, increase in breadth, and 
become elevated and acuminate in form, 
the diameter measuring at this stage 
about a line. In their further growth they 
increase chiefly laterally, and thus become 
flattened. The ultimate size they attain 
varies, although sometimes not advancing 
beyond the size mentioned when they are 
acuminate ; they may become as large as 
a pea: in the former case they can be 
felt, and seem to be but slightly elevated ; 
in the latter they feel hard and even 
" shotty," though this is always much less 
marked than in the rash of smallpox. 
The amount of the rash varies greatly. 
At first much scattered, fresh spots 
quickly appear on the previously unaf- 
fected skin. The spots are generally 
grouped, and often assume the form of 
crescentic or irregularly circular patches. 
Always at first discrete, they may become 
so numerous, that on enlarging laterally 
they coalesce and form patches of various 
size, sometimes sufficiently large to cover 
the chief part of the chest, or one or other 
of the extremities. These patches for the 
most part have their long axis across the 
trunk, they are always abruptly elevated, 
and the redness is sharply defined, though 
generally irregular in outline. Should the 
rash be very intense, the surface and red- 
ness of the patches are quite uniform; 
but mostly in the redness numerous small 
papillae1 can be seen, and even in the for- 
mer case, on the decline of the rash, the 
papillae become visible. 
Mostly abundant on the face, the quan- 
tity of rash developed becomes less the 
lower we descend, and the eruption is 
often only thinly scattered on the furthest 
extremities of the body. 
The individual parts of the rash have a 
very short duration. Each spot, usually 
at its height in twelve hours, has often in 
1 Dr. Veit (in Virchow's Archiv, Bd. xiv. 
Heft. 142 ; reported in Canstatt, iv. p. 225, 
1858) states that petechial eruption is in some 
cases dangerous, whilst in others the disease 
runs a favorable course. When serious, he 
says that the condition is brought about by 
previous excesses or irregularities of life, and 
that such cases are met with in all epidemics. 
He states that if the rash be at its commence- 
ment petechial, it is not an unfavorable sign ; 
but that if it subsequently become so, if the 
rash change from wine-red to black, in form 
of round spots, extensive patches, or in 
streaks, then it is of almost fatal significance. 
It is certain that not unfrequently small 
petechial spots may be met with on the upper 
part of the chest, and occasionally elsewhere, 
in cases which run a favorable course ; but 
extensive and numerous petechiae, especially 
if seated on the legs, are to be looked upon 
as of very serious import; though less so 
than if they occur in scarlet fever or small- 
pox, in which diseases their appearance war- 
rants us in expecting a fatal termination ; 
nevertheless, though this is the rule, cases of 
extensive petechial rash do occur, which 
run throughout a favorable course. [During 
the civil war in the United States of Ame- 
rica, quite a considerable number of cases of 
measles occurred amongst the soldiers, often 
assuming a typhous or malignant character ; 
the rash being ill developed, or petechial and 
dark purple in color, with a tendency to 
prostration throughout the attack. These 
cases corresponded very nearly with what was 
formerly called Black Measles.-H.] 
2 Of twenty-eight cases- 
In 1, the rash appeared in twelve hours. 
2, on the 1st day of the disease. 
6, " 2d " 
6, " 3d 11 
10, " 4th " 
2, " 5th " 
1, " 6th " 
The commencement of the disease in these 
cases was dated from the very earliest symp- 
toms noticed or complained of. 
For some of these cases the author is in- 
debted to Mr. Butt, and also to Mr. J. Bartlett, 
of Notting Hill. 
1 These are much larger than the puncti- 
form elevations seen in scarlet fever. VARIETIES 
109 
twenty-four hours again subsided ; so that 
no elevation remains judging by both sight 
and touch-a mere red mottling being 
left. The rash declines in the order of 
its invasion. In rare instances, if the 
eruption be intense, small, clear, acumi- 
nate vesicles may be developed at the sum- 
mit of the papillae, or minute petechiae 
may occur; these latter, usually not nu- 
merous, are perhaps most frequently met 
with on the neck, upper part of the chest 
and the bend of the elbow. 
Though generally described as of a rose 
color, the rash appears to the author to be 
a mixture of red and yellow, the red 
greatly predominating at the beginning of 
the eruption ; but as the spots enlarge 
and become flat, the redness declines, and 
the yellow tint becomes much more appa- 
rent. 
It is of a brighter and more intensely 
red tint at those parts of the body which 
by exposure have become florid. It is 
thus well marked on the face and the 
hands. On the palms of the hands and 
the soles of the feet the papules generally 
look deeply situated, as if indeed they were 
placed beneath the cuticle. 
By pressure the redness disappears, and 
a slight yellow discoloration of the skin 
remains. 
After the rash has lost its elevation, a 
reddish coppery discoloration is left. The 
redness (which is most marked and re- 
mains longest on the face, where the vas- 
cularity of the skin is greatest) is always 
removable by pressure, quickly declines, 
and leaves a coppery discoloration. This 
coppery discoloration on the other hand is 
unaffected by pressure ; occurring in spots 
a few lines in diameter, it is ill-defined in 
outline; sometimes of a uniform color, 
but more generally punctiform ; is propor- 
tionate to the previous intensity of the 
rash, and is consequently most marked on 
those parts of the body where the rash is 
most developed : hence it is well seen on 
the face, upper part of the trunk, but 
especially on the shoulders and over the 
scapular regions. It lasts a variable time, 
but has mostly disappeared by the tenth 
or twentieth day from the commencement 
of the disease. 
The rash occasionally departs from the 
above description, in respect both of its 
nature and its course. Thus it may ap- 
pear first on the trunk, and then spread, 
sometimes involving, at others leaving 
free, the face ; or the face may be the only 
part affected. In some cases it is very 
limited, the rest of the surface remaining 
free from rash. It is apt to appear earliest 
and to be the most marked in the neigh- 
borhood of sores or inflamed parts of the 
^kin. 
Sometimes, owing to a serious internal 
inflammation, mostly of the lungs, the 
rash suddenly recedes and may entirely 
disappear. 
The desquamation is always slight, and 
is most marked on the face, or where 
the rash has been confluent: it is limited 
to the discolored patches of the skin, and 
sometimes is only seen when the skin is 
tightened and viewed sideways ; it begins 
usually on the sixth or eighth day of the 
disease, and continues eight or ten days. 
The scales that are separated are usu- 
ally very fine, often scarcely visible, un- 
less dropped on a black ground. It is 
very rare for continuous pieces of the 
cuticle to be thrown oft'. 
The elevation of the temperature, or 
fever, varies greatly in degree. The high- 
est temperature reached in ordinary cases 
is usually 103° Fahr. If the temperature 
rises above this, it indicates a severe, if it 
continues below this, a mild attack. 
The temperature corresponds, in respect 
to its daily or other variations, to that of 
most fevers; thus it cannot assist us to 
make a correct diagnosis in doubtful cases. 
The fever is stated to increase till the 
eruption and catarrhal symptoms reach 
their height. 
As measured by the temperature, the 
disease has a very variable duration ; in 
some cases declining on the fourth, or 
continuing to the eighth or tenth day of 
the disease.1 
At the end of the disease, the tempera- 
ture (i. e. fever) suddenly and greatly de- 
clines, but still usually rises slightly (to 
100° or 101° Fahr.) on the one, and some- 
times two days following. After this, it 
becomes normal, and continues so through- 
out convalescence; or it sinks for some 
few days below the point usual in health.2 
The glands behind the jaw, down the 
neck, and in the groin become enlarged. 
The degree of enlargement behind the 
jaw is regulated by the amount of throat 
affection ; that of the glands in the neck 
and groins, by the amount of rash present: 
hence the enlargement is greater in the 
neck than in the groins. The glands usu- 
ally resume their proper size from the 
sixth to the tenth day of the disease. 
The enlargement is rarely so great in 
any of these regions as it is in scarlet 
1 Of 14 cases- 
2 ended on the 4th day. 
4 " 5th " 
4 " 6th " 
2 " 7th " 
1 " 8th " 
1 " 9th " 
It is right to state that in many of these cases 
the rash appeared before the fourth day, in 
several even on the first or second day, cal- 
culating from the day on which the very 
earliest symptoms appeared. 
2 The temperature in convalescence from 
all diseases is often below par, is easily de- 
pressed by exposure, and moreover is very 
slow to rise again after it. 110 
MEASLES. 
fever. Tn both diseases the enlargement 
is greater, the amount of irritation being 
the same in persons whose previous health 
has been bad, and thus the degree of en- 
largement serves as an indication for the 
treatment of the patient. 
There may be no affection of the mu- 
cous membrane of the eyes, nose, throat, 
and lungs. Mostly, however, the whole 
of the tract suffers. 
On the conjunctiva, especially of the 
lids, is seen much fine capilliform and 
ramiform injection ; the former declines 
as the rash fades, but the latter remains 
a few days longer. 
The suffusion of the eyes usually con- 
tinues some days after the injection has 
left, and in some cases may be noticed on 
the twentieth day of the disease. 
Discharge from the nose, at first clear 
and watery, is one of the earliest symp- 
toms observed. The mucous membrane 
of the ate of the nose is red, and not un- 
frequently excoriated. On the decline of 
the rash, the inflammation also subsides ; 
the discharge may cease immediately, but 
more commonly it becomes muco-purulent, 
and continues for a few days longer. If, 
however, the child has been badly nour- 
ished previous to the fever, or is the sub- 
ject of the scrofulous diathesis, these 
symptoms are apt to be much more 
marked and of longer duration. The alee 
of the nose are rather swollen. The mu- 
cous membrane, much excoriated, easily 
bleeds. The discharge is either thin and 
sanious, or thick and muco-purulent. 
This accumulates, dries, and blocks up 
the orifice. The upper lip may become 
much enlarged, hardened, and at first 
painful. The prolabium often cracks, 
bleeds, and scabs. These conditions may 
last from three weeks to as many months. 
Occasionally the discharge from the nose 
brings out an attack of eczema on the lip, 
which may spread over the rest of the 
face. 
These appearances, being due to the 
previously impaired health of the child, 
become important indications in respect 
of the treatment. 
The mucous membrane of the lips, gums, 
cheeks, soft and hard palate, usually red- 
dened, in rare cases remains normal. The 
intensity of the redness varies, and it is 
not equally distributed, being usually 
most marked on the gums1 and lips. On 
the cheeks and palate the redness, some- 
times uniform, is mostly mottled. The 
gums are much reddened, rather swollen, 
and easily bleed. On the lips the redness, 
whilst uniform, is more intensely marked 
at places forming spots, mostly round, 
sharply defined, and especially noticeable 
in the neighborhood of the fraenum. Al- 
most always on the gums, often on the 
lips, and occasionally on the cheeks and 
soft palate, are seen thin opaque white 
patches or films, looking as if the mucous 
membrane had been swept over with a 
solution of nitrate of silver ; these vary in 
size, are often sharply defined, can be 
easily removed, and leave the mucous 
membrane entire, but red and sometimes 
bleeding. On the decline of the rash and 
fever, the inflammation of these parts 
subsides. The redness for the most part 
disappears, leaving only a coarse rami- 
form injection, best seen on the lips. The 
swelling of the gums subsides, but the 
whole mucous membrane retains for some 
time a swollen, spongy, and not unfre- 
quently a glazed appearance. The white 
patches cease to enlarge, thin away, espe- 
cially at their edges, and finally disappear; 
often, however, remaining for ten or 
fifteen days. 
Occasionally ulceration is observed, 
usually slight-but sometimes severe- 
commencing close to the teeth (especially 
the incisors), appearing generally after 
the fever has subsided, but sometimes as 
late as the tenth or twelfth day of the dis- 
ease. If slight, this usually heals in three 
or four days. It is noticed mostly in 
sickly children. 
Aphthae, and superficial, sharply cut 
ulcerations-usually small, round, or oval, 
but occasionally as large as a shilling, and 
irregular in outline, covered in some cases 
with an ash-gray, easily removable exu- 
dation, at others by a tough, smooth, 
leathery adherent membrane-are some- 
times seen on the gums, lips, tongue, &c. 
They especially occur in certain epi- 
demics. Of no danger, they heal in a 
week or ten days ; the membranous form 
being more obstinate, lasting sometimes 
three weeks. 
The tongue is rarely clean throughout; 
mostly thickly coated, moist, and with a 
few red prominent papillae, it is sometimes 
dry and brown, the latter state indicating 
much depression, and being suggestive in 
respect to treatment. It begins to clear 
from the fourth to the eighth day of the 
disease. The fur is at first'thrown off in 
the form of patches-leaving clear spots, 
sharply defined, oval or round, and about 
two to three lines in diameter. The rest 
of the tongue becomes clean by the eighth 
to the twelfth day, but still the patchy 
appearance remains, and can often be seen 
till the twelfth or fifteenth day of the dis- 
ease. If any intercurrent disease super- 
venes, the tongue remains coated for a 
longer time. 
The tonsils and mucous membrane of 
the pharynx, generally red and rather 
swollen, may be severely affected, and t]ie 
tonsils may be so enlarged that they 
nearly meet. The mucous membrane, 
red, and at first dry, on the subsidence of 
1 Especially that part corresponding to the 
incisor and canine teeth. COMPLICATIONS AND SEQUELS. 
111 
the inflammation, becomes moist and cov- 
ered with much muco-purulent matter. 
This ceases in a few days, leaving the 
mucous membrane spongy and sodden in 
appearance. Whilst the inflammation 
lasts, there is usually some pain, especi- 
ally on deglutition. This is usually not 
severe. The Eustachian tube may be in- 
volved, and there is then great pain, and 
difficulty of hearing. This is uncommon. 
Vomiting, not common except at the 
very onset of the disease, may be persist- 
ent and continuous, the blandest food 
being immediately expelled. Sometimes 
the vomited matters are of a grass-green 
color, usually at the same time there is 
diarrhoea with motions of a similar color. 
Such vomiting only occurs in serious 
cases, and calls for a grave prognosis. 
Diarrhoea, beginning usually at the 
time of the eruption, is not infrequent. 
Often severe, and sometimes bloody, it 
may cause death in young children. The 
color of the motions varies; they are 
light-colored, clayey, and sometimes 
green. The diarrhoea continues for a va- 
riable period, often after the fever has 
subsided, even to the tenth or twelfth 
day. The motions may continue clayey 
in color after they have become less fre- 
quent and of greater consistence. 
During the course of the disease, and 
for some time after, the bowels are very 
easily influenced by purgatives, a fact 
that should be borne in mind in the treat- 
ment of the disease. 
The diarrhoea lasts longest in the weak 
and sickly. 
The cough, at first hacking, frequent, 
and troublesome, in a few days becomes 
more annoying, violent, ringing, clang- 
ing, or often paroxysmal in character; 
sometimes so violent as to cause retching, 
and even vomiting: it usually greatly im- 
proves when the rash fades, and often 
disappears in a few days more. It may, 
however, continue for some time, retain- 
ing its paroxysmal character. The cough 
may become paroxysmal as late as the 
eleventh or fourteenth day. 
Expectoration, at first scanty, clear, 
and viscid, on the decline of the rash and 
the subsidence of the inflammation of the 
bronchial tubes, becomes muco-purulent, 
abundant, sometimes of a bright-green 
color, and nummulated, the masses float- 
ing in a clear, thin watery fluid. It usu- 
ally quickly lessens in quantity, and 
mostly disappears by the tenth or twelfth 
day of the disease. 
Urine, scanty, and on cooling deposit- 
ing an abundance of lithates, has gener- 
ally, during the fever, a peculiar yellow 
color. Albumen in small quantities is 
frequently, blood less commonly, found 
during the fever days. Both the urine and 
breath have a peculiar odor. This, in the 
author's experience, is only met with in 
children, in whom it can be detected in all 
acute febrile diseases, especially when the 
mucous membrane of the mouth is affected. 
Complications and Sequelae are 
either the usual anatomical lesions, so in- 
creased in severity, or continued after the 
fever has declined, as to become of serious 
importance; or intercurrent diseases not 
usually attendant on Measles. Very va- 
rious in nature, and often of great seve- 
rity, they not unfrequently terminate in 
death. 
They vary in different epidemics, and 
are, to some extent, influenced by the 
season of the year. Pulmonary affections 
are more common in winter than summer. 
Some are moreover dependent on the pre- 
vious depraved health of the patient, such 
as the gangrenous inflammation. 
Convulsions, not uncommon in children 
at the very commencement of the attack, 
are usually without danger. They may 
however be repeated, and terminate fa- 
tally. Occurring by no means commonly, 
at a later period of the disease, they are 
then usually repeated, and accompanied 
with some severe internal inflammation, 
mostly of the lungs. At this period they 
are generally fatal. 
Laryngitis, commencing with slight 
cough, soon followed by much oppression 
at the chest, hoarse cough, noisy and 
stridulous breathing, occurs before the 
eruption, or with a recession of the same. 
It may be croupous or diphtheritic. 
It mostly disappears on the evolution of 
the rash, and, if not then, on the decline 
of the fever. 
Chronic inflammation of the larynx is 
commonly met with, and generally proves 
obstinate. It disappears only to return 
again on slight exposure to cold. The 
voice and cough are hoarse, and some- 
times at the same time there is deafness 
in one or both ears. When the latter oc- 
curs, the tonsils are usually enlarged, and 
at the same time the patient snores much 
during sleep. This affection may continue 
to recur for several years. 
Chronic inflammation of the bronchial 
tubes, with or without the last-mentioned 
sequelae, may follow Measles. The cough 
is hollow, ringing, hacking, or sometimes 
paroxysmal, and is easily aggravated by 
exposure to cold. With or without ex- 
pectoration, but accompanied usually by 
some oppression of breathing, it may con- 
tinue with remissions, or for a time dis- 
appear ; but may, for years, return on 
exposure to slight exciting causes. 
Capillary bronchitis may occur either 
during or subsequent to the decline of the 
fever. It is almost always fatal in young 
children under two years of age. 
Pneumonia, simple or lobular, occurs 
both as a complication or as one of the 
sequelae. 112 
MEASLES. 
The symptoms of lobar pneumonia are 
mostly well marked and characteristic; 
they may, however, be masked or take on 
the character of those of typhoid fever. 
Bobular pneumonia, by no means un- 
common, is often difficult to diagnose. 
The fever is high, the respirations are 
much hurried, the nares act strongly with 
respiration. Dulness on percussion of the 
chest is absent always at the commence- 
ment, and sometimes throughout the dis- 
ease. There is heard, irregularly scat- 
tered over the whole of both lungs, fine 
crepitation-occurring with both inspira- 
tion and expiration-but in children this 
crepitation is by no means easy to distin- 
guish from the subcrepitant rhonchus of 
bronchitis. 
In bronchitis the rhonchus is at first 
limited to, and always most marked at, 
the bases of the lung. It is usually larger 
and more evenly distributed than the 
crepitation of lobular pneumonia, which 
is generally limited to different parts of 
the lungs. In bronchitis the fever is 
mostly less severe, and there is greater 
lividity of the lips, with less disturbance 
of the respiration. But, though the above 
differences often hold good, yet cases oc- 
cur in which it is often impossible to make 
the diagnosis. Its influence on the rash 
is greater than that of bronchitis, the fever 
being higher. 
Broncho-pneumonia is by no means un- 
common either as a complication or one of 
the sequelae of this disease. The disease 
begins as ordinary bronchitis; this in- 
creases in severity ; abundance of loose, 
subcrepitant rhonchus is heard over the 
chief part of the lungs, at first limited to, 
and always most abundant at the bases. 
This is at first moist and distant; but as 
the consolidation advances, it sounds very 
superficial, ringing, dry, and high-pitched. 
This change in the character of the rhon- 
chus is usually the only sign by which it 
can be told that the bronchitis has passed 
into broncho-pneumonia. For mostly all 
dulness is absent; nay, there may be, and 
at first generally is, increased resonance, 
whilst the respiratory sound is merely 
harsh, or completely covered by the rhon- 
chus. If the consolidated portions coa- 
lesce, dulness may be developed, and 
tubular breathing caught, but this only 
happens in rare and very severe cases. 
In this affection the fever is very high, 
the nares dilate greatly during respiration, 
the face is livid, the respiration very 
greatly labored, the jugular vein often 
full, and the expectoration, where it oc- 
curs, is bronchitic in character.1 The 
child very frequently, perhaps generally, 
sinks; the surface becomes cool; the pulse 
weak, feeble, and fluttering; the respira- 
tion superficial: the expired air cool; 
sordes collect on the teeth and gums; 
delirium of a low muttering character is 
present. There is a muscular trembling, 
picking of the bed-clothes, and after a 
period varying from six to twelve days 
the child dies. 
It mostly occurs in children from two 
to six years of age, and is very frequently 
fatal. Its duration is said to be two to 
four weeks, but the child either dies be- 
fore, or the fever subsides on the eighth 
or tenth day. Rhonchus may continue 
to be heard some time longer. 
Beginning as simple bronchitis, the in- 
flammation spreads laterally from the fine 
bronchial tubes, producing minute red 
spots or streaks. Red and then gray 
hepatization soon follows, and little bodies 
varying in size from a millet seed to a pea 
are formed. 
Ulceration may begin in the mucous 
membrane of the bronchial tubes of the 
hepatized tissue and spread laterally, till 
small cavities, filled with a grayish tena- 
cious fluid, are formed. A bright red 
line in the hepatized portion, and bound- 
ing the cavity, may be seen. These 
hepatized portions of lung may be so 
numerous that as they enlarge laterally 
they coalesce, and thus much of the lung 
may become completely consolidated, and 
such portion is sometimes riddled with 
small cavities. 
When in the state of red hepatization, 
the little bodies mentioned look not unlike 
tubercle, but they are most abundant at 
the base, less sharply defined, stand out 
less prominently, are less dense, and are 
at the same time more granular-looking. 
Gangrenous inflammation of the mouth 
usually begins insidiously : it occurs some- 
times during, but mostly after, the fever. 
There is at first slight excoriation, the in- 
flammaiion then quickly spreads, the 
parts become much swollen, and the eye 
may be closed. The tissues become hard, 
red, and painful. The surface is some- 
times at first covered with a dirty, fetid, 
gray exudation. The tissues slough, the 
cheek may be perforated, the gums de- 
stroyed, and the teeth drop out. Both 
cheeks may be affected. The affection is 
only met with in children, who almost 
always die.1 Similar inflammation occurs 
sometimes in the vulva. 
Acute tuberculosis or chronic phthisis 
may occur during the course of the dis- 
ease, but it usually first gives evidence of 
its existence after the fever has declined. 
Acute tuberculosis follows Measles more 
frequently than any other of the acute 
specific diseases, hooping - cough being 
perhaps excepted. 
Bleeding at the nose in rare cases may 
be so great as to endanger life. 
Inflammation of the ear may at first 
1 Children under twelve rarely expectorate. 
1 See Cancrum Oris. Vol. II. 113 
DIAGNOSIS. 
escape notice. The child cries greatly, 
and apparently without cause, and puts 
its hands to its ears. There may be some 
redness and swelling of the meatus. On 
the third or fourth day a muco-purulent 
discharge occurs. 
[Inflammation of the eyes (conjuncti- 
vitis) is far from uncommon ; sometimes 
leaving the eyes in an irritable state, in- 
capable of much use, for a considerable 
time. Examples of blindness from this 
cause, if they occur, must be rare ; but 
such are said to have occurred ; probably 
from neglect of the ophthalmia present 
during the attack and convalescence.-II.] 
Gangrene of the lung, diphtheritis of 
the labia, acute Bright's disease with 
anasarca, and some other complications, 
may occur. 
It may be added that the complications 
occurring during the eruptive period are 
usually without danger. 
Diagnosis.-This is made chiefly from 
the rash, and the co-existing coryza. 
As the rash in the different stages some- 
what simulates that of scarlet fever, ro- 
seola, smallpox, typhus fever, and syphi- 
litic roseola, the distinction between these 
rashes must be mentioned.1 
Scarlet Fever.-The rash appears on the 
second day of the disease. It is very 
generally diffused. In Measles the pa- 
pilke are often widely scattered. The 
elevations always present in scarlet fever 
are very small (punctiform) ; those in 
Measles much larger (papilliform). Where 
the rash of the Measles forms patches, the 
elevations seen in the general redness are 
larger than those of scarlet fever; the 
edges of these patches in Measles are 
sharply defined and abruptly elevated ; 
in scarlet fever, ill-defined and not at all 
elevated. 
Occasionally in scarlet fever there arc a 
few prominent elevations on the arms and 
legs; these may be mistaken for the pa- 
pillae of Measles, but the rash on the rest 
of the body is sufficient to establish its true 
nature.2 The tint of redness in most cases 
is different in the two eruptions. Coryza 
is not noticed in scarlet fever, though the 
conjunctiva) are almost always injected. 
]{oseola Estiva may have a rash not un- 
like that of Measles. This rash in appear- 
ance is intermediate between Measles and 
scarlet fever, but generally more closely 
resembles the latter. Thus, the rash is 
generally much diffused and ill-defined, 
the elevation is slight, coryza is absent, 
and the fever is trifling. It frequently 
occurs many times in the same patient, 
and often at the same period of the year. 
Smallpox.- This disease in some re- 
spects corresponds to Measles. In both 
there are catarrhal symptoms. In both 
small red points beginning on the face and 
then spreading over the rest of the body, 
are met with. In smallpox the disease 
begins abruptly; in Measles not infre- 
quently insidiously. In smallpox there is 
often severe pain in the back and head, 
with much vomiting. These symptoms 
are most generally absent in Measles. 
The rash of smallpox is from its com- 
mencement hard and "shotty," quickly 
becomes crowned with an umbilicated 
vesicle. Moreover, the fever greatly de- 
clines or even disappears temporarily, 
when the rash is fully out, in both respects 
differing from Measles. In smallpox, if 
unmodified, a characteristic smell is pre- 
sent. The rash appears on the third day 
in smallpox, usually on the fourth day in 
Measles, but the departure from this rule 
in Measles is so frequent, that no great 
stress can be laid on this distinction. - 
Typhus Fever.-The mottling left after 
a severe attack of Measles is often ex- 
tremely like the petechife of typhus fever, 
but the early appearance of the rash of 
Measles will in all cases be sufficient to 
ensure a correct diagnosis. The rash of 
typhus fever, moreover, appears first on 
the wrists. 
The mottling left by the rash of Measles 
is in all respects like the mottling seen in 
syphilitic roseola, but the rashes are dif- 
ferent at their commencement, and the 
mottling left by Measles is most marked 
on the shoulders and over the scapulse, 
the mottling of syphilitic roseola is gene- 
rally absent from these regions, ami is 
most marked on the trunk. Moreover, 
the general symptoms are sufficiently dif- 
ferent to render a mistake impossible.1 
Occasionally copaiba, morphia, and cer- 
tain fish, produce a rash which in some 
instances it is impossible to distinguish 
from that of Measles. The rash, how- 
ever, produced by these causes, is often 
very irregular in its distribution, and lasts 
a much longer time than that of Measles, 
1 The rash of Measles is often, at its com- 
mencement, compared to that of flea-bites, 
but the differences between them are always 
well marked, and by the most superficial ex- 
aminations they can be distinguished. Flea- 
bites take on two different forms. In the 
simpler there is no elevation, but a central 
point of redness, not removable by pressure, 
surrounded by a small ring of a less intense 
color ; this latter redness disappears on pres- 
sure. In another form there is a round firm 
swelling, varying in size, often as large as a 
pea ; this itches greatly. It has all the cha- 
racters of the wheals found in urticaria. 
2 It is stated that the two fevers may co- 
exist, and that these rashes may be mixed. 
No such case has come under the author's 
notice. [See article on Rotheln.-H.J 
1 The author believes that Dr. Hare was 
the first to point out this resemblance be- 
tween the rash of Measles and that of syphi- 
litic roseola. 
VOL. I.-8 114 
MEASLES. 
if the medicine be continued. Occasion- 
ally there are, mixed with this rash, 
wheals of urticaria; when such is the 
case, there is much itching. 
Prognosis.-Usually a mild disease, 
the prognosis is very favorable. 
The degree of danger is dependent on 
the previous health of the patient, on the 
time of year at which the disease occurs, 
and on the nature of the epidemic. 
If the health has been bad, the prog- 
nosis is more serious, but even in such 
cases the result is mostly favorable. 
If the patient be tubercular, the prog- 
nosis becomes grave. Cold and damp 
weather, favoring the development of pul- 
monary affections, increases the danger of 
the disease. 
The severity and the nature of the com- 
plications occurring during different epi- 
demics, vary greatly. Yet, in the worst 
epidemics, the majority of cases recover. 
Treatment. - Not possessing any 
medicine capable of shortening the dura- 
tion of the disease, it must be our object, 
in treatment, to conduct the fever to a 
favorable termination, and to ward off any 
intercurrent disease.1 
The patient must be confined to bed. 
Too much light should be excluded, for 
strong light is annoying to all febrile pa- 
tients, and in Measles causes some pain in 
the inflamed conjunctivae. 
The room should be well ventilated, 
and all excreta and dirty linen imme- 
diately removed. The patient must be 
most carefully protected from draughts. 
The sense of heat and dryness of the body, 
sometimes most distressing to the patient, 
can be much alleviated by washing the 
surface with soap and tepid water; too 
great exposure being avoided by one part 
of the body being cleansed, dried, and 
covered, before the rest is exposed. The 
feeling of tension of the hands and feet 
can be relieved by rubbing these parts 
with some firm greasy matter, such as suet. 
All sources of annoyance or irritation, 
all noises should be avoided, and thus 
sleep is promoted, a condition which most 
materially affects the welfare of the pa- 
tient,-sleep lessening the fever and in- 
creasing the appetite. Food, light and 
nutritious, such as arrow-root, gruel, 
good beef-tea, milk, chicken or veal broth, 
jellies, &c., should be given at the usual 
meal hours. The quantity should be 
moderate, great care being taken that the 
digestion be not impaired by too large in- 
gestion of food. Should the patient be 
very weak, the food must be administered 
in small quantities and at short intervals. 
There is no stimulant so important as 
food. The prospect of recovery in all 
acute febrile diseases is very greatly, if not 
mainly, dependent on the power possessed 
by the patient of digesting and assimilat- 
ing food. J 
If there be often-repeated sickness,1 
food of the very blandest nature, pounded 
raw meat,2 Liebig's beef-tea,3 uncooked 
white of egg diluted with water or barley 
water, should be given in small quanti- 
ties, and be very frequently repeated. 
Thirst must be assuaged, and thus the 
restlessness of the patient allayed by 
drinks regulated with respect both to 
quantity and quality. Large draughts 
should be prohibited, as they tend to im- 
pair the digestion, and cause diarrhoea: 
small quantities, swallowed slowly, or ice 
to suck, are sufficient to allay thirst, and 
they also prove grateful to the patient. 
The patient, however, must be allowed 
to take larger quantities of fluids than in 
health, as an increased quantity is required 
by the system during the existence of fever. 
Acid or acid and bitter drinks are gene- 
rally found to lessen thirst to a greater 
degree than mere water, and are more- 
over grateful to the patient. " Imperial 
drink," lemonade, with very little sugar, 
raspberry vinegar, or weak infusion of 
cascarilla, with a few drops of hydrochlo- 
ric or nitric acid, are all-especially the 
latter-useful. 
Stimulants are administered to support 
the strength of the patient. This they do 
in a great measure by promoting diges- 
tion, and by also directly increasing the 
force of the heart's action; for in fever- 
patients the pulse, under the influence of 
alcohol, most certainly gains in force. 
1 A very unfavorable symptom, for sick- 
ness itself very greatly prostrates the patient, 
and by the vomiting the nutritious matters 
are returned : nay, more, the vomiting is due 
to a condition of the mucous membrane of the 
alimentary tract most unfavorable to digestion. 
2 Before pounding the meat all fat and ten- 
don should be removed. 
3 Liebig's beef-tea is made by cutting one 
pound of beef very small, pouring on this one 
pintof water, to which have been added thirty 
minims of hydrochloric acid and two scruples 
of common salt, and allowing this to stand 
three hours. It should then be strained and 
strongly expressed: it is then fit for use. 
[Better than Liebig's preparation, in the esti- 
mation of many, is beef-tea made by pouring 
a pint of cold water upon two pounds of lean 
beef, chopped small, letting it stand near the 
fire for two hours, then boiling for twenty 
minutes, skimming while hot, and pouring 
off at once, without Jiltration. This contains 
all the nourishing qualities of the meat, in an 
easily assimilable state. It admirably exem- 
plifies the Hippocratic aphorism (ii. 11'), 
'Paov TXnp'ju^dai ttotou 5 mlau.-IL] 
1 The remarks made respecting the treat- 
ment of Measles, of course apply for the most 
part to all febrile diseases, and especially to 
those of long duration. TREATMENT. 
115 
The administration and quantity of 
stimulants given must thus be regulated 
by the condition of the patient. Guidance 
in this respect can be derived from the 
previous history of the patient, the exist- 
ing state of the patient, and the nature of 
the epidemic. 
If the patient previous to the fever, has 
been in an unhealthy state from any 
cause, such as overwork, excesses of any 
kind, or is the subject of scrofulosis or 
tuberculosis, in whom the fever always 
tends to become typhoid in character, and 
to leave one or more of its sequelae1 be- 
hind, stimulants may with benefit be 
given early in moderate quantities: and 
at the same time the patient should be 
carefully watched, so that their quantity 
may be increased in anticipation of any 
great amount of prostration. 
Again, in some epidemics the disease is 
violent, and apt to become typhoid. Pa- 
tients met with in such epidemics may 
have stimulants given them early with 
benefit. But the chief information re- 
specting the administration of stimulants, 
and the quantity of these to be given, is 
derived from the then existing state of 
the patient. If the disease be progress- 
ing favorably (the previous health having 
been good), stimulants had better be alto- 
gether abstained from. But if the patient 
become at all prostrate, the tongue dry, 
the pulse small and frequent, stimulants 
must be given freely and often. It should 
be the anxious endeavor of the physician 
to anticipate such a state, and prevent it 
by the early use of alcohol.2 
In reference to the amount to be given, 
no exact rules can be laid down. Expe- 
rience at the bedside alone can teach this. 
It may, however, be stated that young 
children bear stimulants well in disease. 
It is a matter of but little importance in 
what form the stimulant is given, pro- 
vided it is sound in quality. The patient's 
taste should be consulted. Thus, brandy, 
gin, whiskey, port or sherry wine, bitter 
or draught beer, may be given.3 
Only one kind of stimulant should be 
administered at the same time, though it 
may be frequently changed at the request 
of the patient. 
[There are certainly very many cases of 
Measles, indeed the large majority under 
ordinary circumstances, which require no 
alcoholic stimulation at any period of the 
attack. While young children in states 
of positive exhaustion bear stimulants 
very well, the doses in which they are 
given must, for beneficial action, be re- 
duced in greater proportion than is need- 
ful with any other remedies except opium 
and other narcotics.-II.] 
At the commencement of the disease, 
if vomiting has not occurred, an emetic 
can be often given with benefit, and the 
bowels, if confined, should be opened by 
a mild purgative, it always being borne 
in mind that in Measles the intestines are 
usually very easily influenced by purga- 
tives. Acetate of potash, acetate of am- 
monia, and nitric ether may be given in 
suitable quantities every three or four 
hours; and if the cough be troublesome, 
some ipecacuanha wine may be added. 
If the skin be hot, the pulse hard, and 
incompressible, aconite, given hourly, will 
be of much service. 
Opiates are but rarely required ; sleep 
should be obtained by removing, as far as 
possible, those conditions that are liable 
to render the patient restless. 
Bleeding at the nose, if severe, should 
at once be stopped. This can be accom- 
plished by the injection of cold water, or 
the breathing up of astringents, in fine 
powder, into the nose; should these fail, 
plugging becomes necessary. 
For the convulsions that occur, often 
but little is required, and but little can be 
done-those occurring early quickly dis- 
appearing ; those occurring late almost 
always ending in death. 
In the, treatment of laryngitis, Trous- 
seau warns against the application of 
leeches, and adopts Graves's recommen- 
dation of a sponge wrung out of boiling 
water, and applied over the larynx. 
[Some practitioners of large experience 
believe, nevertheless, that leeches may do 
a great deal of good, at least when the 
application of the hot wet sponge for a 
time does not afford entire relief.-H.] 
If suffocative catarrh supervene, or a 
serious internal inflammation cause the 
recession of the rash with much prostra- 
tion and possibly with coma, a warm bath, 
to which two tablespoonfuls of mustard 
have been added, may be used with bene- 
fit. The child should be kept in the bath 
till the arms of the nurse holding the child 
tingle and smart. 
Gangrenous inflammation is best treated 
locally, by the application of strong hydro- 
chloric or nitric acid, and generally by 
the free use of stimulants, with sesqui-car- 
bonate of ammonia and tonics. 
If there be much inflammation of the 
fauces (but this is not usual), linseed 
1 The probability that the various anatomi- 
cal lesions met with in Measles will become 
chronic, is determined by two conditions- 
first, by idiosyncrasies, inherited or acquired 
-thus patients who have had many attacks 
of bronchitis, will be very liable to have some 
chronic bronchitis left behind ; and secondly, 
and chiefly, by the previously impaired 
health of the patient. 
2 Whilst in such cases stimulants should 
be freely given, it must not be forgotten to 
give the patient food in small quantities, fre- 
quently repeated ; for food is the best and 
most natural stimulant. 
3 The patients will sometimes take stimu- 
lants in this form when they refuse them in 
all others. 116 
MEASLES. 
poultices to the throat, and the inhalation 
of steam or ice to suck will be found of 
benefit. On the subsidence of the inflam- 
mation, if the formation of muco-purulent 
matter continue, adults can use astringent 
gargles. It must be borne in mind that 
children under eight years of age cannot 
gargle, and thus the fluid should be inject- 
ed into the throat with a syringe. There 
is no fear of choking, provided the stream 
of the injected fluid be not too great. 
Inflammation of the lungs, when occur- 
ring in children, requires active stimulant 
treatment. Bleeding in these cases can 
never be borne.1 
The chronic sequelae being dependent 
on the impaired health of the patient, are 
best treated by those means and medicines 
that promote the general health of the 
patient, and also when possible, by local 
applications. The child should be warmly 
clothed, with flannel next the skin. 
Much of the day should be spent in the 
open air and in direct sunlight, unless the 
patient be too young, or the sun's heat 
too powerful. Hours of rest should be 
long, and sleep may be indulged in with 
advantage for a short time during the 
afternoon.2 Simple healthy food, at regu- 
lar hours, with a very moderate allowance 
of stimulants, or even without any, should 
be given. Sea-bathing or cold-sponging 
will be found to be of the very greatest 
advantage for the cure of these sequelae. 
The sea-bath should be taken about three 
hours after breakfast. If the patient be 
very weak, a very short stay in the water 
of one to two minutes at most should be 
allowed. The sea should be smooth, and 
1 [From this dictum it is necessary for the 
American editor to express absolute dissent. 
While it is true that pneumonia complicating 
measles does not often require bleeding, it may, 
at least, in a certain number of cases, be well 
borne, even by children ; and the universal 
employment of active stimulation (by which 
the author means, no doubt, the free use of 
alcohol) to this complication must, it is be- 
lieved, while saving some cases, aggravate 
others to a fatal end.-H. ] 
2 Every care should be taken, during con- 
valescence, to insure sound sleep. The sup- 
per should be light, and be taken one or two 
hours before going to bed. No stimulants 
should be taken during the evening, unless 
the patient be very weak. If baths cause 
restlessness, they must be discontinued for a 
few days, or the patient should be directed to 
remain in the water for a shorter time. Dur- 
ing convalescence the patient is in much the 
same condition as a child. It is a period, if 
not of growth, of great repair-a condition 
analogous to growth. The appetite, digestion, 
and assimilation are greatly influenced by 
sleep. This influence is well seen in ulcers 
on the surface of the body. After a restless 
night these are painful, throbbing, inflamed, 
and swollen, and apt to spread ; whilst after 
a refreshing sleep they have a much healthier 
appearance. 
if the weather be wet or stormy or cold, a 
tepid sea-bath is preferable to open-air 
bathing. Children should be coaxed, not 
dragged into the water, as baths fail to 
act as a tonic, and produce much depres- 
sion in persons laboring under strong 
mental emotions. 
The cold sponge-bath may be used be- 
fore breakfast. If the patient be very 
weak, and the weather very cold, a little 
warm water should be added. The time 
the sponging should be continued depends 
on the condition of the patient ; the 
weaker the subject the shorter the time ; 
thus one to two minutes is in many cases 
as much as can be borne, for if continued 
too long, in such cases no tonic effect fol- 
lows, but depression, which generally lasts 
during the rest of the day. Very young 
children can be much benefited by cold- 
sponging, even during the winter months, 
if the bath be properly used. The spong- 
ing should not be continued longer than a 
minute, and if the weather ami water be 
very cold, the child's feet should be placed 
in warm water, and the bath administered 
before a good fire ; by these means reac- 
tion is promoted. Salt may be added to 
the bath with benefit. 
Under such treatment all the sequelae 
greatly diminish, nor need there be any 
apprehension that the chronic bronchitis 
should be aggravated ; for if the baths be 
administered in the manner described 
above, this disease almost invariably 
greatly improves. 
Of medicines, iron, quinine, and especi- 
ally cod-liver oil, are always very benefi- 
cial. The latter should be administered 
after food, for at this time the bile is 
poured out in largest quantity into the 
intestinal canal, and it is found that 
animal membranes moistened with bile 
allow fats to pass through. 
The chronic discharge from the ears, 
nose, and vagina is usually easily arrested 
by local applications. The affected part 
should be washed frequently (in propor- 
tion to the amount of discharge) during 
the day with tepid water, and injections 
of lead lotion, or of solutions of alum 
(3j. to 9j.), or sulphate of zinc (gr. iv. to 
§j.), will generally promote the cure.1 
The chronic inflammation of the larynx, 
or of the bronchial tubes, is most quickly 
mitigated and generally cured by inhala- 
tion of steam with H]x. to Tfixx. of tr. 
iod. poured on the water, from which the 
steam is given off. Creasote may be 
sometimes used, but does not give such 
good results as the iodine. The inhala- 
tion should be used night and morning 
for about ten minutes.2 The chronic diar- 
1 In the author's experience lead lotions 
are preferable to the others. 
2 The cough is greatly influenced by change 
of climate. If the cough be easy and the ex- 
pectoration scanty, a warm moist climate, but rotiiein; german measles. 
117 
rhoea, which occasionally follows Measles, 
should be treated by a carefully regulated 
diet, and the occasional use of hyd. c. 
creta. If the diarrhoea be exhausting, it 
can be generally temporarily stopped by 
an injection of starch, of the consistence 
of cream, and about two ounces in quan- 
tity; to this some laudanum or one of the 
metallic astringents must be added. 
Raw pounded meat sometimes has a 
beneficial influence on the diarrhoea. 
[ROTHELN; GERMAN MEASLES. 
By Henry Hartshorne, M.D. 
Definition.-An exanthematous dis- 
order, intermediate in character between, 
or composite of, Scarlet fever and Measles. 
Synonym.-Rubeola. This term is, 
by some writers, restricted to it: although 
by many others it is applied indiscrimi- 
nately to Measles. 
History.-Apparently more common 
on the continent of Europe, this affection 
has not been much noticed in Great Brit- 
ain, and has been scarcely described until 
within a few years in the United States. 
Yet there is reason to believe that it has 
long, if not always, been tolerably fre- 
quent ; its resemblance to both Measles 
and Scarlatina causing it to be usually as- 
signed in description" to one or other of 
those diseases. 
Dr. Murchison and others have ex- 
pressed the opinion that it is a distinct 
disease, having nothing to do with either 
Measles or Scarlet fever, and not protect- 
ing its subjects from either of those affec- 
tions. Dr. J. Lewis Smith, of New York,1 
observed and described an epidemic of it 
prevailing in that city in 1874. In 1875 
more than a dozen cases of it occurred 
at Ilaverford College, near Philadelphia. 
More than one such an epidemic has been 
witnessed in rural localities, in Maryland 
and elsewhere; the popular designation 
for the affection being French Measles. 
Symptoms.-In the cases observed at 
Ilaverford, Pa., the early general symp- 
toms were mild; malaise,' headache, slight 
sore throat, loss of appetite, and debility. 
In two or three days, with some increase 
of fever, a rash appeared, having more the 
color of that of Scarlet fever than of Mea- 
sles, but dotted or miliary (sub-papular) 
in form. In some cases it became almost 
continuous, with a moderate amount of 
tumefaction of the limbs and general sur- 
face. In one instance the fauces exhibited 
a scarlet hue to the eye, although no feel- 
ing of soreness of the throat existed in that 
case. Catarrhal symptoms were not no- 
ticed in any of these patients. In some of 
them, the glands of the neck were swollen. 
None had a very high degree of fever. 
The duration of the attack was about a 
week ; and convalescence was rapid. No 
sequelse were observed in any instance. 
Dr. J. Lewis Smith mentions that albumi- 
nuria and dropsy occasionally follow this 
disorder, as well as chronic bronchitis. 
Altogether, in several characters, Rbtheln 
most nearly approaches Scarlet fever; 
while, in the absence of severity in any 
of its symptoms, it is more like Measles. 
Pathology.-Opinions may readily 
differ as to the nature of this affection, 
whether it is a specific disorder, or a hy- 
brid of Measles and Scarlet fever. The 
latter would seem to be at least possible, 
according to the analogy of some other 
diseases ; although hybrid maladies are 
certainly rare. Examples of such are 
met with in malarial regions bordering 
upon yellow fever districts, where malig- 
nant remittent combines the characters of 
two usually distinct fevers; in typho-ma- 
larial fever, seen in many cases in the 
U. S. Army during the civil war of 1861- 
65; and in scorbutic dysentery, occurring 
among soldiers during that war as well as 
in 1854-56 in the Crimea. In the absence 
of any record of fatal cases, the morbid 
anatomy of the affection can only be con- 
jectured ; and its true pathology may be 
considered as yet undetermined. 
Diagnosis.-While a place in descrip- 
tion and classification seems to be practi- 
cally needed for a combination of symp- 
toms not included in the typical account 
of either of the commonly recognized ex- 
anthemata, reasons have already been 
given for obscurity in the diagnosis of its 
examples. In a case occurring some years 
ago in Philadelphia, two physicians of 
similar experience saw the patient within 
if the expectoration be abundant, a warm dry- 
climate is beneficial. 
1 [Sanitarian, July, 1874.] 118 
PAROTITIS. 
an hour of each other; one pronounced 
it Measles and the other Scarlet fever. 
When, however, after about three days of 
indisposition, a rash breaks out which is 
miliary in form, but of a nearly scarlet 
hue, attended with slight sore throat, 
with or without a disposition to cough, 
and moderate fever, all of which symp- 
toms subside within a week, leaving no 
sequela?, and especially when a number 
of such cases occur in the same neighbor- 
hood,exhibiting the same absence of severe 
character, and all followed by rapid conva- 
lescence, we may conclude it to be an epi- 
demic of Rotheln or Rubeola. This is con- 
firmed if neither Scarlet fever nor Measles 
is prevalent at the same time and place. 
Treatment.-Nothing peculiar exists 
in the indications of this affection, apart 
from those of other exanthematous fevers. 
Almost no treatment is usually required. 
Confining the patient to his room as a mea- 
sure of precaution, even if not ill enough to 
seem to need it, a single dose of citrate 
of magnesium or Rochelle salts may be 
given. If the fever should be considera- 
ble at night, solution of citrate of potas- 
sium or acetate of ammonium may be 
prescribed. Flaxseed lemonade will be 
suitable as a demulcent and diluent, if 
either sore throat or cough should call for 
any treatment. These mild measures, 
with care to avoid exposure during con- 
valescence, lest a bronchial attack, or pos- 
sibly suppression of perspiration, renal 
congestion, and anasarca might occur, are 
all that are likely to be appropriate. A 
second attack is not to be expected ; but 
it is not proven that Rbtheln affords pro- 
tection against either Measles or Scarlet 
fever.] 
PAROTITIS. 
Sydney Ringer, M.D. 
Definition.-An acute febrile disease, 
characterized by an anatomical lesion 
situated in one or both parotid glands, 
which runs a short course, and almost in- 
variably terminates favorably. 
Synonyms.-Parotitis ; Cynanche pa- 
rotidea; Ziegenpeter (Germ.); Parotide, 
Parotidite (Dr.); Mumps (Engl.). 
Symptoms.-Beginning abruptly-rare- 
ly with rigors, more commonly with a 
feeling of chilliness, with or without vom- 
iting, pain in the head, back and limbs- 
the disease in its course is accompanied 
by the symptoms common to all febrile 
diseases. The face is sometimes flushed, 
the lips may be dry; impairment of 
strength, variable in degree, is generally 
slight, and sometimes absent; the tongue 
is furred, but usually moist; the appetite, 
in some cases natural throughout, is in 
most impaired, and may be nil. The pa- 
tient usually complains of thirst, and the 
bowels are often confined. 
The pulse and respiration are increased 
in frequency, the former often greatly so, 
especially in children ; it also sometimes 
gains in force ; the urine is scanty and 
high-colored ; the temperature of the body 
is raised, but this elevation varies much 
in degree.1 Usually at the very com- 
mencement of the disease, but occasion- 
ally postponed for twelve, twenty-four, 
or even thirty-six hours, the affection in 
one or other parotid gland, sometimes in 
both, manifests itself by pain, followed in 
a few hours by swelling of the glands and 
stiffness of the jaws. 
The pain and swelling first appear im- 
mediately beneath the ear, and posterior 
to the ramus of the jaw, and from this 
part spread in all directions, upwards to 
the face, downwards and backwards in 
the neck. On the face the swelling ap- 
pears earliest on that part immediately in 
front of the lobe of the ear, and then 
quickly extends upwards to the zygoma- 
tic arch, and forwards involving a varia- 
ble extent of the face. The swelling dis- 
appears in the inverse order of its invasion. 
It is at first flat, but soon becomes more 
prominent, and is usually most marked 
anterior to the lobe of the ear. Firm and 
elastic to the feel, it is generally tolerably 
well defined, but does not pit on pressure; 
and, ■whilst the skin over the enlargement 
is mostly natural in color, it is in some 
cases mottled with a slight red blush, and 
is in rare cases of a bright scarlet hue. 
The redness disappears on pressure, but 
quickly returns on the pressure being re- 
moved. The degree of enlargement va- 
readied was lOlf; in another, however, it 
rose to 103|. 
1 In one case the highest temperature PATHOLOGY. 
119 
ries : whilst in some cases apparent only 
behind the ramus of the jaw, or even so 
slight that it easily escapes notice, it is 
more usually co-extensive with the parotid 
gland, and occasionally extends far be- 
yond this, involving a large part of the 
face and neck, and, in some rare cases, 
reaching to the upper part of the chest, 
giving to the head and neck a pyramidal 
shape. The swelling increases from three 
to six days, then usually remains station- 
ary for twenty-four or forty-eight hours, 
after this rapidly declines, and often has 
entirely disappeared by the eighth or 
twelfth day from the commencement of 
the attack; the redness subsides much ear- 
lier,and is occasionally followed by a super- 
ficial desquamation of the cuticle. Not 
unfrequently one or both submaxillary 
glands are also involved, in which case the 
swelling extends along the body of the 
jaw, reaching nearly to the symphysis. 
The pain and tenderness, dull and 
aching in character, vary greatly in de- 
gree ; sometimes they are only complained 
of on movement of the jaw, and are then 
seated beneath the ear, and behind the 
ramus of the jaw-a fact easily accounted 
for when it is remembered that this part 
of the enlargement is most affected by the 
movement-in other cases, however, the 
pain is constant and severe, and occa- 
sionally extends beyond the limits of the 
apparently affected tissues, reaching even 
to the chest and shoulder. 
The pain more severe in adults than in 
children, usually lasts only during the 
time the swelling is increasing : on the 
other hand, tenderness on pressure, which 
is always present, continues for some days 
longer, and is longest observed in the part 
first affected. The jaw is generally fixed, 
and the mouth slightly open ; moreover, 
its movements are limited, or entirely 
prevented, the degree of impediment being 
proportionate to the amount of pain and 
swelling present. Consequent on the im- 
pediment in the movement of the jaw just 
mentioned, the speech is affected, and 
mastication can be but most imperfectly 
and painfully performed ; and when, as is 
sometimes the case, the tonsils are en- 
larged and inflamed, and the swelling ex- 
tends even to the cellular tissue of the 
pharynx, deglutition also becomes diffi- 
cult, and danger of suffocation, in very 
rare instances, is imminent. The mucous 
membrane of the mouth is unaffected, and 
the salivary secretion, in some cases dim- 
inished, in a very small number increased, 
is usually natural in both quality and 
quantity. 
Occasionally only one parotid gland is 
affected ; in most cases, however, both 
suffer. The left side is most frequently 
the first involved, and the pain and swell- 
ing in it precede that in the right for a 
period varying from twelve to thirty-six 
or forty-eight hours. The side first at- 
tacked sutlers the most severely. It is 
stated that, in rare instances, the gland 
has suppurated. 
Other organs besides the parotid and 
submaxillary may be affected. In many 
the testicles, one or both, may sutler; 
whilst in the female the mammae, the 
labia majora, and uterus are the parts oc- 
casionally attacked. The tonsils and pha- 
rynx may also be involved. When the 
testicle is diseased, the inflammation in- 
volves both the tunica vaginalis and the 
epididymis ; and if the disease be limited 
to one of these organs, this is situated on 
the same side with the parotid, solely or 
most severely, affected. These complica- 
tions, or metastases as they are termed, 
usually make their appearance whilst the 
parotid and the submaxillary glands are 
enlarged ; but, on the other hand, the 
swellings may decline and disappear from 
the glands, and not make their reappear- 
ance elsewhere until a period,' varying 
from a few hours to one or two days, has 
elapsed. In this last case, whilst the 
swellings are in abeyance, active general 
symptoms, sometimes of an alarming cha- 
racter, may occur ; there may be a feeling 
of great anxiety, pallor of the face, cold- 
ness of the extremities, smallness and 
great frequency of the pulse, and to these 
symptoms delirium, vomiting, and purg- 
ing are sometimes added. However, on 
the reappearance of the local mischief at 
any part of the body, these symptoms dis- 
appear. These metastases, rarely occur- 
ring in children,.and by no means common 
in adults, are prone to occur in individuals 
of the same family; in other words, family 
idiosyncrasies tend to their development. 
The duration of the disease varies; thus, 
in mild cases it may run its course in four 
days, whilst in severe cases it may con- 
tinue for ten days. Its duration is usu- 
ally longer, and the fever higher, when 
metastases occur. 
Pathology.- As the disease rarely 
kills, the opportunities for investigation 
on this point are necessarily but few. It 
is generally, however, held that the organ 
affected, and the cellular tissue within and 
around it, are inflamed, and that there is 
an excess of serosity in these parts. 
The glands may remain somewhat en- 
larged and hardened for a considerable 
time after all the acute symptoms have dis- 
appeared, and it is even stated that in rare 
cases the affected testicle has atrophied. 
In Mumps, have we primarily a general 
disease of which the local effects are the 
sequence ; or, on the other hand, is the 
disease in the first instance local, and are 
the general symptoms dependent on such 
local mischief? In the present state of 
medical knowledge, this question cannot 
be answered. Suffice it to say that, whilst 120 
PAROTITIS. 
some diseases, such as typhoid fever and 
dysentery, were formerly thought to be 
primarily "general," further observation 
on these affections has at least rendered 
it possible that both of them are in the 
first instance "local," and that the gene- 
ral symptoms are secondarily dependent 
on these local lesions. Should this be 
fully established, it will go far to render 
probable that most, if not all, diseases 
are at their commencement local, and, 
amongst others, the disease under consi- 
deration. In favor, however, of the older 
view, the author may mention the follow- 
ing case in which, after the temperature 
of the body had become normal (i. e., after 
all fever had disappeared), the right pa- 
rotid, which had previously remained 
healthy, began to enlarge, became pain- 
ful, and corresponded in all respects in its 
behavior to the left, this latter gland 
having been previously affected during 
the time that the temperature of the body 
was raised. As no subsequent elevation 
of the temperature occurred in this case 
at least, the local mischief in the right 
parotid was insufficient to elevate the 
temperature, and was certainly in point 
of time sequential to the general condition. 
Most common between the ages of five to 
fifteen, the liability to the disease rapidly 
diminishes in those under or above these 
ages; and whilst old age does not afford 
an entire protection from the disease, it 
is unknown in children under one year. 
It occurs with equal frequency in both 
sexes. Some authors, however, assert 
that it is more commonly met with in 
boys than girls. 
It is a contagious disease, not usually re- 
curring a second time, subject to epidemic 
influence, said to be most common in 
spring and autumn. Its period of incuba- 
tion varies from eight to twenty-two days. 
Being a disease of short duration and 
of slight intensity, the patient usually re- 
covers quickly both strength and weight. 
As in convalescence from all acute affec- 
tions, so with Mumps, the rapidity of re- 
covery from the anaemia, loss of flesh, 
&c., is proportionate to the age, being 
quicker and more perfect in young than 
old people, and is, moreover, determined 
by the previous health of the patient: if 
this has been good, the recovery is accom- 
plished perfectly and with rapidity; 
whilst, on the other hand, if the health 
has been impaired by excesses of any 
kind, or by bad hygienic conditions of 
life, or if the patient be the subject of 
chronic disease, or of the tubercular or 
scrofulous diathesis, the restoration to 
perfect health is much retarded. 
Diagnosis.-This is rarely difficult. 
An acute febrile disease, accompanied 
with a swelling in, and assuming the 
shape of, the parotid gland, is diagnostic 
of Mumps. 
Parotid bubo1 may in some respects 
simulate this disease. It is, however, a 
rare affection; almost invariably follows 
in the course of one of the acute specific 
fevers. The swelling does not take on 
the shape of the parotid gland, and quickly 
gives evidence of the existence of pus in 
various parts of the swelling. The mam- 
ma, testicle, &c., are never affected. 
Enlarged lymphatic glands situated in 
the neighborhood of the parotid perhaps 
ought to be mentioned, though a careful 
examination would at once establish the 
nature of the swelling. Thus there is 
often more than one enlargement, usually 
the size of a Barcelona nut, commonly 
situated immediately in front of the ear. 
There is no swelling behind the ramus of 
the jaw ; the tumors can be felt to be su- 
perficial to the parotid, over which they 
are mostly movable, and moreover these 
enlargements of the lymphatic glands are 
always due to some irritation in the neigh- 
borhood, which can generally be discov- 
ered. 
Treatment. - In common with the 
other acute specific fevers, Mumps has 
hitherto failed to be arrested in its course 
by any mode of treatment at present 
known. The utmost therefore that can 
be done is to mitigate the severity of the 
symptoms, and thus conduct the disease 
to a favorable termination. Being mostly 
a disease of trifling importance, but little 
danger is to be apprehended and but little 
treatment is required. 
All active treatment, whether general 
or local, is in most cases to be avoided. 
At the very commencement, an emetic 
followed by a purgative will be generally 
useful. The bowels should be kept regu- 
larly open, but active purgation should be 
avoided. By this means the severity of 
the fever is lessened, for it is well known 
1 My friend Dr. H. Jeaffreson, late Resi- 
dent Physician to the London Fever Hospital, 
has supplied me with the following notes 
concerning parotid bubo. It begins below 
the ear and behind the jaw, is hard and 
brawny to the feel, and ill defined. The skin 
over the swelling is almost invariably of a 
dusky red color; is immovable over the swell- 
ing ; in three or four days becomes boggy, 
and in five or six bursts, and discharges pus. 
It is by far most common in persons of mid- 
dle or of old age. It is very rare in children, 
but may occur at the age of five or six. 
Of the acute specific fevers, it almost in- 
variably follows typhus. No case has oc- 
curred for some years past at the Fever Hos- 
pital after measles, scarlet fever, or typhoid 
fever. Not more than 3 per cent, resolve. 
Both parotids may be attacked, and the sub- 
maxillary glands may also be attacked in 
conjunction with, or independently of, en- 
largement of the parotid. The former condi- 
tion is by far more frequent than the latter. TREATMENT. 
121 
that constipation has the effect of elevating 
the temperature in febrile patients. 
In Mumps, as in all fevers, we have an 
undue elevation of the temperature of the 
body, due in part at least to increased 
combustion of some of the tissues. The 
treatment must be directed so as to con- 
trol this increase of waste, and supply the 
loss by appropriate food. This is espe- 
cially needful with patients whose health 
previous to the disease was impaired : for 
in such, a great amount of bodily and 
mental weakness, lasting for a considera- 
ble time, may result. 
With this object in view, two chief 
points should be attended to, namely, 
rest and the appetite. 
Rest and even confinement in bed should 
be enjoined ; for it is found that in all fe- 
brile diseases, exercise, both of mind and 
body, is capable of increasing the abnor- 
mal elevation of the temperature. The 
pain also, which may accompany febrile 
disease, is much allayed by perfect rest. 
The appetite must have strict regard 
paid to it; for the increased waste of the 
tissues is compensated for in proportion 
to the amount of food digested. Should 
no food be taken or assimilated, the pa- 
tient is placed in all respects in the posi- 
tion of a starving person, and to this 
must be added an active, increased con- 
sumption of the tissues. 
To secure or promote the appetite and 
proper digestion of the food, attention 
must specially be paid to pain, sleep, and 
the nature of the diet. 
Pain, if severe, destroys entirely the 
appetite and arrests the digestion of food; 
therefore, should the pain in the affected 
organ be great, appropriate treatment 
must be employed. For the most part, 
hot fomentations or poultices are suffi- 
cient for the purpose. Should, however, 
these fail, one or two leeches applied in 
the neighborhood of the affected organs 
will generally quickly afford great or even 
entire relief. This is especially the case 
when the testicle is affected. The pain is 
further mitigated by perfect rest of the 
part; thus the jaws should be moved as 
little as possible, and the testicle, when it 
is affected, should be carefully supported. 
In regard to the second point-sleep- 
this can in most cases be attained by 
easing the pain of the affected part in the 
manner just described, and by allaying 
any distressing symptoms that may be 
present, such as thirst, heat of skin, &c. 
The thirst can be removed by sucking ice, 
or the patient may be directed to rinse 
out the mouth with cold water, or to 
swallow small draughts of cold water 
slowly, and at short intervals. It may be 
much relieved by drinking acid drinks, 
especially if weak bitter infusions be 
added. Thus, " whey, or common water 
acidulated with currant jelly or raspberry 
vinegar," or a very light infusion of cas- 
carilla acidulated with hydrochloric acid 
(Graves), will generally succeed. Large 
draughts of water should be avoided, as 
they distend the stomach and give rise to 
annoying sensations to the patient, and 
because they retard digestion. Efferves- 
cing drinks, moreover, by distending the 
stomach, are apt to distress the patient. 
Acid fruits will allay thirst, but they must 
be used with moderation, as they may 
produce diarrhoea, flatulence, colic, and 
even nausea. 
The disagreeable sensation due to the 
hot, dry skin, may also increase the rest- 
lessness of the patient and thus prevent 
sleep; this can be allayed by sponging the 
body with cold or tepid water, one part of 
the body only being exposed at one time, 
to prevent the bad effects of cold. Soap 
may be added with advantage to the wa- 
ter, as it cleanses the skin more tho- 
roughly and removes any smell that may 
be connected with the cutaneous excre- 
tion ; this is advantageous, as it is well 
known that smells of any kind, and espe- 
cially when disagreeable, lessen the appe- 
tite, and may cause headache, nausea, 
and even vomiting and much depression. 
And lastly, strict attention should be paid 
to the diet, both in regard to its nature 
and the time and method of its adminis- 
tration. The food should be liquid, so 
that mastication is unnecessary; thus the 
inflammation in the parotid is not in- 
creased by the movement of the parts, 
but at the same time it should not be too 
dilute, otherwise digestion is impaired. 
Thus, good beef-tea, strong mutton or 
veal broth, gruel, or arrowroot, milk and 
eggs may be given, the latter with cau- 
tion, as eggs often disagree with febrile 
patients. Pounded meat, either cooked 
or raw, and without spices, are also ser- 
viceable. Liebig's beef-tea will in some 
instances be found especially beneficial; 
this, indeed, can often be tolerated by the 
stomach when all other foods are rejected. 
In respect of time and manner of ad- 
ministration, it must be borne in mind 
that the digestion of febrile patients is 
mostly impaired, and therefore only small 
quantities of food should be given at one 
time, and these should be taken at the 
ordinary meal-times, and at no others. 
When prostration is great, and the quan- 
tity that can be given at one time is very 
small, the food must be administered at 
shorter intervals, and sometimes even 
every half hour. 
It is inadvisable that the patient should 
take to allay the thirst any nutritious 
food, such as milk, as the appetite for 
food at the proper time is thus much les- 
sened. 
During the grave general symptoms 
that sometimes occur after the disappear- 
ance of the swelling in one organ, and be- SUDAMINA AND MILIARIA. 
122 
fore another is involved, more active 
treatment may be adopted, though mostly 
the disease passes on to a favorable ter- 
mination. 
If the pulse be weak, the surface cool, 
and the features nipped, chloric ether, 
musk, wine, and brandy should be given, 
and warm baths with mustard to the ex- 
tremities may prove of service 
SUDAMINA AND MILIARIA. 
By Sydney Ringer, M.D. 
Although Sudamina and Miliaria 
generally occur at the same time, they 
differ so much in respect of their appear- 
ance and the method of their develop- 
ment, that they require separate descrip- 
tion. 
It may be first stated that, while Suda- 
mina often occur without Miliaria, the 
latter, on the other hand, are generally 
accompanied by Sudamina. The prob- 
able reason of this will afterwards appear. 
Sudamina.-These vesicles are minute 
and highly transparent, spherical or oval 
in shape, and often appear deeply seated 
in the cuticle. They may sometimes be 
so small as easily to escape notice, or on 
the other hand, they may measure two 
lines in diameter at their base. 
Partly on account of their minuteness, 
but chiefly owing to their great transpa- 
rency, they are apt to escape notice. 
They are best seen when looked at ob- 
liquely, and may often be more easily de- 
tected by the touch than the sight. 
These vesicles are sometimes widely, if 
not equally scattered, but at other times 
grouped and limited to particular portions 
of the surface of the body. The skin at 
their base and in their neighborhood is 
usually unaltered, whereas, in rare cases, 
a narrow rim of redness is seen around 
them. They vary greatly in number ; 
being sometimes so few that they can be 
easily counted, and at other times so 
numerous that the chief part of the trunk 
is covered with them. The base of the 
neck, the neighborhood of the navel, and 
the sides of the thorax, are the parts 
mostly affected. They reach their full 
development in a few hours, remain so for 
about one day, and then either burst or 
dry up. When of large size and at the 
height of their development, they look 
tense and full, and feel hard and " shotty. " 
As they decline they lose their tenseness, 
and the cuticle covering them becomes 
wrinkled and loose, at the same time they 
may extend laterally, and lose their regu- 
lar form. If they be numerous, they even 
coalesce, and hence in rare cases rather 
considerable patches of cuticle may be de- 
tached from the corium beneath, the cuti- 
cle itself retaining its continuity. On 
their disappearance, the cuticle forming 
them is detached from the surface of the 
body, leaving the skin entire beneath. If 
the conditions producing them continue, 
fresh crops appear, and run their entire 
course in three or four days. 
These vesicles are most commonly 
limited to the trunk ; they may, however, 
occur on the extremities, but are rarely 
seen on the face, hands, or feet. Occa- 
sionally they become slightly turbid, but 
they mostly remain transparent through- 
out. Their contents, watery, colorless, 
and transparent, are generally acid, oc- 
casionally neutral, and very rarely alka- 
line ; they contain chlorides. No organic 
elements are seen on microscopic exami- 
nation, with the exception of a few epithe- 
lium cells probably derived from their 
cuticular covering. 
They are characteristic of no particular 
disease, but are produced by sweating 
1 Sweating is most commonly due either to 
a fall in the temperature of febrile patients or 
to general weakness and exhaustion. It 
especially occurs towards the close of typhoid 
fever, during the early convalescence of scar- 
let fever, and in the course of phthisis, this 
last-named disease being often accompanied 
by great daily variations in the temperature. 
In scarlet fever, according to the author's ex- 
perience, profuse sweating is more common, 
and lasts longer during the early convales- 
cence of the patient than in other febrile dis- 
eases ; and hence Sudamina, in very large 
quantities, are often met with at that period 
of the malady. Profuse sweating at the com- 
mencement of febrile diseases (with the excep- 
tion of rheumatic fever), when the tempera- 
ture remains permanently high, indicates 
great weakness, and thus adds to the serious- 
ness of the prognosis. 
In non-febrile persons, if sweating be easily 
produced by excitement, exertion, or sleep, MILIARIA. 
123 
and hence they often occur on the decline 
of fevers, and especially on those "critical 
days" when the sweating is most pro- 
fuse. 
Much difference of opinion exists re- 
garding the anatomy and the method of 
production of these vesicles, or Sudamina. 
According to some authorities they are 
due to accumulation of sweat in ob- 
structed and distended sweat ducts. 
Others, Bterensprung for instance, hold 
that they are produced by the exudation 
of the perspiratory fluid between two 
layers of the cuticle, the exudation being 
caused by obstruction of the ducts from 
accumulation of effete epithelium cells. 
As Sudamina produce no annoyance or 
symptoms, no treatment is required. 
They are best prevented by checking as 
far as possible the sweating that produces 
them. This sweating as has been stated, 
is often produced or increased by weak- 
ness and impairment of the health, and 
may be reduced by relaxation from work, 
out-door exercise, sea-bathing, and tonics. 
Dr. Druitt states that the sweating of 
hectic fever can be controlled for some 
hours by the sponging of the body with 
water as hot as can be borne. In many 
cases of phthisis all treatment fails to les- 
sen the amount of perspiration, for in this 
disease the perspiration is caused both 
by the daily fall of the temperature and 
the exhaustion produced by the disease. 
Miliaria.-The vesicles of Miliaria, 
in both their appearance and method of 
development, differ from those of Su- 
damina. They are like the latter, how- 
ever, in size, and are produced by perspi- 
ration. 
They are at first acuminate in form, and 
round or oval at their base ; but in the 
course of twenty-four hours they some- 
times extend and become irregular in out- 
line. They never present the tense ro- 
tund appearance of Sudamina. They are 
almost invariably surrounded at their base 
by a narrow rim of redness, and the sur- 
face on which they are seated is not in- 
frequently somewhat elevated. Their 
contents are from the first turbid, opaque, 
and white ; are acid in reaction, and by 
means of the microscope are seen to con- 
tain a large number of granular cells, 
often shrunken-looking, as if badly devel- 
oped. On the addition of acetic acid, the 
granules disappear, and there are seen 
one, two, or three nuclei. The vesicles of 
Miliaria, when freely exposed, quickly 
dry up, and a little redness remains for a 
short time longer. The skin between 
these vesicles is often mottled with red- 
ness, and here and there small red papillae 
are seen, on the summit of which, by 
means of a lens, a small vesicle can often 
be detected. 
Vesicles, in all respects similar to those 
last described, are not infrequently seen 
during the eruptive stage of scarlet fever, 
and they are situated on the papillae of the 
skin, which are elevated in this disease. 
They are formed only when the rash is 
intense, and on those parts most affected ; 
and are therefore seen most frequently 
under the clavicles and around the navel. 
They may, however, occur on the'extremi- 
ties, and are then best developed on the 
thighs. They are often arranged in elon- 
gated groups, corresponding to the fur- 
rows of the skin. Miliary vesicles are 
often abundant on the surface of patients 
who suffer from rheumatic fever, when 
sweating is profuse, and especially when 
this has an offensive smell. Hence, in 
this disease, they are most developed and 
abundant in young adults, and are rarer 
in children and old people. They are 
probably produced by inflammation. 
This is shown by the large quantity of 
cells they contain. 
To the author it appears probable that 
the vesicles of Miliaria are not formed 
during the act of sweating, but that they 
result from the irritation which the sweat 
causes. This view is supported by the 
following considerations: - The vesicles 
are especially apt to occur on those parts 
of the body from which the free evapora- 
tion of the sweat is prevented. Thus they 
are found under the band of the drawers 
when seen nowhere else ; and in cases of 
profuse sweating, if a piece of flannel be 
worn for some time, firmly tied round the 
neck (at which part of the body these vesi- 
cles are easily produced), they not infre- 
quently appear-ceasing, however, to be 
formed when the flannel is removed. 
Moreover, in rheumatic patients these 
vesicles are very abundant over the back, 
at which part the perspiration is confined, 
and often allowed to accumulate, because 
of the pain caused in such movement of 
the patient as would be required for wash- 
ing this part of the body. They are also 
most numerous in those rheumatic pa- 
tients whose sweat is usually offensive and 
disagreeable. And further,- according to 
the author's experience, they are most 
apt to occur in other patients when, from 
impairment of the health, either by over- 
work, want of sleep, excess of smoking, or 
other causes, the sweat smells offensively, 
and when probably it causes greater irri- 
tation of the skin. 
For the further settlement of this ques- 
tion the following experiments were made: 
Dry spongio-piline was placed on various 
the health is generally impaired. It must, 
however, be recollected that great differences 
in respect of the amount of sweating are met 
with in different individuals. Persons who 
have returned from tropical climates often 
continue to sweat greatly on the slightest 
provocation. 124 
VARICELLA: DEFINITION. 
parts of the body, especially round the 
neck, and kept on the surface several days. 
By the action of this dry spongio-piline, 
fiudamina, but in no case Miliaria, were 
produced. On the same patient, and to 
the same parts, linseed-meal poultices 
(which contain much acrid resin) were 
applied, and vesicles of Miliaria were 
often produced, and especially on the 
neck. Bread poultices, which are less 
irritating, produced these vesicles, but in 
a much smaller number. In favor of this 
view may be further advanced the fact 
that the vesicles of Miliaria are often ac- 
companied by troublesome itching. This 
is most marked over the back, the part 
most dependent in rheumatic patients, 
and it may be very annoying, and prevent 
sleep. 
In the treatment of Miliaria but little is 
required. Frequent sponging of the sur- 
face of the body with soap and tepid 
water lessens their production, and re- 
moves the itching. 
VARICELLA. 
By Samuel Jones Gee, M.D. 
Definition. - A contagious, febrile । 
disease which is attended with an eruption 
of vesicles, does not last longer than a 
week, and does not recur in the same in- 
dividual. 
Just as smallpox and measles were not 
at first distinguished from each other, and 
mediaeval measles included scarlet fever, 
so were smallpox and chicken-pox con- 
fused together until the last century. In 
the year 1730, appeared what seems to be 
the earliest assertion of the doctrine of 
non-identity; we read that " the pesti- 
lence can never breed the smallpox, nor 
the smallpox the measles, nor they the 
crystals or chicken-pox, any more than a 
hen can breed a duck, a wolf a sheep, or 
a thistle figs, and consequently one sort 
cannot be preservative against any other 
sort. " So far, Fuller. In the well-known 
paper read before the College of Physi- 
cians in 1767, Heberden enumerates what 
were to him sufficient reasons for disally- 
ing the two diseases. Yet since that day 
there have never been wanting those who 
have disputed the validity of the distinc- 
tion drawn ; indeed the doctrine of Fuller 
and Heberden has hardly taken fair root 
in any country except their own.1 
Let us review the arguments in favor 
of the non-identity of chicken-pox and 
smallpox. 
1. Chicken-pox and smallpox are not 
interchangeable:- 
(i.) By infection, (a) There is not a 
single authentic instance on record where- 
in either of the diseases was the result of 
exposure to the infection of the other. 
(Trousseau.) (b) Chicken-pox may pre- 
vail as an epidemic isolated completely 
from cases of smallpox. (Mbhl.) Now, 
an epidemic of varioloid, free from con- 
current examples of non-modified small- 
pox, has never yet been seen. 
(ii.) By inoculation, (a) Chicken-pox 
is not inoculable. (Bryce, Trousseau.) 
(b) Smallpox, whether modified or not, 
inoculated, has never yet been proved to 
beget chicken-pox. 
2. Chicken-pox and smallpox are not 
mutually prophylactic:- 
(i.) Smallpox did not prevent the oc- 
currence of chicken-pox. (Heberden: 
Halford, quoted by Gregory.) The read- 
er need not be reminded that undoubted 
smallpox very rarely recurs. 
(ii.) Chicken-pox does not prevent the 
occurrence of smallpox. In the Chil- 
dren's Hospital a girl sickened with chick- 
en-pox on January 17, and communicated 
1 In the first edition of this volume there 
stood in this place a detailed criticism of the 
arguments, in favor of the identity of chick- 
en-pox and smallpox, adduced by Hebra, 
the living Coryphaeus of that doctrine. Since 
Hebra's book has been translated by Dr. 
Fagge for the New Sydenham Society, the 
reader who wishes to know what Hebra has 
to say may easily procure that information. 
I confess that I was annoyed at one or two 
of his assumptions, and amused at his logic; 
I marvelled that a man with so great a repu- 
tation should write so loosely. Was Heber- 
den a physician without experience, Gregory 
a mere apprentice to his art, and Trousseau's 
opinion unworthy of consideration ? If He- 
bra will confuse varicella and varioloid, he 
must even do so; however, let it not be said 
that he does not deny the existence of vari- 
cella as a distinct disease. But " quandoque 
bonus dormitat Homerus" shall cover all 
faults. 125 
CAUSES. 
it to the child in the next bed ; in April, 
the girl first spoken of was attacked with 
modified smallpox (there were good vacci- 
nation marks on her arm), attended by 
severe invasion symptoms (vomiting, 
headache, backache), which preceded the 
eruption several days; she recovered; 
soon afterwards her mother and sister 
were laid up with smallpox. 
3. Chicken-pox and cow-pox are not 
mutually prophylactic. 
(i.) Cow-pox*does not prevent the oc- 
currence of chicken-pox ; this we see every 
day. 
(ii.) Chicken-pox does not prevent the 
occurrence of cow-pox. (Abercrombie, 
Bryce.) 
If the very existence of chicken-pox ad- 
mits of dispute, we cannot be surprised 
when we find that the published descrip- 
tions of the disease present differences and 
discrepancies without end. No doubt all 
physicians who have written upon small- 
pox, from the days of Rhazes downward, 
have left some notices of chicken-pox; 
but these are, with a few exceptions, 
either vague or confused: because up to 
the beginning of the last century the two 
diseases in question were regarded as 
essentially identical; confused, because 
hardly had a clear separation been made, 
before the introduction of vaccination, or 
rather the exaggerated expectations to 
which vaccination gave rise, led men to 
thrust into the realm of Varicella every 
example of varioloid. And even at the 
present day, the evanescence of the dis- 
ease and its lack of all gravity militate 
against better knowledge; the induce- 
ments and the opportunities for study are 
small indeed. 
The epithet chicken-pox is derived from 
cicer (chick-pea) through the French 
chiche. Varicella (varicula) is a legitimate 
diminutive of varus, a pimple. 
Causes.-The efficient cause of Vari- 
cella is "contagion." The disease is 
readily communicated through the air to 
a distance of several yards at least; in de- 
gree of contagiousness chicken-pox "seems 
as infectious as smallpox." (Heberden.) 
Chicken-pox has never been transmitted 
by inoculation. Heberden (naturally 
enough) presumed that the disease was 
inoculable; the only inference he drew 
from his failure to inoculate a person who 
had previously suffered from the disease 
was that it did not recur. About the end 
of the last century, the prevailing opinion 
in France was that chicken-pox could not 
be so transmitted. The instances of sup- 
posed inoculation narrated by Willan are 
most unsatisfactory ; the notion that such 
transmission might be impossible seems 
hardly to have crossed his mind. Berard 
and De Lavit effectively inoculated Vari- 
cella, but Varicella which presented the 
same symptoms, progress, and form of 
pock, as variola. Heim (quoted by Cross) 
was not less successful; he took his lymph 
from umbilicated vesicles which equalled 
in duration the pustules of smallpox. 
Next came Bryce, who in 1818 published 
the result of his attempts to inoculate 
thirteen persons with the fluid of what, 
from his description, we may freely admit 
to have been undoubted Varicella; the 
operation-wound healed up, and that was 
all. Lastly, Trousseau has failed in all 
his inoculation trials. 
Chicken-pox is not known to recur. It 
is a disease of childhood. The following 
table has been drawn up for me from the 
records of the Children's Hospital:- 
Q W 
S* o 
CO M2 
to 
c to 
Under 
1 month. 
GO 
<x to 
Under 
2 months. 
CO 
«o >u 
Under 
3 months. 
d 
to to 
GO CP 
Under 
6 months. 
OH 
to OH 
Under 
12 months. 
K 
to w 
00 £. 
Under 
18 months. 
C1 
co co 
CP Ci 
Under 
2 years. 
00 
co 
to Ci 
Under 
3 years. 
100 
on ►U 
CO -1 
Under 
4 years. 
o 
44 
52 
Under 
5 years. 
OH 
00 
33 
25 
Under 
6 years. 
o 
£ 5 
Under 
7 years. 
to 
o 
CP O 
Under 
8 years. 
1 01 
Cl J- 
U n der 
9 years. 
OH 
to co 
Under 
10 years. 
-1 
Ci H-* 
Under 
12 years. 
349 
378 
Total. 
Judging from the same reports, there 
seems to have been an epidemic of chicken- 
pox in 1856. 
Adult females are occasionally attacked. 
(Gregory.) 
Description of the Disease. - 1. 
Pre-eruptive Period.-(i.) Duration.-It 
does not exceed four days, and is cer- 
tainly less than a week (Gregory): it lasts 
eight or nine days (?) (Heberden) : from 
fifteen to seventeen days (Trousseau) : my 
own observations would lead me to place 
the duration at about a fortnight. (ii. ) 
Symptoms.-There are no symptoms to be 
noticed before the eruption (Gregory) : 
they are absent or slight (Heberden, 
Mohl): poorliness, headache, and fever- 
ishness precede the eruption by a few 
hours (Trousseau): cough is sometimes 
observed. 
2. Eruptive Period.-The eruption ap- 
pears within the first twenty-four hours of 
poorliness in the form of small rose spots, 
slightly acuminated; from ten to fifteen 
come out on the first day ; they appear on 126 
VARICELLA. 
any part of the body. (Trousseau.) Heber- 
den and J. P. Frank also describe a red 
spot as the first appearance of the erup- 
tion of chicken-pox. According to Bryce 
and Gregory, the first thing seen is an 
eruption of vesicles. For my own part, I 
have always noticed the vesicle to be pre- 
ceded by a red spot, and such a spot as I 
should not hesitate to call a papule, but a 
papule due to mere hypersemia of the cu- 
tis vera, and not to an exudation into it, 
for tension of the skin causes the varicel- 
lous papule to disappear. 
On the second day there may be a hun- 
dred or a hundred and fifty fresh spots ; 
those of the previous day have the epi- 
dermis raised in the form of a bleb, some- 
times perfectly round, containing serosity 
as clear as water ; there is no inflamma- 
tory areola. (Trousseau.) The vesicles 
from the first have the size of split pease 
(Bryce and Gregory) ; at any rate that 
size is soon attained or exceeded. The 
patient has the appearance of having been 
subjected to a shower of scalding water. 
(Bryce.) The vesicle is unicellular, not 
umbilicated, has a very delicate cuticle, 
and when pricked collapses perfectly; 
"after the vesicle is emptied, the finger 
passed over it does not detect any swelling 
of the cutis vera or the parts beneath." 
(Bryce, Mbhl, Cross, Gregory.) The lat- 
ter statement seems to me to be much too 
exclusive ; a distinct elevation may often 
be detected, but is, like the swelling of the 
rose spot of typhoid fever, dispersible by 
pressure. The eruption occupies all parts 
of the body, the hairy scalp not excepted. 
The shape of the vesicles on the trunk is 
often oval, the long axis being athwart that 
of the body. Itchiness is common, and im- 
pels the children to rupture the vesicles. 
The next morning a hundred or a hun- 
dred and fifty new spots will have ap- 
peared during the night, the eruption of 
the preceding day having become vesicu- 
lar. (Trousseau.) The contents of vesi- 
cles which have lasted twenty-four hours 
become slightly milky ; the turbidity, how- 
ever, is uniform. A slight inflammatory 
areola appears. 
This nocturnal outburst of spots (which 
become vesicular within ten hours) is re- 
peated for four or five succeeding nights 
from the beginning of the disease. 
(Trousseau.) 
Many vesicles, as soon as they have at- 
tained their full size, get broken, and so 
encrust at once. Those that remain un- 
broken present, on the third, fourth, or 
fifth day of their existence, a small cen- 
tral scab, which quickly attains to the size 
of the vesicle, and falls in a day or two. 
This scab is thin and granular ; it falls 
in fragments, and leaves no enduring red- 
ness and no cicatrix. If the vesicle have 
been subjected to unwonted irritation, the 
scab may be thick, coherent, and may 
leave, when it falls, a permanent pit. 
Gregory never saw a pit left. 
3. Concurrent Symptoms.-These are of 
no importance; the tongue is clean, the 
pulse unaffected, there is no appearance of 
feverishness. (Heberden, Gregory.) There 
are outbursts of fever, sometimes violent, 
for four or five nights, ceasing by day, 
(Trousseau.) Catarrh is common ; it may 
occasionally be serious, as in the case of a 
child who was under the care of Dr. West, 
on account of a chronic swelling of the 
glottidean mucous membrane ; her respi- 
ration was therefore somewhat labored at 
best; by an attack of the chicken-pox she 
was brought to such straits that for forty- 
eight hours it seemed as if she could 
hardly escape tracheotomy ; with the ces- 
sation of the eruption the urgent dyspnoea 
ceased. 
It is with reluctance that no reference 
has been made to the name of Willan ; 
yet I think that the reader who consults 
his book will find it difficult to believe that 
at least some of the cases which afforded 
materials for his descriptions were not 
cases of smallpox, especially those which 
were admissible into the variety of Vari- 
cella coniformis. 
4. Sequela?.-An attack of chicken-pox 
sometimes leaves children in a poor state 
of health, such as may not be overlooked. 
Diagnosis.-Modified smallpox con- 
stantly resembles chicken-pox in (i.) the 
mildness of the symptoms, premonitory 
and concomitant; (ii.) the scarcity of the 
eruption, and its character of coming out 
in successive crops ; (iii.) the shortness of 
the duration of the disease. (Cross.) 
Two or three days' high fever, with 
vomiting, headache, and light headedness, 
before the eruption, would exclude chick- 
en-pox. The absence of those symptoms 
would not exclude smallpox. 
Although the papule of chicken-pox has 
a certain elevation, it is something un- 
mistakably different from the peculiar 
shotty hardness of the papule of smallpox, 
modified or not. "All cases in which any 
of the pocks are observed to be indented 
on the surface, whilst their contents are 
clear, and before incrustation has com- 
menced, are at once to be distinguished 
from the water-pox. " (Cross.) The base 
of the varioloid vesicle is hard and raised 
to a degree never observed in chicken- 
pox. The pocks of varioloid are not ne- 
cessarily indented ; when not, we must 
trust to the "greater firmness and less 
rapid growth, although of equally short 
duration." "An elevation left after the 
scab separates determines the question." 
(Cross.) The commencing scab of Vari- 
cella may be mistaken for umbilication. 
A perfect vaccination scar (it may not be 
unnecessary to add) often coincides with 
varioloid. 127 
SMALLPOX: DEFINITION-HISTORY. 
The characters assigned by Gregory to 
his " variola varicelloides" are: that it 
has at least forty-eight hours of premoni- 
tory fever ; that there are tubercular ele- 
vations of the skin ; that an umbilication 
is always present; and that the scabs dif- 
fer. The last character is comparatively 
unimportant, the first and third are put 
too absolutely. 
Prognosis.-"No physician has ever 
seen a child who has died of chicken-pox ; 
fatal complications are quite independent 
of the exanthematous fever." (Trous- 
seau.) 
Treatment.-"Curatur hie morbus 
quiete animi et corporis, et abstinentia a 
carne, vinoque." As much as possible, 
children should be prevented from picking 
the vesicles and scabs present on the face. 
Small doses of quinine will be useful dur- 
ing convalescence. 
Varieties and Synonyms.-(1) Va- 
ricella lentiformis. (Willan.) On the first 
day of the eruption appear flat red eleva- 
tions, in the centre of each of which a 
vesicle is soon formed; the vesicle never 
exceeds the tenth of an inch in diameter ; 
the scab falls without leaving a scar. 
(2) Varicella coniformis (Willan); swine- 
pox. The vesicles rise suddenly, and have 
a hard inflamed border; on the second 
day the surrounding inflammation is more 
extensive ; on the third the fluid is puru- 
lent ; a permanent scar results from each 
pock. 
(3) Varicella globularis (Willan); hives. 
The vesicles are larger than in varic. len- 
tif. and the cutaneous hardness less than 
in varic. conif. 
(4) Varicella sine varicellis. (Wilson.) 
(5) Varicella solidescens, verrucosa, pa- 
pillaris, variola cornea (Van Swieten), 
pemphigus variolodes solidescens (J. P. 
Frank), stonepox, horn-pox, or wart-pox, 
is a form of true smallpox. 
(6) Varicella cellulosa (Cross), pustular 
umbilicated varicella (Wilson), variola va- 
ricelloides (Gregory), are names for that 
form of modified smallpox which most re- 
sembles Varicella. 
Synonyma of true Chicken-pox.-Crys- 
talli (Ingrassias); variola? crystallin®, 
spuri®, volatic®, benign® (Morton); lym- 
phatic® (Sauvages), pusill® (Heberden); 
pemphigus variolodes vesiculosus (Frank); 
varicella bullosa (Cross); water-pox, wa- 
ter-jags (provincial, to dag, daggle = to 
sprinkle). 
The following are some of the best ac- 
counts of the disease :- 
Wm. Heberden : 1st. Med. Trans. Coll. 
Phys. vol. i. 1768. 2d. Commentarii, 
1802. 
Jno. Cross: Hist, of Variolous Epi- 
demic in Norwich, 1820. 
Nicol C. Mbhl: De Varioloidibus et Va- 
ricellis, 1827. 
Geo. Gregory : 1st. Cyclop. Pract. Med. 
vol. iv. 2d. Lectures on Eruptive Fevers, 
1843. 
A. Trousseau: Clinique Medicale, vol. 
i. 1861. 
SMALLPOX. 
By J. F. Marson. 
Definition.-Smallpox is a febrile, 
eruptive, and infectious disease, the pro- 
duct of a morbid poison ; which, after a 
period of latency, causes the development 
of an eruption on the surface of the body ; 
this passes through the stages of pimple, 
vesicle, pustule, and scab ; and, as a rule, 
exhausts or destroys the susceptibility to 
the disease, in the same person, for the 
remainder of life. 
Synonyms.-Jadarf, Arabic ; Evxoyia, 
Modern Greek ; Variola, Latin ; Small- 
pox, English ; the Pocks, Scotch ; Galra 
breac, Irish ; Petite Verole, French; Blat- 
tern, German ; Vaiuolo, Italian ; Virue- 
las, Spanish. 
History.-The origin of Smallpox is 
involved in much obscurity. A great deal 
of labor and learning have been bestowed 
in endeavoring to trace the beginning of 
the disease, but seemingly without any 
very decided success. The ancient Greeks 
and Romans do not appear by their writ- 
ings to have been acquainted with Small- 
pox, although De Haen, Dr. Willan, Mr. 
Moore, and Dr. Baron have endeavored 
to prove the contrary. Dr. Friend, Dr. 
Mead, and Dr. Mason Good were of 
opinion that the disease was not known 
to the Ancient Greeks ; and Dr. Adams, 
in the Appendix to the Commentary on 
Book Second of his translation of Paulus 
^Egineta, agrees entirely with the opinion 128 
SMALLPOX. 
of Friend and Mead, that the disease was 
not known to the ancient Greeks. 
One of the earliest notices of a disease 
exhibiting the striking characteristics of 
Smallpox is to be found in the historical 
writings of Procopius,1 who lived in the 
middle of the sixth century. The disease2 
" began A. D. 544, at Pelusium in Egypt, 
from whence it spread to Constantinople. " 
This corresponds closely with the era 
commonly assigned in medical books to 
the first appearance of Smallpox, viz., 
A. D. 509, the year of the birth of Maho- 
met. In that year an Abyssinian army, 
under Abrahah the viceroy, appeared be- 
fore Mecca, and was unexpectedly com- 
pelled to raise the siege. Several circum- 
stances concur to render it probable that 
the sudden retreat of the army was owing 
to the breaking out of Smallpox, and the 
dreadful mortality which it occasioned. 
Bruce,3 in his travels, met with a manu- 
script account of the war, which confirms 
this story, and strengthens the opinion 
that Smallpox first appeared in Egypt and 
Arabia about the middle of the sixth cen- 
tury." 
Paulus JEgineta lived at the end of the 
sixth or beginning of the seventh century. 
He professed to have treated, in his seven 
books, on all subjects connected with 
medicine and surgery, yet he says not one 
word to lead us to believe he was ac- 
quainted with Smallpox. 
Rhazes, an Arabian physician, who 
flourished about 910, is generally referred 
to as one of the earliest and best writers 
on Smallpox. No doubt the disease had 
existed for some time before he undertook 
to describe it; indeed, there is evidence 
in his work that it had, and he alludes to 
others who had written about it, especially 
to Ahron of Alexandria, and Messue of 
Bagdad. 
In the East, whence we receive the 
earliest accounts of Smallpox, there is a 
tradition-a mere tradition4-that the dis- 
ease in man had its origin from the camel. 
It is well known that this patient animal 
is extensively used in Arabia, Egypt, &c., 
as a beast of burden. If we may venture 
to reason on the subject from analogy, the 
tradition is not likely to be correct, inas- 
much as all other diseases that have been 
conveyed to man from the lower animals 
are not communicable by infection, only 
by inoculation. When once produced in 
man, they are still not infectious, in the 
usual acceptation of the term, as Smallpox 
is; only producible again, from one to 
another, by inoculation, as in the instances 
of cow-pox, glanders, hydrophobia, &c. 
When Smallpox appeared in this country 
in the sheep in 1847,1 we tried to commu- 
nicate it, by inoculation, to the human 
subject, and thought we had succeeded in 
doing so, and the virus was carried on 
from one to another for several weeks in 
succession. The pock produced was very 
like cow-pox, having only, as we thought, 
a bluer tinge, and was protective against 
Smallpox, as we ascertained by inoculat- 
ing the patient afterwards with the lymph 
of human variola ; but we had unfortu- 
nately used for the original ovination the 
same lancet, instead of having a new one, 
as we ought to have had, that we had 
previously used for vaccinating ; and al- 
though it was, as we believe, perfectly 
clean, and free from vaccine lymph, never- 
theless, as the disease could not be pro- 
duced again in the human subject, either 
by Mr. Ceely, of Aylesbury, who made 
repeated trials with the lymph of sheep- 
pox, or by ourselves, the experiment was 
never brought before the medical profes- 
sion. Sacco writes of having frequently 
succeeded, in Lombardy, in transferring 
the virus of sheep-pox to man, and that 
it was as successful in protecting against 
Smallpox as cow-pox is. There has never 
been any reason to suppose that the Small- 
pox in sheep has produced by infection 
any disease in man. 
Those readers who are desirous of fur- 
ther information on the early history of 
Smallpox, will find a great deal of inte- 
resting reading on the subject in Moore's 
History of Smallpox; Willan's Inquiry 
into the Antiquity of the Smallpox, Mea- 
sles, and Scarlet Fever; Baron's Life of 
Jenner; Monro's Observations on the dif- 
ferent kinds of Smallpox; and in Dr. 
Greenhill's translation of Rhazes, forming 
one of the volumes of the Sydenham's So- 
ciety's publication. 
Description of Smallpox.-The dis- 
ease is divisible into varieties, which, for 
convenience, may be described separately. 
1. Variola Discreta; 2. Variola Semi- 
confluens; 3. Variola Confluens; 4. Vari- 
ola Corymbosa; 5. Variola Maligna; 6. 
Variola Venigna; 7. Variolas Anomalce, 
or irregular forms of the disease, embrac- 
ing those instances in which Smallpox is 
complicated with other diseases. 
It is called discrete, when the pustules 
stand separately; semiconfluent, when they 
partially coalesce; confluent, when they 
join and run into each other; corymbose, 
when the disease appears in patches ; ma- 
lignant, when the eruption, besides being, 
generally, confluent, the initiatory and 
1 De Bello Gothico, lib. ii. 
2 Gregory, Cyclop, of Pract. Med. vol. iii. 
p. 735. 
3 Travels to Discover the Source of the 
Nile, vol. i. p. 514. 
4 Moore's History of Smallpox. 
' For an interesting and able account of 
Variola Ovina, or Smallpox in Sheep, see a 
work by Professor Simonds, of the Royal 
Veterinary College, London, 1848. VARIETIES OF SMALLPOX. 
129 
succeeding symptoms are very severe, 
with hemorrhage from the mucous sur- 
faces, patches of purpura, and discolora- 
tions of the skin as if from having been 
bruised; benign, when, although perhaps 
confluent, the eruption is superficial, and 
the accompanying symptoms are of a mild 
character; anomalous, when the disease is 
implicated with other diseases, eruptive 
or otherwise, as measles, scarlatina, urti- 
caria, &c.-or pneumonia, hooping-cough, 
bronchitis, disease of the brain, mania, &c. 
Smallpox is divisible into four stages:- 
1. The stage of incubation, which lasts 
twelve days, from the date of receiving 
the variolous germ. 2. The stage of 
initiatory or eruptive fever and invasion, 
lasting forty-eight hours. 3. The stage 
of maturation, continuing about nine 
days. 4. The stage of secondary fever, 
desiccation, and decline, lasting, of course, 
an uncertain time ; varying according to 
the severity of the disease. 
1. Stage of Incubation.-Smallpox ap- 
pears on the skin on the fourteenth day 
after the infection of the disease has been 
received into the constitution, the precise 
time being after thirteen times twenty- 
four hours have elapsed from the moment 
of taking the disease; this time will of 
course occupy twelve whole days, and 
part of two others. It is believed by the 
writer that the time from taking the dis- 
ease to its appearance on the skin is never 
longer than fourteen days, and his atten- 
tion has been constantly directed to the 
subject for upwards of twenty years. It 
is true but very few cases afford a decided 
opportunity forjudging of the precise time 
of incubation, not above one perhaps in 
fifty or more, but still these few cases are 
the very cases of value in deciding the 
point; they have to be watched for care- 
fully to be found. Three or four instances 
have occurred in which it seemed likely 
the disease had appeared between the 
tenth and eleventh days after receiving 
the infection ; they were cases occurring 
after vaccination, under which condition 
other stages of the disease are often inter- 
rupted, or cut short; still these cases, 
seemingly decided cases, having been so 
few they can hardly be relied on : but the 
others, on the contrary, so many in the 
aggregate, they can hardly have failed to 
indicate the true time. 
2. Stage of Primary Fever.-The ordi- 
nary course is this,-after twelve days' 
freedom from illness, there is severe in- 
disposition for forty-eight hours, and then 
the eruption of Smallpox begins to ap- 
pear. This is almost the invariable 
course. Still it is not invariable. In a 
few cases, but very few, there is more or 
less illness all through the period of incu- 
bation. The patient has not been so well 
as usual: experienced even at the time of 
taking the disease some unpleasant sen- 
sation, felt some nausea or giddiness, or 
sense of alarm, without knowing why it 
had happened. 
3. Stage of Maturation.-In distinct and 
semiconfluent Smallpox the early consti- 
tutional symptoms are much ameliorated 
on the third day, or about that time, 
when the eruption has been developed on 
the skin ; and the same remark applies 
with some reserve to confluent cases, but 
not so completely as to the distinct and 
semiconfluent forms of the disease; the 
development of the eruption affords only 
partial relief in confluent cases. The 
eruption appears first, usually, on the 
face, forehead, and wrists, and then on 
the rest of the body ; it is generally a 
couple of days later on the legs and feet 
than elsewhere. It is not thrown out at 
random, without order ; it may be ob- 
served to be in threes and fives, forming 
crescents, and in some instances, when 
it happens that two crescents come to- 
gether, they form a complete circle. The 
eruption is at first papular, then vesicular, 
then pustular, and takes about eight days 
to arrive at its full development, before 
the pustules begin to. discharge their con- 
tents. [A marked characteristic at this 
stage is the umbilication, or depression in 
the middle of the mature pustule ; giving 
it somewhat the shape of a hat whose 
crown has been pushed down at the mid- 
dle.-II.] During the stage of matura- 
tion, or concoction as the older authors 
termed it, there is often considerable 
swelling of the face and eyelids, so that 
the patient is popularly said to be blind 
with Smallpox for a certain time: and 
there is ptyalism in many cases, and in 
some a very tender state of the skin, so 
tender that the patient complains of the 
pain from the act of merely feeling the 
pulse ; all these may be looked upon as 
favorable signs of the disease ; patients who 
have the face a good deal swelled for four 
days, who have pretty free salivation, and 
a very tender skin, nearly always do well. 
4. Stage of Secondary Fever, Desiccation, 
and Decline.-When Smallpox is not of 
such severity as to destroy life by the 
eighth or ninth day of eruption, there is a 
great increase of fever again, called the 
secondary fever, which is of vast import- 
ance, and gives rise to a train of severe 
and complicated symptoms, which will be 
described under the heading of Secondary 
Fever. Concurrently with it the pustules 
discharge their contents, and form dry, 
scaly scabs, and in favorable cases the dis- 
ease begins to decline ; especially in those 
cases which will be described under the 
term Variola Benigna, and in modified 
Smallpox, as it is now frequently seen 
after vaccination. 
Varieties of Smallpox.-1. Variola 
Discrcta, or distinct Smallpox, is a term 
VOL. I.-9 130 
SMALLPOX. 
applied to that form of the disease in 
which the pustules stand separately, or 
apart from each other, and might be 
readily counted. It is the simplest form 
of the disease, and is hardly ever attended 
with danger to life, except in children 
who may be cutting teeth at the time, 
and may have convulsions or some affec- 
tion of the brain, produced, it may be, by 
the combined influence of Smallpox and 
teething. 
2. Variola Semiconfluens is that form of 
the disease in which the pustules partially 
coalesce, cannot be said to be distinct 
from each other, nor yet to run generally 
into each other. It is readily distin- 
guished in practice. Patients with this 
form of the disease usually do well; when 
it proves fatal, the cause is from the com- 
bination of circumstances above alluded 
to in children with the distinct form of 
the disease ; or else from some complica- 
tion, as erysipelas, gangrene, &c., or, as 
happens now and then, from the petechial 
or malignant form of the disease being 
associated with only a semiconfluent form 
of eruption. The amount of eruption does 
not alone destroy life in semiconfluent as 
in confluent Smallpox. 
3. Variola Confluens. -This is the form 
of the disease which destroys the greatest 
number of persons ; the danger in fact 
arising principally from the amount of 
pustulation. It is found to prove fatal at 
the Smallpox Hospital, when large num- 
bers are taken into account, at the rate of 
50 per cent. From the first the papulae 
are very numerous, countless, and as the 
disease advances the pustules run into 
each other, and in the worst cases form 
one mass of disease. Even the confluent 
form of the disease may be fairly said to 
have its varieties. When the disease is 
but just confluent, and the patient has 
been previously in good health, with an 
unimpaired constitution, he will probably 
recover. Patients do so in fact, as previ- 
ously stated, at the rate of 50 per cent. ; 
but when the disease is severely confluent, 
when it is almost impossible to put the 
end of a pencil between the pustules in 
many parts of the body, especially on the 
face,-and such cases are often met with, 
-a quarter of the amount of pustulation 
would be enough to destroy life. In cases 
where the eruption is observed at first to 
be generally confluent from head to foot, 
there may be said to be but very little 
chance for the patient's recovery. The 
danger is always rendered greater, coeteris 
paribus, when the eruption is very full 
about the head, face, and neck. 
The marked difference, from the first 
onset of the disease, between the distinct 
and confluent varieties of Smallpox, can- 
not fail to strike all observers. In the 
confluent form the initiatory fever is more 
intense, there is often delirium, sometimes 
of a very violent and uncontrollable kind, 
especially in persons accustomed to live 
freely, and in those more especially in the 
habit of indulging in taking ardent spirits. 
Such persons often require to be put under 
restraint to prevent their injuring them- 
selves or others. They are impressed 
often with the belief that they are about 
to be murdered, and endeavor, accord- 
ingly, to escape from control,-and have 
a tendency to commit suicide ; therefore it 
is desirable to put knives, razors, &c., out 
of their way. The nervous system is im- 
plicated ; there are tremors of the hands 
and lips-a state, in fact, often bordering 
on delirium tremens, produced partly by 
the Smallpox and partly by the previous 
habits of living. Draymen, barmen, pot- 
men, tailors, and women on the town, are 
very unfavorable subjects to be attacked 
with Smallpox, owing to their habits of 
indulging freely, and almost daily, in 
strong drinks. A very large proportion 
of the patients die who suffer in the early 
stage of confluent Smallpox from delirium ; 
it should be looked upon in every instance 
in which it occurs as a very unfavorable 
symptom. 
Fortunately, all cases of confluent 
Smallpox are not of this dangerous kind. 
There is the confluent superficial eruption, 
which often goes through its course with- 
out an untoward symptom, especially in 
persons lately from the country, whose 
health is unimpaired by the injurious 
habits and bad air of a town life. 
Sometimes the pustules in confluent 
cases are very large and flat, they do not 
accumulate well, the edge of them is not 
well defined, and after they have been out 
some days they have a tendency to spread 
out, to become larger. These are danger- 
ous cases, and usually end in death. 
On the top of each pustule, or on many 
of them, a dark spot is formed during the 
stage of maturation in some cases of con- 
fluent Smallpox, and it will be observed, 
when this occurs, the pustules do not acu- 
minate well, they are rather flat; when- 
ever these signs are noticed, the case 
should be looked upon as one of great 
danger, and the patient will most likely 
die. 
Persons of a weakly constitution, those 
especially with fair hair, have sometimes, 
about the eighth day of eruption, large 
bullse, filled with serum, intermixed with 
the Smallpox eruption. This is an un- 
favorable sign ; such patients require wine, 
beef-tea, jellies, &c., early, almost as soon 
as this symptom is observed. 
In some cases of confluent Smallpox 
there is an absence of the damask rose-red 
areola described, and very correctly, by 
the old authors, as surrounding, for a 
short distance, each pustule of the dis- 
ease; and, instead of this, the skin be- 
tween the pustules is generally inflamed VARIETIES OF SMALLPOX. 
131 
from head to foot. These - cases always 
do badly. 
The watery-pock is another dangerous 
variety of confluent Smallpox. These are, 
usually, very offensive cases : are accom- 
panied with a good deal of secondary 
fever: and end fatally for the most part, 
or else there is a very tedious convales- 
cence. 
The eruption of Smallpox is formed on 
some of the mucous surfaces as well as on 
the skin generally,-in the mouth, on the 
tongue, in the nares and fauces, on the 
membrane lining the larynx, trachea, and 
bronchi. When the vari are numerous on 
the.larynx and trachea, the danger of the 
patient is thereby very much increased ; 
they produce a viscid secretion, cough, 
and a peculiar hoarse, metallic sound in 
coughing, indicative of their presence in 
these parts. A constant subject of com- 
plaint in most cases of confluent Smallpox 
is the soreness of the throat. To nearly 
every patient it is necessary to explain 
that this inconvenience is caused by the 
eruption being formed on the roof of the 
mouth, soft palate, fauces, &c., and that 
it is impossible to interrupt its course 
there any more than on the surface of the 
skin generally. Still the inconvenience 
goes off considerably in a few days ; the 
vari on the mucous surfaces have a shorter 
duration than on the skin generally; do 
not maturate and scab as on the outer 
skin, from being constantly kept moist by 
the natural secretion of the mucous sur- 
faces ; they never reach beyond the stage 
of vesicles. 
. 4. Variola Corymbosa.-This is a very 
singular and very fatal form of the dis- 
ease. It is rather rare. It is called co- 
rymbose, from corymbus, a bunch or clus- 
ter of ivy-berries, &c. Corymbose is also 
a botanical term, applied to a class of 
plants, the flowers of which are formed 
in clusters, like those of the carrot. We 
have gone over the register of the Small- 
pox Hospital for thirty years, for the pur- 
pose of investigating minutely the danger 
to life in this form of the disease, and find 
that, in this time, 104 cases of corymbose 
Smallpox have been admitted-29 in un- 
vaccinated persons, 74 in the vaccinated, 
and one after inoculation. Of the 29 
unvaccinated persons, 13 died, or 44 per 
cent. ; of the 74 vaccinated, 32 died; 
and, deducting 2 who died of superadded 
disease, there remains a mortality of 41 
per cent. The single case of corymbose 
Smallpox after inoculation died. It will 
thus be seen that corymbose Smallpox is, 
in all cases, a very fatal form of the dis- 
ease, and brings life into danger nearly as 
much in vaccinated as in unvaccinated 
persons, varying only about 3 per cent. 
The danger in this form of Smallpox often 
seems to be out of all proportion to the 
amount of pustulation, which rules so 
powerfully in other forms of the disease : 
why it is so, it is impossible with our pre- 
sent knowledge to say, and it is probably 
one of those things which will for ever 
remain inexplicable. The disease, as 
stated, appears in clusters, or, it may be, 
that only a single cluster is formed, and 
yet the fatal character before alluded to 
is given to the disease. In other parts of 
the body the eruption is perhaps but 
sparsely scattered, and we might expect 
the disease to rank in danger with a com- 
mon semiconfluent case; such, however, 
is not the fact in practice. It generally 
happens there are two or three patches, 
about the size of the palm of the hand, 
in different parts of the body, in which 
the pimples are as closely set as could be; 
and in the immediate neighborhood of 
each patch the skin is for some distance 
free from eruption, or nearly so, a few 
spots only of the disease being formed. 
There is a great tendency to symmetry in 
this form of the complaint; when a patch 
is formed on one arm, or leg, it often hap- 
pens that a similar patch is formed on the 
same part of the corresponding limb on 
the opposite side. In some instances 
there are numerous corymbose patches in 
different parts of the body, about the size 
of a half-crown or five-shilling piece, 
When these corymbose cases seem to be 
recovering, very frequently some danger- 
ous complications arise to mar our fair 
hopes of a successful termination of the 
malady, and generally, under more favor- 
able circumstances, there is a long and 
tedious convalescence. 
5. Variola Maligna.-This truly fright- 
ful variety of Smallpox was called by the 
early writers on the disease Black Pock, 
or Variola? Nigro?. The symptoms are 
very formidable at the onset. The blood 
appears to be poisoned from the first by 
the disease ; it is rendered very fluid and. 
watery. If a portion be drawn from a 
vein, a large part of it will be found to be 
serum, and what ought to be crassamen- 
tum remains almost fluid ; it is principally 
coloring matter-the fibrin seems to have 
disappeared. The countenance of the 
patient is sunken, the breathing anxious, 
and in some instances death takes place 
before the eruption has been developed, 
leaving some doubt about the real charac- 
ter of the disease in the minds of those 
persons not by practice familiarly ac- 
quainted with its varied appearances ;-a 
doubt whether it was Smallpox, scarlet 
fever, or some other form of idiopathic 
malignant fever. 
The eruption in malignant Smallpox is 
rather slowly developed. There is hem- 
orrhage from some, occasionally from all, 
or nearly all, of the mucous surfaces; 
from the nose, from the mouth, from the 
air-passages, from the bowels; the urine 
is high-colored from blood mixed with it. 132 
SMALLPOX 
In the female there is invariably hemor- 
rhage from the uterus, and abortion in 
cases of pregnancy. The foetus is usually 
born dead. Early in the attack there is 
a patch of effused blood under the conjunc- 
tiva, which should always be looked upon 
as a most dangerous symptom. We have 
seen blood, in some very rare instances, 
ooze from the ears and eyes. Livid 
patches from effused blood are formed on 
the surface of the body, and blood is 
mixed with the fluid formed in the Small- 
pox vesicles, which can scarcely be said to 
become pustules. There is great depres- 
sion, but not often delirium-indeed, but 
rarely ; the intellect usually remains clear 
to the last. A confluent eruption nearly 
always accompanies the malignant form 
of Smallpox, and death commonly takes 
place on the fifth day of the eruption. 
Petechial Smallpox partakes very much of 
the same characters as malignant Small- 
pox. Numerous little dark spots, resem- 
bling flea-bites, especially about the armpits 
and groins, are observable, and the skin 
in these parts has a greenish-yellow hue, 
very like what we see during recovery 
from a bruise. The condition of the fluids 
is no doubt very much the same in these 
two varieties of the disease ; malignant 
and petechial Smallpox are very iiearly 
akin. 
6. Variola Benigna.-Van Swieten and 
others have described a form of natural 
Smallpox under the title of Variola Verru- 
cosa, or cornea, stone-pock, horn-pock, and 
wort-pock, which we sometimes see in these 
days, and in which the disease is of a mild, 
modified character. It is ushered in with 
symptoms as severe as in the dangerous 
confluent form, but on the third or fourth 
day of eruption all the severe symptoms 
begin to subside ; the eruption assumes a 
modified form, such as we constantly see 
in post-vaccinal cases. We have often 
had an opportunity of observing this form 
of the disease in children whose mothers 
were at the hospital with them, and who 
knew perfectly well no attempt had been 
made at vaccination. The pusties are of 
unequal size, some shrivelling and dying 
off, while others are maturing: there is 
no secondary fever, and no pitting. These 
are examples of mild natural Smallpox, 
such as have occurred no doubt at all 
periods to a few favored individuals, and 
in which, fortunately for the objects at- 
tacked, the disease leaves no trace behind. 
7. Varioloe Anomalce.-Smallpox is ren- 
dered irregular by being complicated with 
other diseases. We have seen it in con- 
junction with scarlatina,1 measles, urti- 
caria, syphilis, bronchitis, pneumonia, 
phthisis, dysentery, &c. Pregnancy may 
be mentioned as one of the anomalies; 
and another, the existence of Smallpox on 
the foetus at birth; which must have gone 
through the stage of incubation, the pri- 
mary fever, and early days of eruption, 
before it was born. We have several 
times seen children who were born with 
the eruption of Smallpox out on the body, 
but modified as it is on the mucous sur- 
faces. Mead1 imagined that persons who 
were insusceptible of Smallpox had possi- 
bly gone through the disease before birth. 
First Symptoms of Smallpox, or Primary 
Fever.-This disease begins with rigors, 
fever, thirst, headache, sickness at the 
stomach, sometimes accompanied with 
vomiting, pain in the back, and general 
indisposition; followed, after forty-eight 
hours of illness, by an eruption on the 
skin of pimples, which are generally ob- 
served at first on the forehead, face, and 
wrists. Among the early symptoms of 
the disease should be enumerated, as now 
and then occurring in children, one or 
two convulsive fits. This occasionally 
happens in adults also, but not so often as 
in children. On passing the fingers over 
the points of eruption some hardness is 
felt in the skin, as if a grain of mustard- 
seed, or a small shot-corn, were imbedded 
in it; but the skin is not tender to the 
touch at these points, nor does pressure 
seem to produce any pain. In cases of 
Smallpox after vaccination, which are so 
frequently met with in these days, the 
true or distinctive eruption of Smallpox 
is very often preceded by roseola, which 
lasts two or three days-the roseola exan- 
thematica-which may lead observers, not 
intimately acquainted with the early 
symptoms of Smallpox, to suppose the 
patient has an attack of scarlatina; but 
this eruption may be known from that of 
scarlatina by not being so completely dif- 
fused over the skin as the rash of scarla- 
tina usually is; it is also of a lighter, 
brighter, roseolar scarlet tint, than the 
eruption of scarlatina, which has a rather 
dingy hue; and, above all, it has a mot- 
tled appearance. 
Secondary Fever.-Besides the initia- 
tory fever, the fever of invasion in Small- 
pox, there is what is called the secondary 
fever, which begins, in confluent cases, 
about the eighth or ninth day. In the 
milder cases of Smallpox, secondary fever 
is hardly perceptible; in the malignant 
and severely confluent cases death takes 
place before the secondary fever has 
barely commenced. But, in most in- 
stances of confluent Smallpox, patients 
suffer more or less from secondary fever, 
which seems to be the cause or forerunner 
of a very important chain of events. The 
1 See Med.-Cliir. Trans., vol. xxx. Mar- 
son, on the Co-existence of the Eruptive 
Fevers. 
1 De Variolis et Morbillis, cap. iv. edit. 
1747. FIRST SYMPTOMS OF SMALLPOX. 
133 
pulse is increased in frequency, there is 
thirst, dry tongue, and hot skin ; in many 
cases, particularly in the plethoric, some 
local inflammation arises, often occurring 
at the elbow, seemingly from leaning on 
it when taking food. But cellular inflam- 
mation takes place, in different patients, 
in nearly all parts of the body; sometimes 
it is deeply seated between the large mus- 
cles ; twice we have known abscesses 
formed between the gastrocnemius and 
soleus muscles, causing intense pain dur- 
ing the formation of the matter. These 
deep-seated abscesses in Smallpox are 
sometimes the result of injury received 
months before. In one of the examples 
just mentioned, a seaman, in jumping 
from his ship to the wharf, missed his 
balance, and fell back on the ship, strik- 
ing the calf of his leg against the side of 
the ship; no harm would most likely have 
followed had he not taken Smallpox or 
some other severe febrile disease. 
Numerous small boils take place in 
many cases of confluent Smallpox; phleg- 
monous inflammation in others, involving 
often the greater portion of a limb. Pa- 
tients who, from their previous good state 
of health, just escape dying from the se- 
verity of the eruption, at the usual time, 
viz., from the ninth to the thirteenth day, 
are very apt to suffer severely from sec- 
ondary fever, and its consequences; such 
as pleurisy, pneumonia, ulceration of the 
cornea, &c.: these are amongst the very 
serious evils that may be expected. It is 
difficult to account for this peculiar form 
of fever in Smallpox; some have imagined 
it is owing to the absorption into the cir- 
culation of the pus formed on the surface 
of the body. If this were true, we should 
see, more frequently than we do, the re- 
sults we recognize as belonging to py- 
aemia. These results we do see in some 
instances, but they may be said to be ex- 
ceptional; whereas secondary fever is the 
usual consequence of confluent Smallpox. 
The absorption of some fluid forming part 
of the eruption, and more readily taken 
into the circulation than pus is, we 
strongly suspect, to be the cause of sec- 
ondary fever, but our knowledge of ani- 
mal chemistry at the present day is not 
sufficiently precise to enable any one to 
say what this fluid is; it is one of the 
problems for the industrious and inge- 
nious to solve. Secondary fever com- 
mences after, just after, the pustules have 
begun to discharge their contents; it may 
be that the absorbed fluid is not part of the 
original secretion, but the product of de- 
composition, or of some chemical change 
that takes place after the matter of Small- 
pox has been exposed to the air. In the 
horn-pock, as it is called from its hard- 
ness, in which there is some modification 
of the eruption in the advanced stage of 
the disease, such as we observe frequently 
after vaccination, the matter is dried up 
suddenly without being discharged at all: 
these cases are entirely free from second- 
ary fever; therefore it would seem that 
the discharged matter has something to 
do with secondary fever. 
Pleurisy is one of the most painful and 
fatal sequelae of the secondary fever of 
confluent Smallpox. Patients are attacked 
with it very suddenly, and hardly ever re- 
cover ; it runs a very rapid course, and 
terminates fatally in three or four days, 
sometimes sooner. The symptoms are 
generally at the first of a very decided 
character ; violent pain in the side, wiry 
pulse, shortness of breathing, great diffi- 
culty in drawing the breath, and a very 
anxious expression of countenance. Such 
cases are all but hopeless ; but we have, 
in some very rare instances, seen patients 
recover ; they should, therefore, not be 
entirely given up as past hope ; we had a 
very severe case lately in a young Scotch- 
man, who, after a long convalescence, 
ultimately got well. 
Pneumonia occasionally follows severe 
secondary fever. It comes on much more 
insidiously than pleurisy, and assumes the 
congestive character so well described by 
Mr. Erichsen, under the term of "Con- 
gestive Pneumonia, " in .Med. - Chir. Trans. 
vol. xxvi. p. 29. It is slower in its pro- 
gress than pleurisy, and is very likely to 
have existed two or three days before it is 
discovered. It is more rarely, perhaps, 
seen than pleurisy, and is not so uniformly 
fatal; but it should be viewed as one of 
the very serious complications occurring 
in the advanced stage of Smallpox, and 
very likely to prove fatal. 
Bronchitis is another serious complica- 
tion of advanced Smallpox ; dangerous at 
all times, doubly so when the body is 
weakened by other exhausting disease. 
Glossitis sometimes arises during the 
secondary fever of Smallpox ; the tongue 
becomes very much swollen and dry, so 
that the patient is unable to articulate or 
close the mouth ; it is a very distressing 
and perilous symptom ; those attacked 
with it nearly always die. 
Otitis, followed by abscess in the ear, 
not unusually results from Smallpox. The 
pain produced during the formation of the 
matter is very great, but it is immediately 
relieved on the breaking of the abscess. 
It is probable that, in some instances, per- 
manent injury may remain in the ear 
from this occurrence. 
The abdomen escapes singularly free 
from complications in Smallpox. We do 
now and then meet with peritonitis, but 
very rarely ; diarrhoea more frequently ; 
and sometimes with mucous enteritis in 
children. 
Erysipelas, pytemia, gangrene, &c., are 
frequently met with, at times, in hospital 
practice. They form the most serious SMALLPOX. 
134 
drawbacks to all hospitals, and are, as is 
well known, fatal in their tendency. These 
diseases are amongst the complications of 
Smallpox, and are not confined wholly to 
hospitals; they are met with in private 
practice, occurring after severe confluent 
Smallpox when the disease has lasted a 
fortnight or more. They are very dan- 
gerous. Erysipelas, more particularly of 
the head and face, occurs more frequently 
than any other form of superadded mis- 
chief. Patients with it, for the most part, 
get well; but erysipelas occasionally gives 
rise to pyaemia, which is followed by large 
abscesses, perhaps bed-sores, hectic fever, 
and death. The scrotum is apt to be- 
come gangrenous after Smallpox, especi- 
ally in those who have the ill luck at the 
time to be suffering from gonorrhoea. It 
is a fatal complication ; patients generally 
die who are attacked with it, but not al- 
ways. We have several times seen the 
whole scrotum slough away, and the pa- 
tient entirely recover ; and it is interest- 
ing and surprising to see what a good 
covering is formed afterwards to the tes- 
ticles, almost as good as before the scro- 
tum was injured. 
The women of the town are bad subjects 
for Smallpox. When they have gonor- 
rhoea, they are very likely to have gan- 
grene of the genitals ; and, from their pre- 
vious irregular habits and spirit drinking, 
their illness commonly ends fatally. We 
had a patient two years since with gan- 
grene of the genitals, owing to leucorrhoea ; 
it might, however, have been gonorrhoea ; 
she was barmaid at a large hotel. 
Variolous Ophthalmia and Corneal 
Ulceration. - Conjunctival inflammation 
often begins on the fifth or sixth day in 
Smallpox, and continues for a few days, 
and then subsides under the use of simple 
remedies. But there is another form of 
mischief-ulceration of the cornea-which 
often leads to the loss of an eye; both 
eyes, fortunately, being but rarely affected, 
although this does sometimes happen. 
Formerly a large number of the inmates 
of the asylums for the blind had lost their 
eyes from Smallpox. The injury to the 
eye, by which the organ is destroyed, is 
not from the pustules of Smallpox forming 
on the eye, as used to be supposed, but 
from a destructive form of ulceration be- 
ginning almost invariably at the edge of 
the cornea. 
After having been in constant attend- 
ance at the Smallpox Hospital for up- 
wards of three years, and having witnessed 
the great epidemic of 1838, and having 
seen upwards of 1500 cases of Smallpox, 
the author was induced to write a paper 
on Variolous Ophthalmia, which was read 
before the Westminster Medical Society 
in 1839.1 Out of 1500 cases, no instance 
had then, or for some time afterwards, 
come under his notice in which the pustule 
of Smallpox was formed on the eye. It 
does, however, happen now and then. In 
nearly thirty years the number of cases of 
Smallpox admitted into the hospital has 
exceeded 15,000. Out of this number 26 
instances have been noticed in which the 
primary pustule of Smallpox has formed 
on the eye. It has not, however, in any 
one of these instances, injured the eye in 
any way ; the cases have all done well. 
In these very rare instances in which 
the pustule does form on the conjunctiva, 
it has nearly always been observed to have 
its seat half-way between the cornea and 
the inner canthus of the eye, where the 
conjunctiva is thicker than elsewhere. 
It has never been seen on the cornea. 
Now and then it has been observed half- 
way between the cornea and the outer 
canthus ; the conjunctiva is thicker in this 
part also than over the eye generally. So 
that in these very exceptional instances, 
once in perhaps 500 cases, the pustule of 
Smallpox does form on the conjunctiva, 
but does not destroy or injure the eye in 
the least, so far as has been observed. 
The ulceration of the cornea that leads 
to the destruction of the eye in Smallpox 
begins after the secondary fever has com- 
menced. It has been observed to begin 
as early as the tenth day after the com- 
mencement of the general eruption, and 
as late as the thirtieth ; the fourteenth 
day is a common time for it to be first 
seen. It comes on with redness and 
slight pain in the part affected, and very 
soon an ulcer is formed having its seat 
almost invariably at the margin of the 
cornea: this continues to spread with 
more or less rapidity, according to the 
degree of secondary fever present; in the 
more violent cases an ulcer being formed 
on each side of the cornea at the same 
time, showing the disease to be advancing 
with great severity, and presenting a 
tolerably certain indication that the eye 
will be entirely lost. The ulceration 
passes through the different layers of the 
cornea until the aqueous humor escapes ; 
and if the part of the cornea destroyed be 
large, the iris protrudes through the open- 
ing. In the worst cases there is usually 
hypopyon, and when the matter is dis- 
charged the crystalline lens and vitreous 
humor escape ; or the humors may escape 
from deep and extensive sloughing in the 
first instance, without the formation of 
matter; this being succeeded, of course, 
by the total annihilation of the form of 
the eye as well as the sight. In some 
instances the ulceration proceeds very 
rapidly, the entire cornea being swept 
away within forty-eight hours from the 
apparent commencement of the ulcera- 
tion ; and, what is singular, now and then 
the mischief goes on without the least 
* Medical Gazette, No. 32, May 4, 1839. DIAGNOSIS. 
135 
pain to the patient, or his being aware 
that anything is amiss with his eye. This 
destructive ulceration never goes on rap- 
idly, but when there is a high degree of 
secondary fever present. That is a point 
which should be particularly remarked. 
It is likely to occur when there is a hot 
and dry state of skin, rapid pulse, thirst, 
loaded tongue; these having been pre- 
ceded by a very confluent state of the 
disease, and the patient has just escaped 
dying at the usual time, namely, the 
ninth, tenth, or eleventh day of eruption. 
Then it is that some serious consequence 
may be apprehended, such as the loss of 
an eye, formation of large and deep ab- 
scesses, sloughing of the cellular mem- 
brane, or, may be, formation of matter in 
one side of the chest; some of these serious 
results maybe expected when the second- 
ary fever runs high in confluent Smallpox, 
combined with the circumstances above 
detailed. 
It happens occasionally, unfortunately, 
that persons have had something amiss 
with their eyes before Smallpox comes on 
-some scrofulous tendency, or sensitive 
state of the conjunctival membrane caused 
by their occupation. For instance, a 
chimney-sweep was admitted into the 
hospital, and his eyes were in such a sen- 
sitive state from soot getting into them in 
the course of his work previously, that he 
had been several days in the hospital, 
keeping his head constantly under the 
bed-clothes, before he would allow his 
eyelids to be opened. When this was at 
last accomplished, both eyes were found 
to be entirely lost from ulceration of the 
cornea. 
Conjunctivitis, rather slow in its pro- 
gress, begins in some cases during a 
tedious convalescence as late as the third 
or fourth week of Smallpox : after it has 
existed a few days, there will generally be 
found, on close examination, a small ulcer 
on the cornea; and, in this advanced 
stage of the complaint, the ulcer is com- 
monly not at the margin of the cornea, 
but nearer the centre of it. 
Diagnosis.-It is often of great conse- 
quence to be enabled to decide as soon as 
possible on the nature of a febrile erup- 
tive disease, as, in the cases of persons 
employed in large establishments, ser- 
vants, etc., in order to their removal for 
the safety of others; and, on the other 
hand, it is unjust to the patients them- 
selves to send them amongst Smallpox or 
fever patients, if they are not suffering 
from these respective diseases, where they 
may contract, and even die of, a disease 
of a far more dangerous nature than the 
one they may happen already to be suffer- 
ing from : on this account, early and cor- 
rect diagnosis is of great consequence to 
all persons concerned, as well for the 
credit of the medical practitioner as for 
the safety of the patient. Upwards of 
twenty diseases have been mistaken, within 
the last few years, in the early stage of 
illness, for Smallpox, and the patients 
have been sent as having Smallpox to the 
Smallpox Hospital. It has been observed, 
however, that three or four diseases mis- 
lead much more frequently than others; 
with the symptoms of these diseases, 
therefore, it will be desirable to contrast 
Smallpox. The four diseases are-Measles, 
febrile lichen, varicella, and some forms 
of continued fever. Some of the early 
symptoms of Smallpox are common to the 
other diseases above enumerated, such as 
fever, thirst, headache, sickness, and 
vomiting; but there is in Smallpox what 
there but rarely is in the other diseases- 
and when it exists it is accidental, not 
part of the disease itself-acute pain in 
the back, evidently not muscular pain. ♦ 
1. Diagnosis of Smallpox from Measles.- 
Measles is far more frequently mistaken 
for Smallpox than any other disease is 
mistaken for it. In Smallpox the eruption 
follows on the third day, or after forty- 
eight hours'1 illness. In measles the erup- 
tion generally appears on the fourth day, 
or after seventy-two hours'1 illness ; there is, 
besides, usually some cough, and lachry- 
mal discharge and fiery redness of the 
eyes. The eruption, too, of measles, al- 
though a little elevated above the surface 
of the skin, is not so distinctly felt as in 
Smallpox: it appears more superficial. 
The lapse of forty-eight hours after the 
commencement of illness before the ap- 
pearance of eruption, the pain in the 
back, and the shotty feel of the eruption 
on the skin in Smallpox, contrasted with 
the lapse of seventy-two hours of illness 
before eruption in measles, the cough, red- 
ness of the eyes, and less marked feeling 
of hardness and prominence on the skin, 
should be enough, compared with the 
general appearance of the patient, to dis- 
tinguish the two diseases. 
2. Diagnosis of Smallpox from Febrile 
Lichen.-Febrile lichen is more like Small- 
pox especially, than any other form of 
disease is, not variolous. At first it must 
be confessed there is great difficulty in 
distinguishing between febrile lichen and 
modified Smallpox; still, however, by 
attending minutely to some leading cha- 
racteristics, they may be distinguished: 
and here again time comes materially to 
our aid ; lichen appears on the second day 
of illness, or after twenty-four hours' ill- 
ness, and the eruption is without the or- 
der we observe in Smallpox; it appears 
scattered at random over the surface of 
the skin, and begins to appear at first 
generally on the trunk, as well as on the 
head and face, which is not the case in 
Smallpox. Two or three days will always, 
of course, put an end to any doubts there 136 
SMALLPOX. 
may be on the subject, as no fluid, or next 
to none, is ever found in the eruption 
produced in lichen. 
3. Diagnosis of Smallpox from Varicella 
Vera.-Varicella vera leads to doubt in 
the minds of many practitioners. The 
distinction, however, between the two 
diseases is tolerably easy, and hardly 
ought to admit of mistakes. The initia- 
tory fever of varicella is but very slight, 
scarcely perceptible ; whereas it is general- 
ly rather severe in Smallpox, even where 
the resulting disease is mild. Twenty- 
four hours only elapse in varicella after 
the commencement of indisposition before 
the eruption begins to appear; there is 
no hardness, as in Smallpox, on passing 
the lingers over the points of eruption, 
and no areola at the base of each vesicle, 
or if any, very slight indeed; in most 
cases none. The eruption in varicella 
has its seat just under the cuticle, between 
the external and deeper layers of the epi- 
dermis ; is vesicular, as if raised by a 
shower of boiling water; scattered over 
the skin without the order of threes and 
fives together, forming crescents and cir- 
cles as in Smallpox; there is besides al- 
ways, or nearly so, what is a very good 
guide, one or two large vesicles on the 
shoulders, generally between the shoulder- 
blades, much larger, and more spread out 
than the rest of the eruption, wanting the 
delined edge and hardness of the eruption 
of Smallpox. In the advanced stage the 
contents of the vesicles become purulent; 
but still, those who have watched the 
course of the disease carefully, cannot 
well be in doubt as to its real nature, and 
want of identity with Smallpox. 
[The vesicle of chicken-pox scarcely 
pustulates, as a rule, and never fully um- 
bilicates like that of Smallpox. In a very 
few cases one or two vesicles upon a ten- 
der part (as the face) may involve the true 
skin sufficiently to leave a small mark or 
pit; but this is quite exceptional.-II.] 
Even near the present day,1 the doubt 
has not been altogether removed that 
varicella and variola may be of kindred 
origin. Heberden first pointed out clearly 
the distinction between the two diseases. 
We have no doubt whatever that they are 
quite independent of each other. Patients 
admitted with varicella into the Smallpox 
Hospital have often taken Smallpox dur- 
ing their stay there; and the converse 
happened a few years since ; a child who 
had been in the hospital with variola was 
discharged cured and a short time after- 
wards was readmitted with varicella vera. 
4. Diagnosis of Smallpox from continued 
Fever. - The slow insidious commence- 
ment of continued fever, with none of the 
suddenness and violence of attack observed 
in Smallpox, and the languid and general 
aspect of the patient in fever, ought al- 
ways to be enough to mark the distinction 
between the two diseases, Smallpox and 
continued fever. 
Prognosis.-In foretelling what will 
probably be the result of any particular 
case of Smallpox, the judgment should be 
guided by the most striking points already 
described. 1. The quantity of eruption ; 
2. The age of the patient; 3. Whether or 
not the mucous membrane of the larynx 
and trachea seems to be much implicated ; 
4. The state of the fluids giving rise to the 
malignant or petechial form of the dis- 
ease ; 5. The state of the nervous system, 
and previous habits of living ; 6. Whether 
the patient has been vaccinated, and, if 
so, the number and quality of the cica- 
trices (to be alluded to particularly here- 
after); 7. Whether the disease is compli- 
cated with pregnancy; 8. The favorable 
or unfavorable circumstances in which 
the patient is placed. 
TABLE I. 
Showing the rate per cent, of mortality from 
different forms of eruption in 2654 unvac- 
cinated cases of Smallpox, admitted into 
the Smallpox and Vaccination Hospital, 
London, from 1836 to 1851, inclusive. 
Unvaccinated 
Smallpox. 
Cases. 
Deaths. 
Rate per 
cent, of 
Mortality. 
Confluent . . 
1838 
937 
50 
Semiconfluent . 
614 
51 
8 
Distinct . . . 
202 
8 
4 
2654 
996 
37 
Note.-Eighty-one of the above patients 
who died were affected with antecedent, or 
superadded disease, as well as with Smallpox, 
viz., Confluent, 58; Semiconfluent, 15; Dis- 
tinct, 8. 
1. Confluent Smallpox is always more 
or less dangerous. Whenever the disease 
is confluent, the prognosis should always 
be very guarded in the early stage of the 
illness. Unvaccinated patients with this 
form of the disease die, as shown in Table 
I. at the rate of 50 per cent. Great con- 
fluence about the head and face is always 
to be dreaded, as patients often die with 
it when the eruption is but thinly scat- 
tered on the rest of the body. When the 
pustules are flat, do not acuminate well, 
and when the areolte around them on the 
extremities are of a clarety hue, and the 
eruption on the face is white and of a 
pasty appearance, the patient has but lit- 
tle chance of recovery. Distinct Smallpox 
is a disease of but little danger per se 
when uncomplicated with other symptoms 
of a fatal tendency ; as shown in' Table I. 
1 See Thomson on the Varioloid Epidemic 
of Scotland, 1820. PROGNOSIS. 
137 
it produces a mortality of only 4 per cent.; 
it hardly ever alone endangers life in the 
adult. 
Semiconfluent Smallpox produces, or is 
implicated in producing twice the mor- 
tality of the distinct form of the disease; 
it is sometimes, in rare instances, accom- 
panied with symptoms of malignancy, 
viz., hemorrhage from the mucous sur- 
faces, &c., and may become dangerous 
from the previous bad habits or shattered 
health of the patient. Under these cir- 
cumstances a few deaths take place from 
semiconfluent Smallpox, amounting to 8 
per cent. 
TABLE II. 
Ages of the unvaccinated patients admitted with Smallpox, at the Smallpox and Vaccination 
Hospital, London, from 1836 to 1851 inclusive, with the rate per cent, of mortality, calcu- 
lated at different periods of life. 
Date 1836 to 1851. 
Age in Years. 
Total. 
0-5 
5-10 
10-15 
15-20 
20-25 
25-30 
30-40 
40-50 
50-60 
60-70 
70-80|80-90 
Patients 
356 
334 
270 
571 
669 
270 
154 
18 
8 
2 
1 
1 
2654 
Deaths 
181 
91 
62 
154 
274 
124 
89 
13 
5 
1 
1 
1 
996 
Percentage of deaths . 
50 
27 
23 
26 
40 
45 
57 
69 
75 
37 
Note.-About 2 per cent, of the unvaccinated patients died from Smallpox complicated 
with antecedent or superadded diseases. 
2. Age should occupy an important 
place in the prognosis of Smallpox. Its 
influence is the greatest in early and in 
advanced life. See Table II. 50 per cent, 
die under 5 years of age, and upwards of 
50 per cent, beyond 30 years. The least 
mortality takes place from 10 to 15 years 
of life. 
3. The state of the mucous membrane 
of the air-passages should be duly esti- 
mated; this can be pretty well known by 
the tone of the voice. When the larynx 
is much implicated there will be a good 
deal of cough, and the sound from cough- 
ing, and the voice in speaking, will have 
a hoarse metallic resonance. Laryngeal 
and tracheal complications render the dis- 
ease very dangerous. 
4. A knowledge of the condition of the 
fluids is very important in estimating the 
danger in Smallpox. All symptoms indi- 
cating malignancy, and a putrescent state 
of the blood, should be looked upon as 
very unfavorable signs. Hemorrhage 
from any of the mucous surfaces, pur- 
pura, blood effused under the conjunc- 
tiva, or into the Smallpox vesicles, should 
all be regarded as very dangerous symp- 
toms. 
5. The state of the nervous system is 
amongst the most important points to be 
taken into consideration. Cases accom- 
panied in the early stage with delirium 
generally end fatally. Persons of pletho- 
ric habit and free livers are very apt to 
have delirium, with a nervous, tremulous 
manner, and sleepless nights, and are 
very difficult to manage. The irritable 
temperament is unfavorable in Smallpox, 
Such persons often worry themselves 
about the merest trifles, and when they 
would otherwise do well, but for this irri- 
tability, the case ends in death. Delirium 
coming on for the first time about the 
tenth day is a very bad sign; such patients 
nearly always die. Children who grind 
their teeth hardly ever recover. The 
prognosis in the above cases should be un- 
favorable. On the other hand, a quiet 
state of the brain and nervous system, a 
tranquil cheerful manner, with hope of re- 
covery, are tolerably certain indications of 
a favorable result. 
6. The patient having been vaccinated 
will make a most important difference in 
estimating the danger from Smallpox. If 
the vaccination has been performed in 
four or more places, and corresponding 
cicatrices remain of good quality, readily 
seen, the case will, in all likelihood, end 
well. The early symptoms of Smallpox 
may be very severe, often are so, in well- 
vaccinated cases, but they subside as soon 
as the eruption is thrown out, which is 
usually highly modified, and all goes on 
well. But there are, unfortunately, many 
persons who have not had vaccination 
well performed, and they will suffer from 
Smallpox, probably, accordingly. When 
one or two cicatrices can but just be seen, 
doubtfully seen, the case may be as se- 
vere as if there had been no vaccination 
at all, the eruption pass through its seve- 
ral stages quite unmodified, and the dis- 
ease proceed, and terminate, uninfluenced 
in any way by the previous vaccination. 
7. Pregnancy is a most unfortunate and 
dangerous complication in Smallpox. 
Abortion is very apt to take place. In 
fatal cases the child is usually thrown off 138 
SMALLPOX. 
the day before death. It is generally 
born dead, but not invariably so. Al- 
though the danger in Smallpox is very 
much increased by pregnancy, and should 
always be taken seriously into account in 
forming a prognosis, pregnant patients 
occasionally do well, especially after vac- 
cination. They sometimes abort, and 
sometimes do not; sometimes both mother 
and child do well. 
8. The circumstances under which a 
person is placed in Smallpox may influ- 
ence very much the result; as, for in- 
stance, on board ship; in a small, confined 
ill-ventilated house; hospitals are espe- 
cially dangerous to the pregnant woman, 
witness the mortality in the lying-in hos- 
pitals;1 the prejudices of friends in over- 
heating the patient, and giving cordials 
and strong drinks at unseasonable times; 
all these things may interfere with the 
chance of recovery. 
Susceptibility to Smallpox.-Each 
individual of the human species is born, 
it would seem, with a susceptibility to 
contract Smallpox, measles, scarlatina, 
and perhaps some other diseases, belong- 
ing to what is called the zymotic class- 
those diseases produced by a morbid ani- 
mal poison. There is in the organism, 
most likely in the blood, some inborn 
principle or ingredient, clearly not essen- 
tial to life and well-being, by which we 
are rendered liable to undergo these dis- 
eases. It is no doubt ordained by an 
overruling Providence that we should 
pass through these ordeals, from which 
hardly any are altogether proof, if they 
live but long enough, and from which 
large numbers annually die. After re- 
covery from these diseases, the body is 
generally in no way better or worse for 
having passed through the change pro- 
duced by the diseases, except in those in- 
stances in which the person is disfigured 
by the marks of Smallpox, or the seeds, 
perhaps, of scrofulous disease are brought 
into action ; or, in the case of the measles, 
some pneumonic mischief may be left be- 
hind ; or, in scarlatina, injury to the ears. 
All the functions essential to life usually 
go on as well as before, after passing 
through these diseases ; therefore it would 
seem to be some innate principle in no 
way necessary to the well-being of the in- 
dividual which is destroyed, or got rid of, 
during the attack; a principle or ingre- 
dient by which we are rendered liable to 
undergo these respective diseases. Some 
persons on exposure escape the infection 
of Smallpox over and over again, but take 
it at last. In 1844, a woman, 83 years of 
age, was admitted into the Smallpox Hos- 
pital with severe confluent natural Small- 
pox, of which she died, who had nursed 
her own children and her grandchildren 
with the disease, and had otherwise often 
been exposed to variolous infection, but 
never took it before. A similar instance 
is mentioned by Sir Thomas Watson, in 
his Lectures, of an old woman who had 
for years acted as a village nurse, and had 
nursed a great many persons with Small- 
pox, but at last, at 84 years of age, took 
the disease, of which she died. 
Some persons have been known to pass 
through a long life, frequently exposed to 
Smallpox, but have never taken it; others, 
late in life, have taken it from inoculation, 
who had resisted taking the disease in the 
natural way, as it is called, namely, by 
breathing an infected atmosphere. Some 
few resisted, in inoculation days, both in- 
oculation and the natural mode of taking 
the disease; but these were very rare 
cases. All periods of life seem to be about 
equally susceptible to the influence of the 
contagion. In many parts of this country, 
before the invention of railways, Small- 
pox was absent for twenty years together. 
This happened more especially before the 
introduction of inoculation. Then, on the 
disease breaking out among the inhabit- 
ants of these but little frequented dis- 
tricts, the infection being conveyed to 
them by tramps, or dealers in small wares, 
the disease spread with fearful rapidity, 
and nearly all who came within the sphere 
of infection, whether young, or those more 
advanced in life, since the last invasion, 
took it, and it caused dreadful mortality, 
as it does in the present day to the unvac- 
cinated. All ages being taken together, 
it is found that about one-third, or rather 
more, of those who take Smallpox in the 
unprotected state - that is, who have 
never been vaccinated, or had Smallpox 
before-die of the disease. It is particu- 
larly destructive to the dark-skinned 
races ; the blacks who come to the Small- 
pox Hospital suffer more from the disease 
than the native inhabitants of Great 
Britain. The same thing has been found 
to take place abroad. Dr. Bulkley, in the 
American edition of Dr. Gregory's "Lec- 
tures on the Eruptive Fevers,"1 mentions 
an instance in which a tribe of American 
Indians took Smallpox, and they all died 
of it. Every individual of the tribe was 
swept away. 
Infectious Nature of Smallpox.- 
Boerhaave was the first to point out the 
infectious nature of the disease. Before 
his time it was thought to depend on some 
peculiar influence of the atmosphere, and 
it is a remarkable circumstance that 
Sydenham, who paid so much attention 
to this disease, should have overlooked so 
obvious a property of it. Most likely it 
1 See Lectures by Dr. Barnes, in the Lan- 
cet, 1865, vol. i. p. 141. 
1 Page 34. INFECTIOUS NATURE OF SMALLPOX. 
139 
is communicable from the moment when 
the initiatory fever begins. It may be 
given by the breath of the patient before 
the eruption has appeared on the surface 
of the body. It continues infectious so 
long as any of the dry scabs resulting 
from the original eruption remain adhe- 
rent to the body ; a single breathing of the 
air where it is, is enough to give the dis- 
ease. The dead body, for several days 
after death, has been known to communi- 
cate the disease (see Hawkins, in London 
Med. Gaz., vol. iii.); and in all probability 
it would produce the disease for some 
months afterwards. A few years since a 
lady was walking at Islington, and met a 
person with Smallpox ; twelve days after- 
wards she was taken ill, and for a few 
hours was delirious. The illness passed 
off without eruption. Her married sister, 
who had not been out of the house for 
three months, on account of pregnancy, 
was seized with illness exactly twelve days 
again after her sister's attack, which ill- 
ness proved to be severely confluent but 
modified Smallpox. The case is singular 
and very interesting, as showing that the 
disease may be communicated by a person 
who had the early symptoms of the dis- 
ease, precisely at the usual time after be- 
ing exposed to Smallpox infection, but 
whose illness passed off without the char- 
acteristic eruption; a case in fact of Va- 
riola sine eruptione as first described by 
Sydenham.1 
The infecting source bears no relation 
generally to the resulting disease ; a mild 
case may, and often does, give rise to a 
severe one ; and, on the contrary, a severe 
case may produce a mild one. The dry 
scab of Smallpox would most likely set 
the disease going months, perhaps years, 
afterwards by inoculation, just as the dry 
scab of cow-pox has been found to be ef- 
fectual for the purposes of vaccination 
after being kept a considerable time. 
Clothes that have been worn by a per- 
son when suffering from Smallpox may 
retain the infection for a long time, as 
may the furniture, especially woollen fur- 
niture, of beds, and bedding, unless washed 
and thoroughly purified by exposure to 
the air, &c. 
liecurrent Smallpox.-Smallpox but sel- 
dom occurs the second time. Instances 
of second attacks have, however, been 
recorded from the time of Rhazes to the 
present day. Thirty years ago we began 
to collect minute statistical information 
of all cases of Smallpox admitted into the 
Smallpox Hospital. At that time there 
were probably as many persons in this 
country who owed their protection to 
having been inoculated, or having had 
Smallpox, as to vaccination. We have 
communicated to the Royal Med.-Chir. 
Soc.1 the particulars of this inquiry for 
sixteen years-1836 to 1851. Of 5797 
cases of Smallpox, 2654, or 45 per cent, 
were unvaccinated ; 47 cases, or less than 
1 per cent, were after a previous attack of 
Smallpox or Smallpox inoculation ; 3094 
cases, or 53 per cent., were after vaccina- 
tion. It will, therefore, be seen that the 
cases of reputed Smallpox after Smallpox 
have been but comparatively few, and 
even some of these would perhaps admit 
of doubt; lichen, varicella, and some 
forms of pustular syphilis are difficult to 
distinguish from Variola, and might easily 
be mistaken for it, except by those inti- 
mately acquainted with the minute cha- 
racteristics of eruptive diseases. The 
Smallpox Hospital has been founded 119 
years, but there is no record of a patient 
having been admitted there twice, each 
time suffering from Smallpox. We have, 
however, no doubt of the disease occur- 
ring a second time, as measles and scarla- 
tina do, but we think the instances are 
far more rare. 
An Irishman, the son of a medical offi- 
cer in the army, who had been vaccinated 
in infancy by his father, and had a large 
cicatrix remaining from the vaccination, 
and who was attended by his father for 
Smallpox in early life, and bore decided 
pits of the disease, in 1844, at twenty- 
three years of age, was admitted into the 
Smallpox Hospital with severe confluent 
Smallpox, of which he died. 
We have repeatedly seen the disease 
modified, when it takes place after natural 
Smallpox, or after inoculation, just as it 
is modified by vaccination. Among the 
circumstances that seem to predispose the 
constitution to receive a second attack of 
Smallpox is, as after vaccination, exposure 
for a time to great change of climate, 
either hot or cold. Women who have had 
Smallpox, or have been inoculated for it, 
often have, when suckling children with 
Smallpox, a few irregular spots formed on 
the breast about the nipples ; these spots 
are produced on the breasts by contact 
with the matter of Smallpox from the 
child's lips and face. There hardly ever 
is any accompanying indisposition ; the 
effect is purely local, and cannot properly 
be considered to be a second attack of 
Smallpox. 
Variola sine Eruptione.-Sydenham was 
the first to notice a form of fever without 
eruption, which prevailed at times when 
Smallpox was epidemic, and which he 
calls "Variolous Fever."2 "This Fever 
originated in that particular epidemic 
constitution of the atmosphere, which, at 
the time in question, produced the Small- 
pox. Hence, with the exception only of 
1 Med.-Chir. Trans, vol. xxxvi. 
2 Sydenham, vol. i. ch. 3, sec. 2. Syden- 
ham Soc. Edit. 
* Sydenham, vol. i. ch. 3, sec. 2. 140 
SMALLPOX. 
those symptoms which were the necessary 
effects and consequences of the eruptions, 
it was, if not identical, at least closely 
akin to the Smallpox. Each disease set 
in similarly. In each there was the same 
pain upon pressure over the pit of the 
stomach. The color of the tongue and 
the color of the urine were alike in the two 
complaints. The profuseness and spon- 
taneity of the sweats occurred equally at 
the commencement of both maladies. The 
common tendency to salivation was also 
equal. It occurred during the fever, when 
its heat and violence reached beyond a 
certain intensity. It occurred during the 
Smallpox, when the pustules became con- 
fluent. Finally, as the fever was most 
rife at that particular time when the 
ravages of Smallpox were greater in these 
parts than at any other time within the 
limits of my own observation, there can 
be but little doubt as to the identity of 
character between the two diseases. Of 
this I am certain-all those practical phe- 
nomena which determine treatment were 
the same for the two diseases, with the 
single exception of the eruption of Small- 
pox, and of its effects." 
De Haen has noticed a similar occur- 
rence as having come under his observa- 
tion. We have seen a few such cases that 
confirm the supposition. They occurred 
after vaccination, and are likely to be 
more numerous in these days than in the 
days of Sydenham, as we believe vaccina- 
tion modifies Smallpox, in different per- 
sons, at every stage of its progress. Such 
cases are not likely to be sent in any large 
numbers to the hospital, as the eruption 
is the only decided evidence of the disease 
being Smallpox. Some like cases occur- 
ring in a school, were reported to the 
Epidemiological Society, in 1852, in an- 
swer to a series of questions on Smallpox 
and vaccination extensively circulated 
among the medical profession. 
M. Hedlund, giving an account of the 
Swedish epidemic of 1824, states (Magen- 
die, Journal de Physiologic, tome vi.; and 
Gregory, Library of Medicine, vol. i. p. 
303) "that three different forms of disease 
were then observed, all, as he believes, 
pathologically allied, viz., true Smallpox, 
the varioloid, and the fever without erup- 
tion. This fever, he adds, began and 
ended at the same time with the epidemic. 
The early symptoms were identical with 
those which preceded the variolous erup- 
tion. He considered it as a mild unde- 
veloped Smallpox." 
her efforts. Blisters, heating alexiphar- 
mics, large bleedings, opiates, ointments, 
masks, and lotions to prevent pitting were 
the great measures formerly pursued, not 
one of which can be recommended. What 
think you of a prince of the blood royal of 
England (John, the son of Edward the 
Second) being treated for Smallpox by be- 
ing put into a bed surrounded with red 
hangings, covered with red blankets, and 
a red counterpane, gargling his throat 
with red mulberry wine, and sucking the 
red juice of pomegranates ? Yet this was 
the boasted prescription of John of Gad- 
desden, who took no small credit to him- 
self for bringing his royal patient safely 
through the disease. We may smile at 
this; but if either he, or Gordonius, or 
Gilbertus, were to rise from their graves 
and inquire whether this is one whit worse 
than Mesmerism, or at all more absurd 
than homoeopathy, or hydropathy, we 
should, I fear, look a little foolish. Let 
us, then, avoid the errors of our ancestors, 
without reproaching them." 1 
One of the first things to arrange on 
undertaking to treat a case of Smallpox 
should be, if possible, to place the patient 
in a large airy apartment; bed-hangings, 
carpets, &c., had better be removed. The 
room should be kept cool in summer, and 
agreeably warm in winter, and the air of 
the room should be changed two or three 
times a day. In hospitals, the space 
allowed for Smallpox patients should not 
be less than two thousand cubical feet for 
each patient. 
For a long time the custom was to keep 
patients with Smallpox as warm as possi- 
ble ; to heap bedclothes on them, to shut 
out every breath of air, forbid any ablu- 
tion, or even change of body or bed linen. 
All this proceeding must have produced a 
horrible state of things. To Sydenham 
we are indebted-and a very great debt 
we may be sure we owe him-for having 
revolutionized all this. Like many other 
reformers of abuses, he was not able to 
accomplish the change he sought from 
these abuses without a good deal of oblo- 
quy. Thanks to his perseverance, he suc- 
ceeded. We now use light bed-coverings, 
frequent change of linen, fresh air, ablu- 
tions, and cooling drinks, with the greatest 
benefit to our patients. To Sydenham we 
are also indebted for having first drawn 
the distinction between Smallpox and 
measles ; no very great effort to accom- 
plish, we should perhaps think, for any 
pathologist of the present day, the dis- 
tinction seems so clear between the two ; 
yet it was a step in pathology of great im- 
portance at the time, as Smallpox and 
measles had been for centuries looked up- 
on as only modifications of the same dis- 
Treatment.-There is no specific for 
the cure of Smallpox. " It is a melan- 
choly reflection," says Dr. Gregory, " but 
too true, that for many hundred years the 
efforts of physicians were rather exerted 
to thwart nature, and to add to the malig- 
nancy of the disease, than to aid her in 
1 Lectures on Eruptive Fevers. Leet. V. 
p. 93. American Edition. TREATMENT. 
141 
ease; just as we until quite lately- 
thanks to the sagacity of Steward and 
Jenner-looked upon typhus and typhoid 
fevers as only modifications of the same 
fever. Like most other things, it seems 
easy enough to understand when once it 
has been clearly explained ; but honor and 
praise are none the less due to the original 
observers. Easy as it seems, we might 
not have seen it; most likely we should 
not. 
In the majority of instances it cannot be 
known for the first two or three days of 
Smallpox what febrile ailment is approach- 
ing ; and, even if it were known, the mode 
of treatment would not materially differ. 
It will be right to give a dose of opening 
medicine to relieve the bowels, to keep 
the patient on simple diet, and to give 
saline medicine; nothing, generally, is 
better or more agreeable than citrate of 
potash; or tartrate of soda, in a state of 
effervescence. In confluent cases of Small- 
pox it is necessary to cut the hair close ; 
in the unvaccinated, especially in children, 
the sooner it is done the better. But in 
the vaccinated exceptions should be made : 
to females, especially, it is a great morti- 
fication to lose a fine head of hair, which 
will perhaps take two or more years to 
restore thoroughly; therefore it will be 
proper to wait until the fifth or sixth day 
of eruption to see if the course of the dis- 
ease is modified, because if it is, it will 
not be necessary to cut off the hair. 
The diet of the patient should consist of 
tea and toast, without butter, bread and 
milk, sop, and oatmeal gruel, grapes, the 
juice of oranges, strawberries, and what 
patients are very fond of, and can have at 
all seasons of the year, roasted apples. 
For drink, toast-water, plain water,- 
which many prefer to anything else,- 
lemonade, imperial drink, milk and water, 
apple water, tamarind water, raspberry 
vinegar and water, and, what makes a 
very agreeable drink, some boiling water 
poured on black or red currant jelly. 
Sydenham says : "The moment that un- 
doubted signs of Smallpox have shown 
themselves, I forbid the patient wine, 
meat, and the open air. His ordinary 
drink is weak small beer with a toast put 
in to take the chill off. His food is oat- 
meal porridge, barley broth, roasted ap- 
ples, and the like; articles which are 
neither hot nor cold, and which give no 
trouble to the digestion. I have no objec- 
tion to a form of diet that is common in 
the country, and which consists of a 
roasted apple mashed with milk, only it 
must be taken at intervals, moderately, 
and with the chill off the milk. Hot regi- 
men I forbid altogether. I forbid also all 
such cordials as are used by some under 
the rash notion of propelling the pustules 
towards the skin." 
Fifty years ago, and later, it was not 
unusual to take away blood at the com- 
mencement of Smallpox ; we never think 
of bleeding patients now at the Smallpox 
Hospital. Sydenham, Huxham, and 
others used to recommend bleeding in 
Smallpox, but, notwithstanding the sanc- 
tion of their great names, it must always 
have been a very doubtful proceeding. 
Delirium occurs in confluent Smallpox 
in persons of very different constitutions 
-most commonly, as previously stated, in 
persons of full habit, and free livers ; but 
it also occurs in persons of weakly consti- 
tutions, and who may have lived temper- 
ately : the pulse is small and weak, and 
the features shrunken. Such persons re- 
quire stimulants early-indeed it is about 
the only chance, doubtful as it is, of afford- 
ing any assistance towards recovery. 
This form of delirium should, of course, 
be clearly distinguished, before giving 
stimulants, from the delirium of plethora. 
Most writers on Smallpox allude to sup- 
pression and retention of urine as occur- 
ring in this disease ; occasionally, perhaps 
not above once a year, we are told, at the 
Smallpox Hospital, a patient has not 
passed urine for several hours ; but on 
examining the bladder there is not any 
distension of it. At the next visit, on 
inquiry, we always find urine has been 
passed. We have not had occasion to 
pass a catheter, in a case of Smallpox, for 
five-and-twenty years, therefore we con- 
clude retention of urine must happen but 
very rarely in this disease. 
An invariable complaint in Smallpox is 
soreness of the throat, more or less ; this 
arises from the eruption being formed 
there as well as on the skin, which has to 
be explained to each patient, and it is 
necessary also to explain that we cannot 
stop the progress of the eruption there any 
more than on the skin, that it will go 
through a certain course in defiance of 
any means we may use to interrupt it. 
The spots necessarily cause more incon- 
venience in the throat, from the confor- 
mation of these parts, than on the surface 
of the body. All we can do for the relief 
of it is to recommend some mild gargle, 
or a small quantity of fluid to be taken 
frequently, or a little red or black currant 
jelly to keep the parts moist. 
The bowels should be at once well 
cleared, at the commencement of the dis- 
ease, by a dose, in the plethoric, of three 
or four grains of calomel, and eight grains 
of compound extract of colocynth, with or 
without sulphate of magnesia, and infu- 
sion of senna, and for the first few days 
they should be kept open two or three 
times a day. In the less robust, and in 
females, a salts and senna draught alone 
will, perhaps, do. Afterwards, in the 
course of the disease, if the bowels act 
daily without aperient medicine, all the 
better; if not, they should be relieved 142 
SMALLPOX. 
every two or three days by a salts and 
senna draught. So long as the tongue 
continue loaded with a brownish yellow 
fur, the salts and senna draught answers 
better than anything else; when the 
tongue is clean a dessertspoonful of cas- 
tor oil, or a rhubarb and magnesia 
draught, is more suitable; but so long as 
the tongue is clean, there is but little 
need for opening medicine at all; still the 
bowels should be relieved every few days. 
Not unfrequently it happens in Smallpox 
that the bowels are too much relaxed ; for 
this we keep a mixture always in the 
ward of the hospital, and find it very ser- 
viceable :- 
I}.-Cretae preparatae, 
Pulveris acaciae, 
Sacchari albi, aa giss. 
Aquae §iv. 
Tincturae opii gj. 
Spiritus ammoniae aromaticae, 
Tincturae catechu, aa^ss. 
Aquae menthae piperitae ^iij. Misce. 
Two or three tablespoonfuls' a dose, to be 
repeated in three hours, whether the first 
dose seems to have answered the purpose 
or not; as without the second dose the 
diarrhoea will often return. If after three 
or four doses of the above chalk and laud- 
anum mixture the diarrhoea still continue 
unchecked, having waited a suitable time, 
say three or four hours, it will be right to 
give three tablespoonfuls every four hours, 
of the compound infusion of roses; the 
sulphuric acid often answers the purpose 
of stopping the diarrhoea when the chalk 
mixture has failed, but the chalk mixture 
so generally affords relief that we always 
try it first. Should the two forms, above 
given, fail to stop the diarrhoea, ten grains 
of pulv. kino comp, may be given every 
six hours, or a scruple to half a drachm 
of the pulv. cretae comp, cum opio. Rice 
and milk should be given as diet. If the 
above means all prove to be unsuccessful 
in stopping the diarrhoea, it will perhaps 
be found there is some tenderness, on 
pressure, of the abdomen; then a powder, 
or a pill, may be given every six hours, 
composed of three grains of hydr. cum 
creta, and two grains of pulv. ipecac, co. 
In the early stage of Smallpox many 
patients are restless and unable to sleep 
at night; anodynes fail to procure rest. 
It may be worth while to try them once 
to see the effect, and repeat the dose or 
not as may be judged right. But there is 
in some patients the same wakefulness in 
the advanced stage of the disease, in pa- 
tients who are otherwise doing well; then 
an anodyne given once or twice, just to 
get them into the habit of sleeping, an- 
swers admirably, and nothing does so 
well as the hydrochlorate of morphia: we 
have given it constantly for five-and- 
twenty years; it procures a comfortable 
sleep without causing thirst, or stupor, or 
confining the bowels, as tincture of opium 
does. It is convenient to keep a solution 
of it ready, four grains to the ounce : from 
twenty to thirty minims of the solution is 
a suitable dose; we generally find twenty- 
five minims to answer well. 
One warning we are desirous of giving 
about the use of anodyne draughts: they 
should not be given when there is copious 
salivation and mucous expectoration. Pa- 
tients at such times are very sleepless, 
because they require to be kept vigilant 
to discharge the saliva and viscid mucus 
frequently, almost constantly ; if an ano- 
dyne be given under these circumstances, 
the patient goes to sleep, and the saliva 
and mucus, which ought to be frequently 
got rid of, go on accumulating during 
sleep in the air-passages, and thus the pa- 
tient dies, gradually asphyxiated by the 
secretion accumulated in these parts. 
Although the antiphlogistic treatment 
should be continued for perhaps the first 
few days after secondary fever has set in, 
patients shortly after its commencement 
require some additional support; beef-tea 
or calves'-feet jelly is very suitable to add 
to their diet, and a glass or two of the 
lighter wines may be allowed. The next 
step will be, supposing the patient to be 
going on pretty well, some soup, with a 
few shreds of thoroughly done meat in it. 
So long as the tongue continues furred, a 
meat dinner does not do well. Perhaps 
great weakness is complained of, and the 
appetite is bad ; under these circum- 
stances, a grain and a half of disulphate 
of quinine, with two or three minims of 
dilute sulphuric acid, and half a drachm 
of tincture of ginger in an ounce and a 
half of water, twice a day, will be service- 
able. Game, poultry, or lightly boiled 
eggs might be allowed; and in cases of 
great prostration, some brandy in gruel at 
night. 
When the tongue has become clean, 
meat may be recommended, and some ale 
or porter, with or without wine, port or 
sherry ; care being taken not to try to get 
on too fast. 
Things, unfortunately, do not always 
go on so smoothly as this ; some large col- 
lections of matter may form, with slough- 
ing of the cellular membrane, requiring 
to be opened, or numerous boils harass 
the patient. It often happens that mat- 
ter is formed under the scalp, small in 
amount at first, but it goes on collecting 
and spreading, and there is no disposition 
to point and break in this part as in other 
parts of the body. These collections 
should be opened early to prevent their 
spreading; the operation is rather pain- 
1 [If the stomach be at all irritable, a ta- 
blespoonful every three hours may suffice.- 
H.J 143 
TREATMENT. 
ful, from the thickness of the scalp. A 
simple incision does not answer well; the 
matter collects over and over again, and 
the cavity of the abscess keeps getting 
larger ; it is better done by a crucial inci- 
sion, and the cavity should be filled with 
lint ; these cavities are generally very 
tedious and troublesome in healing; ni- 
trate of silver or a solution of it, freely 
applied to the interior, helps on the pro- 
cess. Instead of opening these abscesses 
by a crucial incision, a better plan, per- 
haps, to adopt is, to pass a seton through 
them, so that the matter may keep con- 
stantly draining away ; we often resort to 
this proceeding with good effect, particu- 
larly when the abscess has been allowed 
to become rather large before anything is 
said about it. 
Some form of steel, with or without qui- 
nine, is a useful medicine often, especially 
to females, during convalescence. Qui- 
nine and tinctura ferri sesquichloridi, or 
mist, ferri comp, should be tried. Cod - 
liver oil may sometimes be advantageously 
given, under such circumstances, as it is 
otherwise found useful, in scrofulous sub- 
jects, or those inclined to phthisis. 
The discharge from the pustules in 
some confluent cases is considerable and 
acrid ; the itching, and discomfort pro- 
duced by it on the skin, are relieved by 
the application of some absorbent powder 
freely used ; flour applied with a common 
dredging box answers very well, or hair 
powder, starch, or calamine, dusted on 
the face, hands, inside of the shirt and 
sheets, will be found serviceable. 
Many patients have numerous boils re- 
sulting from Smallpox ; they leave ulcers 
which are tedious in healing; for some 
time no process of repair seems to be go- 
ing on, and the discharge from the ulcers 
further exhausts the patient. Some de- 
coction of bark, or quinine, with a few 
drops of dilute sulphuric acid, should be 
taken two or three times a day ; and, in 
some instances, where the tongue is rather 
furred, two grains of blue pill, and three 
of compound extract of colocynth, may be 
usefully recommended every second or 
third night for a few times. The ulcers 
improve dressed with ung. elemi, or cera- 
tum calaminse ; bits of lint, dipped in 
black wash, and applied to the wounds, 
and left on a couple of days, seem some- 
times to do good. The majority of pa- 
tients only require the wounds to be cov- 
ered with bits of strapping. 
Some patients like cold, others warm, 
applications in erysipelas; some prefer 
flour dredged over the inflamed part; 
collodion may be tried. If one plan does 
not make the patient tolerably comfort- 
able, another should be tried. A liberal 
supply of wine should be allowed ; the 
same in gangrene: both erysipelas and 
gangrene are generally preceded by bilious 
vomitings and very often by diarrhoea. 
During the sloughing of gangrene, at its 
commencement, nitric acid lotion, a 
drachm to a pint, may be used with bene- 
fit ; later, some antiseptic should be ap- 
plied to the part: one-third liquor calcis 
chloratse to two-thirds water ; or Condy's 
fluid properly diluted. Charcoal may be 
thickly applied, and covered with a lin- 
seed-meal poultice. A poultice made of 
beer grounds some recommend, others 
have a preference for carrot poultice ; we 
generally trust to the solution of chloride 
of lime, or Condy's fluid. 
When there is any gonorrhoeal discharge 
from the genitals, either in the male or fe- 
male, the bidet should be used, if possible, 
twice a day at the least, or some other 
means should be resorted to to keep the 
parts affected cleansed ; if this be neglect- 
ed, gangrene of the genitals is very likely 
to occur. The patient, unfortunately, is 
not well able at these times to use the 
bidet himself or herself, and the cleansing 
of these parts is a very unpleasant office 
for another to perform for them, and 
hence it is very likely to be neglected un- 
less the medical attendant is very strict in 
enforcing his injunctions on the subject of 
cleanliness, and makes a point of inquiring 
daily if the bidet has been used. 
Pleurisy is one of the most dangerous 
complications that can arise in the ad- 
vanced stage of Smallpox. It soon, gene- 
rally, carries off the patient. Bleeding is 
useless, if tried, and is, in fact, practically 
found to do more harm than good, and 
should be considered as inadmissible. 
The best plan to adopt-we believe, in- 
deed, the only one we have seen to do 
good, and we have seen many tried-is at 
once to put a large blister on the side, and 
give a full opiate, forty minims of the 
solution of hydrochlorate of morphia, pre- 
viously alluded to, or a like dose of tinc- 
ture of opium ; the dose to be repeated in 
twelve hours unless the pain has very 
much subsided. Wine, if the patient has 
been taking any, had better, perhaps, be 
withdrawn. 
Pneumonia, like pleurisy, arising in the 
advanced stage of Smallpox in a person 
previously debilitated by an exhausting 
disease, does not admit of, and certainly 
will not be benefited by, any active treat- 
ment. Very likely, on carefully examin- 
ing the chest, some consolidation of the 
lungs will be discovered. A blister should 
be applied, and five grains of blue pill 
given every night, or night and morning, 
for a few days; acetate of ammonia at 
intervals ; an opiate at night, if very rest- 
less, and beef-tea as diet. 
Bronchitis is another of the dangerous 
inflammations occasionally met with in 
the advanced stage of Smallpox, hardly 
ever admitting of anything but palliative 
treatment, yet likely to be fatal. Counter- 144 
SMALLPOX 
irritation promises to be useful, and should 
be tried ; and the inhalation of the steam 
of water, through a proper inhaler, always 
gives some relief. The lowering system, 
with repeated doses of calomel, &c., re- 
commended by some writers, does not do 
well, and should be avoided. 
Variolous ophthalmia, and ulceration of 
the cornea, are amongst the most serious 
results of confluent Smallpox. Bleeding, 
here again, used to be recommended, but 
the practice was bad : we soon saw it did 
a deal of harm, and was inadmissible. 
Quite the opposite mode of treatment, in 
our opinion, is indicated. The patient 
should be put on as generous a diet as 
can be borne, and allowed port wine, two 
or three glasses a day, and take quinine 
or liquor cinchona} twice or thrice daily. 
To the eye, the following application may 
be made: B-Fot. papav. lb. j., pulv. 
aluminis 3 j. pro fotu. Ung. cetacei to 
be applied each night between the eye- 
lids. We sometimes touch the ulcer with 
nitrate of silver, scraped to a point. The 
eye should be fixed with a speculum-the 
one shown in Iley's Surgery answers well 
-and an assistant should be ready with 
some olive oil, in a grooved director, to 
drop into the eye, immediately after the 
caustic has been applied. Or the ulcer 
may be touched, by means of a camel's- 
hair pencil, with a solution of nitrate of 
silver, a scruple to the ounce. 
The conjunctiva, in the advanced stage 
of Smallpox, often as late as the third 
week, becomes inflamed, and after a 
few days a small ulcer may very likely 
be observed on the cornea. In such 
cases, as soon as observed, a blister to 
the temple is nearly always of decided 
benefit. Perhaps a second may be re- 
quired-it often is. Should the conjunc- 
tival inflammation continue and the ulcer 
remain stationary, a solution of nitrate of 
silver, two grains to the ounce, may be 
dropped into the eye every second day, 
two or three times, with a large camel's- 
hair pencil. Should the eye seem irrita- 
ble, perhaps some vinum opii sinearomat. 
(to be had at Savory and Moore's) dropped 
within the lids, once or twice a day, may 
be serviceable. In nearly all cases, when 
lotions are not being applied to the eye, a 
green shade should be recommended to 
be worn. Scrofulous inflammation occurs 
after Smallpox, but it will be readily rec- 
ognized by the great intolerance of light, 
and by its occurring chiefly in childfen. 
From the earliest periods in the history 
of Smallpox strenuous efforts have been 
made to prevent the "pitting" that takes 
place from this disease. It must be con- 
fessed that it disfigures the countenance 
often terribly, and gives a very common 
expression to the handsomest face. We 
need not wonder then at the anxiety of 
friends, as well as of the patients them- 
selves, that something should be done to 
prevent, as far as possible, future disfig- 
urement. Some good can be effected, but 
when the disease is very severe the mis- 
chief arising from this cause cannot be 
wholly avoided. Velpeau recommended 
some years since that each vesicle should 
be opened and cauterized with a stick of 
nitrate of silver scraped to a point; to do 
good the operation should be performed 
on the third or fourth day of eruption. In 
the most confluent cases, those likely to 
produce the greatest disfigurement/ the 
proceeding is scarcely practicable : it may 
be in semiconfluent cases. Mr. Iliggin- 
bottom recommends the whole face to be 
washed with a strong solution of nitrate 
of silver, eight scruples to the ounce of 
water. We think this is much too strong, 
and that it will blister the whole surface ; 
if used, half the strength will be enough. 
A mercurial plaster is used at the Chil- 
dren's Hospital in Paris, the form for 
which is given by Dr. Aitkenit is a 
modification and simplification of the em- 
plastrum vigo cum mercurio.2 It consists 
of twenty-five parts of mercurial ointment, 
ten parts of yellow wax, six parts of black 
pitch. This application has good effect, 
but is most suitable for use in semiconflu- 
ent cases, or those barely confluent, where 
the patient can be prevailed on to use a 
little care in the management herself; in 
severely confluent cases the application 
would soon be rubbed off by the patient's 
restless movements. 
The application recommended by Dr. 
Graves, a few years since, of a solution of 
gutta-percha in chloroform, did no good, 
and by confining the discharge under the 
coating of gutta-percha, produced a most 
offensive condition of the patient. What 
we do generally is this--wait until the 
pustules have been discharged, and the 
discharge has begun to dry, then put on 
some of the best olive oil, or a mixture of 
one-third glycerine and two-thirds of rose- 
water ; some of this may be applied once 
or twice a day, for a few days, until the 
scabs begin to loosen. Cold cream and 
oxide of zinc, or olive oil and lime water, 
form good applications ; or if the discharge 
is thin and excoriating, calamine mixed 
with olive oil. The patient should be 
warned not to allow the scabs to dry and 
remain some time on the nose, and other 
parts of the face, particularly on the fore- 
head and near the end of the nose; when 
this takes place, the dry scabs themselves 
leave deep marks in the skin, worse than 
the eruption of Smallpox itself. The 
pain of removing the dry scabs is some- 
times considerable, and the patient can 
1 Science and Practice of Medicine, vol. i. 
p. 2G3. Third Edition. 
2 See form in "Diseases of the Skin," by 
Erasmus Wilson, F.R.S. 4th Edit. p. 496. MORTALITY FROM SMALLPOX. 
145 
hardly be prevailed on to take them off, 
or allow others to do so. In common the 
pits from the eruption are not deep at 
first, just after the patient has got well, 
and we may deceive ourselves by think- 
ing our efforts to prevent disfiguration 
have been attended with considerable 
success. The disease leaves a peculiar 
brown stain on the skin at first, which 
soon wears off, but the pitting is more 
perceptible a twelvemonth or so after the 
patient has got well. 
One or two warm baths towards the 
end of the treatment should be enjoined 
in all cases of Smallpox. 
Mortality from Smallpox.-Two 
circumstances, wholly different in kind, 
influence very much the mortality from 
Smallpox, as will be seen on referring to 
Tables I. and II. These circumstances 
are, the age of the patients, and the con- 
fluent form of the disease. Infancy and 
advanced age are unfavorable periods for 
undergoing Smallpox. Children under 5 
years of age die at the rate of 50 per cent. ; 
and adults above 30 years die in still 
larger proportions. See Table II. Pa- 
tients estimated at all ages, as they come 
to the Smallpox Hospital, die at the rate 
of 50 per cent, from confluent Smallpox ; 
8 per cent, from semiconfluent, and 4 per 
cent, from the distinct forms of the dis- 
ease. See Table I. The most favorable 
time for taking Smallpox is from 10 to 15 
years of age: beyond 60 years of age 
hardly any who take it escape dying. 
Sydenham was fully aware of the dan- 
gerous day in Smallpox; the eleventh he 
says,' which is the ninth day of eruption, 
as shown in the accompanying Table, No. 
III. The notion of the old authors of the 
critical days in Smallpox being the 7th, 
14th, and 21st, is wholly wrong. The 
critical days, in fact, are really from the 
8th to the 13th day, every one of these 
days being critical; but death may take 
place at any period, as seen in Table III. : 
the extremes being the 2d day in one in- 
stance, and the 168th in another. Pa- 
tients may even die of the severity of the 
blood-poison from Smallpox before any 
eruption has appeared on the skin. 
The following Table, No. III., formed 
from the Register of the Smallpox Hos- 
pital for 10 years-1855 to 1864-shows 
the days of eruption on which 987 cases 
proved fatal: by adding two days to any 
given number the period of illness may 
be known. Two-thirds of the fatal cases, 
it will be observed, took place during the 
second week of eruption:- 
Showing the days of eruption on which 528 unvaccinated, and 459 vaccinated cases proved 
fatal, from Smallpox, at the Smallpox Hospital, London, for the ten years 1855 to 1864 in- 
clusive, and occurring amongst 1537 unvaccinated, and 5622 vaccinated cases. All patients 
having antecedent or superadded diseases of a fatal character have been excluded from the 
list, so as to represent the deaths from Smallpox alone, as accurately as possible. 
TABLE III. 
Unvaccinated Cases 
Died on the 
Died on the 
Vaccinated Cases. 
' 2d day of eruption 0 
3d 2 
4th 9 
5th 15 
6th 18 
. 7th 27 
2d day of eruption 1 
3d 2 
4th .... . 7 
5th 7 
6th 17 
7th 23 
1st week 
71 
57 
'8th 53 
9th 67 
10th 52 
11th 60 
12th 52 
13th 39 
14th 27 
' 8th 32 
9th 50 
10th 57 
11th 64 
12th 39 
13th 28 
14th 36 
2d week 
• 350 
306 
15th 21 
16th 17 
17th 8 
18th 10 
19th 5 
20th 6 
21st 0 
15th 13 
16th 12 
17th 8 
18th 7 
19 th 8 
20th 5 
21st 5 
3d week 
67 
58 
22d 2 
23d 2 
24th 0 
25th 3 
26th 4 
27th 3 
28th 7 
22d 4 
23d 1 
24th . ... . 4 
25th 4 
26th 4 
27th 3 
28th 1 
21 
21 
4th week 
Upwards of four weeks 
19 
17 
VOL. I.-10 
528 
Upwards of four weeks 
459 146 
SMALLPOX. 
Morbid Appearances.-In all cases 
of death from Smallpox, the skin will ex- 
hibit, of course, different diseased appear- 
ances, according to the stage of illness at 
which the person has died. The most 
striking morbid results of internal parts 
are those displayed on opening the larynx 
and trachea, with its branches. These 
phenomena are peculiar to Smallpox. 
When the air-passages have been much 
affected by the disease, and when death 
has followed on the eighth or ninth day, 
the mucous membrane is found to be very 
much congested and inflamed, the epithe- 
lium in some instances separated, caused 
probably, Dr. Petzholdt thinks, by fluid 
effused between it and the mucous mem- 
brane, so as to produce vesication. It is 
also covered with a very viscid mucous 
secretion of a brown color. After this is 
removed, the membrane appears thick- 
ened, pulpy, and in some instances ulcer- 
ated. 
The next most remarkable morbid con- 
dition found in the dead from Smallpox, 
is the state of the chest after pleurisy. 
This can hardly be said to be peculiar to 
the disease, because a very similar state 
occurs after common inflammation. One 
side of the chest only is affected with va- 
riolous pleurisy ; except, perhaps, in some 
very rare instances. The cavity of the 
chest is found filled with sero-purulent 
fluid ; flakes of coagulable lymph floating 
in it; adhesions here and there between 
the pleura costalis and pleura pulmonalis, 
and the lung on that side of the chest 
rendered unusable from the pressure of 
the effused fluid. 
Considerable difference of opinion has 
existed as to whether the pustules of 
Smallpox are ever to be found on the 
lining membrane of the alimentary canal. 
We do not believe that they are; at all 
events we have never found them there. 
If they ever exist, it is in some such rare 
cases as that reported by Dr. Patterson,1 
in which he believes he observed pustules 
on the mucous membrane of the colon. 
Sir Gilbert Blane, Rostan, and others 
have reported cases to a similar effect. 
The majority of writers on Smallpox be- 
lieve that ulcerated spots on the mucous 
membrane of the intestines are due to 
other causes. Sir Thomas Watson says :2 
"It is affirmed by some writers that the 
pustules of Smallpox occur in various in- 
ternal parts of the body, and especially 
upon the mucous membrane of the intes- 
tinal canal. I believe this to be a mis- 
take. The enlarged solitary follicles often 
put on very much the appearance of pus- 
tules. " 
"Many pathologists," writes Dr. Gre- 
gory,1 "•have expressed their belief that 
true variolous pustules have been found 
in the gastro-enterie mucous membrane. 
Others, again, among whom may be men- 
tioned Cotunnius, Wrisberg, and Reil 
(who have paid great attention to the 
subject), are of opinion that this structure 
is incapable of developing variolous pus- 
tules, and that the appearances so de- 
scribed are in reality inflamed, enlarged, 
or ulcerated follicles, with petechial patch- 
es, similar in all respects to what are 
found in the common forms of idiopathic 
or typhoid fever. This pathological prin- 
ciple is fully borne out by the experience 
of the Smallpox Hospital. We may add, 
however, that even these appearances are 
very rare, and that the freedom of the 
abdominal viscera from urgent symptoms 
during life, and from all trace of disorgani- 
zation after death, is a remarkable feature 
in the disorder. Inflammation may, in- 
deed, originate from accidental causes in 
any internal organ during the progress of 
Smallpox, and its effects will be seen after 
death ; but these are not to be confounded 
with the specific and acknowledged effects 
of the variolous poison upon the skin and 
mucous membranes of the throat and 
chest." 
If vesicles of Smallpox are found on the 
gastro-intestinal mucous membrane, their 
course must be very similar to that de- 
scribed in the following quotation from 
Petzholdt, in the Brit, and For. Med. 
Rev. vol. v. p. 473: "There appear on 
the lips and inner sides of the cheeks, 
small white spots, of a round or oval form, 
the centre of which is very frequently 
somewhat darker in color. The epithe- 
lium is at these places much softened, 
and at length rises so as to form a small 
white vesicle, which is at no period 
transparent, the softened epithelium re- 
maining always opaque ami white; it is 
incapable of any great expansion by the 
fluid collecting beneath it, and soon 
bursts. The subjacent mucous mem- 
brane is to be seen at some points eroded 
on its surface. The course of such a 
pock is, consequently, very brief; the 
constantly moist state of the mouth ren- 
dering its actual filling with pus and desic- 
cation, with the formation of a scab, alto- 
gether impossible." 
When the lungs have become inflamed 
during or after the secondary fever of 
Smallpox, the morbid consequences will 
be found to be such as are observed after 
congestive pneumonia. 
Bronchitis occurring during the pro- 
gress of Smallpox leaves results similar 
to those seen after bronchitis generally. 
But we believe we have repeatedly ob- 
served, both during life and after death, 
1 Edinburgh Monthly Journal of Med. Sci- 
ence, Feb. 1849, p. 549. 
s Principles and Practice of Physic, 4th 
Edition, p. 862. 
1 Library of Medicine, vol. i. p. 308. anatomical characters of the variolous pock. 
147 
the air-passages, larynx, trachea, and 
bronchi, all or some parts of them,-the 
larynx and trachea especially,-affected 
with erysipelas, leaving such morbid traces 
as might be expected after this low form 
of inflammation. 
Anatomical Characters of the 
Variolous Pock.-The variolous pock 
has been carefully examined with a view 
of describing its structure, by John Hun- 
ter, Dr. Adams, Petzholdt, Erasmus Wil- 
son, Dr. Gustav Simon, and others. It 
is not so easy as might be supposed to 
fix on the exact spot where the variolous 
pock first begins to be formed. On ex- 
amining a piece of skin of a person who 
has died on the third day of the eruption, 
there will be found to be patches of a 
whitish opaque substance between the 
epidermis and the true skin. These 
patches adhere firmly to the true skin, 
but, as Petzholdt says, they may be re- 
moved by syringing the part carefully 
with water, leaving the true skin nearly 
free from the new substance. If the epi- 
dermis, which includes the cuticle, proper- 
ly so called, and the rete mucosum1 "be 
examined when the eruption of Smallpox 
first breaks out, its undermost layers are 
found to be softened, almost spongy, and 
as if filled with a fluid. If a circular in- 
cision be made into the skin round the 
circumference of a papula, this, being 
loosened by the cut from its lateral con- 
nection with the skin, can be removed 
pretty easily with the pincers, in the form 
of a little knot. This experiment shows 
that, at the period of the disease in ques- 
tion, the connection of the cuticle with 
the cutis is nearly destroyed at those 
parts of the skin which are affected, whilst 
a perpendicular section affords us a ready 
opportunity of satisfying ourselves that 
there is no cavity beneath the cuticle. 
During the growth of the pustules, the 
spongy softening of the cuticle is in- 
creased ; a still greater quantity of fluid 
collects between the substance of its low- 
est layers ; there at length arises a small 
cavity filled with fluid, and, by the in- 
creased accumulation of this fluid the cu- 
ticle is gradually pushed upwards." 
" When the thin covering of a part of the 
skin occupied by a pock is removed, the 
cutis does not come immediately into 
view, but it is covered by a substance, 
varying in color and consistence accord- 
ing to the degree of ripening of the pus- 
tule. At the time at which the formation 
of the cavity or hole described in the pre- 
ceding paragraph commences, the fluid 
that covers the cutis is clear; at a later 
period it is turbid, more tenacious, and at 
length it becomes pure pus. If all these 
matters be removed, which is best done 
by a pretty strong stream of water from a 
small syringe, so as not to injure any of 
the subjacent parts, the following appear- 
ances can be seen with the aid of a micro- 
scope : In all the pocks where pus has 
formed, there remains some of it behind, 
which cannot be washed off; and if we 
employ for these investigations portions 
of skin that have had their vessels filled 
with red coloring matter, it can be seen 
with the naked eye that the pus is, as it 
were, wedged in between the bundles of 
vessels, and is retained by them and be- 
tween them." 
The depression in the pocks Dr. Petz- 
holdt thinks is caused by the ducts of the 
cutaneous glands, which are ruptured as 
the pustules fill with pus and maturate, 
but which, in the early period of the erup- 
tion, bind down the cuticle to the cuta- 
neous glands, and thus produce the pit or 
umbilicus. 
Sir Thomas Watson says:1 "Without 
going minutely into the anatomy of the 
pustules, you may distinctly see if you 
closely examine them when they are five 
or six days old-you may see, at least, in 
many of them-two colors, viz., a central 
whitish disk of lymph, set in, or surround- 
ed by, a circle of yellow puriform matter. 
In truth, there is, in the centre, a reside, 
which is distinct from the pus. You may 
puncture the vesicle, and empty it of its 
contents, without letting out any of the 
pus: or you may puncture the part con- 
taining the pus, and let that out, without 
evacuating the contents of the vesicle. 
The vesicles have even, by careful dissec- 
tion, been taken out entire; and they are 
said to consist of several little cells. It is 
most probable that the lymph contained 
in this separate vesicle is the purest part 
of the variolous poison." 
Mr. Erasmus Wilson writes:2 "When 
a well-formed and mature pustule is ex- 
amined by dissection, it is found to be di- 
vided in its interior by a transverse sep- 
tum into two chambers, both containing 
pus. The upper chamber is the larger of 
the two, and they communicate with each 
other, to a greater or less extent, by the 
rupture of the transverse septum around 
its marginal border. The epidermis form- 
ing the superficial boundary of the pus- 
tule is the segment of a sphere, and con- 
tinuous by its circumference with the 
cuticle covering the adjoining skin. The 
transverse septum is a layer of false mem- 
brane, of a whitish color, which was de- 
posited on the derma at an early stage of 
the pustule. Subsequently this layer be- 
comes separated from the derma, and 
* Principles and Practice of Physic, 4th 
Edition, p. 865. 
2 On Diseases of the Skin, 4th Edition, p. 
489. 
1 British, and Foreign Med. Review, vol. v. 
p. 470. 148 
SMALLPOX. 
raised by the formation of pus beneath it, 
and at the same time it is broken around 
its edges, and permits the pus of the 
deeper cavity to communicate with that 
already contained in the superficial cham- 
ber. In consequence of the peculiarity in 
the mode of its production, this layer of 
false membrane generally retains perma- 
nently the umbilicated form of the primi- 
tive pustule, and is thinner at the centre 
than towards its circumference. When 
the septum is removed, the deep chamber 
is brought into view, and the depressed 
and sometimes ulcerated base of the pock 
exposed. The surface of the base is of a 
bright or purplish-red color, and highly 
vascular. 
"Some difference of opinion subsists 
with regard to the cause of the umbili- 
cated appearance of the pustule of Variola 
during its early stages. Dr. Ileming 
many years since attributed it to the per- 
foration of the pustule by the efferent duct 
of a sebiparous gland. Velpeau, who be- 
lieves that the principal seat of Smallpox 
is the follicles of the derma, would, I sup- 
pose, entertain the same opinion. Other 
writers believe it to be produced by the 
pores of the skin, and Rayer refers it to 
the attachment of the false membrane. I 
agree with Velpeau that the follicles of 
the skin are the primary seat of the vas- 
cular congestion, that this congestion 
gives rise to the production of the papules 
or vari, and consequently that the epi- 
dermal sheath of the follicle is the proba- 
ble cause of the umbilication of the Small- 
pox vesicle. When the vesicle is examined 
at its height of development, it is found 
to be multilocular in structure, and, when 
divided by a transverse section, exhibits 
an appearance which Gendrin has com- 
pared to a spice-box, while Bosquet likens 
it to a severed orange." 
Dr. Gustav Simon1 takes a different 
view of the subject: "I have found that 
variolous pustules are not always consti- 
tuted entirely alike. In many cases where 
a central depression clearly existed, the 
epidermis was entirely raised from the 
subjacent cutis ; and only at the spot cor- 
responding with the umbilicus were both 
membranes united by a thin, whitish 
cord, which, as the microscope evidently 
showed, was a hair-sac. Upon the under 
surface of the epidermis, and for the most 
part also upon the upper surface of the 
cutis, was found a thin layer of a whitish 
mass, which, when looked at with the 
naked eye, possessed the characters indi- 
cated by Rayer;" which are, that "there 
exists in the Smallpox pustule, between 
the cutis and the cuticle, a false mem- 
brane, which in shape resembles a trun- 
cated cone, and has a thickness of half a 
line." " The layer fixed to the epidermis 
was not connected with that lying upon 
the cutis ; nor when the latter layer was 
absent, with the cutis itself; but the hair- 
sacs, ascending from the cutis to the epi- 
dermis, alone connected the two mem- 
branes." 
"Other vesicles manifested a structure 
somewhat different from the above. In 
these also there appeared beneath the epi- 
dermis a white substance; but this, at the 
spot where externally the umbilicus was 
visible, adhered to the surface of the co- 
rium, so that the epidermis seemed fixed 
to the cutis by this white mass alone. 
Now as regards the white mass beneath 
the epidermic covering of the vesicles, 
and often also apparent upon the surface 
of the cutis, which most modern writers 
take for a false membrane, it consists, for 
the most part, of the deeper softened 
layers of the cuticle," &c. "As we are 
accustomed to give the name of false 
membranes to layers of coagulated fibrine, 
we cannot include the above-described 
white mass under this appellation; for, 
as I have before shown, the epidermic ele- 
ments always form its major part." 
"The fact that the described white 
mass, at certain spots of the vesicle, is 
prolonged uninterruptedly from the under 
surface of the epidermis to the cutis, 
while at other points this connection is 
interrupted by the dissociation of the un- 
der layers of the epidermis, or by the 
complete separation of the cuticle from 
the cutis-this fact, I repeat, is the occa- 
sion of the little divisions, or compart- 
ments, mentioned by most authors. These 
are usually of unequal magnitude and ir- 
regularly arranged; but sometimes I have 
seen them arranged with tolerable regu- 
larity. In cases of the latter kind, the 
white mass extended itself from the mid- 
dle of the vesicle in the shape of little 
septa, like the rays of a circle, to the peri- 
phery, so that six or eight chambers of 
tolerably equal size were formed. In the 
middle of the vesicle, from which the ir- 
regularly arranged septa proceeded, a 
hair-sac was sometimes found. Fre- 
quently no separate compartments at all 
existed. In vesicles of this sort the epi- 
dermis was connected to the cutis in the 
middle by a thin white cord, or over a 
larger space; and around this centre ran 
a canal, into which the white mass ex- 
tended, in the form of little clusters or 
lamellae; but the canal was at no point 
interrupted by a complete partition. 
Rayer appears to have observed the same 
thing." 
The reviewer says:1 " That the produc- 
tion of an umbilicus is not dependent on 
the presence of a hair-sac or sebaceous 
1 British and Foreign Med. Rev., vol. iii. 
1849, p. 350. 
1 British and Foreign Med.-Chir. Rev., vol. 
iii. p. 352. SMALLPOX AFTER VACCINATION. 
149 
follicle, is easily proved; for it is well 
known that neither exists in the hollow 
of the hand and foot: yet in children, in 
whom the thin epidermis permits it to 
appear, the central depression is fre- 
quently excellently marked. A remark- 
able peculiarity, first noticed by Bayer, 
characterizes the variolous vesicle, formed 
beneath the horny cuticle, which, in the 
adult, invests the palm of the hand and 
the sole of the foot. On removing the 
epidermic cap of the vesicle and wiping 
off the fluid collected beneath, he observed 
that in the centre of the denuded corium 
a little elevation existed, while the cir- 
cumference was visibly depressed below 
the level of the neighboring healthy cutis. 
Dr. Simon has examined these points mi- 
croscopically, and he finds that the central 
elevation consists of a file of papilla? of 
normal or nearly normal size and condi- 
tion, while the depressed margin is paved 
with papillae, bent down or flattened. The 
explanation is simple. At the centre of 
the vesicle, an organic connection (from 
some yet unexplained cause) exists be- 
tween the cutis and cuticle, and at this 
point no fluid is effused; but around this 
centre, exudation of fluid occurs without 
impediment, and tends to force the cutis 
and cuticle asunder. In other localities 
the cuticle yields, and rises everywhere, 
except at the umbilicus of the vesicle; but 
there the texture of the cuticle is so dense, 
and presents such great resistance to the 
distending power, that the cutis itself 
yields first, and sinks below the ordinary 
level. " " Of the anatomy of pustules, Dr. 
Simon remarks, that the pus frequently 
exists between the cutis and cuticle, the 
process of suppuration commencing upon 
the surface of the cutis; but that fre- 
quently, also, the suppuration begins in 
the tissues of the cutis, extending thence 
beneath the epidermis." 
The following is Wedl's view of the sub- 
ject :* "External integuments.-Exuda- 
tions in this situation are particularly fit- 
ted for study, being accessible to observa- 
tion even during life. The most frequent 
are those which take place in the cuta- 
neous papillce, in which they are either 
confined to small limited districts, within 
which the exudation takes place around 
isolated groups of papillce, or are more 
extensive. An instance of the former 
kind, or of a limited exudation, is afforded 
in Smallpox, in which the spots are at 
first filled with a limpid fluid, containing 
nothing but molecules, and do not become 
pustules till afterwards, when pus-corpus- 
cles are developed in the hyaline exuda- 
tion. The transudation takes place from 
the capillary system of the papillce, the 
exudation as it is poured out gradually 
accumulating between the under surface 
of the epidermis and the upper surface of 
the corium. But since the process is con- 
fined to limited groups of papilke, the epi- 
dermis covering the latter is raised in the 
form of a transparent vesicle, whilst the 
spot at which the hair escapes from its 
sheath, together with the excretory duct 
of the sebaceous follicle, remains depress- 
ed, and constitutes the central pit of the 
vesicle. In those parts of the skin where 
no hairs nor sebaceous follicles exist, as in 
the palm of the hand and sole of the foot, 
the exudation deposited around a point 
where several of the deeper grooves in the 
corium meet, may cause a similar pit, 
since in a situation of this kind the epi- 
dermis constitutes a stronger layer, and is 
of closer texture. When the puriform 
fluid io the pustules begins to dry up, the 
pit becomes shallower and wider, owing 
to the subsidence of the swelling. In the 
integuments of a subject dead of Small- 
pox, it is easy to perceive that the vessels 
of the papilloe are more or less injected, 
when the skin has been macerated long 
enough to allow of the removal of the epi- 
dermis, beneath which the isolated patches 
of vascular injection are immediately ap- 
parent. Perpendicular sections show that 
the papilloe are the constant and principal 
seat of the injection; and it is from their 
vessels also that the hemorrhage takes 
place, in cases of petechial Smallpox." 
Smallpox after Vaccination.- 
Varicelloid, and Modified Small- 
pox. 
Vaccination was announced to the pub- 
lic by Jenner, in 1798. The then preva- 
lent practice of inoculation for Smallpox 
gave origin, no doubt, to the idea in the 
mind of Jenner, of performing a similar 
operation with vaccine lymph; coupled 
with the popular belief among the peas- 
antry of Gloucestershire, that once having 
taken the disease from the cow, in milk- 
ing these animals, such persons remained 
ever afterwards proof against the infection 
of Smallpox. Great hopes were enter- 
tained at first, and for some years, that 
all who availed themselves of vaccination 
would remain secure against Smallpox for 
the remainder of their lives. Indepen- 
dently of the popular belief that cowpox 
afforded protection against Smallpox, it 
was thought by Jenner and the medical 
profession generally, that as there was 
great similarity, if not identity, between 
vaccinia and Variola, and as Variola was 
believed to occur but seldom a second 
time, the same law it was imagined would 
govern the two diseases-that those who 
had had the vaccine disease would remain 
ever after, or nearly so, secure against 
1 Rudiments of Pathological Histology, by 
Carl Wedl, M.D. Translated by George 
Busk, F.R.S., Sydenham Society, p. 206. 150 
SMALLPOX. 
Smallpox; that they would enjoy the same 
immunity as those who had already had 
Smallpox, or at least as those who had 
been inoculated for this disease. 
Unfortunately this doctrine has not 
been altogether realized in practice. It 
has before been shown, p. 139, that at a 
time when there were probably about as 
many persons in England who had had 
Smallpox, or had been inoculated for 
Smallpox, as had been vaccinated, the 
numbers of those admitted into the Small- 
pox Hospital with Smallpox for a series 
of years, were but as 1 per cent, after 
Smallpox or inoculation, to 53 per cent, 
after vaccination. Notwithstanding this 
apparent drawback of vaccination from 
the first statements made about it, it was 
the greatest discovery in relation to dis- 
ease ever made by man for the preserva- 
tion of human life. The misfortune was 
that too much had been promised for it at 
first. Another great misfortune was, 
greater perhaps practically than the first, 
the public were taught to believe that the 
operation was so simple, and required so 
little knowledge and care, that anybody 
might perform it; and thus it has been in 
a great measure left to chance in England. 
It has never been taught by appointed 
teachers until five or six years ago, and 
even now it has not been taken up in a 
proper spirit, and treated by those in 
authority at the examining boards as it 
ought to be, and from its intrinsic import- 
ance really deserves to be. Nearly all 
that has been done in England, in regard 
to the more effectual performance of vac- 
cination, and teaching of students, has 
been done at the suggestion and earnest 
entreaty of Mr. Simon, the able and 
zealous Medical Officer of the Privy Coun- 
cil ; not, as we might reasonably have ex- 
pected, by the Councils of our medical 
and surgical Corporations, who have the 
supervision and direction of medical edu- 
cation. Great care is given to teaching 
and learning the capital operations, as 
they are called, which not one practitioner 
in twenty through the whole country ever 
performs; no care, or next to none, to 
teaching and learning the other, which 
nearly all, when in practice, will have to 
perform frequently. Had certificates, 
fortunately, of having received instruction 
in vaccination been required of students 
at the examining boards, as they ought to 
have been, forty or fifty years since, hun- 
dreds of persons who have died, and 
thousands still living who have been 
badly vaccinated, and will still die of 
Smallpox after vaccination, might have 
been saved. As medical and surgical 
practitioners, our object should be to save 
all the lives we can by our art, no matter 
by what means ; and if a little operation 
-little apparently in practice, but very 
important in its results-well performed 
can save many lives, as most certainly it 
can, and prevent much suffering and sor- 
row, it should surely always be done with 
the greatest care, and in the best known 
way. The success of all operations de- 
pends on nice care and management. 
Operations for hernia and for stone, for 
instance, if roughly, carelessly, and badly 
done, end badly ; so it is with vaccina- 
tion : and so far as the public are con- 
cerned, it is quite as objectionable to 
them, no doubt, to die of Smallpox be- 
cause they have been carelessly and badly 
vaccinated, as it would be to them to die 
of hernia or stone because the operations 
for these complaints, respectively, had 
been badly performed. In the latter 
cases, the day of retribution would come 
immediately ; in the former, unfortunately 
for its correction, it is delayed for perhaps 
twenty years, or more; otherwise, it 
would soon be set right. The operation, 
as an operation, has not been properly 
estimated from the first introduction of it 
in England, and it should be looked upon 
as a blot on our polity that vaccination has 
been worse performed, generally, in Eng- 
land, its birthplace, than in any country 
in Europe.1 
Some cases of Smallpox after vaccina- 
tion were brought forward a few years 
after its first introduction into practice; 
and, in 1818, a work appeared by Dr. 
Monro, of Edinburgh,2 treating particu- 
larly on the subject. In 1819, nineteen 
cases of Smallpox after vaccination were 
admitted into the Smallpox Hospital, 
London, according to the Report of Dr. 
Ashburner, then physician to the hospital, 
to the Court of Governors of the hospital 
held at the end of that year. In 1820 the 
work of Dr. John Thomson3 was pub- 
lished, describing the disease which had 
lately prevailed in Scotland, and naming 
it a "'Varioloid Epidemic." In 1824 
Smallpox after vaccination prevailed to a 
great extent in Sweden. In 1825 Small- 
pox was epidemic in London, and at- 
tacked several persons who had been vac- 
cinated, 147 of whom were admitted in 
that year into the Smallpox Hospital. 
In 1828 there was a severe epidemic of 
Smallpox in Marseilles, when about 2000 
were attacked who had been vaccinated. 
Between July 1831 and June 1836, as re- 
ported by Dr. Heim, 955 persons were 
attacked with Smallpox after vaccination 
in the kingdom of Wirtemberg, of whom 
75 died, or 7'8 per cent. From this period 
1 See Med.-Chir. Trans., vol. xxxvi. p. 381. 
2 Observations on the different kinds of 
Smallpox, and especially on that which 
sometimes follows Vaccination. Edinburgh, 
1818. 
3 An Account of the Varioloid Epidemic, 
which has lately prevailed in Edinburgh and 
other parts of Scotland, 1820. SMALLPOX AFTER VACCINATION. 
151 
cases of Smallpox after vaccination have 
kept gradually increasing in numbers, 
until they now amount to four-fifths of 
the admissions into the Smallpox Hos- 
pital. 
The introduction of vaccination has 
rendered the diagnosis and course of 
Smallpox, and consequently the study of 
the disease, far more intricate than it 
used to be in former days, and now is in 
the unvaccinated. The phases of the dis- 
ease have been made by vaccination far 
more numerous than they were before. 
A large majority of the cases of Smallpox 
occur at the present time (1865) after vac- 
cination. Thirty years since, from 1835 
to 1845, the admissions of patients into 
the Smallpox Hospital were 44 per cent. 
of Smallpox after vaccination; from 1845 
to 1855, 64 per cent.; from 1855 to 1865, 
78 per cent.; and during the last two years 
(1863-4), 83 and 84 per cent, respectively. 
It will therefore be seen that they are 
gradually increasing in numbers; and, 
now that vaccination has been made by 
law compulsory in England, the percent- 
age of cases of Smallpox after vaccination 
will no doubt go on increasing, until it 
will be rather a rare circumstance to see 
Smallpox in the unvaccinated, at least in 
the adult. Unfortunately, the number of 
admissions into the hospital keeps also 
increasing, owing principally, doubtless, 
to the rapid increase of the population of 
the metropolis, thus :- 
Admissions into the 
Smallpox Hospital, 1835 to 1845-3494. 
" " " 1845 " 1855-4546. 
" " " 1855 " 1865-7326. 
Now there can be no doubt that what 
has been observed for the last thirty years 
at the Smallpox Hospital, London, in re- 
lation to the occurrence of Smallpox after 
vaccination, has been going on, in much 
the same way, all over the country, wher- 
ever Smallpox has prevailed.1 
The disease, as modified by vaccination, 
received the name of "varioloid," first 
suggested for it by Dr. John Thomson, of 
Edinburgh, who wrote a work on the sub- 
ject in 18'20.2 This word "varioloid" has 
been adopted generally throughout Europe 
by writers on Smallpox-in France, Ger- 
many, Denmark, &c. &c.-in treating of 
Smallpox as modified by vaccination. It 
appears to us not to have been well chosen, 
inasmuch as the disease is not simply 
" like" Smallpox, as the name implies ; it 
is Smallpox : it will give the disease in 
the most severe form, in the natural way, 
by infection, to the unvaccinated, and 
will produce Smallpox by inoculation just 
as a case of Smallpox uninfluenced' by 
vaccination will do. There is not a good 
name, perhaps, for it at present. When 
the disease is highly influenced, and 
altered in its course, rendered mild, by 
vaccination, we call it, at the Smallpox 
Hospital, Variola Varicelloides1-Variola 
like Varicella, which is a better term than 
"varioloid," the meaning of which is 
simply, "like Variola not a very satis- 
factory way of explaining what is meant. 
Perhaps the best term for it is, "Smallpox 
modified by vaccination," when it is modi- 
fied ; but it is not always modified in per- 
sons who have been vaccinated. Besides, 
there are various degrees of modification, 
•when it is modified ; it is not always even 
like Varicella unfortunately, but often 
hardly modified at all, and such patients 
frequently die. Smallpox after vaccina- 
tion has, in fact, various degrees of sever- 
ity and modification, from the slightest 
form in which there is none, or hardly any 
eruption at all, to the most severe con- 
fluent cases, closely, often exactly, resem- 
bling the disease in the unvaccinated ; 
and it also assumes the petechial and 
malignant types after vaccination just as 
in the unvaccinated state. All this de- 
pends in a great measure on the way in 
which patients have been vaccinated. 
Those who have been fortunate enough to 
have been vaccinated in four or more 
places with lymph that leaves good, easily 
perceptible cicatrices, have almost invari- 
ably a slight form of Smallpox when it 
occurs ; but those who have only one or 
two marks from vaccination, such as are 
hardly visible, will probably have a severe 
form of the disease ; and those who have 
no marks at all are in still worse circum- 
stances. Now, although this rule holds 
good generally, almost invariably, still it is 
not an invariable rule ; and perhaps more 
exceptions will be found-we may say 
will certainly be found-in those who have 
been indifferently vaccinated, than in 
those who have been well vaccinated. 
Persons seemingly indifferently vaccinated 
will oftener afterwards have a light form 
of Smallpox than well-vaccinated persons 
will have a severe form of the disease. 
So far it is fortunate. But what we con- 
tend for, and always have contended for, 
is that, if possible, all should be vaccinated 
in the best way; at least the attempt should 
be made to vaccinate all in the best way, 
that there should be as little as possible of 
hap-hazard vaccination, done with a view 
1 See Report of the Smallpox and Vaccina- 
tion Committee of the Epidemiological Soci- 
ety, ably drawn up by Edward Cator Seaton, 
M.D., Hon. Sec. to the Committee, 1853. Also 
a valuable contribution by the same author, 
"On the Protective and Modifying Powers of 
Vaccination,"-a pamphlet, reprinted from 
the Journal of Public Health and Sanitary 
Review, 1857. 
2 An Account of the Varioloid Epidemic of 
Scotland. 
1 [Varioloid is the term commonly used in 
America.-H.l 152 
SMALLPOX. 
that if the operation takes effect badly it 
can be done again. By such a proceeding 
persons often take vaccination badly, ami 
cannot be made to take it properl}' after- 
wards ; the imperfect success prevents its 
taking fully again, and yet some day they 
may take Smallpox severely, and perhaps 
die of it. Every effort should therefore be 
made that there may be as few imperfect 
vaccinations as possible. 
It is, however, undeniable that a few 
eases occur even to the best vaccinators 
that do not take the vaccination well. 
Children sometimes fall ill from other 
causes just after being vaccinated. There 
cannot always be good subjects at hand to 
vaccinate from ; the weather and other 
circumstances interfere with the regular 
attendance of those who have been vacci- 
nated to afford supplies of lymph for the 
vaccination of others; but careless and 
bad vaccinators avail themselves of these 
untoward circumstances as an excuse for 
having frequent failures. Great care and 
great nicety of management are requisite 
for uniform or almost uniform success in 
vaccinating, and without the observance 
of this nice care and management many 
.cases of vaccination do badly, or do not 
take at all: after two or three failures the 
friends of a child are led to think it can- 
not be got to take the vaccination, and 
they neglect to have further trials made, 
and ultimately the child takes Smallpox, 
perhaps severely ; such results are of fre- 
quent occurrence. 
TABLE IV. 
Analysis of all the cases of Smallpox after Vaccination, admitted at the Smallpox and Vacci- 
nation Hospital, London, for a period of 20 years, viz., from 1836 to 1855, inclusive, show- 
ing, from a careful examination of the cicatrices, the relative amount of security given by 
the number of vesicles produced at vaccination ; and, judging from the character of the 
cicatrices, the probable state of activity and efficacy of the lymph used for Vaccination. 
Kesvltb. 
Patients admitted with Smallpox. 
jo 
Character of 
Cicatrices. 
■ Cases. 
1 Discharged. 
Died. 
Died affected 
by superadded 
disease. 
Kate per cent, of 
Mortality from 
Smallpox, after 
deducting entirely 
the cases affected 
by superadded 
disease. 
1. 
Having one vaccine cicatrix . . 
2001 J 
good 
indifferent 
1032 
969 
978 
835 
54 
134 
15 
21 
3*83 
11-91 
[7-73 
:2. 
Having two vaccine cicatrices . 
1446 J 
good 
indifferent 
873 
573 
841 
516 
32 
57 
12 
10 
2-32 
8-34 
[4-70 
3. 
Having three vaccine cicatrices 
518 | 
good 
indifferent 
307 
211 
300 
202 
7 
9 
4 
2 
0-99 
3*34 
(1-95 
4. 
Having four or more vaccine ) 
cicatrices ) 
544 | 
good 
indifferent 
358 
186 
356 
183 
2 
3 
0 
2 
0-55 
0-54 
[ 0-55 
5. 
Stated to have been vaccina- ) 
ted, but having no cicatrix j 
370 
370 
269 
101 
18 
23-57 
6. 
Stated to have been vaccina- 1 
ted, but particulars of cica- > 
trix not recorded ) 
17 
17 
14 
3 
6-66 
4896 
4896 
4494 
402 
86 
6-56 
Notes.- A good vaccine cicatrix may be described as distinct, foveated, dotted, or indented, 
in some instances radiated, and having a well, or tolerably well, defined edge. 
An indifferent cicatrix-as indistinct, smooth, without indentation, and with an irregular 
and ill-defined edge. 
Aggregate mortality with good vaccine cicatrices, from Smallpox alone, uninfluenced by 
other diseases, 2*52 per cent. 
Aggregate mortality with indifferent vaccine cicatrices, from Smallpox alone, uninfluenced 
by other diseases, 8'82 per cent. 
There is found to be a mortality of about 2 per cent, in vaccinated as well as unvaccinated 
patients, from Smallpox being complicated with antecedent or superadded diseases. 
From the foregoing Table, No. IV., it 
will be seen that nearly five thousand 
cases of Smallpox after vaccination are re- 
ported on, each case having been carefully 
recorded at the time in the hospital regis- 
ter, and the whole subsequently arranged 
under different headings, so as to show 
the value of the different modes of vacci SMALLPOX AFTER VACCINATION. 
153 
nating, in persons who have had Small- 
pox after having Deen vaccinated several 
years previously. 
Three-fourths of the cases had taken 
the vaccination in but one or two places, 
and among these, by far the largest pro- 
portionate mortality from Smallpox has 
fallen ; and what should also be strongly 
impressed upon the memory is, that by far 
the largest amount of suffering and dis- 
figurement have been produced in those 
in this category who recovered. It is not 
simply those who died in the one class of 
cases that suffered more than others to 
which we are desirous of drawing the 
attention, but to those belonging to this 
class who escaped dying that also suffered 
and were disfigured, a great deal more 
than those in another class in whom the 
vaccination had taken effect in four or 
more places and recovered. This is very 
important to keep in mind. By vaccinat- 
ing so as to take effect in four or more 
places, we not only save life, but prevent 
a great deal of suffering and subsequent 
damage to the appearance of the person, 
which in females, at least, is of great con- 
sequence, and not always quite a matter 
of indifference to males. 
It will be observed that of 544 cases 
having four or more vaccine cicatrices, 
only half of 1 per cent, died of Smallpox, 
or 1 in 200; whereas of 969 cases; with 
only one indifferent vaccine cicatrix, just 
upon 12 per cent, died; in each instance 
antecedent or superadded disease has been 
deducted, so as to leave the death, as far 
as could be known, purely the result of 
Smallpox. Here, then, is a very import- 
ant practical point to bear in mind when 
vaccinating: if only one indifferent cica- 
trix remains from the operation, such 
persons, taking Smallpox in after life, die 
at the rate of 12 per cent. ; on the other 
hand, if four or more cicatrices remain, 
only half of 1 per cent, will die of Small- 
pox. 
It should be further observed, that of 
370 persons who believed themselves vac- 
cinated, but who had no cicatrix to show 
for having been vaccinated, but who 
trusted to it for their protection, they 
died of Smallpox at the rate of 234 per 
cent. This again is a very important 
practical point to bear in mind ; persons 
having no cicatrix remaining from vacci- 
nation should by all means be urged to be 
re-vaccinated, else they may very likely 
some day fall a prey to Smallpox; such 
persons are in a very unsafe position. 
Now, what has been going on in Lon- 
don for years past, as seen in patients 
who have been admitted with Smallpox 
at the hospital, has been going on also, 
there can be no doubt, all over the coun- 
try, in persons who bave gone through 
the disease elsewhere -a very large 
majority of the patients admitted at the 
hospital are not Londoners, but persons 
who have come to London from the coun- 
try, to serve in the capacity of servants, or 
are employed in different ways of business. 
They were vaccinated in the country. 
The security of vaccinated persons will 
be seen by Table IV. gradually to rise, 
not only from the number of cicatrices 
produced at vaccination, but also accord- 
ing to the quality of the cicatrices, agree- 
ing with the description given, in the 
notes of the Table, of the characteristics 
of good and indifferent cicatrices. Active 
vaccine lymph, such as leaves clear per- 
manent cicatrices, is evidently indicated 
as the most desirable to select for use in 
vaccinating. Another recommendation 
is, that it takes effect more readily at the 
time of using it. Long humanized lymph 
requires a more dexterous hand to pro- 
duce anything like uniform and perfect 
success. 
In the notes of Table IV. it will be 
seen that the aggregate mortality in per- 
sons who have Smallpox is much less in 
those with good, than in those with indif- 
ferent vaccine cicatrices : thus taking all 
the cases together, regardless of the num- 
ber of cicatrices, those with good cicatrices 
died at the rate of 2| per cent, only ; 
whereas those with indifferent cicatrices 
died at the rate of 8f per cent.: this is 
also a very important subject to remem- 
ber, carrying with it, as it does, the in- 
creased amount of danger and suffering 
when Smallpox arises. One really good, 
circular, radiated, and indented cicatrix, 
is worth two or three indifferent cicatrices 
generally, such as can hardly be seen. 
With good, active, eighth-day lymph, an 
expert vaccinator will hardly ever fail; cer- 
tainly not above once in 150 times. We 
may, indeed, confidently state, from those 
on whom we can rely, and from our own 
experience in vaccinating, that the failures 
will not be nearly so often as once in 150 
times ; they should be very rare occur- 
rences indeed, in good hands. 
In the course of years, vaccine lymph 
becomes humanized, by passing many 
times through the subject, and can only 
be kept in a good state of efficiency by 
having many subjects constantly to select 
from for its continuance, and even then 
the cicatrices it leaves, after many years' 
use, are not so good as they were for- 
merly ; this is a point on which we can 
bear witness from our own experience, 
and it is shown by the above Table how 
very important it is to have lymph that 
leaves good permanent cicatrices. 
Out of large numbers of cases of Small- 
pox after vaccination, viz. 1958, admitted 
into the Smallpox Hospital during the 
years 1863 and 1864-Smallpox having 
been epidemic in London throughout 
these entire years - the mortality after 
vaccination shows a considerable increase. 154 
SMALLPOX 
viz. from 6-5G per cent, as given in Table 
IV., for twenty years-183G to 1855-to a 
mortality of 9'2 per cent, out of 1958 cases 
for the years 18G3-4; all patients mani- 
festing antecedent or superadded diseases 
having been deducted from the calcula- 
tion as in the former instance, in making 
Table IV. 
It is a question that may be fairly and 
properly entertained, and deserves very 
mature deliberation, whether we ought 
not to resort more frequently than has 
hitherto been done to supplies of lymph 
from the cow. A good stock should not 
be carelessly given up ; with many sub- 
jects constantly to operate on, and choose 
from, it can be kept for many years in a 
good active state of efficiency ; and, how- 
ever many may be vaccinated, the lymph 
can only make the circuit of the human 
body fifty-two times every year, yet this 
multiplied by twenty or thirty, as the case 
may be, according to the number of years, 
makes the total number considerable. 
The able and interesting researches of 
Mr. Ccely of Aylesbury,1 by which he 
established the practicability of obtaining 
lymph from the cow, by inoculating these 
animals with the virus of human Small- 
pox, has secured to us the means of pro- 
curing fresh supplies of vaccine lymph 
should it be difficult to meet with the dis- 
ease in its natural state in these animals. 
Mr. Badcock, formerly of Brighton, 
now of Camberwell Grove, informs me 
that he has succeeded thirty-seven times 
during the last twenty-five years, in in- 
oculating the cow with the virus of human 
Smallpox. 
The subject of deterioration of vaccine 
lymph will be of course a disputed point. 
It w ill, perhaps, be argued that diseases 
of this class do not alter ; that they re- 
main perpetually the same ; that Small- 
pox, measles, scarlatina, <fcc., are the same 
now as they wrere originally, and ever will 
be. This argument may be regarded as 
true generally, but it should be remem- 
bered that vaccinia is not genuine Variola, 
even when we know the disease has been 
produced in the cow by inoculation with 
the virus of human Variola. In passing 
the disease through the cow it thereby 
undergoes alteration, and is not after- 
wards communicable to man by infection 
as true Variola is ; nor is vaccinia one of 
the diseases natural to man, but is only 
taken by him through the agency of in- 
oculation : therefore, on this account, it 
is likely from a variety of circumstances 
to undergo degeneration, as it is a disease 
produced at will-artificially-not taken 
when the body is most prone to receive it, 
as we may suppose the body is when dis- 
ease is taken in the natural way. We 
feel bound, however, to state we have fre- 
quently produced, lately, with lymph 
brought into use by Jenner more than 
fifty years since, vaccine vesicles which, 
on comparison, exactly correspond with 
the vesicles sketched in Jenner's original 
work, explaining and illustrating the vac- 
cine disease ; but we also feel bound to 
state for consideration, reflection, and 
practical deduction, the facts with regard 
to Smallpox after vaccination which have 
come before us at the Smallpox Hospital, 
for the last thirty years. 
According to a statement of Dr. San- 
derson,1 as reported to him by the local 
medical practitioners, the cows still suf- 
fer from the true cow-pox every spring, 
or nearly so, in the neighborhood of 
Berkeley, Gloucestershire, the birthplace 
of Jenner. 
Every now and then a patient is ad- 
mitted into the Smallpox Hospital who 
has been vaccinated after the symptoms 
of Smallpox have appeared, the disease 
being known to be Smallpox when the 
vaccination was performed. Several pa- 
tients were thus admitted a few years 
since from one of our largest west-end 
London parishes These vaccinations 
must have been done under a total misap- 
prehension of the powers of vaccination 
to control Smallpox. It does no good 
whatever when so performed, and should 
not be repeated, as it only tends to bring 
vaccination into discredit with the public. 
The facts of the case are these :-Vacci- 
nation to be effective should have gone on 
to the stage of areola before there is any 
illness from Smallpox. It has before been 
stated that when Smallpox has been taken 
into the system there is twelve days' free- 
dom from illness generally, forty-eight 
hours' illness, and then the disease begins 
to appear on the skin. The areola of vac- 
cination is not fully formed until the ninth 
or tenth day of the progress of the vaccine 
vesicles, on those who have never been 
vaccinated before ; so that unless there 
has been time for the areola to be formed 
after the vaccination, before the illness 
produced by Smallpox begins, the vacci- 
nation will not be of the least benefit. 
The progress of vaccination is generally- 
not always-interrupted as soon as the 
illness from Smallpox commences, but as 
it never can be exactly known when 
Smallpox is taken, so long as persons are 
well in a house where it exists it will be 
right to vaccinate or re-vaccinate, as the 
case may be, as soon as possible, all likely 
to contract the disease ; but this is a very 
different thing from vaccinating after the 
1 Observations on the Variolae Vaccinae, 
and Variolation of Cows, by Robert Ceely, 
Esq., Surgeon to the Buckinghamshire In- 
firmary. In Transactions of the Provincial 
Medical and Surgical Association, 1840. 
1 Sixth Report of the Medical Officer of the 
Privy Council, with Appendix, 1863, p. 213. SMALLPOX AFTER VACCINATION. 
155 
symptoms of Smallpox have actually com- 
menced. Example :- Suppose an un- 
vaccinated person to inhale the germ of 
Variola on a Monday : if he be vaccinated 
as late as on the following Wednesday, 
the vaccination will be in time to prevent 
Smallpox being developed ; if it be put 
off until Thursday, the Smallpox will ap- 
pear, but will be modified ; if the vaccina- 
tion be delayed until Friday, it will be of 
no use, it will not have had time to reach 
the stage of areola, the index of safety, 
before the illness of Smallpox begins : this 
we have seen over and over again, and 
know it to be the exact state of the ques- 
tion. Re-vaccination will have effect two 
days later than will vaccination that is 
performed for the first time, because re- 
vaccinated cases reach the stage of areola 
two or three days sooner than in those 
persons vaccinated for the first time. Four 
or five years since, Smallpox occurred in 
a family at Richmond, consisting of a man 
and his wife, and their niece. We received 
the account of the occurrence from the 
man, the only one of the three admitted 
into the hospital. The niece was the first 
attacked with the disease, and died. 
About a fortnight afterwards the woman 
was attacked, and died ; both at Rich- 
mond. During the woman's illness the 
man was vaccinated, and he had five large 
vaccine vesicles on his arm, without any 
areola, on his admission, in the early stage 
of Smallpox, at the hospital. The pro- 
gress of the vaccine vesicles was arrested 
by the Smallpox; the man went through 
confluent Smallpox, wholly unmodified, 
and died. Now had the vaccination been 
performed one day sooner, the Smallpox 
would have been modified-two days 
sooner, and the man would have been 
saved from it altogether: this shows the 
necessity of performing the vaccination as 
promptly as possible in houses where 
Smallpox exists. Three weeks or a month 
had been lost after the first outbreak of 
Smallpox in the house before the vaccina- 
tion was performed on this man. 
lie-vaccination.-It is found on examin- 
ing large numbers of persons attacked 
with Smallpox after vaccination, that the 
majority of those attacked are from eigh- 
teen to twenty-five years old, and that 
they had been almost invariably vacci- 
nated in infancy.1 This may be partly 
accounted for, no doubt, by persons of this 
age coming to London from the country 
to act as servants, in shops, &c. But it 
would seem that all persons at this age 
become more liable to take the disease 
then than earlier, or later in life ; they 
become, in fact, more susceptible to it at 
this age than sooner after vaccination. It 
would, therefore, seem to be a wise course 
to pursue to recommend all persons on 
reaching adult age, especially if about to 
change their place of residence, to be ex- 
amined as to their probable security 
against Smallpox. If they have four or 
more good cicatrices from vaccination they 
are tolerably safe; if, on the other hand, 
they have but one cicatrix, and that such 
as can hardly be seen, or no cicatrix at 
all, such persons had better be re-vacci- 
nated as a matter of precaution. These 
remarks apply especially to persons on 
passing from one part of the world to an- 
other, more particularly if the climate be 
very different from the one where they 
have been living. Any change from either 
a hot to a cold, or colder climate, renders 
persons liable to contract Smallpox. Per- 
sons coming from India to England should 
be re-vaccinated. Vaccination, judging 
from the cicatrices, does not appear to 
take effect so well in India as in England. 
At certain seasons of the year there, dur- 
ing the hot season, the vaccine lymph is 
said to suffer deterioration. However 
this may be, on examining persons who 
have been vaccinated in India, the cica- 
trices left by vaccination will generally 
be found to be very indifferent. Further, 
it would seem, that persons who have 
been inoculated for Smallpox or have had 
Smallpox, are liable to be attacked with 
this disease a second time, under the cir- 
cumstances mentioned, and that a predis- 
position to contract the disease is renewed 
by any great change of climate, either to 
a hotter or colder temperature. 
In commendation of re-vaccination we 
may state that but very few patients have 
been admitted with Smallpox into the 
Smallpox Hospital, who stated that they 
had been re-vaccinated with effect, and 
that these few have had Smallpox in a 
very mild form. For just upon thirty 
years we have re-vaccinated all the nurses 
and servants who had not had Smallpox, 
on their coming to live at the Smallpox 
Hospital, and not one of them has con- 
tracted Smallpox during their stay there. 
Re-vaccination has been extensively prac- 
tised for some years past, at stated inter- 
vals, and seemingly with good effect, on 
the troops of some of the foreign armies, 
more especially and persevcringly on the. 
armies of Germany. Combining all these 
circumstances together, we therefore feel 
perfectly justified in recommending re- 
vaccination for extensive adoption, after 
adult age, in England; especially to per- 
sons who appear, from their cicatrices, to 
have been but indifferently vaccinated in 
infancy. 
For" a very masterly summary of the 
effect produced by vaccination on the in- 
habitants of different parts of the world, 
and a thorough investigation into the 
whole subject of vaccination and Smallpox, 
at home and abroad, we earnestly recom- 
1 See Med.-Chir. Trans., vol. xxxvi. pp. 
377, 380. 156 
SMALLPOX. 
mend to all persons interested in vaccina- 
tion, the perusal of the Blue Book, by 
John Simon, Esq., Medical Officer of the 
Privy Council, entitled " Papers relating 
to the History and Practice of Vaccina- 
tion. 1857." It is to be had of Messrs. 
Longman and Co. 
Epidemic Diffusion of Smallpox. 
-Epidemics of Smallpox begin generally, 
in London, in the autumnal period of the 
year. The moist weather of the autumn 
seems to be favorable to the spread of the 
disease. When, however, it has once been 
set going, it continues often throughout 
all the seasons of the year, quite uninflu- 
enced either by the frosts of winter, or the 
heat of summer. A larger number of pa- 
tients have, on several occasions, during 
epidemic outbreaks of the disease, been 
admitted into the Smallpox Hospital dur- 
ing the month of May than in any other 
month of the year. The present epidemic 
of Smallpox has lasted an unusually long 
time; it has now (September, 1865) been 
going on continuously for three years. 
From 1796 to 1825 there was not any epi- 
demic of Smallpox in London. After that 
came the epidemic of 1838. Since then 
epidemics have followed in rapid succes- 
sion. There was one in the winter of 
1840-1. Smallpox was epidemic again in 
1844-5, in 1848, in 1851-2, in 1854-5-6, in 
1859-60, and in 1863-4-5. The epidemic 
of1844 began in May; all the rest had their 
commencement in the autumnal period of 
the year. We are quite unable to explain 
why the disease becomes at times epi- 
demic, then culminates, and then de- 
clines; nothing has yet occurred to lead 
us to the solution of this question. The 
decline would not seem to be for want of 
subjects to act on, as of late years fresh 
epidemics have commenced two or three 
years only after the preceding epidemics 
had ceased, and the disease has attacked 
numerous persons of adult age who were 
residing in the same place when the dis- 
ease was raging there but a short time 
before, but who missed taking it then. A 
probable explanation of this would be that 
during the epidemic that had just before 
passed, these persons were not so suscepti- 
ble to the influence of the variolous poi- 
son, although they became so a short time 
afterwards; this would seem to be the 
most obvious explanation of the occur- 
rence, whether it is, or is not, the true one. 
Inoculation for Smallpox. 
It is a remakable fact in the history of 
medicine and the treatment of disease, 
that the inventor of variolous inoculation 
should be unknown: even the place where 
inoculation originated is unknown. What 
we do know for certain is that inoculation 
was practised at Constantinople in 1700. 
Dr. Gregory1 writes: "About the year 
1703, rumors of the great success of this 
operation attracted the attention of Dr. 
Timoni, a Greek physician, who had 
studied and graduated at Oxford. He 
subsequently settled at Constantinople, 
and being convinced of the importance of 
the discovery, wrote an account of it, in 
1713, to his English correspondent, Dr. 
Woodward, which in the following year 
was published in the Philosophical Trans- 
actions. In 1715, Dr. Pylarini, the Ve- 
netian consul at Smyrna, having also 
learnt the success of this Turkish prac- 
tice, published an account of it at Venice. 
A notice of this work appeared in the 
Philosophical Transactions for 1716, and 
these favorable accounts were fully cor- 
roborated by the reports of Mr. Kennedy 
(an English surgeon who had travelled in 
Turkey) in his Essay on External Reme- 
dies, published in London in 1715. 
"No notice, however, was taken of 
these important facts by any English phy- 
sician, and the idea of transplanting or 
engrafting Smallpox (as the process was 
called) was well-nigh forgotten in London, 
when the celebrated Letter of Lady Mary 
Wortley Montague appeared, which de- 
scribed the practice in so lively a manner 
as to attract public attention.2 ' The 
Smallpox,' she writes, 'so general and so 
fatal amongst us, is here entirely harmless 
by the invention of engrafting, which is 
the term they give it. There is a set of 
old women who make it their business to 
perform the operation. Every year thou- 
sands undergo it, and the French Ambas- 
sador observes pleasantly that they take 
the Smallpox here by way of diversion, as 
they take the waters in other countries. 
There is no example of any one that has 
died of it, and you may believe I am well 
satisfied of the safety of the experiment, 
since I intend to try it on my dear little 
son. I am patriot enough to take pains 
to bring this careful invention into fashion 
in England.' 
"She kept her word, and to the spirit 
and enterprise of this lady the introduc- 
tion of inoculation into this country is 
altogether due; her own daughter was re- 
served to be the first example of inocula- 
tion in England. This event occurred in 
1721, and its success was complete." 
Through the advice of Drs. Timoni and 
Pylarini, inoculation was begun in Ame- 
rica in 1721, by Dr. Boylston; 244 persons 
were inoculated, and six died. About the 
same time, in England, a son of Lord 
Sunderland, and the butler of Lord Bath- 
urst, both died of inoculation. This 
brought the practice into discredit, and it 
was not until the middle of the last cen- 
1 Cyclop, of Pract. Med., vol. iii. p. 748. 
2 Vol. ii. Letter xxxi., dated April 1, 1717. INOCULATION FOR SMALLPOX. 
157 
tury that it was revived. In 1746, the 
Smallpox and Inoculation Hospital, Lon- 
don, was founded, that the poor might 
partake of the benefits of inoculation, 
which had hitherto been confined in a 
great measure to the rich. Inoculation 
was continued there until 1822. Dr. 
Gregory went carefully over the records 
of the hospital for this period, and found 
that only three in a thousand died of in- 
oculation. The inoculated disease was 
usually very mild, but not invariably so. 
The great objection to it was, that it 
spread Smallpox just as the natural dis- 
ease did. It could be set going anywhere 
by sending in a letter a bit of cotton- 
thread dipped in variolous lymph for the 
purpose of inoculation; so that, although 
the practice was of great advantage to in- 
dividuals, it was very destructive to the 
public at large, and the general mortality 
from Smallpox was thereby greatly in- 
creased. 
About the time the hospital was found- 
ed, two brothers, Robert and Daniel Sut- 
ton, one practising at Bury St. Edmunds, 
in Suffolk, the other at Ingatestone, in 
Essex, by carrying out more fully than 
had been done before, the practice of 
treating Smallpox suggested by Syden- 
ham, improved amazingly the mode of 
managing those under inoculation. Their 
practice was adopted by Baron Dimsdale, 
who obtained great celebrity as an inocu- 
lator. It consisted in giving purgative 
medicine, spare diet, and exposing the 
patient freely to cold air in the day, and 
making him sleep in a large airy apart- 
ment at night. 
" Phenomena of Inoculation: - On the 
second day after the operation, if the part 
be viewed with a lens, there appears an 
orange-colored stain about the incision, 
and the surrounding skin seems contract- 
ed. On the following day a minute papu- 
lar elevation of the skin is perceptible, 
which on the fourth day is transformed 
into a vesicle with a depressed centre. 
The patient perceives an itching in the 
part. On the sixth day, some pain and 
stiffness are felt in the axilla, proving the 
absorption of the virus into the general 
mass of blood. Occasionally on the sev- 
enth, but oftener on the eighth day, rigors 
occur, accompanied sometimes with faint- 
ishness, sometimes with pain of the back, 
headache, or vomiting. The patient com- 
plains of a disagreeable taste in the 
mouth, and the breath is offensive, soon 
after which the eruption shows itself."1 
In 1840, an Act of Parliament was 
passed, rendering variolous inoculation 
unlawful in England; the penalty for in- 
fringing this law is a month's imprison- 
ment. 
Still, however, under certain unfortu- 
nate circumstances inoculation might be 
justifiably had recourse to. First, "for in- 
stance, when Smallpox breaks out on 
board ship, and there is not any vaccine 
lymph at hand, or a probability of any 
being soon obtained, and persons are 
present who have neither been vaccinated 
nor have had Smallpox. Secondly, when 
Smallpox occurs in our colonial posses- 
sions, and several months must elapse be- 
fore vaccine lymph can be procured from 
England, or elsewhere. Under these cir- 
cumstances, on board ship where Small- 
pox exists, or in houses in the colonies 
where unvaccinated persons are unavoid- 
ably compelled to remain in close prox- 
imity to Smallpox, inoculation of them 
would be perfectly justifiable. Then it 
will have to be considered and determined, 
as so many persons now take Smallpox 
after vaccination, and the badly-vacci- 
nated suffer so severely and fatally from 
Smallpox, whether the vaccinated who 
have been badly vaccinated should have 
their vaccination tested by inoculation. 
It may be pretty well known, by attend- 
ing carefully to the previous statements 
in this article, whether persons have been 
well vaccinated or not. If they have four 
or five good vaccine cicatrices, readily dis- 
cernible, they will most likely have Small- 
pox in a mild form if they take it, and 
need not be inoculated. If, on the con- 
trary, they have only one cicatrix that 
can but just be seen, or no cicatrix at all, 
they will probably have Smallpox, if they 
take it, in a severe form. Rather than 
run the risk of contracting a dangerous 
attack of Smallpox by inhalation, it 
would, perhaps, be wiser that they should 
have their vaccination tested by inocula- 
tion. It is no doubt a choice of evils, but 
the evil is likely to be much less of having 
Smallpox by inoculation than of having it 
by inhalation. 
In ships, or in houses in the colonies, 
then, where there is Smallpox, and where 
no vaccine lymph can be obtained to vac- 
cinate those who have not been vaccinated 
or to re-vaccinate those who have been 
badly vaccinated ; and where the inmates 
cannot get away, no further harm would 
be done to the public by inoculating those 
who are presumably unsafe, and unavoid- 
ably obliged to be resident in such ships 
or houses. The greatest objection, as be- 
fore stated, to the practice of inoculation, 
was from its spreading Smallpox by infec- 
tion, to other persons ; but this objection 
would not be valid under the conditions 
above specified - these conditions and 
limitations being observed, inoculation 
might still fairly be considered to be ad- 
missible and justifiable, rather than to 
allow unvaccinated or badly-vaccinated 
persons to take Smallpox in the natural 
way. 
1 Gregory, op. cit. p. 750. 
Whenever, after carefully weighing all 158 
VACCINATION. 
the circumstances of difficulty and danger, 
it is determined to inoculate, the variolous 
lymph for inoculation should be taken 
when limpid, and on the fifth or sixth day 
of eruption, and when practicable, it 
should be chosen from a mild form of dis- 
ease, and inserted into the arm in but one 
place, the object to be aimed at being to 
give Smallpox in the mildest possible way. 
VACCINATION. 
Edward Cator Seaton, M.D. 
Vaccination, or Vaccine Inoculation, 
is the process by which a peculiar specific 
disease-Vaccinia or the Cow-pox (from 
the Latin, mcca, a cow)-is introduced 
into the human system with the view of 
protecting it against an attack of small- 
pox. 
The Cow-pox never originates sponta- 
neously in man, but (as its name implies) 
is a disease natural to, and it is not unfre- 
quently seen in, the cow; particularly, 
and indeed as a disease of spontaneous 
origin almost exclusively, in the milch 
cow. As observed in that animal it is a 
vesicular affection, occurring either casu- 
ally or as an epizootic, the vesicles mani- 
festing themselves chiefly or entirely on 
the teats and udder. It has a very precise 
and definite course. About four days 
from the probable period of invasion, 
without any or with scarcely any appa- 
rent general indisposition, small, red, 
rather tender papules appear near the 
udder and on the body of the teats. 
These become developed into vesicles, the 
most characteristic of which are soon seen 
to have an elevated margin, a central cup- 
like depression, and by the eighth or ninth 
day generally a pale rose or light damask 
areola, not more than a line or two in 
width, about the base. In two or three 
days more the disease has reached its 
acme ; the areola has extended to four or 
five lines, with circumscribed induration 
of adjacent skin and subjacent cellular tis- 
sue : the vesicles, if they have not already 
burst, are turgid with lymph which, be- 
fore perfectly clear, is now becoming 
opaque. By the twelfth day the lymph is 
more decidedly turbid and a process of 
desiccation and incrustation has begun, 
which in five or six days more is complete. 
The crusts so formed separate spontane- 
ously at from the twentieth to the twenty- 
fourth day from invasion, leaving behind 
them permanent slightly-depressed cica- 
trices. From traction in the process of 
milking, the vesicles when fully formed 
very generally burst, and the lymph which 
exudes from them is frequently found to 
produce sores of a definite and similar 
character on the hands of the milkers, 
who, in their turn, transfer the lymph to, 
and become the means of infecting, other 
animals in the dairy. 
A popular notion which existed in the 
county of Gloucester, as in some other 
dairy districts, that milkers who had thus 
been infected were afterwards insuscepti- 
ble of smallpox, attracted about a century 
ago (in 1768) the attention of Edward 
Jenner, at that time apprenticed to a sur- 
geon at Sodbury, near Bristol. The im- 
pression then made on his mind was never 
effaced. At a very early period of his 
medical career he set himself to investigate 
the truth of the popular belief; and, in 
the course of inquiries and reflections 
which satisfied him on this point, his 
genius conceived the idea that it might be 
possible to propagate the Cox-pox at will 
in man, first by directly inoculating it 
from the cow and then from one human 
subject to another, and that therewith 
protection against smallpox might be im- 
parted in perpetuity. Many years, how- 
ever, elapsed before he was able to put 
this idea to experimental proof. But 
when at length he communicated to the 
world (in 1798), in his Inquiry into the 
Causes and Effects of the Variolse Vac- 
cinse-"that masterpiece of medical in- 
duction," as it has justly been called*- 
his great discovery of Vaccination, he had 
already established on a sufficient basis of 
observation and experiment the following 
among other points relative to the Cow- 
pox : (1) That this disease casually com- 
municated to man has the power of ren- 
dering him insusceptible of smallpox ; (2) 
that the specific Cow-pox alone, and not 
other eruptions affecting the cow, which 
might be confounded with it, had this 
protective power; (3) that the Cow-pox 
1 Simon, Letter prefixed to Papers relating 
to the History and Practice of Vaccination, p. 
xii. PHENOMENA OF COW-POX IN THE HUMAN SUBJECT. 
159 
might be communicated at will from the ' 
cow to man by the hand of the surgeon, 
whenever the requisite opportunity ex- 
isted ; and (4) that the Cow-pox, once in- i 
grafted on the human subject, might be 
continued from individual to individual by 
successive transmissions, conferring on 
each the same immunity from smallpox 
as was enjoyed by the one first infected 
direct from the cow. 
It is in this transmission of Vaccinia 
from one human subject to another that 
the practical usefulness of Jenner's dis- 
covery lies; and since the process was 
first made known, all ordinary vaccina- 
tions have been thus carried on. Indeed, 
although at convenient opportunities, or 
on grounds which will be hereafter stated, 
lymph has at various times since Jenner's 
day been obtained direct from the cow, 
and new stocks, as it were, thus intro- 
duced into practice, we may safely say 
that the great bulk of the vaccinations of 
the present day, in this country at least, 
are performed with lymph transmitted 
from the early direct vaccinations of Jen- 
ner himself. 
In endeavoring to give a brief account 
of the present state of our knowledge in 
regard to Vaccination, I shall (1) describe 
the phenomena of Cow-pox as observed 
in the human subject; (2) describe the 
mode or modes of inducing these phe- 
nomena, or of vaccinating ; (3) review the 
evidence we have of the extent and degree 
of protection against smallpox which Vac- 
cination affords; (4) state the pathologi- 
cal relations of variola and vaccinia ; and 
(5) inquire whether Vaccination, in pro- 
tecting mankind against one disease, is, 
or may be, the means of introducing oth- 
ers-whether, in short, the good that it 
is known to effect is counterbalanced by 
any, and what, degree of possible harm. 
I. Phenomena of Cow-pox in the 
human subject.-The symptoms which 
Cowpox manifests in the "human subject 
resemble very closely those already de- 
scribed as observed in the cow. If some 
vaccine lymph be taken on the point of a 
lancet, and inserted by puncture on the 
arm of an infant who has not before been 
vaccinated, no particular local effect is 
noticeable for the first two days ; but if 
the vaccination be about to succeed, by 
the end of the second or by the third day 
a slight papular elevation is percepti- 
ble, which, by the fifth or sixth day, has 
become a distinct vesicle of a bluish-white 
color with a raised edge, and a peculiar, 
central, cup-like depression. By the eighth 
day (the day week from the insertion of 
the lymph) this vesicle has attained its 
highest perfection, is plump, round, and 
more decidedly pearl-colored; the eleva- 
tion of its margin, and the depression of 
its centre, are more marked. At this 
date, or sometimes a few hours earlier, a 
ring of inflammation, termed the areola, 
begins to form about its base, and, for the 
next two days, continues to spread. It 
is circular, and, when fully developed, 
has a diameter of from one to three inch- 
es, and is often attended with considera- 
ble hardness and swelling of the subjacent 
connective tissue. The establishment of 
the areola demands always the attention 
of the practitioner and student, as the 
anatomical evidence that the Cow-pox 
has produced its specific effect on the con- 
stitution. Other proofs of the constitu- 
tional influence of the Vaccination are, 
at this period of its course, generally af- 
forded in the child's restlessness and heat 
of skin, with (frequently) derangement of 
the stomach and bowels, and with (some- 
times) swelling of the axillary glands. 
But these general symptoms, though sel- 
dom altogether absent, are often exceed- 
ingly slight; nor, provided the areola be 
properly formed, are they to be looked 
upon as indispensable for the protective 
effect of Vaccination. After the tenth 
day the areola begins to fade, the vesicle 
begins to dry in the centre, the lymph re- 
maining in it becomes opaque and con- 
cretes, and by the fourteenth or fifteenth 
day, a hard brown scab is formed, which 
contracts, dries, blackens, and, from the 
twentieth to the twenty-fifth day, falls 
off, leaving a cicatrix commonly perma- 
nent, and which in character is circular, 
somewhat depressed, foveated or indented 
with minute pits, and sometimes radiated. 
Occasionally certain constitutional symp- 
toms beyond those already described are 
observed. In young children of full habit, 
especially in hot weather, about the ninth 
or tenth day, when the areola is at its 
height, an eruption of roseola will some- 
times take place, chiefly on the extremi- 
ties ; sometimes the eruption has a papu- 
lar form (vaccine lichen), and sometimes 
it is vesicular. These eruptions are gen- 
erally very transitory; their ordinary 
duration does not extend beyond a week; 
and they very seldom indeed last beyond 
the falling of the scab. 
When the mode of inserting or applying 
the lymph has not been by single punc- 
ture, or by such abrasion of the skin as 
would raise a single vesicle, but by two, 
three, or more punctures close-set to- 
gether, or by scarifications or abrasions 
over some extent of surface in the manner 
that will hereafter be described, so that 
two, three, or more vesicles are developed 
in close proximity, these usually coalesce, 
and a vesicle results, the compound cha- 
racter of which is very obvious : or there 
may be a crop of coalescent vesicles, each 
having its distinct head with characteris- 
tic depression. These compound vesicles 
and crops are round, oval, or of irregular 
outline, according to the manner in which 160 
VACCINATION. 
they have been induced, and the shape of 
the resulting cicatrices varies accordingly. 
The clear, smooth, supple, delicate skin 
of the infant is peculiarly adapted to 
manifesting in perfection the local char- 
acters of the vaccine disease. In elder 
children, and much more in adults, though 
the phenomena of primary vaccination 
are essentially the same as in the infant, 
the vesicle is often wanting in that plump- 
ness, sharp definition of edge, and beau- 
tiful lustre which the experienced vaccina- 
tor delights to see. And, in the adult, 
the course of the disease is frequently 
somewhat retarded, the areola is apt to 
be more diffuse, and swelling of the axil- 
lary glands is more frequently observed. 
When lymph is employed that is derived 
directly or very recently (as within three 
or four removes) from the cow, the course 
of the disease is generally retarded at 
various stages. Papulation is sometimes 
deferred till the seventh, eighth, ninth, or 
even the tenth day, and the areola is not 
complete till from the eleventh to the four 
teenth or even the sixteenth day. The 
areola, when at its height, is more indu- 
rated than is observed in Vaccination 
with ordinary humanized lymph, and is 
said to decline and revive, continuing to 
exhibit a brick-red or purplish hue while 
the hardness remains.1 The papular and 
vesicular eruptions, which have been 
above referred to as occasionally attend- 
ing Vaccination at this stage of its course, 
are more frequently seen. The vesicles 
themselves are commonly not more de- 
veloped than those produced by ordinary 
lymph. Desiccation is generally pro- 
longed, and the crust is often retained till 
the fourth or fifth week. 
Such are the ordinary phenomena in- 
duced by primary Vaccination in the 
human subject. Their course, however, 
is sometimes modified ; and may be (a) 
simply retarded, (b) simply accelerated, 
or (c) altogether irregular and spurious, 
(a) Retarded Cow-pox.-The most simple 
and frequently seen form of retardation is 
a mere delay for a day or two in the course 
of the vesicle ; by the eighth day it has 
not more size or development than ordi- 
narily is met with on the sixth, and the 
areola does not form till the tenth day, or 
even later. This amount of retardation 
is probably more frequently met with in 
cold than in hot weather, especially if the 
cold be accompanied with a dry easterly 
wind. Sometimes the delay is much 
longer ; at the end of a week from the 
Vaccination, when the child is brought 
.for inspection, so little of result is seen 
that it is a question whether the Vaccina- 
tion has not altogether failed : some fresh 
lymph is inserted on another spot, and, as 
the vesicle of the new Vaccination rises, 
that of the first Vaccination is seen also 
to develop itself, and the two run their 
course at the same time. Bousquet refers 
to a case (not in his own practice) in 
which this revival of a dormant Vaccina- 
tion took place, it was said, at the end of 
three weeks.1 I have never seen any case 
in which the vesicle rose after such a 
delay as this; but I have seen cases in 
which, without any recourse to a second 
Vaccination, vesicles have risen a week 
after the usual period, and when success 
had ceased to be looked for. Retarded 
Cow-pox is much more frequently seen 
when Vaccination is performed with dry 
lymph than when it is done direct from 
the arm : no doubt because, in the former 
case, the lymph, when deposited on the 
cutis, is often in an undissolved, or imper- 
fectly dissolved, state. Mere retardation 
of phenomena, if these phenomena be 
regular in their character, does not in 
any way interfere with the protective 
value of the Vaccination. Retardation of 
Vaccination at various stages of its course 
is often independent of any obvious 
cause ; but sometimes it can be traced to 
certain conditions of the system, as the 
incubation of other diseases. If, for in- 
stance, vaccine lymph has unwittingly 
been inserted in a child who happened 
to be incubating measles or scarlatina, and 
the Vaccination has succeeded, the vesi- 
cles will usually, when the rubeolar or 
scarlatinal symptoms set in, be arrested in 
their course, and no areola will be formed 
till the measles or scarlatina have sub- 
sided.2 Again, when Vaccination has 
been performed with effect on a child who 
is incubating smallpox, the vaccine vesi- 
cles usually proceed in the ordinary way 
till the smallpox manifests itself, and, even 
after this, may undergo some further 
local development, the vaccinia and variola 
apparently going on together ; but unless, 
before the smallpox appeared, the Vacci- 
nation had already reached the stage of 
areola, its progress to that stage will be 
arrested, in which case it will have no 
effect in modifying the smallpox. (&) 
Accelerated Cow-pox is to be regarded with 
much more suspicion than retarded Cow- 
pox, spurious vaccination having generally 
an accelerated course. There may be, 
however, simple acceleration ; a course 
some twelve or twenty-four hours in ad- 
vance of the usual course, the vesicle on 
the eighth day being in the state in which 
it is usually seen on the ninth, the areola 
nevertheless being regular, and the crust 
being subsequently duly formed. In such 
case the value of the Vaccination is not 
1 Ceely, Observations on the Variolas Vac- 
cinae in Trans, of Prov. Med. and Surg. Assoc., 
vol. viii. p. 346. 
1 Nouveau Traitg de la Vaccine, p. 176. 
2 Jenner notices this in one of his early 
tracts, Continuation of Inquiry, p. 31. 161 
METHOD OF VACCINATING. 
impaired. (c) Irregular and Spurious 
Cow-pox.-Vaccination sometimes runs an 
entirely irregular course, the varieties of 
irregularity being considerable. In one 
form the most frequent, the course re- 
sembles that of a revaccination (as will 
hereafter be described) instead of that of 
a primary Vaccination ; the vesicle begins 
with itching and irritation; it is acumi- 
nated or conoidal, instead of being flat 
and with central depression, and it con- 
tains straw-colored or opaque fluid, in- 
stead of clear lymph ; it has an early or 
irregular areola, which is at its height by 
the fifth or sixth day, and when seen on 
the eighth day is far on the decline ; there 
is then a small scab on the surface which 
usually drops off by the tenth day. Or 
the local effect may have been even less 
than this, and on the eighth day there 
may be nothing remaining but a very thin 
scab or scale just about to detach itself, 
and which at the lightest touch falls off 
In other cases, the vesicles, when seen on 
the eighth day, are found to have burst, 
and to present an irregular pustuloid or 
scabby appearance, or to be so many open 
sores. It would be difficult, and is quite 
unnecessary, to give a verbal description 
of each form of irregularity that may be 
observed ; the one important practical fact 
being that a Vaccination presenting any de- 
viation from the perfect character of the vesi- 
cle, and the regular development of the areola, 
is not to be relied on as protective against 
smallpox. A spurious and irregular 
course of the vaccine vesicle, no doubt, 
sometimes occurs without assignable 
cause, and in the most experienced hands, 
but it is far more usually due either to the 
use of lymph not well chosen by the vac- 
cinator, or to something amiss in the 
state of the child vaccinated. Thus, it 
may be seen in various forms on several 
children vaccinated from the same source ; 
or it may occur in children who are vac- 
cinated from the undeniably good sources, 
but who themselves, at the time, are suf- 
fering from intertrigo or other affections. 
A spoilt and broken appearance of vesicle, 
which is frequently on the eighth day 
ascribed to rubbing or mechanical irrita- 
tion, is often really an irregularity arising 
from one or other of these causes ; and 
the best proof how much such irregulari- 
ties depend on the care and skill of vacci- 
nators is the frequency with which they 
are seen in the hands of some vaccinators, 
and their extreme rarity in the hands of 
others. Parents, however, should always 
be directed to be very careful to keep the 
vesicles uninjured in their progress, and 
to avoid the premature removal of the 
crust. 
The local and general symptoms of Vac- 
cination seldom call for any treatment. 
Occasionally, however, they run an active 
course; the arm becomes inflamed ; ery- 
thema, or sometimes true erysipelas, de- 
velops itself; the vaccine vesicle degener- 
ates into a purulent ulcer, or sometimes 
into a sloughing sore, leaving a cicatrix 
which has none of the characteristic pit- 
tings, but is simply a puckering, or a flat, 
smooth, shining scar. The treatment of 
such cases would be the treatment of ery- 
sipelas or of inflammation from any other 
cause. It is needless to say that degenera- 
tion of the vesicle thus taking place de- 
prives the Vaccination of all protective 
power. 
Phenomena of Revaccination. - In the 
majority of persons the regular phenomena 
of Vaccination, such as we have described 
them, can only be produced once in a life- 
time ; any subsequent introduction of 
lymph either failing to produce any local 
effect whatever, or (much more commonly) 
producing a modified effect, resembling 
one of the forms of spurious Vaccination. 
The absence of effect is relatively most 
common in the child, the spurious effect 
most common in the adolescent and adult. 
This spurious effect consists either in a 
papule, or (more often) in an acuminated 
vesicle, with a hard and irregular areola. 
The symptoms begin early, reach their 
height by the fifth or sixth day, and then 
decline. The scab, small and imperfect, 
forms generally on the eighth day, and 
soon falls. There is usually much itching, 
and often considerable constitutional irri- 
tation. Severe constitutional symptoms 
are, out of all proportion, more frequent in 
revaccination than in primary Vaccina- 
tion ; and in very exceptional cases the 
vaccine lymph may act as an animal poi- 
son, giving rise to phlegmonous erysipelas : 
some still rarer cases have occurred of 
pyaemia, terminating fatally. In a certain 
proportion of cases the results of revacci- 
nation are the same as those of primary 
Vaccination, the vesicle, in shape and 
character, being in no degree distinguish- 
able ; in such cases the areola is sometimes 
small and transitory, and the scab on fall- 
ing leaves a small inferior cicatrix; at 
other times the areola is perfect, and a 
good cicatrix is left. Normal vesicles 
resulting from revaccination are much 
more frequent in adults than in children, 
but I have seen them in the arms of chil- 
dren a few years old, who had excellent 
marks of their first Vaccination. 
II. Method oe Vaccinating.-For 
the proper and successful conduct of Vac- 
cination, special attention must be given 
to the state of health of the child to be 
vaccinated, to the selection of the lymph 
to be used in the Vaccination, and to the 
thorough insertion of it. 
1. Except for pressing reasons, children 
should only be vaccinated when they are 
in good health. Especially must they be 
free from any acute disease, from diarrheea, 
VOL. I.-11 162 
VACCINATION. 
or from any chronic disease known to in- 
terfere with the regular course of the vac- 
cine vesicle. Of these diseases, the chief 
are herpes, eczema, and intertrigo. The 
latter affection, especially, so often modi- 
fies, or even completely spoils the course 
of Vaccination, that it is of great conse- 
quence, before proceeding to vaccinate a 
child, to see that there is no chafing be- 
hind the ears, in the folds of the neck, or 
in the groins. But cutaneous eruptions of 
all kinds are a contra-indication, and, as 
a rule, great attention should be given to 
having the skin perfectly clear, and free 
from them, before inserting vaccine lymph. 
Of course this rule is liable to be modified 
by circumstances ; and especially when 
there is any immediate risk of smallpox, 
it becomes imperative to perform Vacci- 
nation notwithstanding these contra-indi- 
cations. 
Health permitting, all children should 
be vaccinated in very early infancy. Inas- 
much as one-fourth of the deaths from 
smallpox in England occurs in children 
under the age of one year,1 it is obvious 
that delay is attended with extreme risk ; 
and this risk, it need scarcely be said, is 
greatest in large towns. Plump and 
healthy children, living in large towns, 
should be vaccinated when a month or six 
weeks old ;2 in more delicate children, the 
Vaccination might be postponed till they 
are two or three months old ; but all, ex- 
cept those whose state of health positively 
contra-indicates Vaccination, should be 
vaccinated by the age of three months. 
This early period of life is also particularly 
suitable for Vaccination, as being usually 
free from the disturbing influence of teeth- 
ing. Circumstances connected with lymph- 
supply render a longer delay unavoidable 
in many instances in small towns and 
country districts ; and, when smallpox is 
not present in the localities, such delay, if 
not too long continued, is not of material 
moment. But even children living in 
these districts should always be vaccinated 
within a few months, six or seven at the 
utmost, from birth. 
Under circumstances, however, of di- 
rect exposure to smallpox, it should be 
well understood that no age is too early 
for Vaccination ; infants have repeatedly 
been vaccinated immediately after birth, 
and thereby saved. In all cases of much 
risk, it is of the utmost importance to 
avoid any delay. The loss of a day may 
be the sacrifice of a life. The Vaccination 
may possibly be in time to prevent small- 
pox altogether; but even supposing the 
variolous infection to have entered the 
system before the Vaccination has been 
performed, still if the Vaccination be only 
got to the stage of areola before the small- 
pox manifests itself, it will exert its modi- 
fying power, and the child will be saved.' 
2. The lymph to be used in vaccinating 
should be taken from healthy subjects, 
and from thoroughly characteristic vesi- 
cles. It may be taken as soon as the ves- 
icle will yield it, when, though it can only 
be got in small quantity, it is effective. It 
is usually taken, and for the ordinary pur- 
poses of Vaccination is best taken, when 
the vesicle is fully formed, but either be- 
fore the areola appears, or within a very 
few hours of its commencement. This, in 
regular cases, is on the day week from the 
Vaccination ; the lymph is then easily 
obtained in sufficient quantity. It is a 
very great mistake, but one which is often 
made, to take it at a later period of vesicle 
than this, and when the areola is fully 
complete. No doubt it flows then more 
freely, and may be got in greater abun- 
dance ; no doubt also (as alleged by those 
adopting this practice) it very often takes; 
but it docs not do this with anything like 
the same certainty- ;a point of great conse- 
quence ; and it is also more likely to lead 
to erysipelatous and spurious results. 
Prime lymph has always a certain degree 
of viscidity, and a thin serous lymph, even 
from a vesicle which is not advanced, is to 
be avoided. Babies are much better lymph- 
givers than elder children, or adults. Chil- 
dren of dark complexion, not too florid, 
with a thick, smooth, clear skin, yield the 
finest and most effective lymph. 
3. A child and a vesicle fit for the pur- 
pose having been selected, the vaccinator 
in order to collect the lymph proceeds to 
open the vesicle by a number of minute 
punctures, which must be made on its sur- 
face and not round the base. The object 
1 Of 42,277 deaths from smallpox which 
occurred in England in the ten years 1856-65, 
10,223 were in children under one year of age. 
2 If the parents of a child, apparently 
healthy, were known to have any taint of 
syphilis, it would, in the interests of Vaccina- 
tion generally, be a matter of prudence to 
postpone the Vaccination, unless smallpox 
were imminent, till the age was passed within 
which hereditary syphilis mostly manifests 
itself, i. e. till the completion of the third 
month from birth. For if any syphilitic 
symptoms were to appear after the Vaccina- 
tion, they would most likely be ascribed not 
to their hereditary cause but to the Vaccina- 
tion. 
1 The incubative period of smallpox being 
twelve days, and the time requisite to carry 
Vaccination to the stage of areola being only 
nine days, it is manifest that even a person 
who has actually imbibed the infection of 
smallpox may, by Vaccination within the 
first three days after the reception of the in- 
fection, obtain the modifying benefits of Vac- 
cination. A day more, and the Vaccination 
will be too late : whatever local effect it may 
produce, the smallpox will not be modified 
by it. (See the article Smallpox : see also 
the subject more fully treated in my " Hand- 
book -of Vaccination," pp. 102-106.) METHOD OF VACCINATING. 
163 
in making many punctures is to open the 
various cells of the vesicle, and the reason 
for making these on the surface, and not 
round the base, is to obtain the lymph 
free from any admixture of blood. If by 
accident any blood be drawn, this must be 
allowed to coagulate, and then be care- 
fully removed before taking the lymph : 
for it is a cardinal rule, never to be devi- 
ated from, that the inoculation must be 
with vaccine lymph, and with lymph only. 
When the cells of the vesicle are freely 
opened, the lymph soon exudes, and lies 
on the surface. The lancet or point to be 
charged is then dipped into it; or if a ca- 
pillary tube is to be charged, the end of 
the tube is inserted in the liquid as it lies. 
On no account must there be any pressure 
or squeezing of the vesicle with the lancet 
to make the lymph exude: and when 
lymph ceases spontaneously to stand on 
the surface of a vesicle, that vesicle must 
be considered no longer usable for lymph 
supply. Very generally, however, when 
the lymph which has first exuded has 
been taken, and the surface of the vesicle 
left apparently dry, if the operator wait a 
minute or two, he will find there has been 
a fresh exudation of good usable lymph ; 
and when he does not find this, he may 
often induce it in a way quite unobjec- 
tionable, by wiping very gently the sur- 
face of the vesicle with a soft wet linen 
cloth, thereby removing or dissolving the 
inspissated lymph which clogs the punc- 
tures. Vesicles of perfect character, and 
of the same size and appearance, differ 
very much in their yield of lymph ; ordi- 
narily, from a vesicle of such size as is 
produced by a single deep puncture, 
enough lymph may be got for the direct 
Vaccination of from four to six children, 
or for charging (i. e. for well charging, 
dipping once and again) six to eight ivory 
points. Some vesicles yield much more, 
but the caution already given against a 
thin, serous, too-readily-flowing lymph 
must be borne well in mind. When vesi- 
cles are compound, their yield of lymph is 
of course proportionally increased. 
Lymph should in every instance (where 
practicable) be inserted direct from arm 
to arm. All processes for preserving and 
conveying lymph (valuable, and indeed 
invaluable, as they are for their own 
proper purposes) render in the Jong run 
the taking of the Vaccination a matter of 
inferior certainty and it is only in cases 
of necessity that Vaccination should be 
performed with lymph stored or conveyed. 
But a caution must be here interposed. 
The superior relative advantages of arm- 
to-arm "V accination are so well known, 
that practitioners whose vaccinations are 
few, and whose opportunities of lymph- 
selection are therefore limited, will often 
be induced to take their lymph from sec- 
ond-rate vesicles, rather than lose the op- 
portunity of vaccinating direct from an 
arm. This, which I know to be the source 
of much current inferior Vaccination, is 
a course which should never be adopted. 
The operator, unless he has some preserved 
lymph that he can rely on and unless he can 
rely on his own hand to make preserved 
lymph take, should put off the Vaccination 
till he has the opportunity of doing it from 
a thoroughly satisfactory vesicle. [In the 
United States, many practitioners have 
for a long time been in the habit of using 
the scab, instead of fluid lymph, for vac- 
cination. The scab is allowed to come off 
spontaneously, about the nineteenth or 
twentieth day. When kept covered from, 
the air, it will retain its specific character, 
usually for a month or more ; and the 
vaccine pustules produced by it go 
through all the stages and appearances 
belonging to the Jennerian pustule. For 
the use of the scab, it is only necessary to 
mix a small portion of it with tepid water, 
into a paste, which may be applied to the 
arm in the same manner as the fluid 
lymph.-II.] 
Various methods may be employed for 
inserting lymph-the essential part of all 
of them being either to introduce the 
lymph into the substance of the cutis, or 
to bring it well in contact with its absorb- 
ing surface, (a) One of the most com- 
monly used is that by puncture. When 
it is intended to operate in this way, the 
arm of the child to be vaccinated should 
be grasped by the left hand of the vacci- 
nator, so as to put the skin on the stretch, 
and a very sharp, perfectly clean lancet, 
well charged with the lymph selected, 
should be introduced by valvular puncture 
from above downwards, so that the lymph 
may gravitate into the wound. The lan- 
cet should not be held level with the skin, 
but at an angle of 45°, or thereabouts, 
and made to enter the cutis. If the lymph 
be thus well put in, it is retained by the 
valvular character of the puncture and 
elasticity of the skin ; and any fear that 
the bleeding which ensues will cause the 
Vaccination to fail is quite chimerical. A 
minute and superficial puncture, on the 
other hand, does not unfrequently fail. 
In vaccinating by puncture, not less than 
five should be made, and they should be 
at a distance of half an inch from each 
other. Five or more punctures at this 
distance from each other can very well be 
made on one arm, or, if the operator pre- 
fer it, three or more may be made on each 
arm. In the manipulations by which 
Vaccination is effected by puncture, it is 
a very good plan to make each puncture 
a double one: thus, A finer and 
1 An account of the various methods of 
storing lymph and their relative advantages 
is given in my "Handbook of Vaccination," 
chap. viii. 164 
VACCINATION. 
larger, often oval, compound vesicle is 
thereby raised. For Vaccination by punc- 
ture no instrument is needed but a com- 
mon lancet, very sharp : and many of the 
instruments which have been specially de- 
vised, are not, in my opinion, nearly so 
good. (6) A modification of the plan of 
vaccinating by puncture is that of mul- 
tiple superficial punctures, or tattooing- 
a number of minute superficial punc- 
tures being made with the point of the 
lancet, thus, 
will arise, or more frequently, one oblong 
compound vesicle will be produced, (e) 
Another and very excellent plan of scarifi- 
cation is adopted by many vaccinators, 
which consists in abrading the cuticle by 
a number of fine parallel scratches, thus, 
or by further cross-scratch, thus, 
and the lymph then spread over with the 
flat part of the lancet. The number of 
spots over which this tattooing should 
take place will depend, of course, on the 
extent of surface operated on at each 
spot; but in order that a local effect may 
be produced equal to that of five ordinary 
vesicles, tattooing over such a surface as 
is above depicted should be repeated on at 
least three spots, (c) Another modifica- 
tion of puncture, common in some of the 
northern districts of England, is that of 
first spreading the lymph on the arm of 
the child to be vaccinated, and then rip- 
ping up the cuticle with the point of the 
lancet 
Abrasion should only be carried so far as 
to make it certain, by the appearance of 
blood oozing, that the cutis is reached; 
any such oozing is then rapidly wiped 
away with the finger and the lymph plas- 
tered on. When the abrasions are made 
to cover such a space as is above indicated, 
it is sufficient to make two on each arm, 
or three on one arm, about three-quarters 
of an inch or an inch from each other- 
but when, as by some practitioners, the 
abrasions are made over smaller surface, 
producing vesicles which are not more 
than equal in size to those of good punc- 
ture, there should be at least five such 
abrasions. Vaccination by scarification 
cannot be better done than with a com- 
mon lancet; some practitioners, however, 
prefer the use of a scarifier or rake (in- 
vented by Dr. G. Weir), which consists of 
three or four needle points, inserted in a 
handle of ivory. The skin being held very 
tense, this rake is drawn lightly across in 
one direction, and then, if the operator 
pleases, crossed in another, the lymph 
being then plastered over. 
In cases in which Vaccination has to 
be performed with preserved lymph, if the 
lymph has been preserved liquid, as in 
Husband's tubes, no other directions are 
requisite for the performance of the ope- 
ration than those which have now been 
given. But if the lymph has been pre- 
served by drying, as on points or glasses, 
it will be necessary that it should be re- 
vived or brought back to the liquid state 
in order that it may be taken up by the 
system. This is done by the use of a very 
minute quantity of water ; if the lymph 
to be revived has been preserved on 
glasses, a very small drop of "water is taken 
on the point of +he lancet and well rubbed 
in with the lymph, which is then left for 
some minutes to soften ; or, if the lymph 
has been kept on points, these should be 
very lightly dipped in water and then 
placed for a few minutes on the edge of a 
over a surface equal to a sixpenny-piece, or 
more, with, frequently, a second plaster- 
ing of lymph afterwards; crops of vesicles 
are thus raised, close set together, and 
nearly always confluent, each vesicle, how- 
ever, having its distinct depressed head. 
I have counted as many as eighteen or 
twenty such on one base : but the vesicles 
by the pressure they exercise on each other 
do not attain the size and development of 
separate vesicles. It is usual to make two 
crops, such as I have described, and this 
must be regarded as sufficient for full pro- 
tection. (d) Vaccination is often per- 
formed, not by puncture, but by scratch ; 
three or four longitudinal or transverse 
scratches, each about three-quarters of an 
inch long, are made at distances half an 
inch or an inch apart from each other, 
with the point of a lancet, or with a thick 
needle, and the lymph is rubbed on. In 
the course of each scratch two or three 
separate vesicles METHOD OF VACCINATING. 
165 
book. Much care is required in thus re- 
viving lymph : on the one hand, there 
must be moisture enough to bring the 
lymph back to the state in which it was 
when taken from the vesicle; on the other, 
it is important that the lymph be not too 
much diluted. For puncture-vaccination 
the revived lymph is either taken on the 
lancet-point and inserted as in a Vaccina- 
tion direct from the arm, or, if the mode 
of preserving has been by points, a punc- 
ture is first made with a clean uncharged 
lancet and the ivory point is then itself 
inserted into this puncture and kept in 
position by the thumb for a short time, 
care being taken to press the thumb well 
down as the point is being withdrawn, 
and thereby insure that the lymph on it 
is well wiped off and left in the wound. 
In Vaccination by scarification or abra- 
sion, the flat of the glass, or the flat of the 
point, may be rubbed over the scarified or 
abraded surface. 
Of the different modes of vaccinating 
which I have described, and of numerous 
modifications of them which are met with 
in practice, is there any which can be 
more thoroughly relied on than another 
for infecting the system ? This is a ques- 
tion very frequently put to me, and my 
reply always is that a person properly 
taught aught to be able to infect thoroughly 
by either of them ; and that any one who 
has so learnt, and so habitually practises, 
either plan as to be able to rely on secur- 
ing the results he aims at, should not-so 
much depends on habit-change it for any 
other. By every one of the processes I 
have described, I have seen the most per- 
fect results produced by experienced vac- 
cinators : certainly by no process more 
completely than by the one I first de- 
scribed-that of simple puncture. But 
unusual opportunities of observing Vacci- 
nation as generally practised have shown 
me that many, if not most, practitioners 
do not-for want of original instruction, 
and of attention to various small but 
essential points-by whatever process they 
adopt, succeed as they ought to do; and 
judging by the results in the cicatrices 
which their vaccinations leave, that, as a 
rule, those who vaccinate by simple punc- 
ture are by far less successful than those 
who vaccinate in either of the other ways 
described further, that the best marks, 
on the whole, as regards size, depth, and 
foveation, are those which result from 
the plan last of all described, viz.: that of 
cross scratch or abrasion over a sufficient 
surface. 
And this plan is, in most hands, eminent- 
ly more successful than puncture when 
dry lymph has to be employed. 
Mr. Marson states that " with good 
lymph, and the observance of all proper 
precautions, an experienced vaccinator 
should not fail of success in his attempts 
to vaccinate above once in 150 times."1 
Uis own habitual success is, indeed, far 
greater than this; but so much, at all 
events, he considered might fairly be ex- 
pected of any good vaccinator. That this 
standard is not too high is clear from 
inquiries I have made as to the results ob- 
tained at several large stations where 
Vaccination is well performed and where 
accurate records are kept at which I 
found that the average of failures to infect 
at the first operation did not exceed one 
in 170 cases. Good vaccinators expect 
also to raise a vesicle for every point of 
insertion; and, in their hands, cases in 
which only one or two vesicles result from 
four or five punctures or scarifications are 
as rare as total failures. But such results, 
it must be well understood, will not ensue 
unless patience and diligence be given to 
learn how to select lymph, and how to 
manipulate; nor unless practitioners, 
seriously considering the responsibility 
which rests upon them when they are 
proceeding to vaccinate, act with corre- 
sponding care. If they fail to infect their 
patients at the first, and still more if they 
fail at the second trial, it is very likely 
these will not again present themselves, 
and will remain unprotected. If, en- 
deavoring to raise four or five vesicles, 
they raise only one or two, their patients 
do not get all the protection Vaccination 
is capable of affording. It has happened 
to me for many years past to see, all but 
daily, children growing into manhood and 
womanhood, who were unprotected against 
smallpox, not by their own or their pa- 
rents' neglect of Vaccination, but by the 
want of skill of operators, who (often with 
two, three, and four operations) had failed 
to infect them. Mr. Marson also says, 
"Patients often present themselves with 
smallpox at the hospital, who state they 
have been cut five, six, or eight times, 
or more, for Cow-pox without effect." 
"This," he adds, "is a great evil. It 
would happen but rarely in careful 
1 Chiefly, I believe on account of the min- 
ute and superficial character of the puncture, 
and the very small quantity of absorbing sur- 
face exposed to the action of the lymph. This 
arises in great measure from a chimerical fear 
that if blood be drawn the lymph will be 
washed away. There is a kind of Vaccination 
by scarification which is equally imperfect 
in its results, when a sort of make-believe 
scratch like this | is made, and a little lymph 
put on. 
1 Analytical Examinations of Smallpox and 
Vaccination, Medico - Chirurg. Trans., vol. 
xxxvi. 166 
VACCINATION. 
hands." So far, indeed, are practitioners 
generally from having attained the stand- 
ard which all should reach, that it is no 
uncommon thing to hear 5 and 10 per 
cent, of failures spoken of as a satisfactory 
result, while not a few think they do well 
if they succeed in four operations out of 
five : and constantly practitioners are met 
with, who do not in one-half the cases 
they vaccinate, and many of them not in 
a quarter, raise all the vesicles which they 
have attempted to produce.1 
Insusceptibility to the infection of Cow- 
pox, even for a very limited period, is an 
excessively rare occurrence. For in the 
few cases in which good operators fail at 
the first operation to infect they rarely fail 
at a second trial, but now and then this is 
so, and even a third operation may not 
take. In such cases, if the operations have 
been properly performed, and lymph in- 
serted direct from the arm, it may be as- 
sumed that there is temporary insuscepti- 
bility. Cases have been mentioned to me 
on good authority, but I have never met 
with such myself, in which this insuscep- 
tibility has remained for many years. 
III. Protection afforded by Vac- 
cination against Smallpox.-Persons 
who have once been successfully vacci- 
nated are, as a rule, permanently protected 
against smallpox. A certain but indeter- 
minate proportion of vaccinated persons 
will, however, be liable at some period or 
other of their lives, especially under epi- 
demic influence, to take smallpox in a 
mild and modified form. A very much 
smaller proportion will be liable to take it 
in a severe, disfiguring, or fatal form. 
But the liability of any individual to take 
smallpox severely after Vaccination, and 
probably the liability to take it at all, will 
be inversely as the goodness and amount 
of the Vaccination. 
The protection which Vaccination is 
capable of affording against smallpox was 
held by Jenner to be exactly that-neither 
more nor less-which an attack of small- 
pox, either taken naturally or induced by 
inoculation, was well known to confer 
against a subsequent attack of the same 
disease. Believing Cow-pox and small- 
pox to be identical, he considered that 
the system of a vaccinated person had 
already in fact passed through an attack 
of smallpox. lie was well aware that this 
disease did in some individuals recur, and 
that the having passed through one at- 
tack was not in every instance a security 
against a future attack. He refers repeat- 
edly in his writings to cases of this kind 
seen by himself and by other reliable ob- 
servers, and states the claims of Vaccina- 
tion thus: "Duly and efficiently per- 
formed, it will protect the constitution 
from subsequent attacks of smallpox as 
much as that disease itself will. I never 
expected it would do more; and it will 
not, I believe, do less." It was only, 
however, to efficient Vaccination, i. e., to 
Vaccination which had gone through all 
its stages with perfect regularity and had 
given evidence of infecting the constitu- 
tion, that he attributed this protecting 
power. Inefficient Vaccination, like in- 
efficient inoculation, he knew would fail. 
Observations made since Jenner's day, 
with remarkable care and ability and on 
a scale which gets rid of all sources of 
fallacy, by Mr. Marson of the Smallpox 
Hospital, have conclusively established 
that, for thoroughly infecting the constitu- 
tion, a certain amount of local affection is 
as necessary as a perfect character of vac- 
cine vesicle. We must therefore so far 
extend the meaning of the words "due 
and efficient" performance of Vaccina- 
tion, as to make it include amount as 
well as quality of vaccine influence : and 
with this extension, the experience of 
seventy years tends to show the correct- 
ness of Jenner's estimate. 
The protective power of Vaccination, 
like that of natural or inoculated variola, 
shows itself in two ways: 1st, as regards 
the large majority of persons, in shielding 
the constitution against any future attack, 
however modified, of smallpox; and 2d, 
as regards the remainder, in general so 
modifying the subsequent smallpox that 
that disease is, as a rule, deprived of all 
danger to life, and does not on recovery 
leave behind it those disfiguring traces 
which are not the least of the terrors of 
unmodified variola. 
1. On no subject is medical testimony 
more unanimous than on the very large 
immunity from attacks of smallpox which 
successful Vaccination will confer.1 While 
there are few unvaccinated persons who 
do not at some period or another of their 
lives sustain an attack of variola, the vac- 
cinated are, as a rule, entirely exempt 
from it. Precise data have never been 
collected on a sufficient scale to enable 
us to state with numerical accuracy what 
1 See this testimony as given on a large 
scale in Report of Smallpox and Vaccination 
Committee of Epidemiological Society, 18.53; 
Seaton on Protective and Modifying Powers 
of Vaccination, 1857; and Simon, op. cit. 
pp. Ixxix. Ixxx. The Epidemiological So- 
ciety refer to answers received from above 
2000 medical practitioners in England, besides 
evidence collected from abroad, affirmative of 
the protective value of Vaccination. Simon 
gives the answers, to the like effect, of 540 
distinguished medical men, British and for- 
eign (out of 542 of whom inquiry was made), 
to a question "purposely constructed to elicit 
the expression of every existing doubt on the 
protective influence of Vaccination." 
1 Vide Reports of Medical Officer of Privy 
Council, iii. iv. v. vi. and vii. PROTECTION AFFORDED BY VACCINATION AGAINST SMALLPOX. 
167 
proportion of persons may still be liable 
to take smallpox, who have already had 
variola or who have been successfully 
vaccinated. The proportion in both cases 
will vary, of course, with the degree of 
exposure to the infection, and will no 
doubt also be greatly dependent on the 
presence or absence of epidemic influence. 
We have, however, as regards one limited 
class of the population some very precise 
facts. The records of the Royal Military 
Asylum at Chelsea show that 5,774 boys 
were admitted into that institution in the 
course of the forty-eight years ending De- 
cember, 1851, of whom 1,950 had on ad- 
mission marks of smallpox, and 3,824 
either had marks of Vaccination or were 
on admission vaccinated :l of the former 
6'15 per thousand, and of the latter 7'06 
per thousand, contracted smallpox subse- 
quently during their residence in the asy- 
lum. Dr. Balfour, the able and accurate 
statistician to whom we are indebted for 
these facts, tells us also that in a long 
series of years antecedent to the publica- 
tion of his Memoir,1 the annual number 
of cases of smallpox in the British army 
had not been more than 6'6 per 10,000 
men, one-fifth of the men, it was calcu- 
lated, being protected by previous small- 
pox, and the other four-fifths by Vaccina- 
tion. That portion of the troops which 
was serving in the United Kingdom, and 
was quartered chiefly in large towns (from 
which, to the disgrace of this country, 
smallpox is seldom absent), suffered in 
greater proportion, but still the average 
annual admissions among these were for 
a period of ten years (1837-46) only 22 out 
of every 10,000 men. The returns for the 
four years 1859-62 show on the average a 
considerable diminution even in this ratio.2 
Year. 
Number of Troops 
in United Kingdom. 
Cases of 
Smallpox. 
Deaths. 
Per 10,000. 
Cases. 
Deaths. 
1859 
71,715 
175 
7 
24-3 
0-97 
1860 
85,443 
140 
9 
16-8 
1-05 
1861 
88,955 
51 
4 
5-9 
0-45 
1862 
78,173 
64 
4 
8-1 
0-51 
In civil practice, numerical inquiries 
have sometimes been made as to the pro- 
tection enjoyed by individuals under the 
highest degree of exposure to smallpox- 
members of families in which that disease 
existed, who were living and sleeping at 
home, in the same house, even generally 
in the same room, and sometimes in the 
same bed, with the infected case. The 
result of such an inquiry, made by Mr. 
Cross, of Norwich, was that of 215 unpro- 
tected members of families so circum- 
stanced, 200 contracted the disease and 46 
died ; while of 91 vaccinated, only 2 took 
the disease, and these both had it in its 
modified form. A rather more extensive 
inquiry was made some years later by Mr. 
Marshall, of Chelsea,3 into the facts con- 
nected with 757 individuals in infected 
families. He found that of 231 who had 
been protected by Vaccination, 27 had 
contracted smallpox during an epidemic 
that had just then prevailed ; that of the 
unprotected every one had been attacked 
except 7 ; and that 14 cases had occurred 
in persons who had previously had va- 
riola. The only inquiry of this kind, so 
far as I know, in which regard has been 
had, not merely to the fact of Vaccina- 
1 In 1852; in Medico-Chirurg. Trans., vol. 
XXXV. 
2 The variation in the annual number of 
cases depends on the presence or absence of 
epidemic influence: two epidemic and two 
non-epidemic years are included in the table. 
It will be seen that the recent ratio of cases in 
epidemic years has not exceeded the average of 
ten years, 1837-1846. This improvement is 
no doubt mainly due to the closer scrutiny 
now given on the admission of recruits to the 
evidences of their protection against small- 
pox, and to the performance of revaccination. 
As regards the relative protective value of 
variola and vaccinia the improvement is sig- 
nificant, for the relative number of soldiers 
depending for their protection on vaccinia is 
much greater now than before. 
3 Lancet, vol. xxxvi. 
1 This period extends back as far as 1803 : 
it will be noticed that one out of every three 
children admitted in these forty-eight years 
showed marks of smallpox. No better illus- 
tration of the progress Vaccination has made 
and of its wonderful influence in protecting 
against smallpox can be given than is afforded 
by contrasting this proportion with the pro- 
portion we now find of children of our poorer 
classes who are marked with smallpox. 
When, five years ago, an examination was 
made among school children of this class in 
London, less than one in forty was found to 
have any traces of smallpox. VACCINATION. 
168 
tion, but to its amount and quality, has 
been the one made some years ago by the 
Epidemiological Society, as to the extent 
to which medidal men-who, from their 
profession, would be unusually exposed to 
smallpox-had suffered from that disease 
after Vaccination or after previous va- 
riola. The results of this inquiry were, 
that of 347 who? had been vaccinated, 44, 
or 12-6 per cent., had subsequently con- 
tracted variola, generally in the most 
modified form. Some of these had no 
cicatrix of their Vaccination, and in others 
the cicatrices were indifferent, or were 
only one or two ; but of 57 who had three 
or more good cicatrices, only 2, or 3'5 per 
cent., had had smallpox. Of 82 medical 
men who had had smallpox, most of them 
by inoculation,, in infancy-3, or 3'6 per 
cent., had contracted variola in later life.1 
These observations are strongly confirma- 
tory of Jenner's anticipations as to the 
relative protective value of vaccinia and 
smallpox. 
2. The facts showing the power of vac- 
cinia in modifying smallpox, if it should 
happen to be subsequently contracted, and 
of disarming it of its terrors, are so ample 
that it is difficult to know whence to se- 
lect examples. No epidemic of smallpox 
has occurred in any climate since the in- 
troduction of Vaccination without afford- 
ing the most abundant evidence of it. 
While the mortality of natural smallpox 
is seldom below 20 per cent, and often 
amounts to 30 and 40 per cent, of the 
attacks, the death-rate among the vacci- 
nated (taken indiscriminately and with- 
out regard to the quality of tlmir vaccina- 
tion) is rarely known to exceed 7 per cent, 
and is more frequently 3, 4. and 5 per 
cent. It will have been noticed, in the 
table above given of the cases of smallpox 
among the soldiers in the United King- 
dom in the four years 1859-02, that of 430 
cases of the disease only 24 were fatal, or 
5| per cent. In observations which, on 
account of the large scale on which they 
were made, are of great value, viz. those 
made for twenty-one years in Bohemia 
on four millions of people, it was found 
that the death-rate among vaccinated 
persons who happened to contract small- 
pox was 5^ per cent., while the death- 
rate among non-vaccinated persons when 
they contracted smallpox was 29f per 
cent.1 
But the observations which outweigh 
all others in value, on account of the ex- 
treme accuracy and precision with which 
they have been made, are those which 
Mr. Marson has collected by thirty years? 
labor at the Smallpox Hospital. In this 
hospital above 15,000 cases of smallpox 
have during that time been under his per- 
sonal care, and all particulars respecting 
them have been carefully recorded: and 
it has been found that while the unvacci- 
nated have died at the rate of above 35 
per cent., the vaccinated have died at the 
rate of only per cent. 
But Mr. Marson's observations do far 
more than establish in a general way, in 
concurrence with others, the modifying 
power of Vaccination. They have a merit 
peculiarly their own. They show conclu- 
sively that the degree of modifying power is 
in the exact ratio of the excellence and com- 
pleteness of the Vaccination as shown by the 
cicatrices: in other words, that it is di- 
rectly as the amount of vaccine-marking 
and as the character of the marks. The 
subjoined table will show this at a glance, 
better than any detailed statement :2- 
Classification of Patients affected 
Number of Deaths 
with Smallpox. 
yer cent, in 
each class respectively. 
1. 
Unvaccinated ........ 
. 35 
2. 
Stated to have been vaccinated, but having no cicatrix 
. 23'5" 
3. 
Vaccinated- 
a. Having one vaccine cicatrix3 .... 
. 7'73 
b. Having two vaccine cicatrices3 .... 
. 4-70 
c. Having three vaccine cicatrices .... 
. 1-95 
d. Having four or more vaccine cicatrices 
. 0-55 
a. Having well-marked cicatrices .... 
. 2-52 
A. Having badly-marked cicatrices .... 
. 8-82 
4. 
Haviiig previously had smallpox .... 
. 19 
So that, while the average of vaccinated 
persons, if thSy should ever contract small- 
pox, have about one-sixth of the chance of 
having it fatally which is run by those who 
have not been vaccinated at all; some of 
them, from bad Vaccination, incur in fact 
one-third of that risk, while on the other 
hand others, thoroughly -well vaccinated, 
incur less than one- seventieth part of it. 
1 Simon, op. cit. p. xxvii. 
2 See also the article on Smallpox. The 
deaths from super added disease have been 
deducted both from the unvaccinated and the 
vaccinated. 
9 In these classes the influence of quality 
of cicatrix was remarkably seen. In class a 
1 Seaton, on the Protective and Modifying 
Powers of Vaccination. PROTECTION AFFORDED BY VACCINATION AGAINST SMALLPOX. 
169 
In regard therefore to the expectation of 
any case of smallpox turning out badly, 
the question is not merely whether the 
patient has been vaccinated or not, but 
also how he has been vaccinated. 
These invaluable observations form the 
basis on which Vaccination should always 
be conducted. Nor, relying as we must 
do upon them, is it too much to affirm 
that no practitioner will have done his 
duty in any case in which he is called 
upon to vaccinate, unless, besides all re- 
quisite precautions with regard to the 
genuineness of the lymph employed and 
the means of insuring success, he has also 
taken care to vaccinate sufficiently, i. e., 
to produce, so far as in him lies, four or 
five genuine good-sized vesicles, such as 
resul t from separate punctures, or if vac- 
cinating otherwise than by separate punc- 
ture, to produce equivalent local results. 
Observations made by Dr. Buchanan 
and myself, during the epidemic of small- 
pox in London in 1863, on upwards of 
50,000 children in various national and 
parochial schools, workhouses, &c., 
showed from another point of view the 
necessity of having regard to the quality 
and amount of Vaccination in estimating 
its protective value against smallpox. 
Some of the children examined had never 
been vaccinated : the large majority had 
been vaccinated in various manners and 
degrees. Of every 1000 children without 
any mark of Vaccination we found that no 
fewer than 360 had scars of smallpox ; 
while of every 1000 children who had evi- 
dence of Vaccination, only 1'78 had any 
such traces. And, on further classifica- 
tion with reference to the kind of Vacci- 
nation, we obtained the following re- 
sults :- 
Classification of Children 
examined. 
Proportion marked with 
Smallpox per 1000 Children in 
each class respectively. 
1. Having no vaccine marks ....... 36'0 
2. Vaccinated- 
a. Having one vaccine cicatrix . . . . . 6*80 
b. Having two vaccine cicatrices 2'49 
c. Having three vaccine cicatrices ..... 1'42 
d. Having four or more vaccine cicatrices . . . 0'67 
a. Having cicatrix or cicatrices of bad quality. . . 7'60 
S. Having cicatrix or cicatrices of tolerable quality. . 2'35 
y. Having cicatrix or cicatrices of excellent quality . 1'22 
On taking the extremes, it appeared 
that of children having four or more per- 
fect vaccine marks, only 0'62 per thousand 
had any trace of smallpox, while of those 
who had a single bad mark of Vaccination 
19 per thousand were scarred by smallpox. 
As against smallpox therefore of such ex- 
tent as to leave any traces, the best Vac- 
cination had been upwards of thirty times 
as protective as the worst.1 But this 
numerical statement is far from expressing 
the whole difference ; for the marks small- 
pox had left on the vaccinated, and par- 
ticularly on the well-vaccinated, were for 
the most part very slight-the cases being 
quite exceptional in which there was any- 
thing approaching to disfigurement; while 
of the un vaccinated a very large propor- 
tion were seriously marked and disfigured. 
Many of them were really hideous to look 
at, and in several the smallpox had left 
permanent blindness or deafness.1 
The protective power of Vaccination 
against smallpox extends to every race of 
mankind, and is seen in every climate and 
in every part of the habitable globe. 
Wherever smallpox has been known to 
occur exemption from attack has been the 
rule among the vaccinated, the exception 
among the unvaccinated. Abundant illus- 
trations of this protective value of Vacci- 
nation in hot climates will be found in Dr. 
Kinnis's Report on Smallpox in Ceylon in 
1833-34,2 in information collected by my- 
1 One of the most remarkable illustrations 
of the protective power of Vaccination I have 
ever met with was in a ragged industrial school 
at Hull-a really ragged school, in which the 
children were of the very lowest class. Of 
170 children in the school 33 had no mark of 
Vaccination, and 30 of these had marks of 
smallpox, most of them being greatly dis- 
figured by it. Of the 137 having marks of 
Vaccination, only one had marks of smallpox, 
and these were very slight. Before detecting 
them I had already called the master's at- 
tention to the unsatisfactory character of the 
vaccine marks on the boy's arm. 
2 Report on Smallpox as it appeared in 
Ceylon in 1833-34, by J. Kinnis, M.D. 8vo. 
Colombo, 1835, 
(with one vaccine cicatrix), among cases in 
which this was well marked, the death-rate 
per cent, was 3*83; among cases in which it 
was badly marked the death-rate was 11'91. 
In class b (two vaccine cicatrices), amortg 
cases in which these were well marked, the 
death-rate was 2'32; among cases in which 
they were badly marked it was 8'34. 
1 Sixth Report of Medical Officer of the 
Privy Council, pp. 91-2. 170 
VACCINATION. 
self from the East and West Indies,1 in 
the Annual Reports on Vaccination in the 
Bombay Presidency, &c. &c. And when- 
ever in these climates vaccinated persons 
have contracted smallpox, it has usually 
been in the mild and modified form 
observed in this country. Thus, in an 
epidemic in the Mauritius, in which the 
mortality among unvaccinated patients 
was 42-7 per cent., it was found that of 
such vaccinated persons as contracted the 
disease, only 7 per cent, died, the greater 
part of these having unsatisfactory marks : 
and in the Ceylon epidemics reported by 
Dr. Kinnis, who, in his observations, 
noted in all instances the quality of the 
Vaccination, it was found that, while 
those who were known for certain never 
to have been vaccinated died at the rate 
of 41-5 per cent., and those who could give 
no account of themselves, or professing to 
have been vaccinated, had no marks, or 
bad marks, died at the rate of 26T per 
cent., persons having satisfactory marks of 
Vaccination died at the rate of only 1'6 
per cent. Of 203 fatal cases, in fact, which 
occurred during these epidemics, only 
three were in persons having satisfactory 
marks of Vaccination, and two were in 
persons who had before had smallpox. In 
like manner in an epidemic in Jamaica in 
1851, Drs. Bowerbank and Turner lost of 
477 unprotected cases 75, but of 120 vac- 
cinated patients only 4. Both the protec- 
tive and modifying power was observed in 
the negroes and half-castes, as completely 
as in the white population.2 
In consequence of the remarkable power 
of Vaccination in protecting against small- 
pox, and the adoption of the practice 
universally by educated people and in 
annually increasing proportion by the 
population at large, the present average 
death-rate from smallpox is scarcely in 
any European country one-tenth part, 
and in those countries in which Vaccina- 
tion has been most carefully carried out 
it is much less than one-tenth part, of 
what it was at the end of the last century. 
Thus in Sweden, where before Vaccina- 
tion was discovered the average annual 
death-rate from smallpox was 2050, out of 
every million of population, during the 
forty years 1810-50, it was but 158 ; in 
Westphalia, where the smallpox death- 
rate used to be 2643, it was from 1816-50 
only 114; in Bohemia, Moravia, and 
Austrian Silesia, it has been reduced in 
like manner from 4000 to 200 ; in Copen- 
hagen, from 3128 to 286 ; and in Berlin 
from 3422 to 176.1 And although our own 
country has been, at all events until lately, 
behind most others in Europe, as to the 
extent to which Vaccination has been 
adopted,2 and behind many as to the com- 
pleteness with which it has been per- 
formed,3 yet the smallpox death-rate of 
England and Wales, which at the close of 
last century was estimated by Dr. Lett- 
som and Sir Gilbert Blane at not less than 
3000 per million of population, was for the 
average of the years 1841-53 only 304, and 
on the average of the succeeding twelve 
years 1854-65 has, notwithstanding three 
very severe epidemics, fallen as low as 
202. The following table, exhibiting the 
smallpox mortality in England at various 
periods, not only shows the influence of 
Vaccination in the prevention of small- 
pox, but is of interest also as illustrating 
the value of legislative and administrative 
action in diffusing the blessings of that 
practice :- 
Periods compared. 
Annual deaths 
by Smallpox 
in .England and 
Wales. 
Annual rate 
per million 
of the 
Population. 
1. 
Average of thirty years previous to introduction of Vacci- 
nation estimated by Dr. Lettsorn and Sir Gilbert Blane. . 
3,000 
2. 
Average of three years (1838-404) when Vaccination had 
become to a great extent diffused, but before any public 
provision was made for its gratuitous performance * . . 
11,944 
770 
3. 
Average of nine5 of the years (1841-53) when public Vacci- 
nation was gratuitously provided, but Vaccination was not 
obligatory 
5,221 
304 
4. 
Average of the twelve years (1854-65) during which Vacci- 
nation has been to a certain extent obligatory 
3,967 
202 
1 Board of Health, Papers relating to the 
History and Practice of Vaccination, 1857, p. 
139. 
2 Ibid. 
' Simon, op. cit. p. xxiii. 
2 Report of Smallpox and Vaccination 
Committee of Epidemiological Society, 1853. 
3 Marson, Medico-Chir. Trans., vol. xxxvi. 
4 The present system of registering deaths 
commenced only in 1837. 
6 During the years 1843-46 causes of death 
were not distinguished in the Reports of the 
Registrar-General. PROTECTION AFFORDED BY VACCINATION AGAINST SMALLPOX. 
171 
With such proof of the protective value 
of Vaccination, it might well indeed be a 
matter of astonishment that smallpox 
should still annually make such ravages 
amongst us, if we had not ample evidence 
of the extent to which, through ignorance 
and apathy, and to a certain degree 
through prejudice not yet eradicated, the 
practice of Vaccination has been neg- 
lected, as well as of the imperfect and 
insufficient way in which the operation 
has not unfrequently been performed. 
The inquiries made, under the direction 
of the Government, from 1860 to 1864, by 
Drs. Stevens, Buchanan, Sanderson, and 
myself, into the state of Vaccination 
throughout England, showed that the 
universal performance of Vaccination in 
early infancy which is indispensable for 
the effectual protection of the community 
from smallpox was so far from being at- 
tained, that the proportion unvaccinated, 
even among children old enough to be in 
attendance at public infant schools, ex- 
ceeded 13 per cent. Now, it is in the 
young unvaccinated portion of the popu- 
lation (hat the smallpox mortality chiefly 
occurs. Of the nearly 4000 deaths from 
this disease which are on an average still 
recorded every year in England, 56 per 
cent, are in children under five years of 
age, and as much as 70 per cent, in chil- 
dren under ten years of age.1 We can 
have no hesitation in saying that in all 
the fatal cases at this early age there 
must, with very rare exceptions, have 
been neglect of Vaccination; for when 
that operation has been performed, even 
with the effect of raising a single vesicle 
only, subsequent death from smallpox in 
childhood very seldom indeed occurs.2 We 
know further that of the mortality above 
ten years of age a very large proportion 
takes place in persons in whom Vaccina- 
tion had never been performed. So that 
an estimate which should ascribe four- 
fifths of the present mortality from small- 
pox to the omission of Vaccination would 
most certainly be very much below the 
mark. Many, however, of the deaths 
from smallpox which take place after 
puberty-and there are on an average 
above 1000 deaths annually from this 
cause in England in persons over fifteen 
years of age-are (especially at epidemic 
periods) in individuals who had been vac- 
cinated, and who believed themselves 
protected against smallpox. But as re- 
gards these, there arises the further ques- 
tion, how had they been vaccinated ? 
Now, though we cannot, of course, an- 
swer this question as regards the indivi- 
duals, we may fairly apply to the group 
the observations made in the Smallpox 
Hospital on fatal cases of smallpox in per- 
sons believed to have been successfully 
vaccinated. Of 402 such fatal cases, oc- 
curring in 20 years, 101 exhibited on their 
arms no evidence whatever of having ever 
had effective Vaccination ; 277 had but 
one or two vaccine marks, and these, in 
191 of them, were of imperfect character ; 
16 were in persons who had three cica- 
trices ; and only 5 in persons who had 
been vaccinated in the way which has 
been shown to be the most protective-of 
which 5, two did not die of smallpox, but 
of concurrent or superadded disease.1 We 
may be sure then that in only a few of 
those who die from smallpox after Vacci- 
nation in England, the Vaccination had 
been done in the best way. 
In the official inquiries above referred 
to, in the course of which the arms of 
nearly half a million vaccinated children 
were examined, evidence was obtained of 
the great extent to which imperfect or in- 
sufficient Vaccination had heretofore pre- 
vailed in England; taking the country 
throughout, not more than one child in 
eight was found to be so vaccinated as to 
have the highest degree of protection that 
Vaccination is capable of affording; not 
more than one in three could, on the 
most indulgent estimate, be considered as 
well protected; while in more than one 
in four the Vaccination had been of a 
very inferior kind indeed, resulting in 
marks of imperfect character, or in only 
one or two marks of merely passable cha- 
racter.2 These imperfections were mainly 
traceable to the following causes : (1) the 
frequency with which practitioners, in- 
1 Deaths in England from Smallpox, at dif- 
ferent ages, for the nine years 1855-6 <:- 
All ages. 
Under 1 
Year. 
1-2 
Years. 
2-3 
Y-ars. 
Years. 
Years. 
30,707 
7,334 
3,370 
2,666 
2,152 
1,732 
Under 5 
Years. 
5-10 
Years. 
10-15 
Years. 
15-25 
Years. 
25-35 
Years. 
35 Years 
and 
upwards. 
17,254 
4,078 
1,169 
3,552 
2,422 
2,232 
1 See also the article on Smallpox. 
2 These observations were made on children 
most of whom had been vaccinated by public 
vaccinators, but a large number of whom had 
been operated on by private practitioners, 
and, without affording statistical evidence of 
the fact, they left a strong impression that, 
as a rule, the latter were less well vacci- 
nated than the former. My own experience 
has satisfied me in other ways that many in 
the upper and middle classes in England 
have been very imperfectly vaccinated-the 
chief reason why smallpox is so much less 
met with among them than it is among the 
lower classes being that they are so very 
much less exposed to it. 
2 Gregory, Marson, &c., as quoted in 
"Handbook of Vaccination," pp. 224-5. 172 
VACCINATION. 
stead of attempting fully to infect the 
system, had been satisfied with insertions 
of lymph, sufficient to produce only one, 
two, or three ordinary vesicles; (2) the 
want of due attention to the selection of 
the lymph used in vaccinating ; (3) care- 
lessness and clumsiness in the perform- 
ance of the Vaccination, so that, if the 
operation did not wholly fail, it very fre- 
quently resulted in a less degree of effect 
than it had been the aim of the operator 
to produce; and (4) the great and unne- 
cessary extent to which the use of pre- 
served and conveyed lymph was substi- 
tuted for the Vaccination direct from the 
arm, which should be the rule of all vac- 
cinators.1 
It is satisfactory that these, the chief 
causes of imperfection, are of a kind for 
which we have in future an obvious rem- 
edy (and which, it may be added, are now 
rapidly being remedied), in the proper 
practical instruction of vaccinators in 
the employment of more care and at- 
tention in vaccinating, and in better 
arrangements for transferring lymph. 
Other causes of imperfect Vaccination 
which are quite independent of the vacci- 
nator, though far less widely operative 
than those just enumerated, must not, 
however, be overlooked: as, something 
particular in the child's constitution or 
condition at the time of Vaccination, 
which even the most experienced vacci- 
nator may have been unable to detect; 
aberrations of lymph-rarely indeed, but 
still occasionally, met with - occurring 
under undefinable conditions, of which 
the first manifestation to the vaccinator 
has been the unsatisfactory result; the 
carelessness of parents in allowing the 
vaccine vesicles to be disturbed in their 
course and the crusts to be prematurely 
removed. 
It has been contended that, apart from 
imperfections in the mode of conducting 
Vaccination, the vaccine lymph itself ne- 
cessarily degenerates by repeated trans- 
missions through the human body, and 
loses something of its infective and pro- 
tective power. 
The hypothesis that lymph would de- 
teriorate by mere transmission through 
human bodies was started in the very 
earliest days of Vaccination. Jenner 
thought the notion a very improbable 
one, but could only then say of it that 
time was necessary to determine the ques- 
tion. But after many years' experience 
he felt himself quite justified in pronounc- 
ing the hypothesis as groundless. Draw- 
ing, as he never failed to draw, the broad 
and most important distinction between 
such deterioration of lymph as may result 
if in continuous vaccinations due care be 
not taken in selection of the lymph em- 
ployed, and the doctrine of inevitable de- 
terioration by mere transmission : he re- 
marked, writing in 1816, that lymph in 
passing even from one individual to an- 
other might undergo a change which 
rendered it unfit for further use, but that 
the notion of necessary degeneration was 
a conjecture "he could destroy by facts 
and he referred, in proof, to the vesicles 
he was then producing, which, he says, 
"are in every respect as perfect and cor- 
rect in size, shape, color, state of the 
lymph, the period of the appearance and 
disappearance of the areola, its tint, and 
finally the compact texture of the scab, 
as they were in the first year of Vaccina- 
tion ; and to the best of my knowledge 
the matter from which they are derived 
was that taken from a cow about sixteen 
years ago."1 Numerous trustworthy ob- 
servers, who had watched the vaccine 
disease at the introduction of Vaccina- 
tion, on comparing what they had then 
seen with the effects produced by lymph 
of the earliest stocks, after a lapse of 
thirty or forty years, were unable to detect 
the slightest difference either in the cha- 
racter or course of the vesicles. And the 
same appears certainly to be the case at 
the present day. Having for the last 
thirty years been a close observer of the 
vaccine vesicle, and having during the 
last nine years enjoyed such opportunities 
of witnessing the practice of Vaccination 
in the hands of various vaccinators, and 
of noticing the results of Vaccination in 
the cicatrices left on the arms of individu- 
als vaccinated, as have scarcely perhaps 
fallen to the lot of any other' person, I 
can confidently affirm that the vaccinators 
of the present day who are masters of 
their craft do their work as surely with 
ordinary long-humanized lymph and in- 
fect their patients as completely as the 
earlier vaccinators did, producing vesicles 
which in character and course differ in 
nothing from the description that Jenner 
has given us, and which leave cicatrices 
as perfect as those which I have seen on 
the arms of persons who had been vacci- 
nated by Jenner himself or by his well- 
known contemporary, Dr. Walker.2 What- 
1 For evidence in detail see Reports of 
Medical Officer of Privy Council, iii.-vii. It 
is beyond the limits permissible for the pres- 
ent article to enter into an inquiry into the 
subject of the best arrangements for the per- 
formance of Vaccination and for maintaining 
stocks of active lymph : but it is a subject of 
the utmost importance, and one which I have 
endeavored to treat fully in my ' ' Handbook 
of Vaccination," chap. vii. 
1 Letter in Baron's Life, vol. ii. p. 398. 
M. Bousquet appears to have overlooked this 
passage. See his "Nouveau Traits de la 
Vaccine," p. 399. 
2 See Fourth Report of Medical Officer of 
Privy Council, p. 64. PROTECTION AFFORDED BY VACCINATION AGAINST SMALLPOX. 
173 
ever has been found unsatisfactory in the 
hands of other vaccinators, whether as 
regards the course of the vesicles or the 
character of the cicatrix, was fairly trace- 
able to the causes which have been already 
stated, and especially to looseness and 
carelessness in the selection of lymph: 
and though I have sometimes found it 
desirable to recommend a vaccinator to 
change the stock of lymph he was employ- 
ing, I have always felt it enough to take 
care that the stock substituted was good 
active lymph without troubling myself as 
to the time that had elapsed since it had 
come from the cow. It is quite true that 
the earliest transmissions of lymph from 
the cow to the human subject have usually 
a peculiar intensity of local irritative ef- 
fect. But this result (which is so far from 
being an advantage that it is often found 
to need controlling)1 is generally lost in a 
few transmissions, often indeed in one or 
two transmissions; besides that different 
primary stocks are found to differ much 
as to the local effect they thus produce.2 
Ceely, whose testimony on this subject is 
of the utmost importance, because he, 
more than any other living inquirer, has 
studied the natural disease in the cow, 
and has experimented on its transference 
to the human subject, entirely disclaims 
belief in the superior protective efficacy of 
lymph thus recently transferred over active 
humanized lymph.3 Several practitioners 
residing near the Bridgewater Level, and 
in the Vale of Gloucester (in which dis- 
tricts the natural cow-pox is still not un- 
frequently seen in the dairy farms), stated 
a few years ago to Dr. Sanderson, that 
they had inoculated lymph direct from 
the cow with success ; but all agreed that, 
after the first or second transmission, the 
results did not differ from those of ordi- 
nary Vaccination, either in the character 
or progress of the vesicles. It is in truth 
not to the cow, but to adequate care and 
skill on the part of vaccinators in the se- 
lection of the children and vesicles from 
which lymph is taken, that we must look 
for maintaining stocks of active lymph.4 
Facts are equally at variance with the 
supposition that transmission through 
human bodies causes vaccine lymph to 
lose anything of its protective power. Per- 
sons vaccinated with lymph direct, or only 
a few removes from the cow, and others 
vaccinated with long humanized lymph, 
have been submitted to the test of vario- 
lous inoculation; but the result in each 
class of cases has been the same. This ex- 
periment in fact is made to hand on a large 
scale in every epidemic of smallpox. In 
each such epidemic-no matter at what 
period since the introduction of Vaccina- 
tion-it has not been the persons vacci- 
nated with the then current lymph, the 
lymph furthest from the cow, but those 
vaccinated some sixteen, twenty, or twen- 
ty-five years before, with lymph so much 
nearer to the parent source, who have 
been found to be the chief sufferers from 
post-vaccinal smallpox. 
Another subject for consideration in 
reference to the protective power of vac- 
cination is its permanency in the indi- 
vidual. It has been often said that it is 
undoubtedly a protection, but for a lim- 
ited time only ; that it wears out by age, 
and requires successive renewals. Al- 
though this theory is sometimes thus 
broadly advanced, the permanency of the 
protection which a single efficient Vacci- 
nation gives against smallpox is so com- 
pletely established as the law of the hu- 
man economy, that we need only deal 
with it as offering an explanation of that 
proportion of cases in which smallpox is 
met with in those who have been vacci- 
nated. As regards these, we may observe 
in the first place that at times when epi- 
demic smallpox prevails, and especially 
under circumstances of great exposure, 
as where children are living and sleeping 
in the same room, perhaps sleeping in 
the same bed, with a case of smallpox, the 
disease is sometimes met with in very 
young children, and occasionally very 
shortly after Vaccination. Even so early 
as the year 1806, Willan was able to re- 
cord numerous cases in which a very trivial 
eruption, but of true variolous character, 
appeared in children at intervals which 
varied from five months to seven years 
after Vaccination had been performed. 
Similar examples have been met with in 
every epidemic down to the present time. 
But this eruption is generally so slight 
(except where the Vaccination has been 
' To one unpleasant result frequently met 
with in early vaccinations from the cow, Mr. 
Ceely has especially called attention in a re- 
cent communication; it is the occurrence of a 
special vesicular vaccine eruption called by 
the Germans " Nachpocken," which causes a 
good deal of temporary disfigurement and an- 
noyance, and sometimes, when copious, severe 
and even dangerous symptoms. (See Brit. 
Med. Journ., Jan. 7, 1865.) 
2 Handbook of Vaccination, chap. x„ 
8 Observations on Var. Vacc. in Trans, of 
Prov. Med. Assoc., vol. viii. 
4 The important point, it seems to me, is 
that vaccinators should not be induced to 
look to anything extrinsic and inevitable for 
an explanation of deteriorations which, if 
they occur at all, may be more properly 
ascribed to want of skill and care somewhere. 
So long as this is kept in mind, there can of 
course be no objection to the introduction at 
any time, when opportunity offers, of fresh 
stocks ; but those who are about to undertake 
the transplantation of lymph may meet with 
some difficulties, and would do well to study 
Mr. Ceely's admirable "Observations on the 
Variolse Vaccinae," in Trans, of the Prov. 
Med. Assoc., vols. viii. and x. 174 
VACCINATION. 
spurious, or ineffective) as to attract little 
attention, or only to attract observation 
on account of its amazing contrast with 
the variola of unprotected children. After 
puberty smallpox is met with in vacci- 
nated persons more frequently, and though 
no doubt generally modified, is, if there 
have been any imperfection in the origi- 
nal Vaccination, in not a few cases severe 
and even fatal; even after the most com- 
plete Vaccination, cases are met with, 
some of which are severe, and a very few 
-not much more than the half of 1 per 
cent.-fatal. It has been found, however, 
in the experience of the army, in that of 
the Smallpox Hospital, and in practice 
generally, that cases of smallpox after 
Vaccination occur chiefly between the 
ages of fifteen and twenty-five, and that 
after the age of twenty-five they sensibly 
diminish. Thus, while in the army the 
deaths from smallpox among soldiers un- 
der twenty years of age were 3'4 per 
10,000 of aggregate strength, and those 
among soldiers from twenty to twenty- 
five years old 3T per 10,000 ; the deaths 
from this cause among the soldiers above 
twenty-five years old have been but 1 per 
10,000. And from the observations of 
Professor Heim, on 1055 cases of small- 
pox in vaccinated persons, examined not 
in relation to the age but specially as to 
the number of years that had elapsed 
since Vaccination, we find that while the 
average annual number of cases that oc- 
curred in the first twelve years after Vac- 
cination was twelve, and in the next thir- 
teen years was over fifty-one, the average 
for the following ten years was under twen- 
ty-five. The real explanation appears to 
lie not in the weakening influence of time, 
which would be a progressively increasing 
influence, but rather in certain disturbing 
influences of which, no doubt, puberty is 
the chief. 
The liability of persons to renew their 
susceptibility to smallpox is, unquestion- 
ably, very much a matter of diathesis. 
It is frequently met with in various mem- 
bers of the same family ; and I know of 
many instances in which, under the same 
circumstances, other members of these 
families have suffered from second attacks 
of smallpox. 
tion of persons after even the most perfect 
Vaccination. 
When a child has unfortunately been 
imperfectly vaccinated, no doubt the best 
thing that can be done is to vaccinate 
it again. But the chance revaccination 
may afford of correcting original imperfec- 
tion must never be held for a moment to 
absolve any practitioner from the pains he 
is bound to bestow to make his original 
Vaccination full and complete. For what 
daily happens is thisA child is vacci- 
nated and takes badly ; either at once, or 
at some no distant period, it is vaccinated 
again, and perhaps a third time, and can- 
not be made to take ; it grows up, gets 
smallpox, and very likely dies. Or this 
happens: The parents are directed to 
bring it again at some specified time, and 
fail to do so, and the same fate as in the 
other case befalls it. Take it at the best, 
an originally imperfect or incomplete Vac- 
cination is a very great misfortune. 
But supposing it to have occurred, how 
is the practitioner to act ? Is he to revac- 
cinate at once, or is he to wait till puberty, 
when the chief danger of insufficient Vac- 
cination manifests itself? lie must be 
guided in determining partly by the degree 
of imperfection, and partly by the liability 
to exposure to smallpox. If the Vaccina- 
tion has been spurious, irregular, or dis- 
turbed in such a way as to divest it of 
protective power, he would, unless there 
were something in the child's then state 
of health which might have been the 
cause of these imperfections or irregulari- 
ties, at the earliest opportunity vaccinate 
it again; if anything were found amiss 
with the child, he would of course wait 
till that was corrected. Very likely the 
Vaccination would not take, for quite 
spurious Vaccination will often prevent 
real Vaccination from taking effect after- 
wards. But the chance must be given, 
and given with every care to produce 
effect. If such should result, even though 
it be only the ordinary spurious effect of 
a revaccination, he will have done all he 
can do, and need recommend no further 
proceedings till puberty-at all events un- 
less there should arise some immediate 
danger of smallpox. But if there be no 
local evidence that the lymph applied on 
the revaccination had been absorbed, the 
operation should be repeated at intervals 
until he is satisfied that the child is, for 
the time at all events, insusceptible. 
Supposing, however, the result of the 
primary Vaccination have been one of 
insufficiency rather than of imperfection, 
-that'is, if a single vesicle have risen in- 
stead of the four or five it was desired to 
produce, but that vesicle has run its 
course perfectly,-I do not usually recom- 
mend, except under circumstances of dan- 
ger, any further Vaccination till the child 
grows up. 
Revaccination.-The numerous in- 
stances in which, from whatever cause, 
the protection of Vaccination has proved 
insufficient, have led to the very frequent 
adoption of late years of revaccination. 
By many this practice is looked upon as 
only called for or useful where there has 
been some defect in the primary Vaccina- 
tion ; but there is reason to believe that 
it has a use beyond this-that it extin- 
guishes that renewed susceptibility to 
smallpox which, it has been already point- 
ed out, occurs in an indeterminate propor- 175 
REVACCINATION. 
The same rule guides me in judging 
from the cicatrices left on the arms of 
young children whether revaccination is 
called for. If these be decidedly imperfect 
in character, I advise the parents to seek 
revaccination with as little delay as possi- 
ble ; but if the cicatrices be only deficient 
in number, or if the character, though 
less strikingly good than it might be, is 
yet genuine, I hold the child to be pretty 
safe up to the age of puberty, but strictly 
enjoin its revaccination then. 
The occurrence of a case of smallpox in 
a house leads to a stricter rule as regards 
all the inmates. Those who are past or 
approaching puberty should, except such 
as have already since puberty been suc- 
cessfully vaccinated, be revaccinated at 
once ; and those under puberty who have 
two or more thoroughly characteristic 
marks should not be meddled with; the 
children whose marks are not thoroughly 
good, or who have but a single good mark, 
should be revaccinated. In a crowded 
court this course should not be limited to 
the house in which the smallpox appeared, 
but extended to each house. If, on the 
outbreak of an epidemic of smallpox, this 
plan were uniformly adopted, together, of 
course, with the immediate Vaccination 
of all who in the house or court were 
found unvaccinated, there can be very 
little doubt the epidemic might be cut 
short, and very certainly indeed the occur- 
rence of fatal or severe cases of smallpox 
would be all but entirely prevented.1 
Revaccination about, or after, puberty 
is of extreme importance when the original 
Vaccination has been anything short of 
Mr. Marson's highest class, and is neces- 
sary in proportion as it falls short of it: 
but it seems also certain that those whose 
original Vaccination has been complete 
may derive additional security from a re- 
vaccination at, or after, this period of 
their lives. We have already seen that a 
certain proportion of the most thoroughly 
vaccinated contract smallpox, though no 
doubt with comparatively little danger, 
after growing up: as many as 367 such 
cases were admitted to the Smallpox 
Hospital in the great epidemic of 1863. 
But after effectual revaccination, smallpox, 
even in its most modified form, is found 
very rarely, or scarcely ever, to occur. 
Thus, Heim found that in five years there 
occurred among 14,381 revaccinated sol- 
diers in Wirtemberg, only one instance of 
varioloid, and among 30,000 revaccinated 
persons in civil practice only two cases of 
varioloid, though during these years small- 
pox had prevailed in 344 localities, pro- 
ducing 1,674 cases of modified or unmodi- 
fied smallpox among the not revaccinated, 
and in part not vaccinated, population of 
363,298 persons in those places in which 
it had prevailed. In the Prussian army, 
since the introduction of systematic revac- 
cination of all, the annual deaths from 
smallpox (which at one time were 104) 
have not averaged more than 2; and on 
analysis of 40 fatal cases that occurred in 
twenty years, it appeared that only 4 were 
in persons who were said to have been 
successfully revaccinated.1 Other national 
experience might be referred to, but it 
will be better to have recourse once more 
to Mr. Marson's very precise statements. 
In the thirty-two years and upwards that 
he has been connected with the Smallpox 
Hospital, no nurse or servant has taken 
smallpox, he having taken care always to 
revaccinate them on their coming to live 
in the hospital; and at a time when a 
large number of workpeople were employed 
for several months about the hospital, 
most of whom consented to be revacci- 
nated, two only were attacked by small- 
pox, and these two were amongst the few 
who were not revaccinated. 
These broad facts, while they show the 
great importance of the practice of revac- 
cination, attest at the same time the utter 
uselessness and folly of repeating this ope- 
ration again and again in the same indi- 
vidual, as seems to have become a recent 
fashion, whenever epidemics of smallpox 
arise. One thoroughly primary Vaccina- 
tion to start with, and one careful revac- 
cination after puberty, so conducted as to 
give evidence that the lymph was ab- 
sorbed, are all that is necessary for the 
complete protection of the population 
against smallpox. No doubt by the first 
Vaccination, nine out of ten are perfectly 
well and permanently protected ; but who 
can predicate of any individual whether he 
is one of the nine or the exceptional one ? 
The revaccination, however, must be 
done with all the care that should be em- 
ployed to secure the success of a primary 
Vaccination ; and the practitioner should 
always endeavor to get some evidence 
that the lymph is absorbed. In many 
cases, however, even after repetition of 
the Vaccination, this will not happen ; 
and in these cases a further attempt may 
very properly be made at some future 
time. Revaccination should always be 
done by preference when it can be done 
leisurely, and as part of the ordinary work 
of Vaccination, and not under the alarm 
and influence of panic.2 The wholesale 
1 Simon, op. cit., pp. xxxv. xxxvi. 
2 Under these circumstances the demand 
for revaccination often becomes so great that 
it is difficult to find lymph to meet it. I have 
known revaccination-lymph used under these 
circumstances for performing other revacci- 
nations, and very bad arms resulting. 
1 See a remarkable illustration of this in 
Third Report of Medical Officer of Privy Coun- 
cil, p. 50 ; and see also illustrations in Report 
of Smallpox and Vaccination Committee of 
Epidemiological Society, 1853. 176 
VACCINATION. 
and sham revaccinations, which would 
under such circumstances appear to have 
been practised of late, will tend much, it 
is to be feared, to bring the practice into 
disrepute and contempt.1 
The following table, showing the results 
of revaccination in each 1000 individuals 
revaccinated in the Wirtemberg army in 
1831-5, and in our own army in 1861, will 
give some indication of the local results 
that may be expected from the perform- 
ance of revaccination in adults :- 
Persons in whom the 
Revaccinations were 
performed. 
Degree of 
success of 
Revaccination. 
In those who 
hore marks 
of previous 
Smallpox. 
In those who 
bore good 
marks of 
previous 
Vaccination. 
In those who 
bore doubtful 
or imperfect 
marks of 
previous 
Vaccination. 
In those who 
bore no 
marks of 
previous 
Vaccination 
or Smallpox. 
Wirtemberg Army, 
Perfect 
319-5 
310-4 
280-7 
337-3 
1831-5 
Modified 
248-1 
280-5 
259- 
191-1 
(13,861 cases) 
None 
432-3 
409-2 
460-4 
471-6 
1000 
1000 
1000 
1000 
Soldiers in Brit. Army, 
Perfect 
451-4 
484-6 
236-8 
326- 
not recruits, in 1861 
Modified 
159-6 
157-4 
505-3 
277-5 
(2,053 cases) 
None 
389-0 
358-0 
257-9 
396-5 
1000 
1000 
1000 
1000 
Recruits in Brit. Army 
Perfect 
345-5 
407-3 
461-3 
527-3 
in 1861 
Modified 
266-8 
240-8 
301-3 
202-6 
(4,395 cases) 
None 
387-7 
351-9 
237-4 
270-1 
1000 
1000 
1000 
1000 
A perfect local result following a revac- 
cination is constantly appealed to by prac- 
titioners as evidence that the person in 
whom it was developed was liable to take 
smallpox, or, at all events, more liable 
than those in whom imperfect or no re- 
sults followed. But this conclusion ap- 
pears to me by no means warranted. If 
it were, these curious results would fol- 
low, that (taking as our guide the obser- 
vations in the Wirtemberg army) 319 out 
of 1000 persons having had smallpox, 310 
out of 1000 who had been well-vaccinated, 
and only 281 out of 1000 who had been ill- 
vaccinated, were in present danger of tak- 
ing smallpox ; and of the soldiers (not re- 
cruits) in our own army, 451, 485, and 237 
would represent the ratio in the three 
classes respectively, which is clearly a re- 
ductio ad absurdum. We cannot, indeed, 
that I can see, draw from the local phe- 
nomena of revaccination any inferences 
whatever as to the state in which the re- 
vaccinated person was as to liability to 
smallpox. Jenner himself, indeed, pointed 
this out in his first treatise, and showed 
that the natural cow-pox might be in- 
duced again and again in persons who, 
being protected against variola by their 
first attack of cow-pox, could not be va- 
riolated either by inoculation or by expo- 
sure, and also that cow-pox might be made 
to take on those who had had smallpox.2 
The utility and necessity of revaccination 
stand not upon any speculative reasoning 
from the local effects it produces, but upon 
the broad grounds of observation and ex- 
perience. 
IV. Relations of Vauiola and 
Vaccinia.-Jenner believed the cow-pox 
of the cow and the smallpox of the human 
subject to be essentially the same disease, 
as he implied when he denominated the 
former Variolic Vaccina; : he further be- 
lieved they had a common origin-the 
grease of the horse. lie did not himself 
perform any inoculation of cattle with the 
lymph of human variola. But, as early 
as 1801, Gassner, of Giinsburg, by inocu- 
lating eleven cows with smallpox matter, 
produced on one of them vesicles having 
all the character of vaccine vesicles, and 
from which a stock of genuine vaccine 
lymph was obtained. Another successful 
variolous inoculation of cows, at the Ve- 
terinary College at Berlin, is referred to 
by M. Viborg of Copenhagen so early as 
1802, but no details are given respecting 
it. In 1830, Dr. Sonderland, of Barmen, 
stated that he had infected cows with the 
variolous contagion by enveloping them 
in blankets taken from the bed of a patient 
who had died of smallpox, and also hang- 
ing the blankets up round the head of the 
animal that it might breathe the effluvia 
arising from them. The cows, he says, 
in a few days manifested the symptoms of 
cow-pox, and lymph taken from them pro- 
duced genuine vaccine vesicles in the 
human subject. Dr. Sonderland's experi- 
1 See Sixth Report of Medical Officer of 
Privy Council, p. 113. 
2 Obs. on the Variolse Vaccinse, pp. 21, 22, 
and p. 51 ; Continuation, &c. p. 25. 177 
ALLEGED DANGERS OF VACCINATION. 
merits were repeated in India by Mr. Mac- 
pherson, in this country by Mr. Ceely of 
Aylesbury, and in various places abroad, 
without success. But Mr. Ceely was able, 
by the much more satisfactory process of 
direct inoculation with smallpox virus (in 
February, 1839), to induce vesicles in two 
out of three sturks operated on, and with 
lymph taken from these to vaccinate many 
children, from whom a regular lymph- 
stock was continued.1 In 1840, Mr. Bad- 
cock of Brighton, without previous know- 
ledge of Mr. Geely's experiments, suc- 
ceeded also in variolating the cow, and 
deriving thence a stock of genuine vaccine 
lymph : and since then he has, by inocu- 
lating cows with the lymph of human 
variola, raised stocks of vaccine lymph for 
use on no fewer than thirty-seven separate 
occasions. The common origin, then, of 
smallpox and cow-pox may thus be con- 
sidered as established. 
The case, as regards the grease, appears 
to stand thus : the disease really known 
as grease has nothing to do with cow-pox 
or smallpox ; but the horse is subject at 
times to a true equine pox, which is pre- 
cisely of the same kind as the smallpox in 
man and the cow-pox in the cow. This 
disease is met with as an epizootic, parti- 
cularly when cow-pox is epizootic among 
cows and smallpox is epidemic. The 
equine matter used by Jenner himself,2 
and that used by Sacco and others, for the 
purposes of Vaccination, were derived 
from this equine pox; and on various 
other occasions equine lymph has been 
employed.3 
V. Alleged Dangers of Vaccina- 
tion.-Space renders it quite impossible 
for me to enter into the consideration of 
certain objections that have been urged 
from time to time to the general utility of 
Vaccination, or have been thought to 
prove that it was injurious : such as the 
displacement-of-mortality theory of M. 
Carnot, the allegations that scrofula and 
typhoid fever have become more frequent 
in consequence of the introduction of the 
practice (being in fact, it has been said, 
" vaccinational varieties or introversions 
of smallpox"), and other like absurdities. 
The practitioner who desires to ac- 
quaint himself with all that has been 
brought forward on these subjects will 
find the fallacies of the various statements 
thoroughly exposed, and the questions 
themselves finally settled, in the admira- 
ble memoir which Mr. Simon has prefixed 
to the Papers relating to the History and 
Practice of Vaccination, to which I have 
already so often referred. What is before 
us now to consider is of more limited 
scope, but of much greater real import- 
ance, and relates not to whether Vaccina- 
tion is a proceeding we ought still all to 
adopt, but to the special care and precau- 
tion which should be brought to its prac- 
tice. Is it possible in vaccinating to com- 
municate accidentally other diseases-as 
cutaneous diseases, scrofula, or syphilis ? 
Reserving for separate consideration 
what has to be said regarding syphilis, I 
may state that the invaccination of cuta- 
neous and scrofulous diseases, though a 
popular, has never been a professional be- 
lief. These diseases are met with con- 
stantly in infancy and childhood, as well 
in the unvaccinated as in the vaccinated, 
from the influence of various exciting 
causes acting on constitutional predispo- 
sition. I am not aware of any facts which 
prove, or even render probable, their 
greater frequency among vaccinated than 
among unvaccinated children of the same 
ages respectively. When eczema and 
other eruptions manifest themselves, as 
they may do, shortly after Vaccination 
has been performed,1 this is held by some 
to be-and no doubt very generally is-a 
mere coincidence, and due in reality to 
one of the various eruption-producing in- 
fluences to which children at the usual 
age for Vaccination are subject, such as 
teething, &c. But there are many medi- 
cal men who hold, and with great proba- 
bility, that in a part at least of these cases 
the Vaccination may itself have been, by 
the febrile action it set up, the exciting 
cause. No medical authorities believe in 
the transference of scrofulous and cuta- 
neous diseases from one child to another 
by Vaccination. Parents, however, as 
Mr. Marson observes, "are unwilling to 
believe that there is anything constitu- 
tionally wrong in their offspring; and, 
when other diseases follow, Vaccination 
gets blamed for what is really and truly 
due to other causes." Hence, parental 
complaints that disease has been set up in 
this way are not unfrequent; but, as 
showing the prejudice under which such 
complaints are preferred, it may be worth 
while to state that, though I have care- 
fully investigated a great number of them, 
I have never yet in a single instance found 
that the child from whom the lymph was 
taken was suffering from the disease it 
was said to have imparted. 
1 Obs. on Var. Vacc. in Transactions of 
Prov. Medical Assoc., vol. viii. Three years 
before, Dr. Thiele, of Kasan, in Russia, had 
made similar successful experiments (Henke's 
Zeitschrift, t. xxxvii. h. 1), which were not 
known to Mr. Ceely, and, in fact, were not 
published till 1839. 
2 Baron's Life, vol. i. p. 254. 
3 The limits of this article do not allow me 
to enter further into this interesting subject, 
which is fully discussed in chaps, ii. and iv. 
of my " Handbook of Vaccination." 
1 Such eruptions as are part and parcel of 
the constitutional symptoms of Vaccination 
have been already treated of in Sect. i. 
VOL. I.-12 178 
VACCINATION. 
Those who have had most to do with 
the performance of Vaccination, on the 
one hand, and those who have been most 
concerned in the treatment of infantile 
disease, on the other, concur in the belief 
of the non-communicability of disease by 
Vaccination. Mr. Marson, in the per- 
formance of 50,000 vaccinations and more, 
" has never seen other diseases communi- 
cated with the vaccine disease, nor does he 
believe in the popular report that they are 
so communicated."1 Such also was the 
experience of the late Mr. Leese, whose 
opportunities of observation were scarcely, 
if any, less.2 Sir W. Jenner stated some 
years ago that at University College Hos- 
pital and at the Hospital for Sick Chil- 
dren he had had, in six years, more than 
13,000 sick adults and children under ob- 
servation, and that in no case had he rea- 
son to believe, or even to suspect, that 
any constitutional taint had been conveyed 
from one person to another by Vaccina- 
tion.3 Dr. West's experience on 20,000 
infants and children under his care in 
seventeen years is to the like effect; and 
in stating that he had seen nothing in that 
time to make him believe that Vaccina- 
tion excites cutaneous eruptions in any but 
very exceptional cases, he referred such 
exceptional cases to a disposition in the 
children themselves, brought out by the 
Vaccination as it might have been by 
teething.4 And Professor Paget, speak- 
ing from his large experience among chil- 
dren in the out-patients' room at St. Bar- 
tholomew's, and enumerating some of the 
causes which develop cutaneous diseases 
in young children, says, "Now, Vaccina- 
tion may do, though I believe it very 
rarely does, what these several accidents 
may do ; namely, by disturbing for a time 
the general health, it may give opportu- 
nity for the external manifestation and 
complete evolution of some constitutional 
affection, which, but for it, might have re- 
mained rather longer latent. " " This is," 
he adds, "the worst thing that can with 
any show of reason be charged against 
Vaccination; even this can very seldom 
he charged with truth."5 
Although the direct inoculability of the 
syphilitic poison from one human being 
to another distinguishes it remarkably 
from cutaneous diseases generally and 
from scrofula, I should still, but for cer- 
tain recent occurrences which have ex- 
cited much attention, and to which I shall 
immediately advert, not have thought it 
necessary to speak separately of the com- 
munication of that disease "by Vaccina- 
tion. It was indeed not only included 
with other diseases, but was specially so 
included, in the opinions of the distin- 
guished practitioners whom I have just 
cited ; Dr. West informing us that there 
had never come under his notice " any 
instance in which there seemed the slight- 
est pretext for supposing that syphilis had 
been communicated to infants through the 
medium of the vaccine lymph," and Pro- 
fessor Paget that he does not remember 
"to have heard infantile syphilis ascribed 
to Vaccination, frequent as the instances 
of it (inf. syphilis) are among the out-pa- 
tients." In the experience of Mr. Mar- 
son, Mr. Leese, or the National Vaccine 
Establishment of England, such a case 
has never been met with. And referring 
generally to the experience of practition- 
ers at home and abroad, it may safely be 
said that there is scarcely a subject in 
medicine in which there has been, till 
within the last few years, a more general 
concurrence of opinion.1 One broad gen- 
eral fact seemed to be, and still probably 
is, conclusive on the matter. In the sev- 
enty years that have passed since Vacci- 
nation was introduced, it seems certain 
that, " if syphilis could be diffused by the 
vaccine lymph of children with an heredi- 
tary taint of that disease, this possibility 
must long ago have been made evident on 
a scale far too considerable for ques- 
tion."2 
Scientific authority unites with general 
medical experience to negative the possi- 
bility of the vaccinal communication of 
syphilis, •- it being implied always of 
course that the vaccination is true vacci- 
nation, i. e., with vaccine lymph taken 
from a true Jennerian vesicle. Professor 
Paget states the pathological grounds for 
disbelieving the possibility of any such 
communication to be, (1) because infan- 
tile syphilis (which alone need be here 
considered), though conveyable in some 
instances by its own peculiar morbid pro- 
ducts, does not render the blood of the 
patient capable of directly conveying the 
disease ; and (2) because, if the blood of a 
syphilitic child could so modify the vac- 
cine disease within it as that the vaccine 
lymph should be capable of conveying any 
other disease, there is every reason to be- 
lieve that the vaccine vesicle formed in 
the diseased child would be modified in 
correspondence with the modified lymph. 
"All pathological researches," he ob- 
serves, "accumulate the evidences of the 
constant correspondence between the ma- 
terial in the blood, on which each specific 
disease depends, and the morbid structure, 
by which each is manifested. Thus the 
1 Papers relating to the History and Prac- 
tice of Vaccination, p. 25. 
2 Seaton on Protective and Modifying Powers 
of Vaccination, p. 23. 
3 Papers relating to, &c., p. 75. 
4 Ibid., p. 146. 6 Ibid. 
1 See replies of eminent members of the 
profession to the queries addressed to them 
(in 1856) by Mr. Simon. 
2 Simon, in Papers, &c., p. Ixvi. ALLEGED DANGERS OF VACCINATION. 
179 
transformations of the syphilitic poison 
are indicated in the successive external* 
characters of the primary, secondary, and 
tertiary affections ; the transformation of 
the scarlatina poison by its regular symp- 
toms and its sequelae. And so, if the vac- 
cine virus were capable of any transfor- 
mations besides those which mark its 
regular influence in each patient, such 
transformations, we may be sure, would 
be indicated by corresponding and evi- 
dent changes in the vaccine vesicle. In 
other words, if the vaccine were changed 
into any other virus, there would be no 
vaccine vesicle."1 The opinions of Ilebra 
and other distinguished pathologists are 
to the like effect. 
Direct experiments made on a large 
scale, at many times, and by many indi- 
viduals, have led in every single instance 
to the same conclusion. M. Cullerier and 
other experimenters in France, especially 
M. Taupin, have taken lymph on purpose 
from syphilitic children, have vaccinated 
healthy children with it, and watched the 
result. In no instance has syphilis been 
communicated. Heim made similar ex- 
periments in Germany with the same re- 
sult. It was found no more possible to 
produce syphilis by vaccine lymph taken 
from a syphilitic child, than it is to pro- 
duce smallpox by lymph taken from vac- 
cine vesicles on the arms of patients who 
are incubating, or suffering from that dis- 
ease. This, it is well known, has been 
done hundreds of times, but never has 
smallpox been thus communicated or any- 
thing but a vaccine vesicle resulted.2 
Cases had indeed been from time to 
time recorded, in which it was believed 
or suspected that syphilis had been com- 
municated form one person to another 
along with Vaccinia. But, in searching 
the literature of sixty years, notice can 
scarcely be found of a dozen occasions in 
which events of this kind were supposed 
to have happened, where the circum- 
stances are stated with sufficient detail to 
enable us to form a judgment of the value 
of the evidence; and, in all of these, the 
details, when they were examined, were 
found so wanting in scientific precision, 
and so open to sources of fallacy, that the 
cases had been rejected as worthless for 
proof. So that about eight years ago the 
mind of the profession generally, never 
till then, so far as I am aware, very se- 
riously disturbed, may be said to have 
been at rest on the subject. This quiet- 
ude, however, was soon afterwards broken 
by a very circumstantial account of a sin- 
gular outbreak of endemic syphilis at Ri- 
valta, in 1861, traceable, it was said, to a 
vaccinal origin, and by one or two cases- 
especially by one which occurred in the 
wards of M. Trousseau, at the Hotel Dieu 
in Paris, in 1861-which afforded, it was 
alleged, direct proof of vaccin o-syphilitic 
inoculation. To the events then an- 
nounced a new and adventitious interest 
was imparted by the bearing which proof 
of the occurrence of vaccino-syphilitic in- 
oculation, if it could be afforded, would 
have on the doctrines then being sharply 
contended for by rival schools of syphilo- 
graphers.1 All the cases detailed from 
the earliest days of Vaccination were 
eagerly hunted up; the discussions which 
ensued caused a few fresh (alleged) cases 
to be recorded; and the evidence thus col- 
lected has been held by certain authorities 
in syphilis to establish that the inoculation 
of syphilis in vaccinating from a genuine 
vaccine vesicle, though of excessively rare 
occurrence, is yet possible, supposing that 
the child from whom the lymph was taken 
had, or was incubating, syphilis, and that 
some of the blood of the syphilitic child 
was inoculated along with the vaccine 
lymph. The allegation is not, it will be 
observed, of carelessly syphilizing instead 
of vaccinating, as by taking syphilitic 
matter instead of, or along with, vaccine 
lymph, in which cases we might expect, 
of course, syphilis only, or syphilis with 
Vaccinia, to result. It is that in the ordi- 
nary performance of Vaccination (the ab- 
sence of syphilitic matter on the lancet 
being presupposed), syphilis may be acci- 
dentally implanted along with the vaccine. 
It is not contended, in the face of the ac- 
cumulated evidence to the contrary from 
pathological science, general experience, 
and direct experiment, that vaccine lymph 
would impart syphilis or any other than 
its own specific contagion. But it is said 
that there may be twofold inoculation, 
and the communication may take place 
through the blood.2 Lymph and syphilitic 
i A reader of the recent discussion in the 
Academie de MMecine will be surprised at 
the sort of jubilant tone with which the vac- 
cinal inoculation of syphilis is hailed as giv- 
ing the "dernier coop" to a certain "ecole 
syphilographique," &c. &c., as well as at the 
mere hearsay evidence on which facts are 
pressed into the controversy. 
2 In experiments with the mixed viruses 
made, by Sigmurid, by Friedinger, and by 
Boeck, syphilis only was produced : there was 
no Vaccinia. In one of Friedinger's experi- 
ments, however, and in one out of many ex- 
periments by Baumes and Sperino with the 
matter of soft chancre mixed with vaccine 
lymph, an irregular vesicle resulted, which in 
its development had some considerable points 
of resemblance with a vaccine vesicle, but the 
matter from which, taken on the eighth day, 
produced only chancre (De la Syph. Vacc., 
Paris, 1865, p. 280). As regards true syphi- 
lis, however, one cannot see any reason why, 
if its inoculable products were mixed with 
vaccine lymph and inserted on the arm of a 
1 Papers relating to, &c., p. 139. 
2 Simon, op. cit. p. 43. 180 
VACCINATION. 
blood being inoculated together, each 
within its own period of incubation will 
produce its own specific results. The 
vaccine disease will first run its course, 
and this being over or approaching its 
end, the effects of the blood inoculation 
will manifest themselves. But even of 
the possibility of accidental communica- 
tion in this way it appears to me that the 
very strictest proof, and a complete ab- 
sence of every possible fallacy,1 are de- 
manded : (1) because we have hitherto 
been without any evidence whatever of 
the direct communication of infantile sy- 
philis by inoculation of blood; (2) because 
inoculation of syphilis by blood of the 
adult is a matter of very great difficulty 
and very frequent failure, requiring al- 
ways the exposure of a very large absorb- 
ing surface, while in the cases now 
brought forward the inoculation seems to 
be effected wholesale and by the minutest 
drop of blood; and (3) because in the nu- 
merous vaccinations which in the course 
of seventy years must have been done ac- 
cidentally from syphilitic children, blood 
must often have been invaccinated, and 
in many of the experimental vaccinations 
from syphilitic children blood was pur- 
posely mixed, and yet no syphilis had re- 
sulted. 
Now the cases which have been brought 
forward, whatever ground they may give 
for caution (and in a matter of such ex- 
treme consequence there can never be too 
much caution), do not appear to me to 
afford the strict proof requisite, or indeed 
anything like it ; on the contrary, each 
one of them is wanting in some essential 
point, or is open to some source of fallacy. 
Either there was no evidence that the 
child said to have originated the syphilis 
was at any time syphilitic ; or it was not 
shown that the alleged syphilitic vaccina- 
tion was not in fact a syphilitic inocula- 
tion instead of a vaccination; or there 
was a possibility, and indeed a probability, 
that the lymph used had been mixed with 
the inoculable products of syphilis ; or 
there was reason to believe that the syph- 
ilis which developed itself after the Vaci- 
nation had an independent origin ; or the 
facts were inquired into at too great a dis- 
tance of time, and depended too much on 
the statements of ignorant persons to be 
wholly relied on. Thus, in the occurrences 
at Rivalta the circumstancss were not in- 
quired into till four months after their 
origin. 
It is not intended in this article to con- 
sider the alleged cases of vaccino-syphi- 
litic inoculation in detail. In none of 
them is the proof stronger than in the 
two to which I have already referred-the 
case of M. Trousseau at the Hotel Dieu, 
and the syphilitic endemic at Rivalta; 
it will be sufficient, therefore, to examine 
these. In M. Trousseau's case a young 
woman was revaccinated from a child, 
healthy at the time, and, so far as was 
known, continuing healthy, from which 
child four children received their primary 
Vaccination, went through it perfectly, 
and (certainly) had no subsequent syphi- 
litic affection. Only some small papules 
arose on the arm of the young woman, 
and the revaccination was considered to 
have failed. She remained in the hospital 
a month after the Vaccination, and after 
being out another month came back with 
two undoubtedly syphilitic sores on the 
arm on which she had been vaccinated. 
It was afterwards known, but not at the 
time, that she was a young woman of 
loose character. Now, assuredly no one 
who knows the extraordinary situations 
in which chancres have been met with, 
such as the cheek, the corner of the eye, 
all sorts of situations in which there was 
no suspicion of Vaccination, can say that 
there was no fallacy in this case, espe- 
cially when we consider, first, that there 
was not a shadow of proof adduced that 
the child from whom the lymph was 
taken ever had syphilis, and there was 
every presumption that it had not; and 
secondly, the unusual length of the syph- 
ilitic incubation, supposing it dated from 
the time when the Vaccination was done. 
The syphilitic endemic at Rivalta was 
a very remarkable occurrence, and under 
any point of view is of the deepest inter- 
est. Four other such endemics, said to 
have occurred in 1814, 1821, 1841, and 
1856 respectively, have been ascribed also 
to a vaccinal origin ; and not the least 
curious part of the matter is that all these 
should have occurred in Italy, and that 
none like them should have been met with 
in any other country. In their mode of 
communication, apart from the Vaccina- 
tion-for many persons were affected who 
were not at the time the subjects of Vac- 
cination-they bear a close resemblance 
to what we read of endemics of sibbens 
and other syphiloid diseases, recorded be- 
fore Vaccination was known; not only 
was there communication of disease from 
babies to their nurses and from wives to 
their husbands, but children infected one 
another by the act of kissing, and we are 
even told that when poor people were 
crowded together n confined and neglect- 
ed dwellings, whole families were affected. 
child, each infection should not within its 
own period of incubation produce its own spe- 
cific results ; and this is, in fact, by far the 
most probable explanation of one or two oc- 
currences in which there seems authentic evi- 
dence of vaccinia and syphilis having been 
received at the same operation. (See Hand- 
book of Vaccination, pp. 317-18.) 
1 See particularly the observations made as 
regards some of these by Simon, op. cit. p. 
Ixvi. ALLEGED DANGERS OF VACCINATION. 
181 
In the Rivalta endemic, the alleged vac- 
cinal origin was made the subject of care- 
ful inquiry by a scientific commission. 
But unfortunately this inquiry did not 
take place till four months after the out- 
break ; and, as in no single case of the 
children said to have been syphilized by 
Vaccination had any application been 
made to a medical man on account of the 
condition of the arm, facts and dates, re- 
quiring the closest and most accurate ob- 
servation, with careful record from day 
to day, had to be taken at that distance 
of time on the testimony of the parents 
and villagers. Under these circumstances 
we are not surprised that different con- 
clusions were arrived at; and that though 
Dr. Pachiotti and the other commission- 
ers, after a most careful and painstaking 
inquiry, reported themselves satisfied of 
the vaccinal origin of the disease, Sperino, 
who also went to Rivalta and saw the 
cases, and treated some of them after- 
wards at Turin, was equally satisfied that 
this origin was altogether independent of 
the Vaccination. The story, as regards 
the vaccinal origin, is this:- 
A child (Chiabrera) apparently in good 
health, but really incubating syphilis, 
was vaccinated with some lymph obtain- 
ed in a tube ; this child's arm was used 
on the tenth day for the vaccination of 46 
children, and one of these 46 children, 
named Manzone, again on the tenth day 
furnished lymph for vaccinating 17 chil- 
dren ; of these 63 children 46 had, within 
two months, a disease considered by the 
commission to have been syphilis,-the 
syphilitic symptoms having manifested 
themselves in some cases within ten days, 
and as a mean, at twenty days from the 
Vaccination. It need scarcely be pointed 
out how irreconcilable these dates are 
with all that we have been taught as to 
the incubation period of constitutional 
syphilis. But supposing this teaching to 
have been erroneous (and, unless it is, 
the Rivalta cases as connected with Vac- 
cination fall of themselves), and suppos- 
ing that it is possible to produce the pri- 
mary symptoms of constitutional syphilis 
within ten days of the inoculation of the 
poison, and that from Chiabrera's arm 
the whole mischief arose, there is still the 
question from what sort of vesicle on his 
arm was the lymph taken ? We have not 
only the higher authority of Ricord that 
the chancrous pustule, "initial lesion of 
the primary syphilic ulcer when it de- 
velops itself on the skin," has characters 
which may cause it to be confounded by 
careless persons with the vaccine pustule : 
but we know also that such a vesicle as 
may be produced by mixture of the mat- 
ter of soft chancre with vaccine virus, 
though according to the description given it 
would be impossible for any careful person 
to confound it with the regular vaccine vesicle, 
has yet much of the vaccine character 
about it. Now of the vesicles on Chia- 
brera's arm we have no reliable account: 
nor of the vesicles on the arms of any of 
the other children, at the period of their 
so-called Vaccination. So far as we have 
details of the Vaccination, they are not 
such as to give us any confidence in the 
operation, and it is quite an open ques- 
tion whether the children were not care- 
lessly syphilized instead of being vacci- 
nated.1 When the cases were seen by Dr. 
Catt, or by the Commission of Inquiry, they 
presented either so many syphilitic sores, 
or cicatrices which, according to the de- 
scription given, had no vaccine character 
about them : and the revaccination of five 
of the children afterwards without effect 
(a revaccination which it is not stated was 
repeated) is far from being conclusive. 
In the years which have passed since 
these occurrences became the subject of 
discussion, attention in this country has 
been wide awake to find any that should 
be like them. None have been met with. 
On one occasion one of our ablest, as he is 
1 Mr. Simon informs us that in a child hav- 
ing latent syphilis he has known a clean 
incision, made in performing a trifling sur- 
gical operation, develop in a few days a 
syphilitic sore. I do not say that Chiabrefa's 
arm had such a sore on it; the state of his 
arm is the very thing regarding which we 
want evidence. Knowing the careless and 
miscellaneous way in which Vaccination has 
sometimes been carried on, and the ignorant 
hands into which its performance has some- 
times fallen, I am rather surprised that acci- 
dents have not more frequently occurred. It 
is only a few years ago that I was the means 
of stopping a druggist, who was rather an 
extensive vaccinator, from proceeding to vac- 
cinate some children from an open sore upon 
an arm which had nothing of vaccine charac- 
ter whatever about it, but which he assumed 
to be a vaccine sore, because he had vacci- 
nated the child a week before : and the de- 
tails of some of the Continental vaccinations 
in which accidents have occurred are truly 
astonishing. Further, the importance and 
necessity, in alleged cases of vaccino-syphili- 
tic inoculation, of having precise details, and 
of using care and reserve in the admission of 
statements, are well illustrated by the par- 
ticulars of a case often referred to in the dis- 
cussions in the Acad6mie to show that syph- 
ilis had been implanted by a properly per- 
formed Vaccination. It is the case well 
known as that of " Le Wt^rinaire B."-in 
which 19 out of 24 persons revaccinated by 
him had afterwards signs of syphilis, the stuff 
with which all were vaccinated being, it was 
said, vaccine taken "sur un infant qui etait 
fort, et qui paraissait completemen t sain 
but concerning whom, further inquiry elicited 
this important information, "On sut depuis 
que 1'^ruption vaccinale ne s'^tait pas fait 
regulierement chez lui, que le huitieme jour 
il n'y avait pas encore trace de boutons 1" GLANDERS. 
182 
one of our most candid workers in syphilis, 
met with a case which he stated to the 
Medico-Chirurgical Society was one of 
syphilitic infection communicated in vac- 
cinating, but it turned out that even his 
experienced judgment had been deceived, 
and that, as he allowed subsequently, he 
had mistaken for a syphilitic sore a merely 
degenerated vaccine vesicle. Nor with 
all his vast experience of syphilis has he 
to this day met with any case in which 
there was ground for believing that that 
disease had been communicated in vacci- 
nating. 
The real lesson which, as it appears to 
me, is derivable from the alleged cases of 
vaccino-syphilitic inoculation, is the ex- 
treme care with which Vaccination should 
be conducted. We must not only be on 
our guard against any possible admixture 
of syphilitic matter with our vaccine 
lymph, either through the lancet or other- 
wise ; but we must be careful that our 
lymph itself is taken only from the heal- 
thiest children, from the most perfect and 
regular vesicles at the proper period of 
their course, and that it is pure unmixed 
vaccine lymph, free from the slightest 
stain of blood. We have no right to run 
a merely possible risk that can be avoided. 
GLANDERS-EQUINIA. 
By Arthur Gamgee, M.D., and John Gamgeb. 
Definition.-A febrile disease, due to 
the introduction into the system of a spe- 
cific poison, originating in the horse, ass, 
or mule, and communicated directly or 
indirectly from them to man. 
It is usually ushered in by rigors, which 
are followed by articular pains, and great 
prostration. There is more or less affec- 
tion of the lymphatic vessels and glands, 
which inflame and suppurate. Ulcera- 
tions appear on the pituitary mucous 
membrane, from which there flows an 
aqueous or purulent discharge. A pustu- 
lar eruption often occurs on the surface of 
the skin, which in parts becomes affected 
with inflammation of erysipelatous cha- 
racter. Abscesses form in the subcutane- 
ous cellular tissue. The disease is usually 
fatal. 
Nomenclature and History.-Un- 
the name of Mrxi?, Aristotle1 described a 
disease affecting the ass. which was prob- 
ably identical with the "malleus" or 
"morbus humidus" which an early writer 
on veterinary medicine. Vegetius, subse- 
quently described as affecting the horse, 
and with the disease to which, from an 
early period, the name of Glanders has 
been applied by English writers. The 
terra Glanders includes several affections, 
which, undoubtedly due to the same spe- 
cific virus, must be looked upon as mere 
varieties of one disease, but which, differ- 
ing very remarkably in character, were 
for a long period of time considered to be 
altogether distinct. 
Vegetius, and the authors who followed 
him, described under the term Malleus 
humidus, Morbus humidus,1 Cymoira,2 
Cimoria,3 Capitis morbus, that variety to 
which the term Glanders has been re- 
stricted by English writers-to an affec- 
tion of horses which is characterized by 
ulcerations of the Schneiderian mucous 
membrane, accompaaied by a discharge 
from its surface, and by enlargement and 
induration of the submaxillary glands; 
which may run a long or short course, 
and which may be, but often is not, ac- 
companied by marked constitutional symp- 
toms. They described in addition, under 
the terms Morbus farciminosus,4 Vermis 
equi,® Vermis volativus,6 Farcina equi,7 
Turtac, cutis equorum,8 Glandulse et scro- 
phulse equi,9 an affection which has now 
been proved to be merely a variety of the 
one described, and of which the striking 
and characteristic feature is the formation 
of abscesses and swellings in the course of 
1 Vegetii Renati Artis Veterin arise, sive 
Mulomedicinae, libri quatuor, &c., lib. i. c. 
vii. 
2 Laurentius Rusius, c. Ixxi. p. 72, quoted 
by Heusinger. 
3 Jordanus Ruffus, c. xvi. p. 48, quoted by 
Heusinger. 
4 Vegetius, op. cit. lib. i. c. iii. 
5 Jordanus Ruffus, c. i. p. 23. 
6 Ibid. c. ii. p. 27. 
7 Albertus Magnus, p. 92. 
8 Ibid. p. 589. 
8 De Crescentiis, lib. x. c. xii. p. 275. 
1 Aristotle, De Hist. Anim. lib. viii. cap. 
XXV. VARIETIES. 
183 
the lymphatic vessels and glands, and of 
small tumors beneath the skin, and which 
is unaccompanied by any affection of the 
Schneiderian membrane. This, which for 
a long period of time was looked upon as 
altogether a distinct disease from Glan- 
ders, received, in English, the name of 
Farcy, and will in the following pages be 
described as one of the important forms 
or varieties of Glanders. 
As Glanders is a disease which always 
originates in the horse and ass, never oc- 
curring in man except when communicat- 
ed, directly or indirectly from them, and 
the nomenclature of the disease in man 
having been borrowed, to a great extent, 
from that previously in use among veteri- 
nary writers, its complete history, in the 
first place, necessitates an account of the 
mode in which it originates in the lower 
animals, and of the forms which it pre- 
sents in them. 
Glanders and its Varieties in the 
Horse, Ass, and Mule.-This disease 
appears to affect the horse in all parts of 
the world, although perhaps it is modified 
to a certain extent by climatic and other 
agencies. In the deserts of Arabia it is 
said not to possess the dreadful characters 
which distinguish it elsewhere, and is a 
comparatively rare disease. It may occur 
under four forms, as, 1st, Chronic Glan- 
ders ; 2d, Acute Glanders; 3d, Chronic 
Farcy ; 4th, Acute Farcy. 
Chronic Glanders is the most com- 
mon form affecting the horse. It is pro- 
pagated by contagion and infection (?). 
It never occurs as a termination of acute 
Glanders. Its period of incubation is un- 
certain, and has been stated to vary from 
a few days to a year (?). 
Synonyms.-Morve chronique, French; 
Chronischer Rotz, German; Ciamorro 
cronico, Morva cronica, Italian. 
Semeiology.-The general health is 
little, if at all, affected. There is swelling 
and hardening of the submaxillary lym- 
phatic glands. A discharge occurs from 
one or both nostrils, generally from one 
only (usually the left), which is at first 
of watery consistence, becoming more 
gluey, purulent, sanious, and fetid. Ele- 
vations and ulcerations occur on the 
Schneiderian mucous membrane. A 
horse thus affected often appears to be in 
perfect health. When placed under un- 
favorable circumstances, especially if fed 
scantily, symptoms of acute Glanders 
rapidly make their appearance, and death 
then soon inevitably follows. 
Morbid Anatomy. - The mucous 
membrane lining the cavities of the nose 
and sinuses, presents small white eleva- 
tions, varying in size from a small to a 
large pin's head, and larger patches of a 
yellowish-white color, having a smooth 
surface. These elevations and patches 
soften in the centre, and then present the 
appearance of excavated ulcers. The 
ulcerations sometimes, though not usually, 
implicate the whole thickness of the mu- 
cous membrane, and affect the bones; 
perforation of the septum narium, and of 
the nasal bones, sometimes occurring. 
The mucous membrane of the larynx, 
trachea, and bronchi, presents at an early 
stage of the disease, little white elevations, 
resembling the cicatrices of leech bites ; 
these afterwards coalesce, become in- 
jected, and ulcerate, giving rise to exca- 
vated ulcers, of a deep-red color.1 
The lungs contain small fibrinous de- 
posits, varying in size from a pin's head 
to that of a grain of flax, around which 
the pulmonary texture presents quite a 
healthy appearance. Larger masses, of a 
bluish-white, lardaceous, or gelatiniform 
appearance, which sometimes are of the 
size of a hen's egg, are also observed. A 
condition of lobular pneumonia has been 
described to exist in certain cases. Al- 
though veterinarians have spoken of these 
alterations in the lung as tubercular, there 
is no ground for the opinion, as the re- 
searches of Rayer,2 Tardieu,3 and Trous- 
seau4 have proved. 
Acute Glanders occurs more rarely 
in the horse than the chronic form, of 
which, as of acute and chronic Farcy, it 
is a frequent termination. In the ass 
and mule it is the common form of the 
disease. 
Synonyms. - Morve aigue, French ; 
Acuter Rotz, German ; Ciamorro acuto, 
Morva acuta, Italian. 
Like the chronic, the acute form of 
Glanders is an intensely contagious dis- 
ease. The period of incubation is uncer- 
tain. It has been stated to be only from 
three to five days,5 although it is undoubt- 
edly longer in certain cases. 
Semeiology.-The disease sets in sud- 
denly, a short time (a few days) after ex- 
posure to contagion, with symptoms of 
inflammatory fever. The respirations are 
hurried. A copious yellow, purulent, or 
sanious discharge flows from the nostrils. 
There is watering of the eyes. Sometimes 
an eruption of small cutaneous, or subcu- 
taneous, tumors occurs. Then super- 
venes violent inflammation of the pitui- 
1 Tardieu, De la Morve et du Farcin chro- 
niques chez 1'Homme et les Solipedes. Paris, 
1843. P. 36. 
2 Rayer, De la Morve et du Farcin chez 
1'Homme. Mem. de PAcad. R. de Med. 
Tome sixifeme, pp. 828-833. 
3 Tardieu, op. cit. p. 41. 
4 Trousseau, Recherches Anat, et Pathol, 
faites a Montfaucon. 
5 Hering, Specielle Pathologie undTherapie 
fur Thierarzte. Stuttgart, 1858. P. 98. 184 
GLANDERS. 
tary membrane, which becomes deeply 
and extremely ulcerated. Cough and 
shortness of breathing occur. Death in- 
variably follows. 
Morbid Anatomy. - The mucous 
membrane, lining the nares and frontal 
sinuses, is found acutely inflamed, and 
generally presents a pustular eruption, 
which is bathed in a purulent fluid. If 
the disease lasts for some time, ulcers 
form, which are either small and round, 
or large and irregular; in the latter case 
having been formed by the ulceration of 
several confluent pustules. The ulcers 
are excavated, often appearing as if cut 
with a punch. The lungs are almost con- 
stantly the seat of limited pneumonia, 
and frequently purulent deposits are 
formed in them. Petechise occur on the 
surface of the pleura, pericardium, and 
peritoneum. In certain cases (morve 
aigue, hernorrhagique et gangreneuse, 
Payer) petechise and large ecchymoses 
are noticed, after death, on the pituitary 
membrane. In these cases the mucous 
membrane is generally, over some part of 
its extent, destroyed, softened, and ex- 
hales a gangrenous odor. 
Chronic Farcy is, like the other 
forms of Glanders, highly contagious. It 
may be produced by the inoculation of the 
altered secretions of farcied or glandered 
horses. 
Synomyms.-Farcin chronique, French; 
Ch. Hautwurm,Wurm, German; Farcino, 
Italian. 
Semeiology. - The disease usually 
commences by an indolent inflammation 
of the lymphatic vessels and glands, which 
become red, tender, and acquire a large 
size; the swellings occurring chiefly in 
the situation of the valves of the lymph- 
atics (farcy-buds). 
An eruption of small subcutaneous and 
cutaneous tumors occurs. The large 
glands and cutaneous swellings have a 
tendency to suppurate, and indolent 
ulcers result from the opening of the 
abscesses; these secrete an ichorous dis- 
charge, capable of producing Farcy, or 
Glanders, or both. The general health 
may continue good for a long period of 
time, the disease remaining stationary. 
If the animal be not destroyed, symptoms 
of general constitutional disturbance 
supervene. The animal loses flesh, has a 
staring coat, coughs, and usually falls a 
victim to acute or chronic Glanders. 
Morbid Anatomy.-Structural altera- 
tions of lungs and other organs, as in 
Glanders. Induration and swelling of 
the lymphatics. 
Acute Farcy is distinguished from 
chronic Farcy by the rapidity of its course, 
the urgency of the constitutional symp- 
toms, and by its being almost invariably 
associated with acute or chronic Glanders. 
The chief anatomical difference between 
the two forms is the occurrence, in the 
acute, of truly cutaneous abscesses or 
boils. Acute Farcy proves invariably 
fatal. 
Morbid Anatomy.-The same as that 
of Glanders and chronic Farcy. 
Having described briefly the essential 
characters of the different varieties of 
Glanders, as they occur in the horse, ass, 
and mule, before proceeding to the con- 
sideration of the history of the disease as 
it affects man, it will be well to state 
shortly what appears to have been defi- 
nitely made out, by veterinarians, as to 
the nature of the disease, the relations 
which exist between its various forms; 
and the mode in which it is transmitted. 
It has been satisfactorily proved- 
1st. That the different forms of Glan- 
ders are due to, or are associated with, 
the formation of a specific virus, which 
exists in the blood and secretions of ani- 
mals affected with it. The virus is readily 
absorbed by an excoriated or wounded 
surface, or when matters containing it are 
injected into the blood. It is likewise 
probably absorbed by the unbroken sur- 
face of mucous membranes. 
In one or other of its forms the disease 
may almost certainly be induced by intro- 
ducing beneath the skin of a healthy ani- 
mal, the nasal mucus of a glandered 
horse, or the purulent or ichorous dis- 
charge which flows from the ulcerated 
swellings of Farcy. It may be induced 
by injecting into the circulation of a 
healthy animal, the blood of one suffering 
from Glanders.1 The mucous membrane 
of the alimentary canal appears to be ca- 
pable of absorbing the virus under certain 
circumstances.2 There is reason to be- 
lieve, however, either that gastric diges- 
tion is capable of destroying the virus, or 
that it may pass through the alimentary 
canal without injurious consequences re- 
sulting, provided the mucous surface be 
not abraded.3 
2d. The virus of glanders and farcy is 
identical. The same pus may, if intro- 
duced into the system of one horse, pro- 
duce acute glanders; into that of a sec- 
ond, farcy; into that of a third, chronic 
glanders. 
On certain points the opinions of veteri- 
nary writers have been much divided. 
The chief subjects of dispute are, (1) the 
possibility of the disease originating spon- 
* Travers, An Inquiry concerning that dis- 
turbed State of the Vital Functions usually 
denominated Constitutional Irritation. Lon- 
don, 1826. Vol. i. p. 355. 
2 Sainbel, Vial de St., Experiments and 
Observations on Glandered Horses, p. 109. 
3 Parent Duchatelet, Hygiene Publique, 
topie xi. p. 194. HISTORY OF THE DISEASE IN MAN. 
185 
taneously; (2) the mode of its transmis- 
sion ; whether always by contagion, or by 
contagion and infection. 
The intensely contagious nature of the 
disease is admitted at the present day by 
all writers; nearly all, however, admit- 
ting the possibility of the disease origi- 
nating spontaneously. An impure and 
confined atmosphere, excessive work, and 
insufficient food, are the chief causes 
which have been alleged to induce it. 
That these circumstances favor its spread, 
cannot be doubted ; that they act as most 
powerful predisposing causes, to this as 
to other diseases, has been unequivocally 
proved, by the ravages which Glanders 
has so often caused amongst the horses of 
armies subjected to famine and other in- 
jurious influences. French writers have 
all very strenuously maintained the possi- 
bility of the spontaneous origin of Glan- 
ders, a position which was strongly held 
by our countryman, Professor Coleman, 
who certainly has been one of the chief 
contributors to our knowledge of this dis- 
ease. It was alleged, in an important 
discussion on this matter in the French 
Academy of Medicine, in 1861,' that at a 
period when the fortifications of Paris 
were being constructed, the horses of the 
poor and small contractors were found to 
suffer to a great extent from Glanders, 
whilst those belonging to the wealthier 
contractors escaped the disease. Those 
who adduced these facts attributed the 
occurrence of the disease, in the former 
case, to the insufficient nourishment and 
the harder work which the animals be- 
longing to the poorer contractors received, 
whilst they appear to be susceptible of a 
very different and much more likely ex- 
planation. The laws which exist in 
France for preventing the use of glan- 
dered horses have been inefficiently car- 
ried into execution, glandered horses being 
by some people systematically employed ; 
these horses are necessarily very much 
cheaper than sound ones, and would be 
more likely to be bought by the poor, 
than by the rich contractor. In our own 
country Glanders was, at one time, a most 
prevalent disease, which created the great- 
est ravages. Glandered horses were sys- 
tematically sold and worked. The prac- 
tice caused the greatest pecuniary loss to 
the country at large, for one case of Glan- 
ders having been introduced into a stable, 
the chances were considerable that a ma- 
jority of the horses in it would sooner or 
later die of the disease. To remedy this 
state of matters a most stringent law was 
passed, which prevented the working of 
glandered horses. Carried into execution 
with great rigor, this law has had the ef- 
fect of rendering Glanders, in all its forms, 
a very rare disease in this country. Thou- 
sands of horses are exposed to those causes 
which are supposed to give rise to Glan- 
ders ; are hard worked, ill-fed, and kept 
in badly-ventilated stables, in the same 
way as horses used to be a century ago, 
but yet Glanders does not originate. Glan- 
ders has now almost ceased to affect the 
horses of our army, and the sporadic 
cases which very rarely occur need cause 
no astonishment when we remember that 
the disease is one which still prevails to a 
certain extent, especially in Ireland, 
whence most of our cavalry horses are 
obtained, and that the disease may have 
a long period of incubation. The history 
of Glanders amongst the lower animals in 
this country leads us to form the opinion 
that it never originates spontaneously in 
our climate. We must fully admit, how- 
ever, as we have already done, that bad 
feeding, bad ventilation, and excessive 
work are powerful predisposing causes of 
this disease, and to a great extent explain 
the ravages which it has often caused 
amongst the horses of armies, which in 
time of war, from the large and indis- 
criminate purchases of horses that must 
necessarily be made, contain abundantly 
the germs of the disease. 
Whether actual contact of some article, 
containing the virus, with a mucous mem- 
brane, or a broken cutaneous surface, be 
required to induce the disease, or whether 
its germs may be communicated through 
the atmosphere-whether, in short, Glan- 
ders is always communicated by conta- 
gion, using the term in its more limited 
sense, or by contagion and infection, has 
been warmly argued by various writers. 
Probably in nearly every case actual con- 
tact of glandered matter with an absorb- 
ing surface does take place. The mucus 
flowing from the nose of the glandered 
horse becomes attached to the stable and 
the stable utensils, and comes almost ne- 
cessarily in contact with the water, hay, 
and straw, which horses in the same sta- 
ble employ, so that they are frequently 
exposed to conditions positively known to 
be capable of inducing the disease. 
Some cases have, however, been re- 
corded which cannot well be explained on 
the hypothesis of actual contact, and we 
therefore do not deny the possibility of 
Glanders being transmitted from one lower 
animal to another through the medium of 
the atmosphere, although we believe this 
to occur, if at all, only very rarely. 
History of the Disease in Man.- 
No connection had been traced between 
the terrible diseases in the lower animals 
which have been briefly described, and an 
affection which then as now must have 
occasionally affected those who had charge 
of horses suffering from Glanders and 
Farcy, until the year 1810 when Waldin- 
1 Recueil de Medecine Vet^r., Aout 1861, p. 
645. 186 
GLANDERS. 
ger1 drew attention to the fact that special 
precautions ought to be adopted in the 
dissection of horses affected with Glan- 
ders and Farcy, inasmuch as the direst 
consequences, even death, might result 
from the inoculation of the purulent mat- 
ter. The accuracy of the statements of 
Wadlinger was supported by the publica- 
tion, in 1812, of a paper by a French mili- 
tary surgeon, Lorin, who, under the title 
" Observations sur la Communication du 
Farcin aux Hommes," described the case 
of a veterinary surgeon who, having acci- 
dentally pricked himself whilst operating 
upon a glandered horse, suffered in conse- 
quence from inflammation of the hand.2 
The statements of Waldinger do not, how- 
ever, entitle him to be considered the first 
person who pointed out that Glanders is 
communicable from the lower animals to 
man; for although he stated that dan- 
gerous consequences might result from 
the inoculation of the purulent matter of 
Glanders and Farcy, he did not state that 
the affection induced in man in any way 
resembled that of the horse. Again, the 
observation of Lorin was of the most un- 
satisfactory description, for the case which 
he describes does not differ materially 
from many cases of dissection wounds, 
and possessed, in no respects, the pecu- 
liarities of Farcy. Schilling, however, 
published in 1821,3 under the title " Merk- 
wiirdige Krankheit und Sections Ge- 
schichte einer wahrscheinlich durch ueber- 
tragung eines thierischen Giftes erzeugten 
Brandrose," the case of a man who, hav- 
ing washed out the nares of a glandered 
horse, became affected with a pustular 
eruption on the skin, an offensive dis- 
charge from the nostrils and erysipelatous 
inflammation of the face, and who died 
after an illness of eight days. Bust looked 
upon this as a case of Glanders in man, 
and in support of this view gave the notes 
of another case of a similar nature. Both 
these were indeed most typical cases, and 
must be considered to be the first well- 
marked cases of Glanders occurring in 
man which were published. In the same 
year that Schilling's and Rusts cases were 
published, there appeared in the Edin- 
burgh Medical Journal* a short notice 
copied from a subscription pape1* in the 
Hotel Coffee-house, Leeds. Tnis short 
notice (of nine lines) was signed by T. 
Muscroft, surgeon, Pontefract, and con- 
sisted in an appeal on behalf of the family 
of the dog-feeder of the hounds belonging 
to the Badsworth Hunt, who, in cutting 
up the carcase of a horse which had died 
of Glanders, had accidentally wounded 
his hand. "In a few days he betrayed 
all the symptoms which are at first shown 
in the horses beginning in the above dis- 
ease. He gradually became worse, and at 
the end of the week he died raving mad, 
laboring under a confirmed complaint of 
Glanders." 
Feeling considerably interested in read- 
ing this notice, I wrote to Henry Mus- 
croft, Esq., surgeon, of Pontefract, asking 
if the notice which had appeared in the 
Edinburgh Journal in 1821 had been 
written by a relative of his, and request- 
ing to be put in possession of any infor- 
mation he might possess on the matter. 
Mr. Muscroft informed me in reply that 
the notice had been signed by his father, 
who at that time was practising in Ponte- 
fract, and added that he had never heard 
anything about the case. Stimulated by 
my questions, Mr. Muscroft, however, in- 
stituted inquiries, which ended in his dis- 
covery of the widow of the unfortunate 
man. The old woman is now eighty-six 
years of age; she was, however, able to 
give a very complete account of her hus- 
band's illness. This account was written 
down verbatim by Mr. Muscroft, who has 
sent it to me. Information obtained from 
other sources proves that the dates men- 
tioned in this statement are perfectly cor- 
rect. Mr. Muscroft's pay-book, on being 
referred to, shows that he attended John 
Turpin from March 18, 1821, to March 
27 ; and the parish register of deaths con- 
tains an entry to the effect that John Tur- 
pin died on the 29th March. The state- 
ment of the old woman is interesting, as 
referring to the first case of Glanders, 
which appears to have been recognized as 
such, in this country. 
Statement of Sarah Hazelgrave {formerly 
Turpin), aged eight y-six years. 
My first husband, John Turpin, whilst 
skinning a dead horse, in the month of 
March, 1821, cut the third finger of the 
left hand, and, heeding but little this ac- 
cident, on the following day he left me for 
a week, to fetch home to the Badsworth's 
kennels some young hounds that had been 
reared in the neighborhood of York. 
On his arrival at home, he was very 
weak and scarcely able to walk, and he at 
once said that "he should never go out 
again, he was so ill." He complained of 
severe pain in the head, and there was 
profuse discharge from the nostrils; and 
on different parts of his body there were 
a number of blisters of different sizes, 
which, after a time, became blue. 
Mr. Muscroft was sent for, and after he 
had been at my husband's bedside for 
some time, he said, he was " afraid Tur- 
pin was inoculated by the blood of the 
1 Waldinger, Wahrnehmungen in Pferden. 
2te Aufl. Wien, 1810. 
2 Journ. de Med. Chir. et Pharm., F6v. 1812. 
3 Rust's Magazine, vol. i. p. 480. 
' Edin. Med. and Surg. Journ., vol. xviii. 
p. 321. 187 
HISTORY OF THE DISEASE IN MAN. 
dead horse he had cut up, and that there 
was no remedy, the disease being horse- 
farcy, or glanders, but that, if the finger 
had been taken olf at first, this might not 
have happened." 
Mr. Muscroft gave him medicines, and 
saw him daily until his death, which took 
place ten days after he returned from 
York. lie retained consciousness to the 
last. Large lumps appeared on his fore- 
head and face, and his throat was swelled. 
His head and face became very large. 
The wound of his finger was very bad, 
and the finger looked as if it would rot 
off, and from the wound there were hard 
cords, like the stem of a pipe, up the arm, 
and the armpit also swelled. The smell 
was very bad. 
May 18, 1865. 
Before the publication of the cases of 
Schilling and Rust, and before the notice 
referred to appeared in the Edinburgh 
Medical Journal, certain cases of trans- 
mission of Glanders from horses to man 
had been observed in London, which, 
although not published until some years 
later, received at the time a thorough in- 
vestigation-a study which first and satis- 
factorily proved that the virus of Glanders 
is transmissible from horses to man, and 
generates in him affections which, although 
slightly different in some of their charac- 
ters, are identical with the disease as it is 
observed in the horse. These observations 
were first published by Mr. Travers, at 
page 350 of the first volume of his work on 
"constitutional irritation."1 The first 
and most interesting of these cases oc- 
curred in the year 1817, and was that of 
Mr. William Turner, a veterinary student, 
who injured his finger in examining the 
head of a horse which had died of Glan- 
ders. An ulcer followed with inflamma- 
tion of the absorbents and cellular tissue 
of the hand, and symptomatic fever. 
After some days an abscess formed in the 
opposite arm, and another in the lower 
part of the back. Matter taken from the 
abscess of the arm was sent to Mr. Cole- 
man, who inoculated an ass with it and 
produced fatal Glanders. Mr. Turner's 
health was seriously affected. He became 
hectic, and was sent to Brighton for the 
benefit of sailing and tepid bathing. Sub- 
sequently an abscess formed in his lungs, 
another in his kidney, and after his return 
to his residence at Croydon, at the expira ■ 
tion of several months, abscesses formed 
successively upon each knee-joint. From 
the last, matter was taken for the purpose 
of inoculating an ass, which in eleven 
days died glandered. Shortly after this, 
Mr. Turner's long and painful illness 
terminated in death. The third case, re- 
corded by Mr. Travers, that of Nimrod 
Lambert, is however of greatest import- 
ance. N. L., a healthy hackney coach- 
man, set. 32, in January 1822, infected a 
chap on the inside of the right thumb, by 
inserting it into the nostril of a glandered 
horse, to pull off a scab. lie was taken 
suddenly ill three days after, and suffered 
subsequently from inflammation of the 
lymphatic vessels and glands of the arm, 
which suppurated and ulcerated. " The 
glands at either angle of the lower jaw, 
and in the groin, became swollen, and he 
was much afflicted with pain between the 
eyes and down the nose, and ulcerations 
of the membrana narium, attended with 
discharge." After a long and painful ill- 
ness the man recovered, although his con- 
stitution appears to have been violently 
affected and permanently injured by it. 
An ass, inoculated with the matter from 
this man's sores by Mr. Sewell, died of 
Glanders. The great interest attaching 
to Lambert's case rests in the fact that it 
is the first well-marked case of Glanders 
occurring in man in which the diagnosis 
was rendered perfectly certain by the in- 
oculation of animals with the purulent 
matter. Mr. Turner's case, on the 
other hand, was by no means a well- 
marked instance of chronic Farcy, but is 
valuable as being the first case which 
proved that in its passage through the 
human body, the virus of Glanders loses 
none of its properties, and is again able to 
generate the disease in lower animals. 
With these cases Mr. Travers published a 
letter from Professor Coleman, in which 
that gentleman described the experiments 
which he had made with the pus obtained 
from Mr. Turner's abscess. In this letter 
Mr. Coleman stated the result of a most 
interesting experiment, in which he suc- 
ceeded in inducing Glanders, "by remov- 
ing the healthy blood from an ass, until 
the animal was nearly exhausted, and 
then transferring from a glandered horse 
blood from the carotid artery into the 
jugular vein." (Op. cit. page 355.) Al- 
though Mr. Travers published these cases, 
he does not appear to have considered 
the disease induced in Mr. Turner and 
Lambert, to have been glanders. "The 
reader," says Mr. Travers, "cannot fail 
to perceive some points of analogy be- 
tween the effects produced by the absorp- 
tion of glandered matter, and of the fluids 
of the human body after death. I think 
there can be no difficulty in admitting in 
either of these cases that a poison was 
imbibed, but the evidence gives no ground 
for the conclusion that it was a morbid 
poison, as regards its operation in the 
human subject." (Op. cit. p. 365.) 
1 An Inquiry concerning that disordered 
State of the Vital Functions, usually denomi- 
nated Constitutional Irritation, by Benj. 
Travers. London, 1826. 188 
GLANDERS. 
Grubb,1 Krieg,2 and Brown3 described 
after this several interesting cases of 
Glanders transmitted from the horse to 
man. It was, however, by the publica- 
tion of a memoir entitled " On the Glan- 
ders in the Human Subject,"4 that Dr. 
Elliotson attracted the attention of the 
profession to this subject. In this paper 
lie gave the history of two interesting 
cases of Acute Glanders, which had been 
observed by Dr. Roots and himself, and of 
a third which had been communicated to 
him by Mr. Parrott, of Clapham, and he 
collected nearly all the observations which 
had, up to that date, been placed on 
record. In a second memoir,5 entitled 
"Additional Facts respecting Glanders in 
the Human Subject, " Dr. Elliotson gave 
an account of another case of acute Glan- 
ders which had fallen under his notice. 
Subsequently to the date of Dr. Elliotson's 
papers, several cases of Glanders were 
published in various journals. No very 
valuable addition to the knowledge of the 
subject was however made until the year 
1837, when Rayer, in a splendid memoir, 
entitled "De la Morve et du Farcin chez 
1'Homme,"6 gave an account of all the 
cases of Glanders which had been observed 
up to that date, and gave an original and 
complete description of the different forms 
of Glanders both in the horse and in man. 
The subject of Chronic Glanders and Far- 
cy was afterwards made the subject of 
special investigation by Tardieu, who, in 
a memoir entitled "De la Morve et du 
Farcin chroniques, " 7 supplemented the 
knowledge which Rayer had already col- 
lected on these subjects. It is to the re- 
searches of these distinguished physicians 
that we owe almost the whole of our 
knowledge of the morbid anatomy of the 
various forms of Glanders. 
Since the date of the publication of 
these memoirs, many cases of Glanders 
possessed of great interest have been re- 
corded: no very important addition to the 
existing knowledge of the disease has, 
however, been made. 
Etiology of the Disease in Man.- 
This section of our subject has been al- 
ready so fully treated of in discussing the 
subject of Glanders affecting the horse, 
that it here needs but a very brief consid- 
eration. 
Always communicated from the horse, 
the ass, or the mule to man, those are 
specially predisposed to contract the dis- 
ease whose avocations lead them to come 
in contact with these animals. The great 
majority of the cases recorded have oc- 
curred amongst veterinary surgeons, vet- 
erinary students, grooms, coachmen, cav- 
alry soldiers, horse - slaughterers, &c. 
Writers on Glanders in man have admit- 
ted that, although the disease is often or 
generally due to inoculation of morbid 
matters from glandered horses, it may be 
occasionally communicated to man by in- 
fection. It has been stated, in support of 
this view, that a frequent cause of Glan- 
ders and Farcy is the custom of causing 
men to sleep in stables. Those who hold 
the above view seem to forget that these 
men, besides sleeping in the stables, are, 
from the very nature of their duties, ex- 
posed to the greatest danger of contract- 
ing, inoculation. Glanders from any af- 
fected horse which may be placed under 
their charge. If facts are very scanty to 
support the belief that Glanders is propa- 
gated from horse to horse by infection, 
they assuredly are still more so in the 
case of man. In the immense majority of 
cases of Glanders in man which have oc- 
curred, there is the most conclusive evi- 
dence that the sufferers were in constant 
habit of handling glandered horses, whilst 
in a considerable number of cases there 
has been actual evidence of the disease 
having been transmitted by inoculation. 
To explain, as due to infection (using the 
term in its more limited sense), the cases 
which have occurred in which no history 
of inoculation through a wound is to be 
obtained, appears to the writer altogether 
unjustifiable, when regard is had to the 
facts that the virus of Glanders, besides 
being capable of being absorbed by the 
most trifling cutaneous abrasion, is prob- 
ably absorbed by unbroken mucous mem- 
brane, and that of the very large number 
of persons who formerly used to be 
brought in contact with glandered horses, 
only an excessively small fraction con- 
tracted the disease, although a large num- 
ber of these people were most careless 
and imprudent in their treatment of glan- 
dcred horses. It may, we think, be safely 
stated that Glanders is only communi- 
cable from the lower animals to man by 
inoculation. 
The virus of Glanders may adhere to 
stable utensils, clothes, and other articles, 
for a long period of time, and then when 
brought in contact with an absorbing sur- 
face may give rise to the disease. 
Not only can the disease be transmitted 
from the horse, ass, or mule to man, but 
likewise from one human being to another. 
Several facts have placed this beyond dis- 
pute. A distinguished young French 
veterinarian, M. Gerard, died of Acute 
Glanders induced by a wound which he 
1 Diss, sistens casum singularem morbi con- 
tagio mallei humidi in hominem translate 
orti. Berolin, 1829. 
2 De Typho malloide. Berolin, 1829. 
8 London Medical Gazette, vol. iv. p. 134. 
4 Med.-Chir. Trans., vol. xvi., 1830. 
5 Ibid., vol. xviii., 1833. 
6 Mem. de l'Academie de Medecine, vol. vi. 
p. 625. 
7 Paris, 1843. SEMEIOLOGY. 
189 
inflicted on himself whilst making the 
post-mortem examination of a veterinary 
student who had died of Glanders.1 El- 
liotson,2 in describing a case of Glanders, 
mentions that the laundress who washed 
the clothes of the patient, contracted 
Glanders. An externe of a Paris hospital 
died from Acute Glanders contracted from 
a stableman suffering from Glanders.3 In 
this case, besides dressing the wounds of 
the patient, the externe had taken an ac- 
tive part in the examination of the body 
after death. 
Although usually contact of the virus 
of Glanders with an absorbing surface 
gives rise to the disease, this does not 
invariably follow. 
It has been erroneously stated that a 
weak state of the constitution, intempe- 
rate and irregular habits, predispose indi- 
viduals to attacks of Glanders. What- 
ever influence they may have on its pro- 
gress and issue, there is absolutely no 
proof that they exert any influence in the 
way mentioned. It has, indeed, been cor- 
rectly remarked, that a large majority of 
the recorded cases of Glantlers have oc- 
curred in men of robust constitutions, and 
in the prime of life. 
Semeioeogy.-We shall consider sepa- 
rately the semeiology of the four varieties 
of Glanders which are observed in man 
as in the horse. 
Acute Glanders occurs in man more fre- 
quently than the other forms of the dis- 
ease, and presents in him characters re- 
sembling those of cases in the horse in 
which Acute Glanders and Farcy are 
combined. The period of incubation of 
Acute Glanders varies probably from 
twenty-four hours to a fortnight ; its 
limits, in the majority of cases, being from 
three to eight days. 
The mode of invasion of the disease va- 
ries considerably. In those cases where 
a distinct wound exists, through which 
the virus has been introduced, redness, 
pain, and tension, accompanied by an 
erysipelatous appearance around the 
wound, and swelling of the lymphatics, 
are often noticed before the supervention 
of any constitutional symptoms. Occa- 
sionally no wound can be discovered, or 
the wound through which the virus was 
introduced may remain in a passive con- 
dition. Whether local symptoms have 
been developed or not, the disease is usu- 
ally ushered in by feelings of lassitude, 
headache, and rigors, frequency of the 
pulse, and often by vomiting and diar- 
rhoea. Articular and muscular pains oc- 
cur from an early period of the disease, 
and increase during its progress. The 
limbs and body become the seat of subcu- 
taneous abscesses, which are specially 
found on the face, and near the articula- 
tions. Over the abscesses the skin be- 
comes of a red and violet color, and some- 
times limited gangrene sets in. The pus 
which forms in the abscesses is serous and 
fetid. A remarkable pustular eruption 
generally appears on the surface of the 
body, being specially found on the cheeks, 
arms, and thighs. The pustules com- 
mence as little red spots, which after- 
wards present the appearance of white 
papules, and become full of pus; they are 
often surrounded by a red areola. The 
pustules vary greatly in size, presenting 
a flattened or pointed surface, and either 
occur singly or so closely aggregated as to 
be almost confluent. The pustules are 
often accompanied by bullse of a dark 
color, on the face, trunk, and organs of 
generation. An erysipelatous inflamma- 
tion of the nose, eyes, and neighboring 
parts of the face, sometimes extending to 
the scalp, is far from infrequent. The 
cutaneous eruption, which has been de- 
scribed, has been compared to that of 
varicella, variola, ecthyma, and yaws, but 
is considered by all the best writers on 
Glanders to be quite distinct and charac- 
teristic. (Bayer.) Amongst the most con- 
stant and pathognomonic of all the symp- 
toms of Glanders, is however one which 
has been noticed in the large majority of 
the recorded cases. A yellow, viscous, 
purulent discharge, often mixed with 
blood, and not infrequently possessed of 
great fetor, exudes from the nares. This 
proceeds from the Schneiderian mem- 
brane, which is invariably the seat of a 
pustular eruption, or of ulcerations. 
The mucous membrane of the mouth is 
sometimes likewise the seat of ulcerations 
or pustules, and from it, in certain cases, 
a purulent fluid has been observed to ex- 
ude. The submaxillary lymphatic glands 
are usually not enlarged. 
The prostration, which has been stated 
to usher in the disease, increases during 
its progress. The pulse becomes exces- 
sively frequent, small, and compressible. 
The voice is feeble, and the breath fetid. 
The constipation, which frequently exists 
at the commencement of the disease, is 
replaced by diarrhoea; the stools are ex- 
tremely fetid. A hard, dry cough, ac- 
companied by a little expectoration, and 
often by difficulty of breathing, testify to 
the existence in man, as in the horse, of 
pulmonary complications. With the in-' 
creasing prostration, delirium sets in, 
which is followed by coma, and ultimately 
by death. The duration of the disease 
has varied from three to fifty-nine days. 
As a rule, death has occurred about the, 
end of the second or commencement of 
1 Breschet, Revue Med., tome ii. p. 96, 1826. 
2 Elliotson, Lancet, 1838. 
3 Tardieu, op. cit. pp. 140, 141; and Be- 
rard, Bull, de 1'Acad. de M6d., Nov. 1841, tome 
vii. p. 182. 190 
GLANDEES. 
the third week. Acute Glanders runs an 
unusually rapid course when it occurs as 
a sequela of the other and more chronic 
forms of the disease. 
Chronic Glanders is the rarest form of 
the disease in man. When it occurs, it 
is usually as a sequela of Farcy. Uncom- 
plicated by Farcy, the disease has but 
seldom been observed. When Chronic 
Glanders occurs primarily (i. e. not as a 
sequela of Farcy), it commences with las- 
situde and very severe articular pains, 
which readily pass away, and are followed 
by a cough, sore throat, and a disagreea- 
ble feeling in the nose. 
When Farcy has existed before the ap- 
pearance of Chronic Glanders, no lassi- 
tude or pains may be noticed. In these 
cases, the first symptoms are the sore 
throat, cough, and affection of the nose, 
which have been alluded to. A pain is 
then felt in the trachea, the voice becomes 
altered in character, or true aphonia may 
occur. The cough is accompanied by 
dyspnoea, and often by expectoration. 
Capillary bronchitis and pneumonia some- 
times supervene. The disagreeable sen- 
sations in the nose increase-the patient 
complaining of a feeling of its being 
stopped up; sometimes, although by no 
means always, there is a dull aching pain 
at the root of the nose. On blowing the 
nose, a puriform mucus, mixed with little 
bloodclots, becomes detached, or there 
may be a regular discharge (jetage) from 
the nose. On examining the nares at this 
stage, ulcerations may not infrequently 
be perceived on the Schneiderian mem- 
brane. By the introduction of a probe, 
inequalities of the surface, and even per- 
foration, of the septum narium, may be 
detected. 
Ulcerations may sometimes be likewise 
observed in the pharynx. There is very 
rarely any induration of the submaxillary 
glands. 
The skin is free from eruption. 
In addition to the special phenomena 
which have been described, the patient is 
usually prostrated, suffers from articular 
and muscular pains, diarrhoea, and nausea, 
loses flesh, and falls into a state of maras- 
mus. He may die of simple exhaustion, 
or Acute Glanders may set in and rapidly 
close the scene. This form of Glanders 
has been once observed to terminate in 
recovery (case of Nimrod Lambert). Its 
duration is excessively various; those 
cases which are complicated with Farcy 
proving more rapidly fatal than others. 
As a general rule, the course of the dis- 
ease extends over several months, and 
cases have been recorded where it appears 
to have lasted for some years. 
Acute Farcy presents, almost constantly, 
all the characters which have been de- 
scribed as those of Acute Glanders, with 
the single exception that there is a total 
absence of affection of, or discharge from, 
the nares. So great is the resemblance 
between the two affections, that only cer- 
tain special points in connection with 
Acute Farcy need be alluded to. A sub- 
division of all cases of Acute Farcy may 
be made, into cases accompanied by a cu- 
taneous eruption, and cases unaccom- 
panied by eruption. In some cases of 
Acute Farcy, there is merely an inflam- 
mation of the lymphatic vessels and 
glands, accompanied with the formation 
of soft subcutaneous tumors in various 
parts of the body. In other, and by far 
the greater number of cases, an eruption, 
exactly similar to that of Acute Glanders, 
occurs, such cases being distinguished 
from instances of the latter disease only 
by the absence of affection of the nose. 
These cases are very much more serious 
than those without eruption, and follow 
exactly the same course as Acute Glan- 
ders, proving fatal usually between the 
thirteenth and nineteenth day. (Rayer, 
op. cit. p. 787., In the cases where there 
is no eruption, and which have received 
the special name of cases of acute far- 
cinous angeioleucitis, the disease very fre- 
quently terminates in recovery, or passes 
into Chronic Farcy. 
Chronic Farcy may exist alone, or asso- 
ciated with Chronic Glanders. It is ush- 
ered in by lassitude, wandering pains, 
uneasiness, anorexia, accompanied by 
fever, which often assumes a tertain type. 
An abscess usually forms on the forehead, 
the calves of the legs, or some other part 
of the body, which is followed by other 
indolent and fluctuating tumors. Some of 
these open spontaneously, and give exit to 
blood, or ill-conditioned pus. The lym- 
phatic glands only secondarily, and to a 
slight extent, become affected. With the 
successive appearance of abscesses, the 
general health and strength of the patient 
decline ; he loses flesh ; the skin becomes 
dry, and earthy ; the countenance yellow 
and livid. Frequent rigors occur. The 
open abscesses become converted into hor- 
rible ulcers, which have no tendency to 
heal. A dry cough harasses the patient, 
■who, with his body covered with foul ul- 
cers, falls into a condition of most miser- 
able marasmus. The course of the disease 
is tedious and uncertain. The abscesses 
commence to form from the third to the 
fifteenth day of the disease. The subse- 
quent stage is, however, most protracted 
and uncertain in its issue. It may termi- 
nate by an attack of Acute Glanders, or 
of Chronic Glanders, or the patient may 
die of exhaustion, or from an attack of 
pyaemia. Lastly, recovery may occur. 
The duration of the recorded cases of 
Chronic Farcy has varied from four 
months to three years; it usually termi- DIAGNOSIS - MORBID ANATOMY. 
191 
nates in from ten to fifteen months. Of 
twenty-two cases of the disease, cited by 
Tardieu, six recovered.1 
Diagnosis.-Having described the cha- 
racters of the different varieties of Glan- 
ders, there remains for consideration their 
differential diagnosis. 
Acute Glanders is distinguished by such 
remarkable characters, which are always 
associated together, that when fully devel- 
oped it would be impossible to confound it 
with any known disease. In its early 
stage, when the articular and muscular 
pains are very urgent, it might be mis- 
taken for acute rheumatism. The occu- 
pation of the patient, the existence of a 
wound in a state of irritation, the much 
greater degree of prostration than is com- 
mon in acute rheumatism, the absence 
(usually) of redness and swelling around 
the painful joints, would arouse the sus- 
picions of the physician. At a later stage, 
the association of the peculiar and charac- 
teristic eruption of pustules and bullse, 
with ulceration of, and discharge from the 
nose, taken in connection with the history 
of the affection, distinguish in the clear- 
est manner Acute Glanders, from erysipe- 
las of the face, typhoid fever, malignant 
pustule, pysemia, and some other diseases, 
to which it has been supposed to present 
points of resemblance. 
Chronic Glanders offers much greater 
difficulties in diagnosis than the acute 
form of the disease. When uncompli- 
cated by Farcy, it might be readily mis- 
taken at first sight for one of the different 
forms of ozsena. The occupation of the 
patient, the mode of invasion of the affec- 
tion, the absence of other evidences of 
strumous or syphilitic affections, would 
furnish the data for forming a diagnosis. 
Cases of uncomplicated Chronic Glanders 
are, however, as has been already stated, 
of great variety. In the cases where 
Chronic Glanders and Farcy are com- 
bined, the diagnosis is more simple, for 
an association of symptoms then exists 
which is not presented by any other dis- 
ease. Cases of Chronic Glanders must, 
however, occasionally of necessity occur, 
in which the physician must experience 
great difficulty in forming a correct diag- 
nosis. In these cases an ass, or a horse, 
might be inoculated with some of the 
nasal mucus, if the case were one of un- 
complicated Chronic Glanders; or with 
pus from an abscess, if the affection were 
Chronic Glanders and Farcy. 
Acute Farcy, when occurring in a char- 
acteristic form, could scarcely be mistaken 
for any other disease. The history of the 
case, the great rapidity of its course, and 
the extraordinary pustular eruption, to- 
gether with the numerous subeutaneous 
abscesses and tumors, would distinguish 
the case from cases where multiple ab- 
scesses occur from the introduction of 
other septic matters into the system. In 
cases of Acute Farcy without eruption, 
and of uncomplicated Chronic Farcy, only 
an accurate acquaintance with the early 
history of the case, and an accurate study 
of its progress, could enable the physician 
to arrive at a correct opinion. The super- 
vention of Acute or Chronic Glanders 
would, in a large proportion of such cases, 
remove the difficulties which they at first 
present. 
Morbid Anatomy.-Having describ- 
ed, in the preceding pages, the morbid 
anatomy of the various forms of Glanders 
in the horse, there remains little to be 
said of the morbid anatomy of the disease 
as it affects man, for the structural alter- 
ations of the nasal fossae, of the larynx, 
trachea, and lungs, are as characteristic 
of the disease in man as they are of it in 
the horse. The chief point of difference 
in the morbid anatomy appears to be that, 
in all the different forms of Glanders seen 
in the horse, the lymphatic system is very 
much more involved than in man. 
1. Acute Glanders.-In all cases where 
the nasal fossae have been examined, 
they have been found the seat of disease. 
Sometimes the Schneiderian membrane is 
ecchymosed and gangrenous, whilst often 
it presents numerous little pustules of the 
size of millet seeds. The frontal sinuses 
are frequently found filled with puriform 
mucus. The larynx has been the seat of 
eruption and ulceration in several cases. 
The lungs frequently present patches of 
pneumonia, or purulent formations are 
formed in them. 
2. In Chronic Glanders, the affection of 
the nose differs considerably in character. 
At an early stage, the mucous membrane 
is often found injected and much swollen. 
Small submucous abscesses form. These 
open and become ulcerated; the ulcera- 
tion spreads to the bones and cartilages, 
and necrosis generally follows. These 
ulcerations generally occur on the septum, 
which, in almost every case of Chronic 
Glanders becomes ultimately perforated. 
Ulcerations of the larynx, trachea, and 
bronchi are very commonly found. The 
epiglottis is sometimes ulcerated, but the 
vocal cords are usually unaffected. The 
ulcerations of the trachea are often very 
extensive, and affect the whole thickness 
of the mucous membrane. They exhibit 
a remarkable tendency to heal spontane- 
ously. The lungs are, by no means so 
constantly as in Acute Glanders, the seat 
of the disease. The pleura is often cov- 
ered with small yellow elevations, which, 
on being incised, are found full of pus. 
1 See Tardieu, op. cit. p. 75, from whom the 
above description of Chronic Farcy has been 
abridged. 192 
HYDROPHOBIA. 
Beneath the pleura, deposits of a purely 
fibrinous nature are found. Occasionally 
a portion of lung substance is indurated, 
in consequence of fibrinous exudation ; ^in 
the centre of the indurated portion, pus is 
formed. The lymphatic glands are often 
somewhat enlarged, reddish, and of soft 
consistency. The bronchial glands have, 
in cases where ulcerations of the air-pas- 
sages existed, been found enlarged, soft- 
ened, and in state of suppuration. The 
alimentary canal, the liver, and spleen 
present no peculiar appearance. 
The morbid anatomy of Acute Farcy is 
identical with that of Acute Glanders, ex- 
cept that the Schneiderian membrane is 
found perfectly healthy. 
In Chronic Farcy, the morbid appear- 
ances resemble those of Chronic Glanders. 
There is, however, no affection of the 
nose. 
Prognosis.-In all the forms of Glan- 
ders, the prognosis is of the most unfavor- 
able description. Acute Glanders and 
Acute Farcy, when accompanied by the 
characteristic eruption, are almost neces- 
sarily fatal. One case of Acute Glanders, 
and several of Acute Farcy, have been re- 
corded, in which recovery took place. In 
Farcy, unaccompanied by eruption, the 
prognosis is much more favorable, re- 
covery being the rule, and not the excep- 
tion. CJironic Glanders, especially when 
complicated by Farcy, is almost invaria- 
bly fatal. The case of Lambert, which 
has been referred to, proves, however, 
that even under these desperate circum- 
stances recovery may take place. 
Chronic Farcy, although a most danger- 
ous disease, usually terminates in re- 
covery. 
In forming a prognosis, in apparently 
slight cases of Chronic Glanders or Farcy, 
it must not be forgotten that Acute Glan- 
ders often suddenly supervenes, in the 
course of these affections, and then inva- 
riably proves fatal. 
Therapeutics.-This section of the 
subject need unfortunately be treated of 
very briefly, for no treatment which has 
been adopted, in the cases which have 
hitherto occurred, has appeared to exer- 
cise the slightest influence in checking or 
modifying the progress of the disease. 
Characterized as it is by symptoms of 
the greatest constitutional prostration, a 
stimulant and supporting plan of treat- 
ment appears to be indicated, and has 
been recommended by all writers on 
Glanders. 
All attempts which have been made to 
cure Glanders in the horse have proved 
futile. There is considerable evidence, 
however, that arsenic, especially when 
administered with nux vomica or strych- 
nia, has in some cases of Chronic Glanders 
excited a remarkable influence in check- 
ing the progress of the local affections ; 
and we therefore think a trial of these 
remedies might with propriety be made, • 
in cases of Chronic Glanders occurring in 
man. 
HYDROPHOBIA. 
John Gamgee, and Arthur Gamgee, M.D. 
Definition.-A disease due to a spe- 
cific animal poison which resides in the 
saliva of animals affected with it. It never 
originates spontaneously, and is commu- 
nicated directly or indirectly, and usually 
by biting, from carnivorous or omnivorous 
animals, and especially dogs, to man. It 
is alone recognized by its physiological 
effects on man or animals. It induces 
pain and stiffness in the inoculated part, 
exalted sensitiveness and irritability, 
feverishness, mental anxiety, flitting 
pains, spasm of the throat on the sight of 
liquids, tremors, headache and delirium, 
vomiting, eructations and tympanites, 
great prostration, and death. Its period 
of incubation varies from a few days to 
many months. 
Synonyms.-Avcm, wAwm. vSpo^ofSta ; 
Phobodypson, Pheugydron, Rabies, Ra- 
bies canina, Rabies contagiosa, Entasia 
Lyssa, Canine Madness ; La Rage, Hy- 
drophobie (French); Die Hundswuth, 
Wasserscheu, Tollwuth (German) ; Rab- 
bia, Idrofobia (Italian) ; Hidrophobia 
(Spanish); Watervrees (Dutch). 
History.-Few diseases have, at dif- 
ferent periods of the history of medicine, 
excited greater attention, curiosity, and 
study than Hydrophobia, and few have 193 
HISTORY. 
been described in a more graphic or more 
accurate manner by ancient writers. Cel- 
sus,1 Dioscorides,2 Cielius Aurelianus,3 
and Galen, have left us accounts of the 
disease which equal those of the best 
writers who have followed them. 
It has been argued and indeed generally 
admitted, that the disease was not un- 
known to Homer, and the word Xvosa, 
which is so often employed in the Iliad to 
describe a wild and reckless fury, is sup- 
posed primarily to have been used to de- 
signate the madness of dogs. 
This view has been held since the days 
of Cselius Aurelianus, and is supported by 
the best authorities.4 Thus Dr. Bardsley, 
in a very learned memoir on Hydropho- 
bia,5 says:- 
"We have already said that the disease 
was well known to Homer, and applied by 
him, with his usual critical exactness of 
similitude, to the indiscriminate havoc 
with which Hector sweeps through the 
battle-field of his enemiesand after 
quoting several passages6 in which the 
word Kvcrcra or one of its derivatives is used, 
he adds : " The poet with much propriety 
puts these words into the mouth of Ajax 
his enemy, for dog was already a term of 
reproach among the Greeks as well as the 
Jews." The passages alluded to do not 
appear to us to prove satisfactorily that 
their author was acquainted with Hydro- 
phobia. The word and its deriva- 
tives, is used by Homer on all occasions, 
as it is by many other Greek writers,7 to 
denote martial rage ; and in spite of the 
occurrence of the expression xA Xvcw^pa, 
we feel inclined to believe that this was 
the primary meaning of the word, which 
was only secondarily applied to designate 
the disease of the dog, in the same man- 
ner as madness, rage (Er.) and rabbia 
have in modern European languages been 
secondarily used in a limited and specific 
sense to denote Hydrophobia. Excepting 
that the word was subsequently used to 
designate the madness of dogs, there is no 
evidence that it had that meaning at the 
period when the Homeric poems were 
written; whilst in using the expression 
'xm Xvss^pa,' already referred to, the 
author of the Iliad much more probably 
referred to dogs infuriated with anger 
than to dogs suffering from Hydrophobia. 
All who are practically acquainted with 
the disease will admit that whilst on the 
one hand it is most improbable that the 
snappish ill-temper of rabid dogs should 
have been referred to, as a point of com- 
parison, by Homer in the passages quoted 
by authors, there is on the other hand 
nothing more natural than that he should 
compare an angry man to a furious dog, 
inasmuch as there is nothing more sug- 
gestive of ungovernable passion than the 
•enzy of an infuriated (but not rabid) dog. 
Whatever may have been the primary 
meaning of the word, there can be no 
doubt that, in course of time, the word 
xAaa and its very numerous derivatives 
-XvcJfldw, Kvosmvm, KvOSriSov^vsavitii, Kvootjtvip, 
Kvsoufys, JwsGoSqxtos, 'kvoaiq'tixos-were em- 
ployed to express Hydrophobia, and in 
this sense the word Xvooa is employed by 
Plutarch and Dioscorides. 
Hippocrates only alluded in the faintest 
manner, if at all, to Hydrophobia, and we 
agree with Dr. Bardsley in the opinion 
that when speaking of the 
iBpa^vrtotai,"1 the father of medicine proba- 
bly only means to treat of a "variety of 
phrenitis or mania." 
Democritus, however, who was the con- 
temporary of Hippocrates, if we are to 
believe the statements of Cselius Aure- 
lianus,2 was acquainted with the disease, 
and wrote upon its nature and treatment. 
"Etenim Democritus qui Ilippocrati con- 
vixit, non solum hanc memoravit passio- 
nem, sed etiam ejus causam tradidit, cum 
de opisthotonicis scriberet. " In two other 
passages in his interesting account of Hy- 
drophobia, Cselius alludes to the opinions 
of Democritus as to the affection being 
one of the nervous system, and mentions 
the remedies which that author recom- 
mended for its treatment. 
Aristotle was undoubtedly acquainted 
with the Hydrophobia of dogs. In his 
" Historia Animalium,"3 besides describ- 
ing it, he mentions that the disease is com- 
municable to all animals but man. The 
opinion, although erroneous, points to 
the fact of his having directed attention 
not only to the characters but also to the 
mode of propagation of the disease. Both 
Asclepiades and Themison, according to 
Cselius Aurelianus and Dioscorides, were 
acquainted with Hydrophobia, and enter- 
tained peculiar views as to its nature. 
Themison is indeed said to have been 
himself subject to an attack of Hydro- 
phobia, but as he recovered from the 
1 A. C. Celsi Med. lib. v. cap. xxvii. 
2 P. Dioscoridis Op. omnia. Vienna edi- 
tion, 1598. "SKfAtia. xwoy XtiwivTO^, xal rSiv vvr' 
auTow a. 
3 C. Aurelianus, De Morbis acutis et chro- 
nicis, lib. iii. cap. ix.-xvi. 
4 See Thesaurus Grecae Linguae ab. H. Ste- 
phano construct, vol. iv. fasc. 2 ; also Damm. 
Nov. Lex. Graecum etymol. et real.; cui pro 
basi substratae sunt concordantiae et elucida- 
tiones Homericae et Pindaricae. This author 
derives Xuvva from Xuxo;„ wolf, this animal 
being very often subject to Hydrophobia. 
5 Cyclop, of Pract. Med., vol. ii. art. Hydro- 
phobia. 
6 Iliad, lib. viii. 299 ; ix. 237; xiii. 53. 
7 Plato, Herodotus, Sophocles. 
VOL. I.-13 
1 Predict., lib. i. p. 69. Prsenot. Leet. ii. 
p. 131. 
2 Op. cit., lib. iii. cap. xv. 
8 Hist. Animalium, lib. viii. c. 22. 194 
HYDROPHOBIA. 
affection we may with probability conjec- 
ture that its nature was very different 
from that of true Hydrophobia. 
Of the ancient writers, Celsus and Dios- 
corides, Cadius Aurelianus, Galen, and 
Avicenna, are those to whom we are 
chiefly indebted for our knowledge of Hy- 
drophobia, and to their opinions we shall, 
on more than one occasion, revert. Since 
the period when they wrote, all systematic 
writers on medicine have treated of Hy- 
drophobia. Foremost amongst those who 
have contributed to our knowledge on the 
subject are Van Swieten, Sauvages, Cul- 
len, Fothergill, Mead, Trolliets, and 
Bardsley. 
The recent history of Hydrophobia re- 
fers principally to Europe, not only be- 
cause greater attention has been paid to 
this as to every other disease of men and 
animals in the Old World, but because 
the malady has been to a very great ex- 
tent confined to Europe. We shall after- 
wards attempt an explanation of this fact, 
but in the mean time we may state that 
the oldest report of scientific interest that 
we can trace, refers to wolves afflicted 
with rabies, in Fraconia, in 1271. Con- 
trary to their usual habits, these animals 
spared the herds and flocks, and attacked 
shepherds in the fields, or followed human 
beings into the towns and villages. Up- 
wards of thirty men fell victims to these 
attacks.1 Canine madness prevailed con- 
siderably in Spain in 1500.2 In 1590, we 
are told by Bauhin,3 rabies raged in an 
epizootic form amongst the wolves in the 
province of Monthelliard. In 1604 it pre- 
vailed in Paris, and although it was 
doubtless common there, and after in 
various parts of Europe, we do not hear 
of it again until 1691,4 when the heat of 
summer proved insufferable, the crops 
withered for want of rain, animals died in 
great numbers in Italy, and dogs went 
mad. This reference to the dependence 
of rabies on the hot season must simply 
be regarded as pointing to a coincidence. 
Severe outbreaks of rabies occurred in 
France and Germany from 1719 to 1721, 
in Hungary in 1722 and 1723, and atmo- 
spheric influences were blamed for similar 
attacks in various parts of the continent, 
from 1725 to 1726.5 We learn, however, 
that wolves were affected as well as dogs 
at this period, and special mention is 
made of wild animals being seized with 
the disease in Silesia and Lusatia (now 
Bautzen, in Saxony). The malady was 
rife in London in 1760, in Philadelphia in 
1779, in the West Indian Islands in 1783,* 
and in various parts of Europe from 1785 
to 1789.2 At this period special notice is 
again taken of rabid wolves which com- 
municated the disease and terrified the 
people far more than even rabid dogs. 
It was not till the commencement of 
the present century that foxes were dis- 
covered to sutler much and frequently 
from canine madness. In 1803 these ani- 
mals were seen rabid in large numbers in 
the Pays de Vaud, in various parts of the 
Aubonne, Cossenay, Orbe, and Yserden 
districts at the foot of the Jura, and in 
1804 similar outbreaks were witnessed on 
the northern shore of the Lake of Con- 
stance, and thence extending throughout 
the whole of Germany. Blaine tells us 
that in 1806 rabies in the dog became so 
prevalent in the vicinity of London that 
a day seldom passed without his being 
consulted on one or more cases of it, and 
sometimes he would see three, four, or 
five a day for weeks together. The king- 
dom of Wirtemberg and Grand Duchy of 
Baden were sadly ravaged by it in 1808 
and 1809. Foxes continued to be affected, 
and these usually shy animals faced or 
followed men, cattle, or dogs in open day- 
light, bit them, and communicated the 
disease. The Wirtemberg Government 
ordered a report to be published on this 
subject in 1829, which contains particulars 
of these outbreaks. 
From 1803 to 1820 is a memorable pe- 
riod in the history of Hydrophobia. In 
1810 it spread rapidly through Southern 
Russia, and the same year it appeared in 
America, in the State of Ohio, where it 
destroyed dogs, wolves, and foxes, besides 
other domestic animals, and no small 
number of human beings. In 1815 the 
malady was raging in Denmark. Blaine 
tells us that in 1820 it was again on the 
increase in England, and for three or four 
years "continued alarmingly common" 
but moderated again for a few seasons. 
During the years 1819 and 1829, rabies 
was rife in Italy, and Brera speaks of a 
wolf which bit thirteen persons, of whom 
nine died hydrophobic. Wirth specially 
notices the period from 1819 to 1826 as 
remarkable for rabies amongst the foxes 
of Switzerland and Germany,3 and the 
foxes communicated the malady to dogs, 
cats, horned cattle, horses, pigs, goats, 
and sheep. In 1824 rabies prevailed ex- 
1 Moseley's Treatise on Tropical Diseases. 
2 Schnurrer, ii. p. 389 ; and Fehr, Ueber 
die Hundswuth, Munster, 1739. 
3 Franque, Die Seuche unter den Fuchsen 
und die urspriingliche Wuth Krankheit der 
Hunde ; Frankfort, 1827. Kochlin, Ueber 
die in unsern Zeiten herrschende Krankheit 
unter den Fuchsen ; Zurich, 1835. Wirth, 
Lehrbuch der Seuchen und ansteckenden 
Krankheiten der Hausthiere ; Zurich, 1846. 
1 Addit. ad Lambert, Schafnaburg. 
2 Blaine's Canine Pathology. 
8 J. Bauhin, Memorab. Historia Luporum, 
1591. 
4 Ramazzini, pp. 157-186, and Baglivi 
(1828), vol. ii. p. 331. 
6 Breslau, Sammlungen, xxxiii. p. 90. CAUSES. 
195 
tensively amongst foxes, wolves, cats, 
and reindeer in Sweden, Norway, and 
even Russia. In the Rhine Provinces, 
various cantons of Switzerland, and in 
the kingdom of Wirtemberg, many men 
were bitten by mad foxes in the year 1827, 
but owing to the prompt measures usually 
adopted the individuals escaped; dogs 
and cats thus bitten, however, became 
rabid. 
In 1830 the subject of rabies attracted 
great attention in England, and evidence 
on the subject was laid before a select 
committee of the House of Commons. 
Sir Benjamin C. Brodie, Professor Cole- 
man, Messrs. William Youatt, Morgan of 
Guy's Hospital, Earle of St. Bartholo- 
mew's, Benjamin Travers, and others 
were examined. Some idea of the state 
of popular terror, if not of the number of 
bites by rabid dogs, may be gleaned from 
Mr. Youatt's statement in evidence, to 
the effect that he had applied lunar caus- 
tic to about 400 bitten people, and a sur- 
geon at St. George's declared that within 
a limited time he had similarly operated 
on 4,000 without an accident. Mr. Youatt 
particularly referred to a great increase in 
the prevalence of the disease as contrasted 
with eighteen months previously. Mr. 
Henry Earle, of St. Bartholomew's, fur- 
nished unmistakable evidence of the in- 
creased frequency of the disease in Eng- 
land, and stated that he had seen twenty- 
five cases of Hydrophobia in man in 
twenty-five years, whereas his father had 
only seen one in fifty years, before his 
time. It is certain from the statements 
of Blaine, Coleman, and others, that prior 
to 1830 foxhounds were affected in this 
country to an extent never witnessed be- 
fore nor since. 
That there has been a decided abate- 
ment in the frequency of the malady in 
England during the second quarter of the 
present century, as compared with the 
first, cannot be doubted, and it is believed 
that the law abolishing the use of dogs as 
beasts of burthen has operated greatly in 
favor of the change. That law not only 
led to a diminution in the number of dogs 
owned by a class of persons who could not 
keep these animals in a way calculated to 
prevent the spread of contagious diseases 
amongst them, but indirectly it led to the 
destruction of a lot of roving curs, kept by 
the poorer classes. The dog tax, too, 
which might have been beneficially en- 
forced to a greater extent than it had 
been, no doubt tended to limit the num- 
ber of valueless animals kept. Whatever 
may be the cause, it is certain that there 
is far less canine rabies, hence much less 
human Hydrophobia, in the British isles 
than on the Continent, and during recent 
severe outbreaks of this disease abroad 
little has been heard or seen of it amongst 
us. 
Some remarkable statements have been 
published regarding Hydrophobia in 
France and the German States during 
the thirty-five years of comparative im- 
munity which we have enjoyed. In 1830, 
when attention was attracted by the 
prevalence of the malady in London, 
there was occasion for alarm in Vienna, 
where thirty-nine cases of rabies in the 
dog were reported in rapid succession. 
Few instances of the disease were seen 
there for tlie succeeding seven years, but 
in 1838,117 cases occurred; in 1839, sixty- 
three ; in 1840, 317 ; and in 1841, no less 
than 141. Of the last number only thirty- 
one animals were affected with the dumb 
rabies. Only fifteen of the 141 were 
bitches. Two cases occurred in animals 
under one year, and only one in dogs be- 
tween seven and fourteen years of age. 
The disease was specially rife in the 
months of February and May, in each of 
which twenty-one cases were observed ; 
in January there were sixteen, seventeen 
in April, and eighteen in June. The few- 
est attacks were in the months of Septem- 
ber, November, and December. From 
1839 to 1842, rabies in the dog was very 
prevalent in Wirtemburg, and this was 
attributed by Professor Remy to commu- 
nication from foxes. From the 1st of 
January, 1840, to the last of February, 
1842, no less than 230 cases of rabies oc- 
curred in dogs, and twenty-one in bitches 
in the small Grand Duchy of Baden. In 
1840-41-42, the malady was very destruc- 
tive in Lyons and other parts of France. 
In the space of thirty years, no less than 
779 dogs have died of rabies in the Lyons 
Veterinary School, giving a yearly aver- 
age of nearly twenty-six cases. The 
largest number of these cases occurred in 
the months of June and of April. Only 
so late as 1864, the city of Lyons was in 
great commotion owing to the terrible 
frequency of rabies canina. 
Some idea may be formed of the great 
difference between Great Britain and the 
Continent in relation to the frequency of 
this disease, from the fact that having 
been more or less connected with veteri- 
nary colleges in this country since 1849, 
not a single case of rabies has come under 
our own observation here, whereas many 
instances have been seen by us abroad, 
on almost every occasion that we have 
visited foreign schools. When in Lyons 
and Paris in 1854, many were the cases 
we saw, and often did we see ladies un- 
consciously carrying their rabid pets to be 
visited by the professors. 
Causes.-A glance at the history of 
Hydrophobia suffices to prove that, so far 
as man is concerned, the specific disease 
is due to only one cause, contagion. The 
poison is a fixed one, and flows from the 
sick animal's body with the abundant 196 
IIYDROPIIOBIA. 
saliva which is secreted. It must pene- 
trate the system to take effect, and is 
usually deposited by the teeth of rabid 
animals in and beneath the skin. It is 
not volatile, and the disease is therefore 
not infectious. Many circumstances af- 
fect its transmission, and on this we shall 
say more, after having spoken of the 
malady as it attacks the lower animals. 
It is generally supposed that rabies 
originates spontaneously in the dog and 
other carnivorous animals. So deeply- 
rooted is this belief, tiiat even men of 
eminence have attempted various explana- 
tions of the supposed fact. One of the 
oldest views refers canine rabies to the 
heat of the "dog-days" and the tortures 
of thirst. Another, recently revived, is 
that the malady is developed in dogs kept 
under restraint, and from indulging at 
proper seasons in sexual intercourse. 
These and other theories are so absurd, 
and so opposed to many of the facts which 
we must incidentally allude to in these 
pages, that we may state dogmatically 
they have no foundation in truth. With- 
out entering into a discussion on matters 
of theory, we consider it more profitable 
to refer to the peculiar features of rabies 
in those of the lower animals which un- 
doubtedly are capable of inoculating hu- 
man beings with the rabid virus. We 
shall, therefore, speak of the disease as it 
occurs in the dog, wolf, fox, badger, mar- 
ten, cat, horse, or sheep, pig, and goat. 
Dog.-One of the facts of primary im- 
portance, in the history of canine rabies, 
is that it is far more prevalent in dogs 
than bitches. Professor Coleman stated 
in evidence in 1830, that on the occasion 
of rabies entering fox-kennels, the mad 
dogs bit dogs, but spared the bitches. 
We well know that, as a rule, rabid ani- 
mals retain a certain affection for animals 
and people they know and care for. A 
dog will not bite its master at first, but 
rather avoid the presence of all he likes. 
There is some method in their madness, 
and we have no better proof of this than 
in the way in which bitches are spared 
by the rabid dog. Leblanc has published 
statistics, confirming the extraordinary 
prevalence of the disease in the males of 
the canine species, but he tried to bend 
the facts to demonstrate his theory that 
the disease is connected in its develop- 
ment with the repression of the desire for 
sexual intercourse. There are no experi- 
ments, no reliable facts indicating any 
ground for the belief that canine rabies 
originates in anything else than conta- 
gion, even in the dog ; and the best Brit- 
ish authorities, such as Blaine and Youatt, 
long since advocated this, the undoubt- 
edly correct view of the subject. 
It is singular that, even in relation to 
so active and certain a virus as that of 
rabies, we find instances of remarkable 
constitutional resistance to its effects. 
Thus when I visited the Lyons Veteri- 
nary College, in 1853, a pointer dog was 
in the infirmary which had been bitten 
no less than seventeen times by dogs af- 
fected with rabies, with which he had 
been purposely confined by Professor 
Ray. Other cases of a like kind have 
been recorded, but they may be consid- 
ered rare and exceptional. 
The period of incubation of the disease 
in the dog has been set down as between 
three and seven weeks. Blaine has met 
with a case in which rabid symptoms 
succeeded a bite in a week, though Youatt 
never saw a case with less than seventeen 
intervening days. In 1862 M. Renault 
made a communication to the Academy 
of Sciences at Paris, and stated that 
during twenty-four years he had made 
numerous experiments with a view to 
ascertain the period of incubation of Hy- 
drophobia in the dog. During that pe- 
riod, 131 dogs have, under conditions 
which he describes, been either bitten by 
mad dogs, or inoculated with the foam as 
immediately collected from the mad ani- 
mals. Of this number, 63 having pre- 
sented no signs of disease during the four 
subsequent months, were not further ob- 
served. Of the 68 others, the Hydropho- 
bia was developed at various periods, as 
shown in the following table :- 
In 1 dog between the 5th and 10th days. 
4 dogs " 10th " 15th " 
6 " " 15th " 20th " 
5 " " 20th " 25th " 
9 " " 25th " 30th " 
10 " " 30th " 35th " 
2 " " 35th " 40th " 
8 " " 40th " 45th " 
7 " " 45th " 50th " 
2 " " 50th " 55th " 
2 " " 55th " 60th " 
4 " " 60th " 65th " 
1 dog 11 65th " 70th " 
2 dogs " 70th " 80th " 
There are no premonitory signs of an 
attack of the disease in the dog. When 
the period of incubation is passed, the 
animal is restless, dull, watchful, and 
snaps at dogs, other animals, or men, 
which come in its way. It shuns the 
light, but with much slyness seeks an op- 
portunity of escape, and roves about 
town or' country, manifesting extraordi- 
nary powers of exertion, and marked in- 
sensibility to blows and ill-usage. The 
habits of an animal may not change com- 
pletely at first, and the recognition of 
persons it has been daily in contact with 
is sometimes very remarkable. The di- 
lated pupils, the manner in which the 
eyes follow any object moved before them, 
and the peculiar modification in the bark, 
which is more of the nature of a howl, 
are amongst the most characteristic symp- HYDROPHOBIA in man. 
197 
toms. The appetite is lost, thirst often 
considerable, and the animals usually 
drink without difficulty. The coat is 
staring, skin tight on the ribs, abdomen 
tucked up, head depressed, and nose pro- 
truded, with a dirty mouth and tongue, 
and sometimes a discharge of mucus and 
saliva from the sides of the mouth. In a 
certain number of cases, the nervous 
symptoms are very prominent at this pe- 
riod, and the lower jaw drops from pa- 
ralysis of the muscles connected with it. 
The howl is then lost, hence the name 
dumb rabies for the cases associated with 
this symptom. Emaciation, craving af- 
ter filth, which is swallowed with some 
difficulty, constipation, and a scanty dis- 
charge of high-colored urine, are amongst 
the noticeable symptoms. Mad dogs 
have been known to eat portions of dead 
dogs, and mad bitches to devour their 
young. There is a singular absence of 
any marked acceleration of the pulse and 
breathing during the disease ; the animal 
sinks, often paralyzed in the hind quar- 
ters, and dies somewhat tranquilly from 
the fourth to the eighth day. 
Schrader says that, of 2G7 cases of ra- 
bies, 223 belonged to the barking or raging 
variety, and 44 to the dumb or paralytic 
form. 
[There is good evidence to show that 
Hydrophobia may be produced by the 
bite of a healthy dog, much enraged; as 
in fighting with another animal.-II.] 
Foxes show signs of the disease, as 
stated above, by losing all their shyness, 
following animals and men, biting them, 
losing their consciousness, and becoming 
paralytic, and otherwise presenting most 
of the characters of the disease in the 
dog. 
Wolves are more to be feared than foxes, 
from their greater strength and ferocity. 
They attack human beings without fear, 
and usually bite them about the face, 
neck, and hands. As they approach death, 
they skulk away, and die in retired spots, 
blind, powerless, and in the quiet stupor 
seen in typhus. 
Cats have scarcely less propensity to 
attack the uncovered parts of the bodies of 
individuals, and especially the face, than 
foxes. They scratch, whine in a hoarse 
manner, and die from the third to the 
fourth day. 
Martens and badgers present most of the 
symptoms seen in cats and foxes. 
[The skunk, in the United State, is lia- 
ble to rabies, and has several times been 
known to communicate it, by its bite, to 
human beings.-H.] 
In the pig there is a peculiar restless- 
ness, squealing grunt, disposition to bite, 
gaping, salivation, marasmus, paralysis 
of the hind quarters, and death from the 
fourth to the fifth day. 
Rabies canina has been often observed 
in herbivorous quadrupeds, horses, oxen, 
sheep, deer, and other animals. The 
symptoms are marked and unmistakable, 
presenting all the characters of the signs 
of rabies in the dog. From the imperfect 
powers of biting, communication of the 
disease from vegetable feeders to man is 
rare, and we need not, therefore, enter 
into further particulars on the subject 
here. 
Hydrophobia in Man.-As actual 
contact of the saliva of a rabid animal 
with a wounded or abraded surface is re- 
quired for the development of Hydropho- 
bia, we should expect that, of the total 
number of persons bitten, only a certain 
proportion should fall victims to the dis- 
ease, and this is really found to be the 
case. Whether some individuals are, 
from idiosyncrasy, less prone to contract 
Hydrophobia than others, is not known, 
and it does not appear that age, sex, or 
constitution materially modifies the trans- 
mission of the disease. The situation and, 
character of the wound affect, in all prob- 
ability, the result, for it would appear 
that where the injuries are situated on 
the uncovered portions of the body, as on 
the hands or face, there is greater danger 
of the supervention of Hydrophobia than 
when they have been inflicted on the cov- 
ered portion of the body or limbs. The 
clothing, in the latter case, protects the 
wound from the action of the saliva. The 
bites of wolves appear to have been more 
frequently followed by Hydrophobia than 
those of dogs ; probably owing to the fact 
that, from their natural ferocity, the for- 
mer animals, when attacking men, very 
commonly inflict severe injuries on the 
face and neck. Such circumstances as 
prevent the adoption of an energetic pro- 
phylactic treatment of those bitten by 
rabid animals, obviously favor the devel- 
opment of the malady. 
The actual ratio of cases of Hydropho- 
bia to the total number of persons bitten 
by rabid animals, has been very variously 
estimated by different writers on this sub- 
ject. Whilst some have stated that only 
5 per cent, of all persons bitten by rabid 
dogs become affected with Hydrophobia, 
others have estimated that 55 per cent, of 
the bites inflicted by rabid dogs are effec- 
tual in transmitting the disease. The 
ratio varies very greatly ; probably be- 
tween the limits we have mentioned. In 
the case of the bites inflicted by rabid 
wolves, the ratio of cases of Hydrophobia 
would appear to be as high as GO per cent. 
Symptoms of Hydrophobia in Man. 
-As it affects man, Hydrophobia pre- 
sents symptoms which differ from those 
which have been described as character- 
istic of the affection in the dog. The 
chief point of difference is the almost con- 198 
HYDROPHOBIA. 
stant occurrence in man of the peculiar 
spasms of the pharynx,1 excited when the 
patient makes an effort to drink, and 
which gives rise to the dread of fluids, to 
which the disease owes its name. The 
cerebral symptoms appear to be less con- 
stant in man than in the dog; for- 
whereas amongst the most prominent of 
the symptoms in the dog is the thorough 
change in the natural instincts of the ani- 
mal, and an uncontrollable tendency to 
attack and bite all around him-it would 
appear that in man delirium, although a 
frequent, is by no means a constant or 
necessary accompaniment of the affec- 
tion. 
Period of Incubation.-We are probably 
acquainted with no disease which pos- 
sesses so long a period of incubation as 
Hydrophobia, or in which the period of 
incubation varies to so great an extent. 
This fact was well known to the earlier 
writers on Hydrophobia, one of which 
most accurately remarks that whereas 
the affection usually supervenes within 
•forty days after the infliction of a bite by 
a rabid animal, some are only affected 
after a year or more has elapsed.2 
The disease has been very rarely devel- 
oped sooner than eight days after the bite 
of a rabid animal, and rarely after a 
longer period than two or three months. 
The large majority of cases has occurred 
within four or eight weeks. Many au- 
thentic cases have occurred in which the 
period of incubation extended to eight or 
nine months, and a few where it appeared 
to be much longer. A remarkable case 
has been placed on record, in which a 
man who had been in prison for a period 
of more than two years, became affected 
with Hydrophobia, although he had only 
been bitten by a mad dog seven years 
previously. 
During the period of incubation there 
is nothing which specially distinguishes 
the bite of a rabid from one inflicted by a 
healthy animal. The wound may heal 
rapidly, or it may continue in an irri- 
table condition, no peculiar train of symp- 
toms occurring which can enable us to 
form a prognosis as to the probable issue 
of the case. The period of latency, or de- 
Utescence^ as it has been termed, having 
elapsed, the following train of symptoms 
usually occurs. The wound becomes in- 
tensely painful, the pain often shooting 
from the extremities (if it be situated 
upon them), towards the trunk. If the 
wound have cicatrized, the cicatrix be- 
comes red and irritable, or if, as is gene- 
rally the case when the injuries inflicted 
by the rabid animal have been severe, it 
have not healed, it assumes an unhealthy 
appearance. With this local irritation, 
there is sometimes, though very rarely, 
some affection of the lymphatics of the 
part. In addition to the local phenomena, 
others of a constitutional character soon 
set in. The patient becomes peevish, 
irritable, and depressed ; the skin is hot, 
the pulse rapid, and the appetite is lost. 
The peculiar depression of spirits just 
alluded to lias been thought to be very 
characteristic of this, the first stage of 
Hydrophobia, and is indeed rarely ab- 
sent. The unfortunate patient, who has 
been dreading the consequences of an ac- 
cident of which the gravity is well known 
to him, often deludes himself with the 
hope, from the absence of all symptoms 
for a time, that all fear of danger has 
passed, and only awakens to a feeling of 
the real horror of his position when the 
local phenomena, which have been de- 
scribed, supervene. It is not strange, 
then, that they should be accompanied 
by a feeling of melancholy and impend- 
ing evil. 
The first stage of Hydrophobia has 
been termed that of "recrudescence." 
Its characters are not fixed and invari- 
able, for it has been noticed, in some 
cases, that no local symptoms occurred be- 
fore the development of the true hydro- 
phobic phenomena, and in others that 
melancholy and irritability were absent. 
In these cases, a feeling of general "ma- 
laise" and pyrectic phenomena have alone 
been present. This stage of recrudes- 
cence, of irritation and melancholy, as it 
has been variously styled, is usually of 
very short duration. After a few hours, 
or at most a day or two, the patient be- 
gins to complain of stiffness about the 
head and neck ; and then the most char- 
acteristic manifestation of the disease sets 
in-an affection of the pharyngeal mus- 
cles, which throws them into the most 
painful spasms when the unfortunate suf- 
ferer attempts to eat, but specially to 
drink. The patient suffers from the most 
agonizing thirst, whilst the knowledge of 
the spasms which will accompany any at- 
tempts at drinking cause him to dread 
even the sight of liquids. "Miserrimum 
genus morbi; in quo simul seger et siti 
et aquee metu cruciatur."1 The hot and 
parched mouth becomes full of a clammy 
and viscid saliva which the poor sufferer 
is continually attempting to spit out, 
giving rise to the sound which the older 
writers compared to the barking of a dog. 
The heat of skin, and the frequency of 
the pulse, become excessive ; the counte- 
nance is intensely anxious ; the eye is 
bright and restless, and shuns the sight of 
a bright or luminous object, which often 
causes a fit of the painful spasms which, 
at first, attempts at deglutition only pro- 
1 [The respiratory muscles are usually 
still more affected.-H.] 
2 Csel. Aurel., lib. iii. cap. ix. 
1 Celsi Med., lib. v. cap. xxvii. DIAGNOSIS - MORBID ANATOMY. 
199 
duced, but which afterwards the mere 
sight or even thought of fluids brings on. 
Delirium may be, and often is, absent; 
when present, it is often violent, and al- 
most maniacal. In some cases a fit of 
general convulsions supervenes; in others, 
the spasm becomes weaker, and the pa- 
tient, sinking into a state of comparative 
quiet, may regain, after a period of agita- 
tion and delirium, composure and quiet. 
Death may supervene early; it is often 
preceded by a stage of profound coma. 
A certain paralysis of the lower jaw, 
which drops, and allows the saliva to 
flow from the angles of the mouth, often 
marks the later stages of some cases of 
this sad disease, from which probably no 
one ever recovered. 
The hydrophobic stage, which has just 
been described, is of short duration, death 
usually occurring before the end of the 
second day, life very rarely having been 
prolonged beyond the fourth day. 
Diagnosis.-In its first stage, when the 
phenomena of recrudescence, as they have 
been termed, are first manifesting them- 
selves, it is impossible to form an accurate 
diagnosis. The feverish symptoms, and 
the fresh accession of pain in the bitten 
part, are symptoms which may, and often 
do occur in persons who have been bitten 
by animals not in a rabid condition-bites 
being very liable to heal slowly, to become 
the seat of neuralgic pains, and to give 
rise to considerable constitutional disturb- 
ance. 
When Hydrophobia is fully developed, 
a careful study of all the phenomena can- 
not fail to lead to a correct diagnosis. It 
has apparently been confounded with dis- 
eases whose only resemblance to it con- 
sisted in the occasional occurrence of 
pharyngeal spasms, as inflammation of 
the larynx, trachea, and oesophagus. Hy- 
drophobia may, however, more readily be 
confounded with hysteria, acute mania, 
and tetanus. A perusal of many of the 
recorded cases, especially of those which 
are said to have terminated in recovery, 
will readily convince the inquirer, that 
acute mania has sometimes been mistaken 
for Hydrophobia. In certain cases of this 
disease, it would appear that a dread of 
fluids has been manifested, whilst the 
general appearance of the patient has sin- 
gularly resembled that of patients affected 
with Hydrophobia. The absence of a his- 
tory of a bite, the history of premonitory 
symptoms of mania having existed, the 
duration of the disease, and the rapidity 
of the pulse-which in acute mania is 
very rarely above 90, whilst in Hydro- 
phobia it is usually much higher-are the 
data upon which a differential diagnosis 
should be based. 
French writers have described a defi- 
nite disease under the terms "hydro- 
phobienon rabique," "hydrophobic rabi- 
forme," "rage spontanee," which is said 
to resemble in the closest manner true 
Hydrophobia. 
This affection, it is alleged, has gener- 
ally been caused by fear, which has super- 
vened after the bite of a rabid dog, or 
after communication with persons suffer- 
ing from the disease. Its symptoms are, 
it is said, occasionally quite undistinguish- 
able from those of true Hydrophobia ; 
there is in the spurious form, however, very 
commonly a desire to bite. The patient 
may die in a few hours or days, or may 
remain affected for weeks or years. The 
diagnosis, it is stated, rests chiefly on the 
non-discovery of a part which has been 
bitten. We cannot see the propriety of 
admitting the existence of a non-rabid 
Hydrophobia, for the cases which have 
been described as examples of it may be 
more accurately classified as cases of either 
hysteria, acute mania, or true Hydropho- 
bia, which had not been recognized. 
Tetanus presents certain points of re- 
semblance to Hydrophobia, tetanic spasms 
sometimes affecting the pharyngeal as 
well as the other muscles. The chief 
points of difference are, that Hydropho- 
bia supervenes on a bite, whilst tetanus 
usually follows some other injuries ; that 
the latter disease supervenes sooner after 
the injury than does Hydrophobia; that 
in tetanus the spasms are usually not in- 
termitting ; that trismus usually exists; 
that it is not marked by the distressing 
thirst, or the abundant discharge of sali- 
va, which is so common in Hydrophobia; 
and that delirium very rarely occurs dur- 
ing its course.1 
[The excess of excito-motor suscepti- 
bility is most extreme in Hydrophobia.- 
H.] 
Morbid Anatomy.-There are no ca- 
daveric lesions which can be said in any 
way to characterize Hydrophobia. The 
most constantly observed phenomena 
have been the following :- 
Redness and swelling of the fauces and 
gullet, occasionally accompanied by en- 
largement of the salivary glands, and 
sometimes with redness of the stomach. 
The trachea and bronchi have often been 
found injected, and filled with frothy 
mucus. The lungs are congested, occa- 
sionally inflamed, sometimes empty and 
cedematous. (Trolliet.) 
The brain has been found occasionally 
congested; sometimes there has been ef- 
fusion into the arachnoid and lateral ven- 
tricles. The medulla oblongata, and the 
origins of the seventh, eighth, and ninth 
nerves have been noticed to be congested, 
thickened, and softened. 
1 Holmes' Surgery, vol. i. p. 313, art. "Te- 
tanus," by Mr. Poland. 200 
HYDROPHOBIA 
Prognosis.-When the disease is fully 
established, the prognosis is necessarily 
of the worst description, death being in- 
evitable. Under this section a question 
of greater practical importance may be 
discussed, and the solution of which de- 
pends upon the facts which have already 
been referred to. A patient having been 
bitten by a rabid dog, when can the phy- 
sician give a tolerably favorable opinion 
as to the issue of the case ? when can he 
express a pretty confident opinion as to 
the safety of his patient ? As the large 
majority of all those who are bitten by mad 
dogs escape Hydrophobia, even when no 
treatment is adopted, a favorable and en- 
couraging, though a guarded, opinion can 
and should be given, even immediately 
after the accident. As the greater num- 
ber of cases occur between the thirtieth 
and fortieth days, when the latter period 
is safely passed the prognosis becomes 
more and more favorable. After the end 
of the second month the large majority of 
patients may be considered safe. 
Therapeutics. - Since Hydrophobia 
was first described, all authors have de- 
voted considerable attention to the treat- 
ment of the disease, both prophylactic 
and curative. It has long been known 
that the evil effects of the bite of the mad 
dog are probably often prevented by the 
adoption of an active local treatment of 
the bitten part. Celsus accordingly re- 
commended the application of the cup- 
ping glass to the bitten part, or even the 
employment of the actual cautery. Since 
his time, in addition to the supposed spe- 
cific methods of prophylactic treatment, 
nearly all authors have recognized the 
use of local treatment. Excision of the 
bitten part, the application of the actual 
cautery, or a combination of excision and 
cauterization; the application of various 
caustics, amputation of a bitten limb 
above the seat of the injury, have all been 
suggested and employed by different sur- 
geons, and there appears to be good rea- 
son for believing that good effects have 
followed all these various methods. 
Complete and early excision of a bitten 
surface, as soon as possible after the in- 
fliction of the injury, is the method which 
has found most general favor in this coun- 
try, and is perhaps the best which can be 
adopted. When, from the situation of 
the wound, excision is inadmissible, re- 
course should be had to the free use of 
caustics, and of these we should prefer 
the most powerful at our disposal-such 
as, presumably, would decompose such 
an animal virus as that of Hydrophobia; 
potassa fusa, or strong nitric acid, should 
have the preference. It must be men- 
tioned, however, that, in the opinion of 
some, recourse need not be had to such 
severe methods. The late Mr. Youatt, 
who in the course of a long experience 
had treated a very large number of per- 
sons who had been bitten by dogs un- 
doubtedly rabid, placed the greatest reli- 
ance upon cauterization with solid nitrate 
of silver, which in his experience had in 
every case prevented the development of 
Hydrophobia. 
Besides the local modes of treatment, 
the older physicians believed in the effi- 
ciency of other remedies. Prolonged and 
sudden immersion in cold water was from 
the remotest times considered of great 
value in warding off a fit of Hydrophobia, 
and was practised to within a compara- 
tively recent period. Celsus speaks of the 
plan with much favor, and Desault, in his 
well-known treatise on rabies, describes 
the mode in which the operation was per- 
formed in his day. It is in the memory 
of persons still living, that those bitten by 
mad dogs were, in England, taken to the 
sea-coast and dipped in the sea. 
From the fact that so few of those bit- 
ten by rabid animals actually contract 
Hydrophobia, we should expect that a 
large number of specifics would have been 
proposed for its treatment. A credulous 
physician who happened to have adminis- 
tered some remedy to a few persons bitten 
by a mad dog, finding that no evil conse- 
quences followed, and forgetful that had 
nothing been administered his patients 
would, in all probability, have enjoyed 
equal immunity, was only too ready to 
believe that he had at last discovered a 
specific for a terrible disease. Thus, 
doubtless, it was that the Ormskirk medi- 
cine, a compound of chalk, alum, Arme- 
nian bole, elecampane root, and oil of 
anise; the Tonquin medicine, a mixture 
of musk and cinnabar; and the Tanjore 
pills, a combination of arsenic and mer- 
cury, acquired for a time a wide and fic- 
titious reputation. 
The use of the hot-air and vapor bath 
has lately been recommended as a pro- 
phylactic in Hydrophobia, and it has 
been stated even to have cured the dis- 
ease when fully developed. In the ab- 
sence of any well-authenticated cases, we 
cannot decide upon the value of the rem- 
edy. That it might help to eliminate a 
virus which lurks so long in the system 
before producing its specific effects, is, 
however, not impossible. 
[The hypodermic injection of curara, 
and also that of chloral, are among the 
later experimental remedies employed.- 
H.l 
Amongst the most important questions 
for discussion, in considering the treat- 
ment of Hydrophobia, is the following: 
In the event of the peculiar phenomena 
of recrudescence manifesting themselves 
after a very long interval in a person who 
has been bitten by a rabid animal, should 
any local treatment be adopted ? Should enteric or typhoid fever: synonyms. 
201 
the bitten part or the cicatrix which has 
formed be excised or amputated ? This 
question cannot at present be answered 
positively. As, however, cases have un- 
doubtedly occurred in which such a local 
treatment of a bitten part has, even after 
the always-to-be-dreaded symptoms of 
recrudescence had set in, appeared to 
prevent the development of Hydrophobia, 
we are of opinion that the local treat- 
ment, severe though it may be, should be 
tried. 
In the treatment of Hydrophobia, when 
fully developed, we must rely entirely 
upon general principles of medicine in at- 
tempting to relieve the sufferings of the 
patient. No specific method of treatment 
has been shown to have the slightest in- 
fluence in checking or modifying this dis- 
ease, from which, in all probability, no 
one ever recovered. We should try to 
soothe and comfort the unfortunate pa- 
tient in every way in our power, to attempt 
to allay the great nervous excitement by 
means of sedatives, to support the failing 
strength by stimulants, and chiefly to 
prevent all noises, draughts, and other 
sources of excitement, which are so liable 
to bring on the painful pharyngeal spasms. 
Desault suggested, and apparently with 
good reason, that large fluid enemata 
might with advantage be administered. 
By checking the agonizing thirst they 
would, in all probability, greatly lessen 
the sufferings of the patient. 
[While the production of mere euthana- 
sia will not justify the unlimited employ- 
ment of powerful narcotics, it would seem 
that the use of chloroform by inhalation 
is made suitable by its effect in quieting 
the respiratory spasms; and the system 
is found, in hydrophobia, to have a re- 
markable tolerance of chloroform. A 
child eight years old, under my care, in 
the height of the attack, inhaled several 
drachms of it, with the effect of producing 
tranquillity only, without deep narcotism. 
ENTERIC OR TYPHOID FEVER. 
By John Harley, M.D. Lond., RL.S. 
Definitive Description.-A con- 
tinued febrile condition of uncertain du- 
ration, accompanied by marked intestinal 
derangement, and invariably associated 
with lesion of the solitary and agminated 
glands of the intestines. It commences 
in anorexia, with nausea or vomiting ; its 
progress is marked by profuse diarrhoea 
of light ochre-colored watery stools, asso- 
ciated with abdominal pain, tenderness, 
and tympanitic swelling ; and, if the issue 
be unfavorable, it terminates in exhaus- 
tion, intestinal hemorrhage, or perfora- 
tion of the bowel. Death usually occurs 
in the fourth week. In the early period, 
the disease is attended by more or less 
pyrexia ; as soon as it is fully developed, 
there is well-marked hectic fever. Dur- 
ing the height of the disease a scattered 
papular rash appears in successive crops 
on the abdomen and chest. The rapidity 
with which the symptoms are manifested, 
and the degree to which they are devel- 
oped, vary greatly in different cases. The 
intestinal disease is frequently obscured 
by the concurrence of pulmonary or cere- 
bral complications. 
Synonyms.-German-Abdominal Ty- 
phus, Darm-typhus, Typhus gangliaris 
vel entericus, Ileo-typhus. French - 
Fievre Typhoide, Entente septicemique, 
Fievre muqueuse, Fievre entero-mesen- 
terique, Gastro-enterite, Dothienenterite, 
Enterite-folliculeuse. English-Typhoid 
Fever, Autumnal or Fall Fever, Slow 
Nervous Fever, Common Continued Fe- 
ver, Hectic Fever, Infantile Hectic Fever, 
Infantile Remittent Fever, Entero-mesen- 
teric Fever, Gastric Fever, Enteric Fe- 
ver, Intestinal Fever, Pythogenic Fever, 
Cesspool Fever. Common-Bilious Fe- 
ver, Gastro-bilious Fever, Muco-enteritis. 
The above are the principal synonyms 
in use. Many others could be given ; but 
as they may be either recognized as modi- 
fications of the foregoing, or have no re- 
stricted application to the particular dis- 
ease under consideration, they need not 
be mentioned here. All may be found in 
Dr. Murchison's valuable work on the 
"Continued Fevers of Great Britain," p. 
385, et seq. 
The appellations "Typhoid," "Ab- 
dominal Typhus," and the like, lead to 
an association of two diseases in the 
mind, which does not exist in reality; 
such terms therefore lead to confusion. 
"Gastric" has reference to an organ 
which, at most, only functionally sympa- 202 
ENTERIC OR TYPHOID FEVER. 
thizes with the principal lesion ; the term 
" Pythogenic," introduced by Dr. Mur- 
chison, to imply the putrid source of the 
disease, is, on the one hand, too general, 
since it may be argued, with equal rea- 
son, that other acute diseases, besides the 
one under consideration, arise from this 
cause; and, on the other hand, it is not 
sufficiently comprehensive, since it would 
appear that Enteric Fever may arise from 
other causes than putrid or sewer emana- 
tions. 
In adopting a term to distinguish the 
disease, we should select one which at 
once marks it out from all others, and 
points to a constant feature. Such a term 
is " Entero-mesenteric, " employed by 
MM. Petit and Serres, in 1813. This ap- 
pellation is a brief definition of the dis- 
ease, and but for its inconvenient length 
we would employ it here. Acknowledg- 
ing the direct sympathy which the mesen- 
teric glands have with the intestinal le- 
sion, we prefer, however, to use the 
shorter term, "Enteric Fever." 
Preliminary Observations. - No 
disease presents, in the mode of the acces- 
sion of its characteristic symptoms, in the 
gravity and sequence of these, and in its 
whole course and ending, so many varia- 
tions, irregularities, complications, and 
accidents as Enteric Fever. A complete 
and consequent history of the disease will 
be best obtained by considering : 1st, The 
symptoms attending its development and 
progress, the condition of the secretions, 
and the modes of termination, the acci- 
dents, and sequences of the disease ; 2dly, 
The morbid anatomy ; 3dly, The pathol- 
ogy ; 4thly, The associated pathology, 
meaning thereby a comparative view of 
the development of the particular intesti- 
nal lesion in other acute diseases-an in- 
vestigation of great importance in the 
comprehension of the relation of acute 
diseases generally, but one of especial 
value in the elucidation of the nature of 
Enteric Fever; 5thly, The varieties; 
6thly, The distribution; 7thly, The causes; 
and subsequently, there will remain to be 
considered the Diagnosis, Prognosis, The- 
rapeutics, and Prophylactics of the dis- 
ease. 
Clinical History of the Disease. 
Development and Progress.-In consid- 
ering the clinical history of Enteric Fever, 
it will be convenient, with reference to 
the mode of access and development of 
the symptoms, to group the cases into 
three classes, viz. (1) Those in which the 
symptoms of gastro-intestinal irritation 
remain latent for days, or even weeks, 
after the patient has declined in health ; 
(2) Those in which gastro-intestinal de- 
rangement is the chief feature of the dis- 
ease from its outset to its termination; 
and (3) those which, in the suddenness of 
the invasion, the severity of the symp- 
toms, and in the rapid course of the dis- 
ease, closely resemble cases of narcotico- 
acrid poisoning. 
Many of the cases of Enteric Fever be- 
long to the first class. The disease indeed 
usually commences insidiously, and with- 
out premonitory indications of intestinal 
disorder. The decline of his health has 
been so slowly progressive and uniform, 
that the patient cannot state precisely 
when his illness commenced. For days or 
weeks past he has lost appetite, and felt 
weak, languid, and disinclined for bodily 
or mental occupation, complaining of a 
little headache, chilly sensations, chiefly 
referred to the spine, and of weariness 
and pains in the limbs. His increasing 
weakness sooner or later compels him to 
relinquish his ordinary occupations, and 
to apply for relief. We find the tongue 
moist, and tolerably clean ; the skin cool, 
pallid, and free from rash; the pulse is 
rather small, and slightly accelerated ; the 
mind is clear, and the expression natural; 
the bowels have responded to a purgative, 
but now they are regular, or perhaps 
again constipated ; the abdomen is natu- 
ral ; the other functions of the body are 
regularly performed. The patient may 
remain in this condition for some time, 
but sooner or later the nature of the dis- 
ease is manifested by the appearance of 
its characteristic symptoms. At first, 
there is increase of the early symptoms, 
anorexia is aggravated to nausea, and 
sometimes there is vomiting of green 
fluid ; the skin becomes hot and dry ; the 
pulse is increased in frequency ; [bleeding 
at the nose is common; bronchial cough 
is rarely absent;-H.] the tongue is fur- 
red, and usually presents red prominent 
papilte at the margins and tip ; there are 
great restlessness and increased headache; 
the bowels become loose, and the abdomen 
is a little full, painful, and tender-the 
right iliac fossa especially so, and pres- 
sure upon this part usually produces gur- 
gling. A few round rose-colored papules 
may now be observed upon the abdomen, 
chest, or back. They disappear on pres- 
sure, and closely resemble the papules of 
variola during the first few hours of their 
existence ; but they are not quite so large, 
nor so hard. Their number varies much, 
and the quantity of rash bears no propor- 
tion to the severity of the disease. Usu- 
ally we do not find more than three or 
four papules ; occasionally the chest and 
abdomen are closely spotted with them. In 
one case we observed them profusely scat- 
tered over the thighs, legs, and feet. Dur- 
ing the prevalence of the diarrhoea a few 
fresh spots appear every day, and after 
forty-eight hours the old ones begin to CLINICAL HISTORY OF THE DISEASE. 
203 
fade away. Diarrhoea, frequently associ- 
ated with bilious vomiting, now prevails, 
and the abdomen becomes distended, and 
in many cases more or less tympanitic; 
the alvine dejections are watery, and of 
a light ochre color, and putrid odor. At 
first they are acid, but they soon undergo 
change, and become ammoniacal and have 
an alkaline reaction. 
With the supervention of diarrhoea, all 
the symptoms become greatly aggravated; 
the pulse ranges between 120 and 130; 
the skin is often pungently hot, and occa- 
sionally attains, toward night, a tempera- 
ture of 107 or 108°. During this stage 
there is great irritability, and often con- 
siderable delirium, especially at night. In 
some cases there is no delirium and the 
mind remains clear to the last. Symptoms 
of active pulmonary congestion,-acceler- 
ated breathing, pain in the chest, mucous 
rales, and expectoration streaked with 
blood,-are also liable to arise. The as- 
pect of the patient is usually indicative of 
suffering, but the countenance is clear, 
and the eyes bright, as in scarlatina ; the 
cheeks are suffused with a hectic flush. 
The urine is clear and copious ; it is fre- 
quently retained. 
The patient may continue in this condi- 
tion for several days, the body meantime 
undergoing rapid emaciation. The tongue 
may continue moist, in which case it be- 
comes pale, large, and flabby, and is liable 
to ulceration about its margins, and the 
formation of deep fissures with everted 
margins across the dorsum. In many 
cases the tongue becomes dry, red, con- 
tracted, and fissured at this period. The 
mucous membranes become dry and in- 
flamed ; the gums are liable to bleed, epis- 
taxis frequently appears, and sordes begin 
to form upon the dry teeth. Here is the 
turning point of the disease. If we can 
subdue the gastric irritation, and keep 
food in the stomach, and restrain the 
diarrhoea, the symptoms will usually take 
a favorable turn. The abdominal pain 
and hectic fever diminish ; more nourish- 
ment is taken; the tongue begins to 
moisten at the edge, and the cracks to 
heal; the rough cuticle, especially that of 
the abdomen, to desquamate. Sometimes 
sweating is re-established suddenly, and 
with the appearance of a copious eruption ! 
of sudamina over the chest and abdomen ; । 
the bowels may continue loose, but the 
stools are of a darker, greener color. At 
this stage a relapse is very common-the 
diarrhoea, vomiting, and hectic returning 
with the former severity. The patient is j 
not free from the danger of a relapse, un- 
til the stools have become solid. The im- 
provement is slow, and, the diet being 
restricted, the emaciation persists for 
weeks. The desire for food is usually 
great; the digestive function is ultimately 
completely restored, and the patient re- 
gains his former weight and strength. 
When the case tends to an unfavorable 
issue, the diarrhoea continues unchecked; 
the abdominal pain, and usually the tym- 
panities also, increase; the exhausted 
patients lies motionless upon his side or 
back, drowsy or apathetic, and uttering 
feeble moans; the knees are drawn up, 
and his pinched, flushed countenance 
manifests pain on the slightest disturb- 
ance ; the skin is pungently hot, the pulse 
very fast and thready, the teeth and 
tongue are blackened with sordes, [deaf- 
ness, more or less marked, comes on.-II.] 
the continuous delirium lapses into coma 
-the typhous condition is complete. 
Watery stools are passed involuntarily, 
the patient hourly sinks, and at last 
quietly expires. As soon as the diarrhoea 
appears, and as long as it continues, the 
patient is liable to intestinal hemorrhage. 
The blood may appear repeatedly and in 
considerable quantity day after day in the 
stools, or the patient may become sud- 
denly blanched and die of syncope, with- 
out any discharge of blood per anm. In 
such a case the intestines will be found 
distended with blood. 
Hemorrhage, however, is not the only 
accident we have to anticipate. The pa- 
tient is often cut off by perforation of the 
bowel. This dreaded event may be ex- 
pected if, with a persistence of the diar- 
rhoea, the tenderness and tympanites in- 
crease, and vomiting and hiccup super- 
vene. Perforation is most commonly 
preceded by symptoms of general peritoni- 
tis accompanied by excessive tympanites, 
persistent hiccup, and vomiting. A par- 
oxysm of more intense abdominal pain 
sometimes indicates the occurrence of this 
fatal result. 
As an illustration of the insidiously 
progressive class of cases, I give the fol- 
lowing outline of the history of a patient 
who came successively under the care of 
Dr. Murchison, Dr. Buchanan, and my- 
self, in the London Fever Hospital. 
Case 1.-C. Bushell, aged 24, a well- 
nourished, dark - complexioned woman, 
experienced a feeling of lassitude, accom- 
panied by chilliness, pains in the limbs, 
and slight headaches, with loss of appetite, 
for about four days. She took to her bed 
on the fifth day, and was admitted on the 
sixth. A mild attack of typhus was sus- 
pected, and from day to day the tongue, 
pulse, surface of the chest and abdomen, 
and the nature of the secretions were ex- 
amined. Still no positive disease declared 
itself, and no diagnosis was made. The 
pulse was 80-84, tongue natural, skin not 
hot and free from rash, bowels not acting 
every day, abdomen natural. During the 
time she remained in the hospital she ex- 
hibited no new symptom, complaining 
only of weakness, chilliness, general pains, 
and want of appetite. She ate fish, and 
subsequently meat, and was kept in bed 204 
ENTERIC OR TYPHOID FEVER. 
during a portion only of the time of her 
sojourn in the hospital. As she was ap- 
parently suffering from mere debility, and 
had improved a little, she was discharged 
on the fifteenth day. She was again ad- 
mitted on the twenty-ninth day, and stated 
that she had not been well since she had 
left the hospital, having still suffered from 
excessive weariness and pains in the limbs, 
headache, and chilliness followed by a 
little feverishness. Lately she has had 
shivering, the bowels have been rather 
constipated, she has lost all appetite, and 
feels rather sick ; pulse 120, feeble ; tongue 
moist and white ; no rash; no cerebral or 
pulmonary symptoms. Thirty-first day : 
tongue clean and red at edges, a moist 
thick fur on centre; bowels became rather 
loose, and six or seven rose-colored pap- 
ules appeared on the abdomen ; pain and 
gurgling in the right iliac fossa; pulse 
120; skin hot; face flushed ; sleeps badly. 
Day after day, to the thirty-eighth day, the 
purging increased, and fresh rose papules 
appeared ; the abdominal pain increased ; 
the tongue became dry, brown, and 
cracked ; the pulse rose to 164. She died 
exhausted on the thirty-ninth day. 
Autopsy.-Rotundity of the body pre- 
served ; lungs healthy, excepting engorge- 
ment of one lobe. Stomach, duodenum, 
and jejunum appeared healthy. The soli- 
tary and agminated glands of the lower 
part of the ileum swollen and inflamed; 
those near the valve were ulcerated and 
sloughy, and formed almost one continu- 
ous surface, raggedly disintegrated, and 
greatly swollen, extending around the 
whole of the last two inches of the bowel. 
A few of the solitary glands of the caecum 
and ascending colon were inflamed and 
ulcerated. The corresponding mesenteric 
glands much swollen, congested, and 
softened. Spleen soft, twice its normal 
size; liver enlarged and fatty, weighing 
three pounds nine ounces (avoir.). Gall 
bladder distended with pale brown, watery 
bile, of excessively acid reaction and sul- 
phuretted odor. 
The second class of cases are perhaps 
the most frequent. In these the nature 
of the disease is manifest in the begin- 
ning. The patient may have felt a little 
indisposed previously; but he is in the 
midst of his usual occupations, or upon a 
journey, when he is overtaken with head- 
ache, shivering, and purging, followed by 
general pains and more or less pyrexia ; 
there is complete anorexia, and nausea 
and vomiting are frequently amongst the 
earliest symptoms. There is pain in the 
abdomen, and great thirst. The prostra- 
tion of the strength is very great, and the 
patient soon takes to his bed : the bowels 
continue to act two or three times a day, 
and the febrile symptoms and abdominal 
pain and tenderness persist; the tongue 
is moist, and usually coated with white 
fur; the edges and tip are red, and ex- 
hibit prominent fungiform papillae. On 
the seventh day, or a little later, a few 
rose-colored papules appear upon the ab- 
domen, chest, or arms ; the belly is a little 
full; there is great tenderness and gur- 
gling in the right iliac fossa ; the patient 
is unable to take food, and is distressed 
by occasional vomiting of bilious fluid.1 
The fever runs high, there is great rest- 
lessness by day, and broken sleep and 
delirium at night. [Dulness of hearing is 
almost invariably present.-IL] Great 
pains are complained of in various parts 
of the trunk, the hepatic and splenic re- 
gions are tender, and there is increased 
dulness in the latter, indicating enlarge- 
ment of the spleen. The breathing is 
often quick ; there is some cough ; and 
evidence of the presence of active conges- 
tion, or of acute inflammation of the 
lungs, is rarely wanting at this or a little 
later period. The bladder is very liable 
to become distended at this stage. These 
symptoms may persist with greater or less 
severity for the next week or ten days, 
the patient passing from two to six watery 
ochre-colored stools, containing a few 
shreddy flocculi, every day. The tongue 
becomes dry, with red irritable edges and 
tip, and elsewhere covered with a yellow- 
ish-brown cracked fur. If the patient 
have escaped the dangers of hemorrhage 
and perforation, he may, at the end of 
this time, begin to progress towards re- 
covery, or, if the symptoms take an un- 
favorable turn, he will almost surely die. 
When the purging has persisted for weeks, 
the days are critical. The following is a 
common case of Enteric Fever, beginning 
apparently in ordinary diarrhoea :- 
Case 2.-E. R., aged 19, a w'ell-nour- 
ished healthy woman, taken while on a 
journey of pleasure with shivering and 
purging, followed by headache and gene- 
ral pains. The bowels had been regular 
previously. The purging and other symp- 
toms continued, and she became slightly 
feverish, and lost appetite. She took to 
bed on the fifth day of her indisposition, 
and was admitted into the hospital on the 
ninth, presenting the following symp- 
toms :-Pulse 104, full; skin hot; tongue 
moist, and coated with white fur, which 
is disposed to form cracks ; bowels very 
loose ; motions fluid, light, ochre-colored; 
abdomen tender, three distinct rounded 
and elevated rose-colored papules here 
and there ; there is great thirst, and the 
patient is very feverish and fretful. Tenth 
day : tongue very thickly coated, cracked 
in the centre, clean and red at the tip and 
edges ; bowels very loose ; stools of green- 
ish fluid ; twelve or thirteen fresh papu- 
lar spots on abdomen. Eleventh day : 
[' Vomiting is much more common in chil- 
dren than in adults.-H.] CLINICAL HISTORY OF THE DISEASE. 
205 
pulse 96 ; tongue moist and superficially 
fissured ; bowels still very loose ; twenty- 
two fresh spots on abdomen ; great pain 
across the abdomen and round the back. 
Twelfth day: tongue dry and brown at 
the tip and down the median line, aside 
of which it is covered with a thick crust 
of cracked yellowish-white fur ; sides are 
moist and clean ; stools frequent, copious, 
of light yellowish-brown fluid, possessing 
an acid reaction, and containing ragged 
yellowish flocculi; abdomen a little full; 
great tenderness and gurgling in the right 
iliac fossa; some fresh spots. Sixteenth 
day: the patient is emaciating very ra- 
pidly ; pulse 90; tongue dry and red, de- 
void of fur except at base ; purging a little 
diminished the last few days ; yesterday's 
and this morning's stools together dark- 
ish-brown, fluid, alkaline; retention of 
urine, three pints drawn off; a few fresh 
spots, most of the old ones having faded 
and disappeared. Eighteenth day: no 
fresh spots; pulse 104, feeble; passes 
urine spontaneously. Nineteenth day : 
pulse 120; tongue dry, somewhat con- 
tracted, covered with a thin, dry, cracked, 
yellowish crust; much pain in the back 
and belly; cannot lie on the back "be- 
cause it hurts her breath;" respirations 
26; some fine crepitation at both bases 
behind ; abdomen very tender ; only two 
or three spots now visible; one copious 
ochre-colored stool this morning. Twen- 
tieth day : pulse 136, feeble ; one copious 
light-brown watery stool; skin cooler; 
sleeps well; has been sick two or three 
times. Twenty-third day : is much better; 
pulse 100; tongue clean and moist, ex- 
cepting a dry median streak; bowels not 
opened for two days; the rash has wholly 
disappeared ; hunger. Twenty-fifth day : 
pulse 80; bowels act once in two days; 
stools light fawn-colored, semi-solid ; ab- 
domen natural, bears moderate pressure ; 
tongue moist, but furred ; hunger; to 
take solid food for the first time-fish and 
bread. Thirtieth day: slight relapse to- 
day ; pulse 108; anorexia; thirst; pains 
in limbs; headache ; skin hot; abdomen 
painful; no action of the bowels to-day ; 
no fresh rose spots. Thirty-first day: in- 
crease of the feverish symptoms; pulse 
126; a little diarrhoea; stools light yel- 
low ; a copious eruption of sudamina upon 
the abdomen. From this date she con- 
tinued to improve, and was convalescent 
on the fortieth day. 
In the third class of cases the .symptoms 
are so sudden and severe that there may 
be suspicion of poisoning by some acrid 
narcotic, such as colchicum or poisonous 
mushrooms. We find the patient in a 
state of high fever; there is intense heat 
of the head; acute delirium; frequent 
vomiting and purging ; the tongue is red 
and dry; the abdomen tense and painful. 
We learn that his illness commenced a 
few days ago, with vomiting, purging, 
and great headache. The patient lapses 
into a state of stupor ; the diarrhoea per- 
sists, and he soon passes into the typhous 
condition, and dies on the eighth or fifth 
day, or even earlier. The following is a 
good example of this class of cases :- 
Case 3.-Alfred S., aged 20, a powerful 
well-developed man, was admitted into 
the London Fever Hospital, October 7, 
1865, in a state of stupor, pulse 156, very 
feeble, tongue dry and brown, conjunc- 
tivae injected, head hot. He lay pros- 
trate, passing liquid stools involuntarily, 
and died comatose twelve hours after ad- 
mission ; there was no rose spot or other 
rash upon the skin. His friends stated 
that he was suddenly taken ill with sick- 
ness and purging, followed by fever and 
delirium. The matters voided were of a 
bilious character. 
Autopsy.-Body well nourished, skin 
clear. Head-meninges, and brain, quite 
healthy; the ventricles and theca verte- 
bralis contained only one ounce and a 
half of serum. Chest-lungs engorged, 
weigh three pounds, everywhere crepi- 
tant. Heart healthy, small clot in right 
ventricle. Abdomen-liver weighs three 
pounds three ounces, softish and flabby, 
a little fatty ; gall-bladder distended with 
pale watery faintly acid bile of the color 
of urine. Spleen enlarged, weighs four- 
teen ounces, natural in color and consist- 
ence. Stomach slightly injected at the 
great end; duodenum and jejunum healthy; 
ileum of a violet color externally ; seven 
feet from the ileo-caecal valve, a Peyer's 
gland, an inch long, was slightly swollen, 
and presented a prominent vascular ele- 
vation at one end. In the last six feet 
every Peyer's gland partially or wholly 
red, swollen and reticulated. In the last 
four feet the glands were much elevated 
and the villous surface abraded; the 
larger patches were raised a fourth of an 
inch above the level of the mucous mem- 
brane ; all were very soft, and exceed- 
ingly vascular, and of a fiery red color. 
Between the Peyerian glands were innu- 
merable solitary glands, forming eleva- 
tions the size of a pea, surrounded by 
bright red areolse, and presenting yellow- 
ish unbroken apices. The intervening 
mucous membrane highly inflamed. The 
valve much swollen and deeply wrinkled. 
Caecum and first foot of colon thickly 
strewn with swollen solitary glands as 
large as peas, having sloughy centres. A 
biliary calculus, the size of a kidney bean, 
lay at the lower end of the dilated appen- 
dix, which was healthy, excepting where 
one solitary gland formed a vascular ele- 
vation. A few of the solitary glands in 
the transverse colon were enlarged ; with 
this exception, the large intestine was 
quite healthy. The follicular glands, at 
the root of the tongue, were injected and 206 
ENTERIC OR TYPHOID FEVER. 
swollen. The mesenteric and mesocolic 
glands were enormously swollen, congest- 
ed, and soft. The mucous membrane of 
the larynx, trachea, and bronchi was very 
red and covered with frothy mucus ; the 
kidneys were congested ; the bladder con- 
tained eight ounces of clear urine. 
The two following cases illustrate the 
difference in the progress, termination, 
and effects of the disease in different indi- 
viduals under the same general con- 
ditions :- 
Two young men-J. Bennett and C. 
Beale-of the same age, and equally strong 
and well nourished, and resident together 
in a house in the immediate vicinity of 
King's College Hospital, were taken ill 
with febrile symptoms, the former on the 
14th of August, 18G5, the latter a week 
afterwards. Both patients died; Ben- 
nett on the 12th of September-the thir- 
tieth day of the disease; Beale on the 13th 
of the same month-the twenty-third day 
of his illness. The rose spots were not 
developed in either case. 
Case 4. - Bennett was admitted into 
King's College Hospital on the fourteenth 
day. He stated that he was attacked with 
headache and shivering, followed by sweat- 
ing, general muscular pains, and sore 
throat. An aperient produced a loose 
state of the bowels for a day or two. De- 
glutition was very painful for three or 
four days. He got better, but remained 
very feeble, and did not recover his appe- 
tite. On admission he was pallid and 
weak, the throat had recovered; the tongue 
was moist, and the pulse but slightly ac- 
celerated ; there was no diarrhoea, no 
rash, no abdominal pain or tenderness. 
He appeared to be suffering debility from 
a previous febrile attack. He continued 
to improve, regaining a little strength and 
appetite, and was discharged at the end 
of a week. 
On leaving the hospital he went to his 
work, but soon felt too weak and ill to 
continue it, and after three days he again 
applied for advice, and was readmitted 
into King's College Hospital on the 8th of 
September, when he came under my care. 
He was dull, peevish, and prostrate; since 
he left the hospital the bowels had been 
loose. At this date there was moderate 
diarrhoea. The face and skin were pal- 
lid, the latter hot, perspiring, and free 
from rash; the abdomen slightly tympa- 
nitic and tender. Pulse 108. Tongue 
dry and brown, covered with a thick 
cracked crust. Respirations 42; slight 
dulness and fine crepitation over the back 
of the chest. During the next four days 
he lapsed into stupor, and lay on his back 
with the eyes closed, the knees a little 
drawn up, moaning occasionally, and 
picking with his fingers, the wrists and 
forearms being constantly twitched. The 
diarrhoea was soon checked by sulphate 
of copper and opium, but he resisted when 
attempts were made to open the jaws and 
administer drinks ; the pulse and respira- 
tions increased, and he died comatose, 
four days after admission, on the thirtieth 
day of the disease. 
Necroscopy nine hours and a half after 
death.-Body somewhat emaciated, vis- 
cera warm, blood fluid. Chest - lungs 
congested, bronchi much injected, two 
yellow masses of solid matter, the size of 
peas, like tubercle, in the lower lobe of the 
right lung near the border. Heart healthy, 
contained a pale soft clot. Abdomen- 
liver enlarged, weighed three pounds nine 
ounces ; bile pale, watery, small in quan- 
tity. Spleen of natural consistence and 
color, weighed ten ounces and a half. 
Mucous membrane of the large end of 
stomach much congested. Peyer's gkr Is 
of the upper portion of the ileum swollen, 
vascular, and reticulated; all those, and 
great numbers of the solitary glands in 
the lower four and a half feet of the ileum 
greatly swollen and superficially ulce- 
rated, the larger glands forming fungous 
elevations, with margins raised a fourth 
of an inch above the level of the thin wall 
of the bowel, and resembled large indu- 
rated chancres. Fig. 9 (p. 211) repre- 
sents one of these glands situated at a 
distance of 15 inches from the ileo-csecal 
valve. The centres were slightly de- 
pressed, and stained of a dirty greenish- 
brown color. The swollen glands were 
firm and transversely wrinkled. The 
solitary glands formed smooth rounded 
elevations, the greater number corre- 
sponding in size to the tips of the fingers; 
each one presented a firmly adherent cen- 
tral slough. Caecum healthy, but the 
solitary glands throughout the rest of the 
large intestine, including the upper part 
of the rectum, formed sloughy elevations 
like those of the ileum. In the sigmoid 
flexure there were fifty-four such eleva- 
tions. In the transverse colon only six. 
In the ascending colon they were as 
thickly strewn as in the sigmoid flexure. 
The mesenteric and mesocolic glands were 
greatly enlarged, vascular and softish. 
The brain was not examined; all the 
other organs w'ere healthy. 
Case 5.-Beale was admitted under my 
care into the London Fever Hospital on 
the 1st of September. His illness com- 
menced a week previously with anorexia, 
cold chills, headache, sickness, pain in 
the bowels, and diarrhoea. Eighth day: 
pulse 96; tongue moist and furred at the 
margins; skin pallid and hot, no rash, no 
headache; mind quite clear. Abdomen 
slightly distended; gurgling in the right 
iliac fossa. Eleventh day: bowels became 
very loose, and the abdomen tympanitic 
and tender. Twelfth day: pain in the ab- 
domen; in the evening bowels very loose. 
Eighteenth day: febrile condition con- CLINICAL HISTORY OF THE DISEASE. 
207 
tinues; pulse 108 to 120; tongue moist 
and furred; skin hot, free from rash; face 
very pale. The abdominal symptoms - 
diarrhoea, tympanites, and abdominal 
pain-have daily increased in severity 
since the twelfth day, and to-day there 
is evidence of general peritonitis; six 
leeches were applied to the right iliac 
fossa. Nineteenth day: leeches caused 
profuse bleeding, which was stopped with 
difficulty by the nitrate of silver; pulse 
132, weak; tongue dry and brown; bowels 
quiet. He gradually sank, and died on 
the twenty-third day of his illness, retain- 
ing a clear intellect to the last. 
Autopsy.--Body somewhat emaciated. 
Chest - lungs weighed fourteen ounces, 
floated in water, contained a dirty-brown 
fluid. Heart healthy, contained a color- 
less clot in the right ventricle. Abdomen 
displayed the effects of general peritonitis, 
the lower part of the cavity contained 
about a quart of turbid serum, and the 
coils of the small intestine were adherent 
to each other, and to the lower part of the 
abdominal wall, by layers of solid lymph. 
Liver weighed three pounds and a quar- 
ter, soft, friable, and fatty. Bile mode- 
rate in quantity, of light ochre color, wa- 
tery, and very acid, instantly turning blue 
litmus paper bright red. Spleen weighed 
ten ounces, of natural color and consist- 
ence, but flabby. Intestines distended; 
on separating the purple adherent coils of 
the ileum, a perforation a fourth of an 
inch in diameter was discovered six 
inches from the cscum; the opening in the 
intestinal wall was plugged with the solid 
lymph that adhered to the contiguous 
coils of the bowel, so that there was no 
escape of fecal matter into the peritoneal 
cavity. Stomach, duodenum, and jeju- 
num healthy. Intestines contained some 
smooth, soft, formed feces, varying in 
color from light ochre to dirty white. 
Mucous membrane of the ileum uniformly 
red and inflamed, covered over with tena- 
cious firmly adherent mucus of a bright 
ochre color. The solitary and agminated 
glands of the upper portion of the ileum 
quite healthy; lower down they were vas- 
cular and swollen; two feet from the cae- 
cum the first signs of ulceration, and in 
this last portion of the ileum the solitary 
glands were swollen to the size of a pea, 
and presented ragged excavated centres. 
The last twelve inches contained several 
Peyer's glands in a ragged state of ulcera- 
tion, the ulcers having raised, firm, very 
vascular, and angry-looking edges, and 
irregular depressed surfaces, formed ap- 
parently of yellow sloughs, adhering to a 
raw, almost bleeding surface, beneath. 
These sloughs could be readily separated 
with the finger-nail. Their lower surface 
had a yellowish color; they were friable, 
and some parts had an almost cartilagi- 
nous consistence and paler color. After 
washing and careful examination these 
sloughs were found to be composed of 
solid lymph, agreeing precisely in physi- 
cal and microscopical characters with the 
solid lymph which adhered to the cor- 
responding peritoneal surface of the bowel. 
The harder and whiter portions were com- 
posed of lymph contained in the meshes 
of the areolar tissue of the gland, and 
were, therefore, really sloughs. The more 
advanced ulcers were seated on the in- 
flamed and thickened muscular layer. 
The perforation corresponded to the cen- 
tre of one of the large ulcers. The ceecum, 
colon, and rectum, free from inflamma- 
tion and perfectly healthy throughout, 
and the solitary glands inconspicuous. 
Mesenteric glands greatly congested and 
swollen; those lying in the angle of junc- 
tion between the large and small intes- 
tine, the size of pigeons' eggs. Pancreas 
hardish, but apparently healthy. Blad- 
der empty, healthy, as were the remain- 
ing viscera. 
These two closely-associated cases are 
interesting, as illustrating the influence of 
constitution upon the progress of the dis- 
ease. Bennett died in a typhous state 
from nervous complication, and with an 
amount of intestinal disease at least six 
times greater than that to which Beale 
succumbed a week earlier. Yet the in- 
testinal disease in Bennett's case was la- 
tent to within five or six days of his 
death; the solid thickening of the affected 
glands (see Morbid Anatomy) forming, 
and promising to continue to do so, an 
effectual security against perforation. 
One of the parents of this young man died 
of consumption, and he himself had evi- 
dently been affected with syphilis. 
Condition of the Alvine and Urinary Ex- 
cretions in Enteric Fever.-(a) The Stools 
are remarkable for their fluidity and the 
absence of healthy bile; they have a pale 
ochre or drab color, and a sickly, offensive 
odor. On standing, a flaky matter is de- 
posited, composed of epithelium, disinte- 
grated sloughs from the intestinal ulcers, 
and undigested particles of food. Accord- 
ing to Dr. Parkes (Med. Times, June, 
1850, p. 396), the supernatant liquid has 
a specific gravity of 1015, and contains 
about 40 parts in 1000 of solid matter, 
consisting chiefly of albumen and soluble 
salts, particularly chloride of sodium. 
The stools are already in a state of de- 
composition, and after standing a short 
time are almost invariably alkaline. Im- 
mediately after they are passed they often 
have a neutral and sometimes an acid re- 
action. The offensive ammoniacal fluid 
contains much triple phosphate. 
If salts of bismuth, lead, silver, or cop- 
per, have been administered, the dejec- 
tions have a dark greenish-brown, or 
black color. 
(b) The Urine in Enteric Fever does 208 
ENTERIC OR TYPHOID FEVER. 
not differ appreciably from that excreted 
in other inflammatory diseases. On the 
first accession of the febrile symptoms its 
quantity is usually diminished, but after- 
wards it becomes copious. As in all 
other febrile states, the chlorine is greatly 
diminished and the urea and uric acid in- 
creased. The chlorine is often reduced 
to a mere trace. The quantity of urea 
and uric acid excreted appears to be pro- 
portionate to the degree of fever ; when 
the pyrexia is at its height, the quantity 
of these constituents excreted in twenty- 
four hours is usually doubled, sometimes 
trebled. As the fever declines the quan- 
tity of urea and uric acid diminish to the 
normal quantity or below it, while the 
chlorine reappears more slowly. In case 
2, sixty ounces of darkish-colored, clear, 
acid urine were drawn from the bladder 
on the sixteenth day. After standing 
twenty-four hours it was quite bright and 
free from deposit; specific gravity 1024. 
One fluidounce contained a quantity of 
chlorine equivalent to 0'36 grain of chlo- 
ride of sodium, 14'8 grains of urea, and 
•3 grain of uric acid: or, in the sixty 
ounces, 22 grains of chloride, 889 grains 
of urea, and 18'9 grains of uric acid. On 
the twenty-first day, when the febrile symp- 
toms began to subside, the urine was co- 
pious and neutral; specific gravity 1010'4. 
A fluidounce contained a quantity of 
chlorine equivalent to 3 '9 grains of chlo- 
ride of sodium, and 5*8 grains of urea. 
On the twenty-third, the urine was copious, 
of specific gravity 1010, clear, pale, and a 
fluidounce contained a quantity of chlo- 
rine equivalent to 3'2 grains of chloride 
of sodium, and 5'8 grains of urea. A 
small quantity of albumen often appears 
during the height of the fever. 
Occasional Symptoms and Accidents.- 
Peritonitis, local or general, is liable to 
arise whenever the ulceration of the coats 
of the bowel extends deeply towards the 
peritoneum. This membrane becomes 
highly inflamed in places corresponding 
to the bases of the ulcers, and from these 
circumscribed patches of inflammation 
the increased vascular action may spread 
and involve the peritoneum more gen- 
erally, and produce considerable serous 
effusion. Perforation is occasionally pre- 
vented by the adhesion of the inflamed 
patch to a neighboring coil or coils ; and if 
it should occur after this adhesion has been 
effected, a circumscribed abscess, which 
may ultimately discharge itself into the 
bowel, is formed. Perforation frequently 
occurs, however, under less favorable cir- 
cumstances, and the fecal matter is ex- 
travasated into the peritoneal cavity. 
Sudden increase of pain, accompanied by 
vomiting, and soon followed by cold, 
clammy sweats, and collapse, announce 
the nature of the accident. Sometimes 
sudden collapse alone is the only indica- 
tion of this fatal issue. In other cases 
the perforation has taken place so gradu- 
ally, the aperture formed is so small, and 
the extravasation so inconsiderable, that 
the symptoms of peritonitis come on and 
attain their maximum very gradually, 
and without any sudden increase in the 
severity of the symptoms. 
Perforation of the Bowel usually occurs 
within six inches of the ileo-csecal valve, 
and in almost every case it is the small 
intestine which is perforated Next to 
the lower end of the ileum, the caecum is 
most liable to perforation. "Out of 435 
autopsies recorded by Bretonneau, Cho- 
mel, Montault, Forget, Waters, Jenner, 
Bristowe, or made at the London Fever 
Hospital, perforation was observed in 
sixty cases, or 13'8 per cent." (Murchi- 
son, p. 511.) 
Tympanites is present to some degree 
in almost every severe case. It usually 
comes on a week or nine days after the 
purging sets in. When excessive, it is a 
very grave symptom. It usually precedes 
perforation. 
Intestinal Hemorrhage is a frequent acci- 
dent in severe cases. It was observed in 
twenty-nine out of 139 cases observed by 
Murchison, Louis, and Jenner. It is a 
grave symptom, inasmuch as it generally 
indicates deeply-extended ulceration. The 
hemorrhage, however, frequently has its 
source in the congested capillaries of the 
common mucous surface, near the junc- 
tion of the large and small intestines. 
The blood is never much changed. If the 
intestinal fluid be acid, it will be dark. 
The quantity of blood passed from the 
bowel does not always indicate the amount 
of the hemorrhage. In the case of a young 
girl which I witnessed, under Dr. Todd's 
care, in King's College Hospital, a trifling 
hemorrhage appeared, and shortly after, 
death occurred from syncope. The small 
intestines were found distended with red, 
clotted blood. 
Retention of Urine is frequently present 
at the height of the early pyrexia. This 
condition cannot be overlooked for many 
hours unless there be considerable de- 
lirium. 
Pregnancy.-Abortion is almost certain 
to occur if a pregnant woman be attacked 
with Enteric Fever. The only two preg- 
nant women who have come under my 
care aborted, the one at the third month 
of gestation, the other at the fifth. Both 
recovered well. Phlegmasia dolens is apt 
to be a secondary complication in such 
cases. 
Sequela.--Marasmus is the necessary 
attendant and consequent of extensive 
and prolonged disease of the mesenteric 
glands. After morbid action has ceased 
in these, they often become atrophied, 
and remain for a long time in a shrivelled, 
flaccid condition. In some cases the di- MORBID ANATOMY. 
209 
gestive and assimilating functions remain 
so defective that the patient fails to regain 
appetite and flesh, and slowly starves to 
death. 
Imbecility.-Patients who continue long 
in a state of extreme emaciation com- 
monly manifest proportionate defect of 
mental power. They become forgetful 
and apathetic. 
Tubercle of the Lung is considered by 
some physicians to be a common sequel of 
Enteric Fever. Many cases presenting 
such an apparent sequence may be re- 
garded as instances of tuberculosis ab 
initio. See "Associated Pathology" of 
Enteric Fever. 
Partial Anasarca, unassociated with 
albuminuria, is an occasional sequel of 
Enteric Fever in enfeebled constitutions. 
General Anasarca is rare. A scrofulous 
girl, E. Gain, aged 18, lately came under 
my care in the London Fever Hospital, 
with well-developed Enteric Fever. Gen- 
eral anasarca suddenly appeared on the 
thirty-fourth and thirty-fifth day of the 
disease, when the stools were solid, and 
she was convalescing favorably ; she had 
not, however, left her bed. (Edema ap- 
peared simultaneously in the lower ex- 
tremities, the face, and hands; it was 
preceded by acceleration of the pulse and 
increased heat and dryness of the skin, 
which was pallid, and rough from fine 
desquamation of the cuticle. The tongue 
was red and glazy, with very prominent 
fungiform papillae-a condition which had 
existed throughout. The anasarca in- 
creased from day to day, and was asso- 
ciated with considerable ascites. The 
integuments of the abdomen and chest 
were very oedematous. At one time the 
eyelids were closed by swelling, and the 
patient altogether presented the same 
appearance as one laboring under an 
attack of acute dropsy after scarlatina. 
Simultaneously with the development of 
the anasarca, albumen appeared in the 
urine, and became very abundant. The 
secretion, however, retained its natural 
color, and was normal in quantity, and, 
as long as the patient remained under my 
care, was free from renal casts or other 
deposits. 
Morbid Anatomy. 
Wherever the source of morbid action 
in Enteric Fever may lie, its effects are 
constantly manifested in the small intes- 
tine, and it is upon the solitary and ag- 
minated glands of the lower third of the 
ileum that the disease usually expends its 
virulence. 
Without positive evidence of inflamma- 
tory action in these glands, the disease 
would not be Enteric Fever. How far 
the converse of this-the inflammatory 
lesion of Peyer's patches is always due to 
a specific Enteric Fever-is true, will ap- 
pear upon consideration of the Associated 
Pathology of the disease. 
Morbid changes, consequent upon En- 
teric Fever, are found (a) in the solitary 
and agminated glands of the intestine; 
(6) in the mesenteric glands; (c) in the 
spleen ; (d) in the liver. 
(a) The Solitary and Agminated Glands. 
-A Peyer's gland or "■patch" presents 
in a state of health a variable number of 
rounded, shallow, concave depressions, 
averaging T'a of an inch in diameter, and 
separated by narrow linear ridges of mu- 
cous membrane, running in from the gen- 
eral mucous surface and on a level with 
it, and forming a network, in the meshes 
of which-i. e., in the depressions-the 
so-called "closed follicles" lie. In death, 
after the ninth day, from Enteric Fever, 
we shall rarely fail to find these and the 
solitary follicles in every stage of inflam- 
mation. 
At the distance of four feet from the 
ileo-ciecal valve we shall generally find 
Peyer's glands in their normal condition. 
Six inches nearer the valve we may find 
one in the earliest stage of inflammation ; 
it is slightly swollen, and raised above the 
general level of the surrounding mucous 
membrane, and it is a little more vascular 
than in health.1 On careful examination 
the swelling is found to implicate the net- 
work of mucous membrane chiefly ; the 
ridges between the closed follicles are 
more vascular, wider, and more prominent 
than in health ; and the intervening de- 
pressions are thus contracted and deep- 
ened, and the patch is more distinctly 
reticulated. The follicles themselves ap- 
pear to remain unaltered ; minutely ex- 
amined under water, they have a dark, 
semi-transparent, violet-gray appearance, 
while the intervening ridges are injected 
with minute divergent bloodvessels. Seen 
at a distance, the patch is clearly distin- 
guishable from the common mucous sur- 
face. The general appearance is that of 
a fine pink or white swollen network, with 
dark rounded meshes. Passing downwards 
towards the ileo-cjecal valve, each succeed- 
ing gland presents the above-described 
characters in a more marked degree, and 
the patches consequently become more 
1 Roederer and Wagler call attention to a 
black dotted appearance of these glands, 
" resembling a freshly-shaven beard." This 
is the forme pointille of French writers. We 
have frequently seen this appearance, in per- 
sons dead of disease not affecting the intes- 
tines, produced by the exhibition of metallic 
salts. The cellular constituents of the intes- 
tinal glands become impregnated with the 
iron or copper salt, and on contact with the 
bile, a black sulphide of the metal is formed, 
dyeing these minute corpuscular masses black. 
VOL. I.-14 210 
ENTERIC OR TYPHOID FEVER. 
prominent and distinct. Fig. 1 repre- 
sents an . agminated gland in this early 
stage of inflammation. It was situated 
thirty inches from the ileo-csecal valve. 
dergone further enlargement than slight 
thickening of their walls, which are thus 
rendered very distinct. In many places 
the follicles are seen to be dissected out, 
and only loosely connected with the sur- 
rounding shreddy tissue. The glands in 
the last foot of the ileum are always more 
or less implicated, and the innumerable 
and closely-placed solitary glands which 
form an almost continuous layer around 
the last two inches of the small intestine, 
-and which in some subjects are aggre- 
gated into one great terminal gland, the 
margin of which is coincident with the 
margin of the valve itself,-never alto- 
gether escape: and usually, indeed, the 
inflammation appears to have expended 
its whole force upon the glands of this 
part, and we find nearly the whole circum- 
ference of the last two inches of the mu- 
cous membrane greatly swollen, and in a 
ragged state of disintegration. The mar- 
gin of the valve is not infrequently found 
as thick as the lips of the subject, and 
this part of the bowel usually presents a 
dirty ash-gray appearance, veined with 
blackish-purple ramifications. Some glands 
are merely swollen, and their turgid, evert- 
ed margins overlap the contiguous mu- 
cous membrane ; others are converted into 
ashy sloughs {forme gangreneuse, Cruveil- 
hier), and often deeply stained with bile, 
sometimes dyed with blood. In some 
cases the ulcers are vascular and angry- 
looking ; in others they are pale, anaemic, 
and have but slightly raised margins. 
Just as the inflammation does not always 
equally affect all parts of the Peyer's 
patch, so we very often find that the ulcer- 
ation may be partial. A given gland may 
present one or several distinct ulcers. 
They rarely exceed f ths of an inch in dia- 
meter ; they have rounded, elevated bor- 
ders, and at first sloughy, ragged, broken- 
down centres; the most advanced ones 
have the bare, smooth layer or circular 
muscular fibres, or only a little interven- 
ing areolar tissue, for their bases. In the 
early stage the muscular tissue is pale 
and free from inflammation, but sooner 
or later it becomes red, thickened, and 
soft, and soon yields to the ulcerative pro- 
cess. The longitudinal layer yielding in 
like manner, the diminishing base of the 
ulcer comes to lie upon the peritoneal 
coat. In proportion as the base of the 
ulcer now nears the peritoneum, so does 
that membrane increase in inflammation: 
and if the ulcers be deep and numerous, 
the inflamed patches become confluent, 
and the outer surface presents the appear- 
ance of intense inflammation, and is oc- 
casionally covered with a layer of plastic 
lymph. Occasionally the ulcerative pro- 
cess extends through the peritoneal cover- 
ing, and symptoms of perforation ensue 
immediately, or are retarded for a time 
by the adhesion of solid lymph exuded 
Fig. 1. 
Commencing Inflammation in a Peyer's patch. 
The ridges were wide, prominent, and 
very vascular, and the depression con- 
tracted and deep ; at a, the swelling and 
contraction were greatest. Fig' 2 repre- 
Fig. 2. 
Inflamed agminated gland. 
sents the next patch, nearer the caecum. 
This gland was much swollen and soft, 
and formed a prominent, fungous-like 
projection of the mucous membrane. Its 
borders rose abruptly from the general 
mucous surface, and were smoothly round- 
ed, devoid of reticulation, and slightly 
more elevated than the central parts of 
the patch. The ridges were greatly 
swollen, so as to convert the depressions 
into minute deep pits. The next stage 
consists in the breaking down of the 
swollen mucous membrane around the 
dark pits, and the formation of circular 
aphthous-like ulcers, each having for a 
centre a depression corresponding to a 
closed follicle. If this disintegration be 
general, the swollen gland soon presents 
a ragged, spongy appearance ; examined 
under water, we find the irregular surface 
to be composed of a fine stroma of dirty, 
shreddy, fibrous tissue, containing a num- 
ber of circular, rounded excavations: 
these are the follicles ; they have not uu- MORBID ANATOMY. 
211 
upon its outer surface. The aperture 
formed in the peritoneum rarely exceeds 
three lines, and it is almost always formed 
within a distance of six inches from the 
ileo-csecal valve. Sometimes the whole 
patch is converted by the confluence of 
smaller ulcers into a single deep ragged 
one, the sharp and perpendicular edges 
of which irregularly excavate the red, 
tumid mucous membrane immediately 
surrounding the diseased gland. 
Occasionally the inflammatory process 
does not pass so soon into the gangrenous 
or ulcerative stage, and the glands become 
firmer and more prominent; the reticula- 
tions are completely effaced by the swell- 
ing, and the surface of these expanded, 
mushroom-like projections has a granular 
appearance (forme granuleuse, Cruveil- 
hier). Glands in this condition may be 
restored to their natural state by resolu- 
tion, or they may pass into the subsequent 
stages of gangrene or ulceration. The 
"Plaques dures" of Louis, which "al'in- 
cision offrent une section ferme, lisse, et 
brillante," are very rarely observed in 
Enteric Fever distinguished from tuber- 
culosis. In upwards of thirty fatal cases 
which I have examined, I have found this 
condition in only one (case 4), and in this 
I am inclined to attribute it to syphilitic 
taint. Fig. 3 represents one of the 
lie loosely imbedded in the submucous 
areolar tissue, and in their healthy con- 
dition are hardly perceptible. 
In many cases of Enteric Fever we find 
the last two feet of the ileum strewn with 
minute, round, semi-transparent eleva- 
tions, varying in size from a mustard to a 
hemp seed. These are the solitary glands 
in a state of inflammation. In this early 
stage of the inflammatory process they 
have the appearance of a fine miliary 
eruption, and constitute the condition 
known as " Psorenterie. " When the soli- 
tary glands attain a larger size, and be- 
come a little harder and more opaque, the 
mucous membrane appears as if studded 
with pustules (forme pustuleuse, Cruveil- 
hier). This appearance gave origin to the 
idea that Enteric Fever was "'intestinal 
Variola." These swollen glands, how- 
ever, are almost always solid : in only one 
case have I observed them to contain a 
yellow pultaceous matter, resembling in- 
spissated pus. 
If all the solitary glands be involved in 
the inflammatory process, the mucous 
membrane is thickly studded with them, 
and in the last two feet of the ileum the 
distance between them will average about 
|th of an inch. When an aggregation of 
a few solitary* glands is swollen, a stud- 
shaped elevation is usually formed. 
According to my own observations, the 
solitary glands are affected in proportion 
to the severity of the inflammation of the 
Peyerian glands. 
In very rare cases the solitary glands 
alone are affected in Enteric Fever. 
In many cases the disease is equally de- 
veloped in the small intestine and caecum; 
once I have seen death from perforation 
of the caecum. Occasionally the large in- 
testine is more extensively ulcerated than 
the small. In case 19, for example, the 
small intestine escaped, and the inflam- 
mation affected the solitary glands of the 
large intestine almost exclusively. 
In proportion as the solitary glands are 
inflamed and swollen, they cause a pro- 
jection and thinning of the mucous mem- 
brane. Attentively examined under water 
with a pocket-lens, they are seen to be of 
a delicate pink color, and exhibit a minute 
dark central point. Occasionally the swol- 
len gland presents a yellowish summit 
surrounded by a minutely injected areola 
of converging bloodvessels. Ulceration 
commences by the softening and abrasion 
of the mucous membrane around the sum- 
mit of the gland, the disintegration then 
becomes deeper, and spreading outwards, 
minute circular ulcers, with sloughy, 
shreddy centres, and purple, tumid mar- 
gins, are formed. These ulcers rarely ex- 
ceed j ths of an inch in diameter. Their 
further progress is identical with that of 
the ulcerated agminated glands, and they 
are equally liable to produce hemorrhage 
Fig- 3- 
Thickened and altered Peyer's gland, a. View from 
above, ft. Vertical section. 
chancre-like Peyer's patches from case 4: 
b will serve to convey an idea of the uni- 
form thickening of the gland, overlying 
the unaltered muscular and peritoneal 
layers. 
The solitary glands of the small intes- 
tine, and frequently also those of the 
caecum and ascending colon, share more 
or less in the above-described changes. 
These minute glands occur in increased 
numbers towards the ileo-caecal valve, 
where they become closely aggregated. 
Placed beneath the mucous membrane, 
and attached to its under surface, they 212 
ENTERIC OR TYPHOID FEVER. 
and to perforate the bowel. In most cases 
we find a few of the solitary glands of the 
caecum and large intestine thus inflamed 
and ulcerated. Occasionally the glands 
of the large intestine are more or less im- 
plicated along the chief part of its extent, 
and by the confluence of the small ulcers 
very large ones are sometimes formed in 
the caecum and ascending colon. The 
direction of these ulcers is generally trans- 
verse. In Enteric Fever, ulceration al- 
ways commences in the solitary or agmi- 
nated glands ; and if these were the only 
" follicular glands" in the intestinal canal, 
the term " Follicular Enteritis," by which 
Enteric Fever has been distinguished, 
would be a very suitable one. 
We have now to consider the nature of 
that morbid process, the effects of which 
have been described. From the descrip- 
tion just given, it is clear that the process 
is an inflammatory one. Usually there 
is evidence of very acute inflammation. 
It will be inferred from the foregoing de- 
scription of the diseased glands that the 
inflammatory products are formed around 
the closed follicles, and not in their inte- 
rior. Very careful observation leads me 
to speak positively on this point. If the 
new material were formed within the 
closed follicles, as Goodsir 'concludes, the 
follicles would indeed "become much dis- 
tended," and, as a result, they would form 
projections upon the surface of the Peyer's 
patch, which I have never observed to be 
the case. On the contrary, I have always 
found them in the earliest stages of the 
inflammation to be placed far below the 
swollen ridges of mucous membrane and 
submucous tissue surrounding them ; and 
in the latter stages, the follicles are com- 
pletely buried beneath the inflamed sur- 
face of the patch, and concealed from 
view, and it is only when the excessively 
vascular and turgid ridges of the mucous 
membrane and subjacent tissue are dis- 
integrated, that the follicles are again dis- 
covered, lying deeply in the abundant 
submucous tissue, and exhibiting little or 
no increase of size. The parts imme- 
diately surrounding them appear to have 
undergone considerable disorganization; 
for the follicles are often dissected from 
the surrounding parts, and remain at- 
tached to them by only a few tough fibres. 
In health, each follicle is surrounded by a 
close network of bloodvessels, which, as 
far as I have observed, chiefly constitutes 
the wall of the little gland ; from this pa- 
rietal network other branches, exceedingly 
fine and delicate, pass towards the centre 
of the parenchyma. If the vascular ex- 
citement be moderate, the central, as well 
as the circumferential parts of the gland, 
may increase in size ; but usually the in- 
flammation is acute. Cut off from all other 
parts of the circulation, and surrounded 
by inflamed vessels, congestion and stasis 
would very soon occur in the delicate ves- 
sels which pervade the parenchyma ; and 
thus, whilst the parts external to the fol- 
licles would be increasing under the influ- 
ence of the inflammation, the central 
parenchymatous parts would undergo no 
increase, but would tend to atrophy and 
disintegration. Hence the formation of 
the centrifugal ulcers and sloughs around 
the follicle ; and such indeed must always 
be the results of inflammation in parts 
which have a similar arrangement of 
bloodvessels within them. 
Structure and Characters of the Inflam- 
matory Product.-This we find to be cel- 
lular. On examining vertical sections of 
Peyer's patches in the early stage of in- 
flammation, represented in fig. 1, we find 
that the submucous tissue is composed of 
a very loose network of very elegantly 
waved and reticulated fibrous tissue, from 
which the so-called walls of the closed fol- 
licles are not defined. The meshes of this 
network are filled with finely granular 
corpuscles of various sizes, chiefly spheri- 
cal, and averaging 30'n0th of an inch in 
diameter. (Fig. 4.) A few cells of adi- 
Fig. 4. 
Fibrous reticulum, with inflammatory corpuscles. 
pose tissue, arranged in single rows, are 
occasionally seen. Sections through the 
more advanced and ulcerated patches pre- 
sent the same arrangement of the fibrous 
stroma ; the cells are equally numerous, 
but they are a little larger, and of more 
uniform diameter, averaging ^onth of an 
Fig. 5. 
Enlarged granular corpuscles and reticulated 
structure. 
inch, and a little more darkly granular. 
(Fig. 5.) Here and there a corpuscle is MORBID ANATOMY. 
213 
observed containing one or more spherules 
of oil. Sections of the firmer swellings 
(forme gaufree), and of those in a more 
advanced stage of ulceration, show that 
the corpuscles undergo fatty degeneration, 
and subsequent molecular disintegration. 
In these we observe multitudes of en- 
larged corpuscles containing spherules of 
oil, and much intercorpuscular molecular 
matter. (Fig. 6.) Rokitansky speaks of 
" the deposition of a typhous product" in 
the inflamed glands. The swelling, ac- 
cording to my own observation, is due to 
the rapid growth of the corpuscles form- 
ing the parenchyma of the glands, whether 
Peyerian or mesenteric. 
Not unfrequently fibrinous exudation 
forms upon the surface of the ulcerated 
gland (case 5), or amongst its cellular con- 
stituents (case 4). Sections of the gland, 
which I have delineated in fig. 8, showed 
the elements represented in fig. 6, inter- 
spersed with minuter corpuscular matter 
and molecular fibres. 
certainty the actual condition of the in- 
testinal glands. The following generaliza- 
tions, however, may prove useful (see also 
Diagnosis). For the first nine days the 
glands are undergoing inflammatory swell- 
ing, and at the end of this period they will 
be found projecting three or four lines 
from the mucous membrane, in the form 
of red, or purplish, fungous, soft excres- 
cences, free from erosion. If death occur 
any day before this period, we shall find 
the glands more or less advanced towards 
this condition. About the tenth day the 
inflammation either subsides or increases. 
Resolution is effected in the usual way by 
diminution of the vascularity and swelling. 
If the inflammation increase, the swollen 
glands become a little firmer, and on the 
eleventh and twelfth days present softening, 
and erosion of the mucous membrane 
covering them. Fourteenth day : circular 
disintegrations around the follicles ; a 
spongy sloughy appearance of the abraded 
patch, which is frequently stained of a 
deep ochre color by the bile-the formation 
and separation of ashy sloughs. Sixteenth 
day: complete separation of the sloughs, 
leaving ulcers limited below by muscular 
fibres or peritoneum and surrounded by 
red, swollen margins of mucous membrane; 
erosion of bloodvessels, and hemorrhage. 
Twentieth day: cicatrization begins. For- 
tieth day: cicatrization completed. 
Reparation of the Intestinal and other 
Lesions.-In those who have died during 
a relapse of Enteric Fever, or at an ad- 
vanced period, of pulmonary or other com- 
plication, we may often observe the pro- 
cess of reparation of the local disease. 
The following case exhibits the condition 
of the abdominal viscera during recovery 
from a severe attack of Enteric Fever, 
with pneumonia. The patient died of 
gangrene of the cheek (cancrum oris) and 
lungs. 
Case 6.-Joseph Taylor, aged 15, came 
under my care, August 15, 1865. He had 
been ill three days with headache, nausea, 
diarrhoea, and fever, and presented on ad- 
mission all the symptoms of well-developed 
Enteric Fever (without rose rash, which 
never appeared), and pneumonia of the 
left lung. On the sixteenth day: pulse 
144 ; respirations reduced to 28 ; diarrhoea 
and abdominal tenderness somewhat 
abated; dulness and fine crepitation over 
both bases of lungs behind. Three black 
sloughs, the size of peas, have formed in 
the mouth, two on the gums and the third 
on the centre of the left cheek. Nineteenth 
day: pulse 162, hardly perceptible ; tongue 
dry and brown; bowels very loose; passed 
a considerable quantity of blood in the 
stools to-day; slough on the cheek spread- 
ing; cheek hard and swollen. Twenty- 
second day : pulse 144; moderate intestinal 
hemorrhage every day; diarrhoea re- 
strained ; cheek much swollen, duskily 
Fig. 6. 
Corpuscles from ulcerated, gland. 
The villi upon the diseased patches and 
contiguous mucous membrane have a 
smooth outline and are denuded of their 
epithelium. They present a finely granu- 
lar appearance, due to the presence of in- 
numerable homogeneous, yellowish-tinted, 
refracted granules, which average ynoth 
of an inch in diameter. Some attain 
y^jth of an inch ; others are mere mole- 
cules. Fig. 7 represents a minute portion 
of such villus highly magnified. 
Fig. 7. 
Portion of granulated villus, Peyer's gland. 
Stages of the Local Disease.-Since the 
disease is usually developed so very in- 
sidiously, it will be difficult, and in the 
early stages impossible, to predicate with 214 
ENTERIC OR TYPHOID FEVER. 
flushed, hard, and shining; respirations 
less frequent. Twenty-fourth day: bowels 
quieter; no more hemorrhage; takes 
drink well and sleeps fairly; slough of 
cheek extending, those of the gums sepa- 
rated with the loss of two molar teeth. 
Twenty - sixth day : remains quite con- 
scious and takes drink well. The left 
cheek is livid externally, and the eyelid 
closed by the swelling. From this date 
the pulmonary and abdominal symptoms 
declined, and the bowels acted naturally, 
the stools becoming solid. The gangrene, 
however, spread externally, and involved 
all the central parts of the cheek in a large 
circular slough, and the patient gradually 
sank, retaining a clear intellect through- 
out the disease, and died on the thirty- 
second day. 
Autopsy.-Body much emaciated. Chest 
-lungs weighed together twenty - four 
ounces ; apex of the left gangrenous, and 
partially broken down ; lower lobes of 
both firm, slightly crepitant, pale-red, 
friable - recovering from pneumonia - 
here and there a small circular ashy 
slough; no trace of tubercle. Heart 
healthy; blood fluid; right internal iliac 
vein, at its junction with the cava, firmly 
plugged with a yellow, friable clot. Abdo- 
men- liver weighed two pounds six ounces; 
firm; lobules indistinct, with a whitish 
speckling in the form of minute stellae; 
the gland did not appear to me to be fatty, 
but microscopic examination showed the 
cells to be greatly enlarged, destitute of 
pigmentary matter, and replete with oil. 
Bile abundant, pale ochre-colored, watery, 
acid. Excepting a few patches of minute 
injection of the mucous membrane of the 
stomach, the alimentary canal was healthy 
to within four feet of the ileo-csecal valve. 
This lower portion of the ileum was much 
injected and dark red. At four feet from 
the valve, a small Peyer's gland, the lower 
end of which presented a round, gently 
elevated swelling, with a central irregular 
excavation the size of a hemp seed, limit- 
ed externally by the healing, granular 
margin of the pink mucous membrane. 
Three inches lower down, a larger gland, 
the lower half healthy, the upper with 
four cicatrizing ulcers-three so far healed 
as to be converted into minute stellate 
chinks, surrounded by pale red, wide, 
smooth borders, scarcely elevated above 
the surface of the healthy portion of the 
gland. Below this gland were nineteen 
minute cicatrizing ulcers, chiefly of the 
solitary glands, all with rounded, smooth, 
very soft vascular borders firmly attached 
to the less vascular transverse or longitu- 
dinal layers of muscular fibres, which 
formed clean, smooth bases to all the ul- 
cers. Next occurred six large ulcers 
caused by the destruction of the whole of 
the large Peyer's glands of this part; they 
formed large, smooth, and soft, interrupt- 
ed depressions, limited below by the very 
distinct reddish-gray muscular fibres, and 
surrounded by pale-red, raised, and round- 
ed sinous borders reposing upon the mus- 
cular layer: two or three of these ulcers 
presented rounded islets, or projections of 
smooth red, mucous membrane running in 
from the raised border of the ulcer, and on 
a level with it. (Fig. 8.) One of these 
large patches presented a minute con- 
tracting ulcer at either end, the interven- 
ing space being occupied by a smooth, 
grayish-white, opaquish, slightly-depress- 
ed membrane. Nearer the ileo - caecal 
valve were thirty-one other ulcers chiefly 
affecting the solitary glands, and varying 
in dimensions from mere linear chinks to 
three-fourths of an inch. All were in 
process of cicatrization. In the next por- 
tion of the ileum-the last four inches- 
there were a great many similar ulcers, all 
clean and healing, but not quite so far ad- 
vanced in this process as those situated 
higher up. There were three small and 
distinct healing ulcers in the colon, the 
last one situated at the distance of a foot 
from the caecum. The caecum, and rest of 
the large intestine, including the rectum, 
were perfectly healthy. The solitary 
glands were all visible and marked by a 
central black dot just as they appear in 
the meconium-stained bowel of a newly- 
born infant. 
The mesenteric glands were, for the 
most part, as large as almonds, and so flac- 
cid that they could scarcely be distin- 
guished, in the mesentery, between the 
thumb and finger : they were of a dusky- 
gray or ashy color, and of an almost 
leathery toughness. Entire sections of 
them could be readily made, and these 
were as tough as fibrous membrane, and 
presented an abundant, finely fibrous 
stroma, the ordinary corpuscles, and a 
considerable quantity of highly refractive 
granules. 
Fig. 8. 
Ulcer of Peyer's gland, healing. 
The recaptaculum chyli and thoracic 
duct were collapsed and empty. The 
spleen weighed five ounces and a drachm ; 
it was of natural consistence, and pre- 215 
MORBID ANATOMY. 
sented a bright reddish-brown color on 
section. The remaining viscera were ap- 
parently healthy. 
Floated under water, the rounded vas- 
cular borders of the healing ulcers present 
a double margin, the villi are seen to ter- 
minate in a wavy line, and from within and 
below the border so formed projects the 
paler and quite smooth soft border of ad- 
vancing granulations. (Fig. 8.) Some of 
these spring up from the base of the ulcer, 
and form islands, which ultimately become 
continent with each other and the margins 
of the ulcer, to form a smooth depressed 
membrane, which always remains desti- 
tute of villi and of closed follicles. In 
some of the cicatrized ulcers we occasion- 
ally observe a little cluster of closed folli- 
cles, but this simply points to the fact that 
a portion of the closed follicles of that par- 
ticular gland escaped injury. After these 
follicles have been removed in the inflam- 
matory process they are never regene- 
rated. Years after an attack of Enteric 
Fever the ulcerated Peyer's patches will 
be found to be replaced by pale smooth, 
slightly depressed, but unwrinkled mem- 
branes, which are more firmly adherent 
to the muscular layer than the healthy 
gland, and remain permanently destitute 
of villi. 
(b) The Mesenteric and Mesocolic Glands. 
-Just as inflammation of the tonsils in- 
duces vascular excitement and swelling of 
the lymphatic glands, situated about the 
angle of the jaw, so does inflammation of 
the solitary and agminate glands excite 
inflammation in the corresponding glands 
of the peritoneal folds. The swelling of 
the latter is always proportionate to the 
degree of the intestinal irritation; the 
glands, therefore, which lie in the angle of 
junction between the small and large intes- 
tine are those most affected. In every case 
of Enteric Fever we find that the mesente- 
ric glands are more or less congested, swol- 
len, and softened. They are usually of a 
dark purple color and of the size of hazel- 
nuts. Some often attain the size of a wal- 
nut. Bisected with a sharp scalpel, the 
outer portions are seen to be of a uniform 
dark purple color, the central parts are 
less vascular, and the yellowish-white 
parenchyma is veined with diffuse purple 
streaks and a mottled appearance thus 
produced. The parenchyma seems yel- 
lower than usual, but this is simply the 
effect of contrast. The gland is so soft 
that it is difficult to make a thin section of 
any extent. Microscopically examined, 
we find it to be composed of an exceedingly 
delicate, friable, scarce stroma of indis- 
tinct fibres and of molecular corpuscles of 
various sizes. These latter constitute 
nearly the entire gland ; they are for the 
most part spherical and nucleated: the 
most numerous average 5th of an inch 
in diameter; the larger present well- 
formed nuclei, and average ^gth of an 
inch in diameter. (Fig. 9.) 
Fig. 9. 
Stroma and corpuscles from a mesenteric gland. 
In the subsequent progress of the dis- 
ease the glands may return to their nor- 
mal condition, or the cells may break 
down to a creamy fluid. In one or two 
cases this puriform fluid has increased to 
such an extent as to rupture the peritoneal 
covering of the gland, and general perito- 
nitis has followed the extravasation of its 
contents. 
As soon as resolution of the inflamed, 
and cicatrization of the ulcerated, glands 
of the intestine have taken place, the me- 
senteric glands begin to decrease, and be- 
come for a time shrunken, flabby, and 
tough. 
In those cases in which I have made 
the necessary examination, I have found 
the receptaculum chyli and thoracic duct 
empty and collapsed. 
(c) The Spleen is severely congested in 
almost every case-probably, during the 
inflammatory period of the disease, in 
every case. It is usually enlarged to 
twice or thrice its natural size ; occasion- 
ally it is found four or five times larger 
and heavier. Its color is uniformly pur- 
plish-black throughout, and it is so soft 
and friable that it may be reduced to a 
semi-fluid pulp with the greatest ease. 
Minute granular corpuscles, fibre-cells, 
and molecular branched fibres are the 
only structures I have been able to detect 
under the higher powers. 
(d) The Liver.-A morbid condition of 
this organ and its secretion has been very 
generally observed. Forget does not spe- 
cially mention the condition of the liver in 
many of his cases. Of others he records 
the following observations : " Liver nor- 
mal, gall-bladder containing much or lit- 
tle, thin bile." (Obs. xlv. xlviii. Iv.) 
"Liver voluminous, possessing a fatty 
appearance." (Obs. lx.) "Liver volu- 
minous, gall-bladder almost empty." 
(Obs. Ixviii.) "Liver presented a little 
softening in its right lobe; the gall-blad- 
der contained a thin bile, slightly colored, 
like water." (Obs. Ixxiii.) The liver 
was softer than natural in thirty-two out 
of seventy-three cases examined by Louis, 216 
ENTERIC OR TYPHOID FEVER. 
Jenner, and Murchison. (Murchison, p. 
555.) 
Louis states that the volume of the gland 
was augmented in of his cases, and in 
these it had lost its consistence; the con- 
sistence was diminished, the tissue of the 
organ being sometimes soft, sometimes 
friable, in the majority of his cases, and 
in none did it appear to him to be firmer 
than natural; softening existed in nearly 
half the cases, and in four to such a de- 
gree that the lingers sunk into the gland 
substance without resistance; the color 
was natural in only twelve of the subjects 
examined by him; it was redder than 
usual in eight, five of which were exam- 
ples, more or less marked, of sanguineous 
engorgement. This appearance was no- 
ticed a little more frequently in those who 
died at an early period-from the eighth 
to the twentieth day. The bile was some- 
times red, and very fluid in different de- 
grees in about half the cases ; in ten it 
was more abundant than usual. (Louis, 
Rech. Fievre Typhoide, vol. i. p. 269 et 
seq.) Another careful observer, Gross- 
heim, remarked that, in all the cases ob- 
served by him, " the liver never retained 
its normal color, and the bile was always 
much thinner and clearer than in the 
healthy state. It was frequently trans- 
parent, sometimes clear yellow, sometimes 
of a dirty whitish color; in quantity, it 
was sometimes normal, rarely increased, 
but most frequently of all it was so dimin- 
ished that scarcely any was left." (Edin- 
burgh Med. and Surg. Journal, 1837, vol. 
xlviii. p. 178.) Stannius examined twen- 
ty-three cases of Enteric Fever. "In the 
majority, the liver appeared to be of nor- 
mal consistence and color; not infre- 
quently it was softened generally or par- 
tially. Almost always, both in those cut 
off at the height of the disease, and in 
those destroyed at later stages, the gall- 
bladder contained pale yellow, or yellow- 
ish-green, often watery mucous fluid, not 
reddening litmus paper nor tinging the 
skin." (Ibid. p. 174.) 
My own observations agree with the 
foregoing; but as to the frequency with 
which the liver is found in a morbid con- 
dition, I am led to conclude that the gland 
never escapes without some alteration in 
its texture. In every case which I have 
examined, I have found the liver in a 
more or less advanced state of fatty de- 
generation, and in almost every case 
noted an increase of weight. Even when 
the gland is of normal size and to all ap- 
pearance healthy, or only a little pale, 
microscopic examination will show very 
considerable degeneration of hepatic cells. 
In case 1, above recorded, the liver cells 
were greatly enlarged, averaging of 
an inch in diameter, and frequently con- 
taining spherules of oil of an inch in 
diameter. The bile in this case had the 
low specific gravity of 1018 and strongly 
reddened blue litmus paper. After de- 
positing an abundant pale ochre-colored 
granular-looking matter, composed of col- 
umnar epithelium, it had the color of 
whey, or pale urine with a faint greenish 
tinge. I have constantly found the bile 
thin, watery, and easily filterable; in one 
case the specific gravity was as low as 
1011 "2. Filtered, and evaporated on a 
water bath, such altered bile yields only a 
small quantity of black solid matter, 
greenish-brown, by transmitted light, and 
wholly soluble in water. The bile itself, 
or this solution, gives slowly and faintly, 
sometimes imperfectly, the characteristic 
reactions of bile when tested with the 
mineral acids, or Pettenkofer's test. The 
bile has a strong post-mortem odor, and 
in one case which I examined twelve 
hours after death, when the viscera were 
still warm, and the blood steamed on ex- 
posure to the frosty air, it smelt strongly 
of sulphuretted hydrogen. 
The morbid changes, above described 
as affecting the intestines, the mesenteric 
glands, the spleen, and the liver, are the 
constant and essential lesions of Enteric 
Fever. We now pass on to a cursory ex- 
amination of such morbid phenomena as 
are exhibited by the other organs of the 
body. 
Tongue.-The general condition of this 
organ has been described The charac- 
teristic features are, unusual redness of 
its edges, with enlargement and promi- 
nency of the fungiform papillae, in the 
early period of the disease; and a wrink- 
ling and cracking of the dry glazed sur- 
face, with contraction and reddening of 
the whole organ, at a later period. The 
cracks are very painful and often bleed. 
If the tongue remain moist, it is usually 
flabby, indented, and covered with white 
fur. In this condition it occasionally pre- 
sents spreading ashy ulcers upon the tip 
and sides; and sometimes deep fissural 
ulcers, with pale everted margins, form 
across the dorsum. When nervous symp- 
toms predominate, the tongue becomes 
covered with a thick, brown, firmly-adhe- 
rent crust, very dry and hard, and reticu- 
lately fissured. 
In several cases, I have observed great 
congestion and swelling of the follicular 
glands at the base of the organ. 
The Lips and orifices of the nostrils are 
often cracked and inclined to bleed. 
The Tonsils are rarely affected; ab- 
scesses have been observed in them in a 
few cases. 
The Pharynx and (Esophagus.-Louis 
found small round or oval ulcers of the 
mucous membrane of the lower portions 
of the pharynx and oesophagus in about a 
sixth of his cases. 
The Stomach, Duodenum, and Jejunum 
are usually healthy. In some cases they MORBID ANATOMY. 
217 
present morbid conditions, such as soft- 
ening and minute ulcerations of the mu- 
cous membrane, which are common to 
all inflammatory diseases. 
The Pancreas.-I have usually found 
this gland harder and with the lobules 
more distinct than in health, as if shrunk- 
en. Otherwise it has appeared healthy. 
The Urinary and Generative Organs are 
in the normal condition, or only slightly 
congested. 
[The Peritoneum shows all the signs of 
acute inflammation when perforation of 
the intestine has occurred.-II.] 
The Epiglottis, Larnyx, and Trachea are 
occasionally ulcerated. The mucous mem- 
brane of the bronchial tubes is usually 
red and swollen. 
The Lungs present in almost every case 
evidence of pre-existing inflammation. 
(See Associated Pathology of Enteric Fe- 
ver.) 
The Muscular System.-Agreeably with 
what is observed in other protracted dis- 
eases of an acute character, the muscular 
tissue is found to be liable to degeneration 
in Enteric Fever. Zenker (Veranderun- 
gen der Muskeln in Abdominal. Typhus, 
1864) describes two forms of muscular de- 
generation-granular and waxy. The 
granular form consists in the deposition 
of minute, highly refracting granules in 
the contractile tissue, giving to the fibres 
a dark appearance by transmitted light 
and obscuring the striae. This molecular 
deposit is not wholly composed of fat. 
The degenerated fibres are very friable. 
The waxy form consists in the transforma- 
tion of the sarcous tissue into a homoge- 
neous colorless' mass, glittering like wax, 
and causing a complete obliteration of the 
a finely granular detritus, and this is 
gradually absorbed. The muscles most 
liable to degeneration are the adductors 
of the thigh and the abdominal recti. 
The affected muscles are of a pale grayish- 
red color. Rokitansky observed rupture 
of the abdominal rectus in Enteric Fever, 
and attributed it to spasm. Virchow 
noticed rupture of the muscles associated 
with friability of the muscular fibres in 
four cases of Enteric Fever. Zenker 
noted eleven such cases, all of which oc- 
curred in Enteric Fever. The rupture 
occurred most frequently, but by no 
means exclusively, in the rectus abdomi- 
nis, pectoralis minor, triceps brachii, and 
psoas. The author last mentioned at- 
tributes the rupture of the muscles, and 
extravasation of blood into their sub- 
stance, to the degeneration of the fibres 
above described. The rupture tends to 
produce hemorrhage, and this leads to 
the formation of collections of sanies or 
pus, which must be distinguished from 
general pyaemic deposits. Abscesses in 
the muscles are very rare in Enteric 
Fever. 
The Skin presents us with one of the 
characteristic symptoms of Enteric Fever, 
the "tdc7i.es roses lenticulaires'1'1 of Louis. 
These spots closely resemble the papules 
of variola during the first few hours of 
their existence, but they are not quite so 
large nor so hard. They form slight, 
rounded, discrete elevations of a pale rose 
color, which fades away at the base, form- 
ing a moderately distinct circular outline. 
Each rose papule is a minute circum- 
scribed inflammatory centre, from which 
the blush disappears on pressure. These 
spots usually appear on the abdomen and 
chest alone, but they are often found on 
the back. They are seen occasionally on 
the face and upper and lower extremities. 
The eruption is not always present. "Of 
1820 cases admitted into the London Fe- 
ver Hospital during ten years, it was 
noted in all but 224, or 12*3 per cent." 
(Murchison, p. 470.) The rash usually 
appears on the supervention of the acute 
febrile symptoms. It may be looked for 
at the end of the first week, and may con- 
tinue as long as the febrile symptoms and 
diarrhoea persist. The total number of 
spots rarely exceeds fifty; in some cases 
they are innumerable. There is no rela- 
tion between the quantity of the rash and 
the severity of the symptoms. It appears 
in successive crops; at first only two or 
three spots may be observed, next day 
four or five fresh ones, the next as many 
more. Each crop persists for a few days 
and then disappears. According to Bar- 
thez and Rilliet, and Murchison, the spots 
are fewer in children than in adults ; and 
the former two observers state that in the 
same class of patients they are oftener 
absent in the severe cases than in the 
[Fig. 10. 
A portion of the soleus muscle from a case of 
typhoid fever. Preparation teased after treatment 
with Muller's fluid. X 200» Reduced %. (Green.)] 
striae and nuclei of the fibres, the sarco- 
lemma remaining intact. The waxy cyl- 
inders, thus formed, crack up into numer- 
ous fragments, which crumble down into 218 
ENTERIC OR TYPHOID FEVER. 
mild. These rose spots occasionally ap- 
pear in other acute diseases. In a severe 
case of typhus in a powerful fair-complex- 
ioned man I noted a very copious erup- 
tion of rose papules upon the chest and 
abdomen; they preceded the typhus rash, 
and had wholly disappeared when this 
became petechial. 
The departure of the fever and the re- 
establishment of the cutaneous function is 
often announced by the eruption of suda- 
mina over the whole of the chest and ab- 
domen. 
Roughness and minute desquamation 
of the cuticle, especially of that covering 
the abdomen, are observed after the ces- 
sation of febrile symptoms in severe cases. 
The desquamation occurs independently 
of the pre-existence of sudamina, which 
alone is sufficient to produce it. 
The temperature of the skin usually 
undergoes a progressive increase during 
the first fourteen days of the disease, at- 
taining, in severe cases, 104°, subject to 
the morning and evening vacillations, 
which are observable in other febrile con- 
ditions. If the abdominal or pulmonary 
symptoms undergo no amelioration, this 
temperature is often maintained during 
the earlier part of the day. When the 
intestinal inflammation proceeds to exten- 
sive ulceration, this high temperature 
may persist more or less continuously for 
weeks; but usually during the third week 
there are peculiar alterations of tempera- 
ture, ranging from 4° to 6° per diem, the 
higher readings being observed during 
the hectic exacerbations which take 
place in the evening. Recovery in such 
cases is attended by a gradual diminution 
of temperature. In more favorable cases 
the resolution of the inflammation is de- 
clared by sudden falls of temperature. 
When the Fever is prolonged, the pun- 
gently hot skin becomes very harsh, and 
the papillae as prominent as in the cutis 
anscrina. 
The Lymphatic Glands are usually only 
secondarily affected in cases complicated 
with ulceration of the pharynx and ery- 
sipelas of the surface. In young children, 
suppuration of the cervical glands about 
the angle of the lower jaw is not very un- 
common : three such cases have lately 
come under my care. Parotid inflamma- 
tion, which is so common in typhus and 
in scarlatina, is rare in Enteric Fever. 
Nervous System.-The only lesions dis- 
coverable are slight subarachnoid effu- 
sions, fulness of the bloodvessels, and 
slightly increased vascularity of the cere- 
bral substance. 
Circulatory Organs.-In protracted cases 
the muscular tissue is liable to fatty de- 
generation, and this change becomes first 
apparent in the left ventricle of the heart. 
The Blood.-M. Trousseau, in speaking 
of intestinal hemorrhage in Enteric Fever, 
says the blood is exhaled by the mucous 
surface, as occurs in hsematcmesis, epis- 
taxis, &c. " The proximate cause of this 
sanguineous exhalation," he goes on to 
say, "is a profound alteration experienced 
by the blood, and which is found in that 
state which one has termed 'the state of 
dissolution.'" (Clin. Med. p. 230.) M. 
Forget examined 123 specimens of blood, 
derived from persons in all stages of En- 
teric Fever. Of the blood drawn during 
the first period of the disease, only about 
T\th of the specimens presented appreci- 
able softening. In the second period |th 
of the specimens exhibited this change. 
He concludes generally that an appre- 
ciable alteration of the blood in the seve- 
ral periods of Enteric Fever cannot be 
accepted as a general fact; that the blood 
is rarely altered in the first period ; that 
the alteration is more marked in propor- 
tion as the disease is more advanced; that 
the alteration is not always in proportion 
to the gravity of the disease. (Forget, 
Sur 1'Etat du Sang dans 1'Entente folli- 
culeuse ; Gaz. Medicale.) 
My own observations of the condition of 
the blood of those who have died from 
Enteric Fever accord with those of M. 
Forget. In subjects dead in the third 
week of the disease, I have frequently 
found firm colorless clots of fibrin in the 
heart and roots of the great vessels. In 
protracted cases the blood not only be- 
comes very thin, but is also much dimin- 
ished in quantity, from sheer inanition. 
Pathology. 
If we carefully regard the incipient 
symptoms of Enteric Fever, we shall find 
that they have reference to derangement 
of the hepatic function. Often, long be- 
fore the graver symptoms are developed, 
the patient loses appetite, the bowels are 
constipated, and the stools pale; the 
tongue is foul, and the digestion much 
impaired. All these symptoms point to a 
defective secretion of bile, and to a state 
of approaching inanition. Such a torpid 
condition of the liver may be produced in 
two ways in the development of Enteric 
Fever. It may result from severe or pro- 
longed vascular congestion, in which the 
other internal organs participate; or it 
may be the effect of some morbific agent, 
carried by the portal vein from the intes- 
tinal surface into the liver, and causing, 
by a direct action upon its secreting cor- 
puscles, derangement, or more or less 
complete paralysis, of its functions. 
If in any case a poison be not decom- 
posed in its passage through the alimen- 
tary mucous membrane, it must of neces- 
sity be admitted into the liver. We know 
how readily mineral poisons are conveyed 
and arrested here, and we recognize the PATHOLOGY. 
219 
effects of certain vegetable substances 
upon the hepatic secretion. From these 
facts, and from its situation between the 
intestinal and general circulations, we 
may reasonably conclude, that it is one of 
the offices of the liver to arrest noxious 
matters in their way from the portal into 
the general circulation, to neutralize or 
decompose them, or to eliminate them 
from the blood, and throw them out again 
through the bile ducts into the intestine. 
The very admission of deleterious agents 
into the portal circulation must lead, by 
diminishing the reciprocal attractions of 
the portal blood and the hepatic corpus- 
cles, to congestion of the whole portal 
circulation. 
Thus prepared, and by that concurrence 
of related actions which we everywhere 
witness in the body, the congested capil- 
laries of the intestinal mucous membrane 
relieve themselves by a copious watery 
exudation, by means of which the poison 
set free by the liver is washed out of the 
alimentary canal. Such probably is the 
mode of action of elaterium, colchicum, 
&c. But it is the special function of the 
liver to prevent putrid decomposition 
within the body. If therefore the func- 
tion of this gland be depressed, as in a 
case of simple vascular congestion from 
exposure to cold, for example, a septic 
poison may be generated within the body, 
and set up all the symptoms which follow 
the introduction of a similar poison from 
without. Doubtless, so long as the liver 
is in active healthy condition, any septic 
poison taken into the alimentary canal 
would generally be neutralized ; but if the 
gland should happen to be torpid at the 
time, then the unaltered poison, upon ad- 
mission into the liver, would possibly 
arrest the secreting corpuscles in the elim- 
ination of that very fluid which has the 
power of rendering it innocuous. Very 
little is known of the derangements to 
which the liver is liable, and of the alter- 
ations which its secretion undergoes. We 
readily obtain evidence of the grosser ir- 
regularities of the kidneys, but we can 
judge of those affecting the liver only by 
the color of the feces-a good general 
guide, no doubt; but only rarely is this 
means of diagnosis available in the inci- 
pient stage of diseases. 
Primary vascular congestion of the 
liyer, no matter how produced, leads to a 
vitiation of the secretions of the alimen- 
tary canal; nervous exhaustion results 
from arrested nutrition. Under these 
conditions the liver begins to degenerate, 
and the intestinal mucous membrane 
tends to ulcerate, the blood is imperfectly 
depurated, and general febrile disturbance 
ensues. Surely if high fever, violent de- 
lirium, and coma are the consequences of 
acute suppression of the bile, the pyrexia, 
headache, and the most severe delirium, 
which ever accompany Enteric Fever, 
may be fairly attributed to that diminu- 
tion and derangement of the hepatic func- 
tion which invariably accompany this dis- 
ease. 
That the liver is early and gravely de- 
ranged in Enteric Fever is proved by the 
facts already mentioned in the morbid 
anatomy of the disease, and by the promi- 
nency of those symptoms which have led 
observers in all ages to designate it by the 
terms, "bilious, gastro-bilious, " &c. 
In place of a thick, heavy, alkaline se- 
cretion, rich in biliary acids and coloring 
matter, we find a watery, neutral, or often 
excessively acid bile, notably deficient in 
its essential constituents, and sometimes 
putrid at its very source. M. Trousseau 
considers the flux from the bowels to be 
of the nature of a specific catarrh. But 
what is the nature of this specific catarrh? 
Is the bowel endeavoring to supply defec- 
tive action of the liver by carrying away, 
in some unformed state, constituents of 
the blood which that gland should have 
removed as glycocholic and taurocholic 
acids? We do not think such a theory 
necessary. At the commencement of the 
disease there is probably some attempt at 
elimination, but in the subsequent stages 
we believe that the diarrhoea and intes- 
tinal lesions are rather due to congestion 
and mere local irritation than to any 
specific cause. This would appear to be 
the case from consideration of the fact 
that if we restrain the diarrhoea-the as- 
sumed means of elimination-we do not 
aggravate the general symptoms, but 
positively ameliorate them; and in most 
cases marked improvement follows the 
complete arrest of the diarrhoea. 
Not the least important function of the 
liver is to prevent by its antiseptic pro- 
perties the decomposition of the chyme ; 
take away this preservative influence al- 
together from the system, and fermenta- 
tion with the escape of gas and tympanitic 
distension follow. The impure chyme 
irritates the debilitated and congested 
mucous membrane, and what wonder then 
if inflammation, ending in ulceration of 
Peyer's patches and the follicular glands, 
should result ? 
But why should these particular struc- 
tures suffer more than any other parts of 
the intestinal canal? For two reasons, 
we think : first, on account of the greater 
vascularity of these glands, whereby they 
most readily participate in local conges- 
tion, and, as has been shown, the arrange- 
ments of bloodvessels within them, which, 
when the circulation is obstructed, ren- 
ders them liable to sloughing; and sec- 
ondly, on account of their delicate cellular 
structure, for in febrile conditions it is the 
active growing corpuscles of the paren- 
chymatous organs which most readily 
participate in the inflammatory process. ENTERIC OR TYPHOID FEVER. 
220 
That the glands of the lower three feet 
of the ileum should be most affected may 
perhaps be regarded as a significant fact, 
and it is one for which it is difficult to find 
a satisfactory explanation. Anatomy will 
not allow us to ascribe a difference in func- 
tion between the solitary and agminated 
glands lying near the junction of the small 
and large intestines and those removed to 
a greater distance from it; nor do we find 
that the glands of the upper and lower 
parts of the ileum have such a difference 
in their immediate associations as would 
account for unequal participation in gene- 
ral disease; and we should, therefore, be 
led to assume that if the solitary and 
Peyerian glands were employed in some 
general process connected with the elimi- 
nation of a blood poison, they would be 
similarly affected. Such, however, is 
rarely or almost never the case in Enteric 
Fever, for the Peyerian glands of the 
lower third of the ileum are almost always 
found in a state of extreme inflammation 
when those of the upper two-thirds exhibit 
no morbid change, and we never find 
Peyer's glands of the upper portion of the 
ileum ulcerated when those of the lower 
are uninflamed. 
The following considerations may afford 
some explanation of these facts. First: 
there appears to be a greater tendency to 
congestion of the lower than of any other 
portion of the ileum, due to the greater 
number of vascular solitary and agmi- 
nated glands situated there, and also to 
the manner in which the small and large 
intestines are united. The abrupt fold 
forming the ileo-cjecal valve is similarly 
constituted to the anal sphincter, and, 
like it, necessarily causes some arrest in 
the flow of blood beyond its margins. We 
recognize, therefore, a predisposition in 
the lower part of the ileum, to participate 
in inflammatory action. Secondly: if we 
now regard the derangement which exists 
within the digestive canal we may be able 
to find an exciting cause in the altered 
action, which doubtless results from dis- 
turbance of the reciprocal action of parts 
engaged in the same function, but sepa- 
rated from each other by a considerable 
distance. Can we, for example, attribute 
the lesion of Peyer's glands in the lower 
portion of the ileum to defective action of 
the glandular apparatus situated in the 
higher portions of the alimentary canal ? 
The liver, we have found, secretes bile 
deficient in those essential constituents 
which exert an important influence upon 
the digestive process. The defective bile 
probably contains sufficient of these con- 
stituents to maintain healthy action in 
the upper portion of the small intestine, 
but becoming exhausted of these in the 
lower, it there fails to exercise any anti- 
septic influence, and of itself induces un- 
healthy action. 
But, it may be argued, if this were the 
true explanation of the lesions of the 
small intestine, how is it that the large 
bowel escapes; for, according to the 
theory, we should expect to find that the 
intestinal lesions would progressively in- 
crease from the lower third of the ileum 
downwards, instead of being confined, as 
is usually the case, to the lower third of 
the ileum and csecum ? The frequent im- 
munity of the large intestine from any 
considerable participation in the disease 
may be explained by supposing that the 
irritation set up in the lower portion of 
the ileum, by the vitiated bile, causes 
such a copious exudation of fluid from this 
part of the alimentary canal, that the ir- 
ritating matter is diluted, and at the same 
time so rapidly carried away through the 
great intestine, that the lower portion of 
the alimentary canal usually escapes any 
severe implication in the intestinal lesion. 
There can be very little doubt that the 
dejections in Enteric Fever are chiefly 
thrown off from that part of the intestinal 
canal where the inflammatory irritation is 
greatest-viz. the lower portion of the 
ileum. The caecum, where the secretions 
are necessarily retained for a time, is often 
as gravely affected as the last six inches of 
the ileum. In some cases, moreover, the 
large intestine is often severely involved 
in the disease, and occasionally, as we 
shall have an opportunity of showing, it is 
exclusively affected,-a fact quite consis- 
tent with the theory here advanced. 
Thirdly: the localization of the intestinal 
disease may be supposed to arise from de- 
rangement of that particular part of the 
sympathetic nervous system, which is dis- 
tributed to the lower portion of the ileum, 
just as destruction of the eyeball may fol- 
low injury of the orbital branches of the 
fifth nerve. Morbid anatomy fails, how- 
ever, to reveal such derangement of the 
sympathetic plexuses: and if it did, there 
would still remain the difficulty of account- 
ing for a general febrile condition in such 
limited defect of nervous action. The 
question naturally arises to every inquirer, 
whether the symptoms of Enteric Fever 
are to be attributed to general blood-poi- 
soning, or whether they secondarily arise 
as a consequence of a localized intestinal 
lesion. From the foregoing observations 
it will be seen that we are induced to con- 
clude that the disease arises from a vitia- 
tion of only a portion of the venous blood, 
and that the constitutional symptoms are 
in many cases due to consequent derange- 
ment of the hepatic function. If we ac- 
cept this view, we shall be at no loss to 
account for the great variation in the 
nervous symptoms observable in this dis- 
ease. Some patients retain a clear intel- 
lect to the last hour of their lives (e. g. 
cases 5 and 6); others lapse into a state of 
stupor or coma at a very early period of ASSOCIATED PATHOLOGY OF ENTERIC FEVER. 
221 
the disease (e. g. case 3); and the majority 
manifest great nervous irritability and 
prostration, and at some period or other, 
more or less delirium. In every case there 
can be no doubt that the derangement of 
the digestive, cutaneous, and pulmonary 
functions results in an impure condition of 
the blood ; but we consider that in many 
cases the nervous symptoms are due to 
nervous exhaustion from inanition, or to 
active meningeal congestion, rather than 
to a specific blood-poisoning. The delir- 
ium partakes very much of the character 
of delirium tremens, and there is frequent- 
ly very notable vascular excitement of the 
cerebral circulation. In those cases in 
which the cerebral symptoms are predomi- 
nant, we are forced to recognize a general 
blood-poisoning, and then the question 
arises, Is this due to more or less complete 
suppression of the hepatic function, or to 
the admission of a specific poison into the 
general circulation ? Probably it may be 
due to both of these causes. If the poison 
be arrested by and thrown out from the 
liver, no general blood-poisoning, and, 
therefore, no grave nervous symptoms, 
may ensue. If the liver be unequal to the 
arrest and elimination of the poison, it 
passes unaltered from the portal into the 
general circulation, and symptoms of 
general blood-poisoning at once appear; 
and if the gland be so far deranged in the 
process of elimination as to become almost 
paralyzed in its functions, more or less 
complete suppression of bile would be an 
additional cause of the cerebral symptoms. 
Associated Pathology of Enteric 
Fever. 
Pneumonia.-The lungs and the intesti- 
nal and mesenteric glands manifest very 
great sympathy in morbid action. In two, 
at least, out of every three of the many 
cases of pulmonary phthisis which I have 
examined, I have found the solitary and 
agminated glands of the lower portion of 
the ileum and the mesenteric glands more 
or less infiltrated with tubercle, and the 
former often very gravely ulcerated. The 
same sympathy is observed when the 
lungs are the seat of common inflamma- 
tion, and in pneumonia we shall very 
often find corresponding inflammation of 
the solitary and Peyerian glands of the 
ileum. Reciprocally, of all the complica- 
tions of Enteric Fever, pneumonia is the 
most common. In some stage or degree, 
I believe it is very rarely absent. In many 
cases the inflammation does not proceed 
beyond active congestion, the post-mortem 
evidences of which are engorgement with 
some friability, and the so-called "spleni- 
zation or carnification. "1 According to 
the observations of Louis, inflammation 
of the lungs is more frequent in Enteric 
Fever than in any other acute disease. 
He found that splenization, simple or com- 
plicated with partial inflammation of the 
lung in the first or second degree, existed 
in twenty out of forty-six cases of Enteric 
Fever, and in seventeen there was actual 
inflammation. In only fifteen cases were 
the lungs healthy, or their alterations 
slight, little extended and consisting chief- 
ly of change of color, due apparently to 
diffuse or partial congestions. Thirty- 
eight of his forty-six patients had cough 
at some period or other of the disease. 
(Louis, Recher. Fievre Typhoide, vol. i. 
p. 330 et seq.) These observations of 
Louis are in accordance. with those of 
every other observer. In upwards of thirty 
cases examined by myself I have found 
the lungs free from the effects of more or 
less extensive inflammation only twice. 
[Such a frequency of pneumonia in Ty- 
phoid Fever is not observed either in pri- 
vate or in hospital practice in Philadelphia. 
Bronchitis, of moderate grade, is a usual 
symptom, beginning during the first week. 
Hypostatic congestion of the lungs occurs, 
in some cases, when the patient is allowed 
to lie continuously in one position, on the 
back. It affects the posterior lobes of both 
lungs; and may proceed to splenization 
or hepatization, sometimes with fatal 
result.-II.] The following case shows 
the intimate association of the two dis- 
eases. It is given by M. Forget as an ex- 
ample of "Follicular Enterite of the 
inflammatory form- 
Case 7.-"A strong woman, aged 23, 
after exposure to hard work in the open 
air, experienced a sense of painful weari- 
ness, headache, nausea, vomiting, thirst, 
shiverings followed by heat, &c. Third 
day: diarrhoea. Fourth Any: face flushed ; 
skin hot and dry, pulse frequent, large, 
resisting; respiration frequent, without 
cough or pain ; tongue, white at the cen- 
tre, red at the edges ; abdomen indolent; 
two liquid stools to-day. Fifth day : 
tongue red, denuded ; meteorism ; a liquid 
stool in the night. Sixth day : pulse 120, 
a little nocturnal delirium, dyspnoea, 
thoracic sibilance. Seventh to the twentieth 
day : continued in a typhous condition, 
with purging, dyspnoea, and more or less 
delirium. Twenty-first day : delirium, 
groanings during the whole night, deglu- 
tition difficult, several liquid stools, pulse 
frequent, thready: dyspnoea extreme; 
death. 
"Necroscopy.-Head-notable injection of 
meninges. Chest-old pleuritic adhesions; 
both lungs engorged-a condition which 
but such a condition developed during a gen- 
eral and continued febrile action cannot be 
regarded as being wholly independent of the 
inflammatory process. 
1 M. Louis does not consider "splenization 
or carnification" as the result of inflammation, 222 
ENTERIC OR TYPHOID FEVER. 
appeared to have existed for some time- 
indurated, friable behind and at the bases. 
Abdomen-partial injection of the mucous 
membrane of the stomach and intestines. 
Towards the crncum were met with, at 
first fine reticulated and swollen Peyer's 
glands, then rounded ulcerations, which 
became confluent, confused, fungous in 
the neighborhood of the ileo-csecal valve 
and upon it: large intestine also presented 
traces of inflammation and numerous ul- 
cerations ; smaller, but more numerous 
than in the small intestine, and occupying 
almost its whole length. Mesenteric 
glands engorged, brownish. Spleen slightly 
enlarged, friable. Walls of the mouth and 
pharynx covered with a white pultaceous 
matter." (Traits de 1'Enterite follicu- 
leuse. Obs. Iv. p. 414.) 
In this case diarrhoea and dyspnoea 
appear to have commenced simultane- 
ously. The patient died of pneumonia. 
Take away disease from the one lung, and 
truly we have, as far as the symptoms 
and morbid changes are concerned, a 
typical case of Enteric Fever. Are we, 
therefore, to attribute the lung disease in 
this case to a specific typhoid poison, the 
presence of which must be assumed to be 
proved by the intestinal lesion ? Or may 
we not regard the pneumonia and enteric 
disease as mere local manifestations of 
one common inflammatory condition, prob- 
ably produced by cold ? We are inclined 
to adopt the latter view. In the outbreak 
of Enteric Fever in the two companies of 
soldiers under Dr. Grossheim's care, this 
acute observer could find no other cause 
for the disease, but " the violence and con- 
tinuance of the military exercises, and 
the necessary exposure to great cold after 
being overheated by violent and laborious 
corporeal exertions." (Edin. Med. and 
Surg. Jour., vol. xlviii. p. 187.) 
For the association of pneumonia and 
Enteric Fever, see also cases 6 and 19. 
Pleurisy is almost as often present in 
Enteric Fever as pneumonia. Dr. Mur- 
chison observed recent adhesions, or effu- 
sion of lymph, in six out of nineteen 
cases ; Sir W. Jenner, in six out of fifteen; 
and M. Louis, in two out of forty-six ; but 
he found a greater or less amount of red- 
dish, serous effusion in the pleural cavi- 
ties in nineteen other cases. (Murchison, 
p. 560.) 
Case 8.-Julia Hatch, aged about 30, 
died of pleuro-pneumonia on the forty-fifth 
day of the disease. She was admitted into 
the hospital on the fourth day, when the 
following note was made: - Pulse 120, 
tongue moist and furred, skin cool and 
moist, face flushed, respiration accele- 
rated, slight dulness on percussion, and 
pleuritic friction sound at the base of the 
right lung behind ; bowels regular. She 
improved, and took food with a relish until 
the twenty-fourth day, when the pleurisy 
attacked the left side ; the febrile symp- 
toms increased, respiration became hur- 
ried and oppressive. A second blister and 
mustard poultice, were applied to the 
chest, and on the thirty-sixth day pulse 
was 144, feeble ; respiration much easier ; 
face less livid; tongue clean; mucous 
crepitation and friction sound still heard, 
both before and behind, on both sides. 
Eats mutton-chops well. After this date 
she continues to get worse. On the forty- 
first day, pulse 144 ; respirations 50, la- 
bored ; skin hot and very dusky ; dulness, 
crepitation, and friction sound still heard. 
She continued in the same state till the 
day of her death. The condition of the 
skin, tongue, and abdomen was carefully 
noted from day to day, but, throughout, 
the digestive function was most regularly 
performed, the bowels acted naturally 
every day, and the motions were perfectly 
healthy. Considering her febrile con- 
dition, her appetite for food was unusual. 
On the thirty-fifth day she asked for meat, 
and enjoyed it. The abdomen was flat and 
natural, and there was never any appear- 
ance of rash. 
Autopsy. - Body considerably emaci- 
ated ; abdomen flat. Chest-costal carti- 
lages partially ossified ; extensive pleuritic 
adhesions on both sides, some of which 
were old, others evidently the result of the 
last illness ; lower lobe of right lung ad- 
herent to the diaphragm and side of chest, 
soft, friable, and slightly crepitant, evi- 
dently recovering from recent inflamma- 
tion. No trace of tubercle in any part of 
the lungs. Heart healthy, containing soft, 
yellow clots in the right cavities. Neck- 
fibrinous and serous exudation in the are- 
olar tissue, around the trachea, and be- 
tween the muscles in front of it. Slight 
oedema of the mucous membrane above 
the glottis, and redness of the trachea. 
Follicular glands at the base of the tongue 
much enlarged, with violet, swollen, 
everted margins and gaping orifices. Ton- 
sils a little enlarged. Uvula much swol- 
len. Abdomen-intestines undistended and 
undisturbed ; the coils of the small intes- 
tine dark purple. The whole of the ileum 
was intensely inflamed, and every Pey- 
erian gland swollen and prominent. Those 
in the lower three feet of the bowel, and 
also the intervening solitary glands, were 
greatly swollen and ulcerated - whole 
patches being excavated into ragged ul- 
cers, with rounded, everted, intensely vas- 
cular borders, overlying the contiguous 
mucous membrane ; the irregularly-exca- 
vated centres were deeply stained with 
bile. One ulcer, two inches from the ileo- 
cfecal valve, alone extended to the mus- 
cular coat, exposing a smooth surface, 
half an inch in diameter, of soft, swol- 
len, muscular fibres. The non-ulcerated 
patches formed elevated fungous-like ex- 
pansions. Many of the enlarged solitary ASSOCIATED PATHOLOGY OF ENTERIC FEVER. 
223 
glands were deeply excavated at the cen- 
tre. The intervening mucous membrane 
was excessively vascular. The caecum 
was congested, the large intestine healthy, 
and contained well-formed, solid, bright, 
yellowish-brown feces. Mesenteric glands 
much enlarged, congested, and soft. The 
spleen, liver, kidneys, supra-renal cap- 
sules, and organs of generation were per- 
fectly healthy. The gall bladder was full 
of healthy, green, viscid bile. Although 
the patient was subjected every day to 
close scrutiny, there was no suspicion of 
intestinal mischief at any time ; there was 
not the faintest external indication of it, 
but the reverse. I examined the case 
chiefly with the view of ascertaining how 
far Peyer's glands are affected in acute 
disease, and I was surprised to find rav- 
ages much more extensive than are seen 
ill ordinary cases of Enteric Fever, and 
such as would be considered to be emi- 
nently typical of the disease. 
Laryngitis is a rare complication of En- 
teric Fever. I have noted it in two cases. 
In one it occurred during the height of 
the disease, and yielded to leeching and 
blistering. In the other it came on dur- 
ing convalescence. Suffocation impended 
for two days, but the patient escaped by 
the ejection of fragments of a tough, or- 
ganized membrane. 
[Bronchitis has been already mentioned 
as, in the United States, one of the usual 
symptomatic conditions, most marked 
during the first ten days.-II.] 
Scarlatina and Diphtheria.-A very 
close relationship appears to exist between 
these diseases and one variety at least of 
Enteric Fever. All are, for the most 
part, autumnal diseases, and they may be 
observed to increase and decrease to- 
gether, and all appear to arise spontane- 
ously out of the same conditions. Stober, 
Lbschner, and Friedleben maintain that 
scarlatina and Enteric Fever prevail epi- 
demically in an inverse ratio to each 
other, the one prevailing in proportion as 
the other declines. (Brit, and For. Med.- 
Chir. Bev., July, 1858, p. 162.) I have 
known several instances of scarlatina or 
diphtheria affecting one member of a 
family and Enteric Fever another, simul- 
taneously. The day before C. B. (case 1) 
came into the hospital, her brother, aged 
14, was admitted with "scarlatina in its 
most marked form." Sore throat, accom- 
panied by the exudation of white pulta- 
ceous matter upon the mucous membrane 
of the fauces, frequently accompanies the 
early symptoms of Enteric Fever (e. g., 
cases 4 and 7). Diarrhoea is often a severe 
complication in scarlatina, and in almost 
every fatal case of this disease inflamma- 
tory swelling of the solitary and agminated 
and of the mesenteric glandswill be found. 
After most careful microscopical exami- 
nation of these swollen glands, I have 
failed to distinguish the slightest differ- 
ence between them and those of the first 
period of Enteric Fever. Scarlatina, I 
have reason to believe, often lapses into 
Enteric Fever, and such appears to have 
happened in the case of Julia Hatch (case 
8). I have described this case under 
Pleurisy, but it is probable that its appro- 
priate place would be under Scarlatina. 
I failed to get information as to her pre- 
vious history, but the condition of the 
glands at the root of the tongue, and the 
neighboring inflammatory effusions, cor- 
respond exactly to the effects of scarla- 
tina. Dr. Murchison noted the co-exist- 
ence of scarlatina and Enteric Fever in 
eight cases, and the appearance of scarlet 
rash without sore throat in five other 
cases (pp. 518, 473). Other observers 
have frequently noticed the same facts. 
Barthez and Rilliet noted the co-existence 
of diphtheria and Enteric Fever in six 
cases, Forget in two, Louis in three, and 
Murchison in one. 
The following case of "malignant scar- 
latina," associated with the anatomical 
lesions of Enteric Fever, is related by M. 
Forget:- 
Case 9.-A strong man, aged 20, after 
his usual work, was seized with shivering; 
during the night, sensation of constriction 
in the throat, headache, fever, &c. Third 
day: carried to the hospital; hands, fore- 
arms, thighs, and chest "offrent une belle 
coloration scarlatineuse;" skin burning 
hot; pulse 140, small; tongue red, and 
covered, as well as the mouth, with a 
white pultaceous coating ; throat painful; 
deglutition very painful; no diarrhoea; 
chest normal. FbwrtA day: partial stupor; 
eyes injected; coloration of skin persists; 
sudamina; pulse IGO, thready; pultaceous 
coating of mouth diminished; back of 
throat very red, swollen ; deglutition al- 
most impossible; epigastrium tender ; 
death. 
Necroscopy.-Head-meninges injected. 
Chest-lungs engorged throughout, a little 
friable at the summit; heart filled with 
white clots. Abdomen-gastric and duo- 
denal mucous membrane .red, manifestly 
inflamed; small intestines presented, on 
approaching the csecum, numerous Pey- 
er's glands, of which some were simply 
dotted black, others were reticulated; the 
majority were red, swollen, firm, elastic, 
and prominent (gaufrees); an abundant 
miliary eruption (psorenterie) in a great 
extent of the small and large intestine, 
including the rectum. 
"Ces caracteres anatomiques sont tons 
ceux de 1'enterite folliculeuse tres devel- 
oppee, avant la periode de gangrene et 
d'ulceration." (Forget, Obs. xix. p. 144.) 
On the next page but one, the same ob- 
server gives the history of a case of " scar- 
latina suive d'enterite folliculeuse." 
Such is the association which subsists 224 
ENTERIC OR TYPHOID FEVER. 
between scarlatina and Enteric Fever- 
an association closer and more frequent 
than is observed between the former and 
any other acute disease, and one which 
compels us to acknowledge some closer 
connection than mere accidental intercur- 
rence. 
Tracing the connection still further, we 
observe that the physiognomy, the cha- 
racter of the febrile action and delirium, 
and the condition of the tongue, are the 
same in both diseases. In both there is 
a tendency to epistaxis, cracking of the 
lips, desquamation of the cuticle, and 
dropsy (see Anasarca). In the other dis- 
ease, the solitary and agminated glands of 
the upper part of the alimentary canal 
(the tonsils and intervening follicular 
glands of the tongue), and the neighbor- 
ing lymphatic glands, are affected ; in the 
other we find the corresponding parts (the 
solitary and agminated glands of the 
ileum, and mesenteric glands) of the lower 
portion of the alimentary canal diseased. 
Whether, therefore, we consider these two 
diseases in reference to their origin, their 
mode of development, or their physiolo- 
gical anatomy, we still find in either case 
a resemblance between them. It is only 
in their subsequent progress that we re- 
cognize a clear distinction. 
This distinction has reference, first, to 
the nature of the contagious poison- 
scarlatina tends to spread as scarlatina, 
and contagious Enteric Fever as Enteric 
Fever; and secondly, to the progress of 
the two diseases-the one falls upon the 
cutaneous surface, the other upon the mu- 
cous. With regard to the first point, there 
is nothing in the history of the contagious 
diseases - at least of the diseases here 
compared-to dissuade us from the as- 
sumption that the contagious animal poi- 
sons are developed within the body, and 
derive their specific characters from the 
particular actions to which they may 
happen to be there subjected. Thus, for 
example, putrescent substances admitted, 
on the one hand, in a volatile form by the 
respiratory surface into the arterial blood, 
may be conceived to undergo, during the 
process of absorption, some special and 
definite change, whereby a specific poison 
is formed : and, on the other hand, if the 
same deleterious agent be taken in a liquid 
or solid form into the alimentary canal, 
and thereby admitted into that limited 
portion of the venous system-the portal 
circulation - we may reasonably assume 
that it may be peculiarly modified by the 
agency of the digestive secretions, so as 
to constitute, upon its admission into the 
blood, a poison different from that formed 
in the hmgs, but somewhat related to it 
in its action. 
But even assuming that the septic agent 
be not so diversely modified in the process 
of absorption, we may still find an expla- 
nation of the differences which ultimately 
distinguish the two diseases if we consider 
that, in the one case, the liver, a most po- 
tent converting agent, intervenes between 
the portal and systematic circulations, 
and that by its agency the skin and kid- 
neys-the arterial organs most affected in 
scarlatina-may be in a great measure 
protected from a poison introduced by the 
alimentary canal. If the septic poison be 
simultaneously admitted into the blood by 
the lungs and intestinal surface, a mixed 
disease-scarlatina complicated with En- 
teric Fever, or the converse-may upon 
this theory result. 
Those who have seen most of these two 
diseases, and have studied them side by 
side, will, we feel sure, be most ready to 
acknowledge how soon their distinctive 
characters become lost in the intermediate 
modifications which are observed to occur 
between them. 
The allied affection, croup, is also an oc- 
casional associate of Enteric Fever. The 
following case is taken from M. Louis's 
work on Typhoid Fever :- 
Case 10.-Croup.-A powerful man, 
aged 23, was attacked with slight pain in 
the throat, preceded by fatigue, lowness 
of spirits, anorexia, thirst, diarrhoea, and 
slight epigastric pains. Third day: 
shivering, heat, and sweating; diarrhoea 
each day very considerable ; no sensible 
increase in the pains in the throat. 
Fourth day: considerable diarrhoea. 
Seventh day: considerable epistaxis; 
pains in the throat; soft palate red, 
without swelling; deglutition difficult 
and often excited; a sense of pricking 
and heat in the affected part. Eighth 
day : pain in throat continued ; a shining 
semi-opaque false membrane upon the 
tonsils, sides of the uvula, which is in- 
flamed, and upon the pharynx ; voice a 
little changed ; pain and difficulty of de- 
glutition ; four stools and copious sweats 
during the night; some lenticular rose 
spots upon the abdomen. Ninth day: 
false membrane more opaque, voice angi- 
nose, larynx a little tender, respiration a 
little accelerated. Tenth day : false mem- 
brane extending; deglutition causes in- 
supportable anguish. Eleventh day : very 
fetid breath ; croupal voice ; deglutition 
impossible. Twelfth day : delirium and 
death. 
Necroscopy.-Cervical glands enlarged 
to thrice their size and inflamed ; false 
membrane upon the pharynx, the uvula, 
the soft palate, the epiglottis, and larynx ; 
oesophagus healthy ; mucous membrane 
of stomach and small intestine thickened 
and softened, and elevated by a kind of 
white granulations, miliary in the neigh- 
borhood of the duodenum, then propor- 
tionately larger as the caecum was nearer ; 
Peyer's patches more or less red and 
thickened in the ileum, their thickening 225 
ASSOCIATED PATHOLOGY OF ENTERIC FEVER. 
being due to swelling of the mucous mem- 
brane and subjacent cellular tissue ; me- 
senteric glands large, of an amaranth red, 
especially near the caecum, where they 
were softened ; spleen thrice its natural 
volume. 
"As to the symptoms peculiar to Ty- 
phoid Fever, if they were little marked, 
they announced, nevertheless, from their 
commencement, that the seat of the dis- 
ease was in the abdomen." (Louis, Obs. 
xx. p. 187.) 
Erysipelas is not frequently associated 
with Enteric Fever. Out of 199 cases of 
Enteric Fever, observed by Louis, Cho- 
mel, and Jenner, erysipelas was noticed 
in twenty. The following is given by 
Forget as a case of Enteric Fever. We 
would rather regard it as a case of ery- 
sipelas and phlebitis. 
Case 11.-A strong man, aged 38, was 
under treatment in the surgical wards for 
erysipelas of the left hand, and on a cer- 
tain day, when the inflammation was in 
process of resolution, he was seized, with- 
out known cause, with shivering, followed 
by heat, headache, vertigo, nausea, thirst, 
diarrhoea, and considerable prostration. 
He was transferred the same evening to 
the medical wards; expression stupid, 
sub-icteric tinge, abdomen • tympanitic, 
gurgling, tenderness in right iliac fossa. 
Second day : same state : five liquid stools, 
Third day : pulse 100 ; six liquid stools. 
Fourth day: same state ; diarrhoea ; trem- 
bling of hands. The patient had been 
bled on the first day, and to-day one of 
the punctures is found gaping and exud- 
ing a puriform fluid, and the forearm and 
arm invaded by an inflammatory oedema- 
tous swelling very painful on pressure. 
Fifth day : pulse 120; prostration and 
stupor increasing ; several liquid stools ; 
cough ; disseminated rales ; sub-delirium, 
and death the same evening. 
Necroscopy.-Jaundiced tinge of skin, 
right arm is considerably swollen ; pus 
exudes on pressure from the gaping wound 
in the vein ; vein thickened for length of 
two inches above the wound. Chest- 
lungs healthy, except a little posterior en- 
gorgement. Abdomen-alimentary canal 
healthy to within two feet of the ileo-cae- 
cal valve ; Peyer's glands are met with 
reticulated and swollen ; in the intervals 
a slight psorentary ; nearer the valve, and 
upon it, several patches are in the same 
state, but redder, more swollen, evidently 
inflamed, as were the surrounding parts 
of the intestine; mesentery contained 
glands swollen and reddish; spleen very 
large and friable, and no trace of purulent 
absorption anywhere. 
"Voila, certainement, une enterite fol- 
liculeuse bien constatee, au cinquieme 
jour." (Forget, Obs. xi. p. 119.) We 
confess that we cannot see more than the 
participation of delicate cellular organs- 
the solitary and agminated glands, the 
mesenteric glands and the spleen-in a 
general febrile condition. Had Peyer's 
patches been found in an ulcerated condi- 
tion, the erysipelas, which is clearly the 
primary disease in this case, would prob- 
ably have been considered to be a sec- 
ondary complication of latent Enteric 
Fever. 
The following case shows such implica- 
tion of the solitary and agminated glands 
in a general inflammatory condition, as is 
very common in acute disease. 
Case 12.-Mary W., aged 40, came un- 
der my care for erysipelas of the head and 
face, August 12,1865. She had continued 
pyrexia and muttering delirium. Pulse 
116 to 136 ; the urine was often retained, 
and the bowels were confined; tongue dry 
and brown; evacuations sometimes passed 
involuntarily; urine contained a little al- 
bumen; the stools were solid and natural; 
she died on the tenth day after admission. 
Head-brain healthy, but the vessels con- 
gested ; two ounces of serum in the ven- 
tricles. Chest-lungs congested and car- 
nified below and behind; healthy in front; 
heart normal. Abdomen-stomach, save 
a little finely dotted patch of ecchymosis, 
duodenum, and jejunum, healthy. Lower 
portion of the ileum and commencement 
of the large intestine injected. Peyer's 
glands in the last three feet of the ileum a 
little swollen and prominent; the inter- 
vening mucous membrane strewn with 
enlarged solitary glands the size of hemp- 
seeds, giving to the finger, as it passed 
over the inflamed membrane, a granular 
sensation. The mucous membrane of the 
transverse colon, corresponding to one of 
the longitudinal bands, was highly in- 
flamed. Some Peyer's glands, higher up 
in the intestine, were stained with sul- 
phide of iron, and were dotted with 
black. Here and there the contiguous 
mucous membrane was also stained black. 
She had taken perchloride of iron. The 
colon contained solid natural feces. 
Spleen weighed five ounces, and both it 
and the mesenteric glands were natural 
in size, color, and consistence. Kidneys 
and pancreas congested. Liver weighed 
two pounds fourteen ounces; it was pale, 
soft, and greasy; bile pale yellow. 
Erysipelatous oedema of the glottis has oc- 
casionally caused death in Enteric Fever. 
Several cases are recorded by Jenner and 
Trousseau. 
Case 13. - Myelitis. - "A delicate wo- 
man, aged 32, was seized at the cata- 
menial period with sharp pains in the 
loins, the sides, and lower extremities. 
Menstruation continued the usual time, 
but the pains persisted and increased. 
Fifteenth day: dorsal decubitus, headache, 
prostration; face expressive of pain; 
moans and cries ; the least movement is 
painful; the patient cannot be made to sit 
VOL. i.-15 226 
ENTERIC OR TYPHOID FEVER. 
for the examination of the spine, which is 
the seat of sharp pains in its whole ex- 
tent ; the joints are equally painful; the 
muscles and skin are everywhere ex- 
tremely sensitive ; prickling sensations in 
the hands and soles of the feet; she can- 
not stand; skin hot; pulse 100, small and 
hard ; tongue furred ; mouth clammy; 
anorexia; thirst; abdomen, like all the 
rest of the surface, tender; one stool a 
day. We diagnose a cerebro-spinal affec- 
tion. Seventeenth day : acute pains ; the 
patient says she cannot feel her limbs, but 
when they are touched she complains of 
extreme sensitiveness; spine painful on 
pressure throughout its whole extent; 
bowels confined. Eighteenth day: general 
pains; the patient cannot move. Nine- 
teenth day: delirium, plaints; acute gene- 
ral pains; stools and urine involuntary; 
skin hot; sweating; pulse 112, large and 
supple. Twentieth day : same state ; dia- 
phoresis, sudamina, vomitings, and nu- 
merous stools. Twenty-second day: vom- 
iting ceased; numerous involuntary stools; 
abdominal gurgling ; immobility ; acute 
pains provoked by movement; pulse 120. 
Twenty-third day: continued delirium; 
involuntary stools. Twenty-fourth day: 
the patient is pale, almost pulseless, and 
bathed in cold sweats ; died this day." 
Necropsy twenty-two hours after death. 
-Head-meninges slightly injected; brain 
of natural appearance and consistency; a 
little serum in the ventricles; coverings 
of the cord much injected ; a great quan- 
tity of serum flowed from the spinal canal. 
The spinal marrow 11 est ramollie dans une 
grande etendue, sans changement de cou- 
leur; ce phenomene est evidemment ca- 
daverique." Abdomen-stomach inflamed 
in patches. Small intestines present only 
some vascular ramifications to within two 
feet from the caecum; then granulations 
(psorenterie) appear, then reticulated 
Peyer's patches, others ulcerated very 
numerous; some appear to be cicatrizing, 
and some already cicatrized ; in the large 
intestine some isolated follicles appear to 
be affected; mesenteric glands engorged; 
spleen and liver present nothing of im- 
portance ; the bladder contains turbid 
fetid urine, and its mucous membrane is 
strongly injected and dotted. (Obs. 
xxviii. p. 286.-Forget.) 
M. Forget had headed this case "En- 
tente folliculeuse latente, prise pour une 
affection cerebro-spinale. Forme, rheu- 
matismale." And after he has detailed 
the symptoms and post-mortem appear- 
ances transcribed above, he asks, " Where 
is the practitioner who would not have 
been deceived, as we have been, by ap- 
pearances so fallacious ? How recognize 
a case of follicular enteritis under such a 
predominance of sensitive nervous phe- 
nomena?" Only by regarding lesions of 
Peyer's patches so long and so evclu- 
sively that no other pathological condi- 
tion can be conceived possible, we an- 
swer. 
M. Forget attributes the softening of 
the cord to post-mortem changes, but the 
cord is not softer than the circumferential 
parts of the brain ; it is equally well pro- 
tected from maceration by its vascular 
coverings, and, from its situation in the 
axis of the body, it is less liable to post- 
mortem changes than the brain itself, 
which, in this case, is described " de con- 
sistance et d'aspect naturels. " We know 
of no symptoms, or post-mortem appear- 
ances, which could more positively assure 
us of the existence of inflammatory soft- 
ening of the cord, than those which the 
eminent Strasburg professor here places 
before us. 
Phthisis. - In order to illustrate the 
similarity between the symptoms of tu- 
bercular ulceration of the intestines, asso- 
ciated with pulmonary tuberculosis, and 
those of Enteric Fever, I will here trans- 
late two cases from M. Louis's work on 
Typhoid Fever, and which this eminent 
author gives as examples, the one of or- 
dinary Enteric Fever, accompanied by 
delirium, and the other of latent Enteric 
Fever, but which, with due deference to 
so great an authority on both phthisis 
and Typhoid Fever, we feel bound, from 
our own observations, to regard as cases 
of tubercular disease. We might have 
adduced instances in which the lungs 
were most extensively diseased, from our 
own practice, but we prefer to place be- 
fore the reader the description and con- 
clusions of some other author. The reader 
will form his own opinion on the nature 
of these two cases, bearing in mind the 
frequent co-existence of tubercular disease 
of Peyer's and the solitary glands in pul- 
monary phthisis, and the difficulty which 
exists in distinguishing acute tubercular 
inflammation and ulceration of the glands 
of the ileum, from the corresponding le- 
sions of ordinary Enteric Fever. 
Case 14.-A young woman, aged 17, 
"d'un embonpoint mediocre," had had 
cough for four weeks, and in consequence 
of afflicting intelligence suffered headache, 
loss of appetite and strength, thirst, in- 
creased heat, constipation ; the headache 
was relieved by leeches, the other symp- 
toms continued to the eighth day. She 
took some ipecacuanha, which produced 
bilious vomiting and purging, with pains 
in the hypogastrium ; cough a little in- 
creased. Ninth day: sleepy; slight de- 
lirium at night; belly everywhere tender 
on pressure, supple ; no tympanites; one 
stool; pulse 105 ; intense dry heat; some 
lenticular rose spots on the back and an- 
terior and lateral parts of the chest; cough 
moderately frequent; oppression of the 
chest, mucous rales ; in the evening tran- 
quil but profound delirium. Tenth day : ASSOCIATED PATHOLOGY OF ENTERIC FEVER. 
227 
partly recovered consciousness; tongue 
red and moist; abdomen tympanitic, a 
little tender on pressure ; heat considera- 
ble ; startings continue. Thirteenth day : 
pulse weak; mucous sputa, some streaked 
with blood ; a little crepitation at base of 
right lung behind; continuation of the 
involuntary movements and meteorism; 
continued drowsiness during the day, and 
delirium at night. Fourteenth day: me- 
teorism decreased, three or four involun- 
tary stools; crepitant rales heard over 
the sides of the chest. Fifteenth to nine- 
teenth day: profound drowsiness and de- 
lirium at night; on the evening of the 
nineteenth day respirations much embar- 
rassed, 60. Twentieth day : delirium and 
ineffectual efforts to put the arms out of 
bed; death. 
Necroscopy.-Head-brain and meninges 
apparently normal, only moderately in- 
jected. Chest-lungs free, filling the cav- 
ity of the chest, of a tender rose-color in 
front, a little engorged behind for some 
extent, strewn internally with a great 
number of gray semi-transparent granula- 
tions; bronchi injected, their last divi- 
sions covered with a puriform secretion. 
Abdomen-mucous membrane of the small 
intestine very soft, of an obscure red near 
the cpecum; Peyer's patches were only 
visible in the ileum; those nearest the 
jejunum were pale and obscure, the rest 
red and successively more developed, 
larger, and more thickened in proportion 
as they were nearer the ileo-csecal valve ; 
those in the last foot of the ileum were 
ulcerated, their mucous membrane more 
or less destroyed, and in some the muscu- 
lar fibres, which were red and thickened, 
were discovered. The non-ulceratcd plates 
were about a line in thickness. Between 
Peyer's patches were others much smaller, 
irregular, and otherwise resembling them, 
and some yellow, miliary granulations. 
The last two inches of the mucous mem- 
brane were entirely destroyed around 
nearly the whole of its circumference, and 
the submucous cellular tissue was more 
or less red and thickened. Large intes- 
tine : mucous membrane thickened and 
very soft, and presented a considerable 
number of grayish, lenticular spots, 
marked with a black point in their cen- 
tre. All the mesenteric glands were red 
and livid, and those near the caecum very 
large and soft. The mesocolic glands 
were in the same condition. The spleen 
was nearly double its volume. (Louis: 
Obs. xxxiv. p. 25, vol. ii.) 
It is strange that Louis, of all other ob- 
servers, should consider the foregoing to 
be a case of Typhoid Fever, when the 
history and anatomical characters are so 
plainly those of acute tuberculosis. The 
nature of the other case is still more ap- 
parent. 
Case 15.-A spare man, aged 25, hav- 
ing short breath from the age of ten years, 
is taken with the following symptoms : 
Disgust of food, thirst, cough, shiverings 
followed by heat. These symptoms con- 
tinued, with constipation, until the twenty- 
first day, when he was admitted into the 
hospital of La Charite. lie presented the 
same symptoms with a slight oppression 
at the epigastrium; constipation still; 
heat of skin a little exalted, general mois- 
ture ; pulse large and moderately full; 
cough infrequent; some mucous expec- 
toration ; natural respiratory murmur; 
moderate weakness. Twenty-fifth day : 
some lenticular rose spots on the abdomen 
and chest; pulse 86. Up to the thirty - 
seventh day the patient continued station- 
ary, then for the first time he had spon- 
taneous diarrhoea, and grew paler and 
weaker. Thirty-eighth day: a sudden 
and violent pain in right testicle and cor- 
responding part of hypogastrium, accom- 
panied by a little shivering. The pain 
came on again in the night, and his slen- 
der body was covered with large drops of 
sweat; he had neither nausea, nor vomit- 
ing, nor tympanites ; pulse 104. Thirty- 
ninth day: copious diarrhoea ; several vom- 
itings of green bile; sweats and pain 
continued all day. These symptoms con- 
tinued up to the forty-fifth day, when 
there was great abdominal pain and vom- 
iting. He died this day. 
Necroscopy.-Considerable emaciation. 
Head-slight sub-arachnoid effusion. Chest 
-the summit of the left lung presented 
some cellular adhesions, was a little hard 
and unequal, and offered for the depth of 
two inches a considerable number of gray, 
semi-transparent granulations, in the 
midst of which a tuberculous excavation 
was found, the size of a nut, partly empty, 
and communicating with the bronchi. 
Below, the pulmonary tissue was in the 
normal condition. The right lung was in 
the same condition. Abdomen-general 
peritonitis from perforation of the small 
intestine about five inches from the cae- 
cum ; red patches, due to injection of the 
peritoneum upon the external surface of 
the small intestine; internally, this part 
of the bowel presented, at about twenty- 
four inches from the caecum, a transverse 
ulceration about f ths of an inch in extent, 
opposite the mesentery, having the at- 
tenuated muscular coat for its base, and 
the edges were not very prominent, and 
slightly grayish. Six similar ulcerations 
existed in the last six inches of the ileum, 
and in the centre of the first of them the 
perforation, measuring about a fourth of 
an inch in diameter, was found. The 
edges of this ulcer were very thin, and 
partly formed by the peritoneum alone. 
The mesenteric glands were a little red, 
and three or four times their natural vol- 
ume, and had only half their usual con- 
sistence ; liver a little pale and soft; ENTERIC OR TYPHOID FEVER. 
228 
spleen twice its natural volume, a little 
pale and soft. 
"The thirst, anorexia, pains in the 
head, and the shiverings clearly indicate 
the commencement of the illness in this 
case. It was only after three weeks that 
the pains in the belly were experienced. 
Diarrhoea came on as late as the thirty- 
seventh day. The ulcerations of the in- 
testine being the most profound and with- 
out doubt the oldest lesions observed, to 
these ought to be attributed, in great part 
at least, the febrile symptoms present at 
the commencement. It is requisite, how- 
ever, to remark that the tuberculous affec- 
tion commenced, according to all appear- 
ance, with the principal disease; yet as 
ulcerations of the small intestine had the 
characters of those which occur in the 
course of the typhoid affection, and as the 
state of the mesenteric glands1 could only 
be referred to that condition, this disease 
has evidently had the greatest share in 
producing the symptoms and lesions ob- 
served, and we can only place this case in 
the chapter upon the latent typhoid affec- 
tion." (Louis, Obs. xliii. p/232, et seq.) 
Endemic Intermittent and Eemittent Ee- 
vers. - One of the most general facts 
observed in reference to Enteric Fever, is 
the frequent occurrence of intermittence 
in the pyrexial condition. The commis- 
sioners appointed to investigate the 
French epidemics of Enteric Fever, "call 
attention to the fact that a more or less 
pernicious intermittent or at least remit- 
tent character, was manifested under a 
great variety of circumstances." (De 
Claubry, Mein, de l'Acad. de Med., tome 
xiv. p. 71.) "A great number of cases of 
Typhoid Fever presented, either at the 
commencement of the disease, transient 
symptoms of simple intermittent fever, or 
during its further progress, intermittent 
or at least remittent phenomena, which 
rendered the employment of quinine ne- 
cessary." (Ibid. p. 11.) M. Trousseau 
(Clinique Medicale) records cases to show 
that "Enteric Fever may simulate at first 
intermittent fever, and reciprocally, an 
intermittent fever may assume at the 
commencement the characters of Typhoid 
Fever." (P. 247, 2d Edition.) "It is 
•especially in countries where marsh inter- 
mittent fevers are endemic, and with in- 
dividuals who have recently left their own 
country, that we see Enteric Fever as- 
sume at its commencement an intermit- 
tent type." (P. 250.) 
Intermittent fever is, in the present 
day, nearly extinct in England. Its last 
strongholds are to be found in the north 
part of Kent. There, about the Isle of 
Sheppey, and on the marshy banks of the 
Swale, it still lingers. At Milton, for ex- 
ample, ague is still common in the autumn. 
"The drinking water is obtained from 
wells, and the general sanitary condition, 
as regards drainage and the non-removal 
of nuisances, is unsatisfactory, and there 
has been a considerable amount of Ty- 
phoid Fever at times, and scarlatina in a 
severe form was prevalent at the time of 
the inspection." (Rep. by Dr. G. Whit- 
ley, as to quantity of ague now prevailing 
in England. Sixth Rep. Privy Council, 
1863, p. 432.) 
At Holbeach and Long Sutton, Ague 
and Enteric Fever were both prevalent. 
The drainage of these places is bad, and 
the water supply bad, being from pits (p. 
441). "Very nearly all the medical men 
who had had opportunities of forming an 
opinion concerning the co-existence of 
ague and typhoid fever in the same dis- 
tricts, were of opinion that the local con- 
ditions which produced the former are 
favorable to the development of the latter. 
Thus, Mr. Keddell, with forty years' ex- 
perience in Sheppey, believed that when 
ague, from certain conditions of surface, 
is rife in summer, bilious, remittent, and 
typhoid fevers prevail in autumn." (Ibid, 
p. 452.) 
My friend Mr. Charles Mayo informs 
me, from extensive personal observation, 
that the " camp fever" of the army of the 
Potomac was generally recognized as a 
" typho-malarious fever," in which the 
symptoms of typhoid fever, diarrhoea, 
rose rash, &c. were associated with those 
of intermittent fever. The typhoid symp- 
toms occasionally predominated, and post- 
mortem examination revealed lesions of 
Peyer's glands. [See, on a subsequent 
page, a farther account of American Ty- 
pho-malarial Fever.-H.] 
It is evident from the foregoing obser- 
vation that an investigation into the na- 
ture of Enteric Fever would be very 
incomplete without a brief consideration 
of the symptoms and morbid anatomy of 
the severer forms of intermittent fever. 
The Walcheren fever offers itself as a 
standard of comparison. Dr. Davis1 has 
given a very clear and minute description 
of this disease. "The Walcheren fever," 
he says, "assumed the quotidian, tertian, 
double-tertian, and even remitting type. 
It did not uniformly declare itself with 
the same type, being one while continued, 
then remittent or intermittent, and chang- 
ing its type again from these to the con- 
' Louis appears to regard a vascular, swol- 
len, and softened condition of the mesenteric 
glands as being inconsistent with the exist- 
ence of tubercular disease. We have fre- 
quently seen the mesenteric glands purple, 
soft, and swollen in cases of advanced phthisis 
in which both lungs and intestinal glands 
have been affected. (See Diagnosis.) 
1 View of the Fever of Walcheren and its 
consequences, by J. B. Davis, M.D. 8vo. 
Lond. 1810. 229 
ASSOCIATED PATHOLOGY OF ENTERIC FEVER. 
tinued character. I believe the Walcheren 
fever in many instances would have 
ceased but for the derangement it had 
occasioned in the abdominal viscera, be- 
coming in some measure a secondary dis- 
ease." (P. 12, et seq.) The premonitory 
symptoms were weakness, nausea, head- 
ache, universal languor, dejection of spi- 
rits, always combined with a vitiated 
state, suppression or diminution of the 
intestinal and biliary secretions. 
After the paroxysms, headache, confused 
intellect for two or three days, ending in 
coma and stupor. At other times con- 
tinued pyrexia, whiteness of the tongue, 
distension and uneasiness of the epigastric 
region, and anorexia. Then the bowels 
became painful, and there were diarrhoea, 
discharge of mucus, or much blood inter- 
mingled with feces, &c. &c. These symp- 
toms would be obscured by the paroxysm, 
to reappear after it was over (p. 18). "All 
the patients with the quartan type under 
my care were very prone to diarrhoea and 
dysentery, thirst, pyrexia, emaciation, 
daily exacerbations of hectic, local pains, 
and general irritation, constituting an un- 
manageable disease which wore away the 
patient's strength, and utterly exhausted 
him" (p. 17). Delirium was seldom for- 
midable ; epistaxis frequently occurred. 
Hectic was almost uniformly the character 
of the pyrexia. Gray, clay-colored watery 
stools, and rapid marasmus, were common 
in cases tending to a fatal termination. 
Such were the symptoms of " the con- 
tinued fever or long-continued paroxysm," 
L sually both the small and large intestine 
were involved in the disease, and its rav- 
ages greatest in the latter. Thus, in case 
29, we have a description of the post-mor- 
tem appearances of dysentery implicating 
the small intestine : - Colon ulcerated 
throughout its whole extent. Rectum 
much ulcerated and had sloughed near its 
termination. Jejunum and ileum "inter- 
spersed with black spots internally; the 
intervening spaces red, and raised up into 
little protuberances, resembling granula- 
tions of flesh, not unlike a cock's comb." 
Liver large, black, and soft. Spleen soft, 
of enormous size. Mesenteric glands en- 
larged (p. 173). 
In case 32 the large and small intestines 
appear to have been pretty equally affected. 
" The small intestines were of a deep pur- 
ple color, and interspersed on their inner 
side with tubercles and small ulcers, re- 
sembling chancres. The colon and rectum 
had numerous tuberclesand ulcerations." 
Spleen weighed four pounds, and was uni- 
formly soft throughout. Mesenteric glands 
enlarged (p. 175). 
In case 34 the lesions were more appar- 
ent in the small than in the large intes- 
tine. The convolutions of the small intes- 
tines were united together by condensed 
coagulable lymph. They were of a red- 
dish color, and interspersed with small 
red eminences on their inner surface. 
The coats of the colon were thickened. 
Liver large and black. Spleen firm and 
dark, weighed four pounds. 
The particular characters of the intesti- 
nal lesions are thus clearly described 
by Dr. Davis. The ileum and jeju- 
num were frequently interspersed 
with "tubercles inflamed and ulcer- 
ated in different parts. Here and 
there small eminences of the size of 
a pin's head, or round bodies with 
an ulcer at the point, or little ragged 
ulcers, excavated in the middle, re- 
sembling chancres, or one large, or a 
succession of small ulcers spreading 
wide upon, and deep into, the coats 
of the intestines. Color of these tu- 
bercles various, consistence firm. 
While their points were yellow their 
edges were hard, and their bases al- 
most black, like a lump of decayed 
flesh. They did not come fairly to 
suppuration, but appeared gradually 
to crumble away and degenerate into 
a scabrous ulcer. These bodies had 
their origin beneath the villous coat 
of the intestine." (P. 191.) 
From the above description we may in- 
fer that the morbid condition of the solid 
and agminate glands of the intestine in 
these fatal cases of intermittent fever is 
identical with that which is assumed to be 
characteristic of Enteric Fever. We have 
already seen that both forms of fever are 
developed amidst the same conditions, and 
[Fig. 11. 
Remitting lysis in enteric fever.] 
when the order of the periods became so 
completely overturned that it was difficult 
to bring the fever to its proper type again 
If we now turn to the morbid anatomy 
of the disease, we shall find positive evi- 
dence of lesion of the solitary and agminate 
glands of the small intestines, in at least 
six of the cases recorded by Dr. Davis. 230 
ENTERIC OR TYPHOID FRYER. 
we therefore unhesitatingly conclude that 
Enteric Fever is often a part of intermit- 
tent fever, and the converse. 
Dysentery.-After the foregoing observa- 
tions it may appear superlluous to call 
special attention to the relation between 
Dysentery and Enteric Fever. But the 
connection between these two diseases is 
too important to receive only a cursory 
notice. Even in reference to Enteric Fe- 
ver alone, it is important to observe that 
the ulceration sometimes spreads to the 
large intestines, when the lesions of the 
small intestine are in process of repara- 
tion. The following isolated case recorded 
by Forget, may be briefly mentioned to 
show how the enteric disease may be pro- 
longed by subsequent lesion of the large 
intestine. 
Case 16.-A patient was laid up with 
the ^sual symptoms of Enteric Fever for 
a month, then, after a few days' intermis- 
sion, profuse dysenteric diarrhoea, tenes- 
mus, and colic pains set in, and after con- 
tinuing for about twenty days killed the 
patient. In the last two feet of the ileum, 
"numerous white shining spots, of varia- 
ble extent, smaller than the ulcerated 
Peyer's patches, and evidently cicatrices, 
were found. The ileo-csecal intestine was 
profoundly altered in all its extent from 
the great valve to the anus ; it was brown, 
black, hypertrophied, vegetant, and soft- 
ened, presenting ulcerations of various 
depth." (Forget, Obs. xlii. p. 351.) 
Rokitansky describes " the typhous pro- 
cess in the mucous membrane of the small 
intestine," as distinct from "the dysen- 
teric process" observed in the large intes- 
tine. But this distinction is purely artifi- 
cial. In the following well-marked case 
of Enteric Fever which lately died under 
my care, the large intestine was the more 
extensively ulcerated, and the ulcers in 
both small and large intestine were indis- 
tinguishable from the so-called "dysen- 
teric ulcers." 
Case 17.-Catherine M., aged 23, resid- 
ing at Stanmore, near London, was taken 
ill this autumn with headache, much 
shivering, pain in the back, and diarrhoea. 
Fever and diarrhoea continued ; rose spots 
appeared on the abdomen from the tenth 
to the twenty-second day. Diarrhoea per- 
sisted, and there was much hectic. On 
the twenty-fourth day there was marked 
abdominal tenderness. The diarrhoea con- 
tinued unchecked, and she died on the 
twenty-seventh day. 
Necroscopy. - Chest - lungs congested, 
friable at apices, weighed thirty-three 
ounces. Abdomen.-liver enlarged, weigh- 
ed three pounds five ounces, soft, greasy, 
and pale. Gall-bladder full of pale, thin, 
ochre-colored bile. Stomach, duodenum, 
jejunum, and upper portion of ileum 
healthy ; last two feet of ileum presented 
sixteen ulcerations of Peyer's glands, 
varying from minute vascular abrasions 
to three-eighths of an inch in diameter. 
Four of these pale depressed ulcers were 
situated immediately above the ileo-csecal 
valve, and were evidently in process of 
contraction and cicatrization. In the 
large intestine there were twenty-seven 
ulcers, twenty of which were in the cse- 
cum ; several were situated immediately 
below the ileo-csecal valve, and one of 
these was as large as a shilling, and 
deeply excavated the muscular fibres ; an- 
other, the size of a sixpence, was placed 
at the bottom of the csecal pouch, and it 
lay upon the peritoneum, which presented 
externally a corresponding patch of opacity 
with vascular ramifications. Seven other 
ulcers occurred at intervals in the ascend- 
ing and transverse colon, the last one oc- 
curring at a distance of two feet from the 
ileo-csecal valve. All these ulcers were 
pale, with ashy or smooth bases lying 
upon the muscular fibres; their edges 
were not elevated, and often perpendicu- 
lar. The solitary glands of the large in- 
testine were enlarged, the central parts of 
many were eroded and in a state of inci- 
pient ulceration. The mesenteric and 
mesocolic glands were purple, much en- 
larged, and soft. The spleen weighed six 
and a half ounces, and was of normal 
color and consistence. Kidneys, pancreas, 
and the other organs healthy. 
The day after this young woman died, 
a patient in the same ward, under the 
care of my colleague, Dr. Murchison, also 
died ; and as the case illustrates very well 
how extensively the large intestine may 
be ulcerated by Enteric Fever, I have 
availed myself of Dr. Murchison's kind- 
ness in allowing me to make my observa- 
tions of the case, and briefly detail them 
here. 
Case 18.-Eliza II., aged 26, was ad- 
mitted on the tenth day of her illness with 
fully developed Enteric Fever. She was 
taken ill with headache, heats and chills, 
and diarrhoea, and these symptoms con- 
tinued to the time of her admission. 
Rose spots appeared on the abdomen 
from the tenth to the eighteenth day. The 
bowels continued very loose, and the 
stools were of a light yellow color. Medi- 
cines failed to restrain the diarrhoea, the 
abdomen became distended and tender, 
and the patient died exhausted on the 
twenty-seventh day of her illness. 
Necroscopy.- Chest-lungs healthy, with 
only a little hypostatic congestion. Heart 
contained firm fibrinous clots in all its 
cavities. Abdomen-stomach, duodenum, 
jejunum, and upper portion of ileum per- 
fectly healthy. In the last two feet of the 
ileum there were a dozen pale non-ele- 
vated ulcerations of Peyer's glands; six 
of them were in the immediate neighbor- 
hood of the ileo-csecal valve, and the 
largest did not exceed three-eighths of an 231 
ASSOCIATED PATHOLOGY OF ENTERIC FEVER. 
inch in diameter. All were evidently in 
process of healing. The large intestine 
was in a state of ragged ulceration from 
the under surface of the ileo-csecal valve 
to within an inch of the rectum. In the 
transverse and descending colon there 
were two rows of ulcers, each about a 
foot long ; these ulcers were deeply exca- 
vated, and for the most part confluent, or 
only separated by narrow bands of hyper- 
trophied mucous membrane. Each ulcer, 
or confluent patch, was about an inch 
wide. The edges were two or three lines 
thick, irregular and very vascular, and 
often black ; the surface of the ulcer was 
chiefly formed of ashy sloughs of areolar 
tissue, or disintegrated muscular fibres. 
In the interval between these rows of 
ragged ulcers were a great many circular 
ulcers, and swollen solitary glands advan- 
cing to this condition. Nearer the caecum 
and rectum the ulcers were fewer and 
more discrete. The mesocolic glands were 
greatly enlarged, purple, and soft. The 
spleen weighed eight and a half ounces, 
and was pulpy. The liver was very soft 
and greasy; it weighed forty-four and a 
half ounces. The gall-bladder contained, 
half an ounce of pale yellow watery bile, 
which did not affect turmeric paper, but 
changed blue litmus to red. The other 
organs were quite healthy. 
In the following case of Enteric Fever 
and pneumonia, the intestinal lesion was 
almost entirely confined to the colon :- 
Case 19.-Phoebe Poole, aged 14, was 
admitted into the London Fever Hospital 
on the 8th of September, 1865, on the four- 
teenth day of her illness. She had had 
cough, quick breathing, and diarrhoea, ac- 
companied by high fever. At this date 
the pulse was 150, tongue dry, brown, 
and cracked, skin pungently hot, respira- 
tions 58, cough, dulness with crepitation 
and bronchophony over the lower lobe of 
the right lung behind; there was reten- 
tion of urine, the abdomen was tympanitic 
and tender, there were two rose spots 
upon its surface, and the bowels were 
very loose. The pulmonary and enteric 
inflammation progressed, tubular breath- 
ing was heard over almost the whole of 
the right side of the chest, and the bowels 
continued very loose. A few fresh rose 
spots appeared up to the nineteenth day. 
On the twenty-ninth day the respirations 
were 60, short and snatchy, the pulse 160, 
and the diarrhoea profuse. On the thirty- 
fifth day she died. 
Autopsy.-Chest-right lung completely 
solid and firm, gray and gangrenous. Left 
lung a little engorged. Heart healthy. 
Abdomen-the last Peyer's patch near the 
ileo-csecal valve had two minute ulcera- 
tions, but the rest of the gland, and all 
the other agminated and solitary glands, 
were perfectly healthy. The colic side 
of the caecum, and the first five inches of 
the ascending colon, were in a state of 
ragged ulceration-long clean, transverse 
ulcers, laying bare and dissecting the 
muscular fibres, were repeatedly confluent 
in this part of the bowel, and were inter- 
spersed with islands of soft, greatly-swol- 
len, mucous membrane. Lower down, 
were ulcerated solitary glands, and there 
were six more in the sigmoid flexure. 
The solitary glands and the mucous mem- 
brane of the rest of the large intestine 
were generally healthy. The mesenteric 
glands corresponding to the small intes- 
tine were quite healthy ; the mesocolic 
glands in the neighborhood of the caecum 
were purple, soft, and much enlarged. 
The rest of the viscera appeared healthy. 
The spleen was of natural size. 
Such cases as the foregoing afford typi- 
cal examples of acute dysenteric ulcera- 
tion, and we may question whether the 
distinction between Dysentery and En- 
teric Fever is not somewhat artificial. 
Cholera.-"In the delta of the Ganges, 
the Nile, and the Mississippi the three 
forms of disease called cholera, plague, 
and yellow fever, are constantly seen pre- 
ceding, accompanying, and following in- 
termittent fever, and constitute there the 
reigning endemic diseases; and one is 
forced to recognize a very great analogy, 
not to say an identity, of origin between 
marsh fever and the three great scourges 
above mentioned." (Traite des Fievres 
intermittentes, remittentes, et continues, 
par J. C. M. Boudin, p. 161.) A pro- 
tracted attack of cholera bears a close re- 
semblance to Enteric Fever; the intesti- 
nal lesions of the two diseases, moreover, 
are indistinguishable from each other. 
"The most frequent of all the abnormal 
conditions of the mucous membrane of the 
intestines was prominence of the intestinal 
glands, both aggregate and solitary, but 
especially the latter. This condition, the 
psorenterie of some French writers, was 
found in about two-thirds of the eighty- 
nine fatal cases examined." (W. T. 
Gairdner, M.D., Month. Journ. Med. Sci- 
ence, 1849.) M. Pirogoff examined 500 
fatal cases of cholera. He observed, in 
the earlier periods of the disease, "thick- 
ening and swelling of the mucous mem- 
brane most often accompanied by swelling 
of Peyer's and the solitary glands, as well 
as swelling of the mesenteric glands. In 
the typhoid period, ulceration of these 
glands." (Anatomic Pathologique du 
Cholera Morbus. Folio, St. Petersburg, 
1849.) 
Scurvy is sometimes accompanied by 
ulceration of the solitary and agminate 
glands, with all the symptoms of Enteric 
Fever. An outbreak of scurvy occurred 
in the Milbank Penitentiary, in London, 
in the years 1822-23. An account of it 
was published by P. M. Latham, M.D. 
(8vo. Lond. 1825.) "In addition to the 232 
ENTERIC OR TYPHOID FEVER. 
ordinary symptoms of scurvy-purpura 
hsemorrhagica, spongy and even bleeding 
gums, &c.-there was every degree and 
species of flux ever seen or described. 
There were cases which corresponded 
with the descriptions of the Indian cholera, 
and there were some which corresponded 
with the common autumnal cholera of this 
country, except that they were accom- 
panied by intractable diarrhoea. There 
was every kind and degree of dysentery." 
(P. 32, 33.) In some cases the abdomen 
was soft and natural; in others tympa- 
nitic. Post-mortem examinations re- 
vealed lesions of the intestines, which, 
from the descriptions at pp. 4G-49, are 
clearly to be attributed to swelling and 
ulceration, even to perforation, of the 
solitary and agminated glands. 
Varieties.-After the foregoing re- 
view of the associated pathology of En- 
teric Fever, can we adopt the dogma of 
Chomel ?-"Quand nous trouverons dans 
les auteurs, soit anciens, soit modernes, 
des observations de maladies aigues & la 
suite desquelles on aura rencontre des ul- 
ceres & la fin de 1'intestine ^rele, nous 
aurons le droit de les considerer comme 
des cas d'affection typhoide." (Fievre 
Typhoide, p. 113.) Or, going to the 
other extreme, shall we deny the exist- 
ence of Enteric Fever as a specific dis- 
ease, and regard the intestinal lesions 
merely as the result of an accidental but 
severe local complication which may arise 
in any general febrile condition of the 
body? If we accept the first proposition, 
we must include Tuberculosis under En- 
teric Fever. If we adopt the second, we 
may, with almost equal reason, deny the 
existence of scarlatina as a distinct dis- 
ease. We can only avoid the dilemma 
by admitting that the enteric disease, and 
all its attendant phenomena, may occa- 
sionally become a part of some other more 
general inflammatory condition, and then, 
I think, it can hardly be denied that in 
other cases the disease is due to some 
poison or poisons introduced from with- 
out, in the elimination of which, the di- 
gestive organs especially are deranged. 
In order to include all the phenomena of 
Enteric Fever, I find it necessary to divide 
it into these three varieties: (1) Simple 
Inflammatory Enteric Fever; (2) Conta- 
gious Enteric Fever : (3) Paludal Enteric 
Fever. 
It may seem paradoxical and unphilo- 
sophical to include under one kind conta- 
gious and non-contagious diseases; but 
since the question of contagion is still an 
open one with many, and neither symp- 
toms nor anatomical lesions mark a dis- 
tinction, we must be content thus to clas- 
sify the disease for the present. 
1. Simple Inflammatory Enteric Fever.- 
This variety is non-contagious, due to no 
specific cause, and may arise in any in- 
flammatory condition of the body, such as 
accompanies pneumonia, erysipelas, py- 
aemia, &c. The common enteritis, which 
constitutes autumnal diarrluea, if pro- 
tracted, often lapses into this variety of 
Enteric Fever. Cases 6, 7, 11, 19, &c., 
furnish examples of this variety. The 
recognition of the intercurrence of enteric 
inflammation, with ulceration of the 
glands of the ileum, in acute diseases 
generally, is of very great importance; 
Ibr of all the organs of the body, these 
delicate glands, from their situation with- 
in the thin and vascular intestinal wall, 
are less capable than similarly constituted 
parts elsewhere situated, of enduring pro- 
longed inflammation, without risk of fatal 
accidents ; and at any time the intestinal 
lesion may become much the gravest part 
of the more general disorder. The fre- 
quency with which the intestinal glands 
become implicated in acute disease is 
probably due to their exposed situation, 
their delicate corpuscular structure, their 
great vascularity, and the arrangement of 
their bloodvessels. 
A well-developed healthy lad, aged 15, 
fell from a horse ; the skull was fractured 
and the corresponding surface of the brain 
lacerated ; febrile action followed, and he 
died on the third day. Before the body 
was cold I examined the small intestine. 
In the last nine inches of the ileum I 
found the solitary glands swollen, and of 
a delicate grayish-pink color, and semi- 
transparent appearance, forming rounded 
elevations of the mucous membrane, the 
size of hemp-seeds (psorentery). The 
mesenteric glands were a little increased 
in vascularity and size. There was no 
trace of disease in any part of the body. 
Here we recognize a condition of the soli- 
tary glands, which, under the continuance 
of the general febrile action, might have 
passed into the worst form of "typhoid 
ulceration." 
" But surely," it will be said, " we can 
distinguish the true typhoid ulceration 
from any other at a glance ; moreover, the 
typhoid ulcer is characterized by the de- 
posit of a distinct morbid material-a spe- 
cific typhous cell. " Having shown that the 
inflammatory swelling is due, not to the 
deposit of a specific morbid matter within 
the glands, but to the rapid growth of their 
normal corpuscular constituents under the 
influence of undue vascular excitement, 
we fail to recognize any character by 
which one form of inflammatory action in 
Peyer's glands can be distinguished from 
any other. Ultimately, we shall have 
little or no difficulty in distinguishing a 
tubercular ulcer from any other; but be- 
tween the lesions assumed to be charac- 
teristic of Enteric Fever, and those aris- 
ing from ordinary inflammation, which, 
of course, may affect the intestinal glands VARIETIES. 
233 
in common with every other part and 
organ of the body, there is, I conceive, no 
distinction. As a result of common in- 
flammatory action in the glands, we may 
find Peyer's glands swollen into cock's- 
comb or fungus-like elevations, and exca- 
vated into ragged ulcers, with red everted 
edges, or occupied by sloughy cores. (See 
case 8.) In a well-marked case of Enteric 
Fever, in which the diarrhoea, rose spots, 
and abdominal pain and swelling call 
attention to the abdominal lesion, we 
may, on the other hand, find, as in a case 
which I examined two days ago, a dozen 
angry-looking ulcers in the last foot of the 
ileum, varying in diameter from two lines 
to three-fourths of an inch, and exposing 
the red-streaked muscular fibres, each 
ulcer sharply cut, and the irregular mar- 
gins not raised above the general level of 
the intervening dark-red mucous mem- 
brane. Higher up were seen glands level 
with the inflamed mucous membrane, and 
presenting sloughy erosions, like an aph- 
thous ulcer of the mouth. 
2. Contagious Enteric Fever.-Of this 
variety I can say but little. I am not sure 
that I have seen it; but that it exists, ap- 
pears to be an indisputable fact. Eight 
of the sixty-eight patients referred to be- 
low came from houses in which other resi- 
dents were affected with the fever. The 
disease may have been propagated by con- 
tagion in some of the se cases, but in two 
instances, in each of which three mem- 
bers of the same family were affected, I 
found from personal observation that an 
endemic cause existed in impure drinking 
water. See also cases 4 and 5, and the 
observation upon "Contagion." The as- 
sociations of this variety appear to be, as 
I have already pointed out, with scarla- 
tina and the allied affections, diphtheria 
and croup. Exudations upon the faucial 
and laryngeal mucous membrane appear 
to be frequent in this variety, and the 
course of the disease more rapid than in 
the third variety. 
3. Paludal Enteric Fever.-This we be- 
lieve to be the common form of the dis- 
ease. It arises from putrescent animal 
and vegetable substances. It is non-con- 
tagious, and its course is usually slow. 
Case 2 may be taken to illustrate this 
variety of the disease. 
In thus unreservedly recognizing the 
connection which I cannot doubt exists 
between Intermittent and Enteric Fever, 
it may appear to some that I transgress 
the facts which have been adduced to 
illustrate this view ; but I feel sure that 
justice has not been done to the numerous 
observations which abound in medical 
literature, and which, if collected, would 
together form irresistible evidence of the 
direct connection between these two dis- 
eases. In the low-lying districts on the 
banks of the Thames, within and about 
the metropolis, where ague was formerly 
so rife, Enteric Fever prevails continu- 
ously, becoming very abundant in the 
autumn, while the higher situations are 
comparatively free from it. Of sixty-eight 
cases of well-developed Enteric Fever 
which have come under my care during 
the present autumn (1865), fourteen came 
from the districts of Stanmore, Chelsea, 
Lambeth, Southwark, Stepney, Hackney, 
Bethnal Green ; thirteen from the lowest 
part of the parish of St. Luke alone, 
where cesspools and pumps are still in 
use, and where drainage works are now 
in progress ; twenty-three from the filth- 
iest and most crowded parts of the par- 
ishes of St. Clement Panes, Holborn, and 
St. Giles; and only five from the more 
elevated localities of Soho and Maryle- 
bone, Islington, Holloway, &c. The re- 
mainder resided in Maidstone, Croydon, 
Mitcham, Edmonton, and various other 
country districts near London. 
We find Enteric Fever remarkably pre- 
valent in the spreading outskirts of the 
suburbs, where new houses and streets 
are constantly springing up beyond the 
limits of the drainage works. 
We acknowledge as modifications of the 
same disease, that intermittent form to 
which, when London had its cesspools 
and pumps, and retained all its filth within 
its undrained area, James I. fell a victim, 
and that continued modification which 
still lingers in a subdued form in the same 
locality, and to which a good Prince has 
succumbed in our own generation. 
[ Typho- Malarial Fever.-In the States 
which were the seat of conflict during 
the American civil war, and especially in 
Virginia, in 1862, many cases occurred 
amongst the soldiers of the Union army, 
for which the above is the most fitting 
name. " Chickahominy Fever" was a 
hospital designation, derived from a local- 
ity in which hundreds of cases took their 
origin during the " peninsular" campaign 
of McClellan.1 
Three morbific elements appeared to 
combine in the causation of these cases : 
malaria, camp or "crowd" poison, and 
the dietetic deficiency which produces 
scurvy, and gives the scorbutic taint to 
other diseases. According to the pre- 
dominance of one or another of these 
etiological elements, the resulting malady 
varied. The following brief account is 
cited from a record taken by me upon the 
observation of a large number of these 
cases in two of the Philadelphia Hospitals. 
"Of the form in which the malarial 
element prevailed, the somewhat abrupt 
commencement, gastric disturbance, and 
icteroid skin and tongue, with remissions 
tolerably distinct, were predominant fea- 
1 See Woodward's "Camp Diseases of the 
United States Army." 234 
ENTERIC OR TYPHOID FEVER. 
tures. The lenticular spots of typhoid 
fever, and the sudamina and tympanites, 
were often wanting altogether. 
"A slower onset, less distinct remissions, 
more cerebral disturbance, and diarrhoea, 
with epistaxis and bronchitis sometimes, 
but with both less constantly than in civil 
life, marked the predominance of the 
typhoid pathogenetic element. Deafness, 
under my observation, was less frequent 
than in civil life, but was sometimes very 
well marked. The aspect of the counte- 
nance, and the character of the somno- 
lence and delirium, were precisely the 
same as in ordinary typhoid fever. 
"The scorbutic complication was recog- 
nizable, in the third group of cases, by the 
peculiar mental and bodily prostration 
which preceded and followed the disease 
-the remarkable irritability of the heart, 
the state of the gums, tendency to hemor- 
rhage, discolorations and petechise, pallid, 
large and smooth tongue, and extremely 
protracted convalescence. 
"Morbid Anatomy. - Most important 
was the intestinal lesion, similar to that 
of typhoid or ' enteric' fever, though not 
identical. The following account of this 
is from Dr. Woodward.1 
" 'In the earlier stages there was little 
to distinguish the intestinal lesion from 
the corresponding process of ordinary en- 
teric fever, except, perhaps, the great 
tendency to the deposit of black pigment 
in the enlarged follicles. In the latter 
stages certain peculiarities are often dis- 
tinctive enough to enable the anatomist 
to recognize typho-malarial fever by the 
post-mortem appearances alone. The 
tumefaction in typho-malarial fever rises 
very gradually from the surrounding mu- 
cous membrane, and attains a moderate 
degree of thickness (three to six lines) on 
the edges of the ulcer. In this it differs 
materially from the ordinary typhoid ulcer, 
in which the enlarged patch rises abruptly 
from the mucous membrane in such a way 
that the summit is often larger than the 
constricted base, giving rise to the com- 
parison made by Rokitansky, who likens 
the shape of the tumefaction to that of 
flat sessile fungi. The umbilicated de- 
pression, so frequent in the ordinary 
typhoid patches prior to ulceration, has 
never been observed in typho-malarial 
fever. The ulcer itself presents ragged, 
irregular edges, which are often exten- 
sively undermined in consequence of the 
erosion extending more widely in the sub- 
mucous connective tissue than in the 
glandular tissue of the mucous membrane. 
This characteristic undermining of the 
edges is much more extensive in these 
than in ordinary typhous ulcers. ' 
'' Pathology.-Doubting not at all the 
presence of the malarial element, the ques- 
tion occurs, was the modifying ' febrile' 
cause of the typhous or of the typhoid cha- 
racter ? Granting, that is, that these are 
pathogenetically distinct, we should ex- 
pect that the typhus or 'crowd-poison' 
element must result from the circum- 
stances, as from those which made typhus 
or ' camp fever' the scourge of armies in 
Europe. Only, against this, we have the 
local lesion, of the glands of Peyer and 
mucous membrane of the bowels, recall- 
ing enteric or typhoid fever. 
"But-as, where typho-malarial fever 
occurred, causes of intestinal irritation 
(bad water, deficient food, &c.) were pres- 
ent-I am not satisfied that such an ap- 
pearance (not, as we have seen, identical 
with that of typhoid fever) should exclude 
the idea of the zymotic action being that 
of the typhous cause. In that opinion, as 
a probability, not, of course, now demon- 
strable, I rest. 
" Treatment-From the above view of 
the hybrid and threefold nature of the dis- 
ease, came its rational treatment. More 
quinine than in typhus, more alcohol than 
in remittent, more fresh vegetable food and 
fruit than in either. Experience justified 
this plan. In our hospitals in Philadel- 
phia, few died from fever who were not 
moribund on their arrival from the seat of 
war."1-II.] 
Distribution.-Enteric Fever pre- 
vails in every inhabited part of the world. 
No situation is secure from it. In the re- 
port of the epidemics which have occurred 
in France from 1841 to 1846, De Claubry 
(Mem. de l'Academie de Med., tome xiv.) 
observes: "The situation of the twenty- 
eight departments which have been the 
frequent theatre of destructive epidemics 
of typhoid fever, was such that it ap- 
peared impossible to conclude that it had 
any influence whatever in the production 
of these epidemics." (P. 4.) "If one 
finds typhoid fever on the one hand in vil- 
lages situated in deep valleys, in narrow 
gorges; in lowlands, where the water- 
courses frequently overflow, making the 
submerged soil, upon which the miserable 
dwellings are built, extremely damp : one 
sees it, on the other hand, in villages situ- 
ated, one upon the most elevated points of 
a high chain of mountains, and constantly 
exposed to every wind, and having no un- 
healthy condition in its neighborhood ; 
another situated 600 feet above a little 
flowing stream, commanding an extensive 
view of perfectly cultivated fields ; a third, 
in a very salubrious position, upon an un- 
dulating soil, where the flow of water is 
perfect." (P. 8.) 
Enteric Fever, moreover, attacks every 
class of society indifferently. On one 
1 Op. citat., pp. 102-3. 
[' Essentials of Practical Medicine, 4th ed., 
pp. 367-9.] CAUSES. 
235 
hand, we find it associated with the most 
abject poverty, damp, filth, overcrowding, 
and defective ventilation; and, on the 
other, we witness the disease making 
havoc amongst the wealthy residents of 
spacious, dry, well-built houses, isolated, 
or united to form wide open streets, or 
elevated terraces. 
Causes : (a) Predisposing. - Of the 
causes which predispose to Enteric Fever, 
youth is usually considered to be one ; but 
young people are not more liable to this 
than they are to other inflammatory dis- 
eases. Dr. Murchison states (page 409), 
that slightly more than half of the cases 
of Enteric Fever admitted during ten 
years into the London Fever Hospital 
were between fifteen and twenty - five 
years of age ; one-fifth were under fifteen; 
less than one-seventh above thirty: and 
only one - sixty - eighth exceeded fifty. 
Similar statistical results may probably be 
found in many other acute diseases. 
[More than one attack in the same indi- 
vidual is rare ; but instances of recurrence 
do occur.-II.] 
Seasons have a marked influence on the 
increase and diminution of Enteric Fever. 
" Out of 106 times in which an exact indi- 
cation of the epoch when the epidemics of 
typhoid fever commenced, the reports of 
the years 1841 to 1846 give the following 
results: - First yearly quarter, twenty 
epidemics ; second quarter, twenty-one ; 
third quarter, twenty-nine; fourth, thirty- 
six: or, summer (April to September) 
sixty; winter (October to March) fifty-six. 
Seventy epidemics commenced in the four 
months of August, September, October, 
and November ; while only forty-six com- 
menced in the other eight months of the 
year, from December to July." (De 
Claubry, op. cit. p. 8.) 
" In New England Enteric Fever is not 
infrequently called the autumnal or fall 
fever." (Bartlett on Fevers, p. 101.) 
On examining the accompanying Table 
(vide Table) of the cases which have oc- 
curred at the London Fever Hospital dur- 
ing the last 18 years, the following facts 
appear :-First, that the greater number 
of cases occur during the autumn and 
winter months, and the average of 17 
complete years1 shows that more than 
twice as many cases, or a proportion of 
2T to 1, occur during these periods, as 
compared with those happening during 
the other six months of the year. Second, 
that of all the seasons autumn is the one 
in which Enteric Fever is most prevalent. 
In fourteen out of the seventeen years, 
the number of autumnal cases exceeded 
that of any other season. In one of the 
three remaining years, 1851, an equal 
number of cases occurred in the summer 
and autumn respectively. In the other 
two years, 18G0 and 1862, the greatest 
number of cases occurred during the win- 
ter, exceeding the autumnal cases by six- 
teen. Third, that the disease is least of 
all prevalent in the spring. Excepting 
the years 1852, '56, '59, '60, '61, and '63, 
the least number of cases occurred in 
spring, and in all these exceptional years 
there were only thirty-four spring cases in 
excess of the summer ones. 
It appears from these general facts, and 
from a little closer examination of the 
table, that Enteric Fever obtains its maxi- 
mum development in the months of Sep- 
tember, October, and November, declines 
slowly during the winter and spring, and 
reaching its minimum in May, then be- 
gins to increase progressively with the ad- 
vance of summer. 
Let us now go a step further, and en- 
deavor to find out the conditions which, 
prevailing most in autumn, render this 
season most favorable to the existence of 
Enteric Fever. 
Temperature.-In every year but 1852, 
the combined temperature of the autumn 
and winter was less than the combined 
temperature of spring and summer, and 
in this exceptional year the mean tem- 
peratures were as 5(P'3 to 50°'9. And in 
every year but 1851, '54, '55, '56, and '61, 
the temperature of autumn was less than 
that of summer, and in no year did the 
autumnal temperature exceed that of 
summer more than 1°T. Again, if we 
except the years 1851, '55, '56, and '61, 
October-the month when Enteric Fever 
is most rife-was cooler than May, when 
the disease is at its lowest ebb. It has 
been already stated that in five of the 
years, the number of cases occurring in 
the spring of those years was in excess of 
the number which happened in the 
warmer summers. 
Apart from any other cause, it cannot, 
therefore, be concluded that temperature 
has any influence on the increase of En- 
teric Fever. 
Rainfall.-In considering the influence 
of rain upon the quantity of Enteric Fever, 
attention must be given, not so much to 
the total yearly amount, as to the quanti- 
ty which falls in each month. The ave- 
rage amount of rain for each of the seven- 
teen years is 23T inches. If only one 
inch fall during a period of two months, 
that must be regarded as a season of 
drought. 
Of these seventeen years the most rain, 
34*4 inches, fell in 1852, and in this year 
there were 140 cases of Enteric Fever. 
Next stands the year 1860, when there 
was a rainfall of thirty-two inches, and 
only ninety-five cases-a total consider- 
ably smaller than that of any other year. 
But on further comparison we find that 
in 1860 the rain was not only abundant, 
1 From 1848 to 1864 inclusive. 236 
ENTERIC OR TYPHOID FEVER. 
TABLE showing the number of cases of ENTERIC FEVER treated in the LONDON FEVER HOSPITAL, and certain attendant atmospheric conditions, during the last 
eighteen years. The analytical observations have no reference to 1865, which year was incomplete when they were made 
The first column gives the number of cases admitted during every month, season, and year. It is partly derived from p. 17 of Dr. Murchison's work, and partly from the London Fever 
Hospital Reports. The second column gives the mean temperature of the air during each month, season, and year. The third column shows in like manner the mean degree of 
moisture contained in the air. The numbers have reference to 100, which is taken to represent the greatest quantity of aqueous vapor which the air can at any temperature retain. 
The fourth column gives the total rainfall in each month, season and year. The second, third, and fourth columns are from the Registrar-General's Returns, and are due to Mr. James 
Glaisher, F.R.S 
1848. 
1849. 
1850. 
1851. 
1852. 
1853. 
1854. 
1875. 
1856. 
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January.... 
9 
34'6 
83 
1-2 
9 
40-1 
88 
1-6 
6 
33-7 
89 
1-2 
13 
42-9 
85 
2-7 
10 
420 
84 
3-6 
17 
42 4 
so 
2-0 
13 
39-0 
91 
1-7 
16 
34-9 
91 
1-0 
12 
39-4 
91 
2-6 
February .. 
9 
43-4 
86 
2-6 
7 
43-2 
86 
2-2 
5 
44-7 
83 
1-3 
8 
40-1 
87 
1-2 
12 
40-8 
87 
09 
7 
33-3 
80 
0-9 
13 
39-5 
84 
1-0 
9 
29-4 
91 
1-4 
10 
42-0 
87 
1-1 
March 
7 
43-8 
83 
3-1 
5 
42-5 
80 
0-5 
5 
39 9 
77 
0-3 
12 
42-6 
84 
4-1 
6 
41-3 
81 
0-2 
14 
38-5 
78 
1-5 
7 
43-8 
79 
0-4 
5 
37-9 
86 
1-5 
8 
3S-7 
82 
1-1 
4 J 
Mean temp. & 
April 
hum. of sue. 
3 
43-2 
86 
2-2 
7 
48-5 
79 
2-3 
8 
44-7 
82 
2-3 
7 
45-9 
0-5 
5 
45-2 
77 
3-1 
6 
48-4 
77 
0-6 
8 
45-8 
78 
0*1 
8 
46-S 
74 
2-3 
qr.& total rain 
May 
4 
54*3 
81 
7-3 
4 
54-0 
70 
3-9 
14 
51 -3 
76 
2-4 
16 
50 9 
76 
0-8 
9 
51-5 
77 
1*9 
6 
52-0 
74 
1-6 
8 
50-9 
85 
3-3 
10 
48*8 
£0 
1-8 
7 
49-5 
77 
3-5 
June 
13 
12 
57-9 
71 
0-2 
11 
60-8 
70 
0-9 
24 
58-9 
73 
1-3 
9 
56-1 
78 
4-6 
17 
58-2 
70 
2-8 
10 
55-7 
82 
1-0 
7 
56-9 
74 
0-7 
7 
58-5 
79 
1-6 
July 
16 
16 
62-1 
71 
29 
15 
62-2 
88 
2-9 
29 
60-1 
77 
4-2 
4 
66-6 
73 
2-3 
11 
60-3 
76 
6-0 
15 
60-3 
78 
1-7 
25 
62-1 
80 
5-0 
7 
61-1 
79 
0-9 
August 
17 
5S-6 
78 
8-7 
16 
62-9 
77 
0-45 
13 
60-2 
80 
1-9 
18 
62-3 
76 
2-6 
62-1 
72 
4-5 
33 
60-0 
77 
2-2 
20 
60-9 
77 
2-9 
40 
62-1 
76 
1-1 
28 
63-6 
78 
2-4 
September . 
26 
• • 
19 
58-8 
77 
3 3 
13 
56-4 
75 
1-3 
27 
56-9 
76 
0-5 
19 
56-8 
77 
3-9 
33 
55-3 
84 
2-4 
49 
58-1 
77 
0-7 
26 
57-1 
80 
1-1 
14 
55-2 
75 
2-8 
October 
17 
25 
51-1 
81 
2-7 
17 
47-0 
S2 
1-4 
24 
52-6 
SI 
1-8 
12 
47-9 
80 
3-8 
29 
50-9 
90 
4-3 
51 
49-4 
84 
2-6 
25 
51-2 
89 
4-9 
15 
51-7 
87 
1-6 
November.. 
19 
4.5-9 
88 
7-3 
16 
44-1 
86 
1-5 
17 
46-5 
85 
2-5 
30 
37-9 
82 
0-6 
12 
48-9 
82 
6-0 
26 
42-1 
93 
1-5 
20 
40-5 
91 
1-4 
22 
41-3 
92 
1-3 
28 
40-7 
88 
1-0 
December.. 
11 
6 
39-1 
90 
2-4 
14 
40-6 
92 
1-3 
25 
40-5 
69 
0-6 
IS 
47-6 
79 
2*2 
13 
34-0 
91 
0-7 
16 
41-3 
87 
1-4 
24 
35-6 
79 
1-2 
5 
40-2 
90 
1-3 
(a) Spring.. 
20 
15 
42-9 
84 
49 
17 
44-3 
79 
3-9 
28 
42-5 
84 
7-6 
25 
42-7 
81 
1-0 
26 
39-0 
78 
5-5 
26 
43-9 
80 
20 
22 
37-7 
85 
3-0 
26 
42 5 
81 
4-5 
(5) Summer 
33 
32 
58-0 
70 
7-0 
40 
58-1 
78 
6-2 
69 
56-6 
75 
6-3 
22 
58-0 
76 
8 8 
34 
57-0 
» 
10-4 
33 
55-6 
SI 
6-0 
42 
55-9 
78 
7-5 
21 
56-3 
78 
6-0 
(e) Autumn 
60 
60 
57-6 
78 
6-4 
43 
54-5 
79 
4-6 
69 
57-2 
77 
4-9 
53 
55-6 
76 
12-2 
95 
55-4 
84 
8-9 
120 
56-1 
79 
6-2 
91 
56-8 
81 
7-1 
57 
56-8 
80 
6-8 
(d) Winter. 
39 
.. 
31 
41-1 
88 
5-5 
37 
40-2 
88 
5-0 
68 
40-4 
79 
3-9 
40 
46-2 
82 
11-8 
56 
39-5 
88 
4-2 
49 
40-2 
89 
4-5 
62 
33-9 
87 
3-5 
45 
40-1 
89 
4-9 
Total .. 
152 
13-3 
138 
49-9 
80 
23-8 
137 j 
49-2 
81 
19-7 
234 
49-2 | 
79 
22-7 
140 
50-6 
79 
34-4pll 
47-7 
81 
29-0 
228 
48-9 
82 
18-7 
217 
46-0 
£2 
21-1 
149 
48-9 
82 
222 CAUSES. 
237 
Total... 
(d) Winter. 
(e) Autumn 
(&) Summer 
(a) Spring . 
December.. 
November.. 
October 
September . 
August .... 
^inp 
June 
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(a) Spring-February, March, April. (b) Summer-May, June, July. (c) Autumn-August, September, October. (d) Winter-November, December, January. 
TABLE showing the number of cases of ENTERIC FEVER treated in the LONDON FEVER HOSPITAL, continued:- 238 
ENTERIC OR TYPHOID FEVER. 
but that each month had a due share, 
while in 1852 the still more abundant rain 
was unequally distributed throughout 
the year, the spring and early part of 
summer being unusually dry. If now, on 
the other hand, we regard the influence of 
drought, we find that the largest number 
of cases, 249, occurred in the driest year, 
1804, when only 15'7 inches of rain fell. 
The next driest year was 1858; there 
were only 17'2 inches of rain in this year, 
and one-third of it fell in the summer 
months; the winter was the season of 
drought, and this was associated with an 
unusual increase of Enteric Fever in 
January. 
With the same amount of rain in the 
years 1850 and 1854, there is a difference 
of ninety-one cases of fever, and this may 
be attributed to the inequality of the dis- 
tribution of rain throughout the year, 
which may possibly be greater than is in- 
dicated in the Table. Thus, for example, 
the Table is not sufficiently detailed to 
show that, in 1854, the inch of rain for 
June did not fall on the first day of that 
month, and the 1'7 inch on the last day of 
July, leaving a long interval of drought 
between-as may have been the case. 
Mr. Glaisher's laborious and valuable ob- 
servations are deserving of more detailed 
study in the elucidation of these ques- 
tions. 
The dry winters of 1851, '53, '55, '58, 
and '62, were associated with an increase 
of Enteric Fever. 
The opposite effects of drought and rain 
have been well illustrated during the pres- 
ent summer (1865). Towards the end of 
July there was a great want of rain, but 
from the 30th of this month and through- 
out August there was an unusual amount, 
larger quantities having fallen almost 
every day. As shown by the admissions 
into the London Fever Hospital, Enteric 
Fever was very prevalent during the dry 
season, but after a fortnight's heavy rain 
its further progress received a sudden 
check, which continued until the effects of 
the succeeding drought became manifest. 
It appears clearly from the foregoing 
observations that the absence of rain fur- 
nishes conditions most favorable to the 
increase of Enteric Fever; and since 
drought is necessarily associated with dry- 
ness of the air and exalted temperature, 
we must consider it, thus combined, as 
the one predisposing cause of Enteric 
Fever. 
Other Atmospheric Conditions. - Too 
little is at present known respecting the 
influence of ozone in the production of 
disease; but as this body has been ob- 
served to be absent, or nearly so, from the 
air during the prevalence of cholera and 
other intestinal affections, the following 
general statements made by Dr. Moffatt 
(Chemical News, September, 1861) may 
be borne in mind. The quantity of ozone 
varies according to the time of year, the 
direction of the wind, temperature, atmo- 
spheric pressure, and the pressure of de- 
composing substances. Rain, a south 
wind, fall of the barometer, and increase 
of temperature, separately or combined, 
arc associated with an increase of ozone, 
and the reverse conditions with its de- 
crease. "Ozone periods terminate with 
increasing barometer readings, decrease 
of temperature, and wind from N. points 
of the compass. " Ozone is most abundant 
in January, February, and March ; less so 
in April, May, and June ; and least of all 
in July, August, and September. "The 
greatest number of ozone days is in 
April, and the smallest in August and 
November. Whatever tends to a deflec- 
tion in the direction of the wind leads to 
a corresponding result in ozone observa- 
tions ; and a town, chemical works, drains 
and cesspools, &c. deozonize the air, or 
wind passing over them" (p. 1G7). 
Change of Residence, &c.-Both Louis 
and Chomel have observed that the greater 
number of the patients who came under 
their treatment in Paris had resided there 
only a short time. But change of resi- 
dence, apart from the excitement and fa- 
tigue, the irregularity of living, and the 
distress which very commonly attends it, 
can hardly be considered a predisposing 
cause of Enteric Fever. In the autumn 
of 18G1 a case of Enteric Fever which ter- 
minated fatally came under my care in 
Paris. The patient, a robust, newly-mar- 
ried lady, had been resident there only a 
few weeks, but during the whole of this 
time she had voluntarily lived a life of 
daily excitement and fatigue ; the diges- 
tive functions were deranged by an unu- 
sual diet and irregular mode of living, 
and to these causes the disease was prob- 
ably attributable. 
M. Chomel found that one-third of the 
115 cases to which special inquiry was di- 
rected had been exposed to sudden cold, 
to want of food or to bad diet, to excessive 
fatigue, to mental depression, and to de- 
bility produced by other diseases. 
In his account of the outbreak of En- 
teric Fever in a garrison of 306 soldiers, 
Dr. Grossheim says : "It is difficult, if not 
impossible, to ascribe any deleterious in- 
fluence to the food-all shared alike." 
Tie attributes the disease to the effect of 
military exercises in a changeable season, 
with night bivouac in the open air. (Edin. 
Med. Jour., vol. xlviii.) 
(b) Exciting Causes.- Contagion is sup- 
posed by MM. Leuret, Bretonneau, Gen- 
dron, Dr. William Budd, and other phy- 
sicians, to be the means whereby Enteric 
Fever is propagated. The following ex- 
amples of the spread of the disease fur- 
nish the strongest proof that can perhaps 
be adduced in support of this view :- CAUSES. 
239 
Five persons were successively attacked 
with Enteric Fever in a certain house in 
Geneva. A sixth inhabitant of that town 
spent two nights with the third patient, 
soon contracted Enteric Fever, and died 
of it in the hospital. "At the autopsy, 
ulcerations of the ileum, and all the other 
lesions characteristic of dothinentery, were 
found." A clergyman who visited the 
third patient-a little girl-took the dis- 
ease and died with all the symptoms of 
typhoid fever ; his nurse was also attacked 
with typhoid fever, and died in the third 
week. A young lady also paid the third 
patient a visit, and rendered her some 
service in the sick-chamber, and this per- 
son soon fell ill with symptoms of typhoid 
fever, in another house, in which five 
other persons were subsequently attacked 
by the same disease. (M. Lombard, Gaz. 
Med., 1839, p. 138: quoted by M. Pied- 
vache, Mem. de l'Acad. de Med., tome xv. 
p. 294.) 
Dr. W. Budd had seventeen cases of 
Enteric Fever under his care in the ham- 
let of North Tawton, Devon, and during 
the prevalence of the disease three per- 
sons left the hamlet ill of the fever. 
A went to Morchard and died there, 
and ten days after his death two of his 
children had the fever in the same house. 
B also went to Morchard, and three 
cases of Enteric Fever afterwards occur- 
red in the house where he lay ill. 
C went to Chaffcombe, seven miles from 
North Tawton, and nine other cases of 
Enteric Fever appeared in the farmhouses 
to which he went. One of these nine left 
Chaffcombe and went four miles away, to 
Loosebeare, to be nursed. Several in- 
mates of the house into which this patient 
was received were subsequently attacked 
with Enteric Fever, and from this house 
the disease extended over the whole ham- 
let. An infected boy also left Chaff- 
combe, and took the fever to a cottage 
midway between Bow and North Taw- 
ton, and five persons subsequently fell ill 
of Enteric Fever in the house into which 
he was received, and in the adjoining one. 
Besides these there was no single case of 
the sort nearer to Chaffcombe than North 
Tawton. " There were twenty or thirty 
hamlets in the neighborhood similar in all 
respects to Loosebeare. From the soil of 
all, through month after month of the 
same fine, dry, autumnal weather, human 
and other exuvise exhaled into the air; 
and yet, while at Loosebeare a large pro- 
portion of the inhabitants were lying 
prostrate with intestinal fever, in not one 
of the exactly similar places was there a 
single case." (Dr. W. Budd, Lancet, July 
9, 1859, p. 8.) 
It is reasonable that those who have 
witnessed such instances as these should 
be fully persuaded that Enteric Fever is 
propagated by contagion. But there are 
many physicians, and amongst them 
those who have had the most extensive 
experience of Enteric Fever, who con- 
clude either that the disease is destitute 
altogether of contagious properties, or 
only possesses them in a very slight de- 
gree. 
[Dr. Austin Flint,1 of New York, who 
has contributed one of the most remarka- 
ble series of facts showing the influence of 
tainted drinking water in Typhoid Fever, 
nevertheless writes thus: "Under ordi- 
nary circumstances it is not diffused by 
contagion " facts appear to show the 
spontaneous generation of the causative 
agent in the great majority of cases."- 
H J 
That form of Enteric Fever which pre- 
vails continuously in London is certainly 
non-contagious. I have never had cause 
for the slightest suspicion of contagion in 
any case which has come under my ob- 
servation, either in King's College Hos- 
pital or in the London Fever Hospital, 
and this generally is the experience of 
hospital physicians, both in London and 
in Paris. 
Since writing the above, the following 
instance, in which there is evidently a 
strong probability of contagion, has come 
under my notice. In the present summer 
(1865), four members, A, B, C, D, of a 
family of six adult people, residing at St. 
Peter's Terrace, Notting Hill, were at- 
tacked with Enteric Fever. A and B 
had been residing at Ryde for a month. 
They returned to town with two other 
members of the family on the 26th of 
May. A suffered ever since his return 
with diarrhoea, which continued, and the 
symptoms of Enteric Fever became well 
developed. " On the 28th of June he had 
a severe attack of intestinal hemorrhage, 
which recurred two or three times for 
several days; eventually he recovered." 
About the 7th of June, his sister, B, fell 
ill of the disease, and she died comatose 
on the 29th of June. On July 10th, C 
and D, who had not been absent from 
London, manifested symptoms of Enteric 
Fever, and were sent into King's College 
Hospital, where they came under my col- 
league Dr. George Johnson's care. I saw 
them frequently. They had well-marked 
Enteric Fever, and are, at this present 
date (August 22, 1865), slowly convales- 
cing in the Twining ward. On the 8th of 
August, a nurse in attendance upon these 
patients was taken ill with the same dis- 
ease, and now is under my colleague Dr. 
Beale's care, in the same ward, in a very 
precarious state.2 This last patient, it 
[' Practice of Medicine, 4th Edition, p. 683.] 
2 She died on the 25th of the above month, 
and I witnessed the post-mortem examina- 
tion. There was extensive ulceration of 
Peyer's patches and enlargement of the soli- 240 
ENTERIC OR TYPHOID FEVER. 
must be observed, slept every night at St. 
John's House, situated at a distance from 
the hospital, and between it and the 
Thames; and a great many isolated cases 
of Enteric Fever have occurred in London 
during this month. All but the last pa- 
tient came under the care of my friend, 
Dr. Easton, of Connaught Square, and to 
him I am indebted for the particulars 
having reference to the period before B 
and C were admitted into the hospital. 
Dr. Easton carefully inquired into the 
sanitary condition of the house where the 
disease broke out. No cause could be 
found, and care was taken to mix the 
evacuations with Condy's fluid and dis- 
pose of them immediately they were 
passed. C and D had scarcely any com- 
munication with A and B. 
In considering the question of contagion 
it must be granted that the occurrence of 
any number of cases simultaneously or 
successively in any given house or ham- 
let, can never prove the fact of contagion. 
The general conditions, moreover, favor- 
able to the increase of the disease, are so 
common and wide-spread, that one who 
entertained limited views of the nature of 
the disease, might account for its propa- 
gation among the inhabitants of Geneva, 
above referred to, for example, by assum- 
ing-and not improbably-that the con- 
ditions favorable for the spontaneous de- 
velopment of Enteric Fever existed in 
each of the four or five houses in which 
the patients resided, and that the inter- 
communication which took place between 
them was a curious coincidence-each pa- 
tient in reality being independently af- 
fected. If this explanation be thought 
satisfactory in the first instance adduced, 
it cannot be considered otherwise than 
unlikely and superfluous in the second, in 
which the general evidence of contagion 
appears to be complete. It is true that 
the conditions favorable for the outbreak 
of Enteric Fever appeared to exist equally 
in all these little hamlets ; and if it had 
arisen in any or in all without the inter- 
vention of an infected person - and it 
must have so arisen in the first case-the 
disease in each individual might reason- 
ably have been referred to a spontaneous 
origin. 
M. Gendron himself was unable to ac- 
count for the first cases in many localities, 
and M. Piedvache, after a careful exami- 
nation of the whole question of contagion, 
" feels almost sure that typhoid fever, un- 
der some circumstances, declares itself at 
once and in sufficient numbers to consti- 
tute an epidemic, independently of conta- 
gion." (Mem. de l'Acad. de Med., tome 
xv. p. 137.) 
We have now to inquire into the con- 
ditions with which Enteric Fever is im- 
mediately associated, and the mode of its 
spontaneous origin. 
Spontaneous Origin.-The majority of 
the French physicians who witnessed the 
epidemics which occurred in France, from 
1841 to 1846, "signalize, amongst the 
causes to which they attribute the mani- 
festation of these epidemics, the following 
conditions :-The more or less immediate 
vicinity of stagnant waters, marshes, or 
bogs, from which, chiefly under the influ- 
ence of summer neat, effluvia arise and 
spread over the people-effluvia which 
tend to produce affections of a periodic 
type : the presence of dunghills, often ac- 
cumulated and allowed to remain for a 
long time upon a public way, before 
houses, or the single door of some wretch- 
ed hut; wells of water, level with the 
ground, permeated with water infected 
by drains and dunghills ; an infected pool 
existing in the midst of a commune, and 
furnishing only a brackish, muddy, stink- 
ing water for the common drink of men 
and of animals who come to allay their 
thirst there ; or springs, containing, it is 
true, a pure water and fit to drink, but 
disturbed by all kinds of animals who go 
there to drink and corrupt the water with 
their dung; or further, conduits of im- 
pure water, which become a source of 
infection to the houses near which they 
pass, or, discharging their contents upon 
the public ways, form puddles of stagnant 
water in streets badly kept and unpro- 
vided with suitable means for carrying 
off the fluid accumulations." (M. de 
Claubry, op. cit. p. 11, et seq.) 
The occupants of a farmhouse are at- 
tacked with Enteric Fever, and the only 
discoverable cause is an over-flowing cess- 
pool, or a stagnant, offensive pond, or a 
low-lying fold-yard, covered with a thick 
bed of dung and other refuse matter, from 
which putrescent runnings sink and satu- 
rate the soil in which the well, supplying 
the house, is excavated. 
The accumulated or pent-up sewage of 
a town escapes into the subjacent soil 
within and about it, soaking into the 
wells and defiling the drinking water, and 
giving off filthy emanations into the air, 
and an outbreak of Enteric Fever follows. 
A particular drain becomes obstructed, 
bad odors arise into the houses in commu- 
nication therewith, and sicken their in- 
habitants, and Enteric Fever soon mani- 
fests itself. 
Such are almost constantly observed 
conditions with which Enterit Fever is 
associated, and we must therefore con- 
clude that this disease has a spontaneous 
origin in putrescent matters-that these, 
when preserved from the purifying influ- 
ences of air and water, generate a poison, 
which, when admitted into the body, pro- 
tary glands in the last three feet of the ileum, 
and these constituted the chief anatomical 
lesions. CAUSES. 
241 
duces Enteric Fever. Leaving for the 
present all speculation as to the nature of 
the poison thus generated, we will now 
proceed to inquire how the poison or poi- 
sons gain admission into the system- 
whether by the lungs or by the alimentary 
canal. The inquiry is an important one, 
and we must be careful to avoid the influ- 
ence of partial views. If we except the 
most thoroughly-drained towns (such as 
London, where, perhaps, Enteric Fever 
attains its minimum development), where- 
ever the air is vitiated with filthy odors, 
the subjacent soil is permeated by the 
putrescent source from which they arise, 
and the water is also contaminated. 
Hence, in many cases, it may be difficult 
to determine whether the poison were 
conveyed by the air or by the drinking 
water. Dr. Murchison, in his elaborate 
work on the Continued Fevers of Great 
Britain, endeavors to prove that Enteric 
Fever arises from "sewer emanations." 
"So far as we know," he says, "it is 
necessary for the production of the poison 
of Enteric Fever that the matter under- 
going fermentation be either in a confined 
space, as in a drain or sewer, or that it 
be in a state of stagnation. Free expo- 
sure to the atmosphere, or constant dilu- 
tion in a running stream, may not only 
render the poison inoperative, but may 
altogether prevent its formation. A privy 
outside a house is much less dangerous 
than a badly-appointed water-closet with- 
in." (Pp. 452, 453.) In the instances 
which he adduces to support this view 
nothing is said respecting the water-sup- 
ply. Assuming that there were no sources 
of water within the precincts of the 
buildings, the outbreak of fever in the 
Westminster School - shortly after the 
exhalation, from a foul and neglected 
sewer, of a disagreeable stench, so pow- 
erful as to induce nausea-appears, pretty 
clearly, to have been due to the foul air. 
In outbreaks of disease amongst bodies of 
soldiers, school-children, &c. we must be 
prepared to look for the cause abroad as 
well as at home. A body of young crick- 
eters, for example, may quench their 
thirst in some impure stream, and thus 
contract a disease, for which some appa- 
rent cause may be readily discovered at 
home. There can be little doubt that 
Enteric Fever is occasionally generated 
by exhalation from putrescent matters, 
but usually, we believe, they are ineffec- 
tual in the production of the disease. It 
has never yet been proved experimentally 
that Enteric Fever may be generated by 
emanations from decomposing animal and 
vegetable matters. Nor does it appear 
from the observations of those who have 
made special investigation in this direc- 
tion that individuals whose occupations 
require them to spend much of their time 
in an atmosphere thus contaminated evince 
an unusual proclivity to Enteric Fever. Dr. 
Guy compared the past and present con- 
dition of ninety-six nightmen, with about 
the same number of bricklayers, laborers, 
and brickmakers, and after a most critical 
investigation, he says : "An examination 
of the tabulated results of his inquiries 
must convince the most sceptical that the 
health of scavengers is fully equal to that 
of the laboring man with whom they are 
compared." (Journal Statis. Soc., 1848, 
vol. ii. p. 79.) This agrees with the ob- 
servations of M. Parent du Chatelet and 
others on the health of men who work in 
sewers. In the country it is a common 
practice to empty the privies and spread 
their contents over the gardens or adjoin- 
ing fields. The filthy odors are endured 
as a temporary inconvenience, but expe- 
rience proves that the practice is a harm- 
less one. In two instances I have known 
the inhabitants of a house to be exposed 
for months to the direct emanations-in 
the one case, of a large cesspool; in the 
other, of a common-sewer. In both cases 
a leaden pipe, in communication with the 
water-closets, was carried down inside 
the house and thence into the sewer or 
cesspool. After several unsuccessful ex- 
plorations it was discovered that rats had 
eaten a large hole in the pipe leading to 
the cesspool, and through this aperture 
the fetid exhalations from the surface 
arose directly into one of the sitting- 
rooms and a passage of the building, and 
on hot and damp days the effluvia were 
intolerably offensive. The cesspool was 
emptied at this time, and I witnessed the 
process. The contents were semi-fluid, of 
a dirty-black color, and the surface of the 
pool was covered with large bubbles of 
gas. Now, although several persons were 
continually exposed to filthy exhalations, 
in the one case for many months, and in 
the other for several years, none suffered 
from diarrhoea or Enteric Fever. Nu- 
merous examples of this kind teach us 
that we must not be too ready to attribute 
Enteric Fever to foul air, but that we 
should be prepared to acknowledge other 
means by which the disease may be intro- 
duced into the system. Of these we may 
consider tw'O,-impure water and bad food. 
[In some inquiries into the statistics of 
Typhoid Fever in Philadelphia, obtained 
at my request from the official records of 
the Board of Health by Dr. B. Lee, it was 
ascertained that the largest mortality from 
this disease during a series of years oc- 
curred in two kinds of localities. These 
were: 1, those districts adjoining the 
Schuylkill and Delaware rivers, near the 
outlets of the city sewers ; 2, those whose 
sanitary conditions were otherwise of the 
worst kind, from poverty, ignorance, vice, 
and neglect.-II.] 
The following instance is worthy, from 
the simplicity of the attendant conditions, 
VOL. I.-16 242 
ENTERIC OR TYPHOID FEVER. 
of attentive consideration with reference 
to the spontaneous origin of Enteric Eever. 
An outbreak of Enteric Fever occurred at 
Stangenrod, "a village chiefly seated on 
a naked, exposed, isolated eminence. 
Trees, excepting young brushwood, are 
not seen in the neighborhood, and there 
are but few marshes ; a small stream has 
its source at some distance, but scarcely 
touches the extreme boundaries of the 
district. In several places are flats cov- 
ered with broom and used as pasture 
grounds. The basis is mostly basaltic 
rock, covered with a layer of clay and 
loam mixed with sand and flint. The air 
is keen and pure, and the atmosphere 
rarely disturbed by clouds. The position 
of the town is healthy as to local influ- 
ences, and not favorable to the production 
of endemic disorders, which, it appears, 
had never been observed in it. The in- 
habitants were poor, and chiefly occupied 
in agriculture and pasturage ; comfort and 
wealth were exceptions. The houses were 
small, low, dirty, and surrounded by 
dunghills. The general want of spring- 
water the inhabitants attempt to supply 
by collecting rain-water in bad reser- 
voirs." (Dr. Ebel, Ed. Med. and Surg. 
Jour., 1837, vol. xlviii. p. 160.) The dis- 
ease appeared at the close of July 1833, 
and terminated in April 1834. The 
spring of 1833 was dry, followed by a dry 
summer, with insufferable heat, continu- 
ing to autumn without rain, and with 
little wind (p. 187). 157 out of 318 in- 
habitants were attacked, and 19, or 12 T 
per cent., died. Dr. Ebel believed that 
the chief cause of the disease consisted in 
" the entire want of good fresh water and 
the use of corrupted water. The inhabi- 
tants of the village used for domestic pur- 
poses rain-water obtained from marshes, 
and preserved in insufficient reservoirs 
until required" (p. 188). 
In the latter part of 1859 a severe out- 
break of Enteric Fever occurred at Bed- 
ford, and there was every reason to believe 
that it was due to fecal matter soaking 
into the wells from the numerous cess- 
pools of the town. The water from these 
wells was found to contain a large quan- 
tity of decaying animal matter, evidently 
derived from the sources alluded to. 
(Simon, Report to Privy Council, 1860.) 
Early in October 1847, "intestinal fever" 
broke out almost simultaneously in thir- 
teen houses in a certain terrace at Clifton. 
The houses were far apart in the terrace, 
and there was little or no intercourse be- 
tween their inmates. The inhabitants of 
these thirteen houses drew their drinking 
water from a well situated at one end of 
the terrace, and at the end of September 
it became evident, from the taste and 
smell of the water from the pump, that it 
was tainted with the contents of the sewer. 
The remaining twenty-one houses were 
supplied with water from another source. 
(Dr. W. Budd, Lancet, 1859, p. 432.) 
Other instances of the direct association 
of Enteric Fever with defective drainage 
and contaminated well-water may be 
found in the Sixth Report to the Privy 
Council, 1863. 
Rain, the natural preventive of Enteric 
Fever, may, under certain local condi- 
tions, be the means of diffusing it. This 
appears to have been the case at Festi- 
niog. 
The houses in which the disease ap- 
peared are situated on the slopes or bases 
of mountains on the sides of the valley 
stream. "The majority have no privies 
nor ash-pits, nor have their inhabitants 
access to places of this sort. The custom 
of the neighborhood is to use the fields, or 
when house utensils are employed to 
empty them at a distance from the houses. 
Houses in a row are generally provided 
with one or more privies, with cesspools 
common to the row. The air is pure and 
the natural drainage good; the valley 
stream is exposed to constant contamina- 
tion. The inhabitants stated that water 
for internal use is got from wells on the 
mountain side, presumably situate above 
any possible source of pollution" (see the 
Report to the Privy Council by my col- 
league, Dr. Buchanan; Sixth Report, 
1863, pp. 787-8); but they acknowledge 
that they use the water of the stream in 
the valley for some domestic purposes, 
and it is obvious how readily this may be 
substituted for the purer, on all occasions, 
and particularly when the distant spring 
fails, and laziness or lack of time con- 
strains the water carrier. 
Under such conditions as the above, 
filth accumulates upon the surface during 
a dry season, and remains harmless there 
till drenching rain gradually washes it 
down into the common stream, which thus 
becomes continuously contaminated for 
weeks or months. Dr. Buchanan has 
pointed out these conditions, and is in- 
clined to attribute the prevalence of the 
disease during an unusually wet autumn 
to water contamination, combined with 
exposure to cold and wet. 
Impure water appears to be equally a 
cause of intermittent fever and its compli- 
cations. The Inspector of Hospitals 
writes of Walcheren during the prevalence 
of the severe intermittent fever there: 
" The bottom of every canal that has 
communication with the sea is thickly 
covered with an ooze, which, when the 
tide is out, emits most offensive and noi- 
some effluvia ; every ditch is filled with 
water which is loaded with animal and 
vegetable substances in a state of putre- 
faction ; and the whole island is so flat, 
and so near the level of the sea, that a 
large proportion of it is little better than 
a swamp , there is scarcely a place where CAUSES. 
243 
water of a tolerably good quality can be 
procured." Sir John Pringle mentions 
"that the men-of-war which lay all the 
time at anchor in the channel, between 
South Beveland and Walcheren, even dur- 
ing the worst period of the distemper, 
were not affected with either flux or fever, 
but enjoyed the most perfect health." 
(Davis on the Walcheren Fever, 8vo. 
1810, p. 15.) These sailors were doubt- 
less provided with a supply of good water. 
The inhabitants of a marsh, seated in 
a basin of clay, or level with the bed of a 
river, must of necessity drink water con- 
taminated by their excretions and other 
impure matters, if the water be derived 
from the marsh itself, and the drier the 
season the more concentrated the poison- 
ous impurity. 
Dr. W. Budd most strongly insists that 
the essence of Enteric Fever is contained 
in the alvine dejections of the patient, 
but we cannot adduce any facts recorded 
by himself that give material support to 
this view, and our own observations lead 
us to the conclusion that the intestinal 
discharges do not contain any volatile poi- 
son which is capable of generating Enteric 
Fever. [Dr. Ballard and others' have re- 
ported several instances in which out- 
breaks of typhoid fever, in London and 
elsewhere, have been traced to a close co- 
incidence with the distribution of milk, 
furnished to a number of families from 
the same dairies. The contamination of 
the milk by foul water has been inferred ; 
and, in some of the cases, the existence of 
typhoid fever near the inculpated dairies 
has been shown. It appears, however, to 
be still an open question, in some minds 
at least, whether these instances are to be 
considered as giving evidence of the dif- 
fusion of a specific contagium of Enteric 
Fever, or whether they ought not rather 
to be referred to the category of facts, 
otherwise numerous, showing the promo- 
tion of the disease by foulness of all kinds, 
in air, water, or food.-II.] 
Food in an incipient stage of putrefac- 
tion is also capable of generating symp- 
toms and intestinal lesions apparently 
identical with those of Enteric Fever. 
Dr. Kerner of Weinsberg has collected 
35 observations of poisoning from eating 
a certain kind of smoked puddings, which 
he regards as putrid food. They are 
chiefly composed of animal matters, and 
have a putrid savor and odor. Post- 
mortem examinations often revealed 
traces of inflammation of the oesophagus 
and pharynx ; gangrenous patches of the 
stomach; intestines inflamed in divers 
places, or even gangrenous in part; lungs 
strewn with black spots, or hepatized, 
(Orfila, vol. ii. p. 636, 1843.) Dr. Schu- 
mann records the symptoms and post- 
mortem appearances produced by eating 
similar food. The symptoms were those 
of Enteric Fever, plus inflammation of the 
pharynx, oesophagus, and larynx. Post- 
mortem examinations revealed inflamma- 
tion of the intestinal canal: "L'intestin 
grele, quelquefois tres distendu par les 
gaz, present! des traces d'inflammation 
tres intense, et souvent des plaques gan- 
greneuses." Lungs gorged with blood. 
(Archives Generales de Med., tome xxii.) 
Granting that Enteric Fever may be 
produced by the ingestion of putrid ani- 
mal substances, we shall be at no loss to 
find a cause for the origin of many of the 
isolated cases which occur, for such may 
exist, in every household. There is no- 
thing, for example, more essentially putrid 
than the decomposed cheese with which 
many persons habitually indulge their 
appetites, and persons unaccustomed to 
such food can hardly be supposed to par- 
take of it with impunity. It is a matter 
of common experience that an egg will 
sometimes produce vomiting and purging. 
With regard to the identity and nature 
of the poisonous agent or agents which 
produce Enteric Fever, we know nothing. 
It has never been demonstrated that any 
particular gaseous body can induce the 
lesions found after death from Enteric 
Fever. There are, however, both mineral 
and vegetable substances which, when in- 
troduced into the stomach, produce symp- 
toms and morbid changes, if not identical 
with those of Enteric Fever, at the least 
hard to be distinguished from them. 
Thus, to take vegetable substances:- 
Twenty-four hours after the ingestion of 
poisonous mushrooms, the members of a 
family were taken with nausea, and the 
next day frequent vomitings of bilious 
matters and abdominal pains, of which 
symptoms three children died. The other 
members had insupportable pains in the 
stomach, loins, and abdomen, meteorism, 
retention of urine, tenesmus, glairy san- 
guinolent stools, vomiting, and great 
thirst. On the fifth day, shivering, col- 
lapse, and death. 
The stomach and intestines were found 
covered with whitish or yellowish mucus, 
the valvula? conniventes and mucous fol- 
licles generally very prominent. (C. P. 
Galtier, Traite de Toxicologie, tome ii. 
pp. 564-569.) 
The effects of colchicum still more closely 
resemble those of Enteric Fever. Two 
young women took each about ^iv of 
tincture of colchicum. Both died of vio- 
lent gastro-intestinal inflammation. The 
viscera of one were tied up and sent away 
for analysis. In the other, who died 
twenty-eight hours after taking the poi- 
son, the lungs were healthy, stomach dis- 
tended by gas, and the mucous membrane 
evidently softened. Throughout the 
[' British Med. Journal, Nov. 28, 1870; 
Lancet, April 5,1873 ; lb., Aug. 16,1873, &c.J 244 
ENTERIC OR TYPHOID FEVER. 
whole extent of the intestine the mucipa- 
rous follicles were of the size of millet | 
seeds, and in the inferior third of the I 
ileum the plates resulting from the agglo- 
meration of the mucous crypts were also 
much developed and of a violet color. 
(Galtier, loc. cit. p. 322.) 
In poisoning by Cicuta virosa similar 
symptoms and swelling of the glands of 
the intestine are produced. 
Ilas the poison which so frequently 
generates Enteric Fever any relation to 
the elaborated narcotico-acrid principles 
of these or other plants ? If so, is it gene- 
rated in the process of decomposition, and 
is it possible to obtain it by lixiviation of 
the impure soil, or by precipitation from 
the contaminated water ? Or again, is 
the poisonous agent merely a common 
product of decomposition, and destitute, 
like that common contagious sanies which 
so readily induces phlebitis or erysipelas, 
of any specific character ? Such are the 
speculations into which further inquiries 
respecting the origin of the disease lead us. 
Returning now to the facts above de- 
tailed, we may conclude, (1) that refuse 
animal and vegetable matters, if allowed 
to accumulate and decompose in seasons 
of draught, generate a poison which, if 
not washed away or diluted by sufficient 
rain, rises into the air, or becomes diffused 
in the water; and which, when intro- 
duced into the body by these media, may 
produce Enteric Fever ; (2) that food or 
water rendered impure under conditions 
less general, may also be the means of 
inducing the same disease; (3) that there 
can be little doubt that the usual symp- I 
toms and post-mortem appearances of; 
Enteric Fever may arise during the pro- 
gress of several other acute diseases as a , 
consequence of a general inflammatory 
condition. 
Diagnosis.-The indications of inflam- 
mation and ulceration of Peyer's patches 
are the following: Pain and tenderness 
in the right iliac fossa ; general derange- 
ment of the alimentary canal, accom- 
panied by persistent diarrhoea; light 
ochre-colored watery stools ; hectic fever ; I 
and the eruption of rose-colored papules. 
If these symptoms be associated with any 
febrile condition or complication what- 
ever, we may be sure of the presence of 
enteric inflammation. If they are absent, 
the case may be one of commencing pneu- 
monia, erysipelas, hernia, puerperal fever. 
But each or all of the symptoms of enteric 
inflammation may be latent, and our at- 
tention may, therefore, be altogether 
called away from the abdomen to the i 
head or the chest. In the absence of 
diarrhoea, the other characteristic symp- 
toms being present, we may assume, gen- 
erally, that the intestinal glands are sim- 
ply inflamed and swollen; the presence , 
of the pale, watery, flocculent stools, on 
the other hand, may be taken as indica- 
tive of the ulcerative stage. Diarrhoea 
alone, or even associated with a febrile 
state, does not furnish conclusive evidence 
of intestinal lesion; but there is one un- 
mistakable evidence occasionally present, 
from which, in the absence of every other 
symptom, we may positively declare that 
the agminated glands of the ileum are in 
a state of sloughing inflammation; it is 
the presence of a fragment of a disinte- 
grated Peyer's gland in the stools. If 
the floculent debris, when examined un- 
der water by the aid of a pocket lens, 
present a number of minute, closely-placed 
follicular depressions with minute circular 
orifices, loosely embedded in a ragged 
fibrous stroma (fig. 12), we have direct 
Fig. 12. 
Fragment of a Peyer's gland. 
and positive evidence of the nature and 
progress of the disease. Even while the 
pale stools are still solid, a shreddy frag- 
ment presenting these unequivocal cha- 
racters may be found adherent to their 
surface. To apply the test, the stools 
should be strained through a little cap 
net, the matters arrested thereby should 
then be washed, floated in clear water, 
and examined with a common pocket 
lens. The structure of the agminated 
gland is quite distinct from that of any 
other tissue in the body, not even except- 
ing the thyroid gland and tonsils. Cellu- 
lar vegetable structures, such as the rind 
of an orange, may be mistaken for the 
intestinal slough, but these are distin- 
guished by their softer and more pulpy 
texture, and by their vegetable qualities. 
If there be much fever, with headache 
and delirium before the abdominal symp- 
toms arc developed, Enteric Fever may 
be mistaken for several other acute dis- 
eases, such as scarlatina, variola, typhus. 
In the first of these diseases we have the 
same bright cornea and flushed face, and 
the same lively character of the delirium. 
When characteristic symptoms are ab- 
sent, we must suspend our diagnosis for a 
day or two, using at the same time pre- 
cautionary measures against contagion. 
If the rash and sore throat of scarlatina 
be but slightly developed, or if the rash 
have receded, the diagnosis will be diffi- 
cult and unsatisfactory. 
If, in the accession of variola, the se- 
vere lumbar pain be absent, and the erup- 
tion make its first appearance as a few 
isolated papules upon the chest and abdo- DIAGNOSIS. 
245 
men, the case may be doubtful for a few 
hours, but the hardness of tiie varolous 
papule will speedily remove all doubt. 
Chronic tubercular peritonitis presents 
many of the symptoms of Enteric Fever. 
Hectic flush, pinched features, abdominal 
pain, tenderness, gurgling, and diarrhoea 
are common to both diseases. But in 
tubercular peritonitis the tongue is clean 
and moist, there is no eruption, and fre- 
quently the abdomen is distended with 
fluid effusion; moreover, there may be evi- 
dence of tubercular deposit in the lungs. 
Tubercular ulceration of the intestines, 
with tubercular deposit of the mesenteric 
glands, is a condition frequently mistaken 
for Enteric Fever. Two of M. Louis' 
cases (Ob. xliii. xliv. vol. ii.), given as 
examples of "latent typhoid fever," are 
instances of general tuberculosis simulta- 
neously affecting the lungs and the intes- 
tines. I have already included another 
case (see case 12) recorded by this author 
(Obs. xxxiv.) under Tuberculosis, on ac- 
count of the co-existence of miliary tuber- 
cles in the lungs and ulceration of the 
glands of the ileum, regarding the lesions 
in the chest and abdomen as simultaneous 
manifestations of the same pathological 
condition. If the lungs had presented 
evidence of only common inflammation, 
there would have been no reason for dis- 
tinguishing this case from Enteric Fever. 
Indeed, the distinction between acute 
phthisis simultaneously affecting the lungs 
and intestines, and Enteric Fever, will 
more often turn upon the difference be- 
tween tubercular and simple pneumonia 
than upon a difference in the character of 
the intestinal lesions. Inasmuch as the 
lungs are so commonly affected with in- 
flammation in Enteric Fever, and the 
tubercular ulceration induces all the more 
prominent symptoms of Enteric Fever,- 
such as hectic, abdominal tenderness, 
tympanites, diarrhoea, and even intestinal 
hemorrhage,-the diagnosis is often ex- 
ceedingly difficult. If the patient have 
been long declining in health, with ema- 
ciation, sweating, cough, and expectora- 
tion, and we find dulness at either apex 
of the lungs, gurgling, or amphoric breath- 
ing, we may set down the case to be one 
of phthisis. Doubtless, it is possible for 
tubercle to be deposited nowhere else in 
the body but in the solitary and agminated 
glands of the intestine, and in the neigh- 
boring mesenteric glands; and, in such a 
case, the diagnosis between the two dis- 
eases, hardly or not at all to be obtained 
during life, would turn upon the distinc- 
tion between tubercular deposit and ul- 
ceration, and the nature of the inflamma- 
tory process and ulceration in Enteric 
Fever. I have examined the intestinal 
lesions of individuals in whom, after 
death, the lungs have been found consoli- 
dated with tubercles, and excavated into 
ragged cavities at their superior parts, 
side by side with the corresponding ab- 
dominal lesions of Enteric Fever. In the 
early period of the tubercular disease, I 
have been unable to detect any difference 
in the morbid phenomena; both diseases 
fall with greatest severity upon the soli- 
tary and agminated glands of the lower 
third of the ileum, and the appearance of 
the ulcers is similar, except that in En- 
teric Fever the inflammatory action and 
swelling is usually greater; in both dis- 
eases the contiguous mesenteric glands 
have the same violet color, soft consistence, 
and increased size. The diseased parts 
offer the same microscopical appearances ; 
but the corpuscles of the inflamed glands 
within and without the intestine are a 
little smaller in Tuberculosis than in En- 
teric Fever. In the advanced period of 
the tubercular disease, however, the ul- 
cers are very distinct from those of En- 
teric Fever; they have an irregularly 
circular, thick, often indurated, elevated, 
angry-looking border, inclosing, and here 
and there continuous with, large inter- 
rupted irritable granulations, "between 
which little yellow masses of tubercular 
matter, firmly attached to the base of the 
ulcer, are to be seen. In chronic cases, 
moreover, and before ulceration has be- 
gun, the swollen intestinal and mesenteric 
glands are free from inflammation, and 
the tubercular matter within them has a 
white, opaque appearance. It frequently 
becomes hard, gritty, and cretaceous, and 
sometimes forms compact stony calculi. 
The disease, however, with which En- 
teric Fever is most frequently confused, 
is typhus.1 In our own country, Willis, 
Sydenham, Iluxham, and other acute ob- 
servers in every generation, have recog- 
nized and asserted the distinction between 
these two fevers, but a general confusion 
of the diseases has, nevertheless, prevailed 
amongst the members of the profession, 
until within some twenty years ago, and 
we are greatly indebted to Dr. A. P. 
Stewart of the Middlesex Hospital, and 
to Sir W. Jenner, for reasserting and 
proving that a distinction really exists, 
and for rendering the diagnosis between 
the two diseases more clear and distinct. 
What these observers have done for Eng- 
land, Dr. II. C. Lombard of Geneva, 
Messrs. Gerhard and Pennock of Phila- 
delphia, Ilildenbrand and Griesinger in 
Germany, and Forget, Godelier, Barra- 
lier, and others in France, have done for 
their countries. 
Still, there are physicians who, either 
from partial views, or from insufficient 
experience of the two diseases, do not 
recognize any specific difference between 
them, and regard the abdominal lesion 
merely as a complication of typhus. From 
1 See article Typhus Fever in this volume. 246 
ENTERIC OR TYPHOID FEVER. 
what has been said on the associated pa- 
thology of Enteric Fever, it may, perhaps, 
be argued that the abdominal lesion, which 
is assumed to be characteristic of Enteric 
Fever, is nothing more than a local result 
of a common febrile disorder of the sys- 
tem ; yet it is remarkable that lesions of 
Peyer's patches, which may sometimes be 
found in every other acute disease, are 
never, I believe, found in typhus, in which 
the. febrile condition is both very general 
and very prolonged. I have examined the 
intestines in a great many cases of typhus, 
with the exclusive view of detecting, if 
possible, some participation of Peyer's 
patches in the general inflammation, but 
have always failed to detect either swell- 
ing or ulceration. 
Case 20.-Three months ago, a woman, 
aged 30, and her little daughter, came 
under my care, with well-marked symp- 
toms of typhus. The hot dusky skin of 
both patients was maculated with a dis- 
tinct mulberry, typhus rash, which in the 
mother was petechial on the twelfth day 
of the disease. On the following two days 
the rash was still more plainly marked, 
and the case offered a good example of 
''spotted fever." There were no gastric 
or intestinal symptoms ; sordes formed on 
the teeth, and the tongue was dry and 
brown ; the eyes were dull and suffused ; 
the mind heavy and confused-in short, 
all the symptoms of typhus were most dis- 
tinctly marked. On the fifteenth day the 
bowels became loose, and a considerable 
quantity of blood was passed per anum the 
same day. At 11 A. M. on the sixteenth 
day intestinal hemorrhage was again de- 
clared by the passage of much clotted 
blood. The hemorrhage continued during 
the day, and at one time the bed was satu- 
rated with it and it ran down upon the 
floor. She sank and died at 5.45 P. M. on 
the same day. I was induced to re- 
examine carefully the skin of her little 
daughter who lay in an adjoining bed. A 
dark typhus rash was still out upon the 
chest and abdomen, and there were no 
traces of abdominal mischief. 
On post-mortem examination of the 
body of the mother, which was well de- 
veloped and well nourished, I found the 
small intestine perfectly healthy and pale; 
every Peyer's gland was also pale and 
healthy, and no solitary gland was either 
enlarged or prominent. The mesenteric 
glands and spleen were normal in size 
and appearance. In the caecum, an inch 
and a half beneath the margin of the 
ileo-caecal valve, I found a circular ulcer 
of the mucous membrane a quarter of 
an inch in diameter; the surface was 
grayish-white, like an aphthous ulcer of 
the mouth; the margin was slightly 
excavated, slightly raised, and vascular. 
On the opposite wall of the caecum, a little 
higher up, where it becomes ascending 
colon, there was another much larger ul- 
cer ; it was an inch and a half long by 
half an inch wide, and it lay across the 
bowel; the surface was irregularly exca- 
vated, clean, and pale ; the margins irreg- 
ular and sharp ; it extended below the 
mucous membrane, and lay in the thick- 
ened areolar tissue. In the transverse 
colon there were eight other small ulcers, 
resembling the first one, but deeper, and 
with margins more sharply cut and vas- 
cular. Excepting the largest, all the 
other ulcers were placed over one or other 
of the bands of longitudinal muscular 
fibres. Seven were arranged in a row 
upon one of them, at distances of about 
an inch. The intervening mucous mem- 
brane was congested, but not swollen ; 
the ulcers were plainly the source of the 
hemorrhage. 
Such are the characters and situation of 
the intestinal lesions in typhus fever when 
they occur, but they are very uncommon. 
They do not appear to commence, like 
tubercular ulcers and the ulcers of En- 
teric Fever, in the solitary and agminated 
glands. In the case last described, the 
solitary glands contiguous to the ulcers 
were perfectly healthy. If we now com- 
pare the general symptoms of the two dis- 
eases, we shall find equally well-marked 
differences. The countenance in typhus 
is dusky, or suffused with a dusky Hush, 
which spreads continuously over the face, 
neck, and shoulders ; the eyes are injected 
and the pupils contracted ; the expression 
is heavy, the intellect dull, and the de- 
lirium is generally quiet. In Enteric Fe- 
ver, the expression is bright, the pupils 
are dilated, and the hectic blush patchy, 
and limited to the cheeks ; the delirium is 
often intermittent, becoming worse at 
night, and disappearing during the day. 
Its character is more lively than that of 
typhus. The eruption in typhus is a mere 
indistinct passive congestion, soon be- 
coming a minute extravasation, and forms 
no distinct elevation. The rose spots of 
Enteric Fever are raised inflammatory 
papules. Diarrhoea, often profuse, fre- 
quently accompanies typhus, but the stools 
are always dark; the bile is thick and 
dark colored. The patient has no pecu- 
liar odor in Enteric Fever, but in typhus 
the disgusting exhalations from the skin 
are so strong and peculiar that we may 
often diagnose typhus by means of the 
nose alone. Typhus runs a regular course, 
and is terminated in the third week. En- 
teric Fever has no regular course, no cer- 
tain date of termination. Typhus kills by 
coma or congestion of the lungs, Enteric 
Fever by asthenia, pneumonia, diarrhoea, 
hemorrhage, or perforation-very rarely 
by coma. 
Prognosis.-The prognosis in Enteric 
Fever must be formed with extreme cau- PROGNOSIS - TREATMENT. 
247 
tion ; the worst accidents of the disease 
sometimes occur when all appears to be 
going on well. The mortality, however, 
is not great. Out of 18,602 cases, there 
were 3,447 deaths, or one in every 5'4. 
(Murchison, p. 529.) A pulse continu- 
ously frequent, and much hectic or obsti- 
nate diarrhoea, are very unfavorable symp- 
toms. Hemorrhage, to any considerable 
extent, associated with tympanites, and 
occurring at a late period of the disease, 
is an unfavorable symptom. If there be 
excessive tympanites and abdominal pain, 
there is little hope. A fatal termination 
must also be anticipated if the stupor or 
delirium becomes continuous, and asso- 
ciated with muscular twitchings. The 
delirium sometimes assumes the traumatic 
character, or the patient becomes obsti- 
nate as well as stupid : such features also 
forbode an unfavorable issue. 
On the other hand, we hail a fall in the 
temperature of the skin and the appear- 
ance of a copious eruption of sudamina 
over the abdomen and chest as most favor- 
able indications. 
Treatment.-The early recognition 
of enteric disease is of the utmost import- 
ance, for its progress is frequently so very 
insidious that many patients go about 
their usual occupations at a time when 
Peyer's glands would present very grave 
lesions (e. g. case 4), and complaining of 
nothing more than loss of appetite and 
debility. Our suspicions must be on the 
alert in such cases, and, before all things, 
we must ascertain the condition of the 
alvine secretions. Long before diarrhoea 
sets in, the well-formed feces may be ob- 
served to be of a light-yellow or ochre 
color-a condition in which they may 
exist in the absence of diarrhoea, but at a 
time when the intestine may be gravely 
ulcerated. The indications in the early 
period of the disease are to relieve inter- 
nal congestion, and to revive the function 
of the liver. If the bowels be confined, 
a dose of castor oil, or of compound 
rhubarb powder, should be given. If the 
skin be inactive, the hot bath should be 
used, and a diaphoretic, composed of 
aromatic spirit of ammonia and acetate 
of ammonia, prescribed. With the view 
of arousing the liver to activity, I have 
given the following every three or four 
hours, for two or three days, until some 
improvement was manifest in the con- 
dition of the alvine secretions. When 
necessary, I have continued the adminis- 
tration of the mercurial until its constitu- 
tional effects - slight tenderness of the 
gums and fetor of the breath-began to 
appear. 
IL Hydrargyri cum creta, gr. iij. 
Pulvis cretse aromaticae cum opio, gr. v. 
Sodae bicarbonatis, gr. xx. Misce, et fiat 
pulvis. 
If this relaxes the bowels, I have com- 
bined it with a little more of the chalk 
and opium powder, or suspended its use 
altogether, and trusted to infrictions of 
mercurial ointment into the groins or 
arm-pits. I have employed this treatment 
in all cases which have come under my 
care in the early period of the disease, 
before diarrhoea had become severe, and 
have reason to believe that marked bene- 
fit has resulted therefrom, for the subse- 
quent course of the disease in these cases 
has been uniformly mild. Calomel should 
be avoided; its action is too irritant. 
Saline purgatives and the vegetable ca- 
thartics must never be employed in the 
treatment of this disease, at any period. 
A single dose of jalap, scammony, and 
the like, may suffice to develop the worst 
features of the disease. If, at an early 
period, we succeed in producing a flow of 
healthy bile, with moderate action of the 
bowels, we may arrest further progress of 
the disease and restore the appetite. If 
there be diarrhoea and sickness from the 
commencement, we may prescribe an 
ounce of chalk mixture with ten grains 
of subnitrate of bismuth and five minims 
each of tincture of opium and dilute hy- 
drocyanic acid, every two or three hour's. 
This usually succeeds in allaying the 
vomiting. For simple vomiting of sour 
bilious fluid, a mixture, containing thirty 
grains of bicarbonate of soda and five 
minims of dilute hydrocyanic acid is very 
serviceable. The acid condition of the 
secretions in the upper portion of the 
alimentary canal, and the deficiency or 
total absence of alkali from the bile, are 
facts to be borne in mind in the treatment 
of Enteric Fever. 
If the disease exhibit an intermittent 
character, quinine, gr. v to x may be 
given every evening. In the absence of 
cerebral or gastric disturbance, quinine 
is a most valuable remedy for subduing 
the evening exacerbations of fever so fre- 
quently present. Grains iij to x may be 
given in a glass of water, with this view, 
every or every other day at noon. 
In the further progress of the disease, 
our treatment will have almost exclusive 
reference to the abdominal lesion. 
Diarrhoea must be restrained, some 
physicians think checked, if possible, al- 
together. My own experience, however, 
leads me to believe that moderate diar- 
rhoea in the early period of the disease is 
beneficial in some cases, and more espe- 
cially in those in which delirium appears 
early. In the congested condition of the 
abdominal viscera which exists in Enteric 
Fever, one or two liquid stools in the 
course of the twenty-four hours doubtless 
acts beneficially in all cases, and our ob- 
ject in the early period of the disease 
should be to keep the diarrhoea within 
moderate limits, rather than to stop it 248 
ENTERIC OR TYPHOID FEVER. 
altogether. In the early period, chalk 
and bismuth, with catechu and opium, is 
usually all that is needed to check the 
diarrhoea and allay irritation. As soon, 
however, as the diarrhoea becomes exces- 
sive, or we have reason to suspect ulcera- 
tion, stronger astringents must be given. 
Some physicians use sulphuric acid with 
opium-R. Acidisulphuricidiluti, H|xxx; 
tinctures opii, TH.x; decocti cinchonee, oiss; 
fiat haustus, quartis horis sumendus. We 
prefer the styptic salts, having found 
them much more efficacious : indeed, the 
acid mixture often increases the purging 
and pain. Acetate of lead, nitrate of sil- 
ver, and sulphate of copper are employed. 
The first may be given in the form of 
mixture-R. Plumbi acetatis, gr. iij-v; 
acidi acetici, lljiij; morphiee acetatis, gr. 
|th; aques cinnamomi, §iss; fiat haustus, 
quartis horis sumendus. Acetate of lead 
is a very suitable and efficacious remedy, 
but its continued use in Enteric Fever 
should be avoided, as it may subsequently 
affect the system injuriously. Dr. Twee- 
die and M. Trousseau speak in high terms 
of nitrate of silver. It may be given com- 
bined with a grain or two of compound 
soap-pill in doses of a quarter of a grain 
to one grain, every three or four hours. 
Dr. Tweedie says : "I have prescribed it 
extensively in Enteric Fever, and con- 
tinued its use for a considerable time, and 
have never witnessed any approach to 
discoloration of the skin." (Leets, on 
Continued Fevers, p. 233.) Of all medi- 
cines, we consider sulphate of copper to 
be the most efficacious in restraining the 
diarrhoea of Enteric Fever. We may give 
it in quarter-grain doses, combined with 
two grains of compound soap-pill, to be 
taken every two, three, or four hours. If 
need be, the dose may be increased to a 
grain, a day or two afterwards. For chil- 
dren, it may be prescribed in doses of the 
eighth or sixth of a grain. If too large a 
dose be given at first, it may excite vom- 
iting. In small doses we have often pre- 
scribed it when there has been considera- 
ble irritability of the stomach, in which 
case it appears to act as a sedative. 
Alum, catechu, tannic and gallic acids, 
krameria, hssmatoxylon, &c., are of com- 
paratively little value in the treatment of 
Enteric Fever. 
[Oil of turpentine, the use of which in 
Typhoid Fever was urged by the late Dr. 
G. B. Wood, of Philadelphia, has some- 
times an exceedingly good effect, appa- 
rently as an alterative to the diseased in- 
testinal mucous membrane and glands of 
Peyer. It acts most favorably in small 
doses (ten or twelve drops every 3 or 4 
hours), in mucilage, with a few drops of 
laudanum. -II.] 
Starch and opium enemata-(Mucilagi- 
nis amyli, §iv; tinctures opii, U|xv-xxx; 
fiat enema, nocte vel nocte maneque inji- 
ciendum)-are of great value in allaying 
that irritability of the lower bowel which 
often induces purging. When enemata 
cannot be retained, we may still use sup- 
positories. (Pilules saponis composites, 
gr. v to gr. x.) 
Abdominal pain and tenderness.-The 
disease being localized in the right iliac 
region, we must direct our remedies to 
this part. Hot sedative fomentations, 
turpentine stupes, or poultices containing 
an admixture of mustard, should be fre- 
quently applied to the abdomen. If there 
be much tenderness four or six leeches 
should be applied, partly to the right iliac 
region and partly around the orifice of the 
bowel. Leeching of the anus is the most 
effectual mode of relieving the intestinal 
congestion. If the pain be great, an oc- 
casional full dose of opium will be needed. 
Tympanites.-If there be any increased 
fulness of the abdomen, a flannel or linen 
bandage should be placed around it. In 
commencing tympanites we regard this 
as a very important part of the treatment, 
as it at once diminishes the congestion of 
the inflamed part, and prevents injurious 
distension. It also gives support to the 
painful abdomen in the process of respi- 
ration. Folds of wet cloths may be inter- 
posed between the bandage and the ab- 
domen. 
If the tympanites be considerable, it 
becomes a most distressing symptom, and 
the life of the patient is in great danger 
from distension of the diseased and atten- 
uated bowel; laceration of its ulcerated 
coats being imminent so long as the dis- 
tension continues. To relieve this pain- 
ful and dangerous condition, turpentine 
stupes should be applied over the whole 
abdomen, and a gentle support given by 
means of a thin flannel bandage. An 
assafoetida enema (oxij ad ,^xx enematis 
assafoetides P. B.) often gives much relief. 
If 'we should fail, however, to cause ex- 
pulsion of the air by this means, a long 
elastic tube with wide side openings may 
be passed into the colon and retained 
there at intervals. Dr. Tweedie speaks 
■well of the use of the stomach pump, per 
rectum, in the relief of this condition. 
"I have applied it," he says, " in some 
cases with happy effects, and withdrawn 
the accumulated air which may be passed 
through the lower tube of the stomach 
pump into a basin containing water." 
(Op. cit., p. 237.) Oil of turpentine 
(lljx-xx), or oil of rue (TT[iii-v), com- 
bined with opium and given by mouth, 
are often serviceable in the relief of pain 
and flatulent distension. 
Intestinal Hemorrhage. - Moderate ca- 
pillary hemorrhage from the general mu- 
cous surface of the bowel must be regard- 
ed as beneficial, and we should employ no 
means to check it, but if the blood be 
clotted, in large quantity, and unmixed TREATMENT. 
249 
with mucus, we must fear the erosion of 
a large vessel, and treat for such an acci- 
dent very promptly. A bladder of ice 
bandaged upon the right side of rhe abdo- 
men, and the internal administration of 
gallic acid, solution of perchloride of iron, 
acetate of lead, or turpentine, are the 
most hopeful means of arresting it. Sul- 
phate of copper in combination with soap- 
pill is a very valuable remedy in this con- 
dition also, and one upon which we are 
inclined to place most reliance. If the 
patient have been previously taking the 
copper salt, the dose may be increased at 
once to one or two grains. Turpentine, 
in doses of ten or fifteen minims, given 
every half-hour or hour, is often effectual 
in stopping the hemorrhage, and is espe- 
cially useful in cases where there is a 
tendency to syncope. The solution of 
perchloride of iron of the British Phar- 
macopoeia is a very valuable remedy for 
intestinal hemorrhage; Tf[xx-xxx in a 
wineglassful of water may be given by 
mouth every two or three hours. If the 
hemorrhage be slight and the arterial ac- 
tion much excited, U[xv tincturce digi- 
talis, with Tffxxx tincturse ferri per- 
chloridi, giss aquae menthse piperitae, may 
be given every four hours. This may be 
administered alone or in combination with 
thirty minims of dilute sulphuric acid. 
If we fail to arrest the hemorrhage by 
these means, the bowel may be injected 
with one or other of the following ene- 
mata. B. Plumbi acetatis, gr. x; acidi 
acetici, Tffx; morphiae acetatis, gr. |; 
aquae tepidae, §iv; misce. B. Liquoris 
ferri perchloridi, TIlxv; morphiae hydro- 
chloratis, gr. j ; aquae tepidae, ^iv; misce. 
Cerebral Symptoms. - The indications 
in the treatment of cerebral symptoms 
are to relieve congestion and procure 
sleep. If there be much pain and heat 
of the head, cold water may be applied 
as an occasional douche, a gallon being 
poured in a gentle stream upon the head 
as often as the heat becomes excessive. 
Rags wetted with water, or spirit and 
water, may be applied in the intervals. 
If this treatment fail to restrain the vas- 
cular excitement, a few leeches should be 
applied behind the ears, or a blister upon 
the nape of the neck. As often as they are 
required, full doses of opium should be 
given to procure sleep. In the majority of 
cases the cerebral affection is mild and re- 
quires no direct treatment, and the seda- 
tives given to relieve the abdominal symp- 
toms are usually sufficient to calm the ner- 
vous irritability and procure sleep. When 
the pulse is fast and there is pulmonary in- 
flammation, we must be careful to avoid 
large doses of opium. In some cases the 
delirium makes the patient obstinate, and 
he persists in refusing food and drink, and 
keeps the teeth firmly clenched. In such 
a case, with diarrhoea present or impend- 
ing, we cannot feed per rectum; we must 
therefore gag the patient and use the 
stomach-pump. 
In such a state, too, we should daily 
examine the pubic region. Now and 
then we are painfully reminded of the 
negligence of those in close attention 
upon the patient, by discovering, after 
death, the bladder distended almost to 
the umbilicus, and with its attenuated 
coats inflamed and softened. 
Pulmonary Symptoms.-Bearing in mind 
the frequency of pulmonary complica- 
tions, we should carefully regard the 
breathing, and occasionally examine the 
chest. If pain and crepitation be devel- 
oped in any part of the chest, a blister 
should be applied and mercurial infric- 
tions used. Cough and bronchial dys- 
pnoea may be treated with ipecacuanha 
and senega, and the application of mus- 
tard poultices and turpentine stupes. 
[Prevention of hypostatic pulmonary con- 
gestion and splenization may be promoted 
by care in changing the position of the 
patient every few hours; especially not 
allowing him to lie very long at a time on 
the back.-II.] 
Food.-While we are thus combating 
the disease, the most unwearied atten- 
tion must be given to the support of the 
patient. The blood impoverishes, and 
the body emaciates very rapidly, and our 
endeavor must be to introduce such food 
into the stomach as will be most easily 
digested. All nourishment must be given 
in a fluid or pultaceous form. Eggs, milk, 
vermicelli, arrowroot, or ground rice, 
beef-tea, gelatin-alone, or in various 
combinations-will be the most appro- 
priate articles of diet. The eggs must be 
given in the form of emulsion in a little 
wine whey, tea, or cocoa. Two or three 
should be given daily. Milk-arrowroot, 
containing a little brandy, is a very ap- 
propriate nutriment. The beef-tea must 
be1 thickened with well-stewed vermicelli, 
or isinglass. Small quantities of food 
should be given at a time, and repeated 
every one or two hours. 
Stimulants, in any considerable quan- 
tity, are not needed in the early period of 
the disease. When required they should 
be given well diluted. A few ounces of 
wine in the form of wine whey, or dry 
port mixed with an equal quantity of 
water, may be given with a little sponge- 
cake at intervals. Effervescent wines 
must of course be avoided. If the heart's 
action be weak, or the patient tends to 
lapse into the typhous state, brandy may 
be freely given, carefully avoiding excess. 
The following general rules may be ob- 
served in the administration of alcoholic 
[* May be, rather ; as, if well made, some 
patients will prefer it without such addi- 
tions.-H.] 250 
EXTERIC OR TYPHOID FEVER. 
stimulants in this disease. As long as 
the pulse remains under 1'20 and retains 
moderate force, six to eight ounces of 
wine, or four ounces of brandy, given 
within twenty-four hours, will be suffi- 
cient. When the pulse ranges between 
120 and 130, and is small, we may double 
these quantities; and if the heart does 
not respond to the stimulant after twelve 
hours, thrice the original amount may be 
given. The bulk and force of the pulse 
must be our chief guides; and if these 
notably fail from day to day, we must 
daily increase the quantity of the stimu- 
lant until the patient is supplied with as 
much as half an ounce every half-hour, 
always diluted with a little milk, tea, 
water, &c. When there is much hectic, 
and the pulse is small and sharp, strong 
stimulants often appear to increase the 
irritability of the system, and in such a 
case we should give them sparingly and 
in the early part of the day, trusting to a 
dose of quinine, with or without opium, ac- 
cording to circumstances, in the evening. 
Excepting a little custard, solid food of 
all kinds must be absolutely avoided, until 
a week after the diarrhoea has ceased, and 
the stools become solid. Then we may 
venture to order boiled fish with bread. 
A boiled egg, a little fish, or a ripe pear 
or plum, taken too early, will almost cer- 
tainly bring back the diarrhoea with a 
complete relapse [and danger of intestinal 
perforation.-II.]. 
The patient must return very gradually 
to ordinary diet, and he should be direct- 
ed to eat slowly and masticate the food 
thoroughly. At first boiled rice should 
be taken in place of potatoes. 
Convalescence is sometimes very slow, 
and often retarded by the occasional re- 
currence of diarrhoea. The styptic should 
be continued a week after the stools have 
become solid. At first the bowels are 
usually constipated, and this condition we 
shall do well to maintain for days. Subse- 
quently, it will be advisable to relieve the 
bowels occasionally by a dose of castor oil. 
As soon as the digestive function is re- 
stored, we prescribed cod-liver oil as a 
supplement to the diet, in all cases where 
there is much emaciation, and if, as is 
rarely the case, the oil does not digest, we 
may direct it to be rubbed into the abdo- 
men. 
[Amongst physicians in America, of 
latter years, expectancy has grown more 
generally in favor in the treatment of Ty- 
phoid Fever than in that of almost any 
other disorder; as no malady more evi- 
dently presents a self-limited character. 
Cases of an ordinary grade are often con- 
ducted through their whole course to a 
good convalescence, with no medication, 
or almost none. Great importance be- 
longs, under such management, to the 
regulation of the diet of the patient. This 
must be liquid and concentrated ; milk 
and (unfiltered) beef-tea being the chief 
articles for this use ; these must be given 
in small quantities at short intervals (a 
tablespoonful or two every two or three 
hours), in the more feeble cases, day and 
night. Also, of course, the bed-clothing 
must be attended to ; requiring change in 
the garments next the skin every two or 
three days, or oftener, if soiled by perspi- 
ration or other discharges. The state of 
the bladder must be watched, to antici- 
pate prolonged retention of urine. Change 
of position, from one side to the other, or 
from the back to the side, should be in- 
sisted on, to avoid hypostatic pulmonary 
congestion. Ventilation of the chamber, 
without direct draughts, must be secured. 
These, with the quiet always essential to 
the sick room, and other parts of "good 
nursing," will suffice in the care of not a 
few cases of well-marked, uncomplicated 
Typhoid Fever, without even the addition 
of alcohol to the food. A large minority 
of cases, however, will call for this ad- 
dition. 
Within a comparatively few years, very 
positive treatment for fever as such, in all 
its forms, is advocated by a number of 
medical authorities. Prominently, cold 
bathing has been brought forward, by 
Drasche, Brand, Liebermeister, Ziemssen, 
Wilson Fox, and others. The patient, 
according to this method, is immersed, for 
ten minutes or more at a time, in water 
at about 70° Fahr., to reduce the temper- 
ature. Ziemssen's plan is undoubtedly 
the safest, of placing the ill person in 
water at 95°, which is gradually lowered 
to 80° or 75°, watching the effect upon the 
pulse, respiration, and countenance. The 
indiscriminate use of the sudden cold 
plunge bath in fever is certainly not free 
from danger by excessive depression. 
Quinine is now employed by quite a 
number of practitioners as a direct antipy- 
retic. In order to produce a positive effect 
in lowering the temperature of the body, 
it has to be given in rather large doses; 
ten grains or more, repeated. Salicylic 
acid acts in a similar manner. It remains 
to be shown with certainty that this mode 
of reducing temperature has, on the whole, 
a favorable effect upon the progress of Ty- 
phoid Fever, when it is not complicated 
by the influence of malaria.-II.] 
Prophylaxis.-Sufficient evidence has 
been adduced to prove that Enteric Fever 
commonly arises from the retention of 
refuse animal and vegetable substances 
within an undrained, or imperfectly 
drained soil. If, therefore, the contami- 
nation of the soil be prevented by the con- 
struction of sufficiently inclined sewers 
with impermeable walls, and the inhabit- 
ants be provided with abundance of pure 
water, Enteric Fever may be expected to 
disappear almost entirely. 251 
TYPHUS fever: definition. 
The requirements for the prevention of 
the disease are sufficiently simple, but 
they are not easily fulfilled in every place 
where living beings are congregated. Na- 
ture, indeed, has provided these sanitary 
conditions almost everywhere, and if man 
would be more mindful of them his life 
would be rarely sacrificed to Enteric Fe- 
ver. A house built upon a hillside, with 
its spring of pure water above the founda- 
tion, and its cesspool below it, would be 
free from this disease, as far as external 
conditions are concerned. But reverse 
the position of the cesspool and the spring, 
and the disease may appear at any time. 
If the dwelling be built upon a low-lying 
flat, and there is no near spring or flowing 
stream, these two necessaries-a pump 
and a cesspool-must needs co-exists side 
by side. In such a case they should be as 
widely separated as possible, and the sides 
of the well should be thickly covered with 
concrete. Whenever the premises are 
small, and it can be so contrived, a water- 
closet should be provided, and the excre- 
tions carried in an impermeable drain to 
a distance from the pump. In towns and 
large villages both pumps and cesspools 
should be abolished, and every house pro- 
vided with a water-closet in communica- 
tion with a sewer.1 The water should be 
derived from a distant elevated spring or 
reservoir, preserved from contamination 
at its source, and conveyed in well-joined 
iron pipes to its destination. The soil 
should be well-drained, and during the 
continuance of dry weather the drains and 
sewers should be regularly flushed. 
We cannot positively say that Enteric 
Fever arises from the ingestion of diseased 
meat, but there is a strong probability 
that it does sometimes originate in this 
cause. Whether this cause has been in 
operation during the present year (1865), 
when "contagious typhus" has been so 
generally prevalent amongst, and destruc- 
tive of our horned cattle, there is no di- 
rect evidence to show ; but it is remark- 
able that, co-incidently with the spread of 
the cattle disease, there has been a great 
increase of Enteric Fever. On turning to 
the Table at p. 237, it will appear that the 
number of cases admitted into the Lon- 
don Fever Hospital in 1865 is more than 
double that of every preceding year, and 
more than treble that of the majority. 
The only effectual way of preventing the 
admission of diseased meat into the mar- 
kets would be to establish a limited num- 
ber of slaughter-houses, where the ani- 
mals, previous to being slaughtered and 
afterwards, could be inspected by proper 
officers. The experience of the present 
severe epidemic of cattle disease has 
taught us, that, after death, it is exceed- 
ingly difficult and, to an inexperienced 
eye, impossible, to distinguish positively 
between the flesh of an animal which has 
died of contagious fever, and that of one 
slaughtered in perfect health. In the ab- 
sence of that more general protection 
which is so urgently required, two precau- 
tions should be taken : first, flesh of a 
flabby consistence and of a dusky, dead 
hue should be avoided ; and secondly, all 
meat should be so thoroughly cooked that 
the fibre is quite firm and free from juice, 
which, on exposure to the air, becomes 
red. In the treatment of the contagious 
variety of the disease, the ordinary precau- 
tions against contagion must be taken, 
viz., the isolation of the patient and the 
disinfection of everything that has had 
contact with him. 
TYPHUS FEVER. 
By George Buchanan, M.D. 
Definition. - Typhus Fever is an 
acute specific disease, lasting from four- 
teen to twenty-one days, characterized 
by an eruption of its own that appears be- 
tween the third and sixth day, eminently 
contagious, and forming strongly-marked 
epidemics. 
Under the name " Typhus," the writer 
of one of the Hippocratic treatises de- 
scribes a disease that agrees in its essen- 
tial features with typhoid fever. But the 
term was not afterwards used to signify a 
special disease until the time of Sauvages, 
in whose nosology it is adapted to certain 
forms of continued fever, while the name 
Synochus is used for another class of cases. 
[* The frequent imperfection of water- 
closet connections with sewers, allowing the 
escape of sewer-gas into houses, has lately- 
been credited with the production of a large 
number of cases of Typhoid Fever.-H.] 252 
TYPHUS FEVER. 
The disease as above defined, and now 
known as Typhus, has been separated 
from other forms of continued fever with- 
in the last thirty years. 
Typhus Fever has received a multitude 
of names, almost every epidemic having 
added some fresh one. In English, Spot- 
ted Fever, Petechial Typhus. Epidemic 
or Contagious Fever, Putrid or Malignant 
Fever, Camp or Jail Fever, are samples 
of the names that have been conferred on 
the disease, from various considerations 
of its nature or cause. 
Etiology.-The causes that predispose 
to Typhus may be considered as affecting 
the individual and the community. 
In the individual, sex and age have no 
influence in determining an attack. In 
the writer's experience, at the London 
Fever Hospital, very nearly equal num- 
bers of each sex, and persons of every age, 
from a fortnight to over eighty years, 
have been attacked. Upon the authority 
of death registers and hospital statistics, 
the statement is constantly made that 
Typhus attacks adults more than children; 
but the evidence furnished by these data 
is quite untrustworthy as showing the 
relative proclivity of different ages to an 
attack. Typhus, as it appears on the 
death registers, is indeed incomparably 
more frequent among adults than children; 
but that is because children rarely die of 
it, not because they are rarely attacked. 
And in hospital records a much greater 
proportion of adults than of children are 
seen to be admitted ; but this is because 
of obvious domestic reasons, because of 
the slightness of the fever in children, 
and often because of the rules of the insti- 
tution. When inquiry as to age is made 
to include every case of attack, children 
and adults are found to be quite equally 
susceptible; the actual incidence may 
even be observed to be strongly upon the 
young, partly because of their greater 
numbers, and partly because adults are 
frequently protected by previous attack. 
Depressing mejital influences, overwork, 
and anxiety, appear to be causes that 
render the system more liable to con- 
tagion. Fear of contagion is often al- 
leged, and perhaps justly, to be another 
such cause. It is especially among per- 
sons of better rank of life that these influ- 
ences have been observed to operate. 
Depressing bodily influences are, however, 
of far greater moment. With persons 
temperate and provided with sufficient 
food, the contagion of Typhus, even 
though intense, is usually resisted for 
some time; but with intemperate and ill- 
fed persons, contagion is received so 
readily, and so small a quantity of it pro- 
duces an attack, that it is constantly diffi- 
cult to find out whether in the particular 
case there has been any exposure to con- 
tagion at all. It is essentially among the 
poor underfed population of large towns 
that Typhus epidemics occur. Paupers 
and the class just above paupers are the 
chief, and except in intense epidemics al- 
most the only, sufferers from the disease. 
People whose earnings enable them to get 
more than the bare necessaries of life from 
hand to mouth do not suffer from Typhus 
save in exceptional instances, and usually 
as a consequence of constant communica- 
tion with the sick. 
The most violent epidemics of Typhus 
have been among communities that were 
fed more badly than usual, either through 
social difficulties, or through failure of 
crops; special hardships in war, and in 
civil life, strikes, and commercial distress, 
have at different times determined an epi- 
demic prevalence of the fever. 
The experience of Ireland in 1818 and 
1847 illustrates the influence of privation 
in predisposing a community to Typhus. 
In each of those years an epidemic of this 
fever prevailed (along with relapsing 
fever), as a consequence of the almost 
complete failure of the potato crop ; and 
it is estimated that on each occasion an 
eighth part of the entire population was 
attacked. But it must not be supposed 
that serious epidemics of Typhus require 
exceptional destitution as a necessary 
condition of their occurrence. A marked 
instance to the contrary is afforded by a 
recent intense outbreak at Greenock, 
where circumstances of special commer- 
cial prosperity had (by causing exceptional 
overcrowding) conduced to the epidemic 
spread of Typhus. 
The next predisposing cause of Typhus 
is probably the most important of all, and 
consists in the association of conditions 
known as overcrowding, crowd-poisoning, 
or ochlesis. These conditions are scarcely 
to be separated from each other, but may 
be enumerated as overcrowding of dwell- 
ing-houses upon too limited area, over- 
crowding of rooms by too many occupants, 
bad ventilation of streets and houses, 
domestic and personal dirtiness. It is to 
the operation of this series of conditions 
that the special incidence of Typhus upon 
the laboring population of large towns is 
to be ascribed. 
Illustrations of the effect of crowding 
too many inhabited dwellings upon a 
limited area might be gathered in abund- 
ance from the experience of camps, where 
the superficial space per man has been less 
than in the densest cities with their tall 
houses, and where Typhus has carried off 
large proportions of many armies. But 
they may equally be drawn from the ex- 
perience of civil life. The town of Eng- 
land which habitually has most Typhus, 
and in which the most serious epidemics 
occur, is Liverpool. Here the huddling 
together, of houses with insufficient space ETIOLOGY. 
253 
around them is carried to a greater degree 
than in any other town in the kingdom. 
In Liverpool, a large number of the 
houses are built back to back, in unventi- 
lated courts, and the population is so 
dense that, in some districts, each person 
gets only eight square yards of superficial 
space. In these parts it is that fever spe- 
cially flourishes, and in epidemic periods 
passes by none but those who are protected 
by previous attack. Glasgow is another 
instance of a town in which the packing 
together of houses reaches an extreme 
extent, and in which Typhus correspond- 
ingly prevails; its distribution following 
so exactly the degree of density of popula- 
tion in different parts of the town as to 
leave no doubt of the connection between 
the disease and this condition. 
Overcrowding of the interior of houses 
by too many occupants, with deficient 
ventilation of rooms, may be illustrated as 
a cause of Typhus by the experiences of 
the common lodging-houses of English 
towns. Before the regulation of these by 
law in 1851, dwellings of this class were 
in a state of most miserable filth and 
overcrowding. In London and Liverpool, 
especially, there is evidence that they were 
peculiarly infested with Typhus, far more 
cases of this fever occurring in them than 
among an equal population residing in 
poor tenements of another class. Since 
1851, the number of fever cases in com- 
mon lodging-houses has been accurately 
ascertained, under the same Act of Par- 
liament that has diminished their over- 
crowding and improved their cleanliness ; 
and it is found that in some thousands of 
such houses in London, hardly any Typhus 
exists in non-epidemic times, and that in 
epidemic times they suffer now much less 
than other houses inhabited by the poor. 
In Liverpool, it was upon the overcrowded 
lodging-houses that the chief force of the 
epidemic of 1847 fell; the cases of Typhus 
that occurred in them being numbered by 
thousands. During the year 1863, when 
the fever again became epidemic, in a 
thousand regulated lodging-houses of 
Liverpool, only twenty-four cases occurred, 
a quite inappreciable fraction of the whole 
number of fever cases in the town. 
Doubtless both sorts of overcrowding 
act chiefly by facilitating communication 
between the sick, and contagion from per- 
son to person. And hence comes one ex- 
planation of the different degrees in which 
overcrowding favors Typhus in town and 
country. In many country cottages, very 
considerable crowding of rooms, no venti- 
lation, and habitual dirtiness exist as con- 
stant conditions, and yet Typhus is prac- 
tically unknown. 
Other predisposing cases of Typhus re- 
quire brief consideration. Persons of all 
countries and races exposed to its influ- 
ence contract Typhus with equal readi- 
ness. But the disease is essentially one 
of cold and temperate climates. Within 
such climates there is no country, whose 
epidemics are accurately recorded, that 
does not suffer more or less from Typhus ; 
and, on the other hand, there is no suffi- 
cient evidence that this fever occurs 
within the tropics. Of all countries, 
Great Britain and Ireland are the chief 
seats of Typhus, which occurs here more 
constantly from year to year, and with 
severer accessions of epidemic force than 
elsewhere. 
In the United Kingdom, the large trad- 
ing ports are especially prone to Typhus ; 
but this must be ascribed less to their posi- 
tion on seaboard or river than to the 
greater communication they have with 
localities from which infection may be de- 
rived, and the extreme density of popula- 
tion in such places. 
By season and meteorological influences 
Typhus is not known to be very much in- 
fluenced. It is a very common, though 
not an invariable occurrence, that the last 
month or two of the year is the chosen 
period for an increase in the prevalence of 
Typhus. In the main this connection 
appears to be established through the in- 
fluence of cold upon the vital powers of 
the individual, and upon the social and 
domestic conditions of the poor commu- 
nity. People suffer more from scantiness 
of food and get less ventilation in their 
crowded rooms as winter sets in. Drought, 
again, has sometimes appeared, as recently 
in Bristol, to predispose to Typhus, 
through reducing the supply of the ele- 
ment necessary to cleanliness. Low ele- 
vation of site, again, is a condition that 
renders a place less easily purified by cur- 
rents of air than if it lay higher, and may 
in some minute degree assist in the de- 
velopment of an epidemic. But to such 
atmospheric and climatic conditions as 
these, and they are the most weighty ones 
of their kind, an inferior degree of im- 
portance only is found by experience to 
attach. 
As to the exciting causes of Typhus, 
the great, if not the only one, is the spe- 
cific poison of the disease transmitted 
from person to person by contagion or 
fomites. Evidence of propagation of the 
fever by communication between the sick 
is seen in its epidemic spread when it 
enters a community of susceptible persons, 
and even more conclusively in the way in 
which persons exposed to none of its pre- 
disposing causes catch the fever when 
they are in close attendance upon cases of 
Typhus. Nurses in hospitals, where many 
cases of Typhus are received, invariably 
get Typhus, no matter under what sani- 
tary conditions they are placed. There 
appears to be no exception to this rule, 
unless, indeed, it be that the nurse is per- 
sonally insusceptible of the disease from a 254 
TYPHUS FEVER. 
previous attack of it. Medical men and 
Catholic priests in attendance upon nu- 
merous Typhus cases, are also almost 
sure, sooner or later, to get the Fever, 
and that they do not tall ill with so much 
certainty or rapidity as the nursesappears 
due only to their contact with the sick 
being less constant and intimate. The 
contagious matter of the disease seems 
peculiarly capable of destruction when it 
is diluted with air. Thus tolerably close 
communication with the body of a Typhus 
patient appears requisite for the reception 
of contagion from him. Casual visitors 
to fever wards very seldom get Typhus, 
and in private houses of the better class 
the disease rarely spreads to the atten- 
dants. Extension of Typhus from a hos- 
pital to the adjacent streets is unknown, 
even though there should be hundreds of 
cases congregated within a very short 
distance of other buildings. In these re- 
spects Typhus differs much from smallpox 
and some other diseases of its class. 
There appears reason to believe that 
Typhus can be communicated apart from 
actual intercourse with the sick by resi- 
dence in the house where the fever has 
recently existed, and by the use of articles 
of bedding and clothing that have been 
recently used by Typhus patients. But, 
as compared with scarlatina, for instance, 
the degree to which the contagious matter 
of Typhus can be thus conveyed by fomites 
is very inconsiderable, and, in fact, it ap- 
pears to be very seldom thus conveyed if 
the simplest means of purification by air 
and water are employed. 
Great immunity from an attack of Ty- 
phus is obtained by a person who has 
once suffered under it. Some, but very 
few, well-authenticated cases of second 
attack are on record. 
There are many instances where Typhus 
Fever occurs in individuals who cannot be 
ascertained to have been exposed to any 
contagion, and where the readiest expla- 
nation of the occurrence of the fever is 
that it has originated de novo from the 
intense operation of its predisposing 
causes. Cases of this kind, happening in 
the absence of epidemic influence, and 
constituting the first instance in a com- 
munity among whom the disease after- 
wards spreads by contagion, have been 
collected by Dr. Murchison, and must be 
allowed to have weight in favor of the 
theory advocated by him, that destitution 
and overcrowding are by themselves ca- 
pable of generating afresh the contagious 
matter. If, to this view, the speculative 
objection be opposed that a specific self- 
multiplying matter can only be allowed 
to have a specific origin, the speculative 
answer may be given that at some time 
or other there must have been generated 
a first case of Typhus, and that the same 
de novo production may therefore occur 
again. Considerations of this kind, on 
one or the other side of the argument, 
are of little importance by the side of Dr. 
Murchison's actual observations. The 
most serious obstacle to the reception of 
this theory arises from the analogy of 
other specific diseases as to the present 
production of which by contagion, and 
contagion alone, there is no question. 
Thus, in many outbreaks of scarlatina 
and smallpox, the source of infection in 
the first instance is often as obscure as in 
the cases of apparently spontaneous Ty- 
phus cited by this author, and there are 
cases even of children's syphilis originat- 
ing under circumstances that the most 
experienced investigator has failed to con- 
nect with exposure to the poison. An- 
other consideration which weighs some- 
what against the belief that destitution 
with overcrowding is the condition re- 
quired and sufficing for the de novo pro- 
duction of Typhus, is that outbreaks of 
Typhus, apparently spontaneous, some- 
times occur in persons under excellent 
hygienic circumstances. Thus in a case 
that came under the notice of the writer, 
two boys living in an institution where 
every advantage of diet and lodgment 
was afforded (as may be held proved by 
the fact that the fever did not extend) 
were attacked within a few hours of each 
other with Typhus, and the most careful 
inquiry failed to show that either of the 
boys had had the opportunity of getting 
the fever by contagion. 
Symptomatology.-The period of in- 
cubation of Typhus is not satisfactorily 
determined. It is so rare for persons to 
fall ill of this fever after a single exposure 
that opportunities of ascertaining the 
point in this way do not often occur. 
And in practice it is also extremely diffi- 
cult to get, with any accuracy, at the 
limits of the incubation period from the 
times of first and last exposure. It is 
probable that this period is not constant, 
but that it varies from a few hours to 
several days. 
The invasion of Typhus is generally 
marked by headache, more or less severe, 
loss of appetite and general malaise. For 
a day or two, and in the absence of in- 
formation respecting exposure, there is 
nothing to distinguish the outset of Ty- 
phus from that of any other fever, unless 
it be the absence of the positive symp- 
toms of other specific illness. It is par- 
ticularly difficult to separate the invasion 
of Typhus from an attack of acute dys- 
pepsia. Rigors are of frequent occur- 
rence, but they are not so definite or so 
severe as in smallpox, or in the pyrexia 
accompanying internal inflammation. 
The sense of chilliness commonly com- 
plained of along with the early headache 
may not amount to actual shivering, and SYMPTOMATOLOGY. 
255 
it is often wholly absent. In slight at- 
tacks, especially in children, it may not 
be possible to settle the actual time of 
invasion. On the other hand, in severer 
cases the disease begins very suddenly 
with shivering, headache, and it may be 
vomiting. For three or four days the 
symptoms of the invasion period get 
worse, and are accompanied by sleepless- 
ness and general pyrexial symptoms, 
thirst, heat of skin, pretty complete an- 
orexia, and usually a very peculiar pros- 
tration. In a case of Typhus of any 
gravity the patient gives in to the disease 
within the first three days, leaving oft' his 
work and commonly taking to his bed by 
that time. Patients with an actual Ty- 
phus rash on them, and having been ill 
five or six days, do indeed sometimes ap- 
ply as out-patients of dispensaries and 
hospitals, but this is incomparably of 
rarer occurrence with Typhus than with 
typhoid or smallpox patients. 
Before proceeding to state the symp- 
toms of a fully developed case of Typhus, 
under the heads of the organs and sys- 
tems affected, mention must be made of 
the general appearance of the patient. 
This is so peculiar as to constitute to the 
practised eye a very ready means of diag- 
nosing Typhus, and frequently even an 
important element in deciding on the na- 
ture of a doubtful case. In an average 
attack the patient lies prostrate on his 
back with a most weary and dull expres- 
sion of face, his eyes heavy and with a 
somewhat dusky flush spread uniformly 
over his cheeks. In the advanced stages of 
a severe attack, he lies with his eyes shut 
or half shut, moaning and too prostrate to 
answer questions, to protrude his tongue, 
or to move himself in bed ; or the mouth 
is clenched, the tongue and hands trem- 
ble, and the muscles are twitching and half 
rigid. The dryness of the mouth, the 
sordes on the teeth and lips, the hot dry 
skin, and the deafness are other symptoms 
which strike an observer so immediately 
as to deserve to be included in the physi- 
ognomy of the disease. 
The maximum temperature reached in 
the course of the disease is rarely less than 
104'9 or 105°, and in many cases it reaches 
106'5-107°, sometimes even a higher point 
than this. This high maximum is, as a 
rule, in favorable cases only attained 
once or twice throughout the fever, and 
generally of an evening ; the highest morn- 
ing temperature very rarely exceeds 106°. 
The temperature begins to rise at the 
commencement of the disease, and has 
been observed as high as 103'8-104'9° the 
first evening; it continues rising till the 
third day, when it often reaches 105-107°. 
The maximum is generally attained in the 
middle of the first week, between the 
fourth and sixth days and generally on 
the fourth day, and then a slight though 
appreciable fall takes place. There is 
generally a well-marked remission about 
the seventh day. In Typhus, though less 
than in other forms of lever, there is an 
exacerbation in the evening, and the re- 
mission about the seventh day is, in some 
cases, only indicated by the comparative 
slightness of the evening elevation which 
then takes place. In the more severe 
cases there is no trace of remission at this 
period, but the temperature maintains it- 
self steadily or even rises a little. The 
absence of this remission marks the case 
as likely to be a severe one. 
In the second week the temperature 
rises again, but only for a day or two, and 
rarely reaches the maximum of the first 
week. The elevation may be from half a 
degree to two or three degrees, but ave- 
rages about three-quarters of a degree, 
often lasts but for one evening, sometimes 
continues longer. 
Between the twelfth and fourteenth day 
there is a remission, in both the mild and 
severe forms of the disease ; even in cases 
about to prove fatal, and in those other 
severe cases which showed no decrease of 
temperature at the end of the first week. 
But notwithstanding some remission, the 
temperature in fatal cases often remains 
high (rarely, however, above 105°), and 
shortly before death a very rapid rise 
occurs, indicating that the fatal termina- 
tion is approaching, in some cases the 
temperature being sometimes higher at 
this time than at any previous date of the 
disease. In cases of recovery from an 
average attack, defervescence generally 
occurs some time between the thirteenth 
and seventeenth day, and its approach is 
sometimes announced by a slight exacer- 
bation which renders the subsequent fall 
more conspicuous. The return to the 
normal temperature takes place very 
quickly. In the majority of cases it is 
completed within twenty-four hours, often 
in twelve hours ; it begins very frequently 
in the night, and the abrupt manner in 
which the fever leaves is one of the pecu- 
liar features of the disease, the tempera- 
ture sometimes falling as much as three 
or four degrees in the course of a night. 
By the end of the second half of the third 
week the temperature has usually re- 
turned to its natural standard. 
The difference between the morning and 
evening temperature is smaller in the first 
week and the first half of the second, not 
amounting to more than one degree or 
one degree and an eighth; somewhat 
more considerable from this time to the 
termination of the disease, averaging 
about one degree and a half. The even- 
ing rise is much less than in cases of 
typhoid fever, in which disease the great 
elevation of temperature which precedes 
the fatal issue of the disease, is not so 
marked as in Typhus. TYPHUS FEVER. 
256 
Symptoms referrible to the circulatory sys- 
tem.-The pulse of Typhus is always ac- 
celerated ; in a case of medium severity in 
an adult being about 120, in slighter cases 
not exceeding 80 or 90, while in children 
(by reason of their age), and in more 
serious attacks in adults, the pulse reaches 
up to 140-150, even beyond this to a num- 
ber which cannot be estimated by the 
finger. From the time of attack on the 
one hand to that of improvement or death 
on the other, the pulse seldom fluctuates 
or falls ; it rises steadily up to its maxi- 
mum in favorable cases, maintains the 
same moderate excess for several days, 
and then subsides uniformly and rapidly. 
In graver cases the pulse continues to rise 
until the crisis of the disease is reached. 
A fall in the frequency of the pulse indi- 
cates, in the very great majority of in- 
stances, the commencement of convales- 
cence, and a subsequent rise signifies the 
accession of some local complication. It 
is said that a sudden fall in the pulse, 
especially when it has been excessively 
high, occasionally precedes death. Pro- 
bably this is sometimes the case when 
there are obvious symptoms of impending 
dissolution, but diminution in frequency 
of the pulse has not been observed to pre- 
cede other fatal symptoms. The differ- 
ence between the morning and the evening 
pulse appears to be only a slight exagger- 
ation of that which is observed in health. 
Change from the lying to the sitting pos- 
ture increases the frequency, but not to 
any remarkable degree. 
The character of the pulse is peculiar ; 
it often strikes the observer as being very 
large and strong, but very slight compres- 
sion is ordinarily sufficient to obliterate it 
altogether. In other cases it is distinctly 
feeble and small, and when most rapid is 
often scarcely perceptible to the finger. 
Irregularity of rhythm is observed in some 
severe cases.' A dichrotous pulse is occa- 
sionally found, but more rarely than in 
typhoid. On the other hand, instances 
are sometimes seen when every second 
beat of the heart only gives a pulse at the 
wrist. This circumstance is only tran- 
sient, and must not be confounded with a 
real reduction in the heart's frequency. 
The heart sounds in Typhus may be 
natural, but in severe cases they are weak 
and distant, the first sound especially, as 
has been shown by Stokes, being deficient 
in tone even to the point of being quite 
inaudible. 
The capillary system exhibits also im- 
portant changes in Typhus, showing 
themselves clinically on the conjunctiva 
and skin among the external parts, and 
in congestions of various internal organs. 
The eyes are often bloodshot, and the 
skin much injected, symptoms more ob- 
served in persons below the middle period 
of life than in old persons whose circula- 
tion is inactive. The injection of skin is 
sometimes carried to such a point, that 
tlie linger drawn lightly over the surface 
causes a white stripe to appear in the 
course of a few moments. Besides this 
general injection, a special eruption re- 
sults from congestion and extravasation 
of blood in the vessels of the skin. 
This eruption, constituting the measley 
or mulberry rash of Typhus, is present, 
at some time or other of the disease, in> 
about 95 per cent, of cases, and forms the 
principal diagnostic evidence of the fever. 
It has been described by Jenner and most 
subsequent writers as consisting of two 
portions, but between the two every in- 
termediate link may be found. The one 
is a faint, irregular, dusky-red, fine mot- 
tling, looking as if it lay some little dis- 
tance below the surface of the skin, and 
were seen through a semi-opaque medium. 
This appearance is well expressed by the 
name (which is otherwise inexpressive 
enough) of " subcuticular' ' mottling. The 
other part of the eruption is formed by 
separate spots of small size and purplish 
color, scattered over the mottled surface, 
and looking more or less superficial. These 
are the "maculae" of Typhus. They are 
irregularly roundish in shape, and in color 
vary from brightish-red to livid, fading 
into the color of the adjacent portion of 
skin. At their first appearance, they are 
often a little elevated, and, exceptionally, 
are found to be as much so as the spots of 
typhoid. In the course of a day or two 
they are no longer felt raised above the 
surface. The mottling often exists with- 
out the distinct spots; the spots rarely 
without a considerable degree of mottling. 
Usually, the two exist together, but in 
slighter cases (in children especially) the 
greater part of the eruption is formed by 
the general mottling, while in old persons 
it consists mainly of the distinct maculae. 
As a rule, the eruption of Typhus ap- 
pears on the fourth or fifth day ; it may, 
however, be met with as early as the 
third, and rarely is delayed as late as the 
seventh day from the onset of fever symp- 
toms. It comes first on the backs of the 
wrists, the borders of the axillae, and 
about the epigastrium ; in many cases it 
covers the whole trunk, and frequently 
also the arms and legs. More rarely it is 
met with on the face and neck, but in 
children especially it may be so copious 
on the face as to resemble measles. 
The eruption takes a variable time, un- 
der forty-eight hours, for its complete de- 
velopment, and then undergoes certain 
changes, which, if life is enough pro- 
longed, end in its disappearance; but 
from the establishment of the eruption in 
the first week of the disease, no fresh 
spots are seen. The spots are at first 
wholly obliterated by pressure with the 
finger, but after a few days there is com- SYMPTOMATOLOGY. 
257 
monly some little yellow color left when 
the finger is removed, looking as if the 
coloring matter of the blood had stained 
the skin at the injected spots, and later in 
severer cases pressure fails to remove the 
maculae to any considerable extent, owing 
to an actual escape of blood from the ves- 
sels. The duration of the eruption varies 
according to the relative amount of mot- 
tling or maculation, and according to the 
degree to which the spots become ecchy- 
motic. In slight cases with few distinct 
spots, and occurring among children, the 
mottling may not last more than two 
days, and the skin be then left quite clear. 
In cases of medium severity, the greater 
part of the mottling disappears within a 
few days, going first from the face and 
wrists ; the skin of the trunk still showing 
a crop of the irregular maculse, half ecchy- 
inosed, and, in their later stages, appa- 
rently seated at various depths below the 
surface. In such a case the whole erup- 
tion lasts till the twelfth or fourteenth 
day. But in severer cases, especially 
when the general eruption is livid and 
the maculae immovable by pressure, the 
typhus spots persist later than this, and 
the small ecchymoses may not disappear 
until the twenty-first day or even later. 
Desquamation of the cuticle is not ob- 
served as a consequence of the eruption. 
Another lesion, of rare occurrence, con- 
nected with the circulatory system, is 
local gangrene. This is more commonly 
observed in winter than in summer. The 
toes, the legs, and even the nose may suf- 
fer. More frequently sloughs on the sa- 
crum and heels are seen as the result of 
pressure combined with defective circula- 
tion. Large, heavy people, much pros- 
trated, who lie helplessly on their backs 
day after day, suffer most from these ac- 
cidents. 
Other alterations, connected in nature 
with the circulation, will be considered 
symptomatically under the headings of 
the Brain and Lungs. 
Symptoms referrible to the Digestive Sys- 
tem.-The tongue of Typhus Fever pre- 
sents every variety of appearance. In 
the earlier stages it may be unchanged or 
covered with a thick white fur. Among 
adults uniformly, as the disease advances, 
the tongue becomes dry, the fur forming 
a rough brown coating over a red mucous 
membrane. Often the tongue is so hard 
and the whole of the mouth so dry, that 
from this cause alone there is difficulty in 
protruding it. At the end of the second 
week, in favorable cases, the edges get 
moist, and the tongue clears, the fur dis- 
appearing molecularly or else in patches, 
leaving the mucous membrane shiny and 
red. In severer forms of Typhus, with a 
variable amount of fur, the dry tongue 
cracks and bleeds, giving rise to black 
sordes during the disease, and to fissures 
of which the remains persist after recov- 
ery. The tongue may be intensely red 
and cracked, without there being much 
fur, and in such cases the characteristic 
tongue of typhoid is closely simulated. 
The papillae are rarely enlarged at any 
period. 
The mucous membrane of the mouth 
and throat gets, like the tongue, dry and 
covered with sticky masses of mucus. 
The lips, in bad cases, become covered 
with black sordes like the tongue. 
Thirst is a symptom met with very uni- 
formly, and from the earliest period of 
Typhus. It does not give way until, as 
convalescence begins, the natural secre- 
tion of the mouth suffices to keep the sur- 
face moist. Extreme loss of appetite is 
another symptom of equal constancy. For 
a few days, indeed, in mild cases, 'the 
patient can be persuaded to take light 
food, but as a rule refuses everything 
solid, retaining a desire for stimulants 
only. These, too, are soon distasteful, 
and then the only thing relished is cold 
water. Vomiting is a less uniform symp- 
tom. It sometimes, indeed, occurs at the 
outset, and occasionally forms a trouble- 
some complication in the progress of the 
fever. 
Diarrhoea, with tympanitis, is another 
digestive symptom of not infrequent oc- 
currence. It appears to have much to do 
with the regimen under which the patient 
is put, inasmuch as it certainly occurs 
more in the practice of some institutions 
than of others in the same epidemic.1 It 
is worth while to insist upon this cause of 
diarrhoea, since its occurrence at one time, 
or in one place, might otherwise be mis- 
taken for a special type of the disease 
there. Thus in the practice of the Lon- 
don Fever Hospital, of recent years, 
diarrhoea has been seen in at least one- 
third of the cases of Typhus. In the epi- 
demic of 1856, it was practically absent 
there ; at Liverpool, during the present 
epidemic, there has been little of this 
complication; and even in the present 
London epidemic it has been absent in 
the Typhus treated at some workhouses. 
The symptom appears to be ascribable 
in some measure to the greater amount of 
liquid food that is forced upon the de- 
ranged stomach in the practice of some 
physicians. The plan of the London 
Fever Hospital is to give at short inter- 
vals as much liquid nourishment as the 
patient can be made to take. If the oc- 
currence of diarrhoea do really result from 
this circumstance, it must be confessed to 
constitute a slight drawback to a plan of 
treatment, which for its aggregate results 
is not the less to be warmly advocated. 
When diarrhoea is present there is often 
[' It is quite uncommon in Hospital practice 
in Philadelphia.-H.] 
VOL. I.-17 258 
TYPHUS FEVER. 
considerable tympanites, and some gur- 
gling may be felt, but it is seldom fine or 
confined to the csecal region. The abdo- 
men is in such cases slightly tender on 
pressure, but such tenderness is more 
about the epigastrium than elsewhere. 
On the other hand, in many cases of 
Typhus the bowels are constipated, but 
they are readily acted on by purgatives. 
The stools in this fever differ from those 
of typhoid, even when diarrhoea is pre- 
sent. They are usually dark, and are of 
every consistence, but they do not exhibit 
the appearance of powdery matter sus- 
pended in liquid. Their reaction is stated 
to be acid. 
There is an obscure connection between 
dysentery and Typhus, the fever appear- 
ing under certain circumstances to be 
generated by persons suffering from dysen- 
tery. When this connection has existed, 
the tenesmus and frequent bloody stools 
of dysentery have been observed to com- 
plicate cases of Typhus. 
The writer has seen peritonitis occur- 
ring in one instance only among some 
thousands of cases of Typhus that have 
come under his notice; in that case it re- 
sulted from the rupture of a multiple ab- 
scess in the spleen following on endo- 
carditis. 
Symptoms referrible to the respiratory 
apparatus are so common and so impor- 
tant that they must be regarded as essen- 
tial parts of the disease. In most cases 
of Typhus, during the second week there 
is some little dry rhonchus found at the 
posterior bases of the lungs. The chest 
should be examined daily for this condi- 
tion, even when there is no objective lung 
symptom. By care in this respect, the 
accession of the next series of symptoms 
may constantly be prevented. Thef?e 
consist in increased duskiness of the face, 
livid flush on the cheeks (not specially on 
the malars), dusky color of rash-condi- 
tions indicating defective aeration of the 
blood-and these may exist without any 
cough, but are almost always accompanied 
by some increase in the frequency of re- 
spiration. Tiie patient will make no com- 
plaint, but the smallest degree of any of 
these symptoms should at once point at- 
tention especially to the lungs. Often dry 
rhonchi at the bases will alone be found, 
but frequently also dulness of one or both 
bases. About the lower six inches of one 
base is the amount of dulness usually 
reached, but it may extend up to the 
spine of the scapula on each side. With 
the dulness are found increased vocal fre- 
mitus, high-pitched respiration, and at 
the earlier and later stages of the dulness, 
coarse muco-crepitation. Fine dry crepi- 
tation is less frequently heard over the 
solidified lung. It cannot be too strongly 
insisted on that, with all these evidences 
of lung mischief, there may be no cough, 
and no expectoration, up to the time that 
redux crepitation begins, and very likely 
nothing beyond the duskiness that has 
been mentioned to call attention to the 
state of the chest. Upon the occurrence 
of secondary crepitation, cough often be- 
comes more troublesome, and if there 
have before been no expectoration it now 
appears, and consists of a semi-transpa- 
rent tenacious mucus, scantily aerated, 
and frequently discolored with varying 
blood-tints, as in idiopathic pneumonia. 
Bronchitis and consolidation of the lung 
in Typhus are very apt to improve about 
the period when the fever itself reaches 
its turning-point, which has been stated 
to be usually about the fourteenth day in 
adult patients with moderately severe 
Typhus, and these lung states do not 
often constitute a superadded disease 
after the end of the third week. But 
when they are present they constantly 
obscure the occurrence of a favorable 
crisis, and protract the total convalescence 
of the patient for several days. The phy- 
sical signs in cases of recovery usually 
disappear pretty rapidly, but when dul- 
ness has been considerable it may not be 
quite got rid of for some "weeks, although 
the patient be gaining strength, and have 
no other evidence of chest mischief be- 
yond this dulness, and a pulse that keeps 
up above its natural standard. In cases 
of Typhus fatal from lung complication, 
the lividity of surface and the physical 
signs get gradually worse, and generally 
(but even then not invariably) there is 
visible embarrassment of respiration. 
[The origin of pulmonary embarrassment 
in hypostatic, congestion, due to prolonged 
recumbency without change of position, 
has an important practical bearing in 
Typhus as well as in Typhoid Fever.-H.] 
"The nervous symptoms in Typhus are 
constant and prominent, and it is probably 
through the nervous system that the poi- 
son of the disease primarily operates. It 
is from certain of the nervous symptoms 
that the name of Typhus was originally 
conferred upon continued fever. 
From the very outset of the illness these 
symptoms occur, consisting in rigor, head- 
ache, and weariness of body and mind. 
The amount of head symptoms is greater 
in proportion to the severity of the attack 
and the age of the patient. Restlessness 
and loss of sleep are, even in the slight 
attacks of children, pretty constant from 
the first. Sleeplessness often continues up 
to the time of crisis, and constitutes one 
of the most distressing parts of the illness 
to the patient; and even if he gets a good 
deal of intermitting sleep, he will fre- 
quently protest, with many complaints, 
that he has not slept a wink. The head- 
ache is often intense, but is a dull and 
heavy, and not a sharp pain, and is ac- 
companied with some giddiness and with SYMPTOMATOLOGY. 
259 
noise in the ears. It gets worse through 
the first week, and then gradually disap- 
pears, rarely lasting longer than the tenth 
day. Before the cessation of headache, 
the intellect is heavy, the faculty of appre- 
ciating dates and intervals of time being 
notably confused. 
In a large proportion of cases, delirium 
is a symptom of Typhus. It supervenes 
usually between the fourth and eighth 
days, the headaches going off as the mind 
begins to wander. Subjectively, as learnt 
from the statements of convalescents, the 
delirium is formed by utter confusion 
about time and place and people, and 
even about personal identity. The pa- 
tient often has fancied that he is two or 
three people, and is undergoing several 
sets of miseries and horrors. Objectively 
delirium is of very various amount, and 
in character may be active and maniacal, 
or low and muttering. Much active ex- 
citement is rare in Typhus, but extreme 
degrees of it are occasionally seen, the pa- 
tient praying, bawling, blaspheming, ac- 
cording to his habitual turn of mind, or 
leaving his bed to escape from imaginary 
ill-treatment. Suspiciousness is a not in- 
frequent form of delirium, and the obsti- 
nate refusal of food that comes of this 
mental state may be carried to a degree 
that itself is fatal to the chance of recovery. 
Acute delirium commonly passes after 
some days into the low muttering form, 
the form which is more usually the cha- 
racter of the delirium from the first. In 
this the patient lies talking quietly to him- 
self about matters that interested him at 
the time of his seizure, or on subjects sug- 
gested by what is going on, or he supposes 
to be going on around him. In severer 
Typhus, the muttering delirium passes 
into a heavy stupor, and tremulousness of 
the tongue and hands, with twitching of 
the muscles (substdtus tendinum}, is then 
commonly observed. In very bad cases 
the patient cannot be roused from his 
coma, or a few days before his death he 
falls into the state known as coma-vigil, 
staring vacantly and with fixed eyes while 
in a state of complete unconsciousness. 
To the severe coma, rigidity of the mus- 
cles, fumbling at the bed-clothes, and loss 
of power of swallowing are added before 
death. Convulsions are another symptom 
of occasional occurrence, and of almost 
certainly fatal augury. They are epilepti- 
form in their character, lasting a few min- 
utes only, and giving place to profound 
coma, in which the patient dies, with or 
without a repetition of the convulsion. 
Convulsions in Typhus are almost always 
associated with albuminous urine, and, in 
a few cases where this has been investigat- 
ed, with urea in the blood. 
If the head symptoms have been promi- 
nent, and yet the patient recover, a child- 
ishness of intellect is often left for a few 
weeks. In very rare cases, the patient 
has remained insane for some time, but in 
such of these cases as have come to the 
writer's knowledge the previous history 
of the patient's mind was not satisfactorily 
made out. As a very rare condition in- 
deed, softening of the brain, proving fatal, 
shortly after the fever has subsided, has 
been witnessed. 
All cerebral symptoms are severe, and 
the delirium is commonly earlier and 
more active in persons of the better class 
of life, when they happen to contract Ty- 
phus, probably on account of the habitu- 
ally greater activity of their brains. 
Of the special senses, that of hearing is 
chiefly affected; besides noises in the 
head, deafness is of very frequent occur- 
rence, beginning at the end of the first 
week, being slight, or nearly total in 
amount, and persisting even after the 
advent of convalescence. Nothing is to 
be seen in the ear to account for it. The 
eyes are suffused, and the conjunctival 
vessels injected. The sight is rarely af- 
fected, but much light increases the head- 
ache. The pupils vary a good deal from 
a condition of medium dilatation to one of 
great contraction. Their size has not, in 
the writer's experience, a very constant 
relation to the mental state of the patient, 
nor to the severity of his disease ; but 
small pupils are the rule when coma is 
present. Some sluggishness of the pupil 
to the action of light is then also frequently 
observed. 
Kidneys.--The urine of Typhus has not 
been sufficiently investigated, and many 
of the following statements rest wholly 
upon the writer's own observations. 
In quantity it directly represents the 
amount of fluid ingested, regard being 
had to the other ways in which the body 
gets rid of water. The quantity has been 
found greatest in the first week of the fe- 
ver ; about the same or slightly less, in the 
second ; and notably less during the third 
week after the commencement of convales- 
cence ; the mean of several cases and of 
several days being taken for comparison. 
A belief exists among good authorities 
that much ingested water is retained in 
the body during the whole stage of py- 
rexia, but of this there appears to the 
writer to be no evidence that will bear 
scrutiny. The occurrence of diarrhoea 
diminishes pro tanto the amount of fluid 
carried off by the kidneys ; as to the per- 
spiration, it is not yet demonstrated what 
alteration in its amount goes along with 
the increased temperature of the body; 
it is commonly assumed, and is probable, 
that very little water is got rid of by the 
dry-feeling fever skin. An increased 
amount of urine is said often to accom- 
pany the crisis; this has been observed 
occasionally by the writer, but with no 
approach to constancy. TYPHUS FEVER. 
260 
The color of the urine in Typhus is 
variable. In most cases it is darker than 
usual up to the turn of the disease ; it 
then becomes natural in color, and after 
the third week it is commonly pale. It is 
very rarely pale throughout. The reac- 
tion is acid, probably not more so than in 
health ; and in a case quantitatively ex- 
amined by Parkes, the free acid reached 
to only half the normal standard. 
The twenty-four hours' urine is often 
quite free from deposit; but at some 
period or other of the disease it is usually 
turbid from lithates. A deposit of lithates 
has been said to occur as a critical dis- 
charge ; but in the cases examined by the 
writer, this was observed quite as often at 
earlier as at later periods, and most fre- 
quently a day or two before convales- 
cence. The daily amount of uric acid at 
the height of the fever appears (from one 
analysis by Dr. Parkes, and one by my- 
self) not to be in excess of the healthy 
quantity. In Parkes's case the sulphuric 
acid excreted was rather high ; the phos- 
phoric acid has not been estimated. 
The chlorides of the urine are greatly 
reduced during the pyrexial period of 
Typhus. This partly results from salt 
not being ingested ; but there must be 
some other cause for their disappearance 
from the urine, since all chlorides may be 
withdrawn from a person in health, and 
yet the urine will continue to contain con- 
siderable quantities for some time after. 
In pretty severe cases of Typhus the abo- 
lition of the chlorides may be total; but 
usually there is a small amount secreted, 
estimated volumetrically at from two to 
three grains in the twenty-four hours, and 
just giving an opalescence when acid ni- 
trate of silver is added to the urine. Be- 
fore the advent of convalescence, the diet 
remaining the same, the chlorides reap- 
pear in some quantity, undergoing a grad- 
ual increase, though the quantity ingested 
remains the same from day to day. It is 
not ascertained how far their previous 
dimininution is made up for by greater 
excretion of them during convalescence. 
Their disappearance is not connected with 
diarrhoea, nor is it due to the accession of 
pneumonia. 
When common salt is taken into the 
stomach as a medicine in the early days 
of Typhus, while the natural chlorides 
are being excreted in diminished quantity, 
it does not pass out by the urine. When 
taken at a later period, just before con- 
valescence, it is found freely in the urine. 
In fatal cases, it does not appear up to 
the time of death. In one such case, 
where twelve drachms of salt were given 
to a patient on the ninth and tenth days 
of Typhus, mere traces of it were ex- 
creted by the kidneys, up to the time of 
death on the seventeenth day ; and upon 
examination of the blood, a certain small 
excess, but not accounting for one drachm 
of salt in the whole volume of the blood, 
was detected. It is probable, therefore, 
that the chlorine attaches itself to some 
solid tissue of the body ; or that the ex- 
cess is diffused alike through all the tis- 
sues, and that its retention is intimately 
connected with the febrile condition. 
The daily excretion of urea in Typhus, 
as deduced from sixteen cases accurately 
observed through the several stages of the 
disease, is at first considerably above the 
normal amount. Taking one case with 
another, the daily quantity during the first 
week-the patient being fed on low diet, 
milk and beef-tea-may be stated as about 
double that of the fourth week, when he 
is sitting up and eating his fill of meat. 
The increase is found at the earliest day 
at which the urine has been examined. 
In three fatal cases, it did not diminish in 
quantity during the time that the urine 
could be procured. In cases of recovery 
the amount of urea gets gradually less, 
sometimes, but not always, showing a 
special decrease about the time of crisis.1 
The urine of Typhus is occasionally al- 
buminous. In fifteen male cases of vari- 
ous severity, examined throughout their 
course (some as early as the third or 
fourth day, and most as late as the fourth 
week), albumen was found in two cases. 
One of these was fatal on the tenth day 
without complication, and the urine con- 
tained much albumen on the fourth, fifth, 
and sixth days, the only occasions when 
it could be collected. In the other case, 
a trace was found on the eleventh day, 
but none before or after; here the patient 
died on the twenty-fifth day, from one of 
the rarer sequehe of the disease. Albu- 
men is only found in Typhus of consider- 
able severity; but in some of the cases 
examined, though the fever proved fatal, 
there was none in the urine at any stage. 
The proportion of cases here stated to 
have exhibited albumen is below that 
which is reported as the experience of 
most observers. 
A trace of sugar was observed at one 
time or another in nine cases out of four- 
teen, when it was sought for. It appeared 
at any period between the sixth and 
1 It must not be forgotten that some portion 
of the excess is due to gelatine taken in beef- 
tea. In one case it was attempted to esti- 
mate the influence of this element. For two 
periods the patient was fed on milk, and no 
gelatine, and between these periods he was 
fed upon three pints daily of the strongest 
beef-tea ("so strong it was quite a jelly when 
cold"), and nothing else. The mean of the 
two milk periods was compared with the beef- 
tea period, and an average daily excess of 
11'5 grammes (174 grains) of urea was found 
in the latter. The writer would also like to 
see the influence of alcohol excluded in cer- 
tain observations on the urines of fevers. DURATION - TERMINATION AND SEQUELAE. 
261 
twenty-seventh days, and only lasted a 
day or two. It was probably no more 
than ofte'n occurs in health, and was 
clearly of no clinical significance. 
Convulsions, as connected with kidney 
disease, have already been considered 
under Brain Symptoms. Retention or 
else involuntary passage of urine is fre- 
quent in severe cases. 
Generative System.-The catamenia are 
sometimes present in patients on their 
admission to the London Fever Hospital; 
occasionally to a considerable degree. If 
not present at the earlier stages, the cata- 
menia do not usually appear during the 
progress of the fever nor during the por- 
tion of convalescence that the patient 
passes in hospital. When pregnant 
women get Typhus, if they are past their 
sixth month, they frequently miscarry, 
but this accident adds very little to the 
danger of the case, Typhus Fever herein 
differing much from typhoid or scarlatina. 
Duration.-The duration of Typhus 
Fever may be measured by the fading of 
the eruption, by the fall in the pulse, by 
the decrease of temperature, and by the 
general improvement in the aspect and 
condition of the patient. As a rule, 
amendment begins in all these ways pret- 
ty simultaneously, the fall in pulse and 
temperature being, however, the most re- 
liable indication of approaching convales- 
cence. Measured by these tests, the dura- 
tion of the uncomplicated fever varies 
from twelve to twenty-one days, in mild 
cases (among children particularly) being 
sometimes less than twelve days, but only 
in very rare instances reaching twenty- 
two or twenty-three days. When the 
fever is complicated, for instance with ery- 
sipelas or parotid swelling, the pulse and 
temperature may keep up beyond this lat- 
ter date. In about half the cases, they 
fall on the thirteenth or the fourteenth 
day. Except when petechiie on the skin 
have been very distinct and irremovable, 
the eruption usually fades about the same 
time, and, with very rare exceptions, is 
altogether gone by the end of the third 
week. 
Relapse in cases of Typhus, meaning by 
the word recurrence of the specific disease 
after apparent convalescence, is of exces- 
sively rare occurrence. Once only has it 
happened to the writer to see a true Ty- 
phus rash recur, and this was in the case 
of a woman who lost the eruption on the 
fourteenth day, and appeared to be get- 
ting rapidly well, when, after a few days' 
ailing, the eruption reappeared copiously 
on the twenty-fifth day and remained 
visible for more than a week, the patient 
passing through a second and very severe 
attack of the fever. 
The duration of fatal cases of Typhus 
extends from two or three days to twenty- 
one days, which appears to be the limit of 
risk in cases of uncomplicated Typhus. 
In civil practice it is uncommon for the 
fever to prove fatal before the seventh 
day; but in certain epidemics that have 
Occurred during warfare, death has fre- 
quently occurred at an early period, be- 
fore the development of the eruption. 
The ordinary duration of fatal cases is 
twelve or fourteen days. When parotid 
swelling or other complication appears as 
the cause of death, the fatal result may 
be postponed to the thirtieth day, or even 
later, but it is not then due to the direct 
iniluence of the Typhus poison. 
Termination- and Sequelae.-The 
termination of Typhus in recovery occurs 
often with great rapidity ; the patient who 
the day before lay prostrate, stupid, and 
wandering, with only a slight fall in pulse 
and fever-heat to hint at the commence- 
ment of change, becoming conscious, 
looking comparatively intelligent, chang- 
ing his position (though now feeling for 
the first time his utter weakness), and 
almost suddenly regaining his appetite. 
This improvement is more usually spread 
over two or three days, the lividity of the 
face gradually getting less, the tongue 
cleaning, the thirst disappearing, the 
pulse falling ten or twelve beats a day. 
The fall of temperature takes place pretty 
rapidly in almost all cases; and if it be 
retarded, while the patient appears to im- 
prove in other respects, the accession of 
some complication is commonly imminent. 
Occasionally the pulse does not fall below 
90-100 for many days after manifest im- 
provement in other respects. This is 
commonly due to some thickening of the 
lung remaining behind, and probably in 
other cases to the weakness of the heart 
being extreme. On the other hand, a fall 
in the pulse to a point much below the 
healthy standard is not infrequent in the 
early days of convalescence ; the natural 
frequency being resumed in a short time 
as the patient gains strength. 
From the time when the patient begins 
to mend, he commonly goes on getting 
appetite and strength from day to day. 
Any lung symptoms improve at the same 
time and rapidly disappear. Emaciation, 
which is seen towards the end of the acute 
stage, often continues to increase for 
some little time after the cessation of the 
febrile condition, but soon the convales- 
cent regains what he has lost and returns 
to a state of unimpaired health. Fre- 
quently he finds himself after a month or 
two stronger and better than before his 
illness. 
In cases of Typhus terminating fatally 
through the intensity of the disease itself, 
prostration, subsultus, and carphology in- 
crease, and low delirium passes into com- 
plete coma. The pulse and temperature 262 
TYPHUS FEVER. 
continue to rise; stools and urine are 
passed involuntarily ; food is often obsti- 
nately refused, and there is much diffi- 
culty in swallowing for a day or so before 
death. When there is much bronchitis 
or congestion of the lung, increased livid- 
ity of face with quickened breathing and 
flapping nostrils are observed, but these 
conditions are often less noticed through 
the great prominence of the nervous symp- 
toms. 
A patient ill with Typhus does not 
always convalesce immediately upon the 
cessation of the specific fever. The sequelae, 
of the fever are indeed few and rare, espe- 
cially when it is compared with typhoid 
or scarlet fever, and very seldom does it 
leave behind it any permanent impair- 
ment of health. These sequeke consist 
either in the persistence of some of the 
local complications that have been enu- 
merated in the description of the disease, 
or in the advent about the period of con- 
valescence of certain conditions of an 
erysipelatous nature. 
The complications that occasionally 
continue are consolidation of the lung, 
which occasionally goes on to gangrene, 
but generally mends in the course of a 
week or two ; weakness of the heart, leav- 
ing the pulse feeble, with a tendency to 
palpitation for some short time : bedsores 
and gangrene of the toes of course have 
also to be repaired, or may cause death at 
a late period ; and occasionally a patient 
dies shortly after the twenty-first day 
from the kidney disease that has been set 
up in the course of the fever. 
When erysipelatous affections make 
their appearance, it is usually somewhat 
late in the fever, convalescence being re- 
tarded by their approach. But they may 
also occur during the earlier stages of the 
disease; and, although for practical pur- 
poses they may be regarded as sequelae, 
it is probable they have an intimate con- 
nection in nature with the specific disease. 
Erysipelas itself, following the usual 
course of idiopathic erysipelas, occasion- 
ally occurs about the time of convales- 
cence. It begins at the root of the nose, 
the fauces being at the same time red, and 
may spread over the face and head more 
or less widely, often causing suppuration 
in the eyelids. In three cases lately ob- 
served at the London Fever Hospital, 
rapidly developed oedema of the glottis 
had supervened in patients suffering from 
erysipelas after Typhus. Swelling of the 
extremities-sometimes consisting in in- 
flammatory exudation into the cellular 
tissue, at other times connected with 
phlebitis-and pysemic affections of the 
joints, always ending fatally, are other 
rare conditions of the same sort. 
Of this group of sequelse, the common- 
est is swelling, or bubo, of the salivary 
glands, which are liable to become affect- 
ed at any period of Typhus, but especially 
in the third week ; at any age, but mostly 
in the adult. In a few hours a swelling 
forms that is extremely tender, increases 
rapidly, and, in the majority of cases, 
goes on to suppuration. The parotid is 
the gland most commonly affected, and it 
is not uncommon for both sides to suffer. 
Next, but at a long interval in frequency, 
the submaxillary gland is liable to be af- 
fected, while the sublingual gland is very 
rarely attacked, in the only two cases 
seen by the writer, becoming involved 
after others of the salivary glands had 
swollen. Sometimes, more often in the 
child than the adult, parotid buboes sub- 
side without suppuration, but, usually, 
they go on increasing; in three or four 
days fluctuation is detected, and if the 
swelling be not evacuated artificially, it 
bursts in the mouth, or the meatus of the 
ear, or upon the external surface. These 
swellings appear to occur more in some 
epidemics than in others, and they add 
much to the fatality of the disease. If 
they are at all capable of spreading from 
one patient to another, it is to a very 
slight degree that this occurs, at any rate 
in hospital practice. Upon examination 
of all the evidence bearing on their nature, 
Murchison regards these buboes as form- 
ing a connecting link between Typhus 
and Oriental plague. 
Inflammatory swellings and abscesses 
in other parts of the body are occasionally 
observed after Typhus. Commonly these 
accompany Typhus only as they accom- 
pany smallpox, or other acute specific 
diseases, but there have been some epi- 
demics in which the lymphatic glands of 
the groin and axillae have been observed 
to swell, again appearing to show an af- 
finity of the disease with plague. 
Diagnosis.-The diseases from which 
it is most often required to distinguish 
Typhus, are measles and typhoid fever, 
pneumonia, and certain brain diseases. 
The eruption of Typhus is sometimes, 
though not commonly, a good deal like 
that of measles, and it appears about the 
same day after invasion. If it should 
happen that a child is attacked, and the 
source of contagion is unknown, there 
may be real difficulty in distinguishing 
the two diseases. Coryza, when present 
and distinct, points to measles. The erup- 
tion of Typhus is of a smaller pattern 
than in measles and scarcely ever has any 
crescentic shape. The occurrence of spots 
on the face by no means excludes Typhus. 
Much elevation of the rash is in favor of 
measles. If the diagnosis have remained 
difficult up to the sixth day, it may then 
usually be made with certainty, by noting 
the sudden fall of temperature that then 
characterizes measles, and that does not DIAGNOSIS-PATHOLOGY. 
263 
occur so early or so completely in Typhus. 
Still even this means is only available for 
cases uncomplicated with pneumonia. 
From typhoid fever, Typhus is usually 
pretty easy of diagnosis. Minor elements 
of distinction are, the nature of the fever 
prevailing in the same house and neigh- 
borhood, and the comparative immunity of 
old people from typhoid. In typhoid, the 
invasion symptoms are far more insidious 
than in Typhus; rigor and headache 
are less marked. In the early stages of 
typhoid, epistaxis is sometimes observed, 
a symptom very rare in Typhus, compli- 
cated with scurvy. [The same may be 
said of bronchitis.-H.] The eruption of 
typhoid appears later than that of Typhus, 
rarely being met with before the seventh 
day in typhoid, while in Typhus its ap- 
pearance is very seldom postponed so late 
as this. The mottled, dull-red eruption of 
Typhus, with its irregular, non-elevated 
(at least after the first day), and often 
persistent spots, is not often closely simu- 
lated by the scantier eruption of lenticular, 
rose-colored spots of typhoid. But the 
most essential distinction between the 
two eruptions is, that of Typhus conies 
out in one single crop, while in typhoid 
fresh sets of spots appear day after day, 
and each spot lasts only three to four 
days. Diarrhoea is a much more frequent 
symptom in typhoid than in Typhus ; but 
in the particular case, the presence or ab- 
sence of diarrhoea is not much to be relied 
on for distinguishing the two fevers. The 
character of the stools is more distinctive; 
in Typhus they are natural or dark in 
color, and, if loose, of muddy consistence ; 
while in typhoid they are yellow, and 
consist of powdery-looking matter sus- 
pended in liquid. In typhoid, the stools 
are alkaline, and contain crystals of triple 
phosphate ; but the stools of Typhus come 
to resemble them in these respects when 
there is diarrhoea. The tongue does not 
give much help in diagnosis; for, though 
the typical tongue of Typhus-hard, thick, 
and with much dry brown fur,-resembles 
little the typical tongue of typhoid, flat, 
red, dry, and cracked, with little or thin 
fur; yet either of these descriptions of 
tongue, and every variety of them, may 
occasionally be found in either disease. 
That the tongue should be persistently 
moist, is a circumstance pointing much 
to typhoid. Considerable fluctuations of 
the pulse, and great evening rise of tem- 
perature, are points in which typhoid 
differs from Typhus, but to which appeal 
can rarely be wanted to guide diagnosis. 
The duration of the two fevers will com- 
monly afford a point of distinction, if a 
case should by possibility have remained 
doubtful throughout. Typhus does not 
last more than three weeks, and in the 
attacks with obscure rash (where confu- 
sion with Typhoid is most possible), gen- 
erally a fortnight only ; while, in typhoid, 
the fever, as evidenced by the pyrexia 
and the eruption, goes on to a fourth 
week, and may go on to the thirtieth day, 
er even later. In referring to duration, 
as distinguishing the two diseases, it is, 
of course, necessary to exclude complica- 
tions that may be keeping the patient ill, 
after the specific fever has left him. 
With idiopathic pneumonia, it will ea- 
sily be understood that Typhus may be 
confused, since a species of pneumonia is 
one of the commonest conditions compli- 
cating Typhus. The compressible pulse, 
the great prostration, and the brown 
tongue of Typhus are simulated by cer- 
tain forms of pneumonia, in which, more- 
over, the signs that point to the chest 
may be no more prominent than they are 
in the lung-consolidation of Typhus. The 
presence of a Typhus rash is the essential 
means of separating the fever from the 
idiopathic local disease, and, without it, 
the diagnosis cannot certainly be made. 
In the same way, the existence of Typhus 
eruption is the only way in which cases of 
this fever, complicated with other local 
lesions, can be distinguished from those 
local lesions occurring idiopathically- 
from uraemia or erysipelas, for instance. 
In many cases of Typhus, especially 
when occurring among drunkards, the 
patient, without much apparent prostra- 
tion, has active, suspecting delirium, 
there is total sleeplessness, the muscles 
tremble, and there is considerable resem- 
blance to delirium tremens. But the 
moist tongue and skin, and the absence 
of eruption, usually separate this disease 
from Typhus, from which it also differs in 
the manner of its commencement. 
We have often to make a diagnosis be- 
tween Typhus and acute idiopathic or 
tubercular meningitis. Headache is of a 
sharper character in meningitis, making 
the patient cry out with pain, and it per- 
sists after delirium has set in, which it 
never does in Typhus. Instead of the 
senses being obtuse, as in Typhus, they 
are usually painfully acute in meningitis, 
and the countenance has not the look of 
intense prostration that it commonly has 
in Typhus. Unilateral symptoms, such 
as inequality of the pupils, or ptosis, may 
be seen in meningitis. And in this diag- 
nosis, again, we are guided by the erup- 
tion, if it be present, more surely than by 
any other consideration. 
Pathology.-It has been stated that 
Typhus is the result of a specific poison 
having the power of reproducing itself in 
a healthy person submitted to its influ- 
ence in sufficient quantity and for a suffi- 
cient time. An account of the pathology 
of the disease should explain what tins 
poison is, how it enters the body, and is 
given off to infect other persons, and how 264 
TYPHUS FEVER. 
it operates upon each organ and system I 
to produce the clinical results that have 
been described. Our knowledge goes but 
a very little way towards such an expla- 
nation. The views of Virchow, Parkes, 
and Richardson upon the subject afford 
the most suggestive data, and may be 
combined into some such account as the 
following:- 
The Typhus poison is a complex or- 
ganic substance, probably itself in process 
of decomposition, and capable of produc- i 
ing chemical changes in the albuminous 
tissues and fluids of the body. Upon 
these changes the symptoms of the disease 
depend, and in the course of them a fresh 
amount of the specific poison is produced. 
The nature of these chemical changes is 
not known, but the evidence of their oc- 
currence in the albuminous tissues and 
fluids comes from the changes observed in 
the blood and urine, and the alterations 
seen in the structure of the muscles in 
fatal cases. 
The immediate effect of the mechanical 
change that is brought about by the poi- 
son of Typhus appears to consist in an 
alteration of the osmotic properties of the 
blood. Through this alteration many of 
the phenomena of fever are evolved. The 
interchange of material between the blood 
and the alimentary canal is interfered 
with-an interchange which in health is 
represented by several pints of fluid daily, 
and which is of as much consequence to 
the maintenance of the body as the inter- 
change of gases in the lungs. From this 
interference arise the dryness of the mu- 
cous membrane, the arrested secretion of 
saliva and gastric fluid, the diminished 
secretion of chlorine from the body, and 
probably the febrile phenomena. 
Another consequence of the chemical 
change in the albuminous substances of 
the body is altered metamorphosis of tis- 
sue, firstly, in the way of increase, as we 
see in the great excretion of urea; and 
secondly, in point of quality, the altera- 
tion of the albuminous substances giving 
rise to new products in the secretions. In 
the urine Frerichs shows two abnormal 
albuminous products. In the skin and 
mucous membrane the peculiar odor of 
Typhus, in the absence of chemical proof, 
serves as evidence of some similar change. 
And the self-producing poison of Typhus 
may itself be one of these abnormal ele- 
ments of secretion. 
It has been suggested that ammonia, or 
a compound related to it, is the actual 
poison of Typhus. To the writer it ap- 
pears probable that the matter of this 
poison is of an organic nature less ad- 
vanced in decomposition than the stage 
of ammonia, and that the evidence ad- 
duced to support the ammonia theory 
(even if the fallacy of decomposing matter 
about the mouth have been sufficiently 
excludeil in the experiments upon which 
this theory is chiefly based) points rather 
to the production of ammonia as one of 
the subsequent changes, excretory in na- 
ture, of the altered albuminous com- 
pounds. 
Morbid Anatomy.-The anatomical 
changes that can be appreciated in Ty- 
phus are few, and the only one that is 
quite constant is a change in the blood. 
But changes from the healthy standard 
are seen in the muscles, in the mucous 
membranes and glands, in the kidneys, in 
the lungs, and in the brain, and in other 
organs. 
The body of a Typhus patient is not 
much emaciated, if the patient die at the 
time usually fatal, at the end of the sec- 
ond or in the third week. The Typhus 
macula?, but not the subcuticular mot- 
tling, often persist on the skin after death. 
Decomposition is generally rapid. 
The blood in Typhus is particular^' 
liquid. Drawn from the veins during life 
it coagulates rapidly, but very imperfectly, 
the coagulum being large, dark, and soft. 
Under the microscope it is stated that the 
corpuscles are crenate and misshapen, 
and do not adhere into rolls, but run into 
amorphous heaps. After death the same 
appearances are observed in the blood. 
It is either not coagulated at all, or forms 
in the heart and great vessels large, very 
soft clots, and rapidly becomes putrid. 
Chemical analysis of the blood is as yet 
extremely imperfect. The proportion of 
fibrine is stated to be diminished and that 
of the red corpuscles to be increased, while 
urea and ammonia are said to have been 
found in the blood. Lehmann's account 
is that the fibrine corpuscles and albumen 
are all in excess at first, but that the 
amount of corpuscles diminishes in the 
latter stages, causing the blood to have a 
lower specific gravity. As to the abnormal 
elements of the blood and the chlorides in 
it, no sufficient observations have yet been 
made. 
Morbid changes in the muscles of Ty- 
phus have been long observed in the 
heart's tissue. The organ is soft and 
flabby, and under the microscope the 
fibres are seen in a state of fatty degene- 
ration, probably identical with that ob- 
served in other striated muscles. 
Although softening of the voluntary 
muscles was long ago pointed out by 
Laennec, and they are known to be often 
darker and softer than natural, researches 
into their pathological changes have not 
been followed out. The elaborate re- 
searches of Zenker on the muscles in ty- 
phoid were not extended by him to Typhus 
Fever; but in cases examined by the 
writer the characteristic changes which 
were described by Zenker have been seve- 
ral times observed; the granular and PROGNOSIS AND MORTALITY. 
265 
waxen degeneration having been well 
marked in fibres taken from the rectus 
abdominis and adductor magnus femoris 
muscles. When the cases examined had 
been rapidly fatal, the changes were not 
seen; but when death had occurred in 
the third week, or later than this, from 
some complication, the degeneration was 
well marked. Several instances are on 
record of hemorrhages into the voluntary 
muscles, an occurrence which further 
points to a muscular change in Typhus 
similar to that demonstrated by Zenker in 
typhoid. 
The mucous membrane of the stomach 
is occasionally injected and softened. 
That of the intestines, particularly of the 
colon, is not uncommonly inflamed, its 
vessels being intensely engorged, and soft 
lymph being sometimes exuded on its sur- 
face. This condition is met with when 
during life there has been much diarrhoea. 
The agminated glands, and the solitary 
glands of both large and small intestines, 
may be found enlarged, especially in chil- 
dren who have them naturally very visi- 
ble. But under no circumstances is there 
any deposit in these glands, nor does the 
ulceration of them which is so constant 
in typhoid ever happen in Typhus Fever. 
In those epidemics where dysentery has 
complicated the fever, the characteristic 
lesions of that disease have been observed. 
Of the glands, the liver and spleen are 
frequently hypersemic, large, and softened. 
The spleen is sometimes pulpy in consis- 
tence and enlarged to twice its natural 
volume ; this is seen more when the dis- 
ease has been fatal at a late period. When 
the salivary glands have been swollen in 
Typhus, inflammation and softening, of 
the gland tissue itself is the lesion usually 
observed ; and if the disease is advanced, 
suppuration and sloughing of the gland 
substance and the interstitial areolar tis- 
sue. Some authors have insisted that the 
pathological changes in these glands be- 
gin in the areolar tissue between the 
lobules, but in the writer's experience this 
is not the rule. Under the microscope 
abundance of oil-globules and of granules, 
and of pus cells are found, and the gland 
cells are full of oil-globules. The pancreas 
is frequently injected, but is not known 
to suffer any change resembling that of 
the salivary glands. 
The kidneys are not much or often 
affected by Typhus. Their commonest 
deviation from health is congestion, the 
organs being large and somewhat friable. 
In the rare cases that prove fatal by con- 
vulsions, the kidneys are either found the 
seat of old disease, or they are in some 
stage of recent engorgement up to actual 
acute nephritis, or there may be no lesion 
whatever detected in them. 
The bronchitis that is so very common 
a condition in fatal Typhus offers no ap- 
pearances after death requiring special 
comment. The consolidation of the lungs, 
often met with in most fatal cases, con- 
sists either of true pneumonia or (more 
usually) of hypostatic congestion. In the 
latter the posterior parts of the lung are 
dark, non-aerated, friable, with a section 
that is not granular, as in pneumonia, and 
from which much dark serosity exudes. 
The nervous system commonly shows 
after death no lesion whatever to account 
even for intense head symptoms. The 
utmost change that is usually observed is 
some fulness of the sinuses, coarse injec- 
tion of the meninges, and increased vas- 
cularity of the brain substance, and none 
of these conditions reach any intense de- 
gree. Occasionally a film of hemorrhage 
is seen in the cavity of the arachnoid, and 
the amount of serum in the sulci and ven- 
tricles is greater than usual, but neither 
of these conditions appears to have any 
connection with the brain symptoms dur- 
ing life. Actual meningitis has, however, 
been observed in Typhus, in such a way 
as suggests its occurrence more in some 
epidemics than in others. It is described 
by the physicians of the London Fever 
Hospital in their works, published in 
1830, as of no infrequent occurrence ; but 
in the course of the last ten years, menin- 
gitis has certainly been very seldom seen 
there as a post-mortem appearance in Ty- 
phus. But in the last few years, a form 
of fever, akin to Typhus, if not actually 
identical with it, has been observed in 
America to be often complicated with 
meningitis of the brain and spinal cord. 
And in the present year (1865) a Russian 
physician, Dr. Kremiansky, describes a 
hemorrhagic inflammation of the dura 
mater as a frequent occurrence in persons 
dying of Typhus in St. Petersburg. 
Prognosis and Mortality.-In Ty- 
phus, these are affected by nothing so 
much as by age; but to some degree by 
temperament and habit, by social position 
and nature of previous occupation, and 
also by the characters of the prevailing 
epidemic. 
The rate of mortality from Typhus in a 
community attacked by it is usually stated 
much too high, the experience of hos- 
pitals, into which few children are re- 
ceived, being taken as a basis of calcula- 
tion. When every attack, in persons of 
all ages, is included, the mortality of Ty- 
phus is about 10 per cent. But when 
such cases only as are ordinarily sent to 
hospitals are considered, the mortality is 
about 20 per cent. When age is com- 
pared strictly with age, however, this dif- 
ference, either wholly or for the most 
part, disappears. Between one hospital 
and another, or between hospitals and 
cases treated at their homes, there are in- 
deed some apparent differences of mor- 266 
TYPHUS FEVER. 
tality, but the causes of such differences 
(when real and not dependent merely 
upon age or accident) are not of a nature 
that any general statement of them can 
be made. 
The death-rate of children under ten 
years of age, attacked by Typhus, is about 
5 per cent.; that of persons over sixty 
years is 66 per cent, or upwards, of those 
seized by the disease. Between the two 
there is a regular gradation of fatality. 
For example, at Greenock, the death- 
rate, at seven periods of life, was recently 
found to be, under ten years, 5 per cent. ; 
between ten and twenty, 8'6 per cent. ; 
between twenty and thirty, 15'6 per cent.; 
between thirty and forty, 21 *5 per cent.; 
between forty and fifty, 42 per cent.; and 
over fifty years, 66'6 per cent. ; the mor- 
tality increasing with each decade of age 
that the patient had reached. The death- 
rates of the London Fever Hospital, ana- 
lyzed in detail by Murchison, gave figures 
corresponding in the main with these, but 
all of them slightly higher through the se- 
verity of the cases that are presented to 
that institution. The difference in mor- 
tality, according to age, is so great and so 
universal, that the caution may well be 
given that no comparison between differ- 
ent methods of managing Typhus can 
have the slightest value which does not 
accurately allow for this overshadowing 
influence. 
Bulky, lymphatic, and fat people are 
more likely to die than those of a different 
conformation when they are attacked with 
Typhus. Negroes, treated in the London 
Fever Hospital, have been observed to 
have the fever more severely than whites. 
People of a better class of life, though sel- 
domer attacked, are believed to experi- 
ence a larger mortality than the poor. 
Habits of intemperance very seriously add 
to the unfavorable prognosis. 
Occupational differences only affect the 
prognosis of Typhus in so far as they have 
involved extreme exhaustion and fatigue, 
persons who are attacked under circum- 
stances of that kind usually having a high 
mortality. Overworked soldiers, doctors 
and nurses, for example, get the disease 
with peculiar severity. And if the pa- 
tient try to keep about, going on with his 
work until he takes to his bed from sheer 
inability to stand, he materially dimin- 
ishes his chance of recovery. 
The conditions occurring in an attack 
of Typhus, which gives especial gravity 
of prognosis, are as follow :-Very abun- 
dant rash, with spots scarcely affected by 
pressure ; considerable duskiness of sur- 
face ; a high maximum temperature, as 
107° or above ; continuous rise of temper- 
ature up to the end of the first week, a 
sudden great rise of temperature in the 
third week, this being, it is stated, of fatal 
significance ; very weak pulse, with inau- 
dible first sound of the heart; very rapid 
pulse, death being almost certain if in the 
adult the pulse exceed 150 ; lung compli- 
cations of all kinds make the prognosis 
bad according to their amount; early de- 
lirium ; severe and active delirium, with 
complete sleeplessness; profound coma, 
and especially coma vigil; intense pros- 
tration and subsultus ; convulsions, which 
are almost certainly fatal ; albumen in the 
urine ; obstinate refusal of food ; vomit- 
ing ; uncontrollable diarrhoea. Any of 
the erysipelatous conditions noted as oc- 
curring towards the end of the disease 
contribute to reduce the patient's chances 
of recovery. 
Therapeutics.-Typhus Fever, like 
other diseases of its class, cannot be cured 
nor its duration shortened by any means 
at present known to medical science. Its 
symptoms may be combated, and its com- 
plications may be treated, while the pa- 
tient's strength is supported through the 
time of the fever, but we know of no way 
of encountering the specific disease. Upon 
a full recognition of this truth, the treat- 
ment of a case of Typhus will be most sat- 
isfactorily based. If we propose to our- 
selves to give the patient the best possible 
opportunities of recovery, our treatment 
will be more successful, than if we direct 
our efforts to cutting the disease short by 
any supposed methods of cure. 
In a disease which lasts two or three 
weeks, in which the metamorphosis of tis- 
sue is increased, and in which ordinary 
food cannot be taken, the patient must be 
kept up by nourishment appropriate to 
his new condition, or he will die, as a 
healthy person deprived of food for the 
same length of time would die. The es- 
sential part of the management of Typhus 
consists in giving this appropriate nour- 
ishment, and in preventing the patient 
dying from the want of it while the cura- 
tive processes of nature are going on. 
The character of the nourishment to be 
given requires some detailed considera- 
tion. In the early stages of the fever, if 
the patient have appetite, he may be al- 
lowed anything not positively noxious that 
he has a fancy for. As his dislike for food 
increases, he will still consent to take 
liquids and sick-room delicacies. But 
soon there comes a time, in every severe 
case of fever, when everything but cold 
water is distasteful, and when food has to 
be administered like so much medicine to 
the unwilling patient. At this time, the 
digestive functions are in more or less 
complete abeyance, and the nutriment 
given must be such as requires the sim- 
plest processes for its assimilation. Fore- 
most among nutriments of this kind, ex- 
perience has put beef-tea and broths, milk, THERAPEUTICS. 
267 
eggs, and alcoholic drinks.1 Bread, ar- 
rowrootjellies, are other suitable articles; 
and the nurse who can manage a good 
deal of variety in the choice and combina- 
tion of such things as these, does much 
for her patient's chance of recovery. 
Samples of such variety are Gillon's meat- 
juice ; vermicelli in beef-tea; chicken or 
veal broth ; mutton broth with rice or bits 
of toast; eggs in custards or beaten up 
with milk or with wine; blancmange of 
isinglass or ground rice; syllabubs or wine- 
whey; barley-water or thin arrowroot 
with milk; weak tea or coffee with milk. 
For drinks, lemonade, soda-water, cur- 
rant-water, cold weak tea without sugar 
or milk, or any of these iced, may be al- 
lowed at the patient's choice. Often food 
is taken cold when hot is refused. But 
even of this light diet a little only can be 
taken at once, and it therefore becomes 
desirable that it should be given frequent- 
ly. Every two or three hours the patient 
should be fed, and if he be in a drowsy 
state he should even be roused up to take 
his nourishment. 
But of these means of giving support, 
there is none more important than alco- 
holic drinks judiciously used. It is not 
every patient that requires alcohol; chil- 
dren rarely do, and about half the adult 
cases admitted into hospital may be 
treated without any. But it is especially 
in two classes of patients that we need to 
give stimulants: those who cannot take a 
sufficient quantity of other kinds of nour- 
ishment, and those who are in health 
habituated to the use of strong drinks. 
Besides the use of alcohol as an aliment, 
it has also a medicinal effect upon the 
nervous and circulatory systems, and its 
full employment will much depend upon 
whether this effect is desirable. The 
cases in which alcoholic stimulants are 
most serviceable are (1), in old people al- 
most universally; (2), cases of great pros- 
tration, with low delirium and coma; (3), 
cases where the pulse is very compressi- 
ble and the first sound of the heart feeble, 
also when the pulse intermits and usually 
when it exceeds 120 in frequency; (4), 
cases where the extremities are cold and 
the surface is livid; (5), where there is 
much congestion of the lungs ; (6), where 
there is any erysipelatous complication. 
In a great many cases of Typhus alcohol 
is unnecessary, and appears to do actual 
harm when there is violent maniacal ex- 
citement at an early stage, and also with 
young people in whom, without notable 
depression, there is much bronchitis, or 
in whom true pneumonia can be diag- 
nosed. Alcohol is rarely wanted before 
the appearance of the eruption, and is 
most needful in the second or third week, 
as the patient is approaching the crisis of 
his disease. For ordinary cases requiring 
alcohol, the strong wines are best adapted, 
while lighter wines with water form ex- 
cellent drinks. Beer is a very good form 
of giving alcohol with other nourishing 
principles, and it is often craved for by 
the patient. Severe cases, particularly 
in old persons and in drunkards, require 
spirits, which may be given mixed with 
beef-tea, with milk, or with eggs. A 
moderate allowance to an adult, suffering 
under pretty severe Typhus, with dry 
tongue, moderate delirium, and weak 
pulse of 120, would be a bottle of claret or 
half a bottle of sherry daily. A bad case, 
with livid features, tremulous muscles, 
much low delirium, with coma, and a 
very weak pulse of 140 or 150, may often 
have 12-20 ounces of brandy or whisky 
daily distributed in hourly doses. It of- 
ten happens that in such cases a patient 
for whom there might otherwise be a 
chance, obstinately clenches bis jaws 
against his nourishment, or is made sick 
by it; it is then sometimes possible to 
tide him over the time of crisis by frequent 
enemata of beef-tea and brandy, which 
are usually well retained, even if there 
have been some tendency to diarrhoea. 
[The manner of administration of food 
and stimulants in typhus is very impor- 
tant. After the first few days, if not 
from the start, milk, beef-tea, or some 
other concentrated nutriment, should be 
given in small quantities every two or 
three hours; in cases of extreme prostra- 
tion, every hour, day and night. Having 
had experience of an attack of typhus, 
when resident in a Hospital, I very well 
remember the distressing sense of sinking 
felt on awakening after a couple of hours 
of sleep ; relieved for the time by a table- 
spoonful or two of concentrated liquid 
food. But for watchfulness with this kind 
of care of the patient (especially through 
the weakest time of the twenty-four hours, 
between midnight and morning), not a few 
will, as it were, slip through the fingers. 
1 The writer has no intention to side in the 
controversy concerning the food character of 
alcohol. He accepts the evidence that much 
ingested alcohol is got rid of by the excre- 
tory organs, or is retained for some time in 
the tissues after the manner of many medi- 
cines. But with food in its widest sense, as 
what keeps up the vital functions, the phy- 
sician will have little hesitation in classing 
alcohol, who has observed the common case 
of an habitual tippler maintaining for years a 
fair standard of bodily health upon a quan- 
tity of other nutriment wholly insufficient by 
itself to maintain such health. And to such 
a case a fever patient offers some resemblance. 
He, too, may not be able to take enough of 
other food to maintain him, but alcoholic 
drinks will help him not to starve. And thus 
the writer judges them to have a food value 
apart from their medicinal action. 268 
TYPHUS FEVER. 
When alcohol is needed, it does the most 
good given in milk; say one tablespoonful 
of whisky to two of milk, or, in very feeble 
cases, half and half.-II.] 
But though what has been said is, in 
the writer's experience, the essential part 
of the treatment of fever, there are many 
symptoms and complications that can be 
met by medicinal agents. The thirst is 
best relieved by acidulous draughts, and 
there is no better medicine for slight cases 
of fever than twenty drops of dilute hy- 
drochloric acid in an ounce of water. 
The headache, sleeplessness, and delirium 
are very frequently lessened, even though 
there should be a good deal of suffusion 
of the eyes, by opium; the writer has 
constantly given five minims of laudanum 
every four hours, or else a night dose of 
fifteen minims, with considerable advan- 
tage to these symptoms. He has avoided 
opium when the pupils are very small, 
when there is coma, and when there are 
serious lung complications; but with these 
exceptions, he finds no contra-indications 
to the use of the drug. If opium be given 
with the object of soothing violent de- 
lirium, it should be in full doses at night, 
and not in small frequent doses: but if 
possible it is better not then to use opium. 
Combined with a small quantity of tartar 
emetic, opium has an increased power of 
relieving headache and of inducing sleep. 
When it is desired to use a sedative, but 
to avoid opium, good results have often 
followed from a grain or more of extract 
of cannabis indica given at night. Strong 
coffee is said to have relieved headache; 
the writer has seen no effect from it, either 
upon headache or coma, in the few cases 
where he has employed it. Cold lotions 
to the shaven head and blisters to the 
forehead are each of use in many cases of 
severe headache, and they are means that 
are especially applicable in the cases just 
mentioned where opium must not be used. 
In early furious delirium, two or three 
ounces of blood have been taken from the 
temples with good results; doubtless if 
meningitis were diagnosed, this would be 
right practice then also. When the pa- 
tient's delirium causes him to leave the 
bed, there is no means of restraining him 
equal to the care of an experienced nurse, 
but there is no objection to mechanical 
restraint, for if it be effectually applied 
the patient often ceases to struggle and so 
saves his strength. From deep coma pa- 
tients may sometimes be roused by blis- 
ters to the forehead and nape or to the 
shaven scalp. Subsultus and tremors are 
said to be peculiarly controlled by cam- 
phor and musk. Among stimulating 
remedies that may be used, along with 
much alcohol in cases of great prostration, 
spirit of chloroform and turpentine are 
the most valuable. 
The bowels had best be kept open once 
a day, but slightly confined rather than 
purged. Any but very gentle laxatives 
are apt to cause weakening diarrhoea. 
Should this from any cause be present, 
draughts of sulphuric acid or of chalk and 
catechu may be given ; and when diar- 
rhoea is severe or obstinate, acetate of lead 
in draughts ; or sulphate of copper in pill, 
are most useful, along with small doses of 
opium, if there be no reason against it. 
Starch and opium (fifteen minims of lauda- 
num) injections are also of great use. 
Vomiting is best checked by ice, lime wa- 
ter, or soda water, and by bismuth ; some- 
times by a sinapism to the epigastrium ; 
if it persist in spite of these remedies, it is 
well to let the stomach have complete rest 
for a while, supporting the patient by 
nutritive injections. 
For lung complications of all kinds, one 
of our most valuable remedies in Typhus 
is carbonate of ammonia. The bicarbon- 
ate (formed by exposing powdered sesqui- 
carbonate to the air till its pungency is 
gone) is less irritating to the parched 
mouth, and can be given in larger doses 
than the monocarbonate. Senega assists 
the expectorant action of ammonia, and 
may be given, except for its nastiness, in 
all cases complicated with bronchitis or 
with consolidation of the lungs. Another 
extremely useful remedy for congestion of 
the lungs, especially in old people, is tur- 
pentine, fifteen drops in mucilage. And 
with these internal remedies it is always 
right to use counter-irritants; mustard 
poultices, often repeated, to the back and 
sides of the chest, being the best form of 
them. 
As for the urinary organs, it is import- 
ant to be on the watch against retention 
of urine, and to relieve the bladder duly 
by catheter. Slight albuminuria itself 
calls for no special treatment, beyond 
contra-indicating opium, and being, it is 
thought by some, a reason for not giving 
alcohol very freely. When there is much 
albumen in the urine, or when convulsions 
have occurred, it is right to give gentle 
saline purgatives that may act also as 
diuretics, to use mustard or dry cups to 
the loins, and to get the skin to act by 
means of the hot-air bath. 
Where swelling of the salivary glands 
occurs, the chance of their resolving with- 
out suppuration has seemed to be in- 
creased by blisters over them at an early 
stage. Cotton-wool may be applied over 
the swelling, and when the formation of 
pus cannot be avoided the abscess should 
be poulticed continuously and opened as 
early as ever fluctuation can be detected 
in it. It is of great consequence to give 
extra food to the patient as soon as a 
salivary gland is observed to swell. Eggs, 
fish, panada, and more stimulants should 
be given without any limit but his ability 
to swallow them. Erysipelas supervening relapsing fever: definition. 
269 
on Typhus is best treated by extra food 
and stimulants, by the tincture of iron in- 
ternally, and by wrapping the affected 
parts in cotton-wool. 
In the management of a case of Typhus 
it is of great consequence to place the pa- 
tient in the best hygienic conditions, and 
if he has been attacked in the close crowd- 
ed rooms where the disease mostly occurs, 
his removal to a properly constructed hos- 
pital should be insisted on. An ample 
supply of fresh air of even temperature, 
of clean linen, of soft but cool bedding, 
and the services of an experienced nurse, 
are parts of the treatment as essential as 
the prescriptions of the doctor. Of hy- 
gienic treatment, quiet, cleanliness, fre- 
quent sponging, and occasional changes 
of posture to avoid lung congestion and 
bed-sores, are the most worthy of men- 
tion. 
As soon as the patient passes the crisis 
of the fever, and regains his appetite, he 
may be allowed any article of food that is 
good for him in health, and may eat and 
drink liberally. It often happens that, 
with a tongue still dry and brown, and 
only just moistening at the edges, the pa- 
tient asks for meat, and if it is given him 
finds no ill effects from it. But as a rule 
it is certainly safer to keep him on light 
puddings and fish until his tongue has got 
pretty clean and moist. Beer is generally 
relished in convalescence more than wine, 
of which the palate is tired, and good ale 
or stout may be substituted for a great 
part or for the whole of the other stimu- 
lants. The amount of stimulants must 
be brought to the standard required in 
health by degrees, and not suddenly. 
When during convalescence the patient 
remains childish in intellect, or wandering 
in his mind, it is a reason for giving plenty 
of food and wine, not for diminishing his 
allowance. 
Of the prophylactic measures to be used 
against Typhus little need be said, as they 
consist almost entirely in an avoidance of 
the predisposing causes that have been 
enumerated. Persons in attendance on 
the sick should not be overworked, or de- 
prived too much of their natural rest and 
exercise, and they may be further guarded 
against the reception of the fever by the 
use of disinfectants, of which fresh air and 
cleanliness are incomparably the most 
important. Lime whiting and repapering 
(after lime whiting) of infected rooms, 
stoving the bed and bedding, boiling the 
patient's linen, or soaking it in water im- 
pregnated with chloride of lime, and the 
use of this substance or carbolic acid in 
the water employed for sponging his body, 
are other means that should be employed 
for avoiding contagion. 
Varieties.-The varieties of Typhus 
are few, and consist chiefly in different 
degrees of severity. One epidemic may 
differ from another in its liability to spe- 
cial complications, to dysentery, or to 
cerebral inflammation, for example; or in 
intensity, in this respect being affected by 
the average age of the community in which 
it occurs, and by the degree to which the 
predisposing causes of the diseases are in 
operation. But of such varieties no fur- 
ther consideration is here required. 
RELAPSING FEVER. 
J. Warburton Begbie, M.D. 
This, its familiar name, has been ap- 
plied to one of the forms of continued fe- 
ver, on account of its most characteristic 
and peculiar feature. 
The disease may be defined as follows :- 
Definition.-A contagious1 disease, 
rarely appearing, except as an epidemic ; 
marked by its sudden invasion, the pyrec- 
tic symptoms continuing till about the 
fifth or seventh day, when, after the oc- 
currence of a critical evacuation, their 
abrupt cessation occurs. There succeeds 
an interval of complete freedom from fe- 
ver, followed by sudden relapse on the 
fourteenth day from the commencement 
of the original attack. The condition of 
pyrexia is again terminated by a crisis on 
or about the third day of the relapse, and 
for the most part convalescence ensues. 
Not very infrequently a second, with in- 
creasing rarity a third, fourth, and even 
a fifth relapse, has been noticed. 
History, Nomenclature, and Bib- 
liography.--In 1843 an epidemic of fe- 
[* The application of this term is questioned 
by some, at least, of those who have studied 
the disease.-H.] 270 
RELAPSING FEVER. 
ver appeared in Edinburgh, Glasgow, and 
other of the larget towns of Scotland, 
which, although at first believed to pre- 
sent characters previously undescribed, 
was soon recognized as being similar to 
the fever which had prevailed in the for- 
mer city during the years 1817-18, and 
likewise to the fever which during these 
years and the one subsequent, 1819, as 
well as many previous years, had occurred 
in Ireland. Carefully observed in 1843, 
and very ably described by several Scotch 
physicians, this same fever during a later, 
though by no means so extensive preva- 
lence, in 1847-48, attracted the attention 
of other accurate observers, both in Scot- 
land and England. Since the disappear- 
ance of the last-named epidemic the dis- 
ease has been very little seen. In 1851 
Dr. Murchison informs us that in London, 
as well as in Glasgow, there was a con- 
siderable increase of Relapsing Fever; but 
since 1855, this excellent writer on fever 
remarks, he has reason to believe that not 
a single case of Relapsing Fever has been 
observed in either of these cities.1 As re- 
gards Edinburgh, a very competent au- 
thority, Dr. W. T. Gairdner, has stated 
that he has not seen a single case distinct- 
ly referrible to this type since 1855.2 The 
writer is able to offer an abundant con- 
firmation of the latter statement, for, dur- 
ing his ten years' service as physician in 
the Royal Infirmary, dating from May 
1855, while having at all times charge of 
fever-patients, he has never once encoun- 
tered a case bearing any resemblance 
whatever to the Relapsing Fever. 
Several of the physicians who have en- 
joyed the most extensive opportunities of 
observing the more recent epidemics of 
Relapsing Fever, have occupied them- 
selves with an inquiry into its history ; it 
may therefore be expedient here, before 
entering on the consideration of the phe- 
nomena presented by the disease, to make 
a few observations on the former subject, 
while indicating at the same time the 
different names by which it has been de- 
scribed, as well as the sources from which 
the most reliable information regarding 
Relapsing Fever is to be drawn. In one 
of the important discussions which took 
place in the Medico-Chirurgical Society of 
Edinburgh during the prevalence of fever 
in 1844, the late Dr. Robert Spittai called 
attention to the interesting fact " that the 
present epidemic seems to be exactly the 
same in all its important features as an 
epidemic described by Hippocrates as 
having occurred in the island of Thasus, 
off the coast of Thrace." The chief fea- 
tures of resemblance between the ancient 
and the modern epidemics are the invari- 
able occurrence of relapses, the marked 
character of the crisis, and the frequent 
association with the more ordinary events 
in the disease, of copious perspirations,1 
hemorrhages, particularly epistaxis,"jaun- 
dice,b splenic enlargements,® and in women 
the tendency to miscarry.11 A simple 
mention of the occurrence of one or more 
relapses in the progress of continued 
fever has been made by many writers in 
their descriptions of different epidemics. 
This circumstance alone, it is scarcely 
necessary to observe, does not admit of 
such cases-which were merely excep- 
tional in these visitations of fever-being 
considered examples of the form of fever 
now under consideration. Thus, Dr. 
Brother, in his account of a fatal fever 
which prevailed for two years in London, 
mentions the occurrence of relapses as 
frequent. "Perhaps," he remarks, "we 
may find reason to lay some blame on the 
air for the frequent relapses."2 Dr. 
Lind,3 also, in treating of the contagious 
Typhus of the fleet, alludes to the same. 
"Many," he says, "relapsed." Joseph 
Frank, in his learned account of adynamic 
fevers, refers to the occurrence of relapses, 
but that these were not often witnessed, 
may be gathered from his words, "raro 
recidiva morbi timenda. "4 These quota- 
tions will suffice to establish, firstly, the 
circumstance that occasional relapses in 
cases of continued fever had long been 
observed and described; and secondly, 
that the fevers thus indicated were cer- 
tainly not the disease we are now discuss- 
ing, for in it relapses are not merely 
occasional, nor even frequent, but invari- 
able. We come then to the well-known 
work of Dr. Rutty,5 and in it there is 
* The London and Edinburgh Monthly 
Journal of Medical Science, vol. iv. for 1844, 
p. 177. 
Kat B 'E<m S' rj<ri in pivZv hf^oppaj/na-i. 
b "Eart S' Ml ?X«fOt lyraiMi, 0 Avr'iKa JI c-7rX^> 
tirin' 
d*Hcri JI ^uvE^upn<rE Iv yas-rpi l^ous-jan vos'Hs'cu, 
vratrai aTreipdeipav a; xai iya> oTSa.-Epidemiorum 
Hippocratis, Liber Primus, Sectio Secunda, 
Status Tertius. 
2 Practical Observations on the Epidemi- 
cal Fever which hath reigned so violently for 
these Two Years past, and still rages at this 
present time, by Edward Srother, M.D. Lon- 
don, 1792. P. 121. 
3 An Essay on the most effectual Means of 
preserving the Health of Seamen in the Royal 
Navy, and a Dissertation on Fevers and In- 
fection, by James Lind, M.D. London, 1779. 
P. 190. 
4 Praxeos Medicae Universae Praecepta, Auc- 
toreJosephoFrank. DeFebribusTyphodibus, 
Partis Primae, Volumen Primum. P. 214. 
6 A Chronological History of the Weather 
and Seasons, and of the prevailing Diseases 
in Dublin, by John Rutty, M.D. London, 
1770. Pp. 75, 90. 
1 A Treatise on the Continued Fevers of 
Great Britain, by Charles Murchison, M.D. 
London, 1862. P. 298. 
2 Clinical Medicine, by W. T. Gairdner. 
Edinburgh, 1862. P. 158. HISTORY, NOMENCLATURE, AND BIBLIOGRAPHY. 
271 
afforded ample proof of the existence of 
Relapsing Fever in an epidemic form in 
Dublin, ten years after the London epi- 
demic described by Srother. The former 
writer, in giving an account of the sum- 
mer of 1739, remarks, " The latter part of 
July, and the months of August, Septem- 
ber, and October, were infected with a 
fever, which was very frequent during 
this period, not unlike that of the autumn 
of the preceding year, with which com- 
pare also the years 1741, 1745, and 1748. 
It was attended with an intense pain in 
the head. It terminated sometimes in 
four, for the most part in five or six days, 
sometimes in nine, and commonly in a 
critical sweat; it was far from being mor- 
tal. I was assured of seventy of the 
poorer sort, at the same time in this fever, 
abandoned to the use of whey, and God's 
good providence, who all recovered. The 
crisis, however, was very imperfect, for 
they were subject to relapses, even some- 
times to the third time; nor did their 
urine come to a complete separation. 
Divers of them, as their fever declined, 
had a paroxysm in the evening, and in 
some there succeeded pains in the limbs." 
Again, in describing the summer of 1741, 
the same writer, Rutty, observes : "It 
seems also not unworthy of notice, that 
through the three summer months, there 
was frequent here and there a fever, alto- 
gether without the malignity attending 
the former (an adynamic fever which the 
author had already described), of six or 
seven days' duration, terminating in a 
critical sweat, as did the other also fre- 
quently ; but in this the patients were 
subject to a relapse, even to a third or 
fourth time, and yet recovered." Hux- 
ham, in bearing a strong testimony to the 
value of bark in the advanced stage of 
"the slow nervous fevers," speaks of 
fevers which "are frequently attended 
with dangerous relapses."1 But neither 
in the work from which this statement is 
quoted, nor in his other treatise on epi- 
demics, referred to below, is there any 
account of Relapsing Fever. Dr. John 
Clark, in 1777, observed at Newcastle a 
fever "the duration of which was uncer- 
tain, and some relapsed into the fever." 
This disease about the eighth or tenth 
day presented a white or red miliary 
eruption, and sometimes a more universal 
red rash, resembling the measles ; clearly 
it, too, was other than Relapsing Fever.1 
Drs. Barker and Cheyne, in the conclud- 
ing paragraph of the first chapter of their 
interesting work on Epidemic Fevers of 
Ireland, indicate the occurrence in the 
very earliest years of the present century 
of a fever closely resembling, if not iden- 
tical with, Relapsing Fever. "Certain it 
is," these authors remark, "that the 
fever of 1800 and 1801 very generally ter- 
minated on the fifth or seventh day by 
perspiration ; that the disease was then 
very liable to recur; that the poor were 
the chief sufferers by it; and that it was 
much more fatal amongst the middle and 
upper classes in proportion to the number 
attacked."2 The widespread epidemic 
fever of 1817, and the two succeeding 
years, was in all probability largely com- 
posed of Relapsing Fever. Our chief 
knowledge of the fever as it then occurred, 
is gathered from the works of Barker and 
Cheyne, Harty, Bateman, and Welsh. 
The progress and distribution of the epi- 
demic has been ably sketched by Mr. 
Murchison,3 who has in all probability 
correctly inferred that the proportion of 
typhus to the relapsing cases was greater 
towards the close of the epidemic from the 
circumstance that the rate of mortality 
increased at many places with the advance 
of the disease. Any accurate account of 
the distinctions between the two forms of 
fever composing the epidemic in question 
is not, however, to be expected, and in- 
deed cannot be found. Dr. Christison, to 
whom, as Mr. R. Christison, Dr. Welsh 
in the preface to his work4 refers, can- 
didly admitted in 1844 that, "at the 
time when he had observed the same 
fever twenty years ago, it was the general 
impression that it could produce common 
typhus, and vice versa.'1'1 At the same 
time, Dr. Christison remarked that the 
Fever of 1843-44 was not a new one ; it 
had been described by himself as "Syno- 
cha" in his article on fever in Dr. Tweedie's 
Library of Medicine.5 Allusion has al- 
* Observations on Fevers, especially those 
of the Continued Type, &c., by John Clark, 
M.D., one of the Physicians to the Newcastle 
Dispensary. London, 1780. Pp. 131, 132. 
2 An Account of the Rise, Progress, and 
Decline of the Fever lately epidemical in Ire- 
land, together with Communications from 
Physicians in the Provinces, and various 
Official Documents, by F. Barker, M.D., and 
J. Cheyne, M.D. In 2 vols. London and 
Dublin, 1821. Vol. i. p. 20. 
3 Loc. cit., p. 36. 
4 A Practical Treatise on the Efficacy of 
Blood-letting in the Epidemic Fever of Edin- 
burgh, illustrated by numerous Cases and 
Tables, extracted from the Journals of the 
Queensberry House Fever Hospital, by Ben- 
jamin Welsh, M.D. Edinburgh, 1819. 
5 Discussion in Medico-Chirurgical Society 
of Edinburgh, January 3, 1844. Monthly 
Journal of Medical Science, p. 177. 
1 An Essay on Fevers and their various 
Kinds, as depending on different Constitutions 
of the Blood; with Dissertations on Slow 
Nervous Fevers, &c., by John Huxham, M.D. 
London, 1750. P. 87. 
For a further-notice of Epidemic Fevers, see 
the same author's work, entitled "Observa- 
tiones de 2Ere et Morbis Epidemicis ab Anno 
1728 ad Finem Anni 1737. Plymuthi facta." 
London, 1752. 272 
RELAPSING FEVER. 
ready been made to the circumstance of 
the rever of 1843-44 being at the first re- 
garded as a new disease. The statement 
of Dr. Alison on this point is quite dis- 
tinct. Writing even in 1847, that able 
and excellent man remarked, "The epi- 
demic fever of 1843 is now generally ad- 
mitted to have been a new pestilence, 
hardly anywhere seen in England, and 
not known in Scotland before that year, 
extending rapidly and generally in Scot- 
land, but fortunately causing in itself no 
great mortality."1 But although no cor- 
rect distinction was drawn between the 
two forms of continued fever which un- 
doubtedly composed the epidemic of 1817, 
1818, and 1819, it was otherwise during 
the succeeding epidemic of 1826. Dr. 
O'Brien in particular, who published an 
account of the epidemic as witnessed in 
Dublin in 1826-27, wrote : "At the com- 
mencement of the epidemic two species of 
fever were distinguishable in the wards of 
this hospital, which, to use the words of 
Sydenham, we shall call the fever of the 
old and the fever of the new constitution. 
The first was the ordinary typhus of this 
country, marked by its usual protracted 
periods, running on to the eleventh, four- 
teenth, seventeenth, or twenty-first days. 
This species of fever was inferior in nu- 
merical amount to the other, but far more 
fatal The other species of fever, 
or that of the new constitution, which 
constituted the bulk of this epidemic, was 
one of short periods, terminating in three, 
five, seven, or nine days, but the second 
of these periods was the most frequent. 
.... The patient was destined, perhaps, 
to be harassed by one, two, or three re- 
lapses, which prolonged the whole dura- 
tion of his illness beyond that of the most 
protracted typhus-in fact, the liability to 
frequent relapses was one of the most 
striking characteristics by which this fever 
was distinguished from all previous epi- 
demics, at least which happened in our 
time."2 In respect to the statement of 
O'Brien on the mortality of the epidemic 
at different stages of its progress, Dr. 
Murchison, by a reference to statistical 
facts, has ably shown that in the latter 
part of its continuance the cases of Re- 
lapsing Fever had in all likelihood greatly 
diminished. This result is further corro- 
borated by the statement of Dr. Alison 
regarding the Edinburgh fever of the 
years 1826-27; the mortality in the latter 
year, he has stated, exceeded that of the 
former. 
The epidemic of 1826-27 ended, Re- 
lapsing Fever was probably absent from 
Great Britain till the year 1843, or the 
very close of the preceding year. At that 
time there appeared in Scotland an epi- 
demic, of which excellent accounts were 
published by Drs. Alison, Craigie, Halli- 
day Douglas, and Henderson ; while the 
fulness and accuracy of the treatises writ- 
ten about the same time by Drs. Cormack1" 
and Wardell2 justly entitle them to be 
styled admirable histories of that epi- 
demic. Three complete years separated 
the epidemic just referred to and its suc- 
cessor ; although, during that period, em- 
bracing the years 1844-46, " a few cases 
of Relapsing Fever continued to be ob- 
served, both in Ireland and Britain."3 
In 1847-48, and this is the last occasion 
in these Islands, Relapsing Fever was 
again very prevalent, the particular epi- 
demic being, as aforetime, constituted 
partly of typhus and partly of the shorter 
fever-cases of the latter, about the com- 
mencement of the unusual prevalence of 
fever, being in considerably greater pro- 
portion than those of the typhus. This 
epidemic of fever prevailed in England, as 
well as in Ireland and Scotland. In the 
former, it is probable that throughout its 
entire progress, cases of typhus were 
greatly more frequent than in Ireland, 
and decidedly more so than in Scotland. 
A very careful observer and instructive 
writer on the Irish fever has indeed stated, 
that "cases of genuine typhus were, 
through the whole epidemic, very rare. 
Occasional cases did occur, and these be- 
came more numerous with the advance of 
the epidemic." It is right to note here 
that Dr. Henry Kennedy's opinion, just 
quoted, is not acquiesced in by all author- 
ities ; for example, Dr. Lyons, in his val- 
uable work on fever, makes the following 
observation : " While I admit the frequent 
occurrence of Relapsing Fever in Ireland, 
I must be allowed to record here my pro- 
test against the statements recently cir- 
culated on very insufficient data, that 
Relapsing Fever constituted the large 
majority of the cases of the famine fevers 
of Ireland. The contrary of this I believe 
to be the case ; and having had large and 
extended experience in the last great 
famine visitations of Ireland, 1846, 1847, 
1848, I can certify that the maculated 
1 Observations on the Famine of 1846-47, 
in the Highlands of Scotland, and in Ireland, 
by William Pulteney Alison, M.D. Edin- 
burgh, 1847, p. 9. 
2 Medical Report of the House of Recovery 
and Fever Hospital, Cork Street, Dublin, for 
the Year ending 4th of January, 1827, by 
John O'Brien, M.D., in Transactions of the 
Association of Fellows and Licentiates of the 
King's and Queen's College of Physicians in 
Ireland. Dublin, 1828. Vol. v. pp. 526, 209. 
1 Natural History, Pathology, and Treat- 
ment of the Epidemic Fever at present pre- 
vailing in Edinburgh and other Towns, &c. 
London, 1843. 
2 The Scotch Epidemic Fever of 1843-44. 
London Medical Gazette, 1846-47. 
8 Murchison, loc. cit. p. 295. 273 
GEOGRAPHICAL DISTRIBUTION. 
typhus was the disease which chiefly pre- 
vailed ; while the Relapsing Fever pre- 
sented itself only at the close of the great 
typhus visitation."1 Of the epidemic 
fever of 1847-48, many valuable accounts 
have been written, including those of Dr. 
Robert Paterson,2 of Leith, and Dr. Wil- 
liam Robertson.3 
The works and papers which have been 
already referred to, are among those which 
contain the most satisfactory information 
regarding the Relapsing or Short Fever.4 
Other sources will be indicated in the 
sequel; it may however be stated, once 
for all, that in the exhaustive treatise of 
Dr. Murchison, the fullest, as well as the 
most reliable information respecting this 
and the other forms of continued fever 
which occur in Great Britain is to be 
found. This division of our subject may 
be closed with a notice of the different 
names under which the Relapsing Fever 
has been described. 
The Synonyms are, indeed, numerous, 
and have been suggested by a considera- 
tion of the various particulars in regard 
to the disease itself, or its special epidemic 
prevalence-Short Fever ; Fever of Short 
Periods; Five or Seven Days' Fever; a 
Five Days' Fever, with Relapses ; Remit- 
tent Fever; Febris Becurrens; Das re- 
curirende Fieber; Fievre a Rechute; 
Synocha ; Relapsing Synocha ; Inflamma- 
tory Fever; Mild Yellow Fever, Remit- 
tent Icteric Fever, Bilious Relapsing 
Fever ; Gastro-hepatic Fever ; Famine 
Fever; Die Hungerpest; Fever of the 
New Constitution ; Miliary Fever ; Typhi- 
nia ; Epidemic Fever of Scotland, or of 
Ireland ; and according to the particular 
years in which it prevailed, as of 1843-44, 
1847-48. 
Geographical Distribution. -From 
the foregoing historical statement, it will 
have been gathered that in Ireland and 
Great Britain, the former more especially, 
while in Scotland more than in England, 
epidemics of Relapsing Fever have chiefly 
occurred. But not only has this form of 
fever been more prevalent in Ireland than 
elsewhere, but it has been clearly shown 
by Drs. R. Paterson,5 Wardell,6 Orme- 
rod,' and more recently, and still more 
decidedly, by Dr. Murchison,2 that the 
Irish resident in Great Britain suffers in 
greater proportion than either English or 
Scotch from Relapsing Fever. Notwith- 
standing the statement now made, it is 
to be borne in mind that the epidemic of 
1843 was essentially a Scotch fever, origi- 
nating in Scotland, and showing little 
tendency to extend to any great distance. 
Beyond Great Britain and Ireland, Re- 
lapsing Fever has been seen in the Sile- 
sian provinces of Prussia and Austria ; 
while an able reviewer, in noticing the 
account of the Silesian fever of 1847, by 
Virchow-deputed by the Prussian Gov- 
ernment to investigate it-Biirensprung, 
Diimmler, and Suchanek, has drawn a 
most interesting parallel between the 
Irish and the inhabitants of Upper or 
Prussian Silesia.3 "During the summer 
months of 1855," writes Dr. Lyons, " this 
form of disease was pretty common 
amongst the British troops in the Cri- 
mea."4 It was not fatal, for the same 
author observes, "No fatal cases came 
under our observation in the Crimea." 
Of its existence in Russia we have re- 
cently become aware, for the late exag- 
gerated reports regarding the prevalence 
of a deadly pestilence in that country and 
Siberia, have now been shown to point to 
the occurrence of the Febris Recurrens, 
or Relapsing Fever of Ireland and Great 
Britain, associated, as heretofore in our 
home experience of it, with Typhus, prob- 
ably, also, with Enteric Fever. Finally, 
as regards America, it is evident from the 
analysis of fifteen cases of Continued 
Fever, characterized by Relapses, by Dr. 
Austin Flint, that Relapsing Fever has 
been observed in the Western hemisphere, 
but the information supplied by that able 
writer does not permit us to conclude that 
this form of fever has ever originated in 
America ; the cases detailed by him may 
have owed their occurrence, as the much 
larger numbers occurring in Canada un- 
doubtedly did, to the Irish immigration. 
Dr. Flint's own statement is as follows: 
" The conclusion seems unavoidable, that 
the cases of fever, characterized by re- 
lapses, among those which came under 
my observation in 1850-51, presented the 
distinctive traits attributed to Relapsing 
Fever, sufficiently marked to entitle them 
1 A Treatise on Fever, or Selections from a 
Course of Lectures on Fever, by Robert D, 
Lyons, M.B., T.C.D., &c. London, 1861. P. 
103. 
2 Account of the Epidemic Fever of 1847-48 
in Edinburgh. Edinburgh Medical and Sur- 
gical Journal, No. 177, 1848. 
3 Notes on the Epidemic Fever of 1847^48. 
Edinburgh Monthly Journal of Medical 
Science, vol. ix., 1848. 
4 The disease is well described in Dr. 
Tweedie's Lectures on Fevers. London, 1862. 
5 Loc. cit. 
6 Loc. cit. 
1 Clinical Observation on the Pathology 
and Treatment of Continued Fever, by E. L. 
Ormerod, M.B. London, 1848. 
2 Loc. cit. 
3 The British and Foreign Medico-Chirur- 
gical Review, vol. viii. London, 1851. Arti- 
cle, Diagnosis of Fevers, p. 29. 
4 Lyons, op. cit. p. 106, also p. 108. See 
also Relapsing Fever, in Science and Practice 
of Medicine, by William Aitken, M.D., vol. 
ii. London, 1864. 
VOL. I.-18 274 
RELAPSING FEVER. 
to be ranked in the class of cases which 
have been described by different observers 
as a peculiar form of continued fever."1 
[Dr. Meredith Clymer recognized Re- 
lapsing Fever in some Irish emigrants 
brought to the Philadelphia Hospital in 
1844? Dr. Dubois reported its occur- 
rence, also mostly among emigrants, in 
New York, in 1847-48. During the sum- 
mer of 1870, several hundred well-marked 
cases of it were observed, in localities 
presenting unsanitary conditions, in New 
York and Philadelphia.3 Between April 
and November of that year, 517 cases 
were admitted into the Philadelphia Hos- 
pital ; of which 89 were mortal. The 
whole number of deaths reported to the 
Board of Health in Philadelphia was 
162; of which 107 were of the colored 
race. 26 per cent, of the latter, affected 
with this disease, died; while among 
white patients, but 5 per cent, of those 
attacked died.-H.] 
Etiology.-Relapsing Fever affects 
persons of both sexes and all ages ; the 
statistics of the London Fever Hospital, 
quoted by Dr. Murchison, making it pro- 
bable " that the proportion of the young 
to the aged is greater than in the case of 
typhus."4 The special season of the year 
has little, if any, influence on the preva- 
lence of Relapsing Fever, neither is there 
proof of any particular occupation or em- 
ployment predisposing to the disease. 
This much, however, has long been 
known; and the observation of Relapsing 
Fever when more recently epidemic in 
England and Scotland, as well as in Ire- 
land, has strengthened the belief that this 
disease is peculiarly the fever of the va- 
grant and the unemployed. The contagious 
nature of Relapsing Fever scarcely admits 
of doubt. Two eminent authorities, and 
these only, have expressed the opinion 
that this form of fever is non-contagious. 
One of them, Dr. Cragie, has, indeed, 
almost admitted the contagious nature of 
Relapsing Fever: "This," however, he 
adds, "is rather a presumption than a 
well-founded inference." The other non- 
contagionist is Virchow; but, as Dr. 
Murchison has shown, the importance 
justly attached to the opinion of this emi- 
nent observer is necessarily diminished 
from the consideration that his experience 
of the disease was limited to a single fort- 
night ; he left Berlin on the 20th Febru- 
ary, 1848, and returned to it on the 10th 
of March. An examination thus con- 
ducted must have been cursory and in- 
complete. The opinion, moreover, ex- 
pressed by Virchow, was not shared in by 
the other medical men of Silesia; all 
engaged in practice there believed the 
epidemic malady to be contagious. In all 
the epidemic visitations of Relapsing Fe- 
ver, to which reference has already been 
made, but more especially in those of 
1817, 1818, and 1819, of 1843-44, and 
1847-48, precisely the same facts which 
have been held as sufficient to establish 
the contagious nature of such diseases as 
Typhus, Scarlatina, and Morbilli, were ob- 
served. Physicians engaged in the daily 
observation of the epidemic fever for 
many months together, unanimously form- 
ed the opinion that the Relapsing Fever 
propagated itself by contagion. Concern- 
ing the earliest mentioned of these epi- 
demics, we find Dr. Welsh writing as 
follows: "When acting as clerk to Dr. 
Hamilton in the Royal Infirmary, in the 
course of four months, my three col- 
leagues, two of the young men in the 
apothecary shop, two housemaids, and 
thirteen or fourteen nurses, caught the 
disease, and the matron and one of the 
dressers died of it. Since I left the in- 
firmary, three more of the gentlemen act- 
ing as clerks, one of the young men in the 
shop, and many more of the nurses, have 
caught the infection, but the number I do 
not know. In this hospital (Queensberry 
House), since it was opened on the 23d 
February, 1818, my friends, Messrs. Ste- 
phenson and Christison, the matron, two 
apothecaries in succession, the shop-boy, 
washerwoman, and thirty-eight nurses 
have been infected ; four of the nurses 
have died. With the exception of two or 
three nurses who have been but a short 
time in the hospital, I am now the only 
person in this house who has not caught 
the disease, either here or at the infirmary, 
within the last eight or ten months. Sev- 
eral students, whom curiosity led too near 
the persons of the patients, might be ad- 
duced as additional evidence. When it 
begins in a family, we always expect more 
than one of them to be affected ; I could 
mention instances of four, five, six, and 
seven, being sent to the hospital out of 
one family ; eight, nine, and ten, out of 
one room ; twenty and thirty out of one 
stair; and thirty and forty out of one 
close ; and this all in the course of a few 
months."1 The contagious nature of the 
epidemic fever of 1843-44 is thus insisted 
on by Dr. Wardell: " Most of the medical 
officers connected with the Edinburgh 
Royal Infirmary and additional fever hos- 
pitals were seized with it; eight of the 
resident and clinical clerks in quick suc- 
cession became affected, and, out of that 
1 Clinical Reports on Continued Fever, 
based on an Analysis of One Hundred and 
Sixty-four Cases, &c. &c., by Austin Flint, 
M.D. Philadelphia, 1855. P. 374. 
[2 Fevers, &c., by M. Clymer, M.D., Phila- 
delphia, 1846, p. 99. 
3 Philada. Med. Times, March, 1871.] 
4 Loc. cit. p. 303. 
1 Welsh, loc. cit. p. 45. ETIOLOGY. 
275 
number, no less than six were yellow 
cases, and thus, obviously, in danger of 
their lives. The majority of the nurses 
and domestics took the disease, and of the 
former at one time no less than nineteen 
were laboring under it. Some of the dis- 
pensing physicians and other practitioners 
took the disorder, as also several of the 
clergy, and visitors of the sick, whose du- 
ties brought them to the bedsides of the 
patients."The few cases occurring amongst 
the higher classes, resident in the new 
town, were generally to be traced to the 
influence of contagion, the parties affected 
having had either immediate or indirect 
communication with those suffering under 
the disease."1 And no less decided is the 
testimony borne by Dr. Cormack : " The 
disease," he remarks, "is contagious. Of 
this we have sufficient evidence in the fact 
that almost all the clerks and others ex- 
posed to the contagion have been seized. 
Dr. Heude and his successor, Mr. Reid, 
in the new Fever Hospital; Dr. Bennett, 
my successor there ; Mr. Cameron and 
his successor ; Mr. Balfour, in the adjoin- 
ing fever house; as well as most of the 
resident and clinical clerks in the Royal 
Infirmary, have gone through severe at- 
tacks during the last summer and autumn. 
Hardly any of the nurses, laundry-wo- 
men, or others, coming in contact either 
with the patients or their clothes, have 
escaped ; at one time there were eighteen 
nurses off duty from the fever; and of those 
who have recently been engaged for the 
first time, or of those who have hitherto 
escaped, one and another is, from time to 
time, being laid up."2 It is in language 
closely resembling that employed in the 
sentence now quoted, that Drs. Paterson, 
W. Robertson, and other physicians have 
expressed their belief in the contagious 
property of the Relapsing Fever of 1847- 
48 ; and the writer, whose position as re- 
sident medical officer in the Fever Hos- 
pital while under the care of Dr. Robert- 
son, in the spring months of 1847, afforded 
him the best opportunity for studying the 
nature of the epidemic, arrived at the 
conclusion that the Relapsing Fever, like 
typhus, is capable of communication from 
the sick to the healthy; that, for this pur- 
pose, actual contact with the sick is not 
necessary, the subtle poison of this form 
of continued fever, equally with that of 
typhus, being readily conveyed through 
the air surrounding the latter ; and, last- 
ly, that, by means of fomites or clothes, 
the disease may readily be propagated. 
[In the Philadelphia Hospital, with 517 
cases of Relapsing Fever admitted in 
eight months, no instance of its commu- 
nication to other inmates of the Hospital 
occurred.-H.1] It appears sufficiently 
remarkable that, as specially noted by 
Dr. Cormack in 1843-44, laundry-women 
engaged in washing the clothes of the 
sick, though never brought into direct 
communication with patients themselves, 
suffered frequently from the disease ; but 
this, too, was noticed in regard to epi- 
demic cholera ; and it was an experience 
of precisely the same nature in regard to 
that disease, acquired in the same build- 
ing, the New Fever Hospital of 1843-44, 
being in 1853-54 used as a cholera hospi- 
tal, that, more than anything else, con- 
vinced the writer of the contagious nature 
of epidemic cholera.2 Resembling typhus 
in the mode of its propagation by conta- 
gion, there is one particular in which these 
forms of continued fever remarkably con- 
trast. An attack of typhus, for the most 
part, secures the individual who has thus 
suffered from subsequent attacks. It is 
otherwise with Relapsing Fever ; no such 
immunity is by it secured. Welsh no- 
ticed, in regard to the epidemic of 1817- 
18, that " being once affected with the 
disease seems to afford little, if any, pro- 
tection against a second, or even a third 
attack, and that, too, in the space of a 
few months. I have seen many instances 
of a second attack within the last twelve- 
month."3 It is well known to the many 
personal friends, as well as the profes- 
sional brethren of Dr. Christison, that he 
has frequently suffered from attacks of 
continued fever, and we have his own 
authority for stating that, during the epi- 
demic described by Welsh, he experienced 
three separate attacks within a period of 
fifteen months. Dr. Wardell, Sir W. Jen- 
ner and many other writers on Relapsing 
Fever have noticed the like circumstance. 
It requires little acquaintance, however, 
with Relapsing Fever, and but slight 
familiarity with the remarkable epidemics 
to which reference has been made, more 
especially the last two, those of 1843-44 
and 1847-48, to feel assured that conta- 
gion, while undoubtedly explaining in part 
the progress of the disease, does not do so 
wholly, and stops far short of satisfactorily 
accounting for any of the phenomena 
which were observed, and this more espe- 
cially at the very commencement of the 
different outbreaks. As assisting the bet- 
ter understanding of a subject still encom- 
passed with difficulty, the generation of 
fever, there is, in regard to Relapsing 
Fevers at all events, one consideration of 
f1 Philada. Med. Times, March, 1871.-H.] 
2 Short account of the Cases treated in the 
Cholera Hospital, Surgeon's Square, during 
the late E nic, by J. Warburton Begbie, 
M.D. Edin h Medical and Surgical Jour- 
nal, 1855, p. 
3 Welsh, 1c .xt. p. 46. 
1 Wardell, loc. cit. 
2 Cormack, loc. cit. p. 115. 276 
RELAPSING FEVER. 
very considerable importance. It cannot, 
we think, be denied that an intimate con- 
nection subsists between this form of fever 
and destitution. Dr. Alison-who, in all 
his many writings on fever, as consistently 
held as he ably supported the doctrine 
that intercourse with persons already sick 
of the disease is the only exciting cause 
of continued fever, of the efficacy of which 
we are certain-was evidently greatly im- 
pressed by what he and many other ob- 
servant physicians had noticed of the con- 
nection between destitution, or famine, 
and fever, in the epidemic of 1846-47 
more especially; and he has left it on 
record as his deliberate opinion regarding 
the prevalence of the fever at that time, 
that "although burdening the infirmary 
more than any other which I recollect, it 
has not for many months spread to any 
considerable extent among the working 
classes of the city, but is to be regarded 
as merely the effect of the unavoidable 
connection of this country with the desti- 
tution of Ireland."1 Dr. Murchison has 
adopted an excellent method of demon- 
strating the intimacy of the relationship 
between Relapsing Fever and destitution; 
he has examined the records of the Lon- 
don Fever Hospital and shown that since 
1847, 430, or 97'5 per cent, of the patients 
were paid for by the parochial authorities, 
and totally destitute. Nine of the remain- 
ing patients were admitted free, and were 
also destitute. Not a single patient had 
been a servant in a private family, and in 
only one instance was a fee for admission 
paid by the patient's friends. A large 
proportion of the patients for some time 
previous to their attack had been literally 
starving. Irish writers, with few excep- 
tions, have insisted on the intimate con- 
nection which exists between fever and 
famine. Stokes described the fever of 
1826 as "famine fever," and the well- 
known pamphlet of Dr. Corrigan, con- 
cerning the fever of 1847, had for its title, 
"On Famine and Fever, as Cause and 
Effect in Ireland."2 These physicians, in 
their respective accounts, referred to epi- 
demics largely composed of Relapsing 
Fever. Again, the expressions, "Die 
Hungerpest"and "Famine Fever," clear- 
ly indicate that by German observers, 
as well as by physicians among ourselves, 
this relationship has been noticed. The 
whole subject of the etiology of Relapsing 
Fever has been ably treated by Dr. Mur- 
chison, and the opinion which he has ex- 
pressed of Relapsing Fever being the 
result of destitution, while typhus is pro- 
duced by overcrowding and destitution 
combined, will, we are disposed to believe, 
stand the test of further observation and 
renewed careful investigation. 
Reference has already been made to the 
circumstance that at the commencement 
of the Epidemic Fever of 1843, the dis- 
ease was speedily recognized as present- 
ing remarkable characters. 
"The present epidemic," wrote Dr. 
Henderson, to whom is justly due the 
merit of having first expressed the opinion 
that Relapsing Fever is a separate and 
distinct disease from other forms of con- 
tinued fever, "began to prevail in Feb- 
ruary last, and the very first cases which 
fell under my notice I distinguished at 
once as widely different from every fever 
that I had formerly seen."1 About the 
same time other observers, and more par- 
ticularly Dr. Cormack, from their separate 
and independent observation, were led to 
a similar conclusion; and it is indeed im- 
possible for any one to read attentively 
the descriptions given by Henderson, Cor- 
mack, Wardell, Halliday Douglas, Wil- 
liam Robertson, Paterson, Mackenzie, 
Reid, and more recently, but more par- 
ticularly, Sir W. Jenner, in which the 
whole proof is admirably handled and ex- 
posed-without arriving at the conclusion 
that Relapsing Fever is a form of con- 
tinued fever, wholly different from typhus 
fever, with which it had formerly been 
confounded. These observers - and all 
who have had the opportunity of carefully 
studying the two fevers, must admit the 
accuracy of their statements-pointed out 
that the one fever under no circumstances 
gave rise by communication to the other, 
and that an attack of typhus never con- 
ferred immunity from Relapsing Fever, 
any more than the latter afforded protec- 
tion from typhus. It cannot be consider- 
ed as offering any serious objection to the 
view which has now been expressed, that, 
as in the experience of Dr. Henry Ken- 
nedy of Dublin, in 1847-48, cases of Re- 
lapsing Fever and typhus have been occa- 
sionally met with among the members of 
the same family, and in individuals occu- 
pying at the time of the occurrence the 
same apartment. Dr. Murchison, indeed, 
alludes to such, as an occasional expe- 
rience in the London Fever Hospital, 
since the well known observations of Sir 
W. Jenner were made. The circum- 
stance of the existing epidemic being 
composed of both forms of fever, and the 
further circumstance that both fevers are 
of an infectious nature, satisfactorily ex- 
plain these coincidences. And, upon re- 
1 Observations on the Famine of 1846-47. 
2 Dr. Henry Kennedy's Observations on 
the Connection between Famine and Fever in 
Ireland and elsewhere (Dublin, 1847), con- 
tain much important information and ingeni- 
ous argumentation, but, notwithstanding this 
admission, we adhere to the statements made 
in the text. 
1 On some of the Characters which distin- 
guish the Fever at present epidemic from Ty- 
phus Fever, by W. Henderson, M.D. Edin- 
burgh Medical and Surgical Journal, 1844. SYMPTOMATOLOGY. 
277 
flection, we feel constrained to acknow- 
ledge that were the one form of fever 
capable of producing the other, or, in the 
view of the spontaneous origin of fever, 
were typhus capable of being originated 
in the same way, or under precisely the 
same circumstances as Relapsing Fever; 
then the association of the two fevers in 
the one family, and in the one room 
among the poor, would have been of infi- 
nitely more frequent occurrence than it 
has ever been proved to be. 
Symptomatology. - The suddenness 
of its invasion is characteristic of Relaps- 
ing Fever. The patient is seized with 
coldness and rigors, accompanied by 
headache, pain in the back, and loss of 
strength. The muscular feebleness and 
general prostration, however, are not at 
the first great; for, as Dr. Cormack has 
observed, "many walk long distances 
from the country to the hospital, espe- 
cially during the first days of the disease; 
and a still greater number of the destitute 
town patients lounge about the streets 
after the seizure, and come in to us on 
their legs."1 The feverishness gradually 
increases, while the muscular and articu- 
lar pains and headache become more se- 
vere. By the third day, there is usually 
some amount of epigastric uneasiness, and 
not unfrequently vomiting. No general 
abdominal tenderness, however, presents 
itself, and diarrhoea is of rare occurrence. 
A perspiration, marked in character, and 
general over the body, occurs sometimes 
very early in the disease, on the second 
or third day, bringing with it little or no 
relief to the headache and other symp- 
toms. It is from this circumstance, but 
particularly from the still better marked 
though more rarely-occurring alternation 
of rigors and sweating in the earlier days 
of the illness, that the resemblance to an 
intermittent fever of irregular character 
has been remarked by various physicians. 
On the third or fourth day the fever is at 
its height, and the case is for the most 
part characterized as follows: By the 
greatly augmented temperature of the 
surface (noted at 102° by Halliday Doug- 
las; as high, and this is very high, as 107° 
by Wardell); a very quick pulse (this it 
was which first struck Dr. Henderson as 
remarkable, unlike what he had witnessed 
in typhus), very rarely below 100, often 
120 (125 on the fifth day, being the ave- 
rage frequency in thirty-eight cases noted 
by Henderson); it has, however, been 
noted at 140, and even 160. It was soon 
determined that, unlike what holds true of 
typhus, this rapidity of the pulse did not 
indicate the existence of danger. 
[In Philadelphia, in 1870, the tempera- 
ture was found to rise generally to 104° or 
105° on the second day, and to reach its 
maximum on the day before the critical 
defervescence. On the occurrence of the 
relapse, about the fourteenth day, it again 
rose to 104°, 105°, or even higher; declin- 
ing again with convalescence.-H.] 
With these, the true symptoms of py- 
rexia, are at the same time associated 
very slight disturbance about the head, 
headache frequently, rarely delirium, he- 
patic and splenic tenderness, with vomit- 
ing, great restlessness, thirst, and a white 
condition of the tongue. In a considera- 
ble proportion of the cases a peculiar yel- 
lowness of the skin becomes noticeable, 
best marked in the face, styled by Cor- 
mack "facial bronzing," and to this a 
distinct jaundice, with urgent vomiting, 
sometimes succeeds. To these symptoms 
there occurs, usually on the fifth or sev- 
enth day, an abrupt cessation. Nothing 
can be more remarkable than the sudden 
change-usually ushered in by a profuse 
perspiration, less frequently by an epis- 
taxis, or other hemorrhage, or by diar- 
rhoea- effected in the condition of the 
patient. The frequent pulse and hot skin 
have in a few hours vanished, there is a 
normal appearance presented by the 
tongue, and, as Cormack has described 
it, "one day we hear the patient moan- 
ing and groaning in pain, and on the next 
he is at ease and cheerful, his only com- 
plaint being of hunger and weakness." 
The condition of apyrexia established, the 
patient continues to improve; he gains 
strength, often rapidly, and convalescence 
appears to be altogether satisfactory, ex- 
cept that the pulse sometimes continues 
remarkably slow. On or about the four- 
teenth day from the commencement of 
the original attack the relapse takes place: 
there occurs a second paroxysm of fever 
in all points similar to the first; it may, 
however, be more severe, or on the con- 
trary less severe in its symptoms. The 
duration of the relapse is usually three 
days ; it may extend to five days, or even 
longer, and, when usually mild, it may 
terminate before the third. A second re- 
lapse, usually occurring about the twenty- 
first day, is far from uncommon. "Not 
less than five of these accessions or ' re- 
lapses' have been known to occur."1 
To some of the more remarkable phe- 
nomena now briefly alluded to, and to a 
few other features in the symptomatology, 
it is proper to direct attention a little fur- 
ther in detail. Relapsing Fever, properly 
speaking, is undistinguished by cutaneous 
eruption. The most careful observers 
have failed to notice in it the measly rash 
so characteristic of typhus, no one has 
described the rose-colored spots (taches 
roses lenticulaires of Louis) now regarded 
* British and Foreign Medico-Chirurgical 
Review, vol. viii. p. 8. 
1 Loc. cit., p. 3. 278 
RELAPSING FEVER. 
as equally characteristic of enteric or ty- 
phoid fever. The " measly-looking efflo- 
rescence," noted by Welsh in 1819, as 
occasionally present, may fairly be con- 
sidered to have occurred alone in the cases 
of true typhus which constituted a portion 
of the epidemic he observed. Petechise, 
hemorrhagic spots, and vibices have all 
been described as of occasional occurrence, 
while Dr. Ormerod found a miliary erup- 
tion (sudamina) so common in the Re- 
lapsing Fever of 1847, that in his descrip- 
tion he gave to the disease the name of 
" Miliary Fever."1 Dr. Halliday Douglas 
found sudamina very rarely in the fever 
of 1843-44, and the writer can answer for 
their presence in that of 1847 being like- 
wise quite exceptional. But another cu- 
taneous appearance, although variable, is 
of decided importance-although it is pro- 
bable that its gravity as a symptom has 
been unduly estimated by some physicians 
-namely, a yellowness, or jaundiced hue. 
Welsh also noticed this: "a yellowish, 
dusky state of the skin was not unfre- 
quently observed." In connection with 
it he likewise noticed "that the patient's 
urine distinctly tinged linen cloth or simi- 
lar substances immersed in it."2 In the 
epidemics of 1843 and 1847 jaundice was 
observed, in the former specially by Cor- 
mack, Wardell, and Douglass; in the 
latter by Jenner, in London ; also, but 
with greater rarity than during the pre- 
vious epidemic, in Edinburgh, by William 
Robertson and R. Paterson. 
Nausea and vomiting have been de- 
scribed as common symptoms in Relapsing 
Fever. The matters vomited have usu- 
ally been found to consist of the ingesta, 
frequently tinged with bile. Occasionally 
an appearance resembling the black vomit 
of yellow fever was noted, as by Cormack 
and Wardell, who regarded it as a pecu- 
liarly unfavorable sign, and by Dr. Arnott, 
of Dundee, who, looking upon black vomit 
as quite common in its occurrence, did 
not find it by any means a fatal indication. 
Peculiarities, as regards the appearance 
presented by the tongue, have been noted. 
It is usually from the commencement 
coated with a white or yellowish fur, 
while a small triangular space towards 
the point of the tongue, as well as its 
edges, is clean, and often redder than 
natural. In mild cases the tongue con- 
tinues moist throughout the attack ; but 
in the more severe, dryness, blackness, 
and incrustation with sordes, occur. The 
appetite suffers in Relapsing Fever for the 
most part, as in other febrile disorders, 
but many observers have stated that an 
unusual and sometimes altogether inordi- 
nate desire for food has distinguished par- 
ticular cases. The urine in Relapsing 
Fever was specially examined by Dr. 
Henderson and Mr. (shortly afterwards 
Dr.) Michael Taylor. Occasionally the 
quantity is reduced, or there may even be 
suppression of the secretion, while the 
amount of urea is greatly diminished ; in 
connection with these changes the occur- 
rence of serious cerebral symptoms is to 
be apprehended. Here our knowledge of 
a very important topic ceases. Dr. Parkes 
has truly observed that scarcely anything 
definite is known on the subject.1 Dr. 
Henderson had his attention early directed 
to the condition of the kidneys, and satis- 
fied himself that the occurrence of con- 
vulsions, coma, and less serious symp- 
toms of a nervous nature, were to be as- 
cribed to interference with the proper 
function of these organs. In connection 
with a diminished amount of urea in the 
urine, Dr. Douglass Maclagan deter- 
mined, by investigations undertaken at 
Dr. Henderson's request, the existence of 
an increased amount of urea in the blood. 
There are certain complications and 
sequelae of Relapsing Fever. The inflam- 
matory affections within the chest which 
are known to occur in the course of the 
other forms of continued fever-at times 
seriously influencing the mortality which 
these occasion-are met with also in Re- 
lapsing Fever, bronchitis, broncho-pneu- 
monia, pneumonia and pleurisy. Laryn- 
gitis, requiring tracheotomy, occurred in 
one case in the experience of Dr. Pater- 
son. The writer remembers that the pre- 
sence of a similar inflammation necessi- 
tating the same operation in at least one 
other case, was ascribed, at the time of 
its occurrence in 1848, to the patient hav- 
ing been peculiarly exposed to cold while 
under treatment in one of the temporary 
sheds erected for the accommodation of 
the fever patients admitted to the Royal 
Infirmary of Edinburgh. Hemorrhage's of 
various kinds have been noted to occur, 
for the most part, about the period of 
crisis. Paralysis of a local nature-of the 
deltoid muscles, as observed by Cormack 
-and much more frequently severe mus- 
cular and articular pains, are among the 
number of the nervous complications which 
have been observed. Parotitis, which is 
familiar to us in typhus and enteric fever, 
and other glandular enlargements and 
suppurations, were certainly of uncom- 
mon occurrence in the epidemics of Re- 
lapsing Fever witnessed in this country. 
In the recent Russian epidemic it would 
1 Clinical Observations on the Pathology 
and Treatment of Continued Fever, from 
Cases occurring in the Medical Practice of St. 
Bartholomew's Hospital, by Edward Latham 
Ormerod, M.B. London, 1848. P. 216. 
2 Loc. cit. p. 21. 
1 The Composition of the Urine in Health 
and Disease, and under the Action of Reme- 
dies, by Edmund A. Parkes, M.D. London, 
1860. P. 260. SYMPTOMATOLOGY. 
279 
appear that these buboes are more fre- 
quent ; and Mr. Simon has no doubt cor- 
rectly inferred that "from this circum- 
stance there arose the rumor of plague. "* 
Diarrhoea, sometimes taking the place of 
perspiration, has been described by many 
observers as the critical evacuation in Re- 
lapsing Fever ; with a greater degree of 
frequency it occurred during the relapse, 
or after recovery from the relapse. That 
diarrhoea raised the mortality consider- 
ably, is evidenced by the statements of 
various of the Scotch physicians. 
There are few more interesting circum- 
stances known in regard to Relapsing Fe- 
ver than the frequency with which preg- 
nant women abort or miscarry. By some 
this accident has indeed been described 
as invariable; it is not so, but the excep- 
tions are infrequent. In relation to this 
peculiarity, Dr. Murchison has truly ob- 
served that, on the supposition that Re- 
lapsing Fever is but a mild variety of 
typhus, it would be very remarkable that, 
in the former, abortion is almost invaria- 
ble, and the foetus dies; whereas, in the 
latter, abortion is the exception, and 
when it occurs, the child, if near the full 
time, usually lives.2 A sudden, wholly 
unlooked-for, and at times fatal, syncope 
has distinguished some cases of Relapsing 
Fever. Dr. Halliday Douglas mentions 
one such in which the patient was found 
dead about the period of the first crisis, 
and only half an hour after she had ex- 
pressed herself as .feeling easy. An oc- 
currence of this kind, though fortunately 
not common, may well be considered im- 
portant in a prognostic point of view. 
Lastly, an interesting form of ophthalmia 
presenting two distinct stages, the amau- 
rotic and the inflammatory, has been met 
with and specially described by Dr. Mac- 
kenzie, of Glasgow, as post-febrile oph- 
thalmia. 3 In that city so frequent was 
the eye affection in 1843, that Dr. Andrew 
Anderson speaks of multitudes of cases 
having been treated at one Eye Infirm- 
ary. 4 
When the frequency of the occurrence, 
either of more than one relapse, or one or 
other of the complications or sequelae 
which have been attended to-others less 
frequent and of less severity it has been 
thought unnecessary to mention-is con- 
sidered, it will be understood that Relaps- 
ing Fever, though happily occasioning a 
mortality greatly inferior to typhus, is a 
fever determining-in not a few of the 
sufferers from it-long-continued bodily 
weakness ; while in a still larger number 
convalescence is greatly protracted. 
The account which has been given of 
the symptoms and course of Relapsing 
Fever is sufficient, we think, to establish 
its separate and distinct nature, and to 
allow its being readily distinguished from 
typhus, enteric fever, febricula, remittent, 
or yellow fever, diseases, with the ma- 
jority of which it has been at one time or 
other confounded. The relapse, which is 
the distinguishing feature of this pyrexia, 
is, properly speaking, unknown in any 
other form of fever; and Sir W. Jenner's 
careful observations, confirmed by the ex- 
perience of many competent authorities, 
have proved that Relapsing Fever-a 
contagious disease, as we have already 
seen-is capable only of giving rise to a 
similar disease ; it can engender no other 
form of fever, and no other form of fever 
can engender it. What there is in the 
morbid anatomy of Relapsing Fever, and 
in the mortality it occasions, to sustain 
and confirm this opinion, we shall now 
inquire. As to the former, unlike what 
holds true of pythogenic or enteric fever, 
there is then no constant or invariable 
morbid appearance to be detected. Nev- 
ertheless, there are a few thoroughly as- 
certained facts in regard to this subject, 
which, in the not unlikely event of another 
occurrence of Relapsing Fever, should 
form the groundwork for renewed and 
still more extended investigation. The 
spleen is almost always found altered; 
enlargement and softening, nearly in 
some instances to the extent of diffluence, 
are the most frequent changes, but in- 
creased firmness in its structure, and 
fibrinous deposits in the splenic substance, 
have likewise been observed. Enlarge- 
ment and engorgement of the liver, with- 
out any structural change-even as has 
specially been stated by Cormack and 
others - in the best marked "yellow 
cases," have been generally found. The 
blood, when subjected to microscopic ex- 
amination, has revealed the existence of 
an increased number of white corpuscles, 
similar to what occurs in the now better 
understood conditions of leukaemia. 
[Dr. Hand, of Philadelphia, reported 
the observation of a granulated and cre- 
nated appearance of the red corpuscles. 
Obermeier, of Berlin, discovered minute 
moving filiform organisms, called spirilla, 
in the blood in Relapsing Fever.-IT.] 
The mortality occasioned by Relapsing 
Fever is usually not great, being far in- 
ferior to what is commonly observed in 
1 See his Letter to the Lord President of 
the Council, dated Whitehall, April 19,1865. 
It may be right to mention here, that in the 
experience of the writer, parotitis, hitherto a 
very rarely observed phenomenon by him in 
fever, has during the last twelve months been 
seen frequently, both in typhus and enteric 
fever. 
2 See a confirmation of the last observation 
in an account published by Dr. Matthews 
Duncan, of a case which recently fell under 
the writer's notice. Edinburgh Medical 
Journal, September, 1863. 
3 See Mackenzie, in Medical Gazette, 1843. 
4 Lectures on Fever, p. 135. 280 
RELAPSING FEVER. 
either typhus or enteric fever. In the 
recent Russian epidemic, Relapsing Fever 
is, according to Mr. Simon, "causing 
more than its usual proportion of deaths;" 
but that usual proportion does not exceed 
4*75 per cent., or one death in every 
twenty-one persons attacked. Dr. Mur- 
chison, on placing together the results 
noted at the London Fever Hospital, with 
those detailed by various physicians dur- 
ing the Scotch and Irish epidemics, has 
given as the total 14,119 cases, with 672 
deaths-yielding the rate which has just 
been quoted. Age and habits influence 
the mortality in a manner closely resem- 
bling that which is witnessed in typhus 
and adynamic fevers generally. The 
mode of fatal termination is not always 
alike, the occurrence of a sudden and 
fatal syncope has already been noticed; 
and, as originally indicated by Dr. Hen- 
derson, the impaired action of the kid- 
neys, leading to the imperfect elimination 
of urea, causes death by coma. An as- 
thenic termination, too, may occur in 
those instances of the disease in which 
one or other of the complications already 
adverted to, have manifested themselves. 
Therapeutics.-If, as we believe, 
there is an intimate connection between 
famine-by which is understood poverty 
and destitution - and Relapsing Fever, 
then it will readily be conceded that such 
attention to the wants of the poor, par- 
ticularly as regards due nourishment, as 
ameliorates their condition, will tend di- 
rectly to prevent the origin and to arrest 
the spread of this disease. It is likewise 
contagious, and therefore isolation of the 
sick should, as much as possible, be se- 
cured. Dr. Welsh, to whose account of 
the epidemic fever of 1817 and 1818 we 
have frequently had occasion to refer, 
conceived that blood-letting was the great 
remedy. Little reliance, however, can 
be placed upon the therapeutic observa- 
tions of Welsh, seeing that neither he nor 
other physicians of his time had distin- 
guished between typhus and the fever 
which showed the tendency to relapse. 
Further, it will, we think, appear to any 
attentive reader of Welsh's interesting 
work, that the changes in the condition 
of the patient, particularly the reduction 
of the pulse, the diminution of the fever 
heat, the occurrence of sweating-ascribed 
to the beneficial operation of the blood- 
letting- were in reality merely those 
changes which a subsequent better knowl- 
edge of the disease has led us to recognize 
as the essential phenomena of the fever 
itself, invariably occurring in its course, 
and uninfluenced by any treatment. All 
attempts to ward off the relapse, and for 
the most part attempts to postpone it, 
have signally failed. Those antiperiodic 
remedies in the use of which we place re- 
liance, and the virtues of which in the 
ordinary intermittent and remittent fevers 
have been incontestably established-such 
remedies as quinine, arsenic, bebeerine, 
salicine-have all been faithfully tried, 
and all have failed. 
Emetics of ipecacuanha, or of ipecacu- 
anha with antimony and mild laxatives, 
exhibited early in the disease, have ap- 
peared to be useful in the hands of various 
physicians in relieving portal congestion, 
and producing freedom from the often- 
times distressing pain, or at least uneasi- 
ness experienced in the region of liver, 
stomach, and spleen. Diuretic remedies 
-and particularly the salts of potash- 
were serviceable in relieving the tendency 
to head symptoms, by which, as we have 
already stated, some cases of Relapsing 
Fever "were distinguished. 
Those considerations for the proper 
employment of food, and the administra- 
tion of stimulants, which should guide 
the physician in the treatment of the 
other forms of continued fever, are availa- 
ble likewise in the instances of Relapsing 
Fever. It seems unnecessary to enter on 
an analysis of these here ; and while the 
complications and sequelae of Relapsing 
Fever are, as we have seen, sufficiently 
remarkable, there is only one, the oph- 
thalmic affection, the treatment of which 
seems to require a brief description ; this 
may be given in the words of Dr. Ander- 
son : "We learned very important lessons 
from the treatment of this ophthalmia- 
lessons which tell against some of the the- 
ories which are fashionable at the present 
day. The previous fever and the actual 
debility of the patients made us at first 
eschew anything like depletion; but we 
found on the failure of other means that 
bleeding was the most effectual-the only 
effectual-mode of cutting short this dan- 
gerous ophthalmia."1 After the abstrac- 
tion of blood, calomel and opium were 
administered, until there appeared evi- 
dence of the system being slightly affectgd 
by the mercury. These remedies may be 
prudently combined with quinine and a 
generous diet, while it is almost unneces- 
sary to add that in the treatment of the 
purely and simply amaurotic affection, 
altogether unconnected with hypersemia, 
which occurs as a sequela of Relapsing 
Fever, only tonic remedies and an invigo- 
rating diet are required. 
1 Anderson, op. cit. p. 135. YELLOW FEVER: HISTORY. 
281 
YELLOW FEVER. 
By John Denis Macdonald, M.D., F.R.S. 
Definition. -Infectious continued 
fever, ushered in with languor, chilliness, 
and more or less severe lumbar pain and 
frontal headache ; countenance flushed ; 
eyes at first humid, then suffused, and 
ultimately ferrety ; skin imparting a tin- 
gling heat to the touch, and as the second 
stage advances, gradually acquiring a 
lemon or greenish-yellow tinge; mind 
usually disturbed with hallucinations, or 
more or less violent delirium; restless 
watchfulness, or, possibly, drowsiness, 
even to extreme coma; epigastric unea- 
siness ; spontaneous vomiting without 
effort, first of a clear glairy fluid, but sub- 
sequently with "coffee-ground" flocculi, 
or blood itself, often, towards the close, 
with irrepressible hiccough, and wild 
shrieking or melancholy wailing; ten- 
dency fatal, but the disease generally con- 
fers an immunity from subsequent attacks. 
Synonyms.-Yellow Fever, Bulam 
Fever, Hremagastric Pestilence, Black 
Vomit. Latin-Febris Flava, Synochus 
vel Typhus Icterodes, Synochus Atrabi- 
liosa. Spanish-Fiebre d Calentura Ama- 
rilla Vomitonegro 5 Prieto. French- 
Fievre ou Typhus jaune, Fievre Matti- 
lote, Mal de Siam. Italian - Febbre 
Gialla. 
History.-From the year 1647, when 
the first recorded outbreak of Yellow 
Fever in the West Indies' occurred, to 
the present time, this disease has been 
recurring at irregular intervals in the 
epidemic form, and gradually extending 
its range. It has, moreover, appeared, in 
many instances, to borrow new vigor by 
its importation from one place to another, 
and though it may be said to be perma- 
nently present in some localities, e. g., the 
islands of St. Thomas and St. Domingo, 
there is no proof whatever of its spon- 
taneous development anywhere. Every 
epidemic seems to have some assignable 
source, and even where this is not very 
obvious, there are a priori reasons enough 
to trust that it would be discoverable, 
were investigation properly instituted. 
[The earliest recorded visitation of Yel- 
low Fever in the United States occurred at 
New York, in 1668. It appeared destruc- 
tively in that city also in 1702,1743,1795, 
1798,1803,and 1822. Philadelphia was first 
visited by it in 1695 ; also, in 1793, 1797- 
98-99, 1805; and, with less severity, sev- 
eral times in later years. Mobile was the 
seat of an epidemic of it in 1705 ; New 
Orleans, for the first time, in 1769. The 
years of the most serious epidemics in the 
last-named citv have been, 1819, 1847, 
1853, 1854, 1855, 1858, 1867, and 1878. 
The last epidemic extended to many local- 
ities on both sides of the Mississippi River. 
Several of the Atlantic cities of the United 
States have suffered severely from it in 
different years.-11.1 
The symptoms of Yellow Fever mani- 
festly result from the more or less potent 
operation of some subtle organic poison 
upon the system through the medium of 
the blood ; and the very fatal tendency of 
the malady is probably linked with na- 
ture's efforts to eliminate the poison by 
the gastro-intestinal mucous membrane, 
when both liver and kidney have been 
rendered ineffective in bringing about this 
result. The fact may want confirmation, 
but it has always occurred to the writer, 
that the liver is especially active in per- 
sons perpetually exposed to the specific 
infection of the disease, without, how- 
ever, yielding to its influence ; as though 
the elimination of the poison had been 
effected, in their case, without developing 
the train of symptoms proper to the dis- 
ease. 
Whatever physical conditions-such as 
increase of temperature, moisture, and 
subsequent evaporation, and the like- 
may be favorable to, or merely coincident 
with, the development of Yellow Fever 
on shore, when once communicated to a 
ship, and isolated by far removal from all 
local influences, its phenomena are very 
striking and suggestive. Under such cir- 
cumstances it is difficult to witness the 
spread of the disease from one individual 
to another, and its virulence becoming 
more intensified by the unavoidable 
crowding of the sick, without recognizing 
the important part which the emanations 
and excretions of the human body itself 
must take in the matter. It may be ob- 
jected that all the most potent of the ter- 
restrial or atmospheric conditions alluded 
to are fulfilled in the bilge effluvia ; but as 
these, per se, have never been known to 
originate the disease, we are driven to one 
or other of two positions, either that they 
1 Ligon's History of Barbadoes. 282 
YELLOW FEVER. 
have nothing to do with it, being simply 
coincident like other things that might be 
named, or that they form the nidus for its 
further development and spread subordi- 
nate to a specific cause. It must, how- 
ever, be apparent to a close observer, that 
the human element far outweighs all other 
suppositions, and, in this point of view, 
the refinement and subtlety of the poison 
may be more easily conceived. If Yellow 
Fever be referrible to the zymotic class, 
in support of which idea several cogent 
arguments might be adduced, its mode 
of origin cannot be materially different; 
and few nowadays would attempt to trace 
the whole of the specific virus of rubeola, 
scarlatina, or other true exanthemata, to 
any of the common decompositions of 
cesspools or the effluvia evolved in bad 
drainage, and such, otherwise, certainly 
unwholesome conditions. 
We are in want of proof of the spon- 
taneous development of Yellow Fever in- 
dependently of infected places or persons, 
while a knowledge of the precise nature 
of its specific cause is still a desideratum 
to medical science. But that it is en- 
demic in certain localities, though varying 
much as to its intensity, and the periods 
of its manifestation, cannot be doubted; 
for under similar circumstances, i. e. of 
latitude, or climate, &c., certain other 
localities have never been visited by the 
disease. 
What has just been said in regard to 
Yellow Fever very strikingly points to 
analogous facts in the geographical dis- 
tribution of plants and animals, and the 
curious laws that regulate both their prop- 
agation and decline. But it may be con- 
sidered probable, however much the 
human system may modify their composi- 
tion and manifestation, that the primary 
zymotic poisons owe their origin to the 
development of the humbler and more 
minute, and therefore more subtle, forms 
of animal and vegetable life ; such being 
always coincident with a corresponding 
amount of decomposition, and the evolu- 
tion of new or simply liberated com- 
pounds in a gaseous or diffusible form. 
The presence of offal and filth, or stag- 
nant water, with infused animal and veg- 
etable matter, may be regarded as afford- 
ing something more than predisposing 
conditions; and such a state of things is 
often, though certainly not always, dis- 
coverable where Yellow Fever is rife, but 
more particularly in sultry weather, after 
heavy rains. 
The periodical occurrence of Yellow 
Fever, with intervals of immunity, has its 
parallel in a fact well known to the stu- 
dents of the diatomacese and dermidiacese 
-namely, that particular species, which 
are known to exist in a definite pond or 
pool one season, may be at another re- 
placed by forms never before detected in 
the same spot; while, again, the original 
species, under favorable and often unac- 
countable circumstances, reappear after 
the lapse of a certain time.1 
It is not our intention to make even 
brief reference to all the views that have 
been put forward as to the nature of the 
specific cause of Yellow Fever; but it 
may be remarked that even if they were 
carefully detailed, our conclusions would 
probably be the same ; for upon this head 
very little more than what has been above 
stated is critically known. 
The infectious nature of Yellow Fever 
is now not only generally admitted, but it 
forms one of the most distinctive features 
of the disease, at once marking it off from 
those fevers which in nearly every other 
particular simulate it. 
It is scarcely necessary to multiply or 
repeat the " strong proofs" in this place, 
after the satisfactory evidence lately 
brought before the Epidemiological So- 
ciety of London, in the papers of Dr. Bry- 
son, and the important verbal support of 
the late lamented Dr. M'William. The 
tenets of the writer, derived from actual 
facts, are the following, acknowledging a 
genealogy to the widely-spread family of 
Yellow Fever. 
1. That the first place or the first per- 
son, or both, must have become infected, 
somewhere or somehow. 
2. That by veritable, but unknown, or 
rather untraced, links with this source, 
places, having become infected, may in- 
fect persons. 
3. That persons infected may infect 
other persons and places previously pre- 
sumed to be healthy. 
4. That the clothing of infected persons, 
or of healthy persons having communi- 
cated with infected places or persons, may 
impart infection to other places or persons. 
5. That if places were movable, like 
persons (which is literally true of ships), 
on being infected, they would impart the 
virus to other places in sufficiently close 
proximity. 
6. Finally, from the investigation of the 
history of particular cases, it has been sat- 
isfactorily shown that the period of incu- 
bation, or latency, in this disease, i. e. from 
the imbibition of the poison to the first 
appearance of symptoms, ranges from one 
to fourteen or fifteen days. 
[Of the above account, that which is 
most evidently beyond controversy is the 
statement that Yellow Fever is "endemic 
in certain localities," while, " under simi- 
lar circumstances, of latitude, climate, 
&c., certain other localities have never 
been visited by the disease." This exist- 
ence of a "true Yellow Fever Zone"2 is, 
1 Med. Journal of H.M.S. Icarus for I860, 
N. A. and W. I. Station. 
[2 See Diagnosis, p. 286.] HISTORY. 
283 
indeed, the cardinal fact in the natural 
history of the disease. Its geographical 
"habitat" is as well marked as that of 
almost any plant, which is capable of 
transplantation, but difficult of permanent 
naturalization. 
Dr. R. La Roche, in his exhaustive trea- 
tise on Yellow Fever,1 summing up the 
results of all the history and literature of 
the subject, confirmed by personal obser- 
vation, asserts strongly the non-contagion, 
as well as the locally infectious character 
of this disease. Of ships, he says2 that 
"by them the disease, or its cause, may 
be, and has been, introduced into healthy 
places, and communicated to those who 
have gone on board, or approached suffi- 
ciently near to be placed under the influ- 
ence of the effluvia issuing from them. 
But such an introduction differs materially 
in its consequences from that of a conta- 
gious poison." 
While controversy is endless, from the 
nature of the case, between opposing in- 
terpretations of the same facts in regard 
to the extension of disease from place to 
place, it is important to bear in mind how 
often the most careful and elaborate in- 
vestigation, by competent inquirers, has 
resulted in the conclusion just cited. 
Thus, the London General Board of 
Health, the Superior Council of Health at 
Paris, the Sanitary Commission of New 
Orleans, and other such bodies, have from 
time to time judicially pronounced in favor 
of the discrimination between contagion 
of persons and infection of places (including 
ships) in the causation of Yellow Fever. 
It is true that, in some of the same places, 
a similar official expression in a contrary 
sense has afterwards sometimes been ob- 
tained, by the urgency of a few, under a 
" wave" of alarm in regard to contagion 
and quarantine. But a survey of the 
whole history of the disease leaves it still 
to be concluded, that, at the most, conta- 
gion is to be admitted as a merely possible 
supposition, extremely hard even for its 
advocates to trace with certainty in any 
definite instances ; while the geographical 
relations of the disease, and its promotion 
by local unsanitary conditions, are palpa- 
ble and overwhelmingly important. 
No more deliberate and competent con- 
sideration of this subject was ever given 
forth than that of the Third National 
Quarantine and Sanitary Convention, 
which assembled in New York in 1859. 
As the result of a full discussion, partici- 
pated in by nearly all those who by expe- 
rience and information were entitled to 
judge of the question as one of American 
sanitation, the following resolution was 
adopted, by a vote of 85 yeas to 6 nays :- 
"Resolved, that in the absence of any 
evidence establishing the conclusion that 
Yellow Fever has ever been conveyed by 
one person to another, it is the opinion of 
this Convention that the personal quaran- 
tine of cases of Yellow Fever may be 
safely abolished, provided that fomites of 
every kind be rigidly restricted." 
The majority of this Convention at- 
tached little importance to the clause in 
regard to fomites, except as a part of the 
general system of local sanitation, which 
has been shown to be as indispensable and 
efficacious in the prevention of Yellow Fe- 
ver as in that of any other disease what- 
ever.1 
The geography of Yellow Fever is cer- 
tainly remarkable. It is comprised within 
the borders of the Atlantic Ocean, and the 
waters (Gulf of Mexico, Western Mediter- 
ranean, and the rivers emptying into 
these) communicating with it, in the zone 
between 42° north and 35° south lati- 
tudes. Especially are the West India 
Islands subject to it. Next after these, 
in regard to frequency and severity of 
visitation, have been New Orleans and 
some other cities of the Southern United 
States. 
Rarely does it prevail many miles from 
the sea or from a considerable river. 
None of the far interior cities of either 
continent have ever been visited by it. 
Never, except as, in a very few instances, 
transiently conveyed by infected ships, 
has it been seen upon the coasts of the Pa- 
cific Ocean. The oriental tropical homes 
of cholera and plague have never known 
it. How very different is all this from the 
history of an indefinitely portable, truly 
contagious disease! 
It has been a prominent fact in repeated 
epidemics in different American cities, 
that the infection of Yellow Fever is, from 
time to time, localized in certain limited 
spaces, mostly measurable in fractions of 
a mile. Many times the removal of the 
inhabitants of an infected city, in large 
numbers, has brought them security, 
while the scattering of those who thus 
migrated, some of them with the disease 
in their systems, has not extended it else- 
where. Thus, from Barcelona, in 1821, 
80,000 of the inhabitants escaped by flight; 
while of those who remained in the city, 
one-seventh, 10,000, died.2 During the 
[' At the meeting of the American Public 
Health Association, at Richmond, Va., in 
1878, resolutions were passed pointing in a 
different direction"from the above. But it 
was evident that this meeting, called under 
the pressure of public alarm on account of the 
extended and destructive epidemic of that 
year in the Southwestern States, had not time 
nor material for doing justice to its subject. 
This was clearly indicated in a circular issued 
by the Executive Committee of the Associa- 
tion, shortly after its adjournment.-H.J 
[2 Second Report on Quarantine, 1852.] 
[' In two volumes, Philada., 1855.] 
[2 Op. citat., vol. ii. p. 545.] 284 
YELLOW FEVER. 
war between the United States and Mex- 
ico, in 1846-7, Dr. Bennett Dowler re- 
ported that many thousand instances of 
such removal of individuals proved expe- 
rimentally its advantage to those who 
have left infected localities, and its safety 
to others amongst whom they have gone. 
Practically, we deduce from these facts 
the conclusion, that three things are un- 
questionably needful in the prophylaxis of 
Yellow Fever: 1. Complete and persist- 
ent local sanitation in all places within the 
"Yellow Fever Zone;" 2. Vigilant in- 
spection, at sea and river ports, of all ves- 
sels, so as to detain those found to be un- 
clean, at a distance from city wharves, 
until they have been thoroughly purified 
and disinfected ; 3. Removal of all inhab- 
itants from every spot ascertained to be 
infected, to some open and salubrious lo- 
cality. 1 If but a small fraction of the large 
expenditure provided, by aid of the be- 
nevolence of the people of the Northern 
States, in the summer of 1878, for the care 
of the sick and dying in the stricken cities 
of the South, had been applied to their 
early removal, house by house, and ward 
by ward, as soon as local infection was 
ascertained, hundreds, perhaps thousands, 
of lives might have been saved, and much 
commercial distress averted. Of course 
part of such a plan must be, the choice of 
healthy places for accommodation of those 
removed, and the conservation among 
them of good sanitary conditions.-II.] 
Altitudinal and Horizontal 
Ranges.-It may be very w'ell to assign 
an altitudinal limit to the spread of Yel- 
low Fever-and, roughly speaking, this 
may be estimated at between 2000 and 
3000 feet above the level of the sea-but 
the local conditions of every country seem 
to determine a range peculiar to itself. 
Thus, the disease has been known at 
Newcastle, Jamaica, at an elevation of 
4000 feet; while in the Valley of the Mis- 
sissippi its highest recorded range is about 
600 feet (admitting the Fever of Gallipolis 
to be of the genuine type). Humboldt 
alludes to the Farm of Encero, in Mexico, 
at an elevation of 3243 feet, as the altitu- 
dinal limit of Black Vomit. At St. Do- 
mingo, the mountain encampments of the 
French in 1792 and of the English in 1796, 
enjoyed an immunity from the disease, 
while it was spread far and wide amongst 
the troops in the low country. 
Though the West Indian Islands, and 
the neighboring coasts of North and South 
America, may be looked upon as the focal 
area of Yellow Fever, yet taking the out- 
lying points at which its occurrence in 
the epidemic form has been recorded, its 
geographical range must be regarded as 
very considerable indeed, i. e. between 
97° west and 2° east longitude, and be- 
tween 48° north and 35° south latitude. 
At least for the space of a century and 
a half, up to the year 1850, the river Ama- 
zon, dividing the Brazils from Guiana, 
limited the extension of Yellow Fever 
south of the line ; and while the disease 
was raging at Rio and Bahia at the close 
of that epoch, the Montevideans flattered 
themselves that they were without the 
geographical limit of the pestilence, until 
it fell to their turn to sustain its visita- 
tion several years later, when the illusion 
was dispelled. Similar facts may be ad- 
duced with regard to the extension of the 
disease along the shores of the Pacific; 
so that, however well we may be ac- 
quainted with its present range, making 
all due allowance for temperature, we 
cannot tell what the future may bring 
forth. In this connection it may be men- 
tioned that a temperature of at least 72° 
is assumed to be essential to the develop- 
ment of Yellow Fever, though cases ex- 
ceptional to this rule also may now and 
then happen. 
Symptoms.-With or without such pre- 
monitory symptoms as loss of appetite, 
costiveness, flatulence, sense of debility, 
and the eyes humid and bright, the dis- 
ease frequently makes its invasion with 
chills ; but this will greatly depend upon 
the existing temperature or climate. Thus 
Jackson maintains that they seldom occur 
within the tropics, while they are quite 
usual in more temperate climates. The 
chills alternate with flushes of heat, and 
the latter gradually settle down into reg- 
ular fever, which is often observed to be- 
come more severe towards evening, with 
something approaching a remission in the 
morning. The amount of fever, moreover, 
bears relation to the severity of the chills 
preceding it. Frontal headache is also 
an early symptom, with shooting pains 
through the orbits and temples ; but dis- 
tressing as these may be, they are usually 
trivial in comparison with the agony of 
the lumbar pains which frequently seize 
the patient at this period, and fell him to 
the ground in a writhing and convulsive 
state. In some severe cases, however, 
this symptom is nearly entirely absent. 
From the very commencement the pa- 
tient may be troubled with nausea and 
epigastric tenderness, or they may be de- 
veloped as the reactive stage advances. 
The pulse exhibits great diversity of 
character, being much accelerated, full, 
and strong, in keeping with the force of 
the paroxysm or even soft and weak where 
the febrile reaction is deficient in severe 
cases-the beats ranging between 90 and 
[' What to Do Against Yellow Fever : by 
H. Hartshorne, M.D. Reports and Papers of 
American Public Health Association, vol. i., 
1873.] 
120 in a minute. SYMPTOMS-DIAGNOSIS. 
285 
Also varying with the nature of the 
paroxysm, the skin may be hot and pun- 
gent, dry or perspiring, livid, flabby, and 
even cold. 
The tongue exhibits a creamy-white 
coat on the dorsum, with red tip and 
edges, and injected papillie, with or with- 
out soreness of the throat. 
As the second stage advances irritabil- 
ity of stomach is added to the nausea, 
and the epigastric pain and tenderness 
become more distressing. The patient 
craves for cold drinks, which are immedi- 
ately rejected, first with some retching 
and pain, but subsequently without effort. 
The matters vomited usually have a sus- 
picious appearance : thus, they are some- 
times imbued with bile, lightly streaked 
with blood, or quite serous with small 
chocolate-colored flocculi, discovering the 
tendency to hemorrhagic oozing from the 
lining of the stomach. 
The urine is scanty, high-colored, and 
probably albuminous : the stools become 
gradually more and more deficient of bile; 
and the bowels are often obstinately con- 
stipated. 
The patient begins to be restless and 
vigilant, and disposed to leave his bed, go 
into another, or walk about naked if he be 
permitted. He exhibits an evident de- 
rangement of intellect, though he may 
answer questions coherently. In other 
instances, - with a suffused ferrety eye 
and a drunken expression of countenance, 
-wild hallucinations, similar in every re- 
spect to those of delirium tremens, afflict 
the victim's mind, and may deceive the 
practitioner most seriously in sporadic 
cases. 
Febrile reaction may continue for an 
indefinite period between a few hours and 
two or three days, and its duration is said 
to be in the inverse ratio of the violence 
of the attack. 
"Having run this course," says Dr. La 
Roche, "the fever subsides, never more, 
or very seldom, to return-the disease be- 
ing one of a single paroxysm-and is fol- 
lowed by a state of remission or meta- 
phosis." The nature of this remission is 
all important, as regards the fate of the 
patient. Should all the symptoms be 
alleviated, the pulse becoming less fre- 
quent, or even normal, the delirium sub- 
siding, and, above all, if there is no more 
irritability of stomach ; active diaphoresis, 
epistaxis, or a critical discharge of bile 
from the bowels, may place him on the 
highroad to recovery. Should the skin 
have assumed its lemon-yellow tint, it will 
remain all through the convalescence, to- 
wards the close of which the writer has 
noticed a desquamation of the cuticle 
much resembling that of the ordinary ex- 
anthemata. 
If, on the other hand, the ferrety eye 
whitens, the cheek grows pale, and the 
lips are blanched, while the pulse is weak 
and compressible, and the delirium is per- 
sistent with irritable stomach, the appa- 
rent remission is delusive, and a fatal 
issue is pending. The patient refuses all 
medicine and food, lies down very much 
against his own inclination, cramps gather 
in the calves of his legs, and while they 
are being rubbed by the attendants, his 
delirium becomes frantic, and is probably 
retrospective of former impressions. His 
utterance is supernaturally rapid, keeping 
pace with a panoramic sequence of idea 
in which the mind is absorbed, the pulse 
is imperceptible at the wrist, and just 
when physical exhaustion has merged 
into death a final automatic discharge of 
black vomit closes the tragedy. It is 
only at this period, in many cases, the 
lemon-chrome tint of the skin makes its 
appearance. When it happens in the 
course of the disease, i. e., third stage, it 
is observed to spread from the forehead 
downwards to the face, neck, and chest, 
and then it becomes general. 
In another class of cases, the pulse 
gradually moderates, but thirst increases, 
and epigastric heat and pain are persist- 
ent, with irrepressible vomiting and hic- 
cough, but the mind is calm and coherent 
to the last, though quite conscious of its 
tendency to wander. Indeed, the effort 
of the intellect to correct vagrant ideas, 
and give them a rational form, is often 
affectingly observable, more particularly 
in the case of educated persons. 
Contrasting remarkably with the class 
of cases just described, some persons ex- 
hibit a tendency to drowsiness at a very 
early period of the disease, and finally 
settle down into a placid state of coma, 
not unlike that of severe concussion of the 
brain, without pressure or organic lesion. 
This state of things, no doubt, results 
from uraemic poisoning in connection 
with the suppression of the urinary secre- 
tions. 
It is a fact, worthy of special note, that 
the heart's action may continue long after 
the pulse at the wrist has become imper- 
ceptible, and w'hen all respiratory move- 
ments have ceased. 
Death may happen in the course or at 
the close of any of the three stages of the 
disease, namely: 1st, the accessionary; 2d, 
the reactive ; or 3d, the remissional: and 
this will of course be in accordance with 
the type or variety assumed by the mal- 
ady. 
Further remarks on the symptomatolo- 
gy, rendering the ideas here given of it 
more complete, will be found in the sec- 
tion on the classification and varieties of 
the disease; as it is of importance to 
avoid unnecessary repetition. 
Diagnosis.-Though a very good gen- 
eral sketch of Yellow Fever may be given 286 
YELLOW FEVER. 
by any one who has witnessed an epi- 
demic of the malady, it is not quite so 
easy to isolate the symptoms that may be 
fairly assumed to be pathognomonic. In- 
deed, the whole aspect of the disease is 
often so diversified, or distinguished by 
the absence of this or that symptom where 
the collateral evidence of its identity is 
indubitable, that it is difficult to say 
which Feature is of most diagnostic im- 
portance. Add to this the actual occur- 
rence of the several symptoms of Yellow 
Fever in some part of the course of other 
febrile disorders which, after due consid- 
eration, have been declared to be essen- 
tially distinct, and the difficulty will be 
still more apparent. 
Inasmuch as yellowness of the skin and 
conjunctivae, not merely from the effusion 
of the haematine of the blood itself, as in 
Yellow Fever, sometimes occurs in the 
paludal remittent fevers of various coun- 
tries, that character, singly, cannot be 
pathognomonic of Yellow Fever. Of 
black vomit also the same thing may be 
affirmed, so that two of the most impor- 
tant features of the malady are scarcely 
available for a satisfactory diagnosis. 
Much stress has been laid upon the very 
constant symptom of frontal headache, in 
connection with the watery and suffused 
eye, the white, creamy, or cottony coat of 
the tongue, and its red tip and edges; 
and in particular the early appearance of 
albumen in the urine ; but none of these 
characters, nor even all together, can be 
more definite than the following posi- 
tions :- 
1st. Now that there can be no doubt of 
the infectious nature of the disease, it 
may thus at once be distinguished from 
those disorders with which it is likely to 
be confounded, for this property is sure to 
be developed in every epidemic of specific 
Yellow Fever. 
2d. As Yellow Fever is one of a "sin- 
gle paroxysm," of longer or shorter dura- 
tion, and divisible into three stages, the 
disease is continuous in its type, or it 
runs a definite course without such remis- 
sion and exacerbation as are seen in the 
paludal fever. 
3d. If Yellow Fever shall have passed 
through all its stages without destroying 
life, it in general confers immunity from a 
second attack.1 
The first appearance of Yellow Fever 
not infrequently presents no other symp- 
toms than those of an ordinary ephemeral 
fever; for which the writer very naturally 
mistook the first case of Yellow Fever 
that ever fell under his observation. The 
disease, however, declared itself on the 
second day, and there was no further 
doubt as to its real nature. There is a 
still greater possibility of confounding 
malarial remittents with specific Yellow 
Fever, and even good observers have re- 
garded them as identical. In this con- 
nection, however, we may appropriately 
quote Dr. Maclean's bold diagnostics, as 
given by Dr. Aitken.1 "I am now my- 
self a firm convert to the doctrine that 
Yellow Fever is specially distinct from 
remittent. To this opinion I have come 
with a full knowledge of the fact that 
some cases of remittent fever in India 
closely resemble some of the forms of Yel- 
low Fever. But of this I am now certain, 
that the Yellow Fever of the true yellow 
fever zone is unknown in India, where 
true malarial fevers abound. There is in 
true Yellow Fever, for the most part, an 
absence of that periodicity which is an 
unfailing characteristic of true malarial 
fevers. Then there is the difference, so 
well insisted upon by Blair, in true mala- 
rial fevers. Men do not pass from re- 
covery to health, as is the case in such a 
marked degree in Yellow Fever, after 
which there is no, or very little, evidence 
of the existence of any cachexy. Mala- 
rial fevers exist and are destructive at a 
temperature at which Yellow Fever is at 
once destroyed. Albuminous urine is al- 
most invariable in Yellow Fever-only 
occasional in remittent. There is in Yel- 
low Fever an unexampled range of hem- 
orrhages; in remittent fever these hemor- 
rhages are often, indeed generally, absent. 
Quinine has a po-wer over malarial fevers 
that is beyond the reach of doubt or cavil; 
the same is not true of Yellow Fever. 
Men suffer from malarial fevers again and 
again ; second attacks of Yellow Fever 
are, to say the least, rare." 
[There is reason to believe that what 
the late Dr. S. Dickson (formerly of South 
Carolina) called a "blending of types" 
sometimes occurs, between Yellow Fever 
and remittent fever. This will account 
for the very few instances in which true 
black vomit is said to have been witnessed 
in connection with remittent. If it ever 
is seen in an uncomplicated case of mala- 
rial fever (" country fever"), it must be 
one of the rarest of symptoms.-II.] 
Pathology.-Temperature of the Body. 
-The writer has observed that when pa- 
tients previously treated in the open air 
on board ship were transferred to hospital, 
the body exhibited a marked increase of 
temperature, and the febrile symptoms 
became more active. Moreover, any part 
of the body exposed more than another 
soon evidenced a diminution of animal 
1 In H.M.S. Icarus, in 1860, only five per- 
sons out of about 130 escaped an attack of 
Yellow Fever; yet not a single case of re- 
lapse occurred during the whole course of the 
epidemic. 
1 Science and Practice of Medicine, vol. i. 
pp. 479-80. PATHOLOGY. 
287 
heat. In the axilla the temperature may 
range from blood heat to 107° Fahr., the 
maximum observed by Dr. Blair. In the 
sthenic form," in comparison with 
others, Dr. Lyons noticed a general ele- 
vation of temperature ranging between 3° 
and 7° Fahr. 
Coloration of the Skin.-On the first ac- 
cession of the disease the skin becomes 
pale and, perhaps, shrivelled to a greater 
or less extent; but, as the reactive stage 
sets in, it warms up and grows red, the 
face in particular appearing animated and 
flushed. The depth of this redness, of 
course, bears relation to the intensity of 
the febrile symptoms, and it is looked 
upon as pathognomonic from its very con- 
stant occurrence, whenever reaction is de- 
veloped at all; but should the latter be 
defective, the countenance may be pale, 
livid, or sallow. 
The so-called jaundicing of the conjunc- 
tivae and skin is by no means a constant 
symptom, but may be more or less charac- 
teristic of particular epidemics or of dif- 
ferent stages of the same epidemic. 
It is highly probable that the greenish- 
yellow hue is often due to the presence of 
bile. But, as I believe was first suggested 
by Warren,1 and subsequently by Sir G. 
Blane and others, the lemon-yellow and 
orange tints are unquestionably owing to 
the solution and effusion of the coloring 
matter of the blood. M. Guyon regarded 
it as nothing more than the tinge of con- 
tusion. They should not be confounded 
with the much darker and more greenish 
hue of Yellow Remittent Fever, depend- 
ing altogether upon jaundice, and there- 
fore of a very different nature. 
Though yellowness of the skin may set 
in at any time from the first to the fif- 
teenth day, or even exhibit itself after 
death, yet from Dr. Blair's observations, 
it occurs most frequently on the fourth 
and fifth days of the disease. It is im- 
portant to note, however, that it makes 
its appearance coincidently with the black 
vomit in the generality of cases. 
The Tongue.-It is only when the febrile 
reaction is taking place, or even some 
time after this has begun, that the tongue 
in general assumes its characteristic white 
coating, with red tip and edges. Pre- 
viously to this it may be quite normal in 
appearance, only perhaps bearing the im- 
pressions of the teeth. Indeed, instances 
occur in which it remains without marked 
change, even up to the close of the mal- 
ady, either in recovery or death. The 
characters of the tongue, therefore, can- 
not be always said to go hand in hand 
with the increased heat of skin and accel- 
eration of pulse. 
After having first become coated with 
a white creamy substance this condenses 
into a thick cottony fur, and the marginal 
papillae become enlarged. The coating 
becomes thicker towards the base of the 
tongue, and more discolored; moreover, 
one, two, or more yellowish, brown, or 
black longitudinal bands run down its 
middle. When hemorrhage arises from 
the parts about the mouth, the epithelium 
of the tongue and fauces is soon stripped 
off, leaving the surface glazed with half- 
dried blood and sordes. 
Under such circumstances, the tongue 
is more pointed and smaller than usual, of 
a mahogany-red color, and more or less 
fissured. As might be expected, the de- 
nuded throat is sore and requires special 
treatment. 
The accompanying table, as quoted by 
Dr. La Roche, from the records of Roper 
Hospital, Charleston, during the sickly 
season of 1854, gives a good idea of the 
difference of character presented by the 
tongue in the three stages of Yellow 
Fever. 
1 "This yellowishness, I am persuaded, 
chiefly arises from a more complete colliqua- 
tion or dissolution of the red globules of the 
blood into a yellowish serum, which will natu- 
rally soon give that tincture to the whole 
skin. The same is also observable on human 
bodies soon after bites of some poisonous ser- 
pents, or other venomous animals ; and, in 
such cases, it cannot with any reason be sup- 
posed to proceed from a suffusion of bile, but 
rather from a colliquation, and perhaps a 
gangrenous diathesis of the sanguineous 
mass, occasioned by the force of the delete- 
rious venom that had been infused into it. 
What is observed every day in all common 
bruises of the flesh may serve somewhat fur- 
ther to elucidate the matter : for here, when 
the texture of the extravasated blood begins 
to loosen and dissolve into a liquid serous 
consistence, a very visible yellowness appears 
in and about the part; but this soon goes off 
again, when the matter is fully absorbed back 
into the vessels, where it commits no hurt, 
but is readily overcome by the force of nature, 
as the quantity of such dissolved blood is 
small, and at the same time very innocuous. 
I do not, however, deny but that, through a 
great propensity and straining to vomit, some 
quantity of the bile may be thrown into the 
blood ; but then I must observe, that the yel- 
lowness of this distemper I am speaking of 
very frequently shows itself when there has 
been no vomiting or retching at all, or scarce 
any sensible sickness of the stomach ; for the 
truth of which I can appeal to many."-Trea- 
tise on the Malignant Fever of Barbadoes, p. 
11, as quoted by Dr. La Roche. 288 
YELLOW FEVER. 
Condition of the tongue. 
1st stage. 
2d stage. 
3d stage. 
Total. 
Swollen 
4 
29 
31 
64 
Dry 
52 
23 
14 
89 
Bloody . 
■ a 
3 
31 
34 
Whitish 
44 
33 
18 
95 
Brownish . 
94 
53 
39 
186 
Moist . . . 
. 109 
109 
110 
328 
Red . . . 
43 
26 
33 
102 
Velvety and white 
23 
2 
3 
28 
Black . 
1 
1 
19 
21 
Natural 
. . 2d 
10 
7 
43 
Glazed . . 
4 
2 
6 
Cracked 
. • - 
3 
- 
3 
Total number of observations 
999 
The Pulse.-If the tongue has been ob- 
served to be variable and inconstant in its 
character, the same may be said of the 
pulse, and trusting to it alone a very in- 
correct prognosis may be formed. Thus, 
it has been known to preserve an appa- 
rently normal state, even coincidently 
with the most portentous symptoms ; and 
it has been previously noticed that the 
pulsation of the heart itself may continue 
some time after all respiratory movements 
have ceased. It is easy to imagine the 
evil results that might follow active deple- 
tory measures in the reactive stage, when 
the force of the pulse usually gives so 
false an idea of the stamina of the system 
(for, naturally, without such means, the 
pulse diminishes in force and frequency 
as the third stage sets in); but their em- 
ployment in accordance with primd facie 
indications may render the ebb fatally 
low. 
The pulse in Yellow Fever is usually 
full; but it is assumed to be less tense and 
hard than it may be in other fevers at a 
corresponding stage, and from a frequency 
of 100-110 it will rapidly fall to the healthy 
standard, or even below it, when the 
period of excitement closes. 
The Blood.-Accurate observations on 
the physical characters and chemical pro- 
perties of the blood in Yellow Fever are 
much wanting to improve our knowledge 
of the pathology of the disease. 
The following facts have been observed 
from time to time by various authorities:- 
1. Blood of a bright scarlet color has 
sometimes been drawn at the very onset 
of the malady. 
2. It gradually acquires a darker hue as 
the disease advances. 
3. As observed on both sides of the 
heart, arterial and venous blood exhibit 
no appreciable difference. 
4. It may present the appearance of 
being composed of two differently colored 
fluids. 
5. It may assume a brighter color as it 
flow's from the arm, or on exposure to the 
air. 
6. It may be of the consistence of mo- 
lasses, or a thin fluid from the commence- 
ment, though this is more commonly 
observed in the third stage, or only after 
death. 
7. In many instances the blood remains 
without coagulation, or is very slow in 
the process. 
8. The crassamentum appears as if it 
were undergoing solution at the base. 
9. The serum varies in color from a 
whitish appearance, through yellow and 
orange, to a red, which has been compared 
to the tint of water in which meat had 
been washed. 
10. The amount of serum with respect 
to the clot is smaller than in other cases, 
and at the commencement than at the 
close of the malady. 
11. In all cases in w'hich yellowness of 
the skin presents itself, the serum is also 
found to be yellow from solution of the 
coloring matters, and the blood globules, 
broken up from their nummular arrange- 
ment, are precipitated to the bottom. 
12. The morbid discolorations of the 
blood, of even healthy persons residing 
within the range of infection, show's the 
agreement of Yellow Fever in this parti- 
cular with w hat has been observed in the 
case of other zymotic diseases. 
13. Dr. Blair has shown that the dark 
grumous character of the blood in hemor- 
rhages supports no necessary assumption 
that the blood within the vessels is of the 
same nature. 
14. Persons w'ho have had much to do 
w'ith bleeding in Yellow Fever affirm that 
the odor of the blood, like that of the skin,1 
is quite characteristic of the disease, dif- 
fering appreciably from the odor emitted 
by the blood in other fevers. 
15. Dr. Davy has demonstrated the 
acidity of the blood in Yellow Fever, 
w hile alkalinity of that fluid is known to 
exist in other zymotic diseases. 
16. Chassaniol has detected a larger 
amount of urea in the blood, more parti- 
cularly in that of the third stage, w'hen 
the urinary secretion has been more or 
less suppressed. But Professor Rogers, 
1 See Barruel's remarkable experiments, in 
which even sex has been determined by the 
odor of the blood, so closely resembling that 
of the cutaneous secretions. PATHOLOGY. 
289 
who proved an excess of salts, contrary to 
the views of Stevens, was unable to obtain 
urea in any of the stages. His specimens, 
however, were believed to have been in a 
semi-decomposed state. Chassaniol, with 
great reason, refers the more important 
symptoms of the adynamic stage to the 
presence of urea in the circulation. 
17. As in other diseases arising from a 
specific poison, the proportion of fibrine in 
the blood is much below the normal stan- 
dard in Yellow Fever ; and it is probable 
that whenever buffing and cupping of the 
blood occurs in this disease the condition 
is due to the co-existence of some inflam- 
matory complication. 
18. The destruction of the cell wall of 
the blood corpuscles, said to have been 
observed by M. de Bienperthuy, is, in the 
writer's opinion, a doubtful appearance, 
and certainly not borne out by the re- 
searches of Professor Leidy and Dr. Davy. 
Tendency to Hemorrhage.-As a hemor- 
rhagic tendency is often developed, more 
particularly in the third stage of Yellow 
Fever, it may be well to notice some of 
its leading features in this place. 
Active congestion usually precedes the 
extravasation of blood in the parts affected, 
and discharges of this kind have happened 
from all the outlets of the body without 
exception. But the special seat of the 
hemorrhage, and the amount of it, will 
vary with the type or perhaps with the 
period or locality, of the epidemic. 
Hemorrhagic oozing from the skin, 
without abrasion, is known at Martinique 
under the appellation of " sueur de sang." 
Epistaxis, however, is much more com- 
mon, and usually happens in the third 
stage, though it has been known at the 
close of the first. 
Blood may exude from the inner can- 
thus of the eyes, and from the auditory 
passages, but these hemorrhages are of 
rare occurrence. Bleeding from the 
cavity of the mouth, tongue, gums, and 
lips is usual in every epidemic; and though 
the blood may be at first well-colored, 
when it mixes up with the secretions of 
the mouth its character becomes altered, 
and it assumes a dirty madder-brown hue, 
coating tongue and teeth. 
The menstrual discharge, when not pro- 
fuse at this period, appears to exert a 
salutary influence on the disease; but 
more active coincident hemorrhage, as in 
parturition or abortion, is eminently peril- 
ous. 
Hsematemesis scarcely ever happens 
without the passage of blood by stool, 
which is often critical in its nature. 
Ecchymotic abscesses occurring in the 
neck produce distressing symptoms from 
their pressure on important parts ; and if 
it be found necessary to relieve them, the 
writer would recommend a valvular open- 
ing. As the patients advance towards 
recovery, the bloody, ichorous discharge 
will gradually assume a more purulent 
character, until finally laudable pus is 
formed, and the cure goes on in the usual 
way. 
IF/w'fe and Black Vomit.-Up to the 
commencement of the second stage of the 
disease, namely, on the second, third, 
fourth, or fifth day, the ejections from the 
stomach have been observed to be alka- 
line ; subsequently to which they gradu- 
ally give an acid reaction, and the dis- 
charge of a limpid, ropy, more or less 
transparent or opalescent, fluid, known as 
"white vomit," precedes the black, and 
passes insensibly into it. 
Dr. Davy was of opinion, reasoning 
from analogy, that the white, or precur- 
sory, vomit would be found to be of a se- 
rous nature, and contain albumen; but 
if it " remains clear on the application of 
heat and nitric acid," as stated by Dr. 
Aitken, the presence of albumen is so far 
negatived. 
As conciseness of matter must be our 
object in the present article, without en- 
tering minutely into the merits of the 
prolix reasoning of pathologists in favor 
of the bilious or of the sanguineous theory 
of black vomit, the following summary 
may be given as a fair conclusion from 
the facts adduced. 
When hemorrhagic oozing begins to 
take place from the congested lining mem- 
brane of the stomach, the blood ab initio 
intermixes with the existing and conco- 
mitant acescent secretions of the organ. 
The blood globules aggregated in masses 
lose their colored contents by exosmosis, 
while they become distended with a thin- 
ner fluid, and blend together with a com- 
mon connecting and finely granular sub- 
stance, composed of coagulated albumen 
and the liberated heemato-globulin. Dark 
madder-brown flocculi thus result, float- 
ing in a more or less homogeneously-tinted 
or colorless liquid, and this is probably 
the simplest definition of black vomit. 
Dree hydrochloric acid is the grand 
source of the acidity, tested with litmus 
and brown turmeric papers. 
Nitrate of silver throws down a white 
precipitate, which is redissolved by am- 
monia, though not by nitric acid. 
Liquor potassse being added to black 
vomit, in larger quantity than that re- 
quired to neutralize its acidity, the floccu- 
lent sediment becomes dissolved, with the 
disengagement of ammonia. It effervesces 
with alkaline carbonates, and Dr. Blair 
neutralized gxij with ^j of carbonate of 
potash. 
At the request of Dr. La Roche, Pro- 
fessor Rogers examined several specimens 
of black vomit, with a specific gravity 
ranging between L003 and DOIG, with 
the following results :- 
VOL. I.-19 290 
YELLOW FEVER. 
Albumen 
Sulphuric acid in a state of combination 
Chlorine 
Alkaline bases 
Earthy phosphates 
Iron 
Hydrochloric acid in a free state. 
In his communication to Dr. La Roche, 
he says : " These substances, although 
not the sole ingredients of the blood, are 
yet, all of them, with the exception of 
free hydrochloric acid, constituents of that 
liquid-a fact which, taken in connection 
with other characters, and especially the 
microscopic appearance of the liquids, 
gives strong evidence that they contain 
much altered blood ; indeed, the presence 
of several of the substances enumerated, 
as albumen, iron, and sulphuric acid, 
seems not to admit of any other explana- 
tion, since it could scarcely be possible 
that in that stage of the disease they were 
the results of any food remaining in the 
stomach." 
On submitting black vomit to micro- 
scopic examination all the changes above 
noticed with regard to the blood may be 
distinctly traced out, but no importance 
can be attached to the presence of toruke 
or other humble vegetable organisms, 
which are by no means constant. The 
mention of fatty globules, epithelium (ex- 
cept perhaps that of the tubular glands), 
starch corpuscles, chicken muscle, and 
other matters introduced from without, 
only add scientific jargon to the plain 
facts of the case, and tend to becloud 
them. 
Mr. Wharton Jones states, that in the 
contents of the hepatic ducts of man and 
the sheep, extracted by means of a for- 
ceps and without injuring the organ, he- 
patic cells may be detected. This fact is 
a difficult problem for the microscopic 
anatomist to solve, but it sinks into insig- 
nificance when he is told that Dr. Blair 
has not only found the glandular cells, 
but what he conceived to be " the radical 
secreting ducts of the liver," in black 
vomit. 
The Urine.-The urinary secretion is 
generally diminished in quantity from the 
onset of the malady, and in many in- 
stances becomes almost or altogether sup- 
pressed, when the symptoms of uraemic 
poisoning may be developed. Dr. Blair, 
who was an excellent observer, affirms 
that it is always acid in the first stage of 
the disease, and gives an alkaline reac- 
tion during convalescence, or when bile is 
present in large quantity. 
Albumen makes its appearance gen- 
erally on the second or third day, and it 
may be detected in all severe cases by its 
appropriate tests. 
The color of the urine, in passing from 
its natural standard, changes to a bright 
yellow, a dirty orange, a greenish brown, 
and olivaceous black, or to a more or less 
positive red, from the presence of blood.1 
The ordinary post-mortem appearance 
of the kidney, to say nothing of its minute 
anatomy, precludes the idea of the physi- 
cal detachment of its capillary vessels, or 
even the Malpighian tufts, and their 
escape through the tubular system, so as 
to be commonly witnessed in the urine, as 
stated by Dr. Blair. Dr. Aitken observes 
that this admits of doubt, and that it is 
not borne out by Blair's own specimens 
preserved in the cabinet of microscopic 
preparations of the Army Medical School 
at Netley. Tube casts, fatty cells, free 
fat, and blood disks, full and emptied of 
their contents, with such appearances as 
often characterize the urine in common 
jaundice, were the most invariable objects 
observed by the writer. There was per- 
haps a large amount of torulse and allied 
forms ; but, as in the case of the black 
vomit, notice of them is of little import- 
ance. 
Morbid Anatomy.-External Appear- 
ances.-Should the individual die soon 
after the invasion of the complaint, the 
bulk of the body may be a little increased 
on account of a slight puffiness of the 
skin; but, drained by hemorrhages and 
with no repair of the vital fluid, emacia- 
tion must happen in more protracted 
cases. 
The eye loses the suffused redness it 
previously exhibited, and the yellowness 
of the skin becomes more intense; indeed, 
it sometimes happens that the skin, which 
could scarcely be called yellow before, ac- 
quires that hue after death, and presents 
1 "On chemical analysis," writes Dr. La 
Roche, "urine taken from the bladder after 
death has been found greatly deficient of 
urea. In one case 200 grammes (51 drachms) 
of the fluid contained but one gramme and 
(about 16 grains) of urea, no uric acid, 
and. 0'45 per cent, of albumen. In another 
case, 15 grammes (| oz.) of the fluid ob- 
tained in the same way, gave 0-08 of urea, 
2'50 of albumen, and no uric acid. In sev- 
eral other experiments, conducted in the 
same way, the results were similar. Finally, 
in one case the urine was examined in the 
first stage of the disease, and a short time 
after the death of the patient. In the first 
the fluid was found to contain, in 100 parts :- 
Water 76-08 
Urea ....... 2-64 
Albumen ...... 0-40 
Uric acid ...... 0-08 
Earthy phosphates, sulphates, alka- 
line phosphates, and chlorates . 0-80 
80-00 
"After death, 20 grammes gave more traces 
of urea, 0-50 of albumen, and no uric acid." MORBID ANATOMY. 
291 
a remarkable contrast with the rich pur- 
ple blotches and marblings in the more 
depending parts of the body. 
The extremities of the fingers and toes 
and the tips of the ears are also darkened 
with stagnant blood. 
The tissues in general appear to become 
abnormally friable, even though examined 
very soon after death: this is particularly 
the case with the muscular system, in- 
cluding the heart itself. The flesh is also 
of a dingy color, watery, and sodden. It 
is, however, much paler and softer in 
those who have suffered much wasting. 
The connective tissue, moreover, is in 
general loose and sanguinolent-a condi- 
tion also observable in malarious Yellow 
Fever, which is admitted to be a distinct 
type of disease. The areolar and adipose 
tissues often exhibit a yellowness similar 
to those of the skin. 
Nervous System.-The brain has been 
very closely examined in numerous cases, 
with nearly the same result, namely, that 
no pathological condition in the slightest 
degree noteworthy has been detected, 
even including those cases in which cere- 
bral symptoms, such as active delirium 
or profound coma, existed before death. 
(G-illkrest.) 
The spinal marrow, on the contrary, 
usually exhibits a congested state of the 
vessels, more especially in the lumbar re- 
gion, where also the arachnoid membrane 
has been supposed to be in a state of in- 
flammation. 
Effusion of blood has been found in the 
canal, but we cannot be certain of all 
that has been said about the existence of 
actual inflammation. The ganglionic 
system has also been examined, and with 
apparently still more definite results. 
Thus, the semi-lunar ganglia, solar, cie- 
liac, hepatic, and neighboring plexuses, 
as well as the connecting tissue investing 
them, have been stated, on the authority 
of Dr. Cartwright and others, to be uni- 
formly in a condition indicative of inflam- 
mation. Nevertheless, excellent observers 
are not wanting who have never been 
able to discover any decidedly abnormal 
state of this system. 
Respiratory Organs.-The lungs have 
been carefully scrutinized in epidemics 
occurring in different countries within 
the range of Yellow Fever, and the only 
important particular, not due to other 
complications, appeared to be small san- 
guinolent effusions into the connective 
tissue of the organs themselves, and that 
immediately beneath the pleurae. 
Circulatory System.-Usually no very 
abnormal change is observable in the 
heart, if we except a dusky and flabby 
appearance which it often presents in 
common with the muscular system gen- 
erally. Professor Riddell and others have 
laid much stress upon the pretty constant 
molecular degeneration occurring in the 
muscular fibres of the heart, with a more 
or less complete obliteration of their trans- 
verse strise ; but it is very probable that 
this condition, which is perhaps more 
usual than physicians in general imagine, 
would be detected in the same subjects 
had they died of any other malady. 
In the pericardium, effusions take place, 
with or without marks of inflammation, 
and the fluid may be simply serous, puru- 
lent or sanguineous ; and in one instance 
thus described by Dr. Bache, the pericar- 
dium contained four ounces of a very tur- 
bid greenish-brown fluid, resembling black 
vomit. On pouring this into a bottle and 
allowing it to stand a short time separated 
into two portions: that at the bottom was 
of a white or pale yellow color, while the 
rest remained without change. An ex- 
amination by the microscope proved the 
brownish fluid to be composed of altered 
blood corpuscles, with less of the granular 
amorphous matter than is usually found 
in genuine black vomit. The whitish 
fluid was pus. The heart itself was stained 
of a dark color at its base, and the peri- 
cardium was minutely injected in points. 
(La Roche.) 
Transparent amber-looking clots have 
been frequently detected in the cavities 
of the heart, particularly on the right 
side. In fifty-four post-mortems made by 
Dr. Pennell, at Rio Janeiro, clots of the 
same kind were present. 
The endocardium commonly presents 
no signs of inflammation. 
The Stomach.-As might be expected, 
morbid appearances are more constant in 
the stomach than in any other organ, so 
intimately associated as it is with the 
most serious symptoms of the disease. 
The effusion of the coloring matter of the 
blood into the subserous connective tissue 
may give it a yellowish appearance, but, 
more unusually, no abnormal change pre- 
sents itself externally. 
A certain amount of the matter of 
black vomit is generally found in the 
cavity of the stomach, in some stages of 
conversion, from actual blood to a dark 
grumous fluid, like that ejected by the 
patient while yet alive. It would seem 
as though the mucous membrane of the 
stomach were called upon to compensate 
for the defective secreting and eliminating 
power of the kidneys; and in those cases 
■where little or no black vomit was found 
in the stomach after death, the lining 
membrane presented a thickened appear- 
ance with a muco-sanguineous coating. 
Sometimes the interior of the stomach 
presents little or no trace of congestion or 
inflammation where the mucous mem- 
brane has been cautiously washed; while 
at others the little orifices of the tubular 
glands are seen to be filled up with a dark 
brown matter that may be dislodged with 292 
YELLOW FEVER. 
the point of a needle. This appearance 
has been ignorantly spoken of as the open 
orifices of the hypothetical vessels, known 
to older anatomists as the "exhalents," 
in the act of elimination. There appears 
to be no relation whatever between the 
amount of congestion observed in the mu- 
cous coat and the quantity of matter 
thrown off from it into the cavity of the 
stomach. Thus the hemorrhagic oozing 
may have emptied the capillaries, in some 
instances, while they still remained con- 
gested by the "vis a tergo" filling up the 
loss in others. 
The mucous membrane often becomes 
mammillated, thickened, the longitudi- 
nal folds enlarged, and it is more easily 
stripped off than usual; but veritable 
proofs of inflammation, though decidedly 
present in some cases, are far from being 
universal in this disease. The tints of 
congestion, ranging from rose red to 
claret purple, and dingy gray passing 
into shades of green and greenish yellow, 
impart an iridescent appearance to the 
mucous membrane. 
The Intestines present much the same 
external appearance as the stomach, but 
the glandular organs, Peyer's patches in 
particular, are not so uniformly in a mor- 
bid state as they are in other fevers. In- 
deed, the duodenum and upper part of 
jejunum are often more seriously affected 
than the ileum. 
The Liver is said to become soft and 
friable in those who die within forty-eight 
hours, and a serous discharge may take 
the place of natural bile. 
The gall-bladder is usually found empty, 
or with a small quantity of tarry-looking 
bile in its cavity. 
The capsule and fat surrounding the 
kidney have a yellowish appearance, but 
the organ itself, though prone to fatty 
change, even during the short period of 
the disease, is vet not so decidedly in- 
volved in it as the liver. Indeed, under 
ordinary circumstances, an amount of 
congestion in the liver, only producing 
the slightest biliary derangement, would 
be a very serious occurrence in the kid- 
ney ; and though the latter is a much 
smaller organ, it would appear to occupy 
a longer time in passing on to a state of 
fatty degeneration. Little livid spots and 
ecchymoses are sometimes found in the 
infundibulum and pelvis, and pus has 
been found in the pelvis and ureter. Dr. 
Pennel notices, besides the manifest con- 
gestion of the kidney, that the papillse 
yielded upon pressure a glutinous tena- 
cious exudation sufficient to interfere me- 
chanically with the escape of the urine. 
This, however, the writer is disposed to 
think was in great part composed of the 
forcibly extruded epithelial lining of the 
little tubes in a manner well known to 
microscopic anatomists. 
The pancreas and spleen present no con- 
stant pathological change worth noticing, 
and the same may be said of the urinary 
bladder, if we except the possible occur- 
rence of a dark grumous fluid, closely re- 
sembling black vomit, recorded by one or 
two observers. 
Prognosis.-It is a difficult matter to 
form a reliable prognosis in almost any 
stage or variety of Yellow Fever, for the 
very cases that would strike the physician 
as affording most promise of speedy re- 
covery may prove to him, by a rapidly 
fatal issue, how uncertain his judgment 
must be. Still, there are symptoms or 
circumstances which experience has shown 
to be usually of good import, and others 
again which augur badly or point to an 
almost immediate dissolution. 
Favorable Signs.-If the pulse approxi- 
mates without reaching 110 in the febrile 
stage;1 if it preserves an even and nor- 
mal force and frequency when the third 
stage sets in; if the urine be in good 
quantity and exhibits no disorganization 
of the kidney, under the microscope-the 
presence of albumen in small amount is 
to be regarded more as a usual than an 
unfavorable symptom-if epigastric ten- 
derness and irritability subside with the 
febrile state, a good hope of the case may 
be entertained. 
Unfavorable Signs.-Dr. Jackson gives 
the following as indicative of danger, 
founded upon his experience of the dis- 
ease, occurring on the south coast of 
Spain:- 
1. A sudden invasion by the fever, with 
intense pain of the head and eyeballs, 
accompanied by sickness and vomiting. 
2. The fever being ushered in by a fit, 
convulsions, or apoplectic stupor, or out- 
rageous delirium. 
3. A torpid, heavy, or statue-like as- 
pect of countenance gave strong suspicion 
of danger. 
4. A dry, rough, milk-white, or swollen 
and red tongue indicated danger. 
5. Distress and anguish at stomach, 
with pain at the epigastrium, forcible 
eructations, or explosions of flatus from 
the stomach, gave impression of much 
danger. 
6. Obscure hiccough marked danger. 
7. A ghastly appearance, with a faint 
nauseous odor from the body, indicated 
extreme danger. 
8. Yellowness of the skin, with turgid 
veins on the conjunctivae in the latter 
stage, "always decisive of a fatal issue." 
9. Torpor of the skin-to such an ex- 
tent as to be insensible to the stimulation 
of blisters and sinapisms-is ranked among 
dangerous signs. 
1 The frequency of the pulse as a rule be- 
ing less in Yellow Fever than in others. THERAPEUTICS. 
293 
10. Extreme dampness or extreme dry- 
ness of the skin indicates great danger. 
11. Petechite are suspicious: streaks, or 
patches, of livid green, or violet color, 
are almost certain indications of approach- 
ing death. 
12. Vomiting of black matter, like the 
grounds of coffee, is reported a sign of the 
highest danger; [but] 
13. Vomiting of bitter bile, whether 
green or yellow, even with straining and 
severe retching, affords a sign of compara- 
tive safety. 
14. Black watery stools, with shreds, 
''are of the worst prognostics" (as quoted 
by Martin). 
To the above may be added :- 
1. A very weak pulse on the invasion 
of the disease. 
2. A pulse much exceeding 110 in the 
febrile stage. 
3. Sudden and excessive lumbar pain, 
or rachialgia. 
4. Countenance swollen, tense, and 
bloated, or on the contrary much pinched 
up, or terror-stricken. 
5. Fiery redness, with prominence of 
the eyes, or on the other hand a pearly 
whiteness of the conjunct!vse. 
6. Widely dilated pupils, indicative of 
cerebral complication. 
7. Suppression of urine, or deposits in- 
dicating a serious condition of the kidney. 
Therapeutics. - Treatment. - There 
can be little doubt that whatever is to be 
done in Yellow Fever should be done 
quickly, and the earlier a clear diagnosis 
is formed the better, if any hope may be 
reposed in medicine. 
We have it on the authority of physi- 
cians of experience, that the disease has 
been cut short by the timely administra- 
tion of remedies that have been tried and 
found wanting at a later period. Dealing 
with the subject in a purely philosophical 
light, the evidence before us is not as 
conclusive as it could be wished ; on this 
point, and "in the present state of our 
knowledge, we can only be guided by the 
common principles of medicine ; for it is 
plain that a specific mode of cure cannot 
be suggested until the nature of the spe- 
cific cause is known. We know also that 
the disease manifests itself with various 
degrees of intensity in different cases, and 
how much of any happy recovery depends 
upon the stamina of the system, or upon 
the means employed, is above all things 
difficult to determine-a fact which should 
never be forgotten by those who may be 
zealously inclined to advocate their own 
suggestions." Even a brief notice of the 
various modes of practice adopted by 
medical men from time to time, in the 
treatment of this disease, would occupy 
more space than would be of advantage 
in the present article ; but we shall pass 
the more important remedial agents in 
review. 
The pediluvium on the first invasion of 
the malady is now very largely employed 
by American practitioners, and the indi- 
cation is further carried out by the use of 
warm drinks to excite diaphoresis and a 
genial warmth. This may be followed by 
a brisk purgative, composed of calomel, 
gr. vi-x, jalap gr. x, and ginger gr. iij, in 
the bolus form, which will be found the 
most convenient and certain mode of ad- 
ministering medicines of this kind on an 
extended scale. 
[Bleeding was largely resorted to and 
favorably reported upon by Dr. Rush and 
others, a century ago.1 Although this 
practice is by general consent now ruled 
out, it cannot be ignored that the relief 
sometimes following moderate sponta- 
neous hemorrhages affords a natural sug- 
gestion in its favor. Leeches to the 
epigastrium, during the first day or two 
of the attack, have certainly sometimes 
done good.-IL] 
A dose of calomel exceeding ten grains 
would appear to be rather experimental 
or empirical than based upon a sound 
physiology. No one has been able to ad- 
vance a therapeutical principle to warrant 
it, in opposition to the evil effects so often 
known to follow in its wake. The same 
also may be said of large doses of quinine, 
which, in Yellow Fever at least only tends 
to impede secretion and derange the cir- 
culation within the head. The employ- 
ment of this medicine at all is more suit- 
able to the convalescent than to the 
patient more immediately under the in- 
fluence of the disease. It is perhaps 
more useful in such febrile states as ex- 
hibit a periodicity in their recurrence. 
Should it be thought expedient to pre- 
scribe quinine in Yellow Fever, small 
doses frequently repeated are to be pre- 
ferred, so that any resulting prejudicial 
effect may be observed in good time and 
the medicine simply omitted without 
doing much mischief. 
As the bowels are commonly sluggish 
in Yellow Fever, an enema may be neces- 
sary after the first dose above suggested ; 
in which case one of turpentine, as recom- 
mended by Drs. Copland and Smith, will 
[> Mathew Carey, in his "Short Account" 
of the Yellow Fever of 1793 in Philadelphia, 
says: " The efficacy of bleeding in all cases 
not attended with putridity was great. The 
quantity of blood taken was, in many cases, 
astonishing. Dr. Griffits was bled seven 
times in five days, and ascribes his recovery 
principally to that operation. Dr. Mease, in 
five days, lost seventy-two ounces of blood, 
by which he was recovered when at the low- 
est stage of the disorder. Many others were 
bled still more, and are now as well as ever 
they were."-H.] 294 
YELLOW FEVER. 
prove to be the most beneficial, as it in 
general brings away feculent and normal- 
looking stools. Turpentine, in drachm 
doses, by the mouth, is advocated by the 
same authorities, but of its use in this 
way the writer has had no experience. 
The most must be made of the time 
now remaining until retching and vomit- 
ing set in. Acetate of ammonia, nitrate 
of potash, nitrous ether, and the tincture 
of squills1 and henbane, may be combined 
and administered in periodical doses, with 
lime juice for drink. In this way exces- 
sive febrile action will be moderated, the 
action of the kidney and the skin pre- 
served, and even if the reaction is defec- 
tive no further depressing influence can be 
exerted. 
Of all the symptoms of Yellow Fever 
the most distressing, to both patient and 
physician, is irritability of the stomach. 
It is so constantly present, and so often 
uncontrollable, that the knowledge of 
every available means of checking it is 
of the greatest importance. 
In the epidemic of Yellow Fever on 
board II.M.S. Icarus, in the West Indies, 
a few drops of chloroform prepared the 
stomach for the reception and retention 
of food, " but the dose should be repeated 
a short time before food is again taken, as 
the effect of chloroform is transitory." 
Creosote and hydrocyanic acid have 
been used with the same intention, but 
the valuable suggestion of chlorodyne 
made by Dr. Aitken, would bid fair to 
supersede every other, if we may except 
that of lime-water, in this connection. 
Lime-water was used with great benefit 
on the Icarus, on the recommendation 
merely of its known therapeutic proper- 
ties in the practice of medicine. But it 
had long previously been employed by the 
American physicians, and with a higher 
object, namely, the correction of acidity 
in the stomach, due to the presence of 
free hydrochloric acid. Dr. Ilosack used 
lime-water most successfully in combina- 
tion with milk, and with porter when the 
milk could not be retained. More stress 
ought to be laid upon the importance of 
this agent by English writers. A chalk 
mixture has also been resorted to with the 
same intention. 
Professor Frost, of Charleston, strongly 
advocates the chlorate of potash ; and it 
is richly worth extensive trial, from its 
known valuable properties in adynamic 
states generally, oxygenating the blood, 
and aiding in elimination by its action on 
the skin and kidneys. It is fair, however, 
to state that some cases, in which it was 
tried, were not very satisfactory. 
Tannic acid, besides the astringency 
which it exerts upon the smaller vessels, 
is reputed to have the property of dimin- 
ishing the irritability of the stomach. 
Pepsine, in regulated doses, so as to as- 
sist an organ incapable of discharging its 
own functions efficiently, requires further 
trial. In connection with pepsine, and 
the internal use of ice in the intervals of 
its exhibition, the essence of beef should 
be unremittingly supplied and suited by 
dilution and seasoning to the nature of 
the case. This will be the time also for 
stimulants-our great object being to ob- 
viate the tendency to death, and to sus- 
tain the vital power in its struggle with 
the foe. Champagne, in particular, will 
be beneficial, when it can be obtained. 
The ward-room cook of II.M.S. Icarus 
had very nearly succumbed at this crisis, 
but he rallied immediately on the admin- 
istration of a stout glass of rum and water, 
and recovered steadily. 
The Yellow Fever poison is evidently 
of an intoxicating kind, and a marked 
difference is apparent between the mild 
and irritable delirium produced by it, 
when thrown out in contact with the 
brain substance and the comatose state 
brought about by those principles, urea 
in particular, that accumulate in the cir- 
culation in consequence of the ineffective 
action of the kidneys and liver. When 
the semi-comatose patient is aroused, he 
may be made to answer rationally; but 
in the delirium, which is characterized by 
vigilance and irritability, this can scarcely 
be expected, and even a coherent reply 
may be in league, as it were, with the 
mental derangement. Morphia certainly 
has the effect of allaying this excitable 
state and procuring sleep. Here, again, 
Dr. Aitken suggests chlorodyne, as the 
administration of "opium in any form," 
on good therapeutic grounds, is objection- 
able. [Ice, dissolved slowly in the mouth 
and swallowed, is very refreshing and 
suitable during the febrile paroxysm. So 
are effervescent drinks; probably none 
are better than carbonic acid water (soda 
water) cooled with ice. Spice poultices 
applied to the epigastrium may materially 
assist in relieving the vomiting and epi- 
gastric tenderness. Cold or cool sponging 
will be appropriate at an early stage ; even 
hot bathing has been found serviceable in 
the later prostration.-H.] 
Varieties, and their Classifica- 
tion. -Notwithstanding all that has been 
written on the subject of the Yellow 
Fever, the gist of nearly every attempted 
classification of its varieties amounts to 
little more than a grouping of them in ac- 
cordance with the several degrees of com- 
parison. Indeed, the phases presented by 
different epidemics, and by the individual 
cases in the same epidemic, with no pos- 
sibility of the interpolation of other com- 
plaints to be confounded with it, would 
[* Many practitioners would prefer to omit 
the squills and nitrate of potassium.-H.] VARIETIES AND THEIR CLASSIFICATION. 
295 
give systematists more than they could 
easily accomplish to define and arrange 
intelligibly. The types, therefore, are 
exceedingly variable, and little practical 
benefit can accrue from their nice discri- 
mination ; but, when they do not trans- 
gress broad boundary lines, they may 
afford a more precise knowledge of the 
symptoms and pathology of the disease as 
a whole. It is notorious that a classifica- 
tion, founded upon the experience of one 
epidemic, may be quite inapplicable to 
another; consequently, whoever has to 
do with one, naturally makes a classifica- 
tion for himself. On this account, sys- 
tems have become so numerous, that we 
can only give place to a notice of one of 
the best of them, namely, that put for- 
ward by Dr. La Roche of Philadelphia, 
whose masterly work on Yellow Fever, 
with a bibliography of sixty-one pages, 
has afforded the writer great assistance 
in the composition of this article. 
According to Dr. La Roche, Yellow 
Fever (as a genus) is divisible into two 
species, viz., 1, the Inflammatory; and 
2, the Congestive ; though these are often 
connected by cases in every conceivable 
degree of transition from one to the other. 
1. The inflammatory species appears 
under three grades, viz. (a) the Intense ; 
(6) the Mild ; and (c) the Ephemeral. 
From all that has been previously said 
in the symptomatology, the character of 
these grades may be easily conceived. In 
the first, the fever is active and short, and 
death commonly happens before the ac- 
cession of black vomit; in the second, the 
fever is more protracted, and may even 
exhibit partial remissions before the final 
stage sets in ; while the third, as its name 
implies, is of short duration, and easily 
amenable to treatment. 
2. The Congestive species is marked by 
the passage of the disease "as it were 
directly from the first sign of indisposition 
to the last stage, without going through 
that of reaction." Of this species there 
are four grades : viz. (a) the Aggravated ; 
(6) the Adynamic or Typhoid; (c) the 
Walking ; and (d) the Apoplectic. 
(a) The Aggravated grade is attended 
from the commencement with considerable 
prostration, giddiness, stupor, and loss of 
memory, delirium, or coma. The tongue 
is natural, or with white patches and red 
tip and edges. The countenance is livid 
and apathetic, and the skin yellow or 
bronzed. Hemorrhage occurs from one 
or more of the natural outlets, and the 
patient keeps up a low monotonous wail- 
ing. In some cases the pulse is nearly 
natural, the tongue clean, and the stomach 
calm ; but these are attended with exces- 
sive restlessless, anxiety, and distress, 
soon followed by black vomit and fatal 
collapse. 
(6) The Adynamic or Typhoid grade oc- 
curs in persons deficient in vital power, 
ushered in with chills, followed by burning 
heat, partially distributed over the body, 
viz., principally on the under parts of the 
arm and inner surface of the thighs. The 
pulse is small and weak. The skin as- 
sumes an olive hue, and is covered with 
petechise or vibices. Hemorrhages are 
common from the natural outlets, or into 
the connective tissue beneath the skin, or 
amongst the muscles. 
(c) The Walking grade.-Here the func- 
tions of organic life appear to be at first 
alone implicated, those of animal life re- 
maining unaffected. The patient, though 
sometimes in bed, is found more fre- 
quently walking about his room. He only 
feels weak, but his eye is watery, and his 
countenance dull and listless; his pulse 
grows fainter and fainter, until at last he 
is overtaken by black vomit, and death 
speedily ensues.1 
(d) The Apoplectic grade.-The patient 
is more or less suddenly struck down with 
stupor or coma, and death, preceded by 
convulsions, soon follows. The pulse is 
rather weak, and finally becomes faltering. 
The skin is cold and clammy, or some- 
times dry and flabby. " In the mean time 
the patient lies as if stunned, with dilated 
pupils and an expression of gloom upon 
the countenance. From this unpromising 
state an effort at reaction occasionally 
takes place, but this scarcely ever leads to 
a successful result. More generally, the 
patient becomes perfectly comatose, the 
eyes assume a glassy appearance, the 
pulse fades away, involuntary discharges 
and profuse hemorrhages supervene, and 
death soon ensues." 
Some few years ago2 the writer sur- 
mised the possibility of the extension of 
the range of Yellow Fever to our own 
shores, all favorable conditions being ful- 
filled, and this has been realized in the 
late epidemic of Yellow Fever at Swan- 
sea, reported in a very able manner by 
Dr. Buchanan. The circumstances are 
briefly the following :- 
On the 9th September, 1865, the Hecla 
barque, laden with coppei' ore, returned 
from Cuba to Swansea, with one case of 
Yellow Fever on board, three having 
proved fatal on the voyage home. 
The remaining case (James Saunders) 
and two convalescents were sent on shore. 
Soon, also, the crew had left the ship and 
distributed themselves over the town, 
and two passengers with their luggage 
were landed. Moreover, a good many 
people boarded the vessel as she entered 
the dock. 
An outbreak of Yellow Fever thus 
1 Several well-marked cases of this grade 
occurred on board H.M.S. Icarus. 
2 Health of the Navy for 1860. 296 
EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
originated ashore, and in a well drawn-up 
table of the cases Dr. Buchanan shows 
their invariable connection with the source 
of the malady, directly or indirectly, add- 
ing further proof of its infectious nature, 
should such be required. 
Note.-As bearing upon the question of in- 
fection, the following important quotation is 
from the remarks of Deputy Inspector-General 
R. D. Mason of Port Royal Hospital, recorded 
in the Statistical Report of the Health of the 
Navy for 1866 :- 
"During the Christmas quarter nine cases 
of Yellow Fever have been received into hos- 
pital, of which eight terminated fatally. The 
first case received was that of the command- 
ing officer of the gunboat Nettle. The Nettle 
had been employed between the 1st of Octo- 
ber and 25th of November at Morant Bay and 
Port Morant, spending a week alternately at 
each place. At Morant Bay this officer re- 
sided on shore, passing scarcely any time on 
board. The servant died of Yellow Fever at 
Morant Bay on the 22d of November, after 
about four days' illness ; and a staff assistant- 
surgeon, who lived in the same house and 
who attended him, was subsequently attacked 
with the same disease and died on the 10th 
of December. 
"Up to the time that the Nettle left Morant 
Bay no other cases were known to have oc- 
curred, and there had been no unusual amount 
of sickness, nor any cases of Yellow Fever, as 
far as I have been able to ascertain. 
"The surgeon of the Cadmus states, how- 
ever, that as far back as the month of July, 
it was reported that a merchant-ship from 
St. Thomas, then lying at Morant Bay, or one 
of the eastern ports of the island, had cases of 
Yellow Fever on board : cause and effect are 
also shown in the fact that the chaplain of 
the Cadmus had on several occasions visited 
the commander of the Nettle during his ill- 
ness, and that the surgeon was at his bedside 
about an hour before his death, and that the 
Cadmus, previously a healthy ship, had sub- 
sequently sent eleven cases of Yellow Fever 
to hospital." 
Circumstances like these may appear very 
unimportant at the time of their occurrence, 
but it may be safely affirmed that such are 
always traceable in connection with the com- 
munication and spread of Yellow Fever. 
EPIDEMIC CEREBRO-SPINAL MENINGITIS 
By J. Netten Radcliffe. 
Definition.-An acute, epidemic dis- 
ease, characterized by profound disturb- 
ance of the central nervous system ; indi- 
cated, at the outset, chiefly by shivering, 
intense headache, or vertigo, or both, and 
persistent vomiting ; subsequently by de- 
lirium, often violent, alternating with 
somnolence, or with a state of apathy or 
stupor; an acute painful condition with 
spasm-sometimes tetanoid-of certain 
groups of muscles, especially the posterior 
muscles of the neck, occasioning retraction 
of the head; and an increased sensitive- 
ness of the surface of the body. Through- 
out the disease there is marked depression 
of the vital powers ; not unfrequently col- 
lapse ; and in its course an eruption of 
vesicles, petechise, or purpuric spots, or 
mottling of the skin, is apt to occur. If 
the disease tend to recovery, the symptoms 
gradually subside without any critical 
phenomena, and convalescence is pro- 
tracted : if to a fatal termination, death 
is almost invariably preceded by coma. 
After death, the enveloping membranes 
of the brain and spinal cord are found in 
a morbid state, of which the most notable 
signs are engorgement of the bloodvessels, 
usually excessive, and an effusion of sero- 
purulent matter into the meshes of the pia 
mater, and beneath the arachnoid. 
Synonyms. - (a) Technical:-Cerebro- 
spinal fever1 (Boy al College of Physicians)] 
cerebro-spinal arachnitis; typhus syncopa- 
lis; tifo apoplettico tetanico; typhus cere- 
bro-spinal (Boudin)] cerebral typhus; epi- 
1 Since the completion of this article the 
Royal College of Physicians, in its "Nomen- 
clature of Disease," has adopted the following 
designation and definition of this malady: 
" Cerebro-spinal Fever. A malignant epidemic 
fever, attended by painful contraction of the 
muscles of the neck, and retraction of the 
head. In certain epidemics it is frequently 
accompanied by a profuse purpuric eruption, 
and occasionally by secondary effusions into 
certain joints. Lesions of the brain and spinal 
cord and their membranes are found on dis- 
section." It is, however, determined to re- 
tain the name by which this affection was de- 
scribed in the first edition of this System of 
Medicine, and for the simple reason that such 
name, while sufficient for the purpose of re- 
cognition, conveys no opinion as to the nature 
of the disease.-Editor. DESCRIPTION OF THE DISEASE. 
297 
demic meningitis (Stille, U. S.); petechial 
fever (G. B. Wood, U. S.); fever with ce- 
rebro-spinal meningitis (S. Gordon)', ma- 
lignant purpuric fever (W. Stokes)1, malig- 
nant purple fever ; nervo-purpuric fever 
(Mapother)-, malignant purpuree (1WSwin- 
ney)', pestilential purpuree (Banks)', febris 
nigra (R. D. Lyons).-(b) Popular:-Spot- 
ted fever (New England) ; cold plague 
(Southern States, U. S.) ; Kolik, Nacken- 
starre, Genickkrampf (Germany)', Nacks- 
juka, Dragsjuka (Sweden). 
Description of the Disease. - I. 
General Symptoms :-Epidemic cerebro- 
spinal meningitis is observed in three 
principal forms : A.-Simple, in which the 
symptoms indicative of disorder of the 
nervous centres predominate throughout 
the whole course of the disease ; b.-Ful- 
minant, in which the depressed state of 
the vital powers, with profound blood- 
change-as shown by hemorrhage of vari- 
ous forms into the cutis-characterizes 
the disease; and c.-Purpuric, in which 
the cerebro-spinal symptoms, and the 
symptoms which mark blood-change (pete- 
chice, purpurce, vibices, &c.), and flagging 
of the vital powers, occur together. The 
proportion in which the three forms of the 
disease are manifest varies considerably 
in different epidemics. In every out- 
break cases are observed which link, by 
insensible gradations, one form with an- 
other ; while in other, and rarer cases, 
the characteristic symptoms of the three 
forms are merged together. Continental 
and American writers have described an 
abortive form of the disease, the term 
being given (ct) to certain anomalous 
symptoms observed in communities among 
which the disease is active : and (b) to 
sundry symptoms characteristic . of the 
malady, but of transitory duration : such 
as severe cephalalgia, a sense of dragging 
at the back of the neck, or actual slight 
retraction of the head ; cardialgia, enter- 
algia ;-these symptoms often ending con- 
temporaneously with the appearance of 
profuse perspiration, or epistaxis. 
(A.y Simple Epidemic Cerebro-spinal 
Meningitis.-In the majority of the cases 
before the onset of the disease the patient 
suffers from more or less indisposition. 
There are discomfort in the head, neural- 
gic pains in the back, the principal groups 
of muscles, and the abdomen ; failure of 
the appetite, indifference to exertion, per- 
haps also slight shiverings, and a quasi- 
febrile state. These indications of dis- 
ordered innervation may persist from 
three to seven days, or may be manifested 
only during a few hours, before the con- 
firmed malady fully declares itself. But 
in numerous cases the onset of the dis- 
ease is sudden and characteristic. In 
both classes the accession of the malady 
is declared by similar well-marked signs. 
Acute shivering is followed or accom- 
panied by severe, commonly intolerable, 
headache, or vertigo, or both; and after 
a short interval, or contemporaneously, 
profuse and irrepressible vomiting takes 
place, rarely preceded by nausea. Or 
vomiting may be the initiatory symptom, 
the shivering, headache, or vertigo fol- 
lowing quickly after. The intensity of 
the symptoms marking the onset of the 
disease is remarkable and characteristic. 
The sickness is often, and from the outset 
accompanied by severe abdominal pain, 
apparently neuralgic; and not unfre- 
quently this pain precedes the disorder of 
the stomach, as the cephalalgia precedes 
mental confusion. In like manner, the 
shivering ushers in, or is accompanied by, 
an acutely painful state of the muscles, 
more or less general, the forerunner of 
spasm. Cephalalgia and delirium, abdo- 
minal neuralgia and vomiting, and myal- 
gia and spasm are the principal morbid 
factors of simple epidemic cerebro-spinal 
meningitis. They distinguish the malady, 
and the varying prominence with which 
they occur in different outbreaks gives 
rise to many diversities in the grouping 
of symptoms during the progress of the 
disease. The onward course of the dis- 
order is usually rapid. The headache con- 
tinues, often without a lull ; vertigo oc- 
curs frequently ; and after the lapse of a 
very brief period, measured usually by a 
few hours, the mind becomes confused, 
and, in some cases, a state of restlessness 
supervenes not unlike that observed in 
delirium tremens. The mental confusion 
assumes the form of muttering delirium, 
with periods of somnolence, often inter- 
rupted by cries provoked by the intense 
cephalalgia, or by the neuralgic pain else- 
where ; or the patient falls into a state of 
apathy or stupor, from which he may be 
partially roused, but into which he re- 
lapses when left undisturbed, the mind 
acting as in a dream ; or there is acute 
and violent delirium. Contemporane- 
ously with, or immediately prior to, the 
mental disturbance, the painful state of 
the muscles increases, certain groups being 
more manifestly affected than others, espe- 
cially the posterior muscles of the neck, 
the muscles of the spinal column, and 
those of the lower extremities. The pain, 
often of an acutely neuralgic character, 
shoots along the spine and limbs, and 
across the walls of the abdomen. Partly 
as a voluntary action, partly as a conse- 
quence of spasm of the painful muscles, 
the head is drawn backwards. The re- 
traction thus arising is one of the com- 
monest and most characteristic symptoms 
of the disease. As the malady advances 
an actual or apparent tetanoid contrac- 
tion of other groups of muscles may oc- 
cur, the trunk most frequently being 
curved backwards, and the legs bent upon 298 
EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
the thighs. At the same time there may 
be fleeting spasmodic action of some of 
the muscles of the face, and occasionally 
of the eyeballs; or in some cases tonic 
contraction of these muscles, giving rise 
to the so-called sardonic laugh, or to per- 
sistent strabismus. In many cases cuta- 
neous sensibility is much exaggerated, 
and very frequently a vesicular or roseo- 
lar eruption is developed, the former par- 
ticularly about the lips. The aspect of 
the patient as the disease advances is de- 
pendent upon the degree of pain, the state 
of delirium or stupor, and extent of spasm 
which may be present. The countenance 
is rigid and contracted, the expression of 
face betokening acute pain ; or it is domi- 
nated by the delirious fancies ; or reflects 
the mental torpidity; or is distorted by 
spasm. There is frequently a slight suffu- 
sion of the eyes, altogether different from 
the dusky appearance of typhus ; and the 
face is commonly pale and sunken, seldom 
and only transitorily flushed and swollen, 
except when affected more or less exten- 
sively by the vesicular eruption. The 
surface sometimes moist, sometimes dry, 
rarely gives to the hand a sensation of 
febrile heat, although the temperature of 
the body ranges above the normal stand- 
ard. The pulse from the outset is wanting 
in firmness, and the indications of defec- 
tive tone increase as the disease advances. 
The respiration exhibits no marked dis- 
turbance, excepting an increase of rapid- 
ity witnessed during accessions of pain and 
restlessness, and in the advanced stage 
of the malady the diminution dependent 
upon failing circulation and innervation. 
The alimentary canal, apart from the vom- 
iting, which usually ceases as the disease 
becomes fully developed, presents little 
indication of disturbance. The tongue is 
as frequently clean and moist as dry, foul 
and discolored; and the bowels may be 
either costive or loose, the former, per- 
haps, more commonly than the latter. 
In some outbreaks, indeed, costiveness 
has been marked and almost general, but 
in others diarrhoea has been prevalent. 
The renal secretion is rarely much dis- 
turbed. 
As the malady proceeds, if it tends to- 
wards a fatal termination, the spasmodic 
symptoms increase, the patient becomes 
comatose, and death may occur either 
from asphyxia or exhaustion in from ten 
or twelve hours to seven or eight days. If 
the disease be prolonged beyond this pe- 
riod, various secondary lesions are apt to 
occur, especially certain inflammatory 
states of the eyes and the ears, the mis- 
chief in the former organs being shown by 
ulceration of the cornea, iritis, and some- 
times suppuration of the globe ; in the lat- 
ter by less obvious structural changes 
during life except as indicated by deafness. 
Or there may be paralysis affecting one- 
half of the body, or one side of the face, or 
one of the limbs, or an isolated group of 
muscles. Or there may be an inflamma- 
tory state, with sero-purulent effusion 
into one or more of the large joints. Or, 
finally, the patient may fall into a state of 
marasmus and nervous exhaustion, often 
protracted and not rarely fatal. If the 
malady proceed to a favorable termina- 
tion without any of these sequences, health 
may be recovered in from three to four 
weeks. If the progress of the disorder, 
otherwise favorable, be interrupted by one 
other complication, the period of recovery 
is uncertain and often long postponed. 
(b. ) Fulminant Epidemic Cerebrospinal 
Meningitis.-In the fulminant form of the 
malady the onset is without premonition. 
The patient suddenly falls into a state of 
collapse. The surface of the body has 
often a cyanotic aspect, and is cold and 
clammy to the touch, or covered with pro- 
fuse perspiration, the face being not rarely 
shrunken and livid, and the eyes deep 
sunk as in the algide stage of cholera. 
There may be some shivering at intervals, 
more or less pain of the head, and occa- 
sional vomiting, sometimes of a grumous 
black or coffee-colored fluid. Drowsiness, 
if not present at the outset, rapidly super- 
venes, followed by or concurrently with 
delirium. Coma, rarely other than the 
precursor of death, quickly succeeds. In 
the mean time purpuric spots show them- 
selves over the surface of the body gener- 
ally, red or purple and circumscribed in 
the beginning, but rapidly becoming black, 
and often extending their margins so as 
to form irregular inky blotches, or streaks, 
or great patches; and not unfrequently 
several of the spots become gangrenous. 
Sometimes the purpuric spots appear con- 
temporaneously with the collapse at the 
outset of the attack. The respiration is 
preternaturally slow, and the pulse (if it 
has not been absent at the wrist from the 
beginning) falls with the progress of the 
disease. The urine is loaded with albu- 
men. Life may be extinguished in less 
than^ve hours, or it may be prolonged for 
two or three days. Recovery from this 
form of epidemic cerebro-spinal menin- 
gitis is not unknown, but it is an exceed- 
ingly rare event. 
(c.) Purpuric Epidemic Cerebrospinal 
Meningitis.-In the purpuric form of epi- 
demic cerebro-spinal meningitis, the symp- 
toms which distinguish the simple and 
fulminant forms of the disease occur com- 
bined together in various proportions, 
some cases approximating more or less 
closely to the latter, others, as is most 
common, to the former variety of the 
affection. Thus concurrently with shiver- 
ing, intense headache, vomiting, rachial- 
gia and retraction of the head, there may 
be depression of the vital powers approach- 
ing collapse, or collapse itself, with the DESCRIPTION OF THE DISEASE. 
299 
development of petechise or purpurse, vi- 
bices, ecchymoses, hemorrhage from mu- 
cous tracts, delirium, coma, and rapid 
dissolution. In by fa' the greater num- 
ber of cases, however, the disease follows 
the course of simple epidemic cerebro-spi- 
nal meningitis; but within twenty-four 
hours, or from this period to the fourth 
day, or still later in the progress of the 
malady petechise or purpurse are devel- 
oped more or less copiously, and occasion- 
ally hemorrhage occurs from the mucous 
tracts. This phase of epidemic cerebro- 
spinal meningitis does not appear to be 
more fatal than the simple form of the 
disease. It has been observed more com- 
monly in the United States than on the 
continent of Europe, and it was the prin- 
cipal variety which occurred during the 
outbreak in Ireland in 1867. 
II. Special Symptoms.-1. The Nervous 
System.-Headache is almost constant, 
and it is remarkable for its early and per- 
sistent severity. At the outset it is not 
localized in any particular part of tlie 
head. It may be referred to the forehead, 
the sides, the vertex, or the occiput; or it 
may be general. Later in the disease, 
the occiput is, perhaps, most commonly 
the seat of pain. The intensity of the 
headache is, as a rule, peculiar. The pa- 
tients describe the pain as sharp, lanci- 
nating, stabbing, plunging, tensive, throb- 
bing, boring, or crushing. It is so intol- 
erable as to elicit groans and cries from 
the sufferer; often, even during delirium 
or stupor, the exclamations, the contrac- 
tion of the forehead, and the manner in 
which the hands are moved towards the 
head, show that the pain continues. In 
young children this state closely resembles 
that which is so significant of tubercular 
meningitis. The headache may cease 
when the disease has become fully devel- 
oped, or as is probably more common, it 
may persist throughout the whole course 
of the malady so long as consciousness 
remains. Occasionally, indeed, when re- 
covery takes place, it will continue far 
into the period of convalescence. 
llachialgia is rarely absent. It is some- 
times general throughout the spinal re- 
gion, but more frequently it is limited to 
the loins, the dorsal region, or, as is most 
usual, to the posterior part of the neck. 
Occasionally the pain radiates from the 
neck to the extremities and walls of the 
abdominal and thoracic cavities. In rare 
cases the pain has commenced at some 
point of the peripheral nervous system, 
and spread thence to the back, occurring 
in paroxysms. This pain has the same 
character as the cephalalgia, and the 
words (intolerable, atrocious, tensive, &c.) 
used to indicate the nature of the latter 
may be employed also to describe the for- 
mer. It is augmented by movements, 
and its chief seat is in the muscles of the 
spinal column. 
The nuchal pain and its consequences 
constitute one of the most characteristic 
signs of the disease. Frequently, at the 
outset of the malady, this pain is preceded 
by a dragging sensation at the back of the 
head. As the pain increases in intensity, 
the head is voluntarily thrown back to re- 
lieve all strain upon the exquisitely sensi- 
tive muscles. Or, in conjunction with 
the pain, spasm of the affected muscles 
occurs, and the head is forcibly drawn 
backwards. Among the popular terms of 
the disease, those arising from this symp- 
tom (Nackenstarre, Genickkrampf, Nacks- 
juka, &c.) are very prominent. When the 
rachialgia is more diffused, and the pain 
extends also to the limbs, adapted or 
spasmodic contractions of the trunk and 
lower extremities are apt to occur. Ra- 
chialgia is not present in the fulminant 
and in severe cases of the purpuric forms 
of the affection. It is noteworthy that 
pressure on the spinous processes, during 
the most acute rachialgia, rarely causes 
pain. 
Enteralgia and other Neuralgic Pains.- 
Abdominal pain, neuralgic in character, 
and more or less closely linked to the pain 
in the course of the spine, is not unfre- 
quent, and it is often closely associated 
with uncontrollable vomiting. In some 
epidemics, as in that of 1865 on the Lower 
Vistula, enteralgia was so common among 
children seized with cerebro-spinal menin- 
gitis that it gave rise to the trivial desig- 
nation "belly-ache," as one of the popu- 
lar names of the disease. Neuralgic 
pains in the limbs, referred to in connec- 
tion with rachialgia, are less common 
than like pains along the course of the 
spine and in the abdomen. 
Increased Sensitiveness of the Surface of 
the Body has been described as frequent 
in several outbreaks. During the late 
prevalence of the disease in the United 
States (1861-67), cutaneous hypersesthesia 
is said to have been a characteristic symp- 
tom of the malady in its fully developed 
state. During the outbreak on the Lower 
Vistula, an increase of cutaneous sensi- 
tiveness was also observed very commonly, 
but it was not regarded by Dr. Burdon 
Sanderson as a characteristic symptom, 
but "a mere consequence or interlude of 
pain: " being, in fact, an excessive tender- 
ness experienced during intermissions, or 
after the cessation of pain. 
Spasm.-Sufficient care has not always 
been taken to discriminate between appa- 
rent and actual spasm in this disease. 
Tourdes, in 1843, showed that the retrac- 
tion of the head and curvature of the 
spine did not in all cases arise from a 
spasmodic contraction of the muscles, but 
that the position was not rarely volun- 
tarily or instinctively assumed by the pa- 
tient as most conducive to relief of the 
spinal pain. Dr. Burdon Sanderson con- 300 
EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
firmed this observation of Tourdes, so far 
as retraction of the head was concerned, 
in 1865. In the cases observed by him, 
in which the head was apparently drawn 
backwards, it was practicable to extend 
the seemingly contracted muscles, al- 
though the effort gave rise to exquisite 
pain and instinctive resistance. There 
was not any tension of the muscles except 
such as arose from this resistance; no 
tightness was felt so long as they were at 
rest. "It was not till the neck was com- 
pletely extended that the muscles became 
hard, and even then the hardness was not 
for a moment comparable to that which is 
felt in tetanus. " The position in bed of 
the patients observed by Dr. Burdon 
Sanderson was that which would produce 
the greatest relaxation of painful groups 
more rarely in general convulsions. Tonic 
spasm of the muscles of the face, jaws, 
(trismus), and gullet, and of the limbsand 
trunk, may also occur, giving rise to true 
opisthotonos, emprosthotonos, or general 
tetanic rigidity of the trunk and limbs. 
Paralysis is not of very common occur- 
rence during the progress of epidemic 
cerebro-spinal meningitis. Hemiplegia 
has been occasionally noticed, and paraly- 
sis more or less complete of one or both 
extremities, upper and lower, of the mus- 
cles of deglutition, of articulation, and of 
certain other associated groups, the latter 
chiefly towards the close of the malady. 
The general paralysis noticed by some 
writers was usually significant of, and in- 
deed a part of the phenomena of, ap- 
proaching dissolution. 
The special senses do not often manifest 
much change, except as a consequence of 
certain structural lesions. Increased, 
sometimes exquisite, sensitiveness of sight 
and hearing has occasionally been noticed, 
concurrently with augmented sensitive- 
ness to other external impressions, espe- 
cially towards the close of the malady, 
when complete consciousness returns. 
Amaurosis has also occurred, without ap- 
parent change in the ocular apparatus. 
It may be noted, moreover, of the eye and 
sight, that occasionally there are strabis- 
mus and double vision. The pupils may 
be normal in aspect and action, or they 
may present various changes. They may 
be dilated or contracted, or one dilated 
and the other contracted, or they may 
exhibit curious alternations of contraction 
and dilatation under the influence of the 
same degree of light. Both the eyes and 
the ears are liable to undergo certain 
structural lesions, consisting in well- 
marked inflammatory changes. These 
commence, in the former organs, some- 
times in the cornea, sometimes in the 
deeper tissues. Most commonly keratitis 
is set up, ending in opacity or ulceration ; 
and, in the latter case, the iris may be- 
come involved. Or, iritis may occur in- 
dependently, with effusion of lymph or 
pus, and the consequences thereof (syne- 
chia posterior and distortion of the iris are 
particularly noted). Among more deeply- 
seated changes may be mentioned opacity 
of the lens or of the vitreous humor, sepa- 
ration of the retina from the choroid, 
purulent infiltration, or atrophy of the 
eyeball. The ear suffers, perhaps, more 
frequently than the eye. Deafness is 
probably more common than defects of 
vision, and it is largely dependent upon 
inflammatory changes set up in the organ, 
and particularly affecting the lining mem- 
brane at the vestibule and semicircular 
canals. Occasionally, the external meatus 
has been affected, and a profuse purulent 
discharge has flowed from it. These le- 
sions of the organs of sight and hearing 
[Fig. 13. 
Cerebro-spinal Fever (J. Lewis Smith).] 
of muscles. There can be no doubt, how- 
ever, that spasm is a frequent accompani- 
ment of epidemic cerebro-spinal meningi- 
tis. In the clonic form it is witnessed in 
some cases as transitory contractions of 
the facial muscles, cramps of the extremi- 
ties, the convulsive agitation and trem- 
bling referred to in the general description 
as somewhat like what is observed in 
delirium tremens, very rarely in local 
convulsions of a single limb, and still DESCRIPTION OF THE DISEASE. 
301 
may occur either early or late in the 
course of the disease. The sense of smell 
very rarely suffers. Its loss in one nostril 
has been recorded in a single case, and 
this was, perhaps, dependent upon inflam- 
matory changes in the lining membrane 
of the nose ; as purulent discharge from 
the nostrils has occasionally taken place 
in other instances. 
Vertigo is sometimes observed as an in- 
itial symptom of the disease in conjunc- 
tion with the cephalalgia. Instances are 
recorded in which the first accession of 
the disease was marked by severe giddi- 
ness, during which the patient either 
staggered about like a drunken man, or 
turned round several times, and then fell. 
Delirium is rarely absent. It varies 
much in character, and may occur at any 
period of the seizure. It may be quiet or 
violent, transitory or more or less persist- 
ent. It sometimes, but rarely, forms one 
of the symptoms of invasion, when its 
access is sudden and its character acute. 
It may supervene with violence after the 
malady has continued from several hours 
to two or three days. In the acute form 
of delirium, the patient is very noisy, and 
often so violent as to require restraint. 
Sometimes it happens that paroxysms of 
furious excitement occur with intervals of 
placid delirium. Hence the necessity of 
great watchfulness in the care of these 
cases. Most commonly the delirium fol- 
lows closely upon the initiatory symptoms, 
and is aggravated as the disease advances. 
At the beginning, the confusion of thought 
may not be so great but that the patient 
can be roused so as to answer questions 
intelligibly. Later, the incoherence be- 
comes much greater, and is usually accom- 
panied with considerable agitation. Much 
difference is observed, not only in the de- 
gree of impairment of the consciousness, 
but also in the periods of manifestation of 
the impairment. In some cases, the de- 
lirium occurs chiefly during the night; in 
others, and very commonly, it alternates 
with periods of somnolence or of quietude. 
In the more persistent cases there are 
usually exacerbations. If the disease 
tend to a fatal ending, the delirium is fol- 
lowed by coma ; if to recovery, conscious- 
ness is, as a rule, gradually recovered: 
but, at times, a period of stupor inter- 
venes between the subsidence of the de- 
lirium and returning perception. In the 
slightest cases of the malady the delirium 
may be transient only, taking place at 
intervals, and chiefly during the night. 
In the gravest cases, when death occurs in 
a few hours, delirium is most commonly 
present. The duration of the delirium 
depends entirely upon the nature and 
duration of the case. Instances are re- 
corded in which furious delirium has oc- 
curred for three nights in succession. In 
other instances a delirious state has per- 
sisted more or less continuously for fifteen 
days. 
Stupor and Coma.-In not a few pro- 
tracted cases, delirium is followed by a 
prolonged state of stupor, the patient 
lying completely indifferent to external 
impressions. In six cases observed by 
Dr. Burdon Sanderson, in which there 
had been violent delirium at the outset, 
this state lasted from one week to five 
weeks, the mean duration of the several 
cases being nineteen days. The observer 
remarks, however, that as four of the 
cases "emerged from their stupor in a 
state of complete deafness, there was 
much difficulty in limiting accurately the 
period of unconsciousness." Sometimes 
the state of stupor supervenes without the 
intervention of violent delirium. Coma 
occurs in nearly all fatal cases, and is, in- 
deed, generally the forerunner of death. 
2. The Digestive System.-The uncon- 
trollable vomiting, which is one of the 
characteristic initiatory symptoms of the 
disorder, is an effect of the cerebral mis- 
chief. Most frequent at the beginning of 
the malady, the vomiting diminishes as 
the disease advances, occasionally increas- 
ing during exacerbations. The matter 
evacuated, after the stomach has been 
emptied of food, is usually of a greenish 
or yellowish color and bitter taste, and is 
composed largely of bile ; more rarely it 
is viscid and white. Occasionally, in the 
fulminant and purpuric forms of the mal- 
ady, a grumous black or coffee-colored 
fluid is vomited. In several outbreaks, 
the vomiting of large quantities of Asca- 
rides lumbricoides has been specially noted. 
The buccal cavity and tongue do not ex- 
hibit any particular signs, except in those 
rare cases in which there is hemorrhage 
from the gums. As a rule, the tongue is 
clean and natural at the outset, and its 
subsequent state depends upon the degree 
of febrile excitement which may be set 
up, or upon the development of a typhous 
state, when it may become foul with va- 
rious well-known aspects, or with dry and 
black sordes accumulating on the teeth. 
From the beginning of the attack the 
appetite for food is destroyed, whatever 
the state of the buccal cavity ; and some- 
times there is much, at others, insatiable, 
thirst. The bowels are more commonly 
costive than the reverse. In some out- 
breaks costiveness has been of general 
occurrence. Diarrhoea, late in the dis- 
ease, is not unfrequently to be attributed 
to the previous administration of purga- 
tives, and involuntary stools are usually 
one of the accompaniments of complete 
nervous and vital prostration. 
3. The Urinary System.-In the simple 
form of epidemic cerebro-spinal menin- 
gitis the urine does not exhibit any 
marked change. It may be more abun- 
dant, and slight deposits of lithic acid 302 
EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
may occur. In the fulminant, and in 
severe cases of the purpuric forms, it com- 
monly (in the first-named form perhaps 
invariably) contains albumen, sometimes 
in large amount, and occasionally cylin- 
drical casts and blood-corpuscles. Reten- 
tion or incontinence of urine has occurred 
in the progress of the disease. 
4. 77ie Respiratory System.-In all the 
graver cases the respiration is more or 
less altered. It is sighing, labored, or in- 
terrupted. Dr. Burdon Sanderson writes 
of the outbreak on the Lower Vistula: 
"In all severe cases, whether of children 
or adults, the breathing was embarrassed 
in proportion to the general gravity of the 
symptoms. This embarrassment was 
marked by a slow labored inspiration, 
followed by quick respiration and a long 
pause,-that condition of breathing which 
is so frequently observed in continued fe- 
ver (especially in typhoid), and is often 
called suspirous. In all the fatal cases 
which came under my notice, the most 
prominent symptoms which preceded 
death were those which indicate impair- 
ment and perversion of the respiratory 
function. As the breathing became more 
hurried and difficult, the general depres- 
sion became more intense, the pulse be- 
came weaker and quicker, and the tem- 
perature of the skin more elevated. " Dr. 
S. Gordon records a case, fatal in less 
than five hours, in which the respirations 
rapidly fell to nine per minute, the pulse 
at the time being 120. 
5. 1'he Circulatory System.-The cardi- 
nal point with respect to the circulation, 
as indicated by the radial pulse, is defect 
of arterial tension. This has been com- 
mon to all epidemics, with hardly an ex- 
ception ; and the exceptional instances 
have probably been more apparent than 
real. The frequency of the pulse does 
not admit of general statement. It has a 
wide range. In the epidemic on the 
Lower Vistula, the pulse in six adult 
cases observed by Dr. Burdon Sanderson 
varied from 56 to 98, the average beats 
being 85. In several cases noted by the 
same observer, "its frequency varied con- 
siderably from day to day, without appa- 
rent relation to the condition of the pa- 
tient in other respects." During the 
Philadelphia outbreak of 1866, in 98 cases 
observed by Dr. W. H. II. Githens, the 
pulse varied from the normal beat to 150 
per minute in uncomplicated cases, and 
reached as high as 160 in two cases in 
puerperal women. "It was in all very 
weak, with a dichrotic tendency, some- 
times entirely imperceptible in the radial 
artery, and always interrupted by slight 
pressure." 
6. The Cutaneous System.-In respect 
of dryness or moisture or feeling to the 
touch, the skin presents no constant con- 
dition ; but, in numerous cases, it is the 
seat of various forms of eruption of re- 
markable interest. The extent of preva- 
lence or predominance of one or other of 
these different forms of eruption has varied 
considerably in the numerous recorded 
outbreaks. In the epidemics which have 
occurred in the United States, petechioe 
have been so common as to have given 
rise to the popular name of the disease 
(spotted fever), and to have induced Dr. G. 
B. Wood, Professor of the Theory and 
Practice of Medicine in the University of 
Pennsylvania, to adopt as the technical 
designation of the disease the term pete- 
chial fever. During the recent outbreak 
in Ireland (1866-67), purpura was the 
predominant form of eruption, and Pro- 
fessor Stokes proposed to designate the 
malady malignant purpuric fever; other 
observers also suggested terms founded 
upon this character. In the outbreak on 
the Lower Vistula (1865), an herpetic 
eruption was most common. In all the 
greater outbreaks, each form of eruption 
mentioned in the definition of the disease 
has been observed; but the proportion of 
cases in which one or other form of erup- 
tion has prevailed has varied greatly in 
each outbreak. In some of the earlier 
outbreaks in the United States few cases 
occurred in which a petechial eruption 
was not noted. Of 98 cases admitted 
into the Philadelphia Hospital (Blockley) 
in 1866, 36 had petechise ; 13 mixed pete- 
chia; and erythema ; 9 erythema and urti- 
caria ; 3 indistinct petechial mottling; 
and 37 no eruption at all (Githens). In 
the outbreak on the Lower Vistula the 
proportion of cases exhibiting an eruption 
was comparatively small; in the recent 
outbreak in Ireland, large. The forms 
of eruption observed are as follows: (a) 
Vesicles. A vesicular eruption (eczema, 
Hirsch), sometimes herpetic in character, 
chiefly appearing in the vicinity of the 
lips, but occasionally extending over the 
sides of the face, diffused more or less on 
the trunk, or showing itself in patches on 
the limbs. This symptom has occasion- 
ally taken the form of shingles. It is 
most commonly noticed in the simple 
form of the disease, but it may take place 
in either of the other forms, and when 
associated with purpura, the vesicles may 
be flattened and rest upon a livid base, 
presenting a horrible aspect. This form 
of eruption may appear as early as the 
second day. (b) Purpura. 1. True pete- 
chice. 2. Purpuric spots, varying in size 
from a split pea to half-a-crown, with 
more or less extensive effusions of blood, 
or of its coloring matter, into the cutis 
(vibices, ecchymoses). The spots have 
sometimes a regular, sometimes an ir- 
regular, even a ragged, outline. Their 
size may remain fixed from the time of 
their first appearance, or it may increase 
largely or rapidly. They may be of a COMPLICATIONS - DURATION. 
303 
light or dark red color at the outset, sub- 
sequently becoming purple and black; 
or, as is most common, they may from 
the beginning be dark purple or black, 
their blackness being often fittingly 
likened to that of ink-the eruption re- 
sembling "spots" or "splashes" of that 
fluid. They may appear on the trunk or 
limbs only, or they may be scattered co- 
piously over the whole surface of the 
body, including the face. The purpuric 
spots are frequently hard to the touch, 
the margin being defined, and giving the 
impression to the fingers of being raised 
above the surface; sometimes a vesicle 
forms above several of the spots, and gan- 
grene of the adjacent tissue takes place. 
Dr. S. Gordon writes of the recent epi- 
demic in Ireland: "Many cases are ac- 
companied by a distinct eruption, which 
comes out with great rapidity; is found 
over all parts of the body, but chiefly on the 
lower extremities; is of a very dark color, 
sometimes a very deep brown, or purple, 
or even black. The spots are of various 
sizes and shapes, some small and round, 
others large and irregular; some appear 
like large spots of very black purpura, 
only more mottled and more irregular in 
color and shape; others are more con- 
fined, and raised above the level of the 
skin, consisting of an effusion into its sub- 
stance : many patients die in this stage, 
but in some the disease progresses, and 
these spots are absorbed, leaving a yellow- 
ish mark under the cuticle; or they pass 
into superficial gangrene, which was 
spreading at the time of the patient's 
death, or is healed with loss of substance. " 
Purpuric spots are sometimes, although 
rarely, one of the earliest signs of the ful- 
minant and purpuric forms of the malady; 
or they may occur at any period during 
the more advanced stages. Usually they 
appear at some period during the first 
four days, chiefly perhaps during the first 
or second day. Sometimes, with or with- 
out the purpuric spots, there is a cyanosed 
aspect of the skin, or a peculiar livid mot- 
tling. During recovery the purpuric 
spots gradually lose their refined charac- 
ter and fade away, passing through the 
different stages of color which mark a 
healing bruise, (c) Roseola, erythema, &c. 
Rose-colored spots or patches are occa- 
sionally observed; also erythema, more 
or less diffused, a rubeoloid eruption, and 
urticaria. 
7. Temperature. - The temperature of 
the body, as marked in the axilla, is 
heightened in every case; except, per- 
haps, those accompanied by profound col- 
lapse from the beginning. In many cases 
this heightened temperature is found con- 
temporaneously with the invasion of the 
disease; in other cases there is no conspi- 
cuous increment until the second or third 
day. When the characteristic symptoms 
of the malady are developed, the tempe- 
rature rarely falls below 100° Fahr., and, 
as the disease advances, it ranges in 
adults from 100° to 105°, in children some- 
times even higher. There is no constant 
or conspicuous difference between the 
morning and the evening temperature, as 
in typhus and typhoid. A steady fall 
marks the decline of the disease and the 
approach of recovery ; a rapid fall ushers 
in collapse or death. 
Complications.-The course of the 
disease is liable to be modified by certain 
complications. Of these the chief are as 
follows : - (ct) Thoracic inflammations : 
pleurisy, pneumonia, bronchitis, or peri- 
carditis. Dr. S. Gordon describes oedema 
of the lung and diffuse pulmonary apo- 
plexy. (6) Swelling or inflammation of 
the parotids. (c) Inflammation of the 
large joints, marked by swelling and pain, 
and sometimes ending in sero-purulent 
effusion. This complication, in its less 
aggravated form, has been described by 
some writers as rheumatic, (d) An in- 
flammatory condition of the eyes and 
ears, as already noted, (e) Bed-sores. 
Large, deep, black sloughs occurred in 
four cases out of 161 treated in the Phila- 
delphia Hospital in 1866. (/) The course 
of the disease has also been complicated 
by the supervention of other maladies, 
namely (1) Intermittent fever, or certain 
paroxysmal phenomena simulating mala- 
rious poisoning: a complication which 
has led to erroneous notions of the nature 
of the disease. In the outbreak on the 
Lower Vistula cases were observed in 
which regular or irregular intermissions 
took place that could not be assigned to 
a malarious origin. (2) Typhoid fever, the 
two diseases prevailing simultaneously in 
the same district. The symptoms of both 
diseases more or less modified, pursue 
their course together, and the character- 
istic lesions of typhoid fever as well as of 
epidemic cerebro-spinal meningitis are 
discovered after death. (3) Measles and 
scarlet fever. (4) Cholera (Levy). 
Duration. - In the outbreak on the 
Lower Vistula, the most acute cases ter- 
minated fatally in from 12 to 72 hours. 
Cases of less intensity, but in which the 
patient eventually died in a typhous state, 
lasted from 8 to 14 days, the characteristic 
symptoms of the disease persisting to the 
end. In the more protracted, or compli- 
cated cases, from 5 to 8 weeks have passed 
before a patient entered upon convales- 
cence, and death has taken place in the 
6th or 7th week. Of the cases observed 
in the Philadelphia Hospital (1866), the 
duration of those which ended fatally was 
from 24 hours to 14 days ; of those which 
recovered, from 20 to 30 days, the acute 
symptoms rarely exceeding a fortnight. 304 
EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
In the outbreak of 1866 in Ireland Dr. S. 
Gordon reported a well-marked case which 
ended fatally after less than five hours'1 
duration. A large proportion of the fatal 
cases in that outbreak died in from 10 to 
48 hours ; in other cases the fatal ending 
did not occur until the close of the second 
and during the course of the third week 
of the disease. The duration of the dis- 
ease, as shown by death, may be clearly 
stated; as marked by the beginning of 
convalescence, it does not admit of defi- 
nite description. Moreover, convales- 
cence is often very protracted. The course 
of the disease towards recovery is some- 
times interrupted by relapses. 
Termination. - The disease termi- 
nates, after a longer or shorter period of 
convalescence, in health; or it entails 
during convalescence a series of physical 
or mental ills ; or it ends in death. The 
rate of mortality of the disease is the 
measure of probable recovery. It varies 
much in different outbreaks, but is at all 
times formidable. Among the cases ob- 
served in the Philadelphia Hospital in 
1866 the mortality was 33 per cent. ; in 
the Hardwicke Hospital, Dublin, the same 
year, the mortality was 80 per cent. Dr. 
Stille remarks that, "while ten epidemics 
in various places, occurring between 1838 
and 1848, presented an average mortality 
of 70 per cent., a similar number occur- 
ring during the decade from 1855 to 1865 
gives an average mortality of about 30 per 
cent. This remarkable fact would seem 
to indicate a gradual decline of power in 
the epidemic." The minimum rate of 
mortality recorded is 20 per cent. The 
proportion of fatal cases is greatest, and 
the duration of these cases least, at the 
commencement of an outbreak. The 
sequelae which interfere with the restora- 
tion of the patient to perfect health are : 
-Deafness ; impaired vision from struc- 
tural changes in one or both eyes ; para- 
lysis of one or more limbs or of certain 
groups of muscles ; impaired memory; 
carbuncles, and boils. Dr. S. Gordon de- 
scribes a case in which the patient "re- 
covered from all the acute symptoms, but 
gradually passed into a state of almost 
organic life. He ate, drank, and slept 
well; he passed solid feces and urine with- 
out giving any notice, yet, evidently, not 
unconsciously ; he was excessively ema- 
ciated, and there was a peculiar mouse- 
like smell from him ; he seemed to under- 
stand what was said to him, but he could 
not answer ; he never called for anything; 
his breathing was rather slow ; his pulse, 
120; his heart acting with a peculiar 
strong jerking motion ; his eye was quite 
well, as also his knee (he had suffered 
from ulceration of the right cornea and 
immense effusion into the right knee- 
joint); he could draw his legs and arms up 
to him ; but he could not use his hands at 
all." Such was the condition of the pa- 
tient fifty-eight days after the invasion of 
the disease. 
Mode of Death.-Death chiefly oc- 
curs from (a) asphyxia, caused by damage 
to the respiratory nerve-centres ; (6) from 
asthenia ; and (c) in some of the fulminant 
cases probably from necrsemia, so pro- 
found are the changes observed in the 
blood. 
Diagnosis.-In some instances the dis- 
ease approximates in certain symptoms to 
typhus or typhoid, and it occasionally pre- 
vails contemporaneously with both mala- 
dies. But the history of the development 
and progress of the disease, with the ab- 
sence of characteristic eruption, will 
usually clear up any doubt. From spora- 
dic spinal meningitis the disease is distin- 
guished by its epidemicity, the almost 
constant concurrence of cerebral disorder, 
the tendency to cutaneous eruptions, the 
great mortality, and the rareness of pro- 
tracted or permanent paralysis or contrac- 
tion of the lower limbs. The distinction 
between the disease and cerebral meningi- 
tis is less defined as to particular symptoms, 
especially in children, but the mode of 
development of the malady will rarely 
leave much room for doubt during an 
outbreak. Tetanus (so-called idiopathic), 
with which it is suggested that epidemic 
cerebro-spinal meningitis may, under cer- 
tain states of spasm, be confounded, never 
manifests the early grave cerebral symp- 
toms which occur in the latter disease. 
The tetanoid contraction also observed in 
epidemic cerebro-spinal meningitis, is 
rarely, if ever, as in tetanus, aggravated 
by sudden and painful spasms. The 
grouping of the symptoms in the two dis- 
eases is, moreover, altogether different. 
Dr. S. Gordon points out the possibility 
of confounding the purpuric form of epi- 
demic cerebro-spinal meningitis with ma- 
lignant measles, which malady has often 
prevailed at the same time. The last- 
named disease may resemble the fulminant 
form of the first-named in several respects, 
particularly the rapidity of development, 
the dark color of the eruption, and the 
rapid appearance of petechife ; also in the 
sudden and often extreme collapse which 
accompanies the invasion of the affection. 
But the eruption of measles rarely loses 
its characteristic form, and the affection 
of the respiratory passages is commonly 
present, while purpuric spots and patches 
are seldom observed. Dr. S. Gordon also 
states that he has known several cases in 
which the earlier symptoms of epidemic 
cerebro-spinal meningitis in young excita- 
ble females have been mistaken for hysteria. 
Dr. Murchison records a case which pre- 
sented the symptoms of cerebro-spinal 305 
PROGNOSIS-MORBID ANATOMY. 
fever, including severe headache, moaning, 
retraction of the head, rigidity of arms, 
and vomiting ; but in which, after death, 
the duration of the case having been ten 
days, "no appreciable lesion of the mem- 
branes of the brain or spinal cord could be 
discovered, and the cause of death was 
ascertained to have been uraemia from 
contracted kidneys, and recent pericar- 
ditis."1 
Prognosis.-At the best, the prognosis 
of the disease is very grave. The mortal- 
ity may be equally great in each of the 
three varieties, and petechiae and purpura 
do not, as in other acute diseases, neces- 
sarily indicate an aggravated degree of 
danger. In 50 per cent, of the cases re- 
corded by Dr. Grithens, in one of the least 
fatal outbreaks known, petechiae were 
present, and it is especially remarked that 
neither this nor any other form of erup- 
tion had "any reference to the progno- 
sis." But when hemorrhage into the 
cutis is extensive, either from the number 
or the size of the spots, and is accompa- 
nied by marked signs of vital prostration, 
it indicates an extremity of danger, al- 
though not a certainty of death. The 
disease is more fatal among infants and 
young children than among youths and 
adults in the prime of life ; but, in some 
outbreaks, the latter have suffered most. 
After thirty years of age it becomes more 
dangerous. Life is most endangered in 
the earlier days of the disease, particu- 
larly during the first five. But danger is 
present at all periods of the malady, and 
the convalescent is not entirely safe until 
health is fully restored. Of the special 
symptoms, whether of excitement or de- 
pression, the rules of prognosis hold good 
which apply to other highly fatal acute 
maladies. 
Morbid Anatomy.-The essential an- 
atomical characteristics of the disease, 
found after death, are hypersemia, often 
intense, of the pia mater of the brain and 
spinal cord ; with more or less copious 
subarachnoid and interstitial effusion into 
the meshes of the congested pia mater, 
either of serum, or of a transparent, gela- 
tinous material, or of purulent matter: 
the latter more frequently than either of 
the two former. The purulent effusion is 
of greenish or yellowish color, and is some- 
times flaky. It has been found in a case 
in which death took place in less than five 
hours from the invasion of the disease (S. 
Gordon). The extent to which these ap- 
pearances are observed and the amount of 
effusion varies greatly in different cases. 
No part of the encephalic or spinal pia 
mater and arachnoid may be free, or cer- 
tain portions alone may be affected ; but 
effusion is limited to the sub-arachnoid 
space, and does not occur into the arach- 
noid cavity. Under the microscope, ac- 
cording to Dr. Burdon Sanderson, the 
gelatinous material is " always found to 
consist of cell-like bodies, either adhering 
to each other so closely that they could 
not be completely separated, or imbedded 
in a transparent interstitial substance ; 
while the sero-purulent liquid which occu- 
pied the spinal sub-arachnoid space, and 
in some cases the ventricles, exhibited 
corpuscles and granules floating freely. 
The cell-like bodies, although in general 
resembling pus corpuscles, did not present 
that uniformity of size and character 
which is met with in normal pus. They 
were usually, but not always, of regular 
circular contour, and varied in diameter 
from to T^th of an inch. Occa- 
sionally they exhibited the appearance of 
an external cell-membrane, but in most 
instances this could not be made out even 
in perfectly fresh exudations-as, e. p., in 
those cases which were examined as early 
as eight hours after death. They invari- 
ably contained numerous granules, some 
of which were cleared away on the addi- 
tion of acetic acid. Those which re- 
mained were highly refractive, but did not 
assume any special form of arrangement. 
The interstitial substance was beset with 
granules, some of which were albuminous, 
others fatty. It was most abundant and 
distinct on the surface of the spinal arach- 
noid, where it infiltrated the fine connect- 
ing tissue and minute bloodvessels of the 
pia mater." 
For the rest, the nervous system of the 
brain and spinal cord is usually gorged 
with blood, unless death has taken place 
late in the course of the disease. The vis- 
ceral arachnoid is frequently thickened 
and opaque. Dr. Klebs1 has shown that 
often, where the eye detects opacity alone, 
the microscope reveals extensive cell for- 
mation, purulent in character. Softening 
of some portion of the spinal cord has 
sometimes been observed ; and Mr. J. Si- 
mon thinks that, "for practical purposes, 
the state of the covering membranes of the 
nervous centres may be regarded as a 
mere index of changes more or less dis- 
tinctive, which those centres in their own 
intimate composition have at the same 
time undergone ; and hence it is that the 
essential phenomena of the disease during 
life consist in disturbances, more or less 
grave, of the functions of these all-impor- 
tant organs. " Dr. Klebs describes oedema 
of the medullary substance and loosening 
1 Zur Pathologie der Epidemischen Menin- 
gitis. Virchow's Archiv. Band xxxiv. Brit- 
ish and Foreign Medico-Chirurgical Review, 
1868. 
1 Proceedings of the Pathological Society, 
vol. xviii. 
vol. i.-20 306 
EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
of the nervous elements, and suggests that 
this may explain the extensive motor dis- 
turbances which have been observed in 
some cases, in which purulent effusion 
into the subarachnoid space has been 
slight. The same author has observed 
also purulent encephalitis. 
In fatal cases of the simple and pur- 
puric forms of epidemic cerebro-spinal 
meningitis the characteristic anatomical 
lesions are almost invariably found. In 
the fulminant form of the disease they are 
often absent. The cases in which there is 
no indication of morbid change in the 
nervous centres are exceedingly few. It 
has been suggested that in these cases 
death has occurred so rapidly that there 
was insufficient time for the formation of 
a structural lesion. In connection with 
this explanation the case recorded by Dr. 
S. Gordon must be borne in mind, in 
which purulent effusion was found, al- 
though the whole duration of the attack 
was under five hours. Practically the ap- 
parent absence of characteristic anatom- 
ical change in the nervous centres, in cer- 
tain rare cases of epidemic cerebro-spinal 
meningitis, is a phenomenon analogous to 
that which sometimes occurs in rapidly 
fatal cases of malarious, variolous, and 
scarlatinous poisoning, in which the char- 
acteristic eruptions or lesions of the dis- 
eases have not been developed. 
No lesions manifestly peculiar to epi- 
demic cerebro-spinal meningitis have, as 
yet, been found in other organs of the 
body. Such lesions as occur elsewhere 
than in the coverings of the brain and 
spinal cord usually have a definite relation 
to the thoracic, abdominal, or genito-uri- 
nary complications which may have hap- 
pened during the progress of the malady. 
Dr. Klebs, however, describes certain 
changes in the intimate structure of the 
kidneys and liver, which he believes to be 
characteristic of the disease. In the fatal 
cases of the purpuric form of the affection 
recorded by Dr. S. Gordon, and other 
writers, an excessive fluidity of the blood 
was noted. 
History and Geographical Distri- 
bution.-The scientific history of epi- 
demic cerebro-spinal meningitis dates 
only from the fourth decennium of the 
present century. At that period the dis- 
ease was, for the first time, clearly distin- 
guished as an independent malady ; and 
with the light then obtained, outbreaks 
which had occurred earlier in the cen- 
tury, in various localities of both the 
Eastern and Western hemispheres, and 
had been recorded under other names, 
were recognized as of a similar character. 
It has been sought, indeed, to show that 
epidemic cerebro-spinal meningitis has 
probably existed from remote periods 
(Tourdes, Boudin). The probability may 
be admitted, for the first recognition of a 
malady as an independent affection does 
not necessarily imply that the malady is 
new. 
In 1837 epidemic cerebro-spinal menin- 
gitis broke out in the southwest of France, 
and prevailed in various localities of the 
district intervening between Bayonne and 
La Rochelle, and along the whole line of 
the Pyrenean frontier. Dax, Bordeaux, 
Audi, Foix, Narbonne, and Perpignan 
suffered, as well as the two cities pre- 
viously named. The disease, according 
to Boudin, at the commencement and 
during the continuance of this outbreak, 
chiefly showed itself among troops in gar- 
rison. During 1837 and 1838 the garri- 
sons of Bayonne, Dax, Bordeaux, Roche- 
fort, and La Rochelle suffered. From 
1838 to 1841 the disease was prevalent 
among the garrisons of southeastern 
France, particularly those of the valley 
of the Rhone. Thus it broke out at Tou- 
lon, Marseilles, Aigues-Mortes, Nismes, 
Avignon, and Pont-Saint-Esprit. In the 
course of the four years 1839-40-41-42, 
the malady appeared in succession among 
the troops occupying the fortresses of 
Strasburg, Schelestadt, Calmar, Nancy, 
Metz, and Givet. From 1839 to 1842 it 
prevailed among the forces at Versailles, 
Saint-Cloud, Rambouillet, and Chartres. 
Those stationed along the coast of Brit- 
tany, at Brest, L'Orient, Nantes, and 
Ancenis, suffered in 1841; and during 
1840 and 1841 the disease manifested it- 
self among divers detachments of a regi- 
ment scattered at Laval, Le Mans, Cha- 
teau-Gontier, Tours, and Poitiers. It was 
during the outbreak-of which the most 
remarkable episode is thus sketched by 
Boudin-that a scientific knowledge of 
epidemic cerebro-spinal meningitis was 
first obtained. From 1837 to 1848 inclu- 
sive, forty-seven outbreaks of the malady 
were recorded in thirty-six of the eighty- 
six departments into which France was 
then divided. These outbreaks were dis- 
tributed in the departments of the Loire, 
Rhone, Bouches-du-Rhone, Bas-Rhin, 
Seine, Seine-et-Oise, Landes, Basses-Py- 
renees, Charente -Inferieure, Gard, Vau- 
cluse, Var, Moselle, and Loiret. The 
three first-named departments suffered 
most. In 1840 the disease appeared in 
Naples and prevailed in the Papal States. 
The same year it broke out among the 
French garrison at Douera, Algeria, and 
during the next seven years it attacked 
numerous towns and localities of the 
province, affecting the civil population, 
both European and native, as well as the 
military. In 1844 an outbreak of the dis- 
ease took place among the civil population 
of Gibraltar; and in 1846 the malady 
showed itself slightly in Ireland among 
the inmates of the Bathdown, South Dub- 
lin, and Belfast workhouses, and several HISTORY AND GEOGRAPHICAL DISTRIBUTION. 
307 
cases occurred, among the population of 
Dublin. During 1849 and 1850 the dis- 
ease was prevalent to some extent among 
the French troops in Italy, and in the 
last - named year several localities of 
France suffered from it. Epidemic cere- 
bro-spinal meningitis appeared in Den- 
mark in 1841, and prevailed in that coun- 
try until 1848. The disease was first no- 
ticed in Sweden in 1854, this country 
again suffering from it in 1861. In Nor- 
way the malady broke out in 1859, and it 
prevailed in that country more or less 
until 1867, if not to a later period. Dur- 
ing 1860 the disease was prevalent in Hol- 
land ; and the same year it was widely 
spread in Portugal. In 1863, 1864, and 
1865 an extensive outbreak occurred in 
North Germany; and in 1866 the malady 
broke out in Dublin and elsewhere in Ire- 
land. Cases were recorded in St. Peters- 
burg during 1866 and 1867. 
In the United States (where the disease 
may be traced back to the commencement 
of the century), epidemic cerebro-spinal 
meningitis became prevalent about the 
same time that it exhibited great activity 
in Europe. From 1842 to 1850 inclusive, 
a series of outbreaks took place in the 
States of Kentucky, Tennessee, South Illi- 
nois, Mississippi, Arkansas, Alabama, 
Pennsylvania, Massachusetts, New York, 
and North Carolina. After this period 
there would appear to have been an inter- 
val of comparative inactivity. In 1861 the 
disease broke out in North and Central 
Missouri, and from that time to the pre- 
sent it has prevailed, more or less exten- 
sively, in almost all, if not all, the States 
of the Union, with the exception, perhaps, 
of the Pacific States. In 1862 outbreaks 
were recorded in Connecticut, Kentucky, 
Indiana, and Tennessee; in 1863, in 
Rhode Island; in 1864, in Pennsylvania, 
Ohio, Illinois, New York, Maryland, 
Massachusetts, and Vermont; and in 
1865, in North Carolina and other Southern 
States. During 1867 and 1868 the disease 
was active in several States. 
It must be borne in mind that these 
historical notes very imperfectly represent 
the probable prevalence and geographical 
distribution of the disease. They simply 
include a brief summary of outbreaks 
which have come under the notice of 
thoughtful observers who have published 
their observations. The history of the 
malady in the British Islands is, perhaps, 
less liable to error from this source. The 
earliest recorded outbreak of the disease 
occurred in Ireland during the early 
months of 1846. It broke out to a very 
limited extent among the boys living in 
the Rathdown Union, South Dublin, and 
Belfast workhouses ; and two cases, both 
in females, one aged 17 years, the other 
36 years, were admitted into the Hard- 
wicke Hospital, Dublin.1 Prior to this 
outbreak, there is not any trustworthy 
history of the presence of epidemic cerebro- 
spinal meningitis in the British Islands. 
It is not improbable, however, that the 
disease existed at Blackaton, in Devon- 
shire, in 1807 ;2 and at Sunderland in 
1830.3 Dr. Benjamin W. Richardson 
saw, he believes, a case at Mortlake, 
Surrey, in 1843.4 From the time of the 
outbreak in 1846, cases of a similar 
malady were occasionally observed in 
Dublin, until the latter half of 1850, when 
they became more common.5 There is no 
further notice of epidemic cerebro-spinal 
meningitis in Ireland until the year 1865, 
when cases began to be again observed in 
Dublin.6 A case of cerebro-spinal menin- 
gitis was observed by Dr. Samuel Wilks, 
in each of the three years 1856, 1858, 
1859, in the metropolis.7 In October 
1859, a fatal case of cere bro-spinal disorder 
with petechial eruption, came under the 
notice of Dr. Henry Day, in the vicinity 
of Stafford. In this case, hypersemia of 
the meninges of the brain and spinal cord, 
and copious effusion of fluid at the base of 
the brain, were discovered after death. 
A similar but more rapidly fatal case was 
also observed by Dr. Day, in the Stafford 
General Infirmary in September, 1865? 
The largest and most fatal outbreak of 
epidemic cerebro-spinal meningitis which 
has occurred within the limits of the 
United Kingdom began in Ireland in 
March 1866, and attained its chief develop- 
ment in the subsequent winter. Its effects 
were almost entirely limited to the sister 
island, and the brunt of the outbreak fell 
upon Dublin. Other localities affected, 
during the first year of prevalence, were 
Tullamore, Parsonstown, Mitchelstown, 
Thurles, Clondalkin, and the Curragh 
camp. Subsequently cases were recorded 
in the counties of Cork, Waterford, Clare, 
Galway, Meath, Down, &c. The cases 
were not very numerous in Dublin ; and 
in the country towns they were compara- 
tively few. It is noteworthy that, as in 
the earlier outbreaks in France, the mili- 
tary in Ireland, in proportion to their 
strength; suffered prominently from the 
disease. In some of the country districts 
1 Dr. Robt. Mayne, Dublin Quarterly Jour- 
nal of Medical Science, 1846, vol. ii. p. 95. 
2 Mr. Henry Gervis, Medico-Chirurgical 
Society's Transactions, vol. ii. 
3 Dr. John Scott, Medical Times and Gazette, 
1865, vol. i. p. 515. 
4 Social Science Review, May 1865, p. 398. 
5 Dr. McDowell, The London Journal of 
Medicine, 1851, vol. iii. p. 858. 
6 Dr. Kennedy, The Medical Press and Cir- 
cular, June 12, 1861, p. 551. 
7 The Lancet, April 15, 1865, p. 389. 
8 Clinical Histories and Commentaries 
1866, pp. 3-7. 308 
EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
cases were recorded among the troops 
alone, or among persons in immediate 
connection with them.1 In January and 
February 1867, an outbreak of a disease 
characterized by severe rigors, tetanic 
convulsions, intense neuralgic pain in the 
head and upper part of the trunk, in- 
creased sensitiveness of the surface, obsti- 
nate vomiting, restlessness, and, in one 
instance at least, by a dark purple erup- 
tion, but of which not a single case died, 
took place at Bardney, in Lincolnshire, a 
village about ten miles east of Lincoln, on 
the verge of a fen country, and having a 
population of 1500, the bulk of whom are 
engaged in agricultural pursuits.2 Two 
cases of epidemic cerebro-spinal meningi- 
tis were recorded in London in the sum- 
mer of 1867. One, a case of the fulminant 
form of the malady, in which death 
occurred in twenty-seven hours, took place 
in June ;3 the other, a case of the purpuric 
form, in which death occurred in seven 
days, took place in June.4 Since the at- 
tention of English practitioners has been 
more fully directed to epidemic cerebro- 
spinal meningitis by the late outbreak in 
Ireland, so-called sporadic instances of the 
disease have been noted in various parts 
of the kingdom, under circumstances 
which lead to the surmise that the malady 
is not so rare among the population as 
had previously been supposed. 
The peculiarity of distribution of the 
disease in the British Islands, its epi- 
demic manifestations being limited to one 
portion of the kingdom, and chiefly, even 
in recurrent outbreaks, to a small section 
of the population of that portion, is not an 
isolated phenomenon. Notwithstanding 
the wide geographical prevalence of the 
malady as shown by the foregoing details, 
it must not be concluded that this preva- 
lence represents a general diffusion of the 
disease among the different populations 
during the periods of its activity. The 
outbreaks of epidemic cebro-spinal men- 
ingitis, as a rule, are limited to small sec- 
tions of a population, and its distribution 
is by a series of isolated outbreaks, rather 
than by extensive spreading. This was 
shown remarkably, as already described, 
during the outbreak in France in 1837 
and following years, when the ravages of 
the malady were principally confined to 
certain garrisons, and even to small sec- 
tions of a garrison, without affecting the 
surrounding population. A like limita- 
tion of the disease to certain detachments 
of troops was observed during the recent 
war in the United States; and the re- 
striction of the malady to small portions 
of workhouse populations, as in the first 
outbreak in Ireland, is an analogous phe- 
nomenon. Perhaps the sole outbreak in 
which an extensive diffusion of the dis- 
ease among a community has occurred 
was that in the province of Dantzic, in 
1864-65. The tendency to reproduction 
in a locality, as in Dublin, was particu- 
larly observed during the great outbreak 
in France from 1838 to 1848, when the 
disease reappeared again and again among 
the forces in Bayonne, Versailles, and 
Avignon, notwithstanding changes of gar- 
rison. The freedom of England and Scot- 
land from epidemic outbreaks of so widely 
spread a malady is very remarkable ; par- 
ticularly if the seeming occasional cases 
of the disease to which reference has been 
made are to be regarded as true examples. 
Etiology.-(a) Predisposing Causes.- 
Age. The personal liability to the dis- 
ease is not governed in any definite man- 
ner by age. In some epidemics children, 
in others young people, in others again 
adults of from thirty to fifty years, have 
suffered in greatest proportion. - Sex. 
Generally, and in some outbreaks very 
markedly, males are more liable to the 
disease than females.-Profession. Dur- 
ing the outbreaks of the disease in France 
from 1837 to 1849, a peculiar proclivity to 
the disease was observed among soldiers. 
But in subsequent outbreaks in France, 
and wide-spread outbreaks elsewhere, no 
special liability to the disease was mani- 
fested among any vocation.-Climate and 
Seasons. In the Eastern hemisphere our 
knowledge of the disease is limited to 
Western and Central Europe and Alge- 
ria, the northern boundary of the district 
not passing beyond lat. 61° N., the south- 
ern not beyond lat. 35° S.-the one ex- 
treme closely approaching the arctic, the 
other the torrid zone. In the Western 
hemisphere the records of the malady are 
confined to the populous districts of the 
eastern division of the United States, 
from lat. 30° N. to lat. 48° N. It is note- 
worthy that the northern and southern 
limits of distribution in both hemispheres 
but slightly overlap the isothermal lines 
5° and 20°. Season acts as an unques- 
tionable and powerful predisposing cause 
of epidemic cerebro-spinal meningitis, 
which is especially a disease of the cola 
months. Of 216 local outbreaks in France 
and the United States, 166 prevailed be- 
tween December 1st and May 31st; 50 in 
the other six months of the year. In 
Sweden, of 417 local outbreaks, 311 took 
1 Dr. E. D. Mapother, and Staff-surgeon 
Dr. Jeffrey A. Marston, The Lancet, July 6, 
and July 13, 1867 ; also Transactions of the 
Epidemiological Society, vol. iii. p. 118, and 
p. 129. 
2 G. M. Lowe, M.B., The Lancet, June 26, 
1867, p. 790 ; Mr. Geo. Newnham Woolley, 
The Lancet, Aug. 3, 1867, p. 130. 
3 Dr. Edward Crisp, The Lancet, June 22, 
1867, p. 773. 
4 Dr. Thomas Clark, The Lancet, July 13, 
1867. ETIOLOGY. 
309 
place in the former period of the year, 
106 in the latter (Stille). During the re- 
cent outbreak in Ireland, the brunt of the 
disease fell between January and July, 
1867. Of 85 outbreaks in various parts of 
Europe and the United States, noted by 
Hirsch, 33 prevailed in winter, 24 in winter 
and spring, 11 in spring, 1 in spring and 
summer, 2 in summer, 1 in summer and 
autumn, 1 in autumn, 1 in autumn and 
winter, 3 in autumn, winter, and spring, 
and 6 prevailed throughout the whole 
year.-Locality and soil do not, so far as 
yet ascertained, exercise any manifest in- 
fluence over the disease. It has been 
observed indifferently on low grounds, on 
highlands, and on soils of the most vari- 
ous character.-Sanitary conditions. No 
definite relation exists between the occur- 
rence of the disease and the sanitary state 
of habitations or of individuals. It has 
prevailed in some epidemics alike among 
the affluent and the impoverished-among 
those who are well-fed, well-housed, and 
well-clothed, as among those who are ill- 
fed, ill-housed, and insufficiently clothed. 
In certain outbreaks, as in that on the 
Lower Vistula, the prosperous classes suf- 
fered to a much less extent from the ma- 
lady than the poor and miserable, who 
were subjected to privation and to much 
foulness of persons, dwellings, and atmos- 
phere. 
(6) Exciting Causes.-Fatigue has been 
mentioned as an exciting cause. In some 
of the early outbreaks of the disease 
among French troops, France being at 
war at the time, fatigue apparently exer- 
cised a determining influence. Again, 
during the recent outbreak in Ireland, the 
malady appeared very early among a 
"flying column" of troops occupied in the 
suppression of the Fenian disturbance, 
and exposed to great fatigue and in- 
clemency of weather. But fatigue has 
played little or no part in determining the 
disease among the civil population, espe- 
cially among children and the inmates of 
workhouses and prisons. - Cold. The 
marked predominance of the disease in 
the winter and spring months has sug- 
gested a causal connection with cold. 
Hirsch has submitted the question to a 
detailed examination, and with this result: 
that, although we cannot exclude the sus- 
picion that the temperature of winter and 
spring may have some direct effect upon 
the genesis of the disease, "the modifica- 
tions in the mode of living incidental to 
these seasons exert, in a far higher degree, 
an influence favorable to the presence of 
this as of many other infectious maladies. 
-Certain Insanitary States. There is not 
any constant or even common relationship 
between any insanitary state and the ap- 
pearance of the disease. Neither foulness 
of house and its surroundings, nor of the 
atmosphere, whether from putrid emana- 
tions or from overcrowding, nor impurity 
of any other kind, has any determinate 
relation with epidemic cerebro - spinal 
meningitis. But Hirsch remarks' of the 
outbreak in the province of Dantzic in 
1865, that "the disease prevailed exactly 
in that season of the year in which, on ac- 
count of inclement weather, many indi- 
viduals were crowded together into small 
and dirty rooms kept constantly closed by 
their occupants, and from which all venti- 
lation was excluded, and in which the 
before - mentioned unfavorable hygienic 
conditions (dampness, great filth, and an 
atmosphere loaded with putrid emana- 
tions) were extremely perceptible." The 
causes here suggested have been held to 
be not altogether inoperative in other and 
more circumscribed outbreaks.-Commu- 
nication of the sick with the well. The great 
majority of observers have come to the 
conclusion that the disease is incommuni- 
cable from the sick to the well. Among 
the minority who hesitate to accept this 
deduction without reservation are Profes- 
sor Hirsch, Professor Stokes, and Mr. J. 
Simon. The facts which suggest the pos- 
sibility of the active cause of the disease 
being portable in some way are of the fol- 
lowing character:-(a) A child was seized 
with epidemic cerebro-spinal meningitis, 
and died. A second child of the same 
family was attacked with the malady a 
few days later. The day following the 
attack of this child, the mother, who slept 
in the same bed with it, sickened of the 
disease.2 (b) 1. On the 8th of February, 
1865, a youth, aged 20 years, was attacked 
with the characteristic symptoms of epi- 
demic cerebro-spinal meningitis. He was 
nursed by a woman from another village. 
The youth died, and after his death the 
woman returned home. She soon sick- 
ened, and she died of the epidemic disease 
on the 26th February. There had been 
but one case previously in the village. To 
the interment of the woman came a family 
from another locality, the funeral obse- 
quies, as customary in the district, being 
performed with the coffin opened. After 
the return home of this family, a child, 
three months old, sickened immediately 
of meningitis and died within twenty-four 
hours. Then a man who had accompanied 
the family to the interment was attacked 
with the disease, and died on the 2d of 
March. Lastly, a girl, in the same local- 
ity, who had also been at the funeral, was 
seized, and died on the 7th March. 2. At 
another village, two children of one family, 
aged three and a half and one and a half 
1 Transactions of the Epidemiological So- 
ciety, vol. ii. p. 369. 
1 Ibid. vol. ii. p. 372. 
2 Professor Stokes, The Medical Press and 
Circular, June 19, 1867, p. 581. 310 
EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
years respectively, died of the epidemic, 
one on the 27th January, the other on the 
7th February. The clothes of the de- 
ceased were taken to a neighboring vil- 
lage, and came into the possession of a 
girl aged five years. She soon sickened of 
the epidemic, and died on the 14th Feb- 
ruary.1 (c) Boudin relates instances of 
the appearance of the disease in garrisons, 
and among the civil population of towns, 
after the introduction of detachments of 
troops among whom the disease had pre- 
vailed or was prevailing at the time. 
[The occurrence of this affection in gar- 
risons has been too frequent to be other- 
wise than important. During the civil 
war in the United States, many cases oc- 
curred amongst soldiers in camp, and at 
their homes in Northern cities upon their 
return from service. Two cases at least 
occurred in Philadelphia, the origination 
of which coincided with exposure to the 
effluvia from filthy clothing of returned pri- 
vate soldiers. But this is, most probably, 
evidence of the existence of a peculiar 
morbid poison generated by slow organic 
decay; not at all necessarily giving proof 
of somatic contagion. The idea of the 
personal communicability of cerebro-spi- 
nal fever has met with no support in the 
general experience of American practi- 
tioners.-II.] 
The foregoing facts simply suggest the 
possibility of the active cause of epidemic 
cerebro-spinal meningitis being communi- 
cable by the sick to the well. This possi- 
bility, notwithstanding the apparent for- 
midable array of facts to the contrary, 
is not to be lightly dealt with. The lesson 
taught by the difficulties and doubts which 
beset the discovery of the communicability 
of typhoid fever and cholera, will have 
been strangely misunderstood if it is ne- 
cessary to urge upon observers, the im- 
portance of keeping the question of the 
possible communicability of epidemic cere- 
bro-spinal meningitis constantly before 
the mind. In the consideration of this 
question, however, a caution is needed. 
The term "contagion" is used too indis- 
criminately. It has been so long employed 
to express the manner of transmission of 
disease which is witnessed in smallpox, 
scarlet fever, or typhus, that it is difficult 
to dissociate the idea of this manner from 
the word. It is almost impossible, in 
reading the opinions of those writers who 
have come to the conclusion that epidemic 
cerebro-spinal meningitis is not a "conta- 
gious" disease, to avoid the suspicion, 
from their use of the adjective, that they 
have looked upon the question too exclu- 
sively from the point of view suggested 
by the diseases named. It is obvious that 
contagiousness of a like character to that 
of smallpox, scarlet fever, or typhus, is 
not possessed by the malady under con- 
sideration. The question is : Does epi- 
demic meningitis, like typhoid fever or 
cholera, possess a peculiar contagiousness 
of its own, a property of communicability 
peculiar to itself? This has yet to be 
solved. Another explanation of the facts 
which appear to indicate a possible com- 
municability of the disease from the sick 
to the well is, however, open, and is set 
forth in the next paragraph. 
Diseased grain.-Dr. B. W. Richardson 
has suggested that epidemic cerebro-spi- 
nal meningitis may possibly arise from the 
consumption of diseased grain after the 
manner of ergotism, and perhaps acro- 
dynia. Ue thinks that the probabilities 
are altogether in favor of the suggestion, 
that " the cause in fact is a diseased grain, 
or fungus, contained in some kinds of 
Hour out of which the breadstuff's are made. 
This fungus may not be present in large 
quantities, and many persons may eat of 
the food without getting a poisonous part; 
but one will get it out of a number, and 
this without any communication beyond 
the breaking of bread together: the dis- 
ease may occur in one member of a fam- 
ily, leaving the rest free, and in this irreg- 
ular way it may be distributed, in an epi- 
demic form, over a large surface of coun- 
try." He adds, "If my hypothesis, as 
regards cause, be correct, there is little 
danger of the disorder extending widely 
in this country ; for of our cereals used as 
food, nearly the whole of the population 
now select w'heat, and our wheat gener- 
ally is selected for the market w ith great 
judgment and circumspection. Any cases, 
therefore, that might occur wrould be iso- 
lated, and w ould be easily traced out and 
prevented."1 This suggestion opens out 
an altogether new field of inquiry respect- 
ing the origin of the disease, and it de- 
mands active and thoughtful considera- 
tion in subsequent outbreaks. Dr. H. 
Day, of Stafford, has endeavored, by ex- 
periments on the lower animals, to obtain 
some light on the subject. He fed three 
rabbits with unsound grain (wheat, oats, 
ergot of rye, and mouldy bread) with this 
result: In all the animals a spasmodic 
affection was produced, and in two in- 
flammatory changes in the right eye, pro- 
ceeding in one case to ulceration of the 
cornea, and evacuation of the contents of 
the globe. One of the rabbits died on the 
eighth day, the other tw'o were killed on 
the twelfth day, and in all more or less 
congestion of the membranes of the spinal 
cord was found on dissection.2 
The sum of our knowledge of the etiology 
of epidemic cerebro-spinal meningitis is 
1 Social Science Review, May, 1865, p. 403. 
2 Clinical Histories and Comments, pp. 18 
-23. 
1 Hirsch, Transactions of Epidemiological 
Society, vol. ii. p. 373. NATURE. 
311 
this-that the clue to its explanation has 
not as yet been discovered. 
Nature.-1. Is the disease malarious, 
as suggested by some writers? The out- 
breaks in which the disease has occurred 
in malarious districts, or in which the 
malady has shown an intermittent charac- 
ter, are too few in number to admit of 
much, if any, doubt resting upon the an- 
swer. There is no sufficient ground for 
believing that the malady is of malarious 
origin. The numerous examples pf prev- 
alence of the disease in localities free from 
malaria set the question aside definitely. 
Even when intermissions or remissions 
have been observed in the progress of the 
malady, it must not be hastily assumed 
that they are consequent upon malarious 
poisoning. Hirsch has shown that cer- 
tain cases of epidemic cerebro-spinal men- 
ingitis, distinguished by intermissions and 
remissions, which came under his own ob- 
servation, took place in the course of an 
outbreak in a district free from malaria. 
Further, he states that this outbreak pre- 
vailed at a season (winter) and in a state 
of climate (intense cold) which notoriously 
exclude the prevalence of malarious dis- 
ease, even where endemic ; that the period 
of life (1-5 years) least liable to malarious 
disease furnished the largest contingent 
of victims, while the classes most ad- 
vanced in life, and who are most liable, 
escaped the epidemic in a remarkable 
decree. Finally, the infallible test of ma- 
larious disease, quinine, by its inutility 
in cases of the epidemic which assumed 
an intermittent or remittent character, 
showed the non-malarious nature of the 
affection.1 2. Is epidemic cerebro-spinal 
meningitis a form of, or allied to, typhus? 
Epidemic cerebro-spinal meningitis differs 
from typhus in the aspect of the patient, 
progress of the disease, range and course 
of temperature, form of cerebral affection, 
character of eruption, sequelte, rate of 
mortality, anatomical lesions, and man- 
ner of dissemination. Differing in all 
essential particulars, doubt can only arise 
when the two diseases prevail together. 
Under such circumstances, cases of the 
fulminant and purpuric forms of the one 
malady may be difficult to discriminate 
from the graver and more rapidly fatal 
forms of the other. Doubt also may arise 
when in the course of the former disease 
typhous or typhoid symptoms occur. But 
such a doubt applies equally to the dis- 
crimination of the disease from measles 
and typhoid fever, as from typhus. 3. Is 
epidemic cerebro-spinal meningitis a true or 
a pseudo-epidemic disease? Is this disease 
a true epidemic disease in the sense of its 
being due to a specific febrile poison (to 
which class of diseases the term epidemic is 
now well-nigh alone restricted) ? Or is it a 
pseudo-epidemic malady, as being an ex- 
aggerated and more prevalent form, from 
certain climatic or other conditions, of an 
idiopathic inflammatory affection of the 
brain and spinal cord ? No absolute dis- 
tinction can be drawn between sporadic 
cerebro-spinal meningitis and the epi- 
demic malady of the same name. But 
there are certain broad and well-defined 
differences. The conjoined inflamma- 
tory affection of the covering membranes 
of the brain and spinal cord, which is 
the rule in epidemic cerebro-spinal men- 
ingitis, is a rare exception in sporadic 
inflammation of the envelopes of the cen- 
tral nervous centres. Again, the indica- 
tions of blood-change which are so com- 
mon in the epidemic disease have been 
witnessed only in exceptional cases in the 
sporadic disease. The question arises 
whether the exceptional cases are in- 
stances of idiopathic cerebro-spinal men- 
ingitis or of the epidemic form of the 
malady. This cannot be determined ar- 
bitrarily. It is certain that cases of cere- 
bro-spinal meningitis, indistinguishable 
from the epidemic disease, are observed, 
in the intervals of prevalence of the lat- 
ter, even in this country (II. Day, Wilks, 
&c.). These cases are of much, although 
as yet of indeterminate, interest, in refer- 
ence to the etiology of the malady. It has 
been suggested that the blood-change and 
herpetic and purpuric eruptions may be 
of nervous origin, and consequent upon 
the profound alteration in the nervous 
system.1 It has been suggested, also, that 
the purpuric eruption of epidemic cere- 
bro-spinal meningitis may be one of seve- 
rd signs of a general tendency to purpura 
in disease at the time of prevalence, and 
merely an incidental phenomenon of the 
epidemic malady. Thus in Dublin (1866- 
67), purpura has been observed in rheu- 
matic fever, and there was an outbreak 
of purpura among swine,2 contemporane- 
ously with the epidemic. The first sug- 
gestion touches a very curious question, 
which as yet does not admit of solution. 
But it is worthy of remark that the form of 
eruption which of all others is peculiar to 
epidemic cerebro-spinal meningitis is the 
herpetic-a form which, in some of its 
manifestations at least, as in herpes labi- 
alis, and in shingles, has singular neurotic 
relations. Mr. Jonathan Hutchinson has 
propounded the riddle, Is herpes zoster an 
exanthem or neurosis?0 This is certain, 
that it is a symptom which has some defi- 
nite connection with lesions of nerve 
' Dr. Banks, The Medical Press and Circu- 
lar, June 19, 1867, p. 580. 
2 Dr. Mapother, The Lancet, July 13,1867, 
p. 39. 
3 London Hosp. Reps., vol. iii. p. 70. 
1 Transactions of the Epidemiological So- 
ciety, vol. ii. p. 377. 312 
EPIDEMIC CEREBRO-SPINAL MENINGITIS. 
trunks, if not of nerve centres.' The facts 
upon which the second suggestion is based 
are of interest, but they form too narrow 
a basis for conclusions. 4. Is epidemic 
cerebro-spinal meningitis a disease, sui ge- 
neris ? The association of symptoms shows 
that it is an independent malady; the 
aptitude to blood-changes in the course of 
the disease, judged by analogy with like 
changes which occur in acute specific dis- 
eases, suggests the inference that it also is 
dependent upon a specific poison, from 
whatever source derived. This is the con- 
clusion which appears to have the highest 
degree of probability in the present state 
of our knowledge. 
An intercurrent question arises here- 
Is the fulminant form of epidemic cerebro- 
spinal meningitis really a variety of the 
disease, or a different malady altogether ? 
Dr. R. D. Lyons maintains that during 
the prevalence of the epidemic in Dublin 
in 1866, two independent diseases existed. 
The one, characterized by collapse, pro- 
fuse purpuric eruption, great rapidity of 
course, excessive fatality, and absence of 
anatomical lesion in the nervous centres 
after death, he designates febris nigra; the 
other was the disease commonly known as 
cerebro-spinal meningitis. But it is to be 
remarked that the two varieties of disease 
have never been observed except in the 
same epidemic ; that they pass by insensi- 
ble grades the one into the other ; that the 
most highly developed symptoms of the 
so-called febris niyra sometimes occur to- 
gether with the most marked symptoms 
of cerebro-spinal meningitis ; and that it 
is more consistent with experience to con- 
sider the two series of symptoms as indi- 
cations of one and the same malady, rather 
than two maladies going forward at the 
same time in the same patient. A second 
intercurrent question is, whether the pur- 
puric form of the disease be of scorbutic 
origin ? The question amounts to little 
more than a suggestion. There are no 
facts which support an affirmative an- 
swer; for, apart from other well-known 
signs, purpuric spots are not indications 
of a scorbutic taint. 
Treatment. - Prophylactic. - Igno- 
rance of the true etiology of the disease 
limits our preventive efforts to general 
sanitary measures, applicable to all epi- 
demic diseases, for the purification of 
houses and localities. Mr. J. Simon, re- 
cording the conditions under which the 
disease has prevailed, writes: " I am 
strongly of opinion that the best sanitary 
precaution which in the present state of 
knowledge can be taken against the dis- 
ease, must consist in care for the ventila- 
tion of dwellings." He adds, however, 
" that in some cases, according to local 
reports, the distribution of an epidemic 
has very decidedly not been governed by 
conditions of overcrowding and ill-ventila- 
tion." Dr. B. W. Richardson's sugges- 
tion as to the cause of the disease should 
lead to the careful microscopic examina- 
tion of all breadstuffs and farinaceous 
preparations in use among families and 
communities where the disease breaks 
out, and the disuse of such as maybe of 
doubtful character. 
Curative.-The treatment of epidemic 
cerebro-spinal meningitis is as unsatisfac- 
tory as that of cholera. The evidence of 
the course of the disease having been ben- 
eficially affected in any outbreak by the 
administration of medicine is very doubt- 
ful. The too common rapid progress of 
the malady to death, as in cholera, and 
the nature of the lesions determining 
death, necessarily set at naught efforts to 
check it; medicine not being guilty either 
of inaptitude or inactivity. The control 
of this disease, as of cholera or trichiniasis, 
is a question of preventive rather than 
curative treatment, and must depend 
upon the discovery and limitation of its 
cause. In the earlier outbreaks, epidemic 
cerebro-spinal meningitis was treated, as 
an acute inflammatory affection, by bleed- 
ing and purgatives, with the general re- 
sult that the fatality of the malady was 
probably almost invariably augmented. 
During the outbreak of 1866 in Philadel- 
phia, it was found that, in the more 
sthenic cases, cupping the nape of the 
1 Dr. II. Day (Lancet, vol. i. 18G7, p. 731) 
expresses the opinion that an eruption would, 
probably be more commonly found in cases of 
sporadic cerebro-spinal meningitis if it were 
more carefully looked for; and he remarks 
that the petechial spots which he has ob- 
served in cases coming under his own notice, 
sometimes do not appear until after death. 
My own observations coincide with those of 
Dr. Day. In connection with this subject it 
is well to bear in mind Trousseau's so-called. 
cerebral or meningeal macula (Lectures on Clin- 
ical Medicine, Bazire's Trans., vol. i. p. 459), 
a phenomenon of wider occurrence in diseases 
of the central nervous system than even the 
distinguished professor suspected. I may 
add, that a short time ago I was present at 
the examination of the body of a patient who 
had died from a syphilitic disease of the right 
hemisphere of the brain. I was particularly 
struck with a peculiarity in the after-death 
lividity which seemed to me not uninstruc- 
tive with regard to the purpuric forms of 
cerebro-spinal fever. Life had been extinct 
eighteen hours. The greater part of the de- 
pending portions of the body was ecchymotic ; 
but, in addition, many livid, circular spots, 
of about the size of a split pea, a few of larger 
size, were scattered over the upper aspect 
(dorsal) of the feet, and of the legs beneath 
the knees ; also, over the upper aspect (dor- 
sal) of the hands, and of the arms beneath 
the elbow. These spots, had they been ob- 
served in a case of cerebro-spinal meningitis, 
would have been designated "purpuric." TREATMENT. 
313 
neck was "of essential service in mitigat- 
ing, and generally, indeed, in wholly re- 
moving the neuralgic pains which form so 
prominent and so severe a symptom in 
many cases of the disease" (Stille). When 
the state of the patient forbade the ab- 
straction of blood, dry cupping used in the 
same locality afforded signal relief, and 
rendered the effects of vesication more 
prompt and complete. This was the ex- 
perience in one of the least fatal outbreaks 
recorded. The experience of the majority 
of epidemics has been against any blood- 
letting, local or general. The deduction 
to be derived as to depletion from the gen- 
eral state of the circulation, entirely coin- 
cides with the results of practice. For, 
as a rule, the pulse from the very outset 
contraindicates the withdrawal of blood ; 
and, if in any case it should seem from the 
general symptoms that depletion might 
exercise some control over the central 
mischief, a thoughtful regard should be 
given to the future. The application of 
cold to the head and spine, either by 
means of ice or a freezing mixture, in 
Esmarch's india-rubber bags, is not open 
to the same objection as blood-letting, and 
has furnished by far the most satisfactory 
results of all direct treatment of the acute 
cerebro-spinal symptoms In its use care 
should be taken not to prolong the appli- 
cation so as to depress, or increase the 
depression already existing of, the whole 
system. When the acute nervous symp- 
toms are accompanied by marked prostra- 
tion, it is advisable during the application 
of the ice to swathe the limbs in hot flan- 
nels, to pack the legs and thighs with 
hot-water bottles, or bags filled with hot 
sand or salt, and to cover the abdomen 
with thick layers of flannel or cotton-wool. 
From the very outset of the disease, care 
should be taken to economize the tempe- 
rature of the body, and anticipate its fall; 
and in cases characterized by collapse, or 
much vital depression, the application of 
external heat in the manner just suggested 
is a cardinal point of treatment. Of med- 
icaments directly addressed to the nervous 
symptoms, opium is the most valuable. 
It is especially indicated when there is 
much restlessness, acute delirium, sleep- 
lessness, hypersesthesia, or painful spasm. 
Morphia is the best form of administra- 
tion, and subcutaneous injection perhaps 
the best mode. The drug should be given 
in decided and frequently-repeated doses, 
and carefully watched. Stille says of its 
use during the late outbreak in Philadel- 
phia : " We were in the habit of giving 
one grain of opium every hour, in very 
severe, and every two hours in moderately 
severe cases, and in no instance was pro- 
duced either narcotism or even an ap- 
proach to that condition. Under the 
influence of the medicine the pain and 
spasm subsided, the skin grew warmer, 
and the pulse fuller, and the entire condi- 
tion of the patient more hopeful. It 
seemed probable, however, that the full 
benefit of the opium treatment could be 
received by those only who were subjected 
to it in the early stages of the attack. 
Direct experience is here in perfect accord 
with the expectation which a knowledge 
of the pathological processes involved in 
the disease would naturally suggest." 
A Committee of the American Medical 
Association has reported favorably of the 
sulphate of quinta in large doses, given at 
the very beginning of the disease. In 
some instances the drug seemed to abort 
the attack. The committee speaks also 
of favorable results reported from the 
combined use of ergot and chloride of iron. 
[Dr. Joseph Klapp, of Philadelphia, as- 
serts the recovery of a number of cases, 
some of them of a very threatening cha- 
racter, under the early and free use of 
tincture of chloride of iron; 20 to 25 
drops every two or three hours.- II.] 
Some American physicians have given 
ergot in combination with belladonna and 
belladonna in combination with quinine, 
but with equivocal benefit. Mercurials 
have been freely used, particularly in the 
form of calomel, but their effect has been 
most questionable, except as purgatives. 
Their indiscriminate use is to be utterly 
condemned, and their use at all to be dis- 
countenanced. A host of other medica- 
ments have been made use of, of which it is 
requisite to note only iodide of potassium, 
bromide of potassium, and arsenite of pot- 
ash. The circumstances under which the 
two former drugs have been used, and are 
most likely to prove beneficial, will sug- 
gest themselves to the practitioner. It 
does not appear that any decided good has 
arisen from their administration. In pro- 
tracted cases of convalescence the arsenite 
of potash may prove a valuable remedy. 
Of the general treatment of the patient 
the hot bath (102°-106°) is, when prac- 
ticable, the most important feature. The 
Committee of the American Medical As- 
sociation recommend, when the surface is 
cold, friction with hot, coarse towels, or 
even with warm oil of turpentine, after 
the bath. The regimen should be gene- 
rous and nutritious from the beginning of 
the disease. In the acute stages soup of 
some kind or other, or milk, is needed ; 
and as soon as appetite returns, solid 
viands of any digestible character must 
be given. In the graver cases, when 
there is much restlessness and spasm or 
stupor, and food cannot be given by the 
mouth from the patient's refusal or in- 
ability to swallow, an attempt should be 
made to administer it by the rectum : 
when there is much thirst, the patient's 
fierce desire for drinks may be freely in- 
dulged. The state of the pulse is the 
principal guide to the use of stimulants. 314 
THE PLAGUE. 
Their administration as a special remedy 
independently of the indications which 
generally govern their use has not been 
followed by good results ; but they are 
called for when the condition of the pulse 
and the aspect of the patient show mani- 
fest flagging of vital power. The sequelae 
of the disease must be traced ok. ordinary 
principles. 
Too frequently the state of the patient 
as to delirium, spasm, and irritability of 
the stomach limits the use of medicine to 
subcutaneous injections, prevents the pro- 
per administration of food, and restricts 
even the application of external mea- 
sures. To this unhappy combination of 
unfortunate and uncontrollable conditions 
the inefficiency of treatment may partly 
be attributed. 
Bibliography. - In addition to the 
references in the text may be noted : The 
Eighth Report of the Medical Officer of 
the Privy Council, containing Mr. J. 
Simon's Memorandum on the Disease, and 
Dr. J. Burdon Sanderson's Report on the 
Epidemics prevailing about the Lower 
Vistula in the beginning of 1865.-Dis- 
cussion in the Medical Society of the Col- 
lege of Physicians of Ireland ; The Medi- 
cal Press and Circular for May 29th, June 
5th, 12th, and 19th, 1867.-Transactions 
of the American Medical Association, vol. 
xiii. 1866, containing a Report of a Coin- 
mittee on the Disease.-Dr. W. H. H. 
Githen's Notes of 98 cases ; The Ameri- 
can Journal of the Medical Sciences, July, 
1867.-Dr. S. Gordon ; Dublin Quarterly 
Journal of Medical Science, May, 1867. 
-Dr. C. Murchison ; The Lancet, 1865, 
vol. i. p. 41.-Prof. A. Hirsch, Handbuch 
der historisch-geographischen Pathologic, 
1866, vol. i. p. 163 : Die Meningitis Cere- 
bro-spinalis Epidemica vom historisch- 
geographischen und pathologisch-thera- 
peutischen Standpunkte, 1866.-Dr. Stille, 
Epidemic Meningitis or Cerebro-spinal 
Meningitis, 8vo., 1867, Philadelphia. This 
work contains a very copious bibliogra- 
phy, particularly valuable for its refer- 
ences to American monographs. - G. 
Tourdes, Histoire de 1'Epidemie de Men- 
ingite Cerebro-Spinale observee a Stras- 
bourg en 1840 et 1841. Paris, 1842.-J. 
Ch. M. Boudin, Traite de Geographic et 
Statistique Medicales et des Maladies de 
Endemiques, vol. ii. p. 564 ; Paris, 1857.- 
Dr. Sandford B. Hunt, on Cerebro-spinal 
Meningitis (Contributions relating to the 
Causation and Prevention of Diseases, 
and to Camp Diseases. Edited by Austin 
Flint, M.D., for the United States Sani- 
tary Commission. Ch. xi.).-Dr. Ed. W. 
Collins, Report upon Epidemic Cerebro- 
spinal Fever (Dublin Quarterly Journal 
of Medical Science, August, 1868).-Con- 
sult Hirsch's monograph and great work, 
to which reference has been made already. 
THE PLAGUE. 
By Gavin Milroy, M.D. 
Definition.-The Plague may be 
briefly defined to be a fever, usually of an 
adynamic type, accompanied with bubos, 
carbuncles, and petechiee. 
Synonyms.-This is the of Hip- 
pocrates and Galen ; the Pestilentia of 
Celsus and other Roman writers ; the Pes- 
tis ; Typhus pestilentialis ; Typhus gra- 
vissimus ; Typhus bubonicus, &c., of many 
nosologists. It is the Pebris Adeno-ner- 
vosa of Pinel, and the Peste Orientale, 
Typhus d'Orient, of other French au- 
thors ; the Black Death, Levant Plague, 
Pestilential Fever, of English writers. 
Dr. Copland terms it the Septic or Gland- 
ular Pestilence. 
Symptoms.-The bubos may be in the 
groins, axillse, or the neck ; occasionally, 
but very rarely, the popliteal glands have 
been affected. The carbuncles are gen- 
erally on the upper or lower extremities 
-most frequently on the legs, but some- 
times on the chest, back, or cheek. Their 
number may be from one or two to a 
dozen or more, and they vary much in 
size and in the tendency to become gan- 
grenous. The petechise and vibices may 
be scattered over every part of the body. 
The pyrexial symptoms of the Plague dif- 
fer in no respect from those in other 
forms of pernicious or malignant fever. 
There are the usual prodromal phenom- 
ena of lassitude, rigors, nausea, headache, 
and vertigo; oppression about the pne- 
cordia, anxiety and restlessness, with a 
heavy stupid expression of countenance, 
and a muddy or suffused state of the eyes. 
Then follow heat of the skin and great DIAGNOSIS. 
315 
thirst, frequent vomiting, a coated tongue 
and fetid breath, a rapid, weak, or irregular 
pulse, prostration with, perhaps, tendency 
to syncope, in some cases high excitement 
and delirium, and in other cases heavi- 
ness and stupor. The bowels are more 
frequently relaxed than constipated, and 
the stools are generally dark and very 
offensive. The matters vomited are 
sometimes nearly black; and the urine, 
which is often very scanty, and in bad 
cases almost suppressed, is occasionally 
sanguinolent. Hemorrhage from the 
mouth, stomach, and bowels, or from the 
respiratory passages, is not an unfrequent 
accompaniment. In some cases the in- 
tellect remains unclouded to the last, 
while in others the patient dies convulsed 
or comatose. 
To describe at length the different va- 
rieties of the Plague, which have been 
enumerated by authors, would be very 
unprofitable, and only serve to obscure a 
subject which has often been made unne- 
cessarily intricate by extreme verbiage in 
the attempt at over-subtle distinctions. 
The fever may vary from a simple syno- 
chus, or even an urgent synocha with 
violent delirium, &c., to typhus of a pu- 
trid type, with rapid sinking and speedy 
death. The three forms or varieties of 
some recent writers appear to be merely 
three degrees of malignancy, according 
to the intensity or virulence of the febrific 
poison, the constitution and condition of 
the patient, the sanitary state of the lo- 
cality attacked, and the general sickliness 
of the season. In an epidemic outbreak 
the fever is usually much more malignant 
and deadly at first than at a later period 
of the invasion, its intractability and fa- 
tality very sensibly abating after a period. 
Sydenham tells us that, "in the infancy 
of the Plague (in 1665), scarce a day 
passed but some of those who were at- 
tacked died suddenly in the streets, with- 
out having had any previous sickness; 
the purple spots, which denoted imme- 
diate death, coming out all over the body; 
whereas after it had continued for some 
time, it destroyed none unless a fever and 
other symptoms had preceded. ' ' It seems 
not improbable that panic has often had 
a good deal to do with the very rapidly- 
fatal cases to which the name of ' Pcste 
foudroyante' has been given by French 
writers. Clot-Bey, in his account of the 
Plague in Egypt, says that the worst 
cases usually proved fatal on the second 
or third day, the cases next in point of 
severity on the fifth or sixth day, and 
that in the milder cases death did not 
generally occur till the second or third 
week after the first setting in of the symp- 
toms.1 
During an epidemic, many persons 
have often been affected with glandular 
pains and swellings, and occasionally also 
with carbuncles, but with so little febrile 
disturbance that they have been able to 
follow their occupations, and have speed- 
ily got quite well under very simple treat- 
ment. Such cases have often been the 
occasion of no little controversy as to 
whether the persons should be considered 
as infected with the Plague, and there- 
fore liable to an enforced segregation un- 
der the old system of quarantine police. 
In connection with this point, it may be 
noticed that in Egypt and some other 
countries, where the Plague used to be a 
frequent visitant, glandular swellings and 
carbuncular disease are extremely com- 
mon affections in most seasons. 
Diagnosis.-If the presence of bubos, 
carbuncles, and petechiie were an invaria- 
ble and necessary feature of the Plague, 
and of no other febrile disease, there 
would, of course, be no greater difficulty 
in discriminating it than there is in dis- 
criminating smallpox or measles from 
other pyrexise. But such is far from be- 
ing the case. Fevers have repeatedly 
been alleged in certain countries, and at 
certain epochs, to be cases of the Plague, 
although they were at the time unattended 
with these external phenomena ; and, on 
the other hand, fevers accompanied with 
these symptoms, occurring in other coun- 
tries and at other epochs, have as fre- 
quently not been designated or considered 
cases of the true pest. Diemerbroeck, 
who saw much of the Plague in Holland, 
during the early part of the seventeenth 
century, distinctly states that there is no 
one characteristic or pathognomonic symp- 
tom of the Plague; and the remark of 
Heberden, that, "on first breaking out, 
the disease has never been known to be 
the Plague," strictly accords with the 
observation of all the most experienced 
writers of the present century, as well as 
of former times. It is well known that 
in Constantinople, or in Cairo, no physi- 
cian ever ventured to say what was the 
true nature of a prevailing fever, however 
fatal it might be, or would give it the 
name of the Plague, until a case occurred 
in which a distinct bubo or carbuncle was 
seen. This hesitation was mainly due to 
the universal unwillingness to admit the 
presence of a disease, the bare mention of 
whose name carried with it such dire con- 
sequences to the freedom of personal and 
commercial intercourse; and the result 
was, that the pestilence had generally 
existed among a community for a consid- 
erable time before any prophylactic or 
precautionary measures were adopted. 
That glandular swellings, and occasion- 
ally also carbuncles, may be present in 
other forms of pernicious fever, malarial 
1 De la Peste observee en Egypte. Paris, 
1840. 316 
THE PLAGUE. 
or not, besides the Plague, has been fre- 
quently noticed by writers of different 
countries. For example, the endemic 
fevers of the Danubian Principalities, 
which were so terribly destructive to the 
Russian armies in the campaign against 
the Turks in 1828-29, as on all former 
occasions, and which were called some- 
times putrid typhus, and at other times 
pernicious intermittent, are described as 
being often accompanied with bubos, car- 
buncles, and purple blotches on the skin. 
Their greatest malignancy was in the 
months of August and September. In 
the earlier part of the year dysentery, 
with ordinary intermittents and remit- 
tents, were very common and fatal; the 
latter insensibly lapsed into the pestoid 
fever. The worst cases were evidently 
undistinguishable from the Plague; but 
the authorities studiously avoided all 
mention of the word, from dread of the 
panic among the troops that would have 
inevitably ensued. 
In the fever known as the "Pali 
Plague" in India, to which reference will 
be subsequently made, the symptoms 
were often closely akin to, if not identical 
with, the pestilence of the Levant, &c. ; 
and the same has been the case in some 
other pernicious fevers, both in India and 
in other tropical countries. In the en- 
demic typhoid fevers of Syria petechise 
and enlargement of the parotid glands 
have been noticed as being frequently 
present, so that it has been difficult at 
times to distinguish them from the true 
pestilence; and it is well known that 
glandular swellings, and even carbuncles, 
not unfrequently occur in the typhus of 
our own country. Some striking instances 
are on record of a fever directly produced 
by the inhalation of putrescent animal 
effluvia, exhibiting all the characteristic 
phenomena of the Plague. In the Medi- 
co-Chi rurgical Review for January, 1825, 
is related a case of this sort, which oc- 
curred to four sailors at Whampoa, who 
had gone on shore to bury the body of a 
comrade, who had died of dysentery. On 
digging the grave, they accidently opened 
a coffin which contained a putrid corpse. 
Two of the men were immediately struck 
down with the horrible stench, and soon 
afterwards were attacked with fever, ac- 
companied with petechia? over the breast 
and arms; in one of the patients a bubo 
formed in the right groin and axilla. 
Both men died-one on the fourth, the 
other on the fifth day. On dissection, 
most of the inguinal and axillary glands 
were found enlarged and hardened ; sev- 
eral of them, when cut into, contained 
matter. Another man of the party did 
not sicken with fever until the eighth day 
after exposure ; but for two or three days 
previously one of the inguinal glands had 
been swollen and painful. The symptoms 
were serious for a few days, but eventually 
the patient recovered. The fourth man 
was but slightly indisposed. 
To make use of so uncertain and varia- 
ble an attribute as the contagiousness, or 
the degree of contagiousness, of an exist- 
ing fever, as a diagnostic mark of the 
Plague-as some nosologists and other 
medical writers have done-is obviously 
illogical, and must inevitably serve to 
mislead. In the case of the malignant 
Danubian fevers, several of the Russian 
medical officers denied their pestilential 
character, on the sole ground that no dis- 
tinct proofs of "contagion par attouche- 
ment" had been observed ; while they ad- 
mitted that all the symptomatic charac- 
ters of the true Plague were present. 
Many similar instances might be cited 
where this fallacious test has been trusted 
to. Indeed, most of the absurd errors in 
the history of the disease during the pre- 
sent and last century may be traced to 
this very source. 
Morbid Anatomy.-The necroscopic 
appearances observed by Bulard,1 Clot- 
Bey, and other French and Italian physi- 
cians in Egypt, were in most respects the 
same as have been noticed in the bodies of 
patients who have died from malignant 
congestive fevers, continued or remittent, 
in other countries, tropical and temperate. 
The viscera and their investing mem- 
branes, whether of the head, chest, or 
abdomen, exhibited marks of great ve- 
nous injection, and there was usually 
more or less serous effusion into the cere- 
bral ventricles, and the cavities of the 
pleura and peritoneum. All the paren- 
chymatous viscera were loaded with fluid 
dark blood, and were generally much 
more lax and softened in texture than in 
health ; the spleen in an especial degree. 
On the peritoneal covering of these organs, 
and also of the stomach and intestines, 
patches of ecchymosis and petechial spots 
were frequently met with. The mucous 
surface of the gastro-intestinal canal fre- 
quently exhibited the same appearance ; 
and the stomach often contained a quan- 
tity of dirty viscid fluid, like a mixture of 
bile and semi-putrid blood. Some writers 
have asserted that the mesenteric glands, 
and indeed the whole lymphatic glandular 
system, internal as well as external, are 
always more or less diseased, swollen, dis- 
colored, and often softened, or otherwise 
altered in structure. Bulard has found 
the entire chain of glands from the groin 
to the solar plexus enormously developed, 
forming a compact mass, to which the 
veins, arteries, and nerves closely adhered, 
and imbedded in blood effused into the 
1 De la Peste orientate d'apres les MatSriaux 
recueilles & Alexandria, A Smyrne, &c., pen- 
dant les AnuSes 1833 A 1838. Paris, 1839. natural history, causation, prophylaxis, etc. 
317 
surrounding cellular texture. Similar 
appearances have been observed along the 
course of the auxiliary glands, when they 
were chiefly affected. Clot-Bey remarks, 
that the bubos in the Plague are always 
formed by swollen lymphatic glands; 
tluse in the neck and about the angles of 
the j.iws being independent of the salivary 
glands, which usually remain unaffected. 
Even in cases which had proved fatal be- 
fore the outward appearance of any bubos, 
some of the lymphatic glands were, he 
states, almost always found on dissection 
to be affected ; the morbid change vary- 
ing according to the stage of the disease, 
from simple enlargement and increased 
hardness to dark-colored softening and 
putrescent degeneration. 
The blood, whether drawn during life or 
observed only after death, has very gene- 
rally been found to be darker and more 
fluid than in health, and only imperfectly 
coagulating; the clot being loose and 
pliable, and never exhibiting a true fibrin- 
ous or butty coat, while the serum is often 
excessive in quantity, and occasionally 
more or less deeply sanguinolent. After 
resting for some time, oily globules have 
been sometimes noticed on the surface, 
and the whole mass has been observed to 
pass rapidly into putrefaction. 
Curative Treatment.-There is lit- 
tle on this head in medical writings at all 
satisfactory or encouraging in respect of 
the recovery of the sick, but much that is 
admonitory as to the baneful effects of an 
over-active and meddlesome medication, 
and of neglecting the prime essential in 
the treatment of all fevers, viz., the inha- 
lation of a pure atmosphere, of equable 
temperature, at all times, both night and 
day. Without this indispensable condi- 
tion, other remedies will be of compara- 
tively little avail.* The perusal of the 
recorded histories of cases of Plague, as 
observed at Malta in 1813, and in Egypt 
in 1835, leaves the impression on the mind 
that the patients would have fared better 
had they been treated with light nourish- 
ing food and cordials frequently adminis- 
tered, together with simple saline or acid 
medicines, and without active purgation, 
blood-letting, and such energetic mea- 
sures. The treatment which is most suit- 
able for ordinary typhus is doubtless that 
which is applicable to the Plague. In 
anticipating or in estimating results, it is 
always most needful to have regard to the 
period of an epidemic, when the remedies 
have been employed ; otherwise, the most 
misleading mistakes may be fallen into 
respecting the value of remedies or modes 
of treatment. I cannot better close these 
few remarks on this head than by quoting 
the words of a recent experienced writer,1 
in regard of the treatment of other bad 
forms of fever, viz., the pernicious remit- 
tent and yellow fevers of tropical climates. 
"In considering this subject, it should 
ever be kept in mind that not only in dif- 
ferent situations and countries, but also 
in different years, these diseases, what- 
ever the form of fever, may vary more or 
less, and if not in type and character, at 
least in intensity and complications; so 
that the remedial means which may have 
been found useful in one epidemic may 
fail in another, each, it may be, having a 
constitution of its own. We are told by 
Sydenham how difficult he found it, on 
the breaking out of an epidemic, to deter- 
mine on the best mode of practice to be 
pursued, and how he came to a decision 
only after ingenti adhibita cantela, intestique 
animi nervis-nn example, this, well de- 
serving to be followed." 
Natural History, Causation, Pro- 
phylaxis, &C.-Prior to the end of the 
seventeenth century, the Plague seems 
to have been as truly endemic-with oc- 
casional outbursts of epidemic violence- 
in most of the countries of Europe, in- 
cluding our own, as it wras in the Levant 
and in Egypt from remote times, and con- 
tinued to be during the first forty years of 
the nineteenth century. In London, for 
example, during the first seventy years of 
the century, not a year passed without 
some deaths from the Plague being regis- 
tered ; and epidemics occurred in 1603, 
1625, 1636, and 1665. The last, known as 
the Great Plague, was followed by a 
marked decline in the prevalence of the 
fever; the number of deaths from it be- 
came fewer and fewer, and after 1679 
none have been recorded in the bills of 
mortality of the metropolis. Whether it 
continued to linger in other parts of Eng- 
land after this date, I am unable to say; 
for it is to be remembered that the disease 
had not been limited to London, but was 
widely spread over different parts of the 
kingdom, just as typhus is at the present 
1 Nowhere have the effects of crowding the 
sick, and the neglect of hygienic measures 
in fever, been so dreadful as in the pest hos- 
pitals or lazarettos, even within the last 
thirty years. Dr. Bulard said of the hospital 
at Smyrna, "Il n'est que le vestibule du 
s^pulcre and it was doubly, literally true, 
for the cemetery was within the walls of the 
establishment. In the British colony of 
Malta matters were no better in 1813 ; few of 
the patients sent to the lazaret left it alive. 
Of twenty-eight inmates seen by Sir B. Faulk- 
ner on one occasion, and some of whom then 
seemed to have not been seriously ill, all 
perished within forty-eight hours ; the only 
attendants were convicts ! See his Treatise 
on the Plague, from facts collected during the 
author's residence in Malta. London, 1820. 
1 On Diseases of the Army, by Dr. J. Davy, 
F.R.S. 1863. 318 
THE PLAGUE. 
day. In Holland, too, the decline and 
disappearance of the pestilence seem to 
have taken place about the same time as 
in England, or somewhat later. 
During the eighteenth century, although 
there was a marked diminution in the 
persistency of the disease in a sporadic 
form, and in the frequency of occasional 
wide-spread outbursts throughout Europe 
generally, many severe and very fatal epi- 
demics occurred in different countries, as 
in Poland, including Dantzic, and other 
ports in the Baltic, in 1710; in Provence 
and other parts of Southern Erance, and 
especially Marseilles, in 1720-21; at 
Rochefort in 1741; at Messina and other 
towns in Sicily in 1743; in several dis- 
tricts of Portugal in 1757 ; in Wallachia, 
Podolio, &c., in 1770; and at Moscow in 
1771. 
In the present century the chief seats of 
the pestilence have been in Egypt, Syria, 
Asia Minor, and the coast of Barbary. 
For details on this point I would refer to 
a ''Sketch of the Geography, &c., of the 
Plague," in the Brit, and For. Med.- 
Chirurg. Rev. for April, 1864. 
The most recent recognized appearance 
of the pestilence occurred in the neighbor- 
hood of Benghazi, between Alexandria 
and Tripoli, on the African coast, in 1858. 
It has been described by Dr. Bartoletti, 
who was sent by the Turkish Government 
to investigate its history, in a memoir ad- 
dressed to the Imperial Society of Medi- 
cine of Constantinople, in August of that 
year, and of which an abstract is given in 
the Quarantine Parliamentary papers af- 
terwards referred to. A brief notice of 
the " Pali Plague" of India may be here 
introduced. 
This pestoid fever was first recognized 
in Cutch, in the summer of 1815, after a 
season of great scarcity and distress. 
From that year to 1820 it prevailed in 
different places in Guzarat, spreading to 
Scinde in a N. W. direction, and also to- 
wards Ahmedabad and other places in 
the British possessions eastward. The 
fever was remittent in character, with a 
great tendency to become continued, of a 
very adynamic type, and extremely fatal. 
In most cases there were glandular swell- 
ings in the groins, axillae, and neck. Car- 
buncles or petechiae are not mentioned as 
being present. There was often dyspnoea 
with cough and bloody expectoration. 
Vomiting, of at first bilious matter, and 
subsequently of a dark coffee-colored fluid, 
was likewise a not unfrequent symptom. 
In some cases the urine was sanguinolent, 
and blood oozed from the gums. After 
the beginning of 1821, there was no recur- 
rence of the lever known until 1836, when 
it was observed in the town of Pali (lat. 
26° N. and long. 74° E.), then the prin- 
cipal depot of traffic between the coast 
and the N. W. Provinces of India. It 
spread to numerous places in Marwar in 
that year, and in 1837 on ro the middle of 
1838. In 1849 there was a similar fever 
in Gurwah and Kumaon, on the southern 
slopes of the Himalayas, and in 1853 in 
Rohilcund. As to the nature and affini- 
ties of the fever, Dr. Morehead, in his 
valuable Clinical Researches on Disease 
in India, remarks :-" The description of 
jail or hospital fever by Pringle, in his 
work on the Diseases of the Army, has con- 
siderable resemblance to that of the fever 
at Pali. . . . The causes were supposed 
to be crowding, filth, and effluvia from 
decomposing animal and vegetable mat- 
ters."-Second Edition, p. 158. 
In every country where the Plague (and 
pestoid fevers in general) has prevailed, 
certain local conditions have been found 
to favor its development and spread. " The 
principal of these are, residence upon 
marshy alluvial soils along the Mediter- 
ranean, or near certain rivers, as the 
Nile, Euphrates, and Danube ; the dwell- 
ings of the people being low, crowded, and 
badly ventilated ; a warm, moist atmo- 
sphere ; the action of putrescent animal 
and vegetable matters ; insufficient and 
unwholesome food; and physical and 
moral wretchedness."1 An elevated site, 
even in the immediate neighborhood of 
an infected city, has often remained quite 
exempt, although intercommunication 
was not interrupted-e.g., the citadel of 
Cairo, and the village of Alem-Daghe, 
near to Constantinople. The higher parts 
of Valetta suffered very little in the Malta 
epidemic of 1813; the ratio of the attacked 
became greater and greater in descending 
from the higher to the lower levels of the 
city, towards the foul shores of the har- 
bor ; and so much less frequently were 
the occupants of the upper and more airy 
stories of the lofty houses attacked than 
those of the basement floors, that it was a 
common remark, Dr. Hennen (in his 
Medical Topography of the Mediterra- 
nean) says, that "the Plague was a dis- 
ease which seldom went up stairs." It 
has been very generally in the crowded 
and filthy parts of a town that the earliest 
cases of an epidemic have occurred, and 
the chief sufferers have been invariably 
the poor and neglected. The state of 
most Turkish or Egyptian towns in the 
present age represents very nearly what 
London and many other European cities 
were in the seventeenth century. 
Outbreaks of the Plague, as of typhus, 
have often followed in the wake of famines 
and other desolating calamities. This 
was strikingly the case with the visitation 
at Benghazi. For two or three years pre- 
viously there had been an unusual drought, 
1 Rapport & l'Acad&nie Royale de M^decine, 
sur la Peste et les Quarantaines, fait, au nom 
d'une Commission, par Dr. Prus. Paris, 1846. NATURAL HISTORY, CAUSATION, PROPHYLAXIS, ETC. 
319 
and the cattle had perished in great num- 
bers from an epidemic disease. In 1857 
the destitution of the Bedouin tribes be- 
came extreme, and it was then that the 
pestilence commenced. "Why it was 
the Plague rather than typhus, I know 
not," says Dr. Bartoletti; " but the fact 
was so; and I may add that the great 
epidemic of Plague at Erzeroum, in 1841, 
was also preceded by a terrible famine. 
One of the essential conditions for the 
production of typhus was wanting, viz. 
the agglomeration of human beings in a 
confined space." 
Epidemic Plague has generally been 
preceded by a sickly season,-the sickli- 
ness consisting in the great prevalence 
and severity of the ordinary endemic 
fevers, of fluxes and other forms of bowel 
complaints, and not unfrequently also of 
catarrh. Sydenham's account of the epi- 
demic constitution, previous to the great 
Plague of London, may be taken as typical 
of what usually occurred in respect of the 
disease during the sixteenth and seven- 
teenth centuries in this and in other coun- 
tries of Europe. In the Spring of 1665 
catarrhs and pulmonic disorders were very 
prevalent and fatal. About the same 
time a bad form of fever, attended with 
vomiting, diarrhoea, &c., began to be very 
common, and this was increased in 
severity as the season advanced. Towards 
Midsummer, cases of this fever (which 
Sydenham calls "pestilential") were ac- 
companied with bubos and carbuncles on 
the surface ; then only was it recognized 
and designated as the Plague. The pes- 
tilence went on increasing in deadliness 
until the third week in September, when 
nearly 8000 died in the course of the 
week, although two-thirds of the inhabit- 
ants had by this time fled from the city. 
It had then reached its acme, and forth- 
with began to abate. It very nearly 
ceased on the approach of cold weather ; 
a few sporadic cases only occurred during 
the winter and following spring. The 
same form of fever, however, as had pre- 
ceded the first recognized cases of the 
Plague, was again observed throughout 
1666 ; but it was not so general as in the 
previous year. Sydenham expressly says 
that it was of the same species as the 
Plague, only not so violent-revera enim 
cum ipsissima Peste specie conven'd, nec ab 
ea nisi ob gradum remissiorem discrimi- 
natur. 
Morton, a contemporary of Sydenham, 
has remarked of the Plague, as he saw it 
in London, that " it often appeared under 
the form of a continued or remittent 
fever; but this changed into the other, 
and vice versd; and that each in its turn 
became epidemic, the one yielding to the 
other. " A similar remark has been made 
by many other writers in former, as well 
as in more recent, times. The epidemics 
in Egypt in 1835 and 1841 were ushered 
in by the unusual prevalence of the ordi- 
nary endemic fevers, in some places of a 
continued, and in other places of a 
periodic, type. 
The influence of season on the preva- 
lence of epidemic Plague will be seen 
from the following facts. In England the 
pestilence was most severe in the epi- 
demic years 1603, 1625, 1636, and 1665, 
from about the middle of July to the first 
or second week in October. The Plague 
at Marseilles raged most fatally in the 
autumn months ; and the same was the 
case at Moscow in the epidemic of 1771, 
when upwards of 1200 deaths took place 
for several days out of a population of 
150,000. In Constantinople it has gene- 
rally reached its acme in September; in 
Smyrna about a month sooner; and the 
same may be said of Tunis, Algiers, and 
other places on the North African coast, 
where it has usually manifested itself in 
spring, and committed its greatest ravages 
in July and August. Malta suffered most 
in July. In Syria the summer months 
have ordinarily been the most fatal. In 
Egypt most epidemics have commenced 
toward the end of the year, and gradually 
advanced, reaching their acme in March 
or April, when the southerly winds are 
most prevalent. The disease generally 
ceased in the second or third week of 
June. At Cairo it never continued, it has 
been said, beyond St. John's Day, 24th 
June. It thus seems that in Egypt the 
chief prevalence has generally been a 
good deal earlier than in other countries. 
Volney remarked on this subject:-"The 
winter stops the Plague at Constantino- 
ple, because the cold is great; and the 
summer lights it up, because the heat is 
then humid : while in Egypt the winter 
favors it, because the climate is then warm 
and moist; and the summer stops it, be- 
cause it is hot and dry. The heat is only 
injurious when associated with hu- 
midity." That the peculiar meteorology 
of the climate of Lower Egypt may have 
something to do with the point in question 
seems very probable. 
Mention is often made, in the history of 
Plague epidemics, of the weather having 
been before, and during, their prevalence 
remarkably oppressive and distempered. 
This was notably the case, according to 
Maitland in his History of London, in the 
Great Plague, when, for months, scarcely 
a breath of air was to be felt, and the 
little that there was came from the south ; 
it was generally hot and stagnant, and 
mildews were abundant. A like state of 
atmosphere has often been noticed in 
other countries. Dr. Brayer specially 
alludes to the circumstance in his account 
of the Plague in Constantinople. Dr. 
Ilennen, in his narrative of the visitation 
at Malta, relates the fact, as indicative 320 
THE PLAGUE 
of a distempered atmosphere, that, during 
the prevalence of the fever, "every whit- 
low festered, and every scratch became an 
ugly sore ; a tight shoe was sufficient to 
produce a livid boil. The military hospi- 
tals were crowded with such cases." 
The mode in which the pestilence has 
been wont to manifest itself in a place, 
and to spread among a community, may 
be gathered from what has been said 
above respecting the usual antecedent 
state of the public health, and the physi- 
cal conditions, &c. of the localities chiefly 
attacked. It has been often alleged that 
outbreaks of the Plague have been known 
to occur among a population previously 
quite healthy, immediately or very soon 
after the arrival or introduction ab extra 
of a person or object already affected with 
the disease, or believed to be impregnated 
with its infective poison; and that from 
the first case or cases, as from a focus or 
centre, the subsequent extension could be 
distinctly traced. But whenever there 
has been an opportunity of ascertaining 
the real and complete history of the facts, 
the course of events has been found to be 
much less simple and consecutive. Un- 
fortunately, most of the past history of 
Plague epidemics rests on mere rumor, or 
on most imperfect information. It has 
only been within the last thirty years that 
thoroughly trustworthy records on the 
subject have been published. The admira- 
ble Report of the French Academy has 
shown that the pestilence has generally 
appeared in single cases or small groups 
of cases, at or about the same time, in dif- 
ferent spots or localities of a town, or per- 
haps in different districts of a region, often 
considerably distant from each other, and 
without any traceable direct communica- 
tion between the persons attacked. Some- 
times several towns have become the seats 
of the fever nearly simultaneously, the 
intermediate villages remaining exempt, 
while at other times it has advanced in a 
more regularly progressive manner, invad- 
ing a number of places il de proche en pro- 
che^'1 and in succession, over an extensive 
tract of country. That the Plague may 
be diffused by transmission from the sick 
to the healthy near to them-in other 
words, by personal contagion-cannot be 
reasonably doubted ; and it is equally cer- 
tain that both its development and spread 
have often occurred independently of such 
agency. Extravagant opinions on this 
subject were in vogue amongst most phy- 
sicians until of recent years, when the ac- 
curate observation of facts and a rigorous 
examination of previously recorded testi- 
mony sufficed to show that the influence 
of contagion in the dissemination of the 
Plague is very much the same as in the 
dissemination of the bad forms of typhus, 
and that the laws which regulate its ac- 
tivity and power in the one disease are 
equally true in respect of the other. The 
limits of the present paper preclude any 
discussion of the various important ques- 
tions of State Medicine connected with 
this subject, and which relate to the pub- 
lic measures to be adopted for the preven- 
tion or arrest of the Plague, and for the 
protection of countries from its introduc- 
tion by shipping and other channels of 
intercourse. To such measures the term 
of Quarantine has been usually applied. 
For full information on the subject I 
would refer to the Report of the French 
Academy,1 and to the elaborate documen- 
tary evidence, and report thereon, pre- 
pared by a committee of the National 
Association for the Promotion of Social 
Science, and printed, by order of the 
House of Commons, in May and August, 
1860, and August, 1861. 
[Early in 1879, alarm was produced in 
Europe by an outbreak of Plague in As- 
trakhan, which proved very destructive 
in some villages, and threatened to extend 
into different parts of Russia. 
There is evidence that its existence in 
the same and neighboring regions really 
dated back as far as May, 1878.2 Even in 
1877, it appears from Russian official in- 
formation, that Plague had been widely 
scattered in Russia; especially near the 
river Volga. At the beginning of the 
year 1879, its devastations became known, 
as they occurred in Vetlianka and a num- 
ber of other fishing villages, extending on 
both sides of the Volga for a hundred 
miles. In a few places, the mortality was 
as great as 95 per cent, of those attacked. 
These villages are described as being in 
an extreme state of filth. Nothing but 
fire could disinfect such localities. By 
order of the Imperial government, a num- 
ber of villages were destroyed ; their in- 
habitants being elsewhere cared for at the 
public expense. The immediate danger 
of the spread of the disease appeared 
then to be averted. 
From reports and papers by Dr. G. 
Milroy, J. Netten Radcliffe, and others, it 
appears that this outbreak in Astrakhan 
was only one of several occurring in differ- 
ent places, especially in Mesopotamia and 
Persia, since 1873. In 1875 it was fatal to 
about 4000 people ; and a yet larger num- 
ber perished from it in 1876 ; although it 
ceased in the hottest weather of that year, 
Bagdad lost about 1700 lives by it in 1877. 
At Resht, in the province of Ghitan, near 
the Caspian Sea, it destroyed about 4000 
lives. 
1 A summary of this Report, with Introduc- 
tory Observations, Extracts from Parliament- 
ary Correspondence, and Notes, was published 
by the writer of this article in 1846. 
[2 The Plague as it Concerns England; 
From Official and other Sources. London, 
Hardwicke & Bogue, 1879.] ERYSIPELAS: NATURAL HISTORY. 
321 
It does not seem irrelevant to the prac- 
tical purposes of this work, to cite here 
the conclusions of two eminent medical 
and sanitary officers, in regard to the pre- 
vention of danger from Plague, as well as 
from other diseases kindred to it. Dr. E. 
C. Seaton,1 in a memorandum "On the 
Systematic Action in Use in England to 
Prevent the Importation of Infectious 
Diseases," uses the following language : 
" Of systematic action adopted in Eng- 
land for the prevention of the importation 
of infectious diseases, the system of quar- 
antine (in the commonly received sense 
of that term) forms an extremely small 
part, if, indeed, it may not be said to be 
abandoned; an altogether different sys- 
tem, called the system of medical inspec- 
tion, having for some time past been em- 
ployed." 
Dr. Seaton quotes, in the same memo- 
randum, with approval, this expression of 
his predecessor, Mr. Simon : 
"A quarantine which is ineffective is 
a mere irrational derangement of com- 
merce ; and a quarantine of the kind 
which insures success is more easily im- 
agined than realized. Only in proportion 
as a community lives apart from the great 
highways and emporia of commerce, or is 
ready aiid able to treat its commerce as a 
subordinate political interest, only in such 
proportion can quarantine be made effec- 
tual for protecting it. In proportion as 
these circumstances are reversed, it be- 
comes impossible to reduce to practice the 
paper plausibilities of quarantine. The 
conditions which have to be fulfilled are 
conditions of national seclusion." 
Accepting these views as correct, it 
needs only to be added, that ' ' what is true of 
typhus," in regard to prevention by meas- 
ures of local sanitation, "ought to be true 
of Plague." In any but tropical or sub- 
tropical countries, it must be much easier 
to exclude Plague than typhus. There 
is abundant reason to conclude that the 
non-appearance of Plague in England 
since the visitation of 1665 has been due, 
not in any sense to measures of quaran- 
tine, but altogether to improvements in 
local and general sanitation.-H.] 
ERYSIPELAS. 
By J. Russell Reynolds, M.D., F.R.S. 
Definition.-An acute specific dis- 
ease characterized by fever of a low type 
and a peculiar inflammation of the skin. 
This inflammation exhibits a marked ten- 
dency to spread over the surface, to induce 
serous infiltration and suppuration of the 
areolar tissue in its neighborhood, to affect 
the lymphatic vessels and lymphatic 
glands, and to cause serous exudation be- 
tween the cutis and the cuticle. 
Synonyms.-Scientific Names. -Ipwlit- 
(Greek) ; Febris erysipelatosa (Syden- 
ham) ; F. erysipelacea (Hoffmann) ; Rosa 
(Sennert); die erysipelatbse Dermatitis 
(German); Erysipele (France); Risipola 
(Italian). 
Papular Names.-Ignis sacer (Latin); 
die Rose, der Rothlauf (German); the 
Rose (Scotland); Saint Anthony's fire 
(England). 
Natural History.-Causes.-Local 
irritations of the skin, such as the appli- 
cation of blistering fluids, or of boiling 
water, produce dermatitis, but they do 
not, of necessity, cause Erysipelas. The 
inflammation they produce may be very 
severe, and may resemble that disease; 
but the differences between such common 
inflammation and the special malady we 
are now describing are greater in number 
and more important in kind than are 
their points of resemblance. There is, 
then, some "cause" of Erysipelas over 
and above that, whatever it may be, which 
produces simple inflammation of the skin. 
There are some facts which go far to show 
that this cause, or that some one or more 
of a number of concurrent causes, may 
exist in the "individual;" for it is well 
known that some persons are liable to 
suffer from repeated attacks of Erysipelas, 
and these either with or without the 
slightest provocation; whereas others 
may be blistered, burned, cut, torn, or 
otherwise injured, without exhibiting any 
indication of the existence of such ten- 
dency. On the other hand, it is equally 
clear that Erysipelas sometimes has an 
"epidemic" character; and it is still 
more common to find it haunting certain 
[* Seventh Annual Report of the Local Gov- 
ernment Board ; Supplement: Report of the 
Medical Officer for 1877.] 
VOL. I.-21 322 
ERYSIPELAS. 
localities, and thus exhibiting the features 
that we term " endemic so that in these 
cases its most effective cause would seem 
to be outside the individual, viz., in some 
external circumstances. If we admit, as 
indeed we must do, the special liability of 
some individuals or families to the occur- 
rence of this disease, then the conditions 
underlying such liability must be regarded 
as "predisposing causes" of Erysipelas, 
and we must seek still further for the so- 
called " exciting causes" of the affection ; 
and these may commonly, but not invari- 
ably, be found in accidental or other in- 
juries to the skin, such as exposure to cold 
or heat, to moisture, or physical abrasion. 
If we accept, on the other hand, the pres- 
ence of a distinct morbific agent-either 
epidemic or endemic - as the efficient 
cause of Erysipelas, then the constitu- 
tional state of the sufferer sinks into com- 
parative unimportance, although we may 
still retain some belief in its action as a 
predisponent. 
The truth as to causation lies, most 
probably, not between these two ideas, 
but in their combination ; and such con- 
clusion is by no means at variance with 
the belief that sometimes the one and 
sometimes the other factor is the more 
influential. It may be that either one 
may sometimes be so potent as, per se, to 
produce the disease ; but it is more proba- 
ble that, in all cases, there is some consti- 
tutional predisposition, and also some 
agent operating from without. 
Among constitutional predisponents the 
most important is that of which we know 
nothing more than the fact of its exist- 
ence, viz., an individual or family pro- 
clivity to the disease. The next in value 
is age. Erysipelas is common in newly- 
born infants, but rarely occurs between 
the first year of life and the twentieth; 
after this period it is frequent, as an acute 
affection, till the fortieth year; whereas 
in more advanced age it is seldom seen 
except as a chronic, or subacute, and less 
important malady. It has been stated 
that women are much more liable than 
men, and especially so during menstrua- 
tion, and at the climacteric period ; but 
such statement is not supported by relia- 
ble facts, although a woman, subject to 
Erysipelas, may exhibit the disease with 
especial frequency during the catamenial 
। flow. Little that is of any value can be 
| said of " temperament" as a predisponent; 
but it appears probable that the "gouty 
diathesis" increases the frequency of its 
occurrence. 
In addition to the " exciting" causes 
already mentioned-viz., all undue im- 
pressions upon the skin-we must enume- 
rate errors in diet, and especially the 
taking of certain things, such as shell-fish, 
or improperly smoked, dried, salted, or 
otherwise " half-preserved" meats. But 
by far the most important cause, acting 
from without, is the "poison," whatever 
may be its nature, which exists in one 
case and can be communicated to another, 
either by inoculation, simple contact, 
transmission through the air, or bv fo- 
mites. 
It is not intended in this work to deal 
with Erysipelas as it is commonly seen in 
the surgical wards of hospitals, but with 
that form of it which, arising often with- 
out any distinctly defined external cause, 
and certainly in the absence of any proved 
contagion, has a history differing widely 
from that of the disease as it is seen to 
follow surgical operations, under circum- 
stances of apparently endemic aggrava- 
tion. It is not asserted that the disease 
is essentially different in the two classes 
of cases ; but it is held that their clinical 
history is so different that it is desirable 
to treat them separately, and to confine 
the description given in this "System of 
Medicine" to the latter, which usually 
falls under the care of the physician. 
Symptoms.-These are both general 
and local: on the one hand there is fever, 
on the other definite structural change in 
the skin, mucous membrane, and, it may 
be, in the subcutaneous and submucous 
tissues. When fever precedes the ap- 
pearance of redness on the skin, the dis- 
ease resembles one of the exanthemata : 
when local inflammation exists before 
marked pyrexial change, the case, in its 
general career, is more like that of pneu- 
monia, pleuritis, or inflammation of any 
other organ. The former course is the 
more common of the two. 
The commencement of Erysipelas is usu- 
ally marked by uneasiness of not very 
definite character; rigors, slight shiver- 
ing, or only a feeling of chilliness may 
mark the onset of the malady ; but more 
commonly rigors do not exist at the be- 
ginning, they occur after several hours of 
discomfort, and either immediately before 
or simultaneously with the appearance of 
local inflammation. Usually, then, prior' 
to the occurrence of rigors, there is ma- 
laise, aching of the limbs, loss of appe- 
tite, thirst, nausea, or vomiting, diarrhoea, 
soreness of the throat, increased heat of 
skin, and frequency of pulse, headache, 
giddiness, confusion of thought, feeling of 
depression in spirits, epistaxis-as an oc- 
casional event-and, in fact, all the signs 
of pyrexial disturbance, without any such 
special predominance of any one of them 
as should enable the physician to forecast 
the nature of the impending evil. 
It is not possible to affix a definite dura- 
tion to these symptoms : sometimes they 
commence after, sometimes simultane- 
ously with, the local changes ; but more 
commonly they precede the latter by a 
few hours, i. e., from eight to ten, of by SYMPTOMS. 
323 
two or even three days. It often happens 
that a man feels well in the morning and 
at mid-day, but towards evening is un- 
easy ; passes a restless night, growing 
worse from hour to hour; and on the 
morning of the next day observes some 
redness of his nose or ear. Or feeling 
better, but not well, on the second morn- 
ing, he goes through a day of increasing 
discomfort, which becomes very consider- 
able towards evening; passes a second 
night worse than the first, sometimes ac- 
companied by delirium ; and the special 
phenomena of Erysipelas appear on the 
third day. But their appearance may be 
delayed until the fourth or even fifth day 
from the onset of symptoms. 
On the appearance of the cutaneous in- 
flammation there is no remission of the 
pyrexial symptoms ; on the contrary, they 
are sometimes aggravated in intensity. 
The usual site for their development is 
some part of the head; but they may ap- 
pear in any other portion of the body. 
Local disease or injury of the skin, or 
even of the subcutaneous tissues, may de- 
termine the place of commencement. 
Abrasions, scratches, or wounds, wher- 
ever they are situated, may be the start- 
ing places of specific inflammation of the 
skin ; whether this be of the kind we call 
Erysipelas, measles, or scarlet fever. But 
this determining power is not limited to 
such injuries or affections as " break the 
skin for the locality of appearance, and 
even recurrence, of Erysipelas may be de- 
termined by the presence of gout in a par- 
ticular joint of either the upper or lower 
extremity, and also by the irritation of 
diseased teeth in either the upper or lower 
jaw. 
Usually, however, the nose or the ear 
is the point at which the inflammation 
may first be seen. The change is, so far 
as my own observations extend, com- 
monly seen to commence in close prox- 
imity to one of the passages through the 
skin, i. e., where the skin undergoes that 
transition which consists in its becoming 
what we term mucous membrane. Thus, 
not only at the nose and at the ear does 
Erysipelas begin, but it commences just 
where the skin of the nose turns upwards 
into the nostril, or just at the point where 
the skin of the ear loses the dryness and 
other characteristics of ordinary skin. 
Again, Erysipelas often is noticed first at 
the angles of the mouth, or at the edges 
of the eyelids ; it is met with at the anus, 
about the genital organs, and in the neigh- 
borhood of the recently-divided umbilical 
cord. 
To the patient the part affected feels 
hot and irritable ; and, upon touching it, 
sore, stinging, and smarting. It is of red 
color and shining aspect; it is warmer 
and harder than the surrounding tissues, 
swollen, and, as the disease advances, 
very tender to the touch. The inflamma- 
tion extends from the spot first affected, 
sometimes in all directions, but more com- 
monly in one much more rapidly and 
more widely than in another. For in- 
stance, Erysipelas starting from the ear 
will sometimes extend downwards and 
not upwards, backwards and not for- 
wards, and so on ; whereas in other but, 
I believe, rarer cases, the progression ap- 
pears to radiate about equally in all direc- 
tions. At the advancing edge of Ery- 
sipelas the elevation of skin (swelling) 
may often be not only felt but seen, and 
that most distinctly ; whereas at the re- 
ceding margin there is so gradual a de- 
cline of swelling that it would be difficult 
to say with certainty that it existed. 
Where the inflammation is advancing the 
line is marked not only by elevation of 
the surface, but by sharply-defined differ- 
ence of color; the white or pale healthy 
skin is invaded by a distinct line of red, 
with an occasional streak, branched or 
not, in advance of the general boundary. 
Where the skin-affection is receding there 
is no such abrupt transition, but the 
heightened tint of the most active inflam- 
mation is gradually shaded down through 
medium and mixed tints until, without 
any clear line of demarcation, the skin 
is found in its ordinary healthy state. 
Sometimes the amount of swelling is 
not considerable ; at other times it is enor- 
mous ; and the disfigurement is such that 
none would recognize the features of the 
sufferer, nor for a moment think that they 
were features at all, or even parts of any 
human being. The amount of swelling is 
greatest where the skin is the most loosely 
attached to the subjacent structures, and. 
where there is much areolar tissue which 
can be distended with fluid. Thus we 
find the eyelids and the neighborhood of 
the mouth the most disfigured in appear- 
ance, and all trace of the former may be 
completely obliterated by the effusion. 
The swelling, when confined to the skin, 
is moderate in amount, uniform in ele- 
vation, hard to the touch, pitting only 
slightly on pressure, and shading off on 
the side of recession, but terminating 
more or less abruptly on that of advance. 
When the areolar tissue is much infil- 
trated, the swelling is carried to a higher 
degree, its surface is irregular in elevation 
and consistence, and there is often deep 
pitting upon pressure. Under the latter 
circumstances there is generally suppura- 
tion, probably determined by the slough- 
ing of small or larger portions of the sub- 
cutaneous areolar tissue. 
The surface of the inflamed skin re- 
mains, in mild cases, intact throughout, 
exhibiting, besides redness, only slight 
increase of desquamation as the malady 
dies away. In more severe and more 
common cases there is some vesication of 324 
ERYSIPELAS. 
the surface; little bladders are seen like 
those produced by a blistering fluid, or a 
scald. Whereas, in very severe cases, 
large bullae, of irregular shape, make 
their appearance; they soon burst, and 
leave dry and thick crusts, which render 
still more hideous the face that they have 
covered. It often happens that the in- 
flammation is extending in one direction 
and receding in another, so that Erysipe- 
las in all its stages may be witnessed at 
the same time in the same individual; 
but the maximum of redness and of swell- 
ing is usually reached on the second or 
third day. 
In almost all cases there is distinct in- 
flammation of the neighboring lymphatic 
vessels, with pain, swelling, and tender- 
ness of the lymphatic glands: but sup- 
puration of the latter is not met with in 
ordinary cases, although severe. Inflam- 
mation of the lymphatics is most com- 
monly observed when Erysipelas has been 
set up by a poisoned wound.1 
The pulse is generally full and with a 
frequency varying from 100 to 120 in the 
minute ; the heat of skin is well marked, 
perhaps over the inflamed surface unduly 
marked in comparison with the elevation 
of the temperature generally. This may 
be owing to the local arrest or diminution 
of transudation and evaporation. 
In a severe case, recently under my 
care, the temperature in the morning of 
the eighth day of illness, but fifth day of 
eruption, was 104° Fahr.; on the next 
day 102; on the following 103|°; then 
came twenty-four hours in which it ranged 
between 99?° and 100j°; to be followed 
by another rise,-coincident with some 
extension of the inflammation,-to 102f °; 
. after which it became normal. The even- 
' ing temperature in this case was daily 
lower, and sometimes considerably lower 
(2° to 4° and even 5°) than that of the 
\ morning. A similar relation between the 
morning and evening temperature was 
observed in another almost equally severe 
case occurring at the same time. The 
prevailing relation between morning and 
evening temperatures is, however, similar 
to that observed in other acute specific 
diseases, viz., an excess of elevation in 
the evening; but the variation from this 
general type is, I believe, more common 
than is supposed not only in Erysipelas 
but in other allied maladies. It is quite 
clear that relapses are attended by re- 
newed rise of the thermometer; and such 
relapses may occur in the morning as 
well as in the evening, and so pervert the 
characteristic febrile course. Such re- 
lapses may possibly be overlooked, as in 
some cases the symptoms are almost im- 
perceptible to the patient, and may occur 
in some locality which is not necessarily 
exposed to the eye of the physician ; and 
yet, although so slight as not to attract 
attention in any other way, they may do 
so by their effect on the thermometer. 
Lately, for example, in a patient appa- 
rently convalescent, - feeling tolerably 
well, and taking food with relish, the 
temperature having been normal for two 
days,-I have seen a sudden rise in the'' 
thermometer, unattended by any return 
of pain or malaise, but, upon examination, 
shown to be coincident with renewal of 
the inflammation below the shoulder . 
blades; it having commenced at the ears, 
extended to the back of the neck, and for 
some days stopped at the level of the, 
scapular spines. 
The fever, as measured by the ther- 
mometer, is very variable in duration; 
and the temperature, after having re- 
turned to the normal amount, may ex- 
hibit several re-elevations coincident with 
extensions of the inflammation. Usually 
the maximum is reached on the third day 
of eruption, and the decline commences 
on the fifth or sixth. 
The pulse,-usually exhibiting an in- 
creased frequency bearing direct relation 
to the abnormal elevation of temperature, 
-may revert to the habitual standard at 
the end of the third or fourth day, and not 
again rise far above this, although one or 
more relapses may occur, each of which is 
marked by a rise in the thermometer. 
Albumen appears in the urine in many 
cases. It may make its appearance from 
the fourth to the eighth day, or even 
later, in relapse. Unless there be pre- 
existent disease of the kidneys, it is small 
in amount and of short duration; it has 
been noticed to be absent on the fifth day, 
present on the sixth, and again absent on 
the seventh. The quantity of urea is nA 
creased, while that of the chlorides is di-J 
minished. 
The course of symptoms varies widely. 
In one class of cases there is a speedy 
diminution of their severity both locally 
and generally; whereas in others the re- 
verse is observed. Sundry local changes, 
proportionate to the amount of swelling, 
may occur, and become excessively an- 
noying. Such, for example, are blind- 
ness, deafness, and impossibility of breath- 
ing through the nose. But, beyond these 
and the relapses which have been already 
mentioned, there are others depending 
upon the sloughing and suppuration of 
areolar tissue. When such changes take 
place, the symptoms become much more 
distinctly adynamic; and in bad cases the 
tongue is brown, the lips and gums are 
covered with sordes, the pulse rises in 
frequency and loses in force so that it is 
often quite uncountable; there is low 
muttering delirium, with jerking contrac- 
tions of the limbs, and, indeed, all the 
other signs of impending dissolution. 
1 Niemeyer, Lehrbuch der speciellen Pa- 
thologic und Therapie. Bd. ii. p. 396. 325 
DIAGNOSIS - MORBID ANATOMY. 
Diagnosis.-It is not very easy to con- 
found Erysipelas with any other malady 
when once its ordinary symptoms are de- 
veloped; but it may sometimes be inferred 
to be present before the skin has shown 
signs of inflammation. Where there is 
marked pyrexia, with vomiting at its 
commencement, without notable pain in 
the back, or obvious change in the mu- 
cous membrane of the throat or nose, but 
with enlargement, pain, and tenderness 
of the lymphatic glands in the neck, Ery- 
sipelas may be, and ought to be, suspect- 
ed. Attention to the description of 
symptoms already given will be sufficient 
to prevent any errors of diagnosis. The 
spreading character of the inflammation, 
as this is seen in the skin and also in the 
subcutaneous cellular tissue, distinguishes 
Erysipelas from true phlegmon, where 
lymph speedily circumscribes the swell- 
ing. Although the symptoms of Erysipe- 
las occasionally exhibit intermissions, and 
by no means rarely some remissions, it 
would be difficult now for the mistake 
between it and intermittent fever to recur. 
From what has been termed "diffuse 
cellular inflammation," Erysipelas may 
be distinguished by a constant presence 
of inflammation of the skin, which latter 
bears a direct ratio to the affection of the 
areolar tissue, and precedes it, as a rule, 
in regard to time. 
Erythema differs from Erysipelas in the 
comparative mildness of its general symp- 
toms, in the absence of swelling of the skin, 
and in the tendency which it exhibits to 
form patches, of various sizes and shapes, 
which show no marked tendency to 
spread. 
Pathology.-There can be no doubt 
that some cases of Erysipelas resemble 
those of simple erythema, or simple in- 
flammatory redness of the skin, such as 
may be produced by a mustard poultice. 
Nor can there be any doubt that, on the 
other hand, there are cases of Erysipelas 
which resemble more closely diffuse cellu- 
litis and pyaemia. Between these ex- 
tremes there are patients whose symptoms 
are those of phlebitis or of inflamed ab- 
sorbents ; and others whose cases can 
hardly be distinguished from genuine 
phlegmon. In all these we may have no 
doubt of the existence of Erysipelas ; but 
the idea we entertain of the "pathology" 
of this disease will be determined by the fre- 
quency with which we find it assuming this 
or that typical form, the amount of import- 
ance we attach to these several associated 
conditions, and the clearness of our knowl- 
edge about them. Thus, Erysipelas may 
be regarded as a disease having its first 
local manifestation in the absorbent sys- 
tem, or it may be held to be essentially a 
blood disease, always called into play by 
some external injury, however slight that 
injury may be ; it may be thought to be 
so distinctly hajmic, that it should find its 
place among the symptoms of pyaemia ; 
while, on the other hand, the view may 
be entertained that a true inflammation 
of the cutis is its one essential condition- 
that Erysipelas is a morbus per se, having 
powers of easy association with each of 
those maladies alluded to, but being, at 
the same time, essentially distinct from 
all of them. Those who entertain the last 
opinion, again differ among themselves, 
some regarding the inflammation as iden- 
tical in its essence with that which might 
be produced by an irritant; others, as 
being of special type, the result of one 
specific poison, the presence of which in 
the system is the sine qua non of the exist- 
ence of that form of inflammation which 
we term Erysipelas. And here, in this 
last resort, diversity of opinion may still 
be found ; for some hold that the poison is 
developed from within, that it arises from 
"crudities," from "digestive derange- 
ments," and the like ; while others believe 
that it is always imported into the body 
from without; and it would seem that yet 
a third view might be taken, viz., that it 
is by the conjunction of these two elements 
that the disease is established ; that is to 
say, neither internal conditions (predispo- 
nents), existing alone, nor external poi- 
sons (septics, or endemic influences), act- 
ing by themselves, can produce Erysipelas; 
but that the outside poison, however ac- 
tive, or however greedily swallowed by the 
organism it may be, is inoperative unless 
it finds in that organism the proper, i. e., 
"special," nidus, conditions, or material 
for its development. 
It would be possible so to select and ar- 
range the facts about Erysipelas as to 
make them support any one of these theo- 
ries or pathological positions ; but, taking 
them without selection, and only arrange 
ing them so far as to render the teaching 
intelligible, the conclusion most consist- 
ent with them appears to me to be that 
which is expressed the last in the forego- 
ing paragraphs, and in the definition of 
the disease : viz., that Erysipelas is an 
inflammation of the skin, that it may in- 
volve the absorbent or the venous sys- 
tems, that it may change the character of 
the blood ; but that it may act independ- 
ently of any such complication ; further, 
that it is an inflammation of "special" 
character; and, lastly, that it depends 
upon the action of a particular poison 
upon a peculiarly predisposed constitu- 
tion. ' 
Morbid Anatomy.-The slighter cases 
of this disease rarely furnish opportuni- 
ties for the study of their anatomical con- 
ditions, but analogous states of the skin 
and neighboring tissues may be observed 
in the outskirts of the severest inflamma- 326 
ERYSIPELAS 
tion in cases of fatal Erysipelas. In them, 
after death, as well as during life, the dis- 
ease may sometimes, but of course at dif- 
ferent points, be observed in all its stages, 
and in all its degrees of intensity. 
The skin is thickened by increase of 
vascularity and of serous infiltration, 
while there is a marked absence of lymph 
so thrown out as to circumscribe the swell- 
ing. In mild cases, no suppuration is ob- 
served, but, in the less mild, there are de- 
tached patches of suppuration, sometimes 
affecting the cutis only, but more com- 
monly extending into the areolar tissue ; 
whereas, in severer cases the skin may be 
completely separated from the subjacent 
tissues, and this for a very considerable 
extent, by large quantities of pus, in 
which shreds of sloughing or dead areolar 
tissue may be found, semi-detached or 
floating. The disease, although com- 
monly limited to the skin and its imme- 
diately connected tissues, sometimes ex- 
tends to the deeper and more important 
structures, and then muscles and liga- 
ments and bones become involved in the 
general mischief. 
Mr. C. de Morgan' states that a very im- 
portant fact had been " mentioned" to him 
by Busk, viz., "that in all the fatal cases 
which he examined, the lungs were highly 
congested, and that, on close inspection, 
the smaller pulmonary vessels were always 
found to contain pus; that, in fact, a 
minor degree of pyaemia was always pre- 
sent. lie (Mr. Busk) has observed the 
same thing in the small vessels of the 
head, when that part has been the seat of 
Erysipelas." Dr. Bastian has found 
minute embolic masses in the small arte- 
ries and capillaries of the gray matter of 
the cerebral convolutions. Some of these 
masses, which are small, appear to be 
made up of white blood-corpuscles; but 
the larger, irregular, and rounded bodies 
are, in Dr. Bastian's opinion, amorphous 
masses of albuminoid material, separated 
from the blood-plasma.2 Dr. Copland3 
says, " The veins proceeding from the 
part chiefly affected are often inflamed, or 
contain pus, as first observed by M. Ribes 
and confirmed by Messrs. Dance, Arnott, 
and by my own observations." It is well 
known that in many cases of fatal Erysipe- 
las evidences of disease may be found in 
the spleen, liver, kidneys, lungs, bronchi, 
larynx, trachea, and fauces ; but there is 
nothing specific in the character of the 
changes discovered in these organs-no- 
thing, that is, which is peculiar to the dis- 
ease called Erysipelas-nothing, indeed, 
which depends upon the Erysipelas per se; 
but all that may be found is only the sign 
of such general blood-change as may be 
associated not only with the disease now 
under consideration, but also with that 
large group of maladies which stand in 
close relation with pyaemia. (See p. 330.) 
Occasionally, gangrene is found in some 
portions of the inflamed skin or cellular 
tissues ; and this particular termination 
of Erysipelas has appeared to me the most 
common in those cases which are asso- 
ciated with dropsical effusions. Some- 
times the Erysipelas has appeared around 
natural or artificial openings made for the 
escape of serum, and then either portions 
of the integuments of the lower extremi- 
ties, or, more commonly, of the genital 
organs, become greatly inflamed and gan- 
grenous. The association of gangrene 
with dropsy may be due, in some measure, 
to the altered blood-condition-which 
almost always exists in extensive ana- 
sarca, whatever may be the seat of that 
mechanical obstruction to which it is re- 
ferred, and which determines the locality 
of its appearance,-an altered blood-state, 
moreover, which in some dropsies appears 
to constitute the whole of the essential 
condition for their development. But, in 
addition to the blood-change, there is, in 
the fact of the existence of dropsical effu- 
sion in the cellular tissue, a change in the 
nutrition of the vessels, and an altered 
relation of the fluids and solids of the parts 
involved: and there is, further, a simple 
mechanical interference with the circula- 
tion in the skin, exerted by the pressure 
of the effused fluid not only on the capilla- 
ries, but on the vessels which lead to and 
from them. Thus, dropsical limbs are, 
unless reddened by Erysipelas or other 
conditions not essential to the dropsy, ill- 
nourished, pale, and cold ; and a slight 
addition of difficulty to the already em- 
barrassed circulation of the part, often 
ends in gangrene. 
Prognosis.-A case of Erysipelas is 
bad in proportion to the predominance of 
the symptoms of blood-poisoning over 
those of simple inflammation. It is bad 
just in the degree to which it resembles 
typhoid fever or pysemia, rather than sim- 
ple dermatitis. Mere extent of inflamma- 
tion is not of itself of evil augury ; a high 
degree of inflammation is of no greater 
value; but a very rapid and weak pulse, 
with a dry brown tongue, and low mut- 
tering delirium, with marked prostration 
of the strength, is of almost fatal omen, 
although the local changes may be closely 
limited in both distribution and severity.' 
Cases which arise from the introduction 
of poisonous matter are worse than those 
in which the malady appears sponta- 
neously ; and this, whether the poison has 
been introduced by a wound made with 
an infected implement, such as a dissec- 
tion wound, the prick by a bone from dis- 
1 Holmes's Surgery, vol. i. p. 237. 
2 British Medical Journal, January 23, 
1869. 
8 Dictionary, art. " Erysipelas." TREATMENT. 
327 
eased meat, &c.; or whether it has been 
conveyed through the air, or by other 
means, to a wounded surface, placed 
where Erysipelas is endemic. 
The extremes of age, the presence of 
disease in either the kidneys or the liver, 
the dropsical constitution, a state of 
chronic alcoholism, or of any morbid 
blood-condition, are prognostic of an un- 
favorable termination. 
The extension of Erysipelas to the 
throat may introduce a source of danger 
altogether different from that which be- 
longs to the disease itself. Life may be 
threatened and indeed terminated, and 
that too very suddenly, by apnoea. The 
inflammation of the fauces may bring 
about serous or other infiltration of the 
neighboring submucous tissues, and the 
opening into the windpipe may be closed. 
In Erysipelas of the head or neck it will 
always, therefore be necessary to examine 
the throat most carefully, and to observe 
the manner and number of respirations, 
as well as the tint of the skin, in order to 
guard the prognosis against a false 
security. It is the more necessary to do 
this, because in some cases the patient- 
owing probably to the dulled state of his 
sensations and perceptions, brought about 
by the poisoned condition of his blood- 
may make no complaint of dyspnoea, or of 
discomfort in the throat; whereas an 
altered tone of voice or cough, an occa- 
sionally hurried respiration, a slight 
lividity of the lips or finger nails, an undue 
movement of the alie nasi, or any other 
signs of impaired respiration, may lead to 
the discovery of danger the most grave 
and imminent. 
Again, the appearance of symptoms of 
disturbance in the nervous centres, over 
and above, or out of all proportion to that 
which might be accounted for by the gene- 
ral febrile condition, is of very serious 
omen. The occurrence of delirium, and 
especially of nocturnal delirium, is of com- 
paratively little importance; but a marked 
drowsiness- sometimes alternating with 
delirium, sometimes persisting and in- 
creasing in intensity-is a very serious 
symptom, forecasting that mode of termi- 
nation which is by no means rare in Ery- 
sipelas, viz., " coma" from either effusion 
within the cranium or impairment of the 
brain-nutrition by embolism of the small 
vessels. It is, however, by no means 
probable that in all cases terminating 
thus, there is or has been an extension or 
metastasis of inflammation to the mem- 
branes of the brain. In some instances 
there are symptoms of "meningitis" ob- 
served during life, and evidences of its 
presence and its results may be discovered 
after death ; but in others the cerebral 
symptoms are those of oppression rather 
than excitement, and the post-mortem ap- 
pearances are those of effusion only, or 
of that embolic occlusion of vessels de- 
scribed by Dr. Bastian. In the latter 
class of cases the symptoms are probably 
due partly to the direct effect of altered 
blood upon the nervous centres, and also 
to the indirect effects of that alteration in 
leading to passive effusion, or ^obstructed 
circulation. The relation between dropsy 
and Erysipelas has already elicited re- 
mark. 
Erysipelas is a much more serious dis- 
ease when epidemic or endemic than when 
it occurs sporadically ; and the "type" of 
the epidemic-as observed in other in- 
stances which have been watched to their 
termination-will be the basis for an 
opinion as to the probable issue of a par- 
ticular case. 
It is said that the wandering or " er- 
ratic" form of the disease is attended 
with considerable danger, but in my own 
experience cases'have exhibited this cha- 
racter to a high degree and yet have not 
only terminated happily, but have never 
exhibited the slightest disposition to do 
otherwise. 
The cases of Erysipelas which are the 
most dangerous are those which, com- 
monly occurring after wounds of consid- 
erable extent-either accidentally or scien- 
tifically produced - are attended with 
much diffuse cellular inflammation; and 
which, finding their way, if not from 
their commencement, at least very early 
in their history, into the hands of the sur- 
geon, will not be described in this place. 
Treatment.-As I believe that the 
class of cases which have been described 
in such manner as to justify the use of 
antiphlogistic treatment, do not exist ex- 
cept in the histories of the past and the 
imaginations of the present, it appears to 
me unnecessary to say how much blood 
should be taken from the arm of a man, 
provided that he is found in a condition 
that we may never meet with. 
The general medical treatment of Ery- 
sipelas resembles rather that of the ady- 
namic fevers than of inflammations, even 
supposing that the latter should present 
occasionally what is called a "sthenic" 
form. Almost all the cases-so far as ray 
own experience reaches, all-that come 
under the care of the physician from the 
first, not only bear well, but are positively 
benefited by, supporting and tonic treat- 
ment. The kind and degree of such 
treatment must be determined by, and 
proportionate to, the severity of the symp- 
toms which have been already described. 
In some cases, stimulants are required 
from the first, the conditions which neces- 
sitate the employment being identical 
with those which are common to that 
large group of diseases in which Erysipe- 
las finds its place. When stimulants are 
not required at the onset, little or nothing 328 
ERYSIPELAS 
is gained by such use of salines, or any 
other general treatment, as shall do more 
than maintain a normal amount of the 
secretions. Thus, in very mild cases, 
in persons of average health, one or two 
doses of the simplest saline aperient may 
be all that is requisite. When the dis- 
ease is more severe, and exhibits a ten- 
dency to spread after the balance of 
secretion has been restored, the patient 
at the same time becoming restless and 
exhausted, the most efficacious general 
treatment consists in the administration 
of bark with ammonia, during the day, 
and an efficient but not heroic opiate at 
night. Should the adynamic symptoms 
increase, large quantities of alcoholic 
stimulant are required at short intervals ; 
and the amount that may be taken with 
advantage is as large as that which has 
been found useful in any of the specific 
fevers. 
[In the period preceding the recent 
prevalence of alcoholic stimulation in 
practice, ample opportunity occurred for 
the observation of cases of hospital Ery- 
sipelas, in the treatment of which the use 
of alcohol was the exception rather than 
the rule; and which often did very well 
without any stimulation at all.1 The 
same experience has been prolonged much 
later with cases occurring in private med- 
ical practice. The conviction has hence 
resulted, that neither alcohol nor the 
tincture of iron is a necessity in all cases 
of Erysipelas. Like other inflammatory 
affections (see the last sentence under 
Pathology, supra), it may occur with 
either a sthenic or an asthenic type.-H.] 
The tincture of the sesquichloride of 
iron of the London Pharmacopoeia is by 
far the most useful medicine that I know 
of in the treatment of these cases. So 
marked is its action that it has been 
thought by some to exert a "specific" 
influence in Erysipelas; but without as- 
serting that it possesses such power in the 
strict sense of the word " specific," it may 
be well to mention that its utility appears 
equally great in diphtheria, and perhaps 
still greater in cases of diphtheroid sore 
throat. The essential condition of its 
success is its administration in large and 
quickly repeated doses ; it has often hap- 
pened that disappointment has arisen in 
the use of this tincture of iron, but in 
most of these instances the tincture has 
been given in doses of ten or fifteen min- 
ims three times daily, and such doses are 
certainly useless. But when the tincture 
is given in doses of forty minims, or even 
more, every four hours, the results have 
usually been most favorable. The most 
convenient form for its administration is 
a mixture containing in each dose forty 
minims of the tincture with an equal 
quantity of spirit of chloroform and gly- 
cerine, with an ounce and a half of water. 
The effects of this medicine may be seen 
sometimes after the first, often after the 
second, dose: the local inflammation 
ceases to extend ; the inflamed part be- 
comes paler, less tender, less swollen ; the 
feeling of exhaustion is diminished, and 
vzith it such symptoms of exhaustion as 
exaggerated frequency of pulse, and dry 
brown tongue ; the temperature falls ; and 
sleep frequently ensues. As soon as such 
changes take place the quantity of the 
tincture may be reduced. It is not, how- 
ever, safe to trust to this medicine alone ; 
alcoholic stimulant is often required at the 
same time, but the action of the former 
has been too obvious in numerous cases 
for it to be confounded with that of the 
latter, or to be mistaken for those cura- 
tive processes which occur in the natural 
history of the disease. 
In the local treatment of Erysipelas two 
things are to be strenuously avoided ; the 
one anything which shall expose the skin 
to variations of temperature, and the 
other anything which shall interrupt its 
natural function. Among the former are 
included exposure to draughts, and to the 
chilling effect of wet applications ; among 
the latter the covering of the skin with 
any oily matters, ointments, &c. It has 
occurred to me frequently to see Erysipe- 
las spreading rapidly under the use of 
"cooling lotions," and to see it arrested 
by their discontinuance, and the applica- 
tion of simple dry flour, violet powder, or 
oxide of zinc-the inflamed part being 
sometimes covered lightly with dry cotton 
wool; the latter, however, being really 
necessary only when wishing to protect 
the patient from such draughts of air as 
are almost unavoidable in any large rooms, 
and which are sometimes quite unavoida- 
ble, and absolutely pernicious to certain 
classes of cases which find their way into 
the very well-ventilated wards of hospitals. 
The application of collodion has ap- 
peared to me of use only when the Ery- 
sipelas has been closely limited in extent. 
Its application over a large surface has 
not only failed to do good, but, in conse- 
quence of its cracking and leaving rough 
edges, has done positive harm. 
[Not only by this application, but by 
nitrate of silver, acetate of lead, ice water, 
&c., the direct suppression of the cuta- 
neous affection over an extended surface 
appears to be unsafe ; being sometimes 
followed (as in the analogous instances of 
scarlet fever, measles, &c.), by cerebral or 
pulmonary congestion.-II.] 
Various attempts have been made to 
arrest the spread of the inflammation, by 
some applications to the sound skin in the 
direction of, but beyond, its extending 
margin. The most approved of these has 
I1 E. g., in the Pennsylvania Hospital, 
1845-50, et seq.-H.] VARIETIES. 
329 
been, and is, the application of nitrate of 
silver, and there are facts to warrant this 
approval. It is desirable, however, not 
to attach too much importance to this 
measure. When nitrate of silver is ap- 
plied in such manner as to affect the in- . 
tegrity of the true skin, I have seen Ery- 
sipelas start from the line of its application 
as from a new focus; and when, on the 
other hand, this evil has been carefully 
avoided, I have seen the Erysipelas ex- 
tend through the line upon which it had 
been used. 
[At the very beginning of an attack of 
Erysipelas, a facility of arrest by the 
mildest emollient applications, especially 
fresh lard or cold cream (unguentum aquse 
rosse), reminds one of the prevention of a 
conflagration by the extinction of a fire at 
its commencement. Probably no local 
application will do more good at any 
stage, than such unguents, unless when 
the subcutaneous areolar tissue, lymphatic 
vessels or veins are so deeply involved as I 
to make appropriate the use of poultices 1 
of bread, slippery-elm bark, or flaxseed 
meal.-IL] 
As already stated, the tendency to death 
from Erysipelas exists in three principal 
directions. To that by asthenia I have 
already referred ; the other two which are 
most important, are either by implication 
of the brain, or by obstruction to the res- 
piration. In the former the symptoms 
may be due to the blood-poisoning, or to 
extension of the inflammation to the me- 
ninges. When the cerebral symptoms are 
referable to the condition of the blood, no 
change in the treatment is required ; but 
when to meningitis or meningeal conges- 
tion-supposing that this diagnosis can 
be accurately made-the application of ice 
to the head, and warmth to the extremi- i 
ties, together with free purgation, will be 
found useful. It is certain that such mea- 
sures will relieve and lead to the cure of 
many cases of a most unpromising ap- 
pearance. 
When the danger to life depends upon 
interference with the respiration, either 
the fauces or the glottis is the most usual 
seat of mischief. It is then necessary to 
relieve, if possible, the swollen mucous 
membrane, and so allow of the passage of 
air through the larynx ; but when this 
cannot be accomplished, the surgeon 
should be ready to perform laryngotomy 
or tracheotomy. 
When pus is known or is supposed to 
exist, even in small quantity, in the neigh- 
borhood of important organs, such as the 
eye or the glottis, it is necessary that in- 
cisions should be made for its evacuation. 
When it exists in larger quantity under 
the skin of limbs, in the neighborhood of 
joints, or glands, the same plan should be 
adopted ; and a fortiori, when large tracts 
of cellular tissue are so affected, and the 
case resembles that of " diffuse cellular in- 
flammation," free incisions are necessary. 
For all the details of the treatment of 
Erysipelas, when thus requiring surgical 
interference, the reader is referred to sys- 
tematic and' other treatises on surgery. 
In conclusion, it need only be stated 
that all those hygienic measures, such as 
good feeding, fresh air, and quiet, which 
are essential in the treatment of all acute 
specific diseases, are required and under 
similar direction in the treatment of Ery-, 
sipelas. 
Varieties.-The following terms have 
found their way into ancient and modern 
books, and have been used to denote the 
several so-called varieties of Erysipelas:- 
E. neonatorum. 
E. complicatum, et simplex. 
E. idiopathicum, et symptomaticum. 
E. verum, et spurium. 
E. phlegmonosum, vesiculare, bullosum, 
&c. 
E. acutum. 
E. erraticum. 
E. nervosum, oedematodes, &c. 
The above list shows that the principles 
of nomenclature have varied widely; 
names having been constructed on the 
fact of their representing such conditions 
as-the age of the individual attacked ; 
the presence or absence of complications ; 
the supposed mode of origin; the fact of 
the disease being Erysipelas or something 
else ; the degree of development of one or 
more anatomical elements of the disease ; 
the time of its duration ; the mode of its 
distribution ; and the nature of its com- 
plications. 
It does not appear to me to be neces- 
sary to explain these words; their enu- 
meration is sufficient to show their unsci- 
entific character and practical inutility, 
and to lead towards the hope that they 
may not be perpetuated. 330 
PYEMIA. 
PY2EMIA. 
John Syer Bristowe, M.D. 
The present article will be limited to 1 
the consideration of that morbid state of 
the system to which the term "Pysemia" 
has of late years been generally applied. 
This morbid state is closely related to 
phlebitis ; with which disease it was until 
recently confounded, and on which it un- 
doubtedly often supervenes. It is related 
to those diseased processes which Virchow 
has named " thrombosis" and " embolia;" 
for the secondary deposits which charac- 
terize Pysemia immediately depend, in 
great measure if not solely, on the obstruc- 
tion by solid material of the vessels lead- 
ing to the spots in which these deposits 
occur. It is related to erysipelas, and 
such like "unhealthy" inflammations; 
for not only does it occur as a sequela of 
these affections, but their neighborhood 
serves often to induce Pysemia in patients 
who but for this neighborhood would have 
escaped. Again, it is related to puerperal 
fever; or, to speak more precisely, the 
loosely applied term "puerperal fever" 
includes, with many other diseases, a 
large number of cases of puerperal Pyse- 
mia. And lastly it is related to several 
more or less well-defined morbid condi- 
tions of the system (septicaemia) brought 
on by the entrance into the blood, through 
the veins or lymphatics, of various non- 
specific animal poisons. These related 
affections will all be fully discussed in 
their proper places; and will be noticed 
here so far only as the due elucidation of 
the subject before us renders necessary. 
I. Etymology. 
The word " Pysemia, " derived from the 
two Greek words rtvov and aiua, signifies 
literally pus in the blood. Its English 
synonyms are "purulent absorption" and 
"purulent infection. " Every one of these 
terms implies a theory, viz. - that an 
essential feature in the disease to which it 
relates is the presence in the circulating 
fluids of the elements of pus. In this 
respect they are all objectionable; for 
while some authors accept this theory of 
the disease, others (whose opinions are 
equally well entitled to respect) reject it, 
and to them the name is necessarily the 
embodiment of error. The term "Pyae- 
mia" is nevertheless a convenient one ; it 
has come to signify to the practising medi- 
cal man, quite apart from all theoretical 
considerations, a form of disease attended 
with certain definite symptoms and cer- 
tain definite anatomical lesions ; and even 
if some equally euphonious but less objec- 
tionable term were now to be proposed, it 
is more than doubtful whether the incon- 
venience of its substitution would be at- 
tended with any adequate compensatory 
advantage. In this qualified sense the 
term "Pyaemia" will be used in the fol- 
lowing pages. 
II. Definition of Pyemia. 
Pyaemia is a disease originating often in 
contagion, and attacking for .the most part 
those who are suffering from the results of 
serious injuries attended with wounds, or 
who have undergone grave surgical opera- 
tions, or who are laboring under acute 
suppurative inflammation involving bones, 
or in whom parturition has recently oc- 
curred. Its onset is usually sudden, and 
marked by the occurrence of a severe 
rigor followed by profuse perspiration. 
Rigors succeeded by perspirations for the 
most part recur ; the pulse becomes feeble, 
rapid, variable, often intermittent, the 
respirations shallow and frequent, and 
cough (attended or not with expectora- 
tion) commonly shows itself; the tongue 
generally becomes dry and furred ; the 
appetite fails ; and nausea, vomiting, and 
diarrhoea not unfrequently supervene; the 
surface generally soon gets sallow or even 
distinctly jaundiced ; the patient acquires 
very much the aspect of a person suffering 
from enteric fever-delirium at night often 
comes on; but he remains for the most 
part conscious, at least when roused ; and 
soon becomes excessively feeble and pros- 
trate. It happens often that, in the pro- 
gress of the malady, inflammation, or 
even suppuration, occurs in some accessi- 
ble part or parts, especially in or about 
the joints and in the muscular and cellular 
tissues. The duration of Pysemia is gene- 
rally from about four to ten days; but it now 
and then becomes chronic, and may then 
last for several weeks or even longer. Its 
result is almost invariably fatal. The 
chief lesions discoverable after death are 
patches of hemorrhage, or of inflammatory 
consolidation, or abscesses, scattered in 
various proportions among the different 331 
PATHOLOGY OF PYEMIA. 
organs and tissues of the body, but occur- 
ring far more often and far more numer- 
ously in the lungs than elsewhere. The 
part antecedently affected is generally 
found in a state of suppuration, and un- 
healthily inflamed or sloughy. 
The most characteristic features of Py- 
semia seem to befirst, its supervention 
on certain special conditions of the system; 
second, the occurrence of rigors with per- 
spirations; third, the presence of jaundice; 
fourth, the formation of external abscesses; 
fifth, the great prostration and early death; 
and sixth, the occurrence of certain charac- 
teristic lesions, easily to be recognized 
after death. 
III. Pathology of Pyaemia. 
1. Morbid Anatomy. 
Discarding, in our detailed account of 
the morbid anatomy of Pyaemia, those ab- 
normal conditions of organs and tissues 
which may be now and then discovered 
after death from this disease, but have 
only a fortuitous connection with it, we 
will limit ourselves to the consideration 
of those morbid changes only which form, 
so to speak, an integral part of Pyaemia. 
(a) Morbid Anatomy considered gene- 
rally. - The lesions which characterize 
Pyaemia consist in local congestions, ex- 
travasations of blood, inflammatory de- 
posits, abscesses, and necroses. Simple 
congestion is a phenomenon which is apt 
to disappear after death, or to be modified 
and masked by mere post-mortem changes; 
it is frequently observed during life to ac- 
company superficial pysemic inflamma- 
tions, it is frequently recognized after 
death in the vicinity of so-called " secon- 
dary deposits," and doubtless as a rule it 
precedes all the more important changes 
which attend this disease. Congestion 
is therefore a real and important link in 
the chain of pysemic events, but its pre- 
sence or absence post mortem cannot in all 
cases be taken as trustworthy evidence of 
its presence or absence during life. Ex- 
travasations of blood are of almost con- 
stant occurrence ; sometimes they appear 
as petechial spots or vibices ; sometimes 
as clots infiltrating the tissues of organs- 
abruptly marginated and resembling 
patches of pulmonary apoplexy ; some- 
times they form decolorized fibrinous 
masses, much like the fibrinous " blocks" 
observed under other conditions in the 
spleen, in the liver, and in the kidney. 
Inflammatory deposits are rarely if ever 
absent; and may be associated or mixed 
up with other morbid conditions, such as 
extravasations of blood, or may occur in- 
dependently of them. In the former case 
they often surround the extravasations, 
and in connection with serous surfaces 
form distinct false membranes. In the 
latter case they constitute, in the lung, 
patches of lobular hepatization ; and pro- 
duce in other organs nearly equally well- 
marked changes. The term " secondary 
abscess" has been largely employed to 
designate the localized morbid processes 
taking place in the course of Pyaemia. 
And in most cases of Pyaemia abscesses 
doubtless exist. Sometimes, especially in 
joints and certain other places, suppura- 
tion takes place so instantaneously that 
the formation of pus would almost seem 
to be the first evidence in them of a de- 
parture from the condition of health. But 
more commonly the formation of an ab- 
scess is distinctly a later process, super- 
vening on the extravasation of blood or 
on the effusion of lymph, and commencing 
either at the margins of the diseased patch, 
or at some central point in it, or involv- 
ing the patch simultaneously in its whole 
extent. In some cases the cavities which 
pass for abscesses would seem rather to 
be the results of circumscribed gangrene 
than of true suppuration ; for they yield 
a gangrenous odor, and contain a soft 
shreddy material, more or less adherent 
to the parietes, and infiltrated with a 
dirty-looking fetid puriform fluid. A few 
words will comprise all that need be here 
said generally in regard to the microscopic 
appearances observed in the several mor- 
bid conditions above described. The 
elements of blood, more or less modified, 
may of course be discovered in abundance 
in the hemorrhagic patches; fibrillated 
lymph, of the usual character, may be 
recognized in the inflammatory deposits, 
especially in those occurring on serous 
surfaces ; and in those deposits occupying 
the parenchyma of organs granular mat- 
ter, exudation corpuscles, and compound 
granule'cells are generally abundant; true 
pus cells are by no means infrequent in 
pyaemic abscesses, but the puriform fluid 
is sometimes found to consist of the debris 
of tissue, oily particles, and disintegrating 
cell-forms only. 
Although the description which has 
just been given is generally applicable to 
pyaemic lesions, in whatever part of the 
body they may occur; there are yet so 
many differences between different organs 
in regard to the relative frequency with 
which they become involved, in regard to 
the relative frequency with which the 
various forms of lesions above enumerated 
affect them, so many minor differences 
dependent probably on structural and 
other peculiarities in the organs them- 
selves, that a special description of these 
lesions, as they occur in the more impor- 
tant organs at least, can scarcely be 
avoided. 
(&) Morbid Anatomy of Lungs.-In the 
lungs the diseased patches are scattered 
irregularly, but are generally most abun- 332 
PYJEMIA 
dant in the lower part. Their numbers 
vary considerably ; sometimes they are 
exceedingly numerous, while one lung is 
affected, the other lung is quite healthy. 
Most of them abut more or less exten- 
sively on the surface of the lung. The 
individual patches range generally in size 
between that of a filbert and that of a 
pea. Sometimes they are smaller, and 
not infrequently larger ; but in the latter 
case the increase of size is generally pro- 
duced by the coalescence of contiguous 
patches. The characters of these patches 
vary very considerably. Sometimes they 
are distinctly apoplectic; that is to say, 
they are reddish-black, void of air, firm, 
abruptly marginated, yield blood-stained 
serum on pressure, and differ in no respect, 
but that of size, from the pulmonary ex- 
travasations due to mitral-valve disease. 
More frequently, although still distinctly 
apoplectic, they have undergone changes; 
they have become more or less decolor- 
ized, the margin has assumed a pale buff 
color, and the more central portions a 
rusty or brownish hue ; at the same time 
some degree of softening has generally 
taken place. This softening often begins 
in, and may be limited to, the outer buff- 
colored layer, which then forms an inter- 
rupted puriform interval between the bulk 
of the diseased patch and the surrounding 
healthy tissues ; at other times this pro- 
cess commences internally, probably in 
connection with the bronchial passages 
leading into the affected portion of lung ; 
at yet other times a more general soften- 
ing takes place, and the whole patch comes 
to form an abscess-like cavity. Some- 
times, though much more rarely, the 
patches of lung disease are rather pneu- 
monic than apoplectic, and then strictly 
resemble the patches of lobular pneumonia 
which supervene on laryngitis, diphtheria, 
and other diseases obstructing the larger 
air-passages. Under these circumstances 
the patches vary considerably in color, 
according to the relative degrees in which 
congestion and inflammatory deposits 
may be present in them, but are granular 
and have the ordinary aspect of inflamed 
lung tissue. Pneumonia of this kind, 
however, is more often combined with 
other pyeemic changes in the lung, than 
it is an uncomplicated phenomenon; some- 
times surrounding apoplectic and other 
patches, and it may be combining several 
of these into a common mass of consolida- 
tion ; sometimes forming independent 
patches scattered indiscriminately among 
them. Abscesses or collections of puri- 
form matter are common, but very far 
from universal; often they are formed, as 
has been described, by the breaking down 
of clots, still more often they result from 
the purulent infiltration of pneumonic 
patches, and in both such cases are found 
in combination with patches of hemor- 
rhage, or of inflammation, or of both. 
But there are some cases of Pyaemia where 
abscesses alone, sometimes surrounded by 
solid infiltrated parietes, sometimes by 
breaking-down tissue, are discovered. In 
these cases it would almost seem that the 
process is different from the beginning; 
that in some of them the formation of pus 
takes place coincidently with, if not prior 
to, whatever other inflammatory changes 
may be found associated with it; that in 
others the diseased and puriform patches 
are the simple result of necrosial disinte- 
gration or sloughing. 
The lung tissue in which the diseased 
patches are imbedded may be, and often 
is, healthy ; but very frequently more or 
less of it is congested or oedematous or 
even carnified. The bronchial tubes 
mostly present an excess of secretion, 
and those which are directly connected 
with the diseased tracts often contain pus, 
and sometimes the rusty tenacious fluid 
which characterizes pneumonia. 
The subpleural tissue, especially that 
investing the lung, is generally the seat 
of extravasations of blood ; and appears 
therefore studded more or less thickly and 
more or less irregularly with petechial 
spots and vibices. The surface of the 
pleura may be smooth and healthy-look- 
ing; or it may be invested in its whole 
extent by a layer of recently effused 
lymph; and the cavity may be occupied 
in a greater or less degree by transparent, 
opaline, or even distinctly purulent fluid. 
But, perhaps more commonly, the lung is 
only partially covered with lymph-each 
lump of pulmonary disease, which abuts 
on the surface, forming a centre of in- 
flammation and of a disk of inflammatory 
exudation which is thickest at the centre 
and becomes thinner and thinner as it re- 
cedes from that point, until at length it 
ceases. This lymph presents a reticu- 
lated surface, and differs in no degree, 
microscopically or otherwise, from that 
of ordinary pleuritis. 
(c) Morbid Anatomy of Heart.-The sur- 
face of the heart, like that of the lung, 
is often studded with extravasations of 
blood ; and these are generally most abun- 
dant about its basal portion. Similar 
extravasations may also be seen in the 
substance of the muscular parietes, and 
beneath the endocardium. In the walls 
of the heart, too, may not infrequently be 
discovered (generally in the midst of ex- 
travasated blood, or at all events within a 
zone of congestion) yellowish spots, from 
the size perhaps of a horse-bean down- 
wards, which consist either of muscular 
tissue infiltrated with some inflammatory 
exudation or of a cavity full of pus or 
puriform fluid, or of broken-down and 
disintegrated tissue. The muscular fibres 
in and around these spots will be found 
under the microscope to be more or less PATHOLOGY OF PYEMIA. 
333 
broken into fragments, devoid of trans- 
verse markings, and studded thickly with 
minute oily molecules. The diseased 
patches in the heart vary much in num- 
ber ; sometimes not more than one is 
present, sometimes they are almost innu- 
merable. They vary too as regards their 
position; perhaps they are most common 
about the base of the ventricles, but no 
part is free from liability to them, and 
they are sometimes found in the musculi 
papillares. As in the case of the lungs, 
so here, the patches of disease act as cen- 
tres of inflammation. When they reach 
the pericardial surface, they induce in- 
flammation in that membrane, with exu- 
dation of lymph; and when they reach 
the endocardial surface, they may lead to 
important changes in the endocardium it- 
self. In the former case the exudation is 
of the same nature as that which occurs 
in connection with the pleura ; in the lat- 
ter case the endocardium itself is apt to 
become thick and granular, from intersti- 
tial inflammatory deposit, and its free sur- 
face to be studded with so-called "vegeta- 
tions." Occasionally vegetations become 
deposited upon the valves. Excepting 
the various morbid conditions just de- 
scribed, the heart is generally found quite 
healthy. 
(d) Morbid Anatomy of Liver. - Jaun- 
dice is a marked, though not an invari- 
able symptom of Pyaemia; yet nothing 
has been detected post mortem, in the con- 
dition of the liver to explain its occur- 
rence. Frerichs asserts1 that " the bile 
ducts are open, and usually pour out a lit- 
tle thin secretion," and that "the organ 
itself is in most cases anaemic and dry." 
The liver in these cases has, in fact, a 
healthy appearance, except in so far as it 
happens to be the seat of special pysemic 
changes. These changes consist in con- 
gestions, inflammatory exudations, and 
localized disintegrations or suppurations. 
They have no special seat. The earliest 
condition of disease, and one that is often 
alone seen, is the presence of congested 
patches of a port-wine hue. These vary 
in size and shape, have often a superficial 
area of two or three square inches, dip to 
a greater or less extent into the substance 
of the organ, and for the most part in- 
clude irregular patches of unnatural pal- 
lor. Such patches often differ, so far as 
can be ascertained, in color only from the 
surrounding healthy tissues. Sometimes 
studding these patches, sometimes occur- 
ring independently of them, spots may be 
seen of an opaque buff color, in which the 
liver tissue is evidently infiltrated and 
softened, and it may be broken down into 
a puriform pulp. These spots have usu- 
ally around them a halo of congestion, 
and their contents consist sometimes 
chiefly of pus-corpuscles, sometimes of 
disintegrated liver substance only. But 
besides these, larger abscesses are not in- 
frequently met with-abscesses the size 
of a filbert, a chestnut, a hen's egg, or of 
still larger dimensions. These generally 
contain a greenish-colored purulent fluid ; 
and are sometimes, judging both from 
their odor and from their appearance, 
distinctly gangrenous. 
(e) Morbid Anatomy of Spleen.-When 
the spleen is secondarily affected in Pyae- 
mia, the morbid appearances which it pre- 
sents are very much like those observed 
in cases of heart disease. They consist 
generally either of circumscribed extrava- 
sations of blood, or of fibrinous "blocks," 
which are both often of considerable size. 
The "apoplectic" clots tend to become 
decolorized at the surface and to break 
down variously into a puriform pulp ; the 
fibrinous blocks are usually softer and 
more juicy than those of heart disease, 
and tend, like the clots, to liquefy. Dis- 
tinct abscesses, too, of various sizes are 
often scattered throughout the organ. 
(/) Morbid Anatomy of Kidneys.-The 
kidneys are frequently involved ; and the 
morbid changes which occur in them are 
observed both more frequently and to a 
greater extent in the cortex than in the 
medulla. The medulla, however, by no 
means escapes. Sometimes these changes 
are limited to a single spot in one kidney, 
sometimes they affect both organs almost 
universally. But more commonly they 
are present in both and in some interme- 
diate degree of severity. Occasionally no 
abscesses have formed, but almost the 
whole tissue of the organ is mapped out 
by tracts and bands of deep congestion, 
which alternate with and surround patches, 
of which the color is unnaturally pale. 
More frequently distinct abscesses are 
present; these are generally small and 
tend to become clustered ; and both the 
individual abscesses and the groups of ab- 
scesses assume a linear arrangement, per- 
pendicular to the surface of the kidney. 
The abscesses contain a distinctly puru- 
lent fluid, have invariably a margin of in- 
tense congestion, and vary generally in 
size from that of a pea or horse-bean to 
an extreme degree of minuteness. Some- 
times, however, they are so large as to 
contain an ounce or two of pus. They 
can almost always be seen on removing 
the capsule of the organ, and very often 
the removal of the capsule allows the con- 
tents of the more superficial ones to es- 
cape. The formation of pus in these ab- 
scesses seems to take place, originally at 
least, in the intertubular tissue ; and very 
often in the early stages the Malpighian 
bodies and tubules in the affected spot are 
quite healthy. 
(y) Morbid Anatomy of other Abdominal 
1 Klinik der Leber-Krankheiten : Sydenham 
Soc. Transl., vol. i. p. 162. 334 
PYEMIA. 
Organs and of Peritoneum.-Congestions 
anil petechial extravasations are apt to 
occur, both in the gastro-intestinal mu- 
cous membrane, and in that of the genito- 
urinary apparatus. As regards the first- 
named mucous tract, it is an interesting 
fact that there are occasionally observed 
upon it, and more especially on that part 
of it which belongs to the caecum and co- 
lon, patches of granular exudation. Oc- 
casionally, too, the intestinal submucous 
tissue becomes the seat of well-marked 
pysemic deposits, which may lead to the 
destruction of the mucous surface over 
them, and the production of a sloughy 
ulcer, not unlike the ulcer of enteric fever 
or that which follows the opening of a 
boil. 
As regards other organs connected with 
the abdomen little need be said. They 
are rarely affected secondarily, and even 
when they are thus affected they present 
few points of importance or interest either 
to the pathologist or practitioner. Of 
them all, the prostate and the testicle 
probably most often undergo suppura- 
tion. 
The pysemic affections of the perito- 
neum resemble those of the pleura and 
pericardium. Sub-serous extravasations 
of blood are common; and inflammatory 
changes occurring within viscera (especi- 
ally the liver and the spleen) lead to in- 
flammation in the serous surface external 
to them, which may remain limited in 
extent, or become general peritonitis. 
Very often an abscess forms between the 
surface of the diseased lump and what- 
ever organ or part is in contact with it- 
the abscess being limited laterally by ad- 
hesions, which correspond accurately to 
the margin of the lump. The same thing, 
though on a much more minute scale, is 
of general occurrence in the case of the 
lungs and pleura. 
(/i) Morbid Anatomy of Brain.-The 
brain does not appear to be a very fre- 
quent seat of pyaemic changes. When 
present, however, they consist of conges- 
tions with extravasations of circumscribed 
softenings, and of abscesses. The ex- 
travasations affect chiefly the surface of 
the organ, and though perhaps generally 
petechial, sometimes become sufficiently 
abundant to occupy an extensive tract of 
the subarachnoid tissue. The circum- 
scribed softenings and abscesses occupy 
indifferently any part of the brain-the 
gray matter, the white matter, the cere- 
brum, the cerebellum, the corpus striata, 
the optic thalami, the pons Varolii-no 
part necessarily escapes. The former are 
yellowish, more or less congested, more 
or less softened, patches, such as are met 
with in cases of so-called "embolism" of 
the brain, but of smaller size, varying 
mostly from that of a horse-bean down- 
wards ; the latter are distinct abscesses 
containing glairy greenish-yellow pus, and 
sometimes attain considerable dimensions. 
The number of foci of disease present at 
one time varies very considerably ; some- 
times not more than one or two are dis- 
covered, sometimes they are so numerous 
that scarcely any part of the brain, so 
large even as a chestnut, is found free 
from them. The softened patches con- 
tain, in addition to disintegrated nervous 
tissue, vast numbers of compound granule 
cells. 
(i) Morbid Anatomy of Organs of Sense. 
-Of the organs of sense the eye only calls 
for special remark. This organ occasion- 
ally becomes the seat of suppurative in- 
flammation, especially in cases of puer- 
peral Pyaemia. In these cases the affection 
of the eye is characterized1 "by redness 
of the conjunctiva, intolerance of light, 
and contracted pupil; rapidly followed by 
opacity of the cornea, and excessive che- 
mosis." The eye ultimately sloughs, and 
its contents escape. 
(k) Morbid Anatomy of Bones and Joints. 
-Suppuration sometimes takes place in 
connection with bones. The affected bone 
or portion of bone then becomes rapidly 
denuded of periosteum; fetid pus accu- 
mulates upon its surface, while at the 
same time probably pus infiltrates its can- 
cellous texture, and rapid necrosis ensues. 
The joints are much more frequently 
affected than the bones. The synovial 
fringes become intensely congested, and 
the synovia increased in quantity or re- 
placed by pus or puriform fluid. The 
capsule of the affected joint becomes dis- 
tended, and the parts external to it be- 
come more or less inflamed. When the 
fluid within the joint assumes a purulent 
character, which is by no means always 
the case, it often happens that the parts 
of the lining membrane which had been 
congested become pale, that destruction 
of cartilage takes place, that the joint, in 
fact, becomes disorganized. AH joints, 
small as well as large, are liable to be 
affected. 
(I) Morbid Anatomy of Cellular Tissue 
and Muscles.-Again, the secondary effects 
of Pyaemia show themselves constantly 
among the muscles and in the cellular 
tissue of the body generally. Extravasa- 
tions of blood here are exceedingly com- 
mon, inflammatory congestions and exu- 
dations frequently occur, and abscesses 
(often of large size) form rapidly, and 
almost without warning. These morbid 
changes are often observed in the walls of 
the chest and belly, and in the neighbor- 
hood especially of joints, for inflammation 
of which latter parts they are then very 
liable to be mistaken. Pysemic abscesses 
have been met with in the tongue. 
1 Arnott, Medico-Chirurgical Transactions, 
vol. xv. PATHOLOGY OF PYEMIA. 
335 
(m) Morbid Anatomy of Skin.-The skin 
necessarily partakes sooner or later in any 
morbid process which is going on imme- 
diately below it; and hence discoloration 
of skin is frequently observed over super- 
ficial pysemic infiltrations and abscesses. 
When jaundice is present, the skin neces- 
sarily partakes in the general icteroid 
tinge. Apart from the above, the morbid 
conditions of the skin in pyaemia are not 
very important. Petechiae are not very 
common ; sudamina are frequently present; 
and occasionally vesicular and pustular 
eruptions have been observed. 
(n) Ilelative Frequency with which Organs 
are affected.- There is considerable differ- 
ence in the relative frequency with which 
the various organs and tissues of the 
body become secondarily affected in Py- 
aemia. The lungs rarely escape, and not 
infrequently are the only parts in which 
morbid changes are observed. The vis- 
cera affected next in frequency to the 
lungs would seem to be the kidneys. 
After these the liver, spleen, and heart. 
Then perhaps the brain. Among organs 
less often affected may be enumerated the 
intestinal canal, the testis, the prostate, 
and the eye. The joints and the general 
cellular tissue of the body become of course 
very frequently the seat of secondary affec- 
tions. And indeed, from the great extent 
of the one and the great number of the 
other, disease in these parts is without 
doubt constantly overlooked. The serous 
membranes, at least one or two of them, 
are rarely found uninflamed : this condi- 
tion may occasionally depend on morbid 
processes originating in themselves, but 
in the great majority of cases, as has been 
already explained, is due to the extension 
of inflammation from some subjacent 
organ. 
(o) Morbid Condition of Blood. - The 
chemistry of the blood in Pyaemia has not, 
so far as we know, been investigated. 
We must content ourselves therefore with 
the discussion of its physical properties. 
With certain important exceptions, which 
will be presently fully considered, the 
blood in Pyaemia presents no important 
differences from the blood of health; it 
retains its natural color, the blood disks 
and the white corpuscles preserve their 
due numerical relation to each other and 
to the mass of the blood, and so far as can 
be recognized their normal characters. 
Sometimes the blood appears to be unu- 
sually fluid, to present in the cavities of 
the heart and in the larger vessels only 
traces of coagulum. More commonly it 
coagulates in the usual way ; and we find 
distinct clots in one or more or all of the 
cavities of the heart. Sometimes these 
are ordinary-colored post-mortem clots, 
sometimes they consist wholly or almost 
wholly of pure fibrine ; and in either case 
they may be prolonged in a cylindrical 
form into the large vessels. There is no 
special tendency for the right side of the 
heart to be occupied, far less to be occu- 
pied exclusively, by these clots. They 
may be found there, it is true, and found 
there while the left cavities are contracted 
and empty. But in many cases, while 
the right side is empty, the left is dis- 
tended with them. In fact there is noth- 
ing in the situation or character of these 
clots to distinguish them from those which 
are found in many other forms of disease. 
The adherent rounded clots, which soften 
in their interior into a puriform pulp, 
have sometimes been supposed to charac- 
terize Pyaemia. But this is clearly a mis- 
take.1 Such clots are far more commonly 
observed in other cases ; indeed are alto- 
gether exceptional in Pyaemia ; and when 
present are evidently accidental and pro- 
bably trivial complications. 
The most important and characteristic 
changes of the blood in pyaemic cases are 
manifested more particularly in the veins 
of the part at which infection is supposed 
to have occurred, and in the small arterial 
twigs leading to the spots in which secon- 
dary lesions have become developed. The 
"veins leading from the seat of supposed 
infection have been examined over and 
over again with extreme care ; and the 
general results of these examinations may 
be shortly summarized. In some cases 
the veins, though traced into suppurating 
and even sloughing regions, are found, 
both as regards their walls and their con- 
tents, apparently entirely healthy; in 
other and more numerous cases they are 
seen to be in various ways and degrees 
diseased. Their parietes are thickened 
and indurated ; they may be seen to com- 
municate by orifices, resulting from ulcer- 
ation or some other cause, with the mor- 
bific elements in which they are lying 
imbedded ; and their interior is occupied 
by coagula. These coagula are mostly 
adherent, and more or less decolorized; 
they may be solid throughout, but more 
commonly are reduced in their interior 
into a reddish or yellowish puriform pulp 
or fluid. This fluid appears generally to 
consist merely of disintegrated fibrine, 
but in some cases is undoubtedly true 
pus.2 It is mostly, but not always, sepa- 
1 See Papers on Softening Clots in the 
Heart, in the Transactions of the Pathological 
Society of London. Vol. ii. p. 134, and vol. 
xiv. p. 71. 
2 The following case bears out the state- 
ment in the text. A man died of erysipelas 
of the face and Pyaemia. " The brawny tissue 
of the face was infiltrated with pus, and pus 
oozed from numerous divided vessels. The 
facial vein of the right side was thickened 
and surrounded by indurated adherent tissue, 
and its canal was dilated. The first inch of 
its course was occupied by thick purulent 
fluid ; to this succeeded a cylindrical adherent PYJEMIA. 
336 
rated from the venous walls by a layer of 
still consistent fibrine; and is generally 
shut out from the proximal portion of the 
venous channel in which it lies by a con- 
tinuation of this layer of fibrine, which 
forms a kind of septum or diaphragm be- 
tween them. Generally the rounded ex- 
tremity of the hollow fibrinous cylinder 
thus formed has adherent to it and pro- 
longed from it a process of ordinary 
colored clot. Sometimes one, sometimes 
several veins are found thus affected, and 
sometimes a considerable length of one is 
converted into an elongated abscess. 
The ultimate arterial twigs, distributed 
in the lungs to the masses of diseased 
lung structure, seem to be invariably oc- 
cupied, indeed distended, by a soft pulpy 
yellowish material, or by something more 
nearly approaching to ordinary coagulum, 
This material is found to consist mostly 
of mere disintegrated fibrine presenting 
the debris only of cells. But sometimes 
it contains distinct pus1-that is to say 
cells resembling in all their visible charac- 
ters pus-corpuscles or the white corpus- 
cles of the blood, but so abundant and so 
closely aggregated as wholly to negative 
the notion of their being normal blood- 
elements. Similar coagula have been de- 
tected in the small vessels leading to the 
diseased patches occurring in other organs 
besides the lungs-in the vessels for ex- 
ample of the heart, the spleen, and the 
kidneys. 
(p) Connection between blocked-up Con- 
dition of Vessels and Secondary Deposits.- 
So constantly are these coagula found in 
the small arteries, if looked for carefully, 
that the conclusion is forced upon patholo- 
gists that there is between them and the 
patches of diseased tissue a relationship 
of cause and effect. It might be surmised 
that the coagula in the bloodvessels are 
secondary to "the local pysemic formations 
with which they are connected, due to 
obstruction in the capillaries of the af- 
fected part and consequent stagnation of 
blood in the vessels leading to them. The 
characters of the coagula show, however, 
that this cannot be the true explanation 
of their mode of formation. They are 
not mere coagulated blood, nor even mere 
coagulated fibrine; but, if flbrine at all, 
are fibrine which has undergone changes, 
requiring time for their production, and 
often in point of time clearly in advance 
of the changes which have taken place in 
the patches of diseased tissue. There 
can be no doubt indeed that the sequence 
of events occurs in the reverse order; that 
the small afferent vessels become blocked 
up, and that on this blocking up super- 
vene those changes which, according to 
circumstances, end in extravasation of 
blood, inflammation, purulent infiltration, 
or gangrene. This view is partly based 
on direct observation in Pyaemia itself, 
partly on corroborative evidence derived 
from other sources. 
Thus, it has been clearly established by 
experiments that if a small artery leading 
to any spot be obstructed, that spot be- 
comes the seat of congestion and inflam- 
mation. The careful experiments of ^Ir. 
Wharton Jones1 show that if in the frog's 
foot such an artery be divided, and the 
capillary area to which it leads be thus 
cut off from all direct supply of blood, 
these capillaries nevertheless become filled 
with blood by regurgitation from neigh- 
boring anastomosing vessels; and further, 
that since by the same operation they 
have been cut off from the direct influence 
of the heart's systole, the blood which is 
poured into them becomes stagnant there, 
and intense congestion results. Again, 
the experiments of Cruveilhier, Sedillot,2 
Henry Lee,3 and others show that, if mer- 
cury, oil, pus, fibrine, be injected into the 
veins, they become impacted in the small 
arteries connected with the network of 
capillaries next beyond the seat of opera- 
tion, occlude them, and induce conges- 
tion, if not hemorrhage, and inflammation 
in the respective areas to which they lead. 
Each of these experiments has no doubt 
some point of special interest, but all con- 
cur in establishing one common fact of 
fundamental importance, viz., that the 
sudden stoppage of the direct supply of 
blood to a limited area tends to the pro- 
duction in that area of congestion and in- 
flammation-of the very processes in fact 
which mark the secondary effects of Py- 
aemia. 
The analogies afforded by other forms 
fibrinous coagulum, the distal extremity of 
which formed a hollow cone. The lower or 
proximal extremity gradually dwindled away, 
and was succeeded by purulent fluid : this 
latter continued throughout the rest of the 
facial vein as far as its junction with the 
jugular. No coagulum or adhesion separated 
this fluid from the general circulation. The 
purulent fluid found in the veins presented 
under the microscope large numbers of cor- 
puscles, but they were mostly smaller and 
more irregular in shape and size than normal 
pus corpuscles ; and few, if any, presented 
division of their contents under the influence 
of acetic acid. There were numerous secon- 
dary abscesses in the lungs."-Manuscript 
Notes of Post-mortem Examinations, St. Thomas's 
Hospital. Nov. 2, 1857. 
1 See Transactions of Path. Soc. ef London, 
vol. xiii. pp. 203, 204. See also Dr. Wilks's 
Report on Pyaemia, in the Guy's Hospital Re- 
ports, vol. vii. 1861. 
1 Astley Cooper Prize Essay, "On the State 
of the Blood and Bloodvessels in Inflamma- 
tion." Guy's Hospital Reports, Second Se- 
ries, vol. vii. p. 23 et seq. 
2 SSdillot, De 1'Infection purulente. 
3 Lee on Phlebitis. PATHOLOGY OF PYEMIA. 
337 
of disease are still more to the point. 
When arteries become obstructed either 
from morbid changes in their walls, or 
from plugs in their interior, the parts 
which they supply fall into an unhealthy 
condition. It is needless to dwell upon 
the changes which take place in the lower 
extremities, when in old age the arteries 
become closed by accumulated atheroma- 
tous and earthy deposits, or even upon 
the circumscribed softenings in the sub- 
stance of the heart (leading to rupture), 
which attend similar changes in branches 
of the coronary artery. The effects, how- 
ever, of thrombi and emboli must be con- 
sidered a little more in detail. It has 
been clearly ascertained by the researches 
of Virchow, Kirkes, and succeeding ob- 
servers, that, in cases of heart disease 
with vegetations on the valves, these 
vegetations are apt to be detached, car- 
ried with the onward current of the blood, 
and impacted in the first artery they 
reach which is too small to permit of their 
transit. It has been clearly ascertained 
that such detached fragments, or "embo- 
li" as they are termed, become fixed in 
the arteries of the brain (more especially 
in the middle cerebral artery), and lead, 
in the brain structure beyond, to circum- 
scribed congestion, inflammatory soften- 
ing, and disintegration of tissue; that 
they become fixed in the small arteries of 
the spleen, and lead to extravasations of 
blood and so-called "fibrinous blocks;" 
that they become fixed in the renal ar- 
teries, and lead at one time to exudation 
of blood and lymph, at another time to 
minute abscesses; that they become fixed 
in the arteries of the retina, and lead to 
similar results there; that in fact they 
may occlude any artery of any organ, and 
thus lead to specific changes in the bit of 
tissue which that artery supplies. It has 
been clearly ascertained also that clots or 
"thrombi" formed in the interior of veins 
break down and crumble ; and that their 
fragments, swept away by the stream of 
the blood, pass onwards with it from the 
smaller to the larger veins, through the 
cardiac cavities and orifices, and thence 
still onwards along the arteries, until, 
like the broken off cardiac vegetations, 
they become impacted, and by their im- 
paction produce identical results. Fur- 
ther, it has been ascertained that clots 
form spontaneously, so to speak, not in 
the veins alone, but in the heart's cavi- 
ties, and in the arterial system ; and that 
the clots thus formed in the latter situa- 
tion occlude the arteries in which they 
arise, and lead in the parts beyond to the 
same changes as have been described in 
connection with emboli. Here again, 
throughout the whole series of allied but 
not identical processes, we find that ob- 
struction of the supplying artery causes 
in the part supplied precisely those lesions 
which occur as the specific local manifes- 
tations of Pyaemia. 
It has been already stated that the 
secondary effects of thrombosis and em- 
bolia are identical with those of Pyaemia ; 
and essentially no doubt they are so. Yet 
there are between them certain minor dif- 
ferences-differences chiefly of degree- 
which it may be desirable to consider. 
This will be most conveniently done by 
taking three or four important organs and 
comparing the effects of these diseases up- 
on them. In the brain the influence of 
embolia or thrombosis is almost invaria- 
bly limited to a single spot; Pyaemia pro- 
duces many spots of disease. The region 
affected in embolia is generally larger, at 
least in the beginning, than the individual 
regions affected in Pyaemia. Moreover, 
in the former case breaking down of tissue 
is far less rapid than in the latter case, 
and actual suppuration rarely if ever oc- 
curs. The pulmonary apoplexy attendant 
on heart disease is we believe generally, 
if not always, due immediately to throm- 
bosis of branches of the pulmonary artery 
belonging to the apoplectic region, fol- 
lowed by congestion and rupture of the 
capillary network of the part. Now the 
clots of ordinary pulmonary apoplexy are 
almost identical with the pulmonary clots 
of certain cases of Pyaemia. Like them 
they become decolorized upon the surface, 
like them they may become more or less 
perfectly surrounded by a rim of softening 
or suppuration, or may present similar 
changes in their interior, and like them, 
when they abut on the surface of the lung, 
they lead to the deposition of a layer of 
fibrine on the overlying pleural lamina. 
But as a rule they are less numerous, and 
individually much larger, than pysemic 
clots; and their tendency to soften, to 
suppurate, to slough, is far less. In the 
spleen, the wedges or blocks of effused 
blood, or fibrinous exudation, which so 
commonly result from cardiac emboli, are 
in their general aspect almost exactly like 
those connected with Pysemia; but here 
again the tendency to rapid suppuration 
or decomposition distinguishes for the 
most part the one form of deposit from the 
other. In the case of the kidneys the dif- 
ferences are less pronounced : in both af- 
fections minute abscesses are of common 
and early occurrence; in both, hemor- 
rhages and exudations of fibrine alone are 
occasionally met with. It would seem 
then that the chief distinction between 
pysemic deposits and those resulting from 
simple embolia resides in the fact of the 
greater tendency of the former to undergo 
changes of degeneration and destruction. 
But this after all is chiefly a difference of 
degree; and the difference in this respect 
between them is no greater than the differ- 
ence which may often be observed between 
actual cases of Pyaemia. Thus in one case 
VOL. I.-22 338 
PY2EMIA. 
of Pyaemia hemorrhagic effusions only will 
be discovered in the internal organs, in 
another case patches of inflammation only, 
in a third abscesses, in a fourth gangren- 
ous excavations ; though more commonly 
doubtless these various conditions are to 
a greater or less extent commingled. 
2. General Pathology of Pyaemia. 
(a) Conditions of System essential for the 
Development of Pyaemia.-Exclusive of a 
few cases in which, from want of a trust- 
worthy history or from some other cause, 
it has been impossible to determine what 
has been the original seat of disease ; and 
of a few other cases which may be found 
recorded, wherein after very minute and 
careful investigation nothing that could 
be regarded as a starting-point for Pyaemia 
has been discovered, and which may pos- 
sibly, therefore, have been idiopathic- 
exclusive of these, all cases of Pyaemia ap- 
pear to take their origin in some one or 
more well-marked local conditions of dis- 
ease; some coming naturally under the care 
of the physician, others under the care of 
the accoucheur, others under the care of the 
surgeon. We will enumerate them with- 
out particular reference to the department 
of practice to which they respectively be- 
long. First.-Pyaemia frequently follows 
on accidental injuries, such as extensive 
burns or scalds, bruising and lacerating of 
tissues, and compound fractures, especially 
on fractures of the long bones, and of the 
bones of the head and pelvis. Such acci- 
dents often, of course, become repaired 
without any untoward complication; often 
they are followed by serious results, and 
even death, quite independently of any- 
thing approaching to Pyaemia ; but often, 
and even at a time when they appear to 
be progressing favorably, the symptoms of 
Pyaemia come on and the patient dies 
rapidly of this disease. The occurrence 
of Pyaemia in these cases is generally dis- 
tinctly preceded by sloughing, unhealthy 
suppuration, by erysipelatous inflamma- 
tion, or some allied process. Second.- 
Pyaemia is the bane of certain operations. 
No operation possibly can be regarded as 
absolutely free from liability to the super- 
vention of Pyaemia; but large operations, 
operations that is to say which leave ex- 
tensive raw surfaces, especially therefore 
amputations of the larger limbs, opera- 
tions too in which bones are involved, and 
operations in which certain parts (the 
bladder, prostate, and urethra, to wit) are 
implicated, are especially liable to the 
supervention of Pyaemia. But. here again 
the pysemic symptoms are mostly preceded 
by the occurrence of unhealthy processes 
at the seat of operation. Third.-Pyae- 
mia is peculiarly apt to follow on acute 
suppuration taking place in connection 
with bones. Sometimes from an accident 
(unattended by breach of surface), some- 
times, so far as can be made out, sponta- 
neously, acute inflammation is suddenly 
lit up in connection with one of the bones 
-probably one of the long bones-suppu- 
ration rapidly takes place on the surface 
of the bone, between it and the periosteum, 
and in its interior ; the bone dies ; and in 
the course of these processes the symp- 
toms of Pyaemia suddenly declare them- 
selves. Fourth. -Phlebitis, as the disease 
is called, whether it be idiopathic or 
whether it be induced by injury or by 
operation,1 is a pregnant cause of Pyaemia. 
This complication lias been especially ob- 
served in connection with the operation of 
phlebotomy, in operations on varicose 
veins and hemorrhoids, and in connection 
with the wounding or tying of large veins 
in the course of certain other operations. 
Fifth.-Pyaemia is by no means an un- 
common sequela of suppuration involving 
certain of the organs of sense, such as the 
eye and the internal ear. Sixth.-So- 
called " low inflammations" attended with 
suppuration-in the male in connection 
with the bladder, prostate, and urethra, 
and in the female in connection with the 
ovaries and other genito-urinary organs- 
are not infrequently succeeded by Pyaemia. 
Seventh.-The period immediately after 
parturition is peculiarly obnoxious to the 
occurrence of Pyaemia. " Puerperal fever" 
is the generic term which is used for a 
variety of diseases occurring shortly after 
child-birth. What these diseases are it is 
not our province now to discuss ; but cer- 
tainly one form of so-called "puerperal 
fever" and one which causes no incon- 
siderable proportion of the deaths ascribed 
to puerperal fever, is Pyaemia. Eighth.- 
Certain forms of so-called "unhealthy" 
inflammation are not infrequently followed 
by Pyaemia. Such are phlegmonous ery- 
sipelas, diffuse cellular inflammation, car- 
buncle, dissecting wounds, malignant pus- 
tule. Ninth.-Pyaemia is described as 
taking place occasionally in the course of 
certain febrile affections, such as typhus, 
enteric fever, and variola. 
Now, in reviewing the above series of 
cases in which specially Pyaemia is apt to 
occur, several facts come into prominent 
relief. It would seem in the first place 
that, in such cases, Pyaemia is almost in- 
variably, if not always, preceded by some 
local suppuration, and that this suppura- 
tion is erysipelatous, gangrenous, or other- 
wise unhealthy. Such is the case after in- 
juries, after operations, after affections of 
the bones, of the organs of sense, of the 
genito-urinary organs, of the veins ; such 
too is certainly often the case in puerperal 
1 Pysemia is described as following on the 
operation of tying the funis in the new-born 
child. PATHOLOGY OF PYJEMIA. 
339 
women. It would seem in the second 
place that Pyaemia is peculiarly apt to 
supervene in cases in which bones are in- 
volved in these morbid processes. It 
would seem further that in the great ma- 
jority of cases, if not in all, there is reason 
to believe that veins are in some way 
or other specially implicated. Thus it 
has been conclusively determined that 
wounds and injuries of veins, and suppu- 
ration taking place in connection with 
them, not infrequently lead to Pyaemia ; 
it has been pointed out that the veins in 
the interior of bones are peculiarly thin- 
walled, and at the same time from their 
connections prevented from readily con- 
tracting, and that when inflammatory 
processes are going on in the interior of 
bones these vessels are necessarily pecu- 
liarly implicated ; as regards the skull, 
again, it is clear that the bones which 
form it, besides having in their interior 
the veins of the diploe, are related by 
their inner surface to the venous sinuses- 
channels which if not thin-walled like the 
veins of bones, are like them permanently 
patent; the eye and the ear stand in much 
the same position as the skull itself, they 
are bounded in fact by osseous tissue 
which almost necessarily becomes in- 
volved when serious inflammation occurs 
in the adjacent structures, and they com- 
municate almost directly by special veins 
with the sinuses, the peculiarities of which 
have been pointed out; again the prostate 
and neighboring parts are supplied with 
an almost superabundant net-work of 
veins ; and lastly in parturient women 
the uterine portion of the placenta is pro- 
vided with huge thin-walled venous si- 
nuses which receive blood from the curl- 
ing arteries and pour it into large uterine 
veins : at the time of parturition these 
are necessarily ruptured, and although by 
contraction of the uterus their orifices be- 
come in great measure closed, it is obvious 
that they are so circumstanced as to be 
peculiarly exposed to the influence of poi- 
sonous and other injurious processes going 
on in the interior of the uterus, or in con- 
nection with its lining membrane. 
(6) Essential Cause of Pycemia.-We are 
now in a position to consider what is the 
essential cause of Pysemia. The sudden 
onset of the disease, the markedly febrile 
and characteristic symptoms which it ex- 
hibits, the limited term of its duration, 
and its terrible mortality, together with 
the occurrence of specific lesions, all sug- 
gest a close analogy on the one hand be- 
tween it and certain contagious fevers- 
typhus fever, enteric fever, smallpox, 
diphtheria, and the like ; on the other 
hand, between it and certain diseases, 
such as glanders and hydrophobia, arising 
from the inoculation of animal poisons. 
In each of these analogous cases the dis- 
ease is due to the entrance into the system 
of some morbid poison, to the circulation 
of this poison through the vessels with the 
blood, the chemical changes thereby in- 
duced in the blood, and through the agency 
of the blood in the system generally. In 
Pyaemia, too, it is manifest that the symp- 
toms are due to the entrance into the 
blood of some materies morbi, and to 
changes thereby induced in that fluid and 
in the tissues through which it circulates. 
There are, however, marked points of dif- 
ference as regards the mode in which the 
several classes of poisons above referred 
to enter the system. In contagious fevers 
it is mostly by the breath that the conta- 
gium takes effect; in glanders and in 
hydrophobia it is by inoculation; but 
Pyaemia, though in a certain sense con- 
tagious, is never imparted through the 
instrumentality of gaseous exhalations 
alone, and never even by inoculation, ex- 
cept the appropriate condition be present 
of a raw, suppurating, or sloughing sur- 
face. Further, though it may be imparted 
by some contagious influence, it may, 
equally originate de novo, but never prob- 
ably becomes developed even in the latter 
case except in connection with some area 
of suppuration, and through the direct 
agency of that area. The poison which 
produces Pyaemia is evidently something 
more gross, something less subtle, than 
the poisons of those diseases with which 
we have compared it, and is capable only 
of acting on parts especially prepared as it 
were to receive and to develop it. 
It is important to determine what this 
poison is, and how it gains an entrance 
into the system. It was at one time be- 
lieved that pus, as such, is absorbed by 
the veins from the region of primary sup- 
puration, and carried bodily to the various 
localities in which secondary accumula- 
tions of pus are discovered-that a true 
process of metastasis takes place. Again, 
it was imagined that this disease is simply 
phlebitis, in which the inflammation of 
the veins has extended to the vena cava 
and the heart. Arnott1 maintained that 
the cause of what is now termed "Pyse- 
mia" is "inflammation of the veins, the 
consequent production of pus in their cavi- 
ties, and the entrance of this into the cir- 
culation." And since the period at which 
Mr. Arnott wrote, his views, with various 
more or less important modifications, have 
generally found acceptance. Thus, some 
have believed with Mr. Arnott that pus 
finds its way into the blood in conse- 
quence of the secretion of pus by the inner 
surface of some vein or veins inflamed by 
the extension of inflammation from sur- 
rounding parts ; others have considered 
that pus is absorbed from some suppurat- 
ing region by the open orifices of veins 
-orifices existing naturally (as in the 
* Med. Chir. Trans, vol. xv. PYEMIA. 
340 
uterus), or made by operation or disease; 
others again, have supposed that tlie pus- 
corpuscles carried with the blood become 
arrested in the capillary vessels of the 
lung, and there produce the characteristic 
lesions of Pyaemia, either by multiplying 
by means of cell-growth and thus forming 
an abscess, or by acting as foreign bodies 
and thus inducing congestion and inflam- 
mation in the surrounding parts. In sup- 
port of some at least of these views, it has 
been pointed out that the veins connected 
with the seat of primary disease are often 
thickened, and occupied by adherent 
coagula containing within them a puri- 
form fluid ; it has been maintained that 
pus-corpuscles may be recognized in the 
circulating fluid; and it has been found 
experimentally that the introduction of 
pus into the veins leads to changes in re- 
mote organs like those of Pyaemia. But 
Virchow1 (whose researches in connection 
with Pyaemia are most important) main- 
tains that the puriform fluid in the affected 
veins is not pus, but simply disintegrated 
clot, that the clot is formed in the veins 
wholly independent of phlebitis, and that 
the diseased condition of the venous walls 
is not the cause, but (if related to it at all) 
the consequence of the clot within it. 
Again, though Sedillot2 has taken pains 
to show that pus-corpuscles circulate in 
the blood in cases of Pyaemia, and may by 
their microscopic characters be recognized 
there, it is now generally allowed that 
pus-corpuscles do not mingle with the 
blood in the manner supposed, and that 
even if they did it would be impossible to 
distinguish them from the white corpus- 
cles of the blood itself. And lastly, 
although it has been shown that pus in- 
troduced artificially into the systemic 
veins may produce lobular inflammation 
of the lungs, it has been shown that the 
pus acts in such cases as an embolus, and 
much in the same way as other sub- 
stances which lead to mechanical obstruc- 
tion of the small pulmonary vessels. The 
theory which at present finds perhaps most 
general acceptance is that of which Vir- 
chow3 is the chief exponent. He denies 
that in Pyaemia pus (meaning, by pus, pus- 
corpuscles) enters the blood ; he denies 
that pus is ever found either in the thrombi 
occupying the veins of the region primarily 
diseased, or in the small vessels leading to 
the patches of secondary disease; he 
asserts that what had been regarded as 
pus is merely disintegrated fibrine, and 
that the material choking up the small 
afferent vessels of a secondarily-diseased 
tract is simply an embolus resulting from 
the crumbling away of the fibrinous mate- 
rial occupying the veins at the seat of 
primary disease; he maintains that all 
secondary pysemic formations and changes 
are thus the result of embolia, but that 
the differences which these formations 
exhibit in different cases are due to the 
difference of process which has led to the 
disintegration of the original thrombus. 
So much with regard to his explanation 
of the mode of production of secondary 
pysemic lesions : to explain, however, the 
general symptoms of Pyaemia, to explain 
certain diffused inflammatory processes 
(as inflammation of joints and of serous 
surfaces), which do not seem to be easily 
explicable on the embolic theory, he 
assumes that in many cases of Pyaemia, 
at least, certain ichorous juices are also 
absorbed into and act upon the system. 
Thus, according to Virchow, it would 
appear that Pyaemia is a complex condi- 
tion ; that from the veins at the seat of a 
primary disease solid matters and poison- 
ous fluids are circulated throughout the 
system; that the solid matters lead to the 
more material secondary lesions, the 
fluid matters to the more subtle changes, 
which combine to constitute the disease 
under consideration. 
These views are intelligible, and give a 
plausible explanation of most of the phe- 
nomena of Pyaemia ; but they do not, we 
conceive, explain all the phenomena of 
the disease, neither, as it seems to us, are 
they based on an impartial appreciation 
of all the facts. We admit that in the 
majority of cases the puriform fluid in 
clots is simply disintegrated clot, but we 
maintain that the true pus is occasionally 
met with in venous clots and in the clots 
of arteries, and that pus is occasionally 
discovered in transitu in the blood-not, 
we allow, in the form of scattered pus- 
cells, but in that of soft pellets.1 We see 
1 The following case of malignant and ra- 
pidly fatal scarlet fever may be quoted in 
confirmation of this statement:-"There were 
no pyaemic deposits ; but the following was 
the condition of the blood in the heart's cavi- 
ties : The left ventricle was empty, but all 
the other cavities were filled with largish 
fibrinous coagula. The greater part of the 
clot in the right ventricle consisted of per- 
fectly decolorized, recently deposited fibrine, 
straw-colored, elastic, and semi-transparent. 
Embedded in its substance were a few small 
opaque whitish masses, which looked like 
clots of older formation entangled in the sub- 
stance of the more recent one. These in- 
creased in number towards the pulmonic 
valves, and were very numerous in the cylin- 
der of clot occupying the trunk of the pulmo- 
nary artery and its left branch, rendering it 
in fact somewhat nodulated. All these masses 
had an opaque, buff-colored, creamy aspect, 
were irregular in shape, and appeared in the 
majority of instances to consist of convoluted, 
folded, wrinkled, or twisted fragments as 
1 Virchow's Cellular Pathology, translated 
by Dr. Chance. 
2 De 1'Infection Purulente. 
8 Cellular Pathology, Lectures IX. and X. PATHOLOGY OF PY.EMIA. 
341 
no sufficient reason to believe that veins 
do not share in the morbid changes which 
are going on around them, or that phle- 
bitis may not exist at a time when no ap- 
preciable thickening of their walls has 
taken place indeed, we have reason to 
believe that pus may be formed not only 
on the lining surface of these tubes, but 
even in the interior of clots adherent to 
them, by the communication to them of 
those tendencies to cell-production which 
are a part of the inflammatory process. 
We believe that in the above views undue 
importance has been attached to the em- 
bolic theory, too little to the independent 
formation of thrombi within the arterial 
system. We do not see how the embolic 
theory explains satisfactorily those cases 
of Pyaemia, starting from some portion of 
the systemic venous system, in which the 
lungs escape in great measure, or en- 
tirely, while secondary deposits are found, 
it may be, abundantly in other organs. 
Lastly, it seems to us as erroneous to re- 
gard the corpuscular element of pus only 
as pus, as it would be to attach that name 
to the liquor puris exclusively. Pus con- 
sists of both a solid and a fluid portion. 
On the whole, we are disposed to believe 
that, owing to some form of unhealthy 
process supervening in the region of pri- 
mary disease, unhealthy pus or the ele- 
ment of unhealthy pus (call it ichor if you 
will) finds its way into the circulating 
fluid, and poisons it; that this poisoning 
partly shows itself in producing in the 
blood a tendency to coagulate in the 
smaller vessels, partly shows itself by in- 
ducing more subtle but even more serious 
effects upon the system at large. We are 
not disposed to deny that some of the local 
effects may really be due to embolism, 
some even to the impaction of coagulated 
masses of pus-cells ; but we believe that 
thrombosis alone is the more general ex- 
planation of that obstruction of the minute 
vessels which leads to the secondary de- 
posits. 
(c) Cause of relative Frequency of Pycemic 
Deposits in different Organs.-On either 
view of the question, it is easy to under- 
stand why the lungs should be, as they 
generally are, first and most seriously 
affected. For since the majority of cases 
of Pyaemia originate in connection with 
the systemic venous system, the poisonous 
matters which induce the disease must 
reach first the pulmonary capillaries; and 
in connection with these, which act as a 
kind of filter and purifier, their effects are 
naturally earliest manifested. Further, 
since, as regards the circulation, the lungs 
may be regarded as the equivalent of the 
whole of the body besides, it is obvious 
that even if all the morbid effects of Pyae- 
mia throughout the system were produced 
simultaneously, the lungs would be still 
(if the morbid processes in them held any 
relation to the amount of blood passing 
through them) the equivalent in quantity 
of pyaemic disease of all the rest of the 
body, and would therefore far surpass in 
their liability to secondary deposits any 
other one viscus. It is not so easy to 
understand the differences presented by 
other organs as regards their relative lia- 
bility to disease; why, for example, the 
brain should so often escape, why the 
spleen, the liver, and the kidneys should 
so often suffer : all are equally exposed to 
the effect of emboli originating in the 
lung; all are equally liable, it might be 
supposed, to the formation of thrombi in 
their smaller vessels. To explain these 
differences there must, we imagine, be 
something in the character of the circula- 
tion, something in the formation of the 
various organs, which modify both the 
tendencies to morbid changes in the blood 
circulating in them, and the mode in 
which these morbid changes affect their 
tissues. 
(d) Cause of different Character of Pyce- 
mic Deposits in different Cases.-What, we 
may now ask, is the explanation of those 
differences as regards the character of the 
local deposits (described on a former page) 
though, they had been formed and moulded 
in other parts, and had become entangled 
and compressed by the surrounding clot. The 
masses were somewhat soft, and could be 
separated readily from the fibrine investing 
them; and when separated some of them 
could be unfolded, but at the same time gave 
no clear indication as to what their original 
shape had been ; some looked as though they 
might be collapsed bags, others were possibly 
cylindrical; none contained fluid. The same 
appearances were found in the right auricle. 
The left auricle contained, besides an ordi- 
nary clot, a single soft mass of the same kind 
as those that were found on the right side. 
Under the microscope the ordinary fibrinous 
coagula presented the usual characters of 
such formations ; but the soft masses consisted 
entirely of corpuscles, which had the size and 
general characters of pus, and of which (under 
the action of acetic acid) the nuclei were 
divided into two or three spherules."-Manu- 
script Notes of Post-Mortem Examinations, St. 
Thomas's Hospital, September 15, 1858. 
The soft opaque masses above described were 
very likely emboli carried from the seat of 
suppuration in the tonsil; but they were 
also, so at least it seems to the author, un- 
doubtedly pus. 
See also Transactions of the Path. Soc. of 
London, vol. ix. p. 279. 
1 If the presence of phlebitis is to be de- 
nied in all cases where there is an absence 
of thickening and congestion of the venous 
walls, it may with equal justice be denied 
that bronchitis has been present when the 
bronchial mucous membrane is found after 
death neither congested nor thickened. But 
in many cases of fatal bronchitis the mucous 
membrane itself looks quite or nearly healthy. PYAEMIA. 
342 
which distinguish one case of Pyaemia 
from another, and cases of Pyaemia from 
cases of ordinary embolia and thrombosis? 
Something is doubtless due to the different 
dates at which patients die. In those 
persons who succumb early, local pro- 
cesses of disease have had but little oppor- 
tunity to develop themselves; in those 
who die late the later stages of suppura- 
tion and sloughing have had ample time 
to become established. But this explana- 
tion does not apply to all cases; neither 
does it apply to the differences observed 
between cases of embolia and cases of 
Pyaemia. Here, as elsewhere, those sub- 
tle chemical changes (termed vital) so 
deeply interesting, so little understood, 
come into play. Why is it that when a 
cancerous growth has appeared in one 
part of the body, the whole system speed- 
ily becomes influenced, and diseased pro- 
cesses occurring elsewhere assume also 
the cancerous character? Why is it that 
when tubercular disease has manifested 
itself in one organ, the same form of dis- 
ease ere long becomes developed in other 
organs ? Why is it, again, that amongst 
all the varieties-shades-of cancer and 
of tubercle, that one variety which has 
first shown itself in any case is the pattern 
upon which the subsequent deposits of the 
same disease are formed ? It would seem 
that morbid processes, limited in the be- 
ginning to one spot, influence the che- 
mistry of the blood, and that of the system 
generally, and thus produce in the tissues 
a tendency to repeat, under the influence 
of exciting causes, those very morbid pro- 
cesses out of which the tendency arose. 
Again, certain conditions of unhealthi- 
ness, dependent on a variety of causes, 
give a type to the morbid changes acci- 
dentally occurring in different parts of the 
body. Thus, according to the former 
rule, the occurrence of gangrene at one 
part tends to the production of gangrene 
in other parts ; the existence of suppura- 
tion in one corner of the system tends to 
render inflammation suppurative else- 
where : thus, according to the latter rule, 
a certain condition of system (as that ac- 
companying typhus) is apt to favor the 
occurrence of gangrene, another condition 
of the system (as that accompanying con- 
valescence from various febrile affections) 
to favor the formation of local collections 
of pus ; and thus on one or other or both 
of these principles it doubtless depends 
that Pyaemia, which is mostly sequential 
on some localized mortification or suppu- 
ration of tissue, presents in the character 
of its secondary processes not only those 
differences which distinguish it from em- 
bolia and thrombosis, but those differences 
(not due to relative duration of disease) 
which distinguish cases of Pyaemia from 
each other. 
(e) Certain Varieties of Pyaemia Consid- 
ered.-We may here add a few words in 
regard to certain, real, or supposed varie- 
ties of Pyaemia. Pyaemia is generally an 
acute and quickly fatal disease : and when 
this is its character, pyaemic deposits may 
almost invariably be found. The deposits 
however are not generally related numeri- 
cally or otherwise to the severity of the 
case ; and cases are sometimes observed 
which, judging from the symptoms during 
life and from other evidences, are truly 
cases of Pyaemia, yet in which no pyaemic 
deposits are discovered. It would seem 
that Pyaemia resembles the exanthema- 
tous fevers in this respect, viz., that the 
blood-poison occasionally produces death 
ere local lesions have had time to mani- 
fest themselves. Sometimes cases of Pyae- 
mia become chronic ; the evidence that 
such cases are pyaemic being furnished 
chiefly by the occurrence of successive 
suppurations, in joints,1 in the cellular 
tissue, in the eye (it may be), and in other 
parts. Cases of this kind are sometimes 
observed after parturition, and such are 
some of the cases following on enteric and 
other fevers. The frequent occurrence of 
pyaemic deposits in the lungs only has 
suggested the possibility of a local Pyae- 
mia-a Pyaemia in which the poisoned 
condition of the blood is confined within 
certain limits, and effects its secondary 
changes within those limits only. By 
such a local condition of Pyaemia, con- 
fined within the ramifications of the por- 
tal system, Dr. George Budd2 has endea- 
vored to explain the occurrence of hepatic 
abscesses in cases of dysentery. This ex- 
planation of the frequent occurrence of 
dysentery and abscess of the liver is prob- 
ably erroneous ;3 and, indeed, our know- 
ledge of the progress of true Pyaemia 
does not justify us in admitting that the 
poison of Pyaemia can be limited in the 
manner suggested. 
(/) Origin of Pycemia in Contagion.- 
Pyaemia, which probably only occurs in 
the classes of cases which have been enu- 
merated-cases presenting the common 
features of some unhealthy suppurating 
surface-may arise in them either spon- 
taneously or as the result of some con- 
1 Dr. Wilks, in the Guy's Hospital Reports, 
remarks that there is a special tendency in 
Pyaemia to produce inflammation of the joints ; 
that in cases rapidly fatal this tendency has 
scarcely time to manifest itself; but that in 
chronic cases (cases, that is to say, in which 
the blood-poisoning has not been excessive 
and in which visceral inflammations have 
been but little pronounced) this special fea- 
ture of Pyaemia has full time for its develop- 
ment. 
2 Budd, On Diseases of the Liver. 
8 See Frerichs, Clinical Treatise on Dis- 
eases of the Liver; Syd. Soc. Translation, 
vol. ii. p. 113 et seq.: also Trans, of Path. 
Soc. of London, vol. ix. p. 241. PATHOLOGY OF PYEMIA. 
343 
tagious influence. Cases of spontaneous 
origin are not infrequent. Many of the 
cases in which (whether as the result of 
injury or not) acute suppuration rapidly 
involves some large portion of bone are 
cases in which there has been no previous 
ill-health, no exposure to morbic influ- 
ences. Many of the cases occurring after 
compound fractures or after operations 
arise under personal and surrounding con- 
ditions of good health. Other cases are 
induced by modes of dressing wounds 
which prevent union by first intention, 
and promote suppuration and unhealthy 
discharges. Many of the deaths ascribed 
to puerperal fever, and occurring sporad- 
ically, arise under similar conditions, and, 
so far as we can see, wholly independently 
of contagion. . There are many cases 
however, and these are in all respects the 
most important, where the occurrence of 
Pyaemia is distinctly due to the agency of 
some contagium. These cases are par- 
ticularly met with in surgical practice 
and in obstetrical practice. As regards 
surgical practice, it is well known that 
Pyaemia may be often absent from a hos- 
pital ward in which cases of serious acci- 
dent and cases of operation are in course 
of treatment, and may continue absent 
for a considerable period ; that after a 
while a case of Pyaemia, or a case of ery- 
sipelas, may be introduced into the ward 
or may originate within it, and that from 
that time operation case after operation 
case, accident case after accident case, 
may be attacked with pyaemic symptoms. 
There can be no doubt here that the 
spread of the disease is due to the pres- 
ence in the ward of some contagious in- 
fluence-not of a pyaemic contagium, for 
the disease cannot be excited in any pa- 
tient who is not suffering from a wound, 
nor in any wound probably unless it have 
become first unhealthy; but of a conta- 
gium which excites first unhealthy pro- 
cesses in the wound, and, by means of 
these unhealthy processes, Pyaemia. This 
contagium originates not only in cases of 
Pyaemia, but also in cases of erysipelas, 
diffuse cellular inflammation, phagedaenic 
processes, and the like, and in cadaveric 
poisons. There is no doubt that the ac- 
cumulation of many wounds in a limited 
space not merely promotes the diffusion of 
such a poison, but serves even to engen- 
der it.1 It is not improbable that the 
poison exerts an influence, to some extent 
at least, through atmospheric diffusion, 
and that this mode of spread is largely 
aided by overcrowding and bad ventila- 
tion. But Pyaemia arises even more 
frequently from actual inoculation of a 
healthy wound, either by the fingers of 
those who are engaged in attending on 
the sick, or by the dressings and appli- 
ances which are employed upon them. 
The same remarks, with scarcely any 
modification, apply to puerperal Pyaemia. 
Puerperal fever has been known over and 
over again to be conveyed by the clothes, 
and more particularly by the hands, of 
nurses and practitioners; and has been 
thus carried, not merely from other cases 
of puerperal fever, but from the poison of 
erysipelas and other unhealthy inflamma- 
tions, and from the dead-house. Further, 
the fact of the heavy mortality from this 
disease in lying-in hospitals,1 compared 
with the mortality from the same disease 
in patients treated at home, is well estab- 
lished ; and the occasional terrible out- 
breaks of puerperal fever, which blacken 
the annals of all these institutions bear 
witness, if not to its spontaneous origin 
therein, at all events to its virulence of 
contagion under circumstances favoring 
its spread. 
(g) Conditions modifying the Tendency to 
Pyceniia.-It has been asserted that the 
presence of organic visceral diseases ; the 
debility attending convalescence from va- 
rious acute maladies; the cachexiae which 
result from intemperate habits, from in- 
sufficient quantity and quality of food; 
untoward circumstances attendant occa- 
sionally on serious accidents and grave 
operations and parturition-shock, hem- 
orrhage, nervous depression, and the like; 
that these, and many other circumstances 
tending to impair the general health, pre- 
dispose in various ways to the occurrence 
of Pyaemia. It is difficult either to prove 
or refute such assertions ; it is difficult to 
believe that unhealthy conditions of sys- 
tem, however produced, should be with- 
out influence in favoring the attacks of 
Pyaemia and diseases related to it ; but, 
on the other hand, it may be confidently 
asserted that the vast majority of pyaemic 
patients have not been suffering from 
chronic visceral diseases ; that but few of 
those attacked are recovering from acute 
diseases ; and that many, very many, vic- 
tims of Pyaemia have enjoyed the best of 
health up to the moment of the accident 
or the operation of the disease which has 
exposed them to the danger of Pyaemia ; 
and that even in many cases the wound 
(if wound there be) has been progressing 
favorably up to within a few days of the 
sudden onset of pyaemic symptoms. It 
may be added as regards the subjects of 
amputations, that many more in propor- 
tion die of Pyaemia of those whose limbs 
have been amputated for injuries than of 
those whose limbs have been amputated 
' See on this subject Report on the Hos- 
pitals of the United Kingdom, by Dr. Bris- 
towe and Mr. Holmes, in the 6th Report of 
the Med. Officer of the Privy Council. 
1 Consult again Dr. Bristowe's and Mr. 
Holmes's Report, and also Dr. Barnes's Lec- 
tures in the Lancet of February, 1865. 344 
PYEMIA. 
for disease-many more, therefore, in this 
particular case of those whose bodily 
health has been good until within a short 
time of the occurrence of Pyaemia, than of 
those who have been reduced by pre- 
viously existing disease. Time of year, 
age, sex, have also been considered among 
predisposing causes. Season has proba- 
bly no very important influence. No 
doubt adults more frequently suffer than 
children, and men than women; but 
whatever differences in these respects 
may be observed are certainly due in an 
overwhelming degree to the relative fre- 
quency of grave accidents in the respec- 
tive sexes, and at the respective ages. 
Neither infants1 nor the aged are exempt. 
Want of ventilation, and filth, are impor- 
tant predisposing causes ; but in order to 
predispose it is necessary that the want of 
ventilation should co-exist with undue 
accumulation of traumatic or puerperal 
cases, or with the presence of unhealthy 
inflammatory processes; that the filth 
should comprise offensive and other ani- 
mal discharges. Mere dirt, mere defi- 
ciency of ventilation, have not, so far as 
we know, a very obvious relationship with 
Pyaemia; at least this may be said with 
certainty in reference to the Pyaemia of 
puerperal women. 
IV. Symptoms of Pyaemia. 
1. Symptoms considered collectively. 
The symptoms which usher in an at- 
tack of Pyaemia are generally well mark- 
ed, unless the condition of the patient, or 
the nature of the disease under which he 
is laboring at the time of its supervention, 
mask the pyaemic symptoms. In some 
cases the accidental injury, or the opera- 
tion, or the puerperal process, seem to be 
going on quite satisfactorily, up to the 
very moment when Pyaemia manifests it- 
self. In other cases the wound made by 
accident or operation has taken on for a 
shorter or longer period some unhealthy 
action-the discharge from it has become 
ichorous and offensive, the process of 
union has become arrested or has retro- 
graded, or sloughing has attacked the 
part, and constitutional symptoms in 
sympathy with these local conditions 
have appeared ; or, in the case of the 
puerperal female, the lochia have become 
scanty and offensive, or have ceased, the 
abdomen has perhaps become tender, and 
high febrile symptoms have shown them- 
selves. But, whatever the previous con- 
dition of the patient may have been, whe- 
ther it have been one of perfect health or 
not, the first symptom to attract attention 
is almost without exception a sudden, se- 
vere, and prolonged rigor, followed by 
profuse perspiration. The patient soon 
recovers from this, and may for a time 
appear so well that the fear inspired by 
the first rigor gives way to the hope that 
it has been a mere accidental phenome- 
non, of no serious import. But before 
long, it may be the next day or at some 
earlier period, the rigor returns with its 
after sweating stage; and again and 
again, at varying intervals, the rigors and 
sweats recur. In the course of a day or 
two the conjunctivae and the skin assume 
a sallow tinge ; the patient becomes dull 
and heavy, or it may be restless, and ac- 
quires very much the aspect and manner of 
a patient suffering from some form of con- 
tinued fever. In company with the symp- 
toms above described, or in succession to 
them, others of more or less importance 
show themselves.' The pulse, which at the 
beginning may have been unchanged, be- 
comes rapid, even exceedingly rapid, weak, 
and perhaps intermittent; and these evi- 
dences of feebleness of the pulse increase 
as the disease advances. The tongue is 
often clean at the outset, but soon becomes 
glazed and fissured or furred, and after a 
time dry and brown ; the lips also become 
parched, and sordes accumulate probably 
about the teeth. The appetite disappears; 
the patient becomes thirsty; and often 
there is nausea or vomiting. Diarrhoea, 
attended with offensive stools, occurs very 
commonly. The respirations become shal- 
low and frequent; cough often super- 
venes, attended it may be with pains in 
the chest, with evidences of consolidation 
or of excess of secretion into the bronchial 
tubes, and with expectoration. The skin, 
in the intervals between the rigors and 
perspirations, and after they have disap- 
peared, is generally hot and dry, and may 
present sudamina, and even it is said a 
pustular eruption. The sallowness gen- 
erally increases, and often before death 
amounts to well-marked jaundice. Pain 
and swellings in or around the joints, or 
in other parts of the cellular tissue, often 
present themselves, and pus may form in 
these situations rapidly. As the above 
symptoms develop themselves and the dis- 
ease advances, the patient becomes exces- 
sively prostrate, his face becomes shrunk 
and generally pale, his mental functions 
become more and more disturbed and im- 
paired, slight delirium comes on, and pos- 
sibly coma, or, but very rarely, convul- 
sions ; and at the end of a short period, 
generally between four and ten days, he 
dies. During the progress of the pyaemia 
symptoms the primary seat of the disease 
(even if it were apparently healthy up to 
the moment when Pyaemia supervened) 
assumes an unhealthy character. Some- 
times Pyaemia takes a more chronic 
1 A child nine months old was recently ad- 
mitted into St. Thomas's Hospital with Pyae- 
mia following on acute necrosis. 345 
SYMPTOMS OF PYEMIA. 
course ; the symptoms are altogether less 
pronounced; the fever attending them 
resembles hectic fever, and abscesses form 
in the external parts, as the joints and 
the cellular tissue ; and the patient sinks, 
perhaps after a few weeks, of exhaustion; 
or after a protracted convalescence, during 
which abscesses cease to form, is restored 
to health. 
2. Symptoms considered in relation to the 
various Organs, etc. 
We will consider separately the symp- 
toms referrible to different parts of the 
system. 
(a) Aspect, Skin, &c.- The aspect of the 
Pysemic patient may vary a good deal; 
but for the most part it resembles that of 
one suffering from enteric fever, or typhus. 
At first it may be healthy-looking or 
nearly so, but soon it becomes heavy and 
oppressed. The face is sometimes highly 
flushed, sometimes extremely pallid, and 
these conditions often alternate. Towards 
the close of the disease, pallor generally 
becomes established; and the counte- 
nance, unless modified in its expression 
by delirium or other conditions, becomes 
shrunken and anxious, or settles down 
into the expressionless dull aspect of the 
last stages of febrile diseases. The rigors 
are some of the most marked and promi- 
nent symptoms of Pyaemia. Cases are 
sometimes observed in which they have 
either been slight and so have escaped 
notice, or in which they have been wholly 
wanting. But in the great majority of 
cases they cannot possibly be overlooked. 
They vary much in number and frequency. 
Sometimes they recur at short and ir- 
regular intervals; sometimes they are 
quotidian, and resemble, and have been 
mistaken for, attacks of ague; generally 
they cease after two or three days, and the 
subsequent progress of the case is free 
from them. Their duration varies; some- 
times each shivering fit lasts for half-an- 
hour or so, sometimes for only a few 
minutes. They are always followed by 
profuse perspirations. The temperature 
of the body rises considerably during the 
rigors.1 In the intervals, the'skin is gene- 
rally harsh and dry. Sudamina, as might 
be supposed, not infrequently appear and 
are sometimes surrounded by a zone of 
congestion. They may then by a careless 
observer be mistaken for the spots of ty- 
phus or of enteric fever. A pustular erup- 
tion has been described as of occasional 
occurrence, by both Mr. Henry Lee and 
Dr. Wilks.2 Sometimes livid discolora- 
tions appear; but these correspond for the 
most part to subcutaneous abscesses, or 
to tracts of diffuse cellular inflammation ; 
ecchymoses are rare on the surface of the 
body. In a large proportion of cases the 
skin and conjunctivae become distinctly 
jaundiced. This is a very important and 
characteristic symptom. It generally 
comes on shortly after the first symptoms 
of Pyaemia have shown themselves, and 
continues to increase up to the fatal issue. 
The jaundice, however, rarely if ever be- 
comes intense, and is often so slight that 
in a bad light or from hastiness of obser- 
vation it may pass unnoticed. 
(b) Organs of Respiration.-The respi- 
ratory movements early become, as in 
other febrile affections, hurried and shal- 
low. And this condition generally be- 
comes more pronounced as the disease 
advances. Then the respirations not in- 
frequently amount to forty or fifty in the 
minute, and are sometimes more numer- 
ous than this. After a while they are apt 
to become moaning or groaning in char- 
acter. It has been asserted that the odor 
of the breath is in these cases peculiar 
and characteristic. The respiratory acts 
assume the characters just described, in- 
dependently of all pulmonary disease, 
and in cases where the lungs are not at all 
affected, or where the affection is so slight 
as not to have caused special symptoms. 
But in the greater number of pysemic 
cases the lungs and pleurae become 
secondarily affected; cough comes on, 
which may or may not be violent; secre- 
tion takes place from the bronchial 
mucous membrane, or fluids get poured 
out from the air-cells into the bronchial 
tubes; and the cough consequently be- 
comes loose, and attended with expecto- 
ration, which may according to circum- 
stances be simply mucous, or purulent, or 
even distinctly pneumonic. The local 
phenomena correspond more or less to the 
morbid processes taking place in the chest. 
Tracts of dulness may sometimes be re- 
cognized on percussion, and sometimes 
uniform dulness at the base ; but partly 
from the scattered arrangement of the 
patches of pulmonary disease, and partly 
from the absence ordinarily of any large 
amount of effusion of fluid into the pleura, 
dulness is often scarcely or not at all re- 
cognizable. Pleural friction-sounds again 
may occasionally be detected ; but owing 
probably to the limited extent of the false 
membranes, and to the shallowness of the 
breath movements, they are not heard so 
often as might be supposed. The local 
signs most commonly present are such 
sounds as are heard in bronchitis, viz., 
crepitation, often amounting to gurgling 
and rhonchus. Pleuritic stitches may be 
complained of. 
(c) Organs of Circulation.-The pulse in 
Pyaemia is specially remarkable for its 
feebleness. At the onset of symptoms it 
1 John Simon, Holmes's System of Surgery, 
vol. i. p. 94. 
2 Op. cit. 346 
PYEMIA. 
may differ little in frequency or in any 
other respect from its previous healthy 
condition. But generally it becomes from 
the very beginning rapid, or if not rapid 
at least variable, so that the slightest ex- 
ertion of mind or body raises it twenty or 
thirty or even forty beats in the minute. 
The rapidity of the pulse however is gen- 
erally considerable, and its rapidity tends 
to increase as the disease advances ; so 
that not infrequently the beats of the 
pulse amount to 140 or 160, and may even 
rise to upwards of 200, in the minute. 
With this increase of rapidity, and with 
this variableness, the pulse also becomes 
very small and very compressible ; and 
very often as the patient's general debil- 
ity increases the pulse becomes irregular 
and intermittent. There is nothing gen- 
erally very characteristic in the cardiac 
phenomena. The action of the organ cor- 
responds with that of the pulse ; and the 
sounds, unless they become masked by 
other sounds, are healthy though feeble. 
Pericardial friction may be looked for, 
but will not always be heard even when 
pericarditis is present. 
(d) Organs of Digestion.-The organs 
concerned in digestion always sympa- 
thize more or less with the general condi- 
tion of the system. The tongue in the be- 
ginning may be clean ; but it soon assumes 
an unhealthy character. There is no- 
thing uniform however as regards its con- 
dition. Sometimes it becomes morbidly 
red and glazed, and may be fissured ; 
sometimes it becomes thickly furred ; but 
generally its final condition is one of dry- 
ness and brownness. Nausea and vomit- 
ing are frequent but not invariable symp- 
toms. They are often amongst the first 
to appear ; but they may arise at any 
time in the progress of the case, and may 
persist throughout its whole duration. 
The appetite mostly fails early, and thirst 
is generally present. Sometimes however 
the patient retains his appetite for a day 
or two, and may be persuaded to take 
even a good deal of stimulus and nourish- 
ment throughout the whole course of his 
illness ; and thirst is by no means neces- 
sarily excessive, nor is it always com- 
plained of. Diarrhoea often shows itself, 
and the stools are then described as being 
highly offensive. This complication be- 
longs to no particular period of the dis- 
ease, and may either be persistent or tem- 
porary. It is interesting to bear in mind, 
in connection with this symptom, the ten- 
dency to slight inflammatory changes, and 
even to pysemic deposits, manifested in 
cases of Pyaemia, by the intestinal mu- 
cous membrane. The frequent occurrence 
of jaundice has been already spoken of. 
That the sallow discoloration in these 
cases is jaundice is proved by its presence 
in the conjunctiva as well as the skin; 
and by the fact that bile-pigment has 
been recognized in the urine, in the serum 
of the blood, and in the effusions into 
serous cavities. The jaundice has no de- 
pendence on the formation of pysemic de- 
posits or abscesses in the liver, and is 
frequently present indeed when the liver 
seems to be altogether healthy. Frerichs* 
remarks that "to all appearances the 
jaundice is here the result of an impaired 
consumption of bile in the blood, arising 
from an abnormal condition of the meta- 
morphic processes which go on in that 
fluid." 
Abdominal pain is sometimes com- 
plained of; but generally it is local, and 
the result of inflammatory processes going 
on in the internal organs (as the liver and 
spleen) and of circumscribed peritonitis 
in connection therewith. In puerperal 
Pyaemia, general peritonitis and tympani- 
tes are more apt to occur than in other 
cases. 
(e) Genito-urinary Organs.-There is lit- 
tle to say in regard to the genito-urinary 
organs. From the inflammatory processes 
which so often go on in the kidneys, it is 
not surprising that the urine is occasion- 
ally found albuminous. We might natu- 
rally expect to find occasionally in it blood 
or pus. Unless the uterus be the primary 
seat of disease, there are rarely, if ever, 
any important symptoms referrible to that 
organ. 
(/) Organs of Locomotion.-It is a com- 
mon thing in Pyaemia, especially in the 
more chronic cases, to have inflammation 
and suppuration occurring in joints, and 
in the cellular tissue, and in connection 
with bones and other organs. The mor- 
bid anatomy of these processes has already 
been considered. It remains therefore 
only to add that these superficial abscesses 
are more common in the chronic than in 
the acute forms of the disease, that they 
often attain considerable dimensions, that 
their origin and progress are often at- 
tended with excruciating pain, and that 
it frequently happens that pain and swell- 
ing attack joints and other superficial 
parts, and subside without leading to any 
further mischief. Muscular debility is 
marked from the beginning, but generally 
soon becomes excessive. 
(g) Nervous System.-The nervous symp- 
toms which appear in connection with 
Pyaemia are almost identical with those 
which accompany enteric fever or typhus. 
The patient is at first perhaps a little 
heavy and dull and drowsy; but generally 
he becomes ere long (more especially at 
night-time) restless and somewhat de- 
lirious ; yet usually he can easily be re- 
called to his senses, and to this extent 
remains conscious up to the time of death. 
The cerebral symptoms vary, however, 
in different cases. Sometimes the patient 
1 Frerichs, op. cit. vol. i. 162. 347 
SYMPTOMS OF PYAEMIA. 
has little or no delirium, and is perfectly 
rational throughout his illness. Some- 
times the delirium becomes violent, and 
he may become partially or even wholly 
comatose before death. But generally 
when coma, and especially when convul- 
sions or paralysis appear, there is some 
actual disease going on in the brain to 
account for these symptoms. 
The evacuations may or may not be 
passed unconsciously. 
3. Further Considerations in regard to 
Pyaemia. 
(a) Time at which Pyaemia arises, and 
Duration of Disease.-As regards the time 
at which Pysemia appears in relation to 
the state of system on which it supervenes, 
nothing very definite can be said. In 
cases of accident and operation Pysemia 
may come on at any moment, from the 
time when a suppurating surface is first 
established until the wound is perfectly 
healed. In cases of carbuncle and of 
erysipelas Pysemia probably does not su- 
pervene until suppuration has taken place. 
In cases of acute suppuration connected 
with bones and acute necrosis, pysemic 
symptoms are present sometimes almost 
from the first. In puerperal cases Pysemia 
usually comes on between about the third 
or fourth and tenth or twelfth day after la- 
bor. The disease is generally very rapid 
in its course ; occasionally its duration is 
limited to three or four days, more com- 
monly it lasts from six to eight days, and 
it may be for a fortnight. In chronic 
cases, especially such as recover, the du- 
ration of the disease may be much pro- 
tracted. 
(6) Prognosis and Mortality.-The prog- 
nosis of Pysemia is exceedingly unfavora- 
ble. In surgical practice nearly all pyse- 
mic cases die; in midwifery practice a 
larger proportion probably recover. There 
is much difficulty, however, in arriving at 
the exact truth in reference to this point; 
for, although the symptoms of a typical 
case of Pysemia are collectively ample 
proof of the existence of this disease, 
there is no one symptom, like the rash of 
typhus or the exudation of diphtheria, 
absolutely distinctive, and no one symp- 
tom which is invariably present. Hence 
the diagnosis of the least well-marked 
cases of Pysemia is not always to be re- 
lied upon ; and as cases which are said to 
have recovered mostly belong to this 
class, there is generally some, more or 
less justifiable, room for doubt in regard 
to the true nature of cases which are re- 
corded to have got well. Still, there can 
be no reasonable doubt that of cases of 
Pysemia coming under the care of the 
surgeon a certain proportion recover. 
Now and then cases are met with, having 
most of the usual symptoms of Pyfemia, 
and in which it is at least reasonable to 
suppose that Pysemia, in a mild form per- 
haps, exists, which yet escape from the 
toils in which they seem to be involved. 
The probability that such cases are truly 
pysemic is enhanced by the fact that they 
are apt to occur in a ward in which Pyae- 
mia is prevalent, and that in some of 
them abscesses in external parts appear 
from time to time during their progress, 
and stamp their real character. But 
cases of recovery, with or without the 
formation of external abscesses, are far 
more common in obstetrical cases; at least 
it is in lying-in hospitals chiefly that, dur- 
ing the epidemic prevalence of Pyaemia, re- 
coveries not infrequently take place after 
the supervention of symptoms, which in 
other cases usher in a rapidly fatal illness. 
Nevertheless, the disease is one of the 
most fatal with wdiich practitioners have 
to deal; its premonitory symptoms are 
ground for the gravest alarm, and from a 
fully developed and unmistakable attack 
recovery is almost quite hopeless. 
(c) Diagnosis.-The diagnosis of Pyse- 
mia is not generally difficult, if the cir- 
cumstances of the case and the symptoms 
be all considered. Still, its own symp- 
toms are often so mixed up with those of 
the disease out of which it arises, or with 
those of the complications which become 
developed during its progress, and are 
often so modified by them, that the Pyse- 
mia may be recognized with difficulty or 
even wholly overlooked; and further, there 
are several diseases with the symptoms of 
which its own have a decided, and even 
close, affinity, and with which therefore 
it is apt to be confounded. 
It would be impossible to enumerate, 
still more to discuss, the various condi- 
tions which mask the onset, and it may 
be the progress, of the disease. An ex- 
ample or two must suffice. A patient 
has had an injury to the skull; after a 
while rigors come on and perspirations ; 
and, with these, cerebral symptoms. An 
abscess has probably formed beneath the 
skull. Now the symptoms here are al- 
most, if not quite, identical with those of 
commencing Pysemia. But whether Py- 
semia has come on as well is a point that 
probably cannot be then determined. 
The further progress of the case may 
clear up the doubt, but not always. 
Again, a patient, suffering from a large 
carbuncle, or from extensive diffuse cellu- 
lar inflammation, becomes pysemic; but 
it is more than probable, if the patient be 
suffering largely at the time from "con- 
stitutional irritation," that the additional 
" constitutional irritation" due to Pysemia 
will be inappreciable. So again in a case 
of acute deep-seated suppuration connect- 
ed with some bone (say the femur), and 
so again in puerperal peritonitis, the 348 
PYAEMIA. 
symptoms of the primary disease may be 
so sudden and so severe, and at the same 
time in many respects so like those of 
Pyaemia, that the supervention of the 
latter disease is very apt to pass unob- 
served. 
The diseases, which above all others 
Pyaemia resembles, are typhus and enteric 
fevers, internal acute inflammations (espe- 
cially of the lungs), urethral and bladder 
affections in which the kidneys have be- 
come involved, and acute rheumatism. 
The resemblance to fever is proved by the 
fact that even surgeons of experience oc- 
casionally mistake Pyaemia for typhus or 
enteric fever. The general symptoms and 
the aspect of the pyaemic patient are in- 
deed almost identical with the general 
symptoms and aspect belonging to the fe- 
vers just named, and the frequent pres- 
ence of diarrhoea approximates Pyaemia 
particularly to enteric fever. The liability 
to error is necessarily much increased 
when the Pyaemia depends on some deep- 
seated suppuration, which possibly escapes 
detection. The differences however are 
generally well pronounced; the severe 
rigors and perspirations of Pyaemia have 
scarcely any counterpart in either form of 
fever, in which for the most part rigors 
are scarcely marked, and the skin is dry. 
Moreover, the eruptions characteristic of 
typhus and of enteric fever are absent in 
Pyaemia, and the jaundice which generally 
attends the latter disease is rarely present 
in either of the former. The morbid 
anatomy and the progress of the several 
diseases will suggest other marks of dis- 
tinction. In pneumonia not only is the 
general aspect of the patient like that of a 
patient suffering from Pyaemia, but the 
rigors, the profuse perspirations, the 
jaundice, and even the diarrhoea, may all 
be present; while in Pyaemia more or less 
of the lung is mostly involved, and there 
may even be pneumonic expectoration. 
It is obvious, therefore, that there might 
be great difficulty, even impossibility, in 
distinguishing a case of pneumonia, sec- 
ondary (say) to a compound fracture, 
from a case of Pyaemia, supervening on a 
similar injury. On the other hand a case 
of Pyaemia, in which the source of pyaemic 
affection is not obvious, might without 
much carelessness be taken for a case of 
pneumonia. Again, when inflammation 
and suppuration of the kidney-structures 
come on as a result of vesical inflamma- 
tion, or of any other disease obstructing 
the passage of urine, febrile disturbance 
with delirium follows, and the combined 
symptoms differ often but little from those 
of Pyaemia supervening on the same local 
diseases ; and here the difficulty of distin- 
guishing between them is often greatly 
enhanced by the fact that both forms of 
disease are not uncommon sequelae of sup- 
puration occurring about the neck and 
base of the bladder. Further, acute 
rheumatism has many features in common 
with Pyaemia: in both there are profuse 
perspirations; in both inflammation in 
connection with bones and joints is com- 
mon (and it must be recollected that joints 
often inflame in Pyaemia without suppu- 
rating, and that in some cases of Pyaemia 
pain in the course of a bone, with sub- 
periosteal suppuration, is the first evi- 
dence of disease); in both, again, peri- 
cardial complication is not infrequent. 
We have considered somewhat in detail 
the resemblances between the several dis- 
eases above enumerated and Pyaemia, 
partly because they are really striking, 
partly because we have known them lead 
to errors of diagnosis. We have not how- 
ever dwelt generally on the points which 
serve to distinguish them, for to discuss 
these completely or even usefully here 
would be to forestall needlessly descrip- 
tions of diseases which will be fully given 
elsewhere. There are yet other affections 
which, under certain circumstances, Pyae- 
mia may simulate : such are delirium tre- 
mens, tubercular meningitis, and other 
inflammatory conditions of the brain or 
its membranes, ague, &c. It is needless, 
however, to do more than mention them. 
V. Treatment of Pyemia. 
The treatment of Pyaemia is exceeding- 
ly unsatisfactory. But, as in so many 
other instances, although the medical 
treatment of a case of the disease may be 
of little avail either to arrest or modify its 
course, preventive measures are often in 
the highest degree useful both against its 
origin and its spread. 
1. Prophylactic Treatment.1 
In considering the subject of preventive 
measures, the simplest plan will probably 
be to take the case of a private patient, 
on whom some grave operation-amputa- 
tion, for example-has been performed. 
To take precautions against Pyaemia is to 
take precautions also against those other 
unhealthy conditions out of which Pyae- 
mia mostly arises. To prevent, so far as 
may be, their occurrence it is important 
to maintain both the general health of the 
patient and the healthy progress of his 
wound. To this end the patient's strength 
should be supported by appropriate and 
adequate nourishment; pain, sleepless- 
ness, and irritability should be treated 
with opiates and seclusion from needless 
visitors and intruders ; ample ventilation 
should be secured, and in aid of this cur- 
tains and all unnecessary hangings should 
1 See Bristowe and. Holmes, loc. cit. TREATMENT OF PYEMIA. 
349 
be removed; further, perfect cleanliness 
should be maintained, and especially all 
evacuations, all offensive discharges, all 
dressings, should be removed at the earli- 
est opportunity, and never allowed to ac- 
cumulate in the patient's room. As re- 
gards his wound, that should be lightly 
dressed and kept cool, and never treated 
with the abundant dressings which are 
employed in some foreign hospitals, and 
which there promote suppuration and, in 
our belief, erysipelas and Pyaemia. The 
dressings should be of the simplest kind, 
and neither these nor sponges and such 
like things which have been used for the 
purpose of cleansing the wound should be 
used a second time. If erysipelas or 
sloughing or suppuration ensues, the 
treatment appropriate to these conditions 
must be employed ; in the case of slough- 
ing, charcoal, carbolic acid, and other 
antiseptics are valuable applications ; but 
above all things it is essential to allow 
early and very free escape of pus and 
ichorous fluids. The same remarks apply 
to the treatment which should be adopted 
in the case of compound fractures and 
other injuries.1 And in regard to cases of 
deep-seated suppurations, acute necrosis, 
carbuncle, and diffuse cellular inflamma- 
tion, there is no doubt that free and early 
incisions are especially important in pre- 
venting the supervention of Pyaemia. In 
hospitals, or other places where many sick 
are accumulated, the precautionary meas- 
ures above insisted on become doubly im- 
portant, especially those of ventilation 
and cleanliness. In discussing these two 
measures we open up the old subject of 
hospital construction and hygiene-a sub- 
ject which, even if in many respects ap- 
propriate to the present article, is far too 
extensive to be considered even briefly 
here. It may however be stated gene- 
rally, that there should be abundant cubi- 
cal space to each bed, abundant space be- 
tween the beds, plenty of ventilation by 
means of open windows, aided by open 
fireplaces; that the walls, the floors, the 
ceilings, should be kept scrupulously clean; 
that the wards should be periodically 
emptied; that water-closets should be so 
arranged as in no degree to infect the 
ward ; that sponges should never be used 
in the cleansing of wounds-nor anything 
absorbent in fact which might be used on 
a second occasion or in' the treatment of 
another case. But the danger of Pyaemia, 
incidental to wards or places in which 
many sick are accumulated, is less due to 
mere accumulation of sick than to undue 
accumulation of such as are suffering from 
certain forms of sickness, such namely as 
are suffering from open wounds, whether 
arising from accident or disease or design. 
The presence of what has been termed a 
"traumatic atmosphere" would seem to 
have quite a special influence over the de- 
velopment of Pyaemia, and for that reason 
the creation of a traumatic atmosphere 
should be as much as possible avoided. 
This may be effected partly by the means 
just adverted to-viz., free ventilation, 
and avoidance of overcrowding-but espe- 
cially by so distributing traumatic cases 
as to allow of no undue accumulation of 
them in any one ward of a hospital, or 
generally in any one spot. 
The presence of erysipelas, diffuse cel- 
lular inflammation, phagedsena, or any 
other unhealthy inflammation, and espe- 
cially the presence or recent occurrence 
of Pyaemia in a ward, should be the signal 
for redoubled vigilance in securing that 
all sanitary regulations are as far as pos- 
sible systematically carried out. Then, 
especially, all danger of inoculating the 
healthy with the unhealthy secretions of 
the diseased should be most watchfully 
guarded against; all dressings, &c., should 
be destroyed the moment they are done 
with; and neither nurses, nor dressers, 
nor surgeons, should pass from attendance 
on those whose wounds are unhealthy, 
above all from handling their wounds, to 
attendance on those whose wounds are 
healthy, until by proper precautions their 
persons, and especially their hands, are 
thoroughly disinfected. It may be added 
further that no one should at any time 
come direct from the dissecting room or 
post-mortem theatre (especially if he have 
taken part in the dissections going on 
there) to the treatment of surgical cases, 
without thorough purification and disin- 
fection. Again, when diseases of the 
kind above specified have been received 
into a ward, and especially if they have 
shown any disposition to spread, it may 
become necessary either to remove them 
thence, or, still better, to avoid receiving 
into that ward for a time all accident 
cases attended with wounds, and to avoid 
operations on patients who happen to be 
therein. But notwithstanding all such 
precautions, these diseases will sometimes 
be found to cling as it were to a ward. 
Under such circumstances it becomes ab- 
solutely necessary to empty and dismantle 
the ward, to purify it thoroughly, and to 
keep it unoccupied for a shorter or longer 
period. Sometimes those forms of disease 
out of which Pyaemia is apt to arise, some- 
times Pyaemia itself, may (dependent 
apparently on atmospheric conditions, or 
at least on local conditions of insalubrity) 
prevail over a district. If such be the 
case, the importance of temporarily sus- 
pending the performance of operations in 
that district becomes obvious. 
The various precautions, of which the 
importance in relation to surgical practice 
has just been discussed, are if possible of 
1 See Professor Lister's papers on the treat- 
ment of compound fractures, &c. 350 
PYEMIA. 
still greater importance in relation to the 
practice of midwifery. In sporadic mid- 
wifery (if the term may be thus used), as 
in sporadic surgery, precautions are less 
absolutely needed than where midwifery 
is concentrated, as it is in a lying-in hos- 
pital. But in the former case puerperal 
Pyaemia has been known over and over 
again to be conveyed by the nurse or the 
medical attendant, who have brought in- 
fection in their person or in their clothes 
either from other puerperal cases, or from 
cases of unhealthy inflammation, or from 
the dead-house. In the latter case (the 
case of lying-in hospitals) the presence, so 
to speak, of a "parturient atmosphere" 
intensifies the liability to Pyaemia as it 
does to other infectious puerperal dis- 
eases, and leads often to terrible mortality. 
There is no doubt that no attendant is 
justified in running the risk of conveying 
such infection from one patient to another, 
and that if he have from circumstances 
become a possible source of danger, he is 
bound for a while to abstain from mid- 
wifery practice. As regards lying-in hos- 
pitals, every possible precaution ought to 
be systematically taken ; and on the very 
first appearance of infection they ought at 
once to be emptied and purified. But we 
are very strongly of opinion that such in- 
stitutions are dangerous institutions, and 
ought not, unless under exceptional cir- 
cumstances, to exist; certainly they are 
not required as schools of midwifery, cer- 
tainly every poor woman, who has a home 
however mean in which to be delivered, 
will be far safer in that home than in a 
hospital. 
It must not be forgotten, however, that 
Pyaemia is not limited to hospital prac- 
tice ; that even in hospitals it may arise 
quite independently of hospital influences ; 
and that many cases originate in private 
quite independently, so far as we know, 
of external deleterious agencies. Against 
such cases prophylactic measures are of 
course out of the question. 
2. Medical Treatment. 
The treatment of a case of Pyaemia re- 
solves itself into the treatment of the 
original lesion, the treatment of the dis- 
ease, the treatment of the complications 
of the disease, the general hygienic treat- 
ment of the patient. 
(a) Treatment of Primary Lesion.-As 
regards the original lesion, it has been 
shown that in cases where Pyaemia super- 
venes on wounds (whether from accident 
or from operation) the wounds have gen- 
erally already assumed an unhealthy as- 
pect. According to the nature of this 
unhealthy process must be the local treat- 
ment ; but especially it would seem im- 
portant that the parts should be kept 
clean and cool, that disinfectant applica- 
tions should be employed, that free incis- 
ions to admit of the escape of pent-up pus 
should be made. In cases where the 
wound appears to be healthy, there is 
probably some deep-seated suppuration in 
progress ; and here, though the exact seat 
of suppuration may be difficult to detect, 
it is most important that it should be de- 
tected, and the pus therein thoroughly 
evacuated. The same rule applies with 
equal force to those cases where the pri- 
mary disease is an abscess involving some 
deep-seated bone, or tract of cellular tis- 
sue. The reasons, on which the adoption 
of the above plan of treatment is based, 
are first, that by this plan the further en- 
trance of poisonous matters into the blood 
may possibly be obviated ; second (and 
most important), that by its early adop- 
tion the entrance of poisonous matters 
may be wholly averted and a threatened 
attack of Pyaemia warded off. With the 
same view it was proposed to cauterize 
the superficial veins on the proximal side 
of the diseased part. As regards obstet- 
rical cases, it has been asserted by some 
that puerperal fever is mostly preceded by 
an imperfectly contracted condition of the 
uterus ; but both by those who hold this 
view, and by those who do not, the im- 
portance of securing complete contraction 
of the uterine fibres and consequent 
closure of the ruptured uterine veins, by 
the use of ergot, and other means, has 
been strongly urged. It has been recom- 
mended also to cleanse the cavity of the 
uterus by the injection of disinfectant and 
astringent fluids. 
(6) Curative Treatment.-Of the curative 
treatment of Pyaemia we fear little is 
known. Various plans of treatment have 
been from time to time adopted, and all 
probably have by some been supposed to 
be beneficial, all have by the majority of 
practitioners been found useless. Some 
of these plans have been based on the 
notion of the elimination of the disease ; 
others on the notion of introducing into 
the system substances capable of battling 
with the pyremic poison in the blood it- 
self, and overcoming it there ; others have 
been based on analogy ; and others have 
been wholly empirical. Thus, acting on 
the assumption that the perspirations and 
the diarrhoea of Pysemia are efforts of 
nature to eliminate some morbid poison 
from the system, warm baths and diapho- 
retics have been employed by some; by 
others the diarrhoea has not only not been 
restrained, but has been encouraged by 
laxative and purgative medicines. Thus, 
too, from the resemblance which the re- 
mittent rigors and perspiration of Pyaemia 
sometimes bear to the more regular at- 
tacks of the same kind which characterize 
ague, it has been imagined that quinine 
and arsenic, which are certainly remedial TREATMENT OF PYEMIA. 
351 
in the case of ague, might be remedial in 
the case of Pyfemia. Thus, again, guided 
we presume by the acknowledged fact that 
ample ventilation is one of the most im- 
portant preventives against Pysemia, 
some have looked on fresh air as abso- 
lutely curative, and have exposed their 
pysemic patients to all the winds of heaven. 
And thus, others regarding the disease as 
one of putridity, have treated it with 
various forms of antiseptic agents. It 
would be useless to argue seriatim against 
the above and other modes of treatment; 
it would be unwise to oppose a priori the 
trial of any as yet untried modes of treat- 
ment ; suffice it to say that, so far as we 
know, the mortality of Pysemia is just as 
high now as it ever has been, and the an- 
tidote to it remains to be discovered. 
There is, however, one mode of treat- 
ment, suggested within the last few years 
by Professor Polli,1 of Milan, which, from 
the scientific character of the investiga- 
tions which led to its proposal, and the 
manner in which the proposal has been 
brought under the notice of the medical 
profession, deserves a respectful mention. 
It will be necessary to go a little into the 
history of Professor Polli's investigations, 
and to trace shortly the steps which led 
him to his final conclusions. He assumed 
with most other physicians that septic 
poisons introduced into the blood produce 
their injurious effects through acting on 
the blood as a kind of ferment; and he 
assumed, as again others have assumed, 
that if any substance could be introduced 
into the blood, which, while not acting 
injuriously either on that fluid or on the 
system generally, would arrest this pro- 
cess of fermentation, the exhibition of 
such substance in cases of septic poisoning 
would not improbably be curative. 
Having long studied the effects of sul- 
phurous acid, he had ascertained that it 
is not merely a powerful antiseptic, but 
that it equally prevents the vinous fer- 
mentation, and those other fermentations 
by which starch is converted into glucose, 
by which the pancreatic juice acts on 
fatty substances, and emulsine on amyg- 
daline ; and he came to the conclusion 
that in sulphurous acid we possess a sub- 
stance capable of arresting every form of 
catalytic action. 
But sulphurous acid cannot with im- 
punity be introduced into the animal 
economy. Hence Professor Polli sought 
for other agents which, while having the 
virtues of sulphurous acid, should be free 
from its disadvantages ; and he found such 
agents in the compounds of sulphurous 
acid with soda, potash, magnesia, and 
lime. He found that these sulphites, 
equally with sulphurous acid, prevent all 
forms of fermentation ; he found that they 
may be given safely in large doses over a 
considerable period of time ; and he fur- 
ther found that when taken into the 
stomach they become absorbed, diffused 
throughout the system and eliminated 
without undergoing any chemical change, 
or at most only a very partial chemical 
change. 
He assumed therefore that that power 
of preventing putrefaction and fermenta- 
tion which they exercise outside the body 
they would exercise probably equally well 
within the body. Any further experi- 
ments made by him upon the lower ani- 
mals, by the introduction of putrid mat- 
ters into their blood, and by putting 
them at the same time under the influence 
of the sulphites, led him to believe that 
he had in these agents discovered valua- 
ble remedies for the various forms of sep- 
ticsemia. It would seem that large doses 
of these sulphites (from thirty to sixty 
grains three or four times daily) may be 
given with impunity. We are not aware 
whether this plan of treatment has been 
so largely tested as the promises it seems 
to hold out might justify. We know of 
one case of supposed Pyaemia in which it 
was believed to have wrought a cure, but 
we know that in the practice of Mr. Si- 
mon, at St. Thomas's Hospital, it has 
entirely failed. 
[The tentative use of salicylic acid, on 
the same principle, is justified by analogy. 
No sufficient experience has, however, as 
yet, determined its positive value in Py- 
aemia.-H.] 
(c) Treatment of Symptoms and Compli- 
cations.-When a case of Pyaemia is un- 
der treatment, it always becomes a ques- 
tion of treating, in addition to the general 
disease, certain symptoms as they arise, 
and, it may be, certain of the secondary 
lesions. On this head, again, we fear 
there is little satisfactory to be said. 
Some have recommended, on theoretical 
grounds, that diarrhoea should be encour- 
aged. There seem no valid grounds for 
this course; and certainly if the diarrhoea 
became excessive, we should recommend 
that it be restrained, either by remedies 
administered by the mouth or by opiate 
enemata or suppositories. Again, the 
pulmonary symptoms may become some- 
times exceedingly distressing; and then, 
although probably we have no means of 
either checking or curing the morbid pro- 
cesses going on in the lungs, we may by 
opiates or other sedative medicine, judi- 
ciously administered, render the symp- 
toms more endurable ; or it may be that 
expectorants, especially ammonia, may 
be of benefit. Of course if abscesses form 
in superficial parts, they should be early 
punctured. As regards other symptoms, 
and other complications, we have really 
nothing to say. Many of them will need 
1 See Dublin Journal of Medical Science, 
vol. xxxiii. p. 367, and vol. xxxvi. p. 470. 352 
MALARIAL FEVERS. 
no special treatment at all; and generally 
where special treatment seems to be re- 
quired, the medical man must be guided 
by his general knowledge of his profes- 
sion, and treat them as he would treat 
such complications arising in the course 
of fevers and other allied disorders ; bear- 
ing in mind, however, that where he can- 
not cure, it is better as a rule to aim at 
soothing and quieting, than (in the hope 
of achieving some insignificant advantage 
over the outposts, so to speak, of his pa- 
tient's disease) to adopt a fidgeting line 
of treatment, and so render his few re- 
maining hours miserable. 
(d) Hygienic and Dietetic Treatment.- 
We come lastly to the general manage- 
ment of pysemic cases, that is to say, 
their management as regards diet, stimu- 
lus, and hygienic observances. It need 
scarcely perhaps be pointed out that ob- 
servance of cleanliness and ventilation, 
which we insisted on as an important 
prophylactic measure, should be equally 
persisted in during the whole course of 
treatment of a case of Pyaemia; that, fur- 
ther, the patient should never be op- 
pressed unnecessarily with accumulation 
of bed-clothes-that he should, in fact, be 
kept cool-and that his comforts should 
be carefully considered. Pyaemic patients, 
as has been shown, become at an early 
period excessively feeble ; and in most 
cases excessive prostration is the most 
prominent among the symptoms which 
usher in death. No doubt this debility is 
functional rather than the direct result of 
the waste and degeneration of tissue; the 
consequence and the indication of blood- 
poisoning, rather than of the want of 
either stimulus or food; and theoretically, 
therefore, is to be counteracted by anti- 
dotal treatment rather than by nutriment. 
Whether we possess any mode of treat- 
ment that can be regarded as really anti- 
dotal we have shown to be in the highest 
degree problematical; but we have in 
these cases excessive prostration to deal 
with, and we must deal with it as best we 
can. To this, end, it is manifestly our 
duty to administer both food and stimu- 
lus, and to administer them as largely as 
the condition of the patient will admit. 
The patient's appetite is generally quite 
annulled; and often loathing of food and 
vomiting are present. These conditions 
render it, of course, often exceedingly dif- 
ficult, and sometimes impossible, to carry 
out the objects we have in view; and they 
show the importance of selecting for ad- 
ministration those articles which are least 
liable to offend the stomach, and of ad- 
ministering these in small and if possible 
frequently repeated doses, rather than 
rarely and in large quantities at a time. 
It is not easy to lay down any rule with 
regard either to the nature or the amount 
of food and stimulus to be given. These 
points must be determined in each case 
according to its requirements. But it is 
important to give whatever is to be given 
systematically. As regards food, that 
which is in the form of fluid is generally 
most suitable, such as animal broths, 
eggs beaten up, milk, gruel, arrowroot, 
and the like. As regards stimulus, per- 
haps, considering the irritability of the 
stomach, brandy, sherry, madeira, diluted 
according to the patient's taste, are the 
most generally serviceable. But lighter 
wines will often be found grateful. We 
protest against that excessive exhibition 
(that " pouring in" as it is appropriately 
termed) of stimulus which it has lately 
been the fashion to practise. 
We need perhaps scarcely add that 
when pysemic cases become protracted, 
and especially when they show signs of 
convalescence, and during the progress of 
convalescence, dietetic treatment becomes 
of paramount importance, and tonics 
form important aids to that treatment. 
MALARIAL FEVERS. 
W. C. Maclean, M.D. 
Before entering on the description of 
the remarkable fevers which are to form 
the subject of the following article, it is 
necessary to premise a few observations 
on the peculiar poison which produces 
them. This poison, which gives a dis- 
tinctive name to fevers with periodical re- 
turns, is everywhere recognized by the 
term Malaria. " When a climate is called 
unhealthy, in many cases it is simply 
meant that it is malarious." (Parkes.) 
In this article it is intended only briefly 
to summarize the few facts relating to 
this poison which have been tolerably 
well ascertained. 
No chemist has yet been able to demon- MALARIAL FEVERS. 
353 
strate the existence of malaria. We as- 
sume its existence from certain observed 
effects on the organism, just as we do in 
the case of other poisons which produce 
certain specific diseases. Malaria is be- 
lieved to be the produce of organic de- 
composition in soils, whatever may hap- 
pen to be their mineral composition; 
water is indispensable to the process, and 
a high temperature, although not abso- 
lutely necessary, greatly aids it. 
It is generated in greatest abundance in 
marshes, which contain a high percentage 
of organic matter; hence the name by 
which it is familiarly known, viz., marsh 
miasm. 
It is often found in sandy soils and arid- 
looking plains devoid of vegetation; but 
in all such cases the soil will be found to 
contain a considerable proportion of or- 
ganic matter, and water will be found not 
far from the surface, either in the shape 
of subterraneous streams, or detained by 
a bed of clay below the sand, preventing 
its free passage and keeping up evapora- 
tion. 
Malaria is also generated in hard rocks, 
such as granite and trap, in a disinte- 
grating state. A notable example is the 
island of Hong Kong, which consists en- 
tirely of weathered and decaying granite. 
In such soils, so long as they are undis- 
turbed, the existence of malaria may not 
be suspected. In the case of Hong Kong, 
for example, it was not until extensive 
excavations were made into the disinte- 
grating granite for building purposes, that 
violent and fatal remittent fevers ap- 
peared. 
Dr. Parkes mentions that the soil of 
Hong Kong contains less than two per 
cent, of organic matter, but quotes Frie- 
del to the effect that disintegrated granite, 
which is highly absorbent of water, be- 
comes often permeated by a fungus, and 
suggests the possible relation between the 
development of this fungus and the pro- 
duction of malaria. 
The air of marshes known for ages as 
malarious has been examined by chem- 
ists. Watery vapor and carbonic acid are 
always found in excess; and, under cer- 
tain conditions, sulphuretted hydrogen. 
1,1 Carburetted hydrogen is often present, 
and occasionally free hydrogen and am- 
monia, and, it is said, phosphoretted hy- 
drogen." (Parkes.) Besides the above, 
" various vegetable matters and animals, 
floating in the air, are arrested when the 
air of marshes is drawn through water, 
or sulphuric acid, and debris of plants, in- 
fusoria, insects, and even, it is said, small 
crustacese, are found." (Parkes.) 
Malaria acts with the greatest intensity 
on the human system in situations which 
are low and moist, abounding in vegeta- 
tion undergoing decomposition, e.g., in 
jungly districts during or immediately 
after the rainy season, at the bases of 
great mountain ranges, and in those belts 
of country in India termed terrais, formed 
by the debris of mountains rich in organic 
matter, which retain a large quantity of 
water and are covered with jungle. 
It is capable of drifting along plains to 
a considerable distance from its source, 
particularly in the direction of the pre- 
vailing wind. It ascends mountains, espe- 
cially when favored by ravines and cur- 
rents of air. The height to which it can 
ascend from its source is still matter of 
dispute. Dr. Parkes thinks that 500 feet 
is the limit in temperate climates, and 
from 1000 to 1500 in tropical countries; 
while others maintain that in the latter 
we are not safe from its influence until a 
height of 5000 feet has been reached. It 
is probable that when men suffer from 
malaria at elevations above 2000 feet, it 
is either derived from unsuspected loca, 
sources, or it is carried up ravines by cur 
rents of heated air from the unhealthy 
plains. 
It is a common belief in India that 
water is capable of absorbing malaria, 
and that periodic fevers, dysentery, and 
even cholera, are produced by drinking 
water so charged. 
This absorbing power of water, and 
especially salt-water, has often a bene- 
Lficial effect, when a sufficient breadth of 
it, not less than from three-quarters of a 
mile to a mile, is interposed between our 
habitations and the source of the poison, 
which is either absorbed or rendered in- 
nocuous in its transit. 
Belts of trees interposed in like man- 
ner exercise a protective influence. [Liv- 
ing trees and shrubbery appear to ex- 
ercise an influence in preventing the 
development of the malarial cause. The 
Great Dismal Swamp, on the southern 
border of the State of Virginia, being cov- 
ered chiefly by growing cypress trees, is 
not malarious. The Eucalyptus globulus, 
native to Australia, has the reputation of 
special usefulness in this way. Probably 
it and the Southern Pine do good mainly 
by assisting, by their vigorous growth, the 
drainage of the soil.-H.] 
Malaria disappears before cultivation 
and subsoil drainage, with free exposure 
of the soil to the action of the air and of 
living vegetation. When, however, the 
cultivating hand of man is withdrawn and 
the old conditions reappear, malaria again 
resumes its sway. [Nothing is more evi- 
dent in the history of malaria than its 
general disappearance before the exten- 
sion of closely built cities and towns. 
Suburbs, in which intermittent occurs, 
gradually become, in that respect, more 
healthy as lots are drained and occupied 
by habitations. Exception to this may, 
it is true, exist, when houses are built 
upon made ground, and the drainage con- 
vol. I.-23 354 
MALARIAL FEVERS. 
tinues to be very imperfect for a long time. 
This kind of exception has been observed 
to a considerable extent of late years in 
the city of New York.-II.] 
It is the cause of intermittent and remit- 
tent fevers, and their sequels ; it " under- 
lies" the cause of dysentery and cholera ; 
and by its depraving influence on the con- 
stitution it often silently undermines the 
health without the manifestation of any 
febrile phenomena. Major-General Cot- 
ton, in his evidence before the Indian 
Sanitary Commission, very truly observes 
" that there are many ailments which 
the natives of India call fever, but which 
a medical man does not, which are the 
effects of malaria. " 
When a person has for some time suf- 
fered from the toxic influence of miasm, a 
curious impress of periodicity is sure to 
show itself in all his subsequent ailments, 
whatever be their nature ; and I believe, 
from extensive observation, that this im- 
press of periodicity is never eradicated. 
Casorati, a late Italian physician of 
eminence, in his "Treatise on Intermit- 
tent Fevers," a posthumous work recently 
published, has given it as his opinion 
" that miasm is the cause of an extremely 
small number of intermittent fevers. " He 
says "that there are pernicious intermit- 
tents, the origin of which is simply rheu- 
matic. " Casorati further dwells on the. 
fact that, within the sphere of his obser- 
vation, "nothing is more common than 
to see pregnant women the subjects of 
tertian fever, under which they frequently 
abortand he gives numerous examples 
of diseases, such as menorrhagia, cephal- 
algia, &c. &c., all presenting an intermit- 
ting type, due, as Casorati supposes, not 
to the toxic effect of miasm, but to other 
causes, such as "humidity," "cold,''and 
the like. 
The truth is, that Casorati's sphere of 
clinical observation was in a malarial re- 
gion : the stamp of periodicity was there- 
fore deeply impressed on a great number 
of the diseases that came under his care. 
The proof of this is not far to seek ; for, 
by his own showing, no treatment was 
effective until quinine was given. We do 
not find, where there is no miasm to com- 
plicate the case, that " acute rheumatism" 
or "menorrhagia" or "cephalalgia" de- 
rive benefit from anti-periodic remedies, 
•still less that such are indispensable to all 
treatment. 
No sooner is the blood poisoned by ma- 
laria than it acts on the stomach and ali- 
mentary canal. In all agues, particularly 
of a severe type, there is from the first 
great disturbance of the stomach, and in 
severe remittents this is often the most 
prominent and urgent symptom. Casorati 
goes so far as to state that morbid appear- 
ances in the stomach constitute by far the 
most constant post-mortem appearance 
found in fatal cases of intermittent fevers. 
In the article Dysentery I have given it 
as my opinion that miasm is also the cause 
of that disease. In the present state of 
knowledge, it is not possible to explain 
why malaria should in one case cause 
dysentery, and act with intensity on the 
glandular structures and mucous mem- 
brane of the great intestine, and in an- 
other excite an intermittent or remittent 
fever, with signs of extreme irritation of 
the stomach and duodenum, going on 
often to structural changes in those parts. 
Chemistry may one day reveal to us some 
difference, at present inappreciable, in the 
constitution of miasmata to account for 
the affinities displayed in the different 
cases.1 
The structural changes of a more secon- 
dary kind induced by malaria are, enlarge- 
ment of the spleen and liver, to be more 
particularly described further on. 
INTERMITTENT FEVER. 
Definition.-A specific paroxysmal 
fever, the febrile phenomena observing a 
regular succession, characterized by a 
cold, a hot, and a sweating stage, followed 
by a period of complete apyrexia, varying 
in duration according to the type of the 
fever. 
. Synonyms. - Periodic Fever, Ague, 
Paludal Fever. 
History and Modes of Commence- 
ment.- When the human system has 
been exposed to the influence of malaria, 
sooner or later, according to circum- 
stances, symptoms of disturbance appear: 
as already remarked, many have their 
constitutions silently undermined without 
suffering from periodical fever at all. It 
seems probable that in such cases the poi- 
son is not presented to the system in a 
very concentrated form ; the blood is so 
gradually changed that the organs become 
as it were tolerant of its presence, to such 
an extent at least that febrile phenomena 
are not excited at regular intervals for 
the apparent purpose of expelling it from 
the blood. On the other hand, people in 
perfect health may be exposed to the ac- 
tion of malaria in such a noxious form as 
to be at once completely overwhelmed by 
it. The late Lieutenant-General Sir Mark 
Cubbon informed me that many years 
ago, when on a journey to the Neilgherry 
1 I am informed by Dr. E. Goodeve, late 
professor of medicine in the Calcutta Medical 
College, that the cases of dysentery which 
gave him most anxiety in Calcutta were those 
in which he was at first uncertain whether 
the disease was to be remittent fever or dys- 
entery. 355 
INTERMITTENT FEVER. 
Hills, he was compelled to pass a night at 
the foot of the Segoor Pass, then an un- 
cleared and unhealthy spot. A party of 
three German missionaries were also de- 
tained at the same place, and slept in the 
same house. These gentlemen were fresh 
from Europe, and in high health. On the 
following morning they pursued their 
journey, and were soon "above fever 
range." In less than twenty-four hours 
three out of the four of the party were 
stricken with fever, and two of them died 
in a few days. 
Most frequently the person who has 
been exposed to malaria suffers for some 
days from premonitory symptoms. The 
toxic influence is evidenced by some de- 
gree of nausea and loss of appetite, with 
muscular pains in the back and lower 
limbs, with usually a slight feeling of 
chilliness, soon passing into trifling heat 
of skin, scarcely marked enough to excite 
attention. This may recur for several 
days before a regular paroxysm of ague 
sets in. Or, without such prolonged 
warnings, after an hour or two merely of 
the above symptoms, the patient may be 
seized with the cold stage, in the manner 
to be presently described. In such cases 
there is almost always a considerable 
amount of urinary irritation, the patient 
having frequent calls to pass pale-colored, 
acid, and irritating urine. When this 
symptom is urgent, a severe paroxysm 
may usually be expected. 
Then follow in succession the three 
stages which characterize this fever, viz., 
the cold, the hot, and the sweating stages, 
at the end of which there is a period of 
apyrexia, termed the intermission, the du- 
ration of which varies with the type of 
the fever. The time occupied by a parox- 
ysm and the period of apyrexia that fol- 
lows is somewhat incorrectly termed the 
interval. The types of the fever are 
named according to the length of the in- 
terval. These are the quotidian, which 
recurs daily, having an interval, in the 
above-mentioned acceptation of the term, 
of twenty-four hours; the tertian, with a 
paroxysm every other day, and an inter- 
val of forty-eight hours; the quartan, 
every third day, and an interval of seven- 
ty-two hours. 
These are what have been termed the 
regular types of Intermittent Fever. 
Physicians recognize others which have 
been called irregular: such, for example, 
as the double tertian, which is said to dif- 
fer from a quotidian only in having on 
alternate days fits corresponding in se- 
verity, character, and duration ; the triple 
tertian, which has two fits on one day, and 
one the next: the duplicated tertian, which 
has two paroxysms on alternate days, 
with a fever-free day; the double quartan, 
which has a fit on one day, a mild one the 
next, the third being a fever-free day; 
and so on. What is it that determines 
whether the type of the attack shall be a 
quotidian, tertian, or quartan ? It is 
probable that this is governed simply by 
the extent to which the blood has been 
charged by malaria. The presence of a 
quotidian seems to indicate a high degree 
of saturation, requiring a more frequently 
renewed effort of nature for at least its 
partial elimination than either a tertian 
or a quartan. 
The tertian is said by many authors to 
be the primary type of fever, and to be 
the most common of all. This is certainly 
not the case in India, where without 
doubt the quotidian is the most common, 
and the quartan the rarest of all inter- 
mittents. 
According to my experience in India 
and China, a first attack of ague invariably 
takes the quotidian form. 
The duration of a paroxysm of Inter- 
mittent Fever varies with the type. It is 
longest in the quotidian, which lasts from 
eight to ten or even twelve hours; the 
tertian lasts from six to eight; and the 
quartan from four to six hours. 
The paroxysms do not always occur ex- 
actly at the same hour of the day. In 
the early days of an attack, when the dis- 
ease, not having been interfered ■with by 
treatment, is "waxing," the cold stage 
will almost certainly appear an hour or 
two earlier on the days of the second and 
third paroxysms than on the first. On 
the other hand, when the system has been 
affected by antiperiodics, or the poison has 
by successive paroxysms been to some 
extent eliminated, and the disease is 
"waning," the time of attack will be 
postponed for an hour or two. I have ob- 
served this in my own person, and have 
noted it in others as of almost invariable 
occurrence. 
The length of time to which intermit- 
tents left untreated will run on will de- 
pend much on climate, locality, and sea- 
son, and the extent to which the system 
has been charged by malaria. Mild quo- 
tidians often terminate after ten or twelve 
paroxysms; quartans last longer, and 
may run on for months. 
When once the system has gone through 
the phenomena of an attack of ague, par- 
oxysms are liable to recur quite irrespec- 
tive of fresh exposure to malaria; an error 
in diet, exposure to wet or cold, any cause 
that disturbs the balance of the circula- 
tion, may bring on an attack, and an im- 
press of periodicity is apt to be given to 
any ailment from which the person may 
subsequently suffer. This disposition lasts 
always for years, sometimes for life. 
The type of the disease does not always 
remain the same; a quotidian may pass 
into a tertian or a quartan ; and an inter- 
mittent may, under certain conditions, as- 
sume the more grave form of a remittent. 356 
MALARIAL FEVERS. 
I have repeatedly known sportsmen in 
India, and officers of the Forest Conserv- 
ancy department, whose amusements or 
occupations exposed them only to mild 
intermittents, so long as they remained in 
comparatively cool and elevated regions, 
suffer from severe remittent fever on de- 
scending to the plains, a change in many 
instances apparently due merely to the 
influence of high temperature, for I have 
several times observed it when there was 
no reason to suppose that the sufferers 
had been exposed anew to the influence 
of malaria. 
The direct mortality from Intermittent 
Fevers in India is small. Even in Ben- 
gal, out of a strength of 344,152, with 
111,687 admissions, the percentage of 
deaths to strength is 0'24, and the per- 
centage of deaths to admissions is 0'76. 
But although it is undoubtedly a rare 
thing to see a person die in the course of 
an uncomplicated Intermittent Fever, it 
is nevertheless, indirectly, an exceedingly 
destructive disease ; the fatal results must 
however be looked for under other heads 
in the death returns of malarial regions. 
It is undoubtedly true, as remarked by 
the Indian Sanitary Commissioners, 
"that diseases of important organs, the 
consequences of malarial fevers, occasion 
much of the subsequent sickness, mortal- 
ity, and invaliding among British troops 
serving in India." 
Judging from the writings of Casorati 
and others, Intermittent Fevers seem to 
be more severe and more fatal in Italy 
than in India. How far the system of 
treatment in that country influences the 
mortality I am not prepared to say. In 
many cases of simple, and apparently in 
all complicated agues, Casorati not only 
highly extols blood-letting, but reprobates 
its neglect as culpable and dangerous in a 
high degree. For example, in a case of 
ague with orchitis, Casorati draws a 
pound of blood, and does not hesitate to 
repeat the proceeding; and in all cases 
where gastric irritation, headache of 
•extraordinary severity, and such like 
■symptoms are present, his treatment is 
"decidedly antiphlogistic," comprising 
repeated blood-letting, both general and 
local, with perfect abstinence from food 
for many days. In Italy malarial fevers 
that in the opinion of physicians there 
demand such treatment are termed " per- 
nicious. " In India practitioners of the 
present day would be disposed to transfer 
the term from the fever to the treatment, 
for it is certain, as demonstrated by the 
•experience of the past, that in any of the 
types of the malarial fevers of tropical 
regions antiphlogistic treatment such as 
that urged by the modern Italian school, 
is not only unnecessary, but most dan- 
gerous. 
Causes.-Whatever tends to depress 
the physical or mental powers, and so 
render the system more liable to the in- 
fluence of malaria, is a predisposing cause. 
The exciting cause is undoubtedly an 
exhalation from the soil, given off under 
the conditions already described, to which 
the name of malaria is provisionally ap- 
plied. That specific agues ever arise 
from other causes of malaria I do not be- 
lieve, and am satisfied that where they 
are attributed to "cold," to "moisture," 
to "irritation," to the "influence of the 
mind," and such like supposed causes, it 
will in every such instance be found that 
the sufferer has at some former period 
been in a malarial locality, or that this 
poison, arising, it may be, from an unex- 
pected source, has been in operation just 
before the attack. 
In a most especial manner I desire to 
express my entire dissent from the doc- 
trine that specific agues are the result of 
suppressed cutaneous secretions, under 
sudden impressions of cold ; if it were so, 
we should have agues constantly occurring 
in temperate climates during the summer 
months, in places where no miasm exists, 
which is contrary to all experience. Where 
this poison has been introduced into the 
system, suppressed cutaneous secretion 
under sudden impressions of cold may 
call the poison sooner into action, perhaps 
by concentrating it more in the gastro- 
duodenal mucous membrane during the 
state of congestion that follows the im- 
pression of cold; but to produce a true 
specific ague I believe the presence of ma- 
laria in the blood to be necessary. 
To the question, why the miasmatic 
poison, unlike that of rheumatism, or 
variola, or typhus, should produce a pe- 
riodical, and not a continued fever, no 
satisfactory answer has yet been given ; 
notwithstanding all the ingenious specu- 
lations of scientific inquirers, it remains 
unexplained. 
Symptoms.-After certain premonitory 
symptoms-of which the most prominent 
are nausea, languor, lassitude, muscular 
pains in the back and legs-the cold stage 
commences. In this the patient becomes 
chilly, first in the extremities, then in the 
back, and soon passes into a most un- 
pleasant sensation of coldness all over the 
body. The skin shrivels, the nails be- 
come blue, and rigors, more or less se- 
vere, rapidly succeed each other. In the 
hottest climate the patient demands to 
have bed-clothes heaped upon him, al- 
though he derives little additional warmth 
from them. With the above there is of- 
ten urinary irritation, the patient passing 
at short intervals considerable quantities 
of highly acid urine almost devoid of pig- 
ment. 357 
INTERMITTENT FEVER. 
This symptom, although not commonly 
mentioned by authors, I have very often 
experienced in my own person, and have 
frequently noticed it in others; when 
present in a high degree, it adds much to 
the patient's distress. 
The sensation of cold of which the suf- 
ferer complains is merely a subjective 
symptom. (Parkes.) Incredulous as the 
shivering patient may be, it is certain 
that the temperature of his blood, even 
before the rigors begin, is above the nor- 
mal standard, a fact which is at once de- 
monstrated by placing a thermometer in 
his axilla, which rises rapidly until it in- 
dicates a temperature of 105° to 106'B0 
Fahr. (Parkes, Ringer, Wunderlich.) 
[Fig. 14. 
This sudden rise in temperature is com- 
mon to all the types of malarial fever. 
Headache is sometimes complained of, 
but not always; the mind is inert, and 
occasionally the patient is drowsy. The 
duration of the cold stage is variable ; it 
may last from half an hour to two hours 
and a half, and in rare cases even three 
or four hours. When the paroxysms 
have been often repeated, and the poison 
has been, to a great extent, eliminated, 
the cold stage shortens, until at last the 
patient is only conscious of a passing 
chill. 
Hot stage.-Flushes of heat at first al- 
ternate with slight rigors. By and by a 
grateful feeling of warmth steals over the 
body; the bed-clothes are thrown off; the 
increase of temperature is now apparent 
to the patient and his attendants without 
the aid of a thermometer. The pulse be- 
comes full and frequent; the respiration, 
although still hurried, becomes more 
regular. When the hot stage is fully de- 
veloped, a temperature of 107° or 108° is 
often noted. The agreeable sensations 
that accompanied the first feelings of 
warmth pass away; nausea, and even 
vomiting, often distress the patient; head- 
ache and thirst are complained of; and 
the patient tosses uneasily in a burning 
fever. 
Physicians in the malarial parts of the 
Southern States of America look anx- 
iously for the development of what they 
Temperature in tertian ague.] 
call "a good hot stage," regarding pow- 
erful reaction as conducive to the patient's 
safety ; whereas a quick and feeble pulse, 
with rapid thoracic respiration and low 
temperature, are looked on as dangerous 
symptoms, as indeed they are. 
The duration of the hot stage is usually 
about two hours ; in severe cases it may 
last four or five, and it has known to be 
prolonged through ten or twelve hours. 
Siceating stage.-Perspiration appears 
first on the brow and face, and gradually 
spreads over the entire surface, until the 
patient sweats copiously at every pore. 
The pulse falls infrequency and strength; 
the respiration becomes more natural; the 
temperature rapidly falls to the normal 
standard; headache first abates, and then 
passes away. 
Captain Burton, the renowned African 
traveller, writing of the mild Intermittent 
oi' Seasoning Fever of East Africa, de- 
clares "that there is nothing unpleasant 
in these attacks. The excitement of the 
nerves is like the intoxication produced 
by a plentiful supply of green tea ; the 
brain becomes uncommonly active, peo- 
pled with a host of visions; and the 
imagination is raised almost to Parnas- 
sus. " This mental excitement I have ex- 
perienced, and the observant traveller is 
right when he adds, "the patient pays 
for it when the fit passes off. These 
agreeable sensations do not recur with 
the subsequent paroxysms." 358 
MALARIAL FEVERS. 
During the intermission the patient is 
commonly said to be "well," but this is 
only true in a limited sense ; and if the 
paroxysms be allowed to go unchecked, 
the sufferer, even during the intermission, 
soon becomes incapable of much exertion 
of mind or body. 
Condition of the Urine.-As already 
mentioned, the urine is increased during 
both the cold and hot stages, and appa- 
rently, from the presence of a large quan- 
tity of free acid, is sometimes very irri- 
tating. Convalescence is ushered in by a 
remarkable diminution in its quantity ; it 
now becomes scanty, alkaline, or neutral, 
and of a deep orange color. Intelligent 
patients soon learn to note this, and inti- 
mate to their physicians the occurrence of 
what they deem a critical discharge, by 
informing them that no more quinine is 
required. In the hottest weather, during 
the active stages of Intermittent Fever, 
urine always retains its acid reaction for 
several days. When the fever intermits, 
the urine then rapidly undergoes decom- 
position, and changes from acid to alka- 
line. (Jones.) 
A person with ague, not actually suffer- 
ing from a fit, secretes less urea than a 
person in health. The moment a fit com- 
mences, the urea suddenly increases, 
although every known cause of increase, 
as food and exercise, be avoided. 
The increase lasts during the cold and 
hot stages, and then sinks, sometimes 
gradually, sometimes suddenly, through 
the sweating stage, or into the commence- 
ment of the intermittence. The amount 
then falls below the healthy average. 
(Parkes.) 
There is a very close connection between 
the temperature and the amount of urea. 
(Ringer.) The amount of urea corre- 
sponding to a degree of Fahrenheit is 
greater at a high than a low temperature. 
The pigment is lessened in amount. 
(Jones.) Uric acid is greatly increased 
during the fit. (Parkes.) The chloride of 
sodium, according to Professor Ringer, is 
greatly increased during the cold and hot 
stages. Albumen is found in an uncertain 
proportion of cases during the fit, with 
blood and renal cylinders. I can confirm, 
from personal observations, Dr. Parkes's 
remark that chronic Bright's disease is a 
consequence of ague. Many "old In- 
dians," who have suffered from malarial 
fevers, die of this disease. 
The Blood is changed from the begin- 
ning of the attack, and, probably, for some 
time before. The red globules and fibrin 
are diminished, the coagulum is larger and 
more flabby than that of healthy blood, 
much darker in color-in extreme cases 
approaching to black-and on exposure to 
air, instead of the usual bright red, it only 
assumes a cherry-red color. (Jones.) Its 
serum is dark and muddy, and it has 
sometimes an oily appearance. 
The skin, after a time, assumes a dirty 
pale yellowish hue, a change which is 
often permanent, and which depends, not 
on bilious discoloration, but on some of 
the blood-changes above described. 
Sufferers from Intermittent Fever are 
usually depressed in spirits, and are inca- 
pable of much exertion of mind and body ; 
their appetites and digestions are bad, and 
they are prone to diarrhoea from slight 
causes. 
When this anaemic condition is de- 
veloped, a peculiar cardiac murmur is 
commonly present, which is prolonged 
into the great vessels. This is an ''anae- 
mic bruit," due apparently to the watery 
condition of the blood. 
If the spleen is much enlarged, the 
heart is apt to be displaced upwards, and 
thus to mislead the unwary into a diagno- 
sis of heart disease, when that organ is 
sound. (Morehead.) The heat-generat- 
ing power of all victims to malaria is im- 
paired : hence they suffer from atmosphe- 
ric changes, of which healthy men take no 
note. 
Diagnosis.-Remittent Fever is the 
only disease which appears to me likely 
to be confounded with an ague. The 
regularity of the phenomena, the exist- 
ence of a distinct period of complete apy- 
rexia, will suffice to determine the diag- 
nosis, and in doubtful cases the ther- 
mometerwill settle the point, "for all the 
types of ague present this characteristic 
peculiarity of a sudden and speedy rise of 
the temperature up to 105° or 106° Fahr, 
and of an equally rapid and complete de- 
fervescence, till the period of another 
paroxysm comes about." (Aitken.) 
Morbid Anatomy.-Death in an un- 
complicated intermittent is so uncommon 
that few opportunities for post-mortem 
examination are afforded. 
We have seen that one of the earliest 
indications of disturbed function after the 
action of malaria is given by the stomach ; 
in the mildest agues this disturbance is 
present, and in severe remittents intense 
nausea and urgent vomiting are among 
the most prominent symptoms. Casorati, 
who has had many opportunities of dis- 
secting the bodies of those who have died 
from the "pernicious" agues of Italy, ob- 
served "that sufficiently well-charac- 
terized morbid appearances in the stomach 
constitute by far the most constant post- 
mortem appearance of all those observed. " 
(Vide "British and Foreign Med. Chir. 
Rev." July, 1864.) 
Hypersemia of the stomach and duode- 
num, then, is one of the most common of 
the appearances found post mortem in in- 
termittents. In some of the cases ex- 
amined after death at Walcheren, circular 
ulcers, according to Sir Gilbert Blane, INTERMITTENT FEVER. 
359 
were found in addition to the hypenemia 
above described. 
The liver and spleen also suffer, the 
latter more frequently than the former. 
In recent cases the spleen is generally 
found so softened in its texture as to break 
up under examination ; occasionally it is 
reduced to a dark-colored bloody pulp, 
enveloped by its capsule. In more chronic 
cases the organ is found to be indurated, 
and often so enormously enlarged as to 
extend downwards into the pelvis. That 
the spleen acts as a diverticulum in the 
cold stage of ague there is no doubt; by 
percussion we can demonstrate that it en- 
larges with every fit, and contracts again 
when the paroxysm comes to an end. In 
time the elasticity of its structure is im- 
paired, and some degree of permanent en- 
largement results. But there is another 
cause in operation. Virchow and others 
have shown that the spleen enlarges not 
only in intermittent and typhoid fevers, 
but also in most other morbid processes 
resulting from the presence of noxious 
matters in the blood. Irritation of the 
gland ensues, and the result is increased 
cell-formation in its structure. 
The liver is found in recent cases in 
various states of congestion, often soft in 
texture, and of a dark purple or black 
color. In more chronic cases it is en- 
larged, the malarial poison acting as a 
source of irritation, leading, as in the 
spleen, to increased cell-formation. When 
the bodies of men who have served long 
in malarial regions are examined, one of 
the most common appearances is a deposi- 
tion of black pigment in the spleen, liver, 
and kidneys. 
Prognosis.-I have never seen a per- 
son die from uncomplicated Intermittent 
Fever. 
The prognosis in such cases, under ra- 
tional management, is favorable. 
The danger to life is from the malarial 
cachexia, and the organic changes to 
which it gives rise. When the disease is 
about to yield, not only are the paroxysms 
less severe, but the time of accession is 
postponed for some hours. The appear- 
ance of a copious deposit in the urine, and 
an herpetic eruption about the lips, are 
also favorable signs: so also are the dis- 
appearance of precordial distress, ano- 
rexia, and nausea at the commencement 
of the paroxysm. 
[In several localities in the Southern 
United States, especially in the rice-grow- 
ing region of South Carolina, and some 
places near the lower Mississippi, a type 
of Intermittent Fever prevails, which, in 
the absence of specific treatment, is often 
fatal. This is best designated as Perni- 
cious (also called congestive) Fever. 
In it all the main symptoms of ordinary 
Intermittent are intensified; at least in 
the cold stage. This partakes of the cha- 
racter of the collapse of cholera; except 
in the absence of the colorless watery 
evacuations. The skin is cold, pale, or 
livid ; the countenance haggard ; thirst is 
intense; the pulse is small, weak, often 
rapid or irregular; respiration is oppressed; 
vomiting is common ; the bowels mostly 
are loose, with discharges often like bloody 
water. 
Sometimes cerebral symptoms predomi- 
nate ; delirium being present, passing into 
stupor, with stertorous respiration. Te- 
tanic rigidity occasionally exists during 
the paroxysm. 
After an imperfect reaction, lasting from 
eight to twelve hours or more, another 
attack comes on, unless prevented by treat- 
ment. A third paroxysm is almost always 
fatal. 
The diagnosis of such cases is usually 
not difficult in the localities in which Per- 
nicious Fever is common. In the North- 
ern United States, where examples of the 
same kind now and then are seen, they 
may present more difficulty. Especially 
the variety in which a tendency to stupor 
exists, may not always be easy to discrimi- 
nate from apoplexy. The previous history 
of the patient must then be closely inquired 
into. The coldness of the skin, and gene- 
rally the character of the pulse, will aid 
in drawing this distinction. 
In the morbid anatomy of Pernicious 
Fever, the attention of Southern practi- 
tioners was long ago called to the frequency 
of congestion of the brain, liver, lungs, and 
other organs; giving rise to the title 
"Congestive Fever." There is no doubt, 
however, that this condition of the organs 
is the secondary result of the systemic 
poisoning by malaria. 
Typhoid pneumonia, the winter fever of 
the South, is, in many cases at least, de- 
cidedly a malarious affection, requiring to 
be treated as such. Dysentery, also, is 
not unfrequently impressed with the same 
character, being periodical in the recur- 
rence and remission of its symptoms. 
In the treatment of Pernicious Fever, the 
indications are clearly two: to produce 
reaction from the cold stage, and to pre- 
vent its return by specific medication. If 
the stomach will retain it, quinine may be 
given as the first, perhaps almost the only 
medicine. The amount, when it is given, 
must be larger than in ordinary Intermit- 
tent. Five or ten grain doses, repeated 
at intervals of two or three hours until 
thirty (some say sixty) grains have been 
taken, will do all that can be looked for 
from this remedy. More than sixty grains 
of pure sulphate of quinia in twenty-four 
hours cannot be given with safety to the 
patient; and very seldom will more than 
thirty or forty grains within the same time 
be appropriate. 
Should the stomach be very irritable, 360 
MALARIAL FEVERS. 
ice may be given to quench thirst, and, as 
a stimulant, capsicum, in pills of five 
grains each. To promote reaction, the 
patient may be placed for a short time in 
a hot bath, or bags of hot salt or sand may 
be placed in contact with the back and 
limbs ; a large sinapism, also, being ap- 
plied to the epigastrium. Some physi- 
cians, instead of capsicum, give camphor, 
or opium, or ether, during the paroxysm, 
to promote reaction. A good combination 
is of camphor, opium, and quinine, each 
in moderate doses, in pill, bolus, or pow- 
der, every half hour during the cold stage. 
If a comatose condition occurs, the opium 
should be omitted. When the stomach 
obstinately rejects everything, quinine 
may be introduced by the rectum, or by 
hypodermic injection. Calomel is em- 
ployed, on traditional evidence, by many 
practitioners, in this disease. Experience 
in the North with Pernicious Fever is too 
limited to afford the means of concluding 
absolutely upon its value in this affection. 
Alcoholic stimulants are more apt to be 
needful in a second or third than in a first 
paroxysm; unless in those whose habits 
have been already intemperate, with cor- 
responding feebleness of system. 
Cerebral symptoms, such as low delirium 
or stupor, may be treated by the applica- 
tion of a blister to the back of the neck, 
cqtting short the hair, &c. ; not, however, 
omitting quinine, if the malarious nature 
of the attack is evident.-II.] 
Treatment.-"Happily for us," says 
the observant traveller Burton, "the old 
African treatment is now obsolete. A. B. 
caught fever-gave him calomel, bled him, 
blistered him-died on the third day." 
Happily too for those whose lot is cast in 
India, the same may be said; the anti- 
phlogistic treatment of malarial fevers is 
no more heard of there. So completely is 
this the case, that it seems to me like con- 
tending with a shadow to say a word in 
condemnation of it. In Italy, however, 
this system not only holds its ground, but 
appears to be carried out with a higher 
hand than in the darkest days of African 
practice. Every perversion of normal 
function occurring in the course of an 
ague is still looked on as an inflammation, 
and treated accordingly by general and 
local bleedings, and a rigorous system of 
diet. What Dr. Haldane has recently 
said on this system of treatment generally 
is, as it appears to me, peculiarly applica- 
ble to every form of malarial fever that 
has come under my observation. "For- 
merly, when an inflammation manifested 
itself, it was regarded as something super- 
imposed upon the organism; as an enemy 
attacking the fortress of life, which re- 
quired to be attacked by the most ener- 
getic measures. Its supplies must be cut 
off by the enforcement of a rigorous diet, 
and it must be attacked with the heavy 
artillery of bleeding, mercury, and blisters. 
But it was not kept in mind that by these 
measures the garrison was weakened in 
an equal degree with the enemy, or rather 
in a greater degree, so that even if the 
adversary were overcome and retired from 
the contest, the patient often succumbed, 
owing rather to the severity of the treat- 
ment than to the malignity of the disease. " 
(The Modern Practice of Medicine : a Lec- 
ture by Dr. Rutherford Haldane, M.D., 
F.R.C.P.) 
Most systematic authors direct us to be- 
gin the treatment of all fevers with an 
emetic. In Intermittents, when the 
tongue is very foul or the stomach op- 
pressed by food, an emetic does good, giv- 
ing great relief, and hastening the stage 
of reaction. The longest cold stage I ever 
saw was not in India but in England. 
The sufferer was an Indian officer who 
was subject to ague. He had partaken 
freely of pickled oysters ; in a few hours 
he was seized with intense nausea, head- 
ache, and epigastric oppression, soon fol- 
lowed by severe rigors. When I saw him 
he had been nearly five hours in this state, 
and his condition caused great alarm. I 
immediately gave him a mustard emetic, 
which speedily relieved him, and rapidly 
brought on a short and mild hot stage. 
It is hardly necessary to caution even 
young practitioners against the absurdity 
of giving an emetic to a patient every time 
he has an ague, without regard to the 
special circumstances of his case. 
The same rule applies to purgatives. 
They are useful if the bowels are loaded ; 
the action of a purgative tends to relieve 
the congested condition of the solid ab- 
dominal viscera, and prepares the way for 
the action of quinine. But great caution 
is required in the use of purgatives in per- 
sons laboring under malarial cachexia, 
particularly in Asiatics. 
If there be much urinary irritation, a 
few grains of bicarbonate of potash with 
or without a few drops of tincture of opium 
will relieve it at once. 
During the cold stage the patient should 
have a sufficiency of bed-clothes, but, be- 
yond this, interference is not often called 
for, and more sufferers prefer to be let 
alone. If the cold stage is unusually pro- 
tracted, or it becomes apparent that the 
vital powers are so oppressed as to be un- 
equal to the development of reaction, then 
the external application of warmth and 
the use of stimulants may be required. 
In like manner during the hot stage 
little interference is called for. The bed- 
clothes should be removed as reaction ad- 
vances ; cooling drinks may be given if 
they are relished or called for, which I 
have observed is seldom. If the patient 
be in a debilitated state from any cause, 
instructions should be given to watch the 361 
INTERMITTENT FEVER. 
patient when the sweating stage begins, 
lest symptoms of collapse should appear, 
in which case support and stimulants 
should be promptly given. 
The paroxysm ended, our utmost efforts 
should be directed to counteract the poi- 
son, and prevent, if possible, a repetition 
of the attack. In cases of first attacks it 
is of unspeakable moment to the patient 
to prevent his system from getting, so to 
speak, into the habit of going through the 
phenomena of an ague tit. For, although 
we cannot doubt that the aim and end of 
the process is so far salutary that it rids 
the system of a portion of the poison, it is 
also true that the organism suffers in tlie 
process, and that every paroxysm is a 
step towards the establishment of those 
organic changes I have described. In 
quinine, skilfully used, we have a remedy, 
particularly in first attacks, which almost 
deserves the epithet "divine" which has 
been applied to it. 
I always assume that in first attacks the 
type of the disease will prove to be quoti- 
dian, and I take my measures accordingly, 
making sure that the patient shall have 
thirty grains of quinine between the ter- 
mination of one paroxysm and the hour 
when we may look for another. The first 
dose of ten grains should be given towards 
the close of the sweating stage, and look- 
ing to the fact that when an attack is, as 
I have already expressed it, waxing, we 
may expect the setting in of the cold stage 
perhaps two hours earlier than on the first 
day, the last ten-grain dose should be 
given so as to anticipate that time by at 
least an hour. Quinine in the treatment 
of agues should always, if possible, be 
given in solution, with a few drops of 
diluted sulphuric acid; its bitterness is 
best covered by the addition of a little 
syrup of orange-peel. [Less than thirty 
grains will suffice for tlie interval in the 
type of Intermittent which is usual in the 
Northern United States; fifteen grains, 
given between the end of one paroxysm 
and the time of its expected recurrence, 
will, in ordinary cases, almost never fail 
to interrupt the attack. Pernicious fever, 
in the South, requires larger doses. In 
ordinary ague, especially when the sto- 
mach is irritable, the method of Dr. G. B. 
Wood is best, in the opinion of many 
who have tried it, viz., giving one or two 
grains of quinine at a time, repeated at 
sufficiently short intervals to get in the 
amount required for sufficient " cinchoni- 
zation" during the interval.-H.] 
If irritability of stomach be present to 
such an extent as to lead to vomiting, no 
time should be lost in giving the quinine 
by enema. The lower bowel must first be 
washed out with a little warm water, and 
fifteen grains should then be given by the 
rectum in four ounces of beef-tea, if that 
be at hand, if not, in a little thin starch ; 
and the irritability of stomach still con- 
tinuing, this should be repeated twice at 
proper intervals during the apyrexia. I 
have been in the habit of administering 
quinine in this way with advantage for 
the last fifteen years. [Hypodermic in- 
jection of a solution of sulphate of quinia 
is resorted to not unfrequently, when the 
stomach will not retain it. The amount 
needed is somewhat in the way of this 
method of administration, and local irri- 
tation is somewhat more frequent than 
after other hypodermic injections.-II.] 
If we are fortunate enough to prevent 
the recurrence of the paroxysm in this our 
first attempt, the gain to our patient is 
great, and it is well to maintain a mode- 
rate degree of cinchonism for some days, 
evidenced by " ringing in the ears. " This 
can be effected by giving three or four 
grains of quinine in solution every four 
hours. But our duty to the patient is not 
yet discharged. We must not dismiss 
him from our thoughts because we have 
successfully managed his case so far. 
In a lunar month from the date of his^ 
first attack, even should he not in the in- 
terval be exposed to malaria afresh, there 
will be a tendency in his system to repeat 
the same phenomena as before, and this 
tendency will be strengthened by every 
successive attack. A day or two, then, 
before the time, the patient should again 
be brought under the influence of quinine, 
which should be maintained until that 
time is past. 
[American experience favors bringing 
the patient again under the influence of 
quinine at the end of a week instead of a 
month. Many times the attack will, 
without that precaution, recur on the 
eighth day following the last chill.-H.] 
In military and naval practice we have 
great facilities for carrying out this pro- 
phylactic plan, by simply keeping the 
names of the men in a list, and requiring 
their attendance at the hospital for a few 
minutes daily at the proper time. 
Speaking from a large experience, I 
promise those who may try it the happiest 
results, not only to the men themselves, 
but to the State, whose costly servants 
they are. 
When our object has been attained, and 
the paroxysms have been broken, it is 
well, if quinine excites nausea or irrita- 
bility of stomach, to give what may still 
be required after food, which will entirely 
obviate any such unpleasant effect; and, 
what is of no small consequence, prevent 
the patient from being disgusted with the 
remedy. 
If we fail in entirely checking the return 
of the paroxysm, we are nevertheless 
pretty certain to have made some impres- 
sion, and it will be a favorable sign if it is 
postponed for two or more hours, as is 
almost certain to be the case. Under 362 
MALARIAL FEVERS. 
such circumstances we must proceed as 
before, slightly increasing the dose of qui- 
nine, if we are not satisfied with the ex- 
tent to which cinchonism was induced. 
Most American authors describe qui- 
nine as the antidote to the poison of malaria. 
According to Herapath's experiments, 
not much of the quinine taken into the 
system is excreted from it, at all events 
when disease is present. Out of forty 
grains given to a man with tetanus, only 
a fifth part was detected in the urine ; the 
remaining four-fifths were either assimi- 
lated in the body, or destroyed in their 
transit through the vascular system. 
When given in ague it does not appear 
so soon in the urine as in health. (Parkes; 
Ringer.) "It has no marked effect on 
the water, urea, and chloride of sodium, 
though it may at once arrest the rise of 
temperature;" and Dr. Parkes adds, 
"After ague has been apparently cured 
by quinine, there occurs in the next two 
or three days an increase in urea, chlo- 
rine, and water, at the hours when the 
f fit would have occurred but for the qui- 
nine. In other words, the quinine disso- 
ciates these two symptoms, increased 
temperature and ureal increase ; it stops 
the first at once, but not the second for 
some days." 
[There is no room to doubt the fitness 
of the designation of antidote, as applied 
to quinine in the cure of Malarial Fever. 
How it acts, we cannot know while the 
nature of the morbid poison is unknown. 
The " fungus theory" has much to com- 
mend it as probable, and quinine is 
found to be destructive of low forms of 
vegetation; yet demonstration is here 
wanting.1 A remarkable observation 
of Dr. H. Bence Jones, concerning the 
existence of a fluorescent substance in 
human blood, was confirmed in 1867 at 
the Pennsylvania Hospital by Drs. E. 
Rhoads and W. Pepper. These observers 
also ascertained that, in malarial cases, 
there occurred a notable diminution of 
this fluorescence, and that it was restored 
after the administration of sulphate of 
cinchonia in therapeutic doses.2-H.] 
We occasionally meet with cases in 
which quinine appears to have lost its 
control over the malarial poison, the 
paroxysms returning with unfailing regu- 
larity month after month, in spite of the 
regular prophylactic use of the "antidote. " 
In such cases it will be found that the 
sufferers have been long in a malarious 
locality ; and, whether or not we can de- 
tect enlargement of liver or spleen by pal- 
pation or percussion, the miasmatic and 
melancholic aspect of the patients, and 
the presence of bile in the urine, point to 
the imperfect manner in which the hepatic 
functions are being performed. In such 
cases a course of the fluid extract of tar- 
axacum with small doses of podophyline 
are most useful; and if to the above be 
added the free use for some days of such 
blood depurants as the bicarbonate, or 
acetate, or citrate of potash, considerably 
diluted, it will be found that quinine, be- 
fore useless, will soon reassert its power. 
I have seen this again and again, and by 
this method have cured agues deemed be- 
yond the reach of art without a change of 
climate. I have not space to enter into 
the question of the modus operandi of such 
remedies. It is probable that they act 
chemically on the effete matters in the 
blood, which in some way interfere with the 
due action of quinine on the materics morbi. 
Next to quinine as a therapeutic agent 
in this disease comes arsenic. It has been 
used in the East in the cure of agues and 
their sequels from remote antiquity. 
Having always been fortunate enough to 
have access to an abundant supply of 
quinine, I have not used arsenic much in 
the treatment of agues. From motives of 
economy it is much used in the French 
army, and in much larger doses than 
British physicians are in the habit of pre- 
scribing. Boudin, acting on the principle 
that in paludal fevers there is great toler- 
ance of arsenious acid, is in the habit of 
giving it in divided doses, and, with the 
watchfulness always required in the use 
of this powerful poison, to the extent of a 
grain and even a grain and a half in the 
intermission. (Morehead, Clinical Re- 
searches.) Like quinine, its use should be 
continued for some time after the cessa- 
tion of the fever, of course in diminished 
doses. We should carefully look for the 
earliest signs of its constitutional action ; 
these are watering of the mouth, a silvery 
appearance of the tongue, redness of the 
eyes : and the medicine, as a rule, should 
be given after food. In the brow-ache 
and hemicrania of malarial localities arse- 
nious acid is very efficacious-often more 
so than quinine. 
I gave an extensive and careful trial of 
sulphate of bibeerine, prepared by Messrs. 
Duncan and Flockhart, of Edinburgh, and 
found it useless in the treatment of all 
forms of Intermittent Fever. Barberry, 
a very old remedy in ague, I have also 
tried in the shape of tincture. I think it 
possesses some power as a febrifuge, but 
it is so uncertain in its action, so immeas- 
urably inferior to quinine, that, in my 
judgment, to use barberry when quinine 
is available, is to trifle with the constitu- 
tions of our patients. Of Warburg's 
Tincture, as a febrifuge of undoubted effi- 
cacy, I shall have to speak when I come 
to remittent fever. 
[* See, on this topic, Dr. Salisbury, Am. 
Journ. of Med. Sciences, Jan. 1866, and Dr. 
II. C. Wood, same journal, Oct. 1868.] 
[2 Pennsylvania Hospital Reports, 1868, 
p. 269.-H.] INTERMITTENT FEVER. 
363 
[Various substitutes for quinine have 
been proposed and largely tried. Among 
these, opium, chloroform (by the mouth, 
in f$j doses), and bromide of potassium 
have had a number of successes. Dog- 
wood bark (Cornus florida), salicin from 
willow bark, piperin, the leaves of Euca- 
lyptus globulus, and other vegetable ma- 
terials have been used with variable, often 
iavorable, results. 
Other derivatives of Peruvian bark have 
been much subjected to experimental use 
of late years. Sulphate of cinchonia has, 
in doses once and a half larger, equal 
efficacy with the sulphate of quinia. It 
less often affects the head, but is some- 
times more trying to the stomach. Sul- 
phate of quinidia will act very well in 
doses not much larger than those of 
quinine. Similar accounts are given, by 
physicians practising in malarial districts, 
of sulphate of cinchonidia, quinoidine, and 
dextro-quinine. All of these are less ex- 
pensive than quinine.-II.] 
Diet.-I have already shown that Cap- 
tain Burton has sound therapeutic notions 
on malarial fevers; I think him equally 
sound in what he says on diet. He ob- 
serves : "People will act up to the old 
nursery saying, ' Starve a fever, feed a 
cold. ' My experience in East Africa long 
ago untaught me that tenet. I have ever 
since preferred to support exhausted na- 
ture with essence of meat, and beef-tea, 
and, when such things are procurable, 
with champagne, brandy cum soda, and 
ye oldest hock in ye cellar." These may 
not be available for hospital purposes ; but 
when such wines are used, they should be 
"the best in the cellar," or they should 
not be used at all. Dr. Blair, of Guiana, 
in his admirable Treatise on Yellow 
Fever, is quite as explicit on this point as 
Captain Burton. In the adynamic forms 
of intermittent, or in any form occurring 
in asthenic subjects, due attention to 
support during the intermission is the 
most essential part of the treatment, and 
it has been very well insisted on by Dr. 
Morehead, in his great work. 
Treatment of Complications. - In the 
course of an Intermittent Fever, cerebral, 
pulmonary, hepatic, and gastric complica- 
tions may occasionally be expected. After 
no small experience, I unhesitatingly say, 
that the occurrence of drowsiness, mental 
confusion, suffusion of countenance, and 
such like symptoms, should not mislead 
us into the use of routine remedies direct- 
ed against them. Let all our efforts be 
used to cure the fever, to stop the parox- 
ysms, and to the due support of our pa- 
tients. When these objects are attained, 
the head symptoms will disappear. In 
like manner the presence of cough or 
asthma, or of hepatic congestion, should 
never induce us to lay aside quinine and 
the other means recommended above, in 
order to direct routine treatment to coun- 
teract this or that incidental symptom 
occurring in the course of a malarial lever. 
Those who do so often put the lives of 
their patients in great peril. 
Practitioners who omit the use of qui- 
nine from a groundless fear of aggravating 
such symptoms, and substitute strong 
measures of a so-called antiphlogistic 
kind, applying leeches and cold to the 
head, giving nauseating expectorants and 
active purgatives, merely because of the 
head symptoms already mentioned, the 
presence of some bronchitic rales and 
cough, or some tumefaction of the side, 
will not only have little success in the 
treatment of malarial fevers, but will 
aggravate the complications they seek to 
cure, hasten alarming exhaustion, or 
bring on sudden collapse. 
I have seen epilepsy, long dormant, de- 
veloped again during the course of a 
severe Intermittent Fever. The same 
principle guided me in the management 
of this case ; I redoubled my efforts to 
extinguish the fever with quinine, and 
succeeded, and with the fever the epilep- 
tic attacks disappeared. Had I inter- 
rupted the administration of quinine and 
directed my efforts against the nervous 
complication, I feel assured that I should 
have made no impression on it. With 
each recurring paroxysm, the epileptic 
attack would have been repeated, the old 
habit would have been re-established, and, 
if nothing worse happened, my patient 
would have become a confirmed epileptic. 
It is an old observation that nervous dis- 
eases are sometimes remedied or super- 
seded by Intermittent Fever. One case, 
and one only, lending some support to 
this supposed fact, has come under my 
observation. A medical officer in India 
became subject to epileptic attacks, which 
resisted treatment. It was feared that he 
had become a confirmed epileptic. He 
was attacked by Intermittent Fever, 
which affected him at intervals for many 
years; but from the date of his first parox- 
ysm of ague he never had another epileptic 
attack. I knew this officer in India well; 
the fits of epilepsy were genuine, and the 
attacks severe and frequent. 
Treatment of Malarial Cachexia.-The 
first and most essential part of the treat- 
ment is removal to a non-malarious cli- 
mate. If for this end a sea voyage be 
possible, so much the better; but unless 
the ship on which the voyage is made be 
one in which strict hygienic discipline is 
maintained, much of the good to be ex- 
pected from this measure will be lost; and 
if, from inattention to proper dietetic 
rules, a scorbutic taint be added, the con- 
dition of the patient will be seriously ag- 
gravated. I have dwelt on this at some 
length in the Army Medical lieport for 
the year 1861-62. 364 
MALARIAL FEVERS. 
A nutritious diet, abundance of exer- 
cise, pure air, and pure, water, are power- 
ful curative means. The careful use of 
some of the means practised by the so- 
called "hydropathists" for restoring the 
functions of the skin is strongly to be 
recommended; a walking tour on the 
mountains of Scotland, or, better still, a 
season or two on the moors, will do much 
to work the poison of malaria out of the 
system. Great attention should be paid 
to clothing, which should be warm, par- 
ticularly on first coming into high lati- 
tudes. Sir Ranald Martin has well shown 
the evil consequences resulting from want 
of attention to this. 
Returns x)f Intermittent Fever should 
be met by the prophylactic use of quinine, 
so given as not to excite gastric irritabil- 
ity. If the patient's appetite be bad, he 
may take a course of syrup of the phos- 
phate of iron, quinine, and strychnine ; a 
formula for this preparation (now much 
used at the R. V. Hospital, Netley) is 
given below,1 for which I am indebted to 
my colleague, Dr. Aitken. Some of the 
other preparations of iron may be, after 
a time, substituted; a very suitable one 
is the tincture of the acetate, from the 
old Dublin Pharmacopoeia. 
[The great value of iron in the treat- 
ment of recurrent or chronic Intermittent, 
which, in certain cases, although inter- 
rupted, is not cured by quinine, is far 
from being appreciated by the profession 
generally. Few cases will resist the ef- 
fect upon the system of Vallet's Pil. Ferri 
Carb.,1 given for three or four weeks, af- 
ter "breaking" the chills in the usual 
way with quinine.-II.] 
Treatment of Enlarged Spleen.-This 
"ductless vascular gland" enlarges, as 
has been already stated, under the influ- 
ence of malaria, without, as well as with, 
the intervention of fever. The treatment 
advised above, exercising, as it is calcu- 
lated to do, a favorable influence on the 
constitution of the blood, often acts bene- 
ficially also on the enlarged spleen. Should 
this organ, however, continue undimin- 
ished in size, we have a powerful remedy 
in the ointment of the biniodide of mer- 
cury, applied over the gland. The ex- 
perience of many practitioners in India 
having demonstrated the extraordinary 
efficacy of this remedy in cases of goitre, it 
has of late years been successfully used in 
some parts of India as a remedy in solid 
enlargements of the spleen. 
When used in goitre, a portion about 
the size of a nutmeg is applied over the 
swelling with a smooth spatula, the pa- 
tient is directed to expose his goitre to 
the sun's rays as long as he can bear the 
smarting which quickly follows. A sec- 
ond application is immediately made, and 
it rarely happens that any further treat- 
ment is necessary. 
Within the last six months we have 
been very successful in the R. V. Hos- 
pital, Netley, in treating enlarged mala- 
rial spleens and livers with this ointment. 
I have pursued the same plan, substituting 
the heat of the fire for that of an Indian 
sun. In some cases, where the spleen 
has extended down into the pelvis, it has, 
after several applications, been reduced 
almost to its normal limits; and in only a 
few cases has it failed to reduce the size 
of the organ most signally. It has acted 
just as energetically on enlarged malarial 
livers. 
The mode of treatment is worthy of ex- 
tensive trial, and I am the more induced 
to recommend it to the notice of the pro- 
fession in England because in not a single 
example has it induced any unpleasant 
constitutional action. 
I am so impressed with the unsuitable- 
ness of mercurialization in cases of mer- 
curial poison, that I have watched nar- 
1 The following is Dr. Easton's formula for 
the preparation of the syrup of the phosphates 
of iron, quinia, and strychnia (syrupus ferri, 
quiniae, et strychnias phosphat.):- 
Ferri Sulph., $v; Sodae Phosph., Jvi; 
Quiniae Sulph., grs. cxcii; Acid. Sulph. Dil., 
q. s.; Aquae Ammoniae, q. s.; Strychniae, grs. 
vi; Acid. Phosph. Dil,, §xiv ; Sacchar. Alb., 
5xiv\ 
" Dissolve the sulphate of iron in one ounce 
of boiling water, and the phosphate of soda 
in two ounces of boiling water. Mix the so- 
lutions, and wash the precipitated phosphate 
of iron till the washings are tasteless. With 
sufficient diluted sulphuric acid, dissolve the 
sulphate of quinia in two ounces of water. 
Precipitate the quiniae with ammonia water, 
and carefully wash it. Dissolve the phos- 
phate of iron and the quinia thus obtained, 
as also the strychnia, in the diluted phos- 
phoric acid; then add the sugar, and dissolve 
the whole, and mix without heat. 
" The above syrup contains about one grain 
phosphate of iron, one grain phosphate of 
quinia, and one thirty-second of a grain of 
phosphate of strychnia in each drachm. The 
amount of phosphate of quinia might be in- 
creased according to circumstances, and if 
eight grains of strychnia were employed in 
place of six, as in the above, the phosphate 
ot strychnia would be in the proportion of 
the one twenty-fourth of a grain in every 
fluid drachm of the syrup. I would scarcely 
venture on a much larger dose. In cases of 
delicate children, with pale countenances 
and deficient appetites, I have given, with 
great benefit, a combination of equal parts of 
the above syrup, and of that prepared by Mr. 
Edward Parrish, often called 'Chemical 
food.' To children between two and five 
years of age the dose of this combination may 
be a teaspoonful three times daily." (Vide 
Aitken's Science and Practice of Medicine, 
vol. ii. 657.) 
[l Three or four grains thrice daily.-H.J REMITTENT FEVER. 
365 
rowly for any ill effects from the use of 
this compound, without observing any- 
thing to justify my fears; on the contrary, 
in every case where it has acted on the 
spleen or liver in the manner above de- 
scribed, an immediate improvement in 1 
the patient's general health has been the 
invariable result. 
REMITTENT FEVER. 
Definition.-A specific paroxysmal 
fever, with exacerbations and remissions, 
characterized by a slight and ill-defined 
cold stage, which does not recur at every 
exacerbation ; an intense hot stage, with 
violent headache and gastric irritation; 
and an almost imperceptible sweating 
stage, which is sometimes wanting. 
Synonyms.-Bilious Fever, Bilious 
Remittent, Endemic Fever, Marsh Re- 
mittent, Gastric Malarious Remittent, 'I 
Jungle Fever. 
History.-This, the gravest form of 
true miasmatic fevers, has been observed 
wherever malaria is generated in sufficient 
concentration, both in hot and in tempe- 
rate climates, but it is most prevalent and 
fatal when high temperature and malaria 
act in combination. 
Our armies have suffered from it in 
Spain and Portugal, at Walcheren, and in 
the Mediterranean ; it prevails with great 
intensity on the western shores of Africa, 
ami in the course of its great rivers. In 
the East Indies it is most common as well 
as fatal in the delta of the Ganges, in the 
terrais, in the jungles at the base of 
mountain ranges, and, at certain seasons, 
in many uncultivated and jungly plains. 
It is found in America, North and 
South, prevailing chiefly, with varying de- 
grees of severity, in the vast region be- 
tween the northern lakes and the Gulf of 
Mexico, and it is a formidable endemic in 
the West India Islands. 
Remittent Fever is a more serious dis- 
ease than any type of intermittent, and 
the direct mortality from it is much 
higher. 
In all intermittent fevers there is a 
period of complete apyrexia ; in remit- 
tents, the defervescence is not complete. 
The more urgent symptoms between one 
exacerbation and another abate ; in some 
cases this abatement is well marked, in 
others it is so slight that the period of so- 
called remission may escape the notice of 
all but a wary and experienced observer. 
A remittent fever may, after a time, 
pass into one or other of the types of an 
intermittent; and conversely, an inter- 
mittent may assume the graver form of 
remittent, either under the influence of a 
fresh charge of malaria, or as I have fre- j 
quently observed under the stimulus 
merely of exposure to a high tempera- 
ture. 
Remittent Fever, as we have seen, has 
many synonyms, but there is one, the use 
of which I earnestly deprecate, viz., In- 
flammatory Remittent, still used by many 
authors, although not always in the same 
sense. Some employ the term merely to 
denote a high degree of intensity in the 
febrile phenomena, without wishing to 
imply the existence of inflammatory ac- 
tion ; while others use it in the belief that 
the terrible disturbance of the vascular 
and nervous systems is due to a genuine 
phlogosis. In either view the term is 
objectionable ; one is based on false views 
of the true pathology of the disease, and 
both are calculated to mislead in treat- 
ment. 
Modes of Commencement.-As in all palu- 
dal Fevers, so in this, symptoms of gastric 
irritation are the first evidence of ap- 
proaching disorder. The patient com- 
plains of pnecordial anxiety, anorexia, 
and nausea, with weariness, languor, and 
lassitude. Uneasiness, sometimes amount- 
ing to great oppression, at the epigastrium, 
is perhaps the most constant, as it cer- 
tainly is the most distressing, of the signs 
of an approaching attack of Remittent 
Fever; it is sometimes present for twenty- 
four or thirty-six hours before the setting 
in of the cold stage. 
The time of day at which the first 
paroxysm takes place is not uniform, but 
when the disease is established a morning 
remission is almost an invariable rule. 
(Wood; Hunter; Morehead; Balfour.) 
It is a point of great practical importance 
to observe in each case the periods of ex- 
acerbation and remission, and the dura- 
tion of each. If the exacerbation begins 
at noon it will usually decline about mid- 
night, or a little before, and the remission 
will last till noon next day. Such cases 
are usually comparatively slight and 
manageable. Or the exacerbation may 
begin at midnight, continue all night, 
and remit in the morning, the remission 
lasting till midnight. Or, in severe cases, 
there may be a double exacerbation, at 
noon anil at midnight, the remissions 
being in the evening and morning, the last 
being invariably the most distinct. 
When the disease assumes this type, the 
evening remission is sometimes so slight 
as to escape notice: but for the invariable 
morning remission it might be mistaken 
for a continued Fever. Treatment will of 
course have an effect on the periods of 
exacerbation and remission, just as it has 
on the paroxysms of an intermittent. 
Duration.-This may be stated at from 
five to fourteen days. Like all forms of 
miasmatic fevers, the duration of the dis- 
ease is much affected by treatment and 
the action of antiperiodic remedies. 366 
MALARIAL FEVERS. 
Modes of Termination.-The Fever ter- 
minates in recovery, or by passing into 
some type of intermittent, or in death. 
When the disease ends in recovery, as it 
usually does, the fever generally culmi- 
nates in a profuse perspiration, and so 
ends. Sometimes the amendment is gra- 
dual, the exacerbations become less 
severe, the heat of skin is less pungent, 
the vomiting and oppression at the epi- 
gastrium subside, the pulse diminishes in 
force and frequency, the tongue becomes 
moist and clean, the remissions are longer 
and more distinct, and they are ushered 
in by free action of the skin; and in this 
gradual way the Fever subsides. 
In some remittents, in which the pa- 
roxysmal character has been from the 
first well marked, if antiperiodic remedies 
have not been skilfully used, the disease 
is apt to become chronic, and to pass into 
one or other of the intermittent types. 
I have never seen death take place 
earlier than the eighth day. This event 
appears to be determined by the destruc- 
tion of the vitality of the blood by the 
agency of the morbific cause. 
When death occurs at a later period, 
the patient sinks, partly from the cause 
just mentioned, and partly from exhaus- 
tion, consequent on the excessive and 
prolonged excitement of the system. 
Here again treatment exerts a powerful 
influence, and may determine not only 
the time but the mode of death. 
Cause.-On this subject I have nothing 
to add to what has already been said 
under the head of intermittent fever. I 
believe that all forms of Remittent Fever 
are due to the same miasmatic cause as 
intermittent, aided probably by high tem- 
perature. When a Remittent follows expo- 
sure to malaria it is reasonable to suppose 
that the morbific agent has been absorbed 
in a high degree of concentration. 
I attribute some effect to the agency of 
high temperature, because remittents are 
more common in hot malarious countries 
than where the same poison exists in tem- 
perate regions, and because, as already 
mentioned, I have, in a great many in- 
stances, observed intermittents pass at 
once into a severe type of the remittent 
form, apparently from no other cause than 
the descent from comparatively cool and 
elevated regions into the heated plains, 
and this under circumstances when there 
was no reason to believe that the suffer- 
ers had been again exposed to malaria. 
The period of incubation is also, I think, 
much influenced by temperature-being 
shorter in hot, longer in cold climates- 
and doubtless also by the degree of con- 
centration of the poison. I have already 
given an example of a fatal miasmatic 
lever being developed within a few hours 
after exposure to the cause in a notori- 
ous malarial locality. From a week to 
ten days or a fortnight have in my experi- 
ence been the most common periods of in- 
cubation. 
Symptoms. - These in an uncompli- 
cated Remittent Fever, occurring in an 
adult of a tolerably vigorous constitution, 
are as follows: The most constant, as 
well as the most urgent, of the premoni- 
tory symptoms, already described, is op- 
pression at the epigastrium. The cold 
stage is neither so complete nor so long 
continued as in ague ; in some of the 
worst remittents I have ever seen, no 
rigors were observed at all, a passing 
sensation of chilliness, alternating with 
flushes of heat being all that the patients 
complained of, as regards temperature. 
In other cases rigors are present, but they 
are seldom severe ; here, as in ague, these 
sensations of cold are merely subjective, 
the thermometer indicating already a tem- 
perature perhaps 2° above the natural 
standard, which, as the hot stage devel- 
ops, mounts to 7° or 8°, and, according to 
some observers, even 10° above that 
standard. 
As the hot stage advances, vomiting 
often begins, and continues throughout 
the disease a distressing and embarrassing 
symptom. The sense of fulness and op- 
presion at the epigastrium is not relieved 
by the vomiting, although the amount of 
fluid thrown off is out of all proportion to 
the quantity taken. The tongue is furred, 
and, as the temperature of the body rises, 
dry. The pulse, which in the premoni- 
tory stage was slow, small, and irregular, 
now rises rapidly to 100 or 120; in men 
of sthenic habits it is full; in adynamic 
cases from the first, although very fre- 
quent, it is small and compressible. 
The countenance is flushed, the eyes 
suffused, and the patient complains of 
rending headache, with pains in the limbs 
and loins ; the skin is red and distended ; 
the heat ardent and stinging; the sufferer 
is restless, and tosses in his bed in the 
vain search for an easy posture. 
When the above symptoms have lasted 
for from six to twelve hours, they begin to 
abate ; a slight degree of moisture breaks 
out on the brow and neck, and grad- 
ually spreads over the body; the pulse 
conies down in force and frequency; the 
heat of skin diminishes ; there is some re- 
lief of headache ; vomiting ceases; and 
the patient obtains some sleep. 
This is the period of remission. 
In severe fevers it is sometimes hardly 
possible to distinguish any but the morn- 
ing remission, so slight is the abatement. 
Keeping this in mind, it should be anx- 
iously looked for. The pulse will often 
give the only indication, and the phy- 
sician who knowrs how precious for treat- 
ment such golden moments of remission 
are, will diligently watch for the earliest REMITTENT FEVER. 
367 
signs of lull in the midst of this tempestu- 
ous action of the system. 
After a respite of some hours, varying 
from two hours to eight or twelve-seldom 
so long-the fever returns, often without 
a chill, or so slight a one as hardly to at- 
tract notice ; all the symptoms above de- 
scribed are renewed, and always in an 
aggravated form. This is technically 
called the exacerbation, which in due 
time passes into the remission again. 
I have already pointed out the usual 
course of the periods of remission and 
exacerbation, but I repeat once more that 
the attack is dangerous just in proportion 
as the disease resembles a continued and 
not a paroxysmal fever. 
Of all the symptoms nausea and vomit- 
ing are the most constant and the most 
exhausting: the vomited matters at first 
consist of any food that may be in the 
stomach, then of a watery fluid, often in 
surprising quantity. Soon bilious regur- 
gitation takes place into the stomach, and 
the rejected matters become of a greenish- 
yellow color, then brown, and finally in 
extreme cases, black, resembling the 
"black vomit" of yellow fever. The re- 
semblance will be more striking if, as 
sometimes happens, the skin assumes a 
yellow tinge, and a hemorrhagic ten- 
dency be evinced. I have seen two cases 
at Madras, both in officers of the Forest 
Conservancy department, in which the 
hemorrhagic range was most extensive, 
the patients passing blood from the stom- 
ach, bowels, and kidneys. 
In one of these cases I had the advan- 
tage of the assistance of Dr. Cornish, the 
able Secretary of the Principal Inspector- 
General of the Madras Army, and we 
both agreed that the symptoms in this 
case came nearer in their ensemble to 
those of true yellow fever, than any we 
had ever seen in the whole range of our 
experience in the east. 
Headache is a prominent symptom. It 
is described as throbbing at first, passing, 
in subsequent paroxysms, into a constant 
pain, with some degree of tension of the 
brow, sometimes said to be " rending." 
Delirium.-Some confusion of thought 
is common enough, but violent delirium 
is rare. In very adynamic cases, or where 
depletion has been freely used, low mut- 
tering delirium precedes the coma in 
which cases of this description often close. 
Hiccough is often troublesome where 
gastric irritability is severe, but it usually 
appears as the disease is passing off. In 
one of the cases alluded to above, it lasted 
for days. 
The Bowels are usually constipated in 
the first instance, sometimes large watery 
evacuations appear early in the disease, 
at other times when it is passing away. 
Practitioners whose choicest weapon 
against "bilious" remittents is calomel, 
are but too familiar with the dark brown- 
ish-black evacuations of cadaverous odor, 
the appearance of which too surely indi- 
cates that an unfavorable termination of 
the case is at hand. 
The state of the urine is deserving of 
the closest study. 
Many authors of great authority write 
of it as always scanty, high colored, and 
of high specific gravity. But in severe 
Indian Remittents I have noticed the op- 
posite condition. Dr. Cornish, I am sure, 
must remember that in the case we saw 
together there was even diuresis through- 
out, until convalescence was established. 
I have notes of three other cases, in which 
the same condition prevailed ; in all four 
the urine was bloody. It is invariably 
acid, seldom contains albumen, so seldom 
that Dr. Parkes has proposed this as one 
of his points in the diagnosis between yel- 
low fever and malarious Remittent, on 
the strength of Ballot's observation, who 
found the urine albuminous in 300 cases 
of yellow fever. According to Jones of 
Georgia, the urea is increased in severe 
Remittent Fever ; and the uric acid lessen- 
ed till convalescence, when it increases. 
The pigment also is lessened. (Parkes on 
Urine.) 
The older authors describe, and very 
graphic some of their descriptions are, 
what they called putrid Remittents. 
These, as Sir Ranald Martin has well 
shown, were all complicated with scurvy, 
the inevitable result of protracted sea 
voyages to India in overcrowded and 
otherwise unsanitary transports, not sup- 
plied with antiscorbutic remedies. Sol- 
diers treated in this way were landed on 
the malarious shores of Bengal, and when 
smitten with the endemic Fevers of the 
country, the symptoms presented " pu- 
trid" phenomena, and the mortality was 
shocking. The medical officers of the first 
expedition to China in the year 1840, had 
an opportunity of observing, under the un- 
sanitary arrangements which character- 
ized so conspicuously the first occupation 
of Chusan, the terrible effects of malaria 
and scorbutus combined. An entire regi- 
ment, 900 strong, was almost destroyed by 
malarious Fevers and bowel complaints in 
a few weeks, and. such of us as survive can 
bear testimony to the truthfulness of the 
description of " putrid" Remittent Fevers 
given by the writers above alluded to. 
Without, however, any scorbutic taint, 
we may have Remittent Fever presenting 
from the commencement an adynamic 
character. I was very familiar with cases 
of this kind when serving in the imme- 
diate vicinity of the great native city of 
Hyderabad in the Deccan. From the 
malarial quarters of that densely popu- 
lated and most unsanitary city, I used to 
receive into the Residency Hospital, dur- 
ing the autumnal months, a number of 368 
MALARIAL FEVERS. 
cases of this kind, presenting from the 
first signs of great depression, the fever 
after the second or third exacerbation be- 
coming almost continued, the skin being 
yellowish and covered with petechise, the 
pulse exceeding 120, small and compres- 
sible, the tongue dry and black, the teeth 
covered with sordes, the respiration quick, 
and sometimes irregular, the abdomen 
distended, the bowels loose, and a dispo- 
sition to hemorrhage from nose, mouth, 
and bowels, and almost invariably deli- 
rium, with a tendency to coma. Such 
cases, unless energetically treated, hasten 
rapidly to a fatal termination by exhaus- 
tion and coma. 
Remittent Fever with cerebral affection 
is usually met with in India in sthenic 
Europeans lately arrived in the country, 
who have been living imprudently and at 
the same time exposing themselves to the 
sun. 
In such cases the exacerbation is severe, 
with ardent fever, a full and firm pulse, 
mental confusion, and even delirium. 
Hepatitis is a rare complication. This 
is Morehead's experience ; in twenty-two 
years' service in India I never saw a gen- 
uine case of this complication. I have 
repeatedly alluded to gastro-duodenal irri- 
tation as a prominent symptom in mala- 
rial fevers; tenderness, proceeding from 
this cause, is often mistaken for hepatic 
inflammation. 
Jaundice.-Some degree of yellowness of 
the skin is common in remittents, both of 
an ardent and adynamic type ; but com- 
pletely developed jaundice is more rare. 
It occurred in twenty-eight out of 114 
of Dr. Morehead's select clinical cases; I 
have seen a few examples of this compli- 
cation, but never had an opportunity of 
examining one after death. Ten of More- 
head's cases proved fatal. 
Pressure on the common biliary duct by 
the head of the pancreas was found in 
one ; in another the hepatic and common 
ducts were obstructed by a lumbricus; 
and in two there was constriction of the 
cystic duct. Traces of inflammation of 
the mucous membrane of the stomach and 
duodenum was observed in six cases. In 
almost all there was enlargement of the 
lymphatic glands situated near the en- 
trance of the common biliary duct into the 
duodenum, but not to such an extent as 
to cause pressure. (Morehead.) 
Splenic enlargement is found, as in 
other types of malarial fever, but not so 
frequently as in Intermittents, probably 
because the cold stage in remittents is not 
so prolonged, and also because the whole 
duration of a remittent is shorter than 
that of an intermittent fever. When 
found after death it may, as in some of 
Morehead's clinical cases, be traced to 
the influence of previous attacks of an in- 
termitting character. 
Diagnosis.-After what has been said, 
it is unnecessary to enter into the points 
of difference between an intermittent and 
Remittent Fever. 
There can be no doubt that enteric fever 
and adynamic forms of remittent have 
often been confounded in India, and yet 
the diagnosis to a careful observer is not 
difficult. In the former, if the character- 
istic eruption appears, it will settle the 
point; but, in India, this is more fre- 
quently absent than in this country. 
Gastric and duodenal irritability are pres- 
ent in all remittent fevers, absent in 
enteric. 
The fever is more or less paroxysmal in 
the former, continued in the latter. In 
Remittent the skin is frequently yellow- 
ish ; not so in enteric fever. In the former, 
apart from the epigastric and hepatic 
regions, abdominal tenderness is generally 
absent; present in the latter. In Remit- 
tent, the stools are dark colored and 
bilious ; in enteric fever, they are brown- 
ish yellow, with whitish yellow-colored 
flocculi floating in them. 
If hemorrhagic tendency evinces itself 
in the course of a Remittent, the blood 
proceeds from the mouth, nose, urinary 
organs, and bowels ; while in enteric fever, 
it is from the intestines only, at an ad- 
vanced stage, during the separation of the 
glandular sloughs. Lastly, careful exam- 
ination into the history of the case, with 
an eye to causation, will materially assist 
the diagnosis. 
Specific yellow fever being unknown in 
India, no question as to diagnosis between 
it and Remittent Fever can arise there. 
Elsewhere, the diagnosis will be estab- 
lished, as it appears to me, by attention 
to the following points :- 
Yellow fever is continued ; all Malarial 
Fevers are paroxysmal. 
Albuminous urine is the rule in yellow 
fever-a rare exception in Remittent. The 
spleen enlarges during the paroxysm of 
malarial fever, but is not affected" in the 
other. Hemorrhage from the stomach 
and other viscera is the rule in yellow 
fever; comparatively rare in malarial 
fevers. Death is common in yellow fever 
on the third day, but seldom occurs in the 
most malignant remittents before the 
seventh. 
Over yellow fever quinine has no power, 
save when there is a malarial complica- 
tion ; over true malarial fevers of every 
type, its power is beyond the reach of 
question. Convalescence after yellow 
fever is rapid and agreeable ; slow after 
malarial fevers. 
Pathology.-Having gone fully into 
the pathology and post-mortem appear- 
ances of Malarial Fevers in the previous 
article, it is unnecessary to enter again 
into a description which would involve REMITTENT FEVER. 
369 
much useless repetition; such points as 
more especially belong to Remittent 
Fevers I have incidentally considered in 
connection with the symptoms. 
Prognosis.-Death from an uncompli- 
cated Remittent Fever ought to be a rare 
occurrence, and, under good management, 
so it is. Even in ardent cases in sthenic 
constitutions, the prognosis is favorable ; 
and, if skilfully treated, recovery may be 
confidently looked for, in a large majority 
even of adynamic cases, if seen sufficiently 
early. 
The early subsidence of gastric irrita- 
bility, headache, and frequency of pulse, 
are favorable signs. Distinct remissions, 
with action of the skin, and postponement 
of the exacerbation, are also evidence of 
an approaching favorable change. On 
the other hand, if the fever is more con- 
tinued than paroxysmal, with a pulse 
failing in strength while it gains in fre- 
quency : if there be a tendency to collapse 
at the close of the exacerbation, profuse 
hemorrhage from the stomach or bowels, 
cold sweats, delirium, and coma ; in a 
word, signs of extreme exhaustion, these 
all point to danger, and indicate the neces- 
sity for restorative treatment of an ener- 
getic character. 
Treatment.-The disease is not an 
inflammation ; therefore, bleeding or anti- 
phlogistic remedies have no legitimate 
sphere of action in the contest. I freely 
admit that a young physician has no more 
difficult lesson to learn on being brought 
face to face with his first case of tropical 
Remittent Fever, in the person of a young 
and vigorous adult, than to restrain his 
hands from the use of such means. When 
he feels the burning heat of skin and full 
pulse, sees the flushed face and congested 
eye, the tongue furred and dry, and lis- 
tens to complaints of a head racked with 
pain, and limbs vainly seeking relief in 
incessant change of posture ; and, in addi- 
tion, sees his patient distressed by an in- 
tolerable sense of oppression at the 
stomach, which is not only not relieved, 
but is even aggravated by almost inces- 
sant vomitingwhen, I say, all this is 
seen for the first time, an inexperienced 
man is apt to say this is the " inflamma- 
tory remittent of so and so; here anti- 
phlogistic treatment must be used, or my 
patient is lost." 
I believe there is another and a better 
line of treatment available. 
The best possible hygienic arrange- 
ments should be made, and care taken to 
secure careful ventilation of the room or 
ward. 
The history of the case should be in- 
quired into, particularly with a view to 
ascertain the hour of first accession, so 
that the period of probable remission may, 
as nearly as possible, be calculated, in 
order that the visits of the attendant 
should be so timed as to insure the patient 
being seen, particularly at the morning 
remission. 
Cold stage.-This, in Remittent Fever, 
is so transient that patients are seldom 
seen at this time, and no special treat- 
ment is required. 
Hot stage.-It is seldom necessary to 
order an emetic in fulfilment of the time- 
honored practice of beginning the treat- 
ment of all fevers with one. Vomiting, 
in a great many cases, requires rather to 
be checked than encouraged: where, how- 
ever, there is much nausea and oppression, 
or sense of fulness at the epigastrium, 
without vomiting, a few tumblers of tepid 
water may be given, which will answer 
the purpose. It is well, also, that the 
bowels should be thoroughly cleared as 
soon as possible. For this purpose, from 
three to five grains of calomel, extract of 
colocynth, and scammony should be given, 
with a few drops of any aromatic oil. I 
have found this combination very effec- 
tual ; it rarely, if ever, gripes or causes 
nausea; it appears to act on the whole 
tract of the intestine, and seldom requires 
a nauseous draught to aid its operation. 
If the hot stage be mild, without much 
headache, ardent heat of skin, epigastric 
or hepatic tenderness, not much inter- 
ference is required, beyond giving the 
patient small quantities at a time of iced 
or well-cooled water, soda-water, or lemon- 
ade, if any of these are relished. 
If, however, the reaction be very vigor- 
ous in a sthenic adult, with severe head- 
ache, pungent heat of skin, severe pain in 
the loins, and much restlessness, some- 
thing must be done for his relief. The 
hair should be cut close, and cold should 
be assiduously applied to the head, taking 
care that this is not done, as it often is, so 
as to act as a fomentation. 
The inordinate heat of the skin may be 
reduced (a) by cold affusion ; (&) by spong- 
ing the surface with tepid wrater; (c) by 
enveloping the body in a sheet, wrung out 
of cold water, and changed two or three 
times; (cZ) by packing the patient in a wet 
sheet, after the manner used in hydro- 
pathic establishments. Each method has 
its advocates ; and in such cases as I have 
described above, I do not think there is 
risk in any of them. Where, however, 
there is marked epigastric or hepatic ten- 
derness, with a tendency to extreme he- 
patic or splenic congestion, as pointed out 
by Morehead, the use of the wet sheet 
alone is objectionable, as tending to aggra- 
vate that condition. The wet sheet-pack- 
ing acts powerfully on the skin, and is 
more likely to relieve, than to increase, 
congestion of internal organs. This 
method, however, must be used with cau- 
tion, if at all, in cases of an* adynamic 
vol. i.-24 370 
MALARIAL FEVERS. 
character, as exhaustion and even col- 
lapse might follow the powerful sudorific 
action it generally excites. The sponging 
of the surface with tepid water is always 
safe and grateful to the patient. 
Vomiting in severe and so-called "bil- 
ious" Remittents is often one of the most 
distressing symptoms. I have seen it in- 
duce great exhaustion. It is best com- 
bated by giving small quantities of ice- 
cold water, or by sucking small lumps of 
ice in the folds of a handkerchief, by the 
repeated application of sinapisms to the 
epigastrium, by inhaling the vapor of a 
few drops of chloroform, or by the addition 
of the same to an effervescing draught. I 
have seen the wet sheet-packing most ef- 
fectual in restraining vomiting and reliev- 
ing the distressing sense of oppression at 
the stomach, which the sufferer vainly 
endeavors to get rid of by incessant retch- 
ing. 
Hepatic and splenic tenderness should 
be relieved by fomentations, stupes, or 
sinapisms. Sometimes a pad of lint well 
sprinkled with chloroform covered with 
oiled silk, and applied to the epigastrium, 
is very soothing. By treatment of this 
kind, diligently used, the necessity for 
abstracting blood by leeches is obviated. 
Treatment during the Remission.-On the 
first signs of this, as soon, that is, as mois- 
ture appears, and the heat of skin abates, 
and the pulse comes down in force and 
frequency, quinine should be given in an 
effective dose of not less than ten grains. 
I have given fifteen often, twenty some- 
times ; I am no advocate for excessive 
doses, and any quantity over twenty grains 
I deem to be excessive. I am never de- 
terred from giving quinine merely be- 
cause, even in the remission there may be 
headache or foul tongue. Experience has 
taught me that the best remedy against 
those conditions is the one that acts on 
the toxic agent that is the primary cause 
of all the disturbance. 
I am never deterred from giving qui- 
nine, because the remission is slight; so 
soon as I am satisfied that there is an 
abatement of symptoms I proceed to give 
the remedy, in the full belief that if I make 
a skilful use of these golden moments of 
remission, however slight this may be, I 
shall be rewarded at the end of the second 
exacerbation with one more distinct and 
perfect than the first, knowing also that if 
through timidity I suffer the first remis- 
sion to pass unimproved, the next may be 
more faint, unsatisfactory, and difficult to 
recognize. I by no means wish to imply 
that there is always so much difficulty in 
recognizing the remission. I desire only 
to guard the inexperienced against expect- 
ing to find the remission always so dis- 
tinct as we find it described in books. 
If quinine is rejected, and the irritabil- 
ity of the stomach is such that a second 
dose is also vomited, twenty grains ought 
at once to be administered, in any bland 
fluid, by enema. If the stomach re- 
tains the medicine, it should be repeated 
every second hour until thirty or thirty- 
five grains have been taken before the hour 
of expected exacerbation. 
Suppose the purgative has not operated, 
are we to wait for its operation before giv- 
ing quinine ? I have done so, but finding 
that I lost more ground by delaying qui- 
nine than I gained by the action of the 
purgative, I abandoned the practice. At 
the same time I am fully alive to the ne- 
cessity of securing free action of the 
bowels at as early a period as possible. 
As soon as the second remission ap- 
pears, quinine must be given as before, 
and continued until full saturation of the 
system is evidenced by cinchonism, or by 
a distinct abatement of the disease. Ring- 
ing in the ears and deafness are unequiv- 
ocal signs of cinchonism. So soon as this 
state is brought about, in a vast majority 
of instances, the exacerbationswill become 
milder, and terminate in a copious sweat, 
and the patient will enter on a state of 
convalescence. 
Having ventured to write with so much 
confidence on quinine used in this way, I 
am glad to be able to adduce the testi- 
mony of Dr. Davy to the safety of the mea- 
sure. This high authority says, "That 
in the Remittent Fevers of the West In- 
dies, during the first quarter after the 
practice was introduced of giving quinine 
in full doses to cinchonism, out of 165 
cases only two proved fatal, and the record 
of the post-mortem examination in the 
two fatal cases shows that they were 
rather instances of latent phlegmasi&e 
than of fever of the remittent type." 
To this unexceptionable testimony I 
shall only add the evidence of one other 
observer of equal reputation and experi- 
ence. The late Dr. David Blair, Surgeon- 
General of British Guiana, thus expresses 
himself on the question of the safety of 
quinine : "It has been prescribed by me 
to patients of both sexes and all ages, 
and, where ascertainable, almost invaria- 
bly to cinchonism, during thirteen years, 
and probably to the extent of several 
thousand ounces of the sulphate, and 
during that time I have seen no danger 
from its effects, with the exception of 
three or four cases of imputed abortion." 
During the remission the patient should 
have mild farinaceous diet, milk, chicken 
tea, and such like. As soon as the gas- 
tric irritability subsides, beef-tea should 
be given, and on the first sign of exhaus- 
tion, nourishment and stimulants should 
be given at Short intervals. 
Should quinine ever be given during 
the exacerbation ? In the adynamic form 
of the disease, such as I described as 
coming from the malarial quarters of the REMITTENT FEVER. 
371 
city of Hyderabad, I never waited for a 
remission, but gave it at once by mouth 
or rectum, or both, combining with it the 
assiduous use of support and stimulants 
at short intervals. 
The American physicians led the way 
in this practice, and demonstrated its 
safety. 
Again, when called to cases which have 
been mismanaged in their early stages, 
either by the neglect of quinine, or the 
too free use of antiphlogistic means, we 
must act in the same way. There is no 
time to wait for a remission: the low 
form of exacerbation then present will 
hourly assume more and more a continued 
type ; the remissions, if they appear, will 
be of short duration, and it will soon be 
hardly possible to recognize them at all. 
Such cases can only be saved by energetic 
means, by quinine, support, and stimu- 
lants, given in quantities regulated by 
their effects. In this way most hopeless- 
looking cases may be snatched from the 
jaws of death, as I have seen in a great 
many instances. What I wrote on the 
treatment of the complications of ague, I 
repeat here emphatically. Practitioners 
who relax in their efforts to stop the ex- 
acerbations, who pause in the use of qui- 
nine while they apply routine remedies 
for this or that symptom, now applying 
leeches to the head because delirium or 
headache is present, to the epigastrium be- 
cause there is some tenderness there, will 
have little success in the treatment of the 
worst form of Indian Remittents. 
My experience has satisfied me that 
such symptoms are most effectually met 
by the means which directly tend to coun- 
teract the poison which is keeping up the 
excitement, and disturbing the functions 
of the organs to which it is conveyed by 
the circulation ; at the same time, active 
stimulation of the skin over affected or- 
gans should not be neglected. It is sur- 
prising how much relief may be given by 
sinapisms, turpentine-stupes, or stimula- 
ting embrocations, without having re- 
course to so double-edged a remedy as 
depletion. 
Mercury has been largely used in the 
treatment of Remittent Fever. When I 
first went to India, calomel, chiefly in com- 
bination with James's Powder, was used 
to an extent that, to practitioners of the 
present day, is hardly credible. "Inflam- 
mation" was thought to play an active 
part in this fever, and as calomel, next to 
the lancet, was regarded as the most di- 
rect antiphlogistic remedy, it was used 
with the intention of subduing this in- 
flammation. 
The end sought was to "affect the 
mouth," and quinine, when given at all, 
was only ventured on when this desired 
consummation was attained, and then 
timidly in utter ignorance of its real value 
and true therapeutic action. A practi- 
tioner of this school in India in the pres- 
ent day would be an object of terror to all 
educated men within reach of his pre- 
scriptions. 
Beyond measure miserable is the spec- 
tacle of a man whose system, already 
saturated with malaria, is still further 
depraved by the mercurial cachexy. 
This was the system which, introduced 
into India by the late Dr. James Johnson 
and some of his followers, superseded the 
admirable treatment recommended by 
Lind, and others of his day. The conse- 
quences were not creditable to our art, 
and the return to more rational treat- 
ment, based on a sounder pathology, has 
been attended with a signal diminution 
in the mortality from all forms of malarial 
fevers. 
Before concluding, I must add a few 
words on a febrifuge, which, in Southern 
India at least, has attained a high repu- 
tation. I mean Warburg's Tincture. 
This is a remedy the exact composition 
of which is kept a secret in the family of 
its inventor. 
In common with the whole profession, 
I deprecate the use of secret remedies, 
and, as a general rule, decline to use 
them. 
But it is no secret that quinine enters 
largely into this combination, and is its 
most active ingredient. Whatever be the 
exact nature of its composition, I am 
bound to say that in Remittent Fever this 
tincture is, without doubt, an efficacious 
remedy. It is the most powerful sudorific 
I know. A person under its influence 
sweats until he saturates not merely his 
linen and bedding, but also the mattress 
on which he sleeps ; and his breath and 
skin for days exhale a powerful and pecu- 
liar aromatic odor. I have seen it, in at 
least thirty cases treated by myself, cut 
short severe remittents after one or two 
exacerbations. 
It has been largely used for many years 
by officers in the Mysore Commission, 
whose duties often expose them to fevers 
of a dangerous type, in the malarial dis- 
tricts of that province. Major-General 
Frederick Cotton, of the Madras Royal 
Engineers, in his evidence before the In- 
dian Sanitary Commission, thus expressed 
himself regarding this remedy : " Those 
engaged in opening the passes through 
the fatal jungles of the western coast of 
India found that medicine invaluable. In 
the Parambaddy Pass, especially, a trial 
of it was made on a very extensive scale, 
and with admirable results. 
"When its efficacy became known, the 
coolies employed would work in the most 
dangerous parts of the forest, if they 
were sure that the medicine was at hand. " 
The tincture is sold at a high price, in 
small bottles containing two doses. After 372 
DYSENTERY. 
the bowels have been opened by an aperi- 
ent, one-half a bottle is given, all drink is 
withheld, and at the end of three hours, 
the remainder is administered. 
It has a fine golden yellow color, appa- 
rently from tincture of aloes, and its taste 
is persistently bitter. Sometimes in three 
hours after the first dose, more frequently 
in an hour after the second, profuse dia- 
phoresis sets in, and this goes on until the 
bedding is saturated. 
In a great many cases there is no exa- 
cerbation after this sudorific action. So 
great is this action of the skin, and in 
some cases so exhausting, that this re- 
medy, used in the manner above described, 
would be highly dangerous in adynamic 
cases-a fact not adverted to in the printed 
directions which accompany every bottle. 
If used at all in such cases, it should be 
in much smaller quantities than those 
ordered ; and support should be given as 
soon as the skin begins to act. 
My friend Dr. Morehead speaks slight- 
ingly of this tincture, but after many 
trials of it, and a full knowledge of the 
success that has followed its use in many 
formidable types of Malarial Fever, I do 
not hesitate to recommend that careful 
trials should be made of this remedy in 
regions where these fevers prevail. But, 
I repeat, it requires caution ; if given in- 
discriminately in the manner recom- 
mended by Warburg, I am confident its 
use must often be disastrous. 
[The approval above expressed of the 
American practice of giving quinine early, 
during the exacerbation, is confirmed by 
the experience of a large number of prac- 
titioners in the Southern States. In the 
Northern and Middle States, however, 
where the malarial poisoning is evidently 
less intense in degree, with a less marked 
adynamic tendency, it certainly answers 
well, in most cases, to put off giving qui- 
nine until the fever has at least begun to 
remit; and then to give it in more mode- 
rate doses than are usual in the South.- 
H.] 
DYSENTERY. 
By Professor W. C. Maclean, M.D. 
Definition. - A specific febrile dis- 
ease, characterized by nervous depres- 
sion ; by inflammation and sloughing of 
the glandular apparatus of the mucous 
membrane of the large intestine (some- 
times extending into the small gut); by 
tormina and tenesmus, with scanty, mu- 
cous, and bloody stools of a peculiar odor, 
changing, as the disease advances, to se- 
rous, and giving off a gangrenous effluvia.1 
Terminology. - Sv? diffi- 
culty, and evtspov an intestine; Dysenteria, 
Tormina, Fluxus Dysentericus, Colonia, 
Colonitis; Dysentery, Flux. Bloody Flux; 
Dyssenterie. Flux de sang, Fr.; die Ruhr, 
die rothe Ruhr, German; Dissenterie, 
Itai; the Looseness (vulg.). 
History.-Dysentery was well known 
to the most ancient writers on medicine, 
and has largely occupied the attention of 
modern physicians, particularly of those 
[' Most physicians will agree, however, 
that all the characteristic dysenteric symp- 
toms sometimes occur so as to constitute it a 
local affection ; a colonitis, instead of a spe- 
cific systemic disorder.-H.] 
who have served in fleets and armies. It 
has been seen in all climates, in the tem • 
perate as well as in the torrid zone. No 
country has been exempt from it; some- 
times appearing alone, at others as a 
formidable complication of malarial fevers 
or scurvy, often treading in the footsteps 
of devastating wars, for in all ages it has 
been the scourge of armies, and one of the 
chief causes of mortality in unsanitary 
camps and garrisons. 
In the pre-sanitary age it was as com- 
mon and nearly as destructive to human 
life in Britain as it is now in unhealthy 
tropical regions as yet unvisited by the 
sanitary reformer. 
In Ireland "the looseness," as it was 
called, was a common endemic disease, 
causing great mortality throughout the 
seventeenth century, and prevailing occa- 
sionally in an epidemic form down to the 
year 1818. 
Dysentery has ceased to be a destruc- 
tive disease in this kingdom; it has dis- 
appeared before a higher civilization, and 
what it brings in its train, viz., improved 
agriculture and drainage, more particu- 
larly subsoil drainage, the removal of 
filth from the vicinity of dwellings, the MODES OF COMMENCEMENT - CAUSES 
373 
supply of pure water to our cities, in a 
word, increased attention to hygiene. 
Just in proportion as Malaria, the pro- 
duct of moisture and organic decomposi- 
tion in soils, has been banished from our 
midst, so has Dysentery ceased to be a 
prevalent and fatal disease. 
In India, among Europeans of all 
classes, this disease comes next to fevers 
in frequency, but the direct mortality 
caused by it is greater than from all the 
forms of fever known in that country. 
" Out of an aggregate British force of 
25,433 men of Her Majesty's Army serving 
in periods of eight and ten years respec- 
tively in the stations of Calcutta, Chin- 
surah, and Berhampore, all in Bengal 
Proper, there occurred 8499 cases of Dys- 
entery and diarrhcea.-In the presidency 
of Madras, again, out of an aggregate 
British force of 82,342 men serving there 
from 1842 to 1848, there occurred 10,531 
cases of Dysentery, and 9189 cases of 
diarrhcea, making a total of 19,720 cases 
of bowel disease exclusive of cholera."1 
Nor is this all, for most of the casualties 
which occur amongst sick soldiers on the 
voyage homewards from India are from 
chronic Dysentery. 
The Naval Medical Reports show that 
of late years, except on the East India, 
China, and West Coast of Africa Stations, 
bowel complaints do not cause a high 
mortality. In the Report for 1860 it is 
said that the "intractable flux" of China 
was, as usual, far more destructive of 
health and life than any other disease that 
attacked the force. The death rate from 
this cause was in the ratio of 13*6, and 
the invaliding 25'9 per 1000 of mean 
strength. 
Modes of Commencement.-Dysen- 
tery in all its varieties commences in one 
or other of the following ways. After the 
presence for a longer or shorter time of 
signs of constitutional disturbance, the 
patient is severely griped, with frequent 
calls to stool, the motions becoming scanty, 
mucous, and bloody. Or, there is a burst 
of unhealthy semi-feculent biliary dis- 
charges, which soon give place to the 
characteristic stools first described. In 
either case the odor is offensive and pecu- 
liar, becoming gangrenous as death ap- 
proaches, after extensive sloughing of the 
intestinal tissues. 
The Course of the disease will depend 
on a variety of conditions, such as its 
type, whether it be mild or sthenic, mala- 
rial, typhoid, or scorbutic ; also on the 
stage at which treatment has commenced, 
and still more on the nature of that treat- 
ment. In mild acute Dysentery, under 
favorable circumstances and rational 
treatment, the intestinal lesions are gen- 
erally moderate in extent and degree ; the 
duration of the attack seldom exceeds 
eight or ten days, sometimes not more 
than half that time; healthy alvine dis- 
charges, a copious lateritious sediment in 
the urine, and a free perspiration pro- 
claiming restoration to health. Under 
less favorable circumstances, injudicious 
treatment, or, it may be, some impru- 
dence on the part of the patient, the issue 
may be less fortunate, and the case may 
pass into the chronic form. In sthenic 
Dysentery, the constitutional symptoms 
are more urgent, the local lesions are 
more severe, more rapid, more destruc- 
tive, leading, if not checked by early 
treatment, to changes incompatible with 
life, or, after much destruction of the 
glandular and mucous tissues of the great 
intestine and much suffering, to an imper- 
fect recovery. Still, this form of the dis- 
ease, when early seen and well treated, 
gives a high ratio of speedy and complete 
recoveries. The duration of the disease 
is from nine days to three weeks. It may 
prove fatal on the eighth or ninth day, or 
death may not take place until the end of 
the third week; this termination is 
ushered in by sudden cessation of abdomi- 
nal pain, increased fluidity, and gangren- 
ous effluvia of the stools, and delirium. 
In the malarial form, the course of the 
disease partakes of the periodic nature of 
the complication. There are remissions 
and exacerbations of the febrile symptoms, 
the solid viscera of the abdomen are apt 
to be deeply implicated, and hepatic, 
splenic, or renal symptoms may seriously 
complicate the case, and determine an 
unfavorable issue. 
The typhoid or malignant form, often 
with a scorbutic taint grafted on it, is the 
most hopeless and fatal type of the dis- 
ease. This is the form seen in unsanitary 
camps and besieged garrisons, in beaten 
armies after great privations, and some- 
times in armies that have not sustained 
any military disaster, but have the mis- 
fortune to be commanded by generals who 
set at nought the laws of health, as was 
the case notably in the first wars in Bur- 
mah and China, and more conspicuously, 
in the Crimea. 
In this form the lesions are not confined 
to the colon, but, passing the ileo-colic 
valve, extend into the small intestine. 
The disease runs its course in about fifteen 
days or less ; nervous depression is ex- 
treme, and the tendency to death is by 
exhaustion. 
Causes.-When we consider the variety 
of causes to which this disease has been 
attributed, it is impossible to admit that 
agents so many and various can give rise 
to an affection which in all climates has 
presented so much uniformity in its symp- 
toms and anatomical lesions. 
1 Sir R. Martin. 374 
DYSENTERY 
It appears to me that many of the so- 
called "causes" of Dysentery must be 
regarded more as active agents of propa- 
gation than of causation. For my own 
part, I believe Dysentery to be caused by 
the action on the blood of a poison having 
a peculiar affinity for the glandular struc- 
tures of the large intestine. This poison 
I believe to be a malaria generated in the 
soil by the decomposition of organic mat- 
ter. Once a common and fatal disease in 
this country, it is now so rare that a Lon- 
don hospital physician rarely, if ever, 
sees a case of genuine specific Dysentery, 
save such as have been imported from 
malarious countries. How comes it that 
a disease with which our predecessors 
were so familiar has become so rare ? 
Many of the commonly received " causes" 
are as much in operation now as then; 
e. g., the combined action of cold and 
moisture, the action of irritants on the 
mucous membrane, unripe fruit, unwhole- 
some and indigestible food of all kinds, 
feculent and other accumulations in the 
larger intestines, yet Dysentery does not 
result. Is it not that for the reasons al- 
ready assigned, less malaria is evolved 
from the soil ? 
It seems that just in proportion as we 
have banished malaria, so have we got 
rid of Dysentery. For a long time the 
prisoners in the Penitentiary at Millbank 
were subject to visitations of Dysentery at 
those seasons, and in those states of atmos- 
phere, which most favor the decomposi- 
tion of organic matter in the soil. 
The late Dr. Baly, then physician to the 
prison, in the Gulstonian Lectures for 
1847, has given a most instructive account 
of an outbreak of this kind. Dr. Baly has 
shown that the disease which prevailed in 
Millbank prison was precisely the same in 
its symptoms, course, and lesions, as that 
described by Sydenham, and by writers 
on tropical diseases of the present time. 
He investigated its cause with much care, 
and was led to the conclusion that it was 
" due to a poison introduced from without, 
viz., a malaria rising from the soil," and 
that all the conditions required for its pro- 
duction abounded in the close vicinity of 
the prison. 
In India, Dysentery prevails most and 
is most fatal in moist alluvial soils con- 
taining organic matter in a state of decom- 
position, as for example, verv notably. in 
Calcutta. 
It is no doubt true that the disease is 
sometimes seen, and that in a malignant 
form, in places which are not alluvial. I 
cannot give, a better example of this than 
the old infantry barracks at Secunderabad 
in the Deccan of dysenteric notoriety ; 
but there, as at Millbank, the conditions 
necessary for the production of malaria 
were only too abundant. 
The sad but instructive history of those 
barracks has been given by Staff-Surgeon 
Crawford and the writer of this article, 
in the Army Sanitary Report for 1860. 
The barracks stand (for notwithstanding 
their dreadful history they are still in use) 
on low ground, swampy on one side, and 
overshadowed by rocks on the other, ex- 
posed to the malarious influences of the 
marsh in the southwest monsoon, while 
the rocks on the other side shut out the 
invigorating northeast wind. A grave- 
yard, now closed, is placed close to the 
buildings, on a higher level, and in the 
direction of the natural drainage; an- 
other, at a greater distance and in a less 
objectionable site, is on the south side. 
The surface and subsoil are thoroughly 
saturated with organic matter, the re- 
moval of which is impracticable. The 
neighboring soil until recently, when some- 
thing has been done to fill them up, was 
furrowed by ravines, in which ordure was 
deposited by natives; the privy accom- 
modation was of the -worst possible con- 
struction and badly placed, the barracks 
were invariably overcrowded, and sur- 
rounded by a high wall. Here were all 
the conditions for the production of mala- 
ria, and the causation and propagation of 
disease. 
For half a century the loss of life in 
these buildings, chiefly from malignant 
Dysentery, was shocking. For some years 
it was nearly one in three of strength; so 
late as 1826 it was nearly one in every 
five. Between the years 1837 and 1858, 
out of the annual strength of 834'44 occu- 
pying those buildings, the admissions into 
hospital were 1529'40, and the deaths 
37'20. In 1858 the " Royals" occupied 
the barracks, with an average strength of 
1098; there were 2497 admissions into 
hospital and 104 deaths, being nearly ten 
per cent, of the strength. 
Here we have two examples, one in 
England the other in India, of the local 
existence of malaria with a like result, 
the production of malignant Dysentery; 
the symptoms and anatomical lesions 
being alike in both cases, with this excep- 
tion, that in the barracks, hepatic compli- 
cations were common, due probably to the 
greater intensity of the cause, combined 
with high temperature and intemperance 
among the soldiers. It is quite true that 
the provisional term malaria is a vague 
one. In the present state of knowledge 
we cannot isolate it, and must here take 
it to mean a poison resulting from the 
decay of organic matter in the soil, which, 
when conveyed into the body, is capable 
of causing a disease, of which certain ana- 
tomical lesions of the great intestine are a 
characteristic and invariable incident. 
The following are usually named as 
"exciting" causes, but, as already re- 
marked, it is more than probable that 
some of them are merely active agents in SYMPTOMS 
375 
propagating a disease that has a specific 
cause. 
Impure Water.-"There is," says Dr. 
Che vers, " the strongest reason for be- 
lieving that much of the cholera and Dys- 
entery which occur on board the vessels 
in the port of Calcutta is caused by drink- 
ing the always muddy and filthy and often 
brackish water taken up in buckets over 
the ship's side. Nearly every person, 
native or European, who comes to Cal- 
cutta suffers, more or less, just at first, 
from some kind of bowel complaint, but 
none suffer so much as seafaring men 
and no wonder ; for the same authority 
informs us, "that opposite Calcutta the 
water is frightfully impure. There it re- 
ceives some forty tons of excreta daily"-• 
(and we may confidently assume that this 
enormous mass of impurity contains no 
inconsiderable proportion of cholera and 
Dysentery stools, for these diseases are 
always present in that most unsanitary 
city)-" a multitude of bodies of dead 
cattle, and some 15,000 corpses yearly." 
Dr. Rose makes precisely similar obser- 
vations as regards seamen frequenting the 
port of Shanghai in China, and attributes 
the heavy mortality among them from 
Dysentery to the same cause, viz., drink- 
ing river water loaded with organic im- 
purity, and still further polluted by the 
excrements of an immense population. 
Miss Nightingale, in her summary of 
the Indian Sanitary Report observes, with 
too much truth, "there is no reason to 
hope that any station (in India) has what 
in this country would be called a pure 
water-supply, and at some it is to be 
feared that, when men drink water, they 
drink cholera with it," and we may add, 
Dysentery also. 
Exposure to Cold.-Dr. Mackay, R. N., 
describes the mode in which this cause 
operates among seamen serving in the 
malarious rivers of China. The men, 
when they lie down on the deck to sleep, 
pull up their frocks and coarse under flan- 
nel jackets, so as to expose the abdomen. 
When the cool night wind sets in, the ex- 
posed skin of the sleepers, from being 
bathed in perspiration, becomes dry and 
finally chilled, and in a very short time 
they awaken griped, and perhaps sick, 
and so commences very frequently an 
attack of what Dr. Mackay calls "Spora- 
dic Dysentery. "_ 
Impure Air. - Dysentery once estab- 
lished is propagated by the effluvia from 
the evacuations of those affected. In 
most Indian barracks a few years ago, the 
latrines were so badly constructed, so in- 
judiciously placed, and so ill-kept, as to 
aid materially in propagating both Dysen- 
tery and cholera, by exposing the healthy 
to the effluvia arising from the evacua- 
tions of those affected. I affirm from 
frequent observation, that barrack-rooms 
most exposed to the effluvia of latrines 
always furnish the largest number of 
dysenteric cases, and the heaviest mor- 
tality. 
In like manner I have seen the disease 
propagated in hospitals by the practice of 
preserving the evacuations of large num- 
bers of dysenteric patients, for the inspec- 
tion of medical officers at morning and 
evening visit. No single measure of a 
preventive kind yet tried has exercised a 
more beneficial effect on the health of 
troops in India, than the improvement 
which has been introduced in the position, 
construction, and conservancy of barrack 
and hospital latrines. 
Symptoms.-These will of course vary 
with the type of the disease. It is not 
pretended that in practice we can always 
expect to find the line separating one type 
of Dysentery from another to be sharply 
defined. The distinctions are not, how- 
ever, fanciful, or adopted here merely for 
the sake of convenience in description; 
for those who have seen much of the dis- 
ease in tropical countries must be familiar 
with the different forms about to be de- 
scribed. One form, it is true, often passes 
into another by insensible gradations, and 
a strong family likeness runs through 
them alh 
Mild Dysentery.-Careless exposure to 
cold night air, or to a chill after exertion, 
is, in malarious regions, the most common 
exciting cause of this form of the com- 
plaint. The chill is succeeded by slight 
heat of skin, loss of appetite, and some- 
times nausea. Griping pains in the belly, 
technically termed tormina, follow, with 
frequent calls to stool, the evacuations 
consisting of semi-feculent mucus, with 
or without an admixture of blood, passed 
with painful straining, called tenesmus. 
There is seldom much abdominal tender- 
ness on pressure. The tongue is white 
and moist, thirst is not urgent, but even 
where the appetite is not much impaired, 
the griping which soon follows all but the 
mildest articles of diet makes the patient 
averse to solid nourishment. 
The course, duration, and termination 
of every form of Dysentery are so much 
influenced by the patient's prudence or 
the reverse, and by the treatment to 
which he is subjected, that it is not easy 
to describe them. If he is reasonably 
prudent, abstaining from stimulants, un- 
suitable food, and the use of irritating 
purgatives, the disease will probably sub- 
side in from seven to fourteen days : under 
good treatment I have seen it do so in 
forty-eight hours, or less. The skin re- 
sumes its action, and the more this is the 
case the more rapid and complete is the re- 
storation to health. Fecrdent evacuations 
return, griping and straining cease, and 
the urine deposits a copious red sediment. 376 
DYSENTERY. 
It is not always that the disease runs so 
happy a course, and has such a fortunate 
termination. Too often young and inex- 
perienced sufferers seek delusive ease 
from stimulants, strong port wine, or 
brandy, or both, while the more ignorant 
and needy try to quench their sufferings 
in the poisonous and fiery spirits of the 
nearest bazaar. Under such manage- 
ment the disease may soon assume a more 
formidable aspect, passing into the acute 
form, to be presently described, or, after 
a longer or shorter period of suffering, 
varying according to circumstances, it 
may become chronic. 
Acute Dysentery.-The disease begins 
with a chill or well-marked rigor, soon 
followed by more or less heat of skin, with 
a quick but usually compressible pulse, 
and nervous depression. Tormina is much 
more urgent than in the mild form de- 
scribed above, and the calls to stool are 
more frequent and pressing. At first the 
evacuations may be semi-feculent and 
watery, but this state does not last long ; 
soon they become scanty, muciform, and 
bloody. If the rectum is much implicated, 
tenesmus will be a distressing symptom. 
If the seat of the disease be higher up, 
not only will tenesmus be less urgent, but 
the nature of the stools will be different. 
In the latter case, depraved biliary secre- 
tions will be more abundant, and will be 
intimately blended with mucus, epithe- 
lium, and blood. If the rectum be deeply 
affected, the bladder will often sympa- 
thize, being either irritable or so paralyzed 
as to require the use of a catheter, while 
the stools will be more muciform and the 
blood less intimately incorporated with 
them. 
From the first the stools are very offen- 
sive ; they give out an odor which is 
peculiar to Dysentery, an odor justly said 
by Dr. Parkes to be "the most offensive 
of all the organic effluvia." It is difficult 
to describe it, but once experienced it is 
never forgotten, and is in itself conclusive 
evidence as to the nature of the disease ; 
and not only so, but an experienced phy- 
sician can in some degree form an opinion 
from it as to the nature and extent of the 
mischief going on in the tissues of the 
affected bowel. The absence of tenesmus, 
although a great relief to the patient, is 
by no means per se evidence of a slight 
amount of disease ; it merely indicates 
that the rectum is less involved than 
other parts of the colon. 
Soon the calls to stool become more 
urgent and frequent, the patient is hardly 
in bed ere he desires to rise again, each 
time convinced that he is about to pass 
something that will relieve him. The ab- 
domen becomes tumid, and, in the region 
over the parts most implicated, tender. 
Often this tenderness is well marked at 
one point and absent in others. At last 
the patient can hardly be induced to leave 
the close stool ; he desires to remain on 
it, and strains involuntarily. Uis pa- 
tience and temper give way,* he becomes 
irritable, nervous depression increases, 
and the countenance indicates suffering 
and despondency. The stools, which at 
first consisted of a little feculence with 
bloody mucus, now contain portions of 
shreddy, granular exudative matter, often 
resembling washed raw meat. The dis- 
ease still advancing, the countenance be- 
comes more anxious and depressed; ir- 
regular febrile paroxysms come on ; the 
pulse rises in frequency, while it dimin- 
ishes in force ; the abdomen grows more 
tympanitic; the tongue, still continuing 
foul in the centre, becomes red at the 
edges and dry, then dark brown, and 
finally black. If no improvement takes 
place, another change in the stools fol- 
lows ; they become serous, of a brownish 
color, and very copious, exhausting the 
patient terribly. The effluvia become in- 
supportably fetid, even cadaverous, per- 
vading the whole ward, and penetrating 
into neighboring rooms, unless the nursing 
is good. The abdomen becomes more 
tumid, but pain ceases. In this state the 
patient often flatters himself that all is 
well, deeming the cessation of pain a 
favorable symptom ; by and by his mind 
begins to wander, and, as if in some de- 
gree to compensate for past sufferings, 
his delirium takes pleasing forms, and he 
dies exhausted without more pain. Under 
happier circumstances and good treat- 
ment, amendment begins before destruc- 
tion of the affected tissues has gone to 
such a degree as to be incompatible with 
life. The stools improve, become fecu- 
lent, and lose the dysenteric odor ; blood 
and mucus disappear, the abdomen be- 
comes less tumid and tender, the counte- 
nance improves (a most favorable sign), 
the febrile paroxysms disappear, the pulse 
gains in volume and loses in frequency, 
and the state of nervous depression passes 
away. There is still a third termination ; 
the case may pass into the chronic stage ; 
or this state may result after convalescence 
from the acute attack has been well ad- 
vanced, in consequence of some impru- 
dence on the part of the patient or those 
about him ; errors in diet; or, in military 
life, from exposure to hardships before 
health has been sufficiently restored. 
Chronic Dysentery. - As the patient 
sinks into this unhappy condition, he con- 
tinues to lose flesh. The discharges, still 
maintaining much of the dysenteric odor, 
are for the most part fluid, but they vary 
from day to day, and even on the same 
day, being muciform, serous, and bloody. 
Sometimes they are tolerably natural, and 
even formed ; more frequently they con- 
sist of thin feculence, of a reddish-brown 
color and most offensive smell. Often SYMPTOMS 
377 
they are pale and frothy, and in this con- 
dition are usually voided with violence. 
Power over the sphincter is impaired, 
often lost entirely. The sufferer does not 
gain flesh, the appetite may be tolerably 
good, or capricious, or bad. In any case 
the food is hurried along the intestine, 
and the patient is poorly nourished; the 
tongue is red and glazed, sometimes deeply 
fissured; night sweats are frequent, the 
hair drops off, boils are common in various 
parts of the body, and the patient looks 
older than he is. This is the general con- 
dition, but it is liable to be modified by 
any complication that may be present, the 
malarious, or syphilitic, or scorbutic ca- 
chexia, or by hepatic disease. The con- 
dition of the patient will also depend on 
the extent of injury done in the acute 
stage to the mucous and glandular struc- 
tures of the intestine, the presence or not 
of unhealed ulcers, the condition of the 
intestine as regards thickening of its 
coats, or the opposite state of atrophy: 
whether or not the lesions are bounded 
by the ileo-colic valve, or pass into the 
small intestine; and, in no small degree, 
on the extent to which the solid viscera, 
liver, spleen, and kidneys are implicated. 
Thus it will be seen that chronic Dys- 
entery is not, as many suppose, merely 
due to abortive cicatrization of the ulcers 
left by the acute stage, but is often a much 
more complex state. 
I believe, and shall presently demon- 
strate, that Acute Dysentery is in a high 
degree amenable to early and judicious 
treatment. On the other hand, speaking 
from a large experience, I affirm that 
complete restoration to health by the un- 
aided efforts of nature, is an extremely rare 
occurrence; one of two things happens, 
either the disease destroys the patient, or 
it passes into the chronic form just de- 
scribed. 
Malarious Dysentery.-By this term I 
mean to indicate those cases in which 
malaria acts with a high degree of inten- 
sity on the system, developing, in addi- 
tion to the symptoms already described, 
those which are characteristic of mala- 
rious fevers. 
It is in this form that we find hepatic 
complications most frequently present- 
complications which add greatly to the 
gravity of the disease, and unfavorably 
influence the prognosis : such cases will 
be recognized by the periodicity of the 
febrile paroxysms, the presence of gastric 
irritability, such as we see in remittent 
fevers, and by the peculiar nature of the 
evacuations, which from the first are se- 
rous and contain little blood, but have the 
characteristic dysenteric odor. There is 
also a therapeutic aid to diagnosis ; ipe- 
cacuanha is not well borne, and quinine 
acts powerfully in checking the febrile 
paroxysms. 
Malignant Dysentery.-I have already 
described the conditions under which the 
disease is generated; it has been described 
as "Dysentery plus the typhoid condi- 
tion." From the first, the patient has a 
cachectic aspect, the countenance soon 
becomes sunken, listless, and sodden, a 
burning heat in the belly is complained 
of, with great oppression and sinking ; the 
voice is weak, the stomach irritable, and 
pulse frequent, small, and compressible. 
The evacuations are serous and bloody, 
attended with tormina and tenesmus, and 
the dysenteric odor is intense from the 
beginning. For a short time after the 
first burst, the stools may be mucifonn 
and bloody, but this condition does not 
last long; they again become abundant, 
serous, and bloody, consisting of dissolved 
blood, serum, epithelium, and gangrenous 
portions of semi-dissolved mucous mem- 
brane, exhaling an insupportable gan- 
grenous odor. The urine is scanty, scald- 
ing, and fetid, and in extreme cases the 
secretion is suppressed entirely, as in 
cholera. The skin is in general cold and 
clammy, and immense discharges of blood 
often take place from the bowels, deter- 
mining the fatal issue, and also from the 
mouth and nostrils. 
Scorbutic Dysentery is met with when 
the conditions which induce that cachexy 
are superadded to any type of Dysentery. 
I had an opportunity of seeing the ravages 
worked by this form of the disease during 
the first occupation of Chusan in 1840, 
one of the most disgraceful episodes in our 
military history. Here we have the usual 
signs of the scorbutic cachexy-pallor, 
emaciation, extreme lassitude, pains in 
the loins and limbs, a spongy condition of 
the gums, which bleed on the slightest 
pressure. Soon livid and purple-colored 
spots appear on the legs, and ulcers of a 
weak and unhealthy kind follow the least 
injury to the surface, the pulse is feeble, 
the appetite bad, and the debility ex- 
treme. To the above are added the symp- 
toms of Dysentery, only the evacuations 
are, from the first, fluid, bloody and 
nearly as offensive as in the malignant 
form. Scorbutic Dysentery does not run 
so rapid a course as the sthenic or malig- 
nant (typhoid) form, rarely proving fatal 
in less than three weeks, and, in the more 
chronic form, it may extend over as many 
months. 
[In the IT. S. army Chickahominy expe- 
rience, in 1862, a considerable number of 
cases of Scorbutic Dysentery and diar- 
rhoea occurred. Great emaciation and 
debility existed, with loss of digestive ca- 
pacity and purple blotches upon the trunk 
and limbs. Several cases were compli- 
cated with pneumonia, found, post-mortem, 
to have involved chiefly the lower and pos- 
terior portions of both lungs. Death re- 
sulted in a number of instances ; but the 378 
DYSENTERY. 
larger number recovered under antiscor- 
butic treatment.-H.] 
Diagnosis.-This ought not to present 
any difficulty. In acute cases the tormi- 
na, tenesmus, muciform and bloody stools, 
and above all, their peculiar odor, will 
distinguish Dysentery from diarrhoea. If 
seen in a more advanced stage, when the 
stools have become more fluid, the history 
of the case, the nervous depression, the 
blood in the discharges, and once more, 
they* cadaveric odor, will establish the 
diagnosis. 
The author once saw a case in which a 
grave error in diagnosis had been made. 
A lad between thirteen and fourteen years 
of age, the son of European parents in In- 
dia, was seized with frequent calls to 
stool, with much gastric irritation, nau- 
sea, vomiting, restlessness, and oppres- 
sion. The practitioner who first saw the 
case, seeing that the stools were scanty 
and muciform, without feculence, and 
passed with griping, pronounced the case 
to be one of Dysentery, and proceeded to 
treat it with calomel and opium. Under 
this treatment the stools, still presenting 
the same characteristic appearance, be- 
came of a greenish color, and the gastric 
symptoms were aggravated. Seeing the 
patient at this stage, the first thing he 
noticed was the entire absence of the pe- 
culiar dysenteric odor in the evacuations. 
On inquiry, it was found that before the 
appearance of the so-called dysenteric 
symptoms, the patient, after slight febrile 
and catarrhal symptoms, had an eruption 
on his skin, which, after imprudent expo- 
sure to a cool sea-breeze, suddenly receded, 
the recession of the eruption being followed 
by the symptoms mistaken for those of 
Dysentery. The patient was placed at 
once in a hot bath ; soon the characteris- 
tic rash of measles appeared, nausea and 
vomiting subsided. Under simple treat- 
ment the disease ran a mild course, and 
the lad soon recovered. 
Pathology.-From what has already 
been said, it will be seen that I regard 
Dysentery to be as much the consequence 
of a specific poison as any of the recog- 
nized miasmatic diseases. Why this poi- 
son should, as Baly has expressed it, have 
such an affinity for the glandular struc- 
tures of the large Intestine, we can no 
more explain than we can tell why the 
poison of enteric fever should evince a 
like affinity for the glands of the small in- 
testine. 
Looking to the whole history of the dis- 
ease, its mode of propagation and its cha- 
racteristic lesions, it seems impossible to 
regard it as a simple inflammation of the 
mucous membrane, a mere colonitis, but 
rather as a specific disease, of which in- 
flammation of the glandular structures 
and mucous membrane of the great gut, 
and its consequences, are characteristic 
and invariable incidents. 
Morbid Anatomy.-It is difficult to 
give a perfectly accurate description of the 
Morbid Anatomy of the complex struc- 
tures involved in this disease. The de- 
scriptions of authors are at variance with 
one another. The confusion has arisen 
partly from the ignorance of some of the 
observers of the healthy structure of the 
parts described ; and also, in some in- 
stances, from not tracing the change of 
structure from its earliest manifestations 
to its ultimate results, a fault due in many 
instances to lack of opportunity. 
So great is the confusion in the descrip- 
tions, that my colleague Dr. Aitken has 
asked (1) "Whether distinct epidemics 
are characterized by distinct local lesions? 
(2) Whether two or more distinct dis- 
eases have not been confounded under 
the one name of Dysentery ? Or (3) 
Whether the various local lesions de- 
scribed by different writers are only so 
many varieties, forms, or types of the 
same diseased process-a process modified 
in particular cases by constitutional pecu- 
liarities, or by other circumstances." 
This latter view Dr. Aitken is of opinion 
is the one most consistent with observa- 
tion, and in accordance with what we 
know of the history of other miasmatic 
diseases. 
In the Dysentery of temperate climates, 
it is seldom that more than one or two of 
the anatomical divisions of the great in- 
testine are implicated. In tropical coun- 
tries, not unfrequently, the morbid pro- 
cess affects the whole tract of the intes- 
tine from the caecum to the anus. Except 
in Scorbutic Dysentery, it is rare to find 
the lesion extending into the small intes- 
tine. 
I propose to describe the morbid ap- 
pearances under the three heads of Con- 
gestion, Ulceration, and Exudation. 
In the rare instances in which the af- 
fected bowel has been seen before ulcera- 
tion of the glandular apparatus has com- 
menced, it has been observed to be swollen 
and somewhat softened, the color of the 
affected parts being rosy red, purplish, or 
of a brownish and sometimes a leaden 
hue. This discoloration of the mucous 
membrane is by no means uniform ; in the 
non-febrile forms of the disease I have 
seen the membrane between the ulcers 
unchanged, and even paler than natural, 
and there is as much diversity in the de- 
grees of softening of the tissues. 
Ulceration.- It is mainly to the careful 
observations of Drs. Parkes and Baly that 
pathologists are indebted for an accurate 
description of this process. At the very 
commencement of the morbid action, Dr. 
Parkes has shown that the solitary glands MORBID ANATOMY. 
379 
are enlarged in various degrees, "from 
the size of a millet-seed to a small shot" 
(Baly). They are seen to be distended 
with a white exudation, some with a dark 
central spot, and all surrounded by a vas- 
cular ring. It is on and about these 
glands that the ulceration, or, as Baly 
prefers to call it, sloughing process, be- 
gins, spreading from them into the mu- 
cous membrane. Dr. Parkes was led 
from his dissections to the belief that ul- 
ceration almost always begins in the 
glands themselves, very rarely around 
them, and only occasionally, in very rapid 
cases, by effusion of fluid beneath the mu- 
cous membrane. This last is the " circum- 
scribed sub-mucous suppuration," leading 
to the formation of circular and other 
shaped ulcers, described by Morehead, 
Haspel, and Bleeker. This commence- 
ment of the ulcerative process must be 
familiar to all who have seen the rapidly 
destructive type of Dysentery which so 
long prevailed in the old infantry barracks 
in Secunderabad, before described. The 
ulcers are at first circular and have 
rounded edges, but as they enlarge the 
edges become flat, and they spread out 
into irregular shapes, having for the most 
part their long diameter in the direction 
of the plicte of the mucous membrane 
round the intestine. In the more ad- 
vanced cases the whole tract of the gut is 
studded with ulcers of all shapes, sizes, 
and degrees of development, presenting 
in different cases a great variety of ap- 
pearances-some deep and irritable-look- 
ing, others more superficial and pale, 
some having their floors covered with 
lymph of various shades, others having 
their floors formed by the muscular coats. 
In the rapidly destructive sloughing Dys- 
entery, I am of opinion that the process 
begins by sub-mucous purulent effusion, 
detaching the mucous membrane, which 
rapidly becomes gangrenous. I have seen 
the whole tract of the mucous membrane, 
from the rectum to the transverse colon, 
presenting a black gangrenous mass, in 
which it was impossible to distinguish a 
shred of healthy tissue. 
As soon as the diseased action impli- 
cates the other coats, lymph is effused be- 
tween them. In chronic cases, in ema- 
ciated subjects, the colon can be grasped 
through the parietes, as a patient of mine 
once expressed it, " like a ruler." Some- 
times the coats of the intestine themselves 
become thickened and fleshy-looking. 
Cicatrization of Intestinal Ulcers.-The 
process has been well described by Drs. 
Parkes and Baly. A fibrinous exudation 
takes place on the floor of the ulcer, which 
becomes organized. The edges, after 
being rounded, are drawn down to meet 
the floor, and from them a delicate lamina 
shows inwards till the whole surface is 
covered (Baly). 
Exudation. -I have already described 
an exudative process as being seen at an 
early period of the disease in the solitary 
glands, to which, however, it is not con- 
fined ; it soon fills the neighboring tubular 
glands, and spreads over portions of the 
mucous membrane of the colon and rec- 
tum, sometimes, but in India rarely, and 
then only in chronic cases, extending over 
the entire surface of the intestine, and 
even passing into the ileum. Usually of 
a yellow or gray color, it forms a thin 
granular layer: when this is detached, 
the subjacent membrane is found to be 
vascular and red. This exudation, when 
microscopically examined, is composed of 
epithelium and fibrinous granules, but in 
the severer forms, Dr. Aitken describes it 
as consisting of " fine germs with nuclei, 
mixed with elongated cell-forms" (con- 
nective tissue cells). 
This exudation is either detached in 
fragments with much griping and distress, 
or becoming to a certain extent organized, 
it is finally, by a process of ulceration, de- 
tached in tubular portions, a process, as 
shown by Morehead, to be sometimes at- 
tended with hemorrhage. 
In Chronic Dysentery. - There is no 
more common error than to suppose that 
the symptoms in Chronic Dysentery are 
invariably due to the presence of unhealed 
ulcers in some portion of the mucous 
membrane. We constantly see cases in 
which not a single breach of continuity is 
found. There is, in such examples, 
abundant evidence of previous ulceration, 
and the whole surface of the mucous mem- 
brane will be found thickened by a depo- 
sition of black granular matter, the result, 
as Dr. Aitken thinks, " of excessive vas- 
cular action and of subsequent changes in 
the extravasated blood." In other cases 
abundant ulceration is found, particularly 
in the rectum and sigmoid flexure of the 
colon, the ulcers being in every condition, 
some cicatrized, others undergoing that 
process, most without vitality enough for 
healing. Sometimes the whole of the ali- 
mentary canal is in a state of atrophy, the 
glandular structures having disappeared, 
and the tissues being so attenuated that 
they are quite transparent. In such cases 
the general emaciation of the sufferer is 
extreme. In more recent cases great 
thickening of the connective tissues, and 
even of the coats of the intestine will be 
found. In this condition, the exudation 
is usually found to have undergone the 
process of organization already mentioned, 
and it may be found in a state of ulcera- 
tion like any part of the natural tissue 
(Aitken). 
The coincidence of Dysentery and he- 
patic abscess is one of the most familiar 
facts in pathology. But it is often as- 
sumed because no abscess is found at a 
post-mortem examination in a case of Dys- 380 
DYSENTERY. 
entery, that the liver is normal. Now, in 
a case of tropical Dysentery it is extremely 
rare to find the liver healthy. This need 
not excite surprise, for when to the pre- 
disposing, or exciting causes of the dis- 
ease we add a high temperature, a diet 
too stimulating for the climate, and habits 
of intemperance, we have enough to ex- 
plain the various hepatic diseases, func- 
tional and organic, which so often in 
tropical climates seriously complicate 
Dysentery. And this without having re- 
course to any theory of blood poisoning by 
the absorption of discharges from the 
sloughing intestine. This view is strength- 
ened by a consideration of the fact that 
liver abscess is exceedingly rare in the 
Dysentery of temperate climates. In all 
Dr. Baly's cases in the Millbank Peni- 
tentiary there was not a single case of 
hepatic abscess. 
Prognosis.-The grounds for a favorite 
prognosis are, (1) The original slightness 
of the attack. (2) The absence of much 
nervous depression. (3) A natural coun- 
tenance, with a pulse of good strength 
and moderate frequency. (4) The ab- 
sence of gangrenous odor in the stools. 
(5) The early appearance of feculence in 
the stools ; and lastly, the absence of any 
signs of serious hepatic complication. 
On the other hand, rapid failure of the 
nervous and circulatory systems ; a pulse 
increasing in frequency and failing in 
strength; an anxious and sodden coun- 
tenance ; extreme restlessness; sudden 
subsiding of pain with increasing fetor of 
the stools of a gangrenous character; 
hemorrhage from the bowels, mouth, or 
nose ; hiccup ; black and dry tongue ; sup- 
pression of urine, and delirium, all point 
to extreme danger. 
Treatment.1-It is impossible to over- 
estimate the importance of early treat- 
ment in tropical Dysentery. So rapid is 
the progress of the disease, so terrible the 
lesions it causes in a space of time appa- 
rently insignificant, that no pains should 
be spared, more particularly by military 
and naval surgeons, to impress on the 
minds of those committed to their charge 
the necessity of seeking medical aid on 
the first manifestation of the symptoms of 
the disease. 
Mild Dysentery.-In this form I have 
much confidence in the use of the hot 
bath as a powerful means of restoring the 
suppressed action of the skin. The bath 
should be brought to the bedside of the 
patient and should be maintained at a 
high temperature, and the patient should 
be kept in it until he feels faint. After 
being quickly and carefully dried he should 
be put to bed, and a dose, not less than 
from fifteen to twenty grains, of ipecacu- 
anha should be given in the manner to be 
presently explained. This may require to 
be repeated in eight or ten hours. 
If the patient abstains from all fluid for 
some hours after taking the medicine, it 
is seldom that much nausea or vomiting 
is produced, provided the horizontal posi- 
tion is maintained, which it ought to be. 
The result generally is free action of the 
skin, rapid subsidence of griping, and the 
appearance of feculent motions. In some 
cases it may be necessary to give a few 
drachms of fresh castor-oil, guarded by a 
few minims of tincture of opium, or a 
few drops of chloroform. And it is well 
also to stimulate the abdominal surface by 
the application of a few turpentine stupes. 
The above simple treatment will suflice 
in a great many cases of that mild form 
of disease which follows chills without 
much charging of the system with mala- 
ria, provided it be had recourse to suffi- 
ciently early. 
Morehead speaks slightingly of the hot 
bath in the treatment of any form of Dys- 
entery, but I have found it to be a most 
useful remedy, used with the precautions 
and in the manner advised above. 
Acute Dysentery.-In this form it is even 
of more importance than before that the 
patient should be early seen and treated, 
lie should at once be ordered to bed, and 
as quickly as possible brought under the 
influence of ipecacuanha in large doses. 
Some insist on the propriety of first giv- 
ing a full dose of Battley's sedative, tinc- 
ture of opium, or a few drops of chloro- 
form, with the intention of making the 
stomach tolerant of the remedy, and re- 
straining nausea and vomiting. 
I believe that the sedative in some 
cases is useful, and acts in the manner 
just described. On the other hand, I 
have often seen ipecacuanha do its work 
well, and with little disturbance of the 
stomach, without opium. Should it be 
determined to premise opium, thirty drops 
of the tincture should be given, and in 
half an hour followed by from twenty-five 
to thirty grains of ipecacuanha, which 
should be given in as small a quantity of 
fluid as possible ; a little syrup of orange- 
peel covers the taste as well as anything 
else. As already advised, the patient 
should keep perfectly still, and abstain 
from fluid for at least three hours. If 
thirsty, he may suck a little ice, or a tea- 
spoonful of cold water at a time may be 
allowed. 
It is seldom that under this manage- 
1 In every form of Dysentery, both in pub- 
lic and private practice, the stools ought to 
be received in glazed vessels containing some 
disinfectant solution, instantly removed from 
the house $r hospital, and carefully and 
deeply buried. I cannot too earnestly im- 
press this caution on the minds of military 
and naval surgeons. TREATMENT. 
381 
ment nausea is excessive, and vomiting is 
rarely troublesome, seldom setting in for 
at least two hours after the medicine has 
been taken. The abdomen should be 
covered with a large sinapism, or a sheet 
of spongio-piline sprinkled with a little 
turpentine after being wrung out of hot 
water. 
In from eight to ten hours, according to 
the urgency of the symptoms, and the 
effect produced by the first dose, ipecacu- 
anha in a reduced dose should be re- 
peated, with the same precautions as be- 
fore. All who have had opportunities of 
trying this mode of treating Dysentery 
can bear testimony to the surprising effects 
that often follow the administration of 
one or two doses of ipecacuanha given in 
this manner. The tormina and tenesmus 
subside, the motions quickly become fecu- 
lent, blood and slime disappear, and often, 
after profuse action of the skin, the pa- 
tient falls into a tranquil sleep and 
awakens refreshed. The treatment may 
require to be continued for some days, the 
medicine being given in diminished doses, 
care being taken to allow a sufficient in- 
terval to admit of the patient taking some 
mild nourishment suited to the stage of 
the disease. 
This, in a few words, is the system of 
treating acute Dysentery now almost in- 
variably followed in India. It has been 
long enough in use on a sufficiently large 
scale to enable us to appeal to statistics 
and bring it to the test of figures. It has 
almost entirely superseded the old plan of 
general and local bleeding, with mercu- 
rialization, either by calomel in scruple 
doses, or in smaller quantities at short in- 
tervals, in combination with opium. Here 
are the results, derived entirely from offi- 
cial sources:- 
Under the old system in Bengal the 
mortality among Europeans during the 
forty-two years, from 1812 to 1853-54, 
amounted to 88'2 in the thousand. 
During 1860, when large doses of ipeca- 
cuanha were give to the almost complete 
exclusion of all other methods of cure, 
the mortality was 28'87 in the thousand. 
In the Madras presidency under the 
old treatment the mortality from the dis- 
ease during seventeen years was 71 per 
thousand treated, but when ipecacuanha 
was largely used, as above described, it 
fell to 13'5 in the thousand. 
In the 44th Regiment, quartered at 
Fort St. George, Madras, Surgeon Mee 
treated 68 cases " in the ordinary way" 
-with a mortality of 6, or 8'8 per cent. 
Subsequently 59 were treated with large 
doses of ipecacuanha, and all recovered. 
Mr. Docker, surgeon of the 2d Batta- 
lion of the 7th Royal Fusiliers, to whom 
is undoubtedly due the honor of recalling 
us to a more rational and successful way 
of treating Dysentery, after he had re- 
course at the Mauritius to the plan of 
using large closes of ipecacuanha, lost only- 
one out of fifty-three cases. 
I have not space to enter into the com- 
plete history of ipecacuanha as a remedy 
in Dysentery. I must refer my readers to 
an excellent and exhaustive paper on the 
subject by Dr. Blacklock of the Madras 
army in the Madras Quarterly Journal of 
Medical Science, and to a paper on the 
same subject by Dr. Ewart of the Bengal 
army, in the sixteenth number of the In- 
dian Annals of Medicine. Known from 
remote times in Peru as a remedy for 
Dysentery, it was introduced into this 
country as the Radix Anti-Rysenterica. It 
appears to have been used in Europe in 
the treatment of the disease more as an 
adjuvant to other remedies than trusted 
to alone. In process of time ipecacuanha 
came to be used almost exclusively as an 
emetic and expectorant, and, in combi- 
nation with opium, as a diaphoretic in 
the form of Dover's powder. In the 
Madras presidency for many years before 
the publication of Mr. Docker's paper, it 
was used as a remedy in Dysentery, chiefly 
after the example of the late Drs. Geddes 
and Mortimer, and, as I can testify from 
twenty-two years' experience of its use, 
with a marked superiority over the plan 
of treatment by mercurials. The great 
merit of Mr. Docker was the introduction 
of the plan of using it in the large and 
effective doses of which I have spoken, 
with the gratifying results given above. 
It is probable that ipecacuanha owes 
much of its usefulness in this disease to 
its action as an evacuant. It is a blood 
depurant of an effective kind. It appears 
to increase the secretion of the whole ali- 
mentary canal, as well as that of the liver 
and pancreas ; under its use tormina and 
tenesmus disappear, and feculent evacua- 
tions are more quickly restored than by 
any other known remedy. 
It also promotes free action of the skin, 
and exercises a sedative action on the 
circulation. "In fine," says Dr. Ewart, 
" ipecacuanha in large doses may be said 
to fulfil many indications. 
" It produces all the good effects that 
have been ascribed to blood-letting with- 
out robbing the system of one drop of 
blood, of mercurial and other purgatives 
without their irritating action, of anti- 
monials and sudorifics without their un- 
certainty, and of opium without masking 
the disease." I may add, that it is the 
most simple, the most successful, the 
most conservative, and the least distress- 
ing mode of treatment I have ever seen 
used in Dysentery. Year by year under 
its use the number of chronic cases is be- 
coming smaller, and hepatic abscess as a 
complication is less frequently seen. Al- 
though most effective in the early stage 
of the acute form, it may be given at a 382 
DYSENTERYj, 
much latter period with advantage ; and 
even in chronic cases, where from any 
cause subacute symptoms have set in, I 
often give it with the best results. Some 
authors caution us against its use in large 
doses in adynamic cases, and doubtless in 
such cases very large doses are not advi- 
sable. Still, I have used it even where 
the powers of life were very low, and with 
the best effect. I well remember the case 
of a lady, sent to Madras from Calcutta, 
who landed in such a state of exhaustion 
that it was with difficulty I could hear 
her voice. With some misgivings, the 
symptoms being urgent and the case criti- 
cal, I ga ve twenty-grain doses of ipecacu- 
anha at intervals of eight hours, interpos- 
ing support between the doses ; after the 
third dose this lady was out of danger and 
made a rapid recovery. 
If unmanageable vomiting follows the 
use of ipecacuanha, hepatic complication 
of a serious kind may be suspected-or 
the vomiting may arise from the system' 
being overcharged with malaria, severe 
gastric symptoms of this kind being ex- 
tremely common in remittent fever. 
As soon as the disease abates, the dose 
of the remedy should be abated also. It 
is well, however, for some days to ad- 
minister ten or twelve grains at bedtime, 
for a night or two after the stools are to 
all appearance healthy. Fomentations 
[flaxseed or hot mush poultices.-II.], 
stupes with turpentine, or the application 
of strong chloroform liniment to the ab- 
domen, help to lessen tormina and dimin- 
ish suffering. If a little diarrhoea, with- 
out the dysenteric odor remains, it may 
be checked with a little astringent mix- 
ture such as the compound chalk powder, 
with or without opium. Astringents in 
any shape during the acute stage are not 
only useless but dangerous. [After the 
excitement of the first period has abated, 
however, the obstinate persistence of dys- 
enteric discharges may often be advan- 
tageously met by the use of an enema, 
containing three grains of acetate of lead 
with thirty or forty drops of laudanum, 
diffused in a small amount (f?ss) of starch. 
This may be repeated after several hours, 
if necessary. Small injections of starch, 
with laudanum, without lead or other as- 
tringent, sometimes give important relief 
in dysentery.-II.] 
In Malarious Dysentery quinine in full 
doses should be given, not less than a 
scruple in solution some time before the 
ipecacuanha, and repeated until cincho- 
nism, as evidenced by ringing in the ears, is 
induced. Ipecacuanha and quinine should 
be given in alternate doses until the 
characteristic effects of both are produced. 
In the malignant Dysentery of camps our 
utmost efforts must be directed to improve 
the hygienic conditions of fehe sick, and 
in addition to the means already men- 
tioned, carefully modified to suit the con- 
dition of our patients, the solution of the 
pernitrate of iron should be given in full 
and frequent doses. In some cases I have 
given ten drops every hour with advan- 
tage, and it may be combined with qui- 
nine, while the patient is at the same 
time sustained by milk in small quantities 
and at short intervals, with beef tea when 
it can be retained, with wine and brandy 
when required. 
In Scorbutic Dysentery our utmost efforts 
must be directed to improve the condition 
of the patient's blood. It is in this form 
of the disease that fresh Bael fruit has 
been found so successful in Bengal and 
other parts of India. I have had occasion 
to prescribe this frequently in Madras to 
officers and others who had contracted 
Scorbutic Dysentery in the province of 
Pegu, and often with the best effect. 
Bael fruit has often fallen into disrepute 
as a remedy in Dysentery, simply from its 
indiscriminate use. My conviction is that 
where there is no scorbutic taint it is 
without efficacy. The Bael fruit is used 
in India in many forms, as a sherbet, a 
conserve, a marmalade, or an extract. 
The former is probably the most effica- 
cious. Sir Banaid Martin in the Lancet, 
and Dr. Alexander Grant of the Bengal 
Medical Service, in the first volume of the 
Indian Annals of Medicine, have both 
written interesting accounts of the various 
modes of preparing and using this remedy. 
It is doubtless in the same form of the 
disease that the " Grape cure" has been 
found so efficacious. One caution I can- 
not help giving. I remember the case of 
a young officer at Secunderabad, who, 
while convalescing from Acute Dysentery, 
partook freely of grapes. Shortly after, 
he was seized with all the symptoms of 
peritonitis from perforation, and rapidly 
sunk. After death it was found that a 
grape stone had become entangled in one 
of the half cicatrized ulcers in the colon, 
where it acted like a pea-issue ; a minute 
perforation resulted, causing the death of 
the patient. 
Many of the invalids from India, suffer- 
ing from chronic Dysentery, arrive at 
Netley in a more or less scorbutic state ; 
all are benefited and some cured simply 
by causing them to use whatever fruits are 
in season. [The same was true of the 
U. S. A. Chickahominy cases, before al- 
luded to.-H.] 
Chronic Dysentery.-Whenever the dis- 
ease falls into this stage and resists treat- 
ment, the patient should as soon as 
possible be sent to a better climate. If 
the locality be malarious, this should be 
done at once. Often moving him to the 
sea-coast suffices. More frequently a 
voyage to Europe is essential to recovery; 
many lives are lost by delaying this meas- 
ure until it is too late, and many men are TREATMENT. 
383 
embarked in such an advanced state of 
disease that they die after being a few 
days on board. As already stated, the 
chief mortality among Indian invalids on 
the voyage home is from Dysentery. 
I have elsewhere (Army Medical Re- 
ports) insisted on the necessity of extreme 
care in the management, diet, and cloth- 
ing of men suffering from the disease at 
sea. To men in this condition the salt 
ration is simply destruction, and unless 
they be warmly clothed on entering high 
latitudes, they are certain to have their 
sufferings miserably aggravated. 
Whenever the symptoms assume an 
acute or subacute form, the patient ought 
at once to be placed in bed, and ipecacu- 
anha should be given as recommended in 
the acute stage, in doses suited to the con- 
dition of the patient, and the violence of 
the symptoms. Gentlemen who have 
done duty in the clinical wards at Netley 
have often seen me use this remedy under 
such circumstances with the happiest 
effect. 
I recommend the use of a water-belt 
over the abdomen for some hours daily. 
This acts as a fomentation, and the 
steady, uniform pressure it maintains 
seems to favor the absorption of the 
fibrine effused between the intestinal 
coats. If there be much uneasiness about 
the fundament, a water compress over the 
anus often affords more relief than opiate 
enemata. 
The cold hip-bath should be used daily 
for a few minutes. I have seen this most 
serviceable. The greatest attention should 
be paid to diet. The proper nutrition of 
the patient is often the most difficult part 
of the treatment. In those cases where 
atrophy of the small intestine is much 
advanced, with perhaps fatty or amyloid 
degeneration of the liver, or both, it is 
almost, if not quite, impossible, and the 
patient dies starved. If the state of the 
gums point to a scorbutic taint, the diet 
must be regulated on the principles al- 
ready laid down under that head. In 
extreme cases milk must be our chief 
resource, sometimes with a little lime- 
water, or beat up with egg, and good 
sherry or brandy ; a teaspoonful of cura- 
90a added is often highly relished. Rice 
flour, sago, arrowroot, or stale bread may 
be added, and changed so as to suit the 
capricious appetite. When solid food can 
be taken without suffering, it should be 
given; tender mutton should be broiled 
"quickly and not too much," and eaten 
with bread and butter. These rules are 
quite as applicable to the acute stage, 
where food, while the acute symptoms 
last, should be simple and farinaceous, 
and the return to solid food should be 
gradual. 
With regard.to medicine, where astrin- 
gents are indicated, they should clearly 
be of such a kind as do not tend to lower 
the already sufficiently low state of the 
patient. Acetate of lead, sulphate of 
copper, and suchlike remedies, I use with 
a sparing hand, and only under the pres- 
sure of necessity. My favorite remedy, 
particularly in men returning from tropi- 
cal regions, ansemic from loss of blood 
and the depraving influence of malaria, 
is the solution of the pernitrate of iron, 
which I use at Net ley very freely, and 
often with the happiest effect. Under 
this remedy the whole system often rallies 
wonderfully, the condition of the blood 
improves, color returns to the blanched 
cheek, the stools become more natural 
and less frequent, the appetite improves, 
and digestion is more perfectly performed. 
The citrate of iron and quinine may after 
a time be substituted. 
When astringents of a more direct kind 
are necessary, the decoction of logwood 
with lime-water, catechu, gallic acid, and 
suchlike may be used. Pain must be al- 
layed by opiate enemata, gentle douches 
to the anus are often most soothing, and 
the use of liniments containing chloroform 
often allays irritation. [In obstinate 
chronic Dysentery, with evidence of ul- 
ceration of the intestine, enemata con- 
taining metallic astringents are sometimes 
very useful. In the Pennsylvania Hospi- 
tal, in 1847-48, a number of soldiers 
returning with severe chronic Dysentery 
from the Mexican war, were cured by the 
use of injections of sulphate of zinc. 
Even large doses (gr. v to x in f.^iv of 
flaxseed infusion) were well borne in 
those cases. Strong solution of alum 
sometimes produces a similar beneficial 
effect.-IL] 
In Conclusion.-It will not fail to be 
remarked that I have not only not ad- 
vised but by implication have deprecated 
the use of mercury in all stages and forms 
of the disease. 
My first objection to the use of mercury, 
particularly in military practice, is one 
that was forced on me more than twenty- 
two years ago by observing this fact. 
Whenever soldiers find that in addition to 
the misery inseparable from an attack of 
Dysentery they are to be subjected to that 
of ptyalism in its mildest degree, they will 
not present themselves at the hospital 
gates until further concealment of the 
complaint is impossible. Secondly, be- 
cause in ipecacuanha we have a remedy 
that effects all that mercury can do as an 
evacuant, without its irritating effects. 
Thirdly, because experience has shown 
that men " cured " by mercurial treat- 
ment are as a rule cachectic, ex-sanguine, 
prematurely old-looking, extremely sen- 
sitive to atmospheric changes and to re- 
lapses from trivial causes. Fourthly, 
because chronic Dysentery is more fre- 
quent after mercurial treatment than 384 
EPIDEMIC CHOLERA. 
when the disease is treated by ipecacuanha. 
And, lastly, "because men actually under 
the influence of mercury are very predis- 
posed to the disease." (Morehead.) 
In many text-books and works of high 
authority, blood-letting is still insisted on 
as an essential part of the treatment of 
acute Dysentery. 
I respectfully dissent from this doctrine, 
first, because, although from the violence 
of the symptoms there is an appearance 
of power, this is deceptive, for alarming 
depression often follows free depletion. 
Secondly, even where the measure appears 
to relieve symptoms, the heart's action is 
weakened to such an extent that conges- 
tion of the affected mucous membrane 
remains, a condition which Dr. Blacklock 
has shown to be nearly as destructive 
to the tissues as the more acute action. 
Thirdly, because convalescence after 
bleeding is tedious. Fourthly, because 
although bleeding has fallen into disuse the 
mortality from Dysentery has decreased. 
Lastly, it appears to me that the authors 
who still urge it in this affection and ma- 
larial fevers take no account of the state 
of public opinion on this question. What- 
ever may be the case elsewhere, a gene- 
ration has certainly arisen in India that 
knows not the lancet. Men know, on the 
other hand, for they see it daily, that 
those who are not bled recover in a larger 
proportion than in the days when bleeding 
was the rule of practice. In short, out of 
a military hospital where patients have 
no option but to obey, I assert that it 
would be simply impossible to carry out 
the rules for blood-letting which still stand 
in some of our text-books. I cannot help 
thinking that treatment of this kind is 
much in the position of certain penal 
statutes, which, although still in the sta- 
tute-book, have become obsolete by the 
force of enlightened public opinion. I 
am confident that were it possible even for 
Robert Jackson, the most sagacious and 
far-seeing physician the British army ever 
produced, to reappear once more on the 
scenes of his former labors, it would be 
impossible for him, with all the influence 
of his great name, and all the authority 
of his vast experience, to induce the men 
and women of the present day to submit 
to treatment which they believe to be mis- 
chievous, and know to be unnecessary. 
[Acute inflammatory Dysentery occurs, 
however, sporadically, in climates free 
from endemic or epidemic influences, so 
sthenic in character, that those who are 
willing to resort to local, and, in a few 
cases, general blood-letting, may find ad- 
vantage in it. Application of leeches, 
rather freely, to the lower portion of the 
abdomen, has been known to give very 
important relief and aid in treatment. 
In the same class of cases, some practi- 
tioners have reported excellent effects from 
the use of small but repeated doses of a 
solution of sulphate of magnesium. By 
its diffusive action over the intestine, pro- 
moting secretion from the congested mu- 
cous membrane, and also by its sedative 
influence upon the circulation, we may 
explain the benefit which, empirically, 
has been obtained from it.-II.] 
EPIDEMIC CHOLERA. 
By Edward Goodbye, M.B. 
Definition.-An epidemic, and in 
some places an endemic disease of great 
mortality. Typical Epidemic Cholera is 
characterized, in its developed stages, by 
vomiting and purging of watery fluid ; by 
rapidly causing a state of the body called 
collapse, in which there is extreme depres- 
sion or diminution of nearly all the func- 
tions of life; by terminating in death- 
often within twenty-four hours from the 
first symptoms of the disease-or in 
healthy reaction, or in various dangerous 
sequelie, mostly of a typhoid nature. 
Synonyms. - Cholera Morbus-Epi- 
demic Cholera-Asiatic Cholera-Algide 
Cholera - Cholera A sphyxia - Cholera 
Spasmodica-Blue Cholera - Malignant 
Cholera. 
The disease called by the above names 
is a severe epidemic affection, well known 
in India, and which has at intervals ra- 
vaged different parts of Europe, Africa, 
and America. In Calcutta and Bombay 
it prevails so constantly that it may now 
be said to be endemic there. It appears 
frequently in our camps and stations in 
India, and its occurrence therein, in vio- 
lence, is a signal for unwearied toil and 
labor to our regimental and other sur- 
geons, and of anxiety to all. And it may 
well be so, so widespread is its diffusion, HISTORY. 
385 
so destructive are its effects, and so re- 
sistant is it to treatment. It demands, 
indeed, the careful study of all who prac- 
tise medicine, and most especially of those 
who pursue it in our Indian territories. 
History.-In a practical sketch such 
as this, it would be vain to occupy space 
and time with inquiries as to whether 
Cholera was, or was not, known to ancient 
writers. There is little room for doubt 
that our forefathers were acquainted with 
it in Europe. In India, Cholera has been 
observed several times since the English 
have had possession there. There is evi- 
dence of its having been known in Madras 
in 1769, 1770, and 1774. It attacked the 
artillery commanded by Colonel Pearse, 
marching to join Sir Eyre Coote, in 1781, 
and the troops under Colonel Cockerell, 
in 1790. Its occurrence in three or four 
places in different parts of India, in the 
beginning of the present century, is well 
authenticated. The epidemics, though 
apparently sometimes severe, do not seem 
to have been very frequent. Indepen- 
dently, however, of old records, we have 
a prominent starting-point for the history 
of Cholera in 1817, since which time it has 
been frequently prevalent. In 1818 the 
Western world was startled with the in- 
telligence of the appearance in India of a 
disease which was ravaging Lower Bengal, 
and had also attacked the camp of the 
Marquis of Hastings, then engaged in the 
Mahratta war, and who was at that time 
halted on the banks of the Sind, in the 
Upper Provinces. A new disease, or at 
least one unknown in such a terrific form, 
was carrying destruction through all the 
ranks of the army, both European and 
native. The scourge appeared in Lord 
Hastings' camp on the 6th November, 
1817, and in five days destroyed 5000 men. 
In it, in all, 9000 deaths occurred. But 
not in the camp of war only did it cause 
surprise and terror. After having shown 
itself during the previous months in My- 
munsing, Patna, Kishnaghur, Chittagong, 
and some other places, it burst out in 
August, 1817, in the agricultural province 
of Jessore, among the peasants and labor- 
ers of the rice swamps apd palm groves. 
Many thousands were swept away by the 
pestilence in the course of a few weeks. 
There might have been such a disease in 
the mist of past ages, but the memory of 
living man possessed no vivid or substan- 
tial knowledge of it. It burst upon the 
suffering generation with the violence of 
an unheard-of plague ; impressing all with 
dread and consternation. 
From this starting - point in India, 
Cholera spread east and west, far beyond 
the bounds of Hindostan. Its appear- 
ance in other lands may be traced with 
tolerable accuracy. From Bengal it 
spread eastward and southward in the 
following chronological order. We find it 
in 
1818, in Burmah, Arracan, and Ma- 
lacca ; 
1819, in Penang, Sumatra, Siam, Cey- 
lon, and the Mauritius; 
1820, in Tonquin China and China ; 
1822, '23, '24, in all China ; 
1827, in Chinese Tartary. 
Turning to the west, we find it, in 
July 1821, at Muscat and the Persian 
Gulf; in 
1822, in Persia, and prevailing there 
during 1822, '23, '29, '30; and in 
1823, at Astrachan, 
without spreading further westward for 
some years, i. e. until 1829, when it 
reached Orenburgh through Tartary, re- 
visited Astrachan in 1830, and from 
thence started on its course through 
Europe. 
The westward course continued slowly. 
In May 1831, it was very severe at Mos- 
cow and Warsaw ; in July of the same 
year at St. Petersburg!! and Cronstadt; 
in October, at Berlin and Vienna. In 
England the first cases showed themselves 
at Sunderland, in October 1831, and the 
epidemic prevailed in the British Empire 
for fourteen months. It crossed the At- 
lantic and reached Quebec in 1832. This 
fatal malady ravaged the whole of Europe, 
and left that quarter of the globe in 1837, 
the last place affected being Rome. Since 
1817, epidemics of Cholera have been fre- 
quent all over India, so that the disease 
may be said to have been naturalized 
there; causing a large mortality among 
all classes. 
Besides the first great epidemic above 
mentioned, the western parts of the world 
have suffered from two severe visitations 
of Cholera, viz., in 1848-49, and in 1853- 
54. These appear to have travelled from 
the East much in the same manner as 
that of 1832. 
[In 1866, Europe and America were 
again visited. In 1868 it was particularly 
severe in S. America. In 1872, and again 
in 1873-4, it was destructive in Hungary, 
Poland, and Prussia. In 1873 it was the 
cause of great mortality in several towns 
in the Mississippi Valley. Yokohama, 
Japan, and Canton, China, were severely 
visited by it in 1877.-H.] 
Thus Cholera seems to have spread east, 
south, west, and north from its first birth- 
place in Bengal, which became but the 
centre of an epidemic area comprising 
nearly all the world. It travelled slowly 
at first, and not continuously but in irregu- 
lar waves, checked sometimes, but not 
destroyed, by winter cold, Neither clim- 
ate, nor season, nor earth, nor ocean seem 
to have arrested its course, or to have al- 
tered its features. It was equally destruc- 
tive at St. Petersburgh and Moscow as it 
was in India; as fierce and irresistible 
vol. i.-25 386 
EPIDEMIC CHOLERA. 
amongst the snows of Russia as in the 
sunburnt region of India; as destructive 
in the vapory districts of Burmah as in the 
parched provinces of Ilindostan. 
Etiology.-The predisposing causes of 
Cholera are doubtless common to some 
other epidemics. The exciting cause is, 
probably, an aerial, or at all events an air- 
borne poison, and probably of the zymotic 
class. We do not know, however, whether 
it is of an organized, organic, or inorganic 
nature. There are many circumstances 
in favor of its being of organic composi- 
tion, some of its being organized. It has 
hitherto eluded all chemical and micro- 
scopic research. We are much in the 
dark as to its origin, preservation, multi- 
plication, or diffusion. The poison is 
generally supposed to be some addition to 
the ordinary atmosphere, but some writers 
have speculated upon there being merely 
some modification of its ozone or elec- 
tricity, or upon some dynamic change. 
Others have sought for an origin in tel- 
luric influences. In considering the causa- 
tion of Cholera, we must bear in mind that 
we have to account for a disease spreading 
quickly over large areas, often preceded 
by epidemic diarrhoea; frequently devel- 
oping itself with little warning in the 
places attacked, and often disappearing 
suddenly and returning to them after 
brief intervals, remaining absent for many 
years; visiting with great regularity the 
same places on each return ; sometimes 
limiting itself with singular abruptness in 
certain localities, passing over places in its 
route with strange capriciousness, and 
afterwards returning to them, spreading 
sometimes with and sometimes against the 
direction of the prevailing winds. 
It will be well, apart from all theory, to 
consider the various circumstances which 
appear to have some connection with the 
development of Cholera. These may be 
divided into those which act upon the 
individuals in masses or groups, and those 
■which belong to the individual only. To 
the first belong meteorological conditions, 
climate, soil, purity of atmosphere, food, 
water, &c.; to the second class, sex, age, 
occupation, &c. 
Atmospheric Conditions.-No solution of 
the question of the cause of Cholera can 
be found in ordinary atmospheric changes. 
The opposite states of heat and cold, hu- 
midity and dryness, high and low baro- 
metric states, &c., have prevailed or been 
excluded without banishing the disease. 
A certain amount of heat seems to favor 
the spread and severity of the epidemics. 
In Bengal the hot seasons, including the 
hot and dry and rainy seasons, have wit- 
nessed the worst epidemics. In Bombay, 
Dr. Ewart's tables (Vital Statistics of the 
Armies in India) show that for eight 
years the most fatal cholera months for 
European troops were from April to 
September; the admission to strength, 
and the mortality to treated, being much 
higher: the percentage of fatal cases to 
treated giving 50'710 per cent, from April 
to September, and 19'510 per cent, from 
October to March: and in 3676 admis- 
sions during seventeen years, April to 
September gave 2918 cases, and October 
to March 758 cases. Dr. Morehead shows 
that the greatest number of admissions 
into the Bombay European General Hos- 
pital took place in the months from April 
to September inclusive. He mentions, 
however, that Dr. Leith gives rather dif- 
ferent results for natives. In his tables of 
mortality in Bombay for the three years 
1848-52, he reports V112 deaths from Oc- 
tober to March, and 5110 from April to 
September. Dr. Hugh Macpherson has 
shown that, in Calcutta, Cholera is always 
most rife in the hot months, both for Eu- 
ropeans and natives; the severity of the 
disease generally rising from January, 
through March and April, and descend- 
ing from that month to August, when it is 
at its lowest. In the recently published 
Report of the Commission appointed to 
inquire into the Cholera Epidemic of the 
Northwest Provinces of India, in 1861, it 
is shown that the curves of the disease for 
the Northwest Provinces do not quite 
agree with those of Bengal, as will be seen 
presently. In Europe, temperature ap- 
pears to have had an influence. In Eng- 
land, in 1848-49, the highest point of the 
curve line was in September. In 1853-54, 
Mr. Glaisher and others record that the 
greatest violence of the disease was dur- 
ing the months having the highest tem- 
perature. Although the greatest mortal- 
ity in India is in the hot weather, there is 
a considerable amount of it in the cold 
seasons; much less, however, in the cold 
seasons of the Northwest Provinces than 
in those of Bengal. In Europe also it 
prevailed somewhat severely in the win- 
ter of 1848-49, and very severely in Rus- 
sia during the winter of 1830-31. The 
circumstance of the Russian houses being 
kept very warm inside hardly accounts 
for this. If Cholera were extinguished by 
cold, it is difficult to see how this action 
could have been neutralized in entire dis- 
tricts by the warming of the insides of the 
houses. It appears, from the above, that 
Cholera exists under very wide ranges of 
temperature, but that nevertheless it is 
probable that a certain amount of heat 
does contribute to its intensity. 
More persons are attacked in the early 
morning than during the rest of the day. 
The temperature of the individual may be 
lowered during those hours, and this may 
have the effect of predisposing him to suf- 
fer. Possibly the lower temperature of 
the air may cause a greater concentration 
of the poisonous atmosphere near the ETIOLOGY. 
387 
ground at that time. The tendency of 
attacks to commence in the early morn- 
ing has been noticed in Scotland by Dr. 
Adams, and in India by Mr. Twining, 
Dr. Morehead, Sir R. Martin, and others. 
Rain and Moisture.-These do not pre- 
vent the spread of Cholera. It prevails 
most in Calcutta in the dry season. It 
does not do so in the Northwest Provinces 
of India, in Bombay, or in Madras. The 
Northwest Provinces have at times suf- 
fered severely in the hot and dry months, 
but the majority of the epidemics have 
been in the wet months, as shown by the 
Report of the Commission of 1861. Sin- 
gularly enough, though the dry months 
are now the most fatal in Bengal, the 
great and desolating outburst, which 
startled the whole world, ravaged Jessore 
in August, 1817, in the midst of one of 
the wettest seasons known. The combi- 
nation of heat and moisture, when the air 
is moving slowly, or not at all, seems very 
favorable to the spread of Cholera. Thus 
a prevailing hot, moist, and stagnant at- 
mosphere during these epidemics has 
been recorded by many writers. This is 
mentioned by Mr. Thom in his report of 
the memorable outbreak of Cholera at 
Kurrachee in 1846. He states that the 
dew-point was very high, 83°, with ther- 
mometer at 96° in the shade ; and there 
was induced a sense of languor and op- 
pression, a stifled feeling about the respi- 
ration, and inability to undergo the least 
fatigue. This sense of languor and op- 
pression is often felt during the lulls in 
the rains in India, independently of 
Cholera times, and therefore must not be 
considered causative of the disease. A 
warm, moist, stagnant atmosphere in 
Bengal, at any time of the year, is often 
followed by sporadic cases of Cholera, or 
by an increase of cases where the disease 
is endemic. Cholera has been known to 
cease after heavy falls of rain, and, on the 
other hand, to set in immediately after- 
wards, as in the Meerut gaol in 1861. In 
considering the influence of rain, we must 
recollect the temperature prevailing, and 
the time that has elapsed after the said 
fall. A very few hours after a fall of even 
heavy rain, if there be no wind, is suffi- 
cient to produce just the stagnant, hot, 
and moist atmosphere which is so oppres- 
sive to the feelings, and favors so much 
the spread of Cholera. One must not be 
misled by the name of dry months. The 
hot months in Calcutta are called the dry 
months, and are indeed the driest of the 
year, yet a great deal of moisture exists 
dissolved in the warm atmosphere ; abso- 
lutely a greater amount of moisture in the 
air there than in England. In 1853-54 
the atmosphere in England was drier than 
usual, for every month except May and 
December, the rainfall being 18'62 inches, 
or 5'93 less than the average. 
Winds.-The only way in which these 
seem to influence the spread of Cholera is 
when they blow over places charged with 
miasma. It has appeared to prevail in 
certain situations when the air came 
across foul places, as privies, cesspools, 
&c., and shifts of wind have been known 
to have been followed by subsidence of the 
disease. It declined after a hurricane 
which took place in Madras in 1818. In 
Europe there was no fixed relation be- 
tween the quarter from which the wind 
came and the intensity of the disease. 
Though Cholera appears to travel with 
the wind in many instances, it does not 
always do so. Orton reports that it trav- 
elled across a great variety of country 
from the Nerbudda to Bombay, directly 
opposed by a strong wind blowing night 
and day for half the year, at the same 
rate of progress that it passed from Ma- 
dras to Cape Comorin, with the breeze in 
its favor. Absence of horizontal move- 
ment of the air, or a stagnant atmosphere 
in combination with heat and moisture, 
has already been alluded to. 
Electricity - Ozone - Barometric Pres- 
sure.-These have not been found to exer- 
cise any decided influence, or to have 
existed in different conditions during dif- 
ferent epidemics. Most extended obser- 
vations on some of these points, by Mr. 
Glaisher, are to be found in the appendix 
to the Cholera Report for 1853-54, and in 
the Report of the Indian Sanitary Com- 
mission of 1862. 
Much has been written on the influence 
of meteorological states upon the spread of 
Cholera, and there is much confusion and 
apparent contradiction in the results and 
on the inferences drawn. Some connec- 
tion between atmospheric states and the 
epidemics does exist, but it is not that of 
cause and effect. It is very probable that 
heat and moisture, which are so favorable 
to most organic actions and to chemical 
changes, may promote the multiplication 
of the Cholera poison, and that a calm 
stagnant atmosphere may allow of its con- 
centration. We do not look upon heat 
and moisture as the cause of a tree or 
plant; but we find them very influential 
in their developments. Mr. Glaisher's 
observations in concluding his report on 
the Meteorology of London in relation to 
the Cholera epidemic of 1853-54, allude to 
those of 1832 and 1848-49, and show that 
the atmospheric conditions during the pre- 
valence of Cholera are well worthy of 
attentive study. He says: "The three 
epidemics were attended with a particu- 
lar state of atmosphere, characterized by 
a prevalent mist, thin in high places, 
dense in low-during the height of the 
epidemic ; in all cases, the reading of the 
barometer was remarkably high and the 
atmosphere thick. In 1849 and 1854 the 
temperature was above its average, and 388 
EPIDEMIC CHOLERA. 
a total absence of rain, and a stillness 
of air amounting almost to calm, accom- 
panied the progress on each occasion. In 
places near the river, the night tempera- 
tures were high with small diurnal range, 
a dense torpid mist, air charged with 
many impurities arising from the exhala- 
tions of the river and adjoining marshes, 
a deficiency of electricity, and, as shown 
in 1854, a total absence of ozone, most 
probably destroyed by the decomposition 
of the organic matter with which the air 
in these situations is strongly charged." 
"In 1849 and 1854 the first decline of 
the disease was marked by a decrease in 
the readings of the barometer and in the 
temperature of air and water; the air, 
which previously for a long time had con- 
tinued calm, was succeeded by a strong 
southwest wind which soon dissipated the 
former stagnant and poisonous atmos- 
phere. In both periods at the end of Sep- 
tember the temperature of the Thames 
fell below 60° ; but in 1854 the barometer 
again increased, the air became again 
stagnant, and the decline of the disease 
was considerably checked. It continued, 
however, gradually to subside, although 
the months of November and December 
were nearly as misty as that of Septem- 
ber." 
Climate.-We are not in a position to 
estimate the precise value of climate on 
the intensity of the disease. The statis- 
tics of the native populations of India and 
of nations of the Eastern part of the globe 
are not sufficiently well known to enable 
us to compare the virulence of their epi- 
demics with those of Europe. For India, 
we have only the military statistics on 
which we can rely, but they are of too 
exceptional a character to serve the pur- 
pose of the inquiry. Whatever may have 
been the virulence of separate epidemics, 
there is a much greater frequency of the 
epidemic in India' Whereas Cholera has 
visited Europe only twice severely since 
1832, the epidemics are of constant occur- 
rence in some part or other of India. It 
is doubtful whether there is any relation 
between the marsh malaria of a country 
and Cholera. The question of the influ- 
ence of climate will be again referred to 
in the section on mortality and suscepti- 
bility. 
Jyature of the Soil.-Cholera has pre- 
vailed so severely nearly all over the 
world, that it is not likely that the soil 
exerts much influence. Some writers 
have thought that it has been less severe 
on the Laterite foundations, in Madras and 
other places. Dr. Maclelland states that 
stiff clayey soils have had more mortality 
than loose sandy and easily drainable 
ground. Dr. Lorimer found that nearly 
half the epidemics examined took place on 
the black cotton soil. The volcanic for- 
mations of Auvergne escaped in 1842, 
although surrounded with Cholera fields. 
Dr. Farr states that in England it was 
less fatal on the primary geological forma- 
tions than on others. 
Elevation above the Sea Level. -The 
most favored seats of Cholera all over the 
world are places not high above the sea, 
along the banks of rivers, and the estua- 
ries of great streams. In London, the 
lower elevations were most fatal; and as 
the height of the locality increased, mor- 
tality decreased. Doubtless this is not 
from any difference of barometric pres- 
sure, but because these situations gene- 
rally combine so many unfavorable sani- 
tary conditions, as the most moist sub- 
soil, the worst drainage, the least ven- 
tilation and air movement, the most im- 
pure air, and the most dense populations. 
In London and its neighborhood the mor- 
tality was at the rate of 156 per 10,000 in 
the lowest districts, viz., Newington, Ro- 
therhithe, St. George's Southwark, and 
Bermondsey, about the level of the 
Thames; and 15 per 10,000 in the 
highest,viz., Hampstead, Islington, Mary- 
lebone, and St. Pancras. There were 
some exceptions in places in which all 
sanitary conditions were perhaps worse 
than some of the places of a little lower 
level. Cholera is less prevalent in moun- 
tain elevations than on low levels. This 
is the case in the Indian hill stations. 
They have not, however, been exempt 
from severe visitations. Dr. Chevers 
mentions, in his " Review of the Means 
of Preserving the Health of European 
Soldiers in India," that it prevailed in 
1845 at Kussowlie, 6000 feet above the 
sea, and at different periods at Murree, 
Dhurmsala, Darjeeling and Jackatalla, 
6000 to 7000 feet high and in lower eleva- 
tions at Soobathoo, Hazcerabagh, and 
Mabaleshwur, 2000 to 3000 feet above the 
sea. 
Impure Air. - There is abundant evi- 
dence that a foul atmosphere promotes 
the severity of Cholera. For copious 
illustration of this and the numerous 
sources from which the atmosphere may 
be vitiated, the reader is referred to the 
various reports of the Board of Health on 
the occasions of the English epidemics. 
Among others, the evil influence of privy 
emanations has been frequently noticed ; 
and the same evil influence is obvious in 
the Report of the Indian Cholera Com- 
mission for 1861, in the instance of the 
epidemic in the cantonment of Meean 
Meer. On the other hand, it is found 
that in many epidemics some very foul 
and filthy places escape altogether. Thus, 
the filthiest parts of Lahore and Gwalior 
escaped, while the cantonments of Meean 
Meer and Morar, close to these cities, 
were ravaged by Cholera. The immunity 
of the filthy Ghetto at Rome is another 
instance. In some instances places with ETIOLOGY. 
389 
apparently the purest atmosphere did not 
escape, as, for instance, in 1849, the 
healthy parts of Middlesex, Hertford, 
Buckinghamshire and Kent. Neverthe- 
less, in spite of exceptions, the places in 
which the air is most vitiated from pri- 
vies, cesspools, drains, decaying animal 
and vegetable refuse, or overcrowding and 
concentration of human emanations, are 
those in which Cholera has generally been 
most fatal and most widely spread. 
Impure Water.-This, doubtless, plays 
an important part in Cholera epidemics, 
either as a predisposing, or, as some think, 
as an exciting cause. Dr. Snow thought 
that the poison was produced in the ali- 
mentary canal, and existed in the Cholera 
evacuations, and that these, through 
leakage of drains, cesspools, &c. contami- 
nated water, which when drunk commu- 
nicated the disease. Whether this be the 
manner in which Cholera is caused by im- 
pure water or not, it is certain that this 
promotes the spread of the disease. Strong 
evidence of this has been collected by Dr. 
Snow and Mr. Simon. The latter, in his 
report on the last two epidemics of Lon- 
don as affected by impure water, gives us 
a statement of the mortality among the 
consumers of water, supplied by two com- 
panies drawing their water from distinct 
sources, but distributing it in the same 
district, at the same time, and among the 
same class of people ; the pipes of the two 
companies being laid pretty evenly in the 
same areas, in many places running side 
by side in the same streets, and the houses 
supplied pretty equally distributed. The 
Water Companies were the Lambeth 
Water Company and the Southwark and 
Vauxhall Company. The first drew their 
supply at Ditton, above the influence of 
the London sewage and tidal flux, the 
last from the river near Vauxhall and 
Chelsea. The Lambeth supply was tole- 
rably pure, the Vauxhall Company's very 
impure. The deaths in the houses sup- 
plied by the Lambeth Company were at 
the rate of 37 to every 10,900 living ; in 
those supplied by the Southwark and 
Vauxhall, at the rate of 130 to every 
10,000 living. The population drinking 
the foul water appears to have suffered 3| 
times as much as that drinking the pure 
water. This seems to be an experiment 
as free as possible from error ; the popu- 
lation submitted to the test being 400,000 
-500,000 ; the only ascertainable differ- 
ences of circumstances in the two classes 
being in the kind of water supplied. The 
well-known instance of the sickness follow- 
ing the use of the water of a pump in 
Broad Street, Golden Square, affords 
strong evidence of the evil influence of 
water contaminated with cesspool drain- 
age. Dr. Routh attributes the severity 
of Cholera in the winter in Russia to the 
drinking of water from melted snow col- 
lected from the immediate neighborhood 
of dwelling-houses and on which the 
Cholera discharges had been thrown. Im- 
pure water alone will not necessarily pro- 
duce Cholera. There are instances of 
freedom from the disease with bad water 
supply in the same way as there are with 
vitiated atmospheres already mentioned. 
Bad Food.-Mr. Granger, in his Report 
on the Epidemic of 1848-49, says, "Seve- 
ral marked examples were brought under 
my notice where violent attacks of Cholera 
were distinctly traceable to the use of 
putrid fish, bad pickled pork, decayed 
cheese," &c. Dr. Carpenter quotes Dr. 
Brittan as authority for the fact of an 
outbreak of Cholera and Choleraic diar- 
rhoea among a number of school children, 
who had eaten plentifully of spoiled 
oysters, and by which eleven of the suf- 
ferers lost their lives. In the earlier days 
of the appearance of the disease in India 
it was thought that many attacks were 
caused by the eating of diseased rice. I 
remember the case of a gentleman who 
was attacked a few hours after eating 
hermetically sealed fish. In this class of 
causes may be included the noxious effects 
of purgative medicines given during 
Cholera. Numerous Indian writers re- 
cognize the mischief produced by these. 
I believe that this is not confined to the 
saline and hydrogogue purgatives only. 
I have seen milder purgatives followed by 
Cholera. Sir R. Martin and Twining 
caution us against administering during 
Cholera times any purgative medicines 
likely to operate in the early morning; 
i. e., about the time that the first symp- 
toms of Cholera generally commence. 
Regiments marching.-In Madras these 
seem to have been very liable to Cholera, 
as shown by Rogers, Lorimer, and Bal- 
four. From Dr. Rogers's Report on the 
Asiatic Cholera in the regiments of the 
Madras army from 1828-44, this is shown 
both for European and native corps. 
Large bodies or regiments or parties of 
European recruits en route to join their 
corps have suffered greatly. On the other 
hand, treasure parties, consisting of 
smaller numbers of men, from ten or 
twenty to a maximum of 100 or 200 men, 
have suffered little. Thus in the Euro- 
pean corps the ratio of marches attacked 
to marches unattacked has been 23'92 per 
cent.; in the small parties 2'72 per cent.; 
the officers being comparatively exempt. 
Dr. Lorimer's reports go to prove that 
long marches were much more fatal than 
short ones, and that there is a ratio be- 
tween the distances marched and the at- 
tacks. In Madras, in the native troops, 
the attacks were 40 per cent, between 600 
and 800 miles, and 75 per cent, between 
800 and 1250 miles marched. Dr. Rogers 
attributes the difference of susceptibility 
to fatigue, exposure, crowding, and other 390 
EPIDEMIC CHOLERA. 
predisposing causes which act more se- 
verely for reasons shown on large than on 
small bodies of moving troops. The ad- 
herence of Cholera to troops moving seems 
at variance with the beneficial effects so 
often experienced on moving troops out 
of infected cantonments in Cholera epi- 
demics. The difference is probably due 
to there being less fatigue, less crowding, 
better conservancy, and more hopefulness 
and cheerfulness on the part of men leav- 
ing infected cantonments for a short time, 
than in the case of ordinary marches. It 
has been known that a regiment suffering 
severely from Cholera in camp on the 
march has lost it on getting into barracks. 
A remarkable instance of this occurred in 
the case of H. M. 63d Regiment, which 
suffered extremely during the greater part 
of its march from Poonah to Bellary, but 
entirely lost the disease in twro or three 
days after getting into barracks in the 
unhealthy station of Bellary. In this 
case probably extreme heat in tents, over- 
crowding, and fatigue in the month of 
April acted as powerful predisposing 
causes. II. M. 86th Regiment, which suf- 
fered so severely at Kurrachee in 1846, 
had come off a long and fatiguing march 
from Upper Scinde. 
Influeaces belonging to the Individual.- 
Sex.-This has but little influence. In 
London in 1849 the percentage of deaths 
to living was -67 in the male and *65 in 
the female ; in lunatic asylums 6'4 for 
males, and 6'6 for females; the attacks 
8'9 for males and 11'6 for females. In 
India we can depend on the returns of the 
European corps only, and the numbers 
are probably too small to be relied on to 
show the comparative liability of the 
sexes. Ewart's tables give privates 1'74 
per cent., and women 1/58 per cent, ad- 
missions to strength, and among privates 
•70 per cent., and women '50 per cent, of 
deaths to strength. Age.-Mr. Grainger 
states that the liability to fatal attacks 
increases after the age of fifty in both 
sexes; the ages from five to forty-five 
having the lowest comparative mortality. 
In India in 1861 the influence of age was 
hardly perceptible. According to Dr. 
Gull, in England it was most fatal to 
those under one year and over fifty-five, 
corresponding, indeed, with the general 
tendency to mortality in England. 
Residence in India.-It has been thought 
that Europeans of short residence in In- 
dia were more liable to suffer than those 
of long residence, but the opinion does 
not seem to have been formed upon any 
■well-ascertained facts. The Committee 
on the epidemic of 1861 investigated the 
matter forthat outbreak, but they consider 
their data too imperfect for forming opin- 
ions. They say, "We can base no con- 
clusions upon the figures shown in this 
table. The soldiers whose period of ser- 
vice was shortest apparently suffered the 
most. The proportion of deaths to strength 
falls from 7'7 per cent, among men of less 
than two years' Indian service to 3'5 per 
cent, among men who have served more 
than ten years. . . . The proper investi- 
gation of this subject must be left to fu- 
ture observers. It will probably be found 
that the influence exercised by length of 
residence in India upon the liability to 
Cholera is as little important as that of 
the other predisposing causes that have 
been already noticed." 
Previous Health.-Both the strong and 
the weak are susceptible of Cholera. Mr. 
Thom states that some of the most robust 
men of the 86th were struck down at Kur- 
rachee. There are often seen in the Cal- 
cutta hospitals, cholera-stricken, the stout, 
rosy, muscular Affghan, as fine specimens 
of men, in bone and muscle, as can possi- 
bly be conceived. Doubtlessly previous 
debilitating disease influences the mortal- 
ity. It is not so certain that it greatly 
increases the susceptibility, though Dr. 
Morehead mentions that cachectic and de- 
bilitating diseases appeared to have had a 
strong predisposing effect on the attacked 
in the hospital at Bombay. Scurvy and 
diarrhoea have probably some predisposing 
influence. In Dr. Gull's report it appears 
that little predisposition was caused by 
previous disease, and Dr. Gairdner men- 
tions that the post-mortem examinations 
in Edinburgh showed very little disease 
in the bodies of those who died there of 
Cholera. In India, in 1861, the sick in 
hospital furnished 13'5 per cent, of cases 
to strength, while the men in barracks 
afforded but 4'7 per cent. ; but there were 
probably other causes than mere predis- 
position at work in this instance. 
Habits.-I believe that these have less 
influence upon the susceptibility to Chol- 
era than has been supposed. Persons in 
whom habits of intemperance have estab- 
lished organic disease of liver or kidneys 
may be less liable to recover when at- 
tacKed, but the real degree of susceptibil- 
ity engendered by intemperance has not 
been completely ascertained. In India in 
1861 the intemperate were more subject 
to attacks than the abstemious, but their 
chance of recovery in the attack was bet- 
ter. However, the numbers tested were 
small. 
[In the United States, if not elsewhere, 
it was well proven in 1832-3, 1849-50 and 
1854, that, whether more or less suscepti- 
ble than others to Cholera, drunkards 
were more likely to die from it than any 
others.-II.] 
Occupation.-This seems to produce no 
special liability ; but of course those which 
expose the individual to unhealthy influ- 
ences and residence may increase his risks. 
Thus the privates and non-commissioned 
officers of regiments suffer more than the ETIOLOGY. 
391 
officers. Fatigue, want, grief, fright, have 
doubtless some degree of predisposing in- 
fluence, though it would be difficult to 
estimate the amount in figures. Of these, 
fatigue is probably the most injurious. 
Probably most of the causes mentioned 
above may be considered as predisposing 
causes. Impure air and water may con- 
vey the exciting cause, but this will be 
presently referred to. None of these in 
themselves appear to be sufficient to pro- 
duce Cholera, though they may all render 
it more fatal. The existence of all the 
conditions mentioned, both before and 
after Cholera epidemics, without produ- 
cing the disease shows that some special 
agent or cause must be present to give 
rise to it. Before entering upon the ques- 
tion of this specific cause it will be well to 
mention some points in the natural his- 
tory of Cholera not yet spoken of. 
Health of Communities before and during 
Cholera Epidemics.-In Europe a preva- 
lence of several zymotic diseases has been 
noticed in these periods ; particularly ty- 
phus fever, influenza, and diarrhoea. The 
increase of fluxes was so great previous 
to the outbreak of 1848 that Cholera in 
England was looked for long before its 
arrival. There was also an increase of 
typhus fever. Dangerous and fatal in- 
fluenza preceded the epidemics of 1832 
and 1848. Diarrhoea is constantly pres- 
ent during Cholera. In London, for the 
quarter ending September 30, 1849, not- 
withstanding the large mortality from 
Cholera, the deaths from typhus fever 
were nearly equal to those of the four 
preceding corresponding periods; them- 
selves of remarkably high mortality. In 
India, diarrhoea constantly prevails dur- 
ing epidemics, but the precedence and 
concurrence of other zymotic diseases is 
not so well made out. Cholera, how- 
ever, does not seem to banish them. 
From the above we seem justified in 
inferring that circumstances similar to 
those which favor Cholera'promote also 
the spread of the other zymotic diseases. 
Limitation of Areas of Cholera. - This 
is sometimes singularly abrupt. It has 
been known to attack persons on one side 
of a street, of a camp, or a town, only. 
In 1848-49 it attacked one side of a small 
village in Argyleshire, and confined itself 
exactly to one side of the town, which 
consisted only of one main street, divided 
into two equal parts by a toll bar, beyond 
which to the west not a single case oc- 
curred, though the inhabitants were in 
constant intercommunication. Dumdum, 
seven miles from Calcutta, often suffers 
severely, while Calcutta does not, and vice 
versa. One part of a ship may suffer and 
the other not. A wing of a building may 
be ravaged while the rest escapes. The 
limitation to districts is sometimes re- 
markable, and was shown in the case of 
the 9th Lancers on its passage up the 
Ganges in 1842. The regiment travelled 
in boats, by wings, and at separate times. 
When the left wing reached Monghir, 
although there had been no communica- 
tion with the shore, Cholera broke out in 
it, and continued with the detachment for 
about twelve days, until it had got beyond 
the infected districts. When the right 
wing reached Monghir, it, also, was at- 
tacked, and lost the disease exactly at the 
same place that the other did. The lim- 
ited area of infection lias been tested by 
the good effects of moving troops into 
camp when suffering from the disease. 
Numerous instances of this are on record ; 
among the latest some are afforded in the 
Cholera Commission Report for the out- 
break of 1861. A move of a few miles is 
generally sufficient. 
Mode of Invasion of Localities.-We find 
that both in India and Europe it is often 
preceded by diarrhoea, sometimes for 
months, as in England previous to the 
outbreak of 1849. Then a few cases of 
Cholera appear, and in a short time the 
epidemic sets in severely. At other times 
the extreme violence shows itself rapidly 
and suddenly after the prevalence of a 
few cases for a few days, as at Kurrachee. 
Of this outbreak Mr. Thom says: "It 
suddenly burst forth in a few hours in 
every European regiment, whether in 
camp or in barracks, in every tent or in 
every house, and it was at its acme in 
forty-eight hours afterwards, when in- 
stead of spreading further it gradually 
and steadily declined. Now, it appears 
that for some days or even weeks a few 
cases had appeared in the native town of 
Kurrachee, but there also, at the same 
period, the malady became suddenly gen- 
eral over the whole place." In Paris, in 
1832, Dr. Baly relates, that in eighteen 
days from its commencement it had 
reached its climax, and had already ex- 
tended to all the quarters of Paris, and 
had been fatal to 7000 people. In Lord 
Hastings's camp in 1817, 5000 people died 
within the first five days of its appear- 
ance. 
Departure of Cholera Epidemics.-These 
often leave a place rapidly, sometimes 
after sudden atmospheric changes. At 
Dumdum, in 1859, Dr. Hugh Macpherson 
reports that a violent outbreak occurred 
and carried off one-sixth of a detachment 
of recruits and their families in ten days, 
confining itself entirely to the barracks; 
it then disappeared as suddenly as it 
came. In the 2d Madras Europeans, as 
before mentioned, the disease continued 
for a month in hot and sultry weather, 
and disappeared, also, as suddenly as it 
came. The occasional sudden departure 
after high winds and storms has been 
already alluded to. Generally the decline 
of Cholera is more gradual, the intensity 392 
EPIDEMIC CHOLERA. 
of the mortality diminishes, the recoveries 
to attacks are more numerous, and finally 
the disease disappears. In England in 
1848-49 the epidemic was about three 
months from the commencement of its 
decline to its final disappearance from the 
country; having prevailed about sixteen 
months. Cholera is apt to leave a place 
for a time, and then return to it, and be 
as severe on its second as on its first visi- 
tation. In 1848-49, Cholera prevailed 
slightly at Sunderland from October to 
January, was absent for a month, re- 
turned with severity, subsided for two 
months, and returned a third time with 
still greater violence. The epidemics do 
not break out simultaneously all over a 
country, but there is, nevertheless, often 
the beginning of the disease in several 
distant places at the same time ; thus, the 
epidemic of 1848-49 first showed itself on 
the same day in Edinburgh, Sunderland, 
and Hounslow. It broke out at Malta, 
Palermo, and Gozo at the same time. It 
appears that Cholera epidemics have a 
tendency to reach their climax over large 
areas at about the same time. Dr. Baly 
states that the period of the greatest in- 
tensity of the epidemic of 1848-49 was, 
in the majority of cases, in August and 
September; thus, of 226 places affected, 
61 suffered most in August and 118 in 
September, or 179 out of 226, in those 
two months. Also that in large towns or 
cities there was the same general ap- 
proach to simultaneousness, as appeared 
in a comparison of different counties and 
of different towns one with another. Oc- 
casionally in epidemics a smaller climax 
is noticed, and there also is a simultane- 
ousness in the period of this ; that for 
1848-49 was in January, 1849, when a de- 
cline in the intensity of the disease took 
place pretty generally. 
Cholera does not spread uniformly over 
a large area or country ; it seems rather 
to spread from certain centres first at- 
tacked, often passing over places in its 
apparent course, and perhaps subse- 
quently invading them. Some places in- 
deed, although in the track, escape alto- 
gether. It has a tendency, even after 
long intervals, to return to certain haunts 
in the same towns; thus, certain places 
which suffered greatly in 1832 were equally 
attacked in 1848-49, and some remarkable 
coincidences occurred in illustration. It 
has happened that the very first house 
invaded in 1832 gave the first cases in 
1848. 
Protection by previous Attacks.-These 
do not appear to confer any immunity ; 
there are numerous cases on record of 
persons who have had Cholera more than 
once. Some writers have speculated upon 
the susceptibility of individuals being 
diminished by long exposure to Cholera 
atmospheres without being attacked. The 
opinion does not seem to rest on any good 
foundation. 
Channels of Introduction into the System. 
-Being ignorant of the nature of the 
poison, we cannot well say how it enters 
the blood ; it probably enters through the 
respiratory or intestinal surfaces. 
Incubation.-It seems that this may be 
very short for many cases ; perhaps two 
or three days, or even less. Of course if 
we include the Choleraic diarrhoeas and 
those cases which show other preliminary 
disturbances, mentioned hereafter, we 
must allow a much longer time. In the 
case reported by Dr. Barry, and referred 
to in the paragraphs on Contagion, the 
period of incubation does not seem to have 
exceeded forty hours. When Cholera 
breaks out in ships at sea several days 
after leaving port, the attacks are proba- 
bly due to freshly acting causes. [Espe- 
cially when (as happened with a number 
ot vessels in 1849-50 between Europe and 
America) the outbreak commences upon 
a vessel which has been as much as ten 
days or two weeks from land, and when 
no Cholera existed at its port of departure, 
the only rational explanation is that the 
Cholera cause, being migratory indepen- 
dently of human transportation, was pre- 
sent in the atmosphere through which the 
vessel passed in its voyage. One of the 
Copes' line of packet ships between Liver- 
pool and Philadelphia was so attacked at 
sea in 1850. On the day on which the 
greatest number of new cases and deaths 
occurred, a large iceberg came in sight, 
lowering the temperature many degrees. 
From that time the Cholera on board 
ceased ; no new cases occurred.-II.] 
Mortality to Populations.-This varies 
for different epidemics and in different 
districts. In 1848-49, in Dr. Baly's re- 
port, we find that the deaths were 30 to 
every 10,000 living in England and Wales. 
This mortality was not evenly distributed : 
the inland districts giving 17 per 10,000, 
and the coast* districts 50 per 10,000, and 
404 districts 7 per 10,000, and 85 districts 
in which there were none. The denser 
the population to the square mile, the 
greater the comparative mortality; thus 
a population of 915 to the square mile 
gave 65 deaths per 10,000, and 235 inhab- 
itants, 7 per 10,000. In India among 
the European troops, according to Ewart 
the deaths to strength of the men for 7 
years was annually 0-70 per cent.,.or 70 
per 10,000 ; of the officers, 0T2, or 12 per 
10,000. It is not possible to ascertain 
what is the mortality of the native popu- 
lation of India fro in Cholera or any other 
disease. The susceptibility of populations 
is very difficult to ascertain, because a 
large number of attacks not fatal are 
never reported, and therefore, except in 
the case of troops, no reports are to be 
depended on. In India, Dr. Ewart places 393 
ETIOLOGY. 
the liability of European troops to attack 
at 174 annually per 10,000 for the men, 
and 73 annually per 10,000 for officers. 
In India the percentage of attacks is much 
higher for European than for native 
troops. The Cholera Commission has 
shown that the native prisoners in gaols 
have a liability nearly the same as the 
European troops. 
Diffusion of Cholera.-This is of the 
greatest interest. Setting aside for the 
present the question of contagion, it will 
be well to consider the facts of the diffu- 
sion of Cholera by human intercourse. 
From the mass of evidence on this point, 
it is impossible to doubt that in many in- 
stances it has been spread, in some man- 
ner, by such means. Dr. Barry, in the 
Indian Annals, for 1854, relates that Chol- 
era made its appearance in the military 
hospital, at Gowalparah, on the 27th 
April, and that several cases afterwards 
occurred. The first case was that of a 
sepoy who had just arrived with a detach- 
ment from Gowhatty. Now, there was 
no Cholera at Gowhatty when he left, and 
none at Gowalparah when he arrived; 
but the whole detachment had, forty 
hours before, passed through a place 
called Palasbarree, where it was raging. 
It is supposed that the sick man brought 
the disease with him from thence. It 
spread, but not fast, and the first cases 
which occurred at Gowalparah were from 
those who passed through Palasbarree,. 
their comrades who waited upon them in 
hospital, and the sick soldiers in the hos- 
pital into which they were received. The 
dispersion of the children of the Tooting 
school on account of the fearful outbreak 
of Cholera among them, in 1848, was at- 
tended with attacks and deaths among 
the children removed, and seizures among 
the inmates of some of the establishments 
into which they were received, although 
there was at the time no Cholera in the 
institutions or surrounding neighborhood. 
In the Report of the Indian Cholera Com- 
mittee on the epidemic of 1861, some re- 
markable facts are stated with reference 
to the introduction of Cholera into Gur- 
whal and Kumaon in 1852. The Report 
says, " The districts of Kumaon and 
British Gurwhal lie entirely within the 
Himalaya mountains, on the borders of 
Rohilcund. They cover an area of 12,000 
square miles. The population is very 
scanty, scattered for the most part in 
small villages, which are often separated 
from one another by vast mountains and 
tracts of forest. These districts are cut 
off from the plains of Northern India by 
an uninhabited belt of forest, and by the 
swampy and almost deserted region called 
the Terai. These tracts, some twenty 
miles in breadth, effectually cut off the 
inhabitants of the mountains from those 
of the plains. The intercourse between 
them is at all times very little, and con- 
fined to a few particular lines leading to 
places of pilgrimage or trade. Cholera is 
generally as completely absent from these 
mountains as from any part of Europe, 
but it has occasionally spread among 
their inhabitants epidemically with great 
violence." Mr. J. Strachey, C.S., the able 
president of the Cholera Commission, for- 
merly in civil charge of the Hill District 
of Gurwhal, mentions the following facts, 
which occurred under his own immediate 
observation : "In the early part of 1852, 
extensive works of irrigation were in pro- 
gress at the foot of the mountains in 
Kumaon, in the Bhabur" (the strip of 
forest land which divides the mountains 
from the plains), " of which Mr. Colvin 
has spoken in his note. Several thousand 
workmen were collected there from all 
parts of the neighboring hill. Cholera 
broke out among these people with great 
virulence, and they fled panic-stricken to 
their homes, which were generally at a 
distance of several days' journey in the 
interior of the hills. Up to this time 
Cholera had been unheard of in Gurwhal, 
or in any part of the neighboring moun- 
tains. This is a fact which was carefully 
inquired into and thoroughly ascertained. 
Many of the workpeople who had fled 
from the Bhabur died upon the way to 
their homes ; many others were attacked 
when they reached their villages. Then 
Cholera broke out among the other in- 
habitants of the villages, commencing in 
very many instances in the families of the 
men who had brought the disease from 
below. For a considerable time Cholera 
was entirely confined to places which had 
been in direct communication with per- 
sons suffering from the disease, but in the 
course of a few weeks it had become im- 
possible any longer to trace such connec- 
tion, and Cholera became generally epi- 
demic in the hills. Many of the first cases 
were carefully investigated ; it appeared 
to be proved, beyond the possibility of a 
doubt, that in many instances Cholera 
had never been heard of in the villages 
until the arrival of the men from the 
Bhabur, who were the first attacked by 
it There were no other circum- 
stances that could be discoverefl which 
appeared to throw even the possibility of 
doubt upon the fact that Cholera was 
brought by human intercourse into a dis- 
trict which, up to that time, had been 
perfectly free from every sign of the dis- 
ease. "' There are other instances brought 
forward by Mr. Strachey, communicated by 
Mr. B. W. Colvin, C.S., and Dr. F. Pear- 
son, Superintendent of Vaccination in Ku- 
maon, and to these the reader is referred. 
[' Yet, since the epidemic migrates, why 
should it not, per se, reach "the hills" later 
than the lower villages ?-H.] 394 
EPIDEMIC CHOLERA. 
Although it is probable that Cholera is 
spread by human intercourse, it is indis- 
putable that it originates in places without 
it being possible to trace any previous 
communication with infected persons. 
This has happened over and over again in 
towns and large establishments in which 
the outbreaks, after the greatest persever- 
ance, could not be accounted for by any 
previous exposure to infection. Its ap- 
pearance at St. Kilda, in the Western Is- 
lands of Scotland, is as strong an instance 
as can be given. This island was cut oil 
from all communication with the main- 
land, and yet the disease appeared in it 
suddenly without a trace of importation. 
In 1848, Dr. Parkes could not trace any 
contagious origin for the first cases occur- 
ring in London. 
Contagion of Cholera.-The fact of the 
diffusion of Cholera by human intercourse 
leads us to inquire how this operates, and 
to the question of the Contagion of Cholera. 
Diffusion by contagion does not negative 
the possibility of an origin independent of 
infection. The majority of medical men 
in India, accustomed to see Cholera year 
after year, to be in constant intercourse 
with the Cholera sick, and to see the gene- 
ral immunity of hospital attendants and 
of themselves, doubt the contagiousness. 
Some physicians, however, think differ- 
ently. It does not seem proved that con- 
tagion can exist in the shape of a volatile 
poison emanating from the sick and rapidly 
infecting the health. It would not be so 
easy to disprove that there may not be 
some form of poison which may not be 
volatile, or which may require time to be- 
come so, or to develop its poisonous pro- 
perties and capability of infection. A 
volatile poison, at all strong in its action, 
would be most dangerous to all about the 
sick, and yet in India the medical men, 
nurses, hospital coolies, sweepers, and 
others who are constantly engaged about 
the sick, do not appear to be more liable 
than the rest of the population. The dis- 
ease seldom spreads from bed to bed in a 
ward ; on the contrary, when people are 
attacked in hospital they lie generally in 
a distant corner, or in another ward. I 
have noticed this over and over again; 
and though I have been connected with 
the large hospital of the Medical College 
at Calcutta for many years, Ido not recol- 
lect any spreading to the nearest or neigh- 
boring patients. I should, as far as my 
own experience goes, say that Cholera 
does not spread from the sick to the whole 
by any rapidly acting emanation. Dr. 
Morehead's observations support the view 
of the non-spreading of Cholera in hospi- 
tals through contagion. They were care- 
fully conducted through three epidemics 
in Bombay; and though he refrains from 
drawing positive conclusions, his facts are 
not in favor of contagion. His observa- 
tions will be found in his valuable Clinical 
Researches on Diseases in India. Sir 
Ranald Martin states, that of the five na- 
tive keepers and washers of clothes of the 
Calcutta European General Hospital, who 
during twenty-five years had kept and 
washed all the hospital clothing, not one 
had Cholera, nor had those who assisted 
them. The same may be said of the 
dressers and sweepers. In England, in 
spite of some suspicious instances, the 
washers of soiled linen and bedding do 
not seem to have suffered out of propor- 
tion to others. In Dr. Baly's report, he 
analyzes the reputed cases of contagion 
from this cause, and shows that out of 
thirty-five reported cases seven only seem 
to support the contagion theory. It is re- 
markable that the washers of large collec- 
tions of linen, soiled by Cholera patients, 
in many large hospitals, did not suffer 
seriously in 1849. Dr. Waller Lewis's re- 
port to the Board of Health, in 1849, 
shows the error of the assertions of conta- 
gion as regards the case of a number of 
washerwomen reported to have caught 
the disease by washing soiled linen, and 
whose cases he personally investigated. 
Against the foregoing may be quoted 
the cases reported by Dr. Barry before re- 
ferred to ; also the Report of the Commit- 
tee of 1861, which records that, as far as 
that epidemic was concerned, the patients 
in hospital did suffer more than their pro- 
portion of attacks. Out of hospital the 
cases to strength were 4'7, the deaths to 
strength 2*9, and deaths to treated 62'7 
per cent. In hospital, among patients, 
the cases to strength were 13'5, the deaths 
to strength 10'6, and the deaths to cases 
78'5 per cent. This applies to the whole 
of the troops attacked with the epidemic 
in thirteen stations, omitting Meean Meer 
and Morar, in which the proportions were 
higher than the above. Including these 
stations, the cases to strength were 14'7, 
the deaths to strength 11'6, and the 
deaths to cases 79'2 per cent. So that it is 
remarked by the Commission that "the 
virulence of the disease among hospital 
patients was clearly more than twice as 
great as it was among the healthy strength 
of the regiments." The medical officers 
escaped entirely, and subordinate medical 
establishments, which in such epidemics 
may be said almost to live in the hospital, 
and the hospital servants, who must have 
been much more in immediate contact 
with the sick than the patients were, suf- 
fered but slightly; and of thirty men of 
the 31st Native Infantry sent daily to at- 
tend the sick from the 24th of August, 
when the epidemic was at its height, not 
one was attacked. It is not very easy to 
explain these discrepancies and the differ- 
ence between the spreading in hospital in 
this and other recorded epidemics. As 
regards the comparison with the men out ETIOLOGY 
395 
of hospital, there may have been some- 
thing in the situation of the hospitals 
themselves to account for the disease 
spreading so much in them. It appears 
that in several instances the epidemic 
broke out first in them. It is possible 
that the number of patients exposed was 
too small to render the inferences drawn 
from their suffering free from fallacy. 
The returns of the particular regiments 
show that the greatest excess of difference 
was in those in which the patients in hos- 
pital were small, say 3 to 20. The ratio 
in those in which were the two largest 
numbers, viz., 113 and 117, was different; 
one being above and one below the num- 
bers attacked in the lines. 
Infection does not seem to have arisen 
from the dead body, if one may judge 
from the impunity with which an immense 
number of post-mortem examinations 
have been made in most places, and the 
contents of the intestines submitted to all 
kinds of examination. Drs. Mackintosh, 
Aitken, Gairdner, and others bear testi- 
mony to this. 
Portability of the Cholera Poison.-A 
strong instance of this is related by Dr. 
K. Mackinnon in his work on Public 
Health, &c. "A regiment proceeding by 
water down the country had the disease 
badly. It met a corps coming up the 
country, with which it exchanged boats : 
the disease stuck to the boats, left the 
corps it first affected, and attacked the 
new regiment which had a clean bill." 
The breaking out of Cholera in ships 
many days at sea seems also to show that 
the poison may be carried.1 This does 
not necessarily imply that it was thrown 
off by a diseased individual. For aught 
we know, the poison in any district may 
adhere to surfaces of any kind, and be 
carried about or remain attached to walls, 
&c., until fitting circumstances call it into 
action. When attached to movable sur- 
faces, it may be transported to distant 
places, and be one of the means of diffu- 
sion through human intercourse. We 
have no knowledge of the period of the 
disease at which contagious emanations 
from the sick, if there are such miasms, 
are evolved. Those who believe that the 
poison is to be found in the evacuations 
would consider it to be given off with the 
rice-water stools. Dr. W. Budd informed 
me of a case which, he thinks, bears upon 
the question of the possibility of infection 
in the convalescent stages. A gentleman 
was attacked with Cholera in London, 
and in early convalescence came down to 
Bristol, and was nursed by his mother, 
with whom he lived in a very airy, open, 
and elevated part of Bristol. In three or 
four days the lady was attacked and died. 
There was no Cholera in the neighbor- 
hood at the time, though there was some 
in distant parts of Bristol. 
Of late years Dr. William Budd, of 
Clifton, has advocated the contagiousness 
of Cholera through the medium of the 
intestinal discharges. His propositions 
are these: 1st. That the disease is es- 
sentially contagious or communicable; 
and 2d. That it is disseminated, as he 
believes, exclusively by the liquid dis- 
charges from the intestinal canal of 
Cholera patients. Dr. W. Budd believes 
that the poison is rapidly multiplied in 
the human body, and that the rice-water 
discharge contains the product of this 
multiplication and becomes a source of 
infection, so that from one Cholera pa- 
tient virus enough may arise to propagate 
the disease to numerous persons. He 
considers that the poison may be dissemi- 
nated in the following principal ways: 
1st. By the soiled hands of attendants on 
the sick, a mode of communication which 
is probably very common within the 
limits of the family circle ; 2d. By means 
of bed and body linen, and other articles 
tainted with the rice-water discharges; 
and 3d. Through the medium of the soil, 
which, as the discharges are liquid, neces- 
sarily receives the great bulk of them. 
Dr. W. Budd thinks that from these 
places of deposition the poison may spread 
itself by rising into the air with the pro- 
ducts of evaporation, by percolating into 
drinking water, or by atmospheric disper- 
sion, in the form of impalpable dust, after 
it has passed into the dried state. He 
considers that it is a disease which infects the 
ground. He contends that the poison 
may be preserved for months or years in 
a dry state, in the same way that the 
germs of fungi or infusoria may be, and 
that they may in favorable conditions be 
brought into activity, and being received 
into the human organism, after a very 
short incubation produce the disease, and 
by multiplying with enormous rapidity 
provide sufficient material for extensive 
infection. On the other hand, he thinks 
that in unfavorable circumstances the 
germs may as rapidly decay and become 
extinct, and that thus an epidemic may 
end. In short, Dr. W. Budd imagines 
germs capable of preserving a permanent 
dormant vitality with susceptibility of 
immense power of reproduction in the 
living body, and liable to rapid decay 
when placed in unfavorable circum- 
stances. These views are very simple; 
they are by no means far-fetched or be- 
yond the analogy of other epidemic dis- 
eases, and have been received with great 
respect in England. They are supported 
by strong evidence, mainly of this nature : 
Cholera lias been known to rage violently 
among, and to be confined to, one sex, in 
[' Reason has been given, on a previous 
page, for a different interpretation of these 
facts.-H.] 396 
EPIDEMIC CHOLERA. 
establishments containing both male and 
female inmates under the same roof, 
separated from each other merely by walls 
or partitions, and breathing the same air, 
eating the same food, and drinking the 
same water ; the only difference between 
them being in the use of separate privies ; 
the contamination of one of these privies 
by discharges thrown into it from the first 
case explaining the reason of the differ- 
ence of suffering in the two sets of per- 
sons. 
Although, according to Dr. W. Budd's 
view, Cholera is contagious, it is so in a 
very different form and manner than if it 
were so by means of a volatile or gaseous 
emanation proceeding from the sick. 
Doubtlessly it explains the diffusion of 
Cholera in a more satisfactory way than 
the ordinarily received notion of a conta- 
gious poison, and after the facts brought 
forward by him it would be wrong to neg- 
lect the practical application of their 
teaching. I think, however, that more 
evidence is required before it can be 
held to be proved that the specific excit- 
ing cause of Cholera is to be found in the 
discharges only. The theory will hardly 
explain all the phenomena of the spread 
of the disease in all cases. Take, for in- 
stance, the rapid appearance of the dis- 
ease in the Second Madras Europeans, 
mentioned by Rogers ; its rapid diffusion 
at Kurrachee, in 1846, and in Paris, in 
1832, as before stated ; or such a case as 
this, mentioned in Jamison's report; in a 
cantonment perfectly free from disease, 
ten men of the same regiment were 
attacked in a single night, and every case 
proved fatal-no fresh case happening in 
the corps or any other. It is not to be 
supposed that these men were the only 
susceptible persons in the whole regiment. 
It may be difficult to account for the out- 
break on any theory, but not less so on 
Dr. W. Budd's than on any other. It ap- 
pears unable to account for the manner 
in which Cholera becomes milder in the 
decline of an epidemic. The deaths to 
cases are much diminished. We should 
expect that as the epidemic advances the 
virus would be more in quantity, more 
concentrated, more virulent; but such is 
not the case. The susceptibility in the 
population remains to a considerable ex- 
tent, because numerous cases occur, but 
they are milder. We should expect that 
the virulence of the disease would go on 
increasing until the susceptible people 
were quite exhausted. Some other expla- 
nation than decay or partial decay of the 
Cholera germs seems needed. The regu- 
larity with which, over wide areas, 
Cholera epidemics advance, and the 
simultaneousness with which they attain 
their maxima and their decline, seem to 
imply some general law, and not a diffu- 
sion dependent upon the chances of fecal 
contamination only. I think that those 
who have been in the habit of seeing 
much of Cholera will not be inclined to 
think that there is much potency at all 
events in the fresh Cholera discharges. 
It has been my lot, in numerous epi- 
demics, to see many cases at a time, and 
for a long time in my own wards ; to see 
the beds, the sheets, the hands, of attend- 
ants, the floors, frequently-nay con- 
stantly-soiled with discharges : to see the 
utter impossibility of providing fresh beds 
and fresh blankets, &c. for every case ; to 
see abundant opportunities for the diffu- 
sion of the poison from the discharges; 
and yet, as mentioned under the head of 
contagion, not to see Cholera spread in 
the wards. If fresh Cholera discharges 
were so virulent, every bed next to a 
cholera-bed would be a bed of the disease ; 
every bed and metal bed-pan would be a 
source of Cholera to every succeeding pa- 
tient. My own observation is that no 
such evil results. The hospital sweepers, 
whose special duty it is to remove all the 
discharges, do not suffer out of proportion 
to others. Dr. Baly's report on this point 
has been already referred to. It may be 
that decomposing Cholera discharges may 
be more mischievous, as has been sup- 
posed by Pettenkofer. If, as supposed by 
Dr. Budd, the poison is multiplied so 
rapidly in epidemics as to suffice for the 
rapid diffusion which takes place in severe 
epidemics, it ought to be equally power- 
ful when under observation in a sick 
ward. The mode in which Cholera 
spreads in wet weather in India seems 
adverse to its diffusion by the discharges. 
In dry weather, with a strong wind, it is 
easy to suppose that the Cholera dust may 
be spread to a considerable distance ; but 
in the rains of the tropics and bordering 
countries we cannot trace this mode of 
diffusion. All matter infecting the ground 
must be swept away in the violent falls, 
to which English rain is but a trifle ; it 
would, one would suppose, be diluted and 
swept away into rivulets and streams, and 
ultimately into great rivers. Sometimes 
it might overflow tanks, but in many parts 
of Upper India the drinking water is taken 
from deep wells ; and where there are 
tanks, the Hindoos especially are careful 
to keep them pure, so that it is not so 
probable as may be supposed that they 
are often contaminated. And yet it is in 
the rainy seasons of the Northwest Pro- 
vinces that the severest Cholera epidemics 
have raged. Although the specific poison 
of Cholera may not exist in the rice-water 
stools, it must be admitted that Dr. W. 
Budd has brought forward strong evidence 
in support of his views, and the facts 
which he adduces can, in the present 
state of our knowledge, be explained only 
upon the supposition that the evacuations 
of Cholera patients have, in some state or ETIOLOGY 
397 
other, an influence upon the spread of 
Cholera. There are yet many points that 
require elucidation to prove that the 
Cholera poison multiplies in the human 
body, though perfectly in accordance with 
the cases of many other epidemic diseases, 
so that the specific agent is contained pur 
et simple in the rice-water stools. It would 
seem that they are the congenial soil for 
the multiplication of the poison, rather 
than the direct source. It would be a 
good thing for mankind that Dr. W. 
Budd's views should prove correct. It 
would then be a comparatively easy thing 
to prevent the spread of the dire pesti- 
lence. 
[In the absence, however, of any con- 
clusive proof of the correctness of those 
views, it is unfortunate that they should 
have met with so large an acquiescence as 
they have, in England and America, East 
Indian medical authorities do not sustain 
them; in Germany Pettenkofer has op- 
posed them, and in France they are, at 
least, not generally accepted. The disad- 
vantage of maintaining, without proof, that 
the stools of Cholera patients only convey 
the "contagium" of the disease, is,that 
the attention of sanitarians and the gene- 
ral public is thus diverted from the need- 
ful care of other excretions and material 
of organic decomposition, all of which is 
promotive of the spread of Cholera.-H.] 
Cryptogamic Theories of Cholera.-■ 
Chemical analysis of the air has thrown 
no light on the cause of Cholera. It is 
possible, however, that prolonged micro- 
scopic examination of strained air, as in 
the method of Pasteur, might be more suc- 
cessful. Dr. Cowdell has advocated the 
cryptogamic origin of the disease. Dr. 
Britton made some careful examinations 
of air collected by an apparatus from 
Cholera rooms, and discovered therein 
some bodies which resembled others found 
by Dr. Swayne and himself in the rice- 
water discharges, and by Dr. W. Budd in 
the water of districts infected with 
Cholera. These were afterwards shown 
by Mr. Busk to be starch-granules, and a 
species of uredo or blight. Mr. Rainey, 
Dr. R. D. Thomson, and Dr. Hassall ex- 
amined the air in the epidemic of 1853- 
54. The two former made an extensive 
series of observations at St. Thomas's 
Hospital. Although all these observers 
found organic forms in abundance, they 
did not discover any special cause for 
Cholera in those organisms. Neverthe- 
less, there seems much that is attractive 
in the cryptogamic theory of the disease, 
and the whole subject derives additional 
interest from the late researches of Pas- 
teur. Valuable information on this sub- 
ject might be afforded by investigations 
made in India during the presence and 
absence of Cholera epidemics. The 
writer of this has often regretted that he 
never had leisure to undertake such inves- 
tigations. Many of the phenomena ob- 
served during the march of Cholera epi- 
demics might be explained much more 
satisfactorily upon the supposition of the 
exciting cause being masses of organisms 
moving in obedience to atmospheric im- 
pulses and currents, than by most other 
theories. They might multiply wherever 
they found a fitting nidus, which might 
be in privy atmospheres, or in air abound- 
ing in emanations from decaying and 
putrefying matter, or in crowded rooms, 
and indeed, all vitiated atmospheres. 
They might appear to impart an infecting 
character to the choleraic discharges by 
multiplying enormously in them. 
[Klob cf Vienna, Thome of Cologne, 
and Hallier of Jena, have asserted the 
discovery of peculiar fungi in the stools of 
Cholera patients. Hallier ascribes the 
Cholera fungus, which he calls urocystis, to 
the rice plant as its first habitat. Assistant 
Surgeon T. R. Lewis, of the British army 
in India, in a careful investigation of the 
subject, failed to find confirmation of Hal- 
lier's theory. It has been opposed, also, 
by Berkeley, the eminent cryptogamic 
botanist. Loesch of St. Petersburgh, ob- 
served multitudes of cercomonads in Cho- 
lera discharges. Possibly, the presence in 
extraordinary numbers, of minute organ- 
isms not specific or peculiar, may become 
a morbific cause : as trichinae, which are 
almost or quite innocent while few in 
number, produce fatal derangement of the 
system when they accumulate in millions. 
Even if specific organism causative of 
Cholera be not discovered, since it is con- 
ceivable that it may be ultra-microscopic 
in minuteness, we may still hold the view 
that, for this and analogous diseases, the 
"germ theory" has in its favor a large 
preponderance of probability.-H.] 
After allowing all possible latitude to 
the dissemination of Cholera by human 
intercourse, which may include the diffu- 
sion by gaseous emanations acting directly 
through the atmosphere, or through fo- 
mites, or the diffusion through the Cho- 
lera evacuations, it appears that we are 
still unable to explain all the facts of its 
origin in a place, and its spread over the 
land. Summarily we may say that we 
shall still want an explanation of those 
facts which show that Cholera will arise 
without the possibility of tracing any com- 
munication with the sick, or with fomites 
or choleraic discharges. It cannot be said 
that the supposition of a poison, cloud, or 
miasm, spreading through the land, will 
account satisfactorily for all the pheno- 
mena, either such as its strange limitation 
to certain areas, or its passing over a town 
on its apparent track, leaving it un- 
scathed, or nearly so, to show itself vio- 
lently in some place beyond the town so 
spared. The only way in which this ca- 398 
EPIDEMIC CHOLERA. 
pricious action could be accounted for, 
would be on the supposition of clouds of 
matter or of fungi or infusoria, limited in 
their spread by atmospheric currents, 
sometimes compressed into vertical strata 
and touching the earth in a thin line or 
belt only, or lifted upwards by some up- 
ward atmospheric movement, and thus 
being above the places passed over. But 
though it would be possible to conceive 
this mode of progression of a mass of 
organisms obeying the impulses of the 
atmosphere, yet no such organisms have 
been hitherto demonstrated, and, indeed, 
the progress of the disease against strong 
periodical winds would seem to oppose 
the view. May it not be a mistake to 
consider the specific cause at all as a sim- 
ple body, either generated from without, 
and air-wafted to a particular spot, and 
then multiplying itself indefinitely, or as 
a locally-generated agent, and spreading 
over certain areas ? Might it not be more 
in accordance with facts to suppose that 
neither a miasm from without, nor a 
miasm from within, exclusively contains 
the specific poison ? Might it not be that 
two factors are needed, the one some air- 
borne material or some dynamic modifica- 
tion of atmospheric elements coming from 
without, the other some local element: 
neither being potent unless united ? The 
peculiar atmosphere sweeps along hither 
and thither, and it is only when it meets 
with the other peculiar substance that the 
poison is generated. It may be that a 
Cholera evacuation is the most prolific of 
the peculiar local agents. Some general, 
not local law, seems to govern all Cholera 
epidemics. Contagion from Cholera dis- 
charges may operate, but there must be 
something beyond this. Contagious dis- 
eases are not epidemics at all times, even 
in the same places. In Lower Bengal 
every year the native smallpox inoculators 
proceed to inoculate patients. The dis- 
ease in these cases rarely spreads. For 
years successively this may go on without 
evil results, and there is no uncontrolled 
diffusion; but every few years a wide- 
spreading epidemic of smallpox, which 
nothing seems to resist, sweeps over the 
land. There is nothing discoverably dif- 
ferent in the epidemic and the common 
years-the same people, the same habits, 
the same places, the same filth, or the 
same absence of it. In all the seasons there 
is the poison. In all the seasons there is 
the susceptible population; and yet how 
different the results ! It is not to be sup- 
posed that the mere amount of poison 
generated in times of confluent smallpox 
makes the difference ; but even if so, how 
is it that in one year all the cases are con- 
fluent, in others discrete ? Why has the 
inoculated poison such a limited influence 
in favorable years ? If there be poison in 
the Cholera stools, it may bear the same 
relation to Cholera epidemics that the in- 
oculable virus of smallpox in healthy years 
bears to the destructive epidemics of the 
exceptional ones; in certain circumstances 
a sufficient cause-not the only one. 
Though it must be confessed that we do 
not know what is the exciting cause of 
Cholera, we may hope that we arc grasp- 
ing some of its laws. It is impossible to 
deny that it riots far and wide, indepen- 
dently of contagion; but we must admit 
that it may be spread in some way by 
human intercourse. This is perhaps more 
satisfactorily explained by the views of 
Dr. W. Budd, than by other modes of 
contagion. The influence of predisposing 
causes is certain, and it is undoubted that 
they may be rendered less active. It is to 
be hoped that the Sanitary Boards now 
permanently given to India by the recom- 
mendations of the Royal Commission on 
the Sanitary State of the Army in India, 
will do much to diminish the mortality of 
Cholera. While grateful to them for their 
labors and recommendations, we must in 
justice to the officers of the Royal and 
Indian Medical Services state, that many 
of them had earnestly striven in the cause 
of preventive medicine long before the 
committee was formed, and that most of 
the facts published by it were well known 
and appreciated by the said services. 
Among those who have worked in the 
spirit of the Sanitary Committee, and who 
have done much to advance the cause of 
sanitary science in India, either by their 
writings, by their position about those 
high in power, or by their official standing 
or appointments, Kenneth, Mackinnon, 
Martin, Bedford, Chevers, Parkes, Bal- 
four, Morehead, Rogers, Lorimer, Mac- 
lean, Alexander Grant, Forsyth, Hugh 
Macpherson, Ewart, Maclennan, Leith, 
Mouat, and P. Walker may be mentioned 
with special honor. 
Symptoms.-The typical cases of well- 
developed Cholera present well-defined 
symptoms. The descriptions in the fol- 
lowing paragraphs apply to the ordinary 
forms of Epidemic Cholera. In the begin- 
ning of an attack, the most prominent 
symptoms are disturbances of the stomach 
and bowels. Then, in swift succession, 
though not necessarily in that order, the 
circulatory, respiratory, muscular, and 
nervous systems suffer. Then, in severe 
cases, ensues extreme depression of all the 
functions of life, which often terminates 
in death. The symptoms are naturally 
divided into periods or stages, which may 
be called those of Invasion, Development, 
Collapse, and Reaction. 
Stage of Invasion.-We have not very 
often to deal practically with more than 
one or two sets of symptoms in this stage; 
viz., preliminary disturbances of the bow- 
els. There are doubtless other preliml- SYMPTOMS. 
399 
nary signs which are sometimes felt for a 
few hours, or even days, by patients, be- 
fore passing into the well-marked stages. 
Twining, Annesley, Orton, and others 
mention among these preliminary symp- 
toms a feeling of malaise, oppression of 
epigastrium, depression of spirits, pallid, 
anxious, and sorrowful cast of counte- 
nance, sense of exhaustion, vertigo, noise 
in the ears, headache, tremor, and sense 
of debility. Annesley gives the following 
statement of the sensations of a patient, 
related by himself to his surgeon, Mr. 
Colledge : "I must knock off work, I feel 
unable to do more, but do not know what 
is the matter; I have only a little pain in 
the stomach and rumbling in the guts." 
Mr. Colledge says, sighing, peevishness, 
and uneasiness accompanied these com- 
plaints. Annesley relates a case in which, 
from the countenance of the patient, he 
suspected the approach of Cholera, and 
in which he contented himself with merely 
watching him. Nine hours elapsed after 
the establishment of his suspicions from 
premonitory signs, before vomiting, purg- 
ing, and spasm appeared. Without doubt, 
after making due allowances for the fan- 
cies and terror of people during Cholera 
epidemics, preliminary disturbances of the 
nervous system have occurred, and should 
not be made light of. But it must be ac- 
knowledged that in the majority of cases 
no such forewarnings are perceived. A 
premonitory symptom for which medical 
aid is often called, during Cholera epi- 
demics, is diarrhoea. The disease itself 
often begins suddenly with purging or 
vomiting, but in numerous cases there is 
relaxation of the bowels for some days or 
hours before the real attack begins : the 
motions, watery or semifluid, sometimes 
pale, but not always so; three, four, or 
more in the twenty-four hours, perhaps 
with griping. There may be some sense 
of exhaustion with this. There is a strong 
tendency to diarrhoeal complaints during 
Cholera epidemics, and, though some of 
the cases may be harmless, many of them 
do ultimately pass into Cholera. The ne- 
cessity of checking such discharges should 
be earnestly impressed upon the medical 
practitioner. 
Stage of Development.-Evacuation Stage. 
-It is a matter of common observation 
that the attack commences with purging, 
very often early in the morning ; vomiting 
seldom comes on till later. The alvine 
evacuations are copious and fluid. The 
first stools, generally, consist of the ordin- 
ary contents of the intestines mixed with 
much liquid. The patient often describes 
them as rushing from him in a full stream. 
Often so great is the purging, that he sits 
sometimes on the close stool or privy, un- 
til several pints or even quarts of fluid 
have passed from him. Generally the 
evacuations are repeated and frequent; 
they are soon attended with a feeling of 
exhaustion, so that the patient is glad to 
get to his bed again. This excessive 
watery purging characterizes the onset of 
Cholera. It is frequently painless, but 
not always so; therefore we should not 
suppose that a patient has not Cholera be- 
cause he has griping and pain. So exces- 
sive are these evacuations, that in two or 
three hours, or less, an ordinary-sized 
stool-pan will be nearly filled. With the 
exception of those first passed, they are of 
a light straw or pale drab color. 'The sur- 
geon should not be thrown off his guard 
because the evacuations he sees in mass 
are somewhat colored. There is often 
fecal matter enough in the first evacua- 
tions to color the subsequent stools passed 
into the same unemptied vessel. The 
quantity and consistence of the discharge 
and the effect upon the pulse are of infi- 
nitely more importance than the shade of 
color. The name of rice-water stool has 
been given to the genuine unmixed Cholera 
evacuation, and if collected separately, 
after the first two or three have been 
passed, the discharges do, indeed, resem- 
ble water in which rice has been boiled. 
It is a thin, pale, slightly opaque or slightly 
turbid fluid, depositing a sediment on 
standing, which is like fine, minute, flaky 
particles of rice broken down by long boil- 
ing. Occasionally in the evacuation stage, 
the fluid is whitish or somewhat milky, 
or of shades varying between this and the 
whey-like color before mentioned. With 
purging, but generally beginning later 
than it, is combined vomiting. The fluid 
vomited, if unmixed with ingesta, is clear 
and watery, often in quantities of a pint 
or more, and generally ejected with force. 
The vomiting is less constant in its inten- 
sity than the purging, and sometimes is 
very slight, occurs at irregular intervals, 
and is readily excited by medicine or drink. 
When the rice-water evacuations appear, 
cramps generally set in, not often before 
tins ; they are most frequent in the fingers 
and toes, in the calves of the legs, thighs, 
and sometimes in the abdomen; they may 
continue through the next stage. By the 
time that the vomiting and purging have 
become fairly established, and even in the 
earlier stages, the countenance becomes 
altered. It assumes a somewhat leaden 
hue, and has a tendency to shrinking ; a 
stony, staring look, with the capillary 
circulation sluggish. Alteration of coun- 
tenance often points out the character of 
the disease, even before any symptoms 
have been complained of, though they 
may really have existed for some hours. 
Whatever may be the state of the counte- 
nance, if there have been many stools, or 
frequent vomiting, symptoms of depres- 
sion appear; the pulse begins to lose its 
strength and soundness, and the tempera- 
ture of the surface falls. Within six or 400 
EPIDEMIC CHOLERA. 
seven hours from the onset of the purging, 
or even much earlier,the pulse may dwindle 
down to the faintest thread, or may en- 
tirely disappear from the wrist for many 
hours; in others, even in well-marked 
cases, though in milder forms of the dis- 
ease, never quite ceasing to be felt at the 
wrist. This period is one of the greatest 
interest to the surgeon. With the utmost 
anxiety he watches, hour after hour, the 
waning, or the stationary, or the return- 
ing strength of the pulse, its maintenance 
or its extinction heralding either a happy 
issue in the first stages, or a future strug- 
gle of the deepest danger through the next 
stage, that of collapse. In some cases the 
balance oscillates for hours. If it turn ad- 
versely, with the failing circulation come 
the shrunken face, the lessening of bodily 
warmth, and the greater exhaustion ; and 
the patient passes into the stage of col- 
lapse. 
Stage of Collapse.-Algide Stage.-This 
is very much more dangerous than the last. 
Evacuations from the stomach and bowels 
are now less frequent and copious. The 
alvine discharges generally contain less 
liquid ; sometimes still of many ounces in 
each, at others merely a little clear fluid 
with gelatinous mucous-like flakes or 
masses. The stomach often acts, vio- 
lently, perhaps, but with less discharge. 
In the extreme state of the collapse the 
patient nearly resembles a corpse. There 
is the utmost depression possible with a 
capability of recovery. When this stage 
is fully formed, the patient no longer rises 
from his bed, though he often tosses about 
on it with sudden and frantic jerks, throw- 
ing off all covering, as if intensely hot, and 
seeking for cool air. Or he half springs 
up in bed shrieking from agonizing 
cramps, or he is still more exhausted with 
irregular paroxysmal gasping for breath, 
which subsides to be again renewed, and 
may end in the respiration being more 
constantly embarrassed. lie passes stools 
under him, heedlessly or with indiffer- 
ence. Now, the features are shrunk and 
livid, the eyeballs small and buried in 
their orbits, the lower lid drooping, and 
the eye half open. The surface is deadly 
cold, except, perhaps, sometimes the fore- 
head or prsecordia, the tongue icy to the 
touch, the very breath a cold air stream, 
the temperature in the mouth 79° to 88° 
Fahrenheit, in the axilla 90° to 97°. The 
general surface is pale, bluish, or livid ; 
often bathed in profuse sweats, as may be 
the forehead, and the shrivelled hands 
and feet, the hands looking as if they had 
been long soaked in water ; the pulse ab- 
sent from the wrist, and in very bad cases 
from the brachial artery; the blood ob- 
tained with difficulty by venesection, 
sometimes not at all, and, when drawn, 
thickish, or tar-like ; the mind apathetic, 
so that between the times that he is roused 
by cramps or is involuntarily restless, the 
patient lies on his side or back, heedless 
of surrounding objects or persons, but not 
comatose until, perhaps, the last. Thirst 
and sense of heat of epigastrium are at 
times intense and tormenting; water I 
water I is the urgent and frequent suppli- 
cation. If given to him, the sufferer spas- 
modically rises on his elbow, and gulps 
down the cooling liquid with intense 
eagerness, perhaps to vomit it up imme- 
diately. The voice is feeble, whispering, 
or suppressed. Muscular strength is al- 
most always greatly reduced, but in some 
instances it is retained to an extraordi- 
nary and disproportionate extent. A 
man may be sometimes seen to walk 
across a ward, or to sit up in bed, or to 
rise to stool, whose pulse is imperceptible 
at the wrist, In extreme collapse the 
circulation is at its lowest ebb; the car- 
diac sounds scarcely, if at all, distinguish- 
able ; the respiration is embarrassed, or 
with alternations of quiet breathing and 
difficult paroxysms, and, in the later 
stages of fatal cases, always difficult; the 
dusky hue of the surface, the coldness and 
dyspnoea, all show great stagnation in the 
pulmonary vessels. Absorption, which 
in the early stages is strong enough to re- 
move collections of fluid from the smaller 
or even larger shut cavities, is now nearly 
if not quite arrested. Glandular secre- 
tions appear to be stopped also, though at 
times milk seems to have formed in the 
breasts of nursing women. The alvine 
discharges are less, consisting of remnants 
of fluid exuded before marked collapse 
came on ; the motions contain a little 
mucus with a small quantity of liquid. 
There may, nevertheless, be much matter 
retained in the intestines, the muscular 
coats of which are too feeble to expel it. 
The stomach is less frequently excited to 
vomiting, and there is an absence of sa- 
liva in the mouth. The changes between 
the atmosphere and the blood, and be- 
tween the blood and the tissues, are as 
low as is compatible with life ; the amount 
of carbonic acid gas thrown oft' from the 
lungs is about 1'5 per cent, instead of 
about 4. The evacuations are not gene- 
rally of bad smell; but in some prolonged 
cases, in which there has been retention 
in the bowels, they are very offensive in 
the latter stages ; similar to rotten fish. 
There is no more distressing state to 
witness than that of a patient in the state 
of collapse from Cholera. The contrast 
between his state of a few hours previous- 
ly, the sudden affliction of friends and re- 
lations, the apparently hopeless condition 
of the sufferer, all conspire to impress one 
painfully. But with all this, hope need 
not be utterly cast aside. The patient 
may lie for hours without a pulse at the 
wrist, and sometimes even in the brachial 
artery, and yet recover. Cases without SYMPTOMS. 
401 
pulse in the brachial artery and manifest 
permanent impeded pulmonary circula- 
tion, with dusky and livid countenance, 
seldom or never recover; but short of this 
a large number do. 
The state of collapse may last for hours, 
twelve to forty-eight, or in very rare cases 
even longer, and yet recovery may take 
place. The patient may die in three or 
four, he may live twenty-four or more, 
the .pulse never returning, the respiration 
becoming more and more impeded, the 
brain more and more torpid, with onset of 
coma, moaning respiration, and closing in 
death. Or, after lasting a variable time, 
five, ten, twenty hours or more, the pa- 
tient becomes less restless, less thirsty, 
and jactitation and anxiety give way to 
calm ; he dozes quietly with easy respira- 
tion, and this is of most favorable import. 
The pulse at the wrist flickers, we are in 
doubt if we do not feel some movement, 
then we are certain that we do, then this 
beat is unmistakably established, the 
superficial veins show themselves filling 
at the back of the hands, the surface is 
less cold, the countenance assumes more 
and more its natural character, and even 
becomes flushed, respiration is quiet and 
regular, temperature rises, and reaction 
may be considered certain. 
State of lieaction.-The patient has now 
passed through the collapse, and is, in 
many instances, nearly himself again. In 
some persons recovery is as rapid as de- 
cline. The secretions are readily per- 
formed, the strength returns, and health 
is the speedy issue. Twining mentions 
the rapidity with which many Cholera 
patients recover, and that it is not un- 
common to see a man well on the third 
day after an attack of the worst symp- 
toms. Mr. Grainger says, "I have seen 
a man stand at his door on Wednesday, 
who on Monday was in a perfect collapse. " 
Such cases were common in India in 
Twining's day. They are not so common 
in Calcutta now. When the collapse has 
passed away, our anxiety is not at an 
end. The perfect establishment of the 
secretions is our next desire. As said 
before, during collapse all secretions are 
stopped, but after reaction has come on 
they should reappear. The first indica- 
tion of change is in the color and charac- 
ter of the alvine evacuations. Indepen- 
dently of the influence of drugs, such as 
lead, mercury, &c., we find that they be- 
come sometimes milky or whitish, then 
grayish, then darker or muddy, and at 
last brown. We find that the liver is act- 
ing, at all events as far as coloring matter 
is concerned. We also look anxiously for 
the passing of urine. We may have to 
wait ten, twelve, or thirty hours, or even 
more. At first it comes scantily, high 
colored, acid, an ounce or two with a 
strong and peculiar animal smell, deficient 
in urea perhaps, but not in all animal 
principles, generally albuminous with 
many transparent casts. The albumen 
or allied compound when present is not 
always detected by nitric acid, though 
often by heat, giving a deposit not dis- 
solved by nitric acid when the nitric acid 
test alone failed to detect it. The urine 
often turns pinkish with nitric acid. Af- 
ter the first, the secretion becomes co- 
pious, and probably by this time all the 
functions of the system will have become 
natural. 
The above description applies to the 
well-marked evacuation and algide stages 
of severe ordinary cases met with in the 
present day in India. It is not to be sup- 
posed that all these symptoms occur in 
every instance, or that they are always 
equally well developed. There is not 
always the same degree of collapse, the 
same duration of stages, the same appa- 
rent amount of evacuations. The cases 
sketched above are such as have the char- 
acteristic evacuation stage, lasting six or 
eight hours or more ; followed by decided 
and complete collapse. Modifications and. 
variations will be mentioned hereafter. 
As has already been said, the stage of 
reaction is not always the period of safety. 
When the algide stage does not last more 
than eight or ten hours, there is hope of 
regular convalescence; but when it goes 
beyond this-say eighteen or twenty-four, 
or more-we must, in the event of reac- 
tion, expect a much larger proportion of 
secondary risks. 
It seems that in the earlier known epi- 
demics in India the proportion of cases 
with healthy reaction and of rapid recov- 
eries to those of consecutive disease was 
greater than it is in the present day. In 
the great epidemic of 1861, about 22 per 
cent, of the fatal cases died in the reaction 
stages. In England the opinion is preva- 
lent that consecutive risks are less com- 
mon in India than in Europe. Dr. More- 
head shows that this is a mistake, and 
says that practitioners in India are as fa- 
miliar as those of Europe with all the dis- 
eases of the reaction stages. I think that 
most of the surgeons in Lower Bengal 
will confirm this opinion. Dr. J. Mac- 
pherson, in a paper on the Indian Annals, 
shows that for a period of ten years, one- 
fifth of the fatal cases of Cholera in the 
Calcutta General Hospital died after the 
stage of collapse was over. Whatever 
may have been the case formerly, I can 
bear testimony to the large proportion of 
secondary affections which are now met 
with in Calcutta, both among Europeans 
and natives. I regret that writing this 
paper in England, away from my own 
hospital records, I cannot now avail my- 
self of them to prove this and many other 
points by figures. In the Report of the 
General Board of Health on the Cholera 
vol. I.-26 402 
EPIDEMIC CHOLERA 
epidemic of 1853-54, it appears that in 
1777 deaths, 249, or about 14 per cent., 
died of consecutive fever. Dr. Gull states 
that probably not more than one-tenth 
died of it in 1848-49. In the Northwest 
Provinces of India in 1861, as before said, 
the proportion was 22 per cent., which is 
larger than it was in England. I have, 
therefore, little doubt that in India, or at 
all events in Lower Bengal, the diseases 
following reaction are quite as frequently 
seen as in England. The diseases suc- 
ceeding to collapse may be arranged under 
the following heads :- 
1st.-Imperfect reaction, relapse, and 
occasional deviations from normal conva- 
lescence. 
2d. - Complicated reaction ending in 
uraemia, low fevers, gastro-enteritis, diar- 
rhoeas, and various asthenic sequelae. 
Relapse after the circulation has been 
fairly restored, is not very common, but 
it is met with now and then. There is a 
return of vomiting, purging, exhaustion, 
and death in a few hours or two or three 
days. In one case known to me it oc- 
curred after the administration of a very 
mild dose of a resinous purgative. Dr. 
Johnson mentions a case of relapse after 
some pears had been eaten. In the case 
of a lady whom I attended the evacua- 
tions and algide stages were passed safely 
through; during the next day great dysp- 
nma came on, and death, with all the 
symptoms of general collapse, followed. 
In this case I thought that the great dis- 
turbance of the respiration was due to col- 
lapse of the lung tissue. 
The milder deviations from ordinary 
•convalescence are slight febrile excite- 
ment, obstinate vomiting, hiccup, indi- 
gestion, and want of sleep. 
Mild Fever.-In some of the cases after 
<collapse the patient appears drowsy and 
listless, and, though generally easily 
moved, likes to be quiet. There is often 
a slight febrile movement with this, the 
tongue is dryish in the centre, the epithe- 
lial coating of the lips and mucous mem- 
brane of the cheeks thickened and opaque, 
and superficial abrasions occur opposite 
the most prominent teeth. The secre- 
tions appear to go on ; the appetite is ab- 
sent. In most instances this state does 
not last more than four or five days, and 
perfect recovery follows; or the fever as- 
sumes more or less of a remittent or in- 
termittent character, which passes off in 
a few days ; or sometimes it ends in coma 
or decided typhoid symptoms. Occasion- 
ally the fever terminates with an eruption 
somewhat resembling urticaria ; in some 
cases erythema, which may become 
prominent all over the body, last two or 
three days, and then disappear with slight 
burning desquamation. It is not danger- 
>ous. The patient generally recovers as 
the eruption goes off. In some instances 
a red exanthematous efflorescence appears 
for a day or two instead of the urticarial 
elevations. The fever may be accom' 
panied with irritation of the gastric mu- 
cous membrane and slight diarrhoea, but 
these are not essential. 
Vomiting.-Irritability of the stomach 
may be caused by some degree of conges- 
tion of its mucous membrane approaching 
to subacute gastritis, owing to the fre- 
quent straining and vomiting, or to stimu- 
lants incautiously given. It is not neces- 
sarily accompanied with feverishness, but 
there is general thirst and burning heat 
of oesophagus and at epigastrium. The 
patient cannot retain nourishment at 
first; the smallest amount being at once 
rejected. This condition often lasts 
several days, and requires great care and 
attention. I do not remember to have 
seen it fatal. When existing as the only 
symptom, great debility attends it, and 
convalescence is often delayed many days 
by its continuance. Sometimes it passes 
into a dangerous state of gastro-enteritis. 
Hiccup annoys the patient greatly, inter- 
fering with his rest, and is generally pres- 
ent with loss of appetite. It is not al- 
ways constant: sometimes it leaves the 
patient intervals of some hours, then 
comes and goes again. It is generally ac- 
companied with great eructation of gas, 
but is sometimes without it. It is not 
dangerous, though it is very annoying, 
and distresses the patient so much that he 
anxiously demands relief. 
Want of Sleep.-This is very irksome 
when prolonged. I have known it to last 
for two or three days or more, the patient 
longing for sleep, and restless, and im- 
ploring for medicines to soothe him to 
repose. 
Imperfect Reaction.-This is somewhat 
similar to relapse, but reaction does not 
proceed in it as in those which I have 
called relapse cases. In this imperfect 
reaction, the symptoms of great collapse 
pass away or diminish; the pulse im- 
proves, but does not regain its natural 
strength ; the temperature remains low ; 
the purging, though abated, continues, 
the evacuations watery, though often 
slightly tinged with bile; the vomiting 
may continue; there is anorexia and 
much prostration ; the urine flows freely, 
and is apparently natural. Though time 
passes on, the patient does not get 
stronger ; he lives three or four days, and 
then sinks from exhaustion, with disturbed 
respiration and coma. It may, ultimately, 
if the case is sufficiently prolonged, pass 
into the typhoid state. There is no py- 
rexia with this important reaction. It is 
not always fatal, but very frequently is so. 
Urcemia.-This is very common. The 
symptoms of collapse pass off. If the 
urine is not secreted, we are not long 
without indications of mischief. Vomit- SYMPTOMS 
403 
ing often returns soon, the ejecta not now 
colorless, but generally grass-green. Urae- 
mia shortly succeeds. The patient has 
weight about the loins, listlessness, deli- 
rium, drowsiness, coma ; the eyes become 
injected and dark, the tongue dry, the 
teeth foul. Before coma comes on there 
often exists a singular state of muscular 
resistance; the patient opposes all at- 
tempts at overcoming the ordinary con- 
traction of the muscles. He strongly re- 
sists the opening of the eyelids, the de- 
pression of the lower jaw, or the straight- 
ening of the fore-arm. There is not 
spasm, but simple resistance. Dr. More- 
head notes that uraemia is preceded by 
preternatural slowness of pulse. If the 
renal secretion is not established, the 
coma becomes deeper and deeper, and 
death may occur within forty-eight hours 
after the full reaction ; but it is generally 
delayed longer than this ; and even after 
secretion is apparently restored, the pa- 
tient may pass into the typhoid state. 
The length of the collapse has doubtless 
an influence upon the suspension of the 
renal secretion ; the shorter it is-its du- 
ration not exceeding eight or ten hours- 
the greater probability is there that the 
kidneys will act easily within twenty-four 
hours. We must not despair, however, 
if the secretion is retarded for twenty- 
four or even thirty-six hours after reac- 
tion. In extreme" cases even this limit 
may be passed. Dr. Morehead notices 
that, when the collapse has lasted eighteen 
hours or more, there is much greater 
danger of consecutive disease depending 
on defective secretion; and the more 
speedily the full circulation has been re- 
stored after long collapse, the greater is 
the risk from continued suppressed urinary 
secretion. The comatose cases are very 
frequently fatal, but not necessarily so. 
If the kidneys act, bad symptoms will 
probably diminish ; but if they do not, 
death is inevitable. The secretion of 
urine, however, does not always relieve 
the head symptoms, as Dr. Morehead has 
also pointed out. The bowels are some- 
times relaxed, sometimes constipated ; the 
evacuations yellow and feculent. Diar- 
rhoea may carry off some urea, and should 
not be checked. The whole train of symp- 
toms of uraemia need not be described 
here. They are the same as in uraemia 
generally. There is no febrile action, or 
it is but slight. 
Cholera Typhoid.-Writers do not al- 
ways distinguish between this and urae- 
mia. Uraemia may pass into a typhoid 
state, but there does exist a consecutive 
fever independently of uraemia ; or at any 
rate without suppression of urine, or 
without albuminous urine. Possibly the 
blood may not be fully purified of urea, 
and a quantitative investigation might 
prove a deficiency of excretion, but in 
some of the cases I have found sufficient 
urea to crystallize freely on a glass micro- 
scope slide. I have never made a quan- 
titative examination for the twenty-four 
hours. It is likely that other principles, 
besides urea, indicative of the blood being 
loaded with effete matter, might be dis- 
covered, as in the cases mentioned by Dr. 
Letheby. In cases of consecutive fever', 
the patient for two or three days after the 
collapse may appear to be doing fairly, 
the excretions and secretions appear to go 
on sufficiently ; then the tongue becomes 
dryish, and a little quickening of the pulse 
comes on during some part of the twenty- 
four hours; perhaps towards evening. 
Often the febrile movements are pretty 
regularly paroxysmal. The excitement 
is not high, and the pulse, though quicker, 
is generally weak and small. In a short 
time the patient passes into a typhoid 
condition ; sometimes passing through all 
the risks of the extreme adynamic state ; 
very often dying; but the disease is not 
necessarily fatal. The duration of the 
fever varies. I have known a patient to 
die twenty days after the collapse had 
passed away, the urinary and hepatic se- 
cretions being apparently natural through- 
out. Probably the majority die about the 
eighth to the twelfth day. This fever 
may possess all the usual symptoms of 
adynamic fevers-low delirium, coma, 
dry tongue, parched lips, feeble and quick 
pulse, bed-sores, liquefaction of the blood, 
purpura, &c. It would be superfluous to 
describe more fully all the signs of the ty- 
phoid state. The patient may sink under 
it, or slowly recover, and remain for a 
long time in an anaemic, debilitated con- 
dition. Coma sometimes comes on within 
the first day or two after reaction. In 
some cases this may depend upon sudden 
poisoning by urea, but in many the secre- 
tions do not seem to have been in fault. 
It is generally fatal. 
Ulceration of the Cornea. - Disintegra- 
tion of the cornea is sometimes a sequel 
of Cholera in India: most frequently 
among natives, but I have seen it in Euro- 
peans also. It comes on a few days after 
the reaction has set in. An asthenic 
state of the system is necessary to it. 
Generally there are some typhoid symp- 
toms, but it does not always appear in 
the worst state of the low fevers. The 
lower segment of the cornea is the part 
to suffer first. It is not caused by inflam- 
mation ; in the early stages, not a trace 
of an enlarged vessel may be visible. 
During the worst part of the collapse the 
lowet eyelid falls away from the upper, 
the lower segment of the cornea is ex- 
posed, and the uncovered part of the epi- 
thelial layer at the time often looks dry- 
ish and parchment-like. It is probable 
that this leads to the subsequent disinte- 
gration of the part; but whether this ba 404 
EPIDEMIC CHOLERA. 
so or not, the essential cause of the affec- 
tion is defective nutrition of the cornea, 
as in the case of Majendie's dogs. We 
find that in four or five days, or later, 
after reaction a part of the lower seg- 
ment of the cornea on one side becomes 
hazy ; the area of cloudiness not very ac- 
curately defined. There is so far no dis- 
coverable disintegration. In twenty-four 
hours the epithelial layer over part of the 
opaque area shows abrasion, or there may 
be some loss of substance of the deeper 
layers of the cornea, producing a minute 
curved groove about one twenty-fourth of 
an inch from the corneal margin ; the 
groove is less than the hazy part. By 
this time the opposite eye has generally 
become hazy in the same manner as the 
first had been on the previous day. In 
twenty-four hours more the groove in the 
first eye may have doubled its size. Ex- 
amined with a lens, the surface of the 
groove is of a dirty ash color, and opaque, 
aving indeed all the character of a mi- 
nute slough. The ulcer may spread, and 
penetrate the entire thickness of the cor- 
nea, and extend at its margins, but in the 
majority of cases the patient dies before 
such extensive destruction occurs. The 
mischief is generally symmetrical; but 
the eye last attacked is less advanced than 
the first. If the patient recovers, the eye 
is generally preserved without any very 
serious disfigurement. With his general 
improvement the ulcers also improve. 
There is first arrest of disintegration, then 
diminution of haziness and opacity, then 
cleaning of the surface of the ulcer, which 
becomes beautifully clear and transparent. 
Cicatrization follows, perhaps rapidly, and 
the repair is generally perfect, so that un- 
less the ulcer is very deep, in a few days 
it is often difficult to discover where the 
mischief has been. Permanent opacity, 
hernia of the iris, or staphyloma, are 
rarer than would be supposed. In the 
later stages, there may be vascularity of 
conjunctiva and sclerotic, but they are 
effects, not causes, of the ulcers. This 
state of the cornea is frequently met with 
in India, in cases of chronic diarrhoea and 
other debilitating diseases, and of course 
is not peculiar to Cholera. 
Gangrene of Various Parts. - Among 
some of the rarer sequelae, I have seen, 
among the natives of Bengal, complete 
gangrene of the penis and scrotum, and 
partial gangrene of the scrotum and of 
the point of the nose; also superficial gan- 
grene of the mucous membrane of the 
mouth. I have never seen mortification 
of the intestines. When the mortified 
parts are small in extent they may be 
cast off, but in the extensive gangrenes 
of the penis and scrotum I believe that 
death always happens. 
Parotid Glands.-Swelling and inflam- 
mation of these are not unfrequent; they 
often, though not always, end in sup- 
puration. It is unnecessary to give an 
account of the symptoms of this affec- 
tion. It appears during the second or 
third week, and with low fever. Both 
sides generally suffer in succession. The 
patients often sink during its progress. 
It is always a grave symptom, indicating 
a very asthenic state of the system, and 
interfering much with the patient's power 
of taking food. 
Bed-sores, Boils, Ulcers, Low Inflamma- 
tion of Lungs, Pleura, &c.-The patient 
often suffers very much from these. They 
often greatly retard convalescence, but do 
not require any special notice. 
Consideration of the Special Symptoms.- 
It may be well now to consider more in 
detail some points not fully spoken of in 
the foregoing account of the symptoms, 
in order not to interrupt their descrip- 
tion. The intestinal discharges require 
more notice. The quantity evacuated is 
generally considerable. It is difficult to 
ascertain this in hospital patients. They 
amount frequently to 80,100, or 150 ounces 
during the evacuation stages. After the 
feculent portions of the stools have passed 
they have not much smell; but in the 
later stages, as before mentioned, if they 
have been retained in the intestines, they 
are often very offensive, but they are not 
so always. The composition of the Chol- 
era stool has been studied chemically and 
microscopically. The Cholera stool and 
the contents of the intestines after death 
are not exactly alike under microscopic 
examination, and Dr. Parkes has pointed 
out the necessity of remembering that 
Boehm's observations are applicable to 
the intestinal contents, and not to the dis- 
charges collected during life. As before 
said, the Cholera stool separates on stand- 
ing into a thin whey-like fluid, and a vari- 
able quantity of sediment. The specific 
gravity of the liquid portion is 1,005 to 
1,010. The sedimentary flakes and par- 
ticles, according to Parkes, Gull, Gaird- 
ner, and others, contain organic forms, 
which are described as follows, lying in a 
hyaline basis:- 
1. Amorphous granular matter and 
larger granules, often very abundant. 
2. Minute bodies having the general 
character of nuclei, to line in 
diameter. 
3. Fine granular cells; some large, 
some resembling pus cells. 
4. A very small quantity of scaly epi- 
thelium, generally not easily discernible. 
Dr. Parkes states that the actual quan- 
tity of sediment is very small; the dried 
deposit from a pint by measure of a 
Cholera stool weighed four grains only. 
The composition of the solid or gelatinous 
matter of the stools is doubtful: Parkes 
considers it some modification of fibrine ; SYMPTOMS. 
405 
Gairdner thinks that it presents the reac- 
tions of mucus. It is possibly some mod- 
ification of mucus. 
In contrast with the above, the micro- 
scopic appearances of the contents of the 
intestines found after death, as first 
described by Boehm, consist of a large 
quantity of epithelium in various states of 
aggregation, separate cells, and flakes 
which are coherent masses of greater or 
less extent, comprising the coverings of 
small regions, as apices of villi, or cover- 
ing the whole villi and their bases in 
variable quantities. According to the 
state of aggregation or distinctness of the 
epithelial particles, and the quantity of 
fluid in which they are mixed, the appear- 
ance of the whole may vary from a rice- 
water or milky to a creamy, purulent, 
flocculent, or oatmeal consistence. Dr. 
Parkes has shown that there are, mixed 
with these, other organic forms found in 
the stools. There is very little epithelium 
found in the contents of the colon. The 
great difference in the microscopic appear- 
ances of the Cholera stobls and the con- 
tents of the small intestines after death, 
is in the nearly complete absence of epi- 
thelial particles in the stools. The infer- 
ence from this and other considerations 
is, that the shedding of the epithelium 
does not take place during life, but that it 
is due to post-mortem maceration and de- 
tachment. 
Chemistry of the Evacuation.-The spe- 
cific gravity of the liquid part is seldom 
above 1,012 in the height of the stage of 
discharge. The reaction is faintly alka- 
line or neutral. Dr. Parkes, in the Feb- 
ruary number of the "London Journal of 
Medicine," for 1849, has given us valuable 
information as to the composition of the 
stools, and shown that the liquid portion 
is not similar to the serum of the blood ; 
that it contains but little albumen, and 
consists chiefly of the water of the blood 
with saline matter and a small quantity 
of animal matter. The following table, 
copied from his papers, shows at a glance 
the real character of the discharges :- 
Period of the Disease in which the stool was passed. 
Specific 
gravity. 
Albumen 
in 
1000 parts. 
Extractive 
in 
1000 parts. 
Sol. Salts 
in 
1000 parts. 
Total of. 
Solids in 
1000 parts 
Diarrhoeal period 
1,012-9 
0-466 
3-846 
9-04 
13.9 
Diarrhoeal period 
.... 
0-29 
6-82 
5-99 
13.1 
Early Algide stage 
1,009 
1,009-5 
2-4 
1-27 
10-98 
14.65 
Developed and Intense Algide stage 
1-18 
0-55 
9-14 
10.87 
Developed and Intense Algide stage . . 
2-186 
7-52 
9.706 
Developed and Moderate Algide stage . 
1,008-3 
0-27 
2-23 
8-33 
10.83 
Developed and Moderate Algide stage . . 
1,005-8 
1,014-0 
3-2 
5-827 
8.947 
Commencement of reaction 
20-84 
6-34 
27.18 
Commencement of reaction 
1,008-91 
1,017-83 
1-48 
6-055 
9-085 
16.62 
Relapse 
0-855 
17-355 
18.22 
Relapse 
not weigh- 
able. 
4-589 
3-881 
8.47 
Nitric acid occasionally gives red reac- 
tion in the liquid. This is probably due 
to a small quantity of bile mixed somehow 
with the evacuations, but it is not certain 
what it is. 
Blood is rare, but it has occasionally 
been met with both in the stools and in 
the contents of the intestines. The pink 
or reddish discharges often consist only of 
the coloring matter of the blood, the red 
corpuscles being generally absent. 
Although the albumen and animal mat- 
ter found in the stools is very small, the 
quantity of salts contained is considerable. 
The greatest quantitative loss which the 
blood suffers is in its watery element. 
For every 100 ounces passed in the fluid 
evacuation stage, the loss to the blood in 
water is 98 to 99 ounces, and of salts 
nearly or about one ounce. The salts 
exuded are the chlorides of sodium and 
potassium, phosphate of soda, carbonate 
and sulphate of soda, bearing a proportion 
of seven or eight parts in 1000 ; a propor- 
tion nearly resembling the quantity in the 
blood within the vessels. The earthy 
phosphates do not pass through the mu- 
cous membrane as in health. In three 
analyses by Dr. D. Thompson a larger 
proportion of organic matter was found, 
but Dr. Parkes's observations probably 
hold good for the majority of cases. It 
will be seen that the intestinal surface 
removes from the blood a large quantity 
of water, a small quantity of animal mat- 
ter, and much saline matter, doubtless 
causing great change in the blood, and in 
the behavior of the different elements of 
the blood to each other. The chemistry 
of the vomited matters has been less 
studied. In six cases examined by Bec- 
querel, the solid matter in 1000 parts 
varied from 6'37 to 54'70 per 1000, the 
albumen from a non-weighable quantity 
to 31'50 per 1000, the chloride of sodium 
from 2'35 to 8'24 per 1000. No mention 
is made of the matters taken into the 
stomach, nor the period of the disease in 
which the discharges were collected. 
Blood.-The viscidity of the blood in 406 
EPIDEMIC CHOLERA. 
the algide stage has been mentioned. 
Chemistry shows that it has undergone 
considerable changes. The analyses most 
known are those by Sir W. O'Shaugh- 
nessy, Drs. Parkes, Garrod, and Schmidt. 
They show a diminution of water and a 
relatively increased proportion of solids. 
According to Garrod's, taking the maxi- 
mum of solids in health for males at 240, 
and for females at 227 per 1,000, he found 
that the total solids in seven cases were 
251, 360, 271, 271, 275, 282, and 284. The 
blood-globules and albumen were in- 
creased ; the alteration in quantity of the 
fibrine was doubtful, but it was less coagu- 
lable, and it was probably altered in 
quality. Dr. Garrod's observations were 
made on blood obtained, after death, from 
the cavities of the heart and neighboring 
great vessels. Dr. Garrod and Dr. 
O'Shaughnessy differ as to the propor- 
tion of salts. The former thought that 
they bore as high, if not a higher propor- 
tion than in health ; the latter that they 
were diminished. Dr. Schmidt's observa- 
tions were made on blood obtained by 
venesection. His results show an in- 
creased density of the blood and of the 
morphological elements in proportion to 
the duration of the exudation process 
from the surface of the intestinal canal; 
a relative increase of the solids in the 
blood, so that after thirty-six hours of the 
exudation process they reach to nearly 
half more than their normal proportion. 
Schmidt thought that the inorganic salts 
were diminished in the later stages of the 
exudation process, so that the proportion 
of organic matter in the serum was 
doubled. The specific gravity of the fluid 
is higher than natural; 107'6 to 1081 in- 
stead of 1062 to 1060. The blood is some- 
times found acid. Dr. Garrod thinks that 
this is due to the impeded excretion of 
organic acids. Urea in small quantities 
is sometimes found in the collapse, and 
generally in the reaction stages. In the 
main, all the analyses support each other, 
showing in the collapse stage a greater 
consistence of the blood, higher proportion 
of organic solids of all kinds, with im- 
paired coagulability of fibrine, higher spe- 
cific gravity, occasional acidity, occasional 
presence of urea, and an undecided pro- 
portion of inorganic matter, but neverthe- 
less, probably, a diminution in the abso- 
lute quantity of saline elements. In the 
reaction stages they show often a consi- 
derable quantity of urea and softness of 
the coagula. 
Varieties. - As before said, the de- 
scription of the symptoms given applies 
to the ordinary cases of Cholera, but we 
occasionally meet with instances which in 
some points differ from them. Some of 
the cases run a much more rapid course ; 
thus in some the evacuation stages are 
shorter, lasting two or three hours only, 
and collapse may come on with or with- 
out much discharge from the stomach and 
bowels. Others appear yet more rapidly 
fatal. Thus at Kurrachee, in 1846, people 
are said to have died within less than an 
hour from the time that they were seized. 
Dr. Milroy states that at Teheran, in 
1846, those who were attacked dropped 
down suddenly in a state of lethargy, and 
died at the end of two or three hours with- 
out convulsions or vomiting, but from a 
complete stagnation of blood. In these 
cases it is said that the dose of poison is so 
strong that death occurs before there has 
been time for exudation to take place. 
Mr. Thom says : "Among the first hun- 
dred cases which occurred many died in a 
few hours, and some in less time; one 
man, I am told, went off in less than an 
hour. In these vomiting and purging 
were not always present. Sudden col- 
lapse, ending in profuse sweating, were 
the most prominent symptoms-in fact 
asphyxia had already taken place. It 
was often found that the pulse had ceased 
at the wrist, the eyes turned up, the voice 
hollow and feeble, before the natural hue 
had given way to that horrible lividity 
which is characteristic of the disease, so 
instantaneously was the power of life ar- 
rested." And again, "The next class of 
cases were those in which the first seizure 
was equally sudden, and the collapse pre- 
ceded the vomiting and purging. There 
were sudden faintness, prostration of 
strength, restlessness and anxiety, accom- 
panied by vertigo, deafness, loss of vision, 
alteration or hollowness of voice, weak 
and slow respiration performed convul- 
sively or in sighs. These were followed 
by nausea, vomiting, and purging of 
congel-like stools, sensation of burning 
heat at the precordium, intense thirst and 
desire for something cool," &c. 
From such cases as these it has been 
argued that exudation from the blood is 
not a necessary part of Cholera. It should 
be recollected, however, that the amount 
of discharge voided is no positive measure 
of the amount of fluid separated from the 
blood during life, because it often happens 
that a very large amount is retained within 
the intestines during life. This will be 
again referred to. 
In some of the cases there is not the 
same shrivelling of the body as described 
in the typical cases. The body retains 
much of its plumpness, and the skin is 
dry. Collapse, nevertheless, comes on 
early in these cases. 
In a few cases the skin is warm and the 
perspiration warm, even during the earlier 
part of the collapse, which conies on early 
and is complete. 
Mr. Twining and others describe cases 
which appear to have in the first stages 
more of a sthenic character than those usu- VARIETIES. 
407 
ally met with now, and to which the name 
of Spasmodic Cholera was, perhaps, more 
applicable than to those described above. 
They were cases in which the " actions of 
the constitution were evidently febrile, 
and in the febrile stage of the disease were 
attended with violent and painful spasms, 
warmth of surface, and free circulation." 
Dr. Morehead does not find these common 
in Western India. 
Dr. K. Mackinnon relates another modi- 
fication of symptoms which he witnessed 
in a dreadful visitation of Cholera in the 
Tirhool jail. He says: "After a check 
had been put to the vomiting and purging, 
the voice, breathing, and warmth of skin 
became natural, the face had none of the 
peculiar character of the disease, the pa- 
tients walked about and called for food, 
saying that they felt well; on feeling the 
pulse in those cases it was barely percepti- 
ble, I think in some cases not to be felt at 
all. In this extraordinary condition some 
of the men lived for two days ; they all 
died, and, if my memory serves me, inva- 
riably by coma." Dr. Mackinnon does 
not allude to the state of the secretions. 
But the feebleness or absence of the pulse 
with such a degree of muscular strength 
and general well-doing is remarkable. I 
have seen some such cases, and they are 
mentioned by Scot and others. 
Dr. John Macpherson mentions two 
cases with hsematemesis, occurring in the 
reaction stage, and in one of them asso- 
ciated with hemorrhage from the bowels. 
Choleraic Diarrhoea.-This, though per- 
haps not a variety of Cholera, approaches 
that disease so nearly that it may be well 
to allude to it in this place. It almost al- 
ways prevails during Cholera epidemics, 
and sometimes precedes it in a district for 
weeks or months. It is often difficult to 
distinguish from Cholera at its onset, and 
into this, indeed, it often passes. Some 
of the cases have so much the appearance 
of mild attacks of Cholera that it is hardly 
possible to draw a line between them and 
the real disease. At Paris the name of 
Cholerine was given to these diarrhoeas. 
It is probable that the diarrhoea is due to 
a milder dose of the poison than suffices 
to produce true Cholera. The patient's 
most prominent symptoms are those of 
diarrhoea. This begins in the night or 
early in the morning, and without any as- 
signable cause. The motions are three or 
four, sometimes six or seven in twenty- 
four hours-passed without effort or strain- 
ing or griping. This diarrhoea is generally 
painless, which circumstance, combined 
perhaps with an apathetic state of the 
mind, is the cause of the disease being 
frequently allowed to run on unheeded. 
The evacuations are more or less feculent, 
but very liquid, and generally copious; 
the color varies from brown to light yel- 
low or pale straw, and when the disease 
passes into Cholera the motions are in- 
creased, and assume the rice-water cha- 
racter. There may be vomiting, and 
sometimes cramp. There is generally a 
good deal of sense of exhaustion and 
weakness. The patient has not much ap- 
petite, and is more or less ill. The diar- 
rhoea may last twelve or fifteen days, but 
may at any time pass into Cholera. The 
symptoms appear to be amenable to treat- 
ment, but the disease may destroy life by 
exhaustion without passing into Cholera 
or collapse. It is difficult to estimate the 
mortality of this affection, because so 
many of the cases are set down as simple 
diarrhoea, and when they pass into Chol- 
era they are recorded as Cholera. The 
mortality is not great, however, of such 
as remain classified as diarrhoea. The 
deaths from diarrhoea in the Cholera sea- 
son of 1854 appeared to vary from 6 to 18 
per 1000. The great success in the treat- 
ment of these shows how desirable it is to 
check all cases of Choleraic diarrhoea ; by 
so doing, there is little doubt that many 
cases of Cholera are arrested. 
Cholera Fever.-It has been frequently 
noticed that at certain periods of the Chol- 
era epidemic, towards its decline, the 
Choleraic diarrhoeas pass into a sort of 
low fever. In speaking of the Kurrachee 
epidemic, Mr. Thom says, as Cholera 
closed its career it gradually changed its 
type to that of fever; while one out of 
four or five cases ran into Spasmodic 
Cholera, the others would terminate in 
fever, and were registered as such, show- 
ing all the characters of a low remittent. 
Sir Ranald Martin speaks of "Cholera 
Fever" occurring in Calcutta in 1834, and 
at other times during the Cholera sea- 
son, which was remarkable for diarrhoea, 
and for the tendency which this had to 
run into Cholera, especially under doses 
of saline and drastic purgatives, and when 
these were administered over night. It 
is not so easy to say what is the connec- 
tion between these fevers and Cholera. 
In Calcutta one frequently meets with 
fevers which begin with diarrhoea. I 
have elsewhere mentioned this as fre- 
quently ushering in the red fever some- 
times prevailing there, and it is not unu- 
sual for some of the common fevers of 
children to begin in this way. It is prob- 
able that some of these happening to pre- 
vail during Cholera times, are influenced 
by the epidemic constitution of the atmo- 
sphere. It is not likely that the fever is 
avariety of Cholera. We should learn from 
them the practical lesson of not giving 
much purgative medicine, even in fever, 
during Cholera seasons, and especially to 
avoid salines and hydragogue purgatives, 
and the administration of any at bedtime 
likely to operate in the course of the night 
or morning. 
In classifying cases of Cholera, we may,. 408 
EPIDEMIC CHOLERA. 
excluding Choleraic diarrhoeas and fevers 
with Choleraic diarrhoea, arrange them as 
follows:- 
1. Those in which collapse is not per- 
fect. 
2. Those which after vomiting and 
purging pass into well-marked and com- 
plete collapse. 
3. Those in which collapse comes on 
with little or no apparent evacuation. 
4. The sthenic cases. 
The cases most frequently met with are 
of the second class. 
Duration.-This may, including se- 
queke, vary from two to three hours in 
the worst form, to several weeks in those 
protracted by secondary disease. The time 
which elapses from the first symptoms of 
Choleraic evacuations to the period of re- 
action is more limited. In the Report of 
the Board of Health on the epidemic of 
1853-4, the duration of 1744 fatal cases 
from the first symptoms is stated to have 
been an average of not less than 64 hours; 
the duration of 1856 cases of recovery, 
9'06 days. In the general registry of 
deaths, it is mentioned in the same Re- 
port, 9590 fatal cases lasted an average of 
2*39 days. 
The duration of the stages has been al- 
ready alluded to; the diarrhoeal may 
scarcely exist (excepting Choleraic diar- 
rhoea), or extend to 24 hours ; the collapse 
stage may terminate fatally in two hours, 
or it may be prolonged in extreme cases 
to 70 or 80 ; the reaction stages may ter- 
minate favorably within 48 hours, or may 
linger on for many weeks, when compli- 
cated with fever or other sequela;. 
Mortality of the Disease.-This is 
very large, and the averages approach 
each other in different climates and coun- 
tries. The mortality to strength of a 
population may vary greatly, but it has 
been observed for England, that, whether 
in healthy or unhealthy districts, the 
deaths to cases are pretty even ; the dif- 
ference in mortality between such places 
depending more upon insusceptibility of 
the population in healthy places than on 
any actual difference of violence of the 
disease. In India the deaths to cases do 
seem to vary in different ranks of the 
army: the officers having a lower mor- 
tality than the men. We may say in 
round numbers that more than 50 per 
cent, of the attacked recover. In some 
epidemics the mortality is higher, but in 
others, lower : in some, 70 to 80 per cent. ; 
in others, 20 to 30 per cent. The mor- 
tality varies also with the period of the 
■epidemic. It is generally much higher in 
the beginning than in the end or towards 
the end. It varies also in the different 
stages, being greatest in the collapse 
stage. 
In illustration of the above, we find that 
in 1832, in England, the deaths to cases 
were 47 per cent. ; in 1848-49, 45 per 
cent. ; and in 1853-54, 46 per cent. In 
Dr. Ewart's tables for European soldiers 
in India, for eight years ending 1853-54, 
it was : for privates, 40'74 ; officers, 16'66; 
women, 31'74; and children, 39'163 per- 
cent. For the native soldiery in the 
three presidencies, for various long periods 
of years: for Bengal, 30'54; Bombay, 
33'06; Madras, 42'91 per cent. In the 
Report of the Cholera Commission for the 
epidemic of 1861, we find that the mortal- 
ity of the European soldiery for that 
season was very high all over the pro- 
vinces ; the average being 63'8 for all 
classes in the regiments, but it varied 
from a minimum of 42'6 per cent, to a 
maximum of 80 per cent, among bodies of 
men in cantonments, of strength not 
below 500. The mortality to cases among 
the native Indian populations is not ascer- 
tainable. For native prisoners in jails 
for twenty-one years, ending 1853, it was 
42'6 per cent. With reference to the ex- 
cess of mortality in the beginning of epi- 
demics, we find that in 1854, in England, 
in the fortnight from July 16th to 29th, it 
varied from a maximum of 59 per cent, to 
a minimum of 40 per cent. ; but in the 
two last fortnights, ending November 
16th, they were only 23'21 per cent. In 
the severe outburst at Kurrachee, almost 
all the cases were fatal, and after that 
they became much more amenable to 
treatment. Indeed this is the experience 
furnished by nearly all the epidemics. 
The greater mortality in the collapse 
stage may be seen in the results of the 
Indian epidemic of 1861, in which we find 
that of 927 deaths, 717, or 77'4 per cent., 
died in the collapse stage. 
An opinion prevails that Cholera is be- 
coming more fatal to European troops in 
India than it was formerly. Dr. Ewart's 
tables seem to show, that though the dis- 
ease is less frequent than it used to be, the 
ratio of deaths to cases has largely in- 
creased. Thus, in Bengal, for eighteen 
years, from 1818 to 1835, inclusive, the 
percentage of admissions to strength was 
3'25, and the deaths to admissions 26'36, 
or 263 deaths per 1000 attacks ; while for 
the eighteen years from 1836 to 1853-54 
inclusive, the admissions to strength were 
2'62, and the deaths to admissions 39'75, 
or 397 deaths in 1000 attacks ; showing an 
average increase of mortality to attacks 
of above 13 per cent., or at the rate of 134 
per 1000 above the rate of the first series 
of eighteen years. In Madras, from 1829 
to 1838, the deaths were 271 per 1000 
cases, and from 1842 to 1851-52, 502 per 
1000; or an increase of 231 deaths per 
1000 cases. The increase has taken place 
through all the presidencies, but in Madras 
it seems to have been the greatest. It is DIAGNOSIS. 
409 
to be hoped that this increase is not per- 
manent, and that the averages may again 
descend. In another of Dr. Ewart's 
tables, the time is divided into quinquen- 
nial periods, and it appears that although, 
in the main, there has been a rise in the 
mortality within the last and in the later 
quinquennial period, there wrere consider- 
able fluctuations in the earlier terms, 
descending as much as 10 or 12 per cent, 
in Bengal and Bombay, and then ascend- 
ing. In Madras the fluctuations have not 
been felt, but the increase has been main- 
tained during four quinquennial periods. 
It is possible that a great deal of the 
apparent difference has arisen from a dif- 
ferent method of recording cases. Of 
late years those cases only in which the 
presence of the disease was decided, have 
been entered under the head of Cholera ; 
and cases which would formerly have been 
classed under this, are now placed in the 
columns for Diarrhoea. On turning to 
Dr. Ewart's Table 29, it will be found 
that there is an increase of cases of diar- 
rhoea in all the presidencies. The returns 
are not exactly for the same years as those 
for Cholera, but include them. Thus, in 
Bengal the returns from 1812 to 1832 give 
11-55; and 1833 to 1853-54, 12-15 per 
cent, admissions to strength ; in Bombay, 
1803-4 to 1827-28, 6'85 per cent. ; and 
1828-29 to 1852-53, 12-97 per cent. ; and 
in Madras, from 1829 to 1838, 7-8 per 
cent. ; and 1842 to 1851, 10-3 per cent. 
It will be seen that in Bombay and 
Madras, in which the rise in mortality of 
Cholera is apparently the highest, the in- 
crease of percentage of admissions of diar- 
rhoea is also the largest of the three 
presidencies. It is probable, as supposed 
by Dr. Ewart, that the diarrhoeas have 
encroached upon the dysenteries, but I 
think that one may fairly claim a good 
share of them for cases which would have 
been called Cholera in the older returns. 
It would be useful to compare the present 
with the past mortality of all intestinal 
fluxes. 
Mortality to age, sex, population, &c., 
has been noticed in the section on Etiology. 
Diagnosis.-This is easy in marked 
cases. Purging, vomiting, anxious coun- 
tenance, cramps, quick advent of collapse, 
and profuse sweating, are decisive enough 
of the presence of Cholera. 
There is some difficulty in deciding in 
the diarrhoeal stage. Cholera may be 
mistaken for bilious diarrhoea, choleraic 
diarrhoea, purging, produced by irritating 
drugs or poisons, and the onset of some 
fevers. We rely for diagnosis chiefly on 
the absence of any knowm cause for purg- 
ing, the absence or slightness of pain or 
tormina, upon the liquidity and pale color 
of the stools, and copious rush of fluid 
from the bowels; the early tendency to 
exhaustion, and the frequent beginning, 
in the early morning. If the patient is 
passing brown feculent matter not very 
liquid, and if there be griping and colic, 
and a probable cause in improper diet, we 
may be pretty easy, and the disease will 
probably be common diarrhoea. But we 
should nevertheless watch the patient 
carefully for a few hours. Choleraic diar- 
rhoea is less violent in its onset than 
Cholera, and the stools generally contain 
bile, even after the disease has lasted for 
days. There is seldom much or any pain 
in this. It should always be treated as 
Cholera in the beginning. Vomiting 
helps in the diagnosis, but it is sometimes 
absent for the first few hours, and is some- 
times present in diarrhoea. The vomiting 
in Cholera is fluid and colorless generally ; 
that of bilious diarrhoea often consists of 
undigested food or biliary matter. 
The diarrhoea in the beginning of fevers 
is often very exhausting, and at first it 
may be difficult to distinguish it from the 
commencement of Cholera. Generally, 
however, there is less exhaustion; and 
though there may be a tendency to col- 
lapse, this is not deep, and in a few hours 
the pyrexial stage comes on. 
All surgeons in charge of hospitals must 
be familiar with indications afforded by 
the countenances of patients even in the 
earlier stages. Men are often seen look- 
ing somewhat anxious, with the face 
pointed, and perhaps somewhat shrunk 
and mottled or leaden-colored. On being 
questioned, it will perhaps be found that 
the patient has watery purging on him ; 
a closed stool at his bed-side will, per- 
haps, be half or two-thirds full of the 
brownish or pale liquid, and he will be, 
indeed, in the first stage of Cholera, 
though ignorant of it, and making no 
complaint. A glance at a man's face will 
often save his life, and no man, when in 
or out of hospital, whose countenance 
shows this change, should be passed over 
in a routine way, however trivial his own 
complaint may be, or although he may be 
engaged, as sometimes happens, in his 
usual occupations. 
Cases of irritating poisoning often occur 
either from accident or design, and it is 
always well to be alive to such facts when 
called to cases supposed to be Cholera, 
and not take it for granted that all cases 
of vomiting and purging are those of 
Cholera. 
It cannot be too strongly impressed 
upon the young medical practitioner that 
in every case of diarrhoea which he at- 
tends, in seasons of Cholera, he should 
ask to see the evacuations at the very first 
visit. In India fortunately there are few 
privies or cesspools to private houses, so 
that this inquiry is not so difficult as it 
might be in England. If the stools have 
been taken away, the next ones should 410 
EPIDEMIC CHOLERA. 
be reserved. This is most important for 
diagnosis, and for the satisfaction of the 
medical man's own conscience it should 
never be omitted. Neither rank, nor sex, 
nor age of the patient should be a cause 
of the neglect of this. 
It should be remembered that many 
patients brought into hospital with low 
adynamic fever are sufferers from the se- 
quelse of Cholera, and that inquiries 
should be made as to the mode of the be- 
ginning of the disease for satisfactory 
diagnosis, if not for treatment. 
Pathology. -Morbid Anatomy.-This 
must be considered after death in the col- 
lapse and in the reaction stage. 
(a) In Collapse.-The surface is gener- 
ally bluish or mottled, especially in the 
dependent parts, and there are often 
subconjunctival ecchymoses. The ex- 
tremities are shrivelled. The tempera- 
ture, so low during life, often rises a little 
after death, and the body cools slowly. 
According to Dr. Gull, Mr. Barlow and 
others have noticed a rise of two or three 
degrees of Fahrenheit above the tempera- 
ture observed just before death. Rigor 
mortis comes on quickly, and lasts quite 
as long as in other diseases. Muscular 
contractions have been sometimes ob- 
served , and have in rare cases been suffi- 
ciently strong to alter the position of a 
limb. They may come on within the first 
few minutes after death, and last two or 
three hours. Putrefactive changes are 
not hastened in Europe. In India they 
are not more rapid than in other diseases. 
The abdomen often feels doughy and dull 
on percussion, except in the upper parts. 
lilood-Organs of Circulation and Respi- 
ration.-When death occurs in collapse, 
the disease has not lasted long enough to 
cause organic changes. Such changes as 
there are, are chiefly in the distribution 
of the blood. Ecchymoses are frequent. 
They are met with under the serous mem- 
branes, as the pleura and the pericardium ; 
under the mucous membranes of the small 
and great intestines, around the dura 
mater of the spinal cord, and occasionally 
in other places. 
The capillaries of the surface are empty, 
and the blood is chiefly found in the large 
vessels of the lungs and right side of the 
heart, and in the veins and various capil- 
laries of the intestines. Dr. Parkes was 
the first to point out, in his work on 
Asiatic Cholera, the real seats of accu- 
mulation of blood. Most persons who 
have had opportunities of making post- 
mortem examinations of Cholera cases 
will confirm his statements. It was pre- 
viously supposed that the lungs and heart 
were gorged with blood, but he pointed 
out accurately what was the precise situa- 
tion of the congestion. lie showed that 
the gorged parts were the vessels of the 
right side of the heart and the pulmonary 
artery in the roots of the lungs, from the 
right side of the heart to the smaller 
branches ; and that the smaller vessels, 
the pulmonary capillaries, the pulmonary 
veins, and the left side of the heart, were 
nearly empty : in fact, that the blood was 
not arrested in the capillaries of the lungs 
as in common asphyxia, but in the arte- 
ries short of them. On section there was 
free bleeding from the roots of the lungs, 
but there was little or none in the peri- 
pheral parts ; they were generally ex- 
sanguine. He says : " On cutting through 
the roots of the lungs a quantity of blood 
usually escaped from the divided vessels, 
and particularly from the pulmonary ar- 
tery ; in one case the quantity of this was 
two pints, in one case one pint, in one 
twenty-four ounces, in one three ounces, 
in one six ounces, and in nine between 
two and five ounces. In fourteen cases 
the lungs were completely collapsed, ap- 
pearing in some cases like the lung of a 
foetus. In three cases they were con- 
siderably, in eight slightly, collapsed ; 
and in the remaining fourteen cases the 
collapse was in some cases altogether and 
in some partially prevented by old adhe- 
sions." The absence of blood in the 
tissue or substance of the lung was gener- 
ally pretty complete, though in some in- 
stances there was more redness in the 
periphery than in others. The small 
amount of blood in the lungs seems proved 
by their deficient weight. Thus, he found 
that the average weight of fhe right lung 
in twenty-two Europeans was fourteen 
ounces, and of the left twelve ounces six 
drachms. Dr. Clendinning gives the 
average weight of both lungs at forty-six 
ounces, and Dr. Reid at forty-three ounces, 
showing a deficiency in the Cholera cases 
of fifteen to nineteen ounces. The lung 
tissue was flabby, with little crepitation 
when not collapsed, so that it may be con- 
sidered to have been in an extremely 
anaemic state, owing to an arrest of blood 
before it had reached the capillaries and 
smaller arterial twigs. The color of the 
lung on section was pale or dark, or an 
admixture of both. Some writers report 
a congested state of the posterior parts of 
the lungs ; probably from hypostatic con- 
gestion. The right side of the heart was 
generally full ami distended, the blood co- 
agulated, but not firmly. Parkes found 
the blood incoagulable in rather more 
than one-fourth of his cases. The left 
side of the heart was nearly empty, or 
containing only a little black blood with a 
few loose coagula. In following out the 
situations of congestions we find that 
the larger hepatic veins and the branches 
of the portal vein, generally those leading 
from the stomach, duodenum, and small 
intestines and their small ramifications, 
are full both on the mucous and peritoneal PATHOLOGY. 
411 
surfaces of these organs. The blood is 
generally of dark color, but tur s brighter 
on exposure to the air, or to the action of 
the matter in the small intestines. The 
chemistry of the blood has already been 
alluded to. There is some difference of 
opinion as to the state of the coagulability 
of the blood. Parkes, Virchow, Briquet, 
and Mignot have noticed either that it 
coagulates imperfectly, or that there is a 
loose state of the coagulum in the great 
vessels. I think that I have generally 
observed the same. Dr. Gairdner, how- 
ever, says that the coagulation in the ves- 
sels takes place much as in other diseases. 
In the lungs themselves there is little 
change beyond those due to distribution 
of the blood and the collapse of the lung 
tissue. The muscular tissue of the heart 
is generally found rigid or firm. 
Abdomen.-The visceral peritoneum is 
generally much congested ; the venous ca- 
pillaries darkish, becoming bright after 
exposure to the air; the surface duller 
than natural, and sometimes bedewed 
with a slimy moisture. 
Stomach and Intestines.-Mucous mem- 
brane sometimes congested. Mucous 
membrane of small intestines often much 
injected with fine arborescent vascularity. 
There is little organic change in the 
coats; the mucous membrane may seem 
(edematous, and the folds rendered prom- 
inent. Boehm pointed out the promi- 
nence of the glandular structure of the 
mucous membrane of the small intestines, 
and notably of the lower part of the ileum. 
Thus, Peyer's patches and the solitary 
glands are often enlarged, the solitary 
more decidedly than the agminated 
glands. Ulceration not observed in sim- 
ple cases. Occasionally patches of a slight 
grayish exudation have been noticed. 
These have been called diphtherial. If 
the exudation in throat diphtheria is to 
be taken as the pattern, I should hardly 
call the name a good one. These patches 
are not easily removed, as the diphtherial 
layer is from the throat. The exudation 
in Cholera seems more like the granular 
patches which are sometimes seen in the 
lower three or four inches of the ileum in 
severe cases of dysentery, and in a more 
highly developed form in the drab-colored 
granular patches in the colon in dysen- 
tery, and which cannot be removed with- 
out some disintegration of the superficial 
part of the membrane on which they lie. 
This appearance is rare in Cholera. In 
many cases of Cholera, however, there is 
little or no congestion or decided morbid 
change discoverable on examination of 
the mucous membrane or glandular struc- 
ture. The contents of the intestines have 
already been described. They may fill 
the intestines completely, or they may be 
but a small quantity, the consistence va- 
rying from that of an ordinary Cholera 
stool to a creamy or pasty, gritty-looking 
grayish mass, or fluid mixed with gelati- 
nous or fibrinous lumps or flakes, more or 
less adhering to the intestines. There is 
sometimes, but not often, a tinge of yel- 
low, and sometimes, though rarely, a 
large quantity of grumous blood without 
any kind of ulceration being traceable. 
Colon.-In the majority of cases an ab- 
sence of injection of the vessels. In a 
small number there is venous congestion, 
seldom general, but in patches. The mu- 
cous membrane is not so cedematous as 
that of the smaller intestines, though it is 
sometimes somewhat swollen. There is 
not much epithelium mixed up with the 
contents. In some rare cases large ecchy- 
moses, leading to gangrene of the mucous 
membrane, have been seen. 
Liver.-Great venous trunks generally 
full of viscid blood. The parenchyma 
pale and flaccid, and often smaller than 
natural, with some but not constant 
wrinkling of the capsule. There is not 
often general congestion of the organ. 
Microscopic appearances normal. Gall- 
bladder generally full of bile. 
Spleen generally smaller and more flac- 
cid than natural. Some writers have de- 
scribed both the liver and the spleen as 
being congested, but this does not seem 
to me by any means frequently the case. 
Pancreas mostly natural. The mesen- 
teric glands are often enlarged or pale. 
Kidneys.-These are generally congest- 
ed, the veins, especially of the papillae, 
extending outwards into the cortical sub- 
stance, which is enlarged. The epithelium 
is generally natural in shape, very granu- 
lar, probably from some protein deposit. 
Brain and Membranes.-Nothing spe- 
cial or different from the condition in 
many other diseases in 'which the brain is 
not directly involved. 
In summing up the post-mortem ap- 
pearances in collapse, we find an altera- 
tion in the consistence of the blood ; and 
that some of the great internal veins and 
the pulmonary artery are loaded with it; 
a great deficiency of blood in the capilla- 
ries generally except in the majority of 
cases in those of the intestines and kid- 
neys ; generally some prominence of the 
glandular structures of the intestines, and 
post-mortem displacement of the epithe- 
lium of the small intestines, and in many 
instances collapse of the lung tissue. 
[Besides these appearances, many ob- 
servers have reported finding the left side 
of the heart (if examined a few hours after 
death) firmly contracted ; the gall-bladder 
full of bile ; the urinary bladder contracted 
and empty. Dr. George Johnson has as- 
cribed the asphyxia and collapse to a 
spasmodic constriction of the pulmonary 
artery ; causing anaemia of the lungs, and 
deficient aeration of the blood. That this 
is a part of the pathology of the attack, is 412 
EPIDEMIC CHOLERA. 
almost certain ; but there is good reason 
to believe it to be only a part of a general 
affection of the involuntary (as well as 
voluntary ) muscles, under the influence of 
the materies morbi upon the nerve-centres 
of organic life and the spinal cord.1-H.] 
(b) In lieaction Stages.-The morbid ap- 
pearances vary with the nature of the 
secondary causes of death. It will not 
be necessary to give a full description of 
these changes. In the cases of death in 
imperfect reaction they do not vary much 
from those found in collapse, except per- 
haps that there may be more general con- 
gestion of the lungs, more decided promi- 
nence of the glandular structures of the 
small intestines, and injection of the in- 
testinal mucous membrane. 
In persons dying of some of the con- 
secutive febrile conditions, the intestines 
and stomach are often found vividly in- 
jected, the mucous membrane softened. 
The colon sometimes participates in this, 
and the mucous membrane is sometimes 
cedematous and thrown into folds, and 
the so-called diphtheritic exudations are 
met with. In some of the cases not 
marked with symptoms referable to the 
alimentary canal there is less congestion 
and oedema of the small intestines, as has 
been noticed by Reinhardt and Leubus- 
cher. 
In the uraemic cases the kidneys, when 
death appears early, are full and large, of 
purplish color, dripping blood on section ; 
in the latter periods pale, perhaps (edema- 
tous, infiltrated with granular matter of 
pale color ; are easily torn, and the epithe- 
lial tissues more opaque than natural, and 
filled with granules mixed with oil-glob- 
ules. The kidneys are somewhat similar 
to those in cases of scarlatina. In other 
organs the appearances are like those of 
ordinary acute uraemia. Secondary in- 
flammations having sometimes existed, 
we may find evidence of them in the tis- 
sues affected. Urea is found in the blood 
in considerable quantities. Dr. Garrod 
found as much as 1*14 part per 1000. It 
is readily found in blood collected from 
the right side of the heart. 
The other changes possess no special 
characters. There may be signs of low 
inflammation of lungs, pleura, pericar- 
dium, and peritoneum, and of much con- 
gestion of the lungs. The brain and 
membranes sometimes full of blood, as in 
low fevers, in which the blood is in fault. 
The blood coagulates loosely. Of course to 
these must be added gangrenous patches, 
bedsores, ulcers, ulcerated cornea?, boils, 
suppurated or swollen parotid glands, gan- 
grene of lungs, ecchymoses, and purpuric 
or scorbutic patches, which occur occa- 
sionally. 
Pathology During Life.-From the 
study of Cholera as shown in the symp- 
toms and post-mortem appearances, we 
pass to an attempt to account for them. 
In the section on Etiology the nature of 
the cause has been discussed. We have 
now to suppose that a poison has entered 
the blood in some manner, either by the 
channel of the lungs or intestinal surface. 
The poison acts through the blood, pos- 
sibly in the manner of a ferment; but we 
do not know whether it acts by a catalytic 
influence on the blood mass, or whether it 
multiplies itself in the blood, or not; we 
are very much in the dark. However, if 
we cannot trace the minute action of the 
poison we are able to guess at some of its 
effects. It appears that at least two great 
sets of capillaries and small arteries are 
involved in them : those of the lungs and 
intestines. They seem to be very differ- 
ently influenced by it. In the lungs very 
little of the blood passes freely through 
them in the algide stage. In the intes- 
tines an enormous quantity of certain of 
the blood elements passes through the 
capillary walls in the exudation period. 
In both of these sets of actions, parts of 
the nervous system appear to be under a 
morbid influence. In the lungs the mus- 
cular fibres of the small arteries seem 
thrown into a state of contraction. In 
the intestines a sort of paralysis of the 
smaller arteries and capillaries seems to 
exist, much as occurs in the sections of 
the sympathetic nerve in the neck in Ber- 
nard's experiments. That the morbid 
action in the lungs is of nervous charac- 
ter seems probable from the absence after 
death of any discoverable mechanical ob- 
stacle to the passage of the blood, from 
the paroxysmal nature of the dyspnoea at 
first, and from the ease with which the 
pulmonary circulation is re-established 
when recovery begins. The nervous cha- 
racter of the actions in the intestines 
seems probable from its analogy with 
the results of Bernard's experiments on 
the sympathetic, in some of which a sec- 
tion of that nerve in the neck caused the 
[! "The bloodvessels of the whole alimen- 
tary canal press rigidly upon their contained 
fluid, and force its serum out into the stomach 
and bowels; whence it is, by spasmodic ejec- 
tions, thrown out. The very skin is, by its in- 
voluntary muscular fibres, as well as by vas- 
cular constriction everywhere, drawn tightly 
and closely upon the body. The voluntary 
muscles suffer with cramps. All is cramp, 
cramp, within and without. The brain is 
almost in anaesthesia during the collapse-no 
delirium, but apathy-as from cerebral anae- 
mia. The blood, so compressed, grows thick 
as tar-it scarcely flows, is not aerated, and 
cyanosis follows ; it is detained in the capil- 
lary net-works of the interior organs, in 
which congestion is found after death. Cholera 
is, then, a poison-spasm; a ganglionic tetanus." 
Essentials of Practical Medicine, 4th ed., p. 
400.-II.] PATHOLOGY DURING LIFE. 
413 
surface of the skin supplied by the vessels 
under its influence to become bathed in 
sweat. It is a matter of dispute whether 
the disturbances in the lungs and the exu- 
dation through the intestinal walls are 
both effects of the poison, or whether, 
exudation into the intestinal canals hav- 
ing taken place, the pulmonary symptoms 
may not be due to the altered condition 
of the blood, caused by its being inspis- 
sated through the exudation of so much 
of its fluid and saline elements. It must 
be granted that symptoms similar to col- 
lapse may be produced by poisons with- 
out any purging. I have seen people un- 
der the influence of malarious poison in 
Calcutta lie for hours as cold and pulse- 
less, and as embarrassed in the breathing, 
as in Cholera. In gangrene, too, a some- 
what similar condition may come on. It 
appears, then, that symptoms similar to 
those of the cold stage of Cholera may be 
produced in certain diseases without any 
exudation or loss of fluid from the blood. 
Nevertheless, it is doubtful whether we 
can say positively that exudation is not 
necessary to produce the collapse in Chol- 
era. It is true that it is said that some 
of the most rapidly fatal cases of Chol- 
era are those in which there is no purging, 
and that therefore we must seek for some 
other cause of the algide stage. But it 
does not follow, that because there was no 
purging there was no exudation into the 
intestines. The exudation is sometimes 
poured out, and retained there, and we 
should never for a moment confound tran- 
sudation with purging. In numerous in- 
stances in which there has been an absence 
of evacuations, post-mortem examination 
has shown the intestines to be full of fluid. 
In others, the symptoms of full collapse 
have come on before the vomiting and 
purging. Among these a remarkable case 
occurred in the Middlesex Hospital, and is 
reported by the Committee for Scientific 
Inquiries in the Cholera epidemic of 1845. 
A child was admitted in a state of col- 
lapse, having had only one motion and 
vomited a little. Soon after admission it 
was copiously purged. In this, as in the 
other cases, the exudation had taken place, 
but had been retained, and but for the 
evacuation, after the algide stage had 
fully formed, might have been set down 
as a case of collapse without transudation. 
In many cases reported to have died or to 
have passed into collapse without evacua- 
tions, we find the symptoms before col- 
lapse to have been similar to those caused 
by some drain upon the system, as has 
been mentioned under the head of "Va- 
rieties" of the disease. It certainly is 
not common for the practitioner in India 
to meet with these cases of absence of 
evacuations. Every now and then one 
hears the patient's friends say that such 
an one threw up a little water from his 
mouth and sank into collapse, or died at 
once ; but in actual practice they are not 
often met with face to face, as far as my 
experience goes, Further careful observa- 
tions are required to be made upon these 
cases, in which after death the contents of 
the intestines should be measured. It 
may after all turn out that the supposed 
absence of discharges may be in cases in 
which there is retention and not absence 
of exudation. The rapid improvement 
that follows injections into the veins in 
collapse strongly supports the view of the 
dependence of this upon the loss of fluid 
from the blood. It is hardly possible that 
this resuscitation of the patient from the 
depths of exhaustion can be accounted 
for, as Dr. G. Johnson contends, by the 
warmth of the injected fluid. Although 
the subject still demands careful observa- 
tion, there seems great probability that 
the collapse has a relation to the transu- 
dation, if not to the purging. The cases 
which at present most oppose the view 
are those in which the body remains 
rather plump in the collapse stage ; but I 
think that in these there is generally lit- 
tle sweating, and therefore there exists 
one drain the less for the superficial capil- 
laries. I am far from denying the ade- 
quacy of the Cholera poison to produce 
the algide stage by its action on the ves- 
sels of the lungs, or by a sedative in- 
fluence upon the centres of circulation 
and respiration, though I think there is 
not yet full or complete evidence of it. 
It has been argued that the vomiting 
and purging are salutary, and that they 
eliminate the poison. It is very question- 
able whether fluxes produced by organic 
poisons are necessarily eliminative of the 
actual poison that was introduced into 
the system, or of its products. Whether 
the exudations in Cholera are eliminative 
or not, there can be but little doubt that 
they are very destructive methods of cure. 
If this purging were beneficial, we should 
expect to see that cases of Cholera with 
preliminary diarrhoea would be slight; 
whereas we often see that a man has 
diarrhoea for a week or more, quite as 
copious as could be produced by a few 
doses of castor oil, and yet these very 
cases often pass into profuse purging, col- 
lapse, and death. Most men who have 
had much experience in Cholera will say 
that when they succeed in checking the 
discharge, before collapse comes on, their 
patients are saved. They justly fear the 
result of active purgative medicines given 
in seasons of Cholera. It is hardly pos- 
sible that experience can have gone quite 
wrong in these matters. We do not 
know how the poison may be eliminated. 
For aught we know, it may be decom- 
posed in some way, and not eliminated at 
all in its entire state. 
In collapse the patient's state is a re- 414 
EPIDEMIC CHOLERA. 
markable one. Circulation is nearly stop- 
ped, and indeed all vital functions reduced 
to a minimum, as shown in the descrip- 
tion of the symptoms. Little or no natu- 
ral chemical action goes on in the system; 
but it does not follow that some chemical 
changes do not go on in the blood itself, as 
they might do out of the vessels at a simi- 
lar temperature, and in prolonged col- 
lapse this may furnish some impurities 
to the many mingling with it. The alter- 
ed density of the blood consequent upon 
the loss of so much water must have 
brought about many changes, involving 
both the intercellular fluid and the blood- 
globules, and materially affecting the re- 
lations between them. Schmidt supposes 
that after about thirty-six hours the mor- 
phological elements of the blood are nearly 
one-half more than the normal propor- 
tion. The proportion of inorganic salts 
is not increased, except perhaps for the 
first four hours, during which the water 
passes out more rapidly than the salts; 
after eighteen hours they sink much be- 
low the natural standard, and still more 
in thirty-six or forty-eight hours. The 
result is that the proportion of albumi- 
nates in the blood-globules is increased by 
one-half, and in the intercellular fluid to 
double of what would be normal. He 
considers that the solids are retained in 
the vessels with more force than the wa- 
ter, the organic solids with more force 
than the inorganic, the phosphates with 
more than the chlorides, and the salts of 
potash with more force than the salts of 
soda. In the exosmosis from the globules 
into the intercellular fluid, he supposes 
that the same laws of the succession of 
diffusion of their contents prevail; the 
chlorides of the alkalies being the first 
salts to transude both from the intestinal 
capillaries and from the blood cells into 
the liquor sanguinis. It is probable that 
the blood, thus altered in the relations of 
its component parts one to another, does 
not recover its natural state at once, even 
after fluid has been absorbed into it during 
the reaction stage, and that the abnormal 
state thus produced may help to cause 
some of the consecutive disturbances. 
[Amongst others, Binaghi, Loder, Or- 
ton, Delpech, Lizars, "Coste, Favell, 
Greenhow, G. Johnson, and C. W. Bell 
have called attention to the indications of 
disturbed ganglionic innervation in Cho- 
lera. Dr. C. W. Bell's expression is, that 
it is not an adynamic, but a sthenic 
(spasmodic) collapse.-II.] 
In healthy reaction, full purification of 
the blood by the liver, kidneys, and in- 
testinal surface occurs, and this is pro- 
moted by free absorption of water ; and 
the normal composition of the blood is 
further brought about by absorption of 
the saline matter still lying in the intes- 
tines or administered purposely. Dr. 
Morehead has observed that the more 
rapid the reaction without return of the 
secretions, the greater the probability of 
secondary fevers, &c. Doubtless, the 
more rapid the reaction the more rapid 
the tissue changes, and the more rapid 
the accumulation of effete matter in the 
blood ; and hence the greater urgency 
that there should be free secretion and 
excretion. Some writers attribute the 
consecutive morbid actions, or at any rate 
a great part of them, to the stimulants 
wrongly given in the collapse stage. In- 
judicious stimulation and drugging may 
certainly still further poison the blood by 
themselves, or, by inducing over-speedy 
reaction, they may assist in bringing on 
fevers ; but 1 have seen a very large num- 
ber of people suffer from secondary evils, 
who have undergone no treatment what- 
ever, and am convinced that the natural 
progress of the disease is, of itself, suffi- 
cient to bring them on. Judged by the 
coloring matter in the intestines, the func- 
tions of the liver appear to be more readily 
restored than those of the kidneys. Dis- 
turbances of the liver are rarer than those 
of the kidneys. We can scarcely expect 
the secreting functions of any of the organs 
to be restored immediately under any cir- 
cumstances, and some hours must be 
allowed for the return of normal action. 
Prolonged cessation of urinary secretion, 
of course, ends in coma and death. In 
some of these cases the worst symptoms 
may be delayed by the urea being ex- 
creted through the surface of the intes- 
tines and stomach. It is probable that 
in some of the consecutive fevers, without 
there being a suspension of the separation 
of the urea, there may be some diminution 
of the amount passed in the twrenty-four 
hours, and there may be at the same time 
a loading of the blood with creatine, crea- 
tinine, and other effete matters. To some 
of the forms of blood-poisoning are due the 
parotid swellings, purpuric spots, boils, 
and aplastic inflammations of various 
parts. To the deficiency of available ele- 
ments in the blood is due the defective 
nutrition of the cornea, and perhaps the 
gangrenes. I have not seen any reason 
to suppose that any of the last are caused 
by embolism. The causes of the dyspnoea 
may be two-spasm, or constriction of the 
smaller branches of the pulmonary artery 
and collapse of the lung tissue. It is pro- 
bable that constriction of the arteries may 
frequently be the cause, especially in the 
instances in which the embarrassment is 
temporary and paroxysmal, one set of ar- 
teries being contracted at one time, and 
one at another, in areas of varying sizes. 
It seems likely that the permanent dysp- 
noea may be caused by collapse of the lung 
tissue, especially in the later stages of the 
disease. Collapse of lung tissue is not 
necessarily permanent, but the solidified PROGNOSIS-TREATMENT. 
415 
part would probably continue unexpanded 
in the feeble inspiration of the stage of 
exhaustion, if any considerable area of the 
lung were affected. 
The purpuric conditions, besides the 
causes already mentioned, may be pro- 
duced by large doses of calomel. When 
this was used in scruple doses to check 
vomiting, it was not uncommon to give 
two or three such doses. One can imagine 
that forty or fifty, or even fewer, grains 
of calomel, accumulated in the stomach 
or intestines, might be absorbed in reac- 
tion, and be ready to add its liquefactive 
action to the other blood-dissolving agents 
already at work. Cases of this sort, which 
I have seen, have made me cautious 
about the use of large doses of mercury in 
Cholera. 
The ansemia and debility which suc- 
ceed Cholera are readily accounted for by 
the profound disturbance to which all the 
blood elements have been subjected, and 
which may destroy blood-globules, or in- 
terfere with their renewal. 
Chronic diarrhoeas and dysenteries may 
depend upon the irritation which has been 
set up in the small and large intestines 
respectively ; producing in some instances 
ulceration and softening of the mucous 
membrane. The softening of ecchymosed 
blood may also produce symptoms of diar- 
rhoea or dysentery, by giving rise to 
patches of inflammation or disintegration 
of the mucous membrane. 
I once saw a case of chronic albuminuria 
which appeared to have originated in an 
attack of Cholera a year previously. 
hours, refreshing sleep, and tolerance of 
food and drink. 
Unfavorable signs. - Quick disappear- 
ance of pulse from the radial or brachial 
arteries, early embarrassment of respira- 
tion, and lividity of surface, profuse sweat- 
ing. In the lieaction Stage: Suppression 
of urine, advent of typhoid symptoms, 
bloodshot eyes, secondary inflammations. 
Coma is always dangerous. Want of pro- 
gress in the symptoms of improvement, 
and continuance of diarrhoea or vomiting, 
are unfavorable. Pink or bloody stools or 
hemorrhage from the stomach are almost 
always fatal signs. Disproportionate 
muscular strength without corresponding 
improvement in other functions is not 
necessarily favorable. Allusion has al- 
ready been made to this under the head 
of " Varieties." 
Treatment.-This is most successful 
when commenced early; before collapse. 
In full collapse it is pretty certain, as 
remedies cannot be absorbed, that they 
cannot be of much use. Still, it must not 
be supposed that all treatment is useless 
in Cholera, or even that it is useless in all 
the states of the stage of collapse. It can- 
not do much good in perfect and complete 
collapse, but in all the other stages of the 
disease it is as beneficial as in any other 
severe and dangerous illness. Excluding 
collapse, judicious management, free from 
routine, and adapting the treatment to the 
individual case, is of great importance. 
Cholera is not merely a disease of vomit- 
ing and purging ; and this will have been 
apparent from the foregoing pages. 
The treatment should be considered in 
relation to the evacuation, collapse, and 
reaction stages. 
Evacuation Stage. - The discharges 
should be checked, if possible. I believe 
that the great object of treatment is to 
restrain the passage of exudation from 
the blood into the intestines. The reme- 
dies used for this generally check the 
vomiting and purging, so that in the con- 
dition of these, taken with the state of the 
pulse, we have a sort of indication of the 
degree in which the transudation is inter- 
fered with ; a sort of indication, because 
there is not always any close relation be- 
tween the time of the transudation and 
the discharges from the bowels. The first 
medicine given should be a full dose of 
opium-to an adult 2 grains ; in India, 1 
to 5 grains of calomel are generally com- 
bined with it. I do not know that the 
calomel does good ; it does no harm. If 
this dose is retained, probably little more 
medicine will be required. We must not 
expect the purging to cease immediately 
that the medicine is swallowed. Perhaps 
one or two motions will pass away after 
the dose has been,given. Soon after the 
opiate, if it has been retained, say in half 
Prognosis.-Favorable signs.-In the 
Diarrhoeal Stage: The not passing rapidly 
into collapse, the pulse keeping some 
strength, the countenance being tranquil 
and natural. In some cases the prolonged 
diarrhoeal stage may be fatal without col- 
lapse. These are probably choleraic diar- 
rhoea.-In the Collapse Stage: The col- 
lapse not becoming deep, the pulse re- 
maining in the brachial, respiration 
tranquil or not much embarrassed, with- 
out deep lividity, the algide period not 
lasting beyond six or eight hours, the ces- 
sation of jactitations, and the tendency to 
quiet dozing or to snatches of easy sleep, 
gradual return of circulation, progressive 
improvement in strength even if gradual, 
milkiness or grayness of stools. The con- 
tinuance of scanty stools is not of much 
importance; if the belly is at all tumid, 
they are advantageous, because they free 
the intestines of matter already exuded 
into them. The more mucous and gela- 
tinous they are, the better it is that they 
should pass away. Cessation of vomiting 
and purging without reaction after a little 
time is not important.-In the Reaction 
Stage: Early establishment of the secre- 
tions, within twenty-four or thirty-six 416 
EPIDEMIC CHOLERA. 
an hour, in my own practice I give an as- 
tringent, generally the following mixture : 
-B. Plumbi acetatis, gr. xxx; acid. acet. 
1T[x; aquse distillatae, gvj-1 oz. or £ oz. 
every half-hour or hour. At the end of 
an hour from the administration of the 
first dose of opium, if the purging persists, 
I give one grain of opium and continue 
the astringent. The sugar of lead mix- 
ture may be given every half-hour or hour, 
if the purging continues smartly; but if it 
seems inclined to cease, and the pulse 
keeps good, the mixture may be left off, 
or given at wider intervals. It is neces- 
sary that the medicines should be present- 
ed to the stomach in the simplest and 
least irritating form. In the form of pill, 
opium is probably more easily retained 
than laudanum, which often nauseates ; 
but when a pill is not at hand, forty min- 
ims of tincture of opium should be given 
in a little cold or iced water, or in a little 
brandy. The acetate of lead mixture is 
nearly tasteless, or may be made so by the 
addition of a little iced water. Dr. 
Graves's acetate of lead pills may be given 
instead of the mixture, but are probably 
less active than the liquid medicine. 
These pills are made as follows:-Acetate 
of lead, 20 grains, opium, 1 grain, divided 
into twelve pills, of which one may be 
given every hour. It would be better to 
increase the lead to 2 or 2| grains in each 
pill. Tannin or gallic acid may be given 
instead of the lead, but they are more 
likely to cause sickness. If the above 
medicines check the discharges, all danger 
will probably be over in a few hours. 
Consecutive disease is not likely to follow 
such a simple case. When there is vomit- 
ing there is more difficulty. The pill 
should be given as before. If rejected in 
the course of a few minutes, we shall 
probably find it in the discharges. It will 
be well to wait ten to fifteen minutes be- 
fore giving more opium, and (while wait- 
ing) to apply a large sinapism to the epi- 
gastrium. If we are satisfied that the 
first pill has been rejected, we should re- 
peat the dose of two grains in about a 
quarter of an hour after the vomiting. If 
We are uncertain of this, we should in half 
an hour give one grain only. After re- 
moval of the sinapism, if the stomach is 
quiet, the acetate of lead should be given 
in mixture or in pills. Perhaps half-doses 
of the mixture may be retained if the full 
quantity is not. When the stomach is 
very irritable, a solution of half a grain of 
muriate of morphia may be injected hypo- 
dermically. When simple opium cannot 
be tolerated by the stomach, hydrocyanic 
acid and other anti-emetic drugs are rare- 
ly more efficacious. Stimulants are not 
wanted in this stage unless the pulse be- 
gins to flag; then a little brandy and 
water, or, better still, iced water, should 
be given, a teaspoonful or two at a time. 
Champagne is sometimes tolerated, when 
other wines are not retained. In the ma- 
jority of cases a little brandy diluted with 
ice dissolved in it, or with plain cold 
water, is the best stimulant. Cramps are 
generally relieved by friction with chloro- 
form, or with the hand ; if severe, by the 
inhalation of small quantities of chloro- 
form. The doses of opium recommended 
may of course be modified. If the symp- 
toms are mild, one grain may be given in- 
stead of two. Some prefer to give smaller 
doses every half-hour or hour, but it seems 
better to give a decided dose at the onset, 
and not repeat it often, and not to give 
more than three grains in all, within the 
first three hours, unless the medicine has 
been vomited; then the doses should be 
managed so as to make good the quantity 
supposed to have been rejected. As a 
general rule we should limit the quantity 
of opium to three grains and the acetate 
of lead to ten or fifteen grains in the first 
three hours. If the disease should show 
signs of yielding, we can diminish the 
doses, or stop them altogether. In some 
cases, if collapse does not come fast, the 
evacuations still proceeding, the opium 
may be continued in half-grain or grain 
doses about once in three or four hours 
for two doses, beginning three hours after 
the third grain has been given. The lead 
mixture may be continued in half-ounce 
doses every two hours for five or six doses 
if necessary. When the collapse is pro- 
gressive, no opium should be given after 
the third grain, and, indeed, if it seems 
to be approaching fast even the third 
grain should be withheld. 
[A method of treatment which met 
with encouraging success in Philadelphia 
in 1849, and in succeeding epidemics, as 
well as in Columbia, Pa., in 1854, was 
what may be best called antispasmodic 
medication. It was first suggested by the 
late Prof. W. E. Horner, of the University 
of Pennsylvania. It consisted in the ad- 
ministration every five minutes, in incipient 
collapse, of small doses of chloroform, 
laudanum, camphor, and ammonia ; each 
dose being accompanied by a small piece 
of ice to promote its retention by the 
stomach. At the same time sinapisms 
were applied to the epigastrium and back, 
and the limbs were rubbed with whisky 
and red pepper, to produce reaction. A 
number of cases were, by this treatment, 
restored from a well-developed state of col- 
lapse. It is difficult for me, after practical 
acquaintance with this mode of treatment 
and its results, to believe that any other 
method of practice can be more promising 
in Cholera.1-H.] 
[' Dr. Hodder, of Toronto, in 1850, injected 
several ounces of strained milk into the veins 
of three moribund cholera patients. Two of 
them recovered.-H.J TREATMENT. 
417 
Collapse.-When this is complete, opium 
should be entirely avoided, and sugar of 
lead would be useless. The exudation is 
probably quite stopped, and the evacua- 
tions now passed are merely residues of 
matter previously poured into the canal, 
and add nothing to the danger or exhaus- 
tion of the patient. In the worse stages 
of collapse, stimulants are of little avail. 
2Ether and ammonia properly diluted 
may do no harm. If they can be retained, 
small doses may be given every half hour. 
A little weak brandy and water is some- 
times retained better than any other 
stimulant. But the administration of 
stimulants in the stage of collapse requires 
great care and discrimination. If they 
are of use, they make themselves felt in 
the pulse. If it revives under them, ever 
so little, and falls back or disappears in 
their absence, they may be continued 
cautiously; otherwise they, or at all events 
the alcoholic stimuli, should not be per- 
severed with. The dependence of the 
pulse upon the stimulants is certainly 
sometimes seen. Unfortunately, if stim- 
ulants, such as brandy and wine, do not 
act beneficially, they are likely to be 
hurtful in the after stages. A large quan- 
tity of them may be collected in the 
stomach or intestines, and when absorp- 
tion begins they may be taken up into the 
circulation, causing undue rapidity of re- 
action before secretions can be formed, 
and so adding to the mischief already at 
work in the blood. So that we may be 
pretty sure that if they do not work for 
good they will be hurtful. Nothing is 
more pernicious than the system of pour- 
ing large quantities of brandy into a pulse- 
less patient in Cholera. Sometimes when 
the irritability of the stomach has gone off 
he will, in the course of two or three 
hours, swallow a large quantity of brandy, 
water, sether, ammonia, sago, wine, &c., 
and the friends perhaps congratulate 
themselves upon the quietness of the 
stomach; the pulse remaining absent 
nevertheless. In the course of time the 
patient grows very uneasy, and presently 
vomits the whole accumulation, perhaps 
two or three pints. Such cases as these 
show the uselessness of overloading the 
stomach in the torpid condition in which 
the patient is in collapse, and what a re- 
servoir of mischievous elements may be 
provided against the return of the circu- 
lation. We often see cases in which 
stimulants, mixtures, &c., are given and 
as constantly vomited. These are often 
instances of too much medication. The 
irritable stomach is made more so by the 
drugs, and on leaving these off the vomit- 
ing ceases. The dependence of the vomit- 
ing upon the time of giving the doses 
should always be inquired into. We 
ought not to take it for granted that the 
vomiting is always the effect of the disease ; 
it may, and I have so seen it scores of 
times, be due to the administration of 
remedies. A few teaspoonfuls of brandy 
and water and a few doses of sether and 
ammonia will do no harm in the pulseless 
state, but it is vain to expect to do good 
by constantly pouring them down the pa- 
tient's throat. The best thing for him in 
the stage of full collapse is to gratify 
pretty freely his instinctive desire for cold 
water. This cannot do harm.: a little 
may run off by the bowels, or be vomited, 
but if any remains to be absorbed in the 
reaction stages it will have the best possi- 
ble effect. It is of no use to keep up the 
patient's vomiting by giving him as much 
as his morbid thirst impels him to swallow; 
but a considerable quantity may be given 
in the course of two or three hours by 
tablespoonfuls or wineglassfuls at a time ; 
the colder the better. If ice be available, 
it will be better to give iced water, or to 
place pieces of clear ice in the patient's 
mouth frequently. This quenches his 
thirst and seldom causes vomiting. There 
need be no restriction placed upon the 
quantity of water given beyond that it is 
advisable not to provoke too much vomit- 
ing by it. Although I have urged the 
uselessness, nay mischief, of pouring down 
drugs and stimulants into a patient in the 
state of perfect collapse, there are certain 
conditions of collapse in which when 
given cautiously they may be of great use. 
The cases are those in which collapse is 
not perfect, in which the circulation still 
goes on, though feebly, throughout the 
algide stage. In these the volatile stim- 
uli, aether and ammonia, in mixtures, and 
weak brandy and water, are certainly 
beneficial. They maintain the strength, 
as they do in any other diseases with ex- 
haustion. Ten to twenty drops of liquor 
ammonia, or thirty of sulphuric aether 
properly diluted with iced water or cold 
water, given every half hour or hour, with 
an occasional tablespoonful of brandy and 
water, may be continued while the pulse 
seems to be maintained by them. In 
these cases the Cholera mixtures and 
Cholera pills so often used in India are of 
service. They are made up in various 
ways, but contain generally such stimu- 
lants as aether, ammonia, tincture of cam- 
phor, and essential oils, as cajeput, aniseed, 
cinnamon, peppermint, &c., or some of 
them. Most of them also contain lauda- 
num, but it would be better to omit this, 
and add it to the dose when considered 
necessary. Cholera pills can be made of 
camphor, two grains ; asafeetida and long 
pepper, each one grain, with a little muci- 
lage. A pill should be given every one 
and a half or two hours. They are useful 
in the same circumstances that the Cholera 
mixtures are. When acetate of lead has 
been used as the astringent, the liquor 
ammonia should be used in preference to 
vol. I.-27 418 
EPIDEMIC CHOLERA. 
the carbonates of ammonia, or their pre- 
parations. It will be observed that the 
principles advocated in the use of stimu- 
lants are that we should be guided in the 
administration by the pulse. While that 
remains, absorption and other vital ac- 
tions go on, although perhaps in a dimin- 
ished degree; and while these continue, 
stimulants may assist the patient through 
the crisis, and may prevent his passing 
into the pulseless state. The volatile and 
diffusible stimuli are less pernicious than 
alcohol, but a small quantity of the latter 
is useful, and should be occasionally given. 
There are few persons to whom three 
ounces of brandy may not be safely given 
during eight or ten hours if their circula- 
tion responds to it,-in some cases even 
more, but probably not often. As soon 
as it is found that the pulse maintains it- 
self without them the stimulants should 
be withdrawn ; the alcoholic first. Ad- 
ministered in this way they will not do 
harm ; they are taken into the system by 
degrees, and their action is spread over a 
sufficient space of time, and they thus act 
very differently than they might do if 
allowed to accumulate in large quantities 
in the stomach, to be absorbed all at once 
and added in mass to the blood when the 
circulation is renewed. Many of the ex- 
treme collapse cases will come round by 
themselves as 'well as or better without 
stimulants than with them, and, therefore, 
we must not suppose that we are accele- 
rating death by leaving the patient to 
cold water in such cases. For the sake of 
trying whether the pulse can be roused 
we may give a little stimulus now and 
then, taking care that the total quantities 
given shall be too small to do harm. I 
have made these observations because I 
think that there is a tendency to consider 
stimulants as inadmissible in the treat- 
ment of Cholera. Much mischief may 
have been done by them sometimes, but 
with due attention to the principles that 
I have mentioned for both opium and 
stimulants I think that good, not evil, 
may result. The discriminating use is 
very different from the abuse of remedies. 
The profuse perspiration should be 
rubbed off the surface with a dry soft 
towel. In the Indian hospitals dry gin- 
ger powder is often used with friction for 
absorbing the moisture. If used, care 
should be taken that the powder is impal- 
pable, and free from grit or dirt; other- 
wise troublesome excoriations will ensue. 
Cramps are, as in the earlier periods, 
soothed by friction with turpentine and 
chloroform. Even in great debility, mod- 
erate chloroform inhalations may be used 
without increasing the weakness of the 
pulse. Food will not be borne, except, 
perhaps, in the prolonged cases of semi- 
collapse, but when signs of reaction ap- 
pear, a little beef-tea or chicken broth 
may be given. Starchy matters are apt 
to generate gas, but sometimes a little 
sago or gruel may be given with advan- 
tage, as they lubricate the coats of the 
stomach. When the pulse is very weak, 
in cases in which stimulants are given, a 
little port wine may be added to the sago 
or arrowroot. 
Warm baths, or vapor baths, or medi- 
cated wet sheets, are of no use, and the 
patient is so restless, and throws himself 
about so much, that it is difficult to apply 
them. 
lieaction Stages.-If the patient is re- 
gaining strength, and his secretions re- 
turn, there is little to be done. He is best 
left to nature, a little liquid food, and cold 
water. To compensate for the loss of sa- 
line matter from the blood, a little com- 
mon salt should be added to his food, and 
he may occasionally take a draught of 
water to a pint of which a drachm of car- 
bonate of soda is added. This last also is 
grateful to the patient when he has heart- 
burn or heat of stomach. It is not neces- 
sary or desirable to give a dose of aperient 
medicine within the first few hours of re- 
action in order to promote the secretions. 
The officious use of purgatives and mer- 
curials, too soon, often brings on a re- 
lapse. If the bowels are confined, and 
there is tension and uneasiness, a warm 
water enema-say a quart of water with 
a little asafoetida, or sal volatile, or 
sether-will be the safest remedy. 
Vomiting is often continued in the reac- 
tion stage, and may have been caused by 
the irritation left by frequent previous 
retching, or by excess of stimulating rem- 
edies. In these cases a single dose of 
opium or morphia-say a grain of opium 
■-will often act admirably. It may be 
repeated every four or six hours if the 
vomiting continues. The food requires 
careful management. Sometimes a table- 
spoonful of milk with one of lime-water 
may be given every half-hour or hour for 
the first day or two, or a small quantity 
of ice-water only. It is desirable to give 
the stomach as much rest as possible. In 
some cases the irritation is due to sub- 
acute gastritis, and requires a few leeches 
to the epigastrium-a blister is useful in 
all forms of the vomiting in the earlier 
stages of reaction, and sometimes one- 
half or two-thirds of a grain of morphia 
may be applied to the raw surface with 
excellent effect. Food should not be 
pressed upon the patient. For days he 
may not be able to take more than tea- 
spoonfuls or dessertspoonfuls of milk and 
lime-water, arrow-root, barley-water, &c. 
In some instances it will be necessary to 
trust entirely to nutritive enemata. Ef- 
fervescing draughts with excess of soda 
are sometimes useful, and hydrocyanic 
acid may be tried. 
Diarr/icea, if slight, should not be inter- TREATMENT. 
419 
fered with at first, especially if the evacu- 
ations are at all offensive or bilious. 
Where decided enough to be weakening, 
gallic acid, or tannin, or mild opiates, or 
chalk mixture with carbonate of soda, 
should be given. If there be tenesmus, a 
warm water enema with a drachm of car- 
bonate of soda should be used, and fol- 
lowed after operation by one of laudanum 
and a little water. Turpentine stupes 
should be applied to the abdomen in all 
the states of intestinal irritation. 
Hiccup is frequently accompanied with 
much eructation of gas, and is difficult to 
stop ; it is not dangerous. It may be 
treated by sinapisms to the spine, in the 
cervical and dorsal regions, and by ten 
minims of chloroform in mucilage every 
half-hour, or by chloroform inhalation, by 
morphia, or small doses of belladonna, 
and, if there be acidity, by alkalies. The 
common anti-spasmodics seem to have 
little effect. 
Want of sleep, without pyrexia or heat 
of head, may be relieved by a dose of cal- 
omel and opium, and perfect quiet, hot 
pediluvia, and, if very obstinate, chloro- 
form inhalation. Sometimes a mild dose 
of alterative aperient medicine is bene- 
ficial. 
Imperfect reaction is very troublesome. 
Unless the discharges are arrested, the 
patient will sink in three or four days. A 
small dose of calomel and opium may be 
given. The following astringent mixture 
sometimes arrests the vomiting and purg- 
ing : Gallic acid, 10 grains; tincture of 
opium, 10 minims ; dilute sulphuric acid, 
10 minims ; water, 1 ounce. This should 
be mixed with a little cold or iced water, 
and given every four hours. Turpentine 
fomentations to the abdomen, or sina- 
pisms ; non-irritating food should be pre- 
scribed. Champagne is sometimes useful. 
It is better not to give too much liquid, 
but thirst may be moderately gratified. 
Uraemic Stage.-Purging should not be 
checked in this. It is exceedingly diffi- 
cult to restore the renal secretion. The 
kidneys are gorged with blood abounding 
in urea, their natural stimulus, and yet 
they will not act. When it is seen that 
suppuration exists, the patient should be 
encouraged to drink as much water as he 
can. It is the best diuretic ; and sinap- 
isms, dry cupping, or cupping, should be 
applied to the loins. Ue should take a 
drachm of liquor ammoniae acetatis, half 
a drachm of spiritus aetheris nitrici, and 5 
to 10 minims of tincture of digitalis in 
water, every three hours. The special 
symptoms of uraemia should be treated as 
uraemia generally, and need not be de- 
tailed here. When coma comes on or is 
approaching, it would be advisable, if the 
pulse is firm and good, to try the effect of 
a moderate venesection. This might re- 
lieve the renal congestion. There is no 
more unfavorable state to treat than that 
of approaching head symptoms, with vom- 
iting of grass-green matter, and diarrhoea. 
The discharges are exhausting, and if 
stopped, coma is hurried on all the faster, 
because the urea is to a certain extent re- 
lieved by the evacuations. 
Fevers.-The mild cases require little 
interference. They need only a small 
quantity of nourishing food, not forced 
upon the patient, perhaps a little altera- 
tive and mild aperient medicine, efferves- 
cing drinks with excess of alkali, and 
quiet. The more severe fevers need all 
the attention and prolonged care of severe 
adynamic fevers, and, according to the 
state, stimulants, wine, tonics, and nour- 
ishment ; but there is nothing special in 
the treatment. The same may be said 
of boils, gangrenes, inflamed parotids, 
sloughing cornese, purpura, &c. 
Much pallor and debility is often left 
after protracted illness in Cholera. These 
demand quinine, iron, strychnine, and 
other tonics. Change of air is often the 
most efficacious remedy, and such a total 
change as a voyage from India to Europe, 
and residence there, is often demanded. 
Throughout the collapse and subse- 
quent changes of debility, the patient 
should be kept in the recumbent posture, 
and during the uraemia and fevers the 
most scrupulous cleanliness of the bed 
should be preserved, and no wet or soiled 
sheets allowed to remain unchanged. The 
sacrum and hips rapidly excoriate, and 
very troublesome bed-sores are quickly 
formed. The surgeon should examine 
these points himself frequently. The 
hypogastric region should be examined 
twice daily in order that retention should 
not be mistaken for suppression of urine, 
a mistake which may now and then hap- 
pen in the early reaction stages, and 
sometimes in the* typhoid and comatose 
periods. 
From the first to the last there is no 
disease which requires more careful atten- 
tion during treatment than Cholera, or 
more watchfulness on the part of the sur- 
geon. In the early stages it will be im- 
possible to leave patients with mere rou- 
tine directions for treatment if we wish to 
be successful. The when to do, and the 
when not to do, in a disease with such 
rapid changes as Cholera, require much 
more discrimination and knowledge than 
is usually possessed by nurses or friends. 
The case requires throughout the constant 
guidance and vigilance of the surgeon, 
and he must specially assume this action 
during the critical periods of the disease. 
Good nursing is always of the utmost 
value, but patients in Cholera need that 
this should be frequently superintended. 
In military and civil hospitals, especially 
in India, in which the nursing must be 
confined to native servants or to the com- 420 
EPIDEMIC CHOLERA. 
rades of the sick man, the surgeon is 
obliged to be doubly watchful. 
All patients with Cholera should be 
treated in well-ventilated rooms or wards. 
On account of the sad spectacle presented 
to the patients with other diseases in hos- 
pitals, when a large number of patients 
are brought in for treatment, and to avoid 
all possible chance of diffusion of the dis- 
ease, small though that chance may be, it 
is desirable that all Cholera cases should 
be treated in separate wards, and with 
ample space and ventilation about them. 
Should there not be such wards or rooms, 
tents should be used. I prefer rooms to 
tents, if they are well ventilated, and have 
non-absorbing floors and walls that can be 
washed with water and chemical solu- 
tions. Tents, unless they are thoroughly 
cleansed and purified, are as likely to 
spread disease as hospitals are. They are 
colder than rooms, and the attendants 
and patients themselves are likely to keep 
them shut up, and from their size the air 
within them is sooner rendered impure 
than in an airy ward. Those surgeons 
who remember the severity of hospital 
gangrene at Ferozepore, in the Sutlej 
campaign of 1845-46, know that tents 
present no immunity from hospital evils. 
The only real advantage of a tent is the 
power of changing its floor by shifting the 
ground, but against this are to be placed 
the coldness at night, and the discomfort 
and consequent diminished efficiency of 
attendants. Of course there are times 
when the tent must be accepted, but I 
should in preference select to treat my 
Cholera patients in airy wards, in which 
I could regulate the temperature, in which 
I could wash and scrub the floors and 
walls, which permit of economical use of 
nurses and attendants, and in which they 
have that comfort and warmth which pro- 
motes their efficiency. In speaking of 
tents, of course I refer to their use in 
warm climates; in cold climates, except 
in summer, they could hardly be used. 
In India, in the warm seasons, too, we 
are subject to heavy storms, which ren- 
der tents most uncomfortable, and I have 
seen several tents, with wounded men, 
blown down in one night. Those only 
who have spent weeks under canvas in 
the Northwest Provinces in India know 
how exhausting is a sojourn in them in 
the daytime, and how much cooler a well- 
covered house is. In the rains, too, they 
are most uncomfortable; either chilly in 
the heavy showers, or close and stifling if 
shut up. I have made these observations 
because I believe that there is a disposi- 
tion to adopt tents on all occasions for 
treatment of Cholera. I think that this 
is an error. There are times when tents 
must be resorted to, and when to use 
them at all times and all seasons is the 
least of two evils ; but I should use them 
in times of necessity only. 
The duty of the medical practitioner is 
not limited to the treatment of cases pre- 
sented to him. It is most important that 
all cases of diarrhoea, choleraic diarrhoea, 
and incipient Cholera should be treated 
early, and the physician should take the 
initiative in impressing this upon all 
within his reach during Cholera epidem- 
ics. Patients should be provided with 
instructions on the symptoms, and, when 
living in distant places, in addition, with 
remedies that they can use until efficient 
assistance can be had. Surgeons of regi- 
ments should organize daily inspections 
of the men in barracks, and all cases of 
relaxed bowels should be treated on the 
spot, and the patients not sent to hospital 
unless for real Cholera. The fear of being 
sent to hospital constantly prevents men 
from reporting these ailments, which they 
would readily do if it were not for the 
dread of being made in-patients. These 
cases can be readily treated out of hospi- 
tal, and with the advantage of lessening 
the crowding of the wards. 
Treatment of Choleraic Diar- 
rikea and Diarrhcea.-The discharges 
should be restrained. A grain of calomel 
with a grain of opium morning and even- 
ing, and with a dose or two of chalk mix- 
ture and soda, or of tannin or gallic acid, 
with sulphuric acid in the middle of the 
day, will perhaps suffice, if continued for 
two or three days. With these should be 
combined turpentine fomentations to the 
abdomen, light digestible food, and if 
there be exhaustion wine with arrowroot 
or sago, or warm brandy and water occa- 
sionally. The patient should give up 
work, and keep to his bed in cold climates, 
or to his couch or sofa in warm ones. If 
there be rice-water stools the patient 
should be treated as for the first stage of 
Cholera. If the diarrhoea continues for 
several days in spite of treatment, the pa- 
tient should, if possible, be moved alto- 
gether out of the locality in which Cholera 
prevails. Choleraic diarrhoea, like Chole- 
ra, is much more intractable and danger- 
ous in the commencement of epidemics ; 
following indeed the rule of Cholera itself. 
In these periods many cases run into 
Cholera in spite of early and assiduous 
treatment. The disturbances which some- 
times precede both choleraic diarrhoea 
and cholera, may be treated with mix- 
tures containing sal volatile, aether, and 
aromatics, tonics, and regulation of diet. 
Many of these sensations will be due to 
the imagination, to fear, &c. 
[Rest in bed, or, at all events, in the 
recumbent posture, is important in Chole- 
raic diarrhoea, or "Cholerine." Dr. Jules 
Worms, of Paris, has especially advocated 
sulphuric acid, in dilute solution, for this 
affection. Some confirmation of its utility 
was obtained in Philadelphia in 1866. TREATMENT OF CHOLERAIC DIARRHOEA AND DIARRH(EA. 
421 
Drs. Cox, Buxton, and Fuller, in Eng- 
land, made use of the same remedy many 
years ago. Dr. Worms's method is to 
give to patients, having prodromic diar- 
rhoea, a "lemonade" composed of about 
half a drachm of concentrated sulphuric 
acid to a pint or more of sweetened decoc- 
tion of salep. Arrowroot will answer 
equally well as a vehicle.-II.] 
Cholera in children must be treated 
upon the same principles as in the adult. 
Laudanum must be given in preference to 
solid opium. It is necessary to be very 
cautious about the repetition of doses of 
the opiates. Indeed, unless the first dose 
be vomited directly, it had better not be 
repeated for the young child under three- 
quarters of an hour, or an hour, and not 
at all if there be any signs of drowsiness. 
The best stimulants are sal volatile and 
tincture of camphor given in a little iced 
water or thin arrowroot; a few drops of 
port wine or brandy in arrowroot may be 
given occasionally. In reaction it will be 
better not to give it the breast for twenty- 
four hours, but to feed it instead upon 
milk diluted with water and a little lime- 
water. The mother's milk if given should 
be pressed from the breast and diluted 
with a little water ; or, if available, a lit- 
tle donkey's milk may be given. If the 
child has been in the habit of taking 
broths or farinaceous foods they can be 
given in small quantities, and not strong. 
It would be vain to attempt to give an 
account of all the plans of treatment and 
remedies proposed for Cholera. They are 
of opposite character and very numerous ; 
two or three deserve notice. 
Venesection.-This was formerly a good 
deal used in India, but is not often resort- 
ed to now. In the spasmodic febrile forms 
Mr. Twining bled, and he thought with 
advantage, in the early stages. In col- 
lapse little blood flows, and on the whole 
probably when it does the abstraction 
does more harm than good.1 
Saline Injections into the Veins.-This, 
when first introduced, seemed of brilliant 
promise. From the extreme of collapse 
the pulseless man rapidly recovered 
strength and sat up in bed, and talked, 
and looked himself, but the amendment 
did not often last; purging returned, and 
with it the collapse. No means have been 
found of keeping the injected fluid within 
the vessels; alcohol, quinine, laudanum, 
albumen, and other things, have been 
tried, but have failed, and from this the 
injection plan has just missed being a 
great and glorious discovery. The follow- 
ing formulse for the solution have been 
recommended :-By Dr. Latta, carbonate 
of soda, 5j ; muriate of soda, ^iij ; water, 
6 pints. By Schmidt, chloride of sodium, 
60 parts ; chloride of potassium, 6 parts; 
phosphate of soda, 3 parts; carbonate of 
soda, 20 parts-all by weight: 140 grains 
of this mixture to be dissolved in 40 oz. of 
distilled water and filtered. The tempe- 
rature of the injection should be about 
108° to 110°, and the specific gravity 1005 
or 1004. An endeavor is made to make a 
solution of similar composition to the fluid 
lost by the blood. It should be injected 
slowly, not above 40 or 60 ounces at a 
time, and not faster than at the rate of 2 
oz. per minute. If purging and collapse 
return the injection can be repeated. In 
some of the cases it was repeated several 
times. Dr. Owen Bees thought that a 
fluid of higher specific gravity than that 
usually injected should be tried, and 
recommends the following:-Chloride of 
sodium, gij; phosphate of soda, ,*j; car- 
bonate of soda, 5jss; sulphate of soda, 
^ss. To be dissolved in distilled water at 
98° F., making the fluid of specific gravity 
of 1030. This solution would seem to be 
too dense. 
Most of the cases on which the experi- 
ments were tried were in a state of ex- 
treme collapse, but the recoveries, as 
shown by Dr. Wright, Dr. Mackintosh, 
Mr. Twining, and others, do not show that 
more escaped than might have been ex- 
pected if they had been left to themselves. 
Inhalation of Oxygen.-The patient can- 
not use any apparatus so as to inhale 
during collapse; therefore any gas used 
must be brought into contact with the air 
cells by some form of artificial respiration. 
It is doubtful, however, whether oxygen 
would act upon the blood in its altered 
state. Some experiments have been made 
of impregnating the atmosphere with oxy- 
gen gas by decomposing chlorate of potash 
at the bedside, but no real benefit seems 
to have resulted. 
Saline Plan.-Dr. Stevens recommended 
draughts of fluids containing chloride of 
sodium, carbonate of soda, and chloride of 
potassium in order to supply the loss in 
the blood ; but it has been of no avail, the 
mixture would not be absorbed, or if ab- 
sorbed, not retained in the blood. 
Dr. Ayre's Method.-This consisted of 
administering 1 or 2 grains of calomel and 
1 or 2 drops of laudanum every five or ten 
minutes for several hours, the object being 
to bring on a secretion of bile. This plan 
has not proved successful in the main, 
though, at the time of its introduction in 
England, some practitioners thought it 
beneficial. 
Prophylaxis.-Whatever may be our 
views as to the contagion of Cholera, it is 
well to act upon the principle that it may 
under certain circumstances be spread in 
a locality, and thus be upon the safe side. 
[' Bleeding from the arm was practised by 
me in one case of collapse in Philadelphia in 
1849. The patient, a boy 12 years of age, 
reacted and recovered.-II.] 422 
EPIDEMIC CHOLERA. 
We ought not to neglect the evidence 
brought forward by Dr. W. Budd, and at 
all events act as if the fecal discharges 
may become injurious to the healthy. 
They should never be thrown into the 
common privy, but be treated with chlo- 
ride of zinc, and buried in trenches out of 
harm's way, at some distance from habi- 
tations, and where no drainage from them 
may find entrance into wells or cisterns. 
The bed - pans and other vessels used 
should also be washed with chloride of 
zinc, and thoroughly cleansed. The pa- 
tient's bed should be covered with water- 
proof sheeting to prevent the soaking of 
the mattresses, and the sheeting should 
be well cleaned with disinfecting materials. 
Better still, in hospitals the beds should 
be made up of soft straw, and, when once 
used by a patient, the straw should be 
taken out and burned. The covering, the 
bed clothes, and all linen should be boiled 
in alkaline lye, and well washed. I be- 
lieve that there is not the slightest neces- 
sity for burning the linen used. I believe 
that Cholera patients may be safely nursed 
by their relatives or friends, and that they 
run no unnatural risk in attending to them. 
Nursing mothers should not resume suck- 
ling their children, even if their milk re- 
turns, until several days after convales- 
cence; the milk having been previously 
drawn off by some apparatus for the inter- 
vening days. 
Removal out of an Infected Locality.- 
When practicable it would be well for 
people, whose occupations permit them, 
to move out of diseased places, but that 
can never be done on any considerable 
scale, except in the cases of troops. Under 
present rules issued by the Government 
of India, all troops are to move out of 
stations if epidemic Cholera prevails 
among them. This is therefore no longer 
a question for the consideration of the 
medical officer; he has only to do with 
the tune of moving. Hitherto the experi- 
ence of removal has been favorable as far 
as the diminution of cases and cessation 
of the disease are concerned; the deaths 
to cases have not diminished. Without 
doubt there are certain risks to be encoun- 
tered in moving out, but they are smaller 
than the dangers left behind. The risks 
will vary with the weather and the sea- 
sons; but these moves have sometimes 
been made even in hot weather and rains, 
without increase of other sickness. These 
are the cases in which the discomforts and 
risks of tents must be accepted as prefera- 
ble to remaining in the midst of the poison. 
It would be better to have lived under a 
tree or an umbrella than in some of the 
hospitals during the late epidemic at 
Meean Meer. It is not necessary to move 
far; a few miles are sufficient, and the 
march should be at right angles to the 
wind. Of course, in removal into camp, 
there should be realized absence of fatigue, 
good food, pure water, and thorough camp 
conservancy, or else there is no reason 
why troops should not suffer just as much 
from the disease as the Madras regiments 
seem to do, and as the regiments march- 
ing down from the hills to the siege of 
Delhi did in 1857. 
Good food and pure water should be 
especially attended to in Cholera epi- 
demics. Even without these being more 
than predisposing causes, there is sufficient 
necessity for attending to them. All indi- 
gestible food and all tainted articles should 
be specially avoided. It is well to bear in 
mind the teachings of Dr. Snow and Dr. 
W. Budd; and whether we believe that 
the exciting cause can be conveyed into 
the system by drinking water, or not, take 
care that all water consumed be entirely 
free from any fecal pollution. On the 
same grounds that all food or water likely 
to produce irritation of the intestines, and 
thus determine choleraic action, are to be 
avoided, we should be extremely cautious 
about the administration of purgative 
medicines in the times of Cholera epidem- 
ics. Of course, occasionally they will be re- 
quired, but they should not be given with- 
out decided necessity, and then never of 
the saline or hydrogogue character, and 
never at bedtime. 
It has not been intended to give in this 
paper a full account of the hygienic meas- 
ures required in the Cholera epidemics, 
and for lessening their severity. Fortun- 
ately these are fully treated of in Dr. 
Parkes's recent work on Practical Hy- 
giene, Dr. N. Chevers's Review of the 
Means of Preserving the Health of Euro- 
pean Troops in India, and the Report of 
the Commission appointed to Inquire into 
the Cholera Epidemic of 1861 in Northern 
India, which last may, 1 believe, be ob- 
tained in India. These from their nature 
are mostly applicable to troops, but their 
teachings may be made equally useful for 
all classes and for all communities. CONSTITUTIONAL SYPHILIS. 
423 
CONSTITUTIONAL SYPHILIS. 
By Jonathan Hutchinson, F.K.C.S. 
The specific fever known as Syphilis 
differs chiefly from its congeners in the 
much more prolonged duration of its sev- 
eral stages. Like smallpox, measles, scar- 
let fever, and the others in this group, it 
is communicable from the diseased to the 
healthy, and can be produced by no other 
means ; like them it has its several stages 
of incubation, efflorescence, relapses, de- 
cline, and sequelte; as in them, so in Sy- 
philis, the most prominent symptom is an 
exanthem, or cutaneous rash. The vari- 
ous stages of Syphilis tend to pass away 
of themselves in the course of time, just 
as certainly as do those of smallpox ; and 
a well-developed attack affords for a time 
immunity from a second. As is the case 
in the other zymotic diseases, the poison 
of Syphilis is one which possesses the 
power of breeding in the patient's body, 
and the smallest possible quantity of vi- 
rus suffices in due time to inoculate all 
the solids and fluids of the system. The 
time required, however, is much longer, 
and the stages are much more protracted. 
Instead of counting the duration of the 
stages by days, we have to count by 
weeks, or by months. From this cir- 
cumstance there follow in the most natu- 
ral manner certain apparent differences 
between Syphilis and the other fevers. 
Thus, because the evolution of the exan- 
them is slow and gradual, the pyrexial 
disturbance attending it rarely rises to 
any great height; because each stage is 
so much longer, correspondingly wider 
margins of occasional variation in length 
must be allowed. It further follows that 
because the disease extends over years, 
its subject is often not incapacitated by it 
for social life ; many while still infected 
become parents, and transmit their own 
taints to their offspring, a circumstance 
which can but very rarely happen in the 
more short-lived and acute fevers.1 These 
apparent differences are by no means real 
one. Nor is it probably by any means 
correct to allege that Syphilis is the only 
fever which has a tertiary stage. What 
are called the tertiary symptoms of Sy- 
philis find their analogies in many cases 
of smallpox or scarlet fever, in what are 
known as the sequelae of those diseases. 
It is true that these occur only in a 
small proportion of cases, but the same 
holds good of the tertiary syphilitic phe- 
nomena. If we observed more carefully, 
it is probable that the sequelae of the ex- 
anthems might be recognized much more 
often than they now are, and that many 
of the diseases classed as "strumous" in- 
flammations of the eye, the ear, or the 
skin, with also diseases of bones and 
joints, are in reality the tertiary conse- 
quences of some specific fever. So, too, 
if it be alleged that the stages of Syphilis 
may be shortened and otherwise modified 
by treatment, while those of the other 
exanthems cannot, we may reply that 
those of the latter are too short and tran- 
sitory to give time for a fair trial of rem- 
edies, and also that the power of rem- 
edies over syphilitic phenomena have 
probably been much exaggerated. Sy- 
philis does fortunately differ from most of 
the other specific fevers, in that its virus 
is incapable of diffusion in the atmosphere, 
and that consequently it is contagious 
only, and not infectious also, but it is by 
no means solitary in this feature. 
Having thus insisted upon the rank 
which true Syphilis ought to occupy in 
our nosological classifications-a point of 
the utmost importance to our correct ap- 
preciation of its nature-we may next ask 
the question, whether under this name 
we have to deal with one disease or with 
several. Every surgeon is aware that 
there are many venereal sores which are 
not really syphilitic, and very different 
opinions have been entertained as to the' 
relation which these hold to the genuine 
disease. Some have assumed, with Car- 
michael, that there are several distinct 
poisons, and others, especially a modern 
and now very extensive school, hold that 
there are certainly two. Without enter- 
ing at length into the controversy, I will 
simply remark that the evidence in favor 
either of plurality or duality,1 is to my 
1 The doctrine of so-called "duality of 
Syphilis" seems to me to rest on the most 
unsubstantial foundation. Surely it is ab- 
surd to speak of the "duality" of things 
which have scarcely any features in common. 
The production of constitutional phenomena 
is the essential feature of Syphilis, and there 
are not two forms of Syphilis as thus denoted. 
We may freely admit that, in impure sexual 
1 Hereditary transmission happens in all 
specific fevers if it chance that offspring are 
produced while the parent is suffering. 424 
CONSTITUTIONAL SYPHILIS. 
mind quite inconclusive. Let us accept 
clearly the doctrine so essential to the ex- 
planation of numerous pathological phe- 
nomena, that all living pus is contagious, 
and is capable of producing an inflamma- 
tion similar to that in which it originated, 
and we shall not have much difficulty in 
explaining the different forms of venereal 
sores. The majority of the latter are 
probably abortive inoculations. In the per- 
formance of vaccination, the utmost care 
is taken to secure a pure virus, yet every 
now and then an abortive sore is pro- 
duced. If it were the practice to inocu- 
late again from these abortive sores when 
suppurating, we might soon produce an 
analogous state of things to what we now 
have in respect to the soft and hard chan- 
cre. The inoculation of Syphilis is of 
course a matter of mere chance, and the 
virus with which it is effected can be but 
very seldom in a state of purity. How 
rarely in the female do we meet with a 
healthy type of the indurated sore ? 
Then, too, we must remember that this 
stage of the primary sore is transitory, 
and those who have once had it but sel- 
dom have it again. A large proportion 
of the women by whom contagion is com- 
municated have had Syphilis long before, 
and are now no longer capable of origi- 
nating the true virus. The sores which 
they possess are analogous to those caused 
by vaccination in protected persons. At- 
tention to these considerations would, I 
feel confident, enable us to put aside the 
unnecessary hypothesis of duality. 
In a medical essay on Syphilis any de- 
tailed consideration of the primary symp- 
toms would be out of place, since these by 
common consent come under the care of 
the surgeon. We will content ourselves 
by saying that a successful syphilitic in- 
oculation is denoted by the formation of a 
base of induration beneath the abrasion 
first noticed, that this induration usually 
occurs within a week of the contagion, 
but may be delayed for several weeks; 
that it is usually attended by very little 
either of ulceration or suppuration, and 
that it causes an enlargement of the proxi- 
mal lymphatic glands. The bubo shows 
the same tendencies as does the chancre. 
There is hardness with but little swelling, 
and rarely much tendency to the forma- 
tion of pus. These characters will be the 
same, or nearly the same, in both sexes, 
at all ages, and on all parts of the body.1 
Stages of Syphilis.-A successful inocu- 
lation having been effected, a period of 
incubation now ensues, which may last 
from one to three months, and usually 
averages about six weeks. During the 
later part of this period the patient is 
often sensible of slight malaise and discom- 
fort. At length an exanthem makes its 
appearance, affecting both the skin and 
the mucous membranes. The skin shows 
a scattered eruption, which may vary very 
considerably in some of its characters, 
but usually conforms to rule, in being of a 
peculiar coppery hue, and in preferring 
the flexures of the limbs to their dorsal 
aspects. This rash may be merely conges- 
tive, resembling that of measles; it may 
be scaly, papular eczematous, pustular, or 
bullous. In some few cases it is attended 
by ulceration, but as a rule it involves 
only the superficial layers of the skin, 
differing in this respect from the ter- 
tiary manifestations. There is not the 
slightest reason for believing that these dif- 
ferences in the character of the exanthem 
imply difference in the nature of the virus. 
Chancres exactly corresponding in their 
characters may be followed by most di- 
verse kinds of eruption. Simultaneously 
with the eruption on the skin, we usually 
observe evidences of similar implication 
of the mucous surfaces. In the tonsils 
symmetrical ulcers form ; these ulcers are 
of kidney shape, have a tawny gray base 
and abrupt edges. They are attended by 
but little pain, and do not spread either 
laterally or in depth. After lasting for 
a few weeks they usually heal. These 
tonsilar ulcers are rarely absent in the ex- 
anthematous stage. Very often, but not 
nearly so constantly, we observe also cer- 
tain superficial patches of inflamed mu- 
cous membrane in the mouth, on the pha- 
rynx, palate, tongue, or cheeks. On tlie 
tongue, and at the corners of the mouth, 
and sometimes in other positions also, 
these patches become very considerably 
raised, and assume the condition known 
as condylomata. If condylomata be ob- 
served in the pharynx, they will almost 
always be observed at the anus also, and 
vice versa. They are to be regarded as 
patches of cutaneous eruption modified 
by their position, and by the moisture of 
the parts. Whether or not in these cases 
any eruption extends through the ali- 
mentary canal is a point upon which we 
have no evidence. 
The exanthem usually takes from a 
fortnight to a month before it is fully out, 
and about two months are usually occu- 
pied in its gradual decline. In some cases 
it is very transitory, and in some it is 
intercourse, pus of very various qualities and 
endowments may be inoculated, and thus 
very different kinds of local ulcers may re- 
sult, but there is only one which can produce 
Syphilis. 
1 Some writers hold that certain parts 
never exhibit the phenomenon of induration 
when inoculated. My own experience is, 
however, very decidedly in favor of an oppo- 
site view. I have seen chancres with well 
characterized induration on the most various 
positions, e. g., the glans penis, the nipple, 
the lips, the eyelids, the hands, &c. &c. CONSTITUTIONAL SYPHILIS. 
425 
greatly prolonged. When it is at its 
height, or just when it begins to decline, 
it is not unfrequent for inflammation of 
the irides to occur. The iritis, when it 
happens, is usually symmetrical; it is 
attended by the free effusion of lymph, 
often in elevated nodules of a salmon or 
rust tint, the characteristic zone of ciliary 
congestion is usually well marked, and 
there is often a dotted deposit in the pos- 
terior lamina of the cornea. In other 
cases, instead of iritis, or coincident with 
it, inflammation of the retina occurs. 
The retinitis is, I think, usually a little 
later than the iritis, and we rarely see it 
until the eruption on the skin is well dis- 
appearing. This form of retinitis is not 
uncommon, and is a very insidious and 
most important malady. The patient 
notices nothing, excepting that his sight 
is very dim ; he has no pain, no conges- 
tion of the front of the eye, no intolerance 
of light. The ophthalmoscope shows us 
the retina hazy, and as if stained with 
port wine ; the optic disk swollen and its 
margins indistinct; whilst not unfre- 
quently numerous small extravasations of 
blood are seen. 
Whilst the local phenomena just men- 
tioned are occurring, there are usually 
present others of a less definite character. 
The patient loses flesh, he is restless and 
slightly feverish, the appetite is deficient, 
the bones and joints ache, and the hair 
becomes dry and thin. Now and then 
swellings occur on certain bones, more 
especially on those of the skull; but in 
this stage periostitis is always slight and 
transitory, and never leads to suppuration. 
Such are the various symptoms which 
make up what are called the secondary 
symptoms of Syphilis. In many cases 
only a few of them occur, the rash on the 
skin and the ulcers in the tonsils being 
those which are most constant. In many 
individuals all the secondary symptoms 
have disappeared within six months of the 
original contagion; but in a larger num- 
ber, a year elapses before such is the case. 
It is rare for any symptoms belonging to 
the secondary group to linger after eigh- 
teen months have passed, although their 
effects are often seen much later. That 
these symptoms disappear in a most satis- 
factory manner, quite irrespective of any 
treatment which may be adopted, is a fact 
confirmed by every day's experience. 
After the group of secondary symptoms 
has passed away, there usually follows a 
period of apparent health, during which 
the patient believes himself wholly cured.1 
After this interval, which, may vary in 
length from a few months to many years, 
symptoms of a different kind ensue. In- 
flammatory indurations of a chronic cha- 
racter, and tending slowly to suppuration 
and ulceration, occur in the deep-seated 
tissues, or in the deeper parts of the super- 
ficial ones. In this way the skin, the 
subcutaneous tissue, the periosteum, the 
muscles, the internal viscera, the organs 
of special sense, and even the cerebro- 
spinal system itself may be attacked. A 
remarkable difference is to be observed 
between secondary and tertiary symp- 
toms, as regards the symmetry of the in- 
flammations produced. In the secondary 
stage, a tendency to symmetry, often very 
exact, is observed, proving that the pro- 
ducing cause is free in the blood, and is 
supplied impartially to both halves of the 
body. In the tertiary stage, the lesions 
are of tensingle, or, if multiple, they dis- 
play but little accuracy as to symmetrical 
arrangement. This fact implies that they 
result from impaired organization of the 
solids, rather than from any poison still 
periences nothing whatever to remind him of 
his taint. In many others, however, recur- 
rences of symptoms, which it is difficult to 
assign to either group, continue to show 
themselves. Superficial sores on the tongue 
or the mucous membrane of the mouth, 
isolated patches of scaly or desquamating 
eruption on the skin, especially psoriasis 
palmaris, are the more frequent of these. 
Sometimes they are symmetrical; at others 
not so. Such symptoms may continue to re- 
cur for many years (even to twenty) after 
the contagion. They probably depend rather 
on permanent tissue contamination than on 
still existing blood disease. At any rate I 
may safely assert that we never witness any 
true recurrence of the secondary epoch. The 
eruption is rarely very copious, and rarely of 
such a character as to deceive an experienced 
eye: nor is it attended by the ulcers in the 
tonsils and iritis, which are so common in 
the secondary stage. In rare instances, at 
an interval of perhaps a year or eighteen 
months after infection, a relapse of a general 
symmetrical rash may occur. This rash 
may assume the form of rupia and be attend- 
ed by severe constitutional symptoms. 
An idea is prevalent that syphilitic iritis 
may occur-at almost any period in the course 
of the disease. I speak after close attention 
to this subject, when I assert that all our 
well-marked examples of this disease present 
themselves amongst the secondary phenome- 
na. From three to six months after the 
chancre is the usual date. When once iritis 
has occurred, and adhesions have been left, 
relapses are liable to happen, and it is this 
fact which has led to the error which I am 
endeavoring to confute. In these relapsing 
cases, however, the symptoms are very differ- 
ent from those of the first attack. The effu- 
sion of lymph is much less free, no nodules 
are seen, and rarely are both eyes simulta- 
neously affected. 
1 The interval which elapses between the 
well characterized secondary symptoms and 
the well characterized tertiary ones, is one of 
different degrees of immunity in different 
cases. In many, I think the majority, the 
poison is wholly latent, and the patient ex- 426 
CONSTITUTIONAL SYPHILIS. 
existing in the circulating fluids. The 
occurrence of the tertiary symptoms is to 
be explained by the fact, that during the 
exanthematic stage, when the whole blood 
was loaded with the virus, the various 
solids have received from that poisoned 
blood the elements necessary tor their 
growth, and have been built up, so to 
speak, with syphilized plasma. Hence 
an impairment of organization in such 
tissues, and a liability under slight ex- 
citing causes, or even in the ordinary 
course of nutritional change, to the occur- 
rence of specific forms of inflammation. 
It is easy to see, that in Syphilis, with its 
very prolonged period of blood-poisoning, 
the risk of permanent tissue modification 
must be much greater than in the other 
fevers, in which it is so short. During 
the exanthematic stage of smallpox, pro- 
bably but little in the way of nutrition is 
effected ; the changes are chiefly those of 
waste and disintegration. From this, it 
follows that the more prolonged the secon- 
dary stage in Syphilis, the greater the 
risk of tertiary symptoms, and that severe 
febrile disturbance during this stage, by 
interfering with nutritional development, 
tends also in the same direction. Do we 
get from these considerations any glimpse 
into the principles of treatment ? My 
impression is decided that tertiary symp- 
toms, as a rule, follow earlier in the 
young than in the old, and if so, the fact 
may be explained by reference to the 
greater rapidity of elemental change in 
the former. 
The following is a statement, in tabular 
form, of the various symptoms of the dif- 
ferent stages of Syphilis :- 
1st Stage.-Inoculation and Incu- 
bation. 
Average duration, six weeks to 
two months. 
2d Stage.-Exanthem, or Secon- 
dary Symptoms. 
Average duration, two to six 
months: may extend over a 
year. 
3d Stage.-Interval of Latency 
or of Relapses. 
May vary from a few months to 
many years. 
4th Stage.-Tertiary Symptoms 
or Sequela}. 
Of uncertain duration, and cha- 
racterized by a remarkable 
tendency to relapse. 
An ulcer with indurated base and but very 
sparing secretion. Induration of the nearest 
lymphatic glands, with but little adjacent inflam- 
mation or tendency to suppurate. Slight febrile 
disturbance. Slight enlargement of lymphatic 
glands in all parts. 
Symmetrical ulcers in the tonsils, not spreading 
either in width or depth. A symmetrical eruption 
on the skin. Condylomatous patches on the mu- 
cous surfaces, and on the skin adjacent to the 
mucous orifices, usually symmetrical. Iritis or 
retinitis ; mostly symmetrical. Pains in bones and 
joints. Febrile disturbance. Loss of hair. 
In some cases the patient is wholly free from 
symptoms, but in a certain number reminders 
occur from time to time in the form of scattered 
scaly patches, psoriasis palmaris, sores on the 
tongue, lips, &c. 
Unsymmetrical ulcerations in the mouth and 
throat, tending to spread widely and deeply. Un- 
symmetrical ulcerations on the skin. Kodes of 
periosteum, cellular tissue, muscle, tendon, fascia, 
or nerve ; not usually symmetrical, chronic in pro- 
gress, tending to ulcerate or even to slough. 
Diseases of viscera. 
Having thus sketched the normal course 
of syphilitic fever in its several stages and 
its sequelae, we must next consider the 
conditions under which its orderly evolu- 
tion may be interfered with. These con- 
ditions are precisely the same as those 
which disturb the course of any other 
exanthem. We have, 1st, idiosyncrasy ; 
2d, the coexistence of some diathesis or of 
some other specific disease ; 3d, immunity, 
partial or complete, obtained by a pre- 
vious attack of the same disease; 4th, 
inherited immunity, partial or complete ; 
5th, imperfect inoculation ; 6th, the influ- 
ence of treatment. 
1st. To take first idiosyncrasy, I may 
simply remark that it is a matter of 
general experience that certain constitu- 
tions resist the specific animal poisons in 
a most remarkable manner. We are un- 
able to offer any explanation of the fact; 
on the other hand, we meet with those 
who succumb easily and suffer severely. 
The influence of these inexplicable pecu- 
liarities in individuals is frequently ob- 
served in reference to Syphilis. 
2d. The existence of some special dia- 
thesis or of some other specific fever at the 
time of syphilitic inoculation may modify 
the course of the latter. Possibly we 
overrate rather than otherwise the effects 
of these influences. Although it is not 
infrequent to find a delicate scrofulous 
subject suffering with unusual severity 
from syphilitic poisoning, yet the con- 
verse is almost equally common, in which 
either the delicate escape easily or the 
robust suffer very severely. There can 
be little doubt, however, that the tend- 
ency to suppuration and ulceration is 
much greater in those of fair skin and 
sanguine temperament than it is in others. CONSTITUTIONAL SYPHILIS. 
427 
The influence of diathesis (scrofula) is 
also often felt in preventing recourse to 
specific treatment. There is probably no 
reason to believe that the existence either 
of a diathesis or of another specific fever 
will modify the duration of the several 
stages of Syphilis. 
3d. A previous attack of the same disease 
is well known to exert a most important 
influence upon the course of a second in 
the same individual. It is generally un- 
derstood that Syphilis, once had, is pro- 
tective in the majority of cases against 
any second attack, and we have but little 
trustworthy clinical evidence as to the 
nature of second attacks when they do 
occur. There is reason to believe that 
second inoculations are common, and that 
they usually end in the production only 
of the soft chancre (abortive sore). 
I have myself witnessed in one instance 
two attacks of Syphilis in the same pa- 
tient, and in it the disease was slight on 
the second occasion. It appeared to have 
undergone quite as much modification as 
we usually observe in smallpox after suc- 
cessful and recent vaccination. A young 
surgeon consulted me for an indurated 
sore, in 1860. He was treated by mer- 
cury, but suffered very severely from all 
the usual train of secondary symptoms. 
It was two years before he had wholly 
got rid of the latter, and from that time 
to the present he has enjoyed excellent 
health. In April, 1865, he contracted 
another sore, which indurated, and was 
followed in a month by a copious roseolous 
rash. Excepting slight redness in the 
tonsils, there was no sore throat. He 
was scarcely ill, and both chancre and 
rash disappeared in a comparatively short 
time. I have seen other cases in which 
it seemed probable that the patient had 
had true Syphilis twice, but this is the 
only one in which both attacks have oc- 
curred under my own observation. 
M. Diday holds that second attacks are 
not so rare as they have been thought, 
and records twenty-seven cases which 
have been under his own observation. 
Of these, however, in sixteen a chancre 
only occurred, indurated, it is true, but 
without secondary consequences. (Some 
of these may have been examples of the 
relapsing chancre, and not true instances 
of secondary contagion.) In nine others 
the secondary symptoms were mild, and 
in two only were they severe. In these 
last two the average interval between the 
first and second attack was nineteen 
years and a half. (See New Syd. Soc. 
Year-book for 1862, p. 233.) 
It is clear from these facts that second 
attacks of true Syphilis are very infre- 
quent, and that when they occur within 
a moderate period of distance from the 
first the character of the disease is much 
modified. In these respects Syphilis con- 
forms closely to all that is ascertained re- 
garding the other exanthemata. An in- 
teresting fact in connection with my own 
case of second attack of Syphilis (given 
above) is that the same patient had also 
had two well-marked but mild attacks of 
smallpox, the interval between the two 
having been four years. 
4th. Of yet wider importance is the 
question as to the influence of disease in 
the parent in affording protection, partial or 
complete, to the offspring. If we grant, as 
we must, the two postulates-first, that 
Syphilis is transmissible to offspring, and 
second, that it is protective for a certain 
time against second contagion-then we 
are obliged to admit that just as the dis- 
ease itself may be transmitted, so may the 
immunity which it affords. Here again 
we have as yet very little clinical evidence 
on which to build, but what we do possess 
certainly favors the view that those who 
have suffered severely in infancy from in- 
herited disease are to some extent pro- 
tected. In the history of Congenital 
Syphilis, however, nothing is more com- 
mon than to meet with cases in which the 
eldest child of a family suffered severely 
in infancy, the second slightly, the third 
still more slightly, and the others not at 
all. I have at present several families 
under observation in which this has been 
the case, and in which all the children 
have lived, and the intervals between 
them are but short. The younger mem- 
bers of such families often appear to be 
in robust health. Now', if in such cases 
the oldest enjoys immunity, probably the 
second also does so in some degree, and 
so on through the whole, the degree of 
protection diminishing in ratio to the dis- 
tance from the original taint. Do w'e not 
here touch upon a law of the utmost im- 
portance, not only in respect to Syphilis, 
but to its congeners also ? Is it not prob- 
able that a very considerable portion of 
the community, being the descendants of 
those who have suffered, enjoy in a cer- 
tain degree, infinitely slight in many but 
powerful in others, immunity from further 
attacks ? The manner in which a slight 
degree of inherited immunity would be- 
come manifested wmuld probably not be 
in entire escape from contagion, but in 
the production of a much milder form of 
the disease. This is what occurs in cases 
of smallpox after vaccination, or after a 
previous attack of the true disease, and 
indeed in second attacks of any of the 
specific fevers. It is surely impossible to 
believe that the constitution of a person 
who has passed through the stages of any 
of these diseases ever again returns into 
precisely the same condition in relation 
to the virus in question that it occupied 
before, and it is equally inconceivable but 
that some share of this peculiarity shall 
be transmitted to offspring. A child bom 428 
CONSTITUTIONAL SYPHILIS. 
of parents neither of whom are liable to 
smallpox or to Syphilis, as the case may 
be, must be in a different position, as re- 
gards those diseases, from the child of 
parents both of whom are liable. In like 
manner a half result ought to be expected 
where one parent is exempt and the other 
liable. Now it is a matter of well-proven 
observation that any specific disease will 
be especially severe when imported into 
a community previously free from it. The 
ravages of smallpox in a virgin race are 
something far beyond what is ever known 
in a community long accustomed to the 
disease. There are also good reasons for 
believing that Syphilis has become during 
the last two centuries a milder disease 
than it was when it first invaded Europe. 
This amelioration we may most satisfac- 
torily explain by recourse to the hypothesis 
above suggested.1 
5th. The next mortifying influence 
which we have to examine is imperfect 
contagion. A large majority of the acci- 
dental inoculations by which Syphilis is 
conveyed are probably impure in a double 
sense. The essential virus is mixed with 
other fluids, is diluted, drowned, it may 
be, in common pus and other secretions. 
Then again the fluid merely comes in con- 
tact with a thin mucous surface ; no pre- 
cautions are taken to secure its gaining 
entrance into the tissue. Hence, as al- 
ready explained, a majority of such con- 
tagions prove abortive. It is probable 
however that through all these difficulties 
the essential virus retains its characters 
unmodified, and that if it once produce 
its own first effects all the rest will follow. 
However small the quantity producing it, 
if once the sore have become indurated, 
the usual results may be expected. We 
have no reason for believing that there is 
any second variety of constitutional Sy- 
philis, other than that which follows an 
indurated sore. The questions as to im- 
perfect contagion therefore concern the 
surgeon rather than the physician. Un- 
der its influence a great variety of vener- 
eal primary sores are produced, but we 
have no real variations in the specific fe- 
ver and its results.1 
Lastly, we have to ask the all-important 
question, whether the ordinary evolution of 
Syphilis can be altered in any way by meas- 
ures of treatment. It will probably be ad- 
mitted that physicians have abandoned 
the idea that it is practicable by medica- 
tion to regulate in any way the course of 
the other exanthemata. They are gene- 
rally acknowledged to be diseases which 
always run their course. With the excep- 
tion perhaps of cinchonism as a remedy 
for malarial fever, no single specific in the 
present day enjoys any repute as to cut- 
ting short the course of these diseases. 
But we must not too hastily assume a 
priori that the same will hold true as to 
Syphilis. It is possible that the stages of 
the other exanthemata are too short to 
permit of the beneficial influence of anti- 
dotes. Few questions as to therapeutics 
have been more hotly debated than the 
efficiency of certain drugs in reference to 
Syphilis. By some their specific power 
1 This subject will be found very ably 
treated in Mr. Lee's Lectures on Syphilis 
(Lecture xi. page 209). Mr. Lee quotes the 
important observations of Dr. Ferguson (1812) 
as to the mildness of Syphilis amongst the 
Portuguese being explained by the acquisi- 
tion of hereditary immunity, and adds, 
"That which Dr. Ferguson observed in his 
day may be seen at present. A person who 
has had hereditary Syphilis in his youth, 
W'ill either not contract the infecting form of 
Syphilis in after life, or will have it in a 
modified form." 
Four years ago I published in the British 
Medical Journal some cases in which patients 
who had suffered from inherited Syphilis 
subsequently contracted venereal sores. These 
cases were, I believe, the first facts relating 
to the subject which had been recorded. 
Others had arrived at the same conclusions, 
but it was by priori reasoning rather than 
by deduction from facts. 
Subsequently I published a case in which 
a patient who was the subject of inherited 
taint, not only contracted a venereal sore, 
but experienced an outbreak of constitutional 
symptoms. This young man is still under 
my care, and suffers from inherited Syphilis 
and acquired Syphilis at the same time. I 
have recorded a number of facts bearing on 
this subject in the second volume of the Lon- 
don Hospital Reports. 
1 If we reflect on the mode in which syphi- 
litic inoculation is usually effected, the won- 
der will be not that apparent varieties as to 
both primary and secondary symptoms occur, 
but that the disease preserves so close a con- 
nection with its type as it undoubtedly does. 
Here, if anywhere, are the conditions under 
which we might expect a new species to origi- 
nate. In the first place the virus is constantly 
mixed with other secretions, and very fre- 
quently with those of inflammatory origin. 
In the first place the virus is constantly 
mixed with other secretions, and very fre- 
quently with those of inflammatory origin. 
In a great many instances the person from 
whom the contagion is received is one whose 
own body has been previously rendered proof 
against the disease. Most prostitutes proba- 
bly suffer from Syphilis early in life, and 
during the greater part of the period during 
which they continue their vocation are inca- 
pable of being themselves again affected by 
true Syphilis, although still liable to contract 
and to transmit primary sores of a modified 
character. Then not only must we make al- 
lowance for differences in the kind of secre- 
tion with which the inoculation is effected, 
but also for differences in the recipient's 
state as regards it. Hence the differences in 
the type of cutaneous rash which follows; 
from a roseola to psoriasis and to rupia. CONSTITUTIONAL SYPHILIS. 
429 
has been positively asserted, and by others 
as strenuously denied. As far as the pur- 
poses of our present argument are con- 
cerned, we may, I think, admit that there 
is no proof that the exanthematic stage of 
Syphilis can be prevented. If the sore 
have presented well-marked induration, a 
rash more or less copious is almost certain 
to follow in due time. A few exceptions 
occur, but they are as frequent when no 
treatment has been used as under opposite 
conditions. The statistics which have 
been collected on this point are for the 
most part valueless, because the kinds of 
primary sore have not been carefully dis- 
tinguished. Any conclusions of trust- 
worthy character must be based on the 
observation of indurated chancres only. 
For myself, I may state that I have treat- 
ed some hundreds of these by the mercu- 
rial plan, and that in a considerable num- 
ber of others I have carefully abstained 
from all medication, and that I am not in 
a position to record any single instance in 
which after mercurial treatment no exan- 
them followed.1 That mercury can pro- 
cure the healing of syphilitic sores and the 
absorption of syphilitic lymph, no one 
who has had opportunities of observation, 
and who dare credit the evidences of his 
senses, can doubt; but that it can prevent 
the occurrence of one of the stages of the 
disease, is a very different assertion. I 
shall discuss the question of treatment in 
its practical aspects as a further part of 
this essay; for the present, and in refer- 
ence merely to the natural history of the 
disease, it may suffice to observe that 
there is no more proof that it can prevent 
the evolution of the exanthem of Syphilis, 
than that it can do the same in variola. 
Whether the tertiary symptoms can be 
prevented or made milder by treatment is 
again another question, since they, strictly 
speaking, do not constitute a true stage, 
but are rather the sequel, more or less ac- 
cidental, of the secondary one. Any 
remedy which, although important to pre- 
vent, is yet able to modify and shorten the 
secondary stage, may very possibly influ- 
ence the occurrence or otherwise of the 
tertiary inflammations; and whether mer- 
cury does so or not, must be determined 
solely on clinical evidence. 
Modes of Communication.-Whilst the 
other exanthemata are for the most part 
communicable only by direct contagion or 
infection to the individual concerned, 
Syphilis, in consequence of its very pro- 
tracted duration, may be conveyed in any 
one of three different modes. First, con- 
tagion direct to the individual; second, 
contagion indirect through the foetus (pos- 
sible only in women); and third, by he- 
reditary transmission. 
The period during which direct conta- 
gion is possible extends from the first ap- 
pearance of the indurated chancre to the 
decline of the exanthem. The primary 
sore is more actively contagious than are 
any in the secondary stage, but there can 
be no doubt that under favorable condi- 
tions the germs of the disease may be con- 
veyed by the latter. When Syphilis is 
communicated to a mother by contamina- 
tion from the fluids of a foetus with which 
she is pregnant, the course of the disease 
is materially different from what it is 
when received by other means. The ab- 
sorbed materies seems to be scarcely capa- 
ble of breeding in the blood of its recip- 
ient; it merely contaminates it, the degree 
of the contamination being in exact pro- 
portion to the amount received. The evi- 
dence of contamination is greatest during 
the pregnancy, and increases with each 
successive one. The symptoms produced 
are of the tertiary class only ; for the most 
part the secondary stage is wholly omit- 
ted. A taint thus obtained rarely attains 
any high degree of severity. 
When Syphilis is transmitted from pa- 
rent to offspring, various important pecu- 
liarities are observed in its manifestations. 
In the first place the phenomena of the 
secondary and tertiary stages not very un- 
frequently occur together, or at any rate 
we have a superficial rash on the skin re- 
sembling a secondary one, coincident with 
nodes and with deposit in the viscera. 
These cases are, however, exceptional, 
and as a rule the stages occur as in the 
adult, the secondary rash disappearing 
after a few months, and there being a pro- 
longed period of health before the tertiary 
symptoms show themselves. A few symp- 
toms are peculiar to the inherited disease, 
and do not occur in adults who have ac- 
quired it. Amongst these I may mention, 
of the secondary stage, diffuse stomatitis 
without ulcers, diffuse inflammation of 
the mucous membrane, of the nares re- 
sulting in the well-known symptom of 
snuffles, and of the tertiary ones a form of 
phagedeenic lupus and interstitial inflam- 
mation of the cornea. The latter, which 
is a common and very well marked con- 
dition in inherited Syphilis, has no parallel 
condition whatever in the acquired dis- 
ease. Deafness and amaurosis from nerve 
1 By this I mean that I have never seen a 
case in which after a well indurated sore I 
kept the patient continuously under observa- 
tion, and assured myself that he never had 
any constitutional symptoms. I have seen 
many in which the constitutional symptoms 
were so slight that they might easily have 
been overlooked, but these are sufficiently 
frequent without treatment to make us very 
cautious in assuming, when such a result 
follows mercurial treatment, that is a propter 
hoc. Many patients whom I have treated by 
mercury for the chancre have been lost sight 
of as soon as the latter was healed, and it 
is of course possible that in some of these no 
secondary stage occurred. CONSTITUTIONAL SYPHILIS. 
430 
or cerebral disease are both of them far 
more common in the inherited form of the 
disease than they are in that which is 
acquired. The effect of the syphilitic 
poison upon the ovum is in many in- 
stances to destroy its vitality at an early 
period, and consequently to induce abor- 
tion. Unfortunately this is far from being 
its constant effect. In the great majority 
of such conceptions the tainted foetus is 
carried to its full period. In exceptional 
instances it is then brought into the world 
with manifestations of its disease apparent 
in the form of skin disease; but in most 
this is not so, and the infants who when a 
few weeks old will suffer most severely, 
appear at first to be perfectly healthy. In 
these a period of from a fortnight to two 
months usually elapses, and then simul- 
taneously a rash appears, and the nostrils 
become stopped by swelling. At this 
stage the mouth is usually hot, its mucous 
membrane red and tumid, and the gums 
swollen. The child wastes, and assumes 
a shrivelled senile aspect. Sometimes 
acute, well - characterized iritis occurs. 
Condylomata are frequently seen. The 
cutaneous exanthem may vary in charac- 
ter, much as we find it does in the adult. 
Many children die during this evolution of 
secondary symptoms. If they survive 
they usually in the course of a year get 
rid of all traces of disease, excepting per- 
haps an unusual pallor of skin, and certain 
scars which may have been left in the face 
by the eruption, and an expanded nasal 
bridge caused by the long-continued swell- 
ing of the parts within. 
I have said above that the tertiary and 
secondary stages are sometimes strangely 
mixed in the early symptoms presented 
by syphilitic infants. Amongst those 
which we occasionally meet with under 
these circumstances are nodes of the long 
bones, nodes of cellular tissue, of tendon, 
or of muscle, and disease of the liver, kid- 
neys, thymus gland, &c. Such children 
are certainly more liable than others to 
serous inflammations. Serous arachnitis 
to a slight extent is very common, and 
pleurisy is not an infrequent cause of 
death. 
A condition of extreme anaemia usually 
results during the outbreak of early symp- 
toms in a syphilitic infant, and from this 
death often results. In many cases, how- 
ever, the child does not emaciate, but re- 
tains an appearance of good health which 
is remarkable, considering the nature of 
the disease. I have occasionally seen an 
infant who was well grown, stout, and 
strong in an unusual degree, who yet pre- 
sented well-characterized indications of 
inherited taint. 
In the child as in the adult the second- 
ary symptoms pass away in due time, and 
a period of health or latency ensues, of 
variable duration, after which the tertiary 
phenomena show themselves. These arc 
of precisely the same character as in the 
adult, with, however, the addition of seve- 
ral others which are not met with in connec- 
tion with the acquired disease. There are 
few more remarkable facts in the history 
of this most interesting malady than that 
the disease known as Interstitial, or, ac- 
cording to Mr. Dixon, as Syphilitic Kera- 
titis, should never occur as a consequence 
of acquired disease, but only in the in- 
herited form. I must also here note a re- 
markable exception to what I have stated 
to be the characteristic of tertiary symp- 
toms in the adult, that they are excep- 
tionally symmetrical. This form of kera- 
titis, although it often occurs many years 
after the secondary stage, is as a rule sym- 
metrical. So also are the nerve affections, 
which result in the forms of deafness and 
amaurosis which we now and then en- 
counter in these patients. As a rule, I 
believe all syphilitic symptoms in the in- 
herited disease, without regard to stage, 
are symmetrical. In the cases in which 
tertiary and secondary symptoms in in- 
fants appear to occur together, the latter 
are rarely well characterized. Thus I do 
not know of any instance in which a co- 
pious scaly or papular rash with acute 
iritis were coincident with any symptom 
of a tertiary kind. It has been asserted 
that a parent transmits to his child the 
precise form of Syphilis from which he at 
the time suffers. But to any rule of this 
kind exceptions are far more frequent than 
are confirmatory instances. It is very 
common for a man who does not himself 
display a single symptom of any kind, and 
who appears to be in perfect health, to 
beget a syphilitic child, the symptoms dis- 
played by the child being usually those of 
the secondary class. There is no doubt 
that the nearer to the occurrence of the 
primary symptoms in the parent is the 
birth of the offspring, the more certain is 
the latter to show symptoms of a severe 
character, and typically secondary in 
stage. Instances, however, are met with 
in which infants, born ten years after the 
original disease in the parent, still dis- 
played first a secondary rash, with the 
characteristic snuffles, &c. In several 
instances I have known a whole family of 
children, born during a period of from five 
to ten years, display each one the charac- 
teristic and transitory rash soon after 
birth.1 
The following appear to me to be well- 
established conclusions as to the transmis- 
sion of inherited taint. 
1st.-In all stages of constitutional Sy- 
philis-whether during the secondary or 
tertiary symptoms, or even during a pro- 
1 For facts on this subject I may refer the 
reader to my paper in the London Hospital 
Reports, vol. ii. p. 184, et seq. TERTIARY SYMPTOMS OR SEQUEL2E. 
431 
tracted period of latency-an individual 
may become the parent of a tainted child. 
The degree of severity of the inherited 
taint will be in proportion to the shortness 
of the period which has elapsed. 
2d.-A child may inherit Syphilis in a 
severe form from but one parent-from 
its father alone, or from its mother alone. 
3d.-When both parents are the sub- 
jects of Syphilis a child is more certain 
to suffer, and also more likely to suffer 
severely than when only one is so. 
4th.-We have as yet no data on which 
to ground an opinion as to whether a 
child is more likely to suffer severely 
when its father is the source of contamina- 
tion than when it derives the disease from 
its mother, or the reverse. 
5th.-In a large proportion of the cases 
met with in practice, the taint is derived 
from the father only. 
In connection with the hereditary trans- 
mission of Syphilis, an exceedingly im- 
portant question arises as to whether any 
degree of taint is transmissible to the 
third generation. There is no doubt that 
persons of marriageable age often present 
heredito-syphilitic lesions in an active 
stage, such as keratitis and nodes. I 
have repeatedly seen patients of various 
ages, from twenty to eight-and-twenty, 
become the subjects of syphilitic keratitis 
for the first time. We might conjecture 
that such persons would be likely to trans- 
mit to their offspring some degree of taint, 
seeing that the taint is still in full activity 
in their own bodies. I am not aware that 
any facts have as yet been published on 
this question. Conjectures abound, and 
several surgeons have expressed their be- 
lief, that the influence of Syphilis once ac- 
quired is felt through several subsequent 
generations. About eight cases have 
come under my own observation in which 
persons, undoubtedly the subjects of in- 
herited disease, have become parents. 
With one exception, I have never been 
able to discover any evidence of disease 
in the offspring. In several instances the 
offspring appeared to be in excellent 
health. I have always made a point of 
seeing the children for myself, never rely- 
ing upon the parents' statement-a pre- 
caution which is essential, as I have here 
occasion to illustrate. The exceptional 
case just alluded to is strongly in favor of 
the belief that the third generation may 
suffer. As no parallel one is on record, I 
think its details worthy of brief mention. 
A respectable young woman came to me 
about six months ago on account of an in- 
flamed eye. She had interstitial keratitis 
in a typical form, her teeth were notched, 
and her physiognomy characteristic. She 
told me that she was suckling her first 
child, an infant of two months. I in- 
quired if it were healthy. She said it was 
a fine baby and ailed nothing whatever. 
I asked her to bring it with her at her 
next visit. She did so, and on having it 
stripped I found it covered with coppery 
blotches, with condylomata at the anus, 
and snuffles in the nose. Under subse- 
quent treatment by mercury all these 
symptoms disappeared. There remains of 
course the source of fallacy that this child's 
parents, one or other of them, may have 
had acquired Syphilis. As to its father, 
I may state that he has been long under 
my treatment for sycosis, and that I have 
made the most detailed inquiry of him as 
to any venereal disease. I believe strongly 
that he has never had any. A fact, which 
is perhaps of more value than his own 
statement, is, that his sycosis has not been 
in the least benefited by iodide of potas- 
sium. Of course I have not ventured to 
insult him by inquiring as to his wife's 
antecedents, but there is no reason to en- 
tertain suspicion in that quarter, whilst the 
fact that she is the subject of inherited dis- 
ease makes it probable that she would not 
be liable to the acquired disease. Having 
therefore carefully balanced the evidence, 
I incline to believe that we have in this 
instance an example of the transmission 
of Syphilis to the third generation. 
Tertiary Symptoms or Sequelae.- 
I have endeavored to draw a strong line 
of distinction between secondary and ter- 
tiary symptoms. The secondary phe- 
nomena constitute a stage ; they come on 
at a certain known period; they are in 
their nature transitory, and undergo 
spontaneous cure; they affect the two 
halves of the body at the same time, prov- 
ing that they depend upon blood-poison- 
ing ; when once passed they rarely return. 
The tertiary symptoms are not so properly 
a stage, but must count rather as the se- 
quelae, more or less accidental, of the pre- 
ceding stages. They are as a rule not 
symmetrical, making it seem improbable 
that they depend upon blood-taint; they 
have no tendency to spontaneous cure- 
quite the reverse. They relapse over and 
over again after remedial treatment. The 
period which intervenes before their out- 
break is of very different length in differ- 
ent cases, and in many they never occur 
at all. From these facts we infer that 
they are due rather to the ill constitution 
of the affected structure than to any free 
virus still circulating in the blood. Let 
us briefly enumerate the principal tertiary 
symptoms which occur in acquired Syph- 
ilis. 
We may conveniently take them in their 
relation to special organs or structures. 
First, the skin and mucous membranes. 
Tertiary affections of these tissues differ 
in a most marked manner from those 
which occur in the secondary stage. 
With the exception perhaps of palmar 
psoriasis, they all involve ulceration of 432 
CONSTITUTIONAL SYPHILIS. 
greater or less depth, and consequently 
leave cicatrices. Very frequently the 
patch assumes a crescentic form, spread- 
ing at its edges and healing in its centre 
the well known horse-shoe or serpiginous 
ulcer. If the disease commence in the 
middle line it may spread equally on the 
two lines, and may thus appear to be 
symmetrical; but it is decidedly unusual 
for symmetrically-placed patches to ap- 
pear on the opposite limbs or on corres- 
ponding parts of the trunk. In many 
cases the skin is involved secondarily to 
the sub-cutaneous cellular tissue, the dis- 
ease having begun as a gummous tumor 
or node of the cellular tissue. A form of 
lupus attended by rapidly-spreading pha- 
gedsenic ulceration, occasionally occurs in 
tertiary syphilis, but there is good reason 
for believing that the common forms of 
lupus, whether exedens or non-exedens, 
have no connection whatever with syphi- 
litic taint. The appendages of the skin, 
the nails and hair, are frequently affected 
during the secondary stage, and but very 
rarely at later periods. 
The most frequent affection of the mu- 
cous membranes which we encounter in 
connection with tertiary syphilis, is a 
rapidly-spreading ulceration of the palate 
and pharynx. This again is totally differ- 
ent from the throat affections which occur 
in the earlier stages. Instead of being 
superficial and marked chiefly by swelling 
and inflammatory deposit, it is character- 
ized by deep ulceration and loss of tissue. 
Instead of showing itself symmetrically on 
the two sides, it commences at one, two, 
or more points, and spreads quite irregu- 
larly. The cicatrices left by these deep 
ulcerations not infrequently narrow the 
pharynx and occasion difficulty in degluti- 
tion. In a few cases the ulceration may 
extend down the oesophagus, and in many 
the larynx is involved. " Every now and 
then we see cases of tertiary syphilitic 
ulceration of the mucous membrane of the 
rectum, and again we must note that it is 
ulceration, and that it is not attended by 
the development of condylomata or mu- 
cous patches, as usually seen in secondary 
Syphilis. Stricture of the rectum is much 
to be feared when these ulcerations heal. 
Several authors have described cases re- 
sembling dysentery in all their symptoms, 
but occurring in syphilitic patients, and 
cured by anti-syphilitic remedies. Mr. 
Paget has recently recorded a case of this 
kind, and have myself seen some very 
well-marked ones. It is probable that in 
such cases ulceration of the mucous mem- 
brane at a considerable distance above the 
anus is present. I have seen several cases 
in which syphilitic ulceration extended 
higher than the finger could reach. 
The cellular tissue is frequently involved 
in common with muscle, with periosteum, 
or with fascia. In not a few cases, how- 
ever, we meet with what are called cellu- 
lar nodes, in which the disease begins, 
and is, up to a certain period, confined to 
this tissue. 
These may occur in any part of the 
body, but are much more usually met 
with in the lower extremities than in any 
other part. They are very common close 
to the knee, and especially so in the fe- 
male sex. It is a very interesting fact in 
respect to these cellular nodes that they 
are comparatively very infrequent in men. 
Whether this is to be explained by the 
greater abundance of cellular tissue in 
women, or by the fact that many women 
obtain Syphilis in a manner wholly pecu- 
liar to them, that is, by fetal contagion, 
may be open to some question ; probably 
both influences have their share in the re- 
sult. 
In the early stage of a cellular node we 
find a small lump of induration, often ex- 
ceedingly tender. At first it is firm, but 
as it extends it becomes doughy and softer. 
When of considerable size there is fre- 
quently a very deceptive sense of fluctua- 
tion in it. The overlying skin becomes 
adherent and of a dusky red color. At 
length ulceration takes place, and a large 
core is exposed, consisting of sodden and 
infiltrated tissues, much resembling in ap- 
pearance soaked wash-leather. Unless 
specific remedies are used, this core is 
very slow in separating, and the ulcera- 
tion of the skin over it may spread widely. 
Cellular nodes are not infrequently mul- 
tiple, but more usually single. The pa- 
tient frequently has scars of former ones 
on the opposite limb, but it is exceptional 
to find them simultaneously present on 
corresponding parts. 
A period varying from four to ten or 
fifteen years has usually elapsed between 
the occurrence of primary contagion and 
the development of cellular nodes. In 
close connection with syphilitic inflamma- 
tion of the cellular tissue, we must men- 
tion that of the subcutaneous bursa. It is 
not at all uncommon for a bursa to suffer 
in connection with the disease of the tis- 
sue around it, and sometimes there ap- 
pears to be clear evidence that the disease 
began in the bursa itself. The bursa in 
front of the patella is the one most fre- 
quently involved. 
When ulceration takes place the in- 
flamed bursa is usually involved in the 
core, and has to be entirely removed be- 
fore healing can ensue. 
Inflammations of the periosteum and bones 
have for long occupied the most promi- 
nent place amongst the tertiary symptoms 
of Syphilis, and they are still some of the 
most common. In enumerating the symp- 
toms which characterize the secondary 
stage, we have mentioned pains in the 
bones, attended occasionally by slight and 
temporary swelling. This kind of perios- TERTIARY SYMPTOMS OR SEQUELJE. 
433 
titis, however, never lasts long, and, as 
far as my own observation goes, never 
leads to suppuration. True nodes seldom 
occur until at least two years have passed 
since the first contagion, and generally 
the period is much longer. They may 
affect almost any parts of the osseous sys- 
tem, but the bones which are superficial, 
and therefore most exposed to external 
influences, are those most frequently at- 
tacked ; e. g., the calvaria, tibiae, and the 
clavicles. 
The bones of the palate, the alveolar 
processes of the maxillae, the vomer, and 
other bones in the nasal passages, are 
very frequently affected, and when such 
is the case, exfoliation of portions usually 
occurs. 
Syphilitic periostitis may vary consider- 
ably in its degree of severity and in its 
tendencies. 
In some cases there is but little of acute 
inflammation, and the result is a great 
thickening of the bone affected, without 
the occurrence of suppuration. This fre- 
quently occurs in the bones of the skull- 
the whole calvaria acquiring greatly in- 
creased thickness and density. It is also 
not uncommon on the surface of the tibia 
and other long bones, constituting what is 
known as the osseous node. In other 
cases suppuration occurs, and in these 
very frequently large portions of cellular 
tissue become involved, and we have a 
swelling consisting in part of periosteal 
abscess and in part of a cellular node. 
When the bone is exposed by ulceration, 
exfoliation of portions often results. 
When the bones of the skull are at- 
tacked by syphilitic periostitis it is very 
possible that inflammation may occur in- 
ternally as well as superficially, and that 
we may have symptoms referable either 
to irritation of the cerebral coverings or to 
compression consequent upon intra-cranial 
abscess. In association with nodes on the 
skull, various symptoms of mental dis- 
turbance show themselves; extreme irri- 
tability of temper, liability to fits of un- 
controllable passion, melancholia, and 
sometimes acute mania occur. These 
symptoms of mental disturbance may or 
may not be associated with those of local 
paralysis. They not infrequently result 
in attempts at suicide. The proof that 
they really are dependent on syphilitic 
lesions is afforded by the ease and rapidity 
with which they are relieved by the iodide 
of potassium. Some remarkable instances 
of this kind have recently been under my 
care. 
Periosteal nodes are not very frequently 
met with on the short bones; we must, 
however, be prepared to recognize them 
occasionally on these also. The patella 
and the os calcis are not very infrequently 
affected, and now and then the other bones 
of the tarsus or carpus suffer. 
Diseases of the muscular system occu- 
chiefly amongst the most remote sequelae 
of Syphilis, and they are by no means fre- 
quent. They usually take the form of 
nodes or gummata, developed in the sub- 
stance of some single muscle. The indu- 
ration is usually very considerable, and in 
many parts abruptly limited. The diag- 
nosis from cancer is often very difficult, 
and many a mistake leading to an unne- 
cessary operation and to a supposed per- 
manent cure of cancer has occurred. 
The muscular substance of the tongue 
is that most frequently attacked, but they 
have been met with in almost all the 
muscles of the body. We may mention 
especially the sterno-mastoid, the masse- 
ter, the supra- and infra-spinati, the gas- 
trocnemius, and the rectus femoris. 
I have recently had under care an ex- 
tremely interesting case in which a tumor, 
which we at first suspected to be cancer, 
was developed in the left masseter of a 
lady who had twenty years before suffered 
from Syphilis. She presented at the time 
the tumor appeared no other syphilitic 
symptoms, and the correct history was 
only obtained with much difficulty. The 
tumor has wholly disappeared under the 
use of the iodide of potassium. 
Some forms of syphilitic indurations of 
the tongue are exceedingly difficult to dis- 
tinguish from cancer. They are very 
hard, have well-defined edges, are pain- 
ful, and when they ulcerate present an 
unhealthy surface. Iodide of potassium 
in full doses will usually in the course of 
a week or ten days clear up the diagnosis. 
The heart itself is sometimes the seat of 
syphilitic nodes. Of this, M. Ricord1 was, 
I believe, the first to record an example ; 
but several others have been subsequently 
mentioned by other observers. 
The Glandular System.-The chronic 
enlargements of the lymphatic glands, 
sometimes resulting in suppuration, are 
every now and then met with as the se- 
quelae of Syphilis, but it does not appear 
to me that they occupy any very impor- 
tant position. It is a remarkable fact in 
reference to tertiary syphilitic lesions 
generally that they do not cause any 
secondary enlargement of the adjacent 
lymphatic glands. This is true of syphi- 
litic ulcerations of the skin and mucous 
membranes, of all the various forms of 
node, and of syphilitic tumors in muscles, 
and it often constitutes a very useful 
means of differential diagnosis between 
cancer and Syphilis. 
The Internal Viscera.-Of late years the 
investigations of pathologists have fully 
1 See Traite complete des Maladies V6ne- 
riennes, Blanche xxix. In this instance the 
patient was a man aged 41, who had suffered 
from a chancre followed by constitutional 
symptoms eleven years prior to his death. 
vol. i.-28 434 
CONSTITUTIONAL SYPHILIS. 
confirmed the conjectures of the older 
writers on Syphilis, as to the frequency 
with which the viscera of the trunk, and 
more especially the liver, suffer in consti- 
tutional Syphilis. In connection with 
this subject we must especially mention 
the very valuable contributions of Dr. 
Wilks. As to the exact period in the 
course of the disease at which the viscera 
are attacked, it is difficult to obtain any 
positive evidence. What we discover in 
the post-mortem examination is usually 
the result of long past disease, and it is 
comparatively infrequent to find it in a 
recent stage. What evidence we have, 
however, favors the belief that it is not un- 
til the later periods that the viscera suffer. 
The liver appears to be far more fre- 
quently affected than any other organ. 
bulk of the organ is diminished. In re- 
cent disease the affected parts of the or- 
gan are enlarged, and on section exude a 
material not unlike bees-wax, or glutinous 
and gummy. I am not aware that ab- 
scesses have as yet been met with in the 
liver in supposed connection with Syphi- 
lis. Virchow recognizes two forms of 
disease-a capsular hepatitis and an in- 
terstitial hepatitis. Of these the capsular 
inflammation is the more common and 
the less serious. It is probable that the 
two are generally associated to a greater 
or less extent. Ascites occurs every now 
and then in connection with Syphilitic 
disease of the liver. An instance of it in 
a woman, the subject of inherited Syphilis 
with a contracted liver, has recently been 
under my care. The disease was of sev- 
eral years' standing, and paracentesis had 
been repeatedly performed. By a long 
course of iodide of potassium, with am- 
monia, the fluid was entirely removed and 
her health much benefited. Ascites from 
liver disease is not very infrequent in the 
subjects of inherited taint. 
Testes.-Syphilitic sarcocele or syphilitic 
orchitis has usually been classed by au- 
thors as a secondary symptom. I feel 
sure, however, that this is not quite cor- 
rect. It is amongst the earlier of the 
sequela?, but seldom if ever occurs during 
the secondary stage. It is commonly 
met with in conjunction with nodes, and 
with deep ulceration of the skin rather 
than 'with the superficial rash of the sec- 
ondary epoch. It consists of the free ef- 
fusion of lymph (flbro-plastic material) 
into the substance of the testis, or, more 
rarely, into the epididymis. 
The swelling often attains a very con- 
siderable size, and when it does so it pre- 
sents the peculiar feature of feeling very 
light in the hand. Syphilitic sarcocele is 
much more frequently symmetrical than 
any other form of tertiary Syphilis. This 
circumstance we might expect from the 
fact that it occurs much nearer to the 
secondary stage than do most of the oth- 
ers. 1 Still, however, it is only exception- 
ally symmetrical. 
Nervous System.-We come lastly to 
syphilitic affections of the nervous system 
itself. 
I have previously adverted to the occa- 
sional occurrence of cerebral symptoms in 
[Fig. 15. 
The peripheral portion of a gummy growth in the 
kidney. Showing the small-celled granulation growth 
in the intertubular tissue. X 200. (From Green.)] 
Indeed, in the examination of the bodies 
of those who have suffered from tertiary 
Syphilis, it is decidedly exceptional not to 
[Fig. 16. 
From a gummy growth in the kidney. Showing 
the reticulated structure occasionally met with in the 
intermediate zone of these formations. X 200. (From 
Green.)] 
find proof of hepatic mischief. The most 
common condition consists in large white 
patches of fibroid thickening on the sur- 
face of the organ. These patches are evi- 
dently cicatricial. The liver is knotted 
and puckered by them, and bands of cica- 
trix dip from the surface into the sub- 
stance of the organ. Sometimes, when 
the destruction has been great, the whole 
1 On this point Mr. Curling writes, "Sir 
A. Cooper thinks that in the majority of 
cases, the disease attacks both testicles. The 
eight examples recorded in his work do not, 
however, bear out this remark, for in only 
two of them does it appear that both organs 
were attacked. According to my observation, 
the disease is more commonly confined to a 
single gland, though it occasionally affects 
both ; and this also appears to be the opinion 
of Ricord." TREATMENT OF SYPHILIS. 
435 
connection with syphilitic inflammation 
of the bones of the skull, and to the for- 
mation of intra-cranial nodes; but, quite 
apart from the disease of its osseous case, 
the brain itself may suffer directly from 
the formation of tertiary syphilitic depos- 
its in its structure. We may also have 
deposits of like nature into the substance 
of nerve trunks, producing special forms 
of local paralysis. To these isolated de- 
posits the term syphilitic neuromata has 
been given, and several well-authenticated 
cases are on record in which the diagnosis 
has been confirmed by an autopsy. In a 
far greater number of cases the diagnosis 
has received an almost equally valuable 
confirmation in the cure of the disease by 
iodide of potassium. So frequently indeed 
is tertiary Syphilis the cause of paralysis, 
that investigations in this direction ought 
never to be omitted in cases in which the 
nature of the disease is in the least doubt- 
ful. It is, indeed, safe to go further than 
this and to say that in all cases of paraly- 
sis, without evident cause, and in which 
syphilitic antecedents are even possible, 
it is advisable to try the effect of iodide 
of potassium. I allude chiefly to cases of 
paralysis of the cranial nerves, for it would 
appear that neuromata of these are more 
frequent than of the spinal ones. Of the 
cases of paralysis of the fifth nerve, of the 
third, fourth, and sixth, which have come 
under my notice at the Ophthalmic Hos- 
pital, a large proportion of these have 
been of syphilitic origin, and most of these 
have been cured by the administration of 
iodide of potassium. 
Syphilitic affections of the nervous sys- 
tem are usually among the late tertiary 
phenomena. I have rarely seen them at 
an earlier period than about five years 
after the primary disease, and in most in- 
stances the interval is much longer. In 
many cases the patients have had time to 
regain the appearance of good health, and 
almost to forget the malady from which 
they had formerly suffered. Under such 
circumstances the diagnosis is often sur- 
rounded with difficulty. 
Syphilitic affections of the nerves of 
special sense do not appear to be common 
in connection with acquired disease, but 
they are not infrequent as results of in- 
herited taint. In the subjects of the 
latter a form of cerebral deafness is often 
met with, and also one of complete blind- 
ness in association with white atrophy of 
the optic nerves. 
one by the other. Viewing Syphilis as a 
disease of the zymotic class, caused by a 
specific virus which accomplishes its de- 
velopment within the body of the infected 
person, and passes through distinct phases 
or stages, nothing can be more probable 
than that in order to influence its cause 
we shall require very different measures 
in the different stages. The treatment 
which we should adopt in the onset of 
variola is not that which we should resort 
to after the exanthem has disappeared. 
We have then in respect to Syphilis to 
ask: First, what treatment should be 
adopted in the exanthematic or secondary 
stage ? Second, what should be used 
against the very various sequelae classed 
as tertiary symptoms ? Third, whether 
there is any reason for believing that the 
development of stages, more especially of 
the exanthem, can be influenced by in- 
ternal treatment adopted immediately 
after inoculation ? Fourth, whether the 
sequelae are rendered less or more severe 
by interference with the development of 
the early stages of the complaint ? 
As the present essay is on the medical 
aspects of Syphilis, we may suitably leave 
out of debate a matter of the utmost in- 
terest to the surgeon, that, namely, as to 
the prevention of constitutional infection 
by local treatment of the inoculated part 
(so-called "abortive treatment"). 
To cite an array of facts on this exten- 
sive subject would be wearisome, and 
without adequate result, nor should we 
more easily accomplish a summary of the 
very diverse opinions which have been 
published by medical authorities. [A 
general agreement exists among practi- 
tioners as to the propriety of endeavoring 
to arrest the specific morbid process of 
chancre by local applications. Early 
cauterization with solid nitrate of silver 
will sometimes eradicate the disease. If 
that fail, the alterative action of powder 
of calomel may be tried. Iodoform is pre- 
ferred by some. Astringent washes, as 
lime-water, solution of sulphate of copper, 
&c., usually do good. When a bubo 
forms, in the inflammatory stage it may 
be treated with lotions of lead-water and 
poultices. If suppuration occurs, it should 
be freely opened with a bistoury. Should 
it then be slow to heal, the treatment will 
be essentially the same as for an indolent 
ulcer.-II.] The question as to the treat- 
ment of Syphilis resolves itself chiefly into 
one as to the efficiency or otherwise of 
mercury. We will submit for consideration 
answers to the following questions : Does 
mercury in any way influence the course 
of syphilitic symptoms ? On this point I 
think almost all are unanimous. When 
given during the stage of induration of a 
chancre, mercury causes the absorption of 
the induration, and the healing of the 
sore ; when given during the outbreak of 
Treatment of Syphilis. - In ap- 
proaching the question of the treatment 
of Syphilis we must always keep clearly in 
mind the facts which have been estab- 
lished as to its nature. Not indeed that 
a priori reasoning is to supersede empiri- 
cal experience in such a matter, but 
rather that we shall do well to guide the 436 
CONSTITUTIONAL SYPHILIS. 
the secondary rash, it causes the rash 
quickly to disappear; it also causes the 
ulcers in the tonsils to heal. In cases of 
iritis and retinitis we have the most con- 
clusive proof of the rapid absorption of 
syphilitic lymph under mercurial influ- 
ence, inasmuch as in each of these condi- 
tions the inflamed structure is directly 
under our inspection. If we inquire as to 
the value of mercury against the tertiary 
symptoms, we obtain a much less positive 
answer, but we shall still meet with evi- 
dence in proof that over many forms it 
possesses a most decided power. 
Having seen that mercury does, beyond 
all doubt, possess the power of shortening 
the duration of the primary sore, or if not 
used until the secondary manifestations 
have appeared, of causing these latter to 
disappear ; we next have to ask whether 
the mercurial cure of any single stage, 
whether primary or secondary, influences 
beneficially the subsequent progress of the 
disease. The difference between an anti- 
dote for the syphilitic virus and a remedy 
for extant syphilitic inflammations, must 
be clearly recognized. It is one which 
has been acknowledged from the time of 
Hunter to the present day. It appears 
to me that the balance of evidence is in 
favor of the belief that mercury is a most 
potent remedy against syphilitic inflam- 
mations, but that it does not act as an an- 
tidote to the virus. I fear we have but lit- 
tle proof that mercury tends, on the whole, 
to abridge the duration or mitigate the se- 
verity ofthe syphiliticfever and its sequelse. 
During about two years in my practice 
at the Metropolitan Tree Hospital, I sys- 
tematically abstained from adopting any 
treatment in my cases of indurated 
chancre and its consequences. The 
chancre and the rash were allowed to de- 
velop themselves and to disappear spon- 
taneously, and they did so in a fairly 
satisfactory manner. The duration of 
each was considerably longer than when 
mercury is given ; otherwise I could ob- 
serve no difference. The rash did not ap- 
pear earlier, nor was it more copious than 
in the cases in which the remedy had been 
used. On the whole I had no reason to 
think that the patients suffered from the 
experiment beyond the fact of a more 
prolonged illness. As to what may be the 
relative frequency of tertiary symptoms 
in these cases it is as yet too early to speak. 
I have also, in private practice, not infre- 
quently treated indurated chancres and 
secondary rashes without giving mercury.1 
As already stated, I think there is no 
proof whatever that by giving mercury 
for the primary sore, we diminish the pro- 
bability that secondary symptoms will 
occur. These latter are for the most part 
inevitable, whatever may be the treat- 
ment employed. They are sometimes 
very slight indeed, and in some cases, 
perhaps, wholly omitted, but their non- 
occurrence is quite as frequent when mer- 
cury has not been given as under the 
opposite conditions. It is, therefore, un- 
safe to assume because in any one case in 
which mercury was given early, and no 
secondary symptoms ensued, that, there- 
fore, the treatment prevented them. Such 
sequences are probably mere coincidences. 
Thousands of cases may be quoted in 
proof that mercurial absorption of the 
chancre does not prevent the secondary 
stage; and, further, that the mercurial 
treatment of both primary and secondary 
stages does not prevent the occurrence of 
tertiary sequelse. We might also quote 
another class of facts in proof that mer- 
cury is not in any strict sense an antidote, 
those, namely, in which relapses occur 
either during or immediately after its use. 
These cases must be familiar to all. A 
patient, whilst actually salivated on ac- 
count of iritis in one eye, becomes affected 
by the same inflammation in an acute 
form in the other, or just after the mer- 
curial cure of iritis, retinitis occurs. Of 
the latter occurrence I have seen several 
marked examples. I admit that these 
quick relapses are exceptional, but they 
are still sufficiently common to become of 
great value in reference to the question 
under debate. The belief that mercury 
given in the early stages in any way com- 
plicates the case or adds to its subsequent 
severity is, I think, to a very large extent 
an error ; at any rate it is quite certain 
that the worst forms of syphilitic symp- 
toms, whether secondary or tertiary, not 
infrequently occur in cases in which no 
mercury has been used ; especially is this 
a fact as regards tertiary symptoms, such, 
for instance, as extensive disease of the 
bones. In former days, when mercury 
was given so freely, it was not so easy to 
find cases of tertiary Syphilis without the 
history of previous mercurial treatment; 
in the present day, however, it is not at 
all infrequent. 
If I might be allowed to express my own 
impression, founded as it is on a considera- 
ble number of facts, but for obvious reasons 
not easily susceptible of categorical proof, 
it would be to the effect that the course of 
Syphilis is on the whole rendered somewhat 
milder by early mercurial treatment. 
Quite apart from the questions as to the 
general influence of mercury upon the 
course of Syphilis, we must estimate its 
value in the speedy removal of local in- 
1 I have preferred to speak from my own 
experience rather than to refer to the large 
amount of published evidence which exists. 
My own trial of the non-mercurial plan was 
made purely as an experiment, and without 
the slightest sentiment of partisanship. TREATMENT OF SYPHILIS. 
437 
flammations. We have ventured to con- 
sider that it is a proven and admitted 
fact that this remedy does produce the 
rapid absorption of syphilitic lymph. 
When the lymph is effused into the skin, 
or at the base of the original chancre, it 
may be a matter of little or no consequence 
whether it is allowed to remain two weeks 
or two months. There is no material 
danger as to the integrity of the organ 
concerned. In the case of the eye and 
certain other organs, however, the facts 
are very different. If the iritis be allowed 
to proceed unchecked, it will in all proba- 
bility end in obliteration of the pupil, 
either partial or complete. It will effect 
but little to use atropine, unless we use 
mercury also, for in many cases during the 
acute stage of the inflammation the pupil 
can be scarcely made to dilate until the 
lymph effused into the iris is in part ab- 
sorbed. The longer the lymph is allowed 
to remain, the longer the inflammatory 
process is allowed to continue unchecked, 
the greater will be the risk of disorganiza- 
tion of the structure implicated. 
These remarks apply with yet more 
force to syphilitic retinitis than to iritis. 
That it is the bounden duty of the sur- 
geon to administer specific remedies in 
these diseases, no one who has considered 
the facts can, I think, doubt. It is not 
uncommon to see the retina in a case of 
severe retinitis become almost clear after 
a fortnight's mercurial treatment, with 
corresponding benefit to the patient's 
vision. It is on the other hand very com- 
mon to see this disease remain unchanged 
for several months, if mercurial treatment 
be not adopted. 
Those anti-mercurialists who carry their 
doctrines so far as to refuse to employ spe- 
cific remedies when the eye is attacked, 
incur a responsibility probably far greater 
than they suppose. A case has recently 
come under my own observation so much 
to the point that I must mention it. 
A gentleman engaged in the city con- 
sulted me concerning some symptoms 
which I easily recognized as the sequelae 
of Syphilis. Amongst others he had mus- 
cae and evidences of a past attack of reti- 
nitis. He gave me the history that he 
had been treated for the primary disease 
by a surgeon well known as an opponent 
to mercury. This gentleman explained 
to him in very strong terms the evils 
which he supposed to result from that 
drug, and so far secured his confidence 
that he continued under expectant treat- 
ment for several months. The eyes were 
attacked, and still specific remedies were 
abjured. "At length," said my patient, 
"when I was all but blind, and when for 
several weeks no improvement had oc- 
curred, I determined to take other advice, 
and consulted Mr. Critchett. Mr. Crit- 
chett assured me that the fear of mercury 
was all nonsense, and that the only chance 
for my sight was at once to go home, keep 
myself in a warm room, and take mercury 
till the mouth was sore. This I deter- 
mined to do, and the result was that in 
the course of a week, I could see very 
much better, and that subsequently I re- 
gained almost perfect sight." 
In this case, not only did the mercurial 
treatment rapidly cure the retinitis, but 
it removed the syphilitic rash and restored 
the patient's general health in a way 
which, to him, was marvellous. 
When Syphilis attacks the larynx it be- 
comes also of great consequence to adopt 
energetic treatment, on account of the 
danger to life which may accompany the 
local disease. 
Although in the case of the skin we 
have to deal with an organ not essential 
to life, and the functions of which may be 
long interrupted with comparative impu- 
nity, yet it is still probable that a very ex- 
tensive cutaneous inflammation, such as 
occurs in the exanthem of Syphilis, is not 
wholly without its injurious influence on 
the general health; thus there may be 
some reason alleged for preferring to get 
rid of a secondary rash in a few weeks by 
mercury, rather than to allow it to disap- 
pear spontaneously after several months' 
duration. 
We come, lastly, to the question as to 
the treatment of the tertiary symptoms, 
or the sequelae which occur several years 
after the contagion. 
The marvellous power of the iodide of 
potassium in the cure of these affections is 
universally admitted, and has led to the 
almost entire disuse of mercury in their 
treatment. The only drawback to its 
employment is, that cures thus effected 
are rarely permanent, and that relapses 
are very frequent in a short time after its 
suspension. Some surgeons of large ex- 
perience hold that mercury, even in re- 
gard to the tertiary symptoms, is more 
efficient than the iodide in bringing about 
a permanent cure. This is, however, 
open to much doubt. Practically, in all 
cachectic subjects suffering from tertiary 
symptoms, we usually administer the 
iodide alone, and if the cachexia be less 
severe we combine it with a mercurial. 
Another general rule on this point is, that 
the earlier in the role of tertiary symp- 
toms the greater the desirability of mer- 
cury, and the more remote from the original 
taint the more likely is the iodide alone to 
be found efficient. Thus, cases of node, 
of gummous tumor, of tumors in muscles, 
and of affections of the nervous system, 
all of which are among the later of the 
tertiary class, are usually treated most 
satisfactorily by iodide of potassium. 
What little experience I have had of 
the treatment of tertiary Syphilis, either 
by the mineral acids or by sarsaparilla, 438 
CONSTITUTIONAL SYPHILIS. 
has not been favorable to these remedies. 
We must not overlook in the manage- 
ment of cases of syphilitic sequela?, the 
importance of change of air, of nutritious 
diet, and general attention to the patient's 
health. Such sequelse, are especially apt 
to occur and to become severe in patients 
whose general health has been broken 
down. Any debilitating influence brought 
to bear upon a patient the subject of a 
latent taint may permit such taint to be- 
come active. 
Thus, patients who have for many years 
enjoyed excellent health, and have be- 
lieved themselves long ago and completely 
cured, may become, at the climacteric pe- 
riod, or when by any chance underfed 
and enfeebled, the subjects of tertiary Sy- 
philis. Yet, whilst fully admitting the 
importance of sustaining the general vigor 
as a prophylactic measure against tertiary 
Syphilis, we must keep in mind that these 
measures will by no means prove always 
efficient. Many of the worst cases of ter- 
tiary Syphilis, whether consequent on in- 
herited or acquired taint, occur in those 
whose circumstances of life enable them 
to enjoy every hygienic advantage. 
With regard to the details of mercurial 
treatment, differences of opinion still pre- 
vail among surgeons. The majority still 
think the stomach the most fitting organ 
by which to introduce the remedy into the 
blood. There is no doubt that absorption 
by the skin, whether by inunction or the 
moist vapor bath, is very efficient, but 
there is no proof that it is superior to the 
other. Under the able advocacy of Mr. 
Langston Parker, Mr. Lee, and others, 
the calomel vapor bath has of late years 
obtained much repute. I have often used 
it, and have still more frequently seen 
cases in which it has been used by others, 
and have not been able to persuade my- 
self that it possesses any real advantages. 
The fact is, that mercury in any form is 
so prompt in its results against syphilitic 
inflammations, that whoever is in the 
habit of prescribing it in one special form 
is very apt to come to the conclusion that 
his peculiar mode of use must be superior 
to others. 
When there is a rash or ulceration on 
the cutaneous surface, it is always well to 
apply mercury directly to the inflamed 
part in addition to its internal use. This 
may be done conveniently by prescribing 
the mercurial ointment when there is no 
ulceration, and the black wash when the 
latter exists. Of the various preparations 
of mercury, I much prefer calomel or the 
bichloride, and rarely find that these, 
■when used with suitable adjuvants, in 
moderate dose, disagree to any material 
amount. Ter the early forms of second- 
ary rash I usually employ mercury alone, 
and for the latter ones mercury in combi- 
nation with iodide of potassium. A mix- 
ture containing the solution of the bichlo- 
ride with the iodide in excess is extremely 
useful. It probably amounts to bin-iodide 
of mercury with excess of iodide of potas- 
sium. The addition of ammonia to this 
mixture appears to increase its efficacy, 
and the same is the fact as regards its use 
with the iodide of potassium under all cir- 
cumstances. 
In prescribing mercury it is the sur- 
geon's duty to carefully watch its effects 
upon the disease, and upon the patient's 
health. The fact that a given patient is 
cachectic and feeble is not in itself any 
reason for precluding resort to specific 
treatment. On the contrary, it is under 
such circumstances not infrequently that 
the value of the remedy is best shown. 
Nor can we lay down any rule as to the 
avoidance of mercury in treating certain 
forms of rash-ecthyma, rupia, &c. It 
may be stated in general terms that the 
more nearly the rash keeps to the scaly 
type, the more certain is it that mercury 
will agree; whilst the greater the ten- 
dency to ulceration and suppuration, the 
more is the risk that it may disagree. 
Should it disagree in any case, the observ- 
ant surgeon will soon discover the fact. If 
the ulcers spread instead of healing, and 
if the quantity of secretion is increased, 
then mercury should be at once laid aside 
and substituted by iodide of potassium 
with tonics. The cases in which this sub- 
stitution becomes necessary are, I believe, 
often those in which the patient has in- 
herited partial immunity, and conse- 
quently suffers from a modified form of 
the acquired disease. Although mercury 
is very efficacious in the infantile stage 
of Congenital Syphilis, it often disagrees 
most markedly with the subjects of this 
taint when they have attained adult age. 
As a rule, in the management of second- 
ary Syphilis, it is well to push mercury to 
a mild degree of ptyalism. Not infre- 
quently symptoms resist its action until 
the gums are sore, and then yield at once. 
I have often observed this in inflamma- 
tion of the eye, especially in retinitis. 
With regard to the iodide of potassium 
against tertiary symptoms, a few simple 
rules may be given. It is well always to 
combine it with ammonia. It is well to 
begin with a small dose, e. g., five grains 
three times a day, and to gradually in- 
crease, not going beyond ten or twelve 
unless necessary. If the disease does not 
yield to the la tter, the diagnosis being yet 
undoubted, then much larger doses should 
be given; say, half a drachm three times 
daily. In a few rare cases, nothing short 
of these large doses will produce any 
benefit. 
The Diagnosis of Constitutional 
Syphilis.-The power of recognizing 
syphilitic diseases when brought under DIAGNOSIS OF CONSTITUTIONAL SYPHILIS. 
439 
notice is one of the most valuable gifts 
which the physician can possess. These 
diseases meet us at every turn in prac- 
tice, and present a most bewildering 
variety of external aspect. At one time 
we have to distinguish a syphilitic rash 
from a simple one, at another to diagnose 
between Syphilis and Cancer, or Syphilis 
and Rheumatism, or the problem pre- 
sented may be to form a correct opinion 
as to the nature of a paralysis, an ascites, 
or an attack of mania. The first requisite 
to success is a mind constantly awake to 
suspicion, and fully impressed with the 
all-important fact that diseases of the 
most diverse character may have their 
origin in this taint, and that if so they 
will prove to be curable only by treatment 
directed against it. This suspicion must 
be present, whatever may be the position 
in life or the reputation of our patient. 
A gentleman, who now at middle age 
bears the most irreproachable character, 
may chance to have been less circumspect 
during college life, and it is not fair that 
his subsequent purity of conduct should 
be the means of preventing his relief from 
the consequences of youthful error. We 
meet every day with cases in which wo- 
men, whose characters are spotless, have 
become the subjects of syphilitic taint 
without their having the slightest sus- 
picion as to the nature of their malady. 
Under many circumstances it is out of the 
question to make any direct inquiries, and 
the physician must depend upon his own 
acumen for the opinion which shall guide 
his treatment. 
The recognition of syphilitic symptoms 
in the secondary stage is not usually diffi- 
cult. The copiousness of the rash; its 
symmetry ; the copper-tint; the frequent 
coincidence of several of different types 
of skin eruption in the same case ; the 
presence of febrile disturbance ; the ab- 
sence of cutaneous irritation and the co- 
existence of sores on the tonsils, and fre- 
quently on the mucous membrane of the 
cheeks also-are all features which help 
to make the diagnosis easy and certain. 
To these we may add that the syphilitic 
exanthem usually appears first on the ab- 
domen, chest, and fronts of the arms, 
that it very commonly affects the face, 
and that it avoids the backs of the elbows 
and the fronts of the knees, localities 
which are almost always attacked in cases 
of common psoriasis. Although syphilitic 
rashes vary very much in outward charac- 
ters, yet they have always in the features 
just mentioned a basis of close similarity. 
When mistakes occur they are usually 
those of insufficient attention. The pa- 
tient is allowed to show only a small part 
of his surface, instead of being made to 
strip, or at any rate to expose the whole 
of his bust. If the latter course be 
adopted, the symmetry of the rash and 
its other peculiar features will almost al- 
ways arrest the attention of the observer. 
Amongst minor points which occasionally 
assist may be mentioned the gyrate or 
ringed form of the patches, and in some 
cases of syphilitic psoriasis the compara- 
tive absence of desquamation. 
The cases which cause most difficulty 
are those in which Syphilis occurs in a 
patient who is already the subject of some 
other skin disease. In hospital practice 
it is very common to see scabies and a 
syphilitic rash coexisting, and in some 
such it is most difficult to pronounce with 
certainty as to the nature of the eruption. 
Examination of the mouth and throat 
and of the genitals will often remove 
doubt; but if not, a few sulphur baths as 
a measure of diagnosis will usually prove 
successful. 
Next to that of exanthem itself comes 
the diagnosis of the relapses of eruption, 
which often occur between the secondary 
and the tertiary epoch. In these there is 
rarely any copious outbreak, usually only 
a few isolated patches. These are most 
commonly met with in the palms of the 
hands or soles of the feet, or on the front 
aspects of the forearms or legs. They are 
almost dry and attended with peeling of 
the epidermis. Very frequently there are 
small sores in the mouth or on the tongue ; 
at the same time a form of acne, chiefly 
affecting the forehead, and leaving little 
pits or scars, is very often seen in this 
stage. If iritic adhesions are present, or 
if there are pits in the skin of the face 
and trunk, left by a former rash, the sus- 
picion is much strengthened. If the diag- 
nosis remains doubtful, we may cautiously 
try the effect of a short treatment with 
the bichloride or biniodide, and observe 
the result. 
Lastly, we must consider the question 
of the recognition of the various diseases 
which come into the category of tertiary 
symptoms. When these occur, it is often 
many years since the patient has suffered 
from any other; and it is quite possible 
that he may appear to be in excellent 
health. A few of the tertiary symptoms 
have been so long recognized in relation 
to their true cause, and are so rarely met 
with in connection with any other, that 
in themselves they almost constitute their 
own diagnosis, and often also help us to 
that of more obscure lesions. Periosteal 
swellings or nodes are the chief of these. 
To speak generally respecting other forms, 
we may say that the diagnosis must be 
founded in part upon the patient's pre- 
vious history, in part upon any still ex- 
isting remnants of former disease-such, 
for instance, as iritic adhesions-and in 
part upon the peculiarities of the disease 
itself. As regards the patient's antece- 
dents, I may just remark, by way of cau- 
tion, that we must not hastily assume 440 
CONSTITUTIONAL SYPHILIS. 
that he is syphilitic because he tells us 
that he has had the venereal disease. A 
soft chancre with its suppurating bubo, 
or even an attack of gonorrhoea, although 
both of them quite innocent as regards 
constitutional infection, often leave more 
vivid impressions on the patient's mind 
than does an indurated sore and its exan- 
them. Those who are most ready to sus- 
pect a venereal cause, are often those who 
have never had true Syphilis at all. If, 
however, there is a clear history of a 
chancre followed by secondary rash, sore 
throat, &c., then we have obtained a fact 
which, whatever may be the present ail- 
ment, may be safely permitted to modify 
our treatment. The majority of tertiary 
lesions are by conventional usage re- 
garded rather as surgical than medical, 
and it would be out of place to speak in 
detail of the diagnosis of ulcers, gummous 
tumors, &c. I may briefly remark that 
the serpiginous form of ulceration, heal- 
ing in the centre and spreading at the 
margin, is a feature always to be re- 
garded with suspicion ; that tumors in 
muscle, which will only melt away under 
the influence of the iodide, are sometimes 
as hard and as defined as any variety of 
chancre, and have often led to needless 
operations. 
In cases of disease of the nervous sys- 
tem in which Syphilis is suspected, an 
examination of the patient's eyes, throat, 
tongue, and tibiae should never be omitted. 
The existence of iritic adhesions, of cica- 
trices of the soft palate or of periosteal 
nodes, will often decide the question. The 
occurrence of nocturnal exacerbations of 
pain is also always suspicious. If the 
disease implicate only one nerve-trunk, 
especially if only one cranial nerve be in- 
volved, the suspicion of Syphilis becomes 
very strong. Probably a full half of the 
cases of paralysis of the third, fourth, fifth, 
and sixth nerves, when such paralysis 
affects only one nerve, are due to Syphilis 
and are curable by specific treatment. In 
these cases the disease is hardly ever sym- 
metrical, and the paralysis is usually com- 
plete. The seventh nerve is occasionally 
attacked, but not so frequently as the 
others. The nerves of special sense are 
not so frequently affected in acquired 
Syphilis as they are in the inherited form. 
Nevertheless, cases do occasionally occur 
in which amaurosis or complete deafness 
are met with in the subjects of syphilitic 
taint, and without other assignable cause. 
In these the loss of function is usually 
symmetrical, and probably depends upon 
disease of the cerebral centre rather than 
neuromata developed in the nerve-trunks. 
I am not aware of any cases in which 
paralysis of the branches of the eighth 
pair have been traced to Syphilis, but no 
doubt such occur and might be recognized 
by due search. Paralysis of single nerve- 
trunks of any of the spinal plexuses- 
more especially those of the brachil plexus 
-are now and then encountered. 
In cases of tertiary Syphilis the bones 
of the calvaria not infrequently increase 
greatly in thickness and weight without 
any formation of external node, and un- 
der such circumstances there is very often 
a roughened state of the surface in con- 
tact with the dura mater. Various forms 
of disturbance of the sensorial functions 
are usually observed in these cases. In 
addition to violent headache there is irri- 
tability of manner, loss of memory, and 
sometimes actual mania.1 The diagnosis 
must depend upon the facts to which I 
have already adverted. 
The Diagnosis of Constitutional 
Syphilis when consequent upon 
Inherited Taint. 
The diagnosis of inherited Syphilis 
rests on somewhat different data to that of 
the acquired disease. Indeed, the whole 
course of the disease, as thus transmitted, 
presents some remarkable features of dif- 
ference which I have endeavored to bring 
into clear contrast in the appended tabu- 
lar parallel. (See p. 443.) Some local 
lesions, not infrequent in those who have 
inherited the taint, never occur at all in 
those who have acquired it, as for in- 
stance, interstitial keratis. Others pre- 
sent important modifications of charac- 
ter ; thus, when periosteal nodes occur in 
children, they are much more extensive 
than is usually the case in adults. Speak- 
ing generally, the tertiary symptoms of 
inherited Syphilis, however long may 
have been the interval of latency, are for 
the most part symmetrical. We have 
seen that those of acquired Syphilis are 
but rarely so. 
The stages observed in the course of in- 
herited disease are very similar to those 
of the acquired form, but they much more 
frequently run into each other. 
We must consider the question of diag- 
nosis in reference to the three different 
stages : first the infantile period ; second, 
the stage of latency; and lastly, that of 
tertiary symptoms (usually about the age 
of puberty). 
In the infantile period we recognize 
Syphilis by the peculiarity of certain sin- 
gle symptoms, or, more frequently, and 
1 A young man was recently admitted un- 
der my care into the London Hospital, hav- 
ing attempted suicide (by cutting his throat) 
in a state of mania. He had disease of the 
alveolus and nasal bones, which led me to 
diagnose Syphilis. We gave him full doses 
of iodide of potassium, and he rapidly recov- 
ered. When his mental faculties had re- 
turned, he gave us a history which fully 
confirmed our suspicions as to specific taint. DIAGNOSIS OF CONSTITUTIONAL SYPHILIS. 
441 
with greater certainty, by the peculiar 
grouping of several different symptoms. 
First in importance is the rash on the 
skin. The rash, as in acquired Syphilis, 
may vary much in its character, but the 
commonest are those of erythematous or 
papular character. If it is erythema, the 
redness will show itself in abruptly mar- 
gined patches, and will be characterized 
further by its peculiar red or coppery tint, 
compared by some authors to that of the 
lean of ham. Sometimes we see instances 
of dry, scaly rashes in infants, but these 
are rare. Pustular, vesicular and bullous 
rashes are also not infrequently witnessed. 
Condylomata at the anal orifice are com- 
mon, though less frequent during the first 
few months than at later periods. At the 
same time as the rash the little patient 
almost always displays the characteristic 
symptom known as "snuffles," and there 
is usually inflammation of the mucous 
membrane of the mouth, and sores at its 
angles. (See p. 429.) Iritis occurs in a 
few cases and has similar tendencies to 
those witnessed in the acquired form, and 
is equally under the influence of specific 
treatment. It occurs also at the same 
stage, always amongst the secondary 
symptoms. Inflammations of the deep- 
seated structures of the eye-of the vitre- 
ous, retina, choroid-are as frequent as 
they are in the adult, and present the 
same characters. 
During the stage of outbreak of the ex- 
anthem, which lasts on the average from 
the fourth week to the sixth month, the 
child becomes fretful, pale, and emaci- 
ated ; growth is for a time arrested, and 
his shrivelled face resembles that of an 
old man. Emaciation is certainly the 
rule, but it has many marked exceptions, 
and I have often seen syphilitic infants 
who were fat and plump and looked re- 
markably well. 
At or about the age of one year, if the 
child have survived, it is usual for the 
secondary symptoms to wholly disappear. 
The period of latency now ensues, during 
which the child enjoys often very good 
health. Sometimes relapses occur, and 
especially are such subjects liable to be 
affected by condylomata. These relapses 
scarcely ever involve a return of cutane- 
ous rash. I think that all observers will 
bear me out in the statement that the 
characteristic rashes so often seen in 
syphilitic infants are never witnessed at 
later periods of life. The tertiary epoch 
may begin at any period after the fifth 
year, but it is commonly delayed till at or 
near the period of puberty. 
The recognition of the subject of in- 
herited Syphilis, at or after the age of pu- 
berty, may be sometimes made with great 
certainty, and is at others surrounded by 
difficulties. Our most valuable aids are 
the evidences of past disease, more especi- 
ally of the inflammations which may have 
occurred in infancy. A sunken bridge 
of nose, caused by the long-continued 
swelling of the nasal mucous membrane 
when the bones were soft, a skin marked 
by little pits and linear scars, especially 
near the angles of the mouth, the relics of 
an ulcerating eruption, and a protuberant 
forehead, consequent upon infantile arach- 
nitis, are amongst the points which go to 
make up what we recognize as an he- 
redito-syphilitic physiognomy. Added to 
them we have very valuable aid furnished 
by the shape of the incisor teeth. In 
these patients it is very common to find 
all the incisor teeth dwarfed and mal- 
formed. Sometimes the canines are af- 
fected also. These teeth are narrow and 
rounded and peg-like; their edges are 
jagged and notched. Owing to their 
smallness their sides do not touch, and 
interspaces are left. It is, however, the 
upper central incisors which are the most 
reliable for the purposes of diagnosis. 
When the other teeth are affected these 
very rarely escape, and very often they 
are malformed when all the others are of 
fairly good shape. The characteristic 
malformation of the upper central incisors 
consists in a dwarfing of the tooth, which 
is usually both narrow and short, and in 
the atrophy of its middle lobe. This atro- 
phy leaves a single broad notch (vertical) 
in the edge of the tooth, and sometimes 
from this notch a shallow furrow passes 
upwards on both anterior and posterior 
surface nearly to the gum. This notching 
is usually symmetrical. It may vary 
much in degree in different cases; some- 
times the teeth diverge, and at others 
they slant towards each other. The ap- 
pended woodcut (Eig. 17) illustrates a good 
Fig. 17. 
Syphilitic teeth. 
example of the deformity. In any case in 
which the malformation was as marked as 
Fig. 18. 
Syphilitlc teeth. 
in this sketch, I should feel no hesitation 
in pronouncing the possessor of the teeth 442 
CONSTITUTIONAL SYPHILIS. 
to be the subject of inherited Syphilis, 
even in the absence of other testimony. I 
have never yet seen such teeth, excepting 
in patients of this class. In the majority 
of cases, however, the condition of the 
teeth is sufficient only to excite suspicion 
and not to decide the question. In a few 
rare cases only one of the upper central 
incisors is malformed, the other being of 
natural shape and size. A good instance 
of this state of things is shown in Fig. 18. 
In a considerable number of cases of 
heredito-syphilis the teeth show no devia- 
tion whatever from the normal standard, 
and in such the diagnosis must be guided 
by other conditions. In addition to the 
peculiar malformations above described 
and illustrated, there are others which, 
although less characteristic, are yet very 
valuable to a trained observer. They do 
not, however, admit of description with- 
out great risk of misleading the reader. 
Before leaving the subject of dental mal- 
formations, I may again ask attention to 
the fact, that it is only in the permanent 
set that any peculiarities are observed. 
The first set are liable to premature decay, 
but are not malformed. 
In addition to the peculiarities of physi- 
ognomy and the malformations of the 
teeth, the diagnosis may be much helped 
by observing the state of the eyes and of 
the bones. If there be evidences of past 
iritis, or if there be clouds in the sub- 
stance of the cornese, the results of past 
keratitis, or especially if the cornese be 
now attacked by this peculiar inflamma- 
tion in its acute stage, very valuable evi- 
dence will have been obtained. The phe- 
nomena of syphilitic keratitis in its acute 
stage are peculiar and easily recognized. 
Both eyes are usually affected at the same 
time. The corneal tissue becomes very 
extensively opaque by the effusion of 
lymph into its substance. Its tint may 
vary from that of ground glass to a red 
salmon color. There are no ulcers on 
its surface. A zone of ciliary conges- 
tion is usually well marked. The patient 
is often for several months, whilst the dis- 
ease is at its height, practically blind. 
The intolerance of light is usually con- 
siderable. After the inflammation is 
passed away the cornea usually clears in 
a most remarkable manner, but it rarely 
regains such perfect transparency that the 
experienced observer cannot detect traces 
of what has taken place. These traces 
consist in a somewhat dusky and thin 
sclerotic in the ciliary region, and in the 
presence of slight clouds here and there 
in the corneal substance, there being no 
scars in its surface. The difference be- 
tween these interstitial clouds and ordi- 
nary leucomata is easily observed. 
In a few cases the existence of nodes on 
various long bones may help us to a diag- 
nosis, and in others we may obtain aid 
from finding that the patient has become 
deaf without otorrhoea, or that he is par- 
tially amaurotic from choroiditis. 
With regard to the general arrest of de- 
velopment in heredito-syphilis, I may re- 
mark that it is a very untrustworthy indi- 
cation. In a few cases this taint dwarfs 
the whole body in a most remarkable 
manner, but in most cases no retardation 
of general growth is observable. A pale 
complexion is most always met with. It 
is exceedingly rare to meet with a florid 
good complexion in a young adult who is 
the subject of this taint. We do, how- 
ever, every now and then see a physiog- 
nomy which neither in shape of features 
nor in color of cheeks and lips furnishes 
the slightest clue. I have met in one or 
two instances with arrest of sexual devel- 
opment. In one of these, a young woman 
under the care of Dr. Hughlings Jackson 
in the London Hospital, there was such 
an entire absence of all sexual character- 
istics that I could not but suspect that the 
ovaries had been destroyed by syphilitic 
inflammation in early life, 443 
SYMPTOMS IN ACQUIRED AND INHERITED SYPHILIS. 
Contrasted Parallel between the Course of Symptoms in Acquired and 
Inherited Syphilis. 
I have endeavored in the,following tabu- 
lar statement to place as clearly as I can 
the resemblances and differences which 
wre observe in the course of symptoms 
when arising from acquired or from in- 
herited taint. To some of these I have 
already incidentally alluded, and respect- 
ing the others the statements in the table 
will, I trust, explain themselves: 
ACQUIRED DISEASE. 
Primary Stage. - Local or 
stage of inoculation. 
The sore appears after an 
incubation period of from 
ten to twenty-eight days, 
and if not treated may re- 
main from a fortnight to 
six months. Liable to re- 
lapse. 
Secondary Stage.-Constitu- 
tional or exanthematic. 
Usually commences within 
six weeks or two months 
of the inoculation, and if 
not treated, may last from 
three to six months or to 
a year. 
Essentially transitory, and 
will disappear without 
treatment. 
Intermediate Stage.-Stage of 
latency and of relapses. 
This stage may be said to 
commence at from a year 
to a year and a half after 
the contagion, and to ex- 
tend over a period which 
may vary from three to 
five, ten, or even twenty 
years. 
Tertiary Stage or stage of 
sequelae. 
This stage commences at 
from four to ten or to 
twenty years after the 
contagion, and extends 
indefinitely, very often to 
the end of life. 
An ulcer (chancre) usually with indurated base. In- 
durated lymphatic glands, induration is to be regarded 
as the earliest proof of successful inoculation, but the 
latter is sometimes effected without any hardness of the 
original sore having shown itself. 
Febrile disturbance, malaise and muscular pains. 
Slight engorgement of lymphatic glands in many parts. 
A symmetrical, and usually copious eruption on the 
skin, and often on exposed mucous surfaces. Symmet- 
rical ulcers in tonsils. Iritis, retinitis, &c., usually 
symmetrical. Loss of hair, loss of flesh and of strength. 
This stage may be either exceedingly slight or very 
severe. Its severity appears to bear proportion to the 
degree of induration of the preceding chancre. It is 
often noticed that the rash comes out in successive 
crops. The rash may also vary very widely as to its 
character, roseolous, scaly, papular, pustular, ecthyma- 
tous, &c., being modified probably by peculiarity-first, 
in the source of contagion; secondly in the state of 
health of the recipient. 
The patient may be either wholly free from symp- 
toms and in good health, or he may remain pale and 
rather feeble, and liable from time to time to slight re- 
turns of eruption on the skin, sores on the mucous mem- 
branes, condylomata, &c. He is protected as regards 
fresh contagion, and should he beget children they are 
almost certain to suffer. The relapses during this stage 
are usually easy to be distinguished from true secondary 
symptoms. There is little or no febrile disturbance, 
the rash is not copious, and often not symmetrical. 
Acute iritis, retinitis, &c., never occur; that is, they 
do not occur for the first time ; they jnay occur in the 
form of relapses. 
All the symptoms in this stage occur, as a rule, with- 
out symmetry; sometimes multiple, but not infrequently 
single. They consist of chronic inflammations of deep 
tissues, or of the deeper layers of superficial ones, e. g. : 
-Inflammations of periosteum and bone, resulting in 
nodes; of cellular tissue, tendon, or muscle, resulting 
in gummy tumors ; ulcerative destruction of the palate 
and pharynx ; serpiginous ulcerations of the skin ; in- 
flammation of nerves, or even of cerebro-spinal centres, 
inducing various forms of paralysis; deposits in liver, 
lungs, &c. Probably but little liability to transmit the 
disease to offspring. Protection against a new conta- 
gion incomplete. All the inflammations in this stage 
are remarkably under the influence of treatment by 
iodide of potassium, but tend to relapse. Unless so 
treated, all of them tend to progression and permanent 
disorganization of the part attacked, none of them to 
spontaneous recovery. 444 
CONSTITUTIONAL SYPHILIS. 
INHERITED DISEASE. 
Primary Stage. 
The infants usually remain 
without symptoms for 
from one week to three 
months. 
Secondary Stage.-Constitu- 
tional or exanthematic. 
From the age of two to four 
weeks to the end of the 
first year. 
This stage is essentially tran- 
sitory, and will disappear 
without treatment, if the 
child lives. 
Intermediate Stage.-Stage of 
latency. 
This stage extends from the 
end of the first year or 
eighteen months to the 
second dentition, the time 
of puberty, or even very 
much later. 
Tertiary Stage or stage of 
sequelae. 
This stage may commence 
with the second dentition, 
at the time of puberty, or 
not till much later. Its 
duration is quite indefi- 
nite. 
This stage has been, passed through by one or both 
of the sufferer's parents within from a few months to 
twenty years of the infant's birth. The infant is usu- 
ally free from all symptoms at the time of birth. 
Inflammation of nasal mucous membrane causing 
"snuffles." 
A symmetrical and usually copious eruption on the 
skin. Wasting; fretfulness; a peculiar odor ; a with- 
ered, senile aspect; inflammation of the mouth, and 
condylomata at anus; iritis, usually symmetrical; 
arachnitis and slight effusion ; disease of liver (rare); 
nodes (very rare). The eruptions which occur differ 
from those of acquired disease, chiefly in being more 
moist, and in preferring the thighs and genitals. These 
differences may in part be due to peculiarities in the 
skin of young infants, and to the constant irritation 
from urine to which the nates are liable. Dry scaly 
rashes are rare. Iritis is much less frequent than in 
the adult, but just as well characterized when it does 
occur. 
In infants this stage often proves fatal. 
The patient will probably be wholly free from active 
symptoms, but will show various indications of his dia- 
thesis in pallor of skin, sunken nose, protuberant fore- 
head and premature loss of the upper incisor teeth. 
Sometimes there will be a remarkable retardation of 
growth and general development. If second dentition 
have occurred, the central upper incisors will be mal- 
formed. Unlike what happens during this stage in ac- 
quired Syphilis, we scarcely ever observe any tendency 
to recurrence of the secondary symptoms. Now and 
then we see condylomata at the anus returning during 
the first five years, but the rash of infantile Syphilis 
having once disappeared, I think scarcely ever relapses. 
A certain degree of nasal obstruction sometimes per- 
sists, but not often. 
Most of its symptoms are symmetrical:- 
Keratitis (interstitial); kerato-iritis; periosteal nodes; 
cerebral deafness (not infrequent); cerebral blindness 
(rare); disease of liver and kidneys; phagedsenic or 
serpiginous ulcerations of skin; cellular nodes (rare). 
Probably not liable to transmit the disease to offspring. 
Protection against a new contagion incomplete. The 
symmetry of the symptoms is in marked contrast with 
what occurs in this stage of acquired disease. The 
paralyses of single cranial or spinal nerves, so common 
from acquired Syphilis, are, I believe, never met with 
in the inherited form. 
Most of the inflammations tend, unless 
arrested by treatment, to permanent dis- 
organization, but one (interstitial kerati- 
tis) tends to recovery even without treat- 
ment. They are much less easily influ- 
enced by treatment than those of the 
acquired disease. GENERAL DISEASES, OR AFFECTIONS OF THE WHOLE 
SYSTEM.-Continued. 
§ II.-Those determined by conditions existing within the body:- 
Scorbutus. 
Purpura. 
[Chlorosis.] 
Rickets. 
[Scrofula.] 
Gout. 
Rheumatoid Arthritis. 
Rheumatism. 
Gonorrhceal Rheumatism. 
SCORBUTUS. 
Thomas Buzzard, M.D. 
Scurvy, or Scorbutus, as it is techni- 
cally called, is a peculiar state of mal- 
nutrition, supervening gradually upon the 
continued use of a dietary deficient in 
fresh vegetable material, and tending to 
death, after a longer or shorter interval, 
if the circumstances under which it arose 
remain unaltered. The condition is essen- 
tially marked by a dull leaden pallor of 
complexion; excessive bodily debility and 
mental lethargy; dyspnoea upon slight 
exertion, unaccounted for by the auscul- 
tatory signs; spontaneous effusions of 
blood-colored fluid into the various tissues 
of the body, causing petechise and bruise- 
like patches to appear on its surface; to- 
gether with (commonly) a livid, swollen, 
and spongy state of the gums, and a dis- 
position for them to bleed upon the slight- 
est irritation. 
Synonyms.-French, Scorbut; German, 
Scharbock ; Italian, Scorbuto ; Spanish, 
Escorbuto. These terms, as well as the 
English Scurvy, take their origin from the 
Danish Skbrbeck, " Disease of the mouth, " 
of which the word "Scorbutus" is a bar- 
barous Latinized version. 
Etiology.-Very much has been writ- 
ten upon the subject of Scurvy. Long be- 
fore the disease was styled by the name 
which it now bears, and when, indeed, it 
was often called the " unknown disorder," 
historians noted its ravages in armies lo- 
cated, under circumstances of difficulty, 
in foreign lands, or in garrisons shut off 
from obtaining supplies of requisite nutri- 
ment. In the long sea-voyages which the 
intrepid navigators of the fifteenth and 
sixteenth centuries commenced, the crews 
suffered terribly from a disorder which 
destroyed the lives of large numbers, and 
affected the working power of the survi- 
vors in a manner equalled by no other dis- 
ease. It is probable, indeed, from the 
records which have come down to us, that 
Scurvy, either alone or as influencing the 
severity of accompanying maladies, has 
proved more destructive to mankind than 
any other disorder. There is no more 
interesting fact in the history of medicine 
than that this condition, which has been 
looked upon at various times as plague, as 
a mysterious infliction of Divine justice 
against which men could only strive in 
vain, or as a disease inseparable from 
long voyages, should have been proved, 
by evidence of the most satisfactory char- 
acter, to arise from causes in the power of 
man to prevent, and to be curable by 
means which every habitable country 
affords. 
Scurvy only occurs when fresh vegetable 
nutriment has been for some time partially 
or completely withheld. A variety of 
forms of impaired nutrition will follow the 
want of other descriptions of food, but 
this particular condition is only seen as a 
sequel of that special privation. Scurvy 
445 446 
SCORBUTUS. 
does not occur when the supply of whole- 
some and fresh vegetables is abundant, 
even though the food generally may not 
be adequate to perfect nutrition. There 
is a degree of positiveness about these two 
assertions which can rarely be ventured 
upon in the etiology of disease. In this 
case, so abundant and conclusive are the 
proofs, that to assert less strongly would 
be to imply a doubt which cannot be al- 
lowed to exist. The grounds for these 
statements are to be found in the volumi- 
nous records of the circumstances under 
which the disease has occurred, as related 
by observers, either unbiased by any 
theory of their own, or widely differing in 
their opinions as to the cause of the dis- 
order. They may be said to form the 
negative side of the argument. The affir- 
mative is based upon the fact, universally 
allowed by those largely experienced in 
the disease, of the power possessed by 
fresh vegetable material, and by that 
alone, in removing the disease. 
It is not our intention to quote at length 
the records of Scurvy outbreaks, in proof 
of these assertions. We shall but glance 
at some of the more prominent instances 
in recent times, referring the reader for 
more elaborate details to the vast biblio- 
graphy published upon the subject by 
writers of almost every nation. In the 
exhaustive treatise upon this disease, by 
Dr. Budd, in the Library of Medicine, 
will be found a history of Scurvy, which 
has served more than any other publica- 
tion to place the disease in its true light, 
and the views expressed in it have been 
remarkably confirmed by the experience 
of the several outbreaks which have oc- 
curred since it was written. 
In 1846 the potato crop failed in the 
United Kingdom. In the autumn, win- 
ter, and following spring, numerous cases 
of Scurvy occurred amongst all classes of 
society. Dr. Christison has described1 an 
outbreak of the disease amongst the labor- 
ers employed upon the Scotch railways. 
Their food consisted of bread, salt pork, 
butter, cheese, coffee, tea, and sugar. 
"Potatoes were, of course, out of the 
question. Fresh vegetables were never 
thought of, and were, indeed, in most 
places inaccessible." The quantity of 
food seems to have been sufficient. In 
the Royal Infirmary of Glasgow, 83 cases 
were admitted. Dr. Ritchie2 writes: 
" The general fact in regard of the food 
of all was that it failed in variety, and in 
the quantity of its animal constituents, 
and that in all but a fraction of the cases 
in which they were very deficient, the pa- 
tients had been exposed for months to a 
total deprivation of fresh succulent vege- 
tables." "In Carlisle and its vicinity," 
Dr. Lonsdale informs us,1 "the persons 
chiefly afflicted were weavers and their 
wives and daughters working in the fac- 
tories, shoemakers, and comparatively few 
of any other kind of artisans. Bread, oat- 
meal, treacle in very small quantities, tea 
and coffee, with an occasional herring, 
formed their entire food. None had 
tasted potatoes after the harvest of 1846, 
or for a period of seven or more months." 
Dr. Lonsdale states also that in a great 
number of the huts occupied by the rail- 
way excavators, amongst whom there 
were numerous cases of the disease, some 
of which proved fatal, he saw the men 
breakfasting off beef-steaks or mutton- 
chops and bread. The dinner comprised 
bread, boiled beef or bacon, pea soup or 
broth, and suet puddings containing cur- 
rants. The animal food was taken in 
large quantities; there were no potatoes 
or fresh vegetables. At Workington (a 
seaport town of seven thousand inhabit- 
ants) the disease did not show itself. Dr. 
Dickinson, a resident, assigned as a rea- 
son, "that, vegetable food was more abun- 
dant there than in many situations, par- 
ticularly turnips, of which large quantities 
were used." 
The same kind of evidence is adduced 
by Dr. Curran2 in his description of the 
occurrence of the disease in Ireland. " In 
four-fifths of the cases reported to me, 
bread and tea or coffee was what the pa- 
tients had been living on when attacked ; 
the others had been using grains of vari- 
ous kinds, or grains and flesh or fish ; but 
in no single instance could I discover that 
green vegetables or potatoes had formed a 
part of their regular dietary." Dr. Shap- 
ter3 remarks, in reference to the cases of 
Scorbutus observed by him in Exeter, that 
the only difference from the usual diet of 
the sufferers consisted in the absence of 
the potato. 
There is no doubt that the failure in 
the potato crop, besides depriving the 
population of this vegetable, incidentally 
also rendered their nutrition imperfect, 
by increasing the price of provisions in 
general. This circumstance might natu- 
rally, therefore, be believed to bear its 
part in the causation of this particular 
morbid condition, were it not that the dis- 
ease was not confined to the poorer classes 
of society. Dr. Shapter relates that many 
of his patients were persons who had ex- 
perienced no difficulty in procuring an 
abudance of the necessaries of life, with 
the exception, however, of potatoes or 
fresh vegetables. Dr. Christison notes the 
occurrence of Scurvy amongst railway 
laborers "earning ample wages, and 
whose extravagance in good living was a 
1 Edin. Monthly Journal, August, 1847. 
2 Dublin Quarterly Journal, 1847. 
8 Lond. Med. Gazette, vol. iv. 
1 Edin. Monthly Journal, July, 1847. 
2 Ibid. ETIOLOGY. 
447 
frequent subject of remark in their neigh- 
borhood." 
The allied armies of England, France, 
Turkey, and Sardinia suffered severely 
from Scurvy in the Crimea and Asia 
Minor during the war with Russia, 1854- 
56. The disease first began to show itself 
amongst the British troops in Bulgaria, 
when they had been living for some 
months upon an inferior diet, with but a 
very scanty supply of vegetables. On 
their arrival in the Crimea, the men found 
an abundance of grapes, cabbages, &c., 
which were eagerly consumed ; and al- 
though the rations in other respects were 
most imperfect, no cases of the disease 
were recorded in September. As the 
winter advanced, however, and the vege- 
table food ceased, the affection reap- 
peared. It was no part of the ordinary 
duty of the Commissariat to supply vege- 
tables, which did not constitute a part of 
the soldier's rations. In consequence of 
representations, a supply of lime-juice 
was ordered, and arrived by the Esk on 
the 10th December. By one of those ac- 
cidents, of which so many lamentable in- 
stances occurred during the early part of 
the war, no portion of the juice was issued 
until the first week in February, 1855, 
and then the supply was very insufficient. 
In March nearly all the sick arriving at 
Scutari from the Crimea were suffering 
from Scurvy. The total admissions from 
Scurvy during the war amounted to 2096, 
but "the returns convey but a faint con- 
ception of the disastrous part which it 
acted among the troops, for although it 
comparatively rarely presented itself in 
well-defined forms, ami as an independent 
affection, yet the prevalence of scorbutic 
taint was wide-spread, and in a vast pro- 
portion of cases evident indications of it 
existed as a complication of other dis- 
eases, especially fever and affections of the 
bowels."1 As the supply of fresh vege- 
tables and lime-juice became more con- 
stant, the disease gradually disappeared, 
and comparatively few cases occurred 
during the second winter. 
The sufferings of the French from this 
cause were proportionally much greater 
than those of our troops. This must be 
ascribed to the fact that the distribution 
of lime-juice formed no part of their prac- 
tice. In fact, even at the present time, 
the French authorities do not appreciate 
at its full the value of this addition to the 
diet of either soldiers or sailors. No less 
than 23,000 cases of Scurvy are recorded 
as occurring amongst the French troops.2 
From the month of February, 1855, fresh 
meat was supplied to them at first twice 
and then five times a week. It was of 
good quality, but lean. The supply of 
bread was irregular, and fresh vegetables 
formed no part of their rations. Rice 
was allowed, and occasionally dried vege- 
tables, principally peas, beans, and lentils, 
figured in the diet, but in small propor- 
tions.1 There was this which was re- 
markable in the outbreak: The disease 
first showed itself in the winter of 1854- 
55, and committed terrible ravages. As 
the season opened and the earth began to 
bring forth vegetation, Scurvy diminished. 
The troops were encouraged to collect 
herbs, and especially dandelion, which was 
very plentiful, and of which the effects 
are highly anti-scorbutic. The improve- 
ment which took place under these cir- 
cumstances was very marked, and there 
is no reason to believe that it would not 
have been permanent had the supplies 
continued. But as July approached, the 
rays of the sun dried up the surface of 
the ground on which the troops were en- 
camped, no more dandelion was to be 
obtained, and in the course of three 
months, the finest and warmest in the 
year, no less than 5000 cases of Scurvy 
occurred. It may be remarked here, in- 
cidentally, that this outbreak furnishes a 
striking contradiction to the theory which 
ascribes the scorbutic condition to the in- 
fluence of cold and damp. 
The Sardinian army, which arrived in 
the Crimea in the early summer of 1855, 
was very generally affected by Scurvy. 
Its ravages were checked by vegetables 
supplied to the troops as the season ad- 
vanced. 
It is most probable that the Turks ex- 
perienced even more severe losses from 
Scurvy than our other allies; but, from 
the imperfect organization of their medi- 
cal department, exact statistics are want- 
ing. There is no doubt, however, that 
the original force which formed part of 
the expedition from Bulgaria to the Cri- 
mea was almost entirely swept off by dis- 
ease, of which Scurvy formed an important 
element. Of the fresh troops, under the 
command of Omer Pasha, which rein- 
forced these men, and which were posted 
at Eupatoria during the winter of 1854-5, 
as many as 1000 were sent down monthly 
to Varna, all of whom were suffering se- 
verely from this cause, and a very large 
number of whom died upon the passage. 
During the summer the remainder, 
amounting to about 20,000, were en- 
camped in the neighborhood of Balak- 
lava. We had ourselves the opportunity 
of observing them narrowly. Their food 
was very imperfect; but they showed in- 
genuity in availing themselves of such 
1 Med. and Surg. Hist, of the British Army, 
1858. By Authority. 
2 Relation M&lico-Chirurgicale de la Cam- 
pagne d'Orient, par le Dr. G. Scrive. Paris, 
1857. 
• L'Union MGdicale, 1857, p. 419: M. Per- 
rin. 448 
SCORBUTUS. 
fruits and vegetables as were obtainable, 
and they were supplied with onions. 
They consumed, especially, large quanti- 
ties of watermelons, which were procured 
from the Tartars inhabiting the country, 
or from sutlers. No cases of Scurvy fell 
under our observation at that time, nor 
could we detect any scorbutic taint in pa- 
tients suffering from other diseases. In 
November they quitted the Crimea, and 
campaigned in Mingrelia. During the 
winter all supplies of vegetables ceased, 
and, with the early spring, shiploads of 
sick were brought to Trebizond, all of 
whom were severely affected with this 
disease. Large numbers died upon the 
sea-passage, in their transit from the 
shore to the hospital, and soon after their 
admission. The sick included numerous 
examples of Scurvy, developed to an ex- 
tent which recalled the terrible descrip- 
tions of the disorder contained in the nar- 
ratives of our early voyagers. Such cases 
as these were rare amongst the other 
allied troops. In explanation of this fact, 
it must be noticed that throughout the 
winter fresh vegetable food had formed 
no part of the rations distributed to the 
Turks, and, superadded to this, was ab- 
solute starvation, from the absence of 
food in sufficient quantity. Their diet, 
indeed, had consisted entirely of biscuit, 
a little rice, haricot beans, and "yagh," 
a coarse butter made from mutton fat. 
Dr. Hammond informs us that, during 
the recent war in America, no confirmed 
Scurvy appeared among the Federal 
forces, but a scorbutic taint often mani- 
fested itself. He attributed its occurrence 
to occasional deficiency in the supply of 
vegetable food, exposure to cold and 
damp, and mental depression. He did 
not find that salt meat had any influence 
in its production. If the men had vege- 
tables they could eat salt meat with im- 
punity. Baw potatoes preserved in mo- 
lasses were commonly issued to the troops, 
and were found of signal service in pre- 
venting the disorder. 
So also on the Confederate side, Dr. 
Darby, late medical director, in a commu- 
nication which he has been kind enough 
to send to us, says, ' ' The type of the dis- 
ease characterized by petechise and spongy 
gums was rarely known in the Confederate 
army. Diseases and injuries incidental 
to array life assumed at times a scorbutic 
taint, at such seasons and under such 
conditions as give rise to this malady. 
The abundance of proper supplies in the 
early stages of the war prevented scor- 
butic tendencies. In proportion as a de- 
crease of supplies took place, there was 
an increase of the scorbutic type in all 
disease." 
Since the year 1795, Scurvy, unless un- 
der very exceptional circumstances, has 
been all but abolished from the British 
fleet, and for this the name of Dr. James 
Lind, "the father of nautical medicine," 
deserves to be held in lasting honor. The 
combined observation of exploring navi- 
gators had tended to show that the disease 
could be cured by supplies of fresh vege- 
tables, and its occurrence prevented by a 
similar diet. It was reserved for Dr. 
Lind, in his celebrated work on Scurvy, 
published in 1753, to give overwhelming 
proofs of the efficacy of lime-juice as a 
prophylactic in this disease, and forty-two 
years afterwards (!) the Admiralty took 
the hint. To Captain Cook, especially, 
science is indebted for a practical exposi- 
tion of the influence of vegetable food. 
By providing his crew with abundance of 
sauer-kraut, and encouraging them to 
seek wild vegetables wherever he landed, 
he preserved their health completely dur- 
ing a four years' voyage of his ship Dis- 
covery. The same principle, though in 
the more convenient form of a daily ration 
of lime-juice, suffices to prevent the dis- 
ease in the royal navy. The merchant 
service still, however, continues to fur- 
nish cases of this preventable disorder. 
Although the Legislature insists, under a 
penalty, that lime-juice shall be issued to 
the crews, the provisions of the Act are 
but too frequently evaded, and the Dread- 
nought Hospital still continues to receive 
annually an average of ninety cases of the 
disease-about one in twenty-five of all 
patients admitted.1 Practically, in many 
cases, no lime-juice is furnished; or a 
cheap imitation of the juice, consisting of 
tartaric acid, sugar, and water, flavored 
with essence of lemon, is substituted. On 
the other hand, emigrant and convict ves- 
sels sailing to Australia, being under more 
complete Government supervision, convey 
their passengers without loss from the 
disease. 
Now, it may be argued against such 
facts as we have recorded, that inasmuch 
as these outbreaks of Scurvy have always 
occurred amongst persons in an unnatural 
state of existence, in periods of famine, 
landed with insufficient provision in an 
enemy's country, or cooped up on board 
ship in long voyages, there may be some 
other special privation to which the occur- 
rence of Scurvy is quite as likely to be 
1 There is an excellent article upon the 
subject by Dr. Barnes in the Sixth Report of 
the Medical Officer of the Privy Council, 
1863. See also an able report by Mr. Harry 
Leach, resident medical officer to the Dread- 
nought in a House of Commons' return, " Scur- 
vy in Merchant Ships," June, 1865. Mr. 
Leach ascertained by inquiry that of eighty- 
three Scurvy patients admitted in 1864, 
forty-two had received bad lime-juice; 
eighteen had had none at all; fourteen could 
give no exact account; and in the case of 
nine only was good lime-juice declared to 
have been taken. ETIOLOGY. 
449 
due. This argument, in fact, has been 
repeatedly employed, and even at the 
present time it is still occasionally urged. 
In opposition to the view which we advo- 
cate, several causes of Scurvy have been 
insisted upon by various writers. Some 
have attributed the disease to the action 
of some one noxious agent, whilst others, 
and this is more common, urge that a 
combination of circumstances is necessary 
for its production. The point upon which 
there still exists the most important dif- 
ference of opinion is regarding the influ- 
ence of salt meat. There is no doubt that, 
in the great majority of Scurvy outbreaks, 
salt meat has formed an important part 
of the food taken by the sufferers. But, 
in order that this circumstance should be 
possessed of any weight, it would be neces- 
sary to show that the disease was never 
known to occur unless this description of 
food had formed at least a part of the 
dietary. There is evidence in plenty to 
the contrary. 
During the campaign of Louis IX. of 
France, in Egypt, 1249, the army was 
frightfully ravaged by Scurvy, of which a 
most graphic description is afforded us by 
the historian.1 During Lent, which was 
very strictly observed, the troops ate no 
meat, but subsisted "on eel-pouts, which 
is a gluttonous fish." 
During the war in Hungary, in 1720, 
between the Austrians and Turks, many 
thousands of the former were cut off by 
Scurvy. Kramer informs us that they 
ate no salt beef or pork ; but, on the con- 
trary, had plenty of fresh meat at a very 
low price.2 
The French prisoners confined in Sising- 
hurst Castle, in Kent, in the middle of 
the last century, suffered much from 
Scurvy. They had eaten no salt provis- 
ions, but had been served daily with fresh 
meat and bread.3 
At the close of the Punjaub campaign 
of 1848-49, the troops located in the coun- 
try suffered from the disease. They had 
abundance of fresh meat and bread, of 
excellent quality, but no fresh vegetables.4 
For some years after stations for troops 
had been found in the Himalayas, fresh 
vegetables were not procurable in suffi- 
cient quantity. Though the soldiers were 
provided with good fresh meat and bread, 
Scurvy was not only present, but was at- 
tended with its full mortality.5 
In the second Burmese war, a detach- 
ment at Meanday was dieted for several 
months on fresh beef in unlimited quanti- 
ties, biscuit, rum, and rice. The men 
had, however, no fresh vegetables, nor 
any substitute for them. After three 
months, Scurvy made its appearance. 
Lime-juice was procured and issued freely, 
and the disease rapidly abated.1 
Dr. Hammond2 describes having seen 
many cases of Scurvy among troops who 
had fresh-meat rations on four days in the 
week, and game of their own procuring on 
the others. 
The Turks, as noticed above, in the 
Mingrelian campaign of 1855-56, had no 
salt meat, and suffered much more severely 
from Scurvy than did their French and 
English allies at a time when the latter 
were dependent upon it for animal food. 
So, also, during the previous winter, 
"They fed on good sound biscuit, boiled 
rice, fresh meat twice or three times a 
week; salt meat was unknown amongst 
them : they were not overworked or idle, 
and were in excellent spirits at having 
beaten the enemy; and yet I found on 
examination that, on an average, three 
men out of four on duty in the spring of 
1855 were more or less afflicted with 
Scurvy."3 
In 1836, above one hundred cases of 
Scurvy occurred in the 75th regiment 
whilst quartered in Caffreland, at a time 
when the men had no harassing duties, 
and were abundantly supplied with rations 
of good fresh meat, without having had 
an ounce of salt provisions. They had no 
vegetables. The Hottentot troops doing 
duty with them were served with the 
same rations, but sought out for them- 
selves pumpkins, melons, some indigenous 
wild fruits, and esculent roots. They en- 
tirely escaped an attack, as also did the 
27th and 72d European regiments, en- 
camped at a distance of eighteen miles, 
fed with the same rations, but supplied 
also, in addition, with vegetables. 
Cases of Scurvy occur every year in 
North Wales, where fresh meat and milk 
are abundant, but where the cottagers 
rear little or no garden produce. Not 
only the inhabitants, but visitors, located 
in the country for a short time, are known 
to suffer, we are informed, occasionally 
from this disease. 
We have ourselves met with many cases 
of Scurvy amongst the poor of London 
who had eaten no meat at all for several 
weeks, but had lived on tea, bread, and 
butter.4 
1 Histoire de Louis IX. par le Sieur Join- 
ville. Bohn's Antiquarian Library. 
2 Dr. Budd, Library of Medicine, art. 
"Scurvy." 
3 Philosophical Trans. Sir J. Pringle's 
Address, 1776. 
4 Med. and Surg. Hist, of the British Army, 
1858. 
» Ibid. 
1 Dr. Crawford, Med. and Surg. Hist, of 
the British Army, 1858. 
2 Mil. Med. and Surg. Essays, p. 192. 
Philadelphia, 1864. 
3 Dr. Bird, On Scurvy. Lond. 1858. 
4 See also Dublin Med. Press, vol. xviii. 
Dr. Bellingham; " Observations on the Scur- 
vol. i.-29 450 
SCORBUTUS. 
The occurrence of Scurvy so frequently, 
and in such well-defined form, in cases 
when salt meat has been absolutely want- 
ing in the dietary, is sufficient to prove 
that this substance is not a necessary 
antecedent of the disease, and cannot 
therefore be properly termed a cause. 
But it is alleged, sometimes, that it is to 
the use of salt provisions, combined with 
the absence of fresh vegetable food, that 
the disease is owing. If the facts recorded 
above are insufficient to negative this 
view, there are two other circumstances 
which certainly leave the matter in no 
doubt:- 
1st, There is no case of Scurvy on re- 
cord, as occurring in a person who has 
been adequately supplied with fresh suc- 
culent vegetables of good quality. 
2d, The occurrence of Scurvy in persons 
living upon salt meat may be prevented 
by the regular administration of fresh 
vegetables, or the juice of lemon. 
In connection with this subject there is 
an important point to be considered, as 
regards the relative rapidity with which 
Scurvy will appear in persons fed upon 
fresh meat, or salt meat, or who have had 
no animal food at all. There is great 
difficulty in arriving at conclusions upon 
this point. In the crews of vessels, for 
example, which have quitted a port during 
the winter, it often happens that a scor- 
butic taint has been acquired on shore, 
and before the men were exposed to the 
limited dietary of ship life. So also on 
land, before the supply of vegetables is 
entirely cut off by the failure of a crop, or 
by the poverty of the patient, a certain 
amount continues to be taken, although 
insufficient for the preservation of health. 
From these and other causes, reliable sta- 
tistics as to the exact interval which 
elapses before Scurvy makes its appear- 
ance are wanting. The conclusions at 
which we have arrived, from a careful 
consideration of recorded outbreaks, as 
well as from our own personal observation 
of the disease, are that under a salt-meat 
diet, Scurvy will appear sooner than when 
fresh meat has been taken in the ordinary 
quantity, and that the disease will show 
itself more rapidly when the patient has 
been deprived of all animal food than 
when he has obtained supplies of salt 
meat. Liebig has shown that the process 
of salting deprives flesh of a large propor- 
tion of its most important constituents, so 
that the remainder is deficient in nutritive 
properties, and the altered and hardened 
character which it acquires renders even 
such nourishment as it contains difficult 
of assimilation. As a result, a diet of salt 
meat represents only a less degree of 
starvation than the total absence of ani- 
mal food, and starvation has been agreed 
universally to intensify Scurvy. Dr. 
Kane,1 the Arctic explorer, speaks highly 
of the improvement in strength which 
took place amongst his crew when they 
succeeded in procuring fresh walrus meat, 
as a substitute for their salt provisions. 
He arrived at the conclusion that raw 
walrus meat was powerfully anti-scorbutic; 
but his descriptions of the sufferings un- 
dergone by his party from Scurvy, even 
when abundantly supplied with this food, 
fail completely to justify this opinion. Mr. 
Whymper2 expresses an equally favorable 
opinion of walrus and seal meat, but the 
details which he gives are not sufficiently 
elaborate for the purpose of scientific dis- 
cussion. It seems most probable that 
fresh meat of any kind, although satisfac- 
torily proved by the instances we have 
recorded to be incapable of preventing 
Scurvy, will yet, by its powerful nutritive 
properties, help considerably to sustain 
animal strength and retard the develop- 
ment of scorbutic symptoms. So a man, 
deprived of all food, and dying of starva- 
tion, will have life considerably prolonged 
if he can obtain water. Water, however, 
we know to represent only a portion of 
the requirements of man, and to be inca- 
pable, by itself, of preserving his existence 
for more than a short period. 
From the limited variety of food which 
so often accompanies conditions in which 
Scurvy has appeared, such as besieged 
towns, encamped armies, and on board 
ships in long sea-voyages, monotony of 
diet has been frequently urged by writers 
as an important cause of Scurvy. But 
probably one of the most monotonous diet- 
aries in the world is that upon which the 
poor inhabitants of Ireland thrive,3 and 
which consists almost entirely of stirabout, 
milk, and potatoes. So long as they can 
obtain this food in sufficient amount, 
Scurvy is unknown ; but when the mono- 
tony was broken by the failure in the 
potato crop, the disease appeared exten- 
sively. 
The relation, indeed, which such an al- 
leged cause, as well as others which have 
been most insisted upon-namely, cold 
and damp, idleness, and mental depres- 
sion-bears to Scurvy, seems to us simply 
that which obtains generally in modifica- 
1 U. S. Grinnell Expedition. Second Voy- 
age. 
2 Travel and Adventure in Alaska. 1868. 
3 " The general conditions of these popula- 
tions, although wearing an aspect of great 
wretchedness to English eyes, is not now 
unfavorable to health. Throughout the coun- 
try I found them a fine, well-built, and often 
athletic race, with children sufficiently fleshy 
and rosy, and bearing all the marks of 
health."-Dr. E. Smith, Sixth Report of the 
Medical Officer of the Privy Council, 1863. 
vy," by Dr. Mertans; Phil. Trans, vol. 
Ixviii.; Lond. Med. Gazette, vol. iv. Dr. 
Shapter; Lancet, 1851, p. 519, Dr. Boyd. SYMPTOMS. 
451 
tions of health. The fact that these con- 
ditions are certainly not essential to its 
production must exclude them from the 
category of true causes. That they are 
frequent concomitants, and hasten as well 
as intensify the symptoms of the disorder, 
is just what is seen in many other diseased 
conditions which, depending upon a spe- 
cial cause, are yet capable of being injuri- 
ously influenced by circumstances known 
to aftect the assimilation of food and the 
consequent nutrition of the animal eco- 
nomy. 
Symptoms.- The earliest symptom of 
Scurvy is a change in the color of the skin, 
which becomes pale, sallow, or of a green- 
ish tint, according to the variety of the 
natural complexion. Succeeding, and in- 
deed often contemporary with this, is a 
peculiar listlessness of mind, an aversion 
to exercise, and a condition, not so much 
of anxiety as to the state of health, as 
of indisposition to take any trouble re- 
garding it. The patient lounges where 
formerly he has displayed energy in his 
occupation ; he does not care to speak un- 
less addressed. In reply to inquiries he 
will usually complain of flying pains about 
the limbs and back, which he generally 
refers to rheumatism. The change of as- 
pect, where several individuals are ex- 
posed to the same circumstances, will be 
noticed by them of each other, whilst the 
observer is unconscious that he, too, is 
presenting the same appearance.1 Up to 
a certain period the appetite remains good, 
and digestion continues tolerably perfect; 
usually, however, there is some constipa- 
tion. There is no fever. Sleep is ob- 
tained readily enough. It is sometimes 
described as accompanied by dreams, in 
which the luxuries of fruits and vege- 
tables are vividly pictured.2 Gradually 
petechise are observed, especially about 
the legs and thighs. They are small, of a 
reddish-brown color, fading away at the 
edges, and are especially apt to occur at 
the points where hairs perforate the skin. 
They are usually not elevated above the 
surface. Besides this there may be 
larger maculse, apparently formed by the 
convalescence of several petechise, of ir- 
regular outline, and particularly common 
about the lowest part of the legs and on 
the feet. As the disease advances still 
larger markings will be noticed, so much 
resembling bruises as often to be mis- 
taken for the results of violence. Like 
the eruption of variola, they are apt to 
fix upon weak portions of the frame for 
their situation, parts where there has 
been a blow, strain, or other injury some 
time previously. Accompanying these ex- 
ternal signs there is breathlessness, for 
which the ear applied to the chest fails to 
discover any adequate cause. The ex- 
pression of the countenance is dejected, 
or it wears an aspect of indifference. The 
lips are pale. By degrees the face as- 
sumes a bloated appearance. In some 
cases, however, about this period, the 
eye and its surroundings are the only 
parts exhibiting signs of Scurvy. The 
appearance presented is then very re- 
markable. The integument around one 
or both orbits is puffed up into a bruise- 
colored swelling. The conjunctiva cover- 
ing the sclerotic is tumid and of a bril- 
liant red color throughout, "about the 
eighth of an inch in thickness or eleva- 
tion above the cornea, leaving the cornea 
at the bottom of a circular trench or 
well."1 There is nothing inflammatory 
about this condition ; it resembles very 
violent ophthalmia in the color presented, 
but there is no pain or discharge. We 
have seen many cases in which this ap- 
pearance, together with pallor of the 
complexion and listlessness, constituted 
the only evidences of Scurvy, and they 
have generally been of the most serious 
character, often terminating fatally. The 
gums so generally present a remarkable 
alteration in Scurvy that their condition 
has been often described by writers as a 
perfect test of its presence or absence. 
Our own experience does not correspond 
with this, and other observers have re- 
corded a similar opinion.2 All the other 
phenomena may be present and yet the 
gums continue in an unaltered condition, 
except that they are paler than ordinarily. 
But usually, at an early period of the dis- 
ease, the gums, first of all pale and con- 
tracted, begin to show a swelling at their 
free margins. This gradually increases 
so that the teeth are encroached upon, 
and eventually, in some cases, almost dis- 
appear from sight in the huge fleshy 
masses which encompass them. The 
swollen gums are then spongy, of a dark- 
red or livid hue, not sensitive to the touch, 
and disposed to bleed, sometimes slightly, 
at others profusely, when irritated. Under 
these circumstances the teeth become 
loosened in their sockets, and often fall 
out. There is a sickening fetid odor from 
the breath. This is only observed as an 
accompaniment of the swollen state of 
the gums, and is evidently due to the 
sloughing which usually occurs in them. 
1 Bird, On Scurvy, p. 38. See also Dublin 
Medical Press, vol. xviii., a paper by D. Bel- 
lingham. 
2 Dublin Med. Press, Dr. Bellingham; 
"Scurvy in Exeter," Dr. Shapter, Lond. 
Med. Gazette, vol. iv.; L'Union Medicale, 
1857, p. 419: "Scurvy in the French Army 
in the Crimea," M. Perrin; Diet, de Mede- 
cine, art. "Scorbut" (Paris, 1865), 12th. 
edit. 
1 This phenomenon is graphically described 
by Dr. Kane: U. S. Grinnell Expedition. 
2 U. S. Grinnell Expedition, p. 267. 452 
SCORBUTUS. 
So severe is the affection of the gums in 
many cases, that fleshy masses like huge 
granulations are often seen to protrude 
between the lips. Chewing is completely 
impossible, and there is some difficulty 
even in taking fluid nourishment. It is 
impossible to describe the fearful appear- 
ance presented by the sufferer under these 
circumstances. Uis skin harsh, dry, 
dirty-looking, and discolored with bruise 
marks, bloated and puffed up in parts by 
swellings, his whole manner apathetic and 
helpless, the condition appears to a novice 
more irremediable than is seen in almost 
any other disorder. And yet it is re- 
markable that these cases, where the ex- 
ternal manifestations of the disease are 
so strongly marked, are frequently just 
those which yield most rapidly and surely 
to treatment. The change wrought in a 
few hours by the administration of lemon- 
juice or vegetables, coupled with general 
care, is the most extraordinary tiling in 
therapeutics, and of itself furnishes a 
powerful argument in favor of the cause 
of Scurvy existing in the absence of such 
food. 
Besides the petechise and other larger 
ecchymoses under the skin which we have 
described, a most frequent and highly 
characteristic symptom appears in the 
occurrence of swellings in the flexures of 
the joints. A favorite seat of this con- 
dition is the ham. The well between the 
insertions of the flexor muscles is filled 
up more or less completely by a mass 
which is hard, but not so unyielding as to 
be incapable of pitting on pressure. It 
requires, however,'more force to produce 
this effect than in oedematous swelling, 
and the impression is retained for a longer 
period. As this swelling increases, the 
limb is gradually more and more flexed, 
doubtless because extension, by stretching 
the skin over the tumor, is attended with 
great pain. If the effusion occurs, as it 
most commonly does, in the lower ex- 
tremities, the patient is unable to walk. 
A similar swelling is sometimes noticed 
at the bend of the elbow, and still more 
frequently beneath the muscles of the 
jaw. In the latter position the move- 
ments of mastication are very painful. 
Another common seat of such effusion is 
under the muscles in front of the tibia, or 
between the periosteum and that bone 
where it is subcutaneous. Such tumors 
have often been mistaken for syphilitic 
nodes, and mercury has been adminis- 
tered with the result of increasing the 
scorbutic condition to an alarming extent. 
It is one of the facts most universally 
noted, that mercury has a powerfully in- 
jurious effect in Scurvy. The skin cover- 
ing such swellings may retain its color or 
present an ecchymosed aspect according 
as the subcutaneous areolar tissue is in- 
vaded or not by the effusion. 
The breathlessness which we have 
noted as an early symptom in Scurvy be- 
comes more confirmed as the disease pro- 
gresses. On auscultation we find the re- 
spiratory murmur louder than natural, 
but otherwise unaffected. It is very fre- 
quently accompanied by occasional faint- 
ings, especially when the body is made to 
quit the horizontal posture. These attacks 
of syncope are highly perilous. It has 
happened to us on more than one occasion 
to witness death from this cause. The 
patient, previously recumbent, has sud- 
denly sat up in bed to receive our visit, 
and speedily fallen back in a fainting fit, 
from which he could not be restored. At 
Trebizond, notwithstanding that great care 
was used in the transport of sick from the 
ships to the hospital, many died whilst 
being carried up. The danger from faint- 
ing is well known in the Dreadnought 
hospital-ship ; and Mr. Harry Leach, the 
resident medical officer, informs us that 
no scorbutic patient who is severely 
affected is allowed to walk up the steps, 
but is carefully hoisted up the ship's side 
in a recumbent position. 
There is an affection of the chest in 
Scurvy which, especially when the disease 
occurs during the prevalence of cold and 
damp, is very apt to be mistaken for 
pneumonia. Faint rigors, followed by a 
certain amount of feverishness, and accom- 
panied by lancinating pain in one or both 
sides, usher in this condition. The pain 
is felt only in coughing, and a very viscid 
mucus is expectorated. The dyspnoea in- 
creases, and a constriction as though from 
a cord bound tightly round the chest is 
described. Although it occasionally hap- 
pens that these pulmonary symptoms are 
dependent upon true inflammation, they 
are much more commonly associated with 
effusion of sanguineous fluid into the cavity 
of the pleura, or into the substance of the 
lung itself, these structures sharing with 
every other organ in that tendency to effu- 
sion which is the dominant feature of 
Scurvy. When the lung is thus invaded 
the expectoration after a short time be- 
comes dark and sanious, with all the hor- 
rible fetor which is ordinarily associated 
with gangrene of the lung, but which is 
here dependent upon decomposition of the 
bloody fluid poured into the lung sub- 
stance. There are now cold sweats, in- 
creasing dyspnoea and anxiety, a pulse 
small and frequent, softer than in inflam- 
matory pneumonia,1 and death takes place. 
In other cases there is no pain or cough ; 
but the breathing rapidly becomes short 
and laborious, and death occurs suddenly. 
Auscultatory signs of mischief in the lungs 
are usually wanting; but now and then 
there is localized dulness on percussion. 
1 M. Aug. Haspel, Gazette Medicate. 1859, 
p. 70. SYMPTOMS. 
453 
with bronchial breathing. Or mucous 
rales are heard ; sometimes also gurgling 
sounds at certain parts of the chest.1 The 
symptoms of gangrene of the lung, when 
it occurs, are indistinguishable from those 
arising from effusion of fluid which be- 
comes decomposed. The mere occur- 
rence of very fetid and dark sanguinolent 
sputa is not necessarily an indication of 
either condition, as its source may exist 
in the sloughing and bleeding gums. But 
constant and increasing oppression of 
the breath, frequent syncope, and great 
anxiety point unmistakably to pulmonary 
mischief; and cases in which these occur 
are amongst the most hopeless which are 
ever encountered. 
Dulness on percussion may sometimes 
be noted under circumstances when it 
probably may be correctly referred to san- 
guineous effusions into the muscles of the 
chest, and unconnected with lung mis- 
chief. The diaphragm also is sometimes 
invaded by effusion, and great difficulty 
of respiration may be thus produced. It 
is not usually practicable to distinguish 
the dyspnoea arising from this condition 
from that caused by lesion of the pulmo- 
nary substance, but its significance is not 
so serious, and it will generally subside 
with rapidity as the scorbutic state is 
remedied by dietetic treatment. 
As regards the digestive system, the 
tongue is usually clean and moist. The 
color is sometimes red, at others pale, 
with a violet tinge. It is often large and 
flabby, showing the teeth-marks at the 
edges.2 In the early stages of the disease 
there is tendency to constipation. Later 
there is usually more or less of painless 
diarrhoea, often sanguineous in appear- 
ance, but unaccompanied by the other 
symptoms characteristic of dysentery. 
Scurvy, when it occurs in camps, is so 
frequently, if not constantly, complicated 
with the dysenteric diarrhoea which com- 
monly prevails under those conditions, 
that disturbances of the digestive system 
are amongst the most frequent concomi- 
tants of the disorder. It does not appear, 
however, that apart from the exciting 
cause, dysentery is to be considered a 
symptom of the disease. The dejections 
usually consist of undigested food, with a 
quantity of colorless fluid somewhat re- 
sembling the evacuations of cholera, or 
they may be accompanied by a consider- 
able flow of dark blood. The slimy, 
bright, blood-stained, and offensive fseces 
of dysentery are wanting, unless that dis- 
ease be present as an accidental complica- 
tion. A fatal result is not unfrequently 
due to this exhaustive diarrhoea, the pa- 
tient becoming worn out by the frequent 
discharges. 
The intellect of patients suffering from 
Scurvy is usually remarkably free from 
impairment. The listlessness, however, 
to which we have referred above, is con- 
stantly present, and is sometimes accom- 
panied by great depression of spirits. As 
a rule, there is complete coherence of 
ideas, but we have seen cases occasionally 
in which symptoms of excitement of a 
maniacal character were present. Ritchie 
notes this, and describes also tinnitus 
aurium, muscse volitantes, vertigo, and 
deafness as being occasionally complained 
of.' 
In confirmed Scurvy the slightest pres- 
sure suffices to open the skin and to give 
rise to an ulcer, whose edges are hard, 
thick and shining, and the surface fun- 
goid and bleeding. Its tendency is to 
increase rapidly in size, and to invade the 
neighboring structures. An intolerably 
offensive odor is emitted from it. Ulcers, 
such as these, will often eat their way into 
the soft tissues with great rapidity, ex- 
posing and invading large vascular trunks, 
from which dangerous hemorrhage may 
occur. Sometimes the disorganization of 
the flesh is sufficiently complete to expose 
the bones and produce caries. The lips 
and nostrils are occasionally the seat of 
this ulceration, and the patient then pre- 
sents a ghastly appearance, much like 
that of an aggravated case of lupus.2 The 
exhaustion attendant upon these spread- 
ing ulcers is often fatal. Wounds and 
even slight scratches become invaded by 
this process. Its influence in cases of 
frost-bite is most disastrous. 
An affection of the sight, to which the 
title hemeralopia (sometimes also nycta- 
lopia) has been given, is frequently ob- 
served in Scurvy. In some cases, recorded 
by Dr. Bryson,® it was the first symptom 
of the disease noticed. The patients can 
distinguish objects well enough during 
daylight, and even at night can read a 
book held close to a candle, but the mo- 
ment they pass from the influence of the 
light they become absolutely blind, and 
require to be led about. Mr. G. Lawson 
informs us that several such cases have 
fallen under his notice at the Moorfields 
Hospital, but in none has the ophthalma- 
scope revealed any signs of mischief. The 
pupils he finds sometimes dilated and 
sluggish, in other cases natural. The 
condition rapidly subsides under an anti- 
scorbutic regimen. Mr. Soelberg Wells 
1 Haspel, op. cit 
2 There was in general some ptyalism, and 
then the tongue was indented on its sides, 
and the swelling of the parotids and of the 
gums gave the patient the look precisely of a 
mercurialized person."-Ritchie On Scorbutus, 
Edin. Monthly Journal, July, 1847. 
1 Edin. Monthly Journal, July, 1847. 
2 Bird, On Scurvy, p. 9. 
3 Ophthal. Hosp. Reports, July, 1859, p. 
40. 454 
SCORBUTUS. 
has met with the symptom in cases of 
great depression of the nervous system, 
after severe illnesses, and in badly-fed and 
cachectic subjects. It sometimes occurs 
in prisons. "It ought," he writes us, 
"to be carefully distinguished from that 
which depends upon retinitis pigmentosa, 
in which the ophthalmoscopic appearances 
are most marked, which is not amenable 
to treatment, and generally leads, sooner 
or later, to almost, if not complete, blind- 
ness 
Diagnosis.-In typical cases of Scurvy, 
and especially when, from circumstances, 
the occurrence of the disease is probable, 
the diagnosis is very easy. The dirty 
pallor and bloated condition of face, re- 
markable lethargy and indisposition to 
exertion, ecchymosed state of the skin 
generally, with contraction of the limbs 
from effusions, and spongy bleeding state 
of the gums, form a combination of symp- 
toms which readily distinguishes Scurvy 
from every other disease. But in the 
commencement of an outbreak, in spora- 
dic cases, or when the attack is slight, the 
nature of the ailment is very often mis- 
taken. The patients wTho present them- 
selves for medical assistance complain 
of weakness, of pains in the limbs and 
back which are almost always referred to 
rheumatism, or of pain in the stomach. 
They say nothing probably of the state of 
the skin covering their legs, or of any 
sponginess of the gums, so that the con- 
dition of these structures is not perceived 
by the attendant, who applies himself ac- 
cordingly to the relief of the symptoms 
detailed to him by the patient, and the 
true nature of the case is consequently 
overlooked. The color of the skin (espe- 
cially when dirty) in ordinary chlorosis, 
strongly resembles that of a scorbutic pa- 
tient, and in such a case there is often a 
dull heaviness of manner which might 
tend to mislead an observer. In fact, the 
early stage of Scurvy is really a form of 
chlorosis, produced, however, by special 
circumstances, and remediable only by a 
correction of these. A careful examina- 
tion of the skin and gums and the history 
of the illness will serve to distinguish the 
conditions. 
The red and purple spots, livid blotches, 
and bruise-like stains which occur in pur- 
pura, and closely resemble those found in 
Scurvy, may possibly cause some hesita- 
tion in diagnosis. But there is little dif- 
ficulty in distinguishing the two disorders. 
In purpura these appearances often pre- 
sent themselves suddenly in a patient pre- 
viously in fair health. This is never the 
case in Scurvy. The latter disease is 
always gradual in its progress, and it will 
be found, on inquiry, that a period of in- 
creasing pallor, debility, and listlessness, 
preceded the appearance of petechise or 
blotches. The very peculiar dirty pallor 
of complexion so characteristic of Scurvy, 
is absent in purpura. So also is the ten- 
dency to effusions about the joints, caus- 
ing contraction of the limbs, and the 
spongy and bleeding gums. Lastly, the 
occurrence of purpura is entirely indepen- 
dent of the defect in diet which produces 
Scurvy, and it is not cured by fresh vege- 
table juices. There would never indeed 
be any difficulty in the diagnosis of Scurvy 
but for its comparative rarity, at least in 
an advanced form, in civilized life. Un- 
der circumstances of privation, as in win- 
ter campaigns of armies, Arctic expe- 
ditions, and the like, the disease is usually 
expected and recognized as a matter of 
course. Not so, however, in ordinary 
civil practice. Amongst the classes which 
furnish the out-patients to our hospitals, 
dispensaries, and unions, pallor and de- 
bility are more often present than absent. 
Even bruise-marks from accidental inju- 
ries are not at all uncommon, so that un- 
less the possibility of Scurvy be pretty 
constantly remembered, and the symp- 
toms be tested by a reference to that dis- 
order, there is great probability of a num- 
ber of cases being overlooked. There 
would be less liability to such errors if the 
alteration of the gums commonly attracted 
the patient's attention, and was expressly 
pointed out to the medical attendant. 
This very rarely happens. In persons of 
the class referred to the teeth are rarely 
or never brushed, and the gums, conse- 
quently, are often in a more or less un- 
healthy condition, so that a little addi- 
tional discomfort in this respect is scarcely 
regarded. It is considered a trivial mat- 
ter in comparison with the so-called rheu- 
matic pains from which they suffer, and 
and for which alone they ask relief. Wefe 
scorbutic patients voluntarily to tender a 
history of all their symptoms, and the 
dietetic conditions under which they have 
been living, there could be little chance of 
any instructed person, even though he 
had never seen the disease, coming to a 
wrong conclusion. But this, it may safely 
be said, never occurs. The complaints 
made by the patients of debility and pains 
in the limbs are just those symptoms of 
the disorder which are the most likely to 
be referred to other causes, and it is need- 
ful, therefore, that the medical attendant 
should himself institute the inquiries ne- 
cessary to prove the presence of Scurvy 
in his patient. This, of course, he fails 
to do unless an idea of the probable na- 
ture of the disease has presented itself to 
his mind. We are induced to dwell upon 
this point from a conviction that there are 
still many members of the profession who, 
because no patient has ever consulted 
them for a swollen and bleeding state of 
the gums, are under the impression that 
they have never met with a case of Scurvy PATHOLOGY. 
455 
-a conclusion, it will be seen, by no means 
well founded. 
Pathology.-Great obscurity still in- 
volves the question of the ultimate cause 
of Scurvy. That the proximate cause is 
an alteration in the quality of the blood, 
induced by the absence from the ingested 
food of fresh vegetable juices, is suffi- 
ciently manifest from the history of the 
disease. But we are still in the dark upon 
three points of importance- 
1st. What is the essential element con- 
tained in fresh vegetable material by the 
deficiency of which in these cases such re- 
markable changes are produced ? 
2d. Is the influence of this element ex- 
erted upon the chemical or the physical 
quality of the blood ? 
3d. By what physical law does the blood 
so altered in quality exhibit such changes 
in its relation to the tissues ? 
The essential feature of Scurvy, upon 
which is based nearly the whole series of 
organic lesions which takes place, is this- 
that the relation between the blood flow- 
ing in the capillaries and the tissues is so 
altered as to permit of the diversion of 
some or all of the blood constituents from 
their natural receptacles into tissues from 
which they are excluded in a state of 
health. Beyond this, however, there are 
the cases of fatal syncope, which do not 
admit of such an explanation. In such 
instances it would seem, either that the 
muscular structure of the heart is so weak- 
ened by mal-nutrition as to lose the power 
of efficient contraction, or, what is still 
more probable, the phenomenon is due to 
embolism. 
It is impossible to offer any certain solu- 
tion to the second and the third questions. 
Owing to the absence of a perfectly satis- 
factory mode of analysis of the blood, not 
only in cases of Scurvy, but in a state of 
health, no theory can be safely based upon 
such accounts of the alterations manifest- 
ed by scorbutic blood as have been pub- 
lished. The only positive modification 
that can be detected in the blood is a very 
considerable diminution in its density.1 
It is quite conceivable that the exudations 
of sanguineous fluid may depend upon the 
increased tendency to exosmose which such 
an alteration would necessarily produce. 
With regard to the first question, we 
are able to arrive, principally by a pro- 
cess of exclusion, at something which 
probably approaches the truth. We have 
seen that Scurvy will occur where there is 
no deficiency in the albuminous, oleagi- 
nous, or saccharine elements of food, but 
where there is a want of something which 
fresh vegetables can alone supply. Fresh 
lemon-juice may be taken as a convenient 
instance of a material which is able to 
prevent the development of Scurvy, and 
to cure it if it has already appeared. 
Lemon-juice contains free citric acid, mu- 
cus, vegetable albumen, and sugar,1 with 
small quantities of malic acid, and acid 
salts, especially of potash.2 The only in- 
gred.ents which it is necessary to consider 
attentively in this analysis are citric and 
malic acid, and potash. The other sub- 
stances are found abundantly in food 
which is not anti-scorbutic. 
In 1848 Dr. Garrod brought forward a 
very ingenious view of the cause of Scur- 
vy, which has attracted much attention.3 
From examinations of food under the use 
of which Scurvy was capable of occurring, 
he was led to the conclusions, "that in 
all scorbutic diets potash exists in much 
smaller quantities than in those which are 
capable of maintaining health," and " that 
all substances proved to act as anti-scor- 
butics, contain a large amount of potash." 
It is, then, to the absence from the food 
of a requisite amount of potash that he 
attributes the occurrence of Scurvy, and 
it is to the presence of potash in lemon- 
juice that he ascribes the anti-scorbutic 
power of that material. But for his argu- 
ment to have been complete, the converse 
of his second proposition should have been 
true also. It ought to have been shown 
that all substances largely containing pot- 
ash are anti-scorbutic. This is not the 
case. By reference to Dr. Garrod's table 
of analysis, we find that one ounce of 
boiled mutton contains 0'637 grain of pot- 
ash, whilst one fluidounce of lemon-juice 
contains but little more, 0'846 grain. So 
that two ounces of boiled mutton added 
daily to a dietary under which Scurvy is 
occurring should be even more efficacious 
than one ounce of lemon-juice. The nu- 
merous instances on record (to some ot 
which we have referred) of fatal Scurvy 
occurring in persons abundantly supplied 
with fresh meat, and on the other hand 
the indisputable power of lemon-juice in 
preventing the disorder, are sufficient to 
disprove this. Again, in the records of 
Scurvy disasters on board merchant ves- 
sels, pea-soup always figures as a most 
important part of the dietary of the crew. 
They have often been driven to subsist 
almost entirely upon this food, owing to 
the bad quality of the meat. One ounce 
of peas, according to Dr. Garrod's table, 
contains 0'529 grain of potash-a large 
proportion, considering that in an ounce 
of white flour only OT grain is found. 
Yet peas are well known to be utterly 
useless in the prevention or cure of 
Scurvy. 
1 Witt. Chern. Soo. Quart. Journal, vii. p. 
44. 
2 Garrod, loo. cit. 
3 Edin. Monthly Journal, January, 1848. 
1 MM. Becquerel and Rodier, Lancet, 1847, 
vol. ii. 456 
SCORBUTUS. 
The crucial test of administering nitrate 
of potash to Scurvy patients has been ap- 
plied, and found wanting.1 Moreover, 
Dr. J. O. Grant describes the occurrence 
of Scurvy amongst the Ottawa " lumber- 
ers" living upon pork salted with nitrate 
of potash. In one shanty he found 
twenty-five men out of thirty-six attacked 
with the disease.2 
We are thus led to the conclusion that 
it is either to the free organic acids which 
exist in lemon-juice, or to the acid salts, 
that the efficacy of this material is owing. 
Now, the influence of the citric acid of 
commerce in Scurvy is by no means cer- 
tainly proved. Statements and opinions 
on this point are very contradictory, but 
the bulk of evidence is certainly opposed 
to the utility of citric, as well as of tar- 
taric and acetic, acid. There seems 
reason to believe that the bitartrate and 
citrate of potash have some influence as 
anti-scorbutics, though their power is cer- 
tainly far less than that of fresh vegetable 
juices. It is probable, therefore, that al- 
though the organic acids and potash sepa- 
rately do not represent the requisite 
material, it is to be found in the chemical 
combination of the acid and base. Very 
possibly the form in which these salts 
exist in lemon-juice renders them more 
easily absorbed and decomposed by the 
digestive organs than when exhibited 
separately. The Materia Medica gives 
numerous analogous examples of the su- 
perior efficacy of a medicine in its natural 
combinations.3 No artificial imitation of 
mineral waters is equal to the supply from 
their natural source. All anti-scorbutic 
juices contain salts of citric, tartaric, or 
malic acids, and we have no evidence of 
any substances which contain these mate- 
rials in considerable quantity, and are yet 
deficient in the power of preventing 
Scurvy. The mode by which they act is 
still involved in obscurity. 
Morbid Anatomy.-The body of a 
patient who has died of Scurvy is gene- 
rally emaciated, but this is by no means 
always the case. Where the diet has 
been absolutely deficient, or of such a 
nature that its mastication was almost 
impossible from the condition of the 
gums, there is much wasting. But Scurvy, 
as we have seen, may occur when there 
has been not only no lack of food, but the 
nutriment has been of a kind easily taken 
by the patient, although from its quality 
it has not been able to prevent the dis- 
ease. Under such circumstances the 
general bulk and weight of the body are 
preserved, whilst the tissues are found to 
present the appearances characteristic of 
the disorder. 
Externally, the body presents the same 
general aspect as was observed during 
life. Decomposition is more than ordi- 
narily rapid. The extremities are usually 
rigid. Blood is sometimes observed to 
flow from the mucous passages. Blood, 
or fibrinous effusion, more or less strongly 
blood-colored, is found extravasated under 
the skin, into the subcutaneous areolar 
tissue, and into the aponeurotic sheaths 
of the muscles, sometimes bruising and 
breaking the muscular fibres. The lower 
extremities, and especially the hams, are 
generally the most severely affected, but 
the same condition may be found in the 
arms, particularly about the bend of the 
elbow and under the pterygoid muscles of 
the jaw. These effusions, when they 
take place, under the periosteum, some- 
times lead to death of the bone beneath, 
and this has not unfrequently occurred in 
the jaws. Simple serous effusions, be- 
sides, depending apparently on the ob- 
structed circulation, occur, especially 
about the feet and ankles, so as to give a 
peculiarly clumsy appearance to the lower 
extremities. 
The condition of the brain varies con- 
siderably. It is often free from any ap- 
pearance of lesion. Sometimes there is 
effusion of serum under the arachnoid and 
into the ventricles, whilst the vessels on 
the brain surface are empty, and the gen- 
eral aspect of its substance is pale. In 
other cases the cerebral vessels are gorged 
with very dark fluid blood, or coagula; 
and there may be ecchymoses upon the 
surface of the brain, and sanguineous 
effusion into its substance. 
Serous fluid, sometimes in large quanti- 
ties, is frequently found in the pleural 
cavities. The lungs may be pale, shrunk, 
and bloodless in appearance, or gorged 
with serous fluid, and, sometimes, with 
very dark blood. When grave symptoms 
of mischief in the chest have presented 
themselves during life, stains, or violet 
marblings, like to those on the skin, have 
been found upon the surface of the lungs 
after death. On cutting into these they 
are found to be of varying depth, but 
usually superficial. Internally, the vesi- 
cles and small bronchi contain a muco- 
sanguinolent product; there is, besides, 
slight or severe bloody infiltration into 
the cellular interstices of the pulmonary 
vesicles, occupying especially the bases of 
the lungs, and characterized by a red- 
winey tinge, with impregnation of black 
blood. In certain cases the lung offers in 
some points all the characters of the most 
complete engorgement, loss of elasticity, 
crepitation and permeability, increase of 
volume and of weight. These characters, 
1 See Med. Times and Gazette, vol. xx, 
Dr. Murray; Med. Times, March 23, 1850, 
Dr. Bryson, R. N. 
2 Med. Times and Gazette, December 26, 
1863. 
3 Parkes, quoted by Aitken. PROGNOSIS. 
457 
however, are never carried to the extent 
seen in ordinary pneumonia. It is prin- 
cipally at the diaphragmatic aspect in- 
feriorly and posteriorly that this engorge- 
ment is seen ; physical laws tending 
materially to the choice of this site. Lit- 
tle deposits of blood, not coagulated, are 
found in different parts of the lungs. 
These are of variable volume, and consti- 
tute, in fact, a species of ecchymotic col- 
lections, which compress and obliterate 
little by little the pulmonary vesicles. 
They form sometimes largish, fluctuating 
tumors, composed of liquid blood without 
clots, contained in cavities of irregular 
form, which are not lined by any mem- 
brane. The sudden rupture of such 
tumors causes considerable haemoptysis. 
Occasionally the lung will be found gan- 
grenous ; it is then characterized by the 
usual greenish-gray color of its structure, 
mixed with darkened fragments, and im- 
bued with air-bubbles and an ichorous 
bloody liquid, breaking up under slight 
pressure and emitting a most offensive 
odor.1 
An equal uncertainty attends the con- 
dition in which the heart may be found. 
It is sometimes pale and flaccid, with the 
cavities quite empty. In other cases it is 
filled with black liquid blood, and its cavi- 
ties are dilated. Occasionally its lining 
membrane, as also that of the aorta and 
pulmonary artery, is stained with a red- 
dish tinge.2 Black fluid blood is some- 
times found in the pericardium. The 
muscular substance of the heart may be 
ecchymosed. 
The muscular and mucous coats of the 
stomach and intestines are invaded usu- 
ally by sanguineous effusions, and the de- 
posits present all that variety of color 
which is characteristic of bruises in their 
various stages, varying from a pink to a 
blackish green tinge. The intestines 
themselves may contain fluid blood. Dr. 
Ritchie describes an enlarged condition of 
the solitary glands in the lower part of the 
ileum. The mucous surface of the intes- 
tine is sometimes abraded, with minute 
and superficial ulceration, or it may pre- 
sent detached black ulcers of considerable 
size. There is a tendency to increase of 
severity in these towards the lower ex- 
tremity of the bowel.3 
The liver and spleen are often, but by 
no means always, enlarged, gorged with 
dark blood, and their structure softened 
and friable. 
With all the variety which may present 
itself in the post-mortem appearances, 
there is one appearance which is constant 
in all cases of death from Scurvy. In 
some part or other, sanguineous effu- 
sion into the tissues will be discovered. 
Considering the delicate structure of the 
brain, it is remarkable that lesions of this 
organ occur by no means so commonly 
as in other and less vital parts of the 
economy. 
As regards the nature of the effusions 
which play so important a part in the fatal 
results of Scurvy, minute observations 
would seem to show that they are essen- 
tially fibrinous in character, more or less 
colored by blood corpuscles. They are 
sometimes gelatinous in consistence, 
marked with streaks of a pale yellow 
color, somewhat resembling the fibrinous 
clots so often seen in the heart. They 
occasionally exhibit a higher degree of 
organization. Deposits of this kind occur 
in the form of layers of from a quarter of 
a line to a line in thickness, composed, 
apparently, of fibrin of a bright yellowish- 
red color, firm and elastic, affording no 
fluid on pressure ; they are, in fact, false 
membranes, and are quite distinct from 
the surrounding muscles, to which they 
adhere. This kind of deposit has been 
termed " scorbutic formation. " The stiff- 
ness of the joints, and especially of the 
knees, appears to be caused by the firm 
consistence of these effusions.1 Upon in- 
jection, capillary vessels have been dis- 
covered, which in their character and 
mode of distribution are similar to those 
met with in other recently organized ad- 
ventitious tissues. It seems most proba- 
ble that the hypertrophy of the gums 
proceeds from the deposit of a plastic 
material. They are firm, and bleed when 
wounded. The rapid absorption which 
they undergo upon treatment is incon- 
sistent with the supposition that they are 
distended with blood, but is explicable 
upon the view of the fibrinous character 
of the enlargement.2 
Prognosis.-When a patient affected 
with Scurvy is placed under favorable 
circumstances as regards food, shelter, 
&c., his recovery may be safely expected, 
provided that irreparable mischief has not 
already occurred in organs essential to 
life. It is remarkable that the severity 
of the external manifestations of Scurvy 
is by no means an accurate guide to a 
safe prognosis. The fact has been noticed 
by many observers, and we have our- 
selves repeatedly witnessed it, that when 
the patient, from the extent to which his 
skin, muscles, and gums were involved, 
appeared most severely affected, recovery 
1 Gazette Mddicale, 1859, p. 70: M. Haspel. 
The description of the morbid appearances in 
the lungs is mainly derived from M. Haspel's 
minute and graphic account. 
2 Ritchie, loc. cit. 
3 Ibid. 
1 Dr. Himmelstiern, Brit, and Foreign Med. 
Rev. vol. xx. p. 150. 
2 See also Budd on Scurvy, Lib. of Med. 
vol. v. p. 86. 458 
SCORBUTUS. 
would very frequently be much more cer- 
tain and rapid than in cases in which such 
serious external signs were absent. Were 
it not inconsistent with what we know of 
the pathology of the disease, it would ap- 
pear that a degree of safety to internal 
organs was procured by this severe affec- 
tion of the outside of the body ; as though, 
indeed, the fury of the disorder expended 
itself on parts of the economy the least 
essential to life. In general terms the 
prognosis will be favorable, or the re- 
verse, according to the degree to which 
such structures as the brain, lungs, and 
heart have escaped serious lesion, or are 
manifestly much involved. 
Therapeutics. - The treatment of 
Scurvy almost entirely consists in supply- 
ing the patient, in the most easily assimi- 
lable form, with that material by the de- 
ficiency of which his disorder has been 
produced. Combined with this there 
will, of course, be needed such a judicious 
arrangement of general diet as will most 
easily contribute to his general nutrition. 
The choice of this will much depend upon 
the condition of the patient's gums and 
digestive organs. It is very important 
that his diet should be varied as much as 
possible, consistent with the avoidance of 
diarrhoea. Fresh lemon-juice, in the form 
of lemonade, should be administered, as 
the ordinary drink, ad libitum. The ex- 
istence of diarrhoea should be no reason 
for withholding this treatment. The 
looseness of the bowels in Scurvy will be 
uninfluenced by any medical appliance, 
so long as the scorbutic condition of the 
blood remains uncorrected ; and the fresh 
juice of the lemon has been proved to be 
more easily digested than any other form 
of vegetable food. Professor Maclean1 
speaks highly of the use of the Bael fruit 
in the dysentery which is often associated 
with Scurvy. The fruit contains a large 
quantity of tannin with vegetable mucus, 
a bitter principle, and a vegetable acid. 
It is much used in Bengal. Professor 
Maclean has seen it useful when all other 
measures had failed. According to cir- 
cumstances, the food may consist besides 
of good beef-tea, with eggs beaten up with 
wine, or, if the patient can bear it, solid 
fresh meat roasted or boiled, mashed po- 
tatoes, cabbage, milk, salad, or sauer- 
kraut. The diet will require careful obser- 
vation ; but the great general principle is 
to be borne in mind that the anti-scorbutic 
principle must be received by the patient 
in one form or other if his treatment is to 
be successful. When diarrhoea is per- 
sistent, the trisnitrate of bismuth with 
opium may often be given with great ad- 
vantage, the use of fresh lemon-juice 
being, however, continued at the same 
time. When the gums slough and bleed 
very much, they should be brushed over 
daily with solid nitrate of silver. An 
amount of relief is thus afforded which it is 
difficult to explain. Our Turkish patients 
were so alive to this that they used to in- 
dicate to us by pantomime their desire to 
have the application repeated at every 
visit. In effusions under the periosteum 
the iodide of potassium has been found 
very useful in relieving pain and hasten- 
ing absorption.1 
For the offensive fetor of the breath, 
washes of chlorine may be used, and 
probably Condy's fluid freely diluted 
would be a good application. For the 
hard swellings in the hams and legs, fric- 
tion with warm soapsuds and water sev- 
eral times a day, was employed with most 
success in Turkish hospitals. Scorbutic 
ulcers may be dressed with lint steeped in 
lemon-juice and covered with oil-silk. 
But all local remedies are but palliatives, 
and are inert as substitutes for the con- 
stitutional treatment of the disorder. 
Amongst the vegetables which may be 
used as preventives of Scurvy are oranges, 
lemons, limes, cabbage, lettuce, potatoes, 
onions, mustard and cress, dandelion, sor- 
rel, scurvy-grass, the Agave americana 
(cactus), grapes. An ounce of lemon- 
juice should be issued daily, when vege- 
tables run short, and, as on board ship, 
should be begun ten days after the de- 
privation of vegetables.2 Potatoes may 
be conveniently preserved in casks, with 
the addition of molasses. 
Of late years a very ingenious form of 
preserved vegetables has been prepared by 
MM. Masson and Chollet, of Paris. It con- 
sists of cauliflower, carrot, lettuce, peas, 
&c., dried and compressed into solid slabs, 
which are very portable, and keep good 
for a length of time. The preparation re- 
quires soaking for four or five hours in 
water, before use, and then should be 
cooked very slowly. The experience of 
the Crimean and American wars has 
shown it to be convenient and palatable 
enough; but as a preventive of Scurvy, 
far behind the fresh vegetables or lime- 
juice in efficacy. It may be added to 
these with advantage, but cannot replace 
them. Dr. A. Marroin,3 in his record of 
Scurvy in the French fleet, says, " Pre- 
served vegetables retard the outbreak of 
Scurvy : they slacken its march without 
stopping it altogether, when it has thrown 
its roots deeply into the economy." They 
were liberally supplied to the crews of the 
French ships in the Black Sea during 
1855. Yet, in the second quarter of the 
1 Bird, On Scurvy, p. 16. 
2 Parkes, Practical Hygiene, p. 248. 
3 Histoire M6dicale de la Flotte fran?aise, 
p. 104. Paris, 1861. 
1 Aitken's Science and Practice of Medi- 
cine, vol. i. p. 624. THERAPEUTICS. 
459 
year, thirty cases of Scurvy are recorded, 
whilst in the third quarter (the summer 
month) no less than 531 cases occurred. 
In October, 427 cases are mentioned. "In 
November, during the first fifteen days, 
we numbered more than 1000 scorbutics 
on the six vessels in Katcha Roads."1 
One vessel alone, the Friedland, had no 
less than 400 cases on board. Some of 
the ships were then sent down to the 
Bosphorus, with all the scorbutics on 
board. On their arrival the mess tables 
were well supplied with salads, fruits, 
&c. "The change effected by this was 
instantaneous. Those who presented 
symptoms of Scurvy, saw them disap- 
pear ; those (and they were even still 
more numerous) who experienced that 
muscular debility and horror of move- 
ment which constitute the warnings of it, 
were, after a few days, restored to perfect 
health." 
In the Confederate army (Dr. Darby in- 
forms us) the yam, which is generally cul- 
tivated throughout the south, was found 
very beneficial. Syrup from the Chinese 
sugar-cane (sorghum), abundantly manu- 
factured in the last two years of the war, 
was issued as a ration with decided bene- 
fit. When badly made it is liable to fer- 
mentation, and deranges the bowels, yet 
even in this condition it was of great ser- 
vice in scorbutic cases, as was also the ex- 
tracted juice before being boiled. 
Apples certainly possess anti-scorbutic 
properties, but they are inferior to lemons 
and oranges. Cider would appear to be 
deficient in the property. Dr. Boyd2 re- 
lates two cases of Scurvy which occurred 
in lunatics, who had lived for several 
weeks exclusively upon bread and cheese, 
three times daily, with a pint of cider at 
each meal! 
Sauer-kraut has long been recognized as 
very efficacious. It was employed by 
Captain Cook with signal advantage. 
It is probable that the light French 
wines possess considerable anti-scorbutic 
power. 
It is not often that the power of milk, 
as an anti-scorbutic, is able to be tested 
in adults, but the immunity from Scurvy 
of infants subsisting entirely upon this 
food shows that it possesses the property 
to a very large extent. We have lately 
had under our observation an adult pa- 
tient, who, in consequence of organic dis- 
ease of the pylorus, was unable to take 
ordinary diet, and who subsisted for seven 
months upon Oswego boiled with milk, 
without any symptoms of Scurvy occur- 
ring. 
As regards the preservation and use of 
lemon-juice, the following practical sug- 
gestions have been recently issued by the 
Board of Trade for the information of 
shipowners and shipmasters :- 
"Every ship on a long voyage should 
be supplied with a proper quantity of lime 
or lemon-juice. 
"The juice having been received in bulk 
from the vendors, should be examined 
and analyzed by a competent medical offi- 
cer. All measures adopted for its preserva- 
tion are worthless, unless it be clearly 
ascertained that a pure article has been 
supplied. 
"Ten per cent, of brandy (sp. gr. 930), 
or of rum (sp. gr. 890) should afterwards 
be added to it. 
" It should be packed in jars or bottles, 
each containing one gallon or less, covered 
with a layer of oil, and closely packed and 
sealed. 
"Each man should have at least two 
ounces (four tablespoonfuls) twice a week, 
to be increased to an ounce daily if any 
symptoms of Scurvy manifest themselves. 
"The giving out of lime or lemon juice 
should not be delayed longer than a fort- 
night after the vessel has put to sea." 
[Fresh, or even desiccated, vegetables, 
as potatoes, onions, &c., have proved, in 
American army experience, much more 
efficacious in the prevention of Scurvy 
than lemon-juice, or even than fresh lem- 
ons and oranges.-II.] 
1 Marroin, loc. cit. 
2 Lancet, 1851, vol. i. p. 519. 460 
PURPURA 
PURPURA. 
"By Thomas Hillier, M.D. 
Revised by Tilbury Fox, M.D. 
The term Purpura is derived from pur- 
pureas, purple, and, as generally used, it 
signifies a discoloration of the skin, of 
small size, due to the occurrence of hemor- 
rhage into its substance, and unaccompa- 
nied by any serious disturbance of the 
general health, or any appreciable organic 
disease. The hemorrhage into the skin 
is, in fact, the disease. Sometimes, how- 
ever, the term is applied to cutaneous 
hemorrhage occurring in diseases in which 
the general condition is the more impor- 
tant, as in "purpuric" fever. 
The occurrence of hemorrhage in the 
cutis, in fact, from whatever cause, has 
been considered sufficient to warrant the 
use of this term. Cutaneous hemorrhage 
is often seen in typhus fever, in measles, 
in smallpox, in scurvy, and as a result of 
injury, as well as in cases known as Pur- 
pura proper. Typhus fever has been de- 
scribed as Purpura contagiosa, but this 
name is now obsolete; the cutaneous 
hemorrhage which often accompanies it 
being properly regarded as a symptom of 
secondary importance. In scorbutus or 
scurvy we have another well-defined dis- 
ease, in which hemorrhage into the skin 
constitutes an important symptom. Pur- 
pura has been, and often is, confounded 
■with scurvy, but should be carefully dis- 
tinguished from it. With the advance of 
medical knowledge it is very likely that 
the cases even now classed together under 
the name of Purpura, will be further dis- 
tributed under several distinct categories 
according to their real pathological cha- 
racter. It might be well to use the term 
cutaneous hemorrhage for extravasations 
of blood connected with general diseases, 
or violence, and to limit the use of the 
term Purpura to those forms in which the 
skin alone seems to be at fault. 
Willan described four varieties: Pur- 
pura simplex, P. haemorrhagica, P. urti- 
cans, and P. senilis, and classed the dis- 
ease with the exanthemata. Purpura, 
however, is readily distinguished; the 
patches are not transitory, and do not en- 
large, they undergo absorption, changing 
color day by day, like a bruise ; the color 
of true exanthems disappears on pressure, 
the blood still remaining in the vessels, 
whilst in Purpura the coloring matter, 
and sometimes the blood-corpuscles, are 
out of the vessels, and the stain is, there- 
fore, not effaced by pressure. 
In the present day, however, Purpura, 
in its more limited and proper rendering, 
is commonly described under two main 
divisions: Purpura simplex, and Purpura 
heemorrhagica. In Purpura simplex, 
hemorrhage is confined to the skin; in 
Purpura haemorrhagica blood escapes also 
from the mucous surfaces, the alimentary, 
the genito-urinary, and the respiratory. 
Purpura urticans is a compound disease, 
made up of urticaria and Purpura. Pur- 
pura senilis is merely the disease Purpura 
in old people,in which the patches are large. 
Symptoms.-On the skin, a number of 
spots or patches make their appearance ; 
these vary in size from mere points, when 
they are called stigmata, or the size of 
pins' heads or peas (petichioe), to large 
patches of considerable dimensions, even 
several inches in diameter. The term 
vibices is applied to the patches whose 
length much exceeds their breadth, so 
that they resemble a bruise left by a whip 
or stick, and ecchymosis is the name em- 
ployed when the shape is more irregular. 
The color varies from a bright red, espe- 
cially at the early stage of the disease, to 
a violet, deep purple, or blackish tint. 
When the eruption first appears, the 
spots generally have an abrupt, well- 
defined margin; but as they fade, their 
outline is gradually lost in the surround- 
ing skin. Occasionally in the early stage, 
if examined with a lens, the outline may 
be irregular. In some cases, the discolor- 
ation of the skin is preceded by subcu- 
taneous swelling and induration. The 
discolored spots are not themselves raised. 
Occasionally, there is an escape of blood- 
stained fluid under the cuticle, giving rise 
to blebs on the affected patches. Some 
writers express this fact in other words, 
by stating that Purpura is complicated 
with pemphigus. When the hemorrhage 
infiltrates the skin very closely, the derma 
is found, on the removal of the cuticle, to 
be thickened, hard, and of a purple color. 
It speedily dries, and has lost its sensi- 
bility ; it is, in fact, dead. Aggravated 
cases of this kind are of rare occurrence. VARIETIES OF PURPURA. 
461 
Spots of Purpura are distinguished from 
simple exanthems by not disappearing or 
fading on pressure. This is a symptom 
common to all cutaneous hemorrhages. 
In a few days the eruption of Purpura 
changes color, passing through various 
shades of red, orange, and yellow, until 
it completely disappears. Whilst some 
spots are fading, fresh ones appear, or 
successive eruptions may occur, separated 
by intervals in which no eruption is seen. 
Together with the cutaneous phenomena, 
hemorrhages often occur from various 
mucous surfaces, giving rise to epistaxis, 
hsematuria, mehena, hsematemesis, or 
hsemoptysis. It might be said that Pur- 
pura simplex, when severe, may be ac- 
companied by internal hemorrhage, and 
then passes into Purpura hemorrhagica. 
This will be noticed in speaking of Pur- 
pura hemorrhagica. 
Varieties of Purpura. 
Purpura Simplex.-Purpura in its mild- 
est form is commonly seen on the legs in 
the form of small bright-red spots, which 
make their appearance without any other 
symptom beyond slight lassitude, and, in 
some cases, aching of the limbs. The 
first eruption soon disappears, but is often 
speedily followed by a second, and this 
again by a third. Its appearance is 
favored by standing, and the cure is pro- 
moted by rest, and by the use of elastic 
bandages. An attack of this kind often 
occurs during the convalescence from 
rheumatic fever, and in persons whose 
general health is impaired from any cause. 
A special variety, Purpura rheumatica, 
has been indeed named by Schonlein. In 
this form of the disease there are ante- 
cedent pains about the body, especially 
the knees ; the spots are freely and widely 
developed, and have a border oftentimes 
of a somewhat bright hue; they are of 
the size of hemp seed or thereabouts. A 
fresh crop and fresh pains go together. 
This variety is observed to occur in the 
strong; it is most frequent in those be- 
tween the ages of twenty and thirty ; it 
is never seen in children, and is more fre- 
quent in males than females. It is only 
Purpura occurring in rheumatic subjects. 
Purpura senilis is a form of cutaneous 
hemorrhage especially frequent on the 
upper extremities of old women whose 
arms are much exposed to weather and 
local irritants. The degenerate state of 
the tissues of the old predispose to its oc- 
currence, and the extravasation of blood 
often follows more than ordinary exertion 
or direct injury of the skin, or undue 
pressure of some kind. Bateman thus 
describes it: "It appears principally 
along the outside of the forearm, in suc- 
cessive dark purple blotches of an irregu- 
lar form and various magnitude. Each 
of these continues from a week to ten or 
twelve days, when the extravasated blood 
is absorbed. A constant series of these 
ecchymoses had appeared in one case dur- 
ing ten years, and in others for a shorter 
period, but in all the skin of the arms was 
left of a brown color. " It is not attended 
with any constitutional disturbance. 
In diseases of the heart causing ob- 
struction to the capillary circulation, pe- 
techise are occasionally seen. Five inter- 
esting cases of the kind are to be found in 
the Trans. Path. Society, vol. xvii. I860, 
p. 422, by Dr. Ogle. In one case the pur- 
puric spots vanished whenever the patient 
kept his bed. If he were allowed to get 
up and go about, the spots would again 
appear. 
Purpura Haemorrhagica.-So far as the 
skin is concerned, the phenomena are the 
same as in Purpura simplex, except that 
the morbid appearances are commonly 
more aggravated. The term " hemor- 
rhagica" is given when there is, in addi- 
tion to cutaneous hemorrhage, a flow of 
blood from the free surface of mucous 
membranes The most common hemor- 
rhage is epistaxis, which may be slight in 
amount or very profuse. It occurs alone 
or in connection with hemorrhage from 
other mucous surfaces. Hsematemesis is 
of less frequent occurrence ; it is some- 
times very profuse; melama also occurs 
from hemorrhage either into the large or 
small intestines. Bleeding may take 
place from the gums, but is not nearly 
so frequent as in scurvy. Besides the 
blood which escapes from the free sur- 
faces there is sometimes extravasation 
into the substance of the mucous mem- 
branes : this may be often seen on the 
palate, inside the cheeks, or on the gums. 
Small blisters containing bloody serum 
are sometimes found on the tongue and 
other parts of the mouth ; these soon 
break, and their contents escape. 
Hemorrhage into the conjunctiva is not 
uncommon. Heematuria is a frequent 
symptom ; the blood may come from the 
pelvis of the kidneys, the ureters, or the 
bladder. Hsemoptysis, dependent on 
hemorrhage from the bronchi, is not so 
often met with. Menorrhagia and hemor- 
rhage from the external auditory meatus 
are occasional symptoms. It is not often 
that extravasation occurs into the paren- 
chyma of organs ; it has, however, been 
seen in the brain and lungs; and death 
has resulted from cerebral or pulmonary 
apoplexy. Blood is sometimes extrava- 
sated into the substance of the muscles. 
Purpura htemorrhagica, like the simple 
form, is either ushered in by fever or oc- 
curs quite independently of febrile dis- 
turbance. It may occur in the midst of 
apparently good health, or it may be pre- 
ceded for some weeks by great lassitude, 462 
PURPURA. 
faintness, and pains in the limbs and 
joints. It is usually accompanied by a 
sensation of great debility and depression 
of spirits. The pulse is generally weak, 
and may be quickened; it is sometimes, 
on the contrary, full and not frequent; 
occasionally it is intermittent. Parox- 
ysms of fever resembling hectic have been 
sometimes observed. As the disease ad- 
vances, signs of anaemia manifest them- 
selves, great pallor of the mucous mem- 
branes, a venous hum in the neck, tinni- 
tus aurium, and shortness of breath. 
(Edema of the face and feet may some- 
times occur. Some patients are liable to 
attacks of slight faintness or complete 
syncope. The digestive functions are in 
some cases quite unaffected; in others 
they are more or less disordered. There 
may be tenderness in the epigastrium, 
with a sensation of fulness, nausea, and 
either constipation or diarrhoea. Deep- 
seated pains in the abdomen, chest, or 
back are also sometimes present; these 
are either caused by congestion of the 
liver, lungs, kidneys or other viscera, or 
are merely of a neuralgic character. The 
urine sometimes contains blood ; at other 
times, casts of the tubes and albumen. 
This condition may first appear and sub- 
side with the cutaneous phenomena, or 
Purpura may occur in the course of 
chronic Bright's disease, or the renal 
changes may follow Purpura. The dura- 
tion of the disease is very various, from a 
week to several months. 
Dr. Graves in his Clinical Medicine 
(vol. ii. p. 362), describes two cases hav- 
ing some of the characters of Purpura 
hsemorrhagica, but presenting important 
points of difference ; he proposes for them 
the name of "Exanthema hsemorrhagi- 
cum." There -was an eruption of red 
spots, somewhat resembling that of mea- 
sles, but without the crescentic outline 
usually seen in this disease, and more 
nearly resembling that of typhus. The 
patients were strong and healthy previous 
to their attacks. There was but slight 
febrile excitement, and this only at the 
onset; the pulse was slow (in one case 70, 
and in the other 50 in the minute), but it 
was peculiarly hard and thrilling, almost 
dicrotous. There was no headache, de- 
lirium, or loss of sleep. Bleeding took 
place from the intestines and urinary or- 
gans, from the gums, the nares, stomach, 
and other mucous surfaces ; it gradually 
became more profuse, resisting all treat- 
ment. The tongue was dry and brown in 
both cases. The exanthems appeared on 
the skin on the seventh day of illness, in 
one case, and after seventeen days in 
another; the spots never became pete- 
chial, and disappeared in about five days. 
Both cases proved fatal in about four 
weeks. In one case the eruption was 
ushered in by a tingling sensation, resem- 
bling the sting of nettles, and was diffused 
over the trunk and extremities; in the 
other, there was no such tingling, and it 
was limited to the limbs. One man, aged 
34, had been a great spirit-drinker, and 
the symptoms commenced immediately 
after drinking cold water, whilst in a state 
of profuse perspiration. The other man, 
aged 29, was of temperate habits, and no 
probable cause could be thought of. The 
cases appear to have been like acute Pur- 
pura as regards the mucous membranes, 
but unlike it in. presenting an exanthem 
but no hemorrhage in the skin. Whilst 
the pathology of Purpura is so imperfectly 
understood, these cases may be classed 
with it; hereafter, they may be more 
clearly distinguished from it. Dr. Graves 
states that, if cases of this kind should 
again come under his notice, he would 
freely resort to blood-letting, as affording 
the best chance of cure. 
Dr. Lingen (in the British Medical 
Journal, July 27, 1867, p. 61), refers to a 
group of cases of " Irish Purpuric dis- 
ease. ' ' A pig was taken ill, it was drowsy, 
"stiff," and before death exhibited pur- 
puric spots on its belly, face, and nose. 
A servant girl who attended to the pig, 
was attacked with febrile symptoms, and 
was ill a few weeks. The owner of the 
pig had suffered, and had large purpuric 
spots on the loins, the thighs, and smaller 
ones on other parts. The cowman died 
in three days of a similar attack. " Pur- 
ples" in pigs are common in America. 
Purpura urticans is a complication of 
abortive urticaria with Purpura simplex. 
It is characterized by "rounded and red- 
dish elevations of the cuticle, resembling 
wheals, but which are not accompanied 
like the wheals of urticaria, by any sen- 
sation of itching or tingling. ' ' They grad- 
ually form and subside within twenty- 
four or thirty-six hours. They are usually 
seated on the legs, and are interspersed 
with petechise; they are also seen on the 
thighs, breast, and arms. Whilst some 
spots fade, others appear in succession for 
three or four weeks. This form of dis- 
ease is not usually attended with fever; 
it is most common in warm weather; it 
is often accompanied by oedema, and some 
stiffness and pain in the legs. It has 
affinities with erythema tuberculatum. 
This variety of Purpura illustrates an 
important clinical fact, viz., that cutaneous 
hemorrhage may occur, under certain cir- 
cumstances, at the seat of ordinary erup- 
tions, accompanied by congestion; the 
changes in the tissues predisposing to the 
escape of blood from the vessels. " Under 
these conditions, the eruption which is 
supplanted by the hemorrhage is abortive. 
The writer has seen, for instance, a pur- 
puric patch take the place of a cluster of 
vesicles in zoster. The same thing is 
seen sometimes in erythema, and in con- CAUSES - PATHOLOGICAL ANATOMY. 
463 
nection with lichen, constituting lichen 
lividus, which Hebra describes under the 
term Purpura papulosa. 
A form of Purpura attended with py- 
rexia and painful oedema of the subcuta- 
neous cellular tissue is sometimes seen 
in children. In one case reported by MM. 
Barthez and Rilliet, a boy three years old 
was suddenly seized whilst in good health 
with pains in the feet, which soon be- 
came swollen. His skin was hot; on the 
third day there was general anasarca, 
and large round red patches appeared on 
the skin. Two days later, the skin of the 
legs became shining and tender. It was 
then covered with patches, some red and 
some yellowish, round, and varying from 
half a line to five lines in diameter. The 
red spots were very slightly elevated, sur- 
rounded in most cases by a pale rose- 
colored areola, whilst the centre was of 
a claret color, and did not disappear on 
pressure. The child was quite well at the 
end of a week. 
Another case is described by Ollivier 
(Archives de Medecine, vol. xv. 1867, pp. 
206-216). Here the disease was more 
severe, the ecchymoses being larger and 
more numerous ; enteritis was also pre- 
sent. There were several successive crops 
of eruption ; each one accompanied by 
the appearance of oedema. These cases 
are considered by Barthez and Rilliet to 
be allied to Purpura urticans. No men- 
tion is made of the presence or absence of 
albuminuria in either of the cases. They 
seem to have been cases of erythema, 
complicated with extravasation into the 
cutis. 
Causes.-These are not properly un- 
derstood. Cutaneous hemorrhage may 
arise under diversified conditions, many 
of which have been very illogically as- 
signed as causes. Impure air, indiges- 
tible or scanty food, and continued fa- 
tigue, by impairing the process of sangui- 
fication, are supposed to help on the 
development of the disease. Purpura 
frequently occurs as a sequela to small- 
pox, measles, scarlatina, and rheumatic 
fever. Intemperance appears to have in- 
duced it; damp lodgings apd miasmatic 
influence favor the occurrence of hemor- 
rhage, which has also occurred in the 
course of cirrhosis, acute atrophy, and 
cancer of the liver, of ague, of Bright's 
disease, of amyloid disease of the viscera, 
of syphilis, and of long standing suppura- 
tion of bone. Aggravated jaundice is 
often attended with Purpura. In fa^ct the 
old writers recognized some connection 
between it and disease of the liver, in the 
use of the term Purpura hepatica. It has 
also been seen in persons not exposed to 
any specially debilitating causes, and ap- 
parently in good health. Amenorrhcea 
has been assigned as a cause ; it is more 
probable that it was a common effect of 
some unknown cause. Purpura has been 
known to disappear after the occurrence 
of profuse menorrhagia. Ricord mentions 
the case of a syphilitic patient who suf- 
fered from Purpura hsemorrhagica, when- 
ever he was treated with iodide of potas- 
sium. Virchow observed the same effect 
from the administration of this drug to a 
cancerous patient; and other writers 
have also recorded the occurrence of Pur- 
pura in patients when under the influence 
of the iodide of potassium. The want of 
vegetables in food, and an excessive quan- 
tity of salt meat, have been assigned as 
causes of Purpura; but this has arisen 
from confounding Purpura and scurvy. 
It may occur at any age, but is especially 
frequent in children and old people. 
There must be some condition common 
to these various diseased states leading 
to perhaps more or less softening of the 
tissues of the capillaries, and certainly 
rupture ; but before referring to the exact 
nature of the changes in Purpura, it is 
necessary to say a few words on the 
character of those morbid conditions which 
have been found to accompany cutaneous 
hemorrhages. 
Pathological Anatomy. - In the 
first place the petechias and ecchymoses 
in cutaneous hemorrhages are due to 
extravasation of blood,-not merely of its 
coloring matter,-into the cutis. There 
is sometimes hemorrhage into the subcu- 
taneous cellular tissue, and into the 
muscles. Smaller or larger extravasa- 
tions are also often found in the mucous 
membranes of the mouth, pharynx, sto- 
mach, small and large intestines. They 
are less frequently met with on serous 
surfaces, the pleura, pericardium, and 
peritoneum. Hemorrhage in the lungs 
or in the cerebrum is not often seen. 
Blood is often found in the pelvis of the 
kidney. The blood in the body is in some 
cases quite natural, coagulating readily ; 
in other cases it is unusually fluid, and 
indisposed to coagulate. The liver may 
be healthy, or the seat of incipient or 
advanced cirrhosis, of acute atrophy, or 
of amyloid degeneration. The spleen is 
either normal or enlarged. Dr. Haber- 
shon (Guy's Hospital Reports, Third Se- 
ries, vol. iii. 1857) describes cases in which 
the spleen was large, of a red color, stud- 
ded throughout with pale yellow spots 
from one to three lines in diameter, which 
were connected with the capillary circu- 
lation, and consisted of cells, nuclei, and 
granules. The white corpuscles of the 
blood were not in excess, but rather de- 
ficient in number. Dr. Ogle (Path. Soc. 
Trans, vol. xi. p. 269) describes cases of 
enlarged spleen containing adventitious 
material, of which white corpuscles form- 
ed a considerable proportion, and alludes 464 
PURPURA. 
to the circumstance that in several of them 
there was a tendency to purpuric hemor- 
rhage. The kidneys may be healthy, 
or the seat of chronic degeneration, either 
amyloid, or of some other character. 
The capillaries of the skin have been ex- 
amined, and pronounced healthy; but 
this statement must be received with 
caution, owing to the difficulty of the 
examination. In the case of Purpura 
recorded by Dr. William Fox,1 occurring 
in a case of secondary syphilis with severe 
ulceration of the pharynx and larynx, 
amyloid degeneration was detected in the 
spleen, kidneys, liver, and intestines ; the 
same change was also observed in the 
muscles and the capillaries of the skin. 
Dr. W. Fox states that "sections of the 
skin near, but not in the parts affected 
with hemorrhagic extravasations, gave 
either with Schultze's solution (chloride 
of zinc and iodine), or with iodine alone, 
or iodine and sulphuric acid, a most in- 
tense reddish-brown, in portions between 
the fat, besides corresponding to the 
course of the capillaries. This coloration 
did not pass much into the papillae. The 
color, with Schultze's reagent, was some- 
what evanescent; but that with iodine 
lasted from forty-eight to seventy-two 
hours, and in some preparations the mark- 
ing out of the capillaries was beautifully 
effected in this manner. This change 
was not constantly met with in all por- 
tions of the skin tested; but was best 
marked in portions taken in close prox- 
imity to the affected spots. In some of 
these parts, in which I succeeded in iso- 
lating portions of the capillaries and 
smaller arteries, I found that they broke 
up very easily, that some presented a pe- 
culiar glistening, waxy look, while others 
had a non-granular appearance, in no de- 
gree corresponding to the appearances 
observed in health." 
In the same case, there was hemorrhage 
into many of the muscles, and peculiar 
appearances, very similar to those de- 
scribed by Zenker, were seen in other 
parts of the muscle. " Patches of muscle, 
from a quarter to half an inch in diameter, 
arc whitish gray, contrasting markedly 
with the normally-colored tissue around. 
The fibres so affected resemble those of 
fishes. They are dry, friable, and break 
with a granular fracture. They have 
also a strong refraction. These portions 
of muscles stain of an intense reddish 
brown, with iodine." 
Under the microscope these pale patches 
presented a mixture of two appearances, 
(a) Some fibres were excessively pale, had 
a uniform waxy look, and had lost nearly 
all appearance of striation. Many broke 
up very easily, and in many places rup- 
tured within the sarcolemma. Some pre- 
sented an appearance as if made up of in- 
numerable refracting particles, but I could 
not succeed in breaking up these fibres, 
so as to examine separately the constitu- 
tion of these particular particles. These 
fibres were not distinctly enlarged. (6) 
Other fibres in the same field, much paler 
than natural had not the glistening, waxy 
look, but were very finely granular. The 
transverse and longitudinal striation was 
indistinct; but these fibres, in many 
cases, split up very easily into fibrilla?. 
The granules disappeared for the most 
part under liquor potasses or acetic acid, 
leaving a few scattered fat drops in the 
fibre. The nuclei appeared about as dis- 
tinct as usual in the more waxy speci- 
mens; they were indistinct, but not en- 
larged in those which were granular. 
"The exceedingly pale spots in the 
rectus abdominis presented the waxy ap- 
pearance in the most marked degree. 
The heart showed, in a few parts, similar 
waxy fibres, but in the affected spots the 
more general appearance was that the 
fibres were finely granular, with indis- 
tinctness of the transverse striation. The 
granular character disappeared as a rule 
with acids and alkalies; a few fibres here 
and there were distinctly fatty."1 
Au attempt was made to inject the vessels 
of the forearm after death; but although 
great force was used, the injection failed 
for the most part to reach the smaller ves- 
sels. The blood coagulated firmly; at an 
early stage of the disease, the white cor- 
puscles of the blood were seen to be in 
excess, whilst at a later period they had 
decreased in number, and bore relatively 
to the red an apparently normal propor- 
tion. 
Dr. Dickinson (Trans. Path. Soc. vol. 
xvii. p. 13) describes a case of meningeal 
apoplexy associated with Purpura. In a 
cachectic patient, sudden effusions of 
blood occurred in the skin of the arms and 
thighs, one being the size of an egg. Sub- 
sequently the man was seized with pain 
in the neck, rigors, vomiting, and want of 
sleep. He was restless and semi-delirious, 
but not paralytic. He could not speak, 
and death occurred the third day. 
At the post-mortem examination the 
vessels of the pia mater were very care- 
fully examined under the microscope, and 
they were found to be apparently healthy; 
the blood in the body was fluid, and like 
the juice of cooked cherries or plums. 
The liver was cirrhotic. No doubt bile 
products had been plentifully circulating 
in the blood. This case contrasts with 
that of Dr. Wilson Fox, in which the ca- 
pillaries were diseased. The occurrence 
of Purpura in connection with so-called 
amyloid deposit has, however, been no- 
1 Brit, and Foreign Med. Chir. Review, Oc- 
tober, 1865. 
• Wilson Fox, loc. cit. 465 
NATURE. 
ticed in other cases by Dr. Dickinson. 
The same gentleman has also (Trans. 
Path. Soc. vol. xiii. p. 104) recorded a 
case of Purpura in a girl aged 16, who 
was jaundiced from the pressure on the 
hepatic duct by an hydatid cyst, the blood 
containing a large amount of bile, but in 
which there was no appreciable lesion of 
tissue. 
Nature.-Much uncertainty exists as 
to the exact nature of the disease of which 
cutaneous hemorrhage is the outward 
evidence. There must be rupture of the 
vessels to permit the escape of blood, and 
the latter does not take place in health, 
be there ever so much pressure on the 
capillaries. When hemorrhage does oc- 
cur, it might-considering the matter a 
priori-be due to a weakened and dis- 
eased state of the capillaries, the result of 
changes in the blood it may be; or to some 
change in the blood which originates a 
softening of the tissues outside the vessels 
as well; or it might be due to a loss of 
nerve control over the vessels, so that the 
normal force of the heart's action could 
not be withstood. Now the blood has 
been several times analyzed; it has some- 
times been found to contain a deficiency 
of fibrin, sometimes a normal quantity, 
and sometimes an excess of that ingre- 
dient. Becquerel and Rodier have given 
the name of scorbutic condition to all cases 
in which the fibrin is less than 0'2 per 
cent, in the blood. In scurvy proper, 
however, and in Purpura, the fibrin may 
even be increased, so that a deficiency in 
fibrin is certainly not the property of the 
blood on which hemorrhage always de- 
pends. Becquerel found in 1000 parts of 
blood 803'44 water, and 196'56 of solid 
matter. 
In an examination of the blood in two 
cases of Purpura, by Dr. Parkes, the only 
remarkable result was an excess of iron 
with a general deficiency of the solid con- 
stituents. The relative proportion of the 
different organic solid constituents to each 
other was not much affected. In an 
analysis by Routier, quoted by Simon 
(Animal Chemistry, vol. i. p. 319), there 
was no general deficiency of solids, but a 
small proportion of fibrin, '09 per 100. 
Simon examined the bloody fluid dis- 
charged from the mouth of a girl, aged 
twenty years, suffering from Purpura 
hsemorrhagica, and found it to contain no 
fibrin, a few blood-corpuscles, and some 
bile. 
It was long a favorite doctrine, that 
change in the quality of the fibrin, ren- 
dering it liable to coagulate in a peculiarly 
gelatinous manner, existed in cases of 
Purpura and scurvy. Some modern ob- 
servers (Magendie, Marchal, and Pog- 
giale) have adopted this view, but it is 
one to which little importance can be at- 
tached ; in the first place, because this 
form of coagulum is often absent, and in 
the second place, because nothing is 
known of the change which has taken 
place in fibrin which does thus coagulate. 
Deficiency of fibrin might help out the 
disease. 
It has been proved by experiments on 
animals, conducted by Magendie, Vir- 
chow, and others, that the injection of 
putrid matter into the veins will cause 
ecchymoses of the endocardium, of the 
lungs, liver, and kidneys, &c., effusion of 
blood from the intestinal mucous mem- 
brane-this may be by the production of 
thrombosis. The injection of ammonia, 
however, into the blood, has also been 
found to produce hemorrhages. This 
shows that extravasations may follow 
changes in the blood, but proves nothing 
as to the nature of Purpura. Dr. Garrod 
has suggested that a deficiency of potash 
in the blood may be the cause of scurvy, 
and this disease has been cured by the 
administration of salts of potash ; in this 
respect, Purpura is entirely different from 
scurvy. Purpura is not cured by the ad- 
ministration of salts of potash or of fresh 
vegetables. 
The occurrence of cutaneous hemor- 
rhage or Purpura in the more general 
sense of that term, in acute atrophy of 
the liver, as well as in cirrhosis and other 
diseases of that organ, has been variously 
explained by different writers. At one 
time it has been ascribed to debility of the 
heart's action, the general want of tone 
in the system, and the defective nutrition 
of the bloodvessels (Buhl); at another 
time, to the deficient formation of fibrin 
(Monneret); and at another, to an over- 
distended condition of the bloodvessels in 
consequence of a deficiency in the secre- 
tion of bile. Frerichs suggests that there 
is an abnormal attraction between the 
walls of the vessels and the blood which 
has become altered in its composition, 
from which arise obstruction and rupture 
of the capillaries (Clin. Treatise on Dis- 
eases of the Liver, vol. i. p. 232, New 
Sydenham Society). The presence of a 
large quantity of bile in the blood has 
been stated to cause a solution of the 
walls of the blood disks, favoring the 
transudation of hjematine into the tissues. 
It is questionable, however, whether 
change in the blood alone will account for 
the escape of blood-corpuscles from the 
capillaries. If the blood be charged with 
bile, or morbid products, or be deficient 
in fibrin, and obstruction occur, then rup- 
ture might more readily take place. In 
Purpura there is probably always an ac- 
tual escape of the blood disks ; it is not 
merely an extravasation of the coloring 
matter, owing to a solution of the walls of 
the disks. 
The sympathetic nervous system may 
vol. I.-30 466 
PURPURA. 
possibly, besides the blood, be concerned 
in the recurrence of Purpura, for Simon 
produced cutaneous hemorrhage by de- 
stroying several of the great sympathetic 
ganglia in the neck of the frog ; softening 
of the tissues first occurring. 
To explain satisfactorily an escape of 
blood-globules from the capillaries, one 
imagines that lesions of the vessels must 
be assumed to exist. A blood change 
may be the first morbid condition leading 
to these lesions. The nature of the 
changes in the capillaries is not yet ascer- 
tained ; sometimes it may be simple rup- 
ture from over-distension ; but more fre- 
quently there is probably a degenerative 
change in the capillaries, making them 
specially liable to give way as in the case 
of Purpura hsemorrhagica, above referred 
to, observed by Dr. Wilson Fox, where 
the capillaries were in process of larda- 
ceous degeneration. 
Dr. W. Fox observes: "Another very 
important question arises as to how far 
this affection of the capillaries can be logi- 
cally considered to have been the cause of 
the hemorrhage. Any direct association 
of the two changes will probably be con- 
sidered doubtful by many who know that 
lardaceous affections of tissues are rarely 
associated with hemorrhage ; and further, 
that the change in the parenchyma of or- 
gans and in mucous membranes thus 
affected is often preceded by a similar 
change in the smaller vessels.1 The evi- 
dence as it stands at present is decidedly 
against such a theory of causation, unless 
one or two possible hypotheses may be 
admitted to explain the connection of the 
phenomena observed. (1) May this larda- 
ceous degeneration, which we know chiefly 
as a chronic disease, occur occasionally in 
a more acute form, and in this manner so 
rapidly alter the elasticity of the vessels, 
before their diminished calibre can have 
retarded the flow of blood in the part, that 
rupture and hemorrhage ensue ? (2) Is it 
possible that this lardaceous change, oc- 
curring only in tracts of tissue, may throw 
such a stress on the collateral capillary 
circulation of the tissue around, that ad- 
jacent but comparatively unaffected capil- 
laries gave way ? Both theories derive 
some support from the observations made 
on the dissemination of the degeneration 
in this case, and also from the observa- 
tions of Zenker, in a similar degeneration 
of the muscles in typhoid fever."2 But 
then we have the testimony of such cases 
as those of Dr. Dickinson to the contrary, 
in which the capillaries seemed to be 
quite healthy. 
Dr. W. Fox's case of Purpura, though 
not an uncomplicated one, seeing that the 
patient was suffering also from an aggra- 
vated form of secondary syphilis, must lie 
regarded as a valuable contribution to the 
pathology of Purpura ; it may serve as an 
indication of the direction in which inqui- 
ries as to the nature of the disease should 
be instituted. 
Purpura senilis is probably due to a de- 
generation of the capillaries, in parts ex- 
posed to rough usage ; we are not aware 
that this has been confirmed by actual 
observation. 
The general result at which we arrive 
as regards cutaneous hemorrhage, then, is 
this: that it occurs in many diseases in 
which the blood is disordered. When- 
this is French's view-in consequence of 
the altered relation between the blood and 
the tissues, the former passes with diffi- 
culty through the capillaries, and the tis- 
sues are more or less badly nourished in 
common with the whole body, rupture of 
the capillaries is likely to occur, and espe- 
cially if there be, in addition, amyloid de- 
generation of the capillaries or obstruction 
to the general circulation, as in liver dis- 
ease. This applies to cutaneous hemor- 
rhages as a whole. In the disease more 
properly called Purpura, there is no evi- 
dence of diseased capillaries, nor of blood- 
change. Hebra, however, asserts that 
the capillaries must be weak, and that 
Purpura is "due to change in the cohe- 
sion of the tissues surrounding the rup- 
tured capillaries," as in inflammations. 
Hebra thinks that temperature and cloth- 
ing have much to do with the occurrence 
of Purpura. It still remains a question 
how far in progress of time a common 
pathological origin will be assigned to all 
cutaneous hemorrhages, Purpura in- 
cluded. 
Prognosis.-In Purpura simplex re- 
covery usually occurs, but relapses are 
very frequent. Purpura hsemorrhagica is 
always a grave disease; it has often 
proved fatal from exhaustion, or, more 
rarely, from cerebral or pulmonary apo- 
plexy. Recovery ensues in a certain pro- 
portion of cases under judicious treat- 
ment. The prognosis of cutaneous hem- 
orrhage is that of the general disease in 
which it occurs. 
Diagnosis. - The characteristic fea- 
tures of Purpura are the extravasation of 
blood in the cutis, and, in the hemor- 
rhagic variety, loss of blood from other 
parts. The eruption in the skin is known 
from other non-hemorrhagic eruptions, by 
its not disappearing or fading on pressure. 
Typhus fever and hemorrhagic measles will 
be distinguished by the constitutional 
symptoms and history peculiar to those 
diseases. In the former, a history of con- 
1 Virchow, Cellular Pathology. Chance's 
Translation, p. 374. 
2 Ueber die Veranderungen der willkiihr- 
lichen Muskeln in Typhus Abdominalis. 
Leipzig, 1864. TREATMENT. 
467 
tagion, destitution, or overcrowding, ce- 
rebral symptoms, dryness of the tongue, 
and the fact that the spots are small, gen- 
erally spread over the body, and at first 
disappearing on pressure, will prevent any 
mistake; in typhus, too, there are no 
hemorrhages from mucous surfaces, un- 
less it be complicated with scurvy. In 
measles, the rash is brighter, and at first 
disappears on pressure; there are also 
signs of coryza and bronchial congestion, 
preceding the rash for forty-eight hours or 
more. The only disease with which Pur- 
pura is often confounded is scurvy. The 
latter disease is always caused by a want 
of fresh vegetables ; it may be always pre- 
vented, and generally cured by a proper 
supply of vegetables. This is not true of 
Purpura. In scurvy, the gums are usu- 
ally swollen, soft, and sore, which is not 
the case in Purpura. There is a tendency 
to painful swellings of the limbs, and stiff- 
ness of the joints in scurvy, not observed 
in Purpura. The gums are swollen, 
spongy, discolored, and bleeding in scur- 
vy. The eruption of Purpura is often 
bright at the onset, and the lips and 
tongue are frequently of a good color 
when the disease sets in. In scurvy, the 
complexion is pale and sallow, and the 
patient is obviously out of health before 
the hemorrhages take place; this is very 
often not the case in Purpura. Fresh 
vegetable diet at once prevents the occur- 
rence of hemorrhagic spots, and does not 
influence Purpura. 
Ecchymoses from violence may be known 
by their fixed local character, their size, 
and the absence of small petechise. Flea- 
bites in unhealthy persons often retain 
the petechial character for many days, or 
even weeks ; they may be known by their 
nearly uniform size, and the presence of a 
central minute point where the skin was 
punctured by the insect. 
The hemorrhagic diathesis, in which 
there is a tendency to excessive loss of 
blood from very slight causes, must be 
distinguished from Purpura. 
In persons of a hemorrhagic diathesis, 
there is usually some wound, ulcer, or 
contusion of the part from which blood 
escapes; there is not the tendency to gen- 
eral bleeding in all parts of skin and mu- 
cous membranes which characterizes Pur- 
pura. Signs of the diathesis generally 
make their appearance at an early age, 
and there is very often a history in the 
family of an hereditary tendency to the 
same condition. 
Treatment. - According to the dif- 
ferent views entertained of the nature of 
Pnrpura, different lines of treatment have 
been recommended and adopted. The 
cases brought together under the name of 
Purpura, in its wider signification, being 
of very varying nature, agreeing only in 
the circumstance of presenting hemor- 
rhage in the cutis, obviously must not be 
all treated alike. Regard must be paid 
to the diathesis of the patient, whether he 
be rheumatic, gouty, cancerous, or scrofu- 
lous. The antecedent conditions must be 
ascertained-whether his diet has been 
suitable or deficient in any nutritive ele- 
ments, whether he have resided in damp, 
ill-ventilated places, or been exposed to 
malaria. 
At one time, blood-letting was recom- 
mended for Purpura, as for nearly every 
other disease. Its use is now universally 
discarded. If there be signs of plethora, 
with a full, strong pulse, and the mucous 
membranes of a good color, the use of free 
saline purgatives, preceded by a dose of 
calomel, is indicated. The purgative may 
in rare cases be combined with a small 
quantity of antimony. Cases of this kind 
are seldom met with in the present day. 
If there be any sign of hepatic conges- 
tion, the sulphate of magnesia or soda,1 
with dilute sulphuric acid, should be given 
two or three times a day ; a good dose of 
jalap, with a grain or two of calomel, may 
be first given. The perchloride of iron 
has been much extolled in France and 
elsewhere. M. Pize (Journ. de Med. et 
Chir. pratique, August, 1860) regards it 
as an almost infallible cure administered 
in quantities of one drachm in twenty- 
four hours (equal to about four drachms 
of the tincture of the sesquichloride of iron 
of the London Pharmacopoeia). If iron 
be given at all, it should be used in full 
and frequently repeated doses, half a 
drachm or a drachm of the tincture of 
steel every two hours. In the ordinary 
cases of Purpura simplex, the dilute sul- 
phuric acid, with quinine and sulphate of 
magnesia, may be given. 
Dr. Neligan has strongly advocated the 
use of turpentine in large doses, in Pur- 
pura, with or without castor oil. He 
gave from an ounce to an ounce and a 
half to adults, and from two to four 
drachms to children. He reports several 
cases in which it certainly seems to have 
exerted a most remarkably beneficial in- 
fluence. 
I have myself administered it with very 
satisfactory results to two children affected 
with this disease, one in a very severe 
form. I have seen it used in two fatal 
cases in which it appeared to check the 
hemorrhage, but its use was resorted to 
at so advanced a period of the disease as 
not to afford any reasonable hope of pre- 
venting death. 
In one child, aged 11 years, who had 
numerous petechise and ecchymoses of the 
skin, with profuse epistaxis, and was 
losing blood from the kidneys, the bowels, 
1 This salt has been strongly recommended 
in persons of the hemorrhagic diathesis. 468 
CHLOROSIS. 
and the stomach, I gave at first two 
drachms of oil of turpentine, with half an 
ounce of castor oil, once a day; on this 
treatment there was slight improvement. 
She was, at the end of two days, ordered 
olei terebinthinse, $j ; mucilaginis, 5j ; 
syrup ad ^ss ; ol. menthse pip. THij twice 
a day; and an enema consisting of olei 
ricini, ^ss ; olei terebinthinse, ^ss ; de- 
cocti hordei, Oss, once a day. 
In four days a marked improvement 
had taken place; all hemorrhage had 
ceased, and the ecchymoses were rapidly 
disappearing. The turpentine was then 
given once a day for about a week, at the 
end of which she was quite well, regaining 
her color and strength. 
Dr. Hardy, of Dublin (Dubl. Hosp. 
Gazette, 1859), advocates the use of the 
tincture of larch bark, in doses of about 
ten or fifteen drops every hour, or less 
frequently, according to the severity of the 
case. This remedy, probably, acts in the 
same way as turpentine ; it is said to be 
an agreeable medicine to take. 
When the hemorrhage is very profuse 
and the patient is exhausted, astringents, 
such as gallic acid and acetate of lead, are 
usually resorted to, but they are very 
often inefficacious. 
Mr. Hunt recommends arsenic in Pur- 
pura simplex, and in this recommendation 
he is supported by Dr. Habershon, upon 
what ground it is difficult to say. 
In treating a case of Purpura, regard 
should always be had to the circumstances 
of the patient prior to the attack. If the 
diet have been deficient in quantity or 
quality, such deficiency should be made 
up by a well-regulated diet, a due propor- 
tion of animal and vegetable food being 
administered, with a moderate allowance 
of light stimulant, such as claret,imarsala, 
or some pure wine. If the pulse be full 
and firm, and the color of the lips good, 
an emetic of ipecacuanha, or even anti- 
mony, at the outset may be a good intro- 
duction to the turpentine treatment. 
Digitalis has been recommended in cases 
where the pulse is very frequent, but not 
strong enough to justify blood-letting. 
This drug has been found useful in men- 
orrhagia and in pulmonary hemorrhage ; 
it may be worth a further trial in Purpura 
hsemorrhagica. 
Local measures may be resorted to 
wfliere there is great loss of blood from 
parts within reach. For epistaxis and 
uterine hemorrhage, injection of cold lo- 
tions containing alum, tannin, or acetate 
of lead, may be used, or plugging may be 
adopted in extreme cases. In hsemate- 
mesis, ice may be given by the mouth. 
Purpura of the extremities may often be 
checked by careful bandaging of the part. 
In Purpura simplex, following rheuma- 
tism, quinine is often of use. 
Hebra advises in all cases that the pa- 
tient should take rest, and it is always de- 
sirable to keep the patient, if possible, in 
the recumbent posture for some days. 
In convalescence, the administration of 
bark, as recommended by Werlhoff, Beh- 
rend, and Jeller, who first described the 
disease, may be had recourse to if there 
is any symptom of debility. 
[CHLOROSIS. 
By Henry Hartshorne, M.D. 
Synonyms.-Green Sickness ; Chloro- 
ansemia ; Icterus Albus ; Leucopathia ; 
Cachexia Virginum ; Morbus Virgineus. 
History.-Allusion to Green Sickness 
was made by very early writers, even as 
far back as Hippocrates. Sydenham re- 
fers briefly to it. Hoffman, in the eigh- 
teenth century, gave a very good account 
of it. Many more recent writers have 
paid attention to its pathology ; especially 
Blaud, Andral, Becquerel/ Rodier, and 
Trousseau, in France, and Popp, Hirsch, 
and Virchow, in Germany. All who 
have dealt with it, however, are not 
agreed as to its nature; especially in re- 
gard to its relations with antemia. It is 
said to be a particularly common disease 
in the West Indies, Algeria, and Turkey 
in Asia. Huss asserts that it has consi- 
derably increased in Sweden during the 
last half century. 
Symptoms. - Occurring at about the 
age of puberty, in girls, Chlorosis shows 
itself mainly by changes in the condition 
of the skin, digestive system, circulation, 
reproductive apparatus, and nervous sys- 
tem. The complexion becomes pale, with 
a yellowish or green tinge. Often, a ten- 
dency to oedema of the face exists, with 
bluish or blackish circles around the eyes. CAUSATION-DIAGNOSIS. 
469 
Morbid appetite is a characteristic symp- 
tom. The patient has a strange craving 
for ashes, slate pencils, or chalk; occa- 
sionally, instead, for vinegar or other 
acids. The breath is foul; the bowels 
are apt to be constipated. Palpitation of 
the heart is frequent; always the pulse 
and respiration are accelerated by slight 
exertion. A murmur, " bruit de diable,"1 
is heard on auscultation, from the base of 
the heart towards the arteries in the neck. 
Fainting upon the occasion of any nervous 
excitement is not unusual. 
Amenorrhcea nearly, but not quite, al- 
ways attends Chlorosis. The disorder 
most frequently occurs in girls whose 
menstruation has not yet been established, 
but is retarded beyond the normal period. 
The temperature of the body is com- 
monly, in Chlorosis, lower than natural; 
particularly in the extremities. 
Languor and debility exist, with vertigo, 
headache, tinnitus aurium, lowness of 
spirits, irritability or capriciousness of 
temper, and imperfect sleep. Neuralgic 
or myalgic pain is common, especially in 
one or both sides, near the margins of the 
ilia. Tenderness of the spine, in the 
upper dorsal region, is sometimes observa- 
ble. Syncope, or even convulsions, may 
occur from fatigue or excitement. 
Causation.-This is hard to trace in 
many instances. Trousseau and Ham- 
mond have reported cases supervening 
upon fright. Insufficiency of nutrition, of 
exercise, and of wholesome mental occupa- 
tion, are probably promotive of it. What- 
ever much disturbs the nervous system, 
in a female of slender constitution, about 
the period of puberty, is likely to produce 
Chlorosis. 
Pathology.-Formerly it was a cur- 
rent medical opinion that Chlorosis con- 
sisted in a sort of fibrinous plethora; and, 
for the supposed excess of fibrin in the 
blood, venesection was prescribed. Late 
writers generally agree that, in most cases, 
deficiency in the number of red corpuscles 
exists, without any characteristic change 
in the amount of fibrin. Virchow holds 
that the total number of blood corpuscles 
is lessened in Chlorosis ; while in leukae- 
mia, many of the red corpuscles are sub- 
stituted by white corpuscles, and the 
whole number is not diminished. Leich- 
tenstein,2 examining the blood by Vier- 
ordt's method of quantitative spectral 
analysis, asserts that a diminution of 
haemoglobin in the blood appears con- 
stantly in Chlorosis. This observation 
confirms the report of several of those who 
have at different times chemically ana- 
lyzed chlorotic blood. A deficiency of 
iron has been reported by Foedisch, 
Hoefer, Andral and Gavarret, and others. 
The term oligochromcemia has been used 
by some writers to designate a reduction 
in the amount of coloring material in the 
blood; oligocytoemia signifying deficiency 
of the corpuscles. 
Yet, upon the testimony of many prac- 
titioners, anaemia, in either form, cannot 
be said to be invariably present in Chlo- 
rosis. The term Chloroanaemia is, there- 
fore, regarded, especially by several of the 
French pathologists, and by Dr. T. G. 
Thomas, of New York, as inexact. Bec- 
querel and Valleix have considered Chlo- 
rosis rather as a neurosis of the ganglionic 
nervous apparatus. Rokitansky, Vir- 
chow, and other German authors, have 
not accepted this view. It has, neverthe- 
less, great probability in its favor. Re- 
tarded development, at the period when 
menstruation ought to be established, 
may have much to do with its origin in 
many cases ; such organic debility result- 
ing in a ganglionic ataxia or asynergia, 
involving all the functions of the vegeta- 
tive, and some of those of animal life. 
Virchow has proposed the assertion, or 
hypothesis, that a congenital imperfection 
of the vascular system, especially of the 
aorta and arteries generally, is funda- 
mental at least in cases of obstinate or re- 
current Chlorosis.1 Certainly such a de- 
fect of development cannot be supposed 
to exist in the majority of cases, from 
which recovery occurs in a few months. 
Diagnosis.-Accepting the view as cor- 
rect, that Chlorosis is not a mere variety 
of anaemia, but a distinct cachectic dis- 
ease, we may follow Dr. T. G. Thomas's2 
enumeration of the diagnostic differences 
between these two affections. These are 
comprised in the statements that "Chlo- 
rosis is a disease of the nervous system, 
and may occur with or without its most 
common symptom, amemia. Chlorosis 
cannot (while anaemia can) usually be 
accounted for by discovery of special 
cause. Chlorosis occurs in true type usu- 
ally to girls about the time of puberty. Is 
affected favorably only by remedies which 
act upon the nervous system, as altera- 
tives and tonics. Produces a light-green 
color, instead of the puffy and pale ap- 
pearance of simple anaemia. Commonly 
produces sadness and nervous disquietude. 
Is constantly accompanied by visceral 
neuralgia. Iron often fails to benefit; 
[' This term, first applied hy Bouillaud, is 
derived from the French name (diahle) for 
the humming top. Skoda gave to the mur- 
mur, for like reason, the name "nonnen- 
gerausch."] 
[2 Lancet, April 12, 1879.] 
[' See Immermann on Chlorosis; Ziemssen's 
Cyclop, of Pract. of Medicine, vol. xvi.] 
[2 Diseases of Women, 4th Edition, Phila., 
1876, p. 772. J 470 
CHLOROSIS. 
while, in ancemia, iron always does good. 
If the supposed cause be removed, the 
patient will often improve but slowly ; 
the removal of the cause of ansemia being 
followed commonly by rapid improve- 
ment. " 
Some of these characteristics, and par- 
ticularly the absence of improvement, in 
certain cases, under the use of iron and 
other recuperative remedies, will not dis- 
tinguish cases of Chlorosis from examples 
of progressive pernicious ansemia. What 
needs to be remarked upon this last sub- 
ject, however, will be reserved for another 
place.1 
Prognosis. - Chlorosis does not, of 
itself, tend towards a fatal termination. 
Not rarely, however, the congenital de- 
fect or early impairment of constitution, 
which brings on the chlorotic cachexia, 
may result also in phthisis. The continu- 
ance of the symptoms of Chlorosis is usu- 
ally protracted at least through several 
months, sometimes for years. Favorable 
signs are the return of regular menstrua- 
tion and normal appetite and digestion, 
tranquil sleep, and a healthy color. Espe- 
cially, whether as a cause or a conse- 
quence, amenorrhoea is the most signifi- 
cant of the usual features of this disease ; 
and its removal almost always heralds ap- 
proaching recovery. 
Treatment.-We have evidently here 
to deal with-first, a cachexia ; and, sec- 
ondly, certain symptoms and conditions 
affecting the functions and apparatus both 
of organic and of animal life. 
Anaemia being present in a large ma- 
jority of cases, the blood-making power 
must be recuperated. If possible, the 
cause of its curtailment or depression must 
be ascertained and removed. Unfavor- 
able mental impressions often have to do 
with this causation, as grief, anxiety, 
domestic unhappiness; also, sedentary 
habits, with deficiency of sunshine, pure 
atmosphere, and exercise. All that can 
be done towards improving any of such 
conditions will promote the convalescence 
of the chlorotic patient. 
Whatever the causation, however, it is 
certain that hygienic influences will be of 
the greatest importance in the cure of this 
cachexia. Change of residence will often 
do a great deal of good. If the patient 
has been living in town, let her, if practi- 
cable, make a prolonged visit to a healthy 
locality in the country. Mountain air, in 
the summer, will agree well with many 
such patients; camping out, in good, cheer- 
ful company, the best of all ; provided, 
that is, a sufficiently nutritious supply of 
food can be obtained. The sea-shore will 
suit, perhaps, a greater number, with sea 
bathing. Care must be taken, however, 
that a chlorotic subject does not remain 
too long in the surf. A sluggish circula- 
tion will not easily react from the depress- 
ing influence of cold water. Headache, 
diarrhoea, &c., may result from a too pro- 
longed cold bath, and the incipient nisus 
of menstruation may thereby be sup- 
pressed. From five to fifteen minutes at 
a time wfill be sufficient for any invalid or 
valetudinarian to remain in a cold bath, 
even at the highest temperature of the 
water in midsummer at Atlantic City or 
Cape May. 
Diet is of the utmost consequence in 
Chlorosis. Shall we endeavor to prohibit 
altogether the indulgence of the morbid 
cravings of the patient ? Trousseau 
thought otherwise. It will, indeed, be 
almost impossible, without bodily re- 
straint unsuited to the case, to prevent 
the taking of indigestible things into the 
stomach. It is ^ot unreasonable to sup- 
pose that some indication of nature exists 
in the disposition to eat unusual articles. 
Analogy favors this, in the history of 
various diseases. Especially is this fami- 
liar in regard to the desire for acids on 
the one hand, and alkaline substances on 
the other. Most chlorotic patients crave 
earthy or alkaline materials ; a few, vine- 
gar, lemons, &c. Dr. Barnes's suggestion 
is rational, that the salts of the blood may 
be deficient. If we can interpret, at least 
approximately, the natural meaning of 
the extraordinary tastes alluded to, they 
may aid in guiding our medication of the 
case, to which attention will be presently 
given. 
Of course a highly nutritious regimen is 
called for, and, in anaemic cases, one con- 
taining a large proportion of animal food. 
Variety is very desirable. Yet, in the 
enfeebled condition of the digestive or- 
gans, ordinary meals may not be appro- 
priated so fully as to furnish enough for 
the needs of the system. Then extra 
portions must be given between meals, in 
the form of beef-tea, milk, &c. The lack 
of appreciation of the value of beef-tea, 
shown of late by some physicians and 
others, is probably due to its being so 
often made in a manner which wastes the 
greater part of its albuminoid material. 
When prepared by the maceration of 
chopped beef for a couple of hours in 
tepid water, then boiling for less than half 
an hour, and pouring off without filtering 
or straining, merely removing the scum 
which rises to the top, and salting it 
moderately, beef-tea contains all that is 
nourishing and available in meat.1 It 
[* More concentrated, and more acceptable 
to some feeble stomachs, is beef essence; made 
by putting finely chopped beef in a large 
bottle without water; placing the bottle, 
f1 See Progressive Pernicious Anaemia, vol. 
iii.l TREATMENT. 
471 
should have a rich brown color, and should 
be stirred, after standing, before it is 
taken. The clear liquid from which the 
finely divided brown portion settles when 
at rest, is, like Liebig's extract, only the 
serum, so to speak, of beef-tea; except 
that, unlike the serum of blood, it contains 
little or no albumen, only dissolved gela- 
tin and salts. Liebig's view of the real 
function of his preparation is now familiar 
to the profession. He never ascribed to 
it the qualities of a complete food ; it is, 
rather, a subtle nutritive stimulant; often 
serviceable as such, but requiring other 
food stuff to be added to it, to make the 
complement of needed diet.1 
Milk should be, in the diet of Chlorosis, 
a standard article. If slow to be digested, 
lime-water may be added. There will be 
no danger of inconvenience if so much as 
one or two fluidounces of lime-water be 
added to each pint of milk. 
Tea will be better than coffee as an ap- 
petizing and refreshing beverage at break- 
fast, but even tea should be taken only of 
moderate strength, to avoid increasing 
nervous excitability. At times of special 
depression, the exhilarating effect of coffee 
may be tried ; but the tendency to palpi- 
tation of the heart in Chlorosis makes it 
more than usually objectionable in that 
complaint. Cocoa or chocolate will be in- 
nocent and nutritious, if it does not prove 
too heavy for the stomach. 
For the peculiar anorexia (or cacho- 
rexia) of Chlorosis, benefit may be ex- 
pected, as in scurvy, from the moderate 
use of raw vegetable food. Best of all 
will be fresh fruits in season; also, celery, 
lettuce, radishes, &c.; anything, indeed, 
edible and relishing, which "has never 
seen the fire." While we do not know 
what are the chemical elements existing 
in such articles which are destroyed or 
altered by cooking, there is no room to 
doubt their value as a part of every die- 
tary, especially when the appetite is defi- 
cient. 
Light gymnastics may be resorted to, 
when practicable, to systematize the devel- 
opment of the muscles, with equable dis- 
tribution of nervous irritability ; besides 
favoring an improvement in the circu- 
lation and secretions. But more spon- 
taneous and varied exercise, as in ex- 
cursions, riding on horseback, rowing, 
sailing, &c., will be still more beneficial; 
giving refreshment to the mind as well 
as the body. All exertion, however, 
must be kept in moderation, short of ex- 
hausting fatigue. Worst of all, no doubt, 
for chlorotic patients, will be detention, 
day after day, within doors ; either, with 
one class, working in the ill ventilated 
rooms of factories, or, with another, lying 
on sofas and reading exciting works of 
fiction, day and night. 
Of medicines, in Chlorosis, iron claims 
the first place. Yet Dr. Barnes is right 
in urging1 that it may not be well tole- 
rated at the beginning; even when de- 
cided ansemia exists. Headache and a 
feverish condition may attend its too 
early or free administration. Where the 
skin is dry, and especially if it be above 
the normal temperature, saline medicines 
should be given at first. Aitken pre- 
fers carbonate of potassium ; Barnes, the 
freshly prepared effervescent solution of 
acetate of ammonium, or spiritus minde- 
reri. Either will answer very well; and 
so will cream of tartar, if the bowels need 
relaxation. Hyposulphite of sodium is a 
favorite with some practitioners under 
similar indications. 
Gentian, columbo, or other vegetable 
bitters may be called for to improve the 
tone of the stomach. Nothing will be 
likely to meet this indication better than 
the compound tincture of gentian, in flui- 
drachm doses, just before meals. 
Coindet has recommended iodine in 
Chlorosis; Trousseau frequently gave 
iodide of potassium. Liquor ferri iodidi, 
in fifteen or twenty-drop doses, will com- 
bine the effects of the alterative with the 
roborant action of iron, so generally re- 
quired. 
Of other chalybeate preparations, the 
tartrate and citrate of iron seem to be 
especially appropriate to the treatment of 
this disorder ; and the same may be said, 
perhaps, of the phosphate. Vallet's pill 
of the carbonate, however, will do very 
well. Dialyzed iron has disappointed 
some, at least, of those who have used it. 
The tincture of the chloride is rather as- 
tringent for most cases of Chlorosis. 
Shall we attempt especially to medicate 
the amenorrhoea ? The confidence in 
emmenagogues, as such, which was once 
entertained, has latterly very much lost 
ground. The absence or deficiency of 
menstruation is, most probably, only the 
effect, not the cause, of the low state of 
development, or of sanguification; a symp- 
tom of cachexia. Restore the functions of 
the nutritive apparatus, and enrich the 
blood, and menstruation will return. No 
doubt, however, the "vicious circle" of 
deranged actions will be more easily 
broken, if we can bring about the ovarian 
loosely corked, up to the neck in cold, water, 
which is then brought to the temperature of 
ebullition, and boiled for two or three hours. 
This, also, should not be filtered or strained ; 
but merely poured off, skimmed carefully, 
and salted to taste.] 
[' This has been especially proved by the 
high nutritive power shown in South Ameri- 
ca, with animals, to belong to the residuum 
from the manufacture of Liebig's extract.] 
[' Diseases of Women, Philada. edition, p. 
193.1 472 
RICKETS 
and uterine molimen with normal peri- 
odicity. If there is any sign of effort at 
monthly uterine hyperaemia and flux, it 
should be encouraged. Warm hip baths 
near bedtime, and moderate doses of 
aloes, by the mouth or by enema, will be 
amongst the most efficient measures for 
this end. Warner's cordial (aromatic 
tincture of rhubarb and senna) also is 
gently laxative, and promotive of deter- 
mination of blood towards the pelvic or- 
gans. Electricity, applied with moderate 
energy to the abdomen and spine, may 
promote the establishment or return of 
menstruation. Where "serous plethora" 
exists, Aitken advises the abstraction of 
blood, according to Vogel's plan, in very 
small amount (one or two ounces) at a 
time, by venesection, cups to the back, or 
leeches to the anus or inside of the thighs. 
In chlorotic cases not anaemic this treat- 
ment may do good, when headache co- 
exists with fulness of pulse and other 
signs of plethora; but such cases are 
rare. Saline purgatives will most gen- 
erally do all that is called for in re- 
ducing intravascular pressure in Chlo- 
rosis. Some physicians employ digitalis, 
in order to tranquillize the often agi- 
tated heart. The palpitation, however, 
is commonly only a part of the generally 
unstable equilibrium of the system ; to 
be rectified chiefly by restoring constitu- 
tional strength. 
For this end, nervine tonics are ap- 
propriate, in combination with iron, and, 
if the stomach bears it, cod-liver oil. 
Quinine may here serve an excellent pur- 
pose ; given in merely tonic doses, six or 
eight grains per diem. Extract of nux 
vomica, or strychnia, may be prescribed 
in small, tentative doses, watching care- 
fully the effect produced. It will be bet- 
ter, in their use, especially at first, rather 
to fall short than to exceed, in the impres- 
sion made by the drug upon the nervous 
system. With yet greater caution, in 
cases of a depressed character, phospho- 
rus may be employed; preferably in the 
form of phosphide of zinc. Arsenic is a 
favorite medicine in Chlorosis with some 
practitioners ; its use in obstinate cases is 
certainly altogether justifiable. It will 
not need, however, that large doses should 
be given ; three or four drops of Fowler's 
solution of arsenite of potassium two or 
three times a day will suffice. Even with 
such doses, in some cases, headache, nau- 
sea, diarrhoea, or facial oedema may warn 
the practitioner to withdraw it, or reduce 
the amount. 
When tardiness of digestion or general 
debility suggests the administration of 
alcohol to chlorotic patients, careful direc- 
tions should be given as to the quantity 
and frequency of its use. Otherwise, in- 
discretion on the part of the patient or 
her friends may easily make way for the 
habit of excess. Women, and especially 
girls, when unaccustomed to alcoholic 
drinks, are generally extremely suscepti- 
ble to their stimulating effects. For Chlo- 
rosis, malt liquors, and especially ale, will 
usually answer best; a small wineglassful 
(two fluidounces) of this will be enough, 
taken at dinner, and, if sleep be uncer- 
tain, again on going to bed. With young 
girls, even a still smaller dose may be bet- 
ter ; the test being whether or not it 
flushes the face, quickens the pulse, or is 
felt at all in the head. Either of these 
signs will show that the dose has been too 
large to do good, and should be reduced. 
On the whole, the most important part 
of the treatment of Chlorosis is, not the 
employment of medicines, notwithstand- 
ing their freque. t advantage and impor- 
tance ; but rather that which is hygienic ; 
in diet, clothing, atmosphere, and, per- 
haps above all, personal surroundings, 
social circumstances, and mental impres- 
sions and influences. The nature and 
therapeutic indications of the malady 
may be summed up in the expression, 
that it is a neurotic cachexia.] 
RICKETS. 
By W. Aitken, M.D. 
r lyEFTKTTTOX. - A constitutional dis- 
ease, characterized by an unhealthy state 
of the system, which precedes for several 
weeks or months a peculiar lesion of the 
bones and of some of the solid visceral 
organs. The lesion in the bones is char- 
acterized by irregularity in their growth, 
by non-solidification of the growing layers 
of the bone, by the progressive formation 
of medullary cavities in the older or more 
mature bone, thus rendering the bony 
laminae thin and brittle (Virchow). There SYNONYMS-CAUSES. 
473 
is generally albuminoid (amyloid ?) de- 
generation of the spleen and liver. 
Synonyms.-Morbus Puerilis Anglo- 
rum, the RicketsFagellum Anglise seu 
Tabes Anglise ; Rhachitis ;2 Rachitis ;3 
Atrophium infantum Anglicum ;4 Cyrto- 
sis Rachia ;5 Cyrtonosus ; Tabes Pitui- 
tosa; Morbus Auglicus ; Osteomalachia 
infantum ;6 Tabes Pectorea ; Spina No- 
dosa ; Rachitismus; Osteosarcosis; In- 
nutritio Ossium ;7 Osteomalakia ;8 Scrofula 
Rachitis ;9 Rachite, Rachitisme, Riquets, 
Noruire; Englische Krankheit, Zwei- 
wuches; Rachitide. 
Causes.-As with other constitutional 
diseases so with Rickets, the transmissi- 
bility of a defective constitution from 
parent to offspring is the first link in the 
chain of causation which brings about 
the cachexia or unhealthy state of the sys- 
tem peculiar to Rickets. Wiltshire, from 
personal experience, is of this belief. 
Herring affirms true Rickets to be, in the 
highest degree, hereditary ; while, accord- 
ing to Schbnlein, too early marriages, and, 
according to Kiittner, intermarriages, 
mainly conduce to its transmission. Sir 
W. Jenner, on the other hand, knows of 
no facts to prove that Rickets is heredi- 
tary. 
The history of the disease, however, 
appears to show that there are predis- 
posing causes derived from the parents 
or the nurse, which are so capable of 
influencing the health of the child as 
to lead in course of time to the estab- 
lishment of the disease now under con- 
sideration. This is quite different from a 
child inheriting Rickets as a disease which 
its parents had, and which they trans- 
mitted to its constitution. 
Of predisposing causes derived from the 
parents, the influence upon children be- 
gotten of bodies exhausted from chronic 
disease, venereal excesses, or age, has 
been recognized from very early times. 
An innate or congenital debility is thus 
imparted to the infant constitution ; and 
when Rickets becomes a frequent disease 
[as, at one period, it seems to have been 
in this country), its occurrence would 
often seem to be hereditary. Vogel says, 
the father of a rickety child has acknowl- 
edged to him that his system was con- 
taminated by syphilis at the time the 
child was begotten ; and Vogel is also of 
opinion that the existence of constitu- 
tional syphilis in the parent may fre- 
quently explain the occurrence of Rickets 
in the children of the better classes. 
Moreover, it is an ancient belief which 
regards Rickets as a degenerate form of 
syphilis. Nevertheless, Sir W. Jenner is 
opposed to the belief that Rickets is a 
form of congenital syphilis, mainly by a 
consideration of the following facts: 
" The parent who infects his offspring 
[with syphilis] has usually contracted 
syphilis before marriage, and the children 
first begotten after infection are those 
who suffer [from inherited syphilis] ; 
while, as a rule, it is only the younger 
children of the family that suffer from 
Rickets-the first-born being commonly 
healthy, though the later born are highly 
rickety." Sir W. Jenner is also very 
sceptical as to the influence of the father 
in affecting the health of the children ; but 
he believes that the health of the mother 
has a decided influence in the develop- 
ment of Rickets in the child. Of this he 
is sure, that where the mother is of deli- 
cate health-in a state in which anaemia 
and general want of power form the 
prominent features, without being the 
subject of actual disease-that such 
mothers give birth to children which are 
often apt to be affected with Rickets to a 
most decided degree, even although the 
father is in robust health, and when the 
hygienic conditions under which the chil- 
dren are placed may be most favorable. 
With reference to the development of 
Rickets after birth, the experience of Sir 
W. Jenner further leads him to state that 
it is very common for the first, or the first 
two or three children, to be free from any 
signs of Rickets, and yet for every subse- 
quent child to be rickety; and, if a 
woman bear one rickety child, in the 
majority of cases all her subsequent off- 
spring will be rickety. This he explains 
upon the following grounds : " That, 
among the poor, the parents are generally 
worse fed, worse clothed, and worse 
lodged, the larger the number of their 
children-for the man's wages remaining 
stationary, the calls on his means are in- 
creased. And among the rich and poor 
alike, the larger the number of children, 
the more has the mother's constitutional 
strength been taxed, and the more likely 
is she to have lost in general power." 
(Medical Times and Gazette, March, 
1860.) 
The causes of the peculiar ill-health 
which precedes the expression of Rickets 
in the child are the subject of great differ- 
ences of opinion; but generally it may be 
stated that whatever external or intrinsic 
circumstances are favorable to the forma- 
tion of watery blood (hydrsemia) in a child, 
seem favorable to the development of Rick- 
ets. Deficient or improper diet taken 
daily, impure air constantly breathed, de- 
ficient exposure to solar light, want of 
cleanliness, cold, moisture, want of exer- 
cise in the open air, are all, more or less, 
1 Whistler. 2 Glisson. 
3 Sauvages, Vogel, Boerhaave, Cullen. 
' Chuden. 5 Good. 
6 Cumin. 7 Darwin. 
8 Swediaur. 9 Young. 474 
RICKETS. 
influential in the production alike of Rick- 
ets and of other constitutional diseases. 
But details relative to the specific kind of 
improper food, although of most interest, 
are the least known. The influence of 
improper food has been fully proved by 
the experiments of Guerin on animals. 
On the other hand, Dr. W. Cumin, in his 
article on Rickets in the Cyclopaedia of 
Practical Medicine, observes, that whole 
broods of young geese and ducks, young 
pointer and greyhound puppies, and young 
pigs, have Rickets or the "krinckets," 
when they have been continually exposed 
to cold and wet, or have been kept in 
damp kennels and sties. Again, M. 
Trousseau states that of a hundred rickety 
children, ninety-eight were cither never 
suckled at all, or were weaned very 
early; while the experience of Sir W. 
Jenner and of Mr. Lonsdale confirms the 
belief that the improper and unsuitable 
feeding of children is by far the most effi- 
cient cause of Rickets, the nourishment 
being first of all deficient during the period 
of infancy, when the child does not get 
sufficient from the mother, either in the 
quantity or in the quality of the milk se- 
creted ; and Mr. Lonsdale has invariably 
found that in all rickety children the 
parents have had little or no milk for 
their supply, and have been obliged to 
feed the children either partially or wholly 
with food other than the milk of the 
mother. The mothers observe that the 
children never grow properly from the 
first, and it is mainly the improper nature 
of the supplementary food "given by 
hand" which impairs the health of the 
child. Here the evidence of Sir W. Jen- 
ner corroborates and completes the evi- 
dence of Mr. Lonsdale. Among the poor, 
Sir W. Jenner observes that the children 
are dosed with improper food even from 
their birth; and the common mode of 
rearing the children of the poor in London 
is thus described by him :-"For the first 
two or three days after birth their tender 
stomachs are deranged by brown sugar 
and butter, castor-oil and dill-water, gruel 
and starch-water; as soon as the mother's 
milk flows they are, when awake, kept 
constantly at the breast. And well for 
them if they are not again and again cas- 
tor-oiled and dill-watered, and even treat- 
ed with mercurials,-for the poor have 
learned the omnipotent virtues of gray- 
powder. 
"After the first month, bread and water 
sweetened with brown sugar is given sev- 
eral times a day, and during the night the 
child is, when not too soundly asleep, con- 
stantly at the breast. As soon as the 
little ill-used creature can sit erect on its 
mother's arm, it has at parents' meal- 
times 'a little of what we have'-meat, 
potatoes, red herring, fried liver, bacon, 
pork, and even cheese and beer daily, 
and cakes, raw fruits, and trash of the 
most unwholesome quality, as special 
treats, or as provocatives to eat, when its 
stomach rejects its ordinary diet. Then, 
instead of being weaned when from ten to 
twelve months old, the child is kept at the 
breast when the milk is worse than use- 
less, to the injury of the mother's health, 
and to the damage of its after-brothers 
and sisters, in the hopes that thus keeping 
it at the breast may retard the next preg- 
nancy. The children are sacrificed that 
the passions of the parents may not be re- 
strained." (Med. Times and Gazette, 
May 12, 1860.) 
Nevertheless, the causes of Rickets are 
still extremely obscure, as are the causes 
of all the constitutional diseases. The 
extensive exciting causes referred to are 
common antecedents of many affections, 
and seem to induce one or other of these 
diseases, according to circumstances of 
which, as yet, we know nothing. 
The subject requires and merits exten- 
sive investigation, for, primarily or secon- 
darily, Rickets causes more deaths than 
any other disease of childhood ; and, look- 
ing to what we do know of the unhygienic 
circumstances under which it has been 
developed, it is one amongst the most 
preventible of diseases. Without doubt, 
Rickets is " the most common, the most 
important, and, in its effects, the most 
fatal of diseases which exclusively affect 
children." (Jenner.) 
[This is far from being the case in the 
United States. The language of Drs. 
Meigs and Pepper1 corresponds with the 
general experience of American practi- 
tioners: "Rickets must be a vastly more 
common affection among the poorer classes 
in London than among the same classes 
in our large American cities ; nor can we 
say that our own experience agrees with 
that of Jenner, who further says that he 
has ' very often seen it in the children of 
the wealthy.'" "Owing to the better 
accommodations and larger size of the 
houses, the better quality and the greater 
abundance of the food of the lower classes 
in American cities as compared with 
European or English, we escape to a great 
extent the ravages of this fatal disease." 
In nine years, ending with 1870, the mor- 
tality records of Philadelphia reported but 
two deaths from Rickets. This is, how- 
ever, less important as evidence in regard 
to the existence of the disease, than the 
general observation of physicians showing 
its comparative rarity in this country.2- 
[' Treatise on Diseases of Children, Phila., 
p. 633.] 
[2 See an elaborate paper upon Rickets, by 
Dr. J. S. Parry, Amer. Journal of Med. Sci- 
ences, April, 1872.] SYMPTOMS. 
475 
Symptoms. - The commencement of 
Rickets is said to have been recognized in 
the foetus. Bordenave and Pinel have 
mentioned such cases. The latter de- 
scribes the case of a rickety foetus at the 
eighth month, in which the distortion of 
the bones was confined chiefly to the lower 
limbs. Meyer also more recently records 
a case of intra-uterine rachitis. (Henle 
and Pfeufler, Band. vi. § 151, quoted by 
Wiltshire.) Glisson, Henckel, Klein, Lel- 
letier, and other authors referred to by 
Dr. Cumin, have also given examples of 
congenital Rickets. 
Sir W. Jenner, however, in his exten- 
sive experience has never seen congenital 
Rickets, but he has often heard the mother 
say that the rickety deformity of her child 
had existed from its birth; although he 
properly attaches no value to such asser- 
tions if unsupported by strong confirma- 
tory evidence. 
The earliest recognition of the cachexia 
associated with Rickets has been variously 
stated, and these statements have no doubt 
varied with the opportunities of the ob- 
servers for seeing cases at an early period 
of the disease. Opinions, therefore, on 
this point are somewhat conflicting. 
According to Jenner, the impairment of 
the general health (cachexia) rarely be- 
comes apparent before the fourth month, 
and usually between the fourth and twelfth 
month. (Med. Times and Gazette, April 
28, 1860.) 
Rickets, however, is rarely observed be- 
fore the seventh month (Cumin); "and 
most commonly does not declare itself un- 
til the child first begins his attempts to 
walk, or until he suffers from the effects 
of the first dentition." (Cyclop, of Pract. 
Med., vol. iii. p. 616.) 
Dr. Mason Good records that "Rick- 
ets seldom appears earlier than the ninth 
month of infancy, and not often later than 
the second year?' (Study of Medicine, vol. 
v. p. 346.) 
Dr. Copland, who has had considerable 
experience of the disease, is still less defi- 
nite. He states that "the complaint has 
been met with from the earliest months, 
till approaching puberty; but it is most 
commonly observed to commence during 
the first dentition, or from six or seven 
months to three years of age. (Med. Diet., 
vol. iii. p. 643.) 
Dr. Dunglison believes that children 
are unquestionably born with a predispo- 
sition to Rickets, although they rarely ex- 
hibit any evidence of the disease till to- 
wards the termination of the first year ; 
and at first the progress of the disease is 
so very slow as almost to be impercepti- 
ble. (Practice of Medicine, vol. ii. n. 
704.) 
All these observers agree, however, 
that the complaint is one peculiar to in- 
fancy ; and, as such, it is materially as- 
sociated with the development of the 
child-perhaps, the conception of the em- 
bryo-at all events, its phenomena are 
inbred, and undoubtedly, therefore, con- 
stitutional. Some few cases occur of chil- 
dren born with disproportionate develop- 
ment of the bones, which have led to the 
belief that Rickets has been observed in 
the foetus ; but, as Dr. Copland justly ob- 
serves, "It is doubtful whether or not the 
imperfect ossification, and consequently 
softened state of the bones observed con- 
genitally, should be viewed as Rickets; 
as, in this disease, there is a change in 
the state of the affected bones, different 
from a mere delay or simple imperfection 
of osseous formation. (Loc. cit.) 
Out of 346 cases of Rickets observed by 
M. Guerin there had origin- 
Before birth .... 3 cases. 
In the First year ... 98 " 
" Second year . . 176 " 
" Third year . . 35 " 
" Fourth year . . 19 " 
" Fifth year . . 10 " 
" Sixth year . . 5 " 
346 
Of these, 148 were males, and 198 were 
females. 
From these records, the number of cases 
happening in the first and second years of 
life very greatly exceeds those of other 
periods of life; and in the subsequent 
years the numbers diminish very rapidly. 
It seems to take a considerable length 
of time before the phenomena character- 
istic of Rickets become so fully expressed 
as to leave no room for doubt regard- 
ing the nature of the affection. Accord- 
ing to Guerin, there is a period of at 
least six months during which a marked 
series of deranged actions succeed each 
other. But while many of these are com- 
mon to other diseases, there are a few 
characteristic phenomena which, while 
they occur in sequence, are so peculiar as 
to be sufficient to determine the specific 
characters of the disease now under con- 
sideration. 
The phenomena and symptoms of 
Rickets, therefore, may be arranged under 
four classes, namely :- 
First, those which are common to many 
diseases, and in which there is nothing 
diagnostic of Rickets-symptoms which 
might arise from deranged digestion, from 
improper food, or from tuberculosis ; and, 
as Sir W. Jenner observes, they are symp- 
toms too often referred to "the irritation 
of teething," or to the so-called "infan- 
tile remittent fever." This has some- 
times been described as the precursory or 
incubative stage. (Guerin, Guersent, Cop- 
land.) 
Second, those which "at once mark the 
nature of the disease, render the diagnosis 476 
RICKETS. 
easy, and enable us to predicate that the 
true affection will show itself." 
Third, the stage of characteristic defor- 
mity. 
The Fourth class of phenomena may be 
of favorable or unfavorable import; and 
may characterize a period of restoration 
to health, of irremediable atrophy, or of 
approaching dissolution. The symptoms 
peculiar to each of these stages are de- 
scribed from the writings of physicians 
who have had extensive experience and 
opportunities of observing this remarkable 
disease-namely, MM. Guerin and Guer- 
sent in France, and Copland and Jenner 
in this country ; the latter of whom has 
given, from his own observation, the most 
detailed and original account of this dis- 
ease that has ever been given by any phy- 
sician. That account will be found in the 
pages of the Medical Times and Gazette, 
vol. i. for 1860. 
During the precursory or incubative 
period, the most ordinary symptoms of 
impaired general health are those which 
indicate gastro-intestinal irritation. The 
bowels are irregular in their action, some- 
times confined, or only relaxed, but more 
commonly there is diarrhoea, with tumid- 
ity or enlargement of the abdomen, when 
emaciation generally becomes more or less 
obvious. 
The stools are usually unhealthy-look- 
ing, pale, deficient in bile, or of a dirty- 
brown or leaden color, and of a most 
offensive odor. In some respects this odor 
is peculiar in its resemblance to rotten, 
half-decayed meat. Appetite is feeble, 
capricious, or entirely lost; and digestion 
is difficult. The child becomes dull and 
languid, sad, or peevish, and adverse to 
play or to exert itself in any way. There 
is low, febrile irritation present; the skin 
is hot, the temper irritable; and, although 
drowsy, the child sleeps but little. It is 
thirsty, and will drink large quantities of 
water; if it has begun to walk, it "is 
taken off its legsit lies about, and is 
unwilling to play or to be amused, or to 
indulge in any kind of action, preferring 
to sit or lie, and appearing to be feeble or 
indolent, and unable to use exertion of 
any kind. It complains of pains in the 
joints or along the bones; the face be- 
comes pale, and the flesh becomes soft 
and flabby ; the pulse becomes quick, and 
indicates irritability of the heart's action; 
the superficial veins become large, and the 
jugular veins especially are much dilated; 
the hair continues thin upon the scalp, 
and the fontanelle remains widely open. 
But in each or all of these phenomena 
there is, as yet, nothing diagnostic of 
Rickets. They may accompany or usher 
in other maladies. The transition from 
apparent health to the expression of these 
phenomena is always gradual, more or 
less slow, and as Dr. Copland has ob- 
served, some other disorder or malady 
may mark the incubative stage of Rickets, 
and, overlaying as it were that disease, 
may render the possibility 'of diagnosis 
still more protracted and difficult. Ue 
refers especially to bronchitis, hooping- 
cough, and lobular pneumonia, and thus, 
instead of beginning abruptly, Rickets 
may commence and progress most insidi- 
ously, so that the mother cannot say 
when her child first began to suffer, and 
often the deformity and change in the 
shape of the bones are the earliest abnor- 
mities she observes. 
On the other hand, Sir W. Jenner, from 
very extensive experience, has at last 
been able to identify three very distinct 
symptoms as commonly present during 
the approaching development of Rickets, 
which at once mark the nature of the 
disease and which render the diagnosis 
easy, and enable us to predicate that the 
bone affection will show itself. 
These symptoms ought, therefore, to 
stand as they here stand-by themselves 
in the second class of phenomena. The 
most remarkable of these symptoms are 
as follow:- 
(a) Prof use perspiration of the head; or of 
the head, the neck, and upper part of the 
chest. Not uncommonly, says Sir W. 
Jenner, "it is because this symptom has 
arrested the mother's attention that she 
seeks medical aid. She uses the strongest 
terms to express the amount of perspira- 
tion : ' It stands in large drops on his 
forehead!' 'It runs in streams down his 
face !' 'His head is all of a reek !' ' The 
pillow is soaked !' It is especially when 
the child sleeps that these copious perspi- 
rations of the head occur, but they are not 
infrequent at other times, as when the 
child is at the breast, or even resting its 
head on the mother's arm. A little in- 
creased exertion or a little increased tem- 
perature may induce them at any time." 
(Med. Times and Gazette, April 28,1860.) 
Such perspirations are extremely weak- 
ening and colliquative during sleep, and 
when they occur the superficial veins of 
the scalp are generally large and full, the 
jugular veins much dilated, and some- 
times the carotid arteries may be felt 
strongly pulsating. (Copland, Jennef.) 
While the skin generally may be moist 
during the day, during the night the ab- 
domen and extremities are usually dry 
and hot, at the time when the head, face, 
and neck are bathed in perspiration. 
(b) The second symptom recorded by 
Sir W. Jenner as specially indicating the 
general derangement which is the precur- 
sor of the rickety deformity of the bones, 
is the desire and the efforts made by the little 
patient to be cool, particularly at night. 
The child kicks the bed-clothes off, or 
throws its naked legs on the counter-pane. 
"He is always catching cold, because he SYMPTOMS. 
477 
will lie without any clothes at night," is 
the constant language of the mother in 
such cases. Sir W. Jenner says he has 
often gone into the wards of the Hospital 
for Sick Children, after the children have 
been some time asleep, and seen the rick- 
ety ones lying exposed; he has been 
assured by the nurses that they had put 
the bed-clothes over them again and 
again, to but little purpose; 'and this 
even in cold weather, when the other 
children were well covered. "During 
this restlessness at night the little patient 
may be seen frequently to bore its head 
into the pillow, or to rub the back of the 
head on the place where it rests. When 
it wakes in the morning, it will cry if the 
occiput is pressed, or when the head is 
lifted up and washed. If the head is 
examined it will generally be found more 
or less denuded of hair. The whole skull 
feels thinner than usual, as if distended 
like a bladder, or it is flattened behind, 
at the vertex, and protuberant in front." 
The cranial bones may now be found 
"very soft in certain points, yielding 
elastically, like card-board, beneath pres- 
sure, and giving the feeling as if the skull 
might be bent upwards by the finger- 
points upon the brain." (Wiltshire.) 
This rachitic softening of the cranium has 
been now shown to be extremely com- 
mon ; and, in extreme Rickets, is gene- 
rally the first manifestation of the disease, 
so far as the bones are concerned. (El- 
saser, Widtman, Wiltshire.) 
(c) The third characteristic symptom 
referred to by Sir W. Jenner is general 
tenderness. " The child cannot be moved 
without its uttering a cry; pressure on 
any part of its body is followed by like 
evidence of suffering." "He is tender 
all over," says the mother; or, "I can't 
think what has come to the child ; if I do 
but touch him he cries." The condition 
contrasts most forcibly with that of a 
child in health. "A child in health," 
says Sir W. Jenner, " delights in move- 
ments of every kind. It joys to exercise 
every muscle. Strip a child of a few 
months old, and see how it throws its 
limbs in every direction ; it will raise its 
head from the place on which it lies, coil 
itself round, and grasping a foot with both 
hands thrust it into its mouth as far as 
possible, as though the great object of its 
existence at that moment were to turn 
itself inside out. The child suffering 
severely from the general cachexia which 
precedes and accompanies the progressive 
stages of the bone-disease in Rickets, 
ceases its gambols, it lies with outstretch- 
ed limbs as quietly as possible, for volun- 
tary movements produce pain. ' ' But not 
only is the child unwilling to be moved, 
it is often in terror lest it may be moved, 
and it will cry at the approach of those 
who have been accustomed to dance it, 
and whose presence was wont to afford 
the child extreme pleasure. (Stiebel, Jen- 
ner.) 
Dr. Copland, however, would be still 
more convinced if a series of symptoms 
which may be regarded as a fourth set of 
pathognomonic signs of Rickets, were su- 
peradded to the three characteristic sets 
of phenomena just described. 
When with the phenomena already men- 
tioned, the urine is more abundant than 
in health, and when it deposits a copious 
calcareous sediment, or abounds in the 
phosphates, then the early or precursory 
stage of the complaint may be considered 
as already present; and it is in this stage 
especially that the salts are most abun- 
dant in the urine. 
As the disease progresses, the general 
appearance of the child becomes more and 
more significant of the disease. It ac- 
quires a peculiarly staid, steady, or sedate 
aspect. Its natural lively expression is 
replaced by one of languor, of pensiveness, 
and of age. Its face grows broad and 
square ; and when the child is placed up- 
right on its mother's arm, it sits (as she 
says) "all of aheap." Its spine bends, 
and its muscles are too weak to keep it 
erect. The head thus comes to sink be- 
tween the shoulders, and the face turns a 
little upwards. These symptoms, which 
Sir W. Jenner has so carefully and mi- 
nutely detailed, as a painting from the 
life, are so very rarely correctly inter- 
preted, and their significance so little ap- 
preciated, that he has subjoined the fol- 
lowing case in illustration of the charac- 
teristics of this remarkable disease :- 
"A. V., aged 3|, a male. His present 
ailment commenced about four months 
since, shortly after a ' severe cold on the 
chest, ' with the following symptoms :- 
heat of skin, especially at night; thirst; 
loss of appetite ; profuse sweating about 
the head; extreme tenderness of the whole 
body, so that he could not be touched 
without crying from the pain it caused 
him ; relaxed bowels, the stools being, to 
use the mother's own words, ' stinking, ' 
a ' rotteny smell;' a desire to lie exposed 
at night-again to use the mother's words, 
' even in that bitter cold weather he would 
never lie covered over ; in the previous 
winter he liked to lie warm. ' Although 
he had long run alone, he was soon ' taken 
off his legs.' " 
Present State.-" Rather thin ; muscles 
very flabby ; evident tenderness of head, 
trunk, and extremities. The muscles 
seem to partake of the tenderness, and the 
abdominal muscles are as tender as those 
of the thighs. Sits in his chair, unwilling 
to move from morning to night. Cries if 
his brothers or sisters approach him. 
Feverish at night; throws his clothes off; 
sweats over the head profusely ; the per- 
spiration is limited to the head ; appetite 478 
RICKETS. 
very small; bowels act once a day, but 
stools very offensive. Intellect decidedly 
less acute than that of his brothers and 
sisters was at the same age. Head large, 
square. He cut all his teeth long before 
his illness commenced. Spine curved 
backwards from about the first dorsal ver- 
tebra to the sacrum, and forward from 
first to last cervical vertebrae. Ribs very 
soft, so that there is great recession of 
each rib where it joins the costal cartilage 
at each inspiration. Physical signs of 
trifling catarrh. Very little enlargement 
of the ends of the long bones. No en- 
largement of glands, liver, or spleen." 
(Med. Times and Gazette, April 28,1860, 
p. 416.) 
The next set of phenomena which chal- 
lenge attention in cases of Rickets are 
those which are associated with the char- 
acteristic deformity of the skeleton, when 
the consequences of the bone disease are 
superadded to the general derangement of 
the system. If the general ill-health be 
severe enough to attract the notice of 
parents, it will not seem to have lasted 
long before the deformities of the bones 
begin to show themselves; and if the 
general ill-health be very much expressed, 
the softening of the bones will be so great 
as to render the deformities more remark- 
able than the mere enlargement of the 
ends of the long bones-usually so charac- 
teristic an appearance ; and the younger 
the child the softer usually are the bones. 
With increasing pallor of the skin and 
flabbiness of the muscles, the extremities 
of the long bones (such as those of the 
ankles and wrists, and the sternal ends of 
the ribs) indicate, by a swollen and 
knobby, or double-jointed appearance, 
that the lesions of the skeleton are ad- 
vancing so as to cause the deformities 
characteristic of Rickets. The lowermost 
ends of the long bones then begin to yield, 
especially those of the lower limbs; and 
hence, if the child has been able to walk, 
it can no longer do so. The bones gradu- 
ally change their form. Those of the 
lower extremity become bent, so that the 
convexity of the curvature is forwards and 
outwards, and, of course, the concavity 
inwards and backwards. The femora are 
sometimes curved forwards, so that the 
convexity is forwards; and this forward 
curvature is produced before the child 
walks, simply by the weight of the legs 
and feet-the lower portion of the limbs 
hanging pendent from the knee-joint, as 
the child sits in its mother's lap or on a 
chair. The soft femur then yields, so that 
it is curved forwards. After the child 
walks, the weight of its body mainly de- 
termines the curvature of the thigh-bones; 
the curvature is then apt to be mainly 
outwards, and the curve which existed 
before walking will be exaggerated. In 
some cases the heads of the femora will 
be bent at an obtuse or acute angle to the 
shaft. More often, therefore, like the 
tibiee, they are curved so that the con- 
vexity is forwards and outwards. When 
the tibiee curve before the child walks, it 
is an exaggeration only of the normal 
curve of the tibiae in the young child, and 
is produced as the child sits cross-legged, 
leaning on to the floor or bed with the 
outer malleolus. The bones which, in 
health, seem to be the strongest, may 
be bent by the most trifling force ; and if 
this force is constantly applied, so will the 
bending and deformity become more and 
more apparent, and the direction of the 
curves will depend on circumstances which 
determine the point on which the chief 
amount of pressure is brought to bear. 
If the disease becomes developed during 
the later periods of childhood, the knees 
are then generally bent inwards, and the 
feet thrown outwards. The knees thus 
press against each other, and the child 
rests on the inner aspect of the foot ; but 
the continued curvature outwards of both 
femora and tibiae may cause the knees to 
be separated to an unnatural distance. 
The whole of the lower limbs then form 
irregular curvatures, with the convexities 
outwards, and generally greatest at or 
near the knees. (Copland.) 
The spine is so bent that the cervical 
anterior curve is increased. The face is 
thus directed upwards, and the head falls 
backwards ; and this deformity becomes 
the more strongly marked according as 
the muscular debility is the greater. When 
this muscular debility is extreme, the head 
is no longer supported. It therefore falls 
forwards or backwards as circumstances 
may determine-waggles about, in fact, 
not unlike a button loosely attached to a 
garment. 
There are two characteristic curvatures 
of the spine to be distinguished, accord- 
ing as the child is able or unable to walk. 
If the child is unable to walk, there is a 
posterior curvature of the spine, com- 
mencing at the first dorsal, and extend- 
ing to the last lumbar vertebra. If, on 
the contrary, the child is able to walk, 
then this posterior curvature is limited to 
the dorsal region, but is combined with 
an anterior curvature in the lumbar 
region. This posterior curvature in the 
child yet in arms is sometimes so extreme, 
that Sir W. Jenner has known it to be 
mistaken for angular curvature; and, as 
it may be so easily mistaken, he gives the 
following details as to how the curvature 
of Rickets may be distinguished from 
angular curvature:- 
"If a child be held by the upper part 
of its trunk, the weight of the lower 
limbs will usually remove the rickety 
curve, and it may certainly be straight- 
ened, if the nurse hold the child by the 
upper part of the trunk, and the phy- SYMPTOMS. 
479 
sician raises the lower limb with one 
hand, and at the same time places the 
other on the curved spine." (Medical 
Times, March 17, 1860.) 
These curvatures in Rickets are merely 
exaggerations of the natural curve of the 
spine, which always more or less exists 
when a child of three or four months old 
sits unsupported on the nurse's arm. 
Lateral curvatures, in the young child, 
are thus less common than those which 
are antero-posterior. Their direction in 
Rickets, however, is mainly determined 
by the position which may be accident- 
ally assumed by the child ; and, as Sir W. 
Jenner points out, if the child be carried 
constantly on the left arm, there is a dis- 
position to lateral curvature, and the con- 
vexity of the curve will be towards the 
left. Dr. Copland gives the result of his 
experience in favor of the curve of the 
spine being in general outwards ; but it is 
sometimes also lateral, outwards in the 
back or between the shoulders, where the 
curvature is also to one side, and to the 
opposite side in the lumbar region, where 
also there is sometimes a curvature in- 
wards. 
The curvatures of the spine, especially 
those outwards, are generally associated 
with a flattening of the ribs laterally. 
(Diet, of Medicine, vol. iii. p. 644.) The 
deformity entailed upon the thorax thus 
comes to be that which is of the greatest 
interest to the physician, because it is the 
one which is associated with the greatest 
distress and impediment to the functions 
of the heart and lungs. The back is flatten- 
ed, the ribs being at an acute angle where 
the dorsal and lateral regions unite. Be- 
neath each axilla there is a large con- 
cavity or hollow, instead of the normal 
rounded form. At this part the lateral 
diameter of the thorax is the greatest, 
and the ribs pass forwards and inwards 
from their angles to the points where 
they unite with their cartilages, so that 
on the line of junction of the ribs with 
their cartilages the lateral diameter of the 
thorax is the least; the cartilages curv- 
ing outwards before turning in to unite 
themselves with the sternum. The ster- 
num is thus thrown forwards, and the 
antero-posterior diameter of the thorax 
comes to be abnormally great; the sides 
of the chest are compressed, the dorsal 
spine pushed outwards (backwards ?), and 
the sternum outwards (forwards ?); and 
the diameter of the chest from left to 
right being thus diminished, while the 
antero-posterior diameter is increased, the 
deformity known as "pigeon breast" is 
formed. (Jenner, Copland.) The gen- 
eral aspect of the thorax is also otherwise 
changed, so that grooves are formed on 
each side of the sternum, where the ribs 
and cartilages unite. These grooves (as 
Sir W. Jenner describes them) pass from 
above downwards, on the antero-lateral 
aspect of the chest, and extend from the 
first to the ninth or tenth rib ; and the 
deepest part of the furrow is just outside 
the knobs which are formed where the 
ribs and cartilages unite. The furrow 
extends further down on the left than on 
the right side ; but it is deeper over the 
fifth and sixth ribs on the right than on 
the left side ; the heart and the liver re- 
spectively supporting, to some extent, 
their corresponding ribs. The points of 
maximum recession correspond to the 
fifth, sixth, and seventh ribs. The chest 
expands again considerably a little below 
the level of the nipple, the chest walls 
being borne outwards by the liver, stom- 
ach. and spleen. At each descent of the 
diaphragm during the act of inspiration, 
the ribs recede where they are softest, at 
the part where ossification is deficient, 
and the furrows on the chest, described by 
Sir W. Jenner, are the consequence ; and, 
just in proportion as the ends of the ribs 
are forced inwards, so is the sternum car- 
ried outwards. It is also a characteristic 
sign of the deformity in the rickety thorax, 
as Sir W. Jenner has pointed out, that 
the line of recession corresponds to the 
upper margin of the liver, spleen, and 
stomach, these organs preventing reces- 
sion during the act of inspiration. The 
precordial region thus also apparently 
bulges, and the chest-walls covering the 
heart do not recede so much as on the 
opposite side. Therefore, the left side ap- 
pears much fuller than the right, and the 
precordial region appears abnormally full. 
(Jenner.) 
The curvatures of the humerus, clavi- 
cles, ulna, and radius, require some notice. 
Although the bones of the upper extrem- 
ity are said to be much less frequently 
curved than those of the lower, still the 
humerus is sometimes bent at an angle 
just where the deltoid is inserted; simply 
in consequence of the weight of the arms 
bending the softened bone when the limb 
is raised by the action of the deltoid. 
The curvature of the humerus is still 
further increased by the efforts which the 
child makes to support itself by the aid 
of its arms while it sits. It rests on the 
open palms of its hands, and thus throws 
a large share of its weight off the trunk 
on to the bones of the arm and the fore- 
arm. Thus also the radius and ulna 
come to be twisted by pronation of the 
palms as well as curved outwards. 
After the bones of the lower extrem- 
ities, the clavicles are the bones next fre- 
quently deformed. They are the subject 
of extreme angular curvature, mainly at 
two places. The greater curvature is 
always at the spot just outside the part 
where the sterno-deidomastoideus and the 
pedoralis major muscles are attached. 
The lesser curvature is about half an inch 480 
RICKETS. 
from the acromio-clavicular articulation. 
The first curve is forwards and somewhat 
upwards ; the second curve is backwards. 
These curves are produced partly by the 
weight of the arms on the humeral end of 
the clavicle-the sternal end being sup- 
ported by the muscles just mentioned, 
and by its ligaments. But the main 
agent in effecting the curves of the clavi- 
cle is the force which bears upon it when 
the weight of the trunk is thrown on the 
upper extremities, as the child sits with 
the palms of its hands resting on the 
ground ; or as it crawls about on the floor. 
(Jenner.) Many of these deformities are 
thus traceable to the manner of carrying 
or placing the child, or to the weight of 
its body, acting on different parts of the 
softened skeleton, when the child at- 
tempts to stand, walk, or sit, or when it 
crawls about on its hands and knees. 
Some deformities, again, like those of the 
thorax, are mainly influenced by the acts 
of respiration and atmospheric pressure, 
counterbalanced by the pressure outwards 
of the intra-thoracic and abdominal solid 
viscera. (Jenner.) 
The flat bones, like those of the head 
and the growth of the teeth, the scapula, 
and the pelvic bones, are also more or 
less affected, and give rise to character- 
istic deformity in Rickets. 
The deformities of the head in Rickets 
are thus distinguished by Sir W. Jen- 
ner :- 
" 1st. By the length of time the anterior 
fontanelle remains open. In the healthy 
child, it closes completely before the ex- 
piration of the second year. In the rick- 
ety child, it is often widely open at that 
period. 
" 2d. By thickening of the bones. This 
is usually most perceptible just outside the 
sutures-the situation of the sutures being 
indicated by deep furrows. 
"3d. By the relative length of the 
antero-posterior diameter of the head. 
"4th. By the height, squareness, and 
projection of the forehead. 
" The first two of these peculiarities of 
the rickety head are the result of the 
affection of the bones: the last two are 
due chiefly to disease of the cerebrum." 
As a whole, the head of the child in 
Rickets is generally unusually large, the 
vertex flattened, and the forehead promi- 
nent, broad, and square, with considerable 
expansion at the centres of the parietal 
bones. The sutures also are sometimes 
expanded, or they remain open. Th 
forehead, however, seems to project more 
than it really does, in consequence of the 
arrest of growth of the bones of the face 
and expansion of the frontal sinuses or of 
the nasal and ethmoidal cavities. The 
bones of the upper jaw, and the malar 
bones, are also arrested in their growth, 
while the under jaw appears elongated. 
The process of dentition is invariably 
arrested or delayed in rickety children; 
and if the teeth have formed, they soon 
decay ; or they early fall from their sock- 
ets. Sir W. Jenner has seen the incisor 
teeth fall from the jaws before the second 
molars of the first set had made their way 
through the gums. So important is the 
knowledge to be got from the progress of 
dentition, that Sir W. Jenner lays down 
the following rule of practice, namely :- 
"If a child pass over the ninth month 
without teeth, you should carefully in- 
quire for the cause. It may be that an 
acute illness has retarded dentition. It 
may be (but this is very rare) that there 
is some condition of the gum which inter- 
feres with the advance of the teeth. It 
may be (and this is infinitely the most 
common cause of late dentition) that the 
child is rickety ; fail not then, when called 
to a child in whom the teeth are late in 
appearing, to look if it be rickety, for if 
you do fail to look for Rickets, you will 
most likely attribute to the irritation of 
teething symptoms which are the conse- 
quence of the rickety diathesis-the late 
dentition in Rickets being in itself merely 
a symptom of the general disorder. The 
rickety deformities may be very trifling, 
and yet the teeth considerably retarded 
in their development." (Medical Times 
and Gazette, April 7, I860.) 
The scapulae are in a few instances so 
deformed as to embarrass more or less the 
movements of the shoulder. (Copland.) 
With regard to the pelvis, its form 
varies in rickety children according to the 
direction in which its component bones 
are compressed by the spine and superin- 
cumbent parts on the one side, and the 
heads of the thigh bones on the other. 
The direction of the forces which are thus 
constantly influencing the form of the 
pelvis and shape of its component bones, 
vary as the child is the greater part of its 
time lying, sitting, crawling on all-fours, 
walking, or shuffling along on the floor. 
On the other hand, the form of the pelvis 
varies also according to the age of the 
child when the compressing forces are 
brought to bear on the walls of the pelvis, 
and the consequent differences in the de- 
gree of ossification of the pelvic bones- 
the cartilages being less yielding than the 
bones. The rickety pelvis is therefore 
extremely variable as to shape, and is 
much more frequently triangular than 
oval. (Jenner.) 
Next to the deformity of the thorax, 
that of the pelvis comes to be of the great- 
est practical importance, especially in the 
after-life of the female, relative to the 
functions of generation. 
The sacrum and pubis may be carried 
either backwards or forwards; the ilia 
may be directed inwards, or otherwise 
altered; the lower nart of the sacrum may SYMPTOMS. 
481 
be pushed upwards ; and the outlet of the 
pelvis may thus be variously altered in 
form, and diminished in its diameters. 
The progress of deformity, in relation 
to the order in which the individual bones 
are affected, has been attempted to be 
laid down by Guerin ; but when it is un- 
derstood that Rickets is a constitutional 
disease, and therefore one affecting the 
whole system generally, it will readily be 
seen that the bones are affected as one 
organ, and are variously deformed accord- 
ing to the predominating influence of the 
circumstances already mentioned. No 
one bone, therefore, is ever affected with- 
out all of them suffering ; and the deform- 
ities may manifest themselves by enlarge- 
ment of the ends of the bones, or by 
softening of the bones, or both, in a vari- 
able degree. If a child is the subject of 
Rickets before it walks, the ribs, clavi- 
cles, and upper extremities become de- 
formed ; while the tibiae escape bowing, 
unless the child sits so as to press upon 
them. (Jenner.) 
In a child suffering from Rickets, the 
large size of the wrists is generally the 
first deformity which attracts attention. 
The costal ends of the ribs, the malleoli 
at the ankles, the olecranon process of the 
tilna, and the ends of the long bones gen- 
erally, are all similarly enlarged. This 
enlargement of the ends of the bones, and 
the softening, however, do not progress 
in an equal degree, either condition being 
often out of proportion to the severity or 
progress of the other; and Sir W. Jenner 
has also observed, that it is not uncom- 
mon to see the thoracic deformity lessen 
at the time the legs are bending-a cir- 
cumstance which he considers due to the 
disease having greatly diminished, and 
the muscular power having increased, so 
as to permit of the child walking before 
the bones of the leg are strong enough to 
bear the weight of the body. (Med. Times, 
April 7, I860.) 
The extreme deformity which results 
from Rickets is not only very common 
among the poor, but it is not so uncommon 
as has been supposed among the rich. 
(Jenner.) "All degrees of softening of 
the bones may be seen, from that in which 
the ribs only yield to extraordinary forces 
(as during bronchitis, and then only suffi- 
ciently to flatten the antero-lateral aspect 
of the chest), to that in which the ribs 
yield at every inspiration; all degrees of 
enlargement of the ends of the ribs and of 
the long bones-from that where one might 
maintain that the enlargement was only 
that proper to the child, to that in which 
the projections on the anterior wall of the 
thorax and the enlargement of the wrist 
would strike the most careless observer." 
(Jenner, loc. cit.) The consequences of 
the bone-disease are often attended with 
extreme distress to the child, and are thus 
described in the eloquent word-painting 
of Sir W. Jenner: " It is strange to see a 
little cliild sitting placidly on the bed, 
without moving for hours together-its 
legs placed so as to escape pressure, its 
spine bowed, its head thrown backward, 
the chief weight of its body cast on its 
arms; and to know that, notwithstanding 
the apparent calm, the tiny thing is in- 
deed fighting the battle of life: for it is 
striving with all the energy it has to keep 
in constant action every one of its muscles 
of inspiration-endeavoring so to supply 
the mechanical defects of its respiratory 
apparatus, due to the softening of the 
ribs. It wants no toys. It is the best of 
children if you only leave it alone ; move 
it, and you inflict pain on its tender 
frame ; show it the horse or the doll that 
was once its delight, and it turns away its 
head or stares vacantly: to notice would 
divert its attention too much from the 
performance of those respiratory move- 
ments which are essential to its exist- 
ence." (Med. Times and Gazette, 1860, 
p. 416.) 
Amongst the phenomena which are sig- 
nificant of Rickets, the condition of the 
intellect has been generally described as 
precocious. Both Copland and Jenner, 
however, agree that such is not always 
the case. On the contrary, the child con- 
tinues dull, taciturn, or stupid, or even 
idiotic; and, in children who are the sub- 
jects of extreme Rickets, intellectual ca- 
pacity and power are always deficient; 
and the mental, like the muscular power, 
retrogrades as the constitutional ill health 
of Rickets continues to progress. The 
error regarding precocity of intellect is 
variously explained away. Thus, on the 
one hand, it has been believed that the 
openness of the sutures-by allowing the 
circulation within the cranium, and the 
development of the brain, to advance un- 
impeded, and even at an increased rate- 
has permitted the faculties of the mind to 
expand unduly, whilst on the other hand, 
the closing of the sutures, and the conse- 
quent unyielding state of the cranial 
bones, has been thought to confine and 
embarrass the growth and functions of 
the brain, and so occasion deficiency of 
the intellect rather than precocity. But 
again, according to the experience of Dr. 
Copland, precocity of intellect has not 
always been found to exist in Rickets in 
connection with openness of the sutures, 
nor has stupidity been concurrent with 
their closure. Sir W. Jenner's explana- 
tion is, perhaps, the more satisfactory. 
Speaking generally, he believes that the 
mother's opinion must be well weighed 
before it is received as correct. She is apt 
to believe her child is very clever-quite a 
prodigy-when it is only a few degrees 
removed from an idiot. "The rickety 
child, separated, in consequence of its 
VOL. I.-31 482 
RICKETS. 
physical defects, from other children, and 
thrown necessarily much into the society 
of adults, catches their tricks of expres- 
sion, their phrases, and even perhaps 
some of their ideas: and hence it is 
thought, by the mother especially, to 
have a larger intellect than other chil- 
dren." (Med. Times and Gazette, loc. 
cit.) 
General Symptoms of Rickets during the 
Progress of the Bone Deformity. - The 
morbid conditions which existed during 
the developmental stage of the disease 
continue throughout the period when the 
bones soften and the body becomes de- 
formed. The abdomen continues tumid, 
sometimes increases in size, and is often 
tympanitic. Emaciation progresses ; the 
muscles of the limbs become flabby; they 
lose their power; they waste and diminish 
in bulk and volume. This loss of power, 
however, is infinitely greater than can be 
accounted for by the mere diminution in 
the size of the muscles. In proof of this 
Sir W. Jenner instances the case of a girl, 
six years of age, who was brought to the 
Hospital for Sick Children, in whom the 
loss of muscular power was so extreme, 
that she was not only unable to stand, but 
even unable to support herself in the least 
possible degree. She lay across the arms 
of the person who carried her like a large 
half-stuffed rag doll. When placed in bed, 
she was incapable of changing her posi- 
tion without assistance; nay, she could 
not raise her arm an inch from the bed. 
Even long aftewards, when greatly im- 
proved, she could not feed herself, and 
had to be tied in a chair with her head 
placed on a pillow at its back. If her 
head fell forward, the nurse had to raise 
it; for, unaided, she could not lift her 
chin from her breast. This child recov- 
ered so much as to walk about without 
assistance; but after her return home she 
unfortunately fell down stairs and was 
killed by the fall. (Med. Times and Ga- 
zette, 1809, vol. i. p. 41G.) Although such 
is an extreme instance of muscular de- 
bility during the acute sta^e of Rickets, 
yet it is very common, as Sir W. Jenner 
observes, to see children of two, three, or 
even four years of age, who are quite un- 
able to support themselves in an erect po- 
sition ; and if a child has commenced to 
walk before it has become the subject of 
extreme Rickets, it loses the power of 
walking. The child continues to become 
more and more languid and weak. The 
perspirations continue free, and are read- 
ily excited to increased flow on the least 
attempt merely at exertion. The thirst 
increases; and although the appetite is 
often good, the bowels are deranged, ir- 
regular, and the stools are often loose, 
pale or white, and devoid of healthy bile. 
They arc fetid, and the food is often 
passed as it is eaten. The pulse becomes 
quick, small, and weak, so that slight hec- 
tic symptoms are developed, and pains 
are complained of in all the bones and 
joints. There is complete cessation of 
growth, particularly of the bones. Sick- 
ness and emaciation increase, and the 
child appears to sutler pains except when 
lying on the back quite still. This stage 
of softening of the bones and progressive 
deformity may last for two or three 
months; and under unfavorable circum- 
stances, when the disease is neglected, it 
may continue for years, the deformity 
slowly increasing or remaining in abey- 
ance. 
The fourth class of phenomena which 
may be recognized in the history of cases 
of Rickets embraces symptoms which may 
be of favorable or of unfavorable import. 
They are phenomena which characterize 
a period of restoration to health, of irre- 
mediable atrophy, or of approaching dis- 
solution. 
During this period various intcrcurrent 
affections are apt to supervene when the 
disease does not tend towards recovery. 
Under such circumstances emaciation 
progresses, the abdomen becomes more 
distended and tumid, and the bowels 
more disordered. The softening and de- 
formity of the bones continue to increase, 
and eventually some visceral affection of 
the thorax or of the abdomen, or of both, 
terminates existence. Death occurs in 
Rickets mainly under one or more of the 
following conditions:- 
(1) Intensity of the general cachexia, 
which, however, rarely proves fatal di- 
rectly, death being in general due to one 
or more of the following morbid states :- 
(2) Catarrh, with general congestion of 
the lungs, general bronchitis, or effusion 
into the pleura. Mechanical difficulties 
to respiration contribute greatly to the 
danger of death from these affections. 
"The softening of the ribs renders the 
mechanical power by which inspiration is 
performed so defective, that the impedi- 
ment offered to the entrance of air by the 
mucus in the bronchial tubes cannot be 
overcome, and collapse of large portions of 
the lungs follows. " (Jenner.) 
(3) Gastro-intestinal irritation, enlarge- 
ment of the mesenteric glands of the 
spleen and of the lymphatic glands. The 
enlargement of these glands is generally 
the result of albuminoid (amyloid ?) infil- 
tration or degeneration ; and the cachexia 
which is most significant of these affec- 
tions is characterized by extreme emacia- 
tion and pallor of the surface of the body. 
Ansemia is extreme. Serum is often ef- 
fused into the subcutaneous areolar tissue, 
and the surface of the skin has that "pe- 
culiar transparent, waxy, greenish-yellow 
tint which is sometimes seen in the anre- 
mia of young women." Sometimes under 
these circumstances there is general ana- SYMPTOMS. 
483 
sarca-the face as well as the extremities, 
the hands as well as the feet, being cede- 
matous. The deformity of the bones in 
such cases may be either extreme or but 
very moderately expressed, and may, ac- 
cording to the experience of Sir W. Jen- 
ner, either precede or follow the infiltra- 
tion of the organs. The lymphatic glands, 
when so affected, vary from a small size 
to the size of a pea, are not tender, and 
never inflamed. They may be felt in the 
groins, in the axilla, and in the neck, roll- 
ing under the finger, and free from adhe- 
sions to the surrounding tissue. They are 
hard to the touch, and of a globate form. 
The spleen is usually at the same time, 
with the glands, the seat of albuminoid 
infiltration. As its enlargement, according 
to the experience of Sir W. Jenner, is 
often overlooked, he has given the follow- 
ing directions for the examination of chil- 
dren in all obscure cases of this descrip- 
tion :-"In every obscure case of early 
childhood the absence of enlargement of 
the spleen should be established. If we 
place the fingers of the right hand directly 
under the left twelfth rib, just outside the 
mass of the lumbar muscles, and the fin- 
gers of the left hand a little to the left of 
the middle line, in front and half-way be- 
tween the umbilicus and the ensiform car- 
tilage, and then press the parts forward 
with the right hand, and backwards and 
to the left with the left hand-the en- 
larged spleen may always be readily felt 
in the left hypochondriac region. We 
know the hard mass we feel to be the 
spleen, by the sharpness of its anterior 
margin, by the anterior margin passing 
from under the cartilage of the eighth, 
ninth, or tenth ribs obliquely downwards 
and inwards towards the median line. 
The obliquity of this line is such that 
usually, if continued downwards, it would 
cross the median line about half-way be- 
tween the umbilicus and the symphysis 
pubis; the anterior edge is usually nearer 
the middle line in front in the child than 
it is in the adult, because in the child 
there is a fold of peritoneum, not usually, 
if at all, described in English books on 
anatomy, extending from the left side of 
the arch of the colon to the left twelfth 
rib, and over the anterior edge of this the 
spleen must pass before it can extend low 
enough to be detected by the hand. This 
fold of peritoneum causes the enlarged 
spleen to lie more forward, as well as to 
have a more oblique position, in the child 
than in the adult." 
The enlarged spleen is still further dis- 
tinguished by its movability: "If the en- 
largement be great, and the parietes of 
the abdomen be thin, the notch in the an- 
terior margin can often be felt." Sir W. 
Jenner says that the liver is seldom so 
greatly enlarged but its edge feels harder 
and sharper to the touch than natural. 
In all these respects the liver and spleen 
correspond in their characters to what be- 
longs to the amyloid degeneration of these 
organs; and, as in that degeneration also, 
the number of the white corpuscles in the 
blood is not increased. 
(4) Sir W. Jenner has specially called 
attention to the connection of laryngismus 
stridulus with Rickets; and that while it 
is an affection so constantly referred to the 
irritation of teething, it ought rather to be 
regarded as one expression of the consti- 
tutional disease now under consideration. 
In every case of laryngismus stridulus (save 
two) which has come within the experi- 
ence of Sir W. Jenner, the child was the 
subject of Rickets. Dr. Wiltshire, also, 
in his account of "some cerebral affections 
of children," says that he has had abun- 
dant evidence of Rickets in cases of cranio- 
tabes; and that in such cases tetaniform 
convulsions were easily propagated to the 
respiratory muscles, giving rise to the dis- 
order frequently known under the names 
of thymic or laryngeal asthma. Dr. Wilt- 
shire also examined the body of a child 
who, at the age of six months, died of 
general convulsions following laryngismus 
stridulus. Cranio-tabes was diagnosed, and 
Dr. Wiltshire was able to cut off the cal- 
varium with a small pair of scissors as 
easily as he could cut cardboard. The 
long bones could be bent like soft wax, 
and the bones of the skull could be folded 
on themselves without breaking. From 
the soft and yielding state of the bones, 
the brain is liable to pressure and other 
irritation; hence- 
(5) Chronic hydrocephalus may super- 
vene and prove fatal. The effusion may 
be within the ventricles or between the 
membranes, and may, or may not, be 
associated with tubercles on the mem- 
branes of the brain. A form of acute 
hydrocephalus has been described as due 
to Rickets. (Portal and Naumann.) 
(6) Convulsions (eklampsia) may prove 
fatal, and nothing be found in the viscera, 
or within the cranium, to account for 
death. Hypertrophy of the brain is not 
uncommon; and it is often strikingly soft 
and anaemic. (Meric, Wiltshire.) 
(7) Persistent diarrhoea may cause 
death; and in such fatal cases it would 
be well to examine the mucous surface of 
the intestines as to whether or not it has 
undergone amyloid degeneration. When 
the case is prolonged, and becomes chronic, 
none of these intercurrent affections prov- 
ing fatal, the deformity continues with no 
abatement in the general symptoms ; but 
oftentimes the softness of the bones dimin- 
ishes, they lose their flexibility, become 
atrophied, and are readily broken. De- 
formity still progresses, recovery rarely 
takes place, the morbid state of the blood 484 
RICKETS. 
and the general cachexia increase, and 
death usually follows from some structural 
changes in the internal organs. 
Such are the phenomena of unfavorable 
import, and which characterize the pro- 
gressive stage of Rickets, terminating in 
an irremediable atrophy, or in death; but 
there is another set of phenomena which 
characterize a period of restoration, and 
which are of favorable import. 
Such favorable changes are mainly indi- 
cated by the condition of the excreta. 
"The urine assumes a more natural ap- 
pearance and composition; the stools are 
more healthy, and colored more deeply by 
bile ; the abdomen appears less tumid and 
less tympanitic; the pulse is less frequent, 
and pain in the limbs is not so much 
complained of. The countenance presents 
more animation, and the hectic or remit- 
tent febrile symptoms, and thirst, subside 
gradually. The appetite is less capricious, 
and more natural; and with the continu- 
ance of these changes, the flesh becomes 
firmer, and voluntary motion is made with 
greater activity. The growth of the limbs, 
which had been suspended till now, pro- 
ceeds with remarkable vigor; the bones 
are gradually restored ; and, if the de- 
formity is not very great, it disappears by 
degrees: the curvatures are either dimin- 
ished or altogether removed; the swell- 
ings of the epiphyses of the bones subside, 
and ossification proceeds with great rapid- 
ity-the affected bones acquiring greater 
density and strength than usual. The 
muscles also acquire a more powerful 
development, so that persons who have 
been rickety in childhood have afterwards 
become remarkable for strength." (Cop- 
land's Medical Dictionary, vol. iii. p. 645.) 
The Urine in Rickets.-The earthy phos- 
phates (constituents of bone) have been 
found in greatly increased amount, both 
by Lehmann and Beneke, in cases of 
Rickets-a phenomenon no doubt con- 
nected with the increased metamorphosis 
of bone. "It has not yet been shown, 
however," writes Dr. Parkes, "that this 
is universal, and Rickets may be connec- 
ted sometimes with simply deficient in- 
gress of the earthy salts without altered 
egress." The urine is commonly pale; 
and, according to Dr. Copland, the urea 
and uric acid are diminished, while the 
salts are increased. A free acid has been 
sometimes observed-said to be phosphoric 
-and a considerable sediment of oxalate 
of lime is not uncommon, while urinary 
calculi are frequent in rickety children. 
The increase in the fixed salts is most con- 
siderable during the advance in the first 
stage, and when the deformity begins to 
appear in the bones. It is less remarkable 
when the disease is far advanced, and 
when the softenings and flexures are the 
greatest. The phosphate of soda and the 
earthy phosphates are then most abundant. 
(Copland.) Lactic acid has also been 
found by Marchand, and by Gorup-Besa- 
nez, associated with lactates and a great 
excess of the earthy phosphates. An hy- 
pothesis has been raised on these observa- 
tions, namely, that "an undue amount of 
lactic acid in the body dissolves and carries 
out the earthy salts." In a case recorded 
by Mr. Solly (Medico-Chirurg. Trans., vol. 
xx. p. 448) three or four times the usual 
amount of phosphate of lime existed in the 
urine. (Parkes, Copland.) 
These phenomena have been described 
with reference to the extreme manifesta- 
tion of the disease, but far less intense 
forms of the constitutional affection and 
disease of the bones are frequently seen. 
Enlargement of the carpo-radial epiphyses 
and curvature of the tibia, are sometimes 
accompanied with so plump and fresh a 
condition of the child, that it is with great 
difficulty the parents can be induced to 
think there is anything amiss with it. 
(Wiltshire.) 
Diagnosis.-The constitutional mani- 
festations of Rickets are to be recognized 
as distinct from those of scrofulosis, tu- 
berculosis, or syphilis; although they 
have by some been all regarded as mere 
modifications of one and the same dis- 
ease. To determine whether similar 
maladies are identical, four things are 
essential to be known :-(1) a knowledge 
of causes ; (2) a knowledge of symptoms ; 
(3) a knowledge of the effects of remedies; 
(4) a knowledge of the morbid appearance 
of the diseases in question. On cempar- 
ing, therefore, the phenomena of Rickets 
in these respects with the corresponding 
phenomena in each of the diseases men- 
tioned, it will at once be seen how differ- 
ent Rickets is from either of those affec- 
tions. The general phenomena of each 
disease respectively are perfectly distinct 
from the phenomena of the others ; and 
the pathological tendencies of each are dis- 
similar. As shown also by the investiga- 
tionsofSir W. Jenner, the pathological ten- 
dencies of any one of these affections are 
rarely manifested by those who are the sub- 
ject of either of the others ; and although 
Rickets does not by any means exclude 
tubercle, yet it is absolutely unfavorable 
to tuberculization. Nevertheless, rickety 
children may be tubercular, just as syphi- 
litic children may be so. Tuberculosis, 
also, is well known to be hereditary ; but 
from what has been already stated under 
the causes of Rickets, it does not appear 
that Rickets is hereditary in the sense 
that phthisis is hereditary. The facts 
collected by Dr. Edwards and Sir W. 
Jenner point to the conclusion that, while 
more than forty per cent, of tuberculous 
children are born of phthisical parents, 
about nine per cent, only of rickety chil- 
dren come of phthisical parents. The PATHOLOGY. 
485 
converse, also, may take expression in the 
fact, that the children of phthisical pa- 
rents are not found to be especially prone 
to Rickets or to scrofulosis ; and although 
several members of one family may be the 
subjects either of Rickets, or of tubercu- 
losis, or of scrofulosis, it is comparatively 
rare for members of the same family to be 
the subjects of more than one of these 
constitutional affections. Lastly, as will 
appear from what has gone before, and 
from what is to follow, the cause, the 
prognosis, the pathology, the morbid an- 
atomy, and the treatment of each of these 
affections are different. (Jenner, Trous- 
seau, Merei.) Dr. Wiltshire, however, 
entertains a modified view, inasmuch as 
he regards Rickets and tuberculosis as 
two distinct forms, or local manifestations, 
of one general dyscrasia-namely, the 
scrofulous. (Med.-Chir. Rev., July, 1856, 
p. 75.) 
From what has been written, it may be 
conjectured that the diagnosis of Rickets 
in the precursory or incubative stage of 
its development will mainly lie between 
tuberculosis, especially of the lungs, the 
peritoneum, or of the brain, or cerebro- 
spinal membranes. A careful observation 
of symptoms of records of temperature, as 
contrasted with those given by Dr. Sidney 
Ringer1 relative to the recognition of tuber- 
culosis, will soon show whether or not the 
phenomena are similar to those described 
under the symptoms of Rickets. When the 
sternal extremities of the ribs begin to 
swell, and become rounded in a club- 
shaped form ; when the softened sternum 
begins to project more than it ought; when, 
with increasing pallor of the skin and in- 
creasing flabbiness of muscle, the carpal 
epiphyses of the radius and ulna become 
enlarged, and greatly so in proportion to 
the metacarpal epiphyses of the wrist 
bones, so as to give a "knotted" or 
"double-jointed" appearance; then the 
disease may be surely recognized. 
Osseous tuberculosis is distinguished 
from osseous Rachitis in the following re- 
spects :- 
The bones in both diseases are loaded 
with morbid blood; but the blood in 
Rickets differs from that in tuberculosis ; 
it is of a brown rather than of a bright- 
scarlet hue, and resembles chocolate rather 
than blood. 
The modifications in the form and di- 
rection of the bones are dependent upon 
the weight and pressure they have to sus- 
tain. 
The state of the bone is in a great mea- 
sure dependent upon a deficiency of earthy 
material, so that the bones are uniformly 
soft. 
The bones tend to produce regular 
curves, as in the spine and thigh-bones ; 
and the pelvis becomes peculiarly distort- 
ed. The heads and necks of the thigh- 
bones become depressed. The joints be- 
come distorted from a yielding of their 
ligaments. These deformities of the bones 
and joints ascend progressively from the 
lower to the higher parts of the skeleton 
-the lower limbs first yielding to the 
superincumbent weight. (Stanley.) 
There are peculiarities also in the indi- 
vidual bones. They tend to form exosto- 
ses. The development and nutrition seem 
to be vitiated from a peculiar cause in Ra- 
chitis, different from that in tuberculosis. 
Rachitis and tuberculosis are rarely as- 
sociated ; and tubercle is less frequently 
found in children who have died from 
Rickets, than in those who have died from 
other diseases. (Ancel on Tuberculosis, 
pp. 31, 32.) 
A diagnosis is also to be established 
between the true Rickets and that soften- 
ing of the bones in adults to which the 
name of osteomalacia, or mollities ossium, 
has been given. In true Rickets, if the 
patient survives, re-ossification or hard- 
ening of the bones is certain to take place; 
but osteomalacia is never followed by 
re-ossification. It rather induces fatty 
degeneration of the bones (never seen in 
Rickets), and irresistibly progresses to a 
fatal termination. (Vogel.) 
Pathology.-The history of the de- 
velopment of Rickets is the history of the 
development of a constitutional disease. 
Such a disease becomes developed under 
the influence of agencies within the body 
itself, and acting through the continuous 
exercise of its functions. The disease is 
thus inbred; the constitutional or the ori- 
ginal organization 'of the child being of 
such a kind that the continued exercise 
of its functions, in place of preserving the 
growth and development of the body in a 
healthy state, becomes associated, in the 
first instance, with slight deviations from 
the standard of health, and ultimately 
leads to well-marked diseases, often of so 
fixed a character and so strongly express- 
ed, that the local lesions have sometimes 
been looked upon as the real disease. 
Hence Rickets has so frequently been 
classed among diseases of the bones, and 
described with reference to softening of 
the bones only and alone, which is a mere 
expression (and only one expression) of a 
general morbid state which implicates the 
whole system and constitution of the body. 
To classify Rickets with diseases of bones 
is therefore a mistake ; for, as Sir W. Jen- 
ner has well observed, "Rickets is no 
more a disease of the bones, than is ty- 
phoid fever a disease of the intestines. 
Rickets leads to disease of the bones in 
the same way that typhoid fever leads to 
1 See ' ' On the Temperature of the Body 
as a Means of Diagnosis in Phthisis and Tu- 
berculosis," by Sidney Ringer, M.D., 1865. 486 
RICKETS 
disease of Peyer's patches." The phe- 
nomena therefore which characterize the 
condition of Rickets are of such a kind 
that they are an expression of the un- 
healthy state of the system, which pre- 
exists the development of the local lesions; 
and a cachectic state, a " bad habit of 
body," is invariably associated with the 
development of the disease. The change 
in the bones is a mere expression, and 
only one of many anatomical signs or 
characters of Rickets ; just as the changes 
in the joints or white tissues are mere 
expressions of rheumatism, each of which 
may be regarded as so many anatomical 
signs or lesions developed under the influ- 
ence of the constitutional disease. 
The lesions characteristic of Rickets are 
rarely limited to one part or system ; and 
before death ensues, or even before the 
constitutional disease abates, several or- 
gans, systems, or tissues become diseased 
or degenerated. 
In all the constitutional diseases of chil- 
dren (as well as of adults), the seats of 
such lesions or structural change are char- 
acteristic of the particular constitutional 
affection; while, for a long time before 
local lesions of structure are expressed, 
various forms of ill-health denote the con- 
stitutional affection. 
There are several well-marked diseases 
of childhood which are thus constitution- 
ally developed ; namely, Rickets, tubercu- 
losis, scrofulosis, and inherited or congenital 
syphilis. 
Each of these constitutional diseases is 
characterized by certain premonitory phe- 
nomena which, taken singly, may not jus- 
tify suspicion, but which, when considered 
collectively, yield presumptive or circum- 
stantial evidence that certain constitu- 
tional phenomena will terminate in the 
characteristic lesions of structure in sys- 
tems or organs of the body, which are pe- 
culiar to each of these diseases. 
The deviations from the standard of 
health in each case may be so slight, that 
it may not seem to merit the name of a 
disease; but when these deviations are 
invariably succeeded by the expression of 
certain well-marked pathological tenden- 
cies, the relation of such slight deviations 
from health to such local manifestations 
of disease can no longer be mistaken, ig- 
nored, or overlooked. 
For example, when the condition of the 
skin is such that it can merely be regarded 
as delicate, no definite diagnosis can be 
come to; but when we find it so often as- 
sociated with the growth of tubercle in 
certain parts, we cannot ignore the patho- 
logical connection between the slight de- 
viation from the standard of health expe- 
rienced by the delicate skin, and the 
morbid tendency of the constitution ex- 
pressed by the development of tubercle in 
certain organs. Again, when the com- 
plexion merely excites attention by the 
thickness and coarseness of the features, 
no definite diagnosis may be pronounced ; 
but when we know that such complexions 
are often associated with a peculiar form of 
ophthalmia, we cannot overlook the path- 
ological connection between the slight de- 
viation from health expressed in the com- 
plexion, and the morbid tendency of the 
constitution expressed by the ophthalmia 
of scrofulosis. 
Again, when the skin attracts attention 
from the mere muddiness of its tint, no 
definite diagnosis may be arrived at; but 
when it is seen that such muddy skins are 
frequently associated with characteristic 
lesions in the skin and mucous mem- 
branes, we cannot fail to connect in path- 
ological relationship the deviation from 
the standard of health expressed in the 
tint of the skin, and the morbid tendency 
of the constitution expressed by the lesions 
of the dermis and mucous membrane pe- 
culiar to syphilis. 
So also, when the muscular power of a 
child attracts attention from its feeble- 
ness merely, no definite diagnosis may be 
warrantable; but when such lowness or 
feebleness of the muscular power is fol- 
lowed by softness of the bones, the patho- 
logical relationship cannot be overlooked, 
which obtains between the slight devia- 
tion from health expressed by the feeble- 
ness of the muscular power, and the mor- 
bid tendency of the constitution expressed 
by the softened bones. 
The leading features of such typical 
pathological relationships as subsist be- 
tween slight deviations from the standard 
of health, and peculiar deviations from 
the healthy structure of particular organs, 
have been thus concisely expressed by Sir 
W. Jenner, in the following tables:- 487 
PATHOLOGY-MORBID ANATOMY. 
LEADING FEATURES IN TYPICAL CASES OF 
Tuberculosis. 
Nervous system highly developed; mind 
and body active; figure slim; adipose tissue 
small in quantity; organization generally 
delicate ; skin thin; complexion clear ; su- 
perficial veins distinct; blush ready; eyes 
bright; pupils large ; eyelashes long ; hair 
silken; face oval and good-looking ; ends of 
long bones small; shafts thin and rigid; 
limbs straight. 
Children, the subject of tuberculosis, usu- 
ally cut their teeth, run alone, and talk, 
_early. 
Leading pathological tendencies.-Fatty de- 
generation of liver and kidneys ; growth of 
tubercle, and consequences thereof; inflam- 
mation of serous membranes. 
Rickets. 
Mental capacity and power small; muscu- 
lar force deficient; mind and body inactive ; 
figure short; closure of the fontanelles re- 
tarded ; face small, but broad; skin opaque, 
often set with downy hairs. 
Children, the subject of Rickets, are late 
in cutting their teeth, in running alone, and 
their teeth drop early from their sockets. 
Leading pathological tendencies.-Softening 
of the bones ; enlargement of the ends of the 
long bones; thickening of the flat bones, and 
deformities consequent on these conditions 
of the bones; so-called hypertrophy of the 
white matter of the brain ; chronic hydroce- 
phalus ; pulmonary collapse; laryngismus 
stridulus ; convulsions ; albuminoid infiltra- 
tion of the liver, spleen, and lymphatic 
glands. 
Rickets, therefore, can no longer be re- 
garded merely as a local disease, charac- 
terized by a mere chemical abnormity of 
the bones-a mere deficiency of their 
earthy salts. Not only is there an insuffi- 
cient deposition of the lime-salts in the 
growing extremities of the long bones, but 
the amount which is deposited there is 
abnormally placed as regards the anato- 
mical constitution of bone. It is found 
in the cartilage cells, instead of in the 
matrix. And not only is there a deficiency 
of the lime-salts, and an abnormal posi- 
tion of those present; but if the bones 
were hard before the disease began, they 
begin to soften, in consequence of the 
absorption of the lime from the shafts of 
the long bones, and from the substance of 
the flat bones. The earthy matter in a 
soluble form enters the blood, and is ex- 
creted by the urine. Moreover, in Rickets 
the growth of bone is abnormal, irrespec- 
tive of the absence of lime ; and the agents 
concerned in the nutrition of the bones 
remove the lime from them, in place of 
taking it to them from the blood. (Jen- 
ner.) 
The excessive formation of acids in the 
stomach of the child has been assigned as 
SCROFULOSIS. 
Temperament phlegmatic; mind and body- 
lethargic ; figure heavy; skin thick and 
opaque; complexion dull, pasty-looking; 
upper lips and aloe of nose thick; nostrils 
expanded; face plain; lymphatic glands 
perceptible to touch ; abdomen full; ends of 
the long bones rather large ; shafts thick. 
Leading pathological tendencies.-Inflamma- 
tion of the mucous membranes of a peculiar 
kind; so-called strumous ophthalmia; in- 
flammation of the tarsi; catarrhal inflamma- 
tion of the mucous membrane of the nose, 
pharynx, bronchi, stomach, and intestines ; 
inflammation and suppuration of the lym- 
phatic glands on trifling irritation; obstinate 
diseases of the skin; caries of the bones. 
Syphilis. 
Adipose tissue small in quantity; muscles 
flabby; cutis rough, deficient in contractility; 
complexion muddy. 
Leading pathological tendencies.-Suppura- 
tive inflammation of the mucous membrane 
of the nose; ulceration of the mucous mem- 
brane of the nose and the lips, mouth, 
throat, and anus ; falling of the hair; erup- 
tions on the skin of peculiar character ; in- 
duration of the liver; suppuration of the 
thymus, lungs, &c. 
the mode in which the phenomena of 
Rickets are brought about. It has been 
supposed that a superabundance of acid 
thus finding its way into the blood, facili- 
tates the removal of the earthy salts from 
the bones ; and it is fully proven that in 
Rickets, as in most other constitutional 
diseases, a superabundance of free acid is 
constantly generated in the primce vice. 
The particular acid is the subject of vari- 
ous statements. Lactic acid (Marchand), 
oxalic acid (Beneke, Ure, Schmidt), phos- 
phoric acid (Weatherhead), and hydro- 
chloric add, have each in their turn been 
deemed the peccant agent in bringing 
about the characteristic lesion in Rickets. 
But all children who suffer from the gene- 
ration of free acid are by no means suffer- 
ers from Rickets. None of the acids have 
been demonstrated in the blood : and al- 
together, there are "no facts which re- 
move the theory from the category of pure 
hypothesis." The theory is also in oppo- 
sition to the fact that the lime is'deposited 
in abnormal situations. 
Morbid Anatomy.-A peculiar mor- 
bid condition of the bones is the anatomical 
sign of Rickets, just as the growth of tu- 488 
RICKETS. 
bercle is of tuberculosis, or as lesions of 
the kidney with anasarca are of Bright's 
disease, or as peculiar affections of the 
joints are of gout and of rheumatism. The 
most constant and striking anatomical 
lesions in Rickets are thus enumerated by 
Sir W. Jenner :- 
" (1) Enlargement of the ends of the 
long bones-of the parts where the bone 
and cartilage are in contact, i. e., where 
the cartilage is preparing for ossification, 
and where ossification is advancing in the 
cartilage. 
"(2) Softening of all the bones. 
" (3) Thickening of the flat bones, e. g., 
the bones of the skull, the scapulae [and 
the pelvic bones]. 
" (4) Deformities which follow as me- 
chanical causes acting on the softened 
bones, e. g., the deformities of the thorax, 
pelvis, spine, and long bones. 
" (5) Arrest of the growth, not only of 
the bones, but of all parts directly related 
anatomically and physiologically to the 
bones, i. c., of the muscles, vessels, nerves, 
and teeth. 
" (6) Certain lesions of the pericardium, 
lungs, and capsule of the spleen - the 
direct consequences of the thoracic de- 
formity. 
"(7) Less constant but highly import- 
ant changes, most commonly affecting the 
nutrition of the brain, spleen, liver, lym- 
phatic glands, and muscles, and now and 
then of every organ." 
The enlargement of the growing ends of 
the long bones is an actual hypertrophy. 
Sir W. Jenner has measured the circum- 
ference of several wrists, in rickety and 
non-rickety children, and he has found 
that, whether reference be made to the 
age, or to the height of the children, or to 
the length of the forearm, the circumfer- 
ence of the wrist was always greater in 
the rickety than in the non-rickety. The 
measurements of three children gave the 
following results:- 
Disease. 
Age. 
Height. 
Length of 
forearm. 
Circumference 
of wrists. 
Rickets 
4 years 
30 inches 
4| inches 
4f- inches 
Rickets 
3 years 2 months 
30 " 
4 " 
4j " 
Tuberculosis . . . 
3 years 
35 " 
5 " 
3f " 
Similar enlargements are found to exist 
at the costal ends of the ribs of the ankles, 
of the olecranon process of the ulna, and, 
generally, over the growing ends of all the 
long bones ; and the bones that are the 
most covered by soft parts suffer equally 
with those which are less covered, and 
therefore more exposed, although the late 
Mr. Stanley taught that actual expansion 
occurs only in those joints which are 
superficial. In the healthy child, the ends 
of the long bones always measure more in 
circumference than the shafts, for as the 
processes of ossification are completed, the 
bone diminishes in girth. 
The microscopical characteristics of the 
osseous substance in the bones of rickety 
children, have been investigated carefully 
by Kolliker, II. Meyer, Rokitansky, Vir- 
chow, and Jenner. 
With regard to ossification in Rickets, 
it has been found that the anatomical 
characters are peculiar in the following 
respects: (1) in the disproportionately 
large epiphysal cartilages, the larger of 
the ossifying cartilage cells (those disposed 
in rows) measuring, instead of half a line, 
as much as from two to five lines; (2) in 
the border of ossification being dentated, 
the cartilage and the bone severally inter- 
locking and interlacing with each other; 
(3) in well-marked rachitic bones, the de- 
position of calcareous granular particles 
at the border of ossification is wanting, 
and the cartilage cells or capsules are 
metamorphosed into bone cells almost in- 
variably shortly before the matrix begins 
to ossify, and are also without any appear- 
ance of calcareous granules. (Kblliker.) 
There is thus excessive formation or hy- 
pertrophy of the structures which precede 
or form the nidus for ossification, while 
there is at the same time retardation or 
incomplete performance of that process. 
It is, in fact, an exaggeration of the con- 
dition usually seen in the first stages of 
ossification in the healthy subject - the 
completion of the process only is stayed. 
There is thus excessive development of the 
spongy tissue of the head of the bone, and 
of the epiphysis, and of the layer of car- 
tilage in which the primary deposit of 
earthy matter takes place. (Jenner.) In 
the ossifying shaft of a rickety bone, Kbl- 
liker has observed that the bone cells are 
formed from the cartilage cells by the 
thickening of their wall, with the simulta- 
neous formation in it of canalicular vacui- 
ties. If the rows of cartilage cells of the 
large hypertrophied ossifying border be 
traced from without to within, it will be 
seen that at the point where the deposi- 
tion of calcareous salts commences, they 
exhibit, instead of a membrane indicated 
by a single tolerably strong line, a much 
thicker coat, which on the inner side pre- MORBID ANATOMY. 
489 
sents delicate indentations. Kblliker be- 
lieves that these cartilage cells are about to 
be transformed into bone cells or lacunje. 
This becomes all the more evident when, 
further on in the growth of the bone, the 
thickness of the membrane, together with 
the simultaneous diminution of the cavity 
of the cell, is seen to be constantly increas- 
ing ; the indentations of the interior con- 
tour line become more and more marked; 
and, accompanying the progress of these 
changes, the walls become more and more 
dark from the addition of calcareous mat- 
ter. The very slow ossification of the 
matrix between the cells, in Rickets, is 
favorable to the observation of these 
changes, and permits of the alterations in 
the cartilage cells, and their formation 
into bone-cells or lacunae, being seen, and 
traced step by step. Cartilage cells, in- 
closing secondary cells within them, are 
connected as a whole into a single com- 
pound bone-cell; and such cells are fre- 
quently met with having two cavities, 
which cells, according to their degree of 
development, are sometimes wide, and 
furnished with strong prolongations, and 
sometimes, from their contracted cavity 
and long canalicnli, resemble in all re- 
spects perfect bone lacunae. The cartilage 
cells lying free, and in close apposition, 
though in a now ossified matrix, thus be- 
come transformed into bone-cells, with 
nuclei and other contents; and so an ulti- 
mate change takes place by which the 
bone substance in Rickets acquires pretty 
nearly the nature of sound tissue. These 
ultimate changes, so far as they affect the 
bone-cells, depend, in the first place, upon 
the commencement of ossification in the 
matrix, but without any primary forma- 
tion of calcareous granules ; secondly, up- 
on the continuous and increasing deposi- 
tion of earthy matter in it, and in the 
thickened cell-walls, owing to which the 
new bone substance becomes more and 
more white to the naked eye. 
Kblliker's account of the lacunae forma- 
tion (of which he has given drawings) is 
supported by Rokitansky and Virchow. 
Virchow shows that the abnormity of the 
process of ossification in Rickets consists 
"not in a process of softening of the old 
bone, but in the non-solidification of the 
fresh layers of bone as they form; and 
that we see the process of growth better 
in rickety than in normal bones, because 
in the rickety bones the view is not ob- 
scured by the deposit of calcareous gran- 
ules. The old layers of bones are con- 
sumed by the normally progressive forma- 
tion of medullary cavities; and the new 
layers remaining soft, the bone becomes 
brittle. There is also a certain irregular- 
ity in the growth of the bone, so that 
stages in the development of bone which, 
when the formation is normal, ought to 
set in late, set in at a very early period in 
Rickets. In normal growth, for example, 
the pointed processes (in which shape the 
calcareous salts shoot up into the carti- 
lage) form, along the margin of calcifica- 
tion, such a completely straight line, that 
it should almost be described as mathe- 
matically regular. " This condition ceases 
to obtain in Rickets, and the more so the 
greater the severity of the case. Inter- 
ruptions occur in such a way that in some 
places the cartilage still reaches a long 
way down, whilst in others the calcifica- 
tion has mounted up to a considerable 
height. These uncalcified parts some- 
times become so completely separated 
from one another, that they remain form- 
ing specks of cartilage in the midst of the 
bone, and surrounded on all sides by it; 
and that cartilage is still found at points 
where the bone ought long since to have 
become transformed into medullary tissue. 
The further the process advances, the 
more do we meet with isolated masses of 
lime scattered in the cartilage ; in many 
instances to such a degree, that the whole 
of the cartilage on section appears dotted 
with white points. The irregularity of 
the process is further shown in this, that 
whilst in the normal course of things the 
medullary spaces should begin to form 
only at a short distance behind the margin 
of calcification, they exceed these limits 
in Rickets, and in many cases a series of 
connected cavities extends far beyond the 
border of calcification, which (cavities) 
are filled with a soft, slightly fibrous tis- 
sue, with vessels running up into them. 
Medullary spaces and vessels are there- 
fore met with where normally and prop- 
erly not a single medullary cell, and 
scarcely a single vessel, ought to have 
been found. Different histological condi- 
tions are thus found side by side, crowded 
into a small space : at one point cartilage, 
at another calcification, at a third bone or 
medullary tissue, and everything lying in 
the greatest confusion : in one place me- 
dullary tissue, above it osteoid tissue or 
bone, by its side calcified cartilage, and 
below it, perhaps, cartilage still retaining 
its original condition. The whole of the 
rachitic portion of the diaphysal cartilage 
acquires no real firmness, and this is one 
of the chief causes of the liability to dis- 
tortion which rickety bones exhibit, not 
in the continuity of the diaphyses, but at 
the articular ends. This is in many cases 
considerable, and is the sole cause of 
many a deformity, as, for example, in the 
thorax. The curvatures in the continuity 
of the bones are also incomplete fractures 
-solutions of continuity-while those of 
the epiphyses are due to the proliferation 
of the cartilage, and constitute simple in- 
flexions. Thus, it is easy to conceive how 
parts which are so entirely deprived of 
their regular development as in Rickets, 
must retain great mobility. The individ- 490 
RICKETS. 
Fig. 19. 
the production of anastomosing processes 
from the cells, the formation of bone-cap- 
sules is completed. At times, isolated 
osteoid cartilage corpuscles calcify alone, 
without the occurrence of any fusion ; and 
whilst between them lies the ordinary in- 
tercellular substance of cartilage, the cap- 
sules of the osteoid corpuscles fill them- 
selves completely with calcareous salts. 
In other places, on the contrary, the fu- 
sion of the capsules with the intercellular 
substance takes place very rapidly; the new 
intercellular substance formed by this fu- 
sion assumes a coarsely fibrous appearance, 
and in the place of several groups of carti- 
lage cells, a fibrous mass is seen, contain- 
ing ja£ged osseous (bone) or osteoid corpus- 
cles. There is therefore no sharply-defined 
boundary in the tissue, but the condensed 
or fibrous substance which surrounds the 
jagged bodies is directly continuous with 
the translucent substance which holds the 
cartilage together. Essentially it is the 
same structure. At the point of transi- 
tion at the zone where the conversion of 
cartilage corpuscles into a perfect osseous 
substance is taking place, numbers of cor- 
puscles may be seen lying close to one 
another like hazel-nuts - distinguished 
from ordinary cartilage corpuscles by their 
dark contours, hard appearance, and un- 
usually great brilliancy, and inclosing in 
a small indented cavity a little cell. These 
little cells are the bone corpuscles-iso- 
lated because their capsules have not yet 
become fused with the basis substance- 
with calcified capsules which they have 
retained from that earlier period in their 
existence when they were cartilage cells. 
(Virchow's Cellular Pathology, pp. 432- 
436; translation by Dr. Chance.) 
Sir W. Jenner does not, however, agree 
with Kolliker and Virchow, that in Rick- 
ets the normal process by which the la- 
cuna} are formed is visible. Uis observa- 
tions have led him to quite another con- 
clusion ; the calcification of the cartilage 
cells in the growing cartilage in Rickets 
seems to Sir W. Jenner identical with the 
calcification of the same parts occasion- 
ally seen in enchondromata. 
Sir W. Jenner regards it as entirely a pa- 
thological process-a petrifaction. " The 
spongy tissue is much more spongy in ap- 
pearance than natural, and from the in- 
terstices of its meshes a deep red pulp is 
expressible, .... composed of colorless 
nucleated cells, usually containing only one 
nucleus, now and then two, and occasion- 
ally several blood-globules, and in some 
cases a very large quantity of free fluid 
fat-evidence of excessive preparation for 
the process of ossification, and arrest of 
the completion of the process. The peri- 
osteum is thickened over the head of the 
bone, as it is over the bone generally, and 
attains its maximum degree of thickening 
just at the point of junction of the bone 
Vertical section of cartilage from the diaphysis of a 
rickety growing tibia from a child two years old. A 
large conical process of medullary tissue sending out 
a lateral band on the left side, extends from m up into 
the cartilage ; it consists of fibrous basis with spindle- 
shaped cells, at the circumference : at c c c the carti- 
lage is in a state of proliferation, with large cells and 
groups of cells; at o' c' commencing thickening and 
internal indentation of the cartilage capsules, which 
at o o coalesce and form osteoid tissue. 300 diameters. 
(After Virchow, p. 634.) 
ual parts in the cartilage that ought at a 
later period to have become bone do not 
calcify, and the junction of medullary 
spaces often takes place a long way up 
above the border of calcification. Large 
and often very vascular conical processes 
of fibrous medullary tissue are seen, ex- 
tending upwards from the bone into the 
cartilage. They do not force their way 
into the cartilage from without, but seem 
to owe their origin to a fibrillation of the 
intercellular substance of the cartilage 
itself. It is around them chiefly that the 
osteoid transformation of the cartilage can 
best be seen, and particularly that gradual 
conversion of a cartilage corpuscle into a 
bone-corpuscle. Out of the cartilage cor- 
puscle, which has a moderately thick cap- 
sular membrane, arises a structure, pro- 
vided with a capsule continually increasing 
in thickness, within which the space for 
the cell constantly grows smaller, and 
which, when it has attained a certain de- 
gree of thickness, acquires indentations on 
its inner wall, like the so-called dotted 
canals of vegetable cells. After this, a 
fusion of the capsule with the basis sub- 
stance very generally ensues, and, with MORBID ANATOMY. 
491 
with the cartilage, and it is more vascular 
over the whole bone, as well as thicker. 
A crimson pulp fills the canal of the bone, 
and all the interstices of the tissue of the 
long bones." (Jenner.) 
siological inquiries thus clearly establish 
the fact that a continuous osteogenetic 
process is going on up to a certain point 
only, during the acute stage of Rickets. 
Layer upon layer, as in health, of new 
matter is deposited, the deeper seat- 
ed of which layers are constantly dis- 
appearing through absorption. These 
layers are soft and puffy ; and so long 
as the cachexia of Rickets persists, 
they never become hard. 
The thickening of the flat bones is 
similarly due to the hypertrophy of 
their growing portions with increased 
vascularity of the periosteum. There 
is a great abundance of nucleated 
cells, which, with blood, form the 
pulp, and occupy all the meshes and 
interstices of the bones ; so that the 
substance of the bone seems mainly 
to consist of diploe. Next within 
the growing margin of the bones,and 
close to the sutures, the thickening 
of the cranial bones is usually the 
greatest, consequently the situations 
of the sutures are usually indicated 
by deep furrows on the scalp. So also 
round the posterior margin of the scapula, 
and at its acromial, coracoid, and articu- 
lating processes, the scapulae are thicker 
than at their centres. 
Hypertrophies and softenings of the 
bones do not always proceed in an equal 
degree - the softening being very often 
out of proportion to the enlargement, 
while the enlargement is sometimes out 
of proportion to the softening. In the 
rickety child the ribs are often softer than 
their cartilages ; in the healthy, and still 
more so in the tubercular child, the car- 
tilages are softer than the ribs. 
The curvature of the dorsal and lumbar 
spine (the symptoms of the deformities 
due to which have been already described) 
is mainly the consequence of muscular 
weakness and softening of the bodies of 
the vertebree. The direction of the curv- 
ature is mainly determined by the weight 
of the head, and is generally an exagge- 
ration of the curvature always existing 
when a child of three or four months old 
sits unsupported on the nurse's arm. Sim- 
ple lateral curvatures are thus less com- 
mon than antero-posterior, with more or 
less rotation of the bodies of the verte- 
brse. These become squeezed in at the 
concavity of the curve on the front or 
side, as the direction may happen to be, 
while on the convexity the articular pro- 
cesses become commensurately both thick- 
ened and enlarged. Antero-posterior 
bending has occurred to such an extent 
as to cause doubling of the aorta, adhe- 
sion of the opposed coats at the folded 
part, and consequent malnutrition of the 
lower limbs. (Miller.) 
When the walls of the thorax are ex- 
amined from the inside of the chest after 
Fig. 20. 
Calcification in the cells of an enchondromatous tumor 
similar to calcification in Rickets. (Dr. Aitken.) 
On reviewing those descriptions, it will 
be seen that the differences in appearance 
and in the interpretation thereof may be 
merely due to the various observers hav- 
ing examined the bones at different stages 
of the disease, and perhaps also in chil- 
dren of very different ages. This account 
of the morbid histology of the rickety bone 
also accounts for the great softness of its 
texture, which is sometimes so great that 
the bones may be bent by the least possi- 
ble force, and the thick bones may be cut 
with a knife or a pair of scissors. Of 
course the softening is obviously due to 
the absence of those elements which ren- 
der bone hard-the calcareous or earthy 
salts. The animal matter, also, of rickety 
bones does not seem to be normal; for in 
the experiments of Lehmann and Mar- 
chand, rickety bones did not yield gela- 
tine on boiling. At an advanced period 
of the disease, Simon also affirms that 
the animal matter is so changed that its 
extract yields on boiling neither chondrin 
nor gelatine." On the other hand, per- 
fect gluten has been obtained from ra- 
chitic cranial and thigh bones, by Schlon- 
berger and Friedleben. They did not find 
that the organic basis of rickety bone had 
undergone a change in chemical reaction, 
but the unossified cartilage contained 
much more water. Putting together the 
result of the analyses of several observers, 
Sir W. Jenner finds that the bones of 
healthy children yield about 37 parts of 
organic and 63 of inorganic matters; 
whereas those of rickety children yield 
about 79 parts of organic to 21 parts of in- 
organic matters.1 Anatomical and phy- 
1 See details of several analyses in Med. 
Chir. Review, July, 1856, pp. 70 and 71. 492 
RICKETS. 
death from Rickets, the projections where 
the ribs join with the cartilages are much 
greater than on the outside; but the 
eleventh and twelfth ribs, which are not 
inflexed (as described previously), have 
the same enlargement in the inside as on 
the outside. (Jenner.) The great de- 
termining cause of thoracic deformity, 
Fig. 21. 
Permanent curvature of the spine, with rotation, produced hy Rickets in early life. (Miller.) 
according to Sir W. Jenner, is atmos- 
pheric pressure, aided by the elasticity of 
the lungs : and he explains as follows the 
mode of its operation : "Suppose," says 
he, "the external thoracic parietes were 
made of unyielding material, then the 
diaphragm could descend only so far as 
the air could enter at the orifice of the 
larynx, and overcome the elasticity of the 
lungs. The thoracic parietes however, in 
their normal condition, are not absolutely 
unyielding, but there is a due relation 
between their strength, the power of the 
diaphragm and the rapidity of its con- 
tractions, the size of the orifice of the 
larynx, and the elasticity of the lungs. 
"The chest-walls being healthy, and 
the orifice of the larynx of normal size, if 
the young child sobs violently-i. e. con- 
tracts the diaphragm with abnormal rapid- 
ity and force-the most flexible parts of 
the thoracic parietes will yield or fall in 
during inspiration. 
"If the orifice of the larynx be nar- 
rowed, and if the diaphragm contract 
with only normal rapidity and force, there 
will be recession of the softer parts of the 
chest-walls at each inspiration. Again, 
if the orifice of the larynx remain nor- 
mal, the diaphragm acting energetically, 
as in a healthy child, and the chest-walls 
be softened (as in Rickets), then, at each 
inspiration, there will be recession of the 
most yielding part of the thoracic walls." 
These are the conditions which we ob- 
tain in Rickets. The part of the rib 
where ossification is imperfect and incom- 
plete is so soft that, at each descent of the 
diaphragm, it recedes, and the furrows on 
the thorax already described at page 479 
are produced. In proportion as the ends 
of ribs are forced inwards, the sternum is 
carried forwards. Sir W. Jenner rightly 
excludes muscular action from all direct 
share in the production of these deformi- 
ties of the thorax or curvatures of the 
long bones in Rickets. He does not agree 
with Rokitansky that the deformity of the 
thorax is the consequence of any want of 
power of the respiratory muscles ; for on 
dissection he finds no correspondence be- 
tween the points of insertion of the muscles 
of inspiration attached to the outer surface 
of the chest-walls and the points of reces- 
sion. Nor does he find that the dia- 
phragm causes circular recession by its 
direct contraction, as by drawing in the 
receding parts at each contraction ; for 
dissections, compared with cases and 
models, prove that the line of recession 
does not correspond to the points of at- 
tachment of the diaphragm, but it cor- MORBID ANATOMY. 
493 
responds to the upper margin of the liver, 
spleen, and stomach, and is produced (as 
the longitudinal thoracic furrow is) by the 
atmospheric pressure : the parts of the 
parietes below being prevented from re- 
ceding by these solid organs, whose in- 
fluence in preventing recession of the 
chest-walls is illustrated by the apparent 
bulging of the precordial region in every 
case of well-marked rickety thorax. The 
chest-walls covering the heart do not re- 
cede so much as those on the opposite 
side ; and as the left side is thus much 
fuller than the right, it might be supposed 
that there is abnormal fulness of the pre- 
cordial region, which there is not. 
Another point fully noticed by Sir W. 
Jenner is the influence of attrition in pro- 
ducing " white spots" or " white patches" 
on the surface of the heart, in children 
whose chests are deformed by Rickets, 
and in such children the chosen seat of 
the " white patch" is on the left ventricle, 
a little above its apex, just at the spot 
which impinges against the fifth rib where 
it projects or knuckles inwards; for the 
sternum of the rickety thorax being forced 
forwards, the relative positions of the 
chest-walls and of the heart are no longer 
normal, and the apex of the heart strikes 
outside the nipple. "White patches," 
similar in nature and origin, may also be 
found on the spleen. They are to be dis- 
tinguished from those due to embolism 
by the fact that they do not extend below 
the fibrous tunic of the organ. 
In connection with the morbid anatomy 
of the skeleton, the results of Mr. Shaw's 
observations must not be overlooked. 
He has shown that arrest of the growth 
of the bones, and of the parts in relation 
with them, is a very important conse- 
quence of Rickets; and the arrest of 
growth commences during the progress of 
Rickets, and persists after the general 
disease has ceased. Hence children are 
not only stunted in growth, when the 
subjects of Rickets, but they never grow 
into ordinary-sized adults. Arrest of 
growth is most strongly marked in the 
legs and thighs, imparting dwarfishness 
to the frame as well as distortion. While 
the bones of the thighs and legs are often 
bent in a variety of fantastic forms, they 
are at the same time flattened, generally 
so that the great diameter of the bone is 
antero-posterior in relation to the curve ; 
consequently, when they ossify and harden 
in after life, as the disease subsides, the 
limbs are not so weak as they otherwise 
would be. The heads and necks of the 
thigh bones bend downwards, and may 
ultimately come to be on a lower level 
than the trochanters. 
The articulating ligaments fail, causing 
deformity of the knee and ankle-joints. 
The pelvis is small, its front wall is flat- 
tened, and forced back upon the sacrum. 
A characteristic hollowness is thus im- 
parted to the loins, by the sacrum being 
thrust downwards; its promontory be- 
coming usually salient, and its posterior 
surface forming the bottom of 
a hollow on the back part of 
the pelvis. At the same time 
both ilia are displaced back- 
wards, so as to overlap the 
sacrum and approach each 
other, sometimes having scarce 
an inch of space between their 
posterior borders. (Miller.) 
According to Mr. Shaw's 
researches, all the bones of the 
adult whose skeleton has suf- 
fered from Rickets are dimin- 
ished in length, but the lower 
limbs are disproportionately 
diminished in size, and the 
face is small in proportion to 
the skull. This arrest of 
growth of the bones of the 
face and the sinuses causes the 
forehead to appear to project 
more than it really does. Mr. 
Shaw's observations were di- 
rected to the examination of 
the relative proportions which 
the different parts of the skel- 
eton bore to each other. The 
relative dimensions of rickety 
skeletons show that they have 
a configuration quite different 
from that which belongs to 
the natural skeleton. (Med.- 
Chir. Trans., vols. xvii. xxvi.) 
Fig. 22. 
Example of limbs deformed by Rickets. (Miller.) RICKETS. 
494 
Such alterations in important visceral 
cavities as have been described, inevitably 
lead to secondary lesions in the contained 
organs. Two lesions of the lungs are 
constantly present when the thorax is 
deformed by Rickets, namely, collapse of 
lung tissue and that form of emphysema 
which has been termed insufflation, due to 
over-distension with air of the vesicular 
tissue of the lung. In the lungs of rickety 
children its site is constant. It invari- 
ably occupies the whole length of the an- 
terior border of both lungs, extending 
backwards for about three-quarters of an 
inch from the free margins. 
The emphysematous portion is sepa- 
rated from the healthy portion of lung by 
a groove formed by the collapsed air-cells 
of the lung ; and this groove of collapsed 
tissue corresponds to those projections in- 
wards of the ribs where they unite with 
their cartilages. 
The mechanism of the production of 
these lesions is thus described by Sir W. 
Jenner: "The softened ribs, instead of 
being drawn outwards at each inspiration, 
are forced inwards by atmospheric pres- 
sure ; the consequence is, that not only 
are the lobules of the lung beneath not 
expanded, but they are compressed ; and 
the compression of the lung, aided by its 
elasticity, causes the collapse." 
The emphysema of the anterior border 
is produced thus : " The lateral diameter 
of the thorax is diminished at the part 
corresponding to the line formed by the 
junction of the ribs and cartilages. But 
at each inspiration the ribs recede ; and 
in proportion as the ribs at this part are 
forced inwards, the sternum must be 
thrust forwards ; and just as less air or no 
air enters into the tissue under the re- 
ceding ends of the ribs, so an excess of air 
is drawn (as we commonly call it) into the 
lung tissue subjacent to the abnormally 
advancing sternum and cartilages of the 
ribs. 
"The collapse is thus directly conse- 
quent on the recession of the ends of the 
ribs during inspiration ; the emphysema 
is directly consequent on the thrusting 
forward during inspiration of the ster- 
num." 
These lesions stand in direct relation to 
the anatomical sign of Rickets, namely, 
the affection of the bones ; but there are 
other lesions which, equally with the bone 
lesion, are anatomical signs of the con- 
stitutional affection, and which as such 
have been described by Sir W. Jenner. 
The emaciation of Rickets is mainly asso- 
ciated with the lesions about to be noticed, 
and which consist in a form of albuminoid 
infiltration of lymphatic glands, spleen, 
liver, brain, kidney, heart, and thymus 
gland. Sir W. Jenner is of opinion that 
these lesions are never limited to one of 
these organs in Rickets: but that every 
one of them is more or less affected, per- 
haps all the tissues. The cut surface of 
such organs is singularly pale and trans- 
parent, compact, smooth, tolerably moist, 
and to the unaided eye uniform in appear- 
ance. The substance is tough and the 
organ heavy in proportion to its size ; and 
although Sir W. Jenner is opposed to the 
belief of such lesions being the same as 
those described by Virchow under the 
name of amyloid degeneration, yet with 
the exception of his failing to get a blue 
reaction with iodine, their characteristics 
appear to be similar. 
Prognosis.- The sooner the disease 
becomes established after birth the more 
certain is the result likely to prove fatal; 
but those in whom the disease appears 
later in life may recover before the fifth 
or sixth year. The general health begins 
gradually to improve, the tumefaction of 
the abdomen begins to subside, and the 
bones to acquire firmness. Thus becoming 
set, as it were, in their abnormal shapes, 
the figure always retains a certain degree 
of deformity. When the disease ceases, 
the mind, like the body, recovers, and re- 
gains all its powers. The muscles of those 
who were once rickety, in after-life are 
often marvellously powerful, their bones 
singularly strong, and their intellect cer- 
tainly not below the average. (Jenner.) 
Recovery sometimes takes place after an 
acute febrile attack, occasionally accom- 
panied by the appearance of a cutaneous 
eruption. (Cumin.) 
At the approach of convalescence, an 
extraordinary liking for particular articles 
of food may be exhibited; and Dr. Cumin 
relates how one patient had so strong a 
desire for salt, that she devoured it like 
sweetmeats. The quantity taken was 
very great, and the parents believed it 
had proved the means of curing the child. 
In severe cases, where deformity of the 
thorax is extreme, the great danger of 
death is from catarrh and bronchitis. The 
danger is not only in proportion to the 
severity of the inflammation of the air- 
passages, but to the degree of softening of 
the ribs. In estimating the danger of 
bronchitis in a sickly child, it is by no 
means sufficient to listen to the ausculta- 
tory signs, or to note the lividity of the 
lips, or action of the nares, or the fre- 
quency or severity of the cough, or evi- 
dence of febrile disturbance ; but the child 
must be stripped, so as to note the degree 
to which the ribs are softened, how much 
they recede during inspiration, and to 
what extent they are forced outwards 
during expiration. (Jenner.) 
If the complaint occur in children about 
the second year of age, or later, although 
it may be of considerable duration, yet 
amendment is generally rapid when it 
commences ; but, even when the growth THERAPEUTICS. 
495 
is stunted and the deformity considerable, 
still the period of puberty may remarkably 
develop growth and diminish deformity, 
especially when a change of air and out- 
door exercise can be enjoyed. 
Generally-if the disease be not far ad- 
vanced, if the child be not greatly debili- 
tated, if the deformity have not greatly 
affected the spine, chest, or pelvis-a 
favorable result may be anticipated ; but 
when the reverse of these conditions pre- 
vails, then complete recovery may not be 
expected. 
Therapeutics.-Looking to the na- 
ture and causes of Rickets, it is obvious 
that no specific remedy will cure the dis- 
ease, nor will any detailed and fixed line 
of treatment be applicable to every case. 
An outline of the principles on which 
cases of Rickets are to be managed may 
be given ; but the selection of particular 
remedies must be made for each case, 
according to the pathological conditions 
of the patient. 
Improvement of the general health is 
the first object to be sought after. Such 
hygienic influences must be obtained as 
to secure for the patient healthy nursing, 
a warm and dry atmosphere, due ventila- 
tion, and pure air. The food must be 
selected as suitable to the respective pe- 
riods of infancy or childhood, as becoming 
in the stages of lactation, weaning, or 
dentition. The diet, therefore, and the 
state of the digestive organs, are to be 
carefully seen to by the physician. If the 
child be under eight months old, and 
" brought up by hand" wholly or in part, 
milk diluted with about one-fourth part 
of lime-water, and with a teaspoonful of 
cream added to the half-pint of fluid, will 
be found the best food. It is better not 
to add sugar to the milk ; and if it is used, 
it is better to be sugar of milk, and not 
cane-sugar. (Jenner.) Gruel, plain bis- 
cuit, aerated bread-crumbs, or baked flour, 
may be added to the milk ; and as the 
child gets older, beef-tea and bread, eggs 
and farinaceous pudding, may be added 
to the diet. If the child be still sucking, 
the milk of the mother or nurse should 
be examined as to its quality and quantity; 
and, if deficient in either, the nurse ought 
to be exchanged for one more suitable, or 
the child entirely weaned, and "brought 
up by hand. " Ass's milk has been rec- 
ommended at this period; or farinaceous 
articles of diet should be given with 
mutton-tea, veal-tea, or beef-tea ; or the 
yolk of an egg with milk may be given 
once or twice a day, if the child is old 
enough. If the child is still to be suckled 
by the mother or nurse, it ought to be 
permitted to take the breast only at stated 
periods ; and it may have at regular in- 
tervals, in addition to the breast milk, 
two or three meals of milk and lime- 
water. 
The child should be kept as much in 
the open air as the weather and tempera- 
ture will permit. Its clothing should be 
warm. Its body should be washed all 
over, at least once in the twenty-four 
hours, with warm water and soap ; and 
daily tepid or cold sponging, according to 
the state of the weather and condition of 
the child, are also beneficial. Warm salt- 
water bathing or sponging, or a tepid 
salt-water douche on the back, loins, 
and limbs, preceded and followed by ac- 
tive friction on the surface of the child, 
may be of service if the strength is suffi- 
cient. The child should sleep alone, and 
the utmost care should be taken to pre- 
serve the bed and bed-clothes clean, fresh, 
and perfectly dry. The sleeping room 
must be well ventilated ; and a lamp may 
be burned in the chimney, to facilitate 
the passage of air through the room and 
its exit by the chimney. (Jenner, Cop- 
land.) 
With regard to the administration of 
medicines, the physician must be guided 
mainly by the presence or absence of 
pyrexia, the state of the urine, the state 
ot the bowels, and the progress of the 
cachexia generally. The irritative fever 
and quickness of the pulse must never in- 
duce the prescription of such lowering 
remedies as antimonials, nor of blood- 
letting. Active depletion in any form is 
not to be thought of; and antimony is to 
held "as a poison to the subject of pro- 
gressive Rickets." Mercury, unless as an 
aperient, in conjunction with some other 
drug, is equally objectionable. The fever 
which attends Rickets being generally 
characterized by asthenia, by copious or 
colliquative perspiration, by pale phos- 
phatic urine, and general pallor of the 
skin and softness of pulse, remedies must 
be restorative and calmative. Alkaline 
remedies are considered serviceable by 
Dr. Copland under these circumstances, 
especially carbonate of potash, liquor pot- 
assce, magnesia, with infusion or decoction 
of cascarilla, or of cinchona, with aro- 
matics. Lime-water charged with fixed 
air is useful as a drink. 
If carbonates are prescribed, small doses 
of dilute hydrocyanic acid, or of the ex- 
tract or tincture of conium, will be of use. 
If the urine be only slightly acid in reac- 
tion, or if it soon becomes alkaline, the 
mineral acids, especially hydrochloric and 
nitric, or nitro-hydrochloric, may be given 
with aromatics, or with small doses of 
hyoscyamus, conium, or of opium. Baths, 
acidulated with hydrochloric acid, are also 
very worthy of use, especially if the stools 
are devoid of bile. 
If the bowels be confined or fecal accu- 
mulations exist, they must be relieved 
and evacuated by stomachic aperients, 
such as compound, decoction of aloes, or 
equal parts of infusion of gentian, senna, 496 
RICKETS. 
or of rhubarb, with aromatics. If the 
stools are offensive, even if the bowels are 
relaxed and the stools yeasty, a teaspoon- 
ful of castor-oil, or of gray powder combined 
with jalap, may be given, and once or 
twice a week a small dose of rhubarb and 
soda; but equal parts of rhubarb, soda, 
and calumba powder are better than gray 
powder, and if continued, as they may be, 
with safety, the acidity of the alimentary 
canal will be held in check. Prepared 
chalk and soda, once or twice a day, may 
also correct superfluous acidity. When 
the stools are yeasty and the bowels 
griped, alkaline remedies should be given 
in lime-water and milk, with minute doses 
of tincture of opium, or of compound cam- 
phor mixture; and an enema containing 
similar alkaline ingredients may be ad- 
ministered. (Copland.) 
When febrile disturbance has been sub- 
dued, the child must be taken as much as 
possible into the open air, and in the sun- 
shine. It should as much as possible live 
in the open air, due regard being had to 
the weather, and care being taken that it 
be warmly clad, and not exposed to cold 
and damp winds. If the child has lived 
in town, it ought to be removed to a dry 
bracing sea-air, such as that of Scarbo- 
rough, Lowestoft, and the east coast of 
England generally, in the hot months, or 
Brighton in the colder or foggy months. 
The waters of Tonbridge are well spoken 
of by Copland and Jenner ; and although 
the place is inland, it has special advan- 
tages, inasmuch as while the air of the 
place is dry and bracing, the water from 
its chalybeate spa is a powerful curative 
agent in Rickets, on account of the iron 
it contains-about a quarter of a grain of 
the oxide of iron in a pint, with just suffi- 
cient carbonic acid to hold the iron in solu- 
tion. The water of the spring has a tem- 
perature of 50° Fahr., and children will 
drink it readily. Steel wine may be added 
to the water, if it is desirable to give more 
iron. It is an extremely useful remedy, 
and, according to Sir W. Jenner, one of 
the best forms for administering iron to 
rickety children. A teaspoonful or two of 
steel wine, with half a grain of quinine, and 
a drop or two of dilute sulphuric acid, con- 
stitutes one of the best mixtures for such 
cases. It is especially useful when the 
skin is flabby, covered with perspiration, 
and anaemia well marked. Tincture of 
perchloride of iron in the infusion of calum- 
ba, or in quassia, or the iodide of iron in 
the syrup of sarza, is the best preparation 
of iodine in Rickets (Copland); and the 
iodide of potassium, in a tonic decoction or 
infusion, is sometimes also of service. A 
preparation new to the pharmacopoeia- 
the syrup of the phosphate of iron-pos- 
sesses the general properties of ferruginous 
compounds, and invigorates and increases 
the powers of digestion. The citrate of 
iron and ammonia will agree with the sto- 
mach sometimes, when it will not bear 
more astringent preparations of iron. It 
is best taken during effervescence in solu- 
tion of citric acid, flavored with tincture of 
orange-peel-the salt being first dissolved 
in the water. (Squire.) 
When the use of iron must be continued 
for a long time, as it is desirable it should 
be in cases of Rickets, magnetic oxide of 
iron is a good preparation to give twice or 
thrice a day. The citrate of iron and 
quinine is also a new and useful prepara- 
tion. 
The influence of nux vomica, iron, and 
quinine in combination ought not to be 
lost sight of; it is one of the most valuable 
of tonic remedies. The formula for its 
composition, as devised by the late Pro- 
fessor Easton of Glasgow, has been given 
by my friend Dr. Maclean, in his article 
on Dysentery ; and therefore it need not 
be repeated here. 
Any of the tonic remedies containing 
iron should be taken just before dinner. 
Cod-liver oil is a remedy often remark- 
ably beneficial. (Copland, Bouchut, Jen- 
ner.) It is best given immediately after 
meals, in orange juice or in orange wine, 
or as an emulsion, with milk and solution 
of compound gum tragacanth. 
The condition of the intestinal dis- 
charges should be examined when cod- 
liver oil is given. I have often seen that 
much too large a dose of the oil is being 
given, by seeing the oil pass by the stools. 
If such should happen, a much less dose 
is sufficient; and generally, too large 
doses of cod-liver oil are prescribed. 
Superfluous acidity must be corrected by 
aperients and alkaline remedies, as al- 
ready indicated. 
The food should be carefully masticated; 
and if the teeth are deficient, Sir W. Jen- 
ner recommends that the food should be 
pounded in a mortar, and potatoes espe- 
cially should be most carefully mashed. 
Children of twenty months or two years 
of age, suffering from Rickets, require 
a small quantity of meat every day, in 
addition to beef-tea; and milk should 
form for all children the evening and 
morning meals. Sir W. Jenner recom- 
mends that when the stools are reported 
white they ought to be examined, so as to 
determine whether or not the whiteness 
is due to the quantity of undigested curd 
contained in them. If such should be the 
case, alkaline remedies are to be given, 
and a little lime-water added to the milk; 
or beef-tea may be substituted for part of 
the milk. The liver is not to be stimu- 
lated by purgative remedies, nor altera- 
tives given in the belief that bile is 
deficient. 
In the inflammatory, bronchial, and 
lung affections of progressive Rickets, 
ammonia, with or without ipecacuanha and 497 
SCROFULA : HISTORY. 
citrate of potash, is the great remedy to be 
relied on ; while for the cure of laryngis- 
mus stridulus, the purely tonic treatment 
comprehended in the combination of air, 
exercise by friction or otherwise, and 
diet, with iron and cod-liver oil, as al- 
ready indicated, constitute the course of 
treatment to be followed up with perse- 
verance. 
Mechanical appliances are not to be 
recommended for straightening deformi- 
ties; but Sir W. Jenner has sometimes 
applied splints in such a way as to project 
below the feet for the purpose of pre- 
venting walking. 
[This prohibition of mechanical appli- 
ances is, perhaps, rather strongly ex- 
pressed ; although such means of treatment 
are undoubtedly often misused or abused. 
Unless very skilfully contrived and care- 
fully employed, they had better be let 
alone altogether.-IL] 
[SCROFULA. 
By Henry Hartshorne, M.D. 
Synonyms.-Scrofulosis, Struma, Tu- 
berculosis, Chceras, ^crouelles, King's 
Evil, The Evil. 
History.-The ancients were well ac- 
quainted with glandular swellings; the 
XOLftaSii of Hippocrates, strumce of Celsus, 
and scrophuloe of later Latin authors. It 
does not appear that the idea of a relation 
between these and a constitutional dis- 
ease, or even with pulmonary consump- 
tion, was thought of until the seventeenth 
century. Silvius (Le Boe) theorized in 
regard to supposed glandular enlarge- 
ments and suppurations in the lungs in 
phthisis ; and other medical writers for a 
time accepted this view. Cullen, in the 
eighteenth century, most distinctly recog- 
nized the characters of the scrofulous con- 
stitution. In the same century Percival 
studied the pathology of phthisis with 
new views concerning tuberculous de- 
posits ; and then Portal, Bayle, Baillie, 
and Laennec (1819) brought in the patho- 
logical doctrines concerning Tuberculosis 
which have remained until within a few 
years undisturbed. 
Popularly, Scrofula has been the subject 
of a curious but quite ancient superstition. 
Serenus Samonicus, in his "Carmen de 
Medicina," written about the beginning 
of the third century of our era, alludes to 
the cure of the "regius morbus" by the 
imperial hand. In England and France, 
many monarchs were supposed to have 
the power to restore, by the touch, those 
affected by it. 
Edward the Confessor in the eleventh 
century, Louis XI. and Charles VIII. in 
the fifteenth, Francis I. in the sixteenth, 
and Charles II. in the seventeenth centu- 
ries, were famous in this respect. Queen 
Anne in England and Louis XVI. in 
France were the last who touched for the 
King's evil; Samuel Johnson, when a boy, 
having been one of those so favored by the 
British queen. A special formula in con- 
nection with this royal office remained in 
the liturgy of the Church of England as 
late as 1719. 
The essential identity of Tuberculosis 
and Scrofulosis has been recognized by 
most pathologists since tubercle has been 
definitely studied. Several eminent au- 
thorities, however, have denied it; while 
the exact nature of their relation con- 
tinues to be much discussed. That either 
tubercle or the cheese-like deposit or de- 
generation of scrofulous glands is an affair 
of merely local disorder, is now main- 
tained by very few. A constitutional ten- 
dency, " diathesis" or " cachexia," is gen- 
erally understood to lie beneath all such 
local manifestations of disease. The im- 
portance of this subject is well expressed 
thus by Aitken "There is perhaps no 
subject in the whole range of medical sci- 
ence which the student ought to study 
more carefully than the cachexia asso- 
ciated with the occurrence of tubercle. 
As a practitioner he will find that he be- 
comes often painfully concerned in the 
deepest interests of families and society, 
through the threatened or actual ravages 
of tuberculous diseases." In England, for 
example, in one year, 1862,2 there were 
reported as dying from- 
[■ Science and Practice of Medicine, Phila. 
edition, vol. ii. p. 227.] 
[2 Tanner, Practice of Medicine, Philada. 
edition, p. 104.] 
vol. I.-32 SCROFULA. 
498 
Scrofula 3,416 
Tabes mesenterica .... 5,203 
Phthisis 50,962 
Hydrocephalus 7,031 
66,612 
In France, about 1 per cent, of the con- 
scripts have been declared unfit for mili- 
tary duty on account of Scrofula. ' 
To the same effect as that above quoted 
is the following language of Birch-IIirsch- 
feld :2 "Practitionershave at all times 
opposed the attempt to get rid of this no- 
sological conception, and, indeed, who- 
ever has had some experience in the dis- 
eases of childhood, must acknowledge that 
the manner in which certain individuals 
react against noxious influences leads to 
the assumption of a definite constitutional 
habit." 
The general agreement of clinical ob- 
servers and pathologists in regard to the 
existence of such a " constitutional habit," 
furnishes sufficient reason for the reten- 
tion of the old term, Scrofula, or Scrofu- 
losis. 
Symptomatology.-Postulating at the 
start the essential identity of the tubercu- 
lar with the scrofulous constitution, it is 
proper to mention the traditional account 
of the strumous physiognomy. 
Miller3 gives the following delineation 
of its characteristics: "The complexion 
is fair, and frequently beautiful, as well 
as the features. The form, though deli- 
cate, is often graceful. The skin is thin, 
of fine texture; and subcutaneous blue 
veins are numerous, shining through the 
otherwise pearly-white integument. The 
pupils are usually spacious ; and the eye- 
balls are not only large, but prominent, 
the sclerotic showing a lustrous whiteness. 
The eyelashes are long and graceful, un- 
less ophthalmia tarsi exist, as not unfre- 
quently is the case; then the eyelashes 
are wanting, and their place is occupied 
by the swollen, red, unseemly margin of 
the lid. 
" In the phlegmatic form the complex- 
ion is dark, the features disagreeable, the 
countenance and aspect altogether forbid- 
ding, the joints large, the general frame 
stinted in growth, or otherwise deformed 
from its fair proportions. The skin is 
thick and sallow; the eyes are dull, though 
usually both large and prominent; the 
general expression is heavy and listless ; 
yet not unfrequently the intellectual pow- 
ers are remarkably acute, as well as capa- 
ble of much and sustained exertion. The 
upper lip is usually tumid, so are the co- 
lumnce and alee of the nose, and the gene- 
ral character of the face is flabby; the 
belly inclines to protuberance ; and the 
extremities of the fingers are flatly 
clubbed, instead of presenting the ordi- 
nary tapering form." 
Dr. Aitken, in the article in the present 
volume upon Rickets, has contrasted (in 
a Table) the appearances and tendencies 
of Tuberculosis and Scrofulosis, along with 
those of Rickets. To this comparison we 
may refer the reader for instructive sug- 
gestions. Not very dissimilar is the de- 
scription given by Birch-Hirschfeld1 of 
the two types, of erethic and torpid Scrofu- 
losis. It may be remarked, however, that 
the necessary connection of each of these 
physiognomies with scrofular or tubercu- 
lar disease can hardly be sustained. What 
is true seems to be, that one (erethic) of 
these habits of constitution affords a deli- 
cacy, which lapses readily into irritability; 
while the other (torpid) manifests a relax- 
ation or atony, easily depressed into de- 
generation. A predisposition only, to 
Scrofulosis, may be inferred from such 
signs; and this predisposition may not 
unfrequently be escaped from, under fa- 
vorable hygienic circumstances, without 
the occurrence of actual disease. 
Scrofulous disorders affect often a quite 
early period of infancy, although seldom 
congenital-the tendency to them, as above 
indicated, being all that is usually trans- 
mitted by inheritance. 
Earliest, are apt to occur morbid affec- 
tions of the skin and mucous membranes; 
after these, those of the serous membranes 
and lymphatic glands; then of the bones; 
and, commonly, though far from always, 
last, of the lungs. This is, it is true, a 
clinical rather than a pathological account 
of the most frequent order of succession. 
Many times, tubercular disease of the 
lungs and serous membranes is latent or 
obscure; and then the superficial or ob- 
vious disorder attracts, for a time, an 
attention out of proportion to its relative 
pathogenetic importance. 
Willigk, in 1317 cases of Tuberculosis 
examined, found the order of frequency 
of invasion of different parts of the body 
as follows : lungs, intestines, mesenteric 
glands, larynx, lymphatic glands, perito- 
neum, spleen, kidneys, pleura, liver, air- 
passages, bones, genital organs, brain, 
cerebral membranes, urinary passages, 
pericardium, stomach, bowels, skin, mus- 
cles, tongue, pharynx, oesophagus, heart. 
Rokitansky has given the following order 
from his enormous experience : lungs, in- 
testines, lymph glands, larynx, serous 
membranes, brain, spleen, kidneys, liver, 
bones, uterus, testicles. 
Young scrofulous subjects are much in- 
[' According to Marc d'Espine, 1'6 per 
cent, of all deaths in Geneva result from 
scrofulous diseases.] 
[2 On Scrofulosis; in Ziemssen's Cyclopae- 
dia of Practical Medicine, vol. xvi.] 
[3 Principles of Surgery, p. 55.] 
P Loc. cit. ] SYMPTOMATOLOGY. 
499 
clined to disease of the skin, especially 
upon the head and face. Yet it can 
hardly be said that any one form of cuta- 
neous eruption is exclusively peculiar to 
scrofula. Scrofuloderma is a term applied 
to those affections, somewhat various, 
which present characters presumed to be 
especially dependent on the strumous 
diathesis. 
Lichen scrofulosorum is named by Hebra 
as a papular disease, consisting of papules 
of the size of millet seeds, reddish or 
brownish-red, in groups, generally on the 
trunk, least often on the limbs. Being 
painless, and itching but little, they may 
exist without being noticed ; but are lia- 
ble to remain for a long time unchanged ; 
or successive eruptions may come out, 
even for years. Males between ten and 
twenty-five years of age are most often 
affected with this disorder. The hair- 
follicles and sebaceous glands are chiefly 
involved in it. 
More common, however, is scrofulous 
eczema. Beginning not unfrequently with 
small papules, this becomes vesicular, or 
pustulating (impetigo), or scabbing, with 
an oozing serum, or drying into crusts 
(crusta lactea of children). If it differs in 
scrofulous patients from the same affec- 
tion in others, it is in its being, with 
them, less inflammatory, and more chronic 
in duration. 
Sometimes we meet with cases in which, 
along with enlargement or destruction 
and cicatrization of lymphatic glands in 
the neck or axilla, there are ulcers or 
small cutaneous abscesses, more or less 
numerous, whose history is almost pathog- 
nomonic of Scrofulosis. The ulcers, in 
this affection, are apt to be rather deep, 
with smooth, undermined edges. The 
discharge from them is thin, and scarcely 
purulent; and the area around them is 
bluish-red or violaceous-not copper-col- 
ored, as in syphilitic cases. After these, 
which are very slow to heal, are left cica- 
trices of an irregular, radiated, or funnel- 
like appearance, sometimes knotty, but 
more often depressed, or with both knots 
and depressions. Such cicatrices, along 
with enlarged cervical glands, or scars 
from, their previous suppuration, always 
point to a scrofulous constitutional origin. 
Children, even young infants, are often 
affected with strumous disorders of the 
mucous membranes. That of the nose is 
the most common seat of this trouble; 
with redness, moderate swelling, and 
soreness, and a discharge, prone to hard- 
en in the nostrils, but flowing out suffi- 
ciently to irritate the skin at their edges, 
and to inflame and thicken the upper lip. 
The external meatus of the ear is fre- 
quently likewise affected. Otorrhoea then 
occurs; at first mucous, afterwards puru- 
lent ; it may be very tedious in duration. 
From the external ear sometimes, but 
more often from the nares, inflammation 
may extend to the middle ear, with dan- 
ger of perforation of the membrana tym- 
pani; or, it may even pass more deeply, 
and affect the brain, with meningitis, 
thrombosis of the cavernous sinuses, or 
cerebral abscess. Such complications or 
sequehe are rare, however. 
Chronic conjunctivitis (scrofulous oph- 
thalmia) is a very common attendant of 
the strumous constitution; although it 
cannot be inferred that every case of ob- 
stinate chronic ophthalmia is scrofulous. 
Occurrence in childhood, without observed 
causes of local irritation, with a particular 
disposition to affect the eyelids, and with 
extreme ijhotophobia, out of proportion to 
the other inflammatory symptoms,-these 
are traits which only need to be found co- 
incident with disease of the lymph-glands 
or of the bones, to establish the diagnosis 
of scrofulous ophthalmia. 
A minute herpetic eruption may exist 
and involve the conjunctiva, and even the 
cornea. Sometimes the iris and deeper 
structures of the eye may suffer serious 
injury. While, however, blindness may 
thus occasionally result, in a large propor- 
tion of cases scrofulous ophthalmia does 
not reach the retina, and leaves the sight 
unimpaired. 
The mucous membrane of the mouth is, 
no doubt often affected with chronic in- 
flammation in scrofulous children, though 
less frequently than the nostrils and ears ; 
unless we ascribe to the same constitution 
numerous cases of sore throat, to which 
infants are subject. More consistently, 
although still far from invariably, we may 
assert the same origin for chronic en- 
largement, without active inflammatory 
symptoms, of one or both tonsils. 
The lymphatic glands are, as has been 
observed since the time of Hippocrates,1 
affected chiefly after the time of infancy. 
From six to sixteen years may be ap- 
proximately named as the time of their 
especial liability to strumous enlargement; 
but it is far from rare both earlier and 
later. 
The glands of the neck are most fre- 
quently affected. Balman2 found these 
involved in 81 per cent, of all cases; the 
axillary glands in 6 per cent, only; the in- 
guinal in 7; those of the knee about 5; and 
those of the popliteal space in less than 1 
per cent. 
Commonly, the swelling of the glands 
is moderate, or increases gradually, with- 
out pain or much soreness. In some 
cases, however, inflammatory symptoms 
are more active; even bringing on febrile 
reaction of the system. S. Ringer's ob- 
servation of the coincidence of elevation 
[' Aphorism iii. 26.] 
[2 Researches and Observations on Scrofu- 
lous Disease: London, 1852.] 500 
SCROFULA. 
of temperature with the deposit of tuber- 
cle, while often confirmed in regard to 
pulmonary tuberculization, has not been 
so extensively noted in connection with 
glandular strumse; in which, nevertheless, 
Schuppel and others have discovered well 
marked tuberculosis. Fever is most apt 
to occur either when several glands com- 
mence to enlarge at once, or when cheesy 
degeneration is followed by softening, 
preliminary to opening and discharge. 
Very often "kernels" may form and 
remain with little change for months or 
years; or they may grow slowly, until 
they become as large as a goose's egg, or 
larger; or, after a time, slow absorption 
may follow a partial softening, and they 
may disappear altogether. Whether really 
more frequent or not, however, the atten- 
tion of the practitioner is most often called 
to those which advance from the condition 
of apparent hypertrophy (hyperplasia of 
Virchow), through caseous metamorpho- 
sis, to softening, discharge, ulceration, 
and cicatrization. Scrofulous ulcers may 
be indolent and slow to heal; but they are 
not invariably so; and it is remarkable 
how fair a share of general health may 
co-exist with them. Quite often a suc- 
cession of single or multiple enlargements 
and degenerations may appear in the 
course of a few years. It is when febrile 
irritation attends them that we have the 
greatest reason to apprehend the later se- 
quence of pulmonary consumption. 
Scrofula does not often affect the sali- 
vary glands. Now and then, however, 
the sub-maxillary, or the parotid, or both, 
may be involved along with the cervical 
glands. Sometimes mumps, occurring in 
strumous subjects, may be followed by 
chronic enlargement of the parotid, or 
even by its degeneration and suppuration. 
The bronchial glands are not unfre- 
quently affected, and may undergo the 
same succession of changes as those of the 
neck, axilla, or groin. The symptoms 
are then modified by the locality of the 
adenoid disease. 
Hooping-cough or measles may be fol- 
lowed by obstinate chronic bronchitis. 
If other signs of the scrofulous predisposi- 
tion exist, we should always in such a 
case suspect bronchial glandular enlarge- 
ment. But it may occur without any 
such exciting cause; being then as "idio- 
pathic" as any other glandular struma. 
Signs of this affection are a dry, irrita- 
tive cough; dyspnoea, rather gradually 
increasing; and, sometimes, tenderness 
on pressure in the intercostal spaces near 
the spine. Percussion resonance will be 
dull from the fourth to the eighth dorsal 
vertebra. Auscultation will give, in the 
same region, a bronchial respiration much 
louder than normal; the breathing sound 
being conducted from the air-tubes by the 
enlarged glands. 
It is much less common with the bron- 
chial than with the cervical glands for 
softening and discharge to take place; un- 
less in cases in which, tuberculization of the 
lungs occurring, the more important and 
destructive lesion masks the earlier and 
lesser one. Cases are observed, however, 
in which caseous or suppurating bronchial 
glands have discharged their contents 
through the bronchi or trachea, in the ab- 
sence of pulmonary disease. 
Pressure of much enlarged bronchial 
glands upon the vena cava may cause 
interference with the circulation; shown 
by distension of the jugular veins, blue- 
ness of the lips, and a tendency to puffi- 
ness of the cheeks. 
The mesenteric glands are liable to scro- 
fulous enlargement, mostly slower in pro- 
gress than that of the bronchial glands, 
and equally obscure in its symptomatic 
manifestations. In cases attended by 
much wasting, the glands may be felt by 
careful abdominal palpation. Tumefac- 
tion of the belly, however, is quite com- 
mon; and, even in its absence, the tumors 
cannot very often be felt. Disorder of di- 
gestion, diarrhoea, debility, and emaciation 
(marasmus) make up the usual ensemble 
of tabes mesenterica. Softening, with dis- 
charge of the contents of the glands, is 
not common. Occasionally it has been 
traced by the passage of caseous matter 
through the bowels; and, more rarely, 
discharge into the cavity of the peritoneum 
has caused peritonitis with a fatal result. 
Tubercular peritonitis may occur, how- 
ever, without any such cause. It is at- 
tended by pain and tenderness on pressure 
over nearly the whole abdomen; with 
tumefaction, and dulness on percussion, 
fever and debility. Fluctuation also 
marks the occurrence of serous effusion. 
Periglandular abscesses form, sometimes, 
when the glands themselves do not soften 
and suppurate. Cold abscesses is an old 
name given to accumulations of pus in 
various places, chiefly of scrofulous origin. 
One locality in the lower abdomen and 
pelvis has long given occasion for the 
name of psoas abscess. These purulent 
collections appear to form sometimes irre- 
spective of glands, in the connective, and, 
perhaps, the muscular, tissue. The pres- 
ence or absence of acute febrile symptoms 
in connection with them seems to depend 
mainly upon the rapidity of their forma- 
tion. Hectic fever, however, attends a 
late stage of them in many cases. The 
result may be favorable, if a discharge of 
the accumulated matter takes place ex- 
ternally, or by the bowels. If we are to 
suppose that a considerable amount of pus 
cannot be safely removed by absorption, 
it is to be inferred that such tumefaction, 
in the abdomen or elsewhere, may occur, 
with only a non-purulent exudation; since 
undoubtedly they do in some instances SYMPTOMATOLOGY. 
501 
disappear, after persisting for several 
weeks or months. Dulness on percussion, 
clearly circumscribed, without fluctuation, 
and with local signs excluding enlarge- 
ment of the spleen, kidney, liver, &c., 
give diagnostic evidence upon these points. 
An important part of the history of 
Scrofulosis, especially in the period of ado- 
lescence, is the frequent occurrence of dis- 
order of the digestive and assimilative 
apparatus, sometimes called strumous 
dyspepsia. This has been especially 
studied and described by Wilson Philip, 
Tweedy Todd, J. Hughes Bennett, and 
Jonathan Hutchinson, as an important 
preliminary condition to phthisis, in a 
great number of cases. Difficulty in the 
digestion of fatty substances is a promi- 
nent feature of it; and Hughes Bennett 
has emphasized this as bearing upon the 
pathogeny of tuberculization. 
Scrofulous disease of the bones includes 
ostitis, periostitis, caries, necrosis, and 
spina ventosa; with inflammatory affec- 
tions also of the joints,-as fungous arthri- 
tis (white swelling), kyphosis (Pott's dis- 
ease of the spine) and coxalgia or hip- 
joint disease. 
Of the bones, the tibia is most often in- 
volved: next in frequency, the femur; 
then the radius, ulna, humerus, and verte- 
brae. Among the joints, next after the 
coxo-femoral articulation, the knee is the 
most liable ; then the ankle and elbow ; 
least so of all, the shoulder and wrist. 
Commencing periostitis, as, e. g., of the 
tibia, is shown by a smooth, slightly red- 
dish swelling of the bone, tender to the 
touch, and suffering an aching pain. As 
the bone itself becomes affected, at last 
perforation occurs, with a semi-purulent 
discharge, ulceration, exfoliation of bone 
in fragments, &c. 
Caries of the spine is attended by de- 
formity, from the weight of the body 
crushing the softened vertebrae. Con- 
Fig. 23. 
firohes touchivy hone through. Cloacce 
Hxternal appearance of limb, the seat of Necrosis of the shaft of the Tibia 
with cloacae leading down to dead bone. 
Fig. 24. 
Necrosis of the whole shaft of the Tibia. 
siderable pain is apt to result, from pres- 
sure upon the spinal nerves, and irritation 
near their roots ; also, disorders of inner- 
vation in the parts supplied by the nerves 
entering and leaving the cord near the 
seat of disease. Indigestion, palpation, 
dyspnoea, neuralgia, and paralysis are 
among the troubles thus produced. Re- 
covery, however, is not very rare. 
Coxalgia, as well as the other affections 
just mentioned (Pott's disease, caries of 
the long bones, &c.), is by general consent 
regarded as a surgical subject, not appro- 
priate for full consideration in a work of 
this kind. It will be suitable here, there- 
fore, only to remind the reader of one or 
two points of interest to the medical prac- 
titioner. 
Every hospital student knows that the 
earliest signs of hip-disease are, pain in 
the knee without other indications of dis- 
ease in that joint, and a limping gait, 
bending the knee of the affected limb, so 
as to touch the toe only to the ground. 
Pressure upon the great trochanter on 
that side, or upward upon the knee or 
heel, will give pain, because of the con- 
cussion of the head of the femur against 
the acetabulum. Atrophy of the muscles 
surrounding the joint follows ; the whole 
limb seeming to become smaller. Destruc- 
tive caries of the head of the femur may 
occur, with suppuration, spontaneous 
opening of the joint and discharge, bur- 
rowing of pus under the muscles and fas- 
ciae, hectic fever, emaciation, and exhaus- 
tion. If the disease gives way to treat- 
ment at an early stage, no deformity may 
be left; if later, the best attainable result 
may be permanent anchylosis of the joint. 502 
SCROFULA. 
White swelling (fungous arthritis, ar- 
throcace) is the designation formerly ap- 
plied especially to scrofulous inflammation 
of the knee-joint. This may begin with 
disease. Pain is not apt to be very severe. 
Lameness of course results. Ulceration 
and suppuration occur in severe cases; 
from which, however, restoration may 
take place, if the constitutional health be 
invigorated. Too often it proves to be the 
case, that the obstinacy of the arthritic 
affection is but one of the manifestations 
of imperfect nutritive power; to be fol- 
lowed, in later adolescence or early matur- 
ity, by fatal phthisis. 
Scrofula (according to the view adopted 
in this article) affects the brain, in chil- 
dren, quite often, with what is denomi- 
nated tubercular meningitis; more rarely 
with cerebral or cerebellar Tuberculosis. 
Several eminent pathologists have record- 
ed the observation, to whose correctness 
I can bear testimony on the basis of my 
own autopsies, that cases having all the 
typical clinical characters of tubercular 
meningitis may prove, after death, to have 
reached their end without any tubercular 
deposits. Bouchut, Rilliet, Hahn, Hughes 
Wiltshire, and Litten may be named as 
having given evidence to a similar effect 
upon this point. The term "scrofulous 
meningitis" has been preferred for such 
reasons, by some of these writers, to the 
ordinary designation of the disorder. 
Broncho-pneumonia and "catarrhal" 
pneumonia, in persons of the strumous 
constitution, are attended in many in- 
stances by caseous deposition or degene- 
ration in the lungs, discriminated by some 
recent pathologists from tuberculization. 
Symptomatically, these cases of pulmo- 
nary caseation present nothing distinctive, 
for clinical description, from phthisis of 
recognized tubercular character. Louis 
is credited with having established the 
general law, that "whenever tubercle oc- 
curs in the body it also exists in the lungs, 
and whenever it occurs in the lungs it ap- 
pears first at the apex." But the opinion 
has also been sustained by such authori- 
ties as Addison, Gairdner, Jenner, Rein- 
hardt, Virchow, and Niemeyer, that pul- 
monary consumption may occur, and pro- 
ceed even to a fatal termination, without 
tubercular deposit in the lungs. Such 
cases, like those of fatal meningitis above 
alluded to, may be safely designated as 
instances of scrofulous phthisis; this term 
referring to the diathesis or cachexia, 
whether tubercular deposition result from 
it or not. 
For the study of the history of all vari- 
eties of consumption, we may refer the 
reader to the article in this work on 
Phthisis (Vol. IT.) by Prof. J. Hughes 
Bennett. On Tubercular Meningitis, full 
information is given in this volume, in the 
article by Dr. Samuel Jones Gee. Our 
present subject, Scrofula, requires now the 
further consideration of some general 
questions, which may be regarded as still 
sub judice. 
Fig. 25. 
Section of head of Coxalgic Femur. 
some violence, particularly if it have had 
an injury as an exciting cause. More 
Fig. 26. 
often, however, its approach and progress 
are gradual. In this case febrile reaction 
belongs to a rather advanced stage of the 
Healthy Femur, section. ANATOMY and pathology. 
503 
Anatomy and Pathology. - Few 
subjects in the domain of medical inquiry 
have been more closely investigated, or 
more variously discussed, in modern 
times, than that of tubercle. When we 
remember how general, although not uni- 
versal, has been the inclusion together of 
Tuberculosis and Scrofulosis as practical 
synonyms, we may perceive how relevant 
and necessary is a view of at least the 
salient points of this discussion to the 
study of Scrofula. 
Two stages may be traced in the ordi- 
nary course of Scrofulosis in glands. First, 
a moderate and not rapidly increasing en- 
largement, with an elastic and tolerably 
firm consistence. In the few instances of 
examination of glands at this stage with 
the microscope,abundant cell-proliferation 
has been observed and reported. Cornil 
asserts, also, that there occurs a prodigious 
development of the connective tissue of 
considers that their substance must in 
such cases be absorbed. More often, 
without sign of softening, there is a per- 
sistent enlargement, whose contents, if 
opened, will be found to be a yellowish- 
white, cheese-like substance, with more 
or less normal gland-structure, crowded 
with altered cells; in some cases having 
undergone calcareous degeneration. Al- 
ways, in the early stage of scrofulous de- 
position, animal material, chiefly albumi- 
nous, predominates ; later, fatty elements 
become more numerous ; last, if not en- 
tirely liquefied, phosphate and carbonate 
of calcium abound. 
Far more frequently, however, gradual 
softening and liquefaction occur, resulting 
in spontaneous opening through the skin, 
with discharge, ulceration, and final 
granulation, leaving the characteristic 
cicatrization before described. 
Through all the recent discussions as to 
what constitutes tubercle, it has been 
generally admitted that, while all casea- 
tion is not tuberculous, true tubercles are 
often found in scrofulous lymphatic glands. 
Bazin, Koster, Friedlander, Nelaton, 
Roux, Lannelongue, and Brissaud have 
observed them in scrofulous diseases of 
the joints and long bones ; Schiippel, in 
those of the skin; Wagner, Rindfleisch, 
and others assert their presence in nearly 
all cases of caseous pneumonia ; Charcot 
declares that, in all instances of the latter 
affection, the caseous deposit is a truly 
tuberculous mass. Friedlander insists 
that tubercles are also found in old non- 
scrofulous ulcers, as of the cervix uteri, 
in syphilitic sores, &c. Virchow con- 
siders that local tuberculosis may occur 
irrespective of any general diathesis, al- 
though the scrofulous constitution un- 
doubtedly predisposes to it. 
To the question, what is tubercle ? lead- 
ing pathologists do not, to-day, give a 
united answer. Formerly, the account 
of it was tolerably simple ;* describing it 
as of two kinds, gray, semi-transparent, 
granular-and yellow, opaque, and case- 
ous ; distributed also in two forms, miliary 
and infiltrated. In both of these varie- 
ties, however distributed, the most char- 
acteristic elements under microscopic 
inspection were considered to be the 
tubercle-corpuscles; irregular, round or 
oval, from to of an inch in 
largest diameter, regarded by some (Vir- 
chow) as shriveled nuclei. With these 
have always been seen elements of disin- 
tegrated tissue ; epithelial cells, oil glob- 
ules, calcareous particles ; also, results of 
inflammation or hemorrhage, as exuda- 
tion corpuscles, blood-corpuscles, &c. 
Now, under the leadership of Virchow, 
caseation is held by many to be a process 
Fig. 27. 
Tuberculosis of a Lymphatic Gland. The earliest 
stage of the process. Showing the giant-cell. X200. 
(From Green.) 
the gland. Secondly, comes the stage of 
caseous metamorphosis. The gland be- 
comes more enlarged and harder. Gra- 
dually it is altered to a dry yellow mass, 
consisting, as seen under the microscope, 
of irregular corpuscles, shriveled cells 
and nuclei, and (Birch-Hirschfeld) "flaky 
elements which may be claimed as giant- 
cells." Schiippel and others assert the 
distinctly tubercular character of the yel- 
lowish-gray nodules found in many such 
glands. Such, it is declared, may exist 
largely in glands without caseation ; also, 
cheesy degeneration may occur without 
being preceded or accompanied by gray 
tubercular deposit, though this is rare in 
the lymphatic glands. 
Subsequently, a strumous gland fre- 
quently softens, and its contents liquefy 
into a material resembling pus to the 
naked eye, but without pus-corpuscles, 
consisting only of granular debris, min- 
gled with the shriveled and altered ele- 
ments of the affected tissue. 
Sometimes, after seeming to have be- 
come caseous, such glandular enlarge- 
ments may slowly disappear. Virchow 
[' See " Phthisis Pulmonalis," by Prof. J. 
Hughes Bennett, in Vol. II. of this work.] SCROFULA. 
504 
of degeneration not peculiar to tubercu- 
lous or scrofulous deposits, although most 
frequently occurring in them. Virchow, 
Herard, and Cornil, with many others, 
attach the name of tubercle only to mili- 
ary, and not to infiltrated, deposits. Rind- 
fleisch asserts1 that the cells found in exu- 
dations from scrofulous inflammation are 
larger than those of other inflammatory 
exudations; and Oscar Schiippel's " giant- 
cells" are commonly regarded as the most 
characteristic elements of tubercle in any 
organ. 
Allusion was made above to the adhe- 
sion of Charcot (so recently as 1878)2 to 
the old doctrine of Laennec, that caseous 
infiltration of the lung in phthisis is truly 
tuberculous. While so much conflict of 
opinion exists, the subject being evidently 
in a transitional state, it would be out of 
place here to dogmatize upon it. Yet an 
opinion, if it be but provisional, must be 
hazarded upon each of the most important 
disputed questions. 
Does only tubercle undergo caseation ? 
It seems" necessary to accept the view 
of several pathologists, that caseation is 
but a modification of fatty degeneration ; 
which may affect morbid products of dif- 
ferent kinds, as, for example, cancer or 
other tumors. Yet, in far the greatest 
number of instances, caseous metamor- 
phosis results from the scrofulous consti- 
tution, predisposing all the organs of the 
body to abnormal vulnerability under slight 
irritation, and deficient restorative power 
when diseased. 
Scrofulous inflammations, therefore, are 
characteristically attended by slowly form- 
ing exudations, crowded with cells of fee- 
ble vitality, whose accumulations are, 
more than any other deposits, liable to 
caseous degeneration. 
Is tubercle ever purely local, not con- 
stitutional ? 
An affirmative answer must be given to 
this question also ; but simply as a mat- 
ter of fact, so far as shown by the ab- 
sence, in certain cases,3 of scrofulous 
symptoms or changes in any but a single 
organ or part of the body. This does 
not at all contravene the judgment that a 
predisposition to similar disease in many 
organs existed in the same individuals ; 
as predispositions are commonly latent for 
a time, being made known only by disease 
under exciting causation. Escape from 
the effects of such predisposition may 
take place, when locally exciting causes 
continue to be absent. 
Is tubercle always inflammatory in 
origin ? 
Notwithstanding the high authority of 
those who have urged that it is invariably 
so, the facts appear to warrant the main- 
tenance of Laennec's doctrine upon this 
point; to the effect that tubercle may be 
deposited, as a local result of a constitu- 
tional fault, without inflammation pre- 
ceding it. Litten, of Berlin, in some re- 
cent elaborate investigations of acute 
Tuberculosis,1 has sustained what may be 
believed to be a true proposition, viz., 
that " tubercles may develop extensively 
in the membranes of the brain, without 
a trace of exudation." Yet much the 
larger part of the clinical history of Scrof- 
ulosis undoubtedly consists in that of 
scrofulous inflammations of various or- 
gans ; sometimes the one process (inflam- 
mation) and sometimes the other (tuber- 
culosis) being primary; and, not unfre- 
quently, the peculiarity of the case being, 
the modification of the local inflammation 
by the diathesis, making it less violent 
but more prolonged and unfavorable in 
result, even without any tubercular de- 
posit at all. 
Does gray tubercle always precede the 
yellow ? 
If in the same part both occur, the 
older doctrine here seems to be best de- 
fended ; notwithstanding the quite oppo- 
site views of Buhl, Waldenburg, Nie- 
meyer, and others. Gray tubercle always 
occurs as a primary form. Yellow no- 
dules or infiltrations result from degenera- 
tion either of gray tubercle or of some 
other material; which may be inflam- 
matory exudation, or (Schroeder van der 
Kblk, Radclyffe Hall) the epithelium of 
the organ involved. 
Is "caseous infiltration" tuberculous 
in nature ? 
Charcot's authority may be (as above 
cited) used in defence of the conviction, 
that, however morphologically different 
from miliary tubercle, the essential na- 
ture of the process and of the product is 
identical in both. To a contrary effect 
are some expressions of Cornil and Ran- 
vier ; for instance :2 that scrofulous and 
tuberculous arthritis are "bien distinctes." 
Is tubercle infective in origin ? 
Following Dittrich, Buhl, in 1857, in- 
troduced the hypothesis of the origin of 
pulmonary tubercle in the "resorption" 
of a virus from scrofulous lymphatic 
glands, or from some other locality of 
primary disease. Villemin (1865), Colin, 
Lebert, and others succeded in producing 
tuberculosis in animals by inoculation. 
These experiments and reasonings are 
well considered and sufficiently disposed 
of by Prof. J. Hughes Bennett, in his 
article in this work (Vol. II.) on Phthisis 
[l See Rindfleisch's article on "Chronic 
and Acute Tuberculosis," in Ziemssen's Cy- 
clopaedia of Practical Medicine, vol. v.] 
[2 British Medical Journal, May 25, 1878.] 
[' Birch-Hirschfeld, loc. cit.] 
[l Volkmann's Sammhmg Klinischer Vor- 
trage, No. 119, 1878.] 
[2 Manuel d'Histologie Patholog. p. 433.] ANATOMY AND PATHOLOGY. 
505 
Pulmonalis. It has been shown that vari- 
ous morbid materials, introduced by inoc- 
ulation into the veins or lymphatics, may 
bring on local tuberculization, by their 
obstructive and irritative action. There 
is no demonstration whatever either of 
the existence of a specific scrofulous 
"virus," or of the origin of tubercle by 
infection, in any true sense. There may 
be added here to Dr. Bennett's denial of 
the theory of infection, the cogent argu- 
ment derived from the observations and 
statistics of Prof. Austin Flint, of New 
York,1 against the recently often asserted 
origin of phthisis in catarrhal pneumo- 
nia. In 670 cases of phthisis, carefully 
analyzed, Prof. Flint obtained ample 
clinical evidence of the small relative 
share taken by inflammation of the lungs 
in the pathogeny of consumption. Prof. 
A. Clark,2 of New York, also, has ad- 
duced serious objections against the 
theory of resorption or injection. A very 
important obstacle to its acceptance is 
the frequency of the occurrence of Scrofu- 
losis of the lymphatic glands, bones, &c., 
especially in children, without phthisis 
following it. 
What is the nature of the " giant cells" 
of tubercle ? 
Schroeder van der Kblk seems to have 
Fig. 28. 
A multinucleated cell from the Lung in a case of 
Chronic Phthisis. Showing the large number of nu- 
clei with bright nucleoli. X 400. (From Green.) 
described these many years ago, as "com- 
pound cells, consisting of epithelium 
charged with the nuclei which become 
Fig. 29. 
Fig. 30. 
A multinucleated cell from the Lung in a 
case of Chronic Phthisis. Showing the long- 
branched processes, which are continuous 
with the reticulum of the surrounding indu- 
rated growth. Some of the processes are in 
connection with smaller nucleated elements. 
X 200. (From Green.) 
Multinucleated and branched cells from a firm gray mi- 
liary tubercle of the Lung in a case of acute Tuberculosis. 
Wide meshes are seen in the immediate vicinity of the 
cells inclosing a few lymphoid elements. The branched 
processes are directly continuous with the adenoid reticu- 
lum of the tubercle. X 200. (From Green.) 
the ordinary tubercle-corpuscles." Vir- 
chow referred to them in his Cellular 
Pathology3 as "larger cells with a mani- 
fold division of the nuclei, so that twelve, 
twenty-four, or thirty are contained in one 
cell." Prof. O. Schiippel, of Tubingen, 
however, has especially insisted on the 
importance of these elements of tubercle 
as characteristic. They somewhat resem- 
ble, but are clearly not identical, even in 
appearance, with the "myeloid cells" of 
some sarcomatous tumors, found espe- 
cially in connection with the beads of the 
long bones. They are irregular in form, 
without any cell-wall, the largest ones 
[* New York Medical Record, Feb. 1,1873.] 
[2 New York Medical Record, Nov. 15, 
1870.] 
[3 Lecture XX.] 506 
SCROFULA. 
having a diameter of about of an 
inch. Each contains from three or four 
up to thirty or forty nuclei, which are 
conspicuously nucleolated. Branching 
processes extend from many of them, 
making a reticulated arrangement, oc- 
cupied, according to Schiippel, with epi- 
thelial cells. These last, however, are 
not always to be seen. 
The origin of these forms has not been 
satisfactorily traced. Klein suggests 
their derivation, in the lungs, from the 
alveolar epithelium. If this occurs, it 
is most probably by the fusion of several „• 
epithelial cells. Certainly the giant- \ 
cells are not found to undergo any fur- ' 
ther development. Quite probably they 
are not entitled to the name of cell at 
all; but are mere masses of epithelioidal 
protoplasm, shaped altogether by their 
surroundings. In a discussion in 1878, 
Cornil'expressed an opinion concerning 
them which has great intrinsic proba- 
bility. TJiis was to the effect that the 
origin of giant-cells is intra-vascular; 
resulting from the coagulation of plasma 
in capillaries in the course of oblitera- i 
tion, whose walls soften and disappear ; 8 
leucocytes, moreover, being entangled f 
been described also by Buhl,1 Lenker 
and Aitken.2 By such an explanation 
as this we may best reconcile the recent 
accounts of tubercle with some of those 
Fig. 32. 
A firm Gray Tubercle from the Lung in a case of acute 
Tuberculosis. Showing the grouping of the elements 
around separate centres, the nodule consisting of several 
giant-cell systems. X33- (From Green.) 
Fig. 31. 
of equally competent observers, 
made but a few years since. 
To resume : we may classify the 
distinctive opinions concerning the 
nature oftubercle as follows : 1, that 
it is an exudation (Rokitansky, An- 
cell, Bennett); 2, an organized neo- 
plasm (Wedl, Vogel, Virchow); 3, 
a degeneration of tissue elements 
(Henle, Reinhardt, Van der Kblk, 
Radclyffe Hall) ; 4, a specific in- 
fection (Villemin, Colin, Schiippel, 
Green3); 5, an abortive formation of 
tissue, followed by degeneration, 
from defect of vital energy (Wil- 
liams, Ziegler,4 Sir J. Clarke, J. 
Hutchinson, Aitken. G. B. Wood.) 
Although Prof. J. Hughes Bennett 
has expressly designated tubercle 
as an exudation, he has contributed 
much towards the establishment of 
the dependence of its origin upon 
a defect or perversion of nutrition; 
which corresponds very nearly with 
the last named of the above views 
concerning its nature. 
That tubercle often does occur in 
coincidence with local inflammation, and 
thus immediately in, and, in a sense, from 
A small soft Gray Tubercle irom the Lung in a case of acute 
Tuberculosis. The whole of the tubercle is shown in the 
drawing, and it is obviously constituted largely of iutra-alveo- 
lar products. X 100, reduced to X- (From Green.) 
in thecoagula, and their nuclei undergoing 
enlargement and proliferation. Deichler 
some years since reported an observation 
of "knots or buckles" of minute arterial 
branches in masses of tubercle ; their 
walls softening as the cells increase in 
number. Aneurismal distension of the 
walls of the pulmonary capillaries has 
[' Virchow's Archiv, 1862, p. 183.] 
[2 Science and Practice of Medicine, vol. ii. 
Phila. edition, p. 238.] 
[3 Infective, at least, according to Green, 
though not specific. See his "Pathology 
and Path. Anatomy," Phila. edition, p. 184.] 
[4 Deutsche Zeitschr. f. pract. Med., 1874, 
No. 5.] 
[* London Medical Record, June 15, 1878.] CAUSATION. 
507 
inflammatory exudation, is certain. But 
we have already seen reason for dissenting 
from the views of Niemeyer, Oppolzer, 
and others, that Tuberculosis always fol- 
lows and depends upon inflammation. It 
may be deposited, as Laennec taught, in 
the lungs or elsewhere, prior to all in- 
flammatory changes. 
Against the "neoplastic" view, not 
much need be said at this time. Tubercle 
is the pathological opposite of cancer. 
While, in the latter, there is a perverted, 
misdirected excess of formative action, in 
Tuberculosis all the phenomena exhibit 
deficiency of histogenetic energy. Nothing 
is more marked than the absence of vascu- 
larity in every tuberculous mass. The 
reverse is true of cancer. 
That a degeneration of already formed 
tissue-elements takes place as a part of 
the tubercular process, is clearly true. 
But it would appear that this is not the 
central, characteristic fact concerning it; 
and only a portion of the appearances pre- 
sented by its morbid anatomy can be thus 
accounted for. 
The hypothesis of a specific virus of in- 
fection has been overthrown by the care- 
ful investigations of Lebert, Frankel, 
Burdon Sanderson, and Wilson Fox. 
Buhl's "resorptive" theory is well dis- 
posed of by Birch-Hirschfeld,1 as "ana- 
tomically improbable, and never demon- 
strated." It is certainly not impossible 
that, when the lymph-glands are in an 
unhealthy state, corpuscles may pass from 
them into the circulation, then accumu- 
lating in the lungs or elsewhere, and pro- 
ducing obstructive disease. But it is at 
least equally probable, when a constitu- 
tional predisposition has been shown to 
lie behind the one local mal-nutrition, 
that it should also account for the other, 
especially as the order of succession of the 
two is variable, and many instances occur 
of each taking place without the other. 
It remains, then, for me to express the 
conviction, that the essence of Scrofulosis 
or Tuberculosis consists in a defect of tissue- 
forming power; showing itself most con- 
spicuously in the organs of assimilation 
(digestive organs and lymph-glands), in 
those of most active chemical change (the 
lungs, skin, and mucous membranes), and 
in those of least vital resistance (bones 
and joints) on account of their minimum of 
vascular supply. Even in the absence of 
inflammatory irritation, these organs may 
be subject to tissue-abortion, constituting 
tubercular deposit. But, in the scrofu- 
lous subject, a special vulnerability is pre- 
sent, so that slight causes induce inflam- 
mation, which is low in activity and 
prolonged in duration, " strumous inflam- 
mation." Degeneration of the products 
of this morbid process, with that also of 
the tissue-elements affected, causes that 
conglomerate of pathological deforma- 
tions, whose description and explanation 
have been the theme of so much debate. 
Causation.-As an account of the 
etiology of phthisis is given in the article 
by Dr. J. Hughes Bennett upon that dis- 
ease (Vol. II.), a brief summary only is 
here needful concerning that of general 
Scrofulosis. 
Hereditary predisposition is universally 
believed to be a principal factor in the 
production of all varieties of Scrofula. 
Every physician must know instances of 
its occurring in several members of the 
same family, in successive generations. 
Yet statistics show that very many cases, 
especially of pulmonary Tuberculosis, are 
non-hereditary. Dr. Pollock,1 amongst 
1200 cases of phthisis, ascertained it to be 
hereditary in 30 TO per cent. Notwith- 
standing our acceptance of the view that 
Scrofula, affecting the skin, glands, mu- 
cous membranes, and bones, is, constitu- 
tionally, identical with phthisis pulmon- 
alis, it cannot be denied or ignored that 
many children suffering with the former 
grow up and live long lives without laps- 
ing into the latter; while many persons 
die in adult life with phthisis who never 
had glandular enlargement or other signs 
of Scrofula during childhood or youth. 
In promoting the tendency to heredi- 
tary Scrofulosis, impairment of the health 
of parents, from any cause, is undoubtedly 
important. Syphilis has long been be- 
lieved to bear, in this way, a close relation 
to Scrofula. Some have even asserted 
the latter to be, so to speak, a descendant, 
with modification, of the former. Kor- 
tum, near the end of the eighteenth cen- 
tury, vigorously opposed this doctrine ; 
which is now nowhere maintained. The 
relation between the two is, clearly, only 
that belonging to the enfeeblement of vital 
energy brought on by Syphilis, in common 
with all other protracted constitutional 
diseases. 
Smallpox has been charged with a simi- 
lar promotive power. Before the time of 
Jenner, this was, there is reason to be- 
lieve, largely shown. Dr. Greenhow re- 
ports that " during the middle of the last 
century, before vaccination was known, 
the scrofulous death-rate was more than 
five times as great as our present one." 
Of course other sanitary improvements 
may have contributed to this result. 
Intemperance must be supposed to act 
unfavorably in preparing the way for 
every vice of constitution. But it has not 
been shown to promote Scrofula, in the 
children of drunkards, so much as it does 
disorders of the brain and nervous system. 
[* Second Report of Hospital for Consump- 
tion, Brompton, 1863.] 
[* Ziemssen's Cyclopaedia, loc. cit. ] SCROFULA. 
508 
Consanguineous marriages are com- 
monly thought to favor Scrofulosis in the 
offspring of parents nearly related. 
Whether this is really the case when no 
family taint had previously existed, has 
been much disputed. At least it is 
true that such a taint is aggravated, 
and is more likely to be manifested, 
in those who issue from parents of 
the same stock. If two scrofulous per- 
sons marry, whether blood-relations or 
not, the probability of an inheritance of 
the predisposition by their children is 
four times as great as if only one of the 
two were scrofulous and the other of a 
faultless constitution. At least this fol- 
lows from the assumption, apparently 
well grounded, that the mingling of " pure 
blood" in marriage with that which is 
tainted, tends to subtract from, or an- 
tagonize, the morbid procreative influence. 
Climate is more important, apparently, 
in regard to the prevalence of pulmonary 
than of glandular Scrofulosis. The sta- 
tistics of the United States show that the 
Northern States have more deaths from 
consumption than the Southern; but 
there is no evidence that so great a differ- 
ence exists in the comparative prevalence 
of general Scrofula. Probably, however, 
while no race nor climate is free from it, 
the artificial conditions of life induced by 
the need of protection from cold, in the 
higher latitudes, make all forms of Scro- 
fula more common, especially in cities, in 
the temperate and cold than in tropical 
regions. 
Change of climate, from a warmer to a 
colder one, has undoubtedly an effect, in 
many cases, in promoting Tuberculosis. 
This is seen in the Negro race, especially, 
when transported to a northern country. 
Monkeys, taken to England, not unfre- 
quently die of consumption. All domestic 
animals, however, are liable, much more 
than the same in the wild state, to tuber- 
cular disease. This has been abundantly 
shown to be the case with the cow, when 
confined in the stable ; also with the sheep 
and the rabbit. Animals naturally wild 
and active in their habits, as the lion, 
tiger, elephant, &c., often die of tubercu- 
lous disease when confined in menageries. 
This appears to be irrespective of climate, 
depending upon the unnatural change in 
their mode of life. 
Dampness of locality has been shown, 
most fully by Dr. Bowditch in this coun- 
try, and Dr. Buchanan in Great Britain, 
to favor Tuberculosis. A. Keith Johnson 
recorded the statistical fact that, in the 
cities of Europe, the mortality from con- 
sumption is in direct proportion to the 
nearness of a locality to the level of the 
sea. This general law has been approxi- 
mately confirmed in America. 
Habitually breathing foul air, made so 
by confinement of persons together in ill- 
ventilated factories, workshops, and dwell- 
ings, is a potent agency in generating 
Scrofulosis. This cause is aided, no doubt, 
by the exclusion of sunlight; as among 
those who work and live in mines. Bau- 
delocque, Carmichael, Arnott, MacCor- 
mac, and Parkes are among those who 
have especially forwarded the demonstra- 
tion of this practically momentous fact. 
Nothing could be more cogent in this re- 
spect than Dr. Parkes's exposition of the 
excessive mortality from consumption of 
British soldiers, living in barracks, in 
various parts of the world. 
Poverty promotes Scrofula, by almost 
compelling close habits of living, in cold 
regions. Also, it involves another very 
serious cause of vital depression, namely, 
deficiency of food. Prof. Bennett has em- 
phasized this as perhaps the most influen- 
tial of all the causes of Tuberculosis. 
Impropriety of food for children, amongst 
ignorant people, whether poor or not, 
acts, evidently, in a similar manner. Dr. 
Tanner states' that during the cotton 
famine in Lancashire, in 1862-63, the 
mortality of infants among the manufac- 
turing population diminished greatly. 
The mothers, who, when at work, ne- 
glected their children, being then unem- 
ployed, attended to feeding them in the 
natural manner; and could less afford, 
moreover, to stuff them with unsuitable 
food. Birch-Hirschfeld2 cites the state- 
ment of Huss, that Scrofulosis is very fre- 
quent in Schonen, the richest province of 
Sweden, where infants, almost as soon as 
they are born, are fed on coffee, sour 
bread, and potatoes. The same author 
asserts that a similar condition of things 
occurs in thrifty districts of Bavaria, 
Saxony, &c. 
An inquiry is alluded to by Birch- 
Hirschfefd, in regard to the possibility of 
the generation of tubercle in human sub- 
jects by their being fed with milk from 
cows having the pearl -disease. Schiippel 
is considered to have shown the identity 
of this affection with Tuberculosis. 
Gerlach, Klebs, Chauveau, and others,3 
have found it possible to produce tubercu- 
lization in animals by feeding them on 
such milk. The pearl disease is not un- 
common amongst cattle in many places. 
It is, therefore, a not unimportant ques- 
tion, whether there is any proportion, in 
such localities, between the prevalence of 
pearl disease in milk cows and Tubercu- 
losis in human beings. At present, there 
seems to be no actual proof of the occur- 
rence of such a coincidence or result. 
Insufficiency of clothing is another of the 
[' Practice of Medicine, Phila. ed., p. 109.] 
[2 Ziemssen's Cyclop., loc. cit.] 
[3 Bollinger, on Tuberculosis by Inocula- 
tion and Feeding. Arch. f. exp. Pharm. und 
Pathol., vol. i. Nos. 4 and 5, 1873.] TREATMENT. 
509 
means by which the poor are often, in the 
colder climates, made to undergo depres- 
sion of vital power, promotive of Scrofula. 
Prevention of the healthy action of the 
skin must impede the removal of impuri- 
ties from the blood. The action of cold, 
too, interferes with the regularity and 
balance of the circulation, not only of the 
blood, but also of the lymph and chyle. 
Thus both the glands and the lungs are 
made vulnerable, and the whole system 
suffers damage to its recuperative ca- 
pacity. 
Treatment.-This must be adapted, 
first, to the constitutional cachexia ; and, 
secondly, to the local disorders present. 
A tuberculous mother is not likely to 
furnish perfect nutriment to her infant 
from her own breast. Many authors ad- 
vise, therefore, that such should never 
suckle their offspring. 
This counsel is judicious, if an alto- 
gether healthy and reliable wet-nurse 
can be obtained. If not, it may be best 
for the mother, when her milk is abun- 
dant, to nurse the child through the ear- 
lier months of infancy, and then gradu- 
ally to wean it. Much experience shows 
that even very feeble women often give 
the best of their substance to their babes, 
which thrive upon it while the mothers 
waste. 
When it is weaned, cow's or goat's milk, 
little if at all diluted, is the nourishment 
to be preferred for the infant. Care is 
needful that solid food be not given too 
soon, and unsuitable, indigestible articles 
never. If the child's appetite be poor, 
and especially if it rejects milk, concen- 
trated animal food, as beef-tea, should 
be afforded to it. The indication for a 
highly nitrogenized diet is never more 
clear at any time of life, or in any con- 
dition, than in a growing infant whose 
powers of assimilation are low. Fatty 
food, moreover, as we have already seen, 
is especially pointed out as desirable for 
the scrofulous in early life. Cream and 
good sound butter are its most available 
examples; but beef and (more doubtfully) 
mutton gravy are sometimes also accepta- 
ble and useful. 
Fresh air is a cardinal requirement in 
the hygiene of those having the tubercu- 
lous predisposition. The country will be, 
for them, better than the town, and active 
out-of-door interests and pursuits better 
than those which are sedentary. Too 
long confinement in the nursery or school, 
or, worst of all, the workshop, factory, or 
mine, may entail the doom of early death or 
lingering disease upon those whom the life 
of the harvest-field or the mountain-side 
might have made robust and of good lon- 
gevity. 
Bathing is another hygienic measure of 
much prophylactic value. During in- 
fancy, tepid bathing is usually the best; 
reaction against cold being then uncertain 
or imperfect. Later, as resistance is 
shown to increase, moderately cold or cool 
water, especially by the shower-bath, or 
salt water, as of the ocean surf, may be 
used. But the notion of hardening deli- 
cate children by severe exposure of any 
kind, is a mistaken one, fraught with 
danger. 
It is only such degrees of cold as can be 
fully overcome by the natural calorific 
processes of the body, that are ever salu- 
tary. Clothing, for scrofulous children, 
or persons of any age, ought to be suffi- 
cient to protect the body, and, most of all, 
the chest and the feet, against ever being 
chilled. In a climate of extreme and 
sudden changes, like that of the Northern 
United States, such persons should wear 
flannel through the whole year ; lighter in 
summer, and heavier in the winter, spring, 
and autumn. The protection afforded by 
silk next to the skin is probably quite as 
great, against vicissitudes ; but the stimu- 
lus of flannel to the circulation of the skin, 
and its absorbent porosity, are advan- 
Mges. Careful avoidance of dampness of 
dwellings and localities, is, of course, of 
great consequence. 
Of medicines believed to be anti-scrofu- 
lous, iodine was, thirty or forty years ago, 
the most trusted. Lugol's essays on the 
effects of iodine in Scrofula wrere trans- 
lated from the French and published in 
London in 1831. "Lugol's Solution" be- 
came the standard remedy, for a long 
time, for Scrofula as well as for goitre. 
Its external use for tumors of all kinds 
was much relied upon. Like other over- 
rated medicines, it has now fallen into 
undeserved neglect. Iodide of potassium, 
however, holds its place in the treatment 
of many disorders, especially constitu- 
tional syphilis ; but it is seldom mentioned 
by authors at the present day in connec- 
tion with Scrofula or Tuberculosis. 
Chloride of calcium and chloride of 
barium have both been advocated by a 
few practitioners, as having anti-strumous 
power. In consumption, particularly, the 
phosphate and hypophosphite of calcium 
have been much lauded and largely used. 
Dr. Churchill, of Paris, attracted general 
attention to this medication about twenty 
years ago. Dr. W. Minor Logan, of Cin- 
cinnati, has emphasized the significance 
of the well-known pathological fact, that 
phosphate of calcium is always present in 
tubercular deposits in large amount. The 
result of the trial of the phosphates and 
hypophosphites by the profession has been 
their failure to sustain general confidence 
in their value in Tuberculosis. My own 
use of them in the treatment of consump- 
tive patients in the Episcopal Hospital of 
Philadelphia, some years ago, as well as 
in private practice, has convinced me that 510 
SCROFULA. 
they cannot, at all events, compare with 
cod-liver oil in analeptic power. 
Dr. AV. M. Logan reports a number of 
cures of phthisis by the use of nitric acid 
internally (30 or 40 drop doses) after 
meals, with tincture of chloride of iron ; 
along with suitable hygienic measures. 
Cod-liver oil, which had been for a long 
time a common remedy for chronic rheu- 
matism, in the coast-regions of Germany, 
Holland, and Great Britain, came into 
use for consumption first in Germany, be- 
tween 1830 and 1840. The introduction 
of it to the knowledge of the profession in 
Germany is credited especially to Schuette; 
in Great Britain to Percival, Donovan, 
and Hughes Bennett; in America to G. 
B. Wood. Its value in the treatment of 
phthisis has been placed beyond doubt; 
and no one has so well expounded the ra- 
tionale of its analeptic action as Prof. J. 
Hughes Bennett.1 
Numerous other remedies have had a 
temporary reputation in the general treat- 
ment of different forms of Tuberculosis. 
One more may be mentioned : koumiss, a 
fermented drink made from mare's or 
cow's milk, used of late years by the 
physicians of Russia. Referring to the 
article by Dr. Bennett on Phthisis (Vol. II.) 
for the special therapeutics of that malady, 
our attention may be given now, in part 
retrospectively, to the treatment of other 
forms of Scrofulous disease. 
Iodine has certainly disappointed the 
hopes of many of those who have used it, 
both internally and externally, with the 
hope of its dissipating glandular or other 
tumors. Yet it would seem reasonable, 
from the evidence accumulated, to employ 
it in moderate doses, especially the iodide 
of iron, in the early treatment of scrofu- 
lous glands. Externally, in tincture or 
ointment, it appears to act simply as a 
stimulant to the circulation of the part, 
without other specific effect. Indeed, the 
expectation of finding any specific against 
Scrofula has now very much passed away. 
If scrofulous glands are inflamed, they 
may be treated like other local inflamma- 
tions ; seldom with the prolonged applica- 
tion of cold, as the "phlogosis" is not apt 
to be intense ; but with soothing poultices 
of bread, slippery-elm bark, or flaxseed 
meal. In all strumous inflammations, of 
the glands, conjunctiva, and bones, I 
have become convinced that the local 
application of carbonate of lead is more 
serviceable than it is in other inflamma- 
tory affections. It is best applied in the 
form of an unguent, made by adding two 
drachms of the carbonate to an ounce of 
simple cerate. 
Cod-liver oil has not shown any remark- 
able power in removing glandular tumors. 
Its recuperative influence, however, in all 
states of defective nutrition, gives reason 
for employing it in general Scrofulosis. 
It certainly does good in cases of caries, 
&c., of the bones. Children dislike it less, 
proportionally, than adults. Beginning 
with small doses, they may be increased, 
until a child of ten years of age may take 
two tablespoonfuls or more in a day. 
Iron is indicated, particularly in the 
feebler cases of Scrofulosis. The syrup of 
the iodide, already mentioned ; or Blan- 
card's pills ; or the citrate, lactate, pyro- 
phosphate, or other chalybeate prepara- 
tions may be used. It should be remem- 
bered (as mentioned in the article on 
Chlorosis) that iron will not always agree 
well, even with anaemic patients. Head- 
ache and indigestion, and sometimes 
feverish symptoms, will, in such cases, 
show that the dose is too large, or that it 
had better be withdrawn for a time. 
The measures of local treatment of 
scrofulous otitis and otorrhoea, as well as 
of ophthalmia, ostitis, and periostitis, 
fungous arthritis of the knee, coxalgia, 
and Pott's disease of the spine, are, in 
detail, most appropriately set forth in 
works on Surgery, general and special. 
A few suggestions only, from the stand- 
point of the medical practitioner, will be 
in place here. 
Scrofulous inflammation, in any part, 
undoubtedly requires and bears less active 
depletory treatment than that of any 
other type. Leeching inflamed strumous 
glands, for instance, is rarely to be thought 
of; and local abstraction of blood is only 
likely to do good in a few cases of scro- 
fulous inflammation of the ears, eyes, 
bones, or joints. Emollient applications 
are, in the early stages, usually the most 
suitable. For continued discharge from 
the ear, lime-water (poured into the ear, 
gently, rather than injected with a sy- 
ringe) is an excellent application. Solu- 
tion of Castile soap; glycerin and rose- 
water (one part in five); and, if the 
discharge be copious and obstinate, solu- 
tion of acetate of lead (one or two grains 
in the ounce of water), are among the 
lotions available in this complaint. For 
an attack of earache, a drop or two of 
laudanum, with two or three drops of 
olive or almond oil, or glycerin, may be 
poured into the ear. 
Leaving strumous ophthalmia to the 
surgeon and oculist for particulars of 
treatment, mention may be made of my 
own experience of the benefit obtained 
from the nightly application of cerate of 
carbonate of lead on the outside of the 
eyelids, upper and lower ; this treatment 
being persevered with for a considerable 
time. White precipitate ointment is an 
old application, and a favorite with many 
physicians, in similar cases. 
In scrofulous periostitis of the tibia, I 
have been in several cases surprised with 
[* Vol. II. loo. cit.] TREATMENT. 
511 
the improvement following the free appli- 
cation of the cerate of carbonate of lead, 
attended in more than one instance by 
the subsidence of the swelling, tender- 
ness, and pain, which, in the same pa- 
tients, had on previous occasions heralded 
prolonged troubles, with caries and ne- 
crosis. 
In one case of "cold abscess" of the 
hypogastric region, attended with febrile 
symptoms, the application of the lead 
cerate freely over the abdomen was fol- 
lowed by recovery in about three weeks 
from the commencement of the treatment. 
Surgical management of these abscesses 
need not be here discussed ; but reference 
may be made to Lister's assertion of the 
safety and advantage of opening them 
freely in many cases, using the antiseptic 
method of operation and subsequent 
dressing.1 
For coxalgia, the treatment by pro- 
longed rest, by aid of a carved splint, is 
associated in American practice with the 
name of Dr. Physick, of Philadelphia. 
Dr. Henry G. Davis, of New York, claims, 
apparently with reason, to have been the 
first2 to add an important principle to 
this, in the management of all chronic in- 
flammations of joints, namely, the removal 
of pressure through separation of the ends 
of the bones, by extension of the limb, or 
other part affected. Elastic extending 
bands serve an excellent purpose here ; 
and not only great relief of suffering, but 
cures, otherwise improbable, have been 
obtained by skilfully constructed and 
watchfully used apparatus. 
Dr. L. A. Sayre, of New York, has 
made known to the profession, within a 
few years, his successful application of 
this principle in the treatment of Pott's 
disease of the spine, by a suspending ap- 
paratus and "plaster jacket." Dr. B. 
Lee, of Philadelphia, and others, use a 
porous felt jacket instead. 
For chronic arthritis of the knee, wrist, 
&c., Trousseau and Dieulafoy have in- 
sisted on the great value of the prolonged 
application of cataplasms. Trousseau's 
cataplasm is made by preparing a poul- 
tice of soaked and steamed bread of a 
"plum pudding" consistence, over which 
is spread a liquid mixture, composed of 
seven parts of camphor, five parts each of 
extract of opium and extract of bella- 
donna, and alcohol q. s. This is applied to 
the joint, covered with oiled silk, and se- 
cured by a flannel bandage over the whole 
joint, over which is bound a calico band- 
age of the same length. It is intended to 
be left on for eight or ten days at a time. 
Returning to Scrofulosis of the glands, 
mucous membranes, and bones, the ad- 
vantageous effect of soft soap upon glandu- 
lar tumors has been asserted by Kapcsser ;* 
in two cases their disappearance resulting, 
followed by rapid recovery also from 
strumous ophthalmia. 
Dr. J. Moleschott, of Turin,2 after an 
experience with it of many years, has re- 
ported that iodoform exhibits remarkable 
power in promoting the removal of scrofu- 
lous glandular enlargements, as well as of 
other accumulations of "formative ele- 
ments and exuded fluid." He prefers 
the application with a brush at night, or 
night and morning, of a combination of 
one part of iodoform with fifteen of elastic 
collodion, or an ointment of the same 
strength.3 
Lastly, allusion must be made to the 
benefit often obtained from massage, with 
inunction, in the management of general 
Scrofulosis. Massage alone, while no 
doubt sometimes beneficial in various 
conditions of debility, has been, in some 
quarters, overrated and overdone. But 
systematic inunction of the whole body, 
in like states of torpor and debility, has 
not received full justice on the part of the 
profession. The wisdom of the ancients 
has, in this, been too little esteemed. 
While it is true that no large amount of 
oleaginous material is absorbed through 
the skin, experience shows that the dispo- 
sition to excessive waste is thereby les- 
sened ; and this is no small part of the 
pathogeny of advanced or advancing 
scrofulous disease. Diminution of general 
irritability of the system is also thus pro- 
moted. Simpson, Inman, E. Wilson, W. 
Taylor, and other British writers have 
favored this practice ; as well as W. R. 
Fisher, W. II. Thompson, E. C. Angell, 
and others in this country.4 Dr. S. Weir 
Mitchell, who strenuously advocates mas- 
sage in cases of nervous debility, encour- 
ages inunction with cocoa oil or vaseline.5 
For scrofulous patients, as well as others, 
olive or cocoa oil may be recommended ; 
although, but for its odor and comparative 
cost, the preference might be awarded to 
cod-liver oil.] 
[' Berliner Klinische Wochenschrift, Feb. 
11, 1878.] 
[2 Giornale della Reale Accademia di Torino; 
cited in London Medical Record, Nov. 15, 
1878.] 
[3 The odor of iodoform is somewhat un- 
pleasant ; but, if used only at night, it can 
be removed by soap and water in the morn- 
ing. Its preparations should be protected 
from the light, which causes their decompo- 
sition.] 
[4 See the Sanitarian, New York, Novem- 
ber, 1878.] 
[5 Fat and Blood, and How to Make Them. 
Phila., 1877, p. 54.] 
[' Med. Times and Gazette, Nov. 1878.] 
[2 Boston Med. and Surgical Journal, Au- 
gust, 1852.] 512 
GOL'T. 
GOUT. 
By Alfred Baring Garrod, M.D., F.R.S. 
Definition.-1. Regular Gout.-A spe- 
cific form of articular inflammation inva- 
riably accompanied with uric acid in the 
blood, and the deposition of urate of soda 
in the affected tissues. 
2. Irregular Gout.-(a) The same spe- 
cific inflammation of non-articular tissues, 
or (b) disturbance of the functions of vari- 
ous organs, accompanied with the same 
abnormal state of the blood. 
Synonyms.-Of Regular Gout.-Poda- 
gra (rtovj, the foot, and aypa, a seizure) ; 
Chiragra (£*<)), the hand) ; Gonagra (ywv, 
the knee): the first only of these syno- 
nyms has been much employed. Arthri- 
tis (apOpov, a joint), a term used for general 
gout by the ancients, has been applied also 
to other joint affections by both ancient 
and modern writers: Goutte, French; 
Gutta, Latin; Gota, Spanish; Gicht, Ger- 
man; terms probably derived from the 
idea of the dropping (Gutta, a drop) of a 
morbid fluid into the joints-first used in 
the thirteenth century by Radulphus. 
Of different forms of Irregular Gout.- 
Non-articular Gout, Anomalous Gout; 
Podagra larvata, Goutte larvee, Goutte 
vague; Misplaced Gout, Retrocedent Gout. 
History.-Gout was well known to 
Hippocrates, and his account of the dis- 
ease shows that he was well acquainted 
with many of its salient phenomena ; his 
remarks upon the seasons of the year at 
which it is most likely to occur, the sub- 
jects which it more commonly attacks, the 
alterations in structures it induces, the 
probable nature of the malady, and the 
difficulties experienced in effecting its cure, 
are well worthy of careful study. 
Prom the time of Hippocrates almost 
every ancient writer on medicine has 
made reference to the subject of Gout. 
Galen speaks of the difference between 
the times in which he lived and those of 
Hippocrates, in respect to the character 
of the subjects afflicted with Gout. Seneca 
also alludes to the same topic; and ac- 
counts of the disease, more or less com- 
plete, may be found in the writings of Cel- 
sus, Aretseus, Coelius Aurelianus, Alex- 
ander Trallianus, Aetius, Paulus JEgineta, 
Demetrius Pepagomenos, and others. 
Nearly all these authors were humoralists, 
and of opinion that the disease depended 
upon the retention of certain matters in 
the blood (as bile, phlegm, &c.), caused 
by imperfect digestion or deficient excre- 
tion ; and that these humors, or even the 
diseased blood itself, were thrown upon 
the textures of the joints, and thus gave 
rise to the production of inflammation, and 
the frequent formation of tophi, or chalk- 
stones. 
Divisions and Classification of Gout.-It 
is stated in the definition that Gout may 
manifest itself, simply, in the form of in- 
flammation of one or more joints, or as 
inflammation of some non-articular struc- 
ture ; or by causing an alteration in the 
functions of certain organs; and these 
latter manifestations may either be inde- 
pendent of, or accompany the articular 
affection. 
When the joints are solely or princi- 
pally involved, the disease may be conve- 
niently designated regular or articular 
Gout, which may be either acute or 
chronic; but when severe affections of in- 
ternal organs ensue, or when inflamma- 
tion of tissues, other than those pertain- 
ing to the joints, arises from the presence 
of Gout, these affections are know n by the 
name of irregular or non-articular Gout. 
The whole phenomena of the disease can 
be conveniently discussed under these tw'O 
Jieads. 
Description of an Attack of Acute Gout, 
and of the Progress of the Disease.-Under 
this heading will be included first a sketch 
of an early and uncomplicated attack of 
Gout, as ordinarily met with in practice ; 
next, an account of the progress of the 
disease when unchecked by hygienic or 
medicinal means ; and this task being ac- 
complished an analysis will be made of 
the different symptoms exhibited during 
the paroxysm, and of any structural al- 
teration caused by it. In many instances 
the first attack of articular Gout comes on 
without previous warning ; or, if there be 
premonitory symptoms, they are so slight 
as to pass unnoticed by the patient. This 
absence of warning, however, is by no 
means so common as is usually supposed, 
and I have met with several cases in 
which the premonitory symptoms have 
been very distressing; although before 
the seizure they wTere not suspected of 
being the precursors of any joint affection. 
Under ordinary circumstances, an indi- 
vidual retires to rest in his usual health, 
but early in the morning, usually from HISTORY. 
513 
two to five, awakes with an uneasy feel- 
ing, probably confined to one of his great 
toes ; on attempting to place his foot on 
the ground, he finds himself unable to 
support the weight of his body, or, if capa- 
ble of so doing, the act is accompanied 
with great pain. 
If the painful part, generally the ball of 
the toe, be examined, it is found to be 
swollen, red, hot, and exquisitely tender, 
and sometimes to such an extent that the 
mere weight of the bed-clothes is intolera- 
ble, and even the vibration of the room 
causes discomfort. The veins proceeding 
from the toe are turgid with blood, and 
the joint stiff. Although occasionally no 
constitutional disturbance is present, yet 
more frequently there is evidence of slight 
fever ; the patient has a feeling of chilli- 
ness, followed by heat of skin and perspi- 
ration, some thirst and loss of appetite, a 
white tongue, and confined bowels, with 
great restlessness, and is unable to find 
an easy position. The urine is usually 
small in quantity, high-colored, and de- 
posits, on cooling, a sediment varying in 
color from pale buff to brick-dust red ; 
occasionally when febrile disturbance runs 
high the fur which encrusts the vessel is 
of intense pink color ; cramps of the legs 
are often present during an attack, and 
add much to the sufferings of the patient. 
If moderate precautions are taken, and 
the foot kept in a horizontal position, the 
inflammation usually subsides in the early 
part of the day, but at evening an exacer- 
bation takes place, and for the greater 
part of the night the patient is kept awake 
by the pain, which again subsides as morn- 
ing advances. 
After a day, or as soon as the swelling 
increases, considerable relief is experi- 
enced, and in a few more days the tension 
becomes diminished, as well as the heat 
and livid redness, and slight sustained 
pressure will then cause distinct pitting. 
Subsequently, as the cause disappears, 
desquamation of the cuticle takes place, 
and occasionally the skin peels off in flakes 
of considerable size. Not all cases, even 
of first attacks, assume this sthenic form; 
in weakly subjects, and especially in wo- 
men, the fit may have an asthenic charac- 
ter ; the pain and heat may be slight, the 
redness and swelling by no means well 
marked, yet as far as ultimate mischief is 
concerned, this variety is often much 
worse than the other. 
The duration of the joint inflammation 
varies considerably in different cases, and 
is much influenced by the diet and regi- 
men adopted, and likewise by the medi- 
cines administered. If no material change 
is made in the diet, and no remedies 
taken, the inflammatory action seldom 
subsides under a week or ten days, and 
occasionally it lasts two or three weeks: 
but, under more favorable circumstances, 
the duration of the fit is usually limited 
to four or five days. After the complete 
subsidence of the joint affection, the pa- 
tient not infrequently expresses himself 
as feeling lighter and altogether better 
than before its occurrence. It will be 
seen that the ball of the great toe has 
been mentioned as the joint especially 
chosen as the seat of the gouty seizure, 
and it is a remarkable fact, that a patient 
may experience repeated attacks of Gout 
in this one joint, without either the tarso- 
metatarsal or the phalangeal articulations 
being in the slightest degree implicated. 
It is not an uncommon occurrence for 
both great toes to be attacked, even in a 
first fit of Gout, sometimes simultaneous- 
ly, but more frequently alternately, the 
inflammation rapidly subsiding in one toe, 
and as quickly appearing in the other. 
Sometimes other joints, as the ankle, are 
affected at the same time as the toes, and 
occasionally the knees, or more rarely 
some joints of the upper extremities. 
In many instances, some two or three 
years elapse before the occurrence of the 
second attack, but in the majority of cases 
not more than twelve months; and then 
either the same joint as in the first seiz- 
ure, or the corresponding joint in the 
other foot, is usually affected. Similar 
intervals elapse between the next few pa- 
roxysms, and again the same joints are 
implicated, or the inflammation extends 
along the foot, involving the articulations 
of the arch and the ankles. 
As time goes on, the disease becomes 
more general, and almost every joint of 
the extremities suffer, those of the lower 
usually taking precedence of those of the 
upper limbs. The hips and shoulders are 
perhaps less liable to be attacked than the 
rest, although they do not necessarily es- 
cape. In exceptional cases, other articu- 
lations, as the spine and jaw, become the 
seat of gouty inflammation. 
In the course of years, the intervals be- 
tween the attacks diminish still more- 
the yearly visitations become half-yearly; 
afterwards the attacks recur every few 
months, until at length the patient can 
scarcely calculate upon being free, so nu- 
merous and uncertain are the visitations 
of his malady. 
Phenomena occurring during an Acute 
Gouty Attack.-It will be interesting to 
examine a little in detail the phenomena 
which present themselves during an acute 
paroxysm of Gout, for our diagnosis must 
be founded in part upon the peculiarities 
exhibited at such a time. 
1. Febrile disturbance.-The febrile dis- 
turbance, indicated by heat of skin, tem- 
perature of axilla, thirst, loss of appetite, 
and rapid pulse, is almost invariably in 
close relation to the number of implicated 
joints, and the intensity of the inflamma- 
tory action; in other words, the fever is 
vol. I.-33 514 
GOUT. 
secondary, and dependent on the joint 
affection. It is important to remember 
this fact, because it will be found that in 
some other diseases - for example, in 
acute rheumatism-a patient may exhibit 
all the symptoms of intense febrile excite- 
ment, at a time when the joint affection 
is scarcely appreciable. 
2. Local Appearances.-The appearance 
of the inflamed joint is usually character- 
istic ; there is much swelling present, and 
enlargement of the veins proceeding from 
the joint, also great tension of the skin. 
As the inflammation subsides, pressure 
produces distinct pitting, indicating the 
presence of oedema. After a further in- 
terval, desquamation of the skin almost 
invariably occurs, usually in a marked 
degree. 
There is a point connected with gouty 
inflammation which is not without inte- 
rest-namely, the fact, that however acute 
in character, it never leads to the forma- 
tion of pus. An inflamed joint may be 
intensely red, even scarlet, the skin shining 
from the distension, and it may altogether 
exhibit the appearance of suppuration; 
yet all these symptoms quickly subside, 
and by resolution merely. When it is 
stated that a part affected by gouty in- 
flammation never suppurates, it should 
be added, unless previously the seat of 
chalk-like deposits; in which case it is not 
uncommon to find matter formed around 
such concretions, this formation of pus 
being probably due not to gouty, but to 
common inflammation set up around pre- 
viously existing deposits, which have by 
their presence acted as foreign and irri- 
tating bodies. In enfeebled conditions of 
the system, such an occurrence is fre- 
quently met with. 
The pain which attends the joint affec- 
tion must not be overlooked. It is a com- 
mon opinion that gouty pain is very in- 
tense, a degree more so than that arising 
from other articular inflammation. Doubt- 
less this is often the case, but it sometimes 
happens that an acute attack of Gout may 
be nearly painless, the amount of suffering 
depending much on the rigidity of the 
structure of the affected articulation as 
well as the peculiarities of the patient. 
The first attack of gouty inflammation in 
a joint-for example, in the wrist-may 
be attended with exquisite pain, but in 
subsequent seizures this symptom may be 
comparatively slight. 
. (Edema of the affected part has been 
specially mentioned among the peculiar 
symptoms of gouty inflammation; and 
although it now and then occurs in other 
forms of inflammation, yet is it scarcely 
ever absent in Gout, it is owing to the 
presence of the oedema that so great ten- 
sion usually accompanies the swelling, 
and probably the subsequent desquama- 
tion of the cuticle is also partly due to it. 
Not only does effusion occur in the tex- 
ture of the skin, but, when a synovial 
membrane is inflamed, a large amount of 
fluid is generally poured into the joints, 
or, when bursse are implicated, they be- 
come rapidly filled ; this copious effusion 
frequently causes considerable alteration 
of shape in the joints. 
Joints affected in Gout. - In giving a 
sketch of the progress of Gout, allusion 
has been made to the order in which dif- 
ferent joints are affected as the attacks 
become multiplied, and it was then stated 
that the great toe is commonly selected as 
the first seat of the disease. The extreme 
frequency of the selection not only of the 
great toe itself, but even of a particular 
joint of this toe, is a fact so peculiar as to 
make it desirable that a few lines should 
be devoted to the consideration of the 
subject. 
The joint of the great toe, so commonly 
the early seat of gouty inflammation, is, 
as before stated, the metatarso-phalangeal 
joint, ordinarily termed the ball of the 
great toe: and from a table collected by 
the late Sir C. Scudamore, it would seem 
that in 512 cases of Gout, at its first 
seizure, the great toe was implicated in 
373 cases ; and in 341 out of 512 cases, one 
or other, or both, great toes were affected, 
to the exclusion of other parts. My own 
experience fully confirms the general ac- 
curacy of these numbers; but it should 
not be forgotten that this joint occasion- 
ally escapes altogether, and cases of se- 
vere Gout, accompanied with excessive 
deposits, have come under my care - 
cases of at least twenty years' duration-- 
in which the great toes have throughout 
remained free 'from disease. The occur- 
rence of inflammation confined to the 
metatarso-phalangeal joint of the great 
toe always conveys suspicion of the exist- 
ence of a gouty habit: but it requires cau- 
tion before making a diagnosis from this 
symptom alone, as the joint may be for a 
time exclusively inflamed in other and 
more serious conditions of the system. It 
is not, however, the great toe which is 
always first attacked; for it often happens 
that an injury to the knee, caused by a 
fall from a horse, will induce the first de- 
velopment of Gout in that joint, although 
after a short time the great toe may be 
likewise affected. Even an old injury 
will, as it were, attract Gout to the dam- 
aged part, and cause it to linger there 
longer than in other localities. 
It is a very common remark that Gout 
differs from rheumatism in implicating 
the smaller articulations of the body. 
This is doubtless true, if it has reference 
solely to the earlier attacks, but after a 
time the larger and smaller joints appear 
to be indiscriminately affected. It is not 
uncommon to hear a patient calling his 
disease Gout as long as it is confined to HISTORY. 
515 
the feet, but rheumatism or rheumatic 
Gout when the upper extremities become 
attacked, although the same condition of 
the system which causes the one gives rise 
to the other also. 
There are certain joints of the extremi- 
ties which appear to.be less liable to suffer 
from Gout than others. Of these the hips 
and shoulders are the chief: still, it must 
not be thought that even these joints are 
unassailable by the disease, for they are 
sometimes severely affected. 
After-effects of Acute Gout.-It has been 
stated above that, after an attack of acute 
Gout, especially if an early one, the pa- 
tient not unfrequently expresses himself 
as feeling even better than before the 
seizure, the affected joint recovers, to all 
appearance, its natural size, the tender- 
ness entirely subsides, and its power of 
movement is not perceptibly interfered 
with. To explain this improvement is 
not difficult. During the occurrence of 
the inflammation, the blood, as we shall 
find, loses to a great extent, if not entirely, 
the morbid condition which previously 
existed, and hence the disappearance of 
the malaise; and the joint, although, as 
will be proved, decidedly altered by the 
attack, may yet be not sufficiently changed 
to interfere with its normal functions. 
This favorable termination is by no means 
constant, for as the disease continues to 
make progress, and the joints have been 
more frequently attacked, some little re- 
maining stiffness is commonly expe- 
rienced, due in part to mischief which is 
irremovable, in part to thickening of the 
tissues and enlargement of the vessels, 
which are long in recovering their natural 
condition. 
At times, even an early attack of Gout 
may lead to much mischief; when, for 
example, the feet are allowed to remain 
inflamed for any lengthened period, either 
from want of treatment, or from treat- 
ment injudiciously applied, considerable 
oedema may remain long after all pain and 
heat have subsided-a state often requir- 
ing special treatment for its removal. 
This result I have several times witnessed 
in patients who have allowed the disease 
to run its own course, and also after ho- 
moeopathic treatment. Occasionally an- 
chylosis of a joint occurs even after a few 
attacks; in some of these cases it is prob- 
able that disease of the joint previously 
existed, although not in itself sufficient to 
produce appreciable inconvenience; in 
others, active and injudicious treatment, 
as the application of leeches to the joint, 
has been the cause of the mischief. 
Number of Joints affected.-In our de- 
scription of an attack of acute Gout, we 
have taken as an illustration a case in 
which only the metatarso - phalangeal 
joint, or the ball of a great toe, has been 
affected. This often happens in the first 
seizure, and may even occur for several 
years in succession; but sooner or later, 
if the disease continues to make progress, 
not only are other joints implicated, but 
several are affected either at the same 
time or in the course of the same attack ; 
and it is not uncommon to find many 
joints, both large and small, of the upper 
and lower extremities, simultaneously in 
a state of acute suffering. When such is 
the case, as the accompanying fever is in 
proportion to the joint affection, the pa- 
tient's malady may easily be mistaken for 
one of acute rheumatism; and unless the 
history is carefully inquired into, the diag- 
nosis is somewhat difficult. 
Premonitory Symptoms of Gout.-Some 
of these are referable to an altered condi- 
tion of the digestive organs ; a form of 
dyspepsia is induced, and the patient ex- 
periences flatulence, often to a very un- 
comfortable degree, accompanied with 
heartburn and acidity. Many gouty sub- 
jects, from the unusual prevalence of 
these symptoms, can predict the advent 
of the acute seizure. In some the func- 
tion of the lower bowel becomes altered, 
and either constipation or diarrhoea en- 
sues. The character of the alvine evacu- 
ations may also be changed. 
A crampy state of the muscles is another 
very common forerunner of a gouty parox- 
ysm, usually in the lower extremities, and 
more especially in the calves of the legs. 
Palpitation of the heart is experienced 
by some patients on the eve of a gouty 
seizure, and this may or may not be ac- 
companied with dyspeptic symptoms. 
In some individuals the respiratory 
function is implicated under like circum- 
stances, and a species of asthma produced. 
At times the urinary secretion undergoes 
a very visible change in character ; from 
being copious and clear it may become 
scanty and turbid. On the other hand, 
the urine sometimes becomes unusually 
abundant and limpid a few hours before 
the establishment of the articular inflam- 
mation. 
In other persons, derangements of some 
portions of the nervous system are pro- 
duced, the temper becomes very irritable, 
unusual drowsiness, or headache, grinding 
of the teeth during sleep, startings of 
limbs, and various other phenomena, may 
be experienced. 
Lastly, it now and then happens that a 
feeling of unusually good health, with ap- 
parent increase of both mental and bodily 
power, is a prelude to a gouty attack. 
All these phenomena are probably de- 
pendent on the altered state of blood which 
always exists previously to the develop- 
ment of articular Gout, and the cause of 
the diversity of the symptoms in different 
persons must be sought for rather in indi- 
vidual peculiarities, and the proneness of 
certain functions to be disturbed, than in 516 
GOUT. 
any variation in the proximate cause of 
such symptoms. When any organ or 
function is implicated in a very marked 
degree, a form of irregular Gout is estab- 
lished, which we will afterwards describe. 
Phenomena of Articular Gout when it 
assumes a Chronic Form.-In Gout, as in 
other inflammatory diseases, it is difficult 
to draw an accurate line between the 
acute and chronic stages; but it is not 
difficult to establish a boundary sufficiently 
well marked for all practical purposes. 
It has already been remarked, that acute 
attacks may come on so frequently, and 
apparently from such slight causes, that 
the patient can never calculate upon being 
free ; but when, in addition to the fre- 
quency of the attacks, their duration is 
prolonged, and a notable change has 
taken place in the structures of the arti- 
culations, the case has assumed the cha- 
racters to which the name of Chronic 
Gout is commonly applied. 
It is a somewhat remarkable fact, that 
although the feet and the joints of the 
lower extremities are usually the seat of 
gouty inflammation, often for many years 
before the hands ; still the latter are fre- 
quently seriously injured when the feet 
have as yet escaped appreciable damage. 
The explanation of this tendency of Gout 
to cause greater mischief in one part than 
another, will be attempted when the 
pathology of the disease is investigated. 
Chalk-stones, or Tophi.-The principal 
changes which take place in parts affected 
with gouty inflammation, are due to the 
deposition of a peculiar chalk-like matter 
in the different structures; and as such 
deposits are not only peculiar to Gout, but 
when capable of being seen become a 
pathognomonic sign of the disease, it will 
be interesting to describe somewat fully 
their nature and origin. 
White spots often appear upon the 
helix of the ear, and an opportunity is 
occasionally afforded of observing the 
whole train of phenomena exhibited from 
the commencement to the full develop- 
ment of the little chalk-stone. The earliest 
appearance presented is that of a small 
vesicle under the skin of the helix, as if 
situated between it and the fibro-cartilage ; 
the contents of the vesicle are at first opa- 
lescent, or milky, but afterwards become 
white and opaque, and acquire the con- 
sistence of cream. After some months, 
the vesicle assumes the appearance of a 
small, hard, and white bead, closely re- 
sembling a pearl, and it may remain as 
such for years ; but occasionally the thin 
skin is worn off, and the bead itself be- 
comes detached from the cartilage, leaving 
only a slight indication of its presence. 
If the vesicle is punctured in the early 
stage, a milky fluid exudes, which pre- 
sents under the microscope the appearance 
of a transparent liquid, in which are float- 
ing a large number of very fine crystalline 
needles ; if the contents are examined at 
a later stage, the crystals are found ag- 
gregated into small bundles ; if the bead 
is solid, it is difficult to separate them, as 
they adhere strongly together, and form a 
closely-interlaced crystalline mass; if, 
instead of the little chalk-white bodies in 
the ear, the formation of deposits in other 
situations is observed, very similar phe- 
nomena are exhibited. 
It will be found as we proceed that al- 
though chalk-stones, or white deposits 
visible upon the surface of the body, are 
far from being constant in cases even of 
long-continued Gout, yet deposition of 
urate of soda invariably occurs within 
some of the structures in every paroxysm; 
and thus stiffening and deformity are 
often induced. When the deposition is 
confined to the cartilages, unless very ex- 
treme, the injury to the mobility of the 
joint is comparatively slight; but when 
the ligaments are infiltrated, they are 
made rigid, and the play of the parts is 
consequently seriously interfered with. 
Much distortion is caused when the bursae 
become infiltrated; this infiltration, at 
times, takes place to an enormous extent; 
but it may be well to state, that the 
amount of secretion of urate of soda has 
no necessary relation to the acuteness of 
the inflammation. 
Without the aid of drawings, it is not 
an easy matter to give even an idea of the 
extent of crippling and deformity which 
occurs in some subjects who have suffered 
from severe chronic Gout. The hands be- 
come greatly altered in appearance : some- 
times, when the deposits are chiefly located 
in the ligaments and tendons, extreme 
stiffening takes place, without any im- 
portant amount of bulging; many of the 
phalangeal joints become rigid and flexed, 
others equally rigid but extended beyond 
the straight line or curved backwards: 
thus the metacarpo-phalangeal of a finger 
may be flexed, the first phalangeal joint 
curved backwards, and the second phalan- 
geal articulation sharply flexed ; one or 
several fingers may be thus affected. At 
other times, not only is there anchylosis 
of several joints, but likewise great depo- 
sition of matter, which causes bulging at 
different points, from the formation of 
concretions more or less hardened. In 
extreme cases, an appearance is presented 
by the hand very closely resembling a 
bundle of French carots with their heads 
forward, the nails appearing to take the 
place of the stalks; sometimes the toes 
are affected, though usually in a less de- 
gree. The bursje over the elbows are 
often distended till they attain the size of 
small oranges ; the bursae over the patellae 
may likewise become enlarged. Deposits 
of different sizes are found along the 
shafts of bones, apparently originating in HISTORY. 
517 
the periosteum; also on the tendinous 
sheaths of some of the muscles; in fact, 
every bursa may be affected, as likewise 
every tendon and membranous structure, 
and thus no limit can be set to the de- 
formity which chronic Gout can produce. 
When external deposits are visible in 
any patient, no possible doubt can exist 
as to the nature of the case, for, as the de- 
position of urate of soda in the tissues oc- 
curs only in Gout, its presence constitutes 
a pathognomonic sign ; but, as before ob- 
served, the occurrence of visible chalk- 
stones is not constant, and it was asserted 
by Sir C. Scudamore that not one gouty 
case in ten exhibited them. This state- 
ment, however, is not correct, for the 
small concretions we have described in 
the ear are extremely frequent, and may 
constitute for many years, or even during 
life, the only visible deposition of urate of 
soda throughout the body; and as they 
produce no amount of inconvenience, they 
may altogether escape notice unless spe- 
cially sought for. Some few years since, 
having been able in some difficult cases to 
make correct diagnosis from the presence 
of these aural deposits, the writer was in- 
duced to investigate the matter, and, in 
thirty-seven cases examined within a 
short period, they were found to be pres- 
ent in sixteen cases; in seven no other 
concretions could be seen; in nine there 
existed deposits around the joints; and in 
one case only were chalk-stones visible 
elsewhere without being present in the 
ears likewise. 
Small chalk-like deposits are found in 
other situations than those above men- 
tioned ; sometimes they can be felt under 
the skin along the tendinous aponeuroses 
of certain muscles, especially those of the 
leg and thigh, varying in size from a flat- 
tened pea to a small bean; they have been 
observed on the sclerotic coat, likewise on 
the tarsal cartilage at the angles of the 
eyes. It is questionable if they ever 
originate in a very vascular tissue such as 
the skin, although it may subsequently 
become pressed upon and involved. 
It has already been stated, that the 
original condition of these deposits is that 
of a liquid, rendered more or less milky or 
opalescent from the presence of acicular 
crystals; that as the fluid part is absorbed, 
the consistence becomes creamy, and at 
last a solid concretion is produced. If the 
effusion has taken place in a bursa, the 
resulting chalk-stone is free and of uni- 
form composition; but, if it has been infil- 
trated in a tissue, the structure of the part 
becomes mixed up with it when solidifica- 
tion occurs; hence the discrepancies which 
have arisen in different statements re- 
garding the composition of chalk-stones. 
Several analyses have been made of 
chalk-stones which have either been re- 
moved during life, or obtained from the 
body after death, and from these it will 
be seen that, omitting the animal matter 
and the soluble salts derived from the 
structures in which the concretions have 
formed, urate of soda is practically the 
only salt which they contain. Possibly 
in some instances, as in a concretion ana- 
lyzed by L'Heretier, the phosphate of lime 
found in large amounts was derived from 
the tissue; but it is not improbable that 
it may be occasionally secreted as the re- 
sult of common inflammation set up by 
the presence of the urate of soda, which 
latter salt has acted as a foreign body, in 
the same manner as tubercular matter 
often becomes infiltrated with bone earth. 
Gouty Abscesses.-When gouty deposits 
increase in size and approach the surface, 
the skin over them becomes gradually 
thinner, and often givesway; a discharge 
takes place, either of a white solid sub- 
stance, should the concretion have been of 
long standing, or of liquid matter, if the 
deposit is more recent; but not unfre- 
quently, however, a mixture of both solid 
and liquid chalk occurs, and thus a gouty 
abscess is established. Such abscesses 
are usually difficult to heal, and may re- 
main open for months, and even years; 
and this is especially the case when the 
morbid matter penetrates to any consider- 
able depth, as, for example, in the neigh- 
borhood of joints; but when in a bursa, 
as that over the olecranon process of the 
elbow, this difficulty is not experienced, 
in fact the healing takes place with as 
much facility as in the case of an ordinary 
abscess. The discharge from these ab- 
scesses may be unaccompanied with pus, 
and consist simply of urate of soda; but 
in exceptional cases, when concretions 
have become very solid, and the patient 
is reduced to a very weak state of health, 
inflammation and suppuration may arise, 
and pus mixed with white fragments is 
then freely discharged. 
It is not uncommon to find that patients, 
in whom chalk-stones have been freely 
formed, have a great number of abscesses 
discharging at one time, and it is aston- 
ishing to see how little disturbance of the 
system is produced by them. Occasion- 
ally five or six such abscesses will be open 
on each hand, and nearly as many on the 
feet; the free outlet thus given to the 
matter appears, in fact, to give relief to 
the system. 
Constitutional Symptoms in Chronic 
Forms of Gout.-It remains, before com- 
pleting the description of chronic Gout, to 
speak of the symptoms which accompany 
the changes of structure above described. 
It may be here assumed (a fact which 
will be afterwards proved) that the blood 
in chronic Gout is always in an impure 
state, and we should expect, therefore, 
that symptoms indicating its irritating 
action upon various organs would be pres- 518 
GOUT. 
ent. This is often the case, and chronic 
dyspepsia, accompanied with acidity, 
heartburn, flatulence, pyrosis, and pain 
after food, are common accompaniments ; 
the bowels are apt to be disordered, and 
the function of the liver impaired, palpi- 
tation and irregular action of the heart 
may be present, and occasionally symp- 
toms referable to the nervous and mus- 
cular systems, as cramps, twitchings of 
limbs, nervous depression, and so forth. 
Although the patient is apt to be afflicted 
with some or even several of the above- 
named miseries, yet it is not always the 
case, for it would seem that in many such 
subjects the system gets gradually accus- 
tomed to the impurity of the circulating 
fluid, and it is only when there is an ex- 
cess of such impurity that they become 
sensible of its presence. 
The urine of patients suffering from 
chronic Gout, with extensive deposit of 
chalk-stones, is generally pale, of light 
weight, and often contains a little albu- 
men ; the occurrence of deposits is rare, 
except about the time of a paroxysm of 
a more acute character. 
Irregular Gout.-1The subject of irregu- 
lar Gout is one of no small difficulty, and 
requires careful handling in order to avoid 
falling into error. Some pathologists ap- 
pear to assume that all the ailments which 
happen to patients subject to Gout neces- 
sarily owe their origin to that diathesis, 
and hence the descriptions given of gouty 
pneumonia, gouty hepatitis, and many 
other inflammatory affections ; but a closer 
investigation of several so-called gouty 
complications has led me to believe that 
they are nothing more than ordinary forms 
of inflammatory disease, modified, indeed, 
to some extent by the diathesis of the pa- 
tient. A man with a gouty diathesis may 
be exposed to cold, and have pneumonia 
developed from such exposure, and yet 
the lung inflammation may not differ in 
its essential character from what occurs in 
a previously healthy person. Such a sub- 
ject is, in fact, as liable to be attacked 
with inflammatory disease as any other 
individual; it is necessary, therefore, that 
good proofs should be shown that a mal- 
ady is truly gouty in its nature, before we 
are justified in coming to the conclusion 
that it is so. On the other hand, it is 
equally important that, the possibility of 
a disease being dependent on a gouty state, 
the habit should not be overlooked, for 
upon a correct diagnosis of such cases 
success in treatment mainly depends. 
As yet we have only described Gout as 
implicating the structure of the joints, or 
at least tissues similar to those of the ar- 
ticulations, and situated near the surface; 
but it must be remembered that like tis- 
sues exist in the deeper-seated parts of 
the body, and it is a question of interest 
to know if they often become affected ; in 
the case of acute rheumatism, in which 
inflammation of the membranes of the 
heart so frequently happens, such occur- 
rences are looked upon as ordinary phe- 
nomena of the disease. 
Retrocedent Gout.-There is a popular 
belief that a patient when laboring under 
gouty inflammation of any joint, if ex- 
posed to cold, is liable to have the local 
malady suddenly checked, and to be at- 
tacked with some acute affection of an 
internal organ, as the stomach, heart, or 
brain ; and when this takes placed the 
term Retrocedent Gout is applied. 
Gout affecting the Nervous System.- 
When the brain or its membranes become 
implicated, the symptoms may be exhib- 
ited in the form of intense pain of the 
head, epilepsy, &c., or the intellect may 
be impaired and delirium ensue. 
Apoplexy has been said to have been 
caused by retrocedent Gout. If the pa- 
tient is suffering from any chronic brain 
disease liable to induce apoplexy it can 
easily be imagined that the suppression of 
articular Gout might cause its rapid de- 
velopment. Serous or congestive apo- 
plexy may possibly result from gouty in- 
flammation ; but these cases are rare: 
the author has not yet witnessed one 
which could be fairly classed under such 
a head; those he has seen have always 
been accompanied with albuminuria. 
A severe form of headache is not very 
uncommon in Gout; sometimes it occurs 
prior to the development of the joint in- 
flammation, and then it usually vanishes 
at once on the occurrence of the latter, 
and now and then the alternation between 
the headache and toe affection is charac- 
teristically and unmistakably marked. At 
times when a patient is suffering from 
Gout in some joint a cessation of the ar- 
ticular pain suddenly ensues ; but this, far 
from being the termination of the disease, 
may be followed by delirium, attended 
with more or less febrile disturbance. 
This condition may last for hours, days, 
or even weeks ; it may be relieved by the 
reappearance of the joint disease, or it 
may gradually disappear without such re- 
development. 
When these symptoms arise in the 
course of articular Gout, to what patho- 
logical condition must they be ascribed ? 
It would seem probable that they may be 
ascribed to the sudden occurrence of gouty 
inflammation about the membranes of the 
brain, or the lining of the skull; and, 
although I am unaware of any trust- 
worthy post-mortem examination proving 
the existence of deposits of urate of soda 
in these structures, still such may arise, 
and the proof of their existence or non- 
existence is a point of much interest and 
importance. Deposits of this kind can 
readily escape notice, unless specially 
sought for; and even those which occur 519 
IIISTORY. 
in the joints in early attacks of Gout 
were not observed till within the last few 
years. 
Epilepsy is not uncommon in gouty 
subjects, and appears to be closely de- 
pendent on the diathesis which gives rise 
to the articular affection ;. it sometimes 
distinctly alternates with the joint affec- 
tion ; at others, the two may occur simul- 
taneously. 
Mania is frequently the result of retro- 
cedent Gout. I have seen numerous 
cases : gout often leaves a joint suddenly 
from exposure to cold or an intense men- 
tal shock and after a short time distinct 
mania is developed ; this may last for 
days or weeks, but generally terminates 
favorably. 
Spinal affections, probably with inflam- 
mation of the meninges, with startings of 
limbs, hyperesthesia and other charac- 
teristic symptoms, occasionally result 
from the sudden suppression of articular 
Gout, or occur along with the joint in- 
flammation. 
Acute neuralgia of different nerves is 
at times closely connected with Gout. 
Sciatica of this character often occurs, 
and facial neuralgia occasionally. These 
affections probably depend on gouty in- 
flammation affecting the sheath of the 
nerves. Forms of local paralysis have 
also been observed apparently due to the 
same cause ; and cramp sometimes be- 
comes so excessively developed, and so 
permanent, as to justify its being looked 
upon and classified as a form of irregular 
Gout. 
Gout affecting the Digestive Organs.- 
When the stomach is affected by gouty 
metastasis, which sometimes occurs from 
the application of cold to the extremities, 
there is usually sudden intense pain and 
spasm in the epigastrium, oppression, and 
vomiting of bilious matter ; at times the 
heart's action is involved, and a feeling of 
great anxiety, with palpitation, produced. 
Many of the cases reported as examples 
of retrocedent Gout will not bear a close 
investigation ; still there is no reason to 
doubt the possibility of such an occur- 
rence. True retrocedent Gout affecting 
the stomach is probably of an inflamma- 
tory nature, though no direct proof has 
been afforded in support of this state- 
ment. 
Sometimes the upper extremity of the 
digestive tube, as the pharynx and oeso- 
phagus, becomes distinctly affected in 
Gout, producing difficulty of swallowing ; 
at other times the rectum is implicated, 
and the patient is troubled with piles or 
tenesmus. Constipation is very common, 
but, on the other hand, diarrhoea may 
prevail, apparently of a conservative 
character, and cases now and then are 
seen in which articular Gout appears to 
be warded off by the discharge from the 
intestinal canal. 
Gout affecting the Circulating Organs.-■ 
"When articular Gout suddenly recedes 
and the heart becomes affected, the symp- 
toms experienced by the patient are a 
sensation of extreme anxiety, difficulty of 
breathing, constriction of the chest, much 
palpitation, often accompanied with in- 
termission, weak thready pulse, and syn- 
cope. The heart's action occasionally 
becomes exceedingly slow, or it may be 
unusually rapid. 
The subject of heart affection in relation 
to Gout is one of considerable interest, 
more so from the fact that the organ is so 
frequently affected in acute rheumatism. 
No conclusive evidence has yet been ad- 
vanced proving the existence of true 
gouty inflammation of the heart; the ex- 
amination of the surface, the lining of the 
organ, and the valves in gouty subjects, 
has not shown the presence of deposits ; 
but it must at the same time be allowed, 
that in cases where the heart has been 
implicated, they have not been specially 
sought for. It has been asserted that the 
post-mortem examination of gouty sub- 
jects has frequently revealed the presence 
of white patches upon the surface of the 
heart, and Dr. Begbie fancies that these 
are often the results of gouty inflamma- 
tion ; he is also inclined to think that the 
endocardial vegetations and puckerings 
are due to the same cause ; no proof, 
however, has been brought forward in 
confirmation of these views, and the 
writer of the present article can state 
positively that his examinations have 
failed to detect urate of soda, either in 
the white patches, the endocardial de- 
posits, or the atheromatous spots. It 
must also be remembered that the causes 
which lead to the production of Gout are 
such as are likely to induce chronic val- 
vular diseases of the heart. 
Gout affecting the Respiratory System.- 
Acute inflammation of the lungs or 
pleurfe, if it ever occurs from retrocedent 
Gout, is certainly very rare indeed, al- 
though some authors have described these 
forms of disease ; but functional affec- 
tions of the respiratory organs are of 
very frequent occurrence in gouty habits, 
and so probably is a form of bronchitis ; 
the most common manifestations of such 
disturbance being shown by asthmatic 
breathing and cough. Occasionally these 
symptoms are unaffected by ordinary 
remedies, and yet yield at once to the de- 
velopment of articular Gout, or to the 
administration of medicines calculated to 
give relief in ordinary Gout. 
Gouty Conditions of the Urinary Organs. 
-The different parts of the urinary tract 
appear peculiarly prone to be affected by 
Gout. The kidneys are undoubtedly im- 520 
GOUT. 
plicated in very many instances, and 
structural alterations are frequently pro- 
duced, which will be described under the 
" Morbid Anatomy" of the disease. 
From many observations and post-mor- 
tem examinations, I am of opinion that 
gouty inflammation of the structure of 
the kidney is by no means rare, and that 
a true deposition of urate of soda takes 
place as its result. That this may occur 
early in the gouty life of a patient is cer- 
tain ; possibly it may at times even pre- 
cede the joint affection. It must be borne 
in mind, when investigating these cases, 
that renal calculi are somewhat common 
in gouty subjects, and the symptoms 
must therefore be carefully analyzed ; in 
irritation of the kidney from a calculus, 
the pain is more likely to be confined to 
one side of the loins ; albumen is not so 
frequently present, and if so, it is prob- 
ably due to a little blood ; and, lastly, 
there is the absence of febrile disturb- 
ance. 
The bladder and urethra may also be- 
come affected with Gout, and a species of 
chronic cystitis and urethritis induced, 
especially in old people. Where the irri- 
tation of these surfaces is simply the result 
of this diathesis, the symptoms are greatly 
relieved or altogether removed when the 
joints are attacked ; but in many instances 
some organic urinary mischief exists, the 
symptoms of which are aggravated by the 
gouty habit. 
Gout affecting the Eye and Ear.-Oph- 
thalmia appears to be occasionally of a 
gouty character, although many of the 
cases recorded have been the result of 
purulent urethral affection. 
I have recently seen two cases of gouty 
sclerotitis accompanied with the white 
deposits of urate of soda on the surface of 
the tissue. 
The occurrence of the little bead-like 
chalk-stone on the helix of the ear has 
already been fully described ; it has been 
supposed that the surfaces of the drum 
and of the ear-bones are at times the seats 
of like deposits ; those I have examined 
have consisted simply of bone earth, and 
have not occurred in gouty subjects. 
The external ear is at times painfully 
affected by acute Gout, even to the extent 
of preventing the patient from resting on 
it. when in bed. 
Gouty Affections of the Skin.-If inquiry 
is made it will be found that skin erup- 
tions are very common in those who are 
the subjects of Gout, and if they are not 
absolutely produced by the state of the 
system which leads to the articular affec- 
tion, still they are evidently kept up by it. 
Psoriasis is, perhaps, the most frequent 
form in which the cutaneous disease man- 
ifests itself, and there are records of many 
cases in which the skin and joint-affection 
are alternated. 
Eczema is likewise not an infrequent 
accompaniment of the gouty diathesis ; 
sometimes it assumes an acute, sometimes 
a chronic character. 
Prurigo is also met with in connection 
with Gout, either in the limited form of 
prurigo ani, or as a more general affec- 
tion. 
Acne, in the face and other parts, is 
sometimes found to be closely dependent 
on the gouty diathesis, and I have known 
one case in which the patient could pre- 
dict the advent of a gouty paroxysm from 
the appearance of these spots. 
Diseases occurring in Gouty States of the 
System.-There are certain diseases to 
which gouty subjects are especially liable, 
and amongst these gravel and calculus 
may be particularly mentioned. 
When the pathology of Gout is consid- 
ered, the occurrence of uric acid gravel 
cannot be a matter of surprise; from a 
very early stage deposits of urate of soda 
take place in the tubules, and Dr. Prout 
has remarked that occasionally patients 
void this salt in considerable quantities. 
Some patients suffer in early life from 
calculus, in after periods from Gout; in 
other subjects calculus and Gout alternate, 
and occasionally the two affections are 
present at the same time. 
Oxalic acid, which is so readily pro- 
duced from uric acid, not infrequently 
occurs in the urine of gouty subjects, and. 
may lead to the formation of calculi. 
The existence of a gouty diathesis has 
been regarded as antagonistic to the de- 
velopment of phthisis ; I have, however, 
seen instances in which phthisis and Gout 
have run a simultaneous course. 
Gout and diabetes occasionally occur in 
the same individual, but the development 
of the latter is usually followed by the 
cessation of the former disease. 
Condition of the Blood in Acute and 
Chronic Gout.-The blood undergoes im- 
portant alterations in Gout, changes 
which are almost in themselves pathog- 
nomonic and which require to be care- 
fully studied and clearly understood. In 
the writings of the ancients, nothing defi- 
nite is found on this subject; and even 
until the past few years our knowledge of 
the state of this fluid in Gout may be said 
to have been of little value. 
The blood-corpuscles, as far as yet 
known, undergo no necessary change 
either in number or quality ; they be- 
come lessened in chronic forms of disease, 
when the general nutrition of the body is 
impaired, but not more so than in other 
maladies. Many of the poorer subjects of 
chronic Gout, it is true, are pale and 
anaemic, and among painters and other 
gouty patients who work in lead, this is 
often due more to the influence of the 
metal which has been imbibed than to any 
other cause. 521 
HISTORY. 
It is in the serum of the blood that the 
chief deviation from the healthy standard 
is discovered ; and in this portion it is not 
so much that the normal constituents are 
affected, as that excretory substances 
which should have been eliminated are 
retained-an effect due to the imperfect 
action of certain of the excreting organs, 
more especially the kidneys. 
In healthy blood, it is impossible by or- 
dinary tests to discover the presence of 
uric acid, the quantity being so extremely 
small-in fact almost inappreciable; but 
in Gout one can easily not only show its 
presence, but even obtain it in a crystal- 
line form. It was first proved to be pre- 
sent by the author in 1847.' The follow- 
ing process can be adopted for its detec- 
tion :-The serum of the blood is first 
dried over a water-bath, then reduced to 
coarse powder, and treated with hot alco- 
hol ; the spirit being removed, the residue 
is afterwards to be digested for some min- 
utes in distilled water, and raised to the 
boiling point; the watery solution is then 
filtered and evaporated to a thin syrupy 
consistence. A drop or two of the solu- 
tion, when heated on a piece of porcelain, 
with nitric acid and ammonia afterwards 
added, exhibits at once the murexide test. 
A small portion of the same solution, if 
acidulated strongly with acetic acid, and 
allowed to evaporate spontaneously, gives 
rise to the crystallization of uric acid, the 
crystals exhibiting its characteristic form; 
and lastly, the syrupy solution, if merely 
allowed to evaporate without the addition 
of any acid, exhibits upon its surface, 
after a few hours, small white tufts of 
acicular crystals of urate of soda; the 
nature of the base being determined by 
the examination of the white alkaline ash 
left after incineration; the acid by the 
murexide and other tests. 
In the clinical examination of the blood, 
this process would be. too elaborate and 
tedious ; but another method,2 which an- 
swers admirably for practical purposes, is 
to put about two drachms of the serum in 
a flat glass dish, somewhat larger than a 
watch-glass, acidulate slightly with acetic 
acid, and having placed in the fluid an 
ultimate fibre from a piece of linen cloth 
(unwashed huckaback answers well), set 
it aside in a safe place until the evapora- 
tion has proceeded sufficiently far to cause 
it to become of a gelatinous consistence. 
If there is uric acid in any abnormal 
quantity in the serum, the fibre becomes 
studded with crystals of uric acid, which 
can be at once recognized by placing the 
glass under the microscope with a low 
power, or by the use of a small pocket 
magnifying-glass. I have never yet, after 
very numerous trials, failed to discover 
uric acid in the blood of gouty patients by 
this method, and the test has an especial 
advantage in only requiring the abstrac- 
tion of a very small quantity of so impor- 
tant a fluid. It may certainly be stated 
as a fact, absolutely proved, that the blood 
in Gout always contains an abnormal 
amount of uric acid, and that this acid 
exists as urate of soda. Besides uric acid, 
urea is frequently found in varying quan- 
tities in the blood in this disease, especi- 
ally when the affection is of long standing, 
and the kidneys have become much in- 
volved and their excreting powers im- 
paired. 
In 1849* the writer discovered the pre- 
sence of oxalic acid in the blood, and 
since that time has, in several instances, 
detected it in gouty subjects ; its presence 
appears due to the decomposition of the 
retained uric acid. 
The other alterations in the serum of 
the blood occasionally met with in cases 
of chronic Gout, are, the lessening of its 
specific gravity, due to the loss of albu- 
men, as well as to the impaired nutrition 
of the body ; and the diminution of its 
alkaline reaction. With the exception of 
collapsed cholera, and perhaps certain 
cases of albuminuria, the reaction of the 
blood is found to be nearer the neutral 
point in severe forms of chronic Gout than 
in any other disease ; this lessening of the 
alkaline condition probably depends on 
the deficient action of the kidneys and the 
retention of acid products, as it is only 
when the kidneys are much affected that 
such a state of the blood is observed. The 
amount of fibrin is always increased when 
active inflammation of the joints is pre- 
sent, and the augmentation appears to be 
in the ratio of the inflammatory action ; 
in fact, the fibrin follows the same laws as 
in other forms of inflammation ; hence, in 
acute Gout, if blood is abstracted, the 
surface of the clot exhibits a buffed and 
often a cupped appearance. 
Condition of the Blood in the intervals be- 
tween the Attacks of Gout.-It is a matter 
of some importance to ascertain the state 
of the blood in gouty subjects, when no 
inflammatory action is present; that is, 
during the complete intervals of the at- 
tacks. Although a somewhat difficult 
task, from the unwillingness of patients to 
be bled when not suffering from pain or 
fever, I have been enabled, in a few in- 
stances, to collect some facts of importance 
on this point. 
1. In the intervals between the early 
attacks of Gout no appreciable amount of 
uric acid was found in the blood. 
2. A very marked decrease of uric acid 
was observed in the blood of patients par- 
tially recovered from an acute attack. 
1 Medico-Chirurgical Transactions, 1848. 
2 Medico-Chirurgical Transactions, vol. 
xxxvii. 1854. 
1 Ibid. vol. xxxii. 1849. 522 
GOUT. 
3. In chronic Gout the blood, even in 
the intervals between the exacerbations, 
was always rich in uric acid. 
4. In some cases when symptoms of ir- 
regular Gout were manifested, without 
any accompanying joint disease, uric acid 
was present in the blood. 
State of the Urine in different forms of 
Gout.-Much error prevails in regard to 
the alterations which the urine of gouty 
subjects exhibits during the progress of 
the disease, and such misunderstandings 
have partly arisen from the prevalent idea, 
that the appearance and non-appearance 
of certain principles in the urine necessa- 
rily indicate their presence or absence in the 
blood ; and partly from a want of accurate 
knowledge of the reaction of healthy urine. 
It must be remembered that healthy 
urine exhibits a strongly-marked acid re- 
action, and that this is, in all probability, 
due, not to the presence of a free acid, but 
to the existence of an acid phosphate, 
probably the phosphate of soda, a salt 
containing two equivalents of water and 
one of soda to each equivalent of tri- 
basic phosphoric acid (2HO, NaO, PO5) 
[Na2HPO4.12H2O]. The acidity of urine 
varies much at different times of the day, 
and is in close relation to the state of 
the digestive functions. The fact of the 
acidity of healthy urine has been specially 
insisted upon, because the application of 
litmus papers is not infrequently made 
both by medical men and patients, and 
very wrong deductions drawn from the 
indications thus obtained. 
It must be remembered that a strong 
acid reaction is no proof of the presence of 
any abnormal state of the urine; and that 
urate of soda is one of its constituents, a 
salt which can exist in a solution of the 
acid phosphate without decomposition, 
and hence the possibility of the coexist- 
ence of the urate of soda with an acid con- 
dition of the urine. 
The amount of uric acid passed by a 
healthy subject during twenty-four hours 
is from eight to ten grains-a quantity 
capable of existing in solution when the 
urine is in a healthy state. 
Having premised thus much, we are 
better prepared to speak of certain changes 
•which are observed in the urinary secre- 
tions in Gout, changes the import of which 
has been often misunderstood. It has 
already been proved that the blood in all 
stages of Gout is invariably rich in uric 
acid, and, as the kidneys are the only 
organs which can be shown to eliminate 
this body, it follows that these organs 
must be inefficient for their required task 
when such a condition of the blood ensues. 
It becomes, then, a matter of some interest 
to discover whether these organs in gouty 
cases lose any of their normal power of 
excreting uric acid, or whether the forma- 
tion of this acid in the system is increased. 
In acute gouty seizures of a sthenic 
character the urine usually becomes scan- 
ty ; it is then high-colored, and not infre- 
quently gives rise, in cooling, to an amor- 
phous deposit, varying in tint from pale 
yellowish red to dark red, or at times an 
intense pink. The color varies under 
different circumstances, such as the 
amount of febrile disturbance which is 
present, the state of the portal system, 
and that of the biliary secretion also. If 
a judgment is formed from the inspection 
of a small specimen, without taking into 
consideration the limited amount passed 
in the twenty-four hours, it may readily 
be supposed that a great excess of uric 
acid is secreted; and such, in fact, has 
been the prevalent idea. However, a 
more careful examination of the urine in 
these cases leads to a different conclusion; 
for example : in a set of observations, 
taking the averages in seven acute cases, 
the daily secretion of uric acid was found 
to be under four grains, an amount far 
below the normal amount, which is from 
eight to ten grains. The cause of the 
prevalent idea that in Gout the uric acid 
exists in the urine in excess has probably 
arisen from the following circumstances: 
During the febrile stage there is usually a 
deficient flow of urine, the acidity of the 
fluid is augmented, thus causing the pre- 
cipitation of the whole of the urates ; at 
the same time the increase of coloring 
matter in the deposit gives the appear- 
ance of a larger amount than actually 
exists. 
It must not be concluded from the 
above that in any given amount of urine 
passed in a gouty paroxysm there may 
not be a larger amount of uric acid than 
that which is found in health-often it is 
so; but our remarks apply not to the 
relative, but to the absolute weight elimi- 
nated in the twenty-four hours. 
The question whether the deficient ex- 
cretion of uric acid is due to a loss of renal 
function, or to a diminished formation of 
the acid in the system, is at once deter- 
mined ; for it can be demonstrated that 
at the time that the urine is deficient in 
this principle, it exists in the blood in ab- 
normal quantities. It is also known that 
in some other diseases, in which uric acid 
is formed in augmented quantities, the 
kidneys are found equal to the task of 
eliminating such excess, and the blood is 
thus kept free from any contamination. 
The excretion of the urea also is proba- 
bly somewhat diminished during the fe- 
brile excitement of acute Gout, but by no 
means in the same ratio as the uric acid. 
As Gout assumes more and more a 
chronic character, so it will be observed 
that the excretion of uric acid becomes 
gradually lessened, even in the intervals 
between the attacks; showing that the 
kidneys are permanently injured, so far MORBID ANATOMY OF GOUT. 
523 
as their uric-acid excreting power is con- 
cerned ; and in the advanced stages of the 
disease, when the chalk-like deposits are 
thrown out in various parts of the body, 
and when the blood is permanently loaded 
with the acid, the renal organs often lose 
entirely, or all but entirely, their elimi- 
nating property for this principle. The 
results obtained from a large number of 
examinations of urine, and in numerous 
cases of chronic Gout, may be thus summed 
up:- 
The urine is generally paler than in 
health, lighter in specific gravity, and 
often passed in augmented quantities. 
There is, for the most part, an absence 
of any deposits on cooling; at times, how- 
ever, such may occur, especially when an 
exacerbation of the disease is passing off. 
The quantity of uric acid eliminated in 
the twenty-four hours is notably dimin- 
ished, and not infrequently it is reduced 
to a mere trace. 
The kidneys sometimes throw out uric 
acid in an intermittent manner; for ex- 
ample, for several days the uric acid 
gradually decreases, until scarcely a trace 
is present, then suddenly a large elimina- 
tion takes place; this has been clearly 
made out in several cases. 
Even in the intervals between the fits, 
the urine of patients suffering from chronic 
Gout is deficient in uric acid. 
The urea also, in many cases, is slightly 
diminished, but not in any remarkable 
degree, if the diet of the patient at the 
time of examination is taken into ac- 
count. 
A small amount of albumen is very fre- 
quently met with, also granular casts; 
and, in some cases, waxy or fibrinous 
casts are likewise found. 
Secretion from the Skin in Gout.-It is a 
common opinion that the production of 
excessive perspiration is the means of get- 
ting rid of gouty matter from the system, 
and the value of hot-air and vapor baths, 
and other modes of increasing the cuta- 
neous secretion, have been thus accounted 
for. There are also to be found, in differ- 
ent works, statements to the effect that 
uric acid is capable of being eliminated 
by the skin, and that a white, powdery 
matter is occasionally seen upon the sur- 
face of patients suffering from a paroxysm 
of Gout. I have made many observations 
upon this subject, which have led me to 
doubt the accuracy of such statements, 
and within the last two years have had 
an opportunity of putting the question to 
a severe test. A gentleman, suffering 
from a very decided attack of Gout, went 
into a Turkish bath, and took precautions 
to enable him to save a considerable 
amount of the perspiration which flowed 
from his body during the operation. To 
this fluid rectified spirit was at once add- 
ed, in order to prevent decomposition, and 
it was afterwards carefully examined by 
the following process: It was first evapo- 
rated to dryness, then heated with abso- 
lute alcohol, and the residue afterwards 
treated with hot water. The alcoholic 
solution yielded a notable amount of urea, 
which was obtained as the crystallized 
nitrate; but no trace of uric acid could 
be discovered in the watery solution by 
the most careful search. This observa- 
tion, coupled with many others above re- 
ferred to, leads me to believe that the 
healthy skin does not possess the power 
of eliminating uric acid, even when it ex- 
ists in normal quantities in the circulating 
fluid. It must, however, be remembered 
that the liquid thrown out from blistered 
surfaces in like cases is rich in uric acid, 
and it is not improbable that in some cu- 
taneous eruptions, as in the secretion in 
eczema when occurring in gouty habits, 
it might be detected. Allusion has been 
made to a white deposit seen on the sur- 
face of patients suffering from Gout; on 
one or two occasions, when I have had 
the opportunity of examining such mat- 
ter, it has been found to consist of epider- 
mic scales, together with dry salts, but to 
be entirely devoid of uric acid. 
Other Secretions in Gout.-It has not 
been determined whether uric acid is con- 
tained in the secretions from the mucous 
membranes of the bowels in subjects 
laboring under Gout, and, when evidence 
of its presence in the blood is beyond 
doubt, it would be worth seeing if it is 
contained in the watery excretions pro- 
duced by the action of saline or other 
purgatives. In morbid secretions uric 
acid is often present: thus it is found in 
the fluid effused in cases of pericarditis, 
also in ascites, when these diseases occur 
in subjects in which the blood is contami- 
nated with this principle. It is also 
found under like circumstances in the 
fluid effused by the action of blisters, and 
we can sometimes make use of this fact 
in diagnosis, employing the blister fluid 
in lieu of the blood serum. There is, 
however, one precaution necessary to be 
observed, which is, to avoid taking the 
fluid from a part affected with gouty in- 
flammation, as it would appear that in- 
flammation has a tendency to destroy the 
uric acid in the blood of the part. This 
fact, if well established, would be of great 
value in elucidating the pathology of the 
disease. 
The thread experiment may be em- 
ployed for the detection of uric acid in the 
blister fluid, as in blood itself. 
Morbid Anatomy of Gout.-Gout is 
seldom fatal, yet opportunities for inves- 
tigating the morbid appearances produced 
by the occurrence of the malady, even in 
its slightest forms, are not difficult to 
obtain, provided that the gouty history of 524 
GOUT. 
cases be carefully taken for a considerable 
period of time in any great public medical 
institution. It is only by this method 
that the writer has been enabled to collect 
the materials of which he now gives a 
short summary and which he hopes will 
go far to elucidate many of the phenomena 
of the disease. 
In one case there had been only two 
very slight attacks of Gout, affecting the 
metatarso-phalangeal joint of the right 
great toe, the first attack occurring two 
years, the second only one year, before 
death. The condition of the joint was as 
follows: On the head of the metatarsal 
bone was a white patch made up of 
minute aggregations of a white deposit, 
occupying altogether about a tenth of the 
articulating surface ; on the cup-shaped 
surface of the phalanx, the same sprink- 
ling of white matter was observed upon 
the cartilage, occupying a greater extent 
of surface than on the metatarsal bone ; 
on the inner surface of the ligaments the 
same substance was here and there ob- 
served ; the surfaces of the scssamoid 
bones were free from any deposits, and, 
although the same joint on the left side, 
as well as many other small and some 
large joints were examined, no deviation 
from the normal state was observed in 
them. The gouty attacks, it will be re- 
membered, had been confined to one 
articulation, and this joint only was found 
to be altered after death. 
In another case, only one attack of 
Gout had occurred, affecting the right 
great toe very severely, the left but 
slightly ; and similar appearances in the 
cartilages and ligaments were discovered, 
but exceedingly slight in the left toe-joint. 
In this case, also, several other joints 
were examined, but found to be free from 
any morbid alteration. 
We thus see that even a single attack 
of Gout leaves marks behind, which ap- 
pear to be very nearly, if not altogether, 
indelible ; for, in the second case, at least 
thirteen years had elapsed from the time 
of the gouty seizure to the death of the 
patient. 
Before proceeding to speak further of 
the morbid appearances produced by 
gouty inflammation it will be necessary 
to point out the nature of the alteration 
we have already noticed-that is, the na- 
ture and situation of the white deposit. 
When the alteration in the joint is slight, 
no appreciable elevation of the surface 
can be discovered; and if we pass the 
finger over it, nothing abnormal is de- 
tected, nor can we remove the deposit by 
moderate friction, nor, in fact, by any 
means short of removing the surface of 
the cartilage' itself. On the other hand, 
if we immerse the bone for some hours in 
water at the temperature of the body, or 
keep it in a cold and weak solution of 
carbonate of potash, the white matter is 
slowly dissolved out, and on afterwards 
drying the bone, the articulating surface 
appears to be restored to its healthy con- 
dition. We can thus show that the de- 
posit is not on the surface of the cartilage, 
but within it, and that it consists of a 
material soluble both by warm water and 
in a weak alkaline solution. A further 
insight into its nature may be obtained 
from a microscopical and chemical exam- 
ination ; if, for example, we make a verti- 
cal section of the cartilage over the seat 
of the white deposit, we at once see, 
either with the naked eye or a simple 
lens, that the infiltrated matter is most 
dense near the free surface, and gradually 
diminishes as it approaches the bone, sel- 
dom, indeed, extending half-way into the 
substance of the cartilage. 
If we place the thin vertical section 
under the microscope, using a quarter- 
inch objective and low eye-piece, a very 
beautiful appearance is exhibited; the 
opaque white matter is observed to con- 
sist of very fine crystalline needles or 
prisms closely interlaced, and according 
to the density of the network, so is the 
amount of opacity produced. As the de- 
posit becomes more sparse, many separate 
crystals are seen, which appear to project 
into the substance of the healthy cartilage. 
If we examine horizontal, in lieu of verti- 
cal, sections of cartilage, we find that, 
after we have removed a few slices, the 
deposit becomes sufficiently thin to allow 
light to pass freely through it, and the 
crystals are for the most part seen to be 
arranged in little clusters radiating from 
centres, the interspaces being nearly free, 
or with only scattered crystals. If, in- 
stead of using ordinary light, we employ 
the polariscope, the appearances above 
described are much intensified, the crys- 
tals become strongly illuminated, and 
more or less colored ; at the same time, 
the healthy portion of the cartilage, if 
sufficiently thin sections be made use of, 
gives a black background. 
The chemical nature of the deposit can 
be readily demonstrated. If slices of the 
altered cartilage be first washed with a 
little cold distilled water, to remove any 
soluble matter, and afterwards digested 
for some hours in hot water under 200° 
Fahr., the infiltrated matter is dissolved, 
and a solution is obtained which, treated 
with a little nitric acid and afterwards 
evaporated in a porcelain capsule, and 
when nearly dry exposed to the vapor of 
ammonia, exhibits an intense purple 
color from the formation of murexide ; on 
the other hand, if some acid, as acetic, 
be added to the solution so as strongly to 
acidulate it, and the whole allowed to 
evaporate spontaneously to a thin syrupy 
consistence, crystals of uric acid, more or 
less colored, are slowly deposited, and the MORBID ANATOMY OF GOUT. 
525 
forms they exhibit under the microscope 
at once distinguish them; again, if the 
watery solution, without the addition of 
any acid, be slowly evaporated to a syrupy 
consistence, and then allowed to cool, 
urate of soda, in bundles of crystalline 
needles, will form on the surface, which 
can be readily collected, and, if necessary, 
chemically examined. 
If a thin vertical section be obtained 
from any articular surface which has not 
been much worn-that is to say, from a 
joint which has not been often attacked, 
or is not liable to injury from friction-a 
distinct organic layer devoid of crystals 
can be seen by the aid of the microscope, 
superficial to the deposit, and probably 
consisting of flattened cartilaginous cells. 
As yet we have only spoken of very 
early cases of Gout, in which merely the 
ball of the great toe has been attacked ; 
if we take more advanced cases, where 
the disease has lasted for several years, 
and in which many of the larger as well 
as the smaller joints have been impli- 
cated, opportunity is afforded of investi- 
gating still further the changes effected 
by the disease. 
If a knee has been but slightly attacked, 
only a few spots or small patches can be 
detected upon the articulating surfaces of 
the femur, tibia, and patella; but if it 
has been severely affected, a large portion 
of the surfaces may exhibit the peculiar 
alteration ; the condyles of the femur are 
often completely incrusted, except at 
their margin, in the situation of the syno- 
vial fringes, the vascularity of which ap- 
pears to protect this part from the de- 
posit the concave surface of the tibia is 
usually less covered ; the patella is often 
extensively coated; and in many in- 
stances the fibro-cartilages and crucial 
ligaments are more or less implicated. In 
such a knee-joint the synovial fluid is 
thickened, and in extreme cases contains 
tufts of urate of soda; the synovial mem- 
brane is also seen to be speckled with 
little white points looking like amorphous 
granules. When these are placed under 
the microscope, they are found to consist 
of acicular crystals radiating from a cen- 
tre, and forming with polarized light a 
very beautiful object. In cases of Gout 
in which the disease has so far advanced 
as to cause considerable stiffening or com- 
plete anchylosis, the ligaments are found 
to be much infiltrated and thereby ren- 
dered rigid ; and, as a rule, the movement 
of the joint is impeded more by the liga- 
mentous than the cartilaginous altera- 
tion. Instances are not uncommon in 
which the movements of the great toe- 
ball are but partially interfered with, al- 
though the ends of the bones are com- 
pletely covered ; but the ligaments in such 
cases have escaped. 
The shoulders and hip-joints often re- 
main free from disease when most of the 
other articulations of the body are impli- 
cated, but occasionally they present simi- 
lar appearances to those above described. 
I have a specimen in which the head of 
the femur is almost completely incrusted ; 
the ligamentum teres, however, is free, 
and the movements of the joint are con- 
sequently preserved. 
The carpus and tarsus are often severely 
attacked by gouty inflammation, and it 
is not unusual to find every articulating 
surface of these bones completely covered 
with the deposit; also the surfaces of the 
metacarpal and metatarsal bones, and 
frequently of several of the phalanges. 
There is, however, one point of interest 
in relation to the joints of the great toe, 
worthy of being borne in mind ; it is the 
fact that, although the metatarso-pha- 
langeal articulation is so constantly afiect- 
ed, the tarso-metatarsal and the pha- 
langeal joints on either side are for the 
most part free from morbid alteration. 
Sometimes urate deposits are found in 
other articulations. I have met with 
them even in the arytenoid cartilages, 
but it requires a special search, not usu- 
ally made in post-mortem examinations, 
to discover their presence. 
It has been asserted that urate deposit 
has been seen in bone itself; Cruveilhier 
found it in the astragalus, os calcis, and 
patella. Although I have carefully 
searched for it in bone, I have not yet 
succeeded in finding evidence of the de- 
posit having originated in this tissue. It 
is true that deposits lie in contact with 
bone, as they often originate in the peri- 
osteum, and sometimes acquire sufficient 
size to press on the osseous tissue and 
cause its absorption. Dr. Charcot, in 
conjunction with M. Cornil, has recently 
(1864) published an account of the post- 
mortem appearances in the case of a 
female, aged 84, who had suffered from 
Gout for many years, and had been long 
crippled and deformed ; a full description 
of the appearances presented to the 
naked eye is given, as well as those seen 
in the microscopic examination; in every 
important respect the results are the 
same as, and confirmatory of, those above 
described. 
Condition of the Kidneys in Gout.-From 
the earliest time it would appear that an 
idea prevailed that Gout and renal dis- 
eases were in some way allied ; Aretseus 
held that opinion, as also Sydenham, 
Morgagni, and others. The idea was de- 
rived from the fact that gravel and calculi 
are so frequently met with in gouty sub- 
jects. 
In the early stages of Gout, should an 
opportunity be afforded of examining the 
1 Dr. W. Budd, Medico-Chirurgical Trans- 
actions, 1855. 526 
GOUT. 
kidneys, little or perhaps no alteration 
will be observed, but occasionally an ap- 
pearance indicating the action of the dis- 
ease may be presented to the eye, and the 
first change usually noticed is found to be 
due to the occurrence of some crystalline 
deposits in the organ. In 1849, the writer, 
when examining the kidneys of a man 
who had suffered from Gout, but who had 
died of another disease, found small white 
streaks which appeared to follow the di- 
rection of the tubes of the pyramidal por- 
tion of the organ ; he also discovered that 
at the extremity or mamilla of each cone 
there were certain white points ;-Dr. 
Todd and Mr. Ceeley had previously no- 
ticed this fact. 
On placing a little piece of the substance 
of the kidney under the microscope, the 
above-mentioned white streaks and points 
were found to be caused by the presence 
of numerous crystals, prismatic in shape, 
and consisting of urate of soda, that is, 
identical with those which form ordinary 
chalk-stones, and which are found in car- 
tilaginous and ligamentous tissues, but 
the crystals are usually larger. Shortly 
afterwards, the same condition of kidney 
was discovered in numerous other sub- 
jects, some of whom had been but slightly 
affected with Gout, and in one only eight 
seizures had occurred, and no external 
deposition or deformity had been pro- 
duced. At first it was thought that the 
white streaks were due to the blocking up 
of the uriniferous tubes, but afterwards 
the conclusion was arrived at that many 
of the crystals were imbedded in the struc- 
ture of the tubes themselves. M. Charcot, 
in an excellent paper, entitled " Contribu- 
tions a 1'Etude des Alterations anato- 
miques de la Goutte, et specialement du 
Rein et des Articulations chez les Gout- 
teux," has investigated this subject very 
thoroughly, and has given good drawings: 
he comes to the conclusion that, as far as 
the kidneys of the subject examined by 
himself were concerned, the deposit, 
which at first sight appeared to be situ- 
ated in the intervals or between the tubes, 
was in reality in part contained within 
them, and in a great measure amorphous; 
there were, however, crystals not within 
the tubes which appeared to radiate from 
the above matter into the intertubular 
structure. 
It would appear from the observations 
which have been made both in this coun- 
try and abroad, that even in the early 
stages of Gout the kidneys become impli- 
cated, probably in some cases much sooner 
than in others: that deposits of urate of 
soda take place in the tubes, which after- 
wards extend into the renal tissues. 
Causes of Gout.-The causes of Gout 
may be conveniently treated of under two 
heads ; first, those depending on the age, 
sex, hereditary and other peculiarities of 
the individual; secondly, those indepen- 
dent of the affected subject. 
Causes dependent on the 
Individual. 
Hereditary Influence.-Some individuals 
are undoubtedly more disposed to Gout 
than others, and in such the disease is 
liable to be induced by agencies which 
would be comparatively harmless if ap- 
plied to other people. There is, in short, 
a proclivity to Gout which may be in- 
herited ; and it is certainly true as regards 
this malady, that the sins of the fathers 
are visited upon the children to the third 
and fourth generation. Instances illus- 
trating the hereditary predisposition to 
Gout are so frequently met with, that no 
one who has had the least acquaintance 
with this disease can have failed to have 
observed it. My own experience would 
show that more than half the gouty sub- 
jects can distinctly trace their ailment to 
hereditary taint; and if patients in the 
upper class of society are exclusively se- 
lected, the percentage is found to be con- 
siderably greater. There exists a popular 
idea that Gout frequently skips over a 
generation, and that it has a peculiar ten- 
dency to attack the grandchildren rather 
than the children : this idea I believe to 
be erroneous, but at the same time ac- 
knowledge that there are often apparent 
grounds for it. Occasionally the child of 
a very gouty patient, having the fear of 
suffering before his eyes, will live such a 
life as to keep the disease at bay; his 
children, however, may be fully under the 
hereditary influence of their grandparent 
and liable to a development of the malady 
from the ordinary exciting causes. When 
true Gout is met with at an early age, the 
existence of hereditary taint may be sus- 
pected, and in the case of children this 
cause is certain to be powerfully opera- 
tive. However, it must not be forgotten 
that Gout may be acquired at a compara- 
tively early age, by the influence of causes 
other than that of hereditary predisposi- 
tion. 
[Modification of the gouty diathesis 
often occurs in the course of hereditary 
transmission. The children or grandchil- 
dren of a person subject to regular Gout, 
may have it in its " flying" or irregular 
forms ; or they may have gouty neuralgia; 
or a proclivity to attacks of indigestion, 
which may be called gouty dyspepsia. 
Another modification not sufficiently ap- 
preciated by systematic writers, is gouty 
rheumatism; an affection which may in- 
volve the digestive apparatus as well as 
the larger joints, muscles, and fibrous tis- 
sues, in attacks which differ more or less 
from typical rheumatic fever; which are CAUSES OF GOUT. 
527 
attended usually by symptoms of indiges- 
tion ; and which are especially more re- 
sponsive to the remedial action of colchi- 
cum, than is the case with ordinary articu- 
lar rheumatism.-II.] 
Influence of Sex.-Men are much more 
frequently the subjects of articular gout 
than women, and the causes of the com- 
parative exemption of females is not diffi- 
cult to understand, when we are acquaint- 
ed with the pathology of the disease. As 
far as hereditary causes are concerned, 
women are similarly circumstanced with 
men ; but there are many reasons explain- 
ing the immunity enjoyed by women. 
Some of these are intimately connected 
with the functional peculiarities of the 
female sex ; others depend upon the habits 
of life more commonly adopted by women. 
The occurrence of the catamenia during a 
long period of female life is doubtless a 
great safeguard against the disease, and, 
as a rule, whenever Gout does occur in 
the female, it is only after the cessation 
of this function. There are, however, 
striking exceptions now and then met 
with-instances of the most severe Gout 
attended with great crippling and deform- 
ity, in comparatively young women ; these 
cases are extremely rare, and most of 
them capable of explanation. 
Influence of Age.-Children are usually 
free from Gout; and, although I have 
been assured of some being attacked when 
very young, yet, in every case where there 
has been an opportunity of strict investi- 
gation into the nature of the affection, 
there has been good cause to distrust the 
accuracy of the diagnosis which had been 
made. Many patients have informed me 
of their having had Gout when at public 
schools, and I have no reason to doubt 
the correctness of their statements, more 
especially as they have afterwards become 
the subjects of Gout in its severe forms ; 
I have myself seen the disease fully de- 
veloped in the great toe at the age of six- 
teen, but always in youths who have 
strongly inherited the affection, and who 
at the same time had not been altogether 
abstemious. As a rule, the stronger the 
hereditary predisposition, the earlier Gout 
develops itself in any individual, and it 
is rare to find it before the age of thirty 
unless some well-marked hereditary pre- 
disposition exists. 
From a table made by the late Sir C. 
Scudamore from a large collection of cases 
it appears that, dividing the period of life 
from twenty to sixty-five into intervals of 
five years, by far the greater number of 
first attacks occur from thirty to thirty- 
five years of age ; below twenty they are 
exceedingly rare ; and after sixty-five 
they are likewise very few in number. 
As there appear to be exceptional cases 
in early life, so also are there in old age, 
and I have known Gout make its first ap- 
pearance after the age of eighty, and in 
one instance when the patient was in her 
ninetieth year. 
Influence of Temperament. - Little that 
is positive can be asserted in regard to 
the influence of what is called the tem- 
perament of the individual upon the de- 
velopment of Gout. The more acute 
varieties of Gout are usually found in 
those of a sanguine temperament and full 
habit of body ; whereas the asthenic and 
irregular forms occur chiefly in spare sub- 
jects of a nervous temperament. 
Causes independent of the 
Individual. 
Alcoholic Beverages.-No one who has 
paid attention to the clinical study of 
Gout can doubt the influence of alcoholic 
drinks, both in laying the foundation of 
the gouty diathesis, and likewise in ex- 
citing attacks of the disease; and, more- 
over, no one who has carefully analyzed 
the causes of this malady can fail to per- 
ceive that different kinds of spirituous 
liquors differ greatly in their power in 
this respect. This subject is of so much 
importance that we shall not hesitate to 
dwell shortly upon it. Distilled spirits 
have certainly less tendency to induce 
Gout than either wine or malt liquor : the 
truth of this remark can be proved by in- 
vestigating the cases which occur in the 
large cities of England, and, more clearly, 
by noting the prevalence of the disease in 
other countries where little of any other 
spirit is taken. Among the laboring 
classes of London, Gout is very frequently 
met with ; whereas, among the same class 
in Edinburgh and Glasgow, it is scarcely 
ever seen : the former partake largely of 
porter and beer, the latter almost entirely 
of whisky, and in no inconsiderable quan- 
tities. The same fact is illustrated in the 
almost entire absence of Gout in many 
cities on the Continent, especially in 
Poland and Russia, where a distilled spirit 
is almost exclusively made use of. 
As predisposing to Gout, I cannot from 
experience say whether all distilled spirits 
are equally innocuous : brandy, whisky, 
and gin have certainly little predisposing; 
power: rum has been asserted to cause 
Gout in the West Indies, but the state- 
ment is old, and there is no good clinical 
evidence in support of it. 
In countries where the lighter kinds of 
wine form the chief or sole alcoholic bev- 
erage of large classes of the people, the 
occurrence of Gout is comparatively rare : 
as, for example, among the working popu- 
lation of France, most parts of Germany, 
and, I believe, also of Italy; but it is 
asserted that in certain parts of Germany, 
as in Berlin and Munich, where malt 
liquor is largely consumed, the disease is 
much more prevalent. 528 
GOUT. 
It must not be thought, however, that 
these light wines can be taken with im- 
punity, for although their gout-producing 
tendency is small, compared with some of 
the stronger wines and malt liquors, still 
it is very decided. Light claret, hock, 
and moselle are probably the best of light 
wines. 
The stronger wines, as port, madeira, 
and sherry, probably also marsala, are 
much more potent as gout-producers, and 
a free indulgence in their use for several 
years will very often bring on the disease 
in those not known to have derived any 
taint from their ancestors. Port enjoys a 
very marked reputation in this respect; 
it is doubtless as we receive it from Portu- 
gal, a wine very likely to cause Gout-per- 
haps more so than any other. Sherry, 
however dry and pure, is by no means the 
innocent beverage, as far as Gout is con- 
cerned, that many people imagine ; I have 
met with several cases of severe Gout 
brought on solely by this ■wine, and have 
also known attacks of the disease kept up 
for an almost indefinite period by the 
patient continuing the use of it, even in 
small quantities. Madeira is fully as in- 
jurious as sherry to the gouty subject, and 
doubtless, if freely partaken of for any 
length of time, would be capable of in- 
ducing the malady in those not previously 
disposed to it. The same remark applies 
to several other wines, possessing charac- 
ters closely allied to those of the above- 
mentioned class. 
That malt liquors predispose strongly 
to the production of Gout is made evident 
by the frequency of this disease among 
the laboring classes and artisans of the 
large cities of England, where porter is so 
freely indulged in : thus Gout is very com- 
mon with brewers' men, ballasters, and 
many others. Even the pale bitter ales, 
though to many so grateful and useful, 
will, when too freely partaken of, give 
rise to the development of Gout, and sev- 
eral cases in which such ale was the sole 
cause have occurred in my practice. 
It only remains for us to investigate the 
influence of one other alcoholic drink- 
that is, cider-which forms so favorite a 
beverage in many of the counties in Eng- 
land, more especially in Herefordshire and 
Devonshire ; also, of the United States of 
America. Concerning its gout-producing 
powers many and diverse opinions have 
been held. Dr. Wood of Philadelphia in- 
formed me that, as a predisposing cause 
of Gout, cider cannot be very potent, else 
the disease would have been more preva- 
lent among the people of New England 
and the Middle Atlantic States, where it 
is very commonly drunk. Having taken 
some pains to investigate the question in 
this country, the results I have arrived at 
are as follows :- 
1st. That fully fermented cider-that 
in which the whole of the saccharine mat- 
ter has been got rid of, and which consti- 
tutes genuine rough cider-has but little 
power in inducing the gouty diathesis. 
2d. That sweet and partially fermented 
cider, when taken in large quantities, pre- 
disposes to Gout. 
3d. That the latter variety, and even 
the former, when taken by gouty indi- 
viduals not much accustomed to its use, 
is apt to excite an attack of the disease. 
Having enumerated the relative powers 
of different alcoholic liquors in common 
use in this and other countries, in indu- 
cing Gout, it becomes a question of inte- 
rest to endeavor, if possible, to get some 
clue as to the cause of such differences; 
or if unable to accomplish this, at any 
rate to point out the known peculiarities 
of each class of such beverages. 
The distilled liquors consist of alcohol, 
more or less diluted, and combined with 
very small amounts of volatile oils or 
ethers : thus, brandy contains oenanthic 
ether, the peculiar principle of all wines ; 
gin, a little oil of juniper; and so on. They 
should not hold in solution any non-vola- 
tile substances, and should be free from 
saccharine matter and acidity. The per- 
centage of real or anhydrous alcohol in 
the different distilled spirits varies greatly, 
ranging from 70 per cent, in undiluted 
rum, to about 30 per cent, in gin. 
Wines consist of diluted alcohol, com- 
bined with certain soluble compounds, as 
oenanthic and other ethers, free acids and 
salts, and, besides these, coloring, astrin- 
gent, and saccharine matters. 
The amount of alcohol varies, from about 
18 to 22 per cent, in ports, sherries, and 
madeiras, to 7 to 9 per cent, in clarets and 
hocks. 
The acids and salts consist chiefly of 
tartaric acid and the acid tartrate of pot- 
ash : there are also small amounts of other 
salts, as phosphates of lime, magnesia, and 
iron. 
The amount of alcohol in port wines 
varies from 17 to 21 per cent. ; in made- 
ria it is about the same ; in sauterne it 
varies from 12 to 15 per cent. ; in red 
French wines from 9 to 14 per cent. ; in 
champagne 10 to 11 per cent. ; in Rhine 
wines 6 to 12 per cent., usually from 9 to 
10 per cent. 
Measured by the amount of acidity, Dr. 
Bence Jones has arranged wines and 
spirits as follows :-Sherry, port, madeira, 
champagne, burgundy, hock, and moselle. 
The least acid of all alcoholic spirits are 
geneva and whisky, then rum and brandy, 
afterwards ale, porter, and stout; all 
wines are found to be more acid than malt 
liquors. 
Measured by the amount of contained 
saccharine matter, commencing with the 
least sweet, spirits, wines, and malt 
liquors may be thus arranged : geneva, CAUSES OF GOUT. 
529 
rum, whisky, claret, burgundy, Rhine 
wines, and moselle have no sugar; then 
brandy, sherry, madeira, champagne, port 
wine, cider, porter, stout, malmsey, ale, 
tokay, samos, paxarete, and Cyprus. 
The knowledge of the coniposition of 
the different kinds of alcoholic fluids has 
not thrown much light upon their varying 
powers of inducing Gout, and the follow- 
ing summary includes nearly all that can 
be clearly made out on the subject:-1 
1. Diluted alcohol, in the form of dis- 
tilled spirits, has little power in causing 
Gout, at least in those who are not pre- 
disposed to it. 
2. Alcohol, when in combination with 
other substances, as in wines and malt 
liquors, becomes a potent cause of Gout, 
and the greater the amount of contained 
spirits in such beverages, the more power- 
ful their influence in producing the disease. 
3. Neither the acid, sugar, nor any 
known principle contained in these liquors, 
can as yet be proved to impart to the al- 
cohol its predisposing influence ; for wines 
the least acid, and liquors the least sweet, 
are among the most baneful. 
4. Alcoholic drinks which have little 
tendency to cause dyspepsia, and those 
which more especially act as diuretics, 
can, as far as Gout is concerned, be taken 
with greater impunity than beverages of 
an opposite character. 
Influence of the Solid Food in causing 
Gout.-It is matter of much difficulty to 
assign the share that different articles of 
solid food have in the production of Gout, 
and likewise to separate the effect of indi- 
gestion caused by any article of diet from 
the secondary influence of the same food 
after its absorption into the system. Cul- 
len remarked that Gout seldom attacked 
persons who lived much on vegetable 
diet, but he added, or persons who were 
employed in constant bodily labor ; and 
doubtless the disease is rare amongst 
those who live in the country, working 
hard, and living abstemiously. Experi- 
ence, moreover, has pretty well estab- 
lished this fact-namely, that an excess 
of food, more especially animal food, fa- 
vors the production of Gout, and it proba- 
bly does so by causing an increased for- 
mation of nitrogenized compounds, more 
especially uric acid. Vegetable substances 
have comparatively little direct influence, 
unless they cause dyspepsia from their 
mechanical structure, or other peculiari- 
ties. As far as composition is concerned, 
it is probable that articles of food contain- 
ing a considerable amount of saline prin- 
ciples, as for instance the salts of potash, 
are useful in keeping up the activity of 
the secreting organs, especially the func- 
tion of the kidneys, and many such sub- 
stances, even if acid to the stomach, yet 
tend to alkalinize the blood and urine from 
the decomposition of the vegetable acid,and 
the formation of a carbonate of the alkali. 
Pie-crust and sweet substances probably 
are injurious rather from the indigestion 
they induce than from containing any 
noxious principles. 
Made dishes, and those which are very 
rich and complex, are liable to upset the 
stomach, and thus act rather as exciting 
than predisposing causes of Gout. 
Indigestion as a Cause of Gout.-In in- 
vestigating this subject, great difficulty is 
experienced in discriminating between the 
dyspepsia leading to Gout and that which 
arises from an already formed gouty dia- 
thesis. Many persons suffer from dys- 
pepsia all their lives, and yet never ex- 
hibit a gouty symptom; on the other 
hand, some of those most severely afflicted 
with Gout have scarcely ever felt the sen- 
sation of indigestion. 
Indigestion, if it causes the production of 
an increased amount of acidity in the sys- 
tem, can easily be supposed to aid the de- 
velopment of Gout, by causing a less alka- 
line state of the blood, and hence favoring 
the insolubility and deposition of the urate 
of soda in the tissues ; it may also act as 
a predisposing cause by promoting the 
formation of uric acid itself. The form of 
dyspepsia which seems most injurious is 
that which is connected with congestion 
of the portal system, and increased vascu- 
larity of the mucous membranes of the 
stomach. 
Although observations have not shown 
that exercise has any marked influence 
upon the amount of uric acid excreted in 
a given time by a healthy person, still it 
is certain that want of exercise soon leads 
to a sluggish performance of the more im- 
portant functions of the body, and the 
production of dyspepsia indirectly favors 
the development of Gout. 
Influence of Nervous Depression.-Any 
circumstance which lowers the tone of the 
nervous system tends very greatly to the 
development of the gouty paroxysm, al- 
though it is questionable if this cause alone 
can produce the gouty diathesis. The 
effect of the mind upon the function of the 
kidneys, is well known and easily appre- 
ciated, and upon the other secreting or- 
gans, although less readily observed, it is 
doubtless equally potent. Any severe 
mental labor is often followed by an at- 
tack, and so is prolonged sorrow; and 
venereal excesses probably act by lower- 
ing the tone of the nervous system. 
Influence of Climate and Season.-There 
is no doubt that Gout is much less preva- 
lent in hot than in cold or temperate 
countries, and it would appear from the 
reports of travellers that the disease is un- 
known among the natives of the interior 
of Africa; it is rare, if not unknown, in 
1 Nature and Treatment of Gout. Second 
edition. 
vol. i.-34 530 
GOUT. 
China, Japan, the East Indies, and Tur- 
key, and much less frequent in the south 
of Europe than in this country. Great 
stress, however, must not be laid on these 
facts, for Gout is scarcely seen among the 
laboring populations in Poland, Kussia, 
and other cold climates. The character 
of the beverages used by these different 
peoples has probably more influence upon 
the production of Gout than the climate 
under which they live. 
As far as regards the development of an 
attack, climate and season have a very 
decided influence : for example, a gouty 
man may often escape his accustomed 
winter attacks by removing from England 
to Malta or Egypt during the cold season 
in this country; and the histories of gouty 
patients afford abundant proof of the com- 
parative frequency of gouty seizures in the 
winter months. 
In the early stage of Gout the attacks 
are most frequent in spring, and are often 
confined to that season ; after a time an 
autumnal seizure is added ; but when the 
disease has become further ingrafted into 
the system, the fits may occur at any sea- 
son, and at most irregular intervals. 
There are occasionally found exceptions 
to the above rules ; for some patients, ow- 
ing probably to individual peculiarities, 
suffer far more in summer than in winter. 
In warm climates and during hot sea- 
sons the function of the skin becomes 
more active, and this fact affords an ex- 
planation of any influence dependent on 
these circumstances. 
Influence of Lead Impregnation in causing 
Gout.-About fifteen years since I was 
struck with the fact that a large percent- 
age of the gouty patients who had come 
under my care in hospital practice con- 
sisted of painters, plumbers, or other 
workers in lead, and a more careful inves- 
tigation of the subject forced the conclusion 
on my mind, that the influence of this 
form of metallic impregnation in inducing 
a gouty condition of the system was very 
considerable.1 Since that period I have 
made many observations on the point, 
and the conclusions may be summed up 
in a few words :- 
1. Among the patients in London hos- 
pitals, a very large proportion of the 
gouty (about thirty per cent, in my hospi- 
tal practice) have been subjected to the 
influence of lead : many of these have had 
painters' (lead) colic ; some have suffered 
from wrist-drop or more severe forms of 
lead paralysis ; and all have exhibited the 
peculiarly characteristic blue line on the 
gums. 
On careful inquiry into the habits of 
these men, nothing remarkable has been 
elicited ; they have been about as temper- 
ate as other men employed in different 
occupations. It is not painters alone who 
form this high percentage, but plumbers, 
composition doll-makers, workers in lead 
mills, and others whose trades have 
caused them to be exposed to the use of 
lead. It may be considered as established, 
that the metal lead acts as a powerful pre- 
disposing cause of Gout. 
2. Many cases have occurred which 
have induced me to believe that indi- 
viduals suffering from the gouty diathesis 
are more susceptible to the influence of 
lead than the majority of other people. 
It is a well-known fact, that when the 
drinking water in any house is slightly 
impregnated with this metal from the cis- 
tern or pipes with which it has come in 
contact, some of the residents in that 
house may experience the symptoms of 
saturnine poisoning, while the rest may 
be unaffected, although drinking an 
equally large quantity of such water; 
thus proving that some people are pecu- 
liarly susceptible to its influence : some 
remarkable examples of this fact have 
come under my notice. In the medicinal 
administration of lead preparations, as in 
cases of hemorrhage, or excessive mucous 
discharges, it will be observed, if patients 
be closely watched, that the blue line ap- 
pears on the gums in some cases with ex- 
treme rapidity, and that even colic pains 
are soon experienced ; but that in others 
the use of the lead salts can be continued 
for a lengthened period, without the pro- 
duction of any such phenomena. In sev- 
eral instances where patients have proved 
to be very easily affected, it has been 
found that they were of a gouty habit, 
and many of them had repeatedly suffered 
from severe attacks of the disease. 
3. In some instances, severe attacks of 
Gout have been induced in gouty patients 
by the medicinal administration of lead 
salts, on account of the occurrence of 
epistaxis or other forms of hemorrhage; 
and the frequent recurrence of the seiz- 
ures, whenever the medicine has been re- 
peated, has satisfactorily shown that the 
phenomena were to each other in the 
relation of cause and effect. 
4. On investigating the physiological 
action of the administration of lead salts, 
it is discovered that a very decided effect 
is produced by that metal upon the se- 
creting power of the kidney, as far as uric 
acid is concerned ; the function is notably 
diminished. 
5. The blood of individuals suffering 
from lead paralysis always contains an 
abnormal amount of uric acid; and the 
same, probably, holds good in all cases of 
lead colic. 
6. There are many facts which seem to 
show that the influence of lead, when un- 
combined with that of fermented liquor, 
is scarcely able to produce gout; for al- 
1 Transactions of Medico-Chirurgical Soci- 
ety, vol. xxxvi., 1854. PATHOLOGY OF GOUT. 
531 
though in England Gout is so common 
among those who work with lead prepara- 
tions, yet neither in France nor Scotland 
has the connection been noticed. In 
Edinburgh, however, even lead poisoning 
appears to be much less frequent among 
painters than in England. 
Before concluding this subject, it should 
be observed that it has long been a mat- 
ter of medical observation, that lead poi- 
soning often gives rise to pains in the 
limbs which have generally been regarded 
as rheumatic or neuralgic in character. 
These pains, however, which appear to 
be likewise produced by some other met- 
als, must not be confounded with Gout, 
with which they probably have no rela- 
tion. 
Pathology of Gout.-Our space is 
insufficient to allow of even a brief sum- 
mary of the different views which have 
been held from time to time, and by dif- 
ferent writers, of the real nature of Gout. 
As the disease has been known from re- 
mote antiquity, and as it is one which 
has always appeared to interest mankind, 
it is not to be wondered at that very nu- 
merous and diverse views have been ad- 
vocated. The existence of an altered 
condition of the blood has been always a 
popular belief among the ancient as well 
as modern pathologists; but various opin- 
ions as to the nature of the alterations 
have been held. The ancients, as was 
their wont, ascribed Gout to the super- 
abundance of phlegm, bile, and other 
natural secretions in the system, and 
they attributed chalk-stones to the con- 
cretions of such matters in the affected 
parts; and such ideas were held by some 
physicians even up to a comparatively 
late date. There have not, however, been 
wanting supporters of a totally different 
doctrine-men who, discarding all ideas 
of a morbid state of the fluids of the body, 
have looked upon the disease as dependent 
upon an alteration in the structure or 
functions of the nervous, vascular, and 
other systems. 
Cullen was the great supporter of the 
anti-humoral doctrine, and brought for- 
ward many cogent reasons for not regard- 
ing gout as due to an altered condition of 
the blood or the secretions therefrom. 
Cullen was a physician whose views are 
always worthy of consideration, and al- 
though many of his statements can now 
be shown to be erroneous, still a short 
summary of his objections may not be 
disadvantageous^- given, if only for the 
purpose of being' combated. Cullen 
thought that there was no evidence of 
the presence of any morbid matter in 
gouty persons; that neither the blood 
nor secretions from it had been proved to 
be altered in this disease, and that pre- 
vious to an attack there was no symptom 
indicating such a change; but that the 
balance of evidence was against this idea, 
seeing that many individuals before a 
seizure were apparently in unusually 
good health. From what has been al- 
ready stated in the present article, it will 
not be difficult to show the error of the 
above opinion; for it has been demon- 
strated beyond doubt, by clinical evi- 
dence, that the blood is invariably altered 
in Gout, from the presence of uric acid in 
the form of urate of soda; that the secre- 
tions from the blood are likewise influ- 
enced ; that symptoms are usually pres- 
ent before the development of the articular 
inflammation; and, lastly, that the in- 
flamed parts are always altered by the 
secretion into their structures of the same 
urate of soda-a phenomenon which has 
never been shown to occur except in this 
disease, and which may therefore be re- 
garded as pathognomonic. 
Cullen, who was necessarily aware of 
the occasional presence of chalk-stones in 
gouty subjects, overcame the difficulty by 
stating that such deposits only occurred 
now and then, and after the disease had 
been present a long time; and, in fact, 
regarded chalk-stones as accidental phe- 
nomena, and in no way essentially con- 
nected with the disease. Cullen consid- 
ered Gout to depend upon a peculiar 
conformation of some portion of the ani- 
mal economy, more especially the nervous 
system; he regarded the chief exciting 
causes, such as intemperance, indigestion, 
cold, and other depressing influences, as 
acting upon the nervous centres, and 
looked upon most of the symptoms of 
retrocedent Gout as affections of the same 
kind. 
Cullen's theory of Gout is best expressed 
in his own words: " In some persons 
there is a certain vigorous and plethoric 
state of the system, which, at a certain 
point of life, is liable to a loss of tone in 
the extremities. This is, in some mea- 
sure, communicated to the whole system, 
but appears more especially in the func- 
tions of the stomach. When this loss of 
tone occurs, while the energy of the brain 
still retains its vigor, the vis medicatrix 
naturce is excited to restore the tone of 
the parts, and accomplishes it by exciting 
an inflammatory affection in some parts 
of the extremities. When this has sub- 
sisted for some days, the tone of the ex- 
tremities and of the whole system is 
restored, and the patient returns to his 
ordinary state of health. This is the 
course of things in the ordinary form of 
the disease, which we name regular Gout; 
but there are circumstances of the body, 
in which this course is interrupted or 
varied. Thus, when the atony has taken 
place, if the reaction do not succeed, the 
atony continues in the stomach, or per- 
haps in other internal parts, and pro- 532 
GOUT. 
duces that state which we have, for rea- 
sons now obvious, named atonic Gout. 
" A second case of variation in the 
course of the Gout is when, to the atony, 
the reaction and inflammation have, to a 
certain degree, succeeded; but, from 
causes either internal or external, the 
tone of the extremities, and perhaps of 
the whole system, is weakened; so that 
the inflammatory state, before it had 
either proceeded to the degree, or con- 
tinued for the time, requisite for restor- 
ing the tone of the system, suddenly and 
entirely ceases. Hence the stomach and 
other internal parts relapse into the state 
of atony, and perhaps have thus increased 
by the atony communicated from the ex- 
tremities ; all which appears in what we 
have termed retrocedent Gout. 
"A third case of variation from the 
ordinary course of Gout is when, to the 
atony usually preceding, an inflammatory 
reaction fully succeeds, but its usual de- 
termination to the joints is by some cir- 
cumstances prevented ; and is, therefore, 
directed to an internal part, where it pro- 
duces an inflammatory affection, and that 
state of things which we have named the 
misplaced Gout." 
It is as easy to show the fallacies in 
this theory of Cullen concerning the na- 
ture of Gout, as to refute the many dog- 
mas which he puts forward ; and, there- 
fore, the mere enumeration of it must be 
considered sufficient. Since Cullen's time 
there have been writers on this disease, 
who, even with the knowledge of some at 
least of the facts recently discovered, still 
cannot bring themselves to admit the 
truth of the humoral doctrine of Gout. 
The late Sir C. Scudamore, although con- 
fessing many difficulties, was, up to a few 
years before his death, of opinion that 
there existed a species of plethora. The 
subject of chalk-stones was already a 
difficulty with him, and the discovery of 
the constant presence of uric acid in the 
blood of gouty patients shook his confi- 
dence in his old ideas upon the subject. 
A recent writer, Dr. Gairdner, believes 
in the existence of a state of plethora of 
the chylopoietic organs as a constant ac- 
companiment of Gout, and thinks like- 
wise that the veins of the part are in a 
varicose state, that the heart is oppressed 
with a flood of returning venous blood, 
made impure from the non-elimination of 
urea, uric acid, and biliary matters; 
and he thus views the phenomena of a 
paroxysm of Gout: "Venous congestion 
I consider the first condition essential to 
the formation of the gouty diathesis. It 
is no new observation ; it is found inter- 
spersed through the writings of all former 
authors. Even those who adopt expla- 
nations inconsistent with such a state of 
things, notwithstanding admit it. This 
state of the blood was first clearly an- 
nounced as the great cause of Gout by 
Galen, whose opinions have continued to 
influence the minds of succeeding phy- 
sicians in a greater or less degree to the 
present day. The truth of the fact being, 
I imagine, unquestionable, it will always 
continue to embarrass the doctrines of 
those who advocate opinions with which 
it is incompatible. But the great venous 
canals of the body, as well as the larger 
arterial vessels, are endowed with a re- 
siliency which enables them to struggle 
well against the flood of returning blood. 
This fluid, then, is compressed between 
two opposing forces-that, namely, which 
is derived from the heart and arterial sys- 
tem, urging it forward on its course, and, 
on the other hand, the antagonistic re- 
sistance of the great veins leading to the 
right auricle. Under this compression, I 
believe that the vessels give way, and a 
true hemorrhage is occasioned in the part 
affected. If the rupture takes place in a 
minute capillary, carrying the serous por- 
tion of the blood only, oedema is the con- 
sequence ; but if the burst bloodvessel be 
one carrying red blood, a true ecchymosis 
is formed." 
And again : "It will surely be admitted 
that the capillary and nutrient vessels, 
distributed on the extreme and sentient 
fibrillse of the nerves, are affected in the 
same manner as the larger venous trunks. 
I believe these distended capillary vessels 
are the real seat and cause of the painful 
phenomena of Gout. Is it not credible 
that such vessels, dilated so as to admit 
fluids for which they were not intended, 
and bound down by the firm fascia?, in 
which Gout has its usual seat, may give 
rise to much suffering ?" 
The great objection to Dr. Gairdner's 
views is, that there is no proof of the oc- 
currence of hemorrhage during the gouty 
seizure ; no one has seen the ecchymosis 
spoken of by him as a constant attendant 
on it, whereas other and frequent changes 
are invariably observed in the inflamed 
part. It is, indeed, true that abdominal 
plethora is often present in gouty habits, 
especially when the disease has been in- 
duced by high living ; but on the other 
hand, in many cases, even when the dis- 
ease is of an inveterate character, no 
symptoms indicating such a condition are 
discoverable. Furthermore, congestion 
of chylopoietic organs, accompanied with 
obstructed cardiac circulation, is very 
frequent and of long duration, and yet no 
Gout is developed. 
Many other authors have, within the 
last half century, published viewrs as to 
the nature of Gout ; amongst whom, in 
this country, may be mentioned Murray, 
Forbes, Parkinson, Wallaston, Parry, 
Sutton, Sir E. Home, and Sir Henry Hol- 
land. The reflections of the last-named 
physician on the subject are well worthy PATHOLOGY OF GOUT. 
533 
of attention. In France the principal 
authors have been Cruveilhier, C. Petit, 
Barthez, Guibert, and Trousseau. Some 
of these have been inclined to favor the 
views of the solidists, but perhaps the 
opinions of the majority have had a de- 
cided tendency to humoralism. 
After these short expositions of some of 
the principal opinions, which have been 
held of the nature of Gout in recent times, 
and which have proved to be wholly or in 
part fallacious, it is necessary to lay be- 
fore our readers the view which we think 
accords more completely with facts than 
any other which has been proposed, and 
one which will explain nearly all the phe- 
nomena presented by the disease. In the 
first place, " it is essential to the produc- 
tion of this form of articular inflammation 
that the blood should contain an abnormal 
amount of uric acid, or rather of urate of 
soda ; and even the phenomena which 
constitute irregular Gout, or are regarded 
as gouty manifestations, demand for their 
occurrence the presence of the same salt 
in the circulating fluid." 
The truth of this proposition has been 
proved by some hundred clinical observa- 
tions upon cases of articular inflamma- 
tion ; and although it has not been fre- 
quently demonstrated in cases of irregular 
Gout, yet this has been done sufficiently 
often to make it matter of certainty. It 
will, therefore, be unnecessary to bring 
forward any further evidence of the cor- 
rectness of the proposition. 
In must not, however, be supposed that 
an excess of urate of soda in the blood 
constitutes Gout; this would be erroneous, 
for the salt is occasionally present in large 
quantities, and yet no gouty phenomena 
are manifested; but the individual so cir- 
cumstanced may be looked upon as espe- 
cially prone to its development, if other 
circumstances arise which favor its pro- 
duction. 
In the next place, " gouty inflamma- 
tion is invariably accompanied with the 
presence of urate of soda in the inflamed 
tissue." 
We have already given much evidence 
of this fact, and in no case in which real 
gouty inflammation has been shown to 
have occurred have the morbid appear- 
ances failed to present themselves when 
sought for. 
Furthermore, "it can be shown that 
the amount of deposited urate of soda is 
not in proportion to the intensity of the 
inflammation, and that in some structures 
the infiltration may ensue and scarcely 
give rise to any inflammatory action; facts 
tending to the supposition that the de- 
posited matter may be looked upon as the 
cause rather than the effect of such inflam- 
mation. " 
It is most important, as bearing con- 
siderably upon the true pathology of Gout, 
that the above proposition should be fully 
substantiated, and it is not difficult to 
bring forward much evidence in its favor. 
If an opportunity occurs of examining a 
joint, as the knee, which has been but once 
attacked, no great amount of alteration 
may be exhibited, although the inflam- 
mation has been intensely acute ; on the 
other hand, after a joint has become, as 
it were, callous, considerable deposition 
can be shown to occur without the pro- 
duction of much local inflammation. The 
same fact is better illustrated in the case 
of the ear, in which, as before stated, 
urate of soda is frequently deposited in 
the fibro-cartilaginous tissue. This phe- 
nomenon, although at times recognized 
from the sensation of heat, pricking, and 
tenderness of the part, yet more commonly 
takes place without the production of any 
symptom-the patient being, in fact, quite 
unconscious of its occurrence. In many 
chronic forms of Gout it is not unusual to 
find large collections of the white matter 
formed near the surface, with compara- 
tively little constitutional disturbance, 
and any one watching the progress of such 
a case must soon become convinced that 
the elimination of the salt is not an effect 
of the inflammation. To show that it is 
probably the cause is equally easy : let us 
compare, for example, the articulating 
surfaces of the knee-joint with the fibro- 
cartilage of the external ear, in respect to 
their liability of becoming inflamed from 
the presence of foreign bodies or the in- 
fliction of injuries; irritation of the former 
is known to be most serious in its results, 
from the acute action which is set up, 
whereas considerable damage may be done 
to the latter without any but the slightest 
inflammation ensuing. Would not a like 
difference exist in the same tissues if a 
substance foreign to their constitution be- 
came infiltrated by the action of disease ? 
" The inflammation of the gouty parox- 
ysm tends to the destruction of the urate 
of soda in the blood of the inflamed part, 
and probably also of the salt which has 
been thrown out." 
When describing the blood and secre- 
tions of gouty subjects, allusion was made 
to the fact that, although the fluid effused 
from the action of a blister usually con- 
tains uric acid, yet an exception occurs in 
the case of its being applied over an 
acutely inflamed surface. Under these 
circumstances, it would appear that the 
uric acid is destroyed by the presence of 
the inflammatory action ; and, if this be 
true, the gouty paroxysm is, at least to 
some extent, a salutary process, tending 
to rid the system of accumulated uric 
acid; but, as the fit is always accompanied 
by local mischief, the good effected is by 
no means unalloyed. 
"■Gouty deposits do not take place in- 
discriminately in any situation or in any 534 
GOUT. 
tissue ; but a selection is made, in close 
relation to the vascularity of the part." 
If the remarks on the morbid anatomy 
of Gout be referred to, it will be observed 
that the structures most liable to become 
affected are those possessing little vascu- 
larity ; as, for example, cartilage, fibro- 
cartilage, ligament, tendon, and synovial 
membrane. It will be seen, also, that the 
deposit, as it were, avoids the contiguity 
of bloodvessels, as exemplified in the knee- 
joints, in which the surfaces in contact 
with the synovial fringes are free. Again, 
in the cartilage itself, the deposition, al- 
though intestinal, commences near the 
free surface, and gradually penetrates 
deeper into the tissues, but, even in ex- 
treme cases, scarcely extends beyond a 
third of its thickness, and is always at 
a considerable distance from the blood- 
vessels of the bone. 
It is probably owing to this freedom 
from deposition which vascular tissues 
enjoy, or to the rapid destruction of the 
urate of soda when placed under circum- 
stances which bring it into contact with 
bloodvessels, that acute gouty inflamma- 
tion does not affect the covering or lining 
membranes of the heart, as is the case 
with rheumatic inflammation. The mor- 
bid changes which are often found in the 
valves of the heart, or the lining mem- 
brane of the aorta, form no exception to 
this statement, for they are not due to the 
presence of urate of soda, but to an alter- 
ation of an entirely different character. 
" The kidneys are often, if not always, 
implicated in Gout, and the affection, 
possibly only functional at first, soon be- 
comes structural. The urinary secretion 
is likewise altered." 
Under the "Morbid Anatomy" of the 
disease it has been affirmed that, in all 
cases where Gout has existed for any 
length of time, some alteration is found 
in the kidneys; deposition within or ex- 
ternal to the tubuli uriniferi is discovered, 
and the normal structure of the secreting 
apparatus is injured. In chronic cases 
the peculiar shrivelled or gouty kidney is 
frequently met with. As yet I have never 
seen this latter form of kidney disease 
without finding the white deposition, and 
I cannot help thinking it probable that 
the presence of the urate may be the ex- 
citing cause of the subsequent changes 
which ensue in the structure ot the kidney. 
The kidney affection, whether func- 
tional or organic, readily explains the 
altered state of the urinary secretion: 
The functional disturbance may cause the 
defect and irregularity of the secretion of 
uric acid ; the organic alteration accounts 
for the further diminution in the excre- 
tory power of the organ, and the frequent 
presence of a small amount of albumen in 
the urine. 
" The impure state of the blood, due to 
the presence of urate of soda, is probably 
the cause of the disturbance which often 
precedes the gouty paroxysm ; that is of 
the so-called premonitory symptoms, as 
well as most of the anomalous affections 
(irregular Gout) to which such patients 
are liable." 
That suppression of the whole urinary 
secretion such as occurs in intense renal 
congestion and advanced forms of albu- 
minuria gives rise to many and alarming 
symptoms, is a well-known and acknowl- 
edged fact ; and hence it is reasonable to 
suppose that a suppressed excretion of one 
of its constituents should manifest itself 
by symptoms of a less intense and fatal 
character. Possibly some of the symp- 
toms may be due to the reaction conse- 
quent upon an attempt at deposition of 
urate of soda in certain unusual situa- 
tions. Dyspepsia, for example, is very 
common in albuminuria ; it is also fre- 
quent in persons of a gouty diathesis. 
" The causes which predispose to Gout, 
independent of those connected with in- 
dividual peculiarity, are either such as 
produce an increased formation of uric 
acid or which lead to its retention in the 
blood." 
Although our knowledge of the causes 
which lead to the undue formation of uric 
acid is most imperfect, yet there can be 
little doubt that over-feeding, especially 
in regard of animal food, portal congestion, 
and deficient exercise, aid very much in 
the production of its excess ; and it is 
known from clinical experience that these 
are predisposing causes of Gout, as ap- 
pears to be also lead impregnation, the 
use of malt liquors, wines, and so on, 
which probably lead to a defective elimi- 
nation of the same acid. Deficient ner- 
vous energy, arising from mental or other 
causes, seems to act in the same manner. 
"The causes exciting a gouty fit are 
those which induce a less alkaline condi- 
tion of the blood, or which greatly aug- 
ment for the time the formation of uric 
acid, or such as temporarily check the 
eliminating power of the kidneys." 
The deposition of urate of soda is caused 
by its insolubility, and this may arise 
either from the large amount which is 
formed, or from the serum of the blood 
becoming less capable of holding it in 
solution. The blood serum is alkaline in 
reaction, and this condition may become 
lessened from various causes, especially 
from deficient action of the skin, the 
taking of a large amount of acid into the 
stomach, and, perhaps, an increased for- 
mation of some acid, arising from dyspep- 
sia : all the above-named circumstances 
will, it is known, often excite a gouty 
attack. It seems probable that there 
may be at times a great temporary iu- PATHOLOGY OF GOUT. 
535 
crease of uric acid found in the system, 
by causes giving rise to an attack of dys- 
pepsia. 
"Deposits of urate of soda in the tex- 
tures of the body never occur but in true 
Gout." 
It has already been shown that urate of 
soda invariably accompanies gouty in- 
flammation, and it can be equally proved 
that it is not thrown out under other cir- 
cumstances. There are, indeed, many 
statements which appear at first to throw 
doubt upon the correctness of the above 
proposition, but which upon closer ex- 
amination can be shown to be erroneous. 
I have seen white nodules on the ears of 
young people who have apparently had 
no gouty tendency : these have been found 
to contain fat and amorphous granular 
matter, but no crystals of urate of soda. 
I once was shown a large tumor, taken 
from the scalp of a young woman, and 
was assured that it had been analyzed 
and found to consist of urate of soda, and 
that there certainly was no gouty ten- 
dency in the patient. On examining a 
portion of the tumor, no trace of uric acid 
could be discovered in it. 
Diseased joints from rheumatoid arthri- 
tis, and other chronic diseases, have been 
also asserted to be covered with a urate 
deposit: in all such cases I have shown 
that bone-earth concretion has been mis- 
taken for urate of soda. 
In examining the large toe-joints of a 
large number of bodies, a little white spot 
was seen in two instances; yet no Gout 
had been known to have occurred during 
life. One of the individuals had been a 
cabman, and had granular kidneys-he 
had died from an injury; the other had 
died of delirium tremens. In each case 
one foot only was affected, and the space 
covered with the deposit did not exceed a 
sixteenth of a square inch. These spots 
were doubtless indicative of very slight 
gouty inflammation, and in the investiga- 
tion of cases of confirmed Gout it is ex- 
tremely common to find that patients 
have complained of twinges and slight 
tenderness of the great toe for several 
years before the occurrence of a distinct 
and unmistakable paroxysm. 
Explanation of other Phenomena which 
occur in Gout.-There are certain pecu- 
liarities in the history of Gout which still 
require explanation, one of which is the 
fact that gouty inflammation in its first 
visitation generally attacks the ball of the 
great toe. Boerhaave and Van Swieten 
tried to explain this by supposing that 
Gout chiefly attacked those tissues in 
which the fluids have most difficulty in 
passing through, as the periosteum, ten- 
dons, nerves, membranes, and ligaments, 
and such as are most remote from the 
heart, most pressed upon and injured, and 
most subject to cold and moisture. I be- 
lieve that there is much truth in these 
remarks, although expressed in terms 
which are not conformable to the patholo- 
gy of the present day. Let us endeavor 
now to explain the phenomenon. 
The great toe contains a considerable 
amount of tissues peculiarly liable to be- 
come the seat of the deposition of urate 
of soda; as, for example, the cartilages 
and ligaments, tissues having either little 
vascularity or nourished independently of 
bloodvessels : the great toe being very re- 
mote from the heart, the circulation is 
weaker there than in many other parts, 
weaker than in the hips or knees. These 
remarks, however, both with regard to 
the tissues and the distance from the 
heart, apply even with greater force to 
the phalangeal joint of the great toe than 
to the metatarso-phalangeal joint, and 
apply also to the joints of the smaller 
toes; but, on the other hand, this latter 
joint is more subject to injury by pressure; 
it often has to bear the whole weight of 
the body, and sudden shocks-as, for in- 
stance, from false steps-are first felt in 
this articulation. In cases where the 
great toe has not been attacked, some pe- 
culiarity has been present in the conform- 
ation of the foot, which has had the effect 
of throwing the pressure on some other 
part. 
That the metatarso-phalangeal joint is 
liable to injury, I have been able to ascer- 
tain from the examination of several 
great-toe joints in subjects who had never 
had Gout; and it was found that in six 
instances only out of twenty were these 
joints absolutely healthy, there being in 
the rest more or less evidence of ulceration 
of the cartilages. The reasons for the 
great toe of one side of the body being 
affected apply equally to the other; and 
hence the disease not uncommonly attacks 
first one and then the other, within the 
space of a few hours or days. 
It is not difficult even to explain the 
sudden shifting of the inflammation from 
one joint to another: it must be remem- 
bered, that the deposition precedes the 
inflammation, and it is well known that 
the establishment of inflammation in one 
part is often followed by its subsidence in 
another. The nervous connection through 
the spine may also explain the alternation 
of inflammation so often observed in sym- 
metrical joints. 
In explanation of the reason why nu- 
merous joints are attacked as Gout gains 
ground, or becomes more engrafted into 
the system, it may be advanced that the 
cartilages and ligamentous structures of 
the earlier implicated articulations bein^ 
infiltrated with the urate, and the blood, 
still remaining impure from the presence 
of the salt, other surfaces are required to 
be selected. The defective circulation in 
the external ear, from the nature of its. GOUT. 
536 
structure and its exposed situation, is 
probably the reason why the small urate 
nodules are so frequently found upon it. 
I may remark that, up to the present 
time, I have never seen the concretions 
on the ears of females; this immunity 
may arise from their being usually cov- 
ered : individuals with cold ears seem to 
be most frequently affected with them. 
The cartilaginous, fibrous, and ligamen- 
tous tissues are peculiarly susceptible 
of becoming the seat of the deposit, 
partly from their little vascularity, and 
probably also from the fluids in these 
structures being less alkaline in reaction 
than the blood itself, and liable to become 
neutral or even acid. After death, in 
chronic gouty cases, the synovial fluid 
has been found in a few instances dis- 
tinctly acid. 
The explanation of the comparative im- 
munity from Gout enjoyed by females is 
to be sought for in their freedom from the 
influences of many extraneous causes, and 
their possession of a function which has a 
tendency to rid the system periodically of 
superfluous blood. As a rule, women 
take much less wine and beer than men, 
and altogether lead lives of greater pru- 
dence. After the cessation of the cata- 
menia, women become more liable to 
gouty paroxysms. Women who inherit 
Gout strongly, even if they live very care- 
fully, are apt to suffer from the irregular 
manifestations of the disease; the same 
remark applies to men who, inheriting the 
disease, and having the fear of it before 
their eyes, have from early life studi- 
ously avoided the causes which engen- 
der it. The reason of the almost certain 
recurrence of Gout, unless the greatest 
care be taken to overcome the tendency, 
must be sought for in the fact that the 
causes of the increased formation of uric 
acid in the system, and of its defective 
elimination, are generally irremovable; 
the periodicity of the disease may be due 
to the gradually increasing impurity of 
the blood from the time of the purification 
which occurs during the fit, and also to 
periodicity of the exciting causes-as the 
recurrence of the vernal and autumnal 
changes. 
Diagnosis of Gout.-To make a cor- 
rect diagnosis in cases of joint disease is a 
matter of importance, not only as regards 
the treatment, but as respects the prog- 
nosis : it is likewise often one of great 
difficulty, and always requires great care, 
even with those who have had most expe- 
rience in the subject. 
To determine if a case be of a true 
gouty character or not:- 
The history of the case should be fully 
inquired into; it must be remembered 
that Gout is strongly hereditary, and 
therefore, if either parent or grandparent 
of the patient suffered from it, the proba- 
bility of his joint affection having the na- 
ture of Gout is much strengthened. 
The age should be taken into account; 
Gout is very rare before puberty, not com- 
mon till after thirty-eight or forty years 
of age ; it may occur at a very advanced 
age. 
The sex of the patient influences the 
diagnosis; Gout is much more frequent 
in males than females ; in the latter it is 
seldom seen till after the catamenia have 
ceased. 
The mode of life of the patient for the 
several past years should be taken into 
consideration. Wine, malt liquors, and 
much animal food, tend to produce Gout; 
spirits have little effect. The history of 
the disease in its early stages should be 
inquired into. If we discover that the 
ball of the great toe was first and specially 
affected, and that the intervals between 
the attacks were of considerable duration, 
the conclusion that it is true Gout is al- 
most certain to be correct; but if the his- 
tory has not been of this characteristic 
nature, it must not be concluded that the 
affection is not gouty. An error may 
sometimes arise from laying too much 
stress upon the toe affection, to the exclu- 
sion of other symptoms ; I have seen a 
great toe swollen, tense, red, and hot, and 
having every appearance of being attacked 
with intense gouty inflammation, which 
has afterwards been proved to depend on 
pysemia. In this instance, a day or two 
from the commencement of the seizure, 
other parts were implicated and the pres- 
ence of pus was manifest; from the very 
first the amount of constitutional disturb- 
ance was far beyond that which occurs in 
Gout affecting one small articulation. 
The character of the symptoms should 
not be neglected. It must be remembered 
that in Gout the pain is generally severe ; 
during the early stage of the inflamma- 
tion the joint is very tense ; that it subse- 
quently pits, or is oedematous, and, lastly, 
desquamates ; that the febrile disturbance 
is usually moderate, and in proportion to 
the extent of the local inflammation. The 
presence or absence of periodicity in the 
attacks must not be overlooked ; Gout, 
especially for the first few years, is almost 
invariably periodic, complete and long in- 
tervals occurring between the paroxysms. 
In true Gout, acute inflammation of the 
heart does not occur ; in rheumatism car- 
diac complication is frequent. 
If a deposit of urate of soda can be dis- 
covered either in the external ear of the 
patient, in the tips of the fingers, the 
bursa? over the olecranon, or in any other 
situation, it is a matter of certainty that 
the patient has the gouty diathesis. Great 
care, however, must be taken not to con- 
found enlargements of other kinds, as of 
the ends of the phalanges, or simple bur- PROGNOSIS OF GOUT. 
537 
sal swellings, with those produced by the 
deposition of urate of soda. 
An examination of the blood of the pa- 
tient almost decides the point: this can 
be effected if only a single ounce is drawn 
from a vein, as not more than one or two 
drachms of the serum are required for the 
thread experiment. The fluid from a 
blister may be used instead of blood se- 
rum, although a negative result obtained 
from it is not so satisfactory. 
Lastly, the presence or absence of a 
trace of albumen in the urine, if the case 
be of a chronic character, may afford 
some assistance, as this symptom is very 
frequent in Gout, and dependent on the 
slight kidney affection which so commonly 
ensues after the disease has lingered in 
the system for a few years. 
A case, showing the importance of at- 
tending to the above differential points, 
has within the last few weeks come under 
observation. 
A woman aged 35, married, with one 
child, has for many years worked in a 
laundry, and has been necessarily exposed 
to damp, and great alternations of tem- 
perature ; says she has always been tem- 
perate, but has drunk beer, and now and 
then a little spirits. 
The patient is very deaf, which renders 
it difficult to ascertain every point either 
in her previous history, or that of the dis- 
ease, and which at first obscured the diag- 
nosis. About two years since she had 
swelling of the left knee, and thinks this 
joint was alone affected ; she was unable 
to move about for five or six months. 
About a year from the commencement of 
the knee affection the knee and ankles 
were attacked and the great toe was im- 
plicated ; does not remember whether it 
was the metatarso-phalangeal or the pha- 
langeal joint; the attack lasted a month 
or so. From this time to the present has 
been frequently obliged to keep her bed 
from joint disease, both the upper and 
lower extremities being involved. When 
first seen, both knees were tender and 
swollen, as likewise the ankles; some 
tenderness also of two or three of the pha- 
langeal joints of the hands, and the first 
phalanx of the left index, and the same 
joint of the right middle finger ; these are 
considerably thickened and swollen, and 
their mobility much impaired ; no visible 
deposits either in ears or elsewhere. No 
amount of febrile disturbance present. 
Catamenia regular. Urine free from al- 
bumen. None of her relations had suf- 
fered from joint disease. 
There was considerable difficulty in 
arriving at a safe conclusion in this case. 
Against the disease being Gout, and in 
favor of its being rheumatoid arthritis, 
there was the following evidence : the sex 
of the patient, her somewhat early age, 
and the catamenia being still present; the 
supposed moderate abstinence from malt 
liquors (though she always took three 
pints of beer a day, with some spirits); the 
absence of any affection of the great toe 
in the first attack and the question as to 
which joint of the toe was implicated in 
subsequent seizures ; the duration of the 
disease and its almost progressive charac- 
ter from the first; the non-discovery of 
chalk-like deposits in the body; and, 
lastly, the probability of the joint affection 
being brought on by cold. 
On the contrary, in favor of its being 
Gout were the following circumstances: 
the appearances of general good health ; 
the distinct interval of six months between 
the first and second seizures; and the 
probability of the patient taking more 
malt liquors than she herself allowed. 
To remove any doubt upon the subject 
a very small venesection was performed, 
and upon analysis the serum was found to 
yield a large quantity of uric acid by the 
thread experiment. This was almost de- 
cisive of its being Gout; but on very close 
inquiry, finding that the elbows had been 
affected several times, the state of the 
bursse over the olecranon process was ex- 
amined, and in the right bursa some thick- 
ening was detected, as likewise the pres- 
ence of two or three flattened little masses, 
doubtless of urate of soda. The presence 
of these little masses in the bursa, con- 
joined with the fact of the blood being 
rich in uric acid, fully established the na- 
ture of the case ; and this discovery was 
of no small importance, not only in the 
treatment of the attack, but as to the 
means to be taken in future to keep the 
disease from making further inroads in 
the system. 
Prognosis of Gout.-An attack of 
acute articular Gout is probably never 
fatal, and individuals are often seen who 
have suffered from severe paroxysms for 
many years, and yet appear to have ex- 
perienced little or no injury beyond their 
sufferings at the time. If the intervals 
between the seizures continue to be of fair 
duration, as one year or half a year, when 
the patient is beyond middle age, the 
prognosis is favorable, and there is no 
reason why any appreciable shortening of 
his life should ensue, provided he is will- 
ing to live according to rule, and is not 
exposed to accidents or other powerful 
causes of the disease. In confirmation of 
this statement is the fact that robust- 
looking persons of very advanced age are 
not infrequently seen, who have been the 
subject of periodic visitations of Gout for 
a great number of years. When, how- 
ever, in comparatively early life, the at- 
tacks are frequent and prolonged, the 
prognosis becomes much less favorable, 
and especially if the urine exhibits any 
trace of albumen, either during the pa- 538 
GOUT. 
roxysms or in the intervals of freedom 
from them. 
The appearance of the patient's urine 
helps us in making a prognosis. If it was 
formerly turbid from urates, or if it gave 
rise to a deposit of crystallized uric acid, 
and has become of late clear and of a 
paler color, the change probably indicates 
that the kidneys have to a considerable 
extent lost their power of eliminating 
uric acid, and that which seems to the 
patient a favorable change is in reality a 
sign of a serious structural alteration in 
an important secreting organ. 
It is a grave sign in Gout to find the 
urine pale, the specific gravity exceed- 
ingly low, and the fluid devoid of uric 
acid ; and if, in addition to this condition, 
albumen is likewise present, the indica- 
tion becomes still more unfavorable. 
Chronic Gout has a decided tendency to 
shorten life, and this fact is recognized by 
insurance companies, who, however, do 
not appear to make much distinction be- 
tween the acute and chronic forms of the 
disease : at different offices varying rates 
are adopted. 
In the early attacks a patient is likely 
to inquire of his physician, if it is possi- 
ble to prevent a return of his ailment-a 
question tantamount to asking if there is 
any known method of absolutely eradi- 
cating the tendency to Gout from the 
system. 
There are records of individuals who 
have experienced but one attack, though 
they have lived to a great age. I have 
known thirty-five years elapse between a 
regular attack of Gout in the great toe and 
the patient's death, which took place after 
he had attained his seventieth year. Sev- 
eral cases have come under my observa- 
tion in which the disease, after having 
recurred periodically for many years, grad- 
ually declined in intensity and duration, 
and at last altogether disappeared. 
The appearance of Gout can never be 
looked upon as a good omen ; a statement 
contrary to a once popular opinion. 
The greater the age at which Gout first 
seizes the individual, the more satisfactory 
the prognosis. 
If it attacks very young subjects, the 
future prospects are bad. 
Hereditary is generally much less tract- 
able than acquired Gout. 
The appearance of chalk-stones on the 
surface is always inauspicious, even if 
confined to the helix of the ears. 
Gouty patients are more liable to suffer 
severely from accidents and exposure than 
the majority of people ; the more the kid- 
neys are implicated, the less able are they 
to withstand the effect of shock upon the 
system. 
In concluding the subject of the prog- 
nosis of Gout, I will remark, that I con- 
sider that a single fit of Gout, however 
slight, should be looked upon as an inti- 
mation that the patient cannot go on with 
impunity in his then habits of life ; it is a 
warning that either he must change them 
or expect returns of the disease, which, 
as time advances, are certain to increase 
both in frequency and duration, and both 
embitter and shorten existence. 
On the other hand, I am equally per- 
suaded that if proper regiminal and medi- 
cinal precautions be taken, the gouty 
patient may be saved from such an alter- 
native and the disease, instead of increas- 
ing in intensity, may be gradually miti- 
gated, and probably interfere but little 
with the comforts of life. 
Treatment.-The subject of the treat- 
ment of Gout naturally divides itself into, 
first, the treatment of the articular inflam- 
mation ; secondly, the management of the 
gouty subject during the intervals of the 
attacks ; and, thirdly, the treatment of the 
complications and irregular manifesta- 
tions of the disease. Under the head or 
Treatment we shall discuss not only the 
medicines which it may be necessary to 
administer, but likewise the dietetic and 
regiminal management. 
Treatment of Acute Gout. - Let us first 
examine if there is any necessity for giv- 
ing medicine at all, and whether or not 
it is prudent to leave the joint disease to 
pursue its own course uninfluenced by 
any drug. 
Cases are now and then met with in 
which the affection has been left to itself, 
and several such have come before me. 
From the opportunities thus afforded, I 
have ascertained that many of the early 
and slighter attacks of Gout will subside 
in a few days, provided the patient is 
moderately careful in diet; but that, if 
the usual mode of living is indulged in, 
the attack may be prolonged, even to 
many weeks or months ; or, if slight re- 
missions take place from time to time, 
they are soon succeeded by exacerbations, 
until at last the patient's general health 
gives way, the appetite fails, and thus 
under a necessarily altered diet the dis- 
ease exalts itself; even then the attack 
may last a long time, as is likewise the 
case under homoeopathic treatment, which, 
if honestly practised, and with the use of 
infinitesimal doses, is, I should imagine, 
exactly equivalent to the non-exhibition 
of medicines. 
When the articular inflammation is al- 
lowed to run its own course, and has been 
endured for a long time, it leaves a con- 
siderable amount of injury in the affected 
parts, the bloodvessels become weakened, 
the distension of veins and the local oede- 
ma remain, and the joints are left in a 
condition liable to take on unhealthy ac- 
tion from trifling constitutional disturb- 
ances. TREATMENT. 
539 
Assuming then, that medicinal treat- 
ment can be of real benefit, it is for us to 
determine the remedial agents best adapt- 
ed to diminish or cure the inflammation. 
There is one drug which has an undoubted 
influence in controlling gouty inflamma- 
tion, and its action in articular Gout ap- 
pears as marked as that of cinchona bark 
in the cure of ague; this remedy is col- 
chicum. It signifies not what part of the 
colchicum plant is taken, whether the 
corm, the seeds, or the flowers, for the 
same principle pervades the whole plant; 
neither does it signify what preparations 
are made use of, whether the wine, the 
tincture, or the extract, provided equiva- 
lent doses be administered, for the effects 
of all are the same. 
Colchicum, as before stated, has a direct 
controlling power over the joint disease, 
and I cannot call to mind a single instance 
in which its influence was not well marked, 
although in many cases a question may 
arise as to the propriety of its exhibition. 
Colchicum in full doses produces a marked 
sedative effect upon the nervous and vas- 
cular systems; it has likewise a distinct 
influence upon the intestinal canal; and 
if continued too long and in too large 
doses, causes tormina, and a very trouble- 
some form of diarrhoea. It also produces 
a peculiar change in the fecal excretions, 
so that those accustomed to its use can 
detect it by this circumstance alone, even 
when otherwise unaware of the exhibition 
of the drug ; this alteration in the alvine 
excretions is probably due to the influence 
of colchicum upon the secreting apparatus 
of the bowels or their appendages, more 
especially the liver and pancreas. Col- 
chicum has generally been supposed to 
cause a more copious flow of urine, and 
to favor the elimination of its solid con- 
stituents ; but of this there will be occa- 
sion to speak further on. 
Although colchicum causes purging, 
still its peculiar influence is quite apart 
from this effect. Occasionally an almost 
magical change is produced by a single 
large dose, without the appearance of the 
least increase in the secretion from any 
organ, the effect being manifested in the 
rapid subsidence of the pain and other 
symptoms of the joint inflammation ; and 
simple purging, even though copious, will 
often fail to produce any notable effect 
under the same circumstances. I am of 
opinion that, in articular Gout, colchicum 
may be advantageously administered dur- 
ing the time that the inflammatory symp- 
toms are present; and the dose of the 
wine of colchicum may be from ten to 
twenty or even twenty-five minims re- 
peated every six hours. Colchicum given 
in the above manner will of itself be suffi- 
cient in most cases to cut short the gouty 
attack, and I have often depended on it 
alone ; but, at the same time, in the ma- 
jority of cases, it is advantageous to com- 
bine it with other remedies, which must 
necessarily vary in different cases. From 
what has been stated of the condition of 
the blood and of the urine, it will at once 
appear that some moderate alkaline plan 
of treatment is likely to prove advan- 
tageous, both for the purpose of increas- 
ing the alkaline state of these fluids, and 
also to keep in solution the salt of uric 
acid, which is liable to be deposited in 
the cartilaginous and ligamentous tissues. 
There can be no doubt of the value of al- 
kaline remedies in the gouty paroxysm, 
and, in many cases, such salts, given in a 
freely diluted form, are sufficient of them- 
selves for its removal, and are peculiarly 
applicable when there are circumstances 
rendering the administration of colchicum 
undesirable. Alkalies may be given either 
in the free state, or combined with car- 
bonic acid, in the form of the carbonates 
or bicarbonates, or united with some 
vegetable acid, as the citric, tartaric, or 
acetic acids. If the stomach is irritated, 
and an over-secretion of acid be present, 
then the free alkalies or their carbonates 
may be administered ; but if, on the other 
hand, there be no such condition, then 
the salts with the vegetable acids may be 
used, which produce an alkaline state of 
the blood and urine, although they do not 
act as antacids in the stomach. These 
alkaline remedies not only tend to keep 
up and restore the normal reaction of the 
blood, but likewise augment the excretion 
of urine, and with it the elimination of 
those solid matters which are unduly re- 
tained in that fluid in gouty states of the 
system. It is important, likewise, to 
make a selection of the alkali, and unless 
there are circumstances which render the 
use of soda desirable, such as an imper- 
fect action of the liver, or a deficient se- 
cretion of bile, this alkali is the least fitted 
for exhibition, as it has much less power 
than other fixed alkalies of dissolving or 
holding in solution uric acid. The salts 
of potash are, in the majority of cases, 
more suitable than the salts of soda, as 
they not only exert a much greater sol- 
vent action upon urate of soda, but like- 
wise augment in a greater degree the 
excretion of the urine. A third fixed 
alkali or its salts can be employed in lieu 
of soda or potash, namely, lithia, an alkali 
now7 able to be procured in quantities suf- 
ficient for medicinal use. 
Besides the administration of alkaline 
remedies and the cautious use of colchi- 
cum, it is important in attacks of acute 
Gout to attend to the state of the intesti- 
nal canal and the skin. If the bowels be 
confined, some aperient must be given, 
and the selection of the drug should de- 
pend upon the peculiarities of the patient. 
If mere constipation exists, a simple pur- 
gative, as the compound colocynth ex- 540 
GOUT. 
tract, may be administered at night, fol- 
lowed by a saline aperient, as a seidlitz 
powder, or the effervescing citro-tartrate 
of soda and magnesia; or, if a more 
active dose be required, the common 
black draught can be substituted for these 
latter. If, however, the portal system 
shows evidence of congestion, and the 
function of the liver is disordered, some 
more powerful cholagogue will be useful, 
especially if the patient has been in the 
habit of taking purgatives. A small 
amount of blue pill or of calomel can be 
combined with the colocynth, or podo- 
phylline, in quarter or half-grain doses, 
may be substituted for the mercurial. It 
should be borne in mind that, in gouty 
habits, mercurials must be used with 
great caution, as in many cases there is a 
considerable susceptibility to their action, 
and very unpleasant consequences may 
follow their administration in repeated 
doses. 
Saline purgatives are very desirable; 
many of them act remotely as antacids, 
and all tend to relieve portal congestion. 
A very useful combination, and one often 
employed in acute attacks of Gout, is a 
draught containing sulphate and carbonate 
of magnesia, to which colchicum alone or 
bicarbonate of potash and colchicum, may 
be added. 
The function of the skin, if very defec- 
tive, may be promoted by the use of a 
hot-air or vapor bath, and at the same 
time the acetate of ammonia may be 
given, combined with other remedies. 
The action of the kidneys is usually suf- 
ficiently promoted by the saline treatment, 
especially if accompanied by the free use 
of diluents. 
Blood-letting, in the form of venesection 
from the arm, was frequently had recourse 
to in former times; but this practice is 
now almost abandoned. The use of small 
bleedings has still perhaps a few advo- 
cates, and of such treatment I had much 
experience some years since. There can 
be no doubt that in some cases of very 
acute Gout, especially when many joints 
are implicated and fever runs high, speedy 
and marked relief is procured by taking a 
small amount of blood from the arm ; but 
it is questionable whether even in such 
instances it would not ultimately have 
been better for the patient to have obtain- 
ed the relief a little more slowly, and 
without the loss of 'so valuable a fluid as 
the blood. The doubtful advantage of 
the practice will be more apparent when 
it is stated that everything that produces 
lowering of the vital powers tends to en- 
graft the disease more permanently upon 
the system. 
A question nowarises,-Although gen- 
eral blood-letting is undesirable, should 
not local depletion be resorted to ? The 
appearance of a joint when acutely in- 
flamed, the state of the tension and red- 
ness, the high temperature, and the ex- 
quisite pain, all seem to point to the 
necessity of, or at least the advantage 
likely to accrue from, the abstraction of 
blood from the part; and the indication 
has often been acted upon. My own ex- 
perience quite accords with that of former 
observers as to the danger of the practice, 
and several instances have come under 
my notice of considerable and irremediable 
injury which has resulted from the use of 
leeches in these cases. I have frequently 
seen great-toe joints stiffened after a few 
attacks, when local depletion has been 
resorted to, and within the last eighteen 
months two remarkable cases, in which 
the patients have completely lost the use 
of both knee-joints from two or three at- 
tacks only : in both instances leeches had 
been applied very freely ; in one more than 
thirty to each joint. I can with confidence 
warn those engaged in the treatment of 
an acutely-inflamed gouty joint never to 
have resort to this mode of combating the 
disease. It would seem that the abstrac- 
tion of blood from the joint allows or 
favors the free deposition of the urate of 
soda in the tissues, and thus the ligaments 
become rigid, and ankylosis ensues. Al- 
though more or less stiffness is not infre- 
quently seen as the result of long-continued 
gouty action in a joint where no local de- 
pletion has been employed, still, as a rule, 
the free movement of a joint is but little 
impaired by even numerous attacks of 
acute Gout. 
As it has been shown that leeches 
should not be made use of in the joint 
affection, the next point is to consider 
whether any or what local remedies may 
be advantageously employed. If the pain 
and redness are slight, all that is neces- 
sary is to cover the part with flannel or 
some other light and warm clothing : this 
precaution is simply for the purpose of 
avoiding the chance of a chill. Should, 
however, the inflammation be very in- 
tense and the suffering great, carded cot- 
ton should be wrapped round the joints 
principally affected, and oil silk or gutta- 
percha sheeting so applied, that the mois- 
ture is retained, and by this means a kind 
of vapor bath is formed. Some care is 
necessary to insure the complete closure 
of the oil silk, so as to prevent the escape 
of vapor; for unless this is effected, the 
warm covering of cotton, instead of giving 
relief, heats and augments the pain. 
As some patients are very intolerant of 
pain, it is at times desirable to apply ano- 
dyne remedies, and the most efficacious 
are belladonna and opium. I prefer a 
solution of atropia and morphia, dissolved 
in spirit and water, in the proportion of 
one grain of atropia and eight grains of hy- 
drochlorate of morphia to the fluidounce ; 
a small piece of lint may be dipped in TREATMENT. 
541 
the solution and placed on the part, the 
oil silk being employed as above de- 
scribed. The tincture of belladonna and 
of opium may be used, but the solution 
of the alkaloids is much more cleanly and 
elegant. Aconite and its alkaloid have 
been proposed for lulling pain in Gout; but 
when strong, they may cause irritation of 
the skin. 
Blisters have been used with advantage, 
when there exists great want of power in 
the system; possibly their value in chronic 
and asthenic Gout may be in part due to 
the fact of the serum withdrawing some 
of the morbid matter from the affected 
joint. 
We have alluded above to the adminis- 
tration of colchicum, and mentioned some 
of the symptoms which may arise from 
its administration in full medicinal doses, 
and also its marked influence in controlling 
gouty inflammation. 
Some practitioners have attributed the 
good effects of the remedy to its action on 
the bowels. That it often purges when 
given in full doses, and that it may give 
rise to a peculiar excretion from the 
bowels, is true ; but it is equally a fact 
that marked and rapid relief frequently 
occurs from its exhibition when no appre- 
ciable influence on the intestinal canal 
can be detected ; and, on the other hand, 
free purging can be induced in a gouty 
patient by other means, without the pro- 
duction of relief to the local inflammation. 
It may hence be safely inferred, that the 
peculiar influence of colchicum does not 
result from its purgative action. Others 
have been disposed to attribute the bene- 
ficial influence of colchicum to its action 
on the kidneys, and have regarded it as a 
diuretic, which not only causes an in- 
creased elimination of the watery portion 
of the urinary excretion, but likewise of 
the solid constituents, and more especially 
the uric acid. If these properties were 
possessed by colchicum, there would be 
little difficulty in accounting for its valua- 
ble influence in controlling Gout; but, 
unfortunately, clinical experience does 
not favor these views. It is true that 
some observers, as Dr. Christison and Dr. 
J. McGregor Maclagan and Professor 
Chelius, have made observations which 
at first sight would render it probable that 
colchicum increased the solid excretion, 
but as only single specimens of urine were 
taken, and no reference made to the total 
elimination in the twenty-four hours, a 
serious source of fallacy existed; the urine 
after the administration of colchicum 
might, it is true, have been higher in spe- 
cific gravity and richer in urates, but this 
circumstance may have been due to a 
diminished secretion. Chelius's observa- 
tions were made on patients recovering 
from gouty attacks, in whom it is not un- 
common to find, for many days, a grad- 
ually increasing amount of uric acid with- 
out the administration of any medicine. 
From numerous observations1 made some 
years since on the influence of colchicum 
upon the secretion of urine in gouty and 
other cases, I arrived at the conclusion 
that, in health, colchicum diminishes 
rather than increases the excretion of uric 
acid and urea by the kidneys, and that 
the elimination of the watery portion of 
the urine is often lessened, more especially 
when purging is caused by the remedy. 
It is probable that the statements as to 
the increase of uric acid have arisen from 
the fact that the analyses have been made 
on urine passed at some one period of the 
day only. 
Having failed to discover any visible 
alteration in the principal secretions pro- 
duced by the administration of colchicum, 
it is necessary to seek some other mode of 
explaining its action. That it is a seda- 
tive to the vascular system is a well-known 
fact, which has been fully proved by clini- 
cal experience; in subjects with weak 
hearts it causes temporary intermission of 
the pulse. Dr. Maclagan found on two 
occasions twenty minims of the tincture 
lowered the number of beats from eighty- 
seven to sixty-five and from eighty-four 
to sixty-two per minute respectively. 
This controlling power exerted upon the 
circulation, although it may explain to 
some extent the relief experienced from 
the drug, still is quite unable to elucidate 
the whole ; for if the sedative action were 
the only effect, colchicum should be 
equally efficacious in acute rheumatism as 
in Gout; but that it is not so has been 
proved beyond doubt. Another explana- 
tion of the effects of colchicum has been 
proposed ; namely, that its action is 
chiefly exerted upon certain tissues of the 
body, especially the ligamentous and car- 
tilaginous, in the same manner as other 
remedies are known to affect particular 
organs, as belladonna the pupil of the eye, 
digitalis the heart, and so on; but the 
same objections hold good here as in the 
former case, for the action of the drug 
should be equally potent in controlling in- 
flammation of the same tissues when not 
gouty in its character. 
Treatment of Chronic Gout.-The treat- 
ment of the acute paroxysm having been 
sufficiently described, it remains for us 
to speak of the manner in which the 
chronic conditions of the disease require 
to be managed; if in acute Gout it is 
necessary to make the treatment depen- 
dent upon the state of the system and the 
idiosyncrasy of the patient, it is even still 
more so when the chronic forms are pre- 
scribed for. We have seen that a gouty 
fit, whether it occurs in the strong and 
1 Medico-Chirurgical Transactions, vol. xli. 
1858. 542 
GOUT. 
robust or in the weak and spare habit, is 
dependent on the same proximate cause ; 
yet that it may be excited by various cir- 
cumstances in different individuals, for in 
one patient the state of the digestive or- 
gans, in a second the function of the skin, 
and in a third the secretion of the kidneys, 
may be principally at fault: and all these 
considerations must be taken into account 
when called upon to treat any one labor- 
ing under chronic Gout. 
Value of CoIchicum.-Colchicum is found 
equally efficacious in subduing the exacer- 
bations in chronic Gout as in combating 
the early fits in the acute disease, due re- 
gard being paid to the strength of the 
patient, and the dose regulated accord- 
ingly- 
It has been asserted, and the opinion is 
a very prevalent one, that the use of col- 
chicum in the acute disease tends to cause 
the attacks to recur more frequently, and 
to induce a chronic state of the malady ; 
but there are no good grounds for such an 
idea, unless the remedy has been much 
abused. It must be remembered that 
Gout, even when left to run its own course, 
and quite independent of medicinal treat- 
ment, has a powerful tendency to return, 
and the natural course of the disease 
should not be confounded with the effects 
of any treatment which may have been 
pursued. 
It is important to disabuse the minds of 
both the profession and public of the pre- 
judice against the guarded use of colchi- 
cum, as the permanent danger caused by 
allowing the inflammation to linger for a 
long period is far greater than any injury 
which the proper use of colchicum can 
entail. It is not improbable, if an attack 
of acute Gout is allowed to run a long 
course, that, at the termination of the fit, 
the patient is for a time more free from 
the disease ; i. e., the blood is purer than 
if the inflammation had been simply ar- 
rested without any care having been taken 
to rid the system of the morbid matter. 
Although colchicum given alone has a 
powerful influence in diminishing the sub- 
acute inflammations in chronic gouty 
cases, yet it may often be very advan- 
tageously combined with other medicines, 
and, amongst these, that which claims 
the first notice is guaiacum. 
Value of Guaiacum.-This resin may be 
given either in the form of the mixture of 
guaiacum of the Pharmacopoeia, in which 
the powdered resin is kept in a state of 
suspension by means of the acacia muci- 
lage, or as a powder combined with aro- 
matics, or in many instances, still more 
advantageously, as the ammoniated tinc- 
ture of guaiacum made up into a draught. 
Guaiacum sometimes acts on the mu- 
cous membrane of the alimentary canal as 
a purgative, but this occurs less frequently 
with the ammoniated tincture than with 
the powdered resin. This aperient action 
is often rather useful than not; but if it 
is not desirable, it may usually be pre- 
vented by the addition of a minim or two 
of laudanum to each dose. The resin 
evidently becomes absorbed, at least in 
part, and after it has entered the circula- 
tion acts as a stimulant to the smaller 
arteries and capillary system of vessels. 
It often promotes the function of the skin, 
and clinical experience appears to show 
that it has a specific effect upon the fibrous 
and ligamentous tissues, as well as on the 
mucous surfaces; it also increases the 
warmth of the extremities, and relieves 
pain connected with a languid circulation. 
Guaiacum may be administered for a long 
period of time without injury; I have Had 
patients under my care who have taken 
it for a whole year. Within the last few 
years I have given this drug extensively, 
and with great advantage ; it is especially 
useful in the asthenic Gout of old subjects, 
but to young patients it may also be given 
with benefit. 
Value of Iodide of Potassium.-Another 
remedy of service in chronic Gout is the 
iodide of potassium. This salt undoubt- 
edly possesses great power in controlling 
inflammation of fibrous tissues ; its action 
on the periosteum is very marked in the 
case of nodes, also in painful neuralgic 
affections dependent upon an inflamma- 
tory state of the nerve coverings; it is 
more especially useful when the pains are 
increased at night and by the heat of bed. 
It is also useful in removing the recent 
thickening of the tissues around joints, 
but proof is still wanting of its possessing 
any power of causing the absorption of 
urate of soda. 
In gouty inflammation, when fluid has 
been thrown into the cavities of the joints, 
and has been slow of absorption, the ad- 
ministration of the iodide of potassium 
has often appeared to be attended with 
great advantage. 
Cinchona Bark and Quinine.-The pre- 
parations of bark and quinine possess an 
undoubted power of controlling inflamma- 
tion, and within the last three or four 
years I have largely employed them for 
this purpose. With regard to the action 
of quinine, there are certain observations 
in relation to its physiological action which 
are of interest, and may also prove of 
therapeutic value. 
Dr. Ranke has stated that quinine has 
the power of diminishing the amount of 
uric acid in the urine. To prove this, Dr. 
Ranke gave in one dose twenty grains of 
sulphate of quinia to a patient, and found 
that the excretion of the acid wras only 
one-half the average : the influence of the 
dose continued for about two days. 
In my own observations the average of 
the excreted uric acid during these days 
was but slightly under that which it had TREATMENT. 
543 
been before the quinine was given. In 
one instance, for example, the average of 
uric acid in the urine for two days was 
5'89grains when no quinine was exhibited, 
and 5'37 grains for three days when the 
patient was taking eighteen grains of the 
sulphate each day, in divided doses. As- 
suming that Dr. Ranke's statement is cor- 
rect, and that the elimination of uric acid 
is much lessened for two days after the 
dose, it is a matter of much interest to in- 
quire if the effect is due to a diminished 
formation, or defective excretion from the 
kidneys. From my observations, I was 
inclined to ascribe the effect to the sudden 
and powerful impression of the drug upon 
the nervous system influencing the excre- 
tion of uric acid, and not to any decrease 
in its formation in the system. I shall, 
however, be unwilling to offer a strong 
opinion upon the subject at present, as I 
consider that further experiments are re- 
quired. Quinine may be beneficial in 
controlling gouty inflammation, whether 
it produces one or other effect: of the in- 
fluence of colchicum there cannot exist a 
doubt; still it has not been proved either 
to augment or diminish in any marked 
degree the elimination or formation of 
uric acid. 
Yellow cinchona bark has been used in 
lieu of quinine, and where there is great 
vascular debility, the astringent principle 
of the bark appears to be of service. 
It is advantageous to unite small doses 
of colchicum to the quinine; and when 
using the former drug in large doses, the 
addition of the latter is of service in pre- 
venting depression of the nervous system. 
Constitutional Treatment of Chronic Gout. 
-Although due attention to the inflam- 
mation of the joints is of great importance 
in the management of chronic Gout, there 
is another object to be steadily kept in 
view, namely, the removal of the morbid 
condition of the blood, and the solubility 
of any uric acid which may fail to be 
eliminated. 
It has already been shown that uric 
acid is thrown out entirely, or almost 
entirely, by the kidneys, and it has also 
been demonstrated that in Gout there is 
always some diminution of the uric-acid 
eliminating power, and often an almost 
entire suppression of this function. It 
follows from this, that one great object 
must be to increase this excreting power, 
and several remedies may be made use of 
to effect this, amongst which alkalies and 
salines stand out prominently. 
Value of Alkalies and Salines.-These 
agents have long enjoyed favor in the 
treatment of chronic Gout, and not with- 
out reason ; sometimes they are given in 
the form of ordinary medicine, sometimes 
in the form of natural or artificial mineral 
waters. It may be observed here that as 
chronic Gout is a disease which has usu- 
ally been many years in becoming fully 
established in the system, so it is one in 
which benefit cannot be expected, except 
from a long-continued perseverance in 
some judicious plan of treatment; and 
when a mere exacerbation of inflammation 
has subsided, the cure must not bethought 
to be effected. Under these circumstances 
it is most desirable that the plan adopted 
should be simple, and neither disagree- 
able nor troublesome ; and it will be found 
in practice that a patient will often per- 
severe for an almost indefinite time with 
the use of mineral waters, when he would 
refuse treatment by the ordinary mode of 
administering drugs. 
The alkalies and alkaline earths most 
commonly ordered are the salts of potash, 
soda, lithia, magnesia, and lime; and 
these are usually combined with carbonic 
or some vegetable acid, and occasionally 
with phosphoric acid. 
If these bases are given in the caustic 
state, they act as direct antacids, and 
many of them influence the mucous mem- 
branes as sedatives, or, in strong doses, 
as irritants: hence potash, soda, and 
lithia are seldom given in the free state, 
unless there are special indications for 
their employment. When carbonates or 
bicarbonates of the bases are adminis- 
tered, the antacid effect is equally pro- 
duced ; but if combined with the vege- 
table acids, as the citric or tartaric, the 
alkalies lose their power of neutralizing 
acidity in the stomach. After absorption 
into the blood, and elimination by the 
kidneys, the alkaline reaction is equally 
produced by the vegetable salts as by the 
carbonates or free alkalies, for the acid is 
broken up in transitu, and the base elimi- 
nated in the form of a carbonate. It is, 
therefore, desirable to select either a car- 
bonate or neutral salt, according as it is 
thought advisable or not to produce an 
alkaline effect upon the stomach. 
In making a selection of the base, sev- 
eral circumstances must be taken into 
consideration, and especially the organs 
and functions peculiarly influenced by the 
different alkalies and earths. 
Potash and its salts act especially on 
the kidneys, causing not only an alkaline 
state of the urine, but usually a marked 
increase in the secretion itself. 
Observation has repeatedly shown that 
potash has a marked effect in augmenting 
the quantity of urine ; its effect on the 
excretion of the different organic solids 
has not been clearly made out ; no uni- 
form results have been obtained sufficient 
to show its influence upon the uric acid ; 
some experiments appear to indicate an 
increased, some a decreased excretion of 
this acid, and others, again, that it was 
unaffected. There are many difficulties 
in the investigation ; in alkaline urine, 
uric acid is soon decomposed, and if the 544 
GOUT. 
quantity of urine is much increased, a 
portion of it may be lost in the analysis. 
Potash and other alkalies may act in more 
than one way ; not only may they increase 
the elimination of uric acid, but they 
probably facilitate its destruction in the 
system, and certainly aid in imparting 
solubility to it in the blood. 
Soda salts have less influence upon the 
kidneys ; they act less powerfully as sol- 
vents of uric acid ; but, on the other 
hand, they appear to aid the secretion of 
bile, or act as hepatic alteratives. They 
are indicated in gouty cases accompanied 
with marked derangement of the liver. 
Lithia salts have only been used as in- 
ternal remedies during the last six years. 
They are active diuretics, more active 
than salts of potash ; they are also power- 
ful solvents of uric acid, and on account 
of the very small equivalent of the metal, 
caustic lithia or its carbonate possesses 
great neutralizing power for acids. The 
urate or lithate of lithia is by far the most 
soluble of all the salts of uric acid. 
When first introduced by the author as 
a remedy for Gout, lithia was supposed to 
exist only in a few minerals, but more 
recently its presence has been discovered 
in a variety of substances. It has been 
found to be a constituent of the human 
body, of many plants, and can be shown 
by means of the spectrum analysis in the 
ashes of the blood, and even of a cigar ; 
it is found, also, in the waters of several 
mineral springs, especially those of Baden- 
Baden ; also in the springs of Carlsbad, 
Aix-la-Chapelle, Marienbad, Vichy, &c. 
Salts of lithia, especially the carbonate 
and citrate, have now been employed ex- 
tensively, and apparently with consider- 
able success. It is, of course, a matter of 
extreme difficulty to form a very strong 
opinion upon the value of any drug, es- 
pecially when the effects are not at once 
evident to the senses, and are long in 
being produced; but lithia appears to 
have many desirable qualities; if the 
opinion of patients can be relied upon, 
lithia salts taken for a long period in a 
very dilute form have the power of pre- 
venting gouty paroxysms in chronic cases, 
and some evidence has been afforded of 
their power of rendering joints more 
movable, and of causing some solution 
and absorption of chalky matter which 
has been already deposited. Lithia salts 
certainly act rapidly and powerfully in 
preventing deposition of urates and uric 
acid in the urine, and in the calculous 
tendencies of many gouty subjects must 
necessarily prove of much value. 
The dose of carbonate of lithia may be 
from five to ten grains dissolved in aerated 
water, or the citrate may be given in 
doses of from eight to twelve grains or 
more. 
Before leaving the subject of the alka- 
lies and their salts, it may be useful to 
allude to the value of administering these 
preparations in a very diluted form. 
Many soluble salts, if given in the form 
of concentrated solutions, will act as pur- 
gatives, whereas if very freely diluted 
they produce diuresis ; and it must be at 
once evident to any one who considers 
the subject, that the introduction of a 
large amount of fluid into the system has 
the effect of rendering the blood more 
capable of holding sparingly soluble mat- 
ters in solution, and of augmenting the 
various secretions from the body, es- 
pecially the urine, and hence of facilitat- 
ing the expulsion of any such matters 
from the system. It is necessary also to 
select proper times for the exhibition of 
these remedies; as the object is to have 
them rapidly absorbed, they should be 
given on an empty stomach, at least an 
hour before food ; if taken at or soon after 
a meal, they are apt to cause distension 
and discomfort, and at the same time 
they are very slowly absorbed: any 
amount of free alkali, when taken at the 
time that digestion is going on, impedes 
the process very seriously by neutralizing 
the free acid of the gastric fluid. This is 
a fact too frequently overlooked in prac- 
tice. 
Small doses of salines, if their use is 
long persevered in, are preferable to large 
ones, as they produce no disturbance of 
the digestive process, act more freely on 
the kidneys and skin, and are not likely to 
cause debility. 
Magnesia and its carbonates have been 
long used in the treatment of chronic 
Gout, and there can be no doubt that 
these salts are of value in many cases. 
Magnesia forms a moderately soluble salt 
with uric acid; it is also an alkali, and 
acts both as a direct and remote antacid ; 
it is useful as an adjunct, and especially 
in instances in which there is great acidity 
in the intestinal canal, and at the same 
time a sluggish state of the bowels. The 
salt formed in the stomach by its union 
with the acid produces a purgative effect, 
which tends to relieve the portal circula- 
tion, and often aids indirectly the func- 
tion of the kidneys. Carbonate of mag- 
nesia dissolved in excess of carbonic acid 
is an elegant form of administering the 
remedy. 
The lime salts offer no special advan- 
tage. Lime water may be employed as an 
antacid if there is much tendency to diar- 
rhoea, as the salts of lime have a consti- 
pating effect. 
There are some other salts, not yet 
alluded to, whose virtue depends partly 
on the acid contained in them; for exam- 
ple, the phosphates of soda and ammonia. 
Both these salts increase the solubility 
of the urate of soda, and may be used 
with advantage in certain instances. The TREATMENT. 
545 
phosphate of ammonia has been employed 
in many cases of chronic Gout, and clin- 
ical observation appears to show that it is 
useful in preventing paroxysms, probably 
by keeping the blood in a purer state. 
The result of my own experience of the 
use of the phosphate of ammonia is favor- 
able ; it is especially indicated in cases in 
which the circulation is feeble, and the 
function of the skin impaired: this re- 
mark applies equally to other ammoniacal 
salts. 
Treatment of Errors of the Digestive 
Function. - As the stomach and other 
parts of the digestive apparatus are gen- 
erally affected in chronic forms of Gout, 
it is of importance that their condition 
should be carefully attended to; purga- 
tives, stomachics, and alteratives are the 
remedies resorted to for correcting any 
morbid state of these organs. 
Value of Purgatives.-it has been already 
stated that free purgation alone will not 
rapidly cure gouty inflammation, and that 
it is impossible to explain the effects of 
colchicum upon this idea; that, for ex- 
ample, sulphate of magnesia, although it 
causes a free watery action, will not re- 
lieve in the same manner as colchicum, 
even when the latter drug produces no 
appreciable action upon the bowels. Pur- 
gatives, however, are often of much value, 
especially when there is a portal conges- 
tion present, and the occasional use of the 
compound colocynth extract, or some 
such preparation, is usually of great ad- 
vantage. Mercurials should, as a rule, be 
avoided, as they are peculiarly prone to 
cause ptyalism in gouty subjects, and as 
their frequent use lowers the powers of 
the system. 
Value of Stomachics and Tonics. - If 
there exists an irritative form of dyspep- 
sia, accompanied with flatulence, acidity, 
and heartburn, this is generally relieved 
by the administration of free or carbonated 
alkalies ; if pain or palpitation is present, 
a few drops of hydrocyanic acid may be 
added to each dose, taking care to relieve 
any sluggish condition of the liver and 
bowels. These alkalies are often advan- 
tageously combined with some bitter 
stomachic, as the juice or extract of ta- 
raxacum ; or, if there appears to be great 
want of tone, the more powerful bitters, 
as chamomile, gentian, chiretta, quassia, 
&c. &c. If much flatulence be present, 
then ginger or capsicum may be likewise 
added. 
Ash-leaves in the form of an infusion 
have been also recommended, and clinical 
proof afforded of their efficiency in chronic 
Gout. I have frequently made use of 
them, and with advantage; but the 
amount of infusion taken each day has 
always been considerable, and the action 
of the diluent must not be forgotten. 
Value of Ferruginous Preparations -In 
the majority of instances iron salts are not 
indicated, but at times cases are met with 
in which their administration is attended 
with striking benefit. They prove most 
useful when the blood is impoverished 
from the diminution of the red corpuscles, 
and the circulation enfeebled from weak- 
ness of the walls of the heart, and where 
the whole nervous system has become ex- 
hausted. It is often a good plan to com- 
bine these with small doses of the extract 
of colchicum. 
The selection of the ferruginous prepa- 
ration should be made according to the 
peculiar requirements of the patient: if 
only the hsematinic property is wanted, 
reduced iron (ferrum reductum) may be 
prescribed ; if the astringent influence is 
required, the sulphate may be made use of. 
Value of Diaphoretics or Sudorifics.- 
Friction of the skin must not be over- 
looked in the treatment of chronic gouty 
cases ; we must remember, that although 
there is no elimination of uric acid from 
the healthy surface, still the skin gives off 
a large amount of some other acid, which, 
when retained, renders the blood serum 
less alkaline. 
The salts of ammonia are useful when 
the skin is particularly in fault, especially 
those in which the alkali is combined with 
a vegetable acid, such as acetic acid ; but 
it is better in most cases to promote the 
due performance of the cutaneous func- 
tion by insisting upon a sufficiency of ex- 
ercise, and the free use of water to the 
skin, combined with friction, and wearing 
flannel next to the skin. 
Hot-air and vapor baths are also valua- 
ble, and, when it can be borne, the Turk- 
ish bath occasionally; hot salt-water baths 
may also be made use of. 
Treatment of the Local Affection.-One 
of the slighter forms of inconvenience, 
arising from long-continued gouty inflam- 
mation in any part, is the production of 
oedema, a symptom evidently depending 
on local debility or weakness of the vessels 
of the affected parts, usually the lower 
extremities : this is often much increased 
by disease of the kidneys, or sometimes of 
the heart. When the swelling is depend- 
ent simply on local weakness, it is best 
treated by the use of some mechanical 
support, as the elastic stocking and slight 
friction, with or without some stimulating 
and lubricating application; the limb 
should be elevated, so as to facilitate the 
free return of blood to the heart. (Edema 
depending on a kidney or cardiac disease 
must be specially treated. 
A far more distressing complication, 
and one far more difficult to deal with, is 
that arising from chalk-stones, and the 
distortion and rigidity of the joints pro- 
duced by deposition within the structure 
of the articulations. 
If chalk-stones appear on superficial 
vol. i.-35 546 
GOUT. 
parts, they may be of little inconvenience, 
and are often spontaneously removed; for 
example, if the nodules on the ears of 
gouty patients are observed for some few 
years, a considerable change is generally 
noticed; they may escape from rupture 
of the cutis, or if they increase in size, so 
as to cause any inconvenience, they may 
be punctured, and by this means dis- 
persed, the contents escaping either in 
the semi-liquid or solid state. 
There is no danger attending an opera- 
tion upon the ears, nor in many other 
situations, when the chalky concretions 
are small, and especially when in a liquid 
state and very superficial, provided the 
patient is at the time in a tolerable condi- 
tion of health; but the case is far other- 
wise if the chalk-stones are large and 
solidified, and specially if their ramifica- 
tions are deep-seated. In such cases the 
removal is apt to be attended with serious 
and even fatal consequences, arising from 
the extreme difficulty in the healing of 
the sore, or the supervention of a low 
form of erysipelas. The greater the 
amount of kidney affection, the greater 
the danger of operating. Not infrequent- 
ly, when the deposits approach the sur- 
face, they burst spontaneously and ab- 
scesses are then formed; these are often 
very difficult to heal on account of the 
matter being deep-seated. I have known 
cases in which such abscesses acted as a 
kind of safety-valve, and their closure has 
been immediately followed by a paroxysm 
of gouty inflammation. The best mode 
of treating these abscesses is to keep upon 
them a water dressing, as long as there is 
a free flow of the matter; then to have 
them dressed with some stimulating oint- 
ment, and occasionally either to apply a 
lotion of sulphate of zinc, or touch the 
surface with a stick of lunar caustic. 
Now and then, if the opening becomes 
nearly closed, at the time that there is a 
large accumulation of the urate of soda 
behind, it is advisable to enlarge the 
opening by a slight incision. 
It has been thought by some physicians, 
both in ancient and modern times, that 
the deposits of urate of soda which occur 
in Gout are capable of being dissipated 
by external applications, and alkaline 
preparations have usually been employed 
for this purpose, such as solution of pot- 
ash, or soda, or lime. I have in some 
cases had compresses, steeped in a solu- 
tion of carbonate of lithia, kept on the 
parts for a long time, and patients have 
assured me that they have found decided 
benefit from them; but although such a 
solution exerts a very powerful solvent 
action upon the deposits when removed 
from the body, it is difficult to imagine 
how they can act through the skin ; but 
as such treatment can do no harm, it is 
worthy of a further trial. ■ 
When joints are much stiffened f. om 
gouty inflammation, considerable relief is 
obtained from the use of a blistering 
liquid. This appears more useful, and, 
upon the whole, less annoying to the pa- 
tient than iodine paint; and it usually 
removes any infused liquid, and chronic 
inflammatory action, which may be lin- 
gering about the part. After all tender- 
ness has disappeared, movement may be 
attempted, very gently at first, but gra- 
dually increased; the joints may also be 
rubbed with some slightly stimulating 
liniment, or with strong salt and water. 
In the treatment of these cases it must 
always be borne in mind, that the rigidity 
is often due to interstitial deposit in the 
ligaments, and that a restoration of these 
structures to a healthy state can hardly 
be hoped for ; still, as this condition may 
often be complicated with a chronic in- 
flammatory action, it is always advisable 
to attempt the removal of such complica- 
tions. 
Treatment of the Irregular Forms of Gout. 
-The treatment of irregular Gout must 
necessarily be very different in different 
cases, and it is a matter of extreme diffi- 
culty to lay down any precise regulations 
for the guidance of the practitioner; how- 
ever, a few general rules may be advan- 
tageously given. 
Should metastasis take place to any im- 
portant organ, it seriously implicates its 
functions, and therefore our main object 
must be to take such steps as will restore 
this function; and, as the metastasis 
usually follows the sudden suppression of 
gouty inflammation of some joint, the one 
very essential part of the treatment con- 
sists in the endeavor to bring back articu- 
lar inflammation. This object is best 
effected by the application of heat or 
counter-irritation to the extremities, as 
by hot bottles, sinapisms, &c. At times 
we may treat the part itself, especially if 
there is evidence of inflammatory action 
existing in it; this may be effected by 
leeches, blisters, and mustard poultices; 
local depletion, however, is rarely neces- 
sary. The peculiar condition of the sys- 
tem, or the existence of the gouty diathe- 
sis, must not be overlooked. A question 
of no little importance at once arises when 
the diathetic condition is considered; it is 
that which relates to the value of colchi- 
cum in irregular Gout. Sir Henry Hol- 
land is of opinion that it can be employed 
with advantage, and as far as my own 
experience goes I quite coincide with him, 
although unable to explain its action. 
This want of knowledge applies with 
equal force to the action of colchicum in 
the genuine articular form of the disease. 
In metastic Gout of the heart and 
lungs, cardiac stimulants, as ammonia, 
ether, and other anti-spasmodics, are espe- 
cially indicated. If the bladder is affected, TREATMENT. 
547 
belladonna and henbane may be advan- 
tageously used to diminish spasm; in 
short, remedies directly influencing the 
implicated organ may in all cases be re- 
sorted to, at the same time that the means 
tending to reinduce the articular inflam- 
mation should not be neglected. 
Value of Mineral Waters in Gout.-Min- 
eral springs are frequently resorted to by 
gouty subjects, and it is important that 
the medical man should know when to 
advise and when to oppose such a step, 
and likewise the waters most suitable for 
different cases. 
Although it cannot be denied that many 
patients receive great benefit from the 
proper administration and use of these 
waters, still it must be allowed that their 
action is not always beneficial, and that 
in some cases it is very injurious. 
All mineral waters have one action in 
common ; it is that of water itself; and 
there is little doubt that the value of this 
agent when properly employed is consid- 
erable. The waters of some of the min- 
eral springs of great reputation contain 
little foreign matter, and must owe most 
of their efficacy to the water alone. The 
other waters employed in gouty cases 
contain either alkaline carbonates, chlo- 
rides, or sulphates. Some of the waters 
are impregnated with sulphuretted hydro- 
gen, and another class owe the chief of 
their powers to the iron which enters into 
their composition. Many of the springs 
are of an elevated temperature ; some of 
mean heat; others cold. 
All mineral waters rich in saline mat- 
ters, if taken too freely, usually set up a 
febrile disturbance or crisis; the system 
becomes oppressed, there is a feeling of 
heaviness, languor, or agitation, and this 
is followed by loss of appetite, thirst, a 
furred tongue, and heat of skin, some- 
times by vomiting and diarrhoea. Such 
symptoms are probably due to the blood 
becoming saturated with the saline mat- 
ter, from the excreting organs being un- 
equal to the task of eliminating the whole 
quantity introduced during the treat- 
ment. 
The different springs of Vichy are all 
rich in carbonate or bicarbonate of soda, 
containing about forty grains to the pint: 
some have the temperature of 101° Fahr. ; 
others are cold. When taken internally 
in even moderate doses, they cause the 
urine to be neutral or alkaline, without 
affecting the transparency of the fluid ; 
when employed in the form of the bath, 
the effects appear to be very similar. 
From the soda contained in them they 
probably act upon the liver ; and from the 
amount of liquid absorbed, and the tem- 
perature at which the water from many 
of the springs is drunk, they also in- 
fluence the function of the skin. 
Vichy waters appear to be adapted for 
the treatment of Gout when it occurs in 
strong subjects in whom the function of 
the liver and digestive organs is at fault, 
and are contra-indicated in very chronic 
cases, especially if there is a tendency to 
the rapid formation of chalk-stones, or if 
the powers of the system have become 
much enfeebled : my own experience is 
that, in this latter class of cases, they 
rather tend to favor the formation of these 
concretions. 
The internal exhibition of the waters is 
usually accompanied with the use of the 
bath; if they disturb the stomach, the 
bath alone should be employed. 
Wiesbaden waters contain a large amount 
of chloride of sodium, and are of a high 
temperature, 160° Fahr. They are less 
debilitating than Vichy waters, and more 
stimulating to the various functions : they 
consequently are more adapted for cases 
in which the circulation is sluggish and 
the secretions deficient; also in cases of 
rigidity from thickening of the textures. 
They are powerless in removing any solid 
deposition of urate of soda. 
Aix-la-Chapelle is frequently resorted 
to ; the waters are slightly saline com- 
pared with those of Wiesbaden, high in 
temperature, 135° Fahr., and in addition 
to chloride of sodium, contain some car- 
bonate and sulphide of sodium, with free 
sulphuretted hydrogen. They act as stim- 
ulants to the secreting organs, and more 
especially to the skin ; they are indicated 
in cases in which the skin is in fault, and 
they have also been found useful in re- 
moving rigidity of the joints. 
The waters of Aix-a-Savoy resemble 
closely, as far as the sulphur is concerned, 
those of Aix-la-Chapelle. 
Carlsbad waters are in great vogue in 
the treatment of Gout. They are rich in 
sulphate of soda, and contain likewise 
carbonate of soda ami chloride of sodium ; 
of a high temperature, 167° Fahr. They 
often cause purgative action, and likewise 
give activity to the kidneys and skin, and 
are useful in cases accompanied by de- 
ficient action of the bowels, with a con- 
gestive state of the liver; but should be 
avoided by weakly patients. 
The waters of Baden-Baden are saline, 
and from recent analysis are said to be 
rich in lithia. Dr. Ruef has affirmed that 
they have proved very useful in Gout, and 
possess the power even of removing visi- 
ble deposits of urate of soda. 
The waters of several other springs, as 
of Kissingen, Marienbad, Homburg, Ems, 
and several other localities, contain saline 
matters, and have occasionally been used 
in the treatment of gouty conditions of 
the habit. 
The waters which possess but little solid 
matter, and which have acquired a repu- 
tation in gouty cases, are those of Wild- 
bad, Teplitz, Gastein, Buxton, and Bath. 548 
GOUT. 
They are all of somewhat elevated tem- 
perature, are chiefly used in the form of 
the bath, and appear to be peculiarly 
adapted for the treatment of the disease 
in the old and infirm. According to nu- 
merous observers, great benefit has been 
often experienced from their employment. 
The following rules may serve as a guide 
in prescribing the use of mineral waters in 
gouty cases:- 
1. They should not be employed when 
there exists any appreciable amount of 
organic disease either of the heart or kid- 
neys. 
2. They should be avoided when an 
acute attack is either present or threaten- 
ing. 
3. The particular water should be 
selected according to the nature of the 
case. When the patient is robust, and of 
full habit, the alkaline springs; when 
torpidity of the bowels predominates, the 
purgative waters; when there is a want 
of vascular action, the saline waters; 
when the skin is inactive, the sulphur 
waters ; lastly, when' debility prevails, 
then the more simple thermal waters 
should be chosen. 
4. In all cases the use of the water 
should be cautiously commenced, and care 
should be taken not to oppress the stomach 
by giving too much liquid, nor to induce 
debility or other injurious effects by allow- 
ing too long a sojourn in the bath. 
5. In every instance, when practicable, 
it is advisable to avoid producing the so- 
called "crisis," for when febrile disturb- 
ance is set up in the system, the secre- 
tions are checked, and an acute paroxysm 
of Gout is almost always induced ; it is 
far better to take a prolonged than a too 
severe course of a mineral water. 
Diet and Regimen in Gout.-The diet in 
the treatment of the different forms of 
Gout is of great importance, far more so 
than in the majority of diseases. When 
the affection is acute in character, and 
the patient robust, he should be confined 
for a few days to a diet consisting of little 
more than farinaceous food and diluents ; 
and this kind of food may be persevered in 
until the inflammation shows a decided 
tendency to abate, the thirst diminishes, 
and the appetite begins to return. Under 
the term farinaceous food arc included 
bread, arrowroot, sago, tapioca, and such- 
like substance ; to these may be added 
milk ; while water, and toast-and-water, 
may be indulged in without restraint; 
provided the liquids are taken upon an 
empty stomach. Stimulants are scarcely 
required under these circumstances ; but 
if the patient has been accustomed to live 
freely, a little brandy may be taken with 
the solid food ; even a moderate indul- 
gence in wine or malt liquor will keep up 
the gouty inflammation for an almost in 
definite period. 
When febrile disturbance has abated, a 
more generous diet may be allowed-at 
first fish, then fowl or game, and at last 
ordinary meat. In strong persons it is 
desirable to keep a moderate curb upon 
the appetite, for fear of inducing a recur- 
rence of the inflammation. 
As soon as possible exercise may be re- 
sumed, and it is most desirable that this 
should be persevered with daily ; but if 
the lower extremities are much affected, 
there is a fear lest too great an amount at 
any one time may excite local irritation 
in parts which have recently been in- 
flamed. 
As yet it has been assumed that the 
gouty attack has occurred in a strong 
individual, and is of an acute and sthenic 
kind ; but this may not always be the 
case, for even a first fit may find a patient 
broken down in constitution, and quite 
unable to bear the least withdrawal of 
nourishment or stimulus. Under these 
circumstances, care must be taken to give 
such nourishment as the digestive organs 
can easily assimilate, as beef-tea, strong 
but plain soups, eggs, milk, &c. ; and, 
when practicable, to confine the stimulus 
to some distilled spirit, as brandy or 
whisky, giving these only to the extent of 
keeping up the action of the heart and the 
efficiency of the circulation. 
A few general rules may be advantage- 
ously given, which will serve as a guide 
for the treatment of gouty patients in 
general, and apply more especially to such 
as suffer from the chronic forms of the 
disease. 
It is desirable to regulate the amount of 
food, so that the system shall be fully 
nourished, and the strength kept up as 
much as possible, but anything taken be- 
yond this is decidedly injurious, as it tends 
to oppress the digestive organs, and in- 
duce debility rather than vigor of frame. 
As to the character of the solid diet, it 
may be stated, that every article which 
causes unpleasant symptoms, recogniza- 
ble by the patient himself, should be stu- 
diously avoided ; and hence the less what 
are termed "made dishes" are partaken 
of the better : the same remark applies to 
all rich and highly-spiced food, and to 
anything that tempts the person to take 
more than he otherwise would. Articles 
of animal food of which the texture has 
been hardened, as salted meats, hams, 
and so on, are less easy of digestion, and 
should be discarded, as also veal and pork, 
which are much less easy of digestion, 
than mutton and good beef; white fish is 
generally digestible, as also fowl and 
game. 
There should be a due admixture of 
animal and vegetable food ; it is an error 
to suppose that an animal diet necessarily 
tends more to the formation of uric acid 
than a vegetable one. The tortoise, feed- TREATMENT. 
549 
ing on a simple lettuce, excretes a large 
quantity of urate of ammonia, far more in 
proportion to the weight of the animal, 
than is excreted by the dog exclusively 
nourished with meat. 
Vegetables, as potatoes, greens, and the 
like, may be partaken of with advantage ; 
the soluble salts which they contain are of 
value in keeping up the activity of the 
secreting organs. 
The same remarks hold good with re- 
gard to soft fruits when partaken of in 
moderation, as strawberries, grapes, and 
oranges; also other fruits when stewed or 
baked, as apples and pears; but these 
latter, as likewise plums and stone fruit 
in general, should be avoided in a raw ; 
state. Extreme moderation should be I 
exercised when saccharine fruits are 
eaten, as sugar is liable in many subjects 
to lead to the production of acidity, and 
hence favor the development of Gout. 
The same precaution is necessary in re- 
ference to the addition of sugar to other 
articles of diet. 
As to beverages, both tea and coffee 
may be taken if they do not disturb the 
nervous system. At one time it was sup- 
posed that the latter was prophylactic 
against Gout, seeing that the Turks en- 
joyed an immunity ; but, if strict Maho- 
metans, they do not take alcohol in any 
shape, and hence avoid its most powerful 
cause. 
It is an important question to decide 
whether alcohol is to be ever allowed, and, 
if so, to determine the form which is best 
adapted for the patient. 
All malt liquors should be eschewed, as 
they almost always cause an increase of 
dyspepsia, and, if at all strong, have un- 
doubtedly a very powerful influence in in- 
ducing the disease and in keeping up a 
paroxysm. 
Strong wines will also prolong an attack 
to an almost indefinite length of time, and 
if they are moderately indulged in will 
often lay the foundation of the gouty dia- 
thesis. 
The wines to be carefully avoided are 
port, sherry, madtira, and any in which 
the fermentation has been checked by the 
addition of alcohol. If wine is taken at 
all, that which is best adapted for the 
majority of patients is a sound claret-one 
free from sugar and without acidity. 
When red wine does not agree with the 
stomach, then hock or moselle may be 
substituted, or even a light and dry sau- 
terne or chablis. 
The beverage best suited for those of a 
strongly-marked gouty diathesis is un- 
doubtly French brandy, taken in very 
limited quantities, and freely diluted with 
water. 
Whisky, hollands, or gin, may in many 
cases be substituted for brandy; but the 
two latter should be avoided if there is 
any appreciable amount of kidney disease, 
or at least should not be taken without 
advice. The distilled spirits should only 
be used at the meal, and from one to three 
ounces may be daily allowed, the amount 
depending upon the former habits of the 
individual. 
If Gout has become developed at a very 
early age, and the youth strongly inherits 
it, a question arises whether it would not 
be desirable to advise an entire abstinence 
from alcoholic drinks. Such a step would 
be the most likely to check the further 
progress of the malady.1 
Exercise must be enjoined, for it is of 
the highest importance, and without it all 
our endeavors may prove futile. The 
kind of exercise must be adapted to the 
peculiarities of the patient; walking and 
horse exercise are equally useful, and may 
be conjoined with advantage. 
Fresh air is of great importance, and in 
many instances a complete change during 
the winter and spring to some warm and 
dry climate will enable the patient to es- 
cape an attack. 
All violent exercise likely to cause ex- 
haustion, all severe mental application 
and late hours, should be studiously es- 
chewed. 
In concluding the subject of the man- 
agement of Gout, the author's opinions 
may be thus summed up:-■ 
1. Gout in its acute form is quite as 
controllable, and as much under the influ- 
ence of remedies, as any other inflamma- 
tory affection. The duration of the parox- 
ysm and the amount of injury to the 
joints depend much upon the treatment. 
2. The more chronic forms of Gout, 
which are met with in every degree of 
severity, are likewise under the control of 
the physician, if not for their radical cure, 
yet for so much relief as will enable the 
patient to enjoy life, and prevent further 
increase of the mischief, so liable to ensue 
if the disorder is allowed to run its own 
course, and more especially if recklessly 
tampered with. 
3. As gout is a disease which is not 
only apt to return with increased severity, 
but to acquire a firmer hold on the consti- 
tution at each visitation, it is a matter of 
serious moment to consider whether it 
may not be prudent in the intervals of the 
attacks, not only to regulate the diet and 
regimen, but even to have recourse to 
means, scarcely to-be called medicinal, by 
which the blood may be kept free from 
the impurities which lead to the produc- 
tion of the paroxysms. 
4. The treatment of Gout founded on 
Cullen's aphorism, of trusting to patience 
and flannel, is to be highly deprecated. 
[* This recommendation may be very ad- 
vantageously extended to all gouty subjects, 
unless greatly debilitated.-H.] 550 
RHEUMATOID ARTHRITIS. 
It may indeed be argued that it is the 
natural treatment, and that nature is a 
sure guide ; but it must be remembered 
that man living in a civilized state is not 
in a normal condition, or in all probability 
he would never have acquired the disease, 
and that when suffering from a disorder 
so acquired, he must be content to have 
recourse to artificial remedies. If he 
could entirely lay aside his usual habits, 
and follow in all respects the dictates of 
nature, there would probably be little 
need to seek relief from medicine. 
5. Although a plan can be sketched out 
which is applicable to the majority of 
cases of Gout, still each individual case 
not only exhibits its own peculiarities, 
and becomes a separate study, but like- 
wise demands, in certain respects, a sepa- 
rate treatment. The neglect of this con- 
sideration is apt to lead to a mere routine 
practice, closely bordering on empiricism. 
RHEUMATOID ARTHRITIS. 
By Alfred Baring Garrod, M.D., F.R.S. 
Definition.-A form of inflammation 
of the joints, accompanied with but little 
febrile' disturbance, and distinguished 
from gout and rheumatism by its pro- 
gressive character, by the peculiar morbid 
changes which it induces, and by the ab- 
sence of any known morbid state of the 
blood. 
Synonyms.-Rheumatic Gout is the 
name commonly given to this disease, but 
equally applied to other joint affections. 
Dr. Adams uses the term Chronic Rheum- 
atic Arthritis. Dr. Todd included it 
under Chronic Rheumatism of the Joints. 
It has been called Nodosity of the Joints 
by Haygarth and Heberden ; Usure des 
Cartilages articulaires by Cruveilhier; 
Rheumatism Noueux, by Trousseau and 
other French writers. The term Rheum- 
atoid Arthritis was applied to this disease 
by the author in 1858. 
History of Rheumatoid Arthri- 
tis.-It will be essential to the clear un- 
derstanding of this subject that some 
explanation be first given of the name 
proposed to be employed to designate this 
disease, and the reason of its adoption; 
and to give reasons for the rejection of 
the many terms which have been used at 
different times. The term "rheumatic 
gout" is one which is very commonly em- 
ployed, both by the profession and the 
public ; but it is difficult to arrive at its 
true significance, seeing that but few have 
described it as a separate disease : the 
term has also been used to signify very 
different diseases. It is not uncommon to 
hear gouty patients say they are suffering 
from rheumatic gout, simply because the 
disease, which for many years was mani- 
fested in the feet only, now implicates 
other joints, as the elbows and hands ; in. 
fact, they regard their malady as gout 
when it is confined to the feet, but as 
rheumatic gout when it affects the upper 
extremities. 
Sometimes the subacute forms of true 
rheumatism are designated as rheumatic 
gout, and more especially if the smaller 
joints are the seats of the attack. There 
exists, however, a third disease, distinct 
both from gout and rheumatism, to which 
the name is more frequently applied: it 
is this malady which we have called 
Rheumatoid Arthritis ; and it is this which 
will engage our attention in the present 
article. 
The name "chronic rheumatic arthri- 
tis" has not been employed, partly from 
the fact that the disease sometimes as- 
sumes an acute character,-if this were 
the only objection, it might be argued that 
we could designate this form by the name 
of "acute rheumatic arthritis,"-and 
partly because the name rheumatic arthri- 
tis implies that the disease partakes of the 
nature of true rheumatism, which we be- 
lieve is not correct. The same objections, 
of course, apply to the words "chronic 
rheumatism of the joints." 
"Usure des cartilages articulaires" 
(wasting of the articular cartilages) is an 
expression limited in its meaning ; it only 
expresses one of the morbid changes which 
result from the disease. 
" Nodosity of the joints," and " rheum- 
atism noueux," express the presence of a 
frequent alteration in appearance, caused 
by the affection-one not constantly found. 
"Morbus coxse senilis" could not be 
used except when one particular joint is 
implicated, and it is a matter of some 
doubt whether this form of the disease has 
the same pathology. DESCRIPTION OF RHEUMATOID ARTHRITIS. 
551 
The term "Rheumatoid Arthritis" has 
been employed for the following reasons :- 
The disease is one chiefly affecting the 
joints, and is of an inflammatory charac- 
ter ; hence the name arthritis. It is also 
one which, at least in its early stages, 
produces external changes closely resem- 
bling those caused by subacute forms of 
rheumatism ; but as it can be shown that 
the nature of the affection is not the same 
as that of rheumatism, the prefix "rheum- 
atoid" instead of "rheumatic" is suffi- 
ciently expressive. 
As the word typhoid is allowed for the 
purpose of designating a form of fever 
somewhat resembling, but not identical 
with, typhus, so no objection can be 
raised to the use of the prefix rheuma- 
toid, when it is intended to signify that 
the articular inflammation, although not 
of the same nature as rheumatism, yet 
resembles it in some of its characters, and 
more especially in those which are readily 
appreciated by the senses. 
With regard to the history of our know- 
ledge of Rheumatoid Arthritis little can 
be said. It is only since the time of Hay- 
garth that it has been looked upon by any 
pathologist as an independent disease, and 
even at the present time it is often de- 
scribed under the name of chronic rheum- 
atism, rheumatic gout, &c., and classed 
as a variety of some other affection. 
Description of Rheumatoid Ar- 
thritis.-Rheumatoid Arthritis is met 
with either as an acute or as a chronic 
disease : the former is much less frequent 
than the latter ; in fact, it has only been 
described within the last few years; it 
will, therefore, under the circumstances, 
be desirable to reverse the ordinary mode 
of treating such subjects, and to describe 
first the more common form, namely, 
chronic Rheumatoid Arthritis. 
Chronic Rheumatoid Arthritis. -The 
affection may occur in both sexes, and at 
almost every age, and its invasion often 
assumes a form very similar to that about 
to be described. A young woman has 
become, from some cause, decidedly out 
of health; perhaps from menorrhagia or 
leucorrhoea, or from hemorrhage during 
parturition, or from prolonged anxiety or 
physical fatigue; she is exposed to cold, 
and, after a few days, feels some pain in 
the knee; there is slight swelling and 
tenderness ; perhaps the temperature is a 
little elevated ; simple rest to the joint 
may be followed by relief, or even a cure, 
for the time, the swelling abating, and 
the tenderness and pain vanishing; or 
perhaps this result may have been expe- 
dited by the application of a blister, or 
some other form of counter-irritation. 
After a few weeks or months, as the 
case may be, perhaps from a second chill, 
another joint, or even that which was 
previously implicated, becomes affected, 
and a similar train of symptoms arises, 
but with this important exception, that, 
in all probability, the inflammation does 
not again subside, but continues fixed to 
the joint, and gradually extends to others. 
During this time there may be no appre- 
ciable constitutional disturbance beyond 
the general ill-health above noticed, but 
in some cases dyspepsia or nervous symp- 
toms are exhibited. 
The disease, if unchecked, travels over 
the whole body, affecting almost every 
articulation of the limbs, and causing 
much deformity and distortion, from the 
enlargements and contractions which it 
produces ; nor are its ravages confined to 
the limbs alone, but other joints may be 
attacked, especially the temporo-maxil- 
lary articulation, causing the closing of 
the jaw; the upper cervical vertebrae may 
likewise be involved, and the neck become 
fixed ; and thus at last the patient is ren- 
dered crippled and altogether helpless 
throughout the remainder of life. 
The above example is, indeed, one in 
which the disease has effected all the 
mischief it is capable of; fortunately, it 
does not always proceed to this length, 
but is arrested at some stage or other of 
its progress, and then only a limited 
amount of distortion is induced. 
The deformities produced by Rheuma- 
toid Arthritis are not altogether charac- 
teristic of this disease, for they are pro- 
duced likewise by chronic gout; but in 
their advanced conditions the separation 
of the one disease from the other is usually 
a matter of no difficulty. 
The changes in the arms and hands, 
when severely affected, are of the follow- 
ing kind: The elbow is flexed, perhaps 
at an angle of 35° from full extension ; 
the forearm in a semi-pronated position ; 
the joint is also much enlarged and mis- 
shaped, more or less rounded from the 
alteration and hypertrophy of the heads 
of the bones, as well as of the soft tissues. 
The wrists are rigid, almost straight, and 
scarcely admit of motion in any direction. 
The hands are usually thin, from the 
absorption of fat, and from the wasting of 
the other soft tissues; the extremities of 
the phalanges are nodular, as also the 
heads of the metacarpal bones. The 
fingers are usually turned outwards and 
their joints rigid, often completely fixed. 
As a rule, the metacarpo-phalangeal ar- 
ticulations of the fingers are flexed, and 
the first phalangeal extended, causing the 
second phalanx to be thrown backwards ; 
the second phalangeal joint is also flexed. 
One, or even every finger in a hand, may 
be thus altered. The phalangeal joint of 
the thumb is usually extended, or bent 
backwards. Sometimes the nodose condi- 
tion is well marked, but not infrequently 
it is but slightly developed; complete dis- 552 
RHEUMATOID ARTHRITIS. 
location of some joints is occasionally met 
with. The knee is generally much en- 
larged and rounded in the same manner 
and from the same causes as the elbow ; 
it is commonly half flexed. Sometimes 
there is evidence of liquid effusion, but in 
the later stages this may be wanting. 
When the hip is affected, the thigh be- 
comes flexed, sometimes abducted, with 
the foot everted; at other times adducted, 
with the foot turned inwards; not infre- 
quently there is felt over the large joints a 
sensation as though the bones were loose. 
As a rule, the hands become crippled 
and distorted at an earlier period than 
the feet. Though frequently attacked, 
the jaw and neck seldom become fixed. 
An affection which, if not identical with 
Rheumatoid Arthritis, at least closely re- 
sembles it, was first made known to the 
profession by Heberden, under the title 
of "digitoruin nodi," and described by 
him as consisting of little hard knobs, 
about the size of a pea, situated upon the 
ends of the fingers, where they remain 
through life, being usually attended with 
little or no pain, and, though they cause 
but slight inconvenience, are decidedly 
unsightly. Heberden thought that they 
had no connection with gout, seeing that 
they occur in persons never afflicted by 
that disease; but Dr. Begbie considers 
them of a gouty character, as they are 
frequently met with in that diathesis. 
The disease is sometimes confined to 
the extreme ends of the fingers, but now 
and then extends to the other small 
joints. When examined, the nodular 
feeling and the peculiar appearances are 
found to be owing to hypertrophy and 
other alterations in the epiphyses of the 
phalanges, and, except in position, and 
the small size of the affected joints, do 
not appear to differ from the enlargements 
and distortions above described as occur- 
ring in other situations. 
Ladies are often much concerned at 
finding these nodules on their fingers, and 
are willing to take any amount of trouble 
to arrest the progress of their formation 
and to attempt their removal. 
Acute Rheumatoid Arthritis.-Now and 
then cases are met with which, in most of 
their symptoms, closely resemble acute 
rheumatism ; several joints are attacked, 
the swelling is considerable, there is dis- 
tinct increase of temperature of the af- 
fected parts, with pain, tenderness, and 
redness. In these instances, constitu- 
tional symptoms, as thirst, loss of appe- 
tite, heat of surface, a rapid pulse, and 
other evidences of febrile excitement, are 
often observed. There are, however, 
wanting some of the characteristics of 
rheumatic fever - namely, the profuse 
sweating and the proneness to acute in- 
flammation of the internal and external 
membranes of the heart, so common in 
acute rheumatism, and likewise the erratic 
disposition or tendency of the inflamma- 
tion to fly from joint to joint. Between 
cases of genuine acute Rheumatoid Arth- 
ritis and those of the very chronic varie- 
ties there is every intermediate shade of 
difference. 
The only real difficulty in these cases is 
to determine whether the acute disease is 
true Rheumatoid Arthritis, or whether it 
is genuine rheumatism which has acted as 
the exciting cause of the former affection. 
As the acute disease is so little known and 
recognized by the profession, it may be well 
to give an illustration, and the following 
case may be taken as a typical example. 
A lady, forty-two years of age, when 
living in Australia, in the bush, was con- 
fined, and being unable to procure a good 
supply of cow's milk was induced to nurse 
her child for a period of twenty months : 
at the same time she herself had but a 
very deficient amount of meat. By these 
means she was reduced to an extremely 
weak state. After a short time she no- 
ticed that some of her joints became af- 
fected ; at first the knees, then the ankles, 
afterwards the elbows and wrists, and, 
lastly, many of the small articulations of 
the hands. These parts were painful, 
somewhat swollen, hot, and tender, but 
the local symptoms were never intense, 
nor was the constitutional disturbance 
very great; that is, there was no high 
degree of febrile excitement. After a few 
weeks some of the joints were much in- 
jured ; the knees, although reduced in 
size from the absorption of the fluid, could 
neither be fully extended nor flexed, and 
the patient was soon unable to stand by 
reason of their rigid condition ; the move- 
ment of several of the other joints was 
also limited, although in a less degree. 
The causes of the debility being removed, 
the patient soon gained strength and flesh, 
and the tendency to the joint affection 
passed off, but not without having inflicted 
irremovable injury. 
Diseases caused by the Rheumatoid Dia- 
thesis. - In both gout and rheumatism, 
symptoms which may be termed irregular 
manifestations are occasionally met with, 
and the same holds good in Rheumatoid 
Arthritis ; in other words, structures other 
than those of the joints, but of a similar 
nature, may take on the same kind of dis- 
eased action. Sometimes these symptoms 
occur simultaneously with the joint affec- 
tion ; sometimes they alternate with it, 
or appear to be altogether independent of 
it. In well-marked cases of this irregular 
form of the disease, the inflammation has 
attacked the eyes, ears, or structures of 
the larynx; producing in the first organ 
sclerotitis, in the second inflammation of 
the internal ear, and in the last hoarse- 
ness, and a peculiar dry cough, not at- 
tributable to pulmonary disease. MORBID anatomy of rheumatoid arthritis. 
553 
Analysis of the Animal Fluids in Rheu- 
matoid Arthritis.-Very little information 
has been obtained from an examination of 
the blood, urine, or sweat of patients, suf- 
fering from Rheumatoid Arthritis, which 
is calculated to throw light upon the na- 
ture of the disease. 
The only analyses of the blood that the 
writer is cognizant of have been made by 
himself, and with simply a negative re- 
sult. If any amount of active inflamma- 
tion is present, the fibrin is increased, and 
the clot becomes firm, cupped, and buffed. 
The serum has the ordinary properties 
of the serum of healthy blood, and yields 
no uric acid. 
The analysis of the urine has likewise 
given negative results. 
The perspiration has not been exam- 
ined, but there is no reason to suppose 
that any peculiar alteration would be 
found in it. 
Morbid Anatomy of Rheumatoid 
Arthritis.-The morbid anatomy of this 
disease has been very elaborately worked 
out by Dr. Adams, to whose volume the 
reader is referred for full details of the 
various changes which take place. In 
the present article a summary only of the 
results found in different cases, and differ- 
ent stages of the malady, will be given. 
If a joint is examined in an early stage 
of the disease, when swelling is promi- 
nent, a considerable increase of synovial 
fluid is found, and the joint exhibits the 
same appearances as in cases of ordinary 
inflammation; the lining membrane is 
often red, from over-injection of the blood- 
vessels. It is not an easy matter to obtain 
an opportunity of examining joints in this 
condition, as Rheumatoid Arthritis is sel- 
dom fatal, except in its very advanced 
stages; but the supervention of other 
maladies sometimes enables us to do so. 
No deposits of urate of soda are found in 
any stage of this disease, and I am per- 
suaded that the statements to the con- 
trary are erroneous, and, as yet, there has 
been certainly no proof given in support of 
such assertions. Of course it is not im- 
possible that a patient may have had gout 
[Fig. 33. 
Fig. 34. 
Arthritis of Knee-joint. 
Changes in the Head and Neck of the Femur and in the 
Acetabulum in Arthritis.] 
in a joint, and that afterwards the same 
articulation may become the seat of Rheu- 
matoid Arthritis; but this, if indeed it 
ever occurs, is most rare, and would not 
in any way favor the idea that deposition 
of urate of soda is a phenomenon of this 
form of inflammation. 
When the effusion in a joint has been 
absorbed, the capsular membrane is usu- 
ally found thickened. In the hip, or 
shoulder, the round ligament or tendon 
of the biceps is probably destroyed ; inter- 
articular cartilages are sometimes ab- 
sorbed, and a case has recently come 
under my observation in which the articu- 
lation of the jaw exhibited this alteration 
in a very complete degree. If the fluid 
becomes absorbed before much serious 
change has taken place in the internal 
structures of the joint, the ligaments have 
generally undergone so much lengthening 
as to allow of unnatural mobility, thus 
rendering dislocation easy. 
From almost the very commencement 
of the inflammatory action, the articular 
cartilage begins to suffer, a slow process 
of absorption takes place, the cartilage 
appears to split up into fibres, vertical to 
the surface of the bone ; little depressions 
are observed, and these at length coalesce, 
and the bone is left in part uncovered ; as 
the disease proceeds, the whole surface 
may be thus denuded, and as the osseous 
surfaces are brought into contact with 
each other in the movements of the ar- 
ticulations, they become polished in a re- 
markable degree by the friction, and an 
ivory-like condition, termed eburnation, 
is produced. Sometimes this eburnation 
occurs in streaks or patches in the direc- 554 
RHEUMATOID ARTHRITIS. 
tion of the motion of the joint; sometimes 
the whole surface may become thus al- 
tered. More rarely the cancellated struc- 
ture of the heads of the bones is exposed 
by the absorption of the denser matter at 
their extremities, and the ends of the 
bones become enlarged and misshapen by 
the deposition of osseous matter. If the 
bone is sawn through, it is often found 
unusually spongy, and contains a large 
amount of oily matter, from the occur- 
rence of a species of fatty degeneration. 
Within the joints vegetations and 
bands are frequently seen, also foreign 
bodies of various sizes, some cartilaginous 
in structure, others having the consist- 
ence and texture of bone ; and these are 
usually adherent to the internal surface 
by ligamentous bands. 
Causes of Rheumatoid Arthritis. 
-The predisposing causes of Rheumatoid 
Arthritis may be thus classified : First, 
those which are inherent in the patient; 
secondly, those which arise independently 
of the individual. 
1. Influences dependent on the Individual. 
-Hereditary Disposition does not appear 
to exert any very special influence, except 
that children of weakly parents probably 
inherit their debility. In looking over 
the histories of a large number of cases, 
the writer cannot find much evidence of 
the direct influence of hereditary predis- 
position ; if it exists, it is very much less 
powerful than in the case of gout. It is 
not uncommon to find one member of a 
large family suffering severely from the 
disease, and the rest entirely free from it. 
Sex.-It is commonly thought that 
women are more liable to Rheumatoid 
Arthritis than men. M. Trousseau speaks 
of the affection as very rare among men, 
very frequent amongst women. Women 
are doubtless very prone to be attacked, 
as they are most likely to be subjected to 
the predisposing causes, especially irregu- 
larities of the uterine function ; and it 
would appear that deranged menstrua- 
tion, independent of hemorrhage, predis- 
poses to the disease. Men, however, are 
by no means free, and some of the most 
severe cases are found among them. 
Age.-Rheumatoid Arthritis may occur 
at almost any age. I have seen it in its 
worst form in children of ten and twelve 
years of age, and I have also seen it com- 
mence in very old people above seventy 
years. 
Individuals of weak frame, whose cir- 
culation is languid, and whose extremities 
are habitually cold, are more liable to the 
disease than others; and it should be 
mentioned that patients having a tuber- 
cular diathesis are often the subjects of 
Rheumatoid Arthritis. 
2. Influences independent of the Indi- 
vidual.-Everything which causes debility 
and loss of tone in the extreme circula- 
tion, as hemorrhages from the uterus or 
elsewhere, deep and prolonged grief, 
severe and protracted mental anxiety, 
acts as a predisposing cause of the dis- 
ease. It not infrequently results from 
rapid child-bearing, or too lengthened 
lactation ; also from night-watching. Cold 
is very frequently an exciting cause of the 
disease, especially if it has been pro- 
longed, and has caused severe depression 
of the functions of the nervous system. 
In one instance I have seen the affection 
in its most severe form apparently the re- 
sult of diabetes mellitus; 
In some cases injuries or shocks appear 
to have acted as exciting causes. 
Now and then acute rheumatism acts 
as an exciting cause of Rheumatoid 
Arthritis. 
Malt liquors and wines do not appear 
to exercise any influence in either causing 
or protracting Rheumatoid Arthritis. 
Pathology of Rheumatoid Arth- 
ritis.-The examination of the blood in 
Rheumatoid .Arthritis has failed to dis- 
cover any constant or pathognomonic 
changes in that fluid ; but as yet the 
number of analyses has been very limited. 
One fact of importance they have elicited, 
namely, the absence of uric acid; and 
thus we are able to distinguish the blood 
in this disease from that in true gout. 
Pathological anatomy has likewise en- 
abled us to distinguish Rheumatoid Arth- 
ritis from gout, on the one hand, and 
from rheumatism on the other, by de- 
monstrating the absence, in the affected 
joints, of deposits of urate of soda, which 
are constant in gout, and by showing the 
presence of ulceration of the cartilages, 
and of other structural alterations, which 
are not found in simple rheumatism, even 
after repeated attacks. 
The consideration of the history and 
progress of the disease has shown that it 
differs completely, in its essential nature, 
from both gout and rheumatism, and fully 
justifies the rejection of the name " rheu- 
matic gout," which must of necessity con- 
vey to every mind the idea of a hybrid 
disease, a compound of both gout and 
rheumatism. If a disease should be so 
designated, because it differs completely 
in its intimate pathology from both affec- 
tions included in its compound name, 
then no fault can be found with the no- 
menclature. 
It seems difficult to persuade those who 
have been brought up in the old idea of 
this hybrid affection that such disease has 
no real existence. 
Dr. Aitken, in his excellent work on 
the Science and Practice of Medicine, al- 
though he admits that Hunter warmly 
opposed this compound appellation, 
"rheumatic gout," deems it is neverthe- diagnosis of rheumatoid arthritis. 
555 
less pathologically correct, and thinks 
that a hybrid disease, depending on the 
combined cachexia of gout and rheu- 
matism, has a real existence, as recog- 
nized by Craigie, Wood, Spencer Wells, 
and Fuller. On turning, however, to the 
last-named author, the following passage 
is met with : " The disease should not be 
regarded as of a hybrid character, or, in 
other words, made up in part of rheuma- 
tism, in part of gout." And again : "It 
has no connection with either of these 
diseases, beyond that which attaches to it 
in virtue of its being a constitutional dis- 
order, producing local manifestations in 
the joints." Might not the very same be 
said of pysemia ? Is this not a constitu- 
tional disease, producing local symptoms 
in the joints ? 
It is a much easier task to prove what 
Rheumatoid Arthritis is not, than to give 
the slightest clue to what it is : at present 
I should hesitate to offer a strong opinion 
as to its nature. It appears to result from 
a peculiar form of mal-nutrition of the 
joint textures, an inflammatory action 
with defective power ; but of its depend- 
ence upon the presence of any morbid 
principle, or upon a weakened condition 
of the vessels or structures of the affected 
parts, no evidence exists upon which any 
reliance can be placed. Thus much only 
appears to be made out: it usually occurs 
in weakened subjects, and exposure to 
cold is in many cases the exciting cause 
of its development. 
A full and searching investigation into 
the nature of Rheumatoid Arthritis is 
still a desideratum. 
Diagnosis of Rheumatoid Arthri- 
tis.-Perhaps there is scarcely a subject 
of greater importance in the whole range 
of joint affections, than the diagnosis of 
Rheumatoid Arthritis ; for upon a correct 
understanding of it depends the future 
comfort and physical well-being of a large 
class of persons. 
Rheumatoid Arthritis, as has been al- 
ready shown, assumes various forms, and 
individual cases of the disease are often 
with difficulty distinguished. The affec- 
tions with which it is apt to be confound- 
ed are gout and rheumatism. It is there- 
fore important to be able at once to dis- 
tinguish Rheumatoid Arthritis from the 
above-named diseases. Ilaygarth thus 
describes the difference between what he 
termed nodosity of the joints (Rheuma- 
toid Arthritis) and gout, &c. :- 
"The nodes appear most nearly to re- 
semble gout: both of them are attended 
with pain and swelling of the joints, but 
they differ essentially in many distinguish- 
able circumstances. In gout the skin and 
other integuments are generally inflamed, 
with pain, which is very acute, soreness 
to the touch, redness and swelling of the 
soft parts, but in no respects like the hard- 
ness of bone. The gout attacks the patient 
in paroxysms of a few days, or weeks, or 
months, and has complete intermissions, 
at first for years, but afterwards for 
shorter periods. The gout attacks men 
much more frequently than women. There 
is one distressful circumstance which dis- 
tinguishes this disorder: it has no inter- 
mission, and but slight remissions, for 
during the remainder of the patient's life 
the nodes gradually enlarge, impeding 
more and more the motion of the limb ; 
the malady spreads to other joints, with- 
out leaving or producing any alleviation 
in those which had been previously at- 
tacked." 
The following considerations will enable 
us to effect the diagnosis in at least the 
majority of cases :- 
It is questionable whether Rheumatoid 
Arthritis is in any marked degree capable 
of being inherited ; whereas gout is dis- 
tinctly hereditary. 
The sex of the patient does not aid us 
much. Both sexes are liable to the dis- 
ease, and the difference in their liability 
is too slight to enable us to give it much 
weight in diagnosis. Nor does the age of 
the patient argue much, as it has been 
shown that Rheumatoid Arthritis attacks 
both children and very aged persons. 
In many instances Rheumatoid Ar- 
thritis is preceded by a condition of ill- 
health ; there are evidences of bad nutri- 
tion and exhaustion of the nervous system. 
Rheumatoid Arthritis usually begins 
as a sub-acute disease, and the joint affec- 
tion gradually increases ; but occasionally 
it commences in an acute form. These 
latter cases may be mistaken for acute 
gout or rheumatic fever. There are, 
however, peculiarities in its course by 
which it can generally be distinguished 
from either of these diseases; the most 
marked being its progressive character, 
which has been fully described above. 
From acute gout it may be distinguished 
by the length of the paroxysm, the absence 
of periodicity, by the large and small joints 
being equally attacked at the outset, and 
the great toe not being specially involved. 
From rheumatic fever or acute rheu- 
matism, by the comparative freedom from 
constitutional disturbance, the longer du- 
ration of the paroxysm, and the absence 
of acute cardiac inflammation. 
From chronic rhumatism it can be dis- 
tinguished by the comparative absence of 
structural alteration in the former disease. 
The most frequent difficulty which oc- 
curs is to separate chronic Rheumatoid 
Arthritis from chronic gout, and, on re- 
ferring to the article "Gout" in the pre- 
sent volume, a case illustrative of this 
difficulty will be seen. There should 
always be a careful search made for 
evidences of urate deposits on the ear and 556 
RHEUMATOID ARTHRITIS. 
at the tips of the fingers, and in the bursae 
over the olecranon process of the elbows ; 
but from mere inspection it is difficult to 
make a diagnosis, especially if the affec- 
tion has become chronic. 
When the diagnosis is very obscure, 
notwithstanding that the above rules have 
been followed, it may be at once cleared 
up by an examination of the blood ; in 
Rheumatoid Arthritis there is no uric 
acid present: there is also, in most cases, 
the absence of any material alteration in 
the urine. 
One disease is with difficulty separated 
from the acute forms of Rheumatoid Ar- 
thritis-namely, the joint affection arising 
from urethral suppuration : the history of 
the case will of course enable us to clear 
up the diagnosis. 
Prognosis of Rheumatoid Arthri- 
tis.-Rheumatoid Arthritis is unques- 
tionably a very intractable disease ; and 
this is not to be wondered at, if we con- 
sider its ordinary antecedents. Its most 
common predisposing cause is a thorough- 
ly impaired condition of the system, and 
this in many instances has arisen from 
influences which have been for years in 
operation: it cannot, therefore, be even 
reasonably hoped that an affection occur- 
ring under such circumstances can be 
rapidly cured : it is often a great achieve- 
ment to arrest its further progress. 
If the disease is far advanced, and the 
joints severely injured, it is impossible to 
restore the articulations to their former 
state, even if the constitutional tendency 
to the disease is thoroughly arrested. 
Still, under such circumstances, it some- 
times happens that patients, who for years 
have been unable to move, will regain 
their power of locomotion, a result caused 
by the formation of a kind of false joint in 
some of the more important articulations. 
When the disease is less advanced, when 
the affected joints are few in number, and 
their mobility but partially interfered 
with; when at the same time there is 
freedom from any disease which must of 
necessity keep up the impaired state of 
health; lastly, when the progress of the 
affection has not been rapid-then a more 
favorable view may be taken of the case, 
and a recovery more or less complete may 
be hoped for. 
When the disease is at its commence- 
ment, or at least when but little damage 
has ensued, and at the same time the af- 
fection shows little tendency to assume an 
acute character, then a complete recovery 
may be anticipated, if proper measures 
be adopted: if, however, the patient is in 
any way weakened, or treated as if he 
were suffering from a sthenic malady, 
then the probability of the disease becom- 
ing deeply engrafted into the system, and 
causing serious mischief, is greatly in- 
creased. J 
The accurate diagnosis and proper treat- 
ment of cases of Rheumatoid Arthritis 
exercise a very important influence upon 
its prognosis. 
Treatment of Rheumatoid Arth- 
ritis. - The treatment of Rheumatoid 
Arthritis is a subject of the highest im- 
portance, more especially in the earlier 
stages of the disease, when as yet the 
joints are not seriously or irremediably 
injured. 
From what has been stated under the 
"Causes" and "Pathology" of Rheuma- 
toid Arthritis, it will be naturally inferred 
that a prolonged sustaining plan of treat- 
ment is imperatively called for, and that 
all depleting measures must tend most 
materially to increase the rapidity and 
severity of the disease. I have witnessed 
a great number of cases in which deple- 
tion has been persevered in for a time, 
and with the effect of producing lamenta- 
ble results, as the joints became perfectly 
disorganized; and in many of these it is 
probable an opposite treatment would 
have been attended with different results. 
We must remember that, during the 
more acute inflammatory stages; the dis- 
ease must not be treated in the manner 
recommended to be adopted in gout. Col- 
chicum is always worse than useless, and 
the patient should be well sustained 
throughout the whole of the treatment; 
neither are the alkalies, so serviceable in 
rheumatism, of any permanent value in 
Rheumatoid Arthritis. 
With the exception of stating that a 
supporting plan must be adopted from 
the first, no rules applicable to all cases 
can be laid down, a fact which must be 
evident, if we consider the different causes 
which lead to a condition of habit favor- 
able to the development of the disease. 
If the disease has been caused by hemor- 
rhage of any kind, and anaemia exists, 
then the first object must be to restore 
the blood to its normal state, and prepa- 
rations of iron are imperatively called for. 
If the mere haematinic influence is re- 
quired, the reduced iron (ferrum reduc- 
tum) may be administered, or the ammo- 
nio-citrate or some other very mild salt of 
this metal; if, however, the anaemia is 
combined with a relaxed state of habit, 
the more astringent preparations should 
be employed, as the sulphate or perchlo- 
ride of iron. If anaemia exists from other 
causes than hemorrhage, similar remedies 
may be had recourse to. 
Ferruginous salts are also of much 
value in keeping up the power of the 
heart, but in all cases they should he 
given in small doses, and persevered in 
for a long time. 
In certain conditions where the nutri- 
tion is imperfect from causes often unable 
to be defined, cod-liver oil may be given TREATMENT OF RHEUMATOID ARTHRITIS. 
557 
with great advantage : if the habit is ma- | 
terially improved by it, the progress of , 
the joint affection is usually checked. 
Cod-liver oil is particularly indicated in 
patients of spare habit, and when the dis- 
ease has been attended with wasting of 
the body. If the nervous system has 
been seriously implicated by depressing 
causes, as anxiety, grief, prolonged at- 
tendance on sickness, then remedies more 
directly affecting this system must be em- 
ployed, either by themselves, or in con- 
junction with those already mentioned. 
Quinine, as a nervine tonic, is often of 
much service, as likewise, when astrin- 
gents are indicated, the preparations of 
cinchona bark; assafoetida, valerian, and 
ammonia are of value when there is much 
mental depression. 
If the circulation is very languid, guai- 
acum may be administered with benefit, 
or guaiacum united with yellow bark; as, 
for example, the ammoniated tincture of 
the former medicine, and the simple tinc- 
ture of the latter. 
Guaiacum appears to exert a marked 
effect upon the capillary circulation, in- 
creasing the warmth of the extremities, 
and rendering the functions of the skin 
more active. 
Arsenical preparations are in some 
cases of considerable value : how they act 
is a subject of considerable difficulty to 
explain. We have clinical evidence de- 
monstrating their peculiar action upon 
the skin, and it may be that their influ- 
ence is exerted also upon the fibrous and 
cartilaginous structures, or they may 
more especially affect the nervous system 
as tonics, and thus prove of service. 
Arsenic may be given either in the form 
of the arsenite of potash (liquor arsenica- 
lis), or the arseniate of soda (liquor sodee 
arseniatis). From repeated trials, I have 
come to the conclusion that arsenic, in 
the state of arsenic acid, is less irritating 
than when in the lower condition of oxi- 
dation, and can be given in larger doses. 
Iodides are of service in some cases, 
especially during the more acute stages, 
or when warmth has a marked effect in 
causing an augmentation of the pain. 
Iodide of potassium may be administered 
alone, or in combination with guaiacum 
or guaiacum and bark ; or the iodide of i 
iron may be given, especially if ferrugi- 
nous preparations are indicated. The 
syrup of iodide of iron, in doses of from 
twenty to thirty drops twice a day, and 
continued for some months, has in seve- 
ral cases proved of much benefit, even to 
the extent of completely arresting the 
progress of the disease. 
In special cases special remedies must 
be employed. If, for example, menor- 
rhagia has been in any way the cause of 
the debility, and still continues, bromide 
of potassium may be advantageously had 
recourse to; and should the muscular 
system have been wasted, especially the 
muscles of the affected limbs, nux vomica 
or strychnine can be given to restore their 
function. 
Mineral waters are often resorted to, 
from a mistaken view of the nature of 
the malady. I have seen much injury 
resulting from their employment from 
the debility they have induced. The 
springs most adapted for the subjects of 
Rheumatoid Arthritis are those of Schwal- 
bach, Pyrmont, and Spa, or any other 
ferruginous waters, which sit easily upon 
the stomach. The stronger saline and 
alkaline waters, as those of Carlsbad, 
Wiesbaden, and Vichy, unless used with 
great care, are apt to aggravate the dis- 
ease. In some very chronic cases, the 
springs of Wildbad and Gastein have 
proved of much service. 
Change of air, occupation, and scenery, 
by aiding the general health, exerts a 
beneficial influence upon the progress of 
the malady. 
Local Treatment of Rheumatoid Arthritis. 
-In the early stages, when there is ten- 
derness and swelling of any joint, relief is 
often experienced from the application of 
blisters, and a most convenient form is 
the cantharides liniment of the British 
Pharmacopoeia : it produces, in almost all 
cases, full vesication, and with little 
annoyance ; it can be frequently applied, 
so as to produce a series of flying blisters. 
Under this treatment the effusion will 
often quickly subside, and the tenderness 
become much lessened or even removed, 
and the liability to serious or permanent 
injury of the joint is thereby greatly les- 
sened. Other forms of counter-irritation, 
as iodine paint, croton oil, may be used, 
but I believe the blister treatment above 
mentioned is productive of more benefit. 
When the affection of any joint has be- 
come more chronic, and blisters have ef- 
fected all they are able to accomplish, fur- 
ther benefit may be obtained from the use 
of plasters, which act not only by the slight 
counter-irritation they produce, but like- 
wise, if properly applied, from the support 
they afford to the joint. The kind of plas- 
ter selected should depend on the require- 
ments of the case. If little more than 
simple support be needed, soap plaster may 
be used, and the joint may be bandaged 
with narrow strips of this, spread by ma- 
chine on linen. If more irritating appli- 
cations are desired, then the galbanum or 
ammoniacal plaster can be used, or the 
ammoniacal and mercurial, or the iodine 
plaster : when using the two latter, severe 
irritation of the skin should be avoided. 
The application of lotions containing 
spirit of such a strength as to cause but 
slight irritation of the skin sometimes 558 
RHEUMATISM. 
gives great relief. If there is much pain, 
the belladonna liniment may be used in 
lieu of the simple spirit. 
Baths are in some cases useful, espe- 
cially when the function of the skin is de- 
fective ; but care must always be taken 
that debility be not induced, otherwise any 
good result is more than counteracted. 
Bathing is certainly not curative in this 
disease, it can only be looked upon as pal- 
liative, and should be employed with this 
understanding. 
In chronic cases, when friction can be 
used without increasing the tenderness of 
the parts, it may be employed either alone, 
or combined with some stimulating lini- 
ment ; or the joint may be well sponged 
with strong brine, and then rubbed dry, 
so as to cause the salt to enter the skin. 
It is often asked whether it is desirable 
to allow movement of the affected joints ? 
I believe the best answer to be this : never 
allow such an amount of movement as 
will cause the joint to be more painful on 
the following day ; but any motion short 
of this may be employed with advantage. 
If this rule were followed, it would pre- 
vent the use of joints recently or acutely 
attacked, and rest in such cases aids the 
subsidence of the inflammation; on the 
other hand, it would allow those articula- 
tions in which the disease has become 
chronic to be moved to such an extent as 
to stay the wasting of the muscles of the 
limb, and to prevent the stiffening of the 
joints. 
[Many practitioners have confidence in 
the utility of mercurial ointment, applied 
once or twice a week to the inflamed joints. 
More benefit is likely to accrue from the 
employment of an ointment of carbonate 
of lead; two drachms to an ounce of simple 
cerate.1-H. ] 
Diet and Regimen in Rheumatoid 
Arthritis.-As far as the fluid portion 
of the diet is concerned, it is a matter of 
indifference whether malt liquors, wines, 
or distilled spirits are taken, provided 
that they agree with the stomach : it is 
far different in true gout. 
Whichever kind of alcoholic beverage 
causes the patient to eat with most relish, 
and digest with most comfort, should be 
selected. There is no necessity to give 
enough to stimulate, but only a sufficient 
amount to sustain the vigor of the assimi- 
lating functions. I am convinced that 
wines and malt liquors have no influence 
in favoring the development of Rheuma- 
toid Arthritis, although they powerfully 
predispose to the production of gout. The 
solid portion of the diet should be of the 
most nutritious character and of easy di- 
gestion, for our main object is to keep up 
the strength of the system : nor have we 
any proof that an excess of animal food 
tends to increase the disease, as is the 
case in gout. Meat should form a good 
proportion of the diet, if the stomach is 
capable of digesting it; and whatever 
articles of diet are found to improve the 
general health may be given with advant- 
age. 
A frequent change of air and scenery 
should be advocated, all prolonged men- 
tal exertion avoided, and, as far as possi- 
ble, all causes of anxiety should be re- 
moved. 
A residence in a moderately warm 
country during the winter months is de- 
sirable, but the air of the place should be 
dry and bracing. Such a climate will en- 
able the patient to take exercise and have 
fresh air when otherwise he would be con- 
fined to the house. 
If the joints allow of it, moderate exer- 
cise should be enjoined, but not sufficient 
to cause subsequent fatigue. 
The clothing should be warm, but much 
perspiration avoided. 
RHEUMATISM. 
Alfred Baring Garrod, M.D., F.R.S. 
The subject of Rheumatism will be dis- 
cussed in the present article under the 
heads of Articular and Muscular Rheuma- 
tism; the first, or Articular Rheumatism, 
in its more acute form, being commonly 
known as Rheumatic Fever. Such a di- 
vision has been adopted, as it is a question 
at the present day whether the articular 
and muscular affections are in reality 
manifestations of the same disease. 
[* This vehicle is preferable to lard on ac- 
count of the softening effect of the carbonate. 
Vaseline is liable to the same objection, in 
this particular mode of application.-H.] DEFINITION - HISTORY. 
559 
A. Articular Rheumatism. 
Definition. - (1) Acute Articular 
Rheumatism. A specific inflammation of 
the structures in and around the joints, 
attended with great febrile disturbance ; 
erratic ; not accompanied with deposits of 
urate of soda, and (?) not leading to sup- 
puration. (2) Sub-acute Articular Rheu- 
matism. The same affection as the above, 
but manifested in a much less intense de- 
gree, and with little febrile disturbance ; 
generally following upon the acute disease. 
Synonyms.-Rheumatic Fever ; Ar- 
thritis. 
History. - Although there is every 
probability that mankind was afflicted 
with Rheumatism from the very earliest 
periods, still we gather from the writings 
of ancient physicians that they did not 
separate this malady from other forms of 
joint disease, but comprehended all of 
them under the general term "arthritis," 
the only distinction being made dependent 
on the particular articulations implicated. 
Monsieur Baillon, a French physician, 
first made use of the word Rheumatism 
(from a stream, a fluxion): in a 
Latin treatise published in 1642, entitled 
" De Rheumatismo et Pleuritide Dorsali, " 
he separates this disease from gout in the 
following sentence : " Gout is a disease of 
a certain part, and periodical; Rheuma- 
tism of the whole body, and more uncer- 
tain in its attack." 
Sydenham afterwards makes a distinc- 
tion between the two affections: "This 
disease, when unattended with fever, is 
frequently mistaken for gout, although it 
differs essentially therefrom, as will easily 
appear to those who are thoroughly ac- 
quainted with both diseases; and hence 
it is, perhaps, that physical authors have 
not mentioned it, unless indeed we esteem 
it a new disease." Cullen thus defines 
Rheumatism : "A disease from an exter- 
nal and often an evident cause ; pyrexia ; 
pain about the joints, following the course 
of the muscles, fixing upon the knees and 
larger joints in preference to those of the 
feet and hands-increased by external 
heat." 
Even since Cullen's time there have 
been authors, both in this country and 
abroad, who have included Rheumatism 
and gout under the same category, amongst 
whom stands prominently the name of M. 
Chomel. 
The late Sir Benjamin Brodie, in his 
work on diseases of the joints, clearly sep- 
arates Rheumatism from rheumatoid ar- 
thritis, although he designates the latter 
affection ulceration of the cartilages. 
At the present time it may be confi- 
dently asserted that, omitting purulent 
affections of the joints and those con- 
nected with urethral suppuration, there 
exist at least three well-marked articular 
diseases dependent on morbid states of 
the system ; these are Rheumatism, gout, 
and rheumatoid arthritis . and probably 
to them we may add a fourth, namely, 
muscular rheumatism. 
Description of Acute and Subacute Rheu- 
matism.-To illustrate this subject we will 
give a sketch of an acute attack of rheu- 
matism, such as is daily met with in prac- 
tice. A young woman, possibly some- 
what out of health, is exposed to severe 
cold, or to cold and damp conjoined ; she 
feels a distinct chill or rigor, and this is 
followed, probably during the second or 
third day from the exposure, by the de- 
velopment of the joint affection; the 
ankles become painful and unable to bear 
the weight of the body, and on examina- 
tion they are found tender to pressure, 
swollen, unduly hot, with a distinct flush 
upon the surface; at the same time the 
system exhibits a state of febrile excite- 
ment, the pulse is rapid and commonly 
hard, the whole surface hot and bathed 
in perspiration, having a peculiar acid, at 
least acrid, odor. The tongue is coated 
with a thick creamy fur; there is loss of 
appetite, but increased thirst and a con- 
stipated state of the bowels ; the urine is 
usually scanty and high-colored, and gives 
rise on cooling to a copious red deposit. 
The inflammation is seldom confined to 
one joint, but gradually extends over the 
whole body. The larger joints are more 
frequently affected than the smaller in the 
earlier periods of the attack. 
The erratic nature of the affection is 
usually well exhibited ; at one time the 
knees and ankles, at another the elbows 
and wrists suffer ; and not infrequently 
the development of inflammation in one 
set of joints is accompanied by its rapid 
subsidence in another. 
A symmetry is often shown in the order 
of attack : the right ankle, then the left; 
the right knee, then the left; and so on 
for the other articulations. It is a matter 
of astonishment to observe how quickly 
and completely the inflammation will sub- 
side in any part. A knee, for example, 
will one day be intensely hot and swollen, 
and so exquisitely tender as not to bear 
the weight of the bed-clothes ; but on the 
following day will scarcely show any evi- 
dence of its previous suffering. This con- 
dition of the patient may continue for 
many days or perhaps weeks, the dura- 
tion depending partly on the intensity of 
the disease, partly on the habit of the 
patient, and partly on the treatment ad- 
opted. Its usual duration, when under 
no special treatment, is from ten days to 
three or four weeks ; but perhaps no dis- 
ease exhibits greater differences in this 
respect, and hence the difficulty, except 
when a number of cases are compared, of 560 
RHEUMATISM. 
accurately estimating the value of the 
various plans of treatment which have 
been employed for its cure. Cases are 
now and then met with which spontane- 
ously terminate in five or six days, others 
which run a course of six or even eight 
weeks. With few exceptions, the pain of 
the joints and the febrile disturbance are 
greater at night than in the day ; but the 
nocturnal exacerbations are less marked 
in rheumatic fever than in acute gout. 
After a varying time the joints become 
free from redness, swelling, and tender- 
ness, the pulse lowered to its healthy 
standard, the temperature and sweating 
of the surface diminished ; at the same 
time the tongue cleans, the thirst abates, 
the appetite returns, the urine clears, and 
in short the system is restored to its 
healthy state, with the exception of a cer- 
tain amount of wasting and debility, 
necessarily induced by the increased wear 
of tissue and the defective nourishment 
which have taken place during the period 
of febrile disturbance. From these, how- 
ever, the patient soon recovers, when able 
to take a generous diet and enjoy fresh 
air and exercise. 
It is not unusual to find that patients 
after recovering from attacks of rheumatic 
fever, as far as regards the constitutional 
symptoms, are liable to suffer from pains 
in those joints which have been the seat 
of inflammation : these pains are not con- 
stant, but assume a neuralgic character, 
and will generally be found to be in pro- 
portion to the length of time the joints 
were affected during the febrile attack. 
Thus far our description has been con- 
fined to a case of acute rheumatism, in 
which the inflammation has been limited 
to the joint structures: unfortunately, 
however, it is not always so, for in a large 
percentage of cases the covering or lining 
membrane of the heart, or even the sub- 
stance of the organ, becomes implicated, 
and peri- and endo-carditis ensue. Some- 
times the heart disease follows a some- 
what sudden subsidence of the joint in- 
flammation, but more commonly the 
articular and cardiac affections run a 
simultaneous course. 
When inflammation of the pericardium 
takes place, the patient usually expe- 
riences a sensation of tightness or pain in 
the chest, but not always, as the acute 
discomfort caused by the condition of the 
joints draws the attention altogether from 
the slight uneasiness due to the cardiac 
complication. On applying the stetho- 
scope a distinct friction or rubbing sound 
is heard, often limited at first to a small 
extent of surface, generally at the base of 
the heart, but it commonly spreads over 
nearly the whole of the surface of the 
organ ; when the amount of effused fluid 
is large, there is increased dulness of the 
percussion note over the cardiac region, 
and the heart's sounds are diminished in 
intensity, and heard as if from a distance. 
When, on the other hand, the endocar- 
dium is implicated, abnormal heart sounds 
are produced usually at the aortic or 
mitral valves, giving rise to basic or apex 
systolic murmurs ; or, if the closure of the 
aortic valve becomes imperfect, a basic 
diastolic murmur is also developed. These 
various phenomena are due to the pour- 
ing out of lymph and serum upon the 
surfaces of the pericardium, or the secre- 
tion of plastic lymph or fibrinous coagula 
upon the valves of the heart. When the 
cardiac substance is involved, great ir- 
regularity and extreme feebleness of the 
action of the heart ensue, often leading 
to sudden and fatal collapse. For further 
details concerning the physical signs and 
symptoms which occur in pericarditis and 
endocarditis the reader is referred to the 
articles devoted to those diseases, as these 
affections, when they arise from rheumatic 
inflammation, follow the same course and 
exhibit the same phenomena as when due 
to other causes. 
Pleurisy of a true rheumatic nature 
sometimes occurs during the progress of 
rheumatic fever, and the phenomena are 
the same as in the ordinary forms of acute 
pleuritis. 
More rarely the peritoneum becomes 
affected by rheumatic inflammation. 
When the heart is implicated, delirium 
is usually present, especially at night; but 
in some few cases the rheumatic condition 
appears to attack the membranes of the 
brain, and then the symptoms of cerebral 
meningitis are produced. Sometimes the 
membranes of the spine are involved, and 
symptoms of spinal meningitis are set up. 
Chorea is apt to supervene in young 
subjects after the cessation of the febrile 
disturbance in rheumatic fever, where the 
heart has been implicated. 
Description of Subacute Articular Rheu- 
matism.-At times, from various causes- 
as the nature of the patient's constitution 
or the presence of cardiac complication- 
articular rheumatism assumes a form to 
which the name subacute may be pro- 
perly applied; the joint symptoms remain, 
but "in a much less severe degree, and 
there is an almost complete absence of 
febrile disturbance. Such a condition 
may continue for weeks oi' even months, 
at one time relieved, at another aggra- 
vated, and the disease may then be com- 
pared to a similar subacute form not in- 
frequently seen in gout, and to which the 
term chronic is applied. 
In subacute rheumatism there is often 
some tenderness of the joints, slight swell- 
ing, and heat, but the disease differs from 
both chronic gout and rheumatoid arth- 
ritis, inasmuch as it may continue for a 561 
HISTORY. 
long time without leading to any great 
deformity or permanent injury to the 
articulations. 
It will be seen that the statements made 
above are at variance with those commonly 
met with in works on this disease, in 
which the results ascribed to the subacute 
affection are so formidable. The differ- 
ence is easily explained : most authors 
attribute to chronic rheumatism the 
changes that in the present work are de- 
scribed under the head of rheumatoid 
arthritis. 
The occurrence of one attack of rheu- 
matic fever imparts a great susceptibility 
to the system for its return, which a sec- 
ond augments, and thus after a time the 
patient is liable to become the victim of 
frequent seizures, though these will pro- 
bably assume a less sthenic form, and are 
often of such a character as to entitle them 
to be called subacute rather than acute. 
When a patient has been brought to this 
condition, the most trifling exposure to 
cold, or even the slightest depressing 
cause, may prove sufficient to light up the 
disorder. 
Even in individuals who have suffered 
long and severely from repeated attacks, 
it is unusual to find any very serious al- 
terations produced in the affected joints ; 
they may for a time remain more or less 
swollen from effusion of fluid, the liga- 
ments may become stretched and relaxed, 
but there is no permanent thickening left 
either from the deposits of the chalk-like 
matter (urate of soda) so constantly found 
in gout, or from the formation of false 
cartilages and other changes, the effect of 
rheumatoid arthritis. 
Consideration of the different Phenomena 
in Acute Rheumatism.-The various symp- 
toms which are observed in cases of acute 
rheumatism demand further investigation 
than could be given them in the above 
sketch, and the first which claim atten- 
tion refer more especially to the joints 
themselves. The pain is generally very 
severe, but less intense than in gout; the 
swelling also is usually less marked than 
in the latter disease; there is rarely found 
extreme tension of the skin, and seldom 
oedema or desquamation of the cuticle; 
the redness is likewise less in Rheumatism 
than in gout, although this symptom may 
sometimes be present in a marked degree; 
and, lastly, the enlargement of the veins 
leading from the inflamed joint is certainly 
much less prominent in this disease than 
in true gout. 
Rheumatic inflammation has a decidedly 
erratic disposition, and, as it were, flies 
from joint to joint, or at least one articula- 
tion suddenly ceases to exhibit inflamma- 
tory symptoms, and another, probably the 
corresponding articulation, becomes as 
suddenly implicated; and this alternation 
may occur many times during a single at- 
tack. A certain amount of symmetrical 
action is likewise observed, as in almost 
all diseases the symptoms of which depend 
on an altered condition of the blood. On 
reflection it will be found that our sur- 
prise should rather be excited by a want 
of symmetry than by its occurrence ; for 
supposing that any morbid element has a 
peculiar attraction to any one joint-a 
knee, for example-it is necessarily drawn 
to the second knee more powerfully than 
to any other joint; or supposing again 
that the circumstances in one particular 
joint more especially favor the develop- 
ment of any specific form of inflammation 
in it, the conditions of the corresponding 
joint on the other side of the body must 
do so likewise. 
It has been stated that the swelling of 
the inflamed joints is less in Rheumatism 
than in gout, and the same holds good 
with the pitting on pressure, and the sub- 
sequent desquamation of the cuticle. This 
last symptom, so constant in gout, is not 
observed after rheumatic inflammation: 
but it must not be concluded that because 
pitting is present the inflammation is not 
rheumatic ; this would be erroneous, for 
cases of genuine rheumatic fever are now 
and then met with in which pitting of the 
skin is well marked : when this pheno- 
menon occurs, it is generally in weak sub- 
jects. In several such instances I have 
proved, not only by carefully examining 
all the symptoms, but also by analyzing 
the blood, that the cases were of a true 
rheumatic character, and had no relation 
to gout. 
The constitutional symptoms which 
are most prominent in acute articular 
rheumatism next require consideration. 
The first of these, one of great importance, 
is the temperature of the body. That 
there is a well-marked heat of surface is 
evident to the touch, but the indications 
of the thermometer are far more trust- 
worthy ; for they show correctly the 
amount of tissue-waste going on in the 
system, and cannot be masked by the in- 
fluence of the mind or other circumstances 
which render some of the subjective symp- 
toms of comparatively little value. 
Dr. Sidney Ringer, whose researches on 
temperature in disease are of much value 
and interest, has made observations on 
three cases of acute rheumatism which 
were communicated to Dr. Aitken, and 
published in his work on the Science and 
Practice of Medicine. In some fatal 
cases, complicated with severe pericar- 
ditis, the temperature rose as high as 
106° Fahr., 109° Fahr., and 110° Fahr, 
before death. 
In some instances of acute articular 
rheumatism I noticed the temperature, 
and found it to vary from 100° Fahr, to 
104° Fahr. ; but these observations have 
been made in cases in which recovery has 
vol. i.-36 562 
RHEUMATISM. 
taken place. The pulse, as already no- 
ticed, is usually quiet in acute rheumatism ; 
it is also hard and full; but exceptional 
cases are now and then met with in which 
the frequency is never great, although the 
febrile disturbance and temperature run 
high. More reliance can be placed upon 
the heat of the body than upon the rapid- 
ity of the heart's action in all cases of 
acute inflammation, and this especially 
holds good in Rheumatism, as the cardiac 
complications so frequently present in this 
disease alter the character of the pulse, 
independently of the amount of tissue- 
change which is going on in the system. 
The perspiration is generally considered 
to be intensely acid in acute rheumatism ; 
in several cases I have found it less acid 
than in healthy subjects ; but it must be 
remembered that the amount of perspira- 
tion is excessive. The peculiarity of the 
skin secretion in this disease depends on 
its acridity perhaps more than on exces- 
sive acidity. 
Condition of the Blood in Acute Articular 
Rheumatism.-In acute rheumatism, if 
blood is drawn from a vein, the clot is 
found to exhibit a huffy coat, and is fre- 
quently cupped-appearances which indi- 
cate that the fibrin is increased in quan- 
tity, and that this principle is also probably 
somewhat altered in quality. 
Many discrepant statements have been 
made upon this subject; according to 
Haller, the blood yields a thick and firm 
clot in this disease, but others assert that 
under the huffy coat the clot is found to 
be loose and friable ;-probably both are 
correct in different instances. 
Andral and Gavarret analyzed the 
blood in fourteen cases of rheumatic 
fever, and found the maximum amount of 
fibrin to be 10'2 parts in the 1000; the 
minimum 2*8 parts ; the mean was 6'7 : 
healthy blood yields, according to these 
observers, three parts per thousand. 
The serum of the blood does not appear 
to be very sensibly altered in composition ; 
Andral and Gavarret found an increase 
in the solid residue left by evaporating 
this fluid, the mean amount being 86-0 
per thousand against 80'0 per thousand 
in healthy blood. 
The same chemists found a diminution 
in the total solids : thus the mean in the 
above-mentioned fourteen cases was 194-G 
parts of solid matter to 805-4 parts of 
water in the 1000 parts of blood ; whereas 
in healthy blood the ratio between the 
solid residue and water is 200-0 to 790'0. 
In several analyses which I have made 
of the blood in acute rheumatism, I have 
found the amount of fibrin notably in- 
creased-namely, from four to six parts 
in the 1000-and the clot has usually been 
buffed and cupped. The serum in thirty- 
five cases was found distinctly alkaline in 
reaction, it presented a healthy appear- 
ance, its specific gravity was somewhat 
less than in health, and in no case was 
any uric acid detected either by the thread 
experiment described in the article on 
Gout, or by the ordinary method of sepa- 
rating this acid from blood. The absence 
of uric acid or urate of soda is important, 
as it at once shows essential difference 
between gout and Rheumatism. 
Urea does not exist in the blood in acute 
rheumatism in quantities larger than in 
health, except in cases in which the kid- 
neys have been either previously affected, 
or have become congested during the pro- 
gress of the disease. As above stated, 
the serum was always distinctly alkaline 
in reaction : this fact was particularly ob- 
served and noted, as it has been affirmed 
that the serum is sometimes acid in 
rheumatic fever. There dre, as yet, no 
recorded observations indicating the 
amount of the alkalinity. No abnormal 
principle has been found in the blood ; 
lactic acid has been assumed to exist in 
it, but no proof has been given of its 
presence. 
In the subacute and chronic varieties of 
Rheumatism no marked alterations are 
found ; the fibrin is increased but slightly, 
and only in proportion to the amount of 
the febrile disturbance. In ten cases the 
maximum of the fibrin was 5T, the mini- 
mum 2'6, and the mean 3'8 parts in the 
1000 parts of blood. 
Urine in Acute Articular Rheumatism. 
-Examinations of the urine in acute 
rheumatism have been frequently made 
with the following results: To the eye its 
appearance varies much in different cases ; 
as a rule it is high-colored and scanty, 
clear when first passed, but speedily be- 
comes turbid from the deposition of urates ; 
when copious it sometimes remains bright 
even after it is cold. These characters 
are by no means peculiar to rheumatic 
fever, but are seen in many febrile affec- 
tions. The deposited urates are often of 
a deep tint from the coloring matters of 
the urine being in excess and attracted to 
the uric acid salts, and if the fever runs 
very high, and especially if portal conges- 
tion is present, the color becomes bright 
red or deep pink. On a more minute ex- 
amination, it is found that the secretion 
of water by the kidneys is usually dimin- 
ished ; the solids of the urine are increased. 
The increase in the solid matter is due 
chiefly to the augmentation of the urea, 
partly also to an increase of the coloring 
matter. The uric acid is augmented : Dr. 
Parkes has found as much as seventeen 
grains in one case ; the largest amount I 
have obtained has been fifteen grains. It 
should be remembered that this increase 
of uric acid in the urine is not peculiar to 
rheumatic fever; it occurs likewise in 
other febrile diseases, unless the excreting 
power of the kidneys is injured. The MORBID ANATOMY OF ARTICULAR RHEUMATISM. 
563 
chlorides are diminished during the febrile 
disturbance, but less so than in pneumo- 
nia. Dr. Parkes found the sulphates 
much increased in several cases in which 
the inflammation of the joints and the 
febrile disturbance were severe. When 
alkaline remedies are not administered, 
the acidity of the urine is usually great. 
Albumen is now and then met with during 
the course of this disease, sometimes only 
for a day or two, but its occurrence is 
much less frequent in rheumatic fever 
than in pneumonia. No proof has yet 
been given that lactic acid exists in the 
urine in rheumatic fever in greater amount 
than in healthy urine. 
Cardiac and other Inflammatory affections 
in Acute Rheumatism.-It has been stated 
that in a large percentage of cases of rheu- 
matic fever the structure of the heart be- 
comes involved, and as such complications 
are of vital importance to the patient, 
they deserve in this place further con- 
sideration. 
It has long been suspected that some 
relation existed between acute articular 
rheumatism and inflammatory diseases of 
the heart. In the first volume of the 
Medico-Chirurgical Transactions there is 
a paper by Sir D. Dundas on this subject, 
in which he states: "In all cases which 
I have seen, this disease has succeeded 
one or more attacks of rheumatic fever. 
In one case, the affection of the heart ap- 
peared at the commencement of the rheu- 
matic fever, and its action was so rapid 
that the pulse could not be counted for 
many days ; much difficulty of breathing 
and oppression, attended with a sense of 
debility, took place; and the inflamma- 
tion, pain, and swelling of the extremities, 
after having shifted from one joint to an- 
other for many weeks, subsided ; but the 
affection of the heart continued, generally 
attended with great pain, producing in 
the progress of the disease, and towards 
its close, a considerable disposition to 
dropsy, under which the patient lingered 
for many months." 
As far back as 1788, it would seem that 
Dr. Pitcairn had noticed that persons sub- 
ject to Rheumatism were attacked more 
frequently than others with symptoms of 
heart disease, and he considered that the 
two diseases often depended on a common 
cause. The connection between Rheuma- 
tism and cardiac disease was also known 
to Dr. Wells, Dr. Baillie, and others. 
The heart affection, however, was re- 
garded by these authors rather as the 
effect of a metastasis of the rheumatic 
inflammation from the joints to this organ, 
than as an essential part of the disease 
itself. Some French authors claim the 
merit of the discovery of the close relation- 
ship for M. Bouillaud, who in his work, 
published in 1840, called special attention 
to the coincidence of pericarditis, endo- 
carditis, and pleurisy with acute articular 
rheumatism. Since the above period, the 
relationship has been fully determined, 
and these diseases are now looked upon 
as portions of the rheumatic affection, and 
not as mere accidental complications. 
There is considerable discrepancy of 
opinion among different authors as to the 
kind of cases of rheumatic fever in which 
cardiac inflammation is most likely to 
occur. Some are of opinion that even in 
the slightest forms of the disease, when 
febrile disturbance is moderate, the struc- 
tures of the heart may become seriously 
affected. Others think that the liability 
to the heart disease is far greater in the 
severe forms of articular rheumatism, and 
that even when the joints are not much 
implicated, still the systemic disturbance 
is always great, and the peculiar phe- 
nomena of the disease strongly marked. 
As far as my own experience goes, it 
amounts to this, namely, that although 
the severer forms of the articular disease 
are very apt to be complicated with cardiac 
inflammation, yet even in the very slight 
forms, measured by the febrile and joint 
symptoms, serious mischief may arise in 
the heart; and several such cases have 
come under my own observation. When 
the heart is much influenced, this will of 
itself be a source of great constitutional 
disturbance. It is supposed by some 
pathologists that the vegetations which 
take place on the valves of the heart are 
not always due to endocardial inflamma- 
tion, but may arise entirely independently 
of such, and are owing rather to an altered 
state of the blood itself. 
It is a matter of extreme difficulty to 
determine the relative frequency of the 
cardiac affection in rheumatic fever; in 
young subjects the heart is much more 
prone to be attacked than in adults ; the 
kind of treatment adopted in the early 
stages appears likewise, from the statistics 
of Dr. Dickinson, to have a considerable 
influence upon the result. Bouillaud 
thought the heart became affected in one- 
half of the cases, but Dr. Macleod in 
about one-fifth only. 
Morbid Anatomy of Articular 
Rheumatism.-The opportunities of ex- 
amining joints affected with rheumatic in- 
flammation are not numerous, as the ar- 
ticular affection never kills, and a fatal 
determination, even when the heart or 
other important organ is attacked, is for- 
tunately rare. In a few instances, where 
death has occurred when inflammation of 
the joints was actually presented, I have 
found considerable redness of the synovial 
membrane, and increased vascularity of 
the synovial fringes ; an augmentation of 
the synovial fluid, and sometimes little 
gelatinous coagula of fibrin; under the 
microscope nucleated cells were seen but 564 
RHEUMATISM. 
none of the ordinary appearances of pus. 
In one case of mono-articular disease, the 
fluid was indeed turbid with pus cells, but 
in this instance, some doubt existed as to 
the true nature of the affection. 
In Dr. Fuller's work a detailed account 
is given of the post-mortem appearances 
in sixteen cases of acute rheumatism in 
St. George's Hospital. In eight of these 
cases the joints were examined : in some 
of them the only morbid appearances 
were increased vascularity, a thick tena- 
cious fluid, with granular globules or a 
few pus cells ; in some the fluid was tur- 
bid, and soft fibrinous coagula were found ; 
in other cases pus is described as being 
present both in the joints and likewise 
along the tendons. 
In two cases nothing abnormal was ob- 
served : but in one the inflammation had 
subsided some weeks before death; and 
in the second, as far as the history is 
given, the local mischief was not great. 
Chomel, who examined a knee-joint two 
days after the cessation of acute rheumatic 
inflammation, found an excess of synovial 
fluid, but no other morbid change. 
In examining joints which had been 
frequently and severely affected in rheu- 
matic fever, but in which the inflamma- 
tion had completely subsided, the only 
appearance I have observed, indicating 
any deviation from the normal condition, 
has been a lax state of the ligaments of 
the articulations, and an opacity of the 
articular cartilages, or a loss of the natural 
bluish-white opalescence of this tissue. 
No mention has been made of ulceration 
of the articular cartilages, and I have had 
proof that at least a dozen attacks of rheu- 
matic inflammation may occur in a joint 
without any such change taking place. 
In no case has the slightest trace of 
urate of soda been found, although very 
carefully looked for, and on one occasion 
I had the opportunity of examining and 
comparing two knee-joints-one that of a 
young man who had died from' heart dis- 
ease at the time that the joint was suffer- 
ing from recent rheumatic inflammation ; 
the other, that of a man who had been 
killed by an accident, which had pre- 
viously caused the development of gouty 
inflammation of the part. The difference 
in the two cases was very striking: the 
vascularity in each was about the same ; 
in the latter there was the characteristic 
white thickening of the cartilages from 
the crystalline deposition, and in the 
former the complete absence of such an 
appearance. 
For the . changes which ensue when 
rheumatic inflammation attacks the peri- 
cardium, endocardium, or substance of 
the heart, as likewise when the pleura or 
membranes of the brain are affected, we 
must refer the reader to the articles on 
the various diseases of those structures. 
Causes of Rheumatism.-The causes 
of acute rheumatism may be divided into 
(1) those which belong to the individual, 
and (2) those which are external to and 
independent of the patient. 
(1) Influences dependent on the Individual. 
-Hereditary Predisposition. - Although 
the influence derived from this cause is 
not so well marked as in the case of gout, 
still it is very powerful. Chomel and 
Requin stated that, in 72 cases, 36 had 
rheumatic parents, 24 had healthy pa- 
rents, and 12 were unable to give any in- 
formation upon the point. This statement, 
however, is of little value, from the fact that 
these physicians did not distinguish cases 
of Rheumatism from those of gout. 
Dr. Fuller traced an hereditary in- 
fluence among the rheumatic patients 
admitted into St. George's Hospital, in 
nearly 29 per cent. : the writer has found 
that in about one-fourth of his patients 
hereditary predisposition could be traced ; 
many other authors have come to a simi- 
lar conclusion ; and it may be looked upon 
as an established fact, that a disposition 
to Rheumatism can be inherited. 
Age.-Young people are much more 
liable to be attacked with rheumatic fever 
than those more advanced in years, and 
in this respect Rheumatism differs essen- 
tially from gout. Heberden gives an in- 
stance in which Rheumatism occurred in 
a child only four years old. Others have 
made similar statements. Haygarth states 
that rheumatic fever affects persons of all 
ages from five to seventy-two inclusive ; 
more frequently from six to thirty, but 
most frequently from sixteen to twenty 
years of age. 
Sex.-In a table given by the writer of 
51 consecutive cases of rheumatic fever 
which came under his care, 31 wrere 
females, and 20 were males. There are, 
however, many discrepant statements 
with regard to this point. From many 
statistics it would appear that men are 
more subject to Rheumatism than women: 
thus it was found that out of 289 cases of 
acute rheumatism admitted into St. 
George's Hospital, 151 were males, and 
138 were females : and again, out of 136 
cases of the same disease recorded by Dr. 
Latham, 75 were males, and 61 females. 
In Dr. Haygarth's cases, 99 were males, 
and 71 were females. 
It has been thought that women, after 
the catamenial period, are as liable to be 
attacked with Rheumatism as men. I 
have no hesitation in saying, that if this 
remark applies to true articular rheuma- 
tism, it has little or no value ; for after 
the age of forty-eight it is very rare to 
find either men or women affected for the 
first time with this disease.- Women, 
however, are prone to have both gout and 
rheumatoid arthritis upon the cessation 
of the menstrual function. PATHOLOGY OF RHEUMATISM. 
565 
State of Health.-There can be little 
doubt that articular rheumatism is more 
apt to become developed in individuals 
who have from some cause or other be- 
come weakened, either from insufficient 
nourishment or from disease : hence one 
cause of its more frequent occurrence 
amongst the poor and ill-fed than amongst 
the rich. It is very common to meet with 
it in women who are suckling, the de- 
bility arising from over-lactation giving 
them greater liability to be attacked. 
(2) Influences external to the Individual.- 
Cold is certainly a very common exciting 
cause of articular rheumatism, and on re- 
ferring to tables which have been con- 
structed by different observers it will be 
found that this cause is far more potent 
than any other. The majority of patients 
are able to trace their malady to some 
one direct exposure to cold, and especially 
to cold combined with moisture. The 
more liable the person is from causes 
within himself, the less is the exposure 
which is necessary to develop the dis- 
ease ; a cold draught when over-heated, 
a damp bed, getting thoroughly wet 
through and becoming chilled, are the 
circumstances most prone to excite articu- 
lar rheumatism. It would appear prob- 
able that cold acts by causing a sudden 
check to the function of the skin. 
Scarlatina is often followed by an ar- 
ticular affection which has all the charac- 
teristics of acute or subacute rheumatism, 
but which must be separated from the 
fearful purulent disease of the joints occa- 
sionally met with under these circum- 
stances. If the Rheumatism which fol- 
lows scarlatina is of the same character 
as rheumatic fever, its occurrence may be 
explained by the fact, that the scarlatina 
poison acts especially upon the skin, and 
greatly influences the cutaneous function, 
which is proved by the subsequent severe 
desquamation of the cuticle. 
It has been supposed that other causes, 
as the suppression of the menstrual dis- 
charge, or of habitual fluxes of various 
kinds, can act as the exciting cause of ar- 
ticular rhematism; but if the recorded 
instances are carefully inquired into, it 
will be found that they are either casep of 
gout, or of some kind of purulent joint 
affection. 
In a certain number of cases of rheu- 
matic fever, the patients are unable to 
state any exciting cause of the attack, and 
if the predisposition to the disease is very 
great, it may often occur without any ap- 
preciable cause. 
Effects of Climate, Seasons, and Weather. 
-Dr. Aitken gives, in his work on Medi- 
cine, the returns, by Colonel Sir A. Tul- 
loch, of Rheumatism in the regiments sta- 
tioned at home and in the different colo- 
nies belonging to this country. Out of 
1000 soldiers admitted at the military hos- 
pitals, in Jamaica, 29; Nova Scotia and 
New Brunswick, 30 ; Bermuda, 33 ; Mal- 
ta, 34; Ionian Islands, 34 j ; Gibraltar, 
38; Canada, 40; Mauritius, 46 ; Wind- 
ward and Leeward Command, 49 ; United 
Kingdom, 50; and Cape of Good Hope, 
57, were sufferers from Rheumatism. The 
following passage from the above work 
contains all that is known on this sub- 
ject " It is not, therefore, in the coldest 
climate that Rheumatism is most preva- 
lent, but in those seasons and in those cli- 
mates remarkable for damp and variable 
weather; and thus, says Sir A. Tulloch, 
' we find in the mild and equable climate of 
the Mediterranean or the Mauritius the 
proportion of the rheumatic affections even 
greater than in the inclement regions of 
Nova Scotia and Canada; and though 
some of the provinces of the Cape of Good 
Hope have been without rain for several 
years, yet Rheumatism is more frequent 
in that command than in the West Indies, 
where the condition of the atmosphere is 
as remarkably the reverse.' Exposure 
to heat, however, would appear to have 
much influence in the production of Rheu- 
matism ; for we find that returns of the 
navy show a considerably larger propor- 
tionate number of attacks than those of the 
army-the number per thousand annual 
mean strength attacked in the Mediterra- 
nean fleet being 63'9, in the West Indies 
and North American station 69, and in 
the South American station 72*3." 
Chomel remarks that Rheumatism is 
seldom met with near either the equator 
or the poles, but that it becomes more fre- 
quent as we proceed from these regions, 
and that it is more especially rife in the 
temperate zones. 
In England the occurrence of rheumatic 
fever appears to be much more common in 
the eastern than in the western counties : 
this is usually accounted for by the expo- 
sure of the former portion of the country 
to the northeast winds. 
As far as seasons are concerned, it may 
be stated that no part of the year is ex- 
empt. Haygarth's tables give the follow- 
ing results in 150 cases:-The disease 
began in January in 21 ; February, 11 ; 
March, 9 ; April, 18 ; May, 11; June, 11; 
July, 14 ; August, 5 ; September, 8 ; Oc- 
tober, 13 ; November, 13 ; December, 16. 
It will be found, however, that in dif- 
ferent years the relative number for each 
month is liable to considerable varia- 
tion. 
Pathology of Rheumatism.-The 
name Rheumatism implies that the dis- 
ease has been considered to be dependent 
upon some altered condition of the blood, 
and the ancients, confusing Rheumatism 
with gout, necessarily regarded it as hav- 
ing the same humoral origin. 
One set of pathologists look upon Rheu- 566 
RHEUMATISM. 
matism simply as an inflammation of cer- 
tain fibrous and serous membranes. This 
was the view held by Cullen, who remarks 
that, although some have attributed the 
disease to the existence of a peculiar 
acrimony in the system, it was without 
reason. 
Sir C. Scudamore held the same views 
as Cullen, and makes the following re- 
mark :-" It may be stated, that the pre- 
disposition to Rheumatism consists in a 
deficiency of healthy tone in textures con- 
nected with joints and muscles, and in 
nerves, so as to be affected in this peculiar 
manner by the influence of variable tem- 
perature. If we lose sight of the humoral 
term Rheumatism, we shall come to the 
simple fact, that, in a condition of sus- 
ceptibility, cold or sudden reduction of 
temperature, makes a particular impres- 
sion on the vessels and nerves near the 
surface, and produces a painful affection 
of certain textures, which is attended with 
more or less inflammation, the phenomena 
of which are so far of a peculiar nature, 
that we either consider the disease spe- 
cific, inasmuch as the symptoms differ in 
their constituent character from those 
produced by other inflammations, or we 
may view the effect in the light of com- 
mon inflammation, modified on the one 
hand by the nature of the exciting cause 
-the external one cold-and on the other 
hand by the particular species of textures 
which become affected." 
With slight modifications, quite un- 
necessary to detail, this view resembles 
that of some authors of the present day 
who look upon Rheumatism as uncon- 
nected with any essential morbid state of 
the animal fluids. 
Similar objections to those which have 
been raised against Cullen's views of gout 
apply to the above attempted explanation 
of the pathology of Rheumatism. 
A second set of pathologists consider 
the phenomena of Rheumatism as pro- 
duced by the presence of some peculiar 
principle in the blood, either one alto- 
gether foreign to its healthy constitution, 
or an augmentation of some normal ingre- 
dient. 
Dr. Prout first threw out the idea that 
lactic acid was the principle in question, 
and this view has found many supporters. 
It has been argued that the skin is the 
great eliminator of lactic acid; that cold 
is the chief exciting cause of Rheumatism; 
and that, perhaps, bad or insufficient 
nourishment may lead to an increased 
formation of this acid, and cold to its de- 
fective excretion, and the combined influ- 
ence may cause a large accumulation in 
the blood. This explanation of the dis- 
ease has much in it which is probable, 
but at present it is devoid of anything 
like absolute proof. The only observa- 
tions which appear to give direct support 
to it are those of Dr. W. B. Richardson, 
who has shown that when lactic acid is 
injected into the peritoneal cavity of dogs, 
it causes both peri- and endo- carditis. 
The post-mortem appearances in different 
animals exhibited a red, thickened, and 
oedematous state of the mitral valve, with 
fibrinous bead-like deposits on its surface; 
the endocardium lining the left ventricle 
was intensely vascular, resembling bright- 
red velvet; and the aortic valve was of a 
deep-red color, its fine borders being 
thickened and everted ; the pericardium 
was red and injected with effused lymph 
upon the surface of the ventricle. In 
some cases the tricuspid valve exhibited 
a similar injected condition. No swelling 
of the joints was observed during the life 
of the animals, and no morbid appear- 
ances exhibited after death. 
These experiments are instructive, but 
they only prove that the absorption of a 
large quantity of a free acid by the perito- 
neum leads to inflammation of other sur- 
faces of a similar nature ; and it has yet 
to be shown whether like phenomena 
would not be induced by the absorption 
of other acid or acrid substances. If the 
injection of other acids, as acetic and 
formic acid, should produce the same re- 
sults, there would be no proof that Rheu- 
matism has any relation to lactic acid. 
The pathology of articular rheumatism 
must be allowed to be in a very unsettled 
state, and further observations and ex- 
periments are required before we can ar- 
rive at any satisfactory conclusion with 
regard to it. 
Diagnosis.-It will be necessary under 
this heading to consider the salient points 
of difference which exist between Rheu- 
matism and the diseases with which it is 
liable to be confounded. 
The affections for which acute rheuma- 
tism is likely to be mistaken are acute 
general gout, acute rheumatoid arthritis, 
pyaemia affecting the joints, and the acute 
forms of urethral rheumatism. 
From acute general gout it may be 
separated by the following peculiarities:- 
The absence of uric acid in the blood. 
The prevalence of extreme sweating, 
and the acrid odor of the perspiration. 
The great amount of constitutional dis- 
turbance compared with the joint affec- 
tion. 
The tendency to acute cardiac inflam- 
mation. 
From acute rheumatoid arthritis, by 
the great constitutional disturbance, the 
acrid sweats, the liability to cardiac in- 
flammation, and the erratic nature of the 
joint disease. 
From pysemia, by the erratic nature of 
the inflammation, by the great amount of 
perspiration, by the liability to cardiac 
inflammation, and by the absence of the TREATMENT OF ARTICULAR RHEUMATISM. 
567 
disorganization of the joints produced by 
the latter disease. 
From acute inflammation dependent on 
urethral suppuration, by ascertaining the 
history of the case, the greater constitu- 
tional disturbance, the more general cha- 
racter of the joint affection, and the ab- 
sence of severe disorganization of the 
articulations. 
The subacute form of articular rheu- 
matism may usually be distinguished 
from chronic gout and rheumatoid arth- 
ritis by attention to the above differences 
and a careful inquiry into the history of 
each case. 
Prognosis of Articular Rheuma- 
tism.-Articular rheumatism, even in its 
most acute form, though extremely pain- 
ful, can scarcely be looked upon as a very 
fatal malady, but it may lay the founda- 
tion of the most serious disease of the 
heart. Dr. Aitken states that the deaths 
from rheumatic fever hardly exceed one 
out of every thousand cases of deaths 
from all causes, but this applies only to 
those immediately resulting from the at- 
tack ; it is almost impossible to arrive at 
anything like a correct estimate of the 
proportion who die from its after-effects. 
When rheumatic fever proves fatal, it is 
either from acute disease of the heart, 
probably involving the substance of the 
walls of the organ, and leading to sudden 
collapse, or, much more rarely, death 
may result from acute cerebral disease. 
The prognosis in acute rheumatism is 
also good as far as relates to the state of 
the affected joints ; it is seldom that any 
very permanent injury is produced, unless 
the patient is otherwise out of health, and 
the rheumatic inflammation becomes the 
exciting cause of other serious and de- 
structive action. 
For an account of the after-changes 
which ensue from the cardiac affection, 
the reader is referred to the articles on 
Pericarditis, Endocarditis, &c. 
Treatment of Articular Rheu- 
matism.-Numerous methods have been 
proposed for the treatment of articular 
rheumatism, and each has had its advo- 
cates ; but, until recently, few have con- 
sidered it feasible to leave such cases to 
nature, merely taking care that the pa- 
tient be placed under favorable hygienic 
conditions. Many practitioners who would 
unhesitatingly adopt either a severe de- 
pleting or powerfully stimulating treat- 
ment, would shrink with alarm from the 
very idea of letting nature have her own 
way. 
For several years I have treated some 
of my rheumatic patients in hospital on a 
purely expectant plan, and although the 
cases have not yet been tabulated, some 
of the results have been so decided as not 
to be mistaken. I am quite certain that 
many cases even of severe rheumatic 
fever get rapidly well without the admin- 
istration of drugs, and on simply colored 
or camphor water the improvement is 
often so quick and satisfactory, that had 
not the nature of the treatment been 
known, great virtue would surely have 
been ascribed to it; on the other hand, in 
many instances, the disease runs a length- 
ened course, with many partial relapses ; 
-such tardiness is often found under 
other plans of treatment. In the Guy's 
Hospital Reports, 1805, are two communi- 
cations containing the result of the treat- 
ment of forty-one cases of rheumatic fever, 
thirty-seven under Dr. Gull, and four 
under Dr. G. O. Rees, scarcely any medi- 
cine being given except mint water. Of 
the forty-one patients, twenty-two were 
males and nineteen females. The ma- 
jority were under thirty years of age, only 
two above the age of forty years. 
Males. 
Females. 
The average number of days 
from the admision into the 
hospital to the cessation of 
pain; skin cool, and no 
relapse 
13-1 
15-5 
The average number of days 
from the admission to com- 
plete convalescence; out of 
bed, and no relapse . . 
16-6 
21-4 
The average number of days 
in hospital 
27-6 
26-8 
The cases were all well-marked instances 
of rheumatic fever. In a large number of 
them the heart was implicated, and in 
such the duration of the symptoms was 
much longer : thus, the average duration 
of the acute symptoms in seven cases, in 
which there was no evidence of the heart 
being involved, was 8'5 days, but in six 
cases in which the heart was decidedly 
affected, 23'6 days. 
The effect of the non-medicinal treat- 
ment on the supervention of heart disease 
could not be determined, as in the large 
majority of instances abnormal cardiac 
sounds were heard on admission. 
Further trials of the expectant plan are 
much wanted, and every detail with re- 
gard to the condition of each patient 
should be carefully noted down and pub- 
lished, in order that the cases may be 
fairly analyzed. 
We will now give a short summary of 
the different methods which have been 
adopted, and have gained favor with the 
profession. 
Venesection has been largely employed, 
and considered one of the most important 
curative agents in rheumatic fever. Syden- 
ham was a strong advocate for this prac- 
tice, and Cullen considered blood-letting 
to be the chief remedy in acute rheuma- 
tism, and thought blood ought to be 568 
RHEUMATISM. 
drawn in large quantities, and the bleed- 
ing repeated in proportion to the fre- 
quency, fulness, and hardness of the 
pulse, and to the violence of the pain : he, 
however, thought that some bounds should 
be set to the bleeding ; otherwise the re- 
covery might prove slow. Bouillaud, in 
France, carried this plan to the fullest 
extent, and many English physicians 
during the present century have not been 
sparing of the lancet. 
The condition of the blood in acute 
rheumatism, as shown by the buffy coat 
and cupped condition of the clot, evi- 
dently favored the idea that bleeding was 
necessary in rheumatic fever, as in other 
forms of acute inflammation. 
Venesection certainly gives speedy re- 
lief to the pains of the joints, even when 
practised to very small amounts, but free 
depletion tends to weaken the patient, 
and retard his restoration to health; it 
also causes the joint affection to linger, 
and favors relapses. Whether there is 
any real advantage in small depletions is 
questionable ; I should certainly hesitate 
to bleed in the majority of instances, as 
there is no proof that it either shortens 
the duration of the joint affection, or les- 
sens the tendency to cardiac complication. 
At' the time when blood-letting was 
commonly employed, some physicians 
were inclined to look upon it as of doubt- 
ful efficacy. Thus, Heberden states that, 
as far as he has been able to observe, the 
benefit of large and repeated bleedings is 
in most cases far from being clear and 
unquestionable. 
Fordyce also remarks that, while it was 
the practice to remove the general inflam- 
mation by bleeding, metastasis frequently 
took place to internal organs and destroyed 
the patient, but that during fifteen years, 
when he entirely left off bleeding in acute 
rheumatism, he only lost two or three 
patients, although he treated several hun- 
dreds during that period. And, lastly, 
Dr. Willan states that he had observed 
that, by frequent bleedings, the pains, 
swellings, and febrile symptoms were not 
only aggravated at the time, but often 
protracted indefinitely, and that sometimes 
under such treatment the disease had 
lasted upwards of two months. 
Mercurials, especially calomel, but a 
few years since were regarded as almost 
absolutely essential in the treatment of 
acute rheumatism, and even at present 
there are comparatively few who would 
venture to treat the cardiac complication 
without their aid : it is, therefore, impor- 
tant to decide the question of their utility. 
If we compare the results obtained from 
cases treated freely by mercurials with 
those treated without mercury, it will be 
seen that, as far as the joint affection is 
concerned, the latter are decidedly more 
favorable than the former : such being the 
case, it seems difficult to understand why, 
if the inflammation of the heart's mem- 
branes be identical with that of the struc- 
tures of the joints, mercurials should be 
of more value in the cardiac than in the 
articular disease. 
Opium has usually been combined with 
calomel, partly to check the action of this 
drug upon the bowels, and partly to alle- 
viate the painful affection of the joints. 
That opium in this disease is far more- 
valuable than the calomel with which it 
is conjoined, is beyond doubt; it gives 
relief from the pain, promotes sleep, and 
prevents exhaustion of the nervous sys- 
tem ; at the same time it encourages the 
true action of the skin, by increasing the 
capillary circulation. 
A small dose of some preparation of 
opium, or of a salt of morphia, may gen- 
erally be advantageously administered at 
night, and even once or twice a day, if 
the symptoms calling for its employment 
be urgent. Moderate doses of calomel 
may now and then be combined with 
opium, to promote the excretion of bile, 
and prevent constipation. 
It is probable that opiates act merely as 
palliatives, and have no direct influence 
on the progress of the disease. 
The use of antimonial preparations, more 
especially of tartar emetic, has been ad- 
vocated in acute rheumatism ; but expe- 
rience seems to show that they have no 
power in checking the duration of the 
joint disease or of mitigating the cardiac 
affection ; they are not much employed at 
the present time, except in very small 
doses, and then simply with the view of 
promoting the action of the skin. 
Colchicum is a medicine which is still 
much used by a large number of practi- 
tioners, from the impression that gout 
and Rheumatism are affections closely al- 
lied to each other, and consequently that 
any drug valuable in the one disease must 
necessarily be useful in the other. Of 
the powers of colchicum in subduing true 
gouty inflammation there is no possible 
doubt; but in regard to acute rheumatism 
the case is very different. As the result 
of my own experience, I may state, that 
colchicum possesses no influence in check- 
ing the progress of rheumatic fever; that 
when given in large doses, so as to lower 
the tone of the vascular system, it affords 
temporary ease, but not more than any 
other vascular depressant; and further- 
more, that colchicum is a dangerous drug 
in many cases, as it acts as a direct car- 
diac sedative, and the chief danger to be 
feared in acute rheumatism is the loss of 
power of the heart.1 
[' This statement is undoubtedly true, as 
a rule; but it requires modification in regard 
to cases of Rheumatism in patients inheriting 
a gouty constitution.-H.] TREATMENT OF ARTICULAR RHEUMATISM. 
569 
Cinchona Bark and Quinine.-Although 
bark had been previously employed in the 
treatment of acute rheumatism, by Drs. 
Morton, Hulse, and Fothergill, Dr. Hay- 
garth was the first who used it extensively, 
and brought forward clinical evidence of 
its utility ; but the treatment did not ap- 
pear to gain much favor with the profes- 
sion ; doubtless the large amount of cin- 
chona bark necessary to produce a decided 
effect upon the system was a great draw- 
back upon its administration: the substi- 
tution of quinine for the bark itself re- 
moved this objection, and the sulphate of 
the alkaloid has been tried very largely 
in France, and in very considerable doses, 
varying from one to six grammes in the 
twenty-four hours. From the statements 
of Briquet, Monneret, and Vinet, this 
remedy has a very decided influence upon 
the course of the fever, acting as a power- 
ful sedative upon the circulation, and 
allaying the pain and -swelling of the ar- 
ticulations ; it often appears to prevent 
the development of cardiac complication, 
and even when this is present, it exercises 
no injurious influence. The effect of the 
quinine upon the disease is most decided 
when given in full doses, even to the ex- 
tent of producing uncomfortable symp- 
toms in the head and stomach. 
Alkaline and Saline Treatment. - The 
treatment of acute rheumatism by saline 
and alkaline remedies has long found 
favor with the profession, and many modi- 
fications have been adopted; but before 
speaking of their relative merits, it will 
be well to define clearly what is meant by 
the saline and alkaline treatment. 
There are certain saline remedies which, 
after absorption into the system, are elim- 
inated by the kidneys in the same state as 
when they enter the stomach ; for exam- 
ple : (1) nitrate of potash, chlorate of 
potash, and other salts in which the base 
is conjoined with a mineral acid ; (2) alka- 
line salts with carbonic acid, in the form 
of the neutral or bicarbonate of the base ; 
(3) salts with alkaline bases united with a 
vegetable acid, as citric or tartaric acid. 
Although these salts are neutral in reac- 
tion, when introduced into the stomach, 
they become speedily altered in the blood, 
the acid is decomposed, and a carbonate 
of the base appears in the urine; and 
hence, although they produce no alkaline 
effect upon the mucous membrane of the 
alimentary canal, yet upon the blood and 
the secretions their alkaline effect is well 
marked. Whether this effect on the 
blood is exactly the same as that of the 
free alkalies, or their carbonates, has not 
yet been determined. 
Saline remedies have sometimes been 
employed in small doses, simply for the 
purpose of acting upon the secreting or- 
gans ; at other times they have been given 
in very large doses, in order to alter the 
character of the blood itself, or powerfully 
influence the vascular system. 
The first saline to be discussed is nitrate 
of potash. This remedy was used about 
a hundred years ago by Dr. Brocklesby, 
in conjunction with bleeding. He ordered 
a dilute solution of the salt in water-gruel 
(about 120 grains to the quart), and as 
much as an ounce or more of nitre in the' 
twenty-four hours. With this he states, 
that he cured many cases in seven or eight, 
days. ' 
Since the above date it has been em- 
ployed by M. Geudinn, M. Martin-Solon,1 
and in this country by Dr. Basham.2 
From M. Martin-Solon's communication 
we cannot deduce the real value of the 
treatment, as the details are not suffi- 
ciently recorded, and it has been shown 
that under any treatment many cases get 
well in a comparatively few days. 
Dr. Basham states that one, two, or 
even three ounces of the nitrate, freely 
diluted, may be taken in the twenty-four 
hours without inconvenience. He looked 
upon and employed the nitre as an ad- 
junct to other remedies, and hence it is 
difficult to determine from his table of 
seventy-nine cases of acute rheumatism 
the real influence of the salt in combating 
the disease. Dr. Basham considers the 
local application of nitre of great value in 
causing abatement of the pain and swell- 
ing of the joints. 
The nitre treatment, upon the whole, 
seems to have been followed by good re- 
sults, and in Dr. Dickinson's record of 
seven cases treated in St. George's Hos- 
pital a favorable result was obtained. 
Alkaline Treatment.-Although an ap- 
parently over-acid state of the body, and 
an increased amount of fibrin in the blood, 
in acute rheumatism, would naturally 
suggest the value of alkalies as remedies 
for this condition, it does not appear that 
they were systematically employed until 
the year 1847, when Dr. Wright published 
a communication on the subject. Since 
that period both Dr. Fuller and the writer 
have made a full trial of them, one ad- 
ministering the alkali combined with some 
vegetable acid, the other prescribing it in 
the form of the bicarbonate. Dr. Fuller's 
results will be found in his work on Rheu- 
matism ; the writer's earlier trials in a 
communication to the Medical and Chi- 
rurgical Society in 1855, in which an ac- 
count is given of fifty-one consecutive 
cases, treated upon the full alkaline plan. 
The average duration of the disease in 
twenty males was 11'3 days, the duration 
under treatment 6'2 days ; the average 
1 De 1'Emploie du Nitrate de Potasse a 
haute Dose dans le Traitement du Rheuma- 
tisine articulaire. (Bulletin gen de Therap. 
aout, septembre et octobre, 1843.) 
2 Med.-Chirur. Trans, vol. xxxii. 570 
RHEUMATISM 
duration of the disease in thirty-one fe- 
males was 15'7 days, the duration under 
treatment 7'3 days. In no case did any 
heart disease occur after the patient had 
taken the remedy forty-eight hours. 
The plan consists in administering a 
dilute solution of bicarbonate of potash in 
about thirty-grain doses, every four hours, 
until the joint symptoms and febrile dis- 
turbance have completely disappeared. 
These doses produce no inconvenience 
either to the stomach or bowels ; the uri- 
nary secretion is not notably increased, 
but" its character is completely altered, 
and the reaction becomes either neutral 
or alkaline ; it usually remains clear, but 
occasionally gives rise to a deposition of 
the triple phosphates. Upon the heart 
the alkaline bicarbonate acts as a sedative, 
reducing the frequency of the pulse some- 
times forty-eight beats in the minute, but 
not causing any faintness. 
When a patient is fully under the alka- 
line treatment, the blood is distinctly 
altered, and the coagulation of the fibrin 
takes place more slowly. 
Many other remedies have been pro- 
posed for the cure of acute rheumatism, 
some of which it will be only necessary to 
enumerate : lemon juice has been pre- 
scribed by Dr. Perkins and Dr. Ciraud on 
the Continent, and in this country by Dr. 
G. O. Rees. It is usually given in quan- 
tities of from three to eight fluid ounces 
each day, and it is supposed to act as a 
sedative to the vascular system. It is 
doubtless a fact that, under its use, many 
cases of the disease rapidly get well, but, 
as has been shown above, this must not 
be taken as a proof of its curative power, 
and before wre can decide upon its value, 
it will be necessary to have the tabulated 
results of a large number of trials of lemon 
juice, and to compare them with those 
obtained from other methods of treat- 
ment. 
Other remedies used, either for the cure 
of the disease or the alleviation of certain 
of its symptoms, are, iodide of potassium, 
guaiacum, aconite, emetics, purgatives, 
diaphoretics, and hot-air baths. 
Iodide of potassium is used to relieve 
the obstinate pains which linger when the 
acute symptoms have passed off, and more 
especially pains which are increased by 
heat, and most troublesome at night. 
Guaiacum is valuable in subacute cases, 
when the circulation is weak, and the 
pains relieved by the application of 
warmth. 
Aconite has been proposed to alleviate 
the acute pain of the joints, but when 
given in efficient doses it is apt to cause 
depression of the heart's action, and may 
be dangerous. 
Hot-air baths exert a soothing influ- 
ence, but great care is required if used 
during the time of febrile disturbance; 
and their curative value is somewhat 
questionable. 
No proof has yet been given of the 
value of a free administration of emetics 
or purgatives ; but proper attention must 
be paid to the state of the bowels. 
[Since its introduction to the notice of 
the profession by Stricker, of Berlin, in 
1870,' the treatment of acute Rheumatism 
with salicylic acid has received much com- 
mendation from practitioners on both 
sides of the Atlantic. Amongst those 
early observing its efficacy have been 
Traube, Broadbent, Maclagan, See, Ile- 
rard, Beaumetz, Jaccoud, and Lepine. 
The doses reported by Stricker and See 
■were large. The former gave twenty or 
thirty grains every hour for six doses ; the 
latter, a drachm and a half daily, in five 
doses; or, an equivalent amount, tw'o 
drachms and a half of salicylate of sodium. 
Other practitioners, however, have found 
that smaller quantities will answer the 
desired purpose; while very large doses 
are not free from danger. Empis and 
Jaccoud have reported cases of sudden 
death, not improbably explained by exces- 
sive doses of the drug. Probably ten 
grains every hour for five or six hours 
will usually suffice to make the powerful 
impression required. After that, the same 
or a less amount may be given thrice 
daily, until convalescence is assured. 
Under its influence two or three days will 
often be the whole period of severity of 
the symptoms. Cardiac complications 
are, there is reason to believe, less fre- 
quent under this than under any other 
treatment. 
Salicylic acid may be given in glycerin, 
or dissolved in alcohol with the aid of 
citrate of ammonium.2 
Salicylate of sodium is generally accepted 
as, on the wfliole, the most available form 
of combination of the acid. From a 
drachm to two drachms or more of the 
salt may be given during the first day of 
treatment; with diminished doses after- 
wards. No other mode of treatment of 
acute Rheumatism has, as yet, received so 
much testimony in its favor.-H.] 
Treatment of Heart, Lung, ana Brain 
Complications in Acute Rheumatism. - 
Having given an account of several of the 
more important methods of treating rheu- 
matic fever, it is desirable that we should 
inquire if any deviations are necessary 
when inflammation attacks the structures 
of the heart, lungs, or other internal or- 
gans. It has been already stated, that 
[' Berliner Klin. Wochenschrift, Nos. 1 
and 2, 1876.] 
[2 An ounce of alcohol, with a drachm of ci- 
trate of ammonium, will dissolve two drachms 
of salicylic acid. Cassan, of Paris, first pro- 
posed this solvent. Bull. General de Thira- 
peutique, April 30, 1876.-H.] TREATMENT OF ARTICULAR RHEUMATISM. 
571 
the articular inflammation leads to but 
little mischief, and that the joints rapidly 
recover their healthy state. It is, how- 
ever, very different in the case of the 
heart; for there is a great disposition, 
both in the endocardial and pericardial 
serous membranes, to throw out lymph, 
which may lead to the thickening of the 
valves and adhesion of the surfaces of the 
pericardium; it is therefore a matter of 
no little moment to ascertain whether any 
plan can be adopted either to prevent 
such mischief supervening, or of rapidly 
and efficiently checking it if it has already 
taken place. 
There appears to be every probability 
that the inflammation of the serous mem- 
branes of the heart is of the same kind as 
that of the joints, but it must be remem- 
bered that the structures themselves are 
of a somewhat different character, and 
remedies which produce little or no effect 
upon the joints may cause a decided action 
upon the cardiac tissues. It must also 
not be forgotten that inflammation lingers 
much longer in the heart, and is modified 
by the incessant movement of the organ. 
It is a very common practice in cases of 
pericarditis, or even of endocarditis, to 
apply leeches over the cardiac region; 
and it is a clinical fact, that the tightness 
of the chest and pain are decidedly relieved 
by their application. Although it is diffi- 
cult to explain the value of the local ab- 
straction of blood in these cases, still I 
believe it is undoubted, and I cannot there- 
fore hesitate to recommend it. The loss 
of blood need not be large, from three to 
twelve leeches are generally sufficient, and 
the bleeding should never be allowed to 
produce any appreciable weakening of the 
patient. Cupping may be employed in 
lieu of leeches, but I am inclined to prefer 
the slow loss of blood by the use of leeches, 
to its more expeditious abstraction by the 
cupping-glass. 
Blisters applied to the heart's region 
are also of much value, either before or 
after the application of leeches: care 
should be taken by previously applying 
collodion to the leech bites, and covering 
the surface of the plaster with tissue 
paper, to avoid the absorption of cantha- 
ridine, and the production of renal irrita- 
tion. Now and then, if there be much 
effusion into the pericardium, the blister 
may be kept open, either with savine oint- 
ment, epispastic papers, or by some other 
means. When leeches have not been pre- 
viously employed, the above precautions 
are less necessary. The simple applica- 
tion of a blister over the cardiac region is 
productive of much relief to the patient, 
and is followed by a decided improvement 
in both the heart's movements and sounds. 
A very important question in the treat- 
ment of the cardiac complications relates 
to the value of mercurials. It has been 
shown that the mercurial treatment of 
the joint affection does not prevent the 
occurrence of inflammation of the heart, 
and it only remains to be ascertained 
whether this metal has any power of ar- 
resting inflammation after it has once 
ensued. A priori it appears scarcely prob- 
able that a remedy, which has no in- 
fluence in preventing inflammation, should 
have the power of arresting it when it has 
already commenced ; but as the mercurial 
treatment is strongly advocated in such 
cases even by some who do not consider it 
as a preventive, it will be necessary to in- 
quire a little further into the matter. 
A few years since, almost every prac- 
titioner would have given this drug, and 
many at the present day scarcely dare 
omit its administration ; for it is supposed 
to limit and control the inflammatory 
action, and to cause the absorption of the 
products which have been thrown out. 
During the time of great febrile excite- 
ment it is very difficult to get the system 
under the influence of mercury, and it 
may be that, when this is effected, it is 
rather due to the prior abatement of the 
inflammation than from the influence of 
the metal. 
For many years I was in the constant 
habit of administering calomel in cases in 
which inflammation of the heart was pres- 
ent, but for the last eight or ten years I 
have not done so as frequently, and have 
seen no reason to regret the change of 
practice: the cardiac inflammation ap- 
pears to have yielded quite as readily, and 
the patient, on the subsidence of the fever, 
has not had to suffer from ptyalism in 
addition to debility. 
As the question cannot be considered 
in any way fully settled, it must be left to 
each practitioner to follow his own course, 
and form his own judgment on the value 
of the mercurial plan of treatment. When 
it is adopted, the common method is to 
give calomel in doses of from one-half 
grain to three or four grains, every four 
or six hours, usually combined with a 
small amount of opium, to prevent the 
purgative action of the mercurial. If 
much difficulty is experienced in pro- 
ducing the effect upon the gums, then in- 
unction is often had recourse to, and this 
may be practised by causing a drachm 
or so of the blue ointment (unguentum 
hydrargyri) to be rubbed thoroughly into 
the skin of the inner side of the thigh, or 
into the axilla ; sometimes a blistered sur- 
face over the heart's region is dressed 
with the mercurial, instead of the green 
ointment. I have frequently adopted this 
latter method, and should prefer it, if 
mercurials are employed at all: it may be 
that the peculiar effect of the metal is 
produced upon the tissues in the neigh- 
borhood of the blister, before the general 
system becomes aftected by it. 572 
RHEUMATISM. 
During the whole course of treatment 
of the cardiac inflammation, the plan 
thought to be most advantageous for the 
joint affection should be steadily perse- 
vered with, as anything which favors the 
abatement of the systematic disease must 
also relieve the internal complications. 
It is always a matter of the highest mo- 
ment to insist upon the most complete 
quiet; constant movement of the organ 
must necessarily take place, but every- 
thing should be shunned which increases 
this movement, or adds to the work which 
the heart has to perform. All chance of 
mental agitation, as well as bodily exer- 
tion, should therefore be strictly avoided. 
After the inflammation has subsided, 
the heart is generally left in an irritable 
state; to allay this, a belladonna plaster 
is useful, and the administration of small 
doses of digitalis, combined with some 
salt of iron. More or less anaemia is 
always produced during the febrile dis- 
turbance, and this tends to keep up the 
excitement of the heart; and hence the 
value of the ferruginous preparations. 
If the pleurae become inflamed during 
the progress of acute rheumatism, the 
affection may be treated upon the same 
principles as the pericarditis ; leeches and 
blisters may be prescribed, and calomel 
and opium given, if considered of value 
by the practitioner; and the same re- 
marks apply to the management of the 
brain and spinal complications which now 
and then arise. 
Local Treatment in Acute Rheumatism.- 
In the majority of cases little or no local 
treatment is needed ; the affected joints 
should be protected by some light cover- 
ing, as cotton-wool, flannel, or even a 
light handkerchief-but nothing further 
is called for: but now and then the pain 
is so excessive, or the patient is so sensi- 
tive to it, as to render it desirable that 
some direct application should be made 
use of. Hot-water fomentations may be 
first tried, but if not found sufficient, bel- 
ladonna may be added ; a very convenient 
preparation for the purpose is the liniment 
of the British Pharmacopoeia, which may 
be either sprinkled upon the hot flannel, 
or diluted with two or three times its bulk 
of hot water, and applied by means of a 
piece of lint, taking care to prevent evap- 
oration by oil-silk or some other imper- 
meable tissue. A solution of atropia, or 
atropia combined with morphia, forms a 
very clean and elegant substitute. The 
extracts of belladonna, henbane, conium, 
and aconite have been recommended, as 
also the tincture of opium and decoction 
of poppy-heads. 
Alkalies and salines have also been ex- 
tolled as topical remedies in acute rheu- 
matism ; Dr. Basham has employed a 
solution of nitrate of potash, and Dr. Ful- 
ler one of the carbonate of potash or soda. 
Leeches have sometimes been used to the 
inflamed joints: I have never seen occa- 
sion for their employment in genuine 
rheumatic fever. 
Blisters applied so as to cover all the 
inflamed joints have been highly spoken 
of by Dr. Dechilly and others; Dr. Mar- 
tin-Solon made a report on the subject to 
the Academy of Medicine in 1850, and in 
the discussion which ensued it was stated, 
that the treatment had no other effect 
than to quicken the subsidence of the in- 
flammation in the joints. Dr. Herbert 
Davies has recently revived the use of 
free blistering, and orders armlets, wrist- 
lets, and even fingerlets of blister plaster, 
at the time when the inflammation is 
most acute ; he recommends linseed-meal 
poultices to be subsequently applied, in 
order to promote the free flow of serum ; 
he places these blisters entirely around 
the affected limbs, and in the case of the 
knees, orders them of at least three inches 
in width, regarding any slight strangury 
which may arise as of little importance 
compared with the benefit afforded by the 
free vesication. 
According to Dr. Davies, the blister 
treatment causes a speedy diminution in 
the frequency of the pulse, rapid subsid- 
ence of the joint affection, and lessens the 
liability to cardiac inflammation ; within 
twenty-four hours after the removal of the 
blisters, the urine is stated to become alka- 
line in reaction. Dr. Davies's results in 
a large number of cases appear to be 
favorable. 
Quino-alkaline Treatment.-During the 
last ten years, since the publication of his 
paper on the treatment of Rheumatism 
with large doses of bicarbonate of potash, 
the writer has made a very extensive use 
of the following plan, from which he thinks 
he has obtained more valuable results 
than from any other; it may be termed 
the quino-alkaline treatment, and is thus 
practised : Sulphate of quinine is ordered 
to be rubbed up with a solution of bicar- 
bonate of potash, to which a little muci- 
lage and some aromatic, as tincture of 
cardamoms or spirit of chloroform, is sub- 
sequently added; each ounce-and-half 
dose contains five grains of the quinine 
and thirty grains of the potash salt, the 
quinine being reduced to the state of car- 
bonate. To the adult the above dose is 
given each four hours, and persevered 
with until the joint affection and febrile 
disturbance have completely abated. 
When the quino-alkaline treatment was 
first made use of, a few days were allowed 
for the exhibition of the alkali alone, and 
then the quinine was added, but of late 
the quinine has been given from the first; 
it neither increases the thirst nor the 
furred state of the tongue, and its influ- 
ence upon the heart is to lower its pulsa- 
tions, but not to weaken them,-and MUSCULAR RHEUMATISM. 
573 
hence, when peri- and endo- carditis are 
present, its employment is not contra- 
indicated. If cardiac complications exist, 
local depletion and counter-irritation may 
be made use of. 
In the subacute forms of articular rheu- 
matism, the same plan may be employed, 
but in a milder form ; that is, the doses 
may be smaller, or fewer in number. 
If desired, the citrate of potash, or some 
other alkaline salt with a vegetable acid, 
may be substituted for the bicarbonate : 
when irritation of the intestinal canal is 
present, the bicarbonate appears to act as 
a valuable sedative, but when there is a 
tendency to constipation, the citrate or 
tartrate may be advantageously given, 
care being taken that absorption of the 
salt be not too much prevented by its 
action on the bowels. 
The potassio-tartrate of iron may be 
added to the quino-alkaline draught after 
a time, and often with much advantage if 
any amount of anaemia is present. 
Although the results obtained from a 
large number of trials have not yet been 
tabulated, the writer feels assured that 
the above treatment is much more effica- 
cious than the simple alkaline plan, that 
there is far less tendency to the occurrence 
of relapses, and that the patient is left in 
a more satisfactory condition after the 
cessation of the febrile disturbance. 
Diet and Regimen in Rheumatism.-In 
acute rheumatism, when the febrile dis- 
turbance runs high, food can only be 
advantageously given in the liquid form : 
it is, however, important to sustain the 
strength of the body as much as possible, 
and tor this purpose milk, if it can be 
assimilated, is one of the best forms of 
nourishment, as it contains all the ele- 
ments necessary for repairing the waste of 
the system. If milk in an undiluted state 
is too heavy, it may be mixed with an 
equal measure of soda water. Besides 
milk, beef-tea, mutton and other meat 
broths, and jellies, may be given. It is 
desirable also to introduce a certain 
amount of amylaceous and saccharine 
matters into the system ; hence arrow- 
root, made with water, milk, or beef-tea, 
may be administered. Soda water, 
lemonade made with cream of tartar or 
citrate of potash, and flavored with lemon, 
toast and water, or plain water, may be 
employed to allay thirst. Alcoholic 
stimulants are seldom needed in the 
young subject, unless there is great de- 
pression from the presence of serious car- 
diac mischief: wine, in true Rheumatism, 
has no tendency to keep up the specific 
inflammatory action. 
As the fever abates, and the power of 
the digestive organs returns, the diet may- 
be impaired ; at first bread, light pud- 
dings, then white fish, fowl, and after- 
wards ordinary meat: but care mus1; be 
taken that the stomach be not distended 
nor the system disturbed by the presence 
of food incapable of being digested. 
Throughout the whole course of the treat- 
ment of Rheumatism, both in its acute 
and subacute varieties, the great object 
should be to sustain as much as possible 
the strength of the patient, for by this 
means the duration of the disease is 
diminished, and the subsequent recovery 
rendered less tedious. 
During the height of the malady, when 
the skin is freely perspiring, care should 
be taken not to allow the surface to be 
suddenly cooled; for although the free 
action of the skin does not appear to give 
relief to the pains, yet a sudden check to 
it cannot fail to be injurious, and may 
lead to metastatic action. 
Individuals who have once suffered from 
rheumatic fever should be extremely care- 
ful as to their clothing ; they should al- 
ways be completely clad in flannel, which 
may vary in thickness at different times 
of the year; the feet should be kept warm, 
and every precaution taken to avoid a 
chill. 
B. Muscular Rheumatism. 
Definition.-An affection of the vol- 
untary muscles, of an inflammatory nature 
(?), but unaccompanied with swelling, 
heat, redness, or febrile disturbance. 
Synonyms.-Designated according to 
the situation of the affected muscles, 
Lumbago, Torticollis, Pleurodynia, &c. ; 
termed also Myositis, Myo-rheumatism, 
and Myodynia. [Myalgia, Inman.1-II.] 
History.-By British writers this dis- 
ease is often included, with other affec- 
tions, under chronic rheumatism, a name 
manifestly incorrect, as the malady often 
assumes an acute character. On the Con- 
tinent some authors have claimed for it a 
separate existence, and the disease can 
scarcely be looked upon as a chronic form 
of articular rheumatism, seeing that its 
pathology is different. 
Description of Muscular Rheuma- 
tism.-Muscular rheumatism usually com- 
mences as an acute disease, but has a 
considerable tendency to assume a chronic 
form : it may affect any of the voluntary 
muscles, but is prone to attack certain 
sets rather than others. The seizures are 
frequently sudden; sometimes, for exam- 
ple, a patient awakes in the morning and 
finds himself incapable of turning in bed 
[* Dr. Inman applied the term myalgia, 
however, to pain of any origin, located in the 
muscles, including, therefore, that resulting 
from over-fatigue, &c.-H.] 574 
RHEUMATISM 
or of twisting the neck, and the attempt 
to do so gives exquisite pain. If the affec- 
tion is very acute, he may suffer pain even 
when quiet, for the muscles are often in- 
voluntarily thrown into a state of spasm ; 
in the less severe forms the patient may 
be comparatively comfortable when at 
rest, but on the least movement he ex- 
periences agony by the paroxysm thereby 
excited. On examining the seat of suffer- 
ing, no external phenomena are visible, 
but there may be slight tenderness on 
pressure ; there is also a freedom from 
febrile excitement, at least at the onset of 
an attack, but as it progresses, thirst, loss 
of appetite, and heat of skin may ensue, 
probably due simply to the continuance of 
the pain, and the loss of sleep thereby oc- 
casioned. In muscular rheumatism the 
pulse is but little affected, and the urinary 
secretion preserves its normal state. A 
very important feature in this disease is 
the absence of inflammation of the heart, 
so characteristic of the articular affection. 
In the acute stages the symptoms increase 
towards evening, and are augmented by 
heat; but when the disease becomes 
chronic, the pain is not unfrequently re- 
lieved by its application. 
The duration of acute muscular rheu- 
matism is generally short, usually not 
more than a few days, seldom exceeding 
a week: but when its intensity has be- 
come mitigated, it often proves tedious, 
and may be prolonged for an indefinite 
period of time; it is also apt to be again 
lighted up, if the patient be exposed to 
any of its exciting causes. 
The principal varieties of muscular 
rheumatism are as follows :- 
Lumbago (lumbodynia), when the large 
masses of muscles on each side of the spine 
in the lumbar region are implicated. 
When acute it renders the patient utterly 
helpless; the most intense agony is in- 
duced on the slightest attempt to rise in 
bed, or even to turn in any direction. 
Torticollis (cervicodynia, or crick in the 
neck) is a term applied when the muscles 
on one side of the neck are affected. The 
patient is compelled to hold his head awry, 
in order to relax the muscles. Sometimes 
the sterno-mastoid is principally impli- 
cated, sometimes the disease extends to the 
muscles at the back of the neck. 
When some of the intercostal muscles 
are the seat of the malady, the affection is 
called Intercostal Rheumatism (pleurody- 
nia) : the symptoms are pain in some part 
of the chest, rendered intense by the act 
of breathing, but relieved by such pres- 
sure as prevents the movement of the 
ribs. 
The above three names are in common 
use, but many others have been occasion- 
ally employed by authors desirous of 
designating diseases simply from their 
locality ; and thus have arisen the terms 
Scapulodynia, Dorsodynia/Cephalodynia, 
according as the muscles about the shouh 
ders, or of the dorsal region of the spine, 
or those of the head, are particularly im- 
plicated. 
As any of the voluntary muscles are 
capable of taking on morbid action, these 
names might be multiplied indefinitely; 
the walls of the abdomen, the muscles of 
the limbs, the tongue, pharynx, dia- 
phragm, are stated to be sometimes impli- 
cated ; and even some of the involuntary 
muscles, as of the (esophagus, stomach, 
intestines, and uterus, appear to be sus- 
ceptible of the disease. 
Causes of Muscular Rheumatism. 
-These may be divided into 1st, those 
dependent on the peculiarities of the indi- 
vidual, and, 2d, those which are altogether 
external. 
Causes dependent on the Individual.- 
True muscular rheumatism is seldom seen 
in very young subjects; it generally oc- 
curs after the age of puberty, and more 
commonly in full adult age. 
One attack of the disease engenders a 
liability to its return, as is the case with 
articular rheumatism. 
Individuals of a gouty habit are fre- 
quently attacked with a muscular affec- 
tion, which cannot well be distinguished 
from ordinary muscular rheumatism. 
Causes external and independent of the 
Individual.-The only external causes of 
muscular rheumatism appear to be cold 
and damp, more especially if combined 
with an over-use of the muscles : lumbago, 
for example, is often produced by strain- 
ing the lumbar region ; and cold draughts 
of air, as from a partially open window 
will frequently prove the exciting cause 
of an attack of torticollis. 
Pathology of Muscular Rheuma- 
tism.-The nature of muscular rheu- 
matism is usually regarded as closely 
allied to articular rheumatism, the differ- 
ence in the symptoms being supposed to 
depend on the peculiarities of the struc- 
tures which are affected in the two dis- 
eases. Some reasonable doubt may, how- 
ever, be entertained of the correctness of 
this opinion, for the following reasons : If 
the proximate cause of the muscular 
affection is the same as that of the articu- 
lar, the heart would probably become in- 
flamed in a certain proportion of the 
cases ; but it is not so : and again, there 
is an absence of the peculiar secretion 
from the skin, so marked in articular 
rheumatism. The state of the blood has 
not yet been ascertained, but there is rea- 
son for believing that the fibrin is not 
much augmented. 
For the present w'e must be content to 
await the result of more numerous ami 
searching inquiries, before attempting to 575 
MUSCULAR RHEUMATISM. 
explain the true nature of muscular rheu- 
matism. 
Diagnosis of Muscular Rheuma- 
tism.- - Acute intercostal rheumatism 
may be mistaken either for pleurisy, or 
for a neuralgic affection so frequent in 
hysterical subjects : from the former it 
may be separated by the absence of the 
friction sound and other signs of inflam- 
mation of the pleura ; from the latter, by 
the absence of well-marked spinal tender- 
ness. It is sometimes difficult to dis- 
tinguish the chronic form of muscular 
rheumatism from the dull pains arising 
from other causes, as from progressive 
muscular atrophy, the presence of metallic 
poisons in the system-especially lead 
and mercury-and likewise the poison of 
syphilis ; also from ordinary inflammation 
of the muscular tissue. Lumbago may 
be mistaken for a painful affection of the 
loins, arising from calculi or gravel in the 
kidneys. 
A careful examination of the history is 
usually sufficient, in each instance, to en- 
able us to arrive at a correct diagnosis. 
Prognosis of Muscular Rheu- 
matism. - Muscular rheumatism, al- 
though difficult to cure, is not attended 
with serious results ; there is not the fear 
of cardiac inflammation, the great source 
of danger in articular rheumatism. The 
sciatica arising from lumbago is often 
both painful and obstinate. 
Treatment of Muscular Rheu- 
matism.-In the acute stages of muscular 
rheumatism, especially in lumbago, local 
depletion, generally by cupping, is re- 
sorted to. That this remedy gives tem- 
porary relief, there cannot be a doubt, 
but whether it be necessary or not is an- 
other question. My own opinion is, that 
it is seldom or never called for, and that 
the same relief may be obtained from 
other topical applications which are less 
open to objection. Hot fomentations are 
very valuable ; as, for example, spongio- 
piline, wrung out of hot water, and ap- 
plied either alone or sprinkled with 
tincture of opium, or the liniment of bel- 
ladonna, or a combination of the two. 
When the affection becomes more chronic, 
then a thinner piline lightly sprinkled 
■with belladonna liniment, with or without 
the addition of the volatile oil of mustard, 
proves very useful, acting as a counter- 
irritant, and at the same time relieving 
pain by the anodyne properties of the bel- 
ladonna. 
Turpentine fomentations, or stupes, 
may be substituted in some instances for 
the above applications. 
Occasionally blisters are applied, and if 
the affection prove obstinate, they may 
be kept open, with the addition of mor- 
phia or some other anodyne. 
The internal remedies which have been 
employed in cases of muscular rheuma- 
tism are numerous. When the affection 
is acute and recent, benefit often arises 
from the use of salines, which act on the 
skin and kidneys, and alter the state of 
the blood. From my own experience I 
should recommend the acetate of ammonia 
in large doses, combined with some alka- 
line salt, as the bicarbonate of potash, 
and with the addition of iodide of potas- 
sium. The time, however, soon arrives 
for the use of some medicinal agent, as 
quinine, which exerts a marked action 
upon the nervous system ; and this may 
be advantageously combined with the 
other remedies. Sometimes large doses 
of the hydrochlorate of ammonia are use- 
ful ; and in cases which occur in gouty 
habits, colchicum alone, or in combination 
with other medicines, may be prescribed 
with much benefit. 
When the disease becomes chronic, 
medicines which increase the capillary 
circulation are generally useful: guaiacum 
stands at the head of the list, and may be 
given either in substance or as the am- 
moniated tincture ; after guaiacum fol- 
lows sassafras, mezereon, turpentines, 
resins, and balsams. 
Sulphur in small doses is frequently of 
much advantage, and it can be adminis- 
tered in substance or in the form of the 
sulphur waters of Aix-la-Chapelle, of Aix 
in Savoy, or Bareges. 
Arsenic is likewise occasionally adopted 
as a remedy in long-standing, obstinate 
cases. 
When the pain has subsided, friction 
and electricity are often resorted to, in 
order to diminish the stiffness and to re- 
store tone and activity to the muscles. 
The diet should be generous, with a 
moderate amount of stimulants ; the pa- 
tient should be warmly clad in flannel, 
and every precaution taken to avoid 
chills. 576 
gonorrikeal rheumatism. 
GONORRHCEAL RHEUMATISM. 
By Bernard Edward Brodhurst, F.R.C.S. 
The affection which is known as Gonor- 
rhoeal Rheumatism consists of inflamma- 
tion of and about the joints, following upon 
urethral irritation, and preceded for the 
most part by a muco-purulent urethral 
discharge. 
Swediaur and Monteggria are said to 
have described this affection, and to have 
published cases illustrative of the disease; 
but there is not anything to be found in 
their writings which entitles them to the 
merit which has been claimed for them ; 
and indeed there ought to be no hesitation 
in saying that the disease does not seem 
to have been recognized until Sir Astley 
Cooper mentioned it in his lectures. Mr. 
South says : " Gonorrhoeal Rheumatism 
and gonorrhoeal ophthalmia were, I be- 
lieve, first mentioned publicly by Astley 
Cooper, and the first of these affections he 
considers is not an infrequent disease ; 
but it appears to have been previously 
observed by the elder Cline, for, in reply 
to the question put to him by Cooper, 
whether he had ever seen rheumatism 
produced from gonorrhoea, he said, ' Sev- 
eral times.' "1 
Sir Benjamin Brodie has given some 
pathological account of this disease, and 
having described its nature, he continues 
thus :-"The disease is usually described 
under the name of Gonorrhoeal Rheuma- 
tism, though it is plain, from the course 
of its symptoms and from the effects of 
remedies, that it differs from ordinary 
rheumatism in many essential circum- 
stances, and though there seems to be no 
doubt that, while it occurs in most in- 
stances as a consequence of gonorrhoea, it 
may take place quite independently of 
gonorrhoeal infection."2 
Sir Astley Cooper relates the following 
case:-"An American gentleman came 
to me with a gonorrhoea, and after he had 
told me his story, I smiled, and said, 'Do 
so and so,' particularizing the treatment, 
and that he would soon be better ; but he 
stopped me, and said, ' Not so fast, sir; 
a gonorrhoea with me is not to be made so 
light of; it is no trifle ; for in a short time 
you will find me with inflammation in the 
eyes, and in a few days after I shall have 
rheumatism in the joints. I do not say 
this from the experience of one gonorrhoea 
only, but from that of two, and on each 
occasion I was afflicted in this manner. ' 
I begged him to be careful to prevent any 
gonorrhoeal matter coming in contact with 
the eye, which he said he would. Three 
days after this I called on him, and he 
said, ' Now you observe what I told you 
a day or two ago is true. ' He had a green 
shade on, and there was ophthalmia of 
each eye. In three days more he sent for 
me rather earlier than usual for a pain in 
his left knee ;.it was stiff and inflamed. I 
ordered some applications, and soon after 
the right knee became affected in a simi- 
lar manner. The ophthalmia was with 
great difficulty cured, and the rheumatism 
continued many weeks afterwards." 
That which is here so graphically re- 
lated may be observed in almost every 
instance of Gonorrhoeal Rheumatism; 
and, with the exception of the ophthal- 
mia, it is exactly the manner in which 
every first attack of Gonorrhoeal Rheuma- 
tism arises and proceeds. Gonorrhoeal 
ophthalmia is much less frequently ob- 
served than gonorrhoeal articular rheuma- 
tism : probably it does not occur more 
than once in a dozen instances of Gonor- 
rhoeal Rheumatism. 
Gonorrhoea then being established, one 
or more joints become, in the course of 
ten days to three weeks, stiff, painful, and 
swollen, the patient having, perhaps, ex- 
posed himself to the weather, sitting or 
walking in wet clothes, or to a draught of 
cold air. At the same time the feet may 
be painful and the conjunctive inflamed ; 
there will be considerable fever, with dry 
skin and a furred tongue. Probably, as 
the articular inflammation increases, the 
urethral discharge will diminish ; again it 
will become more abundant, and at length 
cease or degenerate into a gleet. 
The first attack of Gonorrhoeal Rheu- 
matism is invariably preceded by a spe- 
cific gonorrhoeal discharge ; a subsequent 
attack may be preceded by urethral dis- 
charge which is not of a specific character; 
and, also, the same character of articular 
disease may be re-excited without the 
urethral discharge being developed. 
Both the robust and the debilitated 
suffer from this disease, but they suffer 
differently. The fever and inflammation 
1 A System of Surgery, by Chelius, trans- 
lated by John F. South, vol. i. p. 217. 
2 Pathological and Surgical Observations 
on the Diseases of the Joints. 5th edit. p. 
43. 577 
GONORRHCEAL RHEUMATISM. 
are proportionate to the plethora which 
may exist. In the young and plethoric 
the inflammation is of an acute character, 
and lymph is for the most part deposited 
on the synovial membranes, giving rise to 
false ankylosis ; whereas, in the debili- 
tated, serum will probably alone be effused. 
In both cases the joints are liable to be 
destroyed ; in the former through the de- 
posit of lymph and the production of false 
ankylosis, and in the latter through the 
destruction of cartilage. 
The joint having become inflamed, a 
large effusion of serum takes place into 
the synovial cavity; but, though there 
may be great tension, suppuration never 
occurs. Absorption of the effused serum 
takes place, and the joint may resume its 
healthy action. The limb remains in a 
semi-flexed position during the period of 
effusion into the joint; for in the flexed 
position of the limb the surrounding 
structures are somewhat relaxed, and 
consequently they yield to the bulging 
membrane with its contained fluid. When, 
however, the hip is inflamed, the limb re- 
mains much more extended than in ordi- 
nary hip-joint disease. 
The knee is more frequently affected 
than any other joint, being a large and 
complicated joint, and less protected by 
muscle from atmospheric influence. 
After the first attack of this disease, the 
patient is exceedingly liable to a recur- 
rence of it. Usually the second attack is, 
as the first, the result of gonorrhoea and 
exposure to cold and wet. But, although 
Gonorrhoeal Rheumatism will now almost 
certainly be excited by a specific discharge, 
any urethral discharge or urethral irrita- 
tion would seem to be sufficient to re-ex- 
cite the disease when the patient has once 
suffered from it. 
On this second occasion probably the 
inflammation will be less, but the joints 
will be longer in recovering mobility, and 
one or more will possibly remain anky- 
losed. Sir Benjamin Brodie relates the 
case of a patient who suffered from four 
attacks of this disease in the course of 
some few years, in whom he says that 
" inflammation of the urethra was in all 
of them the first symptom, which was fol- 
lowed by purulent ophthalmia, and after- 
wards by inflammation of the synovial 
membranes and swelling of nearly all the 
joints. In two of these attacks he attrib- 
uted the discharge from the urethra to his 
having received the infection of gonor- 
rhoea ; and in the two others to the use of 
the bougie."1 
Slight stiffness may remain for several 
weeks, and a crackling sensation will pro- 
bably be communicated to the hand on 
moving the limb ; but this may also at 
length cease, and the joint will resume its 
normal condition both in regard of size 
and motion. 
Each attack is more virulent in its cha- 
racter than the preceding, and in propor- 
tion to the debility of the patient. The 
female seldom sutlers from this disease, 
but whenever I have observed an instance, 
it has always terminated in ankylosis. 
When gonorrhoeal ophthalmia occurs, 
the conjunctiva, sclerotic, and iris may all 
become affected. It is not for the most 
part a severe form of ophthalmia, and it 
readily yields to treatment. 
Although the effusion into a joint may 
be very considerable, dislocation never 
occurs, and in this point the disease dif- 
fers widely from ordinary rheumatism, 
wrhere the tendency is for the articular 
surfaces to become more or less displaced; 
but in this disease ankylosis is induced 
rather than dislocation. 
In no case that I have met with has 
there been so much effusion into the joints, 
and so much pain, as in the following in- 
stance ; neither have I met with a case 
where the patient enjoyed such redundant 
health. A dark-haired young man, who 
was attached as lieutenant to one of our 
regiments serving in a tropical climate, 
had contracted gonorrhoea, and having 
laid himself down on a low broad wall he 
fell asleep, and so remained for some 
hours, and until after sunset. He awoke 
in great pain, and, as it seemed to him, 
this pain was spread all over the body, 
but especially it was felt in one hip : here, 
however, the pain was so acute that it 
was with difficulty he could be removed 
to bed. Besides the hip, the shoulders, 
knee, and ankle became affected ; but in 
none of these joints was the inflammation 
so acute as in the hip, and they all passed 
through this inflammatory condition with- 
out material injury, and recovered per- 
fectly. In the hip the effusion was so 
great that it was thought suppuration 
must take place : the swelling, however, 
subsided at length, leaving the joint stiff 
and immovable. Until this effusion was 
removed he suffered an agony of pain. 
Occasionally the urethral discharge al- 
ternates with articular inflammation, or 
it degenerates into a gleety discharge, 
while the articular inflammation assumes 
a chronic character. Thus, a young Jew, 
who had contracted gonorrhoea, was soon 
after seized with pain in several joints. 
The urethral discharge ceased as the ar- 
ticular inflammation became developed, 
and it recurred as the pain in the joints 
was removed. This continued for several 
weeks, until on a winter's evening he was 
exposed to cold, when, an access of in- 
flammation occurring, he found during 
the night a finger-joint excessively pain- 
ful and somewhat swollen. The joint be- 
came ankylosed in the course of some few 
1 Op. cif. 
VOL. I.-37 578 
GONORRIHEAL RHEUMATISM. 
days. All the other joints recovered well. 
The gleet remained for many weeks. 
The articular inflammation appears to 
be of a more injurious character when a 
second or third attack of Gonorrhoeal 
Rheumatism occurs. The first attack 
may leave no trace behind ; but a subse- 
quent attack seldom fails to do so : it may 
cripple the patient for life, as happened in 
the following case of a young man, nine- 
teen years of age, of a somewhat strumous 
diathesis. In this patient gonorrhoea ap- 
peared on the seventh day after infection. 
In the course of a fortnight the knees be- 
came painful and swollen, and they con- 
tinued in this state for about two months, 
when the inflammatory condition sub- 
sided, and the joints resumed their nor- 
mal condition. Two months after this 
first attack had disappeared, he was again 
infected with gonorrhoea. In ten days 
several joints became inflamed, as the 
right temporo-maxillary articulation, as 
well as the hips, the knees, the ankles, the 
shoulders, the elbows, and the thumbs. 
The upper limbs and the ankles recovered 
well and regained their mobility, but the 
hips, knees, and the jaw became anky- 
losed. 
The following is a remarkable case, in 
which, after several attacks of Gonorrhoeal 
Rheumatism, the disease was again set up 
without urethral discharge appearing. A 
gentleman, twenty-five years of age, ac- 
quired gonorrhoea, which was soon fol- 
lowed by pain and swelling of the knees. 
The urethral discharge appeared on the 
seventh day, and some few days later sy- 
novitis supervened with great effusion 
into the knee-joints. The skin was hot 
and dry, and he suffered acutely, so that 
every movement was attended with much 
pain. The urethral discharge continued 
for two months, and then ceased entirely, 
and the swelling and stiffness of the knees 
also at length disappeared, having lasted 
for three months. After another interval 
of three months this individual was again 
affected with gonorrhoea. The urethral 
discharge again appeared on the seventh 
day, and it continued for two months. 
After some days the left hip-joint became 
inflamed, as well as the ankle and tarsal 
joints. This attack was of a much more 
severe character than the former one-the 
effusion was greater and the pain more 
acute. After a period of ten months my 
patient was able to walk with the help of 
sticks. Stiffness and a painful condition 
of the limbs continued yet, however, for 
many months ; but at length he regained 
the use of his limbs. After a lapse of sev- 
eral months, again he contracted gonor- 
rhoea. On this occasion the symptoms 
closely resembled those which occurred on 
former occasions ; but he never entirely 
recovered from the stiffness which resulted 
from this attack of articular inflammation. 
Now, both hips, both ankles, and one 
knee became inflamed, and he also suf- 
fered from ophthalmia. Ankylosis did 
not occur, but there was a certain amount 
of stiffness of the joints which prevented 
him from rising after he had been seated 
for some hours. About six months after 
he was able to walk about, he married. 
Painful attempts were made to consum- 
mate the marriage, but it was found to be 
impossible : Dr. Lever discovered that oc- 
clusion of the vagina had taken place. At 
this time, namely within a very short pe- 
riod of marriage, articular inflammation 
recurred. There was now, however, no 
urethral discharge whatever. But the 
articular inflammation proceeded, and at 
length produced ankylosis of every joint 
in succession; so that in five years the 
whole skeleton was implicated : the atlas 
was ankylosed together with the axis, and 
in consequence the head could not be 
moved ; and all the vertebrae were anky- 
losed together; and the hips, knees, an- 
kles, shoulders, elbows, wrists, and jaw 
were so firmly fixed that no movement 
whatever could be obtained, 
An interesting example of this disease 
has been for some time under treatment 
in St. George's Hospital, of which the fol- 
lowing are the principal points : Edward 
G , aged 46, having been treated as 
an out-patient by Dr. William Ogle for 
some time, was at length admitted into 
Fitzwilliam Ward, on account of effusion 
into and great thickening about the knee- 
joint. The left wrist was firmly anky- 
losed, and the spine in its entire length 
was motionless-ankylosis of all the ver- 
tebrse having taken place. The ribs also 
were ankylosed, and the breathing in con- 
sequence was purely diaphragmatic. 
In the year 1855 (thirteen years prior 
to his second admission), he was a patient 
of Dr. Wilson's, in Cambridge Ward, for 
Gonorrhoeal Rheumatism. 
Three months before he was admitted 
into the hospital, he was exposed in the 
hunting-field, being a groom, to wet and 
cold, at the same time that he was suffer- 
ing from an attack of gonorrhoea. He 
was admitted with pain in the feet and 
shoulders, in the right elbow, and over 
the clavicles ; but at this time the gonor- 
rhoeal discharge had stopped. 
Since that period he has never suffered 
from gonorrhoea ; but he has had pain in 
various joints, and gradually his back and 
neck have become stiff, as well as the left 
wrist and the right knee. He was scarcely 
aware that any morbid process was going 
on in the spine, for there was little or no 
pain, and during the -whole of the time 
between his discharge from the hospital 
and his re-admission he was able to per- 
form his duty as a coachman. TREATMENT. 
579 
Treatment. - When Gonorrhoeal 
Rheumatism is vigorously treated in the 
commencement of the attack, the joints 
may become affected in a slight degree 
only. If there be much constitutional 
disturbance and inflammatory action, pur- 
gatives may be exhibited, and a small 
quantity of blood may be taken from the 
arm ; while local fomentations may be 
employed, and a splint of gutta-percha to 
keep the affected joint perfectly at rest. 
After venesection, a full dose of opium 
gives great relief, and if it is administered 
with ipecacuanha, as in Dover's powder, 
the secretion of the skin is increased. 
The sweating which is thus produced is 
beneficial; but this increased action of the 
skin is best promoted in the Turkish bath. 
I have known the pain about the joints to 
cease entirely in the bath. Some time 
since, I saw a gentleman who suffered 
very acutely from pain and inflammation 
consequent on this form of disease of the 
joints, and in whom the tension from effu- 
sion was also excessive. He was lodged 
by my desire in a house attached to a 
Turkish bath, and each day he was car- 
ried down into the bath. When profuse 
perspiration was obtained, the pain left 
him; and absorption of the fluid within 
the synovial capsules was certainly pro- 
moted by exposing the body to the high 
temperature of the bath. 
In an acute attack, abstinence from 
flesh meat, as well as from fermented and 
distilled liquors, is absolutely necessary. 
When such measures are promptly 
taken, an acute attack of Gonorrhoeal 
Rheumatism may generally be cut short. 
When, however, inflammation tends to 
become chronic, iodide of potassium may 
be given with advantage : thirty to forty 
grains being administered daily. It is 
preferable to abstract a small quantity of 
blood from a vein than to apply leeches to 
the inflamed joints: leeches not unfre- 
quently aggravate some of the symptoms, 
and induce also suppuration in the cellular 
tissue. For these reasons, any benefit to 
be derived from their use is doubtful, and 
at times they certainly increase the evil 
they are intended to mitigate. 
After the first or second attack, or when 
the patient is debilitated, the treatment 
should be of a slightly stimulating and 
tonic character : depletion will aggravate 
all the symptoms, and increase the effu- 
sion. Opium may be given freely, and 
iodide of potassium in small doses. Gutta- 
percha splints should always be used dur- 
ing the period of effusion to prevent motion. 
So soon as pain and swelling have 
ceased, gentle frictions with shampooing 
should be employed to restore mobility. 
Much time will probably be required to 
effect this object, and it may be necessary, 
if adhesions have formed, to flex the 
limbs forcibly after chloroform has been 
inhaled. In many cases mobility may be 
restored, even after very firm adhesions 
have been formed. PART II. 
LOCAL DISEASES. 
INTRODUCTION. 
THE EDITOR. 
A few words are necessary to explain 
the principle of classification adopted with 
regard to the diseases which find their 
place in this, the first, section of "partial 
diseases," or "affections of particular 
organs." 
The maladies which are treated of in 
these volumes have been in the first place 
divided into two large groups, "general" 
and " local," and the reason for such divi- 
sion has been assigned (Classification of 
Diseases, p. 32). Some diseases are "gen- 
eral,"-that is to say, they appear so to 
affect the whole body at once, that all its 
functions are impaired or altered ; and 
not only so, but they are implicated to 
such an equality of degree that it is 
always difficult, and sometimes impossi- 
ble, to say upon which system of organs, 
if upon any, the greater weight of the 
burden falls. Of such diseases Part I. of 
this System of Medicine contained the 
history. We have now to deal with an- 
other class of affections, the "local" or 
"partial," viz., with those in which we 
have little or no difficulty in localizing the 
disease; maladies with regard to which 
we say at once that they are diseases of 
the nervous system, or of one portion of 
the digestive system. It is not intended 
that such diseases are accurately limited 
to the particular systems from which they 
derive their names ; for we know well 
that the digestion is, or may be, disturbed 
in epilepsy, in apoplexy, and in paraple- 
gia ; and, on the other hand, that no 
severe perturbation can occur in the stom- 
ach without the simultaneous develop- 
ment of some corresponding disturbance 
in the nervous centres. Furthermore, we 
know that there is sometimes great diffi- 
culty in determining whether we have to 
deal with a disease universal in its dis- 
tribution at its onset, or with some pri- 
mary lesion of a particular organ, the 
secondary effects of which are general; 
or, even allowing that some particular 
organ is especially affected, the affection 
may be of such kind that it is sometimes 
a matter of grave doubt as to the system 
of organs to which that particular one, in 
this special instance, may be considered 
to belong. Tubercular meningitis has 
been mistaken for typhoid fever, and vice 
versa; abscess of the brain has been con- 
founded with malarial poisoning; and, 
again, tumors in the brain have been re- 
garded as diseases of the stomach; while 
all the symptoms of cancer of the stomach 
have been explained away by the fiction 
of "spinal irritation." ISach organ of 
the body has something in common with 
every other organ; and although two 
viscera may be, locally, as remote as the 
limits of the human body will allow, there 
are between them bonds of union so inti- 
mate that they are, in reality, brought 
very close together in the minute con- 
ditions of pathologic change. Blood, 
bloodvessels, lymphatics, connective tis- 
sue, and nerves are common to all organs 
which take part in the more active pro- 
cesses of life, and in each of them there 
is in progress that common nutrition- 
change which is the necessary condition 
of all functional activity. Although, there- 
fore, the function of the stomach may be 
that of exerting a particular effect on food, 
it must not be forgotten that the stomach 
has nerves, vessels, and connective tis- 
sues, and that diseased processes, exhib- 
iting themselves mainly in its disordered 
functions, may be the expression of some- 
thing wrong in innervation, in blood sup- 
ply, or in general nutrition. And, again, 
although the brain is the organ which 
ministers to the higher functions of the 
nervous system, and records its diseases 
in changes of mind, sensation, or motility, 
it must be remembered that the brain has 
vessels which undergo nutrition-changes 
of degeneration or decay, and that many 
of its so-called special diseases are often 
but the outcome of a more general mal- 
581 582 
INTRODUCTION 
nutrition, which may have had its start- 
ing-point in heart, arteries, or veins. 
While, then, we may speak of "softening 
of the brain" among the diseases of the 
"nervous system," it would be quite as 
correct, in many instances, to place it 
among the effects of disease or degenera- 
tion in the "vascular system." 
All the more important organs of the 
body are so complex in their structure, 
and all have so much in common, that we 
are bound to admit that the lines we draw 
between them, in regard to pathologic 
change, are often determined rather by 
the consideration of their practical utility 
than by the fact of their scientific accu- 
racy. Knowing, however, the inherent 
difficulties of the case-viz., those which 
arise out of the fact that all the systems 
of organs have marvellously close rela- 
tions with each other-and being aware, 
moreover, of those accidental hindrances 
which arise out of either our own ignor- 
ance or want of tact in the application of 
such knowledge as we have attained, we 
still hold it to be desirable that, in this 
System of Medicine, we should maintain 
the distinction between "general" and 
" local" diseases, and that we should take 
as our basis for classification of the latter, 
the particular systems of organs. We 
believe this to be so, because the lines 
which are drawn in making these distinc- 
tions include groups of diseases, the indi- 
vidual members of each of which have 
inter se closer clinical relations than have 
those which belong to different, although 
contiguous groups; and because in the 
vast majority of cases it is comparatively 
easy, and sufficient for all the practical 
purposes of "classification," to say that 
a particular disease under consideration 
is "general" in its character, or is " par- 
tial," in the latter instance especially 
affecting this or that great system of or- 
gans, such as the nervous, the respiratory, 
or the digestive. 
The principle of division thus estab- 
lished with regard to all diseases-viz., 
that of limitation or localization-is again 
applicable, as a means to be employed for 
the primary subdivision of the large group 
of diseases forming the first section to be 
considered in Part IL ; and accordingly 
"diseases of the nervous system" are dis- 
tributed under two headings-the "gen- 
eral" and the "special" or "partial." 
Under the former, the " general, " are 
described those affections which exhibit 
their phenomena in all parts of the ner- 
vous system-those in which brain, spinal 
cord, and nerves seem to be all, more or 
less intensely, and more or less widely, 
involved; while under the latter, the 
" partial," are detailed those in which the 
brunt of the malady is borne by particular 
parts of the nervous system-the brain, 
the cord, the nerves, or their appendages. 
It will be seen at once, by a reference 
to page 584, that under the former, the 
"general," are enumerated, together with 
those which strictly merit that designa- 
tion, some diseases which appear to affect 
certain portions of the nervous system 
either more profoundly or more essentially 
than they influence others; and further 
that some morbid conditions are described 
which, although limited in the distribution 
of their symptoms, have as yet no such 
definite pathological anatomy that we can 
affirm, with anything like satisfaction, 
what part of the nervous system is in them 
primarily at fault. The first large group, 
therefore, is made to include, together 
with those in which the whole nervous 
apparatus is equally disturbed, some dis- 
eases apparently partial in their distribu- 
tion, and others which, in the present 
state of science, are of "undetermined 
seat." Among the members of this first 
large group, for example, there are placed 
epilepsy, hysteria, and such diseases as 
show themselves in altered functions of 
the brain, cord, and nerves-occasionally 
one great division of the nervous system, 
and sometimes another, presenting the 
most marked derangement, but all divi- 
sions being more or less involved in mor- 
bid change of either function or structure, 
or both : -and in the same large group we 
find wasting palsy, chorea, writers' cramp, 
and allied affections, which, although they 
exhibit the maximum of their obvious 
symptoms in particular parts of the ner- 
vous system, are yet of such uncertain 
pathology, that it would be injudicious at 
present to describe them as diseases of 
either brain, cord, or nerves, exclusively. 
So far as the pathology of these will 
allow, they will, when examined in detail, 
be referred to their proper places ; but it 
is thought, for the simple purpose of ar- 
rangement, desirable to keep within the 
limits of ascertained facts and principles, 
by retaining them in the positions already 
described. The other alternative, that of 
placing them under particular headings, 
while it might confer a greater amount of 
apparent scientific precision, would, I be- 
lieve, be attended by less real scientific 
accuracy ; inasmuch as it would give an 
undue prominence to many hypotheses, 
very valuable in themselves, as forming 
the framework of both thought and inves- 
tigation, but which, being as yet no more 
than hypotheses, are not" entitled to hold 
high rank among the conditions upon 
which classification should be based. The 
diseases known, for example, as meningi- 
tis, myelitis, and neuritis, respectively, 
have clinical histories and well-known 
pathological conditions related to one an- 
other in a manner much more definitely 
ascertained than have such affections as 
ataxy, paralysis agitans, and wasting 
palsy. We have referred the symptoms INTRODUCTION. 
583 
of the first series to their anatomical 
changes, whereas it cannot be said that 
we have done so with regard to the second 
group. Much more is known about the 
latter than was known a few years ago ; 
but observations, during life and after 
death, have to be multiplied and verified 
before we can ascribe those diseases, with 
scientific precision, to particular localities 
and special kinds of structural lesion. 
Again, the kind of distinction between 
hemorrhage into the corpus striatum and 
hemorrhage into the spinal cord, is, in its 
clinical relations, widely different from 
that which can be established between 
either of those two affections and ataxy, 
or chorea. In the one we are dealing 
with what is definitely known ; in the 
other, with what is as yet indefinite, and 
only approaching scientific arrangement. 
Upon these grounds, therefore, the prima- 
ry division is made into diseases of "gen- 
eral" distribution, or of undetermined lo- 
cality, and "partial" diseases, or those 
having a recognized pathological anatomy. 
In the second group of diseases of the 
nervous system-viz., those described as 
"partial"-the principle of arrangement 
is sufficiently obvious to need but little 
elucidation. In the first place, a subdivi- 
sion is made upon simply anatomical 
grounds-viz., into affections of the cra- 
nium, the spinal column, and the nerves ; 
and each of these is again subdivided up- 
on an anatomical basis-diseases of the 
cranium being distributed under the cate- 
gories of "meninges" and "nervous tis- 
sues," such as brain, cerebellum, and the 
like ; while diseases of the spinal column 
are distributed in a similar manner. The 
next principle of division is that deter- 
mined by the nature of the anatomical 
changes which these tissues, respectively, 
undergo. Here an attempt has been 
made to place in close proximity those 
affections which have the most highly- 
marked clinical similitude-an attempt, 
however, which is only carried to such a 
degree as shall not interfere with the 
more general arrangement. 
It is not necessary to enter further into 
the detail of this classification, as the 
principles upon which it is based are suffi- 
ciently obvious for all the practical pur- 
poses of this System of Medicine. DISEASES OF THE NERVOUS SYSTEM. 
These diseases are divided into two large groups, viz., A, those of general distribution, 
or of uncertain seat; and B, those which are partial, and which occupy known relations to 
particular portions of the nervous system. 
A.-General Nervous Diseases, and those of uncertain seat 
Insanity. 
Hypochondriasis. 
Hysteria. 
Ecstasy. 
Catalepsy. 
Somnambulism. 
Sunstroke. 
Alcoholism. 
Vertigo. 
Chorea. 
Paralysis Agitans. 
Writers' Cramp. 
Convulsions. 
Epilepsy. 
Locomotor Ataxy.1 
Muscular Anesthesia. 
Wasting Palsy. 
Metallic Tremor. 
INSANITY. 
Henry 
Maudsley 
, M.D., F.R.C.P. 
Synonyms.-Insanity; Madness; Men- 
tal or Cerebro-Mental Disease; Mental 
Derangement; Mental Alienation ; Men- 
tal Aberration ; Unsoundness of Mind ; 
Lunacy. 
the real development of the brain as the 
organ of conscious life, taking place after 
birth in relation to surrounding circum- 
stances, and thus gradually issuing in the 
formation of individual character, is dif- 
ferent in different persons, and accord- 
ingly cerebro - mental diseases present 
manifold varieties of features. As re- 
gards any particular case of Insanity 
which we may have to decide about, it is 
necessary then to fix attention on two 
points: first, on the change of individual 
character-the alteration from the former 
self; secondly, on the want of harmony, 
or the discord, between the individual 
and his surroundings. For although the 
morbid phenomena of the diseased mind 
witness in some measure to the degree of 
its previous development, yet the degene- 
ration which disease implies must needs 
display itself in an alteration in the kind 
of manifestation of feeling, thinking, and 
acting-in other words, in a changed self; 
while again the import, as morbid, of the 
phenomena displayed can only be rightly 
weighed in relation to the individual 
Definition.-So many and various in 
kind and degree are the forms of mental 
derangement included under Insanity, 
that it is not possible to give a definition 
of it that shall be at the same time com- 
prehensive and exact. If the definition is 
wide enough to comprise all varieties, it 
will include eccentricities that fall short 
of disease ; if exact enough to be definite, 
then it must exclude many cases of un- 
doubted mental disease. As various as 
are the features or the voices of men, so 
various are the characters of their minds; 
and as no two persons are exactly alike in 
mental character and development, so in 
no two instances of the degeneration of 
mind do the morbid features correspond 
exactly. The development of other or- 
gans of the body, taking place before 
birth after a common type, is very much 
alike in different persons, and the diseases 
of them have a great resemblance; but 
1 Transferred to description of Spinal Cord. 
584 CLASSIFICATION. 
585 
sphere of life. It is, for example, quite 
possible, though apt to be forgotten in 
practice, that sentiments and acts which 
are habitual in the lowest strata of life 
may be sure signs of mental disease when 
uttered and done by one in a high social 
sphere. 
Bearing in mind the difficulties inherent 
in the nature of the subject, which have 
led to every sort of definition by every 
writer who has not forborne the task in 
despair, I may declare Insanity to con- 
sist essentially in a morbid derangement, 
generally chronic, of the supreme cerebral 
centres-the gray matter of the cerebral con- 
volutions or the intellectorium commune- 
giving rise to perverted feeling, defective or 
erroneous ideation, and discordant conduct, 
conjointly or separately, and more or less in- 
capacitating the individual for his due social 
relations.' We may safely go so far as to 
affirm the mind centres to be in the vesic- 
ular neurine of the convolutions, and In- 
sanity to consist essentially in disorder, 
primary or secondary, of their functions 
-in disordered feeling, disordered intel- 
ligence, and disordered will. 
This definition has the merit of fixing 
attention, first, on the reception of im- 
pressions from the external world-the 
mode of feeling, or the affective life; sec- 
ondly, on the mental fashioning or elabor- 
ation of impressions-the modes of idea- 
tion or intellection, the intellectual life ; 
and, thirdly, on the reaction of the indi- 
vidual on the external world-the mode 
of action or conduct; it answers also to 
the best psychological division of mind 
into feeling, cognition, and ivill. How de- 
sirable it is not entirely to overlook the 
social relations, will be plain when we re- 
flect that it is in the irregularities of the 
individual, as an element in the social 
system, that the morbid character of In- 
sanity fundamentally consists. Certainly 
the definition is far from being perfect, as 
in the nature of things must be the case 
so long as it is impossible to draw the line 
where sanity ends and Insanity begins, or 
even to say positively whether a particu- 
lar person is insane or not; but against 
its manifest defects may be put its posi- 
tive merits-namely, that it fixes the gray 
matter of the convolutions, the undoubted 
nerve-centres of intelligence, as the prin- 
cipal seat of morbid action in Insanity ; 
that it distinctly declares that Insanity 
may be exhibited either in moral perver- 
sion only, or in the actions of the patient, 
or in delusion; and, lastly, that it sets 
forth how Insanity destroys the relations 
and responsibilities of the individual in 
the social system, making him very much 
like what a morbid element is in the or- 
ganic system-something which cannot 
take its due place in the general harmony, 
and which must either be eliminated from 
it or sequestrated and rendered harmless 
in it. A man may certainly have dis- 
ordered feeling, may think and judge er- 
roneously, and act extravagantly, without 
being insane ; but if he does so as a regu- 
lar thing, and without any adequate 
cause in external circumstances-if he 
does so in fact by reason of a steadily act- 
ing internal cause, a derangement of his 
supreme cerebral centres-then he is in- 
sane. The standard by which to measure 
the perversion is, first, that of the kind- 
that which is fixed by the general consent 
of mankind ; and, secondly, that of the 
individual-that which is justified by the 
degree of his previous mental develop- 
ment. 
Many and varied as are the forms which 
madness takes, there are still beneath 
superficial differences certain characters 
of essential agreement; and accordingly 
genuine groups or types may be described, 
notwithstanding the fact that cases mark- 
ing every grade of transition between one 
group and another are met with in prac- 
tice. Of Insanity may still be said what 
Burton long ago said of it: "I could give 
instances of some that have had all three 
kinds semel et simuk and some succes- 
sively What physicians say 
of distinct diseases in their books, it much 
matters not, since that in their patients' 
bodies they are commonly mixed." 
Classification. - The classification 
commonly adopted in this country, and 
yet indispensable for practical purposes, 
is a modification of that proposed by Es- 
quirol, and is as follows :- 
Acute, or Having Madness. 
Chronic. 
Recurrent. 
I. Mania 
II. Monomania. 
III. Melancholia. 
IV. Moral Insanity. 
V. Dementia 
Primary. 
Secondary. 
VI. Idiocy, including Imbecility. 
VII. General Paralysis or Paresis. 
1 Ideation, now so commonly used, was first 
suggested and employed by Mr. James Mill in 
his ''Analysis of the Human Mind." Dr. 
Darwin, in his "Zoonomia," aptly designates 
the common centres of intelligence as the In- 
tellectorium commune. 586 
INSANITY. 
I. Die Depressionzustande. 
1. Die Hypochondrie. 
2. Die Melancholic. 
II. Die Exaltationzustlinde. 
1. Die Tobsucht. 
2. Der Wahnsinn. 
III. Die psychischen Schwiichezustande. 
1. Die Verriicktheit. 
2. Der Blddsinn. 
3. Idiotismus und Cretinismus. 
IV. Der paralytische Bliidsinn, Die all- 
gemeine Paralysie der Irren. 
In Germany, the classification which finds most favor stands thus - 
I. Conditions of depression. 
1. Hypochondria. 
2. Melancholia. 
II. Conditions of exaltation. 
1. Acute Mania. 
2. Monomania. 
III. Conditions of mental weakness. 
1. Craziness or Incoherence. 
2. Dementia or Fatuity. 
3. Idiocy and Cretinism. 
IV. Paralytic dementia, General Paraly- 
sis of the Insane. 
It is easy to perceive the defects of such 
purely psychological classifications. They 
are vague and artificial, embracing in the 
same class forms of disease distinct enough 
to demand a separate description ; more- 
over, there are forms of mental disease 
which, presenting the characters of two 
or more of the different classes, might be 
placed in one or the other, or cannot be 
placed satisfactorily in either. Dr. Skae 
has proposed to classify all the varieties 
of Insanity in natural orders or families, 
grouping them in accordance with the 
natural history of each.2 Why, he asks, 
should we attempt to group and classify 
them by the mental symptoms, and not, 
as we do in other diseases, by the bodily 
disease of which the mental perversions 
are but the signs ? In pursuance of this 
aim he has sketched the outlines of twenty- 
nine natural orders or families, having, 
as he believes, each its natural history, 
its special cause and morbid condition, a 
certain class of symptoms more or less 
peculiar to each, its average duration, 
and probable termination. They stand 
thus:- 
Idiocy, 
Imbecility, 
Moral and intel- 
lectual. 
Senile Mania. 
Phthisical Mania. 
Metastatic Mania. 
Traumatic Mania. 
Syphilitic Mania. 
Delirium Tremens. 
Dipsomania. 
Mania of Alcoholism. 
Post-Febrile Mania. 
Mania of Oxaluria and Phosphaluria. 
General Paralysis, with Insanity. 
Epidemic Mania. 
Insanity, with Epilepsy. 
Insanity of Masturbation. 
Insanity of Pubescence. 
Satyriasis. 
Nymphomania. 
Hysterical Mania. 
Amenorrhoeal Mania. 
Post-Connubial Mania. 
Puerperal Mania. 
Mania of Pregnancy. 
Mania of Lactation. 
Climacteric Mania. 
Ovario-Mania (Utero-Mania). 
Idiopathic Mania, 
[ Sthenic. 
[ Asthenic. 
M. Morel, of Rouen, has propounded a 
classification of mental diseases according 
to their apparent causes-an etiological 
classification. He makes six principal 
groups, each of which has two or three 
classes under it: the first group being that 
of hereditary Insanity ; the second con- 
sisting of Insanity produced by toxic in- 
fluences ; the third, of Insanity produced 
by the transformation of other nervous 
diseases, such as hysteria, epilepsy, hy- 
pochondria ; the fourth, of idiopathic In- 
sanity; the fifth, of sympathetic Insanity; 
and the sixth, including all cases of de- 
mentia. 
[What may be called a physiological 
classification has met with favor on the 
part of some modern authors, as follows : 
1. Sensorial Insanity ; in which halluci- 
nations of the senses are mistaken for 
realities, and so mislead (alienate) their 
subject, by getting him out of normal re- 
lation to the world around him. 2. Intel- 
lectual Insanity ; characterized by delu- 
sions, or confusion of the reasoning 
powers, upon one, many, or all subjects. 
3. Emotional Insanity ; commonly called 
Moral Insanity, involving the affections, 
or propensities, with morbid impulses too 
strong for the will to control. The term 
Impulsive Insanity is sometimes applied 
to the same group of cases. Either of the 
• Die Pathologie und Therapie der psy- 
chischen Krankheiten. Von Dr. W. Griesin- 
ger. Zweite Auflage. 1861.-Die Pathologie 
und Therapie der psychischen Krankheiten. 
Von Dr. M. Leidesdorf. Zweite Auflage. 
1865. 
2 On the Classification of the Various Forms 
of Insanity on a Rational and Practical basis, 
by David Skae, M.D.; Journal of Mental Sci- 
ence, October, 1863. For a fuller account 
and a criticism of this classification, I may 
refer to my work on "The Physiology and 
Pathology of Mind," Second Edition. 587 
CAUSES 
above forms may be acute or chronic; and 
they may be, and in most cases are, espe- 
cially the last two, combined together. 
Dementia, upon such a scheme, would be 
retained to indicate a failure or wreck of all, 
or nearly all, the psychical powers.-II.] 
Adopting for the purposes of description 
the classification in common use, artificial 
as it is, it will be most convenient to de- 
scribe the special features of the different 
varieties of mental disease in the course 
of the account of its causation, symptoma- 
tology, and treatment. 
Causes. - These are usually divided 
into physical and moral, though without 
any exactness in such discrimination be- 
ing really practicable. Two persons are 
exposed to like severe mental trials ; one 
of them becomes insane, the other does 
not. Ilas the madness, then, been pro- 
duced by a moral cause ? In the former 
case, there was probably some innate vice 
of nervous element-some predisposition 
of it to disease, or some accidental nervous 
depression, by reason of physical disease, 
or other cause, whereby Insanity has been 
produced by a moral cause that has had 
no such ill effect in the latter case. The 
entire causes have not, then, been in re- 
ality the same. What should ever be 
borne in mind is, that all the conditions 
which conspire to the production of an 
effect are alike causes, alike agents, and 
that there is, in most cases of Insanity, a 
concurrence of conditions, not one single 
effective cause. Mental alienation often 
appears as the natural issue of all prece- 
dent conditions of life, mental and bodily 
-the outcome of the individual character 
as affected by certain circumstances ; in 
such case, the germs of disease may have 
been latent in the foundations of the cha- 
racter, and the final outbreak is but the 
explosion of a long train of antecedent 
preparations. In vain, then, is it to try 
to fix always upon a single cause, moral 
or physical; a common mistake on the 
part of those who think to do so being to 
fasten upon that which is in reality an 
early symptom as the supposed cause. On 
this rock have hitherto foundered all etio- 
logical classifications of Insanity. It will 
be most convenient to set forth certain 
general considerations respecting sex, age, 
and the like, and then to proceed to treat 
of the proximate or exciting causes of In- 
sanity. It is obviously unscientific to 
enumerate sex and age as causes of In- 
sanity : no one goes mad because he or 
she happens to be a man or woman ; but 
because to each sex, and at certain ages, 
there occur physiological changes that are 
apt to run into pathological effects in 
those who are predisposed to nervous de- 
rangement. 
(ct) General Considerations.-There are 
general causes, such as the climate of a 
country, the form of its government and 
its religion, the state of its civilization, 
the occupation and habits of its inhabi- 
tants, which work together in the course 
of generations to the formation of a na- 
tional type of character, wherein there 
may be greater or less proneness to In- 
sanity. Reliable data respecting the fre- 
quency of Insanity in different countries 
are, unfortunately, still wanting, and even 
the question whether it has increased with 
modern civilization has not been positively 
settled. Travellers certainly agree that 
it is a rare disease among barbarous peo- 
ple ; whilst in the different civilized na- 
tions of the world there is, so far as can 
be ascertained, an average of one insane 
person in 500 inhabitants. The undoubted 
steady increase, again, of the insane un- 
der care and observation, would seem to 
be greater than can be fairly accounted 
for by the greater attention now given to 
their welfare : while theoretical consid- 
erations indicate that the feverish activity 
of life, the numerous passions and the 
great strain of mental work incident to 
the multiplied industries and eager com- 
petition of an active civilization, cannot 
fail to augment the liability to mental dis- 
ease. Though not yet exactly provable 
by statistics, there is still some reason to 
believe that, with the progress of mental 
development through the ages, there is a 
correlative degeneration going on, and 
that Insanity is a penalty which our pre- 
sent civilization necessarily pays.1 
Sex.-Though Esquirol and Haslam 
thought Insanity to be a little more fre- 
quent among women than among men, it 
is now generally agreed that the converse 
is true. Dr. Thurnam affirms men to be 
more liable to mental disorders than 
women ; and Dr. Jarvis came to the same 
conclusion from the examination of the 
statistics of different countries. Recently, 
however, it has been stated that the fe- 
male sex is more liable to suffer from 
hereditary Insanity.2 Pregnancy, the 
puerperal state, the catamenial functions, 
and the climacteric change are conditions 
in women that will favor the disturbance 
1 In 1859 the total number of lunatics in 
England and Wales was 36,762; in 1869 it 
had increased to 53,177. The proportion of 
lunatics to the population had risen from 1 
in 536 to 1 in 411 of the population. In France 
the ratio of lunatics to the population was, in 
1851, 1 to 796; and in 1861, 1 to 444. In 
both countries, however; it is certain that the 
main portion, if not all, of the increase has 
been due to the operation of the lunacy laws, 
by which more accurate registrations of the 
insane have been gradually brought about. 
2 Statistics of Insanity of the Crichton 
Roya1 Institution, by H. G. Stewart, M.D. ; 
Journ. Ment. Science, 1865. Also, Hereditary 
Insanity, by H. G. Stewart, M.D.; Journ. 
Ment. Science, 1864. 588 
INSANITY. 
of the mental balance, especially where 
there is any predisposition thereto ; but 
against these must be weighed tlie larger 
exposure of men to mental wear and tear 
in the competition of life, and their more 
frequent addiction to intemperance and 
other excesses. Women, too, very seldom 
sutler from general paralysis. On which- 
ever side, male or female, the uncertain 
difference lies, it is probably inconsider- 
able. 
Period of Life.-Insanity is rare before 
puberty, though every form of it, except 
general paralysis, may occur even so early 
in life ; it is far more frequent between the 
ages of 16 and 25 ; but it is most frequent 
of all during the period of full mental and 
bodily development-from 25 to 45-when 
there is the widest exposure to its causes. 
The internal revolution which takes place 
in women at the climacteric period leads 
to many outbreaks of Insanity in them 
between 40 and 50. In men there appears to 
be a climacteric period between 50 and 60, 
when Insanity sometimes supervenes : an 
old man may be found to be keeping a mis- 
tress in secret, or to be making foolish 
proposals of marriage, when, forerunning 
complete dementia, sensual impulses, 
clothed in the morbid habit of delusion, 
mock the extinction of sexual function. 
In childhood and early life idiocy and im- 
becility, moral and intellectual, are most 
commonly met with ; after puberty mania 
and, later on in life, melancholia ; in old 
age senile insanity occurs ; and general 
paralysis seldom before 30, the years be- 
tween 30 and 50 being the favorite years 
of its attack. 
Condition of Life.-The statistics hith- 
erto collected in regard to this point are 
of little or no value. Whether a particu- 
lar profession or trade favors the produc- 
tion of Insanity is generally a question of 
the habits incidental to its pursuit - 
whether those who follow it live soberly 
and temperately, or whether they are ad- 
dicted to intemperance and riotous living. 
On the whole, however, those who work 
with the head are more liable to mental 
disease than those who work with the 
hand, and they are less liable to recover 
when once attacked. It is an unproved 
and indeed ill-founded assertion that gov- 
ernesses are the victims of Insanity in 
greater proportion than other persons. 
The statement has originated in the fact 
that a great number of governesses are 
received into Bethlehem Hospital, as 
many as 110 having been admitted in ten 
years. The reason of this is that Bethle- 
hem is intended especially for persons of 
the class of governesses-those who are 
not paupers, but yet cannot pay for care 
and treatment. 
Other things being equal, it is certain 
that Insanity is proportionately more fre- 
quent amongst the unmarried than the 
married. 
Individual Predisposition.-The heritage 
which a man has from his parents may 
alone, or together with the circumstances 
of early education, give rise to an indi- 
vidual predisposition to mental derange- 
ment. Unquestionably some persons have 
what may be called the insane tempera- 
ment- a certain neurosis or diathesis, 
easily prone to degenerate into actual 
disease; they feel impressions in a way 
which other people do not feel them, are 
disposed to sudden impulses of strange 
feelings and desires, to whimsical caprices 
of thought and eccentricities of action, 
and they not unfrequently carry in their 
countenance and bearing the marks of 
their evil heritage. They have what 
Willis long ago called the diathesis spas- 
modica, an irritable weakness of nervous 
constitution, in which, if there be not 
positive disease, there is the well-prepared 
ground of disease. Authors are not 
agreed as to the proportion of cases of In- 
sanity in which positive hereditary taint 
is detectable : some, like Moreau,1 putting 
it as high as nine-tenths; others, as low 
as one-tenth. The most careful researches 
fix the proportion as not lower than one- 
fourth, if not so high as one-half; and 
there can be no doubt that the tendency 
is to increase the proportion as investiga- 
tion becomes more searching and exact. 
When a person cannot endure the ordi- 
nary trials of life, or a natural physiologi- 
cal function, such as the development 
of puberty, it is plain that there must 
be some native infirmity or instability of 
nerve element. It must be borne in mind 
that hereditary predisposition may be of 
every degree of intensity, so as, on the 
one hand, to conspire only with certain 
more or less powerful exciting causes, or, 
on the other hand, to suffice of itself to 
give rise to Insanity even amidst the 
most favorable external circumstances. 
Again, not Insanity only in the parents, 
but any form of nervous disease in them 
-epilepsy, alcoholism, hysteria, and even 
neuralgia-may predispose to Insanity in 
the offspring, as, conversely, Insanity in 
the parent may predispose to other kinds 
of nervous disease in the offspring. Pro- 
creation during the temporary insanity of 
drunkenness, and too much interbreeding 
in families, are both recognized cause of 
a predisposition to mental degeneration. 
Some, like Lugol and Schroeder van der 
Kolk, have maintained that scrofula of 
parents may generate a predisposition to 
Insanity in the children ; and whether 
this be so or not, it can admit of no ques- 
tion that the undoubted transformation 
which diseases undergo through genera- 
tions is a subject deserving of further and 
1 Psychologic Morbide dans ses Rapports 
avec la Philosophic de 1'Histoire. Par Dr. J. 
Moreau. CAUSES. 
589 
more exact study.' Baillarger has proved, 
what Esqnirol observed, that Insanity 
descends more often from the mother than 
the father, and from the mother to the 
daughters more often than to the sons. 
Children born before the outbreak of an 
attack are less likely to suiter than those 
born after an outbreak. 
An injudicious education may aggravate 
an inherent mischief; the parent not only 
transmitting a taint or vice of nature to 
the child, but fostering its increase by the 
influence of a bad example, and by a fool- 
ish training at that period when the young 
mind is very susceptible, and the direction 
given to its development decisive for life. 
Where there is no innate taint, mischief 
may still be wrought by enforcing an un- 
natural precocity, wherein is often planted 
the germ of future disease. Parental 
harshness and neglect, repressing the 
child's feelings, stilling its need of love, 
and driving it to a morbid self-brooding, 
or to take refuge in a world of vague fan- 
cies, is sometimes not less injurious than 
a foolish indulgence, through which it 
never learns the necessary lessons of re- 
nunciation and self-control. There can be 
no doubt that by the influence of good 
education and sound training a predisposi- 
tion to Insanity might often be much 
neutralized and rendered almost harmless; 
but the mischief is that those who procre- 
ate children so afflicted are commonly 
least fit to train them well. 
(6) Exciting Causes. - The so-called 
moral causes are generally, though not 
universally, held to be more frequent than 
the physical causes: Pinel thought them 
to be twice, Esqnirol four times, as fre- 
quent ; while Guislain attributed 66, Par- 
chappe 67, out of 100 cases of Insanity to 
moral causes.2 It is not the way of great 
intellectual exercise, when unaccompanied 
by emotion, to lead to mental derange- 
ment ; mental exercise is favorable to 
length of days and health of mind : it is 
when the feelings are deeply engaged, 
when the mind is the theatre of great pas- 
sions, that it is most moved and its stabil- 
ity most endangered. The depressing 
passions are most effective in this regard : 
grief, religious anxiety, disappointed affec- 
tion or ambition, jealousy, the wounds of 
an exaggerated self-love, and the painful 
feeling of being unequal to responsibilities, 
or other such conditions of mental agita- 
tion and suffering, are most apt to reach 
a violence of action by which the balance 
is lost. It is especially when the individ- 
ual has by a long concentration of thought, 
affection, and desire on a certain aim or 
object grown into definite relations with 
regard to it, and made it, as it were, a 
part of the inner life, that a sudden and 
entire change, shattering long-cherished 
hopes, is most likely to produce Insanity; 
for nothing is so fraught with danger to 
the stability of the strongest mind as a 
sudden great change in external circum- 
stances without the inner life having been 
gradually adapted thereto. Hence, also, 
it is that a great exaltation of fortune, as 
well as a great affliction, rarely fails to 
affect for a time the strongest head and 
sometimes quite overturns a weak one ; 
though the strong mind succeeds after a 
time in establishing an equilibrium be- 
tween itself and its new surroundings, 
which the feeble mind cannot do. Men 
do not, however, often become insane 
from joy ; and when one of the expansive 
passions, as ambition, religious exalta- 
tion, overweening vanity in any of its 
Protean forms, leads to mental derange- 
ment, it does not, like a painful passion, 
act either directly as the sudden cause of 
an outbreak, or indirectly by producing 
organic disorder and subsequent Insanity, 
but it exhibits its effects slowly, as a grad- 
ual development or exaggeration of a par- 
ticular vice of character. 
Among the causes of mental disturbance 
which it would be difficult to pronounce 
other than moral, but which are really 
due to physical conditions, are those inci- 
dent to the great mental revolution pro- 
duced by the development of the sexual 
system at puberty ; when there occurs, as 
Goethe aptly expresses it, "an awakening 
of sensual impulses which clothe them- 
selves in mental forms, of mental necessi- 
ties which clothe themselves in sensual 
images." The great moral commotion 
produced at this period is the cause of an 
unstable equilibrium of mind, which is 
just as dangerous as if it were produced 
by some external cause ; and which, if 
hereditary predisposition exist, may, with- 
out further auxiliary cause, issue in In- 
sanity. 
Of the physical causes of Insanity, in- 
temperance occupies the first place; acting 
not only as a direct cause, but indirectly 
through the emotional agitation incident 
to an irregular life of dissipation and ex- 
cess. Opium, Indian hemp, and other 
narcotics notably give rise to temporary 
disorder of mind, and, if abused by long 
indulgence, they may lead to permanent 
degeneration. Self-abuse in men is the 
cause of a particularly disagreeable form 
of Insanity, characterized by intense self- 
feeling and conceit, indolence and vacilla- 
tion of character, and profound moral dis- 
turbance in the earlier stage, and later, 
by failure of intelligence, nocturnal hallu- 
1 Die Patliologie und Therapie der Geistes- 
krankheiten auf anatomisch-physiologischer 
Grundlage. Von J. L. C. Schroeder van der 
Kolk. 1863. 
2 Pinel, On Insanity, translated by Dr. 
Davis; Esqnirol, Traite des Maladies Men- 
tales ; Guislain, Traite sur l'Alignation Men- 
tale; Parchappe, Traite de la Folie. 590 
INSANITY. 
cinations, and suicidal or homicidal pro- 
pensities. Epilepsy is sometimes followed 
by a most violent and dangerous mania, 
and, when of long standing, produces loss 
of memory and general failure of intelli- 
gence. Sometimes an outbreak of mania 
precedes or takes the place of an epileptic 
attack ; and it may happen that a painful 
form of moral derangement, with periodi- 
cal exacerbations-a masked epilepsy- 
precedes for months the appearance of the 
genuine epileptic convulsions. 
In some instances hysteria produces or 
passes into Insanity. An attack of acute 
maniacal excitement, with great restless- 
ness, rapid and disconnected, but not 
entirely incoherent, conversation, some- 
times tending to the erotic or obscene, 
evidently without abolition of conscious- 
ness ; laughing, singing or rhyming, and 
perverseness of conduct, which is still 
more or less coherent and seemingly wil- 
ful,-may occur in connection with, or in- 
stead of, the usual hysterical convulsions. 
Or the ordinary hysterical symptoms may 
pass by degrees into chronic Insanity. 
Loss of power of will is a characteristic 
symptom of hysteria in all its Protean 
forms, and with the perverted sensations 
and disordered movements there is always 
some degree of moral perversion. This 
increases until it swallows up the other 
symptoms : the patient loses more and 
more self-control, becoming capriciously 
fanciful about her health, imagining or 
feigning strange diseases, and keeping up 
the delusion or the imposture with a per- 
tinacity that might seem incredible, and 
getting more and more indifferent to and 
impatient of the advice and interference 
of others. Outbursts of temper become 
almost outbreaks of mania, particularly at 
the menstrual periods. An erotic tinge is 
sometimes observable in the behavior. 
More or less dulness of intelligence and 
apathy of movement, giving the seeming 
of a degree of imbecility, is common 
enough in chorea, and in some cases there 
is a violent delirium or mania; but be- 
sides these cases there are, I believe, in 
children others in which, without disorder 
of movements, there is a true choreic ma- 
nia : it is an active delirium of ideas 
which is the counterpart of the usual de- 
lirium of movements, and its automatic 
character and marked incoherence are 
very striking; hallucinations of the spe- 
cial senses, and loss or a perversion of 
general sensibility usually accompanying 
delirium. 
Chronic diseases, constitutional and lo- 
cal, favor the production of Insanity in 
many instances. Anaemia plays the same 
weighty part as in the causation of other 
nervous diseases. It is not without in- 
fluence in many cases of hysterical in- 
sanity, as well as in the asthenic form 
which occurs during lactation ; and when 
suddenly produced by great loss of blood, 
it may be the cause of an attack of puer- 
peral mania. The syphilitic virus is now 
known to affect nervous element inju- 
riously, and of late an extreme form of 
dementia has been ascribed to a syphilitic 
exudation, circumscribed or diffused, on 
the surface or within the substance of the 
brain. Tuberculosis is frequently asso- 
ciated with mental disease, one-fourth of 
the deaths in asylums being due to phthi- 
sis ; and a form of suspicious melancholia, 
having something of the character of de- 
mentia about it, has been described as 
phthisical insanity.1 The disappearance 
of a skin disease, or the suppression of an 
accustomed discharge, has of old been 
known to be at times followed by an at- 
tack of mania or melancholia ; and there 
are on record numerous cases of mania 
which have been caused by retrocedent 
gout. Of local diseases favoring the pro- 
duction of Insanity, the influence of those 
of the heart seems to have been over- 
rated ; out of G02 post-mortem examina- 
tions made in the Vienna asylum, the 
heart was found to be affected in one- 
eighth, and in some of these only very 
slightly. Abdominal diseases are some- 
times genuine causes of melancholia ; and 
diseases of the sexual organs in women 
have always had a high place assigned to 
them in the scale of causes. It is certain 
that an attack of mania has followed the 
suppression of the menses, and that the 
return of menstruation is often followed 
by the recovery from Insanity; but it is 
certain also that outbreaks of maniacal 
fury, or of suicidal or homicidal violence, 
have coincided with the period of men- 
struation. Schroeder van der Kolk had a 
patient profoundly melancholic, who suf- 
fered also from prolapsus uteri, and in 
whom the melancholia disappeared di- 
rectly the uterus was restored to its place. 
Flemming relates two similar cases in 
which the melancholia was cured by the 
use of a pessary, in one of them regularly 
returning whenever the pessary was re- 
moved ; and I have seen, in one case, se- 
vere melancholia of two years' duration 
disappear after the cure of a prolapsus 
uteri. Instances are on record in which 
a woman has regularly become insane 
during each pregnancy; and, on the other 
hand, Guislain and Griesingcr mention a 
case, respectively, in which Insanity dis- 
appeared during pregnancy, the patient 
at that time only being rational. 
Under the name of Puerperal Insanity 
are frequently confounded three distinct 
varieties - the Insanity of Pregnancy, 
Puerperal Insanity proper, and the In- 
sanity of Lactation. The first and last 
1 Tuberculosis and Insanity, by T. S. 
Clouston, M.D.; Journ. Ment. Science, April, 
1863. FORMS OF INSANITY AND THEIR SYMPTOMATOLOGY. 
591 
usually have the form of marked melan- 
cholia with suicidal tendency, the second 
appears as an acute and incoherent 
mania. 
The Insanity which sometimes breaks 
out at the change of life in women is com- 
monly a profound melancholia, with vague 
delusions of an extreme character. 
After acute febrile diseases, as typhus 
and typhoid fever, the acute exanthe- 
mata, acute rheumatism, and pneumonia, 
Insanity sometimes follows. In such 
cases it either takes the form of acute de- 
mentia, or of the mild delirium of nervous 
exhaustion, from which recovery takes 
place in a few days; or it steadily passes 
into a chronic and persistent form, espe- 
cially if there be hereditary taint; or it is 
acute, recovery taking place for a time, 
but, as happens after injuries to the head, 
being followed by subsequent marked 
change of temper, and finally Chronic In- 
sanity. 1 
Injuries of the head, when not followed 
by any immediate ill consequences, may 
still, after a time, lead to incurable In- 
sanity, through the degenerative changes 
which they induce in the cortical layers. 
Insolation notably acts perniciously on 
the cerebral centres, either by causing 
acute hypertemia and oedema, or, as is 
more probable, by over-stimulation and 
consequent exhaustion of nervous ele- 
ment. Abscesses and tumors of the 
brain, cysticerci,2 effusions of blood, do 
not directly produce mental disorder, 
which is indeed often absent; and when 
they do give rise to such disorder, they 
seem to act indirectly by a reflex or sympa- 
thetic action. Professor Gerhardt relates 
one case in which mental derangement 
was the first symptom of an embolism, 
the paralytic phenomena following later; 
and in a case recorded by L. Meyer, 
chronic tubercular meningitis gave rise 
to mental disorder.3 Instances are on 
record in which Insanity, like tetanus, 
has been caused by peripheric injury of 
nerve; and of great interest are those 
cases, long since observed by Dr. Darwin, 
in which it occurs as the transference of 
disorder from the spinal centre. 
Let it be distinctly understood, how- 
ever, that of the above enumerated causes 
of Insanity, it scarcely ever happens that 
one acts singly ; many of them would have 
no such ill effect, except through the co- 
operation of hereditary predisposition, and 
the latent hereditary taint might remain 
happily dormant, but for the concurrence 
of unfavorable conditions, physical or 
moral. Whenever such inborn taint does 
exist, it is certain that any great revolu- 
tion in the system, whether arising out of 
external circumstances, or from internal 
causes, such as puberty, pregnancy, and 
the climacteric period, will be fraught 
with danger to the healthy balance of the 
mind. 
[As a fair representation of American 
statistics in regard to Insanity, we may 
refer to those of the Pennsylvania Hospital 
for the Insane, in Philadelphia. Dr. Kirk- 
bride, in his Annual Report published in 
1876, states the supposed causes of 7167 
cases of Insanity, treated in that Hospital 
during 35 years. To ill health of various 
kinds, 1290 cases are ascribed. To intem- 
perance, 637 cases ; loss of property, 230 ; 
disappointed affections, domestic difficulties, 
grief, loss of friends, &c., in all, 570 cases. 
Mental anxiety is credited with 441 
cases ; intense study, with 52 ; intense ap- 
plication to business, 56; want of employ- 
ment, 40 ; puerperal state, 284 ; masturba- 
tion, 93 ; exposure to the sun, or other intense 
heat, 72 ; opium, 27 ; tobacco, 17 cases. 
Of the whole number thus reported 
upon (7167 patients), there were admitted 
between the ages of 20 and 30 years, 2080 
cases; between 30 and 40 years, 1951 
cases ; in each of the other decades of life 
smaller numbers.-H.] 
Forms of Insanity and their Symp- 
tomatology.-A glance at the symp- 
toms of the various forms of mental dis- 
ease reveals at once the existence of two 
well-marked groups: one ofthese including 
all those cases in which the mode of feel- 
ing or the effective life is chiefly or solely 
perverted-in which the whole habit or 
manner of feeling, the mode in which the 
individual is effected by events, is entirely 
changed ; the other, those cases in which 
ideational or intellectual derangement pre- 
dominates. More closely scanning the 
symptoms it is seen that the affective dis- 
order is the fundamental fact; that in the 
great majority of cases it precedes intel- 
lectual disorder ; that it co-exists with the 
latter during its course ; and that it fre- 
quently persists for a time after this has 
disappeared. Esquirol rightly, then, de- 
clared " moral alienation to be the proper 
characteristic of mental derangement." 
"There are madmen,"he says, "in whom 
1 De la Folie Consecutive aux Maladies 
Aigues. Par le Dr. E. Muguier. Paris, 
1865.-Griesinger, op. cit.-On the Delirium 
of Acute Insanity during the Decline of Acute 
Diseases, hy Hermann Weber, M.D.; Med.- 
Chir. Trans., 1848. 
2 On Cysticerci, Archiv der Heilkunde, 
1862, Prof. Griesinger. A case of insanity in 
which several cysticerci were found in the 
brain is related by Joire in the Gazette des 
Hopitaux, 1860; another by Dr. Snell in the 
Zeitschrift fur Psychiatric, 1861; another by 
Baillarger in the Arch. Clin, des Maladies 
Mentales, 1860; and another by Dr. Saunders 
in the Report of the Devon County Asylum 
for 1864. 
3 Prof. Gerhardt, Wiener Med. Presse, No. 
7, 1865; L. Meyer, Zeitschrift fur Psychiatrie, 
1858, p. 716. 592 
INSANITY. 
it is difficult to find any trace of halluci- 
nation, but there are none in whom the 
passions and moral affections are not per- 
verted and destroyed. I have in this par- 
ticular met with no exceptions." This 
experience is in entire accord with that of 
every observer of Insanity, and with the 
principles of a sound psychology. It is 
the feelings that reveal the genuine nature 
of an individual; it is from their depths 
that the impulses of action come, w hile 
the intellect guides and controls ; and ac- 
cordingly in a perversion of the affective 
life is revealed a fundamental disorder of 
the innermost nature, a disorder which 
will be exhibited in acts, rather than, as 
ideational disorder is, in words. To in- 
sist upon the existence of a delusion as a 
criterion of Insanity, is to ignore some of 
the gravest and most dangerous forms of 
mental disease. 
Melancholia. - Here the fundamental 
fact is a deep, painful feeling of profound 
depression and misery, a great mental suf- 
fering. The patient's feeling of external 
objects and events is perverted, so that 
he complains of being strangely and un- 
naturally changed: impressions which 
should rightly be agreeable, or only indif- 
ferent, are felt as painful; friends and 
relatives are regarded with sorrow or 
aversion, and their attentions with sus- 
picion ; he feels himself entirely isolated, 
and can take no interest in his affairs; 
and he either shuns society and seeks 
solitude, lying in bed and unwilling to 
exert himself, or he utters his agony in 
sounds ranging from the moan of dull 
ache to the shrill cry of anguish, or in 
ceaseless gestures of misery, or even in 
some convulsive act of desperate violence. 
All this while there may be no delusion ; 
the patient may be conscious of the 
change in himself, may grieve over his 
unnatural state, and strive to hide or fit- 
fully resist it; but as he gets worse he 
becomes more and more self-absorbed, 
more and more indifferent to, or distrust- 
ful of, those around him, and, finally, suc- 
cumbs entirely to his affliction. Then it 
is, usually, that the vast and formless 
feeling of profound misery takes form as 
a concrete idea-in other words, is con- 
densed into some definite delusion : this 
now being, as it were, the expression of 
it. The patient believes that he has com- 
mitted some great crime, for which he 
must suffer death on the gallows ; that 
he has blasted the happiness of his fam- 
ily ; that he is possessed by the devil, or 
is the victim of a persistent and cruel per- 
secution, by magic or by magnetism; that 
he has committed the unpardonable sin, 
and is for ever damned. The delusion is 
not the cause of the feeling of misery, but 
is engendered of it, and takes different 
forms according to the degree of the pa- 
tient's culture, and the social, political, or 
religious ideas prevailing at the particular 
epoch : what the uneducated person at- 
tributes to witches or to devils, the man 
of some cultivation attributes to magnet- 
ism or to political conspiracy. In certain 
cases it is striking how disproportionate 
the delusion is to the extreme mental an- 
guish-how inadequate it is as the ex- 
pression of it: one, whose agony is that 
of the damned, will aver that it is because 
he has drunk a glass of beer which he 
should not have done, or because he has 
muttered a curse when he ought to have 
uttered a prayer. With him who believes 
that he is doomed to infinite and eternal 
misery, it is not the delusion, but the 
affective disorder, that is the fundamental 
fact; there can be no adequate or definite 
idea of the infinite or eternal, and the in- 
sane delusion of eternal damnation is but 
the vague and futile attempt at expressing 
an unutterable real suffering. It is note- 
worthy, again, how much the affliction of 
the melancholic subsides sometimes w'hen 
a definite delusion is established : the vast 
feeling of vague misery which possessed 
the whole mind has undergone systemati- 
zation in definite morbid action; and 
when the delusion is not active, but re- 
poses in the background, not otherwise 
than as ideas constantly lie dormant in 
the sound mind, the patient may be tole- 
rably cheerful. A suicidal feeling is so 
common that the possibility of its exist- 
ence should always be had in mind ; in 51 
cases of Insanity in which suicide had 
been meditated or attempted, 28 wrere 
cases of melancholia. 
As many as are the varieties of mental 
pain or suffering, so many varieties are 
there of melancholia; the essential cha- 
racter of all of them being an oppression 
of the self, the weight of a great suffering, 
out of which springs the delusion of being 
overpowered by some external agency, 
demoniac or human, or of salvation lost 
through individual sins. The classifica- 
tion of melancholia according to the acci- 
dental character of the delusion is, there- 
fore of little value. Two well-marked 
groups may be distinguished : the first, 
including those who have a definite delu- 
sion-Lypemania; the second, those who 
have no definite cause of terror, but dis- 
play a fearful apprehension of everything 
possible and actual-Pantophobia. 
Hypochondriacal Melancholia represents 
one of the mildest but most persistent 
forms of melancholic depression ; the anxi- 
ety proceeding from an extravagant feel- 
ing of bodily disease and exaggerated 
notions of danger. The morbid feeling, 
which is not usually without some physi- 
cal cause in the organism, may be general, 
or it may be confined to single anomalous 
sensations. The patient is anxious and 
depressed; he complains of anomalous FORMS OF INSANITY AND THEIR SYMPTOMATOLOGY. 
593 
feelings, which he watches and analyzes 
very attentively ; his heart flutters fear- 
fully, a film passes over his eyes, and 
there are strange sensations in his head ; 
he examines his pulse, tongue, and evacu- 
ations, and rarely fails to find something 
abnormal in all of them. He is commonly 
irresolute, sluggish, and indifferent to 
what is not related to the circle of his 
morbid ideas ; but in some cases parox- 
ysms of anguish and despair rise to such 
a height as to sweep away all power of 
self-control, and to issue in suicidal or 
homicidal violence. The intelligence, 
though generally sound in regard to all 
matters that are not overclouded by the 
morbid feelings, is still profoundly affected 
through these. Hence, though hypochon- 
driacal melancholics do not often commit 
suicide or homicide, they may do both ; a 
man in the Somerset Asylum, for ex- 
ample, cut into his belly with a piece of 
glass, and dragged out his small intes- 
tines, in order to let the wind out. The 
transition is indeed gradual from the less 
severe forms to those in which the anoma- 
lous sensations are not merely exaggerated 
and misinterpreted, but are referred to 
some absurdly unreal cause, as to the pre- 
sence of a serpent in the stomach, or to a 
galvanization of the nerves, or even to 
those cases in which the patient supposes 
his legs to be glass, his body butter, or 
himself metamorphosed into a wolf. By 
this declension, hypochondriacal melan- 
choly undoubtedly passes into true melan- 
cholia. 
Climacteric Insanity usually takes the 
form of profound melancholia, with vague 
and vast delusions, as that the world is in 
flames, that it is turned upside down, 
that everything is changed, or that some 
very dreadful but undefined calamity has 
happened or is about to happen. The 
countenance has an expression of a vague 
terror and apprehension. In some cases 
short and transient paroxysms of excite- 
ment break the melancholy gloom ; these 
usually occur at the menstrual periods, 
and may continue to do so for some time 
after the function has ceased. 
In connection seemingly with the de- 
velopment of puberty, or at any rate soon 
afterwards, we sometimes meet with a 
fanciful and quasi-hysterical melancholia in 
girls, which is not very serious when it is 
properly treated. There are periods of 
depression and paroxysms of apparently 
causeless weeping, alternating with times 
of undue excitability, more especially at 
the menstrual periods ; a disinclination is 
evinced to work, to rational amusement, 
to exertion of any kind ; the conduct is 
capricious and soon becomes perverse and 
wilful; the natural affections seem to be 
blunted or abolished, the patient taking 
pleasure in distressing those whose feel- 
ings she would most consider if in health; 
and although there are no fixed delusions, 
there are unfounded suspicions or fears 
and changing morbid fancies. In some of 
these cases, when the disease has become 
chronic, delusions of sexual origin occur, 
and the patient, whose virginity is intact, 
imagines that she is pregnant or has had 
a baby. 
The Insanity of Pregnancy is, as a rule, 
of a marked melancholic type, with sui- 
cidal tendency : a degree of mental weak- 
ness or apparent dementia being some- 
times conjoined with it. Other cases, 
however, exhibit much moral perversion, 
perhaps an uncontrollable craving for 
stimulants, all of which we may perhaps 
regard as an exaggerated display of the 
fanciful cravings, the capriciousness and 
the morbid fears from which women suffer 
in the earlier months of pregnancy. 
The Insanity of Lactation is an asthenic 
melancholia, often with determined sui- 
cidal tendency. The time of its occurrence 
seems to show that the longer the child is 
suckled, the greater is the liability to it. 
Sensibility is commonly much affected 
in melancholia. There may be a general 
diminution of the sensibility of the skin, 
or a local complete loss thereof; and com- 
plaints of preecordial anguish and of 
strange abdominal sensations testify the 
perversion of organic sensibility. These 
anomalous sensations appear sometimes to 
have a relation to the confusion and an- 
guish of mind not unlike that whidh the 
epileptic aura has to the epileptic fit. 
Illusions and hallucinations of the special 
senses are frequent: the patient seeing 
those round him as devils, or smelling a 
corpse in his room, or tasting poison in 
his food, or hearing voices which revile 
and accuse him, or which suggest impious 
thoughts and prompt to violent deeds-it 
may be to imitate Abraham, and sacrifice 
his child.1 
The bodily nutrition usually shares in 
the general depression of tone, although 
it is sometimes remarkable, considering 
the great apparent suffering, how little it 
is affected. When it does suffer, digestion 
fails, and constipation is troublesome; 
the skin loses its freshness, becomes sal- 
low, dry, and harsh; the temperature of 
1 If a person sees, hears, or otherwise per- 
ceives what has no existence external to his 
senses, he has a hallucination; if he sees, hears, 
or otherwise perceives that which has no 
such external existence as he perceives, or 
perceives it with erroneous form or qualities, 
he has an illusion: and if, though perceiving 
external objects as they really exist, he be- 
lieves in the existence of such objects, or con- 
ceives such notions of the properties and 
relations of things, as are absurd to the com- 
mon sense of mankind, he has an insane con- 
ception or a delusion-the ground of the false- 
ness of conception being not error, but a 
morbid condition. 
VOL. i.-38 594 
INSANITY. 
the body is lowered, and the extremities 
are cold ; the respiration is slow, moan- 
ing, and interrupted by deep sighs ; the 
pulse is feeble, sometimes very slow, and 
even intermittent; and menstruation is 
generally irregular or suppressed. Sleep 
is usually deficient, though patients are 
apt to assert that they do not sleep when 
they really do, so little do they feel re- 
freshed by it. Refusal of food, which is 
common, and sometimes very persistent, 
may be due to other causes besides want 
of appetite : it may take place through a 
fear of being poisoned, or in consequence 
of a delusion that the intestines are sealed 
up, or in order to commit suicide by star- 
vation, or in fancied obedience to a voice 
from heaven, or from sheer w ilful obstinacy. 
The behavior of the melancholic accords 
with, or fitly expresses, the character of 
his ideas and feelings; and three well- 
marked groups of melancholia may be 
made according to the different relations 
on the motor side :- 
1. Melancholia with stupor, 3f. attonita 
is interesting because of its close resem- 
blance to dementia, with which it has 
been confounded. The expression of the 
face is that of a vacant, self-absorbed 
amazement, or the fixed form of some 
painful passion; the patient, as if in a 
trance, or as one only partially awake, 
scarce seems to see or hear ; there is par- 
tial or general insensibility of the skin; 
consciousness of time, place, and persons 
is lost, and the bodily wants and necessi- 
ties are alike unheeded ; the muscles are 
generally lax, or some of them are fixed 
in a cataleptic rigidity. The patient- 
•-who, statue-like, must usually be re- 
moved from place to place-is possessed 
with some terrible delusion, as that the 
whole world is in flames, or that he is 
standing on the edge of a sea of blood, 
and when he recovers his senses he is as 
one awakened out of a frightful dream. 
One lady under my care, who was in this 
state for two years, with the exception of 
an occasional break of lucidity for a few 
hours, and who ultimately recovered her 
senses quite suddenly, believed that every 
one who approached her, and even lifeless 
objects, were threatening to murder her. 
As may easily be imagined, it is not 
always possible to distinguish this condi- 
tion from dementia : for as to live in one 
sensation would be equivalent to having 
no sensation at all, so for a mind to be 
entirely absorbed in one terrible delusion, 
to remain in one persistent state of mor- 
bid consciousness, is equivalent, for the 
time being, to there being no mind at all. 
As, however, recovery may take place 
rather suddenly, though it may sometimes 
last only for a few hours or days and then 
be followed by a complete relapse, it is 
plain that melancholia with stupor is dif- 
ferent from the stupor of real dementia. 
2. Melancholia is often accompanied 
with destructive impulses, to sudden acts 
of violence against self or against others. 
Suicidal impulse is very common amongst 
melancholics, some sincerely and bitterly 
grieving over the horrible propensity as 
the sole cause of their unhappiness : but 
what is very remarkable is the sudden 
manner in which patients usually calm 
are at times surprised and overpowered 
by a desperate impulse, and hurried into 
a convulsive act of violence. A quiet 
man, having the delusion that his soul 
was lost, who had been for months under 
my care, and of whom no one suspected 
any mischief, suddenly started out of bed 
one night, without any warning, and 
flung himself out of a window through 
which it would have been thought impos- 
sible that any man could get. lie was 
possessed with terrible hallucinations, 
thought that the world was come to an 
end, and in a fearful state of writhing 
agony cried, "Let me go! let mego!" 
Like paroxysms recurred occasionally 
during the next few weeks, after which 
the man recovered. The time of waking 
from sleep is that at which the desperate 
impulse is most likely to arise, wherefore 
melancholics should never be left alone 
when getting up in the morning. In 
other cases the sudden act of violence may 
be directed against others ; the patient 
injuring or killing some one by reason of 
a sudden hallucination, or in consequence 
of his anguish having reached such a 
height of unendurable agony as to abolish 
all self-control, and irresistibly to utter 
itself in convulsive violence, either against 
a fancied persecutor or a completely indif- 
ferent person (Baptus melancholims). Of 
such are some homicidal lunatics. Others 
act in obedience to a delusion : an evil 
spirit instigates the demono-maniacs to 
desperate deeds in spite of the will; or its 
impulses intensify their misery and lead 
to determined suicidal attempts, in order 
to escape from the intolerable prompt- 
ings. A melancholic mother has killed 
herself to escape the desperate impulse to 
kill her child. Nor is it inconsistent with 
insanity in such cases that the violent 
deed should have been planned with sur- 
prising cunning and effected with sus- 
tained ingenuity. 
So far from the morbid impulse or act 
constituting the insanity, it is but the out- 
ward and visible sign or expression of a 
profound affective derangement, the tend- 
ency of which is to manifest itself, not as 
ideational insanity does, in words, but in 
acts, and which for this very reason is 
much more dangerous than ideational in- 
sanity : it is truly an affective insanity, 
one symptom of which is homicidal or 
suicidal impulse : the delusion, when there 
is one, and the homicidal act, are both 
symptoms of a deeper-lying disease ; and FORMS OF INSANITY AND THEIR SYMPTOMATOLOGY. 
595 
the morbid manifestation of one may be 
as little within control as that of the other, 
or as the suddenly arising hallucination 
is. In the one case the patient is the vic- 
tim of a morbid idea ; in the other, of a 
morbid movement-in both cases, of a 
convulsion more or less co-ordinated. 
Where the disease is less acute, it is the 
feeling of this affective perversion that 
sometimes drives the melancholic to com- 
mit murder in order to be hanged, or im- 
pels a mother to murder her children in 
order to send them from misery on earth 
to happiness in heaven. It admits of no 
question whatever, and should therefore 
be borne clearly in mind, that the calmest 
melancholic is liable to occasional unac- 
countable exacerbations of disease, during 
the paroxysms of which he may perpetrate 
violence against himself or others ; a won- 
derful relief, and even an apparent sanity, 
with endeavor to escape penal conse- 
quences, sometimes following the accom- 
plishment of the act. 
3. There is a melancholia of acute cha- 
racter, with great excitement and rest- 
lessness, that may even pass into mania. 
It is certain that cases marking every step 
of the transition to mania do occur in 
practice : and it is not always easy, not- 
withstanding the painful character of the 
delusion, to distinguish excited melan- 
cholia from mania : there are truly mel- 
ancholics who are maniacal, as there are 
maniacal patients who are melancholic. 
The more activity of movement there is 
as the expression of the mental suffering, 
the more acute the utterance of the agony 
in gesture-language-in the wringing of 
the hands and the writhing of the body- 
the nearer does the case approach mania. 
The manifestations of excitement are, 
however, generally of a more uniform 
character than those of mania, and often 
even monotonous. 
The course of melancholia is generally 
chronic; remissions are common, but 
complete intermissions rare. Still, it is 
striking sometimes how suddenly a great 
change may take place : Griesinger men- 
tions a case of deep melancholia in which 
there occurred a perfect lucid interval for 
the space of a quarter of an hour ; and I 
have more than once seen a profound 
melancholic awake in the morning cheer- 
ful and seemingly quite well, remain so 
for the rest of the day, and yet be as bad 
as ever on the following day. Such sud- 
den recoveries are, like sudden conver- 
sions, greatly to be distrusted. Still, I 
have met with two instances in which 
sudden recoveries were permanent: in 
one, the patient, who had been acutely 
melancholic for six months, recovered 
suddenly after a flood of tears; in the 
other, the patient was quite well in the 
morning, after a sleepless night of much 
mental anguish and excitement. When 
recovery really takes place, it is usually 
gradual, and from within four to twelve 
months from the commencement of the 
disease ; it is rare, but not impossible, 
after a year, although it may occur now 
and then after several years, especially if 
some great shock has aroused the patient 
to exertion. Half, or even more than 
half, of the cases of melancholia get well 
under proper treatment; and of those 
which do not recover, about half decline 
into mental weakness or complete demen- 
tia-the rest remaining chronic or ending 
in death. Death may be caused directly 
by the exhaustion of excitement or re- 
fusal of food, or it may be due to inter- 
current diseases, phthiscal, cardiac, or 
abdominal. Gangrene of the lung was 
found by Guislain most frequently in 
melancholics who had died after long re- 
fusal of food. 
Mania.-In this form of mental disease 
there is an excitement or exaltation of the 
self-feeling of the individual, the expres- 
sion of which takes place either in the 
movements and conduct or in the charac- 
ter of the thoughts. Accordingly, two 
groups of cases may be broadly distin- 
guished, although they pass insensibly 
into one another and are not unfrequently 
mixed ; the first including all those cases 
of acute mania or maniacal fury in which 
the madness is mainly manifest in the 
actions of the patient, who sings, dances, 
declaims, runs about, pulls off his clothes, 
and in all ways acts most extravagantly; 
the second group including those more 
chronic cases in which the derangement 
is expressed in the ideas, is systematized 
in definite delusions-in which, therefore, 
the morbid action has taken deeper hold 
of the individual. The first group cor- 
responds in the main to acute mania, the 
second to monomania. 
It was held by Guislain that a stage of 
melancholic depression, of greater or less 
duration, almost invariably precedes an 
attack of mania ; and there can be no 
doubt that this sequence is traceable in 
many cases. But it is not so in every 
case, as some have maintained. What 
has been commonly overlooked is, that 
there is not only an affective disorder of a 
depressed or melancholic kind, but that 
there is also an affective Insanity which is 
rather of an excited, expansive, or ma- 
niacal kind-a deep derangement of the 
affective life, in which the individual's 
self-feeling is greatly exaggerated or mor- 
bidly exalted, without positive intellec- 
tual alienation. It is a maniacal dis- 
order, so to speak, of the feelings, senti- 
ments, and acts, without delirium ; and 
it is expressed, as the corresponding affec- 
tive melancholia is. not in delusion, but in 
the conduct of the patient. As it is from 
the affective life that the impulses of INSANITY. 
596 
action come, while the function of the 
intellect is to guide and control, it is in 
strict accordance with reason that, when 
there is affective derangement or perver- 
sion of the mental tone, the morbid im- 
pulses that arise should be beyond control 
or guidance of the will, just as the con- 
vulsion of a limb is beyond control when 
there is derangement of the tone of the 
spinal centres. This inceptive maniacal 
state, which may unquestionably be pri- 
mary, though usually following that of 
melancholic depression, is displayed in a 
great change of moral character ; the par- 
simonious becomes extravagant, the mod- 
est man presumptuous and exacting, and 
the affectionate parent indifferent to his 
family; there is an extreme liveliness of 
manner, or a restless and busy activity, 
as of one half intoxicated ; an overween- 
ing self-esteem is a marked feature, and 
an extravagant expenditure of money or 
an excessive sexual indulgence is com- 
mon. Or the exaltation may be less and 
the perversion of the affective life more 
marked ; in other words, the moral aliena- 
tion more extreme, as witnessed in the 
profound moral derangement which some- 
times precedes a series of epileptic fits, or 
takes the place of an epileptic fit, and in 
most of those cases included by Pinel under 
mania sine delirio and by Prichard under 
moral insanity. In such cases, as with the 
cases of so-called irresistible homicidal or 
suicidal impulse, it has been too much the 
practice to fix attention exclusively upon 
the extravagant actions of the patient, to 
the neglect of the profound affective de- 
rangement out of which his acts spring ; 
so that they have been set apart as spe- 
cial and their real relations overlooked. 
They are truly of the same nature as that 
maniacal perversion of the whole manner 
of feeling sometimes forerunning an out- 
break of mania ; and their morbid expres- 
sions in single acts of vicious or violent 
conduct are of the same kind as those 
general symptoms of acute mania which 
are exhibited in the movements or actions 
of the patients. 
Acute Mania; Maniacal Fury or Frenzy; 
or Having Madness.-It seldom breaks 
out without a preceding stage of affective 
derangement, the period of incubation 
being usually of a melancholic character, 
as though there were a painful forefeeling 
of the coming storm. After a shorter or 
longer feeling of such premonitory de- 
pression there follows a marked change in 
the inclinations, habits, and affections : 
the patient, "much, much different from 
the man he was," gets restless, and is 
prone to wander or travel about, is sleep- 
less at night, or is tormented with very 
vivid dreams ; he next becomes lively and 
excitable, as though half intoxicated, and 
the tone of his voice is sometimes strangely 
altered ; his actions are restless, extrava- 
gant, and turbulent; and all the while he 
thinks himself wonderfully well, and 
scorns the suggestion of medical aid. As 
matters become worse there is an irresist- 
ible propensity to utter the internal com- 
motion in outward gestures, acts, or 
words: the patient sings, dances, declaims, 
shouts, and laughs ; or he is industriously 
occupied in restless and aimless work, as 
in polishing the floor with his saliva, in 
tearing his clothes to shreds, or in chang- 
ing the place of every piece of furniture 
about him ; or he explodes in furious out- 
breaks of rage and raving of word and 
action. The organic appetites or instincts 
come markedly into the foreground, the 
veil of reason being withdrawn : the appe- 
tite is ravenous and indiscriminate, gar- 
bage, or even excrement, being devoured 
with apparent avidity ; and the patient, 
forgetful of decency, and abandoned to 
the promptings of the sexual impulse, 
sometimes masturbates as the monkey 
does, without shame or restraint. Withal 
there is often a certain consciousness of 
his state, so that he may restrain himself 
and seem reasonable for a time, and when 
seemingly at his worst he will sometimes 
yield to the show of energy and determi- 
nation. The mood of mind may be brisk 
and humorous, or bitter, angry, and 
scornful in the face of opposition. There 
is no fixed delusion, nor any fixed group 
of delusions ; but the ideas are rapid, con- 
fused, and transitory, and appear as fleet- 
ing delusions, or immediately utter them- 
selves in automatic impulses to words and 
actions ; the idea of an act, the moment it 
arises in the mind, becomes the act. 
Because of the rapidity of the flow of 
ideas in the early stages, the witty obser- 
vations, acute comparisons, and fluent 
rhymes then sometimes made, it has been 
said that there is an increase of mental 
power. But it is only the semblance of 
an increase : though there is a lively re- 
vival of the past with great vivacity of 
expression, there is no due assimilation of 
the present, but an incapacity to perceive 
rightly the relations of things around, to- 
gether with false judgment with regard 
to them, so that the unhappy sufferer is 
extravagantly joyous in a madhouse; 
there is an entire absence of that co-ordi- 
nation of the feelings and ideas which 
marks the highest mental power and is 
the condition of true will. The lively flow 
of scarce coherent ideas marks the excita- 
bility of an irritable weakness, and is the 
forerunner of a restless succession of iso- 
lated ideas and fragmentary associations 
in the more advanced stages, not other- 
wise than as convulsion is the forerunner 
of paralysis. 
It is striking how complete in some 
cases may be, during the attack, the 
memory of the past, and after the attack, FORMS OF INSANITY AND THEIR SYMPTOMATOLOGY. 
597 
of all that has happened during it; whilst, 
in other instances, the patient will forget 
altogether the events of his madness, like 
as a dream is forgotten, though he may 
remember them again during a subse- 
quent attack. It may happen also that, 
immediately before a second attack, 
thoughts and feelings displayed on the 
occasion of a first attack, but latent since, 
will recur, so that even attendants recog- 
nize the evil presages, and can predict the 
outbreak. 
Hallucinations of the different senses 
are common in mania, and illusions still 
more so. In 178 out of 229 cases Brierre 
de Boismont professes to have met with 
such complications; they are generally 
fleeting, like the other morbid phenomena. 
Some have thought that the long endur- 
ance of the great expenditure of energy in 
acute mania is owing to a perversion of 
the muscular sense, by reason of which 
the true condition of the muscles is not 
declared. There can be little doubt that 
illusions of the muscular sense are at the 
root of the delusions with regard to bodily 
movements sometimes exhibited in mania; 
when a person lying in bed believes his 
limbs or himself to be flying through the 
air, it is certain that the muscular sense 
does not give correct information, but is 
affected with hallucinations. 
The bodily functions often bear the 
great mental agitation of acute mania in 
a surprising manner. The pulse may be 
a little quicker in the early stage, when 
there is perhaps some febrile disturbance; 
but it is afterwards scarce raised in fre- 
quency. The temperature of the body is 
only slightly increased ; but in cases of a 
typhoid type, where there is sleeplessness, 
restlessness, gradual wasting, and where 
the tendency is to death from exhaustion, 
Dr. Saunders has found it to be often 
raised from three to five degrees above 
the natural standard.1 In the Insanity 
occurring after acute diseases, Dr. Weber's 
observations show only a slight increase 
of temperature, although this had been 
raised several degrees during the previous 
disease, and immediately rose again on 
the occasion of a relapse.2 The skin may 
be either dry and harsh, or moist and of 
offensive odor. Constipation is common, 
but in some cases there occurs a continued 
and obstinate relaxation of the bowels. 
The urine Dr. Sutherland found to con- 
tain an excess of phosphates in acute 
mania ; and if this were true, it would 
testify, like the increase of temperature, 
to an abnormal disintegration of tissue. 
More recent examinations of the urine, 
by Dr. Addison, result in the assertion 
that "the quantities of the urine, of the 
chloride of sodium, of the urea, phospho- 
ric and sulphuric acids, excreted during 
the course of a maniacal paroxysm, occur- 
ring in acute mania, epilepsy, general 
paralysis, melancholia, or dementia, are 
less than the amounts excreted in an 
equal time during health."1 
The course of mania is not often regu- 
larly progressive; there are generally 
remissions, and sometimes complete in- 
termissions, or even so-called lucid inter- 
vals. The attacks may return at regular 
or irregular intervals, and thus constitute 
a periodic or recurrent mania ; or attacks 
of melancholia may alternate with them, 
and give rise to what the French have 
described as Jolie circulaire, or folie a 
double forme. The duration of an attack 
of mania may be for hours or months, 
and recovery may be sudden or gradual. 
There can be no question of the occasional 
occurrence of a short maniacal fury, a 
furor transitorius, lasting for a few hours 
or days, usually associated with vivid hal- 
lucinations, and comparable to an attack 
of epilepsy,2 and it is interesting to ob- 
serve that these attacks are sometimes 
preceded by a strange anomalous sensa- 
tion rising, like an epileptic aura, from 
some part of the body to the brain. When 
recovery takes place, it is usually within 
the year ; it is rare after two years ; and, 
indeed, the longer the disease lasts the 
worse is the prognosis, which is always 
unfavorable in recurrent mania and in 
mania alternating with melancholia. Re- 
covery not taking place, the disease passes 
into chronic mania, or into dementia, or 
ends fatally. Death may be due to ex- 
haustion, or to some intercurrent disease, 
such as pleurisy or pneumonia. When 
maniacal exhaustion proves fatal, the end 
may be very sudden and unexpected, so 
as to leave in the mind an anxious feeling 
of doubt whether a more energetic treat- 
ment might not have prevented death, or, 
if energetic treatment has been employed, 
whether that has not had something to 
do with hastening the fatal issue. 
I have described the general features of 
the typical form of acute mania, but we 
1 Report of the Devon County Asylum for 
1864.-Dr. Clouston has recently made some 
careful researches respecting the temperature 
of the insane. He finds the evening tempera- 
ture of every form of insanity to be higher 
than the evening temperature of health, and 
excitement to be almost always attended by 
an increased temperature. (Journ. Ment. 
Science, April, 1868.) 
2 On the Delirium of Acute Insanity during 
the Decline of Acute Diseases; Med.-Chir. 
Trans, vol. xlviii. 
1 On the Urine of the Insane, by A. Addi- 
son, M.D.; British and Foreign Med.-Chir. 
Review, 1865. 
2 Ueber Mania Transitoria, von Dr. L. 
Meyer. Virchow's Archiv, Band viii. Die. 
Lehre von der Mania Transitoria, von Dr. R. 
Krafft-Ebing. Erlangen, 1865. 598 
INSANITY. 
meet with several varieties in practice. 
There is a form of very acute mania, 
which might properly be called an acute 
delirious mania or acute maniacal delirium. 
It is characterized by intense excitement, 
great restlessness and jactitation, entire 
incoherence, there not being the co- 
herence of distinct and enduring delu- 
sion, and by only the briefest flash of 
momentary consciousness of what is going 
on around, or by apparent unconscious- 
ness, except so far as fragments of im- 
pressions are caught up, whirled and lost 
in the agitation of delirium. It runs a 
rapid course, very often to exhaustion 
and death, the pulse becoming quick and 
feeble, the skin hot, and the excitement 
and restlessness continuing to the last. 
[What is called by American writers 
upon psychopathology " Bell's Disease," 
from its especially careful study by Dr. 
Luther V. Bell, is thus described by Dr. 
Curwen, of the Penna. State Hospital 
for the Insane, at Harrisburg " In this 
there is excessive restlessness, incessant lo- 
quacity, the most remarkable incoherence 
of thought and expression (tireless bab- 
bling as it is expressed by the French), 
the pulse is rapid, weak, and very com- 
pressible, so as almost to be stopped, the 
skin is cool and also the scalp, and as a 
general rule dry, except after violent ex- 
ertion, and often even then, the tongue 
and mouth very dry from the incessant 
talking, and the attention can scarcely be 
attracted long enough to obtain an answer 
to any question. In ordinary cases of 
acute mania, or in inflammatory dis- 
orders, the attention may be arrested so 
long as to obtain answers to questions, or 
to change the current of thought, but in 
this it seems as if the individual was so 
impelled to give utterance to the words 
that crowd his mind that he had not time 
to stop for any purpose. The resemblance 
of this condition to the symptoms of acute 
meningitis or cerebritis as laid down in 
the books will mislead any one who will 
not give earnest heed to its peculiar diag- 
nostic symptoms, the freedom from all 
feverish heat, the peculiar weakness and 
softness of the pulse, and the physical 
state of depression of the whole sys- 
tem."-II.] 
Puerperal Mania comes on within one 
month of parturition, and like the In- 
sanity of pregnancy, occurs most often in 
primiparse. It is of an acute and inco- 
herent character, marked by noisy rest- 
lessness, sleeplessness, tearing of clothes, 
hallucinations, and in some cases by great 
salacity, which is probably the direct 
mental effect of the irritation of the gen- 
erative organs. Suicide may be attempted 
in an excited purposeless way. The 
bodily symptoms, contradicting the vio- 
lence of the mental excitement, indicate 
feebleness ; the features are pinched, the 
skin is pale, cold, and clammy, and the 
pulse is quick, small, and irritable. Re- 
covery takes place in three out of four 
cases of puerperal mania, usually in a 
few weeks; the patient, after the acute 
symptoms have subsided, sinking into a 
temporary state of confusion and feeble- 
ness of mind, and then waking up as from 
a dream. 
Jiecurrent Mania reminds us of nothing 
so much as epilepsy in the regularity of 
its recurrence, in the uniformity of the 
symptoms of the attack, each being al- 
most an exact image of the other, in its 
comparatively short duration, and in the 
temporary recovery. The patient becomes 
elated, hilarious, talkative, passing soon 
into a state of acute, noisy, and self-con- 
scious mania, which may last for two or 
three weeks or longer, and then sinking 
into a brief stage of more or less depres- 
sion or confusion of mind, whence he 
awakens to calmness and lucidity. In 
vain we flatter ourselves with the hope of 
recovery: after an interval of perfect 
lucidity, of varying duration in different 
cases, the attack recurs, goes through the 
same stages, and ends in the same way, 
only to be followed by other attacks, until 
at last the mind is weakened and there 
are no longer lucid intervals. Could we 
stop the attacks, mental power might 
still be regained by degrees, but we can- 
not ; all the resources of our art fail to 
touch them, and I know no other form of 
Insanity which, while having so much 
the air of being curable, thus far defies 
all efforts to stay its course. 
When the acute symptoms of mania 
have subsided, and the disease has be- 
come chronic, it presents most varied 
characters, according to its cause and the 
degree of mental degeneration. When 
there is considerable intellectual power 
apart from the delusions, as there usually 
is when the disease has been produced by 
moral causes, then the case may properly 
fall under monomania, or partial derange- 
ment of the faculties ; when there is great 
loss of mental power together with delu- 
sions, as there often is when the disease 
has followed acute mania or a physical 
cause, then it may properly fall into one 
or other of the groups of dementia. On 
the one hand, then, chronic mania runs 
insensibly into monomania ; on the other, 
into dementia. It is remarkable in some 
cases how much intellectual power may 
coexist with extravagant delusions: a 
person who fancies that not an event in 
Europe happens which has not some hid- 
den relation to him, who detects a plot 
against himself in the meeting of a cabi- 
net, or in the journey of an emperor to 
his country palace, may yet have an exact 
[* Transactions of Penna. State Medical 
Society, 1869.-H.] 599 
FORMS OF INSANITY AND THEIR SYMPTOMATOLOGY. 
knowledge of all his affairs, and be capa- 
ble of giving a good opinion with regard 
to them. But what such a person cannot 
be depended on to do is to control his 
conduct. 
The form of mental derangement pro- 
duced by self-abuse-the Insanity of mas- 
turbation- furnishes a good example of a 
chronic mania in which there are no acute 
symptoms, the onset of the disease being 
most gradual. The patient becomes offen- 
sively egotistic; he is full of self-feeling 
and self-conceit; insensible to the claims 
of others upon him and of his duties to 
them ; interested only in hypochondriac- 
ally watching his morbid sensations and 
feelings. His mental energy is sapped, 
and though he has extravagant preten- 
sions, and often speaks of great projects 
engendered of his conceit, he never works 
systematically for any aim, but exhibits 
an incredible vacillation of conduct, and 
spends his days in indolent and self-sus- 
picious self-brooding. His relatives he 
thinks hostile to him, because they do not 
show the interest in his sufferings which 
he craves, nor yield sufficiently to his pre- 
tensions. As matters get worse, the gene- 
ral suspicion of the hostility of people 
takes more definite form, and delusions 
spring up that persons speak offensively 
of him, or watch him in the street, or 
comment upon what passes in his mind, 
or play tricks upon him by electricity or 
mesmerism, or in some other mysterious 
way. Still he professes the most exalted 
moral or religious aims. A later and 
worse stage is one of moody self-absorp- 
tion and of extreme loss of mental power. 
He is silent, or if he converses he dis- 
covers delusions of a suspicious or obscene 
character, the perverted sexual passion 
still giving the color to his thoughts. He 
dies at the last a miserable wreck. This 
is a form of insanity which has certainly 
its special exciting cause and its charac- 
teristic features ; nevertheless, self-abuse 
seldom, if ever, produces it without the 
co-operation of the insane neurosis. 
Monomania; Partial Mania; Partial 
Insanity; Delusional Insanity.-The ex- 
alted self-feeling which in acute mania 
uttered itself chiefly in turbulent action 
gets embodied in a fixed delusion, or in a 
group of delusions, which fails not still to 
testify the overweening self-esteem. As 
in melancholia the feeling of oppression of 
self was condensed into a delusion of being 
possessed with a devil, or otherwise 
afflicted, so here the exaggerated self-feel- 
ing is clothed in a corresponding delusion 
of power or grandeur, and the personality 
of the patient is transformed accordingly: 
he would fain have us believe that he has 
resolved the most abstruse problems of 
science ; that he has devised an infallible 
scheme for reforming the world ; that he 
is king, prophet, or divine. Monomania 
is, then, a partial ideational insanity, with 
overweening estimate of self, and fixed 
delusion or delusions upon one subject or 
a few subjects, apart from which the pa- 
tient reasons tolerably correctly. Patho- 
logically it represents a systematization 
of the morbid action in the supreme cere- 
bral centres-the establishment of a defi- 
nite type of morbid nutrition in them. 
Having regard to the mode of origin of 
the delusion, the deep hold which the 
manner of its genesis proves it to have on 
the individual nature, it will be seen how 
erroneous it is to speak of the mind as 
sound apart from the delusion. As in 
melancholia so here, there is a funda- 
mental affective disorder incapacitating 
the individual from a just appreciation of 
those things that really affect the self, 
that touch to the quick those genuine feel- 
ings revealing his innermost nature and 
instigating his conduct; and he is liable 
at any time to outbreaks of fury, which, 
like the delusion, are but expressions of 
the deep-rooted derangement. The mind 
is not unsound upon one point, but an un- 
sound mind expresses itself in a particular 
morbid action. Patients thus suffering 
often seem calm and harmless enough 
under the regular discipline of an asylum; 
but if they are exposed to the excitement 
of ordinary life, seriously crossed in some 
project, or subjected to the stress of ad- 
verse events, they are liable to outbursts 
of uncontrollable rage or of true mania; 
so that one who may have been hitherto 
only interested by their harmless delu- 
sions, will be horrified at the utter mad- 
ness which they exhibit. 
The particular delusions of the mono- 
maniac differ according to his occupation 
in life and the degree of his culture, and 
are frequently colored by the events, 
social, religious, or political, of th© epoch: 
Esquirol boasted that he could write the 
history of the French Revolution from the 
character of the Insanity which accompa- 
nied its different phases. Hallucinations 
and illusions frequently accompany the 
delusions which they appear sometimes to 
generate and always to strengthen. The 
behavior of the patient accords with the 
character of his delusions: one makes 
sweeping plans and projects, enters upon 
vast speculations, and sometimes goes 
through an immense amount of patient 
and systematic work in perfecting some 
marvellous scientific invention; another 
reveals in gait and manner the exalted 
character of his delusion ; and to a third, 
ordinary language does not suffice to ex- 
press the magnificence of his ideas, and he 
invents new and mysterious signs, which, 
unintelligible to every one else, have 
wonderful significance for him. 
The course of monomania, once estab- 
lished, is very seldom towards recovery ; 
for as it is rarely primary, it represents a 600 
INSANITY. 
further degeneration or more advanced 
morbid action than mania or melancholia, 
upon which it usually follows. Even when 
it is primary, the outlook is not much 
more favorable, for it is then commonly 
secondary to some fundamental vice of 
character. Certainly recovery may take 
place, and the patient awake to sense as 
out of a dream; and in some rare in- 
stances it has taken place after years, 
especially under the influence of the revo- 
lution in the system produced by some 
intercurrent disease or at the climacteric 
period. When recovery does not occur, 
the disease becomes more chronic, lasting 
as such, or passes into actual dementia ; 
the more the exaggerated self-feeling 
which inspires the delusion wanes, and 
the more this, losing its inspiration, be- 
comes a mere form of words, the nearer 
the case gets toward incoherent dementia. 
As a general rule, it may be said that re- 
covery does not take place when a fixed 
delusion has lasted for more than half a 
year. 
Dementia.-It is the natural termina- 
tion of mental degeneration, whether 
going on in the individual or through 
generations ; and it is accordingly in the 
great majority of cases chronic, and sec- 
ondary to some other form of mental dis- 
ease. Dementia may, however, be both 
acute and primary, and is then not always 
distinguished from melancholia with 
stupor. 
Acute dementia sometimes occurs after 
an attempt at strangulation, after certain 
acute diseases, and after a series of severe 
epileptic fits; and in one case under my 
observation a masked epilepsy seemed to 
take this form. As a primary disease, it 
sometimes follows a sudden and severe 
moral shock, and is now and then met 
with in young men and women, obscurely 
connected apparently with the state of 
the sexual functions. Dr. Skae describes 
a sexual or post-connubial mania taking 
the form of acute dementia, met with 
both in the male and female sex, but 
more frequently in the latter, and con- 
nected, he believes, with the effect pro- 
duced on the nervous system by sexual 
intercourse. With these exceptions, de- 
mentia is a chronic and secondary dis- 
ease presenting every possible variety in 
the degree of mental decay. 
After the disappearance of a severe at- 
tack of acute mania, the effects of the 
shock are oftentimes visible in a certain 
condition of mental weakness without 
actual intellectual disorder: the force of 
character seems to have been sapped, and 
the finer moral and aesthetic feelings, 
which are, as it were, the bloom of culture, 
are abolished; the physiognomy has lost its 
highest expression, and the individual pro- 
duces the impression of a certain child- 
ishness. This is one end of the scale 01 
degeneration ; but at the other extremity 
mental power is almost obliterated, the 
acquisitions of the past being completely 
razed out, and no interest in the present 
possible, and the patient leads a mere 
vegetative life. Between these two ex- 
tremes every sort of transition is nut 
with in practice, so that it is impossible 
here to do more than indicate certain 
prominent types. 
Most of the permanent residents in asy- 
lums consist of those who, after mania, 
monomania, and melancholia, have sub- 
sided into a chronic state of more or less 
feebleness and incoherence of mind-the 
crazy people, who represent the wrecks of 
these forms of mental disease. Some 
there are who exhibit a few striking delu- 
sions which seem to be automatically ex- 
pressed ; the strong self-feeling which 
underlies or inspires these in monomania 
has faded away, and they are no longer 
full of self-assertion, nor eager, earnest, 
and consistent in carrying out their plans. 
The old paths of associations are broken 
up, and memory is almost abolished; all 
liveliness of feeling is gone, and there is 
little or no interest in what is going on 
around; and the only momentary ex- 
citement which occurs is when fixed 
delusions are attacked. It is remark- 
able, however, how even in these cases 
the excitement of a fever will sometimes 
restore temporarily the functions of the 
mind which seemed to have gone for- 
ever. The countenance no longer ex- 
presses any fixed passion ; there is a want 
of harmony, or, as it were, a dislocation 
of its features, and the most which it 
manifests is the shivered expression of a 
passion or the shattered wreck of a smile. 
There is a corresponding imbecility on 
the motor side: some can certainly con- 
tinue their former occupation, or can do 
a little simple manual work, but there is 
no systematic correspondence of action to 
delusions, and there is not unfrequently 
a useless and busy industry in gathering 
stones, pieces of paper, and sticks. 
Strange propensities of all kinds are ex- 
hibited, as, for example, to stand or 
crouch in a particular corner, to walk 
backwards and forwards for a certain dis- 
tance on a particular slip of ground, or to 
fantastically ornament the person with 
feathers or flowers. The mood may be of 
surly depression, or of more or less exalta- 
tion. Hallucinations and illusions of the 
extremest kind are frequent, and tend to 
sustain the delusions : one woman has in 
her belly the whole tribe of the apostles, 
prophets, and martyrs; another lovingly 
nurses as her child a lump of wood decked 
in rags; a third person, whose singular 
movements seem unaccountable, is busy 
spinning threads out of sunbeams ; while 
a fourth continues the most violent move- FORMS OF INSANITY AND THEIR SYMPTOMATOLOGY. 
601 
ments of his arms in order to prevent the 
motion of the universe or of his own blood 
from coming to a stand. The bodily 
health is usually good, the patient fre- 
quently getting stout as the active symp- 
toms of mania or melancholia subside into 
the calm of dementia. This group repre- 
sents for the most part dementia following 
on monomania. 
In another group of cases there is 
greater external activity, with a more 
general incoherence or craziness. There 
are no fixed delusions, although there is 
evidence in the patient's incoherent ex- 
pressions, or in his senseless, parrot-like 
repetition of certain words, of the wreck 
of such as existed in the maniacal stage. 
The senses are open to the reception of 
impressions, but these do not seem to be 
further fashioned into ideas. There is 
sometimes entire indifference to surround- 
ings, together with great insensibility to 
pain; or there are short outbreaks of in- 
coherent passion or fury; or there may be 
desperate and unaccountable homicidal 
violence. The predominant mood is dif- 
ferent in different cases: some are gay, 
happy, and prone to laugh and chatter ; 
others are gloomy, weep, and display the 
mimicry of sorrow; while others again 
are malicious, spiteful, and addicted to a 
purposeless mischief with a monkey-like 
cunning and persistence. The loss of 
memory is marked: some have entirely 
forgotten their former life and their own 
names, while others, who perhaps forget 
instantly the last thing said, can repro- 
duce the distant past with fidelity. In 
the movements of some there is marked 
feebleness, or the indication of commenc- 
ing paralysis; while others are restless, 
agitated, and run about with ceaseless 
activity. The bodily health is usually 
good : they sleep well, and eat well, often 
gluttonously and without discrimination, 
and are sometimes prone to get fat, until 
an attack of excitement and agitation, to 
which some are periodically liable, re- 
duces them. The physiognomy is blank 
and expressionless, especially so when the 
patient is addressed; it is also prematurely 
aged. 
Lastly, there is a group of demented 
patients, in whom the mind is almost ex- 
tinguished ; who must be fed, clothed, 
and cared for; who manifest little or no 
sensibility; whose only utterance is a 
grunt or a cry; and whose only move- 
ments are to rub their heads or hands. 
Their existence is little more than orga- 
nie, and if not carried off by pneumonia, 
tubercle, or some other disease, as they 
frequently are, they die from effusion 
on the brain, serous or hemorrhagic, or 
from atrophy of the brain, or from the 
effects of accident, to which, through 
their apathetic helplessness, they are much 
exposed. 
Senile dementia is characterized by weak- 
ness of mind, inability to grasp the pre- 
sent, and great loss of memory, especially 
of recent events; the patient talking of 
events long past as if they had just hap- 
pened, perhaps believing himself to be in 
daily intercourse with persons who have 
long been dead, and confounding his pre- 
sent life, the events of which are almost 
immediately forgotten, with his past life. 
The course of secondary dementia is 
from bad to worse : it is impossible that 
recovery should take place, although the 
condition and habits of a patient may be 
much improved by proper care. Those 
who suffer from acute primary dementia 
get well generally ; but, of course, senile 
dementia, though primary, is beyond the 
reach of remedy. Death may be due to 
effusion on the brain, or to atrophy of it, 
or it is produced by accidental disease, as 
tubercle or pneumonia. Dementia is the 
only form of Insanity in which the aver- 
age temperature is below that of health. 
Moral Insanity.-Under this unfortu- 
nate name,1 Dr. Prichard described cases 
of real mental disorder, in which, without 
hallucination, illusion, or delusion, the 
derangement is exhibited in a perverted 
state of those mental faculties which are 
called the active and moral powers-the 
feelings, affections, propensities, and con- 
duct. lie never meant that a vicious act 
or crime, however extreme, should be 
deemed proof of moral insanity; for he 
expressly insists on tracing the disorder 
to certain recognizable causes of disease. 
"There is often," he says, "a strong 
hereditary tendency to Insanity ; the in- 
dividual has previously suffered from an 
attack of madness of a decided character ; 
there has been some great moral shock, as 
a loss of fortune ; or there has been some 
severe physical shock, as an attack of 
paralysis or epilepsy, or some febrile or 
inflammatory disorder, which has pro- 
duced a susceptible change in the habitual 
state of the constitution. In all these 
cases, there has been an alteration in the 
temper and habits."2 In reality, how- 
ever this moral insanity is no special form 
of disease, but a variety of that mental 
derangement already described as affective 
or pathetic; and briefly to enumerate the 
varieties of this affective form of derange- 
ment, all which were confounded by Pinel 
under mania sine delirio^ will best exhibit 
the nature and relations of moral insanity. 
(a) There are attacks of derangement 
in which the moral or affective alienation 
is very great, and in which the intellect 
[* Impulsive Insanity is reasonably pre- 
ferred. by some writers.-H.] 
2 A Treatise on Insanity and other Disor- 
ders affecting the Mind. By J. C. Pritchard, 
M.D., F.R.S. 602 
INSANITY 
is only secondarily affected through the 
moral perversion, the patient reasoning 
very well from the premises of his per- 
verted feeling ; he has no delusion unless 
his whole manner of thought in reference 
to self be called a delusion. These attacks 
are often associated with epilepsy, which 
they may immediately precede, as they 
sometimes precede an outbreak of mania; 
or they may occur at periodical intervals 
for months before actual epilepsy, and 
sometimes take the place of the true 
epileptic seizure afterwards; or again, 
the epileptic fits may cease entirely, and 
be followed by such attacks of profound 
moral derangement, occurring at uncer- 
tain periods, and perhaps passing into 
dementia. It is important to bear in 
mind that when associated with the 
epileptic neurosis they represent a con- 
dition in which vivid hallucinations and 
irresistible impulses of a desperate kind, 
homicidal or suicidal, are apt to arise in- 
stantaneously ; that they, in truth, em- 
brace the most dangerous forms of the 
so-called impulsive insanity-the mono- 
mania instinctive of Esquirol. 
(6) There is the melancholic depression 
of the affective life already described- 
simple melancholia, in which the anguish 
rises to such a pitch as to issue in an ex- 
plosion of convulsive violence, homicidal 
or suicidal, no fixed delusion being pre- 
sent. Some of the cases of so-called im- 
pulsive insanity are examples of this form 
of disease. 
(c) The moral insanity proper of Pri- 
chard (monomanie raissonnante, Esquirol) 
occurs in most instances as the result of 
hereditary taint, aggravated or not by 
unfavorable conditions of life. It is a 
more advanced stage of degeneration than 
that which has been described as the in- 
sane temperament, but it does not reach 
actual intellectual derangement: the 
moral feeling being the highest acquisi- 
tion of human culture in the course of de- 
velopment through the ages, its loss is 
one of the earliest effects of degeneration. 
Moreover, it will always be necessary to 
consider the social condition of any one 
suspected to have moral insanity, inas- 
much as it is in the loss of the social feel- 
ing by reason of disease that the alienation 
essentially consists. If a person in a good 
position, possessed of the feelings that be- 
long to a certain social state, docs, after a 
cause known to be capable of producing 
every kind of Insanity, undergo a great 
change of character, lose all good feelings, 
and from being truthful, temperate, and 
considerate, become a shameless liar, 
shamelessly vicious and brutally perverse, 
then it is impossible not to see the effects 
of the disease. Friends and relatives may 
remonstrate with such a one, and punish- 
ment may be allowed to have its due 
course ; but in the end both friends and 
every one who has to do with him must 
confess that he is the victim of disease- 
that his proper place is not the prison, but 
the asylum. Such moral alienation may 
occur after previous attacks of Insanity, 
after acute fevers, after some form of brain 
disease, or after injury to the head. After 
an attack or two of melancholia with sui- 
cidal tendency, from which recovery has 
taken place, the patient is perhaps attacked 
with genuine moral insanity, which ulti- 
mately passes into intellectual disorder 
and dementia. Or there has been more 
or less congenital moral defect, and mani- 
acal exacerbations of actual moral insan- 
ity, without positive intellectual disorder, 
take place, dementia following after a time; 
these outbreaks may occur at puberty, or 
at the menstrual periods. A moral in- 
sanity again is in some instances the first 
stage of mental degeneration that is pro- 
duced by self-abuse or sexual excesses : it 
now and then occurs in consequence of a 
severe moral shock, as the forerunner of 
more marked Insanity ; and it not unfre- 
quently precedes general paralysis. If 
the evidence from its own nature and 
causation were insufficient, the simple 
fact that it is often the forerunner of the 
severest mental disease, might suffice to 
teach the right interpretation of moral 
insanity. 
(d) There are certain beings who are 
truly moral imbeciles, the original defect 
being due, as in idiocy, to some cause act- 
ing either before birth, or during the first 
years of life. With such moral defect 
there is often associated more or less intel- 
lectual imbecility, though not always 
plainly so; it is remarkable indeed what 
an acute intellect may sometimes coexist 
with an entire absence of the moral sense. 
Some of the notorious gaol-birds amongst 
the criminal classes belong to this group ; 
and in higher social spheres there are now 
and then met with unhappy creatures who, 
from their earliest years, have been ad- 
dicted to lying and stealing, or every sort 
of vicious act-who have been expelled 
from school after school, the hopeless 
pupils of many masters, and who finally 
end in an asylum. They are instinctively 
vicious or criminal, exhibit a complete 
moral insensibility, and commonly mas- 
turbate ; and they sometimes decline into 
mania and dementia. 
Here, then, may conveniently be sum- 
med up in groups, according to their most 
prominent symptoms, the various forms of 
Insanity described, idiocy and general 
paralysis, which yet remain to be described, 
being added:- FORMS OF INSANITY AND THEIR SYMPTOMATOLOGY. 
603 
I. Affective or Pathetic Insanity. 
1. Maniacal perversion of the affective life. 
Mania sine delirio. 
2. Melancholic depression, or Simple Melan- 
cholia. 
3. Moral alienation proper; approaching 
which, but not reaching the degree of 
positive insanity, is the insane tempera- 
ment, or the neurosis spasmodica. 
development of the brain as the minister- 
ing organ of the mental life really takes 
place after birth, and that an arrest there- 
of would take place within the recesses of 
the intimate activity of nervous element 
to which our senses have not gained access 
-where the subtlety of nature yet far ex- 
ceeds the subtlety of human research. 
Marked imperfections of the brain are un- 
doubtedly often met with in idiots. It is 
sometimes abnormally small, the general 
arrest of growth being due either to some 
condition of defective bodily nutrition, or 
to a premature ossification of the sutures 
of the skull and a consequent prevention 
of the growth which normally takes place 
actively during the first years of life. 
While it may be that there is no other 
defect than the abnormal smallness, it 
happens much more frequently that there 
are other anomalies, as hydrocephalus, 
unequal size of the hemispheres, and defi- 
cient development of the convolutions. 
All degrees of unequal size of the hemi- 
spheres have been met with, from that 
slight difference which is natural, to that 
extreme degree where a whole hemisphere 
has been replaced by a meshwork filled 
with fluid. Again, there is scarce a par- 
ticular part of the brain which has not 
occasionally been found wanting: the 
corpus callosum may be defective or ab- 
sent ; there may be a deficient develop- 
ment of the anterior lobes, and a simplicity 
of the convolutions, such as belong to the 
lower animals ; or the posterior lobes may 
not extent! far enough back to cover the 
cerebellum, as normally they do not in some 
monkeys, and in all the animals below 
them. Chronic hydrocephalus, apparent- 
ly primary in some cases, but in many 
others secondary to the atrophy or defect 
of brain, is frequent in idiots, and some- 
times makes them large - headed ; the 
serous fluid may exist in large quantity 
within the ventricles without being fatal, 
and death ultimately occur suddenly from 
a slight increase of it.1 Sclerosis of the 
brain-substance often accompanies atro- 
phy, or defect of development. 
The irregularities of the skull in idiocy 
have been much studied of late. When 
the development of the brain is simply 
arrested, the growth of the bone may be 
arrested also, and then the skull is micro- 
cephalic. More often it would appear 
that owing to some constitutional defect 
of nutrition the arrest of the growth of 
the bone is primary, and a premature clo- 
sure of the sutures takes place, whence 
follows a narrowing or shortening of the 
II. Ideational Insanity. 
1. General: 
a. Mania 
[ Acute. 
Chronic. 
I Recurrent. 
b. Acute Melancholia. 
2. Partial: 
a. Monomania. 
b. Melancholia, Lypemania. 
Primary. 
Secondary. 
3. Dementia 
4. Idiocy. 
5. General Paralysis. 
In making use of this or any other pro- 
visional classification of symptoms, it 
should be clearly understood that the 
forms of Insanity are not actual pathologi- 
cal entities, but different degrees or kinds 
of the degeneration of the mental organi- 
zation-in other words, of deviation from 
healthy mental life : and they are conse- 
quently sometimes found intermixed, re- 
placing one another, or manifested in suc- 
cessive order in the same individual. 
There is a strong propensity not only to 
make divisions in knowledge where there 
are none in nature, and then to impose 
the divisions upon nature, making the 
reality thus conformable to the idea, but 
to go farther than that and to convert the 
generalizations from observation into posi- 
tive entities, and then to permit these 
creations to tyrannize over the thoughts. 
A typical case of madness might be de- 
scribed as one in which the disorder, com- 
mencing in emotional disturbance and ec- 
centricities of actions-in derangement of 
the affective life, passes thence into melan- 
cholia or mania, and finally, by a further 
declension, into dementia. This also is 
the natural course of mental degeneration 
proceeding unchecked through genera- 
tions. The necessity of describing differ- 
ent forms of Insanity under different 
names should never lead to a neglect of 
the real relations which they have to one 
another as different stages of deviation 
from that mental life which we agree to 
regard as ideal or typical. 
Idiocy.-It is an arrest of mental devel- 
opment by reason of some defect of cere- 
bral development which is either congeni- 
tal or occurs soon after birth. It will not 
appear strange that such defect is not al- 
ways detectable when we reflect that the 
1 On Serous Effusion from the Membranes 
and into the Ventricles of the Brain, by John 
Sims, M.D.; Med.-Chir. Trans, vol. xix.- 
Clinical Notes on Chronic Hydrocephalus in 
the Adult, by S. Wilks, M.D. ; Journ. Ment. 
Science, January, 1865. 604 
INSANITY. 
skull. Compensating enlargements there- 
upon take place in some cases, the growth 
of the brain being in the direction of least 
resistance, and increasing the cranial de- 
formity though making the mischief less. 
According to the suture prematurely 
closed, and to the amount and character 
of the compensating enlargement, will be 
the degree and kind of the deformity, of 
which many kinds have been described. 
Virchow has investigated with great care 
what he calls the tribasilar synostosis, 
which, occurring at the base of the skull, 
is the anatomical condition of the skull of 
Cretinism. 
The causes of idiocy are sometimes 
traceable to parents. Frequent inter- 
marriages in families lead to a degenera- 
tion that manifests itself in deaf mutism, 
albinoism, and idiocy; parental intemper- 
ance and excess, according to Dr. Howe,1 
occupy a high place as causes; and the 
natural term of Insanity proceeding un- 
checked through generations is, as Morel2 
has shown, sterile idiocy. During ftetal 
life great fright or mental agitation in the 
mother, or irregularities and excesses on 
her part, may lead to mental defect in the 
child. But perhaps the most frequent 
causes of an arrest of mental development 
are those which operate after birth up to 
the third or fourth year: they are epi- 
lepsy, the acute exanthemata, perhaps 
syphilis, and certainly conditions of bad 
nutrition, such as are produced by over- 
crowding, dirt, and want. Cretinism is 
an endemic idiocy arising out of unknown 
territorial conditions. 
The extremest idiots are destitute of 
any intelligence whatever ; they are apa- 
thetic, torpid beings, having a human 
semblance, whom it is necessary to feed, 
to move, to clothe, to take care of in every 
particular ; who can attend to nothing, 
and remember nothing ; who cannot speak 
a word; who grunt, make unintelligible 
sounds, and are unquiet if their appetites 
are not satisfied, or mechanically continue 
some automatic movement of hand, head, 
or body. The senses are almost invaria- 
bly defective or wanting, the sensibility 
of the skin being commonly very imper- 
fect, the hearing feeble, and smell and 
taste so deficient or perverted that the 
most acrid or filthy matters are eaten 
with indifference. The muscular devel- 
opment shares in the general defect; there 
are cramps of the limbs, contractions or 
paralysis of certain muscles, and epileptic 
convulsions. In Scotland there were, five 
years ago, 2236 imbeciles and idiots, of 
whom 43 were paralytic, 46 hemiplegic, 
10 paraplegic, 17 choreic, and not less 
than 207 epileptic.1 In less extreme cases 
there is evident want of power over the 
muscles ; the walk is staggering and un- 
certain, the eye rolls vacantly, strabismus 
is common, the speech is defective, and 
there is slavering at the mouth. Sexual 
power is absent in the worst cases, and 
notwithstanding the self-abuse practised 
by some idiots, feebleness is in all cases 
more common than excess. 
At the other end of the scale stand the 
so-called imbeciles, the highest of whom 
are only a little lower than those simple- 
minded people not deemed imbecile. The 
difference again between imbecility and 
idiocy is only one of degree, so that it is 
impossible to define it. In all sorts and 
conditions of idiocy two principal types 
may be broadly distinguished : one em- 
bracing the torpid and apathetic beings, 
who have usually some bodily deformity, 
and who give feeble signs of life ; the 
other, those lively and excited beings 
who, rarely observably deformed, are un- 
quiet and restlessly respondent to a rapid 
succession of impressions, who shriek, 
laugh, weep, gesticulate, clap their hands, 
get into mischief, and sometimes pass by 
a turbulent declension into true maniacal 
fury. Even the quiet idiots are occasion- 
ally liable to sudden attacks of fury, in 
which they bite, shriek, scratch, kick, 
beat their heads against the walls, and in 
other ways act viciously enough. Spe- 
cial talents or aptitudes of a remarkable 
kind, for remembering, for drawing, or 
for music, which seem quite inconsistent 
with the general character of their intel- 
ligence, are sometimes exhibited by idiots 
whose disease is of hereditary origin. 
Esquirol divided idiots into three 
classes, according to the condition of 
speech. The first division included those 
who could use words and short phrases ; 
the second, those who could only utter 
monosyllables and certain cries; the 
third, those who had neither speech nor 
monosyllable. Dr. Hack Tuke2 proposes 
a physiological division of them into, 
first, those who exhibit only reflex or ex- 
citom otor movements; secondly, those 
whose acts are sensorimotor and ideomo- 
tor ; and thirdly, those who manifest vo- 
lition. It is a division which, not perhaps 
practically available, serves to mark the 
different degrees of degeneracy. By Grie- 
singer, idiots are grouped in certain types : 
1. Well-formed children in whom the 
mental development, which remains at 
the lowest grade, is the only apparent de- 
1 The Psychology of Idiocy; Journ. Ment. 
Science, April, 1865.-Epileptics: their Men- 
tal Condition, by W. A. F. Browne, Commis- 
sioner in Lunacy for Scotland; Journ. Ment. 
Science, October, 1865. 
2 Manual of Psychological Medicine, by Dr. 
Bucknill and Dr. D. Hack Tuke. 
1 Report on the Causes of Idiocy. 
2 Traitfi des DegSnerescences physiques, 
intellectuelles et morales, de 1'EspSce hu- 
maine, par Dr. B. A. Morel, 1857. FORMS OF INSANITY AND THEIR SYMPTOMATOLOGY. 
605 
feet, the defect not being due to any 
hereditary, but to some accidental cause 
of degeneration. 2. The cases in which 
both bodily and mental development have 
been palpably arrested: these are the 
dwarfs in mind and body. 3. The Cretin, 
or basilar-synostotic type of idiocy or im- 
becility. Cretinism generally manifests 
itself a few months after birth, and is 
frequently associated with bodily de- 
formity and goitre ; and it is supposed to 
be due to some miasmatic influence pri- 
marily affecting the growth of the bones 
of the skull. It is most common amongst 
the mountains of Switzerland, but is met 
with sometimes in badly-drained places, 
and now and then sporadically. 4. The 
Aztec type, consisting of the true micro- 
cephalic idiots. 5. The theroid idiots, 
who have a sort of resemblance to some 
animal. Pinel, for example, gives a 
striking account of an idiot who was very 
like a sheep in habits and manner ; and 
some idiots irresistibly bring to mind the 
monkey. Still, however degraded an 
idiot may be, he never really reverts to 
an animal type ; for he represents a new 
and morbid variety, which but for the 
fostering care of higher beings, would 
speedily be extinguished. 
Though idiots can never reach a nor- 
mal development, their condition in many 
cases may be much improved by perse- 
vering training. The faculties which they 
do possess may thus be brought out in a 
remarkable manner, and they be made 
automatically skilful in certain tasks. 
When epilepsy has coexisted with the 
idiocy, and has afterwards disappeared, 
marked improvements may take place. 
Idiots very seldom attain old age; they 
are " old in their youth, and die ere mid- 
dle age," apparently from lack of vitality. 
In some cases, the disease of brain-atro- 
phy or hydrocephalus-directly leads to 
death. 
General Paralysis.-It is a form of In- 
sanity, first described by Bayle and Cal- 
meil, which is characterized by a progres- 
sive diminution of mental power, and by 
a paralysis which gradually increases and 
invades the whole muscular system. It 
is far more frequent amongst men than 
women, and its most frequent cause is in- 
temperance of some kind. Two of the 
best marked examples of this disease 
which I have seen, occurred, however, in 
teetotallers, who never had been given 
to alcoholic excess ; but in both there was 
hereditary taint, and in both there was 
reason to suspect enervating, though 
marital, sexual excess. 
Much discussion has taken place as to 
whether the mental symptoms precede 
the paralytic phenomena, or whether the 
latter first appear-whether the Insanity 
is primary, or whether, as Baillarger 
holds, the paralysis is the primary and 
main affection, the Insanity secondary 
and accessory. There can be no question 
in the minds of those who, unbiassed by 
any theory, simply observe cases, that 
the mental disorder does sometimes ap- 
pear simultaneously with the motor dis- 
order ; that far more frequently, indeed 
most frequently of all, the mental symp- 
toms are observed some time before there 
is any trace of paralysis; but that in 
some few cases the paralytic phenomena 
do precede by a short period the mental 
symptoms. In fifty-one cases out of 
eighty-six observed carefully by Par- 
chappe, he found the paralysis and mental 
disorder to be simultaneous; in twenty- 
seven cases the paralysis was subsequent, 
and in eight the precedence was undeter- 
mined. Leidesdorf has related one case 
in which the earliest symptoms were 
spinal; and one or two similar cases have 
been recorded.1 
The motor symptoms are first witnessed 
in the tongue, which has to execute the 
most delicate and complex movements 
with so much precision, and especially in 
the articulation of words abounding in 
consonants, where the most complex co- 
ordination is required. When the patient 
speaks earnestly, he does not articulate 
exactly, and there is a certain pause or 
indecision detectable in his utterance, as 
if there was some difficulty in bringing 
out the word ; in some cases the speech is 
slower, more deliberate, with a strong ac- 
centuation of and a lingering on the syl- 
lables, as if the patient were speaking 
with great consideration. When the 
tongue is put out, which is done with 
some difficulty, there is a fibrillar quiver- 
ing or trembling of its muscles, but it is 
not pulled to one side. There is a tremu- 
lousness, also, in the muscles of expres- 
sion when put in action-especially in 
those of the lips, which quiver as in one 
just about to burst into tears. These 
phenomena, which are of fatal omen, may 
not be apparent at first, when the patient 
is calm and collected ; but if he has had 
a sleepless night, or if he is much excited 
from any cause, then they become evi- 
dent. An inequality in the size of the 
pupils is often an early symptom, but it 
is not a characteristic one; it is some- 
times present in other forms of Insanity, 
and it is not always present in general 
paralysis. A transitory squint is observed 
occasionally at the commencement of the 
disease, and at a later period a slight 
ptosis of the upper eyelid. As the dis- 
ease increases, the patient's walk becomes 
affected : the feet are not properly raised 
and firmly put down on the ground ; he 
easily stumbles at a step or on uneven 
1 Beitrage zur Diagnostik der Geisteskrank- 
heiten. Von Dr. M. Leidesdorf. 606 
INSANITY. 
ground, and if asked suddenly to turn 
round when walking straight forward, he 
will stagger like a drunken man. He 
may nevertheless be very active in walk- 
ing, and commonly thinks himself won- 
derfully well and strong. Precise co- 
ordination of movement, such as is neces- 
sary for writing, sewing, and like acquired 
automatic acts, is lost. The disease still 
advancing, the articulation becomes less 
distinct, the walk more and more totter- 
ing ; the knees fail : the patient frequently 
tumbles, and finally cannot get up again 
without help. At last the primary auto- 
matic or reflex movements fail; the pu- 
pils become dilated, but unequal in size ; 
the sphincters lose their power, and the 
patient may be choked by a lump of food 
getting into his larynx. Sometimes there 
are transitory contractions of arm or leg, 
and a grinding or gnashing of the teeth 
is not uncommon. The contractility of 
muscles to the electric stimulus is re- 
tained. 
Cutaneous sensibility is usually dimin- 
ished in the early stages, and at a later 
period. it is sometimes lost. Yet there 
are occasionally transitory conditions of 
extreme hypersesthesia, so that the pa- 
tient shrieks out in great agony, or the 
slightest touch produces reflex movements 
or even convulsions. The muscular sense 
is especially affected, so that the sufferer, 
deprived of power of executing all com- 
plex and delicate movements, deems him- 
self not less skilful than when at his best 
state, or, quite paralyzed, believes himself 
to have a giant's strength. The special 
senses are commonly unaffected until near 
the end, when smell and taste are dimin- 
ished or lost, and vision fails. Sometimes, 
however, the patient has vivid hallucina- 
tions in the night: there were glorious 
visions of angels descending from heaven 
on ladders of gold in one patient under 
my care, and an agonizing vision of his 
own wife in the act of adultery rendered 
another frantic for a time. A great in- 
crease of sexual desire and an excited 
display of it are not unfrequent at the 
beginning of the disease, but there is not 
corresponding power; and what power 
there may be" is soon quite lost. 
The mental derangement is commonly 
marked by an exaggerated feeling of per- 
sonal power and importance. After a 
brief stage of melancholic depression there 
is a notable change in the character, man- 
ifest in different ways: in one there is 
great mental excitement, and he is joy- 
ously and actively busy with wide-sweep- 
ing projects and speculations, indifferent 
to stern realities, and in all ways eager 
and ready to accomplish the impossible : 
in another there is a lack of former energy, 
and he is painfully troubled about little 
things, dull and confused in his thoughts, 
and demented in behavior; while another 
exhibits unwonted perversities of feeling 
and conduct, such as mightily astonish 
his friends ; he breaks out into sexual ex- 
cesses quite foreign to his usual sober 
character, or orders numerous articles of 
jewelry for which he can never pay, or 
even steals what strikes his fancy. Begin 
as it may, the mental disorder, when un- 
checked, generally issues in incoherence 
and extravagant delusions as to personal 
power and grandeur: the miserable suf- 
ferer who can scarce support his tottering 
body avers that he has the might and 
vigor of Hercules; while industriously 
hoarding up pieces of rag, paper, or gla-ss 
as articles of value, he will sign a check 
for countless millions, or make an easy 
present of New York ; maintaining that 
he can command a king to do his pleasure, 
in the same breath he prays piteously to 
be allowed to go to his own humble home ; 
or, with sexual power extinct, boasts 
exultantly that a princess shall be his 
w ife and princes be born of his loins. An 
extreme loss of memory is in striking 
contrast with the semblance of exaltation ; 
the patient forgets entirely how long he 
has been in confinement, or denies angrily 
that he has a wife, though recognizing her 
gladly when she visits him. In some 
cases the delusions are of a terrific charac- 
ter and accompanied with great emotional 
depression ; and a day of melancholic de- 
pression may now and then intervene in 
the course of the exalted form. There is 
a class of patients who present in physi- 
ognomy and habit of body a mixture of 
stupidity and the deepest depression, and 
exhibit sad delusions of as extreme a 
character as the delusions of grandeur: 
they think themselves bodily transformed 
in whole or in part; that their body has 
been immensely enlarged, that their eyes 
cannot see, their ears cannot hear ; that 
their throat is sealed up. Dr. Clouston 
has pointed out that there is an intimate 
relationship between this form of general 
paralysis with depressions and tuberculo- 
sis. In another variety, of rare occur- 
rence, the mental disorder consists in a 
regular decline of intelligence-a gradu- 
ally increasing stupidity from the first. 
Attacks .of great excitement and blind 
violence frequently occur during the pro- 
gress of the disease. During them L. 
Meyer has observed the temperature of 
the head to be raised, and after them the 
mental decay is found to have increased. 
As the disease approaches its end-the 
end of life-the dementia is extreme, and 
the face becomes an expressionless mask 
across which now and then flickers the 
broken ripple of a smile, or it is fixed in a 
ghastly, sardonic grin ; but even in the 
last stage of mental disorganization, when 
the capability of a distinct delusion is DIAGNOSIS. 
607 
gone, the muttered words are oftentimes 
about golden carriages and millions of 
money. 
The course of general paralysis is towards 
death, though not steadily so. Under 
proper treatment a great improvement 
takes place in the early stages, and the 
disease seems to be arrested. Some have 
thought that actual recovery does now and 
then take place ; and certainly there have 
been in exceptional cases intermissions of 
such a length that the disease has lasted 
for ten years. On the whole, however, it 
is irregularly progressive, its duration 
being usually from a few months to about 
three years. It hardly ever occurs before 
the age of thirty. In the more advanced 
stages sudden attacks of loss of conscious- 
ness, with epileptiform convulsions, are 
not unfrequent, after which the paralysis 
and mental decay are both found to have 
increased. Dr. Saunders has observed 
that the temperature of the body in gen- 
eral paralysis is generally one or two 
degrees below the average, but that it 
rises during the excesses of maniacal ex- 
citement, tailing again as calmness re- 
turns. During the so-called congestive 
attacks, again, where there is complete 
coma or epileptiform convulsion, there is 
generally a considerable rise of tempera- 
ture : in one case the temperature was for 
some time 98°, but it rose an hour after 
one of these attacks to 105°, and next day 
to 106°, the patient dying in thirty-six 
hours from the commencement of the at- 
tack.1 Dr. Clouston has found that in 
general paralysis there may be a differ- 
ence of 5*8° in the same individual in 
different stages of the disease. In the 
last miserable stage of all, when life 
flickers before extinction, large sloughing 
bedsores form, notwithstanding the best 
care, and diarrhcea or pneumonia hastens 
the long-expected ending. 
Diagnosis.-The diagnosis of Insanity 
is as difficult in some cases as it is easy in 
others. Acute mania cannot well be con- 
founded with any other disease, and the 
only doubtful question in regard to it will 
be in the event of an impostor attempting 
to simulate it. He must be a clever im- 
postor, however, who can simulate the 
wild restless eye, the quick fragmentary 
associations of ideas, the rapid capricious 
movements, and the volubility of utter- 
ance of acute mania, so as to deceive an 
experienced observer ; nor can he, how- 
ever skilful, pass days without sleep, and 
even weeks with only a few hours' sleep, 
maintaining a constant activity the while, 
as the maniac does. The skin in acute 
mania is dry and harsh, or clammy, but 
the skin of a pretender who tries to keep 
up the muscular agitation will hardly fail 
to be hot and sweating. Meningitis will be 
known from mania by its own positive 
symptoms,-by the premonitory rigors, 
when they occur, the cephalalgia, the 
fever, the contracted pupil, and the in- 
tolerance of light; by a muscular activity, 
paroxysmal, not continuous, and by fre- 
quent spasms or convulsions; by the 
acute severity of the delirium and the 
vivid illusions of the senses ; and by its 
rapid progress either to recovery or death. 
Delirium tremens will also be distinguished 
by its characteristic symptoms-the mus- 
cular tremors, the peculiar fearful illusions 
and hallucinations, the cold skin, feeble 
pulse, and white and tremulous tongue. 
It must not be forgotten, however, that 
persons who have a strong predisposition 
to Insanity, or who have been insane, or 
who have suffered at some time from a 
severe injury to the head, do sometimes 
after an alcoholic debauch become truly 
maniacal for a time. In this condition, 
which may be of short duration, dan- 
gerous hallucinations sometimes arise, and 
the sufferer may perpetrate crime, not 
knowing afterwards what he has done : of 
this fact a searching investigation of in- 
stances can leave no doubt. The result 
again of continued intemperance, or of a 
long debauch, is sometimes to produce, 
not a delirium tremens, but a true mania, 
marked by active and violent delirium. 
Chronic mania is the most likely form 
of Insanity to be feigned, and if feigned 
with the skill of Hamlet, the very elect 
may be deceived. A vulgar impostor will, 
however, generally " o'erstep the modesty 
of nature," and overact the part in the 
extravagance of what he says, and in the 
absurdity or violence of what he does, 
while he will almost of a certainty fall 
short of his part in the emotional expres- 
sion of the maniacal countenance. Hav- 
ing the popular notion that a lunatic is 
widely different from a sane person, he 
will entirely fail to understand the char- 
acter which he wishes to represent, so that 
an experienced person may detect his 
ignorance ; and believing that he must 
make a great display in order to produce 
an adequate impression, he will, like a 
bad actor, exaggerate and rant, so that 
any one with insight, though without 
special experience, may discover his in- 
competency. He will pretend that he 
cannot remember the simplest things, 
that he cannot reckon correctly, and will 
act extravagantly, and answer stupidly or 
wrongly, when a real lunatic would act 
calmly and answer intelligently or rightly ; 
he will moreover show no irritation or 
anger at the suspicion of his sanity. It 
may not be amiss to suggest incidentally 
in his hearing some symptoms which he 
ought to exhibit, and to take notice 
whether he subsequently adopts the hint. 
1 Report of the Devon County Asylum for 
1864. INSANITY. 
608 
If he refuses to converse, feigning apathe- 
tic dementia with dirty habits, which is 
perhaps the form of insanity most often 
feigned, the diagnosis becomes more diffi- 
cult, and a long observation may be neces- 
sary in order to establish it. It is truly 
astonishing how long an impostor will 
sometimes persist : one man, whose story 
Dr. Bucknill tells, kept up the pretence of 
Insanity for more than two years, and 
then broke down in his part. The two 
important considerations to be kept in 
view are, first, the existence of any motive 
for feigning, and secondly, the consistency 
or inconsistency of the symptoms with a 
definite form of mental disease, Perhaps 
it would not be far from the truth to say 
that he who can feign madness so com- 
pletely as to deceive an experienced ob- 
server, is not far from being the character 
which he represents ; for unless there be 
real madness beneath the feigned phe- 
nomena, there will be some want of coher- 
ence in them as a whole, and an incon- 
gruity w'ith any recognized form of men- 
tal disease. 
The discovery of chronic mania or mono- 
mania where it does exist, but where the 
patient is suspicious and strives to hide 
it, may be a very difficult task. There is 
generally some sign of the disease in the 
countenance and bearing of the patient: 
" The principal characteristic in some is," 
says Dr. Bucknill, "a peculiar want of 
harmony in the expression of the fea- 
tures : in others, the fixed expression of 
some intense emotion is remarkable-of 
defiant pride, of sullen obstinacy, of smirk- 
ing vanity, or of leering sensuality. " The 
demeanor may be defiant, sullen, restless, 
or absorbed, and the clothing untidy and 
neglected: in both demeanor and dress 
there are sometimes peculiarities ■which, 
when bottomed, open up a secret mine of 
madness. To detect any delusion the pa- 
tient should be examined carefully on all 
matters intimately touching himself, any- 
thing peculiar or notable in his expres- 
sions or any obscure references, being 
watched for, noted in the mind, and sub- 
sequently quietly followed up. If he 
seems to pass hastily over, or to avoid, 
some subject, he should be unobtrusively 
but steadily pressed upon it; and if he 
declines to speak of the matter, or gets 
angry, the refusal or irritation is alike 
significant. All this should be done in as 
quiet and amiable a manner as possible, 
so as to avoid giving unnecessary offence, 
and to make it a difficult matter for the 
patient to take offence and break off the 
interview. It is an intellectual contest 
between a sound and an unsound intel- 
lect, in which the weakness of the latter is 
compensated by its acting on the defen- 
sive, the superiority of the former lessened 
by its acting on the offensive. Heinroth 
has affirmed, what is popularly thought, 
hat though the insane may often conceal 
their delusions, they cannot deny them. 
This is by no means true of all cases ; 
some will deny their delusions with as 
much energy as Peter showed when he 
denied the dangerous truth, or will even 
labor to explain them away as jokes. 
When all else fails, it may be worth 
while grievously to offend the patient's 
self-love, and to make him extremely 
angry, and in the fury of passion he will 
sometimes, notwithstanding his suspicion, 
reveal the hidden delusion. Failure will 
be rare with the expert who likes to be 
persistent and patient enough. In doubt- 
ful cases, it will always be well to get the 
patient to write, for it is truly surprising 
what extravagant delusions may be ex- 
hibited in a letter by one who manages 
to conceal them in conversation. Careful 
research should of course be made into 
the previous history, in order to discover 
■whether there is hereditary taint, and 
what degree of it; w'hether there has been 
any previous attack of Insanity, and 
W'hether there has been any observed 
change of feelings, character, and habits, 
especially after some efficient cause oi 
Insanity. At the outset a patient some- 
times has a suspicion that he may be 
thought mad, and is very earnest and 
vehement in accounting for his morbid 
feelings, and at great pains to convince 
those around him that he is not mad.1 
Melancholia is not usually difficult to 
recognize, as patients in most cases do 
not care to conceal their painful delusions ; 
still there are some who do not only con- 
ceal but deny them. A patient afflicted 
with homicidal and suicidal impulse, and 
intensely miserable in consequence, will 
positively conceal and deny the morbid 
impulse, in order to throw those around 
off their guard and the better to effect his 
purpose; and more than one such, fool- 
ishly removed from under control by ignor- 
ant but well-meaning friends, has after- 
wards committed suicide or homicide, or 
both. Another, who cannot entirely con- 
ceal his disease, will even attribute his 
depression to the confinement which he is 
undergoing, and asseverate most earnestly 
that he will be quite wrell at home ; this 
intense eagerness to be delivered from 
control being truly the surest sign that he 
is not fit to be from under control. In all 
such cases it is necessary to watch pa- 
tiently from day to day ; for it will some- 
times happen that a delusion, denied on 
one day, is predominant on another, and 
it is very apt to become so, if the patient 
does not see a prospect of release through 
his simulation of sanity. 
1 There are some excellent observations by 
Dr. Buckmil in the Manual of Psychological 
Medicine, on the mode of conducting the ex- 
amination of an insane person, p. 310. 609 
DIAGNOSIS. 
It may be important to distinguish be- 
tween the hypochondriac and the melan- 
cholic, as the former, committing a mur- 
der, would certainly be hanged, the latter 
probably not. The hypochondriac refers 
his sufferings to some organic disturbance 
or disease, in which there may be more or 
less reality; he displays an exaggerated 
sensibility in regard to all his organic pro- 
cesses, or to some one of them in particu- 
lar, so that he has either many delusions 
respecting his health, or his whole habit 
of thought respecting it is perverted ; he 
is fond of talking of his sufferings, and 
of consulting medical men ; he evinces a 
great love of life, and no disposition to 
commit suicide ; his intellect is sound, and 
his feelings are not perverted, apart from 
questions touching his health. The mel- 
ancholic, on the other hand, refers his 
sufferings to some groundless extraneous 
cause, either operating from without, or 
having taken possession of body or soul, 
or both, so that he has frequently a single 
and fixed delusion ; his anguish is a men- 
tal anguish, and he asserts that medi- 
cine can do him no good ; he is often 
suicidal; his affective life is profoundly 
implicated, and he is incapacitated from 
intellectual activity, though there may be 
no marked intellectual derangement apart 
from the delusion. It must not be over- 
looked, however, that hypochondriasis 
may pass into true melancholia, as well 
as coexist with it, and that a true hypo- 
chondriacal melancholy may rise to such 
a pitch as to render the individual irre- 
sponsible for his actions. 
Melancholia with stupor may easily be 
confounded with acute dementia; nor is 
it always possible to distinguish them at 
the outset. The expression of the melan- 
cholic is that of one astonied, or as if fixed 
in a painful trance-the mind veiled, as it 
were, by a great cloud let down between 
it and the external world. The patient 
stands or sits in one place, or moves 
slowly to and fro; he often offers a pas- 
sive resistance to being moved, or to 
being fed ; sometimes he exhibits a strong 
tendency to suicide, and, now and then, a 
temporary excitement; on recovery, he 
remembers his suffering as a painful 
dream, or as a strange and fearful trance, 
during which he was partly conscious of 
things around, but unable to express him- 
self. In dementia, the countenance is 
expressionless ; there is no resistance to 
being moved, or to food ; the patient is 
not suicidal; the bodily functions are less 
affected ; on recovery, there is no memory 
of the attack. 
In certain criminal or civil trials, it 
may be necessary to distinguish between 
eccentricity and Insanity. There is a 
great gap between them : the truly eccen- 
tric man has a strong individuality, but 
little vanity ; he has broad and original 
views, and great moral courage; he is 
emancipated from vulgar prejudice, and 
heeds not much the world's blame or cen- 
sure ; he differs from the majority per- 
haps because he is in advance of the hab- 
its and superstitions to which it is in 
bondage ; and he is not at all likely to 
become insane. But there is a weak affec- 
tation of eccentricity which is very apt 
to end in Insanity : with it are infected 
certain feeble-minded beings, often badly 
bred or badly trained, who are empty of 
any true individuality, but inflated with 
an excessive vanity; who have a small 
intellect which they use in the service of 
their passions ; who do silly and eccentric 
things, not unconsciously as the spontane- 
ous expression of their nature, but out of 
a morbid craving to attract attention ; 
who represent a condition of mental de- 
rangement that is the forerunner of In- 
sanity ; who, when they are not given up 
to sexual excesses, are often masturbators. 
In the diagnosis of so-called moral in- 
sanity, it is necessary to look for a suffi- 
cient cause of mental disease from which 
the vicious or violent acts may be logically 
traced through a train of symptoms, such 
as marked change of character, feelings, 
and habits. Neither vice nor crime, how- 
ever extreme, is proof of Insanity. To be 
so, it must be proved through a chain of 
morbid symptoms to flow not from pas- 
sion, but from disease; and attention 
should not, therefore, be entirely occupied 
by it, but should carefully traverse the 
whole affective life, in order to reveal the 
perversion of nature detectable in a case 
of real moral Insanity, and the connection 
of the morbid change with an efficient 
cause of disease. A man may get into 
the police-court for stealing, in whom one 
may perceive instantly the earliest symp- 
toms of general paralysis ; another may 
commit murder, apparently without mo- 
tive, or from a very inadequate motive, in 
whom a melancholic anguish has risen to 
a convulsive explosion ; and a third may 
perpetrate violence in a state of affective 
derangement, which skilled observation 
recognizes to be premonitory of, or vicari- 
ous of, an attack of epilepsy. 
When it is a question of the existence 
of an irresistible impulse in any case of 
homicidal or other kind of violence, it is 
very necessary to keep in view the possi- 
bility of epilepsy, either in the form of 
epileptic vertigo or in its convulsive form. 
When an epileptic person has done a 
murder without discoverable motive,with- 
out advantage to himself or any one else, 
without premeditation, without malice, 
openly, it is almost certain that he has 
been driven to the crime by an irresistible 
impulse. 
General paralysis is easily recognized 
after it has passed its earliest stage. It 
is not always easy of diagnosis before 
vol. i.-39 610 
INSANITY. 
the physical signs appear ; and yet a man 
may at this stage get into trouble-get 
into the police-court, or get married fool- 
ishly-entirely by reason of the disease. 
It is necessary to weigh carefully the cha- 
racter of the act, whether it is anywise 
explicable, or motiveless and quite unac- 
countable ; to mark well the state of the 
patient's articulation under excitement or 
after a sleepless night; to note his happy 
and elated mood of mind ; and to attend 
to the great exaggeration and general ex- 
travagance of his conversation on all mat- 
ters concerning himself, even when there, 
is no fixed and positive delusion. General 
paralytics, in the early stage, speak so ex- 
travagantly and absurdly regarding things 
which they have seen, or events in which 
they have been concerned, that an inex- 
perienced person might be apt to put 
down the whole as a delusion. It is need- 
ful to bear in mind that there may be some 
foundation of fact in what they say of 
themselves-that they do not at first so 
much invent as outrageously exaggerate. 
It is needful also to remember the alter- 
nations of calmness and apparent sanity 
which occur in the early course of the dis- 
ease. The main points to direct attention 
to are, first, any indications that there 
may be of altered speech and of loss of 
memory and mental power; and, secondly, 
the light in which the patient regards 
these symptoms when they are pointed 
out to him. If they are positively present, 
and there is on his part an entire uncon- 
sciousness of them, or if he laughs at and 
makes light of them, as is often the case, 
affirming that he was never better in his 
life, then it is almost certain that he is 
the victim of incipient general paralysis. 
Pathology. -Though it may be that 
there are no morbid changes detectable in 
the brain of one who has died raving mad, 
it is none the less certain that, with change 
of energy, there is a correlative change in 
the nervous substratum. Nothing is yet 
known of the intimate constitution of 
nervous element, or of the mode of its 
functional action ; and it is beyond ques- 
tion that the difference in its condition 
may be the difference between life and 
death, without any appreciable physical 
or chemical change. As the means of 
research improve, however, the instances 
of Insanity in which morbid changes are 
not found are more and more rare; and 
those who have most studied the matter 
are those who are most certain and speak 
most confidently of the invariable exist- 
ence of such changes. When a morbid 
poison acts with its greatest intensity, 
there are notably fewer traces of struc- 
tural alteration than where its action has 
been less intense and more prolonged; 
and, in like manner, appreciable organic 
changes in Insanity may be justly ex- 
pected only when the degeneration has 
been extreme and long continued-in 
chronic mania, in chronic dementia, in 
general paralysis, and epileptic Insanity. 
Where this has been the case, morbid 
changes are seldom looked for in vain. 
Investigations into the electrical pro- 
perties of nerves, and into the phenomena 
of conduction by them, have not only 
rendered conceivable the existence of im- 
portant, though undetectable, molecular 
changes among their ultimate elements, 
but have proved the necessity of dismiss- 
ing all metaphysical conceptions of ner- 
vous function, and of making positive 
research into the physical and chemical 
conditions which, whatever its nature, de- 
termine its manifestations. So far from 
conduction by nerve being due to the in- 
stantaneous passa ge of some imponderable 
principle, it depends upon a modification 
of its molecular constitution, for which a 
certain time is essential; for it has been 
shown that a definite period of time, vary- 
ing in different persons and at different 
periods in the same person, is necessary 
for the propagation of a stimulus from the 
peripheric ending of a nerve to its central 
ending in the brain; and when the stimu- 
lus has reached the brain, a certain time 
must elapse before the will can transmit 
a message to the muscles so as to produce 
motion. No investigation has yet been 
made of the time-rate of activity of the 
cerebral centres, but there is assuredly a 
considerable variation in the time in which 
the same mental functions are performed 
by different persons, or by the same per- 
son at different times. "The mind in 
health," says Locke, "will boggle and 
stand still, and one cannot get it a step 
forward, and at another time it will press 
forward, and there is no holding it in." 
Appreciable and variable, then, is the 
time-rate of thought, and the measure 
probably of that intimate molecular ac- 
tivity which is the condition of its mani- 
festations. That such molecular activity 
does take place, the " waste" after func- 
tion proves; the chemical reaction of 
nerve becomes acid after activity, owing 
probably to the formation of lactic acid in 
the retrograde metamorphosis; and the 
increase of phosphates in the urine, and 
the bodily exhaustion after great mental 
work, are only to be explained by sup- 
posing an idea to be accompanied by a 
correlative change in the nerve-cells. 
Here, indeed, is a region of most delicate 
activity, which, like that of thermal oscil- 
lations, or of undulations of light, is yet 
impenetrable to sense ; and so far from 
its being improbable that undetected 
morbid changes may exist in Insanity, so 
far from its being wonderful that morbid 
appearances are sometimes not found, the 
wonder truly is that they should have 
been expected always. Where the sub- PATHOLOGY. 
611 
tlety of nature so much exceeds the sub- 
tlety of human investigation, to conclude 
from the non-appearance the non-exist- 
ence of change, would be analogous to 
the blind man asserting that there are no 
colors, the deaf man that there are no 
sounds. 
Not only have erroneous ideas been 
entertained respecting the kind of organic 
change that might suffice to give rise to 
Insanity, but the nervous element itself, 
as a living individual entity with intrinsic 
properties, has been commonly ignored ; 
the main stress having been laid upon the 
bloodvessels, as if they were the primary 
agents in exciting and keeping up the 
mental disorder. The truth is, that the 
first step in Insanity often is, as it is in 
inflammation, a direct change in the indi- 
vidual elements of tissue, the change in 
the bloodvessels being secondary. The 
experiments of Lister1 have proved that 
in the case of mechanical or chemical in- 
jury to some tissue, the individual elements 
are directly injured, and that a determina- 
tion of blood, a dilatation of the vessels, 
and an adhesion of the corpuscles follow 
the local mischief; and it is easy to con- 
ceive that damage to the nervous element 
of the brain, however caused-whether 
from overwork or emotional anxiety, or 
from poison in the blood, or by direct in- 
jury or reflex irritation-may in like man- 
ner declare itself in disordered function, 
and be accompanied or followed by vascu- 
lar disturbance. The nervous element is 
brought to a lowei' state of life, and mani- 
fests its deviation or degeneration from its 
normal kind by an abnormal or degenerate 
energy, while the disturbance of circula- 
tion takes place as a coincident or sequent 
effect of a common cause. Where this is 
hereditary taint, there is innate vice or 
defect in the constitution of nerve element, 
and it will accordingly break down more 
easily under adverse stress. The effects of 
strychnia may serve to illustrate the pre- 
sumed course of events: when a dog is 
poisoned with strychnia, there may be no 
morbid appearances ; but if there be any, 
they are such as congestion of the spinal 
cord, aneurismal dilatation of the capil- 
laries, and perhaps small effusions of blood 
into the gray matter. The congestion is 
plainly a secondary result of the intense 
morbid activity of the directly poisoned 
nervous element. Here, then, is the ab- 
stract and brief chronicle of the order of 
events in many cases of Insanity. Trans- 
fer the convulsive action from the spinal 
cells to the cortical cells of the hemi- 
spheres, the result is a violent and acute 
mania in which the acute determination 
of blood is certainly not the cause, if it be 
not the consequence, of the degenerate 
function. In what is called mania transi- 
toria, the patient falls suddenly into a vio- 
lent fury, in which he raves and often ex- 
hibits destructive impulses; his face is 
flushed, his head hot, and there is plainly 
an active determination of blood to the 
brain ; and in a short time the fury sub- 
sides, and the man is himself again, scarce 
conscious, or quite unconscious, of what 
has happened. Was the rush of blood 
the primary and active agent in the pro- 
duction of the fury? Was it not rather 
secondary to the intense morbid or degen- 
erate action of the nervous centre ; the 
attack representing a sort of epilepsy, and 
the congestion taking place not otherwise 
than as it takes place in the spinal cord 
poisoned by strychnia ? So in chronic 
insanity, the congestion discoverable may 
not be the cause, but the effect and evi- 
dence of the morbid action of nervous ele- 
ment. And in those cases of Insanity in 
which there is no special morbid appear- 
ance after death, though there has been 
fixed delusion during life, it is because the 
definite morbid action which does exist 
takes place in that innermost region of 
activity of individual element to which our 
senses have not yet gained access. Only 
by fixing attention on the individual ele- 
ments will a just conception be formed of 
the mode of that degeneration which re- 
veals itself in mental disorder, but at pres- 
ent is not otherwise revealed; and only 
thus will the morbid appearances that are 
met with receive their right interpreta- 
tion. 
It would be one-sided and mischievous, 
in another way, to overlook the fact that 
disturbance of circulation, of extraneous 
origin, may directly favor and even pro- 
duce Insanity. Having regard to the ex- 
treme susceptibility of nervous element, 
and the abundance of the supply of blood 
to it, there can be no question that the 
quantity and quality of the blood play a 
weighty part in the pathology of Insanity. 
Quantity and Quality of the Blood.- 
Since the time of Hippocrates, it has been 
known that similar symptoms are pro- 
duced by too much and by too little blood 
in the brain. In that continued active 
relation between the blood and the ner- 
vous element, whereby due reparative 
material is brought and waste matter 
carried away, it amounts to much the 
same thing whether, through stasis of the 
blood, the refuse is not carried away, nor 
the supply brought to the spot where it is 
wanted, or whether the like result ensues 
by reason of a defective blood or a defi- 
cient circulation. Now, although tempo- 
rary irregularities in the cerebral circula- 
tion may, and often do, pass away with- 
out leaving behind any abiding ill effects, 
yet when they recur frequently, and be- 
come more lasting, their disappearance is 
1 On the Early Stages of Inflammation, by 
Joseph Lister, F.R.S.; vol. xxxi. Philosophi- 
cal Transactions, 1858. 612 
INSANITY. 
by no means the disappearance of the 
entire evil; they are eilicient to initiate a 
degeneration, which thenceforth continues 
of itself and leads to permanent mental 
derangement. Once the habit of a definite 
morbid action is fixed in a part, it con- 
tinues almost as naturally as, under better 
auspices, the normal physiological action. 
A vitiated state of blood, by reason of 
matters bred in it, or introduced from 
without, may act perniciously on the 
supreme cerebral cells. The rapid recov- 
ery wdiich takes place after moderate 
doses of alcohol, opium, Indian hemp, 
seems to show that the damage they in- 
flict is transitory ; but it admits of no 
question, that when nervous element is 
repeatedly exposed to their poisonous 
agency, it acquires a disposition to a de- 
generate function. The intense gloom 
produced by the presence of bile in the 
blood, and the extreme irritability pro- 
duced by some urinary constituent in the 
blood of a gouty patient, serve to show 
what effects upon the supreme nervous 
centres may be due to the non-evacua- 
tion of the waste matters of the tissues. 
When, furthermore, it is remembered that 
the blood is itself a living, developing 
fluid; that, " burnished with a living 
splendor," it circulates rapidly through 
the body, supplying the material for the 
nutrition of the various tissues, receiving 
the waste matter of their activity, and 
carrying it to those parts where it may 
either be appropriated and so removed by 
nutrition, or eliminated by secretion-it 
is plain that multitudinous changes are 
continually taking place in its constitu- 
tion and composition, that its existence is 
a continued metastasis. There is the 
widest possibility, then, of abnormal 
changes in some of the manifold processes 
of its complex life and function, such as 
may generate products injurious or fatal 
to the life of nervous element. Poverty 
of blood undoubtedly plays a weighty part 
in Insanity, as in other nervous diseases ; 
and there is, in the effects of the viruses 
of acute fevers, ample evidence that mor- 
bid poisons, bred in the organism, or en- 
tering it from without, may act in the 
most baneful manner on the nervous cen- 
tres. In some cases of malignant typhus, 
and in the putrid infection after surgical 
operations, the virus generated is directly 
fatal to the life of nerve element; and 
when it acts with less intensity, it gives 
rise to the delirium of fever, and predis- 
poses probably to the Insanity following 
acute fevers. 
lieflex Action, or Sympathy.- The su- 
preme cerebral centres may-like other 
nervous centres-suffer secondarily from 
morbid irritation in some other part of 
the body ; though why they should do so 
at one time and not at another, we know 
not any more than why epilepsy should 
be caused by an eccentric irritation at one 
time and not another. That they do so, 
many recorded instances clearly testify.1 
When a chronic insanity is brought about 
in this way, the delusion has sometimes a 
relation to the primary morbid cause ; the 
secondary derangement of the cerebral 
centres testifying to the special effect of 
the particular diseased organ-as, for ex- 
ample, when a woman, with uterine or 
ovarian disease, believes she is with child 
by supernatural means, or, with morbid 
irritation of the sexual organs, has sala- 
cious delusions. There is the most perfect 
harmony, the most intimate connection or 
sympathy, between the different organs of 
the body, as the expression of its organic 
life-a unity of the organism beneath con- 
sciousness ; and the brain is quite aware 
that the body has a liver or a stomach, 
and feels the effects of disorder in any one 
of the organs, without declaring it directly 
in consciousness. This unconscious, but 
not unimportant, cerebral activity, which 
is the expression of the organic sympa- 
thies of the brain, receives its most strik- 
ing illustrations in the influence on the 
mind of the development of the sexual 
organs at puberty, and in their subsequent 
influence on dreams; and it is of great 
weight in the production of morbid men- 
tal phenomena. A just appreciation of 
its importance will not fail to teach the 
lesson which a true conception of the or- 
ganism as an individual whole, formed of 
differentiated parts harmoniously co-or- 
dinated, teaches also, that every organic 
motion, visible or invisible, sensible or in- 
sensible, ministrant to the highest aim or 
to the humblest function, does not pass 
issueless, but has its due effect upon the 
whole, and is felt throughout the most 
complex recesses of the mental life.2 
The primary morbid centre, which gives 
rise to secondary derangement by a reflex 
or sympathetic action, may not be in a 
distant organ ; it may be in the brain 
itself. A tumor, abscess, or local soften- 
ing does not interfere with the mental 
processes at one time, while it produces 
the gravest disorder of them at another ; 
and it is not uncommon in abscess of the 
brain for the mental symptoms, when 
there are any, entirely to disappear for a 
time, and then to return suddenly in all 
1 References to such cases may be found in 
Griesinger's work. There is a remarkable 
case also cited by Dr. Brown-Sequard in his 
Lectures on the Physiology and Pathology of 
the Nervous System. 1860. 
2 ' ' Man is all symmetric, 
Full of proportion one limb to another, 
And to all the world besides. 
Each part calls the furthest brother ; 
For head with foot hath private amity, 
And both with moon and tides." 
George Herbert. PATHOLOGY. 
613 
their gravity, the derangement or aboli- 
tion having been due to a sympathetic or 
reflex action. 
Here, then, should be distinguished the 
different kinds of disorder of the cerebral 
centres to which a morbid cause may give 
rise. The sudden appearance and equally 
sudden disappearance of extreme mental 
derangement prove that it is functional; 
it being impossible to conceive the exist- 
ence of serious organic change in such 
case. Although, then, the functional dis- 
order necessarily implies a molecular 
change of some kind in the nervous ele- 
ment, the change may well be one affect- 
ing the polar molecules, such as the re- 
searches of Du Bois Reymond have proved 
may rapidly appear and rapidly disap- 
pear. At any rate the induction, by de- 
finite experiments, of recognizable transi- 
tory changes, in the physical constitution 
and the function of nerve, warrants the 
belief in similar modifications producible 
by morbid causes which are not artificial, 
but which are just as abnormal as if they 
were artificial. The modification of mole- 
cular constitution, which vanishes at first 
with the removal of the cause, will not 
fail, if too great or too prolonged, to de- 
generate into actual nutritive change and 
structural disease, just as an emotion 
which alters a secretion temporarily may, 
when long enduring, lead to nutritive 
change in the secreting organ. 
Excessive functional activity.-The dis- 
play of function being the waste of mat- 
ter, it is plain that if there be not due in- 
tervals of periodical rest, degeneration of 
nervous element must take place as surely 
as when directly injured by morbid poi- 
son, or mechanical irritant, or as surely 
as a fuelless fire must go out. It is sleep 
which thus knits up the ravelled struc- 
ture of nervous element; for during sleep, 
organic assimilation restores as statical 
or '■'latent" the power which has been 
expended in function, or made "actual" 
in energy. Sleeplessness is, accordingly, 
one of the troubles following intense men- 
tal anxiety, or too great mental activity, 
and forerunning Insanity: that which 
should heal the breach is rendered impos- 
sible by the extent of the breach. Like 
Hamlet, according to Polonius, the indi- 
vidual falls into a sadness, thence into a 
watch, then into a lightness, and by this 
declension into the madness wherein he 
finally raves. To provoke repose in him 
is the prime condition of restoration ; the 
power of its " closing the eye of anguish," 
and healing " the great breach in the 
abused nature" of nervous element. 
[It requires some courage to question, 
for a moment, the almost unanimous con- 
clusion of psycopaths at the present day, 
that Insanity always results from a physi- 
cal lesion or disorder of the brain. But 
some cases occur, which (in the absence 
of a fatal result to allow of actual inspec- 
tion of cerebral conditions) may, with the 
greatest probability, admit of a different 
explanation. Accepting the fitness of the 
French term, aliene, any one may be held 
to be insane who, from any cause, be- 
comes so "beside himself," so estranged 
from accordance in his judgment, appre- 
hensions, motives, and actions with the 
realities of the world around him, as to be 
incapable of what all recognize as sane 
conduct and conversation. As with mani- 
festly physically produced Insanity, there 
may be a close limitation of delusions and 
consequent actions, to one subject, or group 
of subjects, in persons who have become 
subjected to gross and injurious errors of 
opinion, so as to "believe a lie." Cases 
of Insanity produced by spiritualism may 
be named as of this kind. Those so af- 
fected continue, sometimes, for years, in 
a state of general health, almost incom- 
patible with any marked disease of the 
brain ; and yet obviously much astray in 
their judgment of facts and conclusions, 
and often led to do very strange actions 
in consequence. Superstitions of various 
kinds may account for similar mental 
alienations; as in the instance of a man 
who took the life of his child, in 1879, in 
one of the Eastern States, under the be- 
lief that he was divinely commanded to 
do so ; his wife and some fellow-believers 
also justifying his conduct. One of the 
most distinguished American chemists 
presented, some time since, a sad instance 
of spiritualistic derangement in his latter 
years ; and, more recently, a case perhaps 
equally remarkable has occurred, in a man 
in the prime of life, a Superintendent of 
Public Education in one of the largest 
cities in America. If, in every such case, 
it be insisted that there must be a causa- 
tive lesion or disorder of the brain, such 
a statement is to be accepted rather as a 
matter of pathological theory or dogma, 
than of necessary inference from the facts 
observed. In some instances, coming 
under the knowledge of the present wri- 
ter, the opinion above implied was first 
suggested by the history of the mental 
aberration, and afterwards confirmed by 
the restoration of those affected after a 
considerable period, simply through their 
being enabled to find the clue which led 
them out of the labyrinth of delusion in 
which their reason was astray. Certainly 
the diagnosis of brain lesion, in such 
cases, would have been difficult to make 
out, on any other ground than that of an 
axiom in psycho-pathology.-H.] 
Thus much from a pathological point of 
view concerning the causation of Insan- 
ity : it now remains to enumerate the 
morbid appearances that have been met 
with in the brain and its membranes. INSANITY. 
614 
Morbid Anatomy.-The broad result 
of investigation is, that the morbid 
changes most constantly met with are 
such as affect the surface of the brain and 
the membranes immediately covering it; 
and of these changes, those in the layers 
of the cortical substance are the principal 
and essential. The signs of more or less 
inflammation of the membranes, especi- 
ally milky opacities of the arachnoid, are 
common enough in the bodies of those who 
have not died insane. But there would 
appear to be some hindrance to inflamma- 
tion spreading easily to adjacent parts that 
are of different structure, whereas, when 
they are of the same structure ; it passes 
readily from element to element of the 
same kind, as it were by an infection ; the 
intercostal muscles are scarcely affected in 
acute pleurisy, the muscular walls of the 
intestines scarcely affected in peritonitis, 
and inflammation takes place in the mem- 
branes of the brain, without seriously im- 
plicating the cortical layers. If these are 
involved, there can be no question that 
the mind suffers. Deaths in the acute 
stage of Insanity are not usual; but if an 
opportunity presents itself of examining 
the brain at this early stage, the morbid 
appearances are those of acute hypersemia 
-namely, great injection of the pia ma- 
ter, with spots of ecchymosis, and more 
or less discoloration and softening of the 
cortical layers, which may be separated 
easily with the handle of a scalpel from 
the white substance beneath ; the discol- 
oration being in red streaks or stains, with 
spots of extravasated blood, and the soft- 
ening of a violet or pinkish hue ; the 
puncta vasculosa of the white substance 
are also increased. There are no observ- 
able differences between the morbid ap- 
pearances met with in acute mania and in 
acute melancholia ; and though such fact 
ill agrees with their different symptoms, 
it is not entirely singular, forasmuch as 
alcohol makes one man lively and another 
melancholic. A differential pathology 
would involve the knowledge of what con- 
stitutes individual disposition or tempera- 
ment. It must be confessed that in both 
mania and melancholia morbid changes 
are sometimes wanting. 
The instances of chronic insanity in 
which no morbid lesions appear are rare: 
the longer the disease has lasted, the more 
evident they usually are. There is mostly 
some degree of thickening or opacity of 
the arachnoid, which may form a white 
opaque layer through which the convolu- 
tions are scarce visible ; and many of the 
more advanced cases exhibit some degree 
of atrophy of the brain, especially of the 
convolutions - these appearing shrunk, 
pale, and ansemic, or as if some were 
wanting and replaced by an effusion of 
clear serum into the subarachnoid space. 
The atrophic change may be, according 
to Dr. Wilks, a simple degeneration, or a 
degeneration associated with the changes 
resulting from chronic inflammation. The 
pia mater is at times adherent to the sur- 
face of the brain, so that there is some 
difficulty in stripping it off without bring- 
ing portions of gray matter away with it. 
This adhesion is not peculiar to general 
paralysis, as some have thought, though 
most often met with in it; for it is now 
and then found in other forms of chronic 
insanity, particularly those following epi- 
lepsy and drunkenness. The ependyma 
of the ventricles is thickened, and some- 
times covered with fine granulations, such 
as have been described also by L. Meyer 
on the arachnoid and inner surface of the 
dura mater.1 Dr. Wilks has seen a mi- 
nutely granular condition of the lining of 
the ventricles, in a case of acute mania ; 
he has often seen it in epilepsy-once, 
when the granules were as large as peas, 
and "the whole surface of the ventricles 
had very much the appearance of an ice- 
plant." In some cases, the exudation is 
in flattened scales or patches.2 
The morbid changes most frequent in 
general paralysis, though in rare instan- 
ces there are scarcely any detectable, are 
great oedema of the membranes, adhesion 
of the pia mater to the gray substance 
beneath, local discoloration or softening 
of the cortical layers, or superficial indu- 
ration of them. More or less atrophy of 
the whole brain, and particularly of the 
convolutions, is common, and is accom- 
panied with greater firmness of its sub- 
stance, enlargement of the ventricles, 
and serous effusion into them. Diffuse 
pachymeningitis, effusion of blood into 
the membranes, or rather into the layers 
of exudation (Virchow, Rokitansky), and 
degeneration, atheromatous and calcare- 
ous, of the arteries, are not unfrequently 
met with. Though these changes are 
more common in general paralysis than 
in any other form of Insanity, they are 
by no means peculiar to it, nor are they 
constant in it; in some cases the evidence 
of meningitis is most marked, in others 
that of atrophy.3 
A diffuse albumino-fibroid exudation of 
low form, glueing the membranes to the 
surface of the brain, has been declared by 
some to be characteristic of syphilitic in- 
sanity. Instead of being diffused, the 
gum-like exudation, or syphiloma, as it has 
1 Virchow's Archiv, B. xvii. s. 209. 
2 Clinical Notes on Atrophy of the Brain, 
by S. Wilks, M.D.; Journ. Ment. Science, 
October, 1864. 
3 A compact account of the morbid changes 
in general paralysis, with exhaustive refer- 
ences, will be found in a paper by Dr. E. 
Salomon on the Pathological Elements of 
General Paresis; Journ. Ment. Science, Octo* 
her, 1862. MORBID ANATOMY. 
615 
been called, may be circumscribed so as 
to form a tumor, and press into the sub- 
stance of the brain, causing softening im- 
mediately around it; or again, it may be 
met with as a diffuse infiltration or a 
tumor within the brain, the membranes 
being unaffected. At the outset it con- 
sists of an exuberant growth of connective 
tissue, which afterwards undergoes more 
or less fatty degeneration ; and it certain- 
ly has not any character by which it can 
be distinguished as a specific product.1 
Researches have been made into the 
absolute weight and specific gravity of the 
brain in Insanity, but they have not been 
sufficiently exact.2 Dr. Skae and Dr. 
Boyd found the absolute weight to be 
slightly increased in the insane, the in- 
crease being greatest in mania, and least 
in general paralysis. The specific gravity 
is also increased, the lowest specific gra- 
vity, which is still above the average, 
occurring in dementia, the highest in 
epilepsy. Dr. Bucknill observed that the 
mode of death influenced the results, and 
found also that the increase of specific 
gravity was due, in some cases, to a de- 
posit of an inert albuminous matter 
amongst the proper nervous elements, 
and the consequent shrinking of these,- 
a condition seemingly not unlike that 
since described by Prof. Albers as paren- 
chi/matous infarction of the brain, and met 
with after typhus, in some cases of old In- 
sanity, and in imbecile children, especi- 
ally those of a scrofulous habit of body. 
A fibrinous or albumino-fibroid exudation 
would appear to be a not uncommon re- 
sult of the degeneration of extreme In- 
sanity ; it is the condition probably of the 
increased consistency, or sclerosis, which 
is the final result of atrophy ; and it is 
comparable with the product of what is 
described as chronic inflammation in other 
organs, as the liver and spleen. A similar 
exudation is the cause of the so-called 
hypertrophy of the brain from which 
children sometimes die, and which is now 
and then met with in single cases of In- 
sanity and epilepsy. 
The microscope has of late years added 
something to our knowledge of the nature 
of the morbid changes in Insanity. The 
most constant result has been to establish 
a rank or exuberant growth of connective 
tissue, and a coincident or sequent decay 
or destruction of the proper nervous ele- 
ments, in Insanity of long standing, and 
especially in general paralysis. The re- 
searches of Rokitansky and Wedl reveal 
a more or less diseased state of the capil- 
laries of the cortical substance in general 
paralysis ; these exhibit aneurismal dila- 
tations, and tortuosities varying from a 
single twist to a more complex twisting 
and even to little knots of varicose vessels.1 
Round the capillaries, small arteries, and 
veins there is a hyaline deposit of embry- 
onic connective tissue beset with oblong 
nuclei; this afterwards becoming more 
and more fibrous, so that the vessel may 
look like a piece of connective tissue, in 
which granules of fat or calcareous matter 
ultimately appear. Other products of the 
retrograde metamorphosis, such as amy- 
loid corpuscles and colloid corpuscles, are 
also found in connection with the hyper- 
trophied tissue, which, whether called in- 
flammatory or not, is itself essentially the 
result of a vital degeneration. The degen- 
eration appears to be of two kinds : first, 
there is a defective nutrition, a retrograde 
nutritive process, whereby the vitality not 
reaching the height necessary for the pro- 
duction of the proper elements of the 
structure, there are engendered from the 
germinal nuclei elements of a lower kind 
-connective tissue instead of a nerve ; 
and, secondly, there is a retrograde meta- 
morphosis of the formed elements of the 
part-a colloid, fatty, or calcareous de- 
generation. Be this as it may, there are 
at any rate three principal stages of the 
degenerative process: (1), a morbid change 
in the vessels, whereby there must be a 
great hindrance to regular nutrition ; (2), 
atrophy of nerve element, either in conse- 
quence of the hindrance to nutrition 
(Rindfleisch2), or from the rank growth of 
connective tissue (Rokitansky) ; (3), the 
increase and subsequent retrograde meta- 
morphosis of connective tissue. Recently 
it has been asserted by Dr. Tigges, that 
there is, even at an early stage, an in- 
crease of nuclei in the ganglionic cells ; 
the numerous scattered nuclei, usually 
1 Des Affections Nerveuses Syphilitiques, 
par Dr. Leon Gros et E. Lancereaux, 1861. 
Ueber die Natur der Constitutionell-syphi- 
litischen Affectionen, von Rudolf Virchow ; 
Archiv, B. xv. Das Syphilom, oder Die Con- 
stitutionell-syphilitische Neubildung, von E. 
Wagner; Archiv der Heilkunde, 1863. Ueber 
Constitutionelle Syphilis des Gehirns, von 
Dr. Ludwig Meyer ; Zeitschrift f. Psychiatrie, 
1861. Des Affections Nerveuses Syphilitiques; 
M. Zambaco. Wiener Medizinal-Halle Zeit- 
schrift, February, 1864; Dr. Leidesdorf. Zeit- 
schrift f. Psychiatrie, 1863 ; Dr. Westphal. 
2 Dr. Bastian's recent researches seem to 
prove that the specific gravity of different 
parts of the gray matter differs considerably 
in health. "On the Specific Gravity of the 
Human BrainJourn. Ment. Science, Janu- 
ary, 1866. 
1 Ueber Bindegewebeswucherung im Ner- 
vensysteme; Rokitansky, 1857. Wedl, Bei- 
trage zur Pathologie der Blutgefasse; Wien, 
1859. 
2 Histologisches Detail zu den grauen De- 
generation von Gehirn und Riickenmark. 
Von Dr. E. Rindfleisch. Virchow's Archiv, 
B. vi. 616 
INSANITY. 
thought to belong to connective tissue, he 
considers to have escaped from ganglionic 
cells at a later stage of their inflammatory 
degeneration.1 Such changes are not pe- 
culiar, as some have said, to general paral- 
ysis ; like changes have been described by 
Wedl2 in the brains of three congenital 
idiots, and have been met with in demen- 
tia following on long-continued Insanity, 
and in tabes dorsalis; and there can be 
little doubt that the morbid product in 
syphilitic dementia is of a similar nature. 
Briefly summed up, then, the kinds of 
degeneration met with in the brain, after 
Insanity, are as follow : 1. There is in 
acute insanity an acute hyperaemia, or the 
early stage of inflammatory degeneration. 
2. There is that degeneration which con- 
sists in the increase of connective tissue, 
and in the atrophy of the nervous ele- 
ments, and which might be called connec- 
tive tissue degeneration. Whether called 
sub-inflammatory or not, is not of much 
moment, so long as we keep in mind the 
true relations of organic element to the 
supply of blood, and the degenerate nature 
of inflammation, whether acute or chronic. 
3. Fatty degeneration takes place not only 
in the small vessels, as in atheroma, and 
in the new morbid products, but also in 
the broken-up nervous elements, and even 
in the nerve-cells. 4. The amyloid de- 
generation is undoubtedly pathological. 
Wedl holds that the amyloid corpuscles 
should be ranked along with the so-called 
colloid bodies, and viewed as the result of 
an increased exudation that may take 
place without hyperemia. Rindfleisch, 
on the other hand, believes that he has 
traced their production from the nucleated 
connective-tissue corpuscles ; while some, 
like Rokitansky, maintain that the gangli- 
onic cells themselves are converted into 
colloid bodies. 5. Pigmentary degeneration 
is sometimes met with. In senile atrophy 
the ganglionic cells are sometimes richly 
filled with brown pigment molecules ; 
and, in one case of dementia, where there 
was partial paralysis of the tongue, 
Schroeder van der Kolk found the cells 
forming the nuclei of the hypoglossal 
nerves in such a state of blackish-brown 
degeneration that he at first mistook them 
for little points of blood, but they were 
filled with granular, dark-brown pigment. 
Dr. Lockhart Clarke has observed similar 
pigmentary degeneration of the cells in 
general paralysis. It is worthy of remark, 
that cases of pigmentary degeneration of 
the retina are often found to occur in the 
same family, to be accompanied with gen- 
eral defective development, mental and 
bodily, occasionally with mutism and 
Cretinism, and to occur in those who, 
like albinos, are sometimes the degenerate 
offspring of marriages of consanguinity.1 
6. Calcareous degeneration is common 
enough in the hypertrophied connective 
tissue and in the small bloodvessels ; and 
it has been observed in the ganglionic 
cells themselves. Erlenmeyer met with 
calcified cells in the optic commissure of a 
monomaniac; Forster figures calcified 
cells found in the gray substance of the 
lumbar enlargement of a boy whose lower 
extremities were paralyzed ; Heschl found 
what he calls ossified cells in the brain of 
a patient who died melancholic; and 
Wilks believes certain bodies, found in 
the brain of a general paralytic, in whom 
the small arteries were calcified, to have 
been ganglionic cells that had undergone 
calcareous degeneration. 
Those who duly weigh the pathological 
import of the kinds of degeneration enu- 
merated, who reflect on the great gap 
which there is between a calcareous gran- 
ule and a nerve-cell in the economy of 
nature, or between a connective-tissue 
corpuscle and a nerve-cell in the histo- 
logical scale of life, must admit that the 
difference is not less great than that be- 
tween dementia and sound mental action, 
and will scarce venture to assert that the 
morbid appearances throw no light what- 
ever upon the nature of Insanity. Even 
the comparatively slight signs of hyper- 
scmia are of weighty significance, if their 
true relations are recognized, if they are 
viewed as results and evidence of that 
degeneration of individual nervous ele- 
ment, of which the mental disorder is also 
result and evidence, if they and the In- 
sanity are viewed as, what they often are, 
concomitant effects of a common cause. 
Prognosis.-Two questions at once 
present themselves : the first, whether the 
disease directly endangers life ; the second, 
and perhaps more solemn one, whether 
there is any prospect of recovery. Re- 
specting the first question, it may "be said 
in general terms that Insanity does cer- 
tainly reduce the mean duration of life, 
and much more so in its recent acute 
forms than in its more chronic forms. Of 
all forms, general paralysis is the most 
fatal, other varieties not being, as a rule, 
1 Zeitschrift fur Psychiatrie, B. xx. In 
Virchow's Archiv, 1865, Dr. Franz Meschede 
has striven to prove that hyperaemia and 
parenchymatous swelling of the inner layer 
of the cortical substance are the beginning, 
and fatty degeneration the end, of the organic 
changes in general paralysis. 
2 Histologische Untersuchungen uber Hirn- 
theile dreier Salzburger Idioten. Von Prof. 
C. Wedl; Medizinische Jahrbiicher der K. K. 
Gesellschaft der Aerzte in Wien. 1863. Heft 
2 und 3. 
1 On Retinitis Pigmentosa, by J. Laurence; 
Ophthalmic Review, No. 5, April, 1865. The 
observations of Prof. Graefe and Liebreich. 
are quoted. PROGNOSIS. 
617 
directly dangerous to life. Still, certain 
cases of acute mania and acute melan- 
cholia do terminate suddenly in death, 
owing probably to exhaustion, and it may 
be utterly impossible to say beforehand 
whether they are going to do so or not. 
When the temperature of the body rises 
several degrees above the natural stan- 
dard, the prognosis is bad ; and any indi- 
cation of motor paralysis, or any kind of 
hybrid epileptiform convulsion, in the 
course of the disease, is of evil omen, 
while an attack of genuine epilepsy, un- 
favorable as regards recovery, is not so as 
regards life. A long-enduring refusal of 
food may sometimes end fatally, both in 
mania and melancholia. 
What prospect there is of recovery in a 
particular case will depend greatly upon 
the cause of the attack, upon its form, and 
upon its duration. The more recent the 
outbreak, the better the chance of reco- 
very, the expectation of which from 
proper treatment adopted within three 
months from the commencement is about 
four to one, while it is less than one to 
four after twelve months' duration of the 
disease. Certainly there do occur in- 
stances in which patients recover after 
being insane for years, but they are ex- 
ceptional. When the stage of secondary 
dementia, incoherent or apathetic, has 
been reached, all hope of recovery is gone. 
Primary dementia is generally curable. 
Of the acute primary forms of mental 
disease, melancholia is more curable than 
mania, although some have thought other- 
wise, deceived probably by the experience 
of an asylum into which simple cases of 
melancholy do not usually come. Next 
to melancholia acute mania, is most cura- 
ble ; when attacks of melancholia and 
mania alternate, the prognosis is very un- 
favorable. A day of great depression and 
weeping intervening in the course of acute 
mania, is of good omen. When the ma- 
niacal fury is subsiding, the prospect is 
good if the patient is sad and depressed, 
begins to inquire about his family, and 
to show other signs of a return to his for- 
mer feelings; it is bad if the feelings re- 
main unmoved, and the intellect is calm 
in its disorder-if, in other words, there 
is evidence of the organization of disor- 
der. Even the disappearance of intellec- 
tual disorder is not a certain sign of re- 
covery, unless there is a return to the old 
healthy feelings, and the patient recog- 
nizes that he has been mad. A periodi- 
cal recurrence of attacks of Insanity, with 
long intermissions, is of decidedly unfa- 
vorable augury; the attacks commonly 
become longer, the intermissions briefer, 
and the outlook gets more and more 
gloomy. 
Monomania is far less curable than 
mania, the fixed delusions marking the 
establishment of a definite type of morbid 
action of a chronic nature. Recovery 
does sometimes take place under the in- 
fluence of systematic moral discipline, or 
from a great shock to the system, whe- 
ther emotional or produced by some inter- 
current disease. In melancholia, where 
there is a fixed delusion that the cause of 
misery is in some external agency, the 
prognosis is unfavorable; but it is more 
favorable in the melancholic who attrib- 
utes his affliction to his own imaginary 
backslidings. In like manner the homi- 
cidal melancholic, who believes himself 
the victim of persecution, seldom recovers; 
the suicidal melancholic, who is not so in 
consequence of any definite delusion, fre- 
quently does recover, especially after some 
serious and almost successful suicidal at- 
tempt. 
In moral insanity the prognosis is bad; 
for these symptoms usually mark the 
tyranny of a bad organization. General 
paralysis may be pronounced incurable. 
When Insanity has been slowly devel- 
oped, the prognosis is more unfavorable 
than when it has been of sudden origin- 
this probably being a part of the larger 
truth, that when Insanity is slowly de- 
veloped it is produced by the egoistic 
passion of some peculiarity of character, 
as pride, ambition, avarice; hut when it 
is suddenly caused, it is by the shock of 
an altruistic emotion, as, for example, 
grief about others. For a like reason a 
frequent alternation of active symptoms 
is more hopeful than a steady persistence 
in a particular group of quiet symptoms. 
Hereditary insanity is generally deemed 
most unfavorable, but recent researches 
prove that it is not so much so during a 
first attack, although the disease is more 
liable to recur than when not of heredi- 
tary origin. In the acute mania some- 
times produced by drunkenness we may 
reasonably look for recovery, but by no 
means so in those cases in which a con- 
tinued intemperance has resulted in men- 
tal weakness, loss of memory, and loss of 
energy of character. When Insanity has 
been caused by habits of self-abuse or by 
sexual excesses, the prognosis is unfavor- 
able in all but the earliest stages. If re- 
ligious excitement purely has been the 
cause of an outbreak, the prognosis is 
most favorable ; but it is necessary to bear 
in mind that a form of religious insanity 
is the vicarious satisfaction of unsatisfied 
sexual love, that more or less nympho- 
mania is oftentimes associated with it, 
and that the outlook then is hopelessly 
bad. When disease of brain, or injury of 
the head, or epilepsy, has been the cause, 
the derangement is practically incurable ; 
but where it occurs during the decline of 
some acute disease, it is generally soon 
curable. The prognosis is bad in Insanity 
after sunstroke; nevertheless Dr. Skae 
mentions one case under his care in which 618 
INSANITY. 
recovery took place, being one of the very ! 
few recoveries on record from Insanity 
produced by this cause. The prognosis 
is favorable in hysterical insanity; as it is 
also in puerperal mania, in the insanity 
of pregnancy, of lactation, and of the cli- 
macteric change. A decidedly bad symp- 
tom is a fixed hallucination, as is also a 
complete preservation of bodily health 
with persistence of mental disorder; when 
there is palpable bodily disorder, as diges- 
tive disturbance, anaemia, menstrual ir- 
regularity, there is good hope that with 
the restoration of bodily health the mind 
may be restored also. 
When Insanity has followed the sup- 
pression of an eruption or an accustomed 
discharge, the prognosis is favorable; 
when associated with phthisis, it is unfa- 
vorable as regards recovery and as regards 
The most favorable age for recovery is 
youth, the probability of it diminishing 
with the advance of age, and few recover- 
ing after fifty ; as many as 86 per cent, of 
males and 91 per cent, of females, at- 
tacked with mania under twenty years of 
age, recovered at the Somerset Asylum. 
This proportion will appear the more favor- 
able when we reflect that children under 
ten or twelve years of age do not recover 
from mental derangement, it being often 
dependent upon defective organization, 
and associated with epilepsy. The re- 
coveries amongst women exceed those 
amongst men, by reason probably of the 
frequency and fatality of general paralysis 
among men. 
The general conclusion of Dr. Thurnam 
from his careful statistics is that, "as re- 
gards the recoveries established during 
any considerable period - say twenty 
years-a proportion of much less than 40 
per cent, of the admissions is under ordi- 
nary circumstances to be regarded as a 
low proportion, and one much exceeding 
45 per cent, as a high proportion." The 
liability to recurrence of the Insanity 
after recovery from the first attack can- 
not, he thinks, be estimated at less than 
50 per cent., or as one in every two cases 
discharged recovered. On the whole, 
then, he holds that, of ten persons at- 
tacked, five recover and five die sooner or 
later. Of the five recoveries, not more 
than two remain well during the rest of 
their lives ; the others have subsequent 
attacks, it may be after long intervals, 
during which at least two of them die.1 
Therapeutics.-The treatment of In- 
sanity is moral and medical, the two 
methods properly being combined. It 
must again be individual, as the case is ; 
for the varieties of the insane character 
demand different moral means, as the 
varieties of causes call for different medi- 
cal treatment. It is necessary to pene- 
trate the individual character, with the 
design of influencing it beneficially, and 
carefully to investigate the concurrence of 
conditions that have issued in Insanity, 
with the object of removing them. Herein 
lies the chief difficulty of treatment; in no 
other disease are there so much conceal- 
ment and so much misrepresentation, 
witting and unwitting, on the part of 
friends. It is before all things necessary 
again that treatment should be begun 
early, before the habit of a definite morbid 
action has been fixed ; but, though early, 
it must not be rashly vigorous and ener- 
getic, with the aim of effecting any sudden 
revolution, but rather patient and system- 
atic, in the hope of a gradual change for 
the better. 'Whilst in other diseases time 
is reckoned by hours and days, it must in 
Insanity be reckoned by weeks and 
months. 
Moral Treatment.-To remove the pa- 
tient from the midst of those circumstances 
under which Insanity has been produced, 
must be the first aim of treatment. There 
is extreme difficulty in treating satisfac- 
torily an insane person in his own house, 
amongst his own kindred, where he has 
been accustomed to exercise authority, or 
to exact attention, and where he continu- 
ally finds new occasions for outbreaks of 
anger or fresh food for his delusions. An 
entire change in the surroundings will 
statistics of the Somerset Asylum for many 
years:- 
Of 1000 Males. 
Of 1000 Females. 
Recovered . . 
. 252 
. . 276 
Relieved . . 
. 55 
. . 79 
Not improved 
. 47 
. . 35 
Died . . . 
. 324 
. . 258 
Remaining 
. 192 
. . 223 
---> 
870 
. . 871 
Re-admissions 
. 130 
. . 129 
■ 1 1 1 
■ ■■■I ■ 
1000 
1000 
The cause of death in 539 cases out of 2000 
-295 males and 244 females-in which post- 
mortem examinations were made, were as 
follows :- 
Males. 
Females. 
Diseases of Respiratory organs in 148 
. 104 
ll 
Nervous system 
. 112 
. 73 
u 
Digestive organs 
. 18 
41 
Cl 
Vascular system 
. 11 
. 18 
n 
Genito-urinary . 
2 
1 
ll 
Locomotor organs 
1 
3 
cc 
Fevers . . . 
0 
2 
n 
Accidents . . . 
3 
2 
295 
244 
1 In an elaborate paper on Vital Statistics 
and Observations, in the Journal of Mental 
Science, January, 1865, Dr. Boyd records the 
The diseases of the respiratory organs which 
proved fatal were principally pneumonia 
and phthisis. 619 
THERAPEUTICS. 
sometimes of itself lead to recovery; if the 
patient is melancholic, he no longer re- 
ceives the impressions of those whom, 
having most loved when well, he now 
most mistrusts, or concerning w'hom he 
grieves that his affections are so much 
changed ; if he is maniacal, he is not spe- 
cially irritated by the opposition of those 
whose acquiescence he has been accus- 
tomed to, or encouraged by their submis- 
sion to his whims and their indulgence of 
his follies. Travelling may be recom- 
mended in the early stages, in order to 
secure change of place and scene ; or if the 
patient cannot travel, he may be removed 
from his own home to another residence, 
and systematically treated there. If the 
pecuniary means do not admit of the 
adoption of either of these expedients, or 
if the patient is furious, or desperately 
suicidal, or persistently refuses food, it 
will be necessary to send him to a suitable 
asylum. It must be borne in mind that 
an insane person cannot, from the very 
nature of his disease, have his own way, 
and that to allow him to do so would be 
directly to aggravate his disease. To put 
him under restraint in some way, to exer- 
cise for him that control which he cannot 
exercise for himself, is indispensable so 
long as there is a hope of cure : to let him 
distinctly understand that this is legally 
done will of itself have a beneficial effect. 
The melancholic who finds himself in an 
asylum finds a real grief to alternate with 
or perhaps to take the place of his fancied 
affliction ; and the maniacal patient, feel- 
ing his wild spirit of exultation to be 
rudely checked by the influence of a sys- 
tematic control, can scarce fail to have 
more sober reflections aroused. It is ex- 
tremely objectionable except in an emer- 
gency to entrap a patient into an asylum ; 
there should be no deception about the 
matter, if possible, but all should be done 
openly and firmly, in the spirit in which 
an act of obedience is inculcated upon a 
child, and in any case inflexibly insisted 
upon. 
The patient having been removed from 
those influences which have contributed 
to the production of the disease and tend 
to keep it up, and having been made to 
recognize from without a control which 
he cannot exercise from within, it remains 
to strive persistently and patiently by 
every inducement to arouse him from his 
self-brooding-or self-exaltation, and to en- 
gage his attention in matters external- 
to make him step out of himself. This is 
best done by engaging him earnestly in 
some occupation or in a variety of amuse- 
ments ; and this will be more easily done 
now that the surroundings are so entirely 
changed. The activity of the morbid 
thoughts and feelings subsiding in the new 
relations and under new impressions, more 
healthy feelings may be gradually awak- 
ened ; and the activity of healthy thought 
and feeling will not fail in its turn further 
to favor the decay of morbid feeling. It 
is not by arguing against a delusion or 
directly contradicting it that any good 
will be done : it were almost as well to 
argue against the east wind or a convul- 
sion ; but by engaging the mind in other 
things, and substituting a healthy energy 
for the morbid energy, this will be most 
likely to abate and finally die out. But 
though it is of little use talking against a 
delusion, it is desirable to avoid agreeing 
with it: by quiet dissent or a mild expres- 
sion of incredulity when it is mentioned, 
the patient should be made to understand 
clearly that he is in a minority of one. It 
is most necessary to a void any harsh word 
or act, a tone of ridicule, or a look of dis- 
gust ; an angry speech will often be re- 
membered when the frenzy has passed off, 
and will leave a sore feeling in the pa- 
tient's mind. It is a mischievous and 
silly practice too to speak to insane per- 
sons as if they were babies: they are often 
more sensitive to such impertinences than 
sane persons, while they seldom fail to be 
influenced beneficially by a sincere, sensi- 
ble, and sympathetic address. 
Medical Treatment.-There is no specific 
agent in the treatment of any form of In- 
sanity. A truly scientific treatment will 
be grounded on the removal of those 
bodily conditions which may appear to 
have acted as causes of the disease and 
on the general improvement of nutrition. 
An attack of melancholia occurring in a 
gouty subject, and perhaps taking the 
place of an attack of gout, is sometimes 
cured by the treatment proper for gout; 
and there are cases on record in which 
acute mental derangement has affected 
persons living in a malarious district in 
regular tertian or quartan attacks, and 
has been cured by quinine. The morbid 
sensations, so common in Insanity, should 
not be overlooked, as they often arise 
from some real bodily derangement, and 
tend to keep up the delusion. Now, 
bodily disease is not always easily de- 
tected in the insane ; for the usual symp- 
toms are very much masked, and they, 
like animals, make no intelligent com- 
plaint. "Insanity," says Dr. Bucknill, 
" is not confined to the brain, and when 
it is confirmed, a man becomes a lunatic 
to his finger ends." It is necessary, there- 
fore, to examine carefully into the state of 
the different bodily functions and to pay 
particular attention to the physical signs 
of disease : there may be no cough, no 
expectoration, when the thermometer or 
the stethoscope reveals advancing phthisis. 
General bloodletting is now rarely, if 
ever, used ; even in the most acute and 
seemingly sthenic insanity it is not simply 
useless, but it is positively pernicious. 
Violent symptoms may abate for a time, INSANITY. 
620 
but the disease is very apt to become 
chronic and to pass rapidly into dementia. 
Local abstraction of blood by leeches or 
by cupping may be useful where there 
appears to be great determination of blood 
to the brain ; by withdrawing blood from 
the overloaded vessels the opportunity of 
rest is afforded to the struggling and suf- 
fering nervous element. It may be well 
to add here that in Insanity it is not 
judicious but mischievous to shave the 
patient's head, to confine him to bed, to 
shut out the light, and to treat him in all 
ways as if he were suffering from an acute 
inflammation of the brain or its mem- 
branes ; on the contrary, in almost all 
cases it is necessary to enjoin abundant 
exercise in the open air. 
The continued application of cold to the 
head by means of a douche pipe, or by 
pouring cold water upon it, while the 
patient lies in a warm bath, is often suc- 
cessful in calming excitement and in pro- 
curing sleep in acute insanity. The warm 
bath alone, taken for about half an hour, 
has a soothing effect, and may induce 
sleep ; and its efficacy has been supposed 
to be wonderfully increased by the addi- 
tion of several handfuls of mustard, so as 
to produce a general redness of the surface 
of the body. Brierre de Boismont pro- 
fesses to get very good results from employ- 
ing the warm bath for eight or ten hours 
at a time ; and Leidesdorf has used for 
three or four hours, and in many cases 
with marked calming effect, a bath con- 
structed by Prof. Ilebra, in which patients 
may be kept night and day at a definite 
temperature. Such a use of the bath must 
obviously be avoided where the pulse is 
feeble and where there is anything like 
commencing paralysis, and it is of no 
avail in cases of chronic insanity. The 
prolonged use of the shower bath and of 
the cold bath, at one time much in fash- 
ion, is now justly abandoned. The shower 
bath or cold douche may certainly be use- 
fully employed in certain cases of melan- 
cholia, where reaction does not fail to 
take place after it, and in cases of chronic 
insanity, with the purpose of rousing the 
patient and giving tone to the system ; 
but its use should never be continued for 
more than three minutes, and it should 
not be with the aim of producing any 
special effect, but on general principles of 
improving the bodily health. Pouring 
water on the head from a hand shower 
bath, or a common garden watering-pot, 
or sponging the forehead and face with 
cold water, is refreshing and grateful to 
the patient suffering from acute excite- 
ment, and has sometimes a good effect 
beyond what might be expected from a 
measure so simple. The virtues of the 
Turkish bath were at one time much 
vaunted by its advocates, but an exact 
discrimination of the cases in which it 
is useful yet remains to be made. Pack- 
ing in a wet sheet has sometimes a bene- 
ficial effect, and is commonly rather grate- 
ful to the patient. 
Counter-irritants are not much used 
now in Insanity. Schroeder van der Kolk, 
however, put much faith in the applica- 
tion of strong tartar-emetic ointment, or 
of a blister to the shaven scalp ; and Dr. 
Bucknill has found it useful to rub croton 
oil into the scalp in the passage from 
acute to chronic insanity or dementia, 
and in chronic melancholy with delusion. 
Blisters to the nape of the neck appear to 
have little other effect than to increase 
mental irritation; and the benefit of setons 
and issues in the neck is very problemat- 
ical. 
After errors of digestion and secretion 
have been duly attended to, the diet of 
the insane should be good ; and it will be 
desirable in most chronic cases, and in 
many acute cases, to allow a moderate use 
of wine. There can be little doubt that an 
attack of Insanity might sometimes be 
warded off by a generous diet and free use 
of wine at a sufficiently early stage. It is at 
any rate a truth worthy of all acceptation, 
that energetic antiphlogistic treatment in 
the course of Insanity is energetic mischief. 
Leeches may be applied to the head, and a 
patient may be kept on low diet, in order 
to subdue maniacal excitement, without 
any other result than an increase of the 
excitement with the increase of exhaustion; 
and the most active purges may be given, 
and given in vain, to overcome an obsti- 
nate constipation, - when brandy and 
beef-tea, reducing exhaustion, will sub- 
due excitement, and a simple enema will 
produce full action of the bowels. [Per 
contra, the following is from Dr. Forbes 
Winslow:1 " In Insanity, when the symp- 
toms are acute, the patient young and 
plethoric, the habitual secretions sup- 
pressed, the head hot and painful, the 
eyes intolerant of light, the conjunctiva 
injected, the pupils contracted, the pulse 
rapid and hard, and the paroxysm sud- 
den and rapid in its development, local 
bleeding will often arrest the progress of 
the cerebral mischief, greatly facilitate 
the operation of the other remedies, and 
ultimately promote recovery. In propor- 
tion as the symptoms of ordinary insanity 
approach those of phrenitis, or menin- 
gitis, shall we be justified in the use of 
depletion. Although it is only occasion- 
ally, in instances presenting peculiar cha- 
racteristic features, cases occurring in the 
higher ranks of life, where the patient has 
been in the habit of living above par, and 
is of a sanguineous temperament, that we 
are justified in having recourse to general 
depletion, there is a class of recent cases 
[' Obscure Diseases of the Brain and Mind, 
2d American edition, p. 424.] THERAPEUTICS. 
621 
presenting themselves in the asylums for 
the insane, both public and private, in the 
treatment of which we should be guilty of 
culpable and cruel negligence, if we were 
to omit to relieve the cerebral symptoms 
by means of the local abstraction of blood. " 
-H.] Active purgation, once so much 
favored, is now quite eschewed in all 
forms of Insanity. The bowels may gen- 
erally be regulated by dietetic means ; 
and if a purge is needed, a dose of aloes, 
rhubarb, or castor oil will answer every 
purpose-a moderate dose of the last often 
succeeding where the most drastic purga- 
tives fail. The state of the bowels ought, 
however, to be carefully attended to, for 
melancholia has sometimes been produced 
by habital constipation, and is always 
made worse by it. A mixture containing 
sulphate of magnesia, sulphate of iron, 
with a little quinine and sulphuric acid, 
will be found very useful. It will, of 
course, be necessary to be guided by the 
bodily state of the patient, and by the 
history of the causation of the disease, as 
to whether wine is given or not in the 
most acute stage ; it may be desirable in 
cases of a sthenic type to do nothing but 
wait patiently, only preventing the pa- 
tient from doing harm to himself or others, 
until the fury of the storm has passed, and 
then to give support. 
Amongst drugs useful in Insanity, 
opium undoubtedly occupies the first 
place. It is especially useful in that state 
of mental hypersesthesia which so often 
precedes the outbreak of Insanity : when 
the mental tone is so changed that almost 
every impression is painful, then opium, 
freely administered, has virtues which can 
scarce be exaggerated. It is useful, again, 
in cases of simple melancholia, when it 
should be given in doses of one, or even 
two, grains twice a day, and continued 
steadily for weeks, notwithstanding an 
apparent want of success at first. In these 
cases it does not usually produce consti- 
pation ; but if it does, then each dose may 
be combined with a grain of extract of 
aloes or a quarter of a grain of podophyl- 
lin. Where there is fixed delusion of 
some standing, it is not of much use, ex- 
cept as an occasional expedient for pro- 
curing sleep. 
As opium agrees better with persons of 
melancholic than with those of sanguine 
temperament, so it appears to be more 
useful in melancholic than in maniacal 
forms of Insanity. The early writers on 
Insanity condemned the use of opium in 
mania, because of the exaggeration of the 
mental symptoms which they observed in 
some cases after sleep occasioned by it. 
Certainly there are cases of acute mania 
in which, after two or three hours of such 
sleep, the patient seems only to have 
gained new vigor for a fresh start in 
frenzy, and in which it is impossible to 
help feeling that the drug has done harm 
rather than good. But there are, on the 
other hand, cases in which there can be 
no reasonable doubt of the benefit con- 
ferred by opium. These are the cases in 
which there is no heat or congestion of 
the head, but where the face is pale, the 
pulse weak, and where a restless activity 
and incoherence are accompanied with 
want of sleep. In the mania caused by 
intemperance, in the mania or delirium of 
nervous exhaustion, and in puerperal ma- 
nia, opium is beneficial; but it is of little 
use in melancholia with stupor, in idio- 
pathic sthenic mania, or in the attacks of 
excitement that occur in the course of 
chronic mania and general paralysis. 
In cases of great excitement, maniacal 
or melancholic, where opium does no 
good, large doses of digitalis sometimes 
produce the best effects, especially where 
there is general excitement of the circula- 
tion. The excitement abates, and the 
pulse, falling in frequency, may be kept 
for a long time at a standard below the 
average. In the attacks of excitement 
which occur in the course of general pa- 
ralysis, the effects of digitalis are excel- 
lent ; a single dose of two drachms, or 
continued doses of half a drachm every 
three or four hours, being safely given. 
Hydrocyanic acid may be usefully com- 
bined with it; and some entertain a high 
opinion of the good effects of this acid 
when given by itself. 
The subcutaneous injection of morphia 
is a valuable expedient to have recourse 
to, where there is a refusal to take medi- 
cine, and it usually operates much more 
effectually than opium taken by the mouth. 
Not more than a quarter of a grain should 
be injected to commence with, and the 
quantity may subsequently be increased, 
if necessary. It will be well to have in 
mind, that neither opium by the mouth, 
nor morphia hypodermically injected, will 
quench the fury of acute mania, and that 
successive doses of opium or successive 
injections of morphia, followed by brief 
snatches of fitful sleep, have been fol- 
lowed also by fatal collapse. 
It is not yet possible to speak positively 
and definitely of the virtues of chloral as 
a remedy in Insanity. So far as my ex- 
perience reaches, it is that, given in doses 
of 30 grains, repeated in an hour or two 
if necessary, it will produce sleep in most 
cases of Insanity, but that permanent good 
follows the sleep only in those asthenic 
cases in which opium does good. There 
can be no question that we have in this 
drug a useful hypnotic, but, it is another 
question whether hypnotics will stay the 
course of acute Insanity. 
Ilyoscyamus is useful also in some cases 
where opium does not agree, but it should 
be given in doses of not less than a drachm 
to begin with, Tartar emetic will often 622 
INSANITY. 
calm for a time the most furious maniac, 
through the prostration which it pro- 
duces, but it does no permanent good, 
and its employment for such purpose is 
rather a relic of the old system of quiet- 
ing a patient by some violent means or 
other, short of actually killing him. If 
mercury be ever useful, and not mischiev- 
ous, in the treatment of Insanity, it is 
when given in small doses of the per- 
chloride, in cases that are becoming 
chronic, or where there is a suspicion of 
syphilis. To administer mercury system- 
atically in general paralysis, as has been 
done, is as unaccountable in theory as it 
is undoubtedly pernicious in practice. 
In hysterical mania, in epileptic mania, 
and in mania connected with sexual or 
uterine excitement, I have never seen any 
good from the use of opium. In all these 
forms of mania, though least markedly in 
epileptic mania, I have, however, seen 
benefit from the employment of bromide 
of potassium, with or without tincture of 
henbane. In one case, that of a widow 
of sanguine temperament and active 
habits, who suffered from acute chattering 
mania, connected seemingly with uterine 
excitement, recovery took place within a 
fortnight under the use of bromide of 
potassium and henbane. Exactly a year 
afterwards she had an exactly similar at- 
tack, when the same treatment was suc- 
cessful in a short time. 
In all those cases of Insanity in which 
tonics seem to be demanded by the state 
of the bodily health-and they are the 
majority of cases, at one period or other 
of their course-iron and quinine may be 
given ; and one of the best ways of giving 
them is in a mixture containing quinine, 
the tincture of the sesquichloride of iron, 
and chloric ether. In some cases it hap- 
pens that an uncontrollable diarrhoea sets 
in and carries the patient off, nothing 
availing to check it: acetate of lead, with 
opium, and enemata of starch and lauda- 
num, are most likely to be useful. 
When Insanity has become chronic, or 
when fixed delusions are established, there 
is small hope of special benefit from drugs. 
The general health being duly attended 
to, a systematic moral treatment will be 
best adapted to restore health of mind. 
Where there is persistent refusal of food, 
it must never be allowed to continue so 
far as to endanger the bodily health ; and 
if persuasion entirely fail, then the stomach 
pump must be used to administer food, or 
this may be given by a tube passed through 
the nostril. Those who are suicidal should 
be carefully watched at all times, and 
especially so on getting up in the morning, 
when the thoughts are gloomy, and the 
desperate impulse is apt to surprise and 
overpower them. The monomaniac, who 
has delusions that he is watched continu- 
ally, or otherwise persecuted, must always 
be deemed dangerous to others ; for at 
any time he may become so impatient of 
his sufferings as to make a fatal attack 
upon his fancied persecutor. Those who 
suffer from moral Insanity are often very 
troublesome to deal with satisfactorily; 
but it will be worth while always to re- 
member that one unequal to the responsi- 
bilities and duties of the social position in 
which he was born may not on that ac- 
count be unequal to the relations of a 
much lower social stratum. It is not be- 
cause a person insists on ruining himself 
that it is justifiable to deprive him of 
liberty by sending him to an asylum. 
In all forms of Insanity, it is most 
necessary to look beyond the mental 
symptoms, whether these be symptoms of 
excitement or of depression, to examine 
closely the physical symptoms co-existing 
with the mental perversion, and to direct 
the medical treatment to the nature of the 
bodily disease which will sometimes be 
found to be at the root of the whole dis- 
order. Neither opium, nor henbane, nor 
digitalis, nor any other drug, will act as a 
specific in any kind of mental derange- 
ment ; and it is vain to hope and a folly to 
attempt to get rid of the disease by merely 
stilling its prominent symptoms. A ra- 
tional method of treatment must be based 
on a careful inquiry into the patient's 
previous history and into the origin of his 
disease, and on a faithful study of all the 
symptoms, bodily and mental, which it 
presents. 
[As connected with the general princi- 
ples of management of Insanity, the sub- 
ject of restraint may be here alluded to. 
Reacting from the barbarous measures 
common until near the end of the last 
century, when Pinel, in France, led the 
movement for their abolition, the ten- 
dency in England of late years has been 
toward the prohibition of all bodily con- 
finement, except that of secure apart- 
ments and the vigilance of trained atten- 
dants. Non-restraint has thus, especially 
by Drs. Hill and Conolly, been made an 
absolute rule. In America this idea has 
not been accepted without qualification 
by the best alienists. All admit that a 
minimum of restraint is the aim to be 
constantly held in view. But men of 
large experience-Dr. Isaac Ray, for ex- 
ample- still hold that cases occur, al- 
though exceptionally, in which the tem- 
porary use of bodily restraint is a measure 
not only of safety, but of real advantage 
to the patient. At the same time, Amer- 
ican hospitals for the insane compare 
favorably with those abroad in their pro- 
vision of arrangements tending to keep out 
of sight and use, as far as possible, every- 
thing which abridges the liberty and ease 
of the patient; " moral treatment" being 
maintained by the aid of liberal resources 
for mental occupation and diversion, of 
wholesome kinds.-II.] hypochondriasis : NOMENCLATURE. 
623 
HYPOCHONDRIASIS. 
By William Withey Gull, M.D., D.C.L., F.R.S., and Francis Edmund 
Anstie, M.D., F.R.C.P. 
Definition.-A disease of the nervous 
system, of unknown and possibly varying 
seat. It is markedly hereditary, being 
one of the transformed neuroses which 
descend from a parent stock strongly 
tainted with insanity. Its principal fea- 
ture is mental depression, occurring with- 
out apparently adequate cause, and taking 
the shape, either from the first, or very 
soon, of a conviction in the patient's mind 
that he is the victim of serious bodily dis- 
ease. The sufferer's belief in this disease 
is so firm, that he describes minutely the 
symptoms which, as he fancies, indicate 
its existence. But he may place the ima- 
ginary malady in almost any organ of the 
body, and he usually describes some symp- 
toms which are anomalous, or even incre- 
dible. Finally, Hypochondriasis may be 
evoked by a real organic disease acting as 
an irritant to an hereditarily predisposed 
nervous system : in this case, the anoma- 
lous nervous symptoms may mask, and 
even conceal, the occurrence of serious 
changes in some viscus. 
Nomenclature.-The same name has 
been applied to the disease since the days 
of Hippocrates : it has always been known 
as "Hypochondriasis," or the "hypo- 
chondriac disorder," and sometimes as 
the " vapors," or the " spleen but these 
last two synonyms are, in fact, mere ex- 
planations of the ancient hypothesis which 
was expressed in the word Hypochondri- 
asis. This hypothesis it is really impor- 
tant to say a few words about, since the 
vulgar conception of the disease still, 
though unconsciously, cherishes it; al- 
though our improved knowledge of the 
relation of the nervous system to the or- 
ganism generally has now made it an 
anachronism. 
The words vTtoxovSpiaxov rtd#o$, applied by 
Hippocrates and Galen to the disease, im- 
ply a belief that the viscera behind the 
xiphoid cartilage, and below the dia- 
phragm,1 were its seats ; and Galen very 
distinctly says that black bile is its cause. 
It is worth while to recall for a moment 
the physiological ideas which Galen, with 
great ingenuity, had compounded from the 
speculations of Plato on the one hand, and 
Hippocrates on the other. According to 
Galen, the functions of the human body 
were maintained by three 7mv,ua-ra(whence, 
remotely, our "vapors"). The lowest of 
these was the nvtvya. $uoascw, and developed 
the natural force in the liver ; the second 
was the rtvevpa &>tlx6v, which elaborated 
the vital force in the heart; and the third 
and highest was the rtvevpa which 
developed the animal or soul force in the 
brain.1 Any one who has been curious 
enough to investigate these questions will 
see at once that the lowest or "natural" 
force of Galen is the counterpart of that 
lowest kind of mortal soul which2 Plato 
represented as residing in the abdominal 
organs, and chiefly in the liver, and as 
having to do with the baser animal pas- 
sions and the supply of the needs of vege- 
table life. The ancient tendency to view 
every source of functional activity as an 
entity-almost a personality-made it 
quite consistent for the long succession of 
Galenist physicians to endow the liver- 
force with a quasi-consciousness and per- 
ception, and even with voluntary activity, 
though of a low kind ; and, on the other 
hand, the Paracelsian and Helmontian 
doctrine of the Archceus rather added to 
than changed anything in the extraordi- 
nary power over the general organism 
which was attributed to tlie abdominal 
organs. Then the absence of any accu- 
rate knowledge of the functions of a cen- 
tral nervous system, the recipient of sen- 
sory impressions, and the originator of 
motor acts, induced men to localize in the 
various organs the source of the functional 
disturbances which appeared to be mani- 
fested therein. The vagaries of hypo- 
chondriacal sensation were therefore, in 
the ancient view, the perturbations of the 
natural force generated in the liver, spleen, 
and pyloric part of the stomach. It is to 
be remarked, moreover, that Hypochon- 
driasis was very generally confounded 
with hysteria (to which it doubtless has a 
relation), quite down to the present cen- 
1 The viscera of the hypochondria, to which 
the ancients attached such importance, seem 
to have been especially the liver, the pyloric 
part of the stomach, the omentum, the mesen- 
tery, and the spleen. The stomach consid- 
ered as a whole they regarded rather lightly. 
' De Loc. Affect, v. De Usu Part v. De 
Usu Resp. 163, 164. 
2 Timaeus, Ed. Stallbaum, §§ 69, 70. 624 
HYPOCHONDRIASIS. 
tury. There is nothing surprising in this. 
The flatulence which is frequently a strik- 
ing symptom both in hysteria and Hypo- 
chondriasis was, for the ancients, a com- 
motion of the natural spirits which re- 
sided in the abdomen. 
Of the long list of authors who have 
treated of Hypochondriasis, since the days 
of Galen, there is scarcely one who viewed 
the disease in any essentially different 
light from that in which Galen regarded 
it, until we come to Thomas Willis, the 
great investigator of the nervous system. 
It is easy to see what were the common 
ideas on the subject at the time by con- 
sulting that curious book, Burton's "Ana- 
tomy of Melancholy,''which was published 
a few years after Willis's death, and which 
represented the knowledge which a learned 
and clever layman might pick up without 
knowing, or without demeaning himself 
to notice, the writings of a contemporary 
countryman. Burton says that the gene- 
ral view of authors represents the hypo- 
chondriac or windy melancholy as arising 
" from the bowels, liver, spleen, or mem- 
brane called mesenterium," and quotes 
Laurentius as dividing it into three kinds, 
the hepatic, the splenetic, and the mesa- 
raick. 
Willis,' on the other hand, placed Hy- 
pochondriasis amongst the diseases proper 
to the diathesis spasmodica; he made it an 
affection of the nervous system, but so far 
conformed to the old ideas as to attribute 
its ultimate causation to impurity of the 
splenic blood. In the next century, 
Flemying2 ventured a more distinct opin- 
ion, that the brain was the part primarily 
affected ; and Cullen3 and Robert Whytt* 
(especially the former) placed great stress 
on the share which the nervous system 
has in the production of the disease. The 
next prominent step was taken by Geor- 
get5 (1819), who protested against the 
view (at that time still commonly prevail- 
ing) of the abdominal origin of Hypochon- 
driasis, and the practice of powerful pur- 
gation. &c., which was based upon it. 
But the most complete and effective attack 
on the old view was made by J. Falret,6 
in 1822. This author dwelt strongly on 
the hereditary character of the disease, 
and the great frequency with which it is 
immediately excited by stress of intellec- 
tual labor, or by moral and emotional 
causes. The view of Falret was perhaps 
carried to excess in limiting the primary 
seat of the disease so strictly to the brain; 
but it has prevailed, and Hypochondria- 
sis is now commonly placed among the 
varieties of Insanity. Griesinger, for in- 
stance, in his admirable treatise on men- 
tal diseases,1 makes Hypochondriasis a 
variety of melancholia, which is his first 
class of "mental diseases characterized 
by depressionand Leidesdorf2 adopts 
the same view. It will be seen that the 
view which we hold differs in some degree 
from this ; but there can no longer be any 
doubt that the true seat of the disease is 
in the nervous centres. 
History.'-The history of a hypochon- 
driac patient is that of his nervous system 
under the two aspects of its congenital 
form and the influences-of nutrition, edu- 
cation, and emotion-to which it has been 
subjected. So far, it is not different from 
the story of the sufferer from any other 
form of nervous disease. But Hypochon- 
driasis is distinguished by this-that a 
more important part is played by the con- 
genital disposition of the nervous system, 
and a less important part by the physio- 
logical and spiritual influences which 
have been brought to bear on it, than is 
the case with the majority of nervous dis- 
eases. It comes nearest, in this respect, 
to insanity on the one hand, and to epi- 
lepsy and neuralgia on the other. It is 
the almost inevitable inheritance of a cer- 
tain percentage of the descendants of any 
individual who may be very strongly 
tainted with insanity. On this subject 
we shall say no more till we can discuss 
more fully the etiology of this singular 
disease. 
Symptoms.-This phrase is pre-emi- 
nently appropriate to the phenomena of 
Hypochondriasis. Of physical signs we 
have almost none to guide us ; and this is 
in perfect agreement with the position 
which this disorder holds in the category 
of diseases generally. All is in the region 
of symptoms. For the most part, too, 
the symptoms are subjective only: still 
there are features which the experienced 
physician can detect, and which can hardly 
be simulated by a malingerer. 
The most important external feature of 
Hypochondriasis is this: that without any 
sufficient reason for such conduct, and 
without any signs of intellectual insanity, 
1 T. Willis, Opera Omnia, 4to. Genevse, 
1676. The whole treatise, De Morbis Convul- 
sivis, and that on Hysteria and Hypochondri- 
asis (in reply to the strictures of Nat. High- 
more), are astonishing efforts of genius, and 
will well repay perusal in the present day. 
2 Neuropathia; sive de Morb. Hypochond. 
et Hyster. Ebor. 1744. 
3 Clinical Lectures. London, 1777, pp. 39 
-57. 
4 Observations on the Causes, Nature, and 
Cure of the Disorders called Nervous, Hypo- 
chondriacal, &c. London, 1777. 
6 De la Phys, du Syst. Nerv. Paris, 1819. 
6 De PHypochondrie et du Suicide. Paris, 
1822. 
1 Die Path, und Therap. der psych. Krank- 
heiten. 2d edit. Stuttgart, 1861. 
2 Path, und Therap. der psych. Krank- 
heiten. Erlangen, 1860. SYMPTOMS. 
625 
the patient is observed to concentrate his 
attention on some particular organ of his 
body, and to fancy that it is seriously dis- 
eased. This concentration of attention is 
often preceded and accompanied by nota- 
ble depression or variability of his spirits, 
with a tendency, on the whole, to depres- 
sion : this is not always the case, however, 
for there is sometimes no antecedent 
symptom connected with the general 
mental state. In many instances the pa- 
tient's first sufferings take the form of 
what he himself considers dyspepsia, but 
which is in fact little more than flatu- 
lence, from the formation of large collec- 
tions of gas in the stomach and bowels. 
Along with this flatulence, there are 
sometimes appearances which give a su- 
perficial color to the idea of a primary 
stomach derangement: the tongue, for 
instance, is often pasted and coated, and 
there may be foul breath ; the appetite is 
not unfrequently ravenous, capricious, or 
well-nigh lost; there is generally obsti- 
nate constipation ; jn rare cases there are 
even attacks of vomiting. 
More commonly there is an antecedent 
mental change, the character of which it 
is at first difficult to seize, and which 
forms one of the grounds for the modern 
practice of including Hypochondriasis in 
the varieties of actual insanity. Before 
any local symptoms have declared them- 
selves, the patient has already become 
changed in his disposition ; in most cases, 
perhaps, the change is simply in the di- 
rection of despondency or vague alarm, 
for which he can give no reason. It is 
remarked by alienists that the mental 
condition, even thus early, is character- 
ized above all things by an expansion of 
the self-feeling, a pre-occupation of the 
patient with his own condition, to the ex- 
clusion of other interests and affections. 
This is true ; but it appears to us that the 
self-concentration is more like that of a 
person in the preliminary stage of an 
acute inflammation or fever, the nature 
of which is not yet declared, than the 
egotistic alteration of character which 
seems to lie at the basis of insanity, and 
which probably depends directly upon 
minute changes taking place in the cor- 
tical substance of the brain. It is a real 
bodily sensation (though at first indescri- 
bable) which enchains the sufferer's atten- 
tion ; and before long this vague feeling 
is exchanged for a positive localized sense 
of uneasiness or actual pain. 
Sometimes the early mental state is one 
not merely or chiefly of despondency, but 
characterized by suspiciousness and irri- 
tability of temper, with quick changes 
from high spirits and loquacity to moody 
silence. In any case, after a time, the 
patient not only exhibits in his aspect 
and conduct the general uneasiness from 
which he suffers, but begins to complain 
of definite subjective symptoms. Prob- 
ably the most common of these is pain of 
a gnawing or burning character, or else a 
sense of great though vague uneasiness 
at the pit of the stomach. But in fact 
any part of the peripheral distribution of 
the sensory nerves may be the apparent 
seat of painful sensation; and besides 
this there is often a generally heightened 
sensibility of the skin. Both the active 
pain and the heightened sensibility of 
(uncomplicated) Hypochondriasis are sub- 
jective, and resemble the similar phe- 
nomena which are so common in hys- 
terical women, in vanishing when the 
patient's attention is powerfully diverted 
from them. The painful sensations of 
which hypochondriacs complain are very 
acute; and their severity concentrates 
the attention of the sufferer exclusively 
upon them, increasing the apparent ego- 
tism of his disposition. But it may here 
be remarked, that the heightened self- 
feeling of Hypochondriasis does not par- 
take of the despondency of true melan- 
cholia, still less of the character of other 
forms of insane egotism. The patient (as 
observed by Leidesdorf), though depress- 
ed in mind, not only wishes to get rid of 
his malady, but has great faith that he 
will do so : a faith which suffers repeated 
shocks, indeed, from the non-suecess of 
particular remedies, but quickly revives 
in favor of some new mode of treatment. 
The eagerness with which he pursues the 
means of cure is the true cause of the 
limitation of his thoughts. 
Next to pseudo-dyspeptic symptoms, 
and the occurrence of pains or anomalous 
feelings at the pit of the stomach, the 
most common morbid sensations in Hy- 
pochondriasis, are, probably, formication 
of the skin, and burning pains in the course 
of particular superficial nerves. It is 
noteworthy that, so far as we are aware, 
the nerve-pains most frequently assume 
the burning type, rather than the lanci- 
nating, throbbing, or aching forms which 
neuralgia more commonly takes. A com- 
mon occurrence is the sudden shifting of 
the pains, or the sense of formication 
from one part of the body to another, or 
their sudden extension from a small area 
which they first affected over almost the 
whole surface of the body. It is import- 
ant to distinguish, from these pains, those 
which occur in the early stages of loco- 
motor ataxy : and, in fact, this may be diffi- 
cult in some instances, for the ataxic pains 
also are singularly shifting. However, 
the pains of ataxy are confined so strictly 
to the limbs (usually to the feet, thighs, 
and nates), that this of itself constitutes 
a difference from hypochondriacal pain. 
Another very frequent subjective symp- 
tom is the feeling of pain or great but in- 
describable uneasiness deep in the heart, 
or the lungs, or the liver, the bladder, or 
vol. i.-40 HYPOCHONDRIASIS. 
626 
the rectum. The development of the 
subjective symptoms is very often seri- 
ously influenced by the fact that the pa- 
tient is driven by his misery to consult 
medical books, or to pester his medical 
friends with questions bearing on his suf- 
ferings : his defective knowledge and dis- 
torted fancy leads him to apply, a tort et a 
tracers, the scraps of information which 
he picks up, and to imagine, successively, 
that he has discovered in himself the 
signs of one, two, or half a dozen serious 
organic diseases. Attention being thus 
directed to particular organs, the subjec- 
tive symptoms naturally increase and 
multiply, and the emotional excitement 
produced also frequently sets up severe 
functional disturbance, such as flushings 
of the face, abdominal pulsation, palpita- 
tion of the heart, partial suppression of 
bile and jaundice, or bilious diarrhoea; 
symptoms which still further confirm the 
sufferer in the belief that he is laboring 
under serious organic disease. A very 
common delusion is the belief that there 
is fatal heart-disease ; and a scarcely less 
frequent one is the persuasion of the pa- 
tient that he is impotent from sperma- 
torrhoea : this last is of course greatly 
fostered by reading pseudo-medical trea- 
tises. In the case of patients whose 
family is strongly tainted with insanity, 
the .anomalous sensations often assume a 
type which approaches to hallucination 
or illusion (as where there is the belief 
that a serpent is writhing about in the 
(entrails, &c. &c.), or the judgment be- 
<o«mes affected to such a degree that the 
:pa>ient entertains preposterous delusions 
((a® that he is made of glass, and in danger 
.every 'moment of being broken, that he is 
heirng magnetized, that people are con- 
spiring to poison him, &c.). The delu- 
sions sometimes are confined, at any rate 
for a time, to one or two organs, but are 
nevertheless so extravagant that it would 
really seem no paradox to say that the 
patient has a mad stomach, a mad liver, 
or a mad bladder, while on all other 
matters his intellect remains healthy, and 
often usually acute. It is probable that 
'tiny portion of the nervous centres may 
Ibe functionally disordered in Hypochon- 
•driasis, ;and thus give rise to disturbances 
-of this .kind in the organs with which 
they are related. But on the subject of 
the Protean symptoms of Hypochondri- 
asis it is really unnecessary to enlarge 
further, and we may refer those who de- 
sire to read a truthful and highly pictur- 
esque description of them to the pages of 
Burton,1 to say nothing of more modern 
writers. 
Diagnosis.-The diagnosis of Hypo- 
chondriasis, from maladies superficially 
resembling it, is proverbially beset with 
difficulties, and the practitionei' can only 
gain confidence in his decision on the 
more doubtful cases by means of long ex- 
perience. Nevertheless, the general prin- 
ciples on which his judgment must be 
formed are not very difficult to state. 
If the anomalous character of a pa- 
tient's subjective symptoms point in the 
direction of Hypochondriasis, the very 
first subject of inquiry should be the 
family history. A well-defined history of 
insanity in the race would at once indi- 
cate the probability that the patient's 
sensations were partly illusory, and not 
referable to their apparent site. On the 
other hand, a decided history of the ab- 
sence of insanity and of the other severe 
neuroses from the. family during two or 
three previous generations would still 
more strongly suggest that the case was 
not one of Hypochondriasis. The next 
point for investigation would be the mode 
of commencement of the illness. A his- 
tory of the primary occurrence of severe 
bodily symptoms, whether in the shape of 
pyrexia, of disturbance of hepatic or gas- 
tric functions, or of pain in the course of 
nerves, is unfavorable to the diagnosis of 
Hypochondriasis, unless these phenomena 
were preceded or accompanied by psychi- 
cal changes such as have been already de- 
scribed. Even a more chronic develop- 
ment of capricious pains, of formication 
of the skin, of flatulence, palpitations, 
and the like, is not specially indicative of 
Hypochondriasis, unless there is unusual 
anxiety on the patient's part, and an ego- 
tistic tendency to dwrell on his sufferings. 
A great deal may be gathered from con- 
siderations of age and sex. Hypochon- 
driasis is pre-eminently a disease of adult 
and middle life ; it is hardly ever seen 
before puberty, and it very rarely makes 
its first appearance after the age of fifty. 
It is greatly more common among men 
than among women ; in the latter sex it 
appears to be replaced, for the most part, 
by hysteria. Still Hypochondriasis may 
occur in women, and the question of diag- 
nosis from hysteria, in such a case, be- 
comes important, and may be very diffi- 
cult. Beyond all other circumstances 
which favor the probability of Hypochon- 
driasis is the fact of a strong hereditary 
taint of insanity. The age at which the 
symptoms commence is important: thus 
the first appearance of hysterical phe- 
nomena nearly always takes place be- 
tween the ages of fourteen and thirty, or 
else at the grand climacteric; and has 
very commonly a marked relation to those 
changes in the nervous system which cor- 
respond with the changes of the sexual 
apparatus ; whereas the development of 
Hypochondriasis is especially associated 
with the circumstances of middle life-in 
the rich and idle with the tedium vitae of a 
1 Anatomy of Melancholy, pp. 270-274. DIAGNOSIS. 
627 
purposeless existence ; in the poor and 
anxious with the cares of a family, and 
perhaps with the added misery of a con- 
scious failure in efforts to support rela- 
tions and dependents. Severe moral and 
emotional shocks maybe followed either by 
hypochondriacal or hysterical disorder; 
but the latter is the infinitely more proba- 
ble result in women who are not descended 
of markedly insane families, and especially 
in women who lead busy lives. 
One of the most important questions in 
diagnosis is the decision whether, if Hypo- 
chondriasis be present, there is not at the 
same time some organic visceral disease; 
for it sometimes happens that the first 
sign of the occurrence of such disease is 
an outbreak of hypochondriacal symp- 
toms, the patient being hereditarily pre- 
disposed to the latter disorder, and his 
nervous system excited to morbid action 
by the irritation of the new organic pro- 
cesses which are going on. Of the dis- 
eases which have been known to produce 
such an effect, structural changes of the 
liver, and, next to them, structural changes 
of the stomach, are probably the most fre- 
quent examples; and, after these, aneu- 
risms of the great vessels, valvular diseases 
of the heart, angina pectoris. It is unneces- 
sary here, even if there were space, for us 
to go into the characteristic symptoms of 
these organic diseases. The first feature 
which may lead the physician to suspect 
the existence of organic visceral disease, 
in the midst of symptoms which he feels 
sure are hypochondriacal, is the persist- 
ence of some one complaint by the pa- 
tient-e. g., of pain in a particular locality: 
especially if this be combined, always in 
the same order, with other symptoms that 
belong to the suspected organic disorder, 
and with which the patient is not likely 
to be acquainted so as to be mentally in- 
fluenced to reproduce them. Thus if, 
along with a fixed complaint of pain in 
the prsecordia increased by swallowing, 
there is the regular occurrence of regurgi- 
tation of some of the food very shortly 
after deglutition, it is a case for inquiry 
as to the possible existence of cancerous 
or other stricture of the cardiac end of 
the stomach, &c. It is needless to say 
that physical signs, when they are pre- 
sent, are the most valuable helps in dis- 
cerning organic disease which is masked 
by Hypochondriasis; yet even here there 
is need of caution. For instance, the oc- 
currence of hardness and tumiditv in the 
epigastrium or the hypochondrium, in 
such a form as closely to imitate a scir- 
rhous tumor (even on repeated examina- 
tions), may be produced by spasmodic 
contraction of one or both recti: in such 
a case the administration of chloroform 
would at once dismiss the suspicion by 
dissolving the "phantom" tumor. A 
circumstance which is always of doubtful 
interpretation is the occurrence of wast- 
ing, especially if combined with jaundice. 
If this takes place with rapidity, it can 
hardly be owing to hypochondriacal dis- 
turbance of digestion and assimilation, 
but is probably due either to the generally- 
depraving effect of cancerous or tubercular 
taint, or to direct interference with nutri- 
tion from the mechanical effects of ulcer, 
stricture, or tumor, upon some of the chy- 
lopoietic viscera. The$>combination of in- 
sidious and unsuspected malarial poison- 
ing with hypochondriacal tendencies may 
produce formidable difficulties in diag- 
nosis, which can only be overcome by 
careful study of the patient's past history, 
sometimes by the discovery of enlarged 
spleen, and above all by the effects of 
anti-periodic medicines. Another variety 
of blood-poisoning, which in hypochon- 
driacal patients may be somewhat masked, 
is chronic alcoholism; but it has been 
shown in another article in the present 
volume, that the symptoms of the latter 
complaint are, after all, tolerably distinct 
and recognizable from their peculiar 
grouping, and even in a hypochondriac 
they may be generally identified. 
A more serious difficulty in diagnosis 
than any which has yet been mentioned 
is the distinction between certain forms 
of Hypochondriasis and true melancholia. 
Given a patient with a decided family 
history of insanity, with a mental condi- 
tion marked by a strong tendency to dwell 
on complaints of bodily misery, and with 
dyspepsia and flatulence, it may be very 
difficult to say whether or not the case 
will pass into true melancholic insanity. 
The following case will give a good idea 
of the occasional uncertainty. A post- 
man, aged forty-three, a widower, was 
much overworked, and especially harassed 
by having to sort the letters in the morn- 
ing before he started on his beat, a task 
which had to be hurriedly done, and 
hence gave him much anxiety lest he 
should make mistakes. He applied for 
relief from dyspepsia and flatulence and 
bilious diarrhoea, but at the same time 
complained that his spirits were dread- 
fully low, that he had thoughts of suicide, 
and that he believed he had "something 
alive in his inside." A simple tonic mix- 
ture of mineral acid and bark, combined 
with the moral influence of encouraging 
assurances from the physician, did this 
patient so much good that he soon seemed 
perfectly well, and remained so for some 
months. He then got married again, and 
his marriage apparently embarrassed his 
means, though not seriously ; but his de- 
spondency now returned in the form of a 
belief that he and his family would have 
to go to the workhouse (of which there 
was really not the least danger), and the 
impulse to suicide again became very 
urgent. At the same time his dyspepsia 628 
HYPOCHONDRIASIS. 
and bilious diarrhoea returned. He ap- 
plied for medical relief, was ordered the 
same treatment as before, and was en- 
couraged to hope for a speedy cure ; but 
the very next day he attempted suicide 
by completely severing the whole of his 
genitals from his body with a razor. He 
was taken to St. George's Hospital, and 
with great difficulty kept alive while the 
wound healed. Six weeks after his dis- 
charge from the hospital he appeared be- 
fore his former attendant, looking fat and 
fresh-colored, but more despondent than 
ever: indeed plainly insane. He was then 
lost sight of, but there could be little 
doubt that he would get worse, and, if 
not carefully watched, would commit 
suicide. 
Such a case as the above has little to 
separate it from Hypochondriasis except 
the one important feature of the early oc- 
currence of suicidal despondency; but this 
feature would probably be sufficient justi- 
fication for a decided diagnosis. It is 
only where the hypochondriac patient has 
been exhausted by a long continuance of 
his sufferings and rendered hopeless by 
the failure of a thousand attempts at cure, 
that he turns his thoughts to self-destruc- 
tion, and by that time he may be consid- 
ered really insane. Indeed, the hypo- 
chondriac proper regards the idea of sui- 
cide with the utmost repulsion and dis- 
gust. 
There is no serious difficulty in distin- 
guishing simple Hypochondriasis from the 
other forms of insanity. 
Prognosis.-The prognosis of Hypo- 
chondriasis varies extremely, not so much 
with the apparent severity of the symp- 
toms as with the circumstances under 
which they arose, the length of time dur- 
ing which they have already persisted, 
and above all the degree to which the pa- 
tient's family has been tainted with insan- 
ity. But in general it may be said that 
the younger the patient, the shorter the 
time during which he has suffered, the 
less that the nutrition of the body has de- 
teriorated, and, above all, the less of de- 
cided family taint of insanity that can be 
traced, the more hopeful is the aspect of 
the case ; and vice versd. 
Etiology.-The "causes of Hypo- 
chondriasis" is an expression even more 
singularly unhappy than the average in- 
stances of a phraseology of causation ap- 
plied to those circumstances which precede 
the outward and visible development of 
functional disorders. To commence with 
those influences which have a conventional 
title to be called " exciting" causes : it is 
undoubtedly true that in a considerable 
number of cases the train of disastrous 
events has seemed to be fired by the moral 
collapse consequent on over-exhausting 
labor, or bitter disappointment of cherish- 
ed hopes, or on the sudden revelation to 
the mind of an idle man that he is a mere 
burden on the face of the earth. Again, 
it is commonly said that reading or con- 
versation on medical topics often frightens 
laymen, and, more rarely, even doctors, 
into a nervous and hypochondriacal frame 
of mind. There is, doubtless, something 
to be attributed to such influences, but 
the most thoughtless person could hardly 
fail to be struck, on reflection, with the 
surprising infrequency of Hypochondriasis 
in comparison with the ubiquitous opera- 
tion of such influences as grief, fatigue, 
the sense of shameful failure, the habit of 
miserable and heart-wearying idleness, 
and the practice by the laity of reading 
medical treatises. If we turn to the events 
which would be conventionally spoken of 
as " predisposing" causes, we are scarcely 
likely to be more satisfied with the appro- 
priateness of the term "cause ; " though 
we come upon facts of far greater practi- 
cal value than those which have just been 
mentioned. The fact of hereditary insane 
taint, for instance, is an antecedent which 
is observed in an immense number of 
cases, if not in all. The preponderance 
of males among hypochondriacs is equally 
unmistakable ; and so is the fact that the 
bulk of cases occur in persons in the prime 
and vigor of life. It is also an undoubted 
fact that the average level of intellect in 
hypochondriacs is not below but rather 
above the general standard; and that 
their bodily health has often been excel- 
lent up to the moment when the nervous 
symptoms made their appearance. But 
instead of saying that these circumstances 
are "causes" of the disease, it will be 
convenient to say that they are conditions 
of its occurrence in the following degree 
and manner : A certain number of the 
descendants of a family strongly tainted 
with insanity will invariably be born with 
peculiarities of the nervous system : these 
peculiarities do not, probably, consist of 
recognizable structural faults, but rather 
of tendencies of one or more (perhaps 
scattered) portions of the central system 
to change interstitially in a certain mor- 
bid direction, at particular crises of life, 
through which healthy organisms pass un- 
harmed. Arrived at such crises the ner- 
vous system will surmount them, or will 
succumb, according to the absence or the 
presence of certain external disadvantages. 
If the morbid change occurs, it will not 
affect the machinery of the intellectual 
and reflective faculties chiefly, perhaps 
not at all; its force will be spent mainly 
on that portion of the nervous apparatus 
which performs the function of translating 
to the mind the perceptions of sensitive 
nerves at the periphery; but it is not im- 
possible that even the primary morbid 
action is occasionally developed in nervous pathology and treatment. 
629 
centres which govern secretion and other 
functions of organic life; and that the 
dyspepsia, and other functional disorders 
of viscera, may in these cases be the direct 
result of a central disease, instead of reflex 
phenomena dependent upon the condition 
of consciousness, as is probably the case 
in many instances. In the latter stages 
of the malady there can be no doubt that 
the mental depression reacts with great 
force upon the machinery of organic life, 
disordering secretions and rhythmic mo- 
tions very extensively. 
The Pathology of Hypochondriasis, 
in the strict sense of the word, does not 
exist, for there are no anatomical or 
physiological facts upon which it can be 
based. Morbid anatomy has revealed ab- 
solutely nothing which in the slightest 
degree explains the occurrence of the dis- 
ease, and the physiology of the symptoms 
is to the last degree obscure and uncer- 
tain in its interpretation. It is only in 
those cases which develop into true insan- 
ity, more especially those which pass into 
dementia, that the brain exhibits any 
notable changes ; and these alterations, 
when they occur, are no proper part of 
Hypochondriasis. It is neither impossible 
nor unlikely that the improved modern 
methods of examining the nervous cen- 
tres, if they could be applied to the cen- 
tral ganglia of certain visceral nerves 
(and especially to the nucleus of the 
vagus), might detect appreciable changes 
even in the early stages of the disease. 
But the opportunities for carefully ex- 
amining the nervous system of patients 
in the early periods of Hypochondriasis 
can rarely be obtained, and it is probable 
enough that the question as to the pre- 
occurrence or not of structural changes 
will never be thoroughly cleared up. 
The Treatment of Hypochondriasis 
consists of the use of moral and constitu- 
tional remedies and of remedies for symp- 
toms. 
It is obvious that the first duty of the 
physician is to encourage the hypochon- 
driac to forget his woes ; but nothing is so 
difficult in practice, and that for the best 
of reasons. It is a fallacy to suppose that 
the sufferings of the patient are unreal ; 
on the contrary, they are most vividly 
real, and it is impossible that he should 
forget them till they cease. Yet the mind 
has a reflex influence upon the bodily dis- 
order, which may be as effective for good 
as for evil; and this fact may be taken 
advantage of. The key to the moral 
treatment is the breaking down of the 
patient's morbid self-concentration, and 
this object may be achieved to some ex- 
tent in many cases by a change in the 
course of his daily life. The class of pa- 
tients with whom this may be most readily 
carried out are those in whom the consti- 
tutional tendency to Hypochondriasis is 
aggravated by the ennui of an idle life: 
for these an active career or pursuit of 
almost any kind is an immense gain ; only 
the new occupation should be one which 
forces them to mix with the world. The 
isolated activity of the student is no real 
diversion from the fancies of Hypochon- 
driasis, as the case of Dr. Johnson, and 
of many other famous intellectual work- 
ers, abundantly proves. It is needless to 
say that all actively depressing influences 
should be removed, such as immoderate 
venereal indulgence, of whatever kind, or 
alcoholic intemperance. On the other 
hand, the influence of new emotions which 
tend to lift the patient out of himself can 
scarcely fail to be beneficial; and it would 
be a real good-fortune to a hypochondriac 
if he could fall in love in a natural and 
healthy manner, or if he could interest 
himself warmly in philanthropic schemes 
or other plans of public usefulness. And, 
above all, something like a police super- 
vision should be exercised as regards his 
studies, in order that he may be rigor- 
ously kept from the perusal of medical or 
other books which might remind him of 
his miseries ; for though we do not believe 
that these things can create Hypochon- 
driasis, yet they can certainly prevent its 
cure. It is well understood, however, 
that no good can be effected by simply 
laughing at his narrative of suffering, or 
bantering him on his fancifulness ; on the 
contrary, it is necessary for the physician 
to be interested and to believe in the 
reality of his painful sensations. If the 
patient once thinks that the doctor is 
taking pains to get at the secret of his 
troubles, he will be inclined to accept the 
first word of encouragement the latter 
throws out; and the reflected influence of 
reviving hope will be certain to assist 
recovery. 
The constitutional treatment is to be 
directed towards improving the general 
nutrition ; and the task here is partly that 
of aiding the primary process of diges- 
tion of food, and partly that of rendering 
more active the processes of decomposi- 
tion and exchange in the tissues gener- 
ally. The hypochondriac either has a de- 
ficient, a capricious, or a ravenous appe- 
tite, but in any case the primary function 
of digestion is almost always markedly 
impaired if the disease has lasted for any 
length of time ; and when this depends on 
a want of tone mainly, or a condition of 
irritation of the stomach (such as is indi- 
cated by a coated tongue with a red or 
strawberry tip), the use of vegetable bit- 
ters and mineral acids will often do great 
good. Defective secondary assimilation, 
which will be especially indicated by the 
condition of the urine, is generally much 
benefited by the use of cod-liver oil for a 630 
HYSTERIA. 
rather prolonged period, if the remedy 
can only be tolerated by the stomach. In 
cases where the oil cannot be borne, 
cream, butter, or some other form of fat, 
will often agree, and may be made the 
first stage to inducing the stomach to re- 
tain the cod-liver oil. Nor is it by any 
means only in cases where there is gen- 
eral emaciation that the administration 
of fat does good; it is probable that the 
nutrition of the nervous tissues is directly 
improved by this treatment in many in- 
stances. The administration of iron is 
doubtless of great use to some anaemic 
patients, and sea-bathing frequently ap- 
pears to exercise a very beneficial in- 
fluence : but the first of these remedies is 
generally most efficacious when taken in 
the form of the chalybeate waters of some 
foreign spa; and there is good reason to 
doubt whether both mineral waters and 
sea-bathing do not owe most of their ap- 
parent power to the moral influences of 
travel and change of scene and mode of 
life. The more specific nervous tonics, 
such as strychnia, quinine, or phosphorus, 
seem to exercise but a doubtful and acci- 
dental influence. 
The treatment of symptoms is a thing 
to be eschewed in Hypochondriasis, with 
certain special exceptions. While, how- 
ever, it is desirable to avoid concentrating 
the patient's attention on parts which 
are the apparent seat of mere morbid sen- 
sations, it is important to relieve him of 
the distress caused by real (though mere 
functional) disorders of the digestive sys- 
tem. Decided acidity of the stomach 
should be counteracted by the use of anti- 
dotes, of which none is more efficacious 
than magnesia ponderosa, in ten-grain 
doses thrice daily, or Brandish's solution 
of potash, ten minims three times a day, 
with gentian or cascarilla. The exces- 
sive or too long continued use of alkalies 
is, of course, to be avoided. The dis- 
tressing flatulence, which is often one of 
the earliest, and also one of. .the most an- 
noying symptoms, is greatly relieved by 
creasote (one drop in a pill twice or thrice 
a day), or the infusion of valerian. Alco- 
holic tinctures should be very cautiously 
employed, if at all; for there is a real 
danger of the patient coming to appreciate 
the comforting sensations given by the 
spirit so highly, that he gradually takes 
to drink : this is especially true in the 
case of hypochondriacal women, as it 
notoriously is in hysteria. We may add 
that it is particularly likely to occur in 
patients exhausted by masturbation, or 
other venereal indulgence. The consti- 
pation, which is frequently so obstinate 
and troublesome, must be remedied, if it 
be anyhow possible, without the use of 
drugs ; for it is most dangerous to stimu- 
late the patient's love of self-doctoring in 
the direction of the habitual use of purga- 
tives. The prescription of fruit, green 
vegetables, &c., as articles of daily food, 
is a far more desirable mode of accom- 
plishing our object : and the habitual 
practice of active bodily exercise is a 
powerful aid to the same end. 
The question of the quantum ft quale of 
physical exercise which may be beneficial 
in Hypochondriasis forms a fitting subject 
with which to conclude our remarks on 
treatment, since this is a remedy which 
directs itself alike to the moral, the con- 
stitutional, and the symptomatic condition 
of the hypochondriac. The only rule, 
however, which it is possible to lay down 
for our guidance in this matter, is the 
direction to employ physical exercise in 
such a manner and to such an amount as 
shall fully exercise the muscles without 
ever producing severe fatigue, and shall 
also be amusing to the patient. It is a 
very dangerous error to carry exercise to 
the fatigue point; a short continuance of 
such malpractice will usually suffice to 
produce a profound deterioration of the 
vigor of the nervous system, and an 
aggravation of the hypochondriacal fan- 
cies. 
HYSTERIA. 
J. Russell Reynolds, M.D., F.R.S. 
The most characteristic feature of Hys- 
teria has been held to be a particular form 
of convulsion, which will be described 
hereafter in detail; but there are many 
phenomena, some falling far short of con- 
vulsion, even when they resemble it in 
kind, and others differing widely from it 
in their form, and these have been termed 
"hysterical." If, therefore, by the word 
" Hysteria" is intended a definite disease, 
the term " hysterical" should be employed 
with a no less definite aim ; but it has un- NATURAL HISTORY: CAUSES. 
631 
fortunately been sometimes used to de- 
note either a mere variety of the "ner- 
vous temperament," a mood or disposi- 
tion of the health of both body and mind, 
or sometimes a vague condition of disor- 
dered function which cannot be conveni- 
ently placed elsewhere. The employment 
of the word "hysterical" may sometimes 
be found indicative of the state of the 
mind of the practitioner rather than of 
that of the patient's health. It simply 
conveys a doubt as to what is the matter, 
but expresses a prevailing conviction that 
it is nothing very serious as to life, and 
that it might culminate in an attack of 
convulsions of the kind called "hysteric." 
The vast preponderance of Hysteria in 
the female sex has given rise to its name, 
and to a theory as to its essential nature 
and mode of production. It has, how- 
ever, and especially of late years, been so 
distinctly shown that Hysteria may exist 
among men, that the older nomenclature, 
although retained on account of its prac- 
tical utility, is virtually exploded as to its 
etymology. Hysteria is not necessarily 
associated with disease or derangement of 
the generative organs of either sex : such 
association may and does very commonly 
exist; but the true nature of the malady 
may be overlooked if regard be paid ex- 
clusively to that particular relation. 
The hysterical condition may exist for 
many years, and yet be unattended by 
any distinct convulsive paroxysm. The 
latter never exists without the former. 
There are at the present time numberless 
individuals whose lives are, to themselves 
and their friends, the sources of more or 
less constant misery, from the fact of their 
being distinctly and definitely hysterical, 
but in whose history there has never oc- 
curred a single attack of characteristic 
convulsion. We cannot, therefore, draw 
the line of definition so as to include the 
paroxysm and exclude all beside; but 
must, on the other hand, regard as essen- 
tial that which is constantly present, and 
recognize as the disease Hysteria a pecu- 
liar condition of the nervous system of 
which the paroxysm is only one, although 
a highly important feature. The mental 
state of the hysteric patient is more con- 
stantly and as characteristically altered 
as is the condition of the muscular system. 
There is a defective or perverted will; an 
increased activity of emotion, and some- 
times of thought; an altered and aug- 
mented general sensibility ; an exaggera- 
tion of all forms of involuntary motility- 
ideational, emotional, sensational, and 
reflex ; and usually some distinct perver- 
sion of the physical health. It is almost 
impossible to frame an accurate " defini- 
tion' ' oi the disease ; and it seems to me 
more desirable to make the above general 
statement than to attempt a less detailed 
description for the purpose of giving it the 
form of a defir ition. 
Natural History.-I. Causes.- 
Sex. Doubtless the most frequently pre- 
disposing cause is that condition of the 
nervous system which is more or less 
characteristic of the female sex. Hyste- 
ric women are met with daily ; hysteric 
men and boys are of comparatively rare 
occurrence. When Hysteria is found in 
either a man or a boy, it is to be observed 
that such person is, either mentally or 
morally, of feminine constitution, or that 
he has been overworked mentally, exposed 
to much emotional disturbance, or greatly 
reduced in physical power. It is well 
known that men have frequently become 
hysterical as the result of some severe 
accident, such as a fall from a horse or a 
collision in a railway train. The predis- 
position to Hysteria does not exist in the 
fact of an individual having the organs of 
one or the other sex, but in the possession 
of a nervous state-an habitual, constitu- 
tional, or induced relation between the 
several elements of mental, moral, and 
physical life-which is common to, but 
not always possessed by women ; unnatu- 
ral to, but sometimes exhibited by men. 
Some women are as little likely to become 
hysterical as some men are to fall preg- 
nant ; they are of masculine build, both 
mentally and bodily, and their existence 
and their predispositions to disease furnish 
another proof of the truth of the general 
proposition, that it is in the nervous en- 
dowments, and not in the nature of the 
reproductive apparatus, that the special 
predisposition lies. 
Age.-In the female sex, Hysteria usu- 
ally commences at or about the time of 
puberty, i. e., between twelve and eighteen 
years of age ; but when once developed, 
the symptoms may remain throughout 
life. At the climacteric period Hysteria 
may become developed in a previously 
healthy person ;-this is, however, com- 
paratively speaking, rare; but examples 
of extreme Hysteria may be met with 
after the climacteric period has been 
passed-and that without unusual discom- 
fort-in some women who were hysterical 
in earlier life, but whose hysterical symp- 
toms were then less pronounced. Of 351 
cases analyzed by Landouzy,' the ages at 
commencement were distributed as fol- 
lows :- 
From 10 years to 15 years 
. 48 cases. 
" 16 " 20 " 
. 105 " 
11 21 " 25 " 
. 80 " 
" 26 " 30 " 
. 40 " 
" 31 " 35 " 
. 38 " 
" 36 " 40 " 
. 15 " 
Above 40 years of age . . 
. 25 11 
351 
Boys sometimes exhibit hysteric symp- 
toms at puberty, but the most marked 
1 Traits complet de 1'Hysterie, Paris, 1846, 
p. 184. 632 
HYSTERIA. 
cases of the disease that I have seen in 
males have been at a more advanced age, 
viz. from thirty-five to fifty and upwards. 
It will be seen therefore that Hysteria 
may occur at any age ; and it must be 
remembered that many of the symptoms 
of senile decay, and many of those which 
accompany chronic degenerative disease 
of the brain in middle life, are often called 
"hysterical," because they correspond 
very exactly with those which, when they 
occur in earlier years, are described, and 
without hesitation, by that word. As de- 
caying life passes on to a " second in- 
fancy," we see the signs of a "second 
childishness but often, before either of 
these terms would be strictly applicable, 
we may observe something that resembles, 
in its nervous characters, the period of 
commencing puberty ; for often the first 
sad signal of faltering power is either un- 
due emotional disturbance or deficient 
control of its display. We call these 
states "hysterical," and may perhaps 
sometimes use that word very loosely ; 
but the resemblances are real, and may 
help us to appreciate the pathology of the 
disease "Hysteria." 
Temperament.-If by nervous tempera- 
ment be meant simply an hysterical con- 
dition, it is unnecessary, and would be 
wrong, to speak of the one as a predispo- 
nent to the other. The two expressions 
are sometimes used interchangeably ; but 
this is a great mistake : the truly nervous 
temperament implies no disproportion, 
inter se, of the several nervous endow- 
ments ; all are alike active. There may 
be in those of nervous temperament a 
higher but a shorter life; an intense 
vitality, which burns itself out before its 
time : but the hysteric condition is essen- 
tially one of disproportion, and it is not 
encountered with any especial frequency 
in those who have previously exhibited 
the exaltation described. This latter is 
peculiar to some individuals, but is not 
necessarily morbid. 
Sexual Condition.-Undoubtedly Hyste- 
ria is more common in the single than in 
the married, but it is not limited to the 
former, and it may exist to its highest 
degree in the latter. It is said that the 
wives of incompetent husbands, and bar- 
ren women, as well as widows and old 
maids, are frequent victims of the hysteric 
malady ; but statements such as these do 
not convey the whole truth in regard of 
the etiology of Hysteria, and it must be 
remembered that Hysteria is met with in 
those who are happily married, in preg- 
nant women, and in nursing mothers.1 
From what has already been said in regard 
of the age at which the disease begins, it 
is obvious that age, rather than sexual 
condition, is the predisposing cause. 
Hysteria commences at a time of life when 
girls are, in this country at least, held to 
be too young for marriage. The fact of 
its existence, to a high degree at any rate, 
does not increase their social chances in 
this particular; they often remain single 
because they are hysteric, and this prob- 
ably quite as often as that they become 
hysteric because they are single. Such a 
condition does not tend to improve itself, 
and the disappointment of being left alone 
may keep up and exaggerate the morbid 
state. The facts that there are to show 
that marriage has sometimes cured the 
malady are not so numerous, nor are they 
of such character, as to outweigh the evi- 
dence to be derived from the persistence, 
and even aggravation, of Hysteria after 
marriage. Moreover, it is well known 
that hysterical women who are married 
are often frigid, and averse to sexual in- 
tercourse, and that their aversion is not 
necessarily due to pain. It is compara- 
tively easy to shrug the shoulders and 
utter innuendoes over a case which baffles 
treatment by well-directed regimen and 
medicine ; but does it not sometimes hap- 
pen that such hints are only a clumsy ex- 
cuse for the failure of therapeutics ? That 
marriage may be of use in Hysteria is not 
denied, but it is asserted that it may be 
so by other than its mere sexual relation- 
ships ; there may be a number of circum- 
stances which are changed by taking this 
step in life-annoyances maybe removed, 
new purposes conferred, work given to do, 
and strong help rendered kindly for the 
doing it; and all these may concur to lift 
the hysteric woman out of her former self. 
If, then, we are regarding Hysteria etio- 
logically, all these points should be con- 
sidered, and the argument from the effects 
of marriage should not be based upon one 
element alone. 
Sexual excesses are held to be some- 
times productive of Hysteria ; and doubt- 
less they are so occasionally in men, but 
there is a deficiency of evidence to prove 
this in regard of women. According to 
Duchatalet, Hysteria does not exist with 
especial frequency in women of the town, 
and in those who are exposed to excesses 
of this kind. 
Temperature, Climate, and Season. - 
There are many facts to show that warmth 
of climate and the seasons of spring and 
summer conduce to a production of the 
hysteric condition, but it has yet to be 
shown what is the element comprised un- 
der those terms which is of etiologic mo- 
ment. 
Occupation.-It is demonstrable that 
absence of employment, as it is commonly 
met with among the upper classes, favors 
the production of Hysteria in women ; 
and it is equally clear that overwork, 
anxiety, and great "strain" upon the in- 
1 Vide Niemeyer, Handbuch, p. 356 ; Hasse, 
in Virchow's Handbuch, p. 212. NATURAL HISTORY: CAUSES. 
633 
tellectual and moral faculties, lead to the 
development of Hysteria in man. It is, 
however, questionable whether the mere 
fact of occupation, or its kind, is either 
favorable or unfavorable to health, or to 
Hysteria. The unoccupied life of woman 
is one of exposure to numberless disturb- 
ing causes, as is also the over-occupied 
life of man. The woman, or the young 
girl, who has nothing to do-nothing se- 
rious to which her mind is turned-finds 
" time" to be egregiously tedious; and 
she has to choose between two evils, either 
that of''doing nothing" with it, or that 
of "getting rid of it" by utterly frivolous 
pursuits, the distraction of reading silly 
books and doing the sillier things that " so- 
ciety" prescribes. She thus brings upon 
herself all the petty annoyances of selfish- 
ness and wounded pride, and all the tease 
and turmoil of unreal and extravagant 
emotions. The man who is " overworked" 
finds, commonly, in that work itself, and 
in that which leads to it, much more than 
mere mental occupation, viz., anxiety, 
suspense, and worry, with their concomi- 
tants, loss of both appetite and rest; and 
it is these which, by the nature of their 
operation, develop the hysteric condition, 
rather than the amount of simple work 
which has to be undertaken or pursued. 
It is then, I believe, neither the presence 
nor absence of occupation, per se, which 
conduces to the development of Hysteria 
in either sex; but in the one sex the 
" nonsense" that takes the place of sober 
work, and, in the other, the emotional 
disturbance that attends upon over-exer- 
tion. These lead, under apparently dis- 
similar circumstances, but in a really 
analogous manner, to the production of 
the same result. That which is common 
to the two conditions is an excess of emo- 
tional disturbance ; but in the one case it 
is the outcome of idleness, in the other it 
is often the cause and motive of overwork. 
Absence of occupation may give time and 
opportunity for the manufacture of feel- 
ings that are tormenting and unreal; 
over-exertion may be the means taken to 
relieve the anxiety and emotion which 
are already pressing. Either condition 
may be met with in either sex, but the 
common distribution of work and idleness 
in relation to Hysteria is that which is 
indicated above. 
Menstruation.-It has already been said 
that Hysteria breaks out most frequently 
at or about the time of the commence- 
ment of puberty ; but it has not yet been 
shown that it has any definite relation to 
the varying conditions of menstruation. 
In an individual already hysterical there 
is or may be more than usual disturbance 
at or near the monthly "periods," and 
this is exaggerated by any kind of irregu- 
larity which may exist/ Menorrhagia, 
by reducing the vital power, through loss 
of blood ; dysmenorrhoea, by affecting the 
same result through nervous exhaustion ; 
or amenorrhoea, by its physically direct, 
and mentally and morally indirect influ- 
ences, may, either of them, conduce to 
the increase, or even development, of the 
hysteric state : but it has yet to be shown, 
that either one of these is of itself suffi- 
cient to produce the disease. For it must 
be remembered that Hysteria may exist 
to its highest degree-it commonly has 
done so in the cases which have fallen 
under my own observation-in individuals 
who have presented no anomaly whatever 
in regard of the menstrual functions; and, 
yet further, that it is found in the male 
sex, which may be influenced much by 
sexual conditions, but which exhibits 
nothing analogous to those perturbations 
that have been mentioned. All that I 
can add to the above is, that I have found 
no one condition, either of excess, defect, 
or perversion of the menstrual function, 
so commonly or prevailingly associated 
with Hysteria as to give to it any special 
claim to consideration in the etiology of 
the disease. Some people become more 
or less hysterical about everything that is 
wrong in the performance of their func- 
tions : it is both obvious and notorious 
that the uterine functions are invested in 
the minds of women with an amount of 
importance that is more than their phy- 
siological due ; and hence it is that men- 
strual derangements are regarded by them 
as exerting much more influence than 
those of the digestive or the excretive 
functions, and are therefore brought promi- 
nently forward in the statement of their 
cases. That they do exert this excessive 
influence may be due partly to their in- 
trinsic nature, but partly also to the re- 
sults of thought and feeling about them ; 
and it is important to bear in mind, for 
etiologic purposes, this latter element in 
their mode of action. 
Hereditary taint has not been shown to 
exert any marked influence in the devel- 
opment of Hysteria. It is well known 
that members of one family occasionally 
exhibit similar symptoms, but then it 
must be remembered that many condi- 
tions besides those of blood-relationship 
are ordinarily common to the individuals 
of one family ; they may share equally in 
what is good or bad in respect of exam- 
ple, education, and surrounding circum- 
stances. M. Briquet states that those 
who are born of hysterical parents are 
twelve times more liable than others to 
the outbreak of Hysteria. Very different 
numerical statements are made by others, 
and we must remember that besides the 
direct transmission of an hereditary taint 
there is much contingent upon having an 
hysterical mother. 
The most frequent determining cause of 
an outbreak of hysteric symptoms is some 634 
HYSTERIA. 
mental or moral disturbance; either a 
violent and unexpected commotion, or 
more commonly the occurrence of a trivial 
circumstance which takes the individual 
by surprise, overcomes the power of re- 
straint, and gives evidence of what is 
often an ill-understood, but long con- 
cealed, annoyance or distress. Some- 
times the determining cause is physical, 
e. g., an accident, a loss of blood, or an 
attack of acute bodily illness, such as one 
of the exanthemata, pneumonia, or pleu- 
risy. It then appears, and sometimes to 
the surprise of even the most intimate 
relatives, that there is a morbid condition 
of both mind and body which is difficult 
to describe, and often much more difficult 
to manage. There may be the extreme 
symptoms of the hysteric paroxysm, or 
some of the marked features of the hys- 
teric state. These have now to be de- 
scribed. 
II. Symptoms.- It is convenient to 
separate the paroxysmal symptoms from 
those which exist in the intervals of at- 
tack ; and the former will be best under- 
stood by those who have become ac- 
quainted with the latter, for the hysteric 
state does much to explain the hysteric 
paroxysm. 
It will be well to divide the interparox- 
ysm al symptoms into several categories, 
describing separately the condition of the 
mental and emotional, the sensorial, mo- 
torial, and general health. 
(a) Interparoxysmal Symptoms.- 
Mental and Emotional State.-The will is 
perverted and defective, while ideas and 
emotions exhibit excessive activity. The 
patient says that she cannot do this, or 
cannot bear that; and, while under the 
belief that these things are impossible, 
they are so. It is often obvious to others 
that no physical impossibility exists ; but 
it must not be supposed, therefore, that 
the patient is pretending or "acting a 
part." For the time being it is often 
true that the hysteric patient states the 
fact. What she wants is motive, and this 
may be sometimes supplied by a sudden 
alarm, or by an accidental circumstance ; 
but under ordinary conditions the motive 
is wanting, or is held in abeyance by some 
imperious idea or emotion. There is an 
exaggeration and perpetuation of what 
exists in all people under certain circum- 
stances. Fear paralyzes the strong man, 
while sudden alarm may make the weak 
man strong. A prevailing idea may limit 
as well as induce movements which the 
will can neither counterfeit nor hinder. 
Let this be remembered, therefore, at the 
outset in describing the symptoms of 
Hysteria. 
The patient asserts that she cannot 
control her thoughts, emotions, expres- 
sions, or general movements; that she 
cannot move this or the other limb ; can- 
not open the eyes ; cannot stand or walk ; 
cannot relax the rigid spasm of the hand 
or of the leg; and what she says is true 
under the existing conditions. But often, 
under the influence of some unexpected 
idea, or emotion, or sensation, she does 
the very things that were said to be im- 
possible. 
A patient may be carried into the room, 
and may fall when left for a moment to 
herself; tell her to walk, and a wooden 
doll seems as capable of movement; but, 
under the stimulus of a wish that what 
she is saying should not be overheard, she 
walks to the open door and closes it. Cer- 
tain ideas seem rampant in her mind ; she 
cries about them, and gesticulates in the 
wildest manner: tell her to be silent, to 
keep them to herself, or to control her 
feelings, and you find them exaggerated, 
and she affirms that "all the world shall 
hear" what she has to say ; but a gentle 
rap at the door, that may come from the 
hand of some one from whom she wishes 
to conceal her state, is sufficient in a mo- 
ment to hush this stormy talk, to com- 
pose her face, to dry her eyes, and make 
her speak and smile with placid compo- 
sure. Sometimes she speaks in a whisper 
only, and if asked to " exert herself," or 
"make an effort," so that some particular 
friend who is a little deaf may hear what 
she has to say, the only effect is that the 
whisper becomes quite inaudible, that she 
makes less sound than ever, and often 
none at all-she moves her lips, but not 
even the ghost of a sound is heard to pass 
them ; and yet this self-same person may, 
when no attention is directed to the voice, 
speak loudly enough to be heard and 
understood in the adjoining room. The 
fact seems to be that the will can be called 
into exercise only by some one dominant 
idea or emotion ; and that it is this which 
determines the varying phases of the 
mental state. Under its influence the 
hysteric patient may submit to pain, an- 
noyance, and privation such as a healthy 
person would shrink from without con- 
cealment ; and under its influence, also, 
she may be unable to do what any one 
else could accomplish without either dif- 
ficulty or fatigue. 
Ideation is often excessively active in 
regard of certain classes of thought; there 
is sometimes quite a preternaturally acute 
condition of intelligence in certain direc- 
tions, i. e., in those directions wherein lie 
the morbid notions which are at the 
foundation of the malady. Often the 
hysteric patient makes many mistakes, 
and attributes to people and circumstances 
motives and meanings which they do not 
possess ; but very often she exhibits mar- 
vellous ingenuity in perceiving the ideas 
of others, and in unravelling the intention NATURAL HISTORY: SYMPTOMS. 
635 
of complicated conditions, when these 
have happened in any way, or to any 
degree, to have had relation to herself. 
Apart from these direct personal relation- 
ships the mind often is, or seems to be, 
a perfect blank; the patient is listless, 
apathetic, and dull; a most uninteresting 
specimen of humanity; becoming of value 
only when her vagaries afford curious 
illustrations of certain pathological laws. 
There is a prevailing belief in the import- 
ance of self, and the patient thinks that 
she differs from every other human being; 
that ordinary laws do not apply to her; 
that she is "not understood," as the 
phrase is; and that only some very outre 
or utterly novel mode of treatment can do 
her any good. She believes all this, and 
acts upon it with a pertinacity "worthy 
of a better cause," exhibiting as much 
energy of purpose in a wrong direction as 
would serve to cure her were it rightly 
ordered. 
Emotion is commonly excessive in itself, 
and also in its expression. The patient is 
hurried from one extreme to the other 
with almost ludicrous rapidity ; and often 
she walks, as it were, constantly upon 
that narrow line where tears and laughter 
meet. Laughter and sobbing not only 
alternate, but coexist; and often without 
any obvious and sufficient reason for 
either. There is sometimes listless indif- 
ference to everything of ordinary interest; 
sometimes absorption in some trivial ob- 
ject : often great restlessness and impa- 
tience, with extreme irritability of temper 
on any attempt being made at control, or 
any suggestion being offered of change. 
These mental and emotional conditions 
are liable to much variation. Sometimes 
the patient exhibits them for a day or two, 
and then becomes like an ordinary mortal; 
sometimes they are persistent, and vary 
only in the degree of their intensity. 
In Hysteria we occasionally meet with 
somnambulism, cataleptic conditions, and 
syncopal attacks, which latter sometimes 
pass into the state of " trance," or appar- 
ent death, of which several cases are on 
record. These are, however, among the 
rarer features of the malady. 
Sensorial Condition.-An exaltation of 
sensibility generally may be the earliest, 
and sometimes the only sign of the hys- 
terical condition. It may, and more com- 
monly does, exist in association with other 
symptoms, or in the intervals of their re- 
currence. But sensibility may be altered 
in several distinct directions ; there may 
be increased, painful, perverted, or dimin- 
ished sensation, or there may be absolute 
though partial aneesthesia and analgesia. 
Ilypereesthesia is very commonly con- 
founded-nominally and perhaps theoreti- 
cally-with painful sensibility or sensa- 
tion ; from which, however, it is quite 
distinct. The hysterical patient often ex- 
hibits true hypersesthesia; she does actu- 
ally see, hear, smell, and taste what would 
not be perceptible to those in health, and 
to herself at other times. The exaggera- 
tion of hearing power is that which is the 
most frequently observed ; hysterical girls 
do sometimes seem to "'hear through stone 
walls:" they detect the minutest change 
in odor or in taste, and exhibit an exalted 
keenness of sight. Their sense of touch 
is also sometimes preternaturally acute. 
Painful sensation, or dyssesthesia, is al- 
most always present to some degree. One 
patient cannot bear the light, another is 
distracted by the slightest sound, to a 
third all ordinary odors are intolerable, 
and to others certain tastes, or the contact 
of sundry innocent articles of clothing, are 
most highly objectionable. Pain on pres- 
sure of the skin is very common ; and 
sometimes the symptom is universal, but 
more commonly it is limited in its distri- 
bution, e. g., to the occiput or the spinal 
column. It is to be observed that the di- 
rection of attention to them always makes 
the painful sensations much more intense; 
the mere fact of asking a question about 
them may sometimes develop them. A 
middle-aged hysteric woman, whom I saw 
in hospital a few days ago, had been lying 
for weeks with her hand before her eyes 
"to keep out the light" of a dull London 
sky. Bringing a candle before her-the 
room being so dark from an accidental fog 
that I could not see the pupils-she shud- 
dered, knit her brows, and held both hands 
between her and its feeble light. There 
was no undue contraction of the pupils, 
and when her mind was distracted to the 
condition of her front teeth-the light be- 
ing still close to her eyes-the brows were 
relaxed, the hands removed, and there 
was no expression whatever of uneasiness. 
This is but one example of a large class of 
dyssesthesise which may be commonly ob- 
served in the hysteric. 
A lady to whom I was speaking lately, 
in a tone by no means loud, exclaimed in 
a voice much noisier than mine, and put- 
ting her hands to her ears at the time, 
"Not so loud-not so loud ;" but, a mo- 
ment afterwards, she stirred the fire so 
vehemently, and made so much noise in 
the process, that it was positively annoy- 
ing to myself, and this without appearing 
to give herself the least uncomfortable 
sensation. Sometimes there is obvious 
and distinct painfulness of sensation upon 
impressions of ordinary intensity, and this 
may be limited to one or another organ. 
Most commonly, however, the pain is not 
necessarily associated with the impression, 
is of variable kind and locality, and inter- 
mittent in its form. 
Besides these alterations of sensibility, 
hysteric patients constantly complain of 
" pain, " more or less spontaneous in its 
development. Such pain, wherever it 636 
HYSTERIA. 
may be situated, usually requires several 
strong adjectives for its description, and 
the account given of it is sometimes te- 
diously minute. I have heard one hys- 
teric lady enumerate and detail nine dif- 
ferent kinds of pain in her chest I Of 
these some wrere bearable, some " intoler- 
able," others "agonizing;" and four or 
five of them usually appeared together, 
and were present at the moment of de- 
scription-and yet the face was calm, and 
simply conveyed the expression of interest 
in the description. 
The localities of pain are very numer- 
ous, but some are much more frequently 
complained of than are others. The 
favorite haunts of hysteric pain are the 
top of the head, the left mammary re- 
gion, the hypogastric, and the sacral. 
Sometimes the coccyx, and often one of 
the joints of the limbs, is fixed upon ; but 
I have rarely observed any definite pain 
in the reproductive organs. When one 
of the joints is painful, and there is much 
tenderness of the affected part, it will 
commonly be found that passive move- 
ments or even suceussion of the limb may 
be borne without complaint, whereas even 
gentle pressure of the skin is described as 
"agonizing in the extreme." 
There are other sensations of which 
much is heard that do not fall into any of 
the foregoing categories. The processes 
of ordinary life, which in health are 
unfelt, become sensible, and sometimes 
painfully so, to the hysteric patient. She 
feels the want of breath, the action of the 
heart, the intestinal movements, the pro- 
cesses of micturition and defecation, and 
those of sexual intercourse to an exag- 
gerated degree, and in a distressing man- 
ner. She feels "short of breath," al- 
though there is no actual acceleration of 
the respiratory movements; "palpita- 
tion," although the action of the heart is 
normal; rolling and rumbling movements, 
■when such are not perceptible to the phy- 
sician ; and distress or difficulty in re- 
lieving either the bladder or the rectum, 
when there is no physical disturbance of 
such processes. Sexual intercourse is 
sometimes quite impossible from some 
morbid sensitiveness of the vulva or spas- 
modic action of the sphincter vagime, 
neither of which can be detected on ex- 
amination by the medical attendant. 
There is, further, the sensation termed 
"globus hystericus," which is often, but 
by no means universally present. It is 
not always of the same character. Some- 
times it is the feeling of a " great lump" 
in the hypogastric region, rising through 
the epigastrium and chest, to the throat ; 
but this is, so far as I have seen, extremely 
rare, and is more frequently met with in 
books than in practice. The commonest 
form of distress is that of a ball or lump 
in the throat; a something which the pa- 
tient cannot swallow, and which she feels 
will " choke" her. Anything round the 
neck is intolerable ; she feels as if " some- 
thing were tight there," although there 
may be nothing present in the form of 
dress; she makes constant attempts to 
swallow, but the " lump will not move ;" 
and these discomforts are exaggerated by 
sobbing efforts which very frequently at- 
tend them. Sometimes the patient puts 
her finger in her throat to cause vomiting, 
that she may "bring it up ;" sometimes 
she drinks largely to "push it down ;" but 
in spite of both classes of effort the lump 
remains. Children when about to cry 
know what the feeling is, and probably it 
is of the same nature in the adult. 
Diminished sensibility, and even actual 
anaesthesia of certain localities, may also 
be found. Anaesthesia may exist over 
the whole or a large portion of the sur- 
face of the body, and may extend to the 
deeper tissues, to the muscles,1 and even 
to the nerves of special sense. It most 
commonly follows an hysteric paroxysm, 
but it may be met with when no such 
seizure has taken place. Commonly it is 
limited to certain parts, such as the back 
of the hand or foot, but it may be para- 
plegic or hemiplegic in its distribution, or 
may be found along the course of one or 
more intercostal nerves, and in the mu- 
cous membrane of the nose or mouth. 
The temperature of anaesthetic limbs is 
sometimes reduced. It is a rare event in 
any locality, but it has existed in several 
cases that I have seen in the mucous 
membrane of the vulva and vagina ; the 
anaesthesia in these instances having been 
absolute, and that in highly hysterical, 
married women, who had borne and were 
still bearing children. Probably, anaes- 
thesia is the cause of occasional retention 
of the urine and of the faeces in hysterical 
patients, as either bladder or rectum may 
be found sometimes enormously distended 
without the patient being aware of any 
other discomfort than that occasioned by 
the swelling. Loss of the senses of sight, 
hearing, smell, and taste also sometimes 
occur as phases of hysteric anaesthesia. 
[Following Piorry, Macario and Gendrin 
in France, and Szokalsky in Germany, 
Briquet, Charcot, Westphal, and others 
have of late years made an extended 
study of Hysterical anaesthesia, and es- 
pecially hemiancesthesia.2 In this, the line 
of demarcation is usually perfect for the 
whole length of the body. Briquet as- 
serts that the left side is affected in 70 
cases, to 20 of the right. There may be 
complete anaesthesia, involving the sense 
of touch, of pain, and of temperature, 
together; or it may be incomplete. In 
1 See article, Muscular Anaesthesia. 
[2 Charcot, Lectures on the Diseases of the 
Nervous System, Lecture X.] 637 
NATURAL HISTORY: SYMPTOMS. 
such a case analgesia (insensibility to pain) 
may exist, and yet heat and cold may be 
perceived and discerned ; or, instead, 
thermo-anaesthesia, insensibility to tem- 
perature, without perfect analgesia. 
The ansesthetic side of the body is apt 
to be pale and cold ; anaemic or ischaemic. 
Sometimes very little blood will flow, 
even from a wound. Charcot supposes 
that possibly the story that, in the " Con- 
vulsionnaires" of Saint Medard, no blood 
followed when they were struck with a 
sword, may meet with a partial explana- 
tion in this way. 
Affections of the special senses not un- 
frequently accompany that of the surface 
of the anaesthetic side. I remember in 
my own practice the case of a girl who, 
for several months, was totally blind in 
one eye, and then, recovering sight upon 
that side, the other eye became blind ; 
this, too, being followed by recovery.1 
Galezowski has called attention to Hys- 
terical achrmnatopsia, color-blindness, as 
occurring upon one side; especially the 
left. 
Charcot points out that hemianaesthesia 
is commonly attended by ovarian hyper- 
aesthesia of the opposite side. If loss of 
muscular power, or contraction of the 
limbs occurs, it is upon the same side as 
the hemianaesthesia. 
As a part of the medical history of 
Hysteria, it is proper to mention in this 
place some facts in connection with the 
recent use of metalloscopy and metallo- 
therapy. Dr. Burq, a French physician, 
obtained, in 1876, the appointment by the 
Societe de Biologie, of a commission, con- 
sisting of Drs. Charcot, Luys, and Du- 
montpallier, to examine into his asserted 
observations. These were to the effect 
that, in patients having hysterical anaes- 
thesia, the internal use, and external ap- 
plication of certain metals, different for 
different patients, had a remarkable power 
in restoring sensibility. The commission 
not only confirmed these statements (at 
least concerning the external contact of 
metals), but also discovered that, when, 
in hemianaesthesia, the sensibility of the 
affected side was restored, a transfer of 
anaesthesia occurred, to the sound side. 
Regnard, Magnan, Westphal, and Adam- 
kiewicz essentially confirmed these re- 
sults ; and Charcot exhibited, in August, 
1878, at the Salpetriere, some of the most 
remarkable of them, to Profs. Virchow, 
Grainger Stewart, Liebreich, Ray Lan- 
kester, Broadbent, and other distinguished 
medical men.2 
Besides simple metals, magnets and 
galvano-electric spirals have been found 
to have similar influences. Some of the 
observers are inclined to refer the action 
in all cases to the effects of galvanic cur- 
rents ; but no satisfactory explanation 
has yet been agreed upon. In reading 
such accounts at a distance, the most na- 
tural suggestion would seem to be, that, 
as the events described take place in hys- 
terical patients, the elements of imagina- 
tion and simulation may play a large part 
in their production. Yet the evidence of 
those who have witnessed, and in great 
degree, confirmed them, entitles them to 
attentive study and record, while await- 
ing the final decision of science in regard 
to them. Farther reference to some of 
the same facts will be made in the article 
on Hystero-epilepsy in this volume.-II.] 
Motorial Condition.-In health there 
are different kinds of movements which 
the muscular system exhibits ; some are 
voluntary, others depend upon idea, a 
third group upon emotion, a fourth upon 
sensation, and a fifth upon impressions 
which are not felt. There is, moreover, 
a certain relation between these which is 
characteristic of health, but either of 
them may be so altered as to disturb the 
balance of well-being, and constitute or 
exhibit either derangement or disease. 
In Hysteria the normal relation is per- 
verted, and there is an excess of the in- 
voluntary motility, and a diminution of 
the volitional; the former overrides the 
latter : and not only so, but the particular 
elements of the former display their 
powers in an altered ratio ; sensational 
movements are not in due relation to 
emotional, nor are the latter to those of 
idea. Generally speaking, the lower ac- 
quires the ascendency, and exhibits the 
most marked phenomena. 
Involuntary muscular activity may be 
increased in regard of either the readiness 
with which it is called into exercise, or 
the force and persistence of its display. 
If these involuntary movements be placed 
in the following order-ideational, emo- 
tional, sensational, reflective, and organic 
-it will be found generally true that the 
increased readiness of action is found at 
its maximum in the first, whereas aug- 
mented force and persistence of action 
are observed most distinctly in the last; 
and that the two kinds of alteration di- 
minish in passing from either one of these 
extremes towards the other. 
Voluntary movements are sluggish, the 
patient often lying about on sofas, or in 
bed, and saying that she is quite incapable 
of doing this or that. Irrational move- 
ments are in excess ; and, under the influ- 
ence of morbid "notions," gestures may 
be assumed, and sundry physical efforts 
performed which transcend the powers of 
health. All the emotional movements 
are exaggerated ; the individual laughs, 
cries, and makes grimaces of the most 
distressing kind, and manages often to do 
[* See a paper by Dr. GL C. Harlan, Phila. 
Med. and Surg. Reporter, August 12, 1876.] 
[2 British Med. Journal, Oct. 12, 1878.] 638 
HYSTERIA. 
that which she could not do under ordi- 
nary circumstances. 
Sensational movements are in excess: 
the brows are knit and the eyelids con- 
tracted upon the approach of light; there 
is starting and tremor upon the occurrence 
of any sudden sound or jar; there is vio- 
lent spasm upon the production of any 
pain ; and this often without any real 
exaggeration or sensibility. Reflex mo- 
tility is greatly increased and perverted, 
so that spasms arise from "irritations" 
which in health would be passed by unno- 
ticed ; and numberless movements, of 
momentary duration and varied locality, 
occur in relation to impressions which are 
quite inadequate to produce them in the 
normal state. Other muscular actions, 
tonic or persistent, exist in various parts 
of the body, which differ from the reflex 
in the fact of their permanence, and must 
be referred to some induced change in 
the nervous centres. Of .these, histrionic 
spasm, cramps, and long-continued spasms 
in the limbs or elsewhere, afford the most 
frequent examples. These tonic spasms 
are not confined to the muscles of the 
limbs, they may affect the pharynx, the 
oesophagus, the stomach, or the intestines; 
causing difficulty of swallowing or breath- 
ing, vomiting movements, strange noises, 
eructations, hiccup, borborygmi, and grip- 
ing pains. 
But besides the alterations mentioned, 
there is another kind which is less com- 
mon, but of more serious character, viz., 
paralysis. Loss of power usually occurs as 
the seque lof an hysteric paroxysm, but it 
may sometimes take place spontaneously 
M. Landouzy1 states that, in 47 cases 
of hysteric paralysis, the distribution of 
the symptoms was as follows :- 
General paralysis of motion and sensation 3 
" " of sensation .... 2 
Complete left hemiplegia 8 
Complete hemiplegia, side being doubtful 6 
Paraplegia 9 
Partial paralysis 19 
Usually only one extremity is involved, 
sometimes only a part of the limb ; but in 
many instances there may be what is 
roughly termed "hemiplegia." In the 
latter case the face and tongue are rarely 
affected, and the paralysis is incomplete; 
and the motion of the partly paralyzed leg 
is not like that of an ordinary hemiplegic 
individual. Dr. Todd says that the patient 
" drags the palsied limb after her, as if it 
were a piece of inanimate matter, and 
uses no act of circumduction, nor effort of 
any kind to lift it from the ground ; the 
foot sweeps the ground as she walks." 2 
This is true of many cases. And there 
is a yet further condition which may be 
noticed, viz., the absence of any special 
paralysis of the extensor muscles of the 
toes. If an ordinary hemiplegic patient 
be made to walk, it is seen that on at- 
tempting to raise the foot from the ground 
the toes droop and the leg is circumducted; 
but the hysteric patient does what the 
healthy person cannot help doing, except 
by a strong effort of the will,-when mak- 
ing the attempt to walk, she causes an 
elevation of the great toe at the time of 
endeavoring to move the foot forwards. 
The paralytic patient looks at his feet, 
the hysteric patient looks at her observers. 
The electric irritability persists in the 
palsied limb, and its nutrition does not 
become affected ; but there is sometimes 
diminished sensibility to the electric cur- 
rent ; it is at other times normal, and in 
some cases notably increased. Occasion- 
ally the electric contractility and sensi- 
bility are both diminished or abolished. 
Paraplegia is a form of malady sometimes 
witnessed, and patients suffering in such 
manner may keep their beds, or leave 
them only to exhibit a most curious mode 
of progression, or a series of falls which 
are quite unlike those arising from organic 
lesion of the spinal cord. At this time I 
have under my care two cases of hysterical 
paraplegia, in which the symptoms are 
almost precisely similar. The limbs are 
well nourished, there is perfect electric 
contractility and sensibility ; the patients 
■when lying in bed can elevate their 
limbs, separately or together, to any 
height that is required; they can move 
all the toes, and cutaneous sensibility is 
intact: but if they attempt to walk, their 
legs appear to be no stronger than pieces 
of wet paper, and they tumble down and 
bruise themselves in various quarters. 
What, however, is peculiar in the attempt 
at walking is this, that no amount of help, 
such as a strong arm on either side, pre- 
vents the staggering and falling, but the 
patients tumble down to within a few 
inches of the ground, and then recover 
themselves without help. An ataxic pa- 
tient would walk, comparatively speaking, 
well with such assistance ; a really para- 
plegic patient could not so recover the 
upright position. Where paraplegia has 
been due to hysteria, I have not found loss 
of power over the expulsors or the sphinc- 
ters of either rectum or bladder; although 
it often happens that the latter exists with- 
out the former. General paralysis is ex- 
tremely rare, and is only imperfect in 
degree. 
Vaso-Motor Condition.-Sometimes hys- 
teric patients, after a slight rigor, exhibit 
a certain amount of fever, with headache, 
and mild delirium, which speedily pass 
away, or give place to paralysis of the 
kind described. An irregular distribution 
of temperature, or the fitful occurrence of 
sweating, of salivation, or of increase in 
1 Traits complet de I'Hyst^rie, p. 106. 
2 Clinical Lectures, p. 620. 639 
NATURAL HISTORY! SYMPTOMS. 
some other secretion, afford further illus- 
trations of disturbance in that portion of 
the nervous system which is related to 
the control of blood-supply. 
The General symptoms in Hysteria, or 
those outside the nervous system, are not 
distinctive in their character. Usually 
the patient is not in robust health ; there 
is some pallor, and failure of nutrition; 
or there may be a great tendency to de- 
posit of adipose tissue. Sometimes there 
is a condition of habitual ill-health, or 
delicacy; digestion is impaired, or the 
uterine functions are irregular, or there is 
some constant, but more or less indefinite, 
grievance in the head, thorax, or abdo- 
men. On the other hand, there are many 
cases of Hysteria in which the general 
health is good; the patient eats, drinks, 
sleeps, feels, and is "well." 
Numbers complain of nausea, and eruc- 
tations, or vomiting ; but in many cases 
these symptoms have been entirely due to 
errors, and even absurdities of diet, and 
in not a few to excess of stimulants. It 
is by no means rare for hysterical people 
to "take to drinking." Alcohol relieves 
them for a time; is often recommended 
by medical advisers; the patients know 
its power to diminish their passing dis- 
comforts, and push, beyond all reasonable 
bounds, their recourse to its aid. Flatu- 
lence and borborygmi of the intestines 
are common enough ; and so are palpita- 
tion of the heart, syncopal feelings, and 
dyspnoea-the last, however, without any 
notable change in the ratio of respiration 
to pulse. Large quantities of pale, lim- 
pid urine, of low specific gravity, are 
passed; but this is also true of epilepsy 
and of many other diseases of the nervous 
system. With regard to affections of the 
generative organs, there is great discrep- 
ancy of opinion. Landouzy states that 
in twenty-six, of twenty-seven cases, there 
was some abnormal condition and, fur- 
ther, that of sixty-seven cases of Hyste- 
ria, the symptoms coincided with material 
alterations of the generative apparatus in 
fifty-eight, and that in nineteen cases the 
Hysteria was cured after the removal of 
the genital affection :2 but it is, so far as 
my experience extends, the exception and 
not the rule to find any definite malady, 
or indeed definite complaint, in this direc- 
tion ; while in a vast number of cases 
there has been absolute health in all 
particulars relating to the reproductive 
organs.3 
When men have presented hysterical 
symptoms, there have always been, in my 
practice, considerable deterioration of the 
general health, an impaired nutrition, 
and a feeble circulation, with exhausted 
brain. 
(6) Paroxysmal Symptoms.-The at- 
tacks of hysteric convulsion do not pass 
through stages that can be defined, like 
those of epilepsy, to which they some- 
times bear a rude resemblance. They 
differ widely in degree of intensity, but 
have a general similitude inter se, and can 
rarely be mistaken in either their slighter 
or severer form. When slight, they are 
but an exaggeration of the interparox- 
ysmal state ; when severe, they have been 
confounded with certain grave diseases. 
The following may be regarded as the 
description of a severe attack : A patient 
is talking vehemently, often unreason- 
ably, and is agitated in manner; she is 
crying or laughing, or both, and perhaps 
apologizing for or lamenting her weak- 
ness ; friends are either scolding or con- 
doling, and sometimes there is a combina- 
tion of both modes of domestic treatment; 
some real or imaginary grievance is upper- 
most in the mind and the conversation, 
and is not "met" or removed by the en- 
deavors of the friends. Suddenly the 
patient gives a scream, or makes a splut- 
tering noise, appears to lose voluntary 
power and self-control; she falls down 
with snorting breathing, and a quasi- 
tonic contraction of the muscles of the 
extremities and the trunk. She makes 
hideous grimaces and outrageous noises, 
throws her limbs about in a disorderly 
manner, utters incoherent sentences, 
adopts histrionic attitudes ; complains of 
her throat and stomach, and breathing; 
appears exhausted, or faint, and some- 
times stupefied ; occasionally she seems to 
lose her consciousness, and then, after a 
fit of "crying," to be "herself again." 
The whole paroxysm may last for a few 
moments only, but more commonly it is 
of much longer duration ; a number of 
absurd gesticulations and irregular con- 
vulsive movements lasting from a few 
minutes to three or four hours, after which 
the patient seems worn out, and falls 
asleep. 
These points may be observed during 
the attack : There is rarely absolute or 
sudden loss of consciousness ; the patient 
does not fall in such manner as to hurt 
herself, or tear her clothes ; there is some- 
body near who shall see the phenomenon ; 
hysteric paroxysms do not occur during 
sleep, or when the patient is alone ; there 
is something artistic in the mode of their 
approach - the hysteric patient gathers 
her robe around her, and falls gracefully ; 
she appears to the casual observer to be 
unconscious, but there is not real or ab- 
* Traite, p. 171. 2 Op. cit. p. 174. 
3 Niemeyer says: "Unterden Krankheiten 
des Uterus sind es ausser dem Infarct nament- 
lich die Geschwiire des Muttermundes und 
vor Allem die Knickungen der Gebarmutter, 
welche am Hiiufigsten zu H. fuliren, wahrend 
bei bosartigen Neubildungen und bei destruct- 
iven Prozessen hysterische Zufalle weit soft- 
ener sind."-Handbuch, 2er Band, p. 356. 640 
HYSTERIA. 
solute loss of sense or of perception ; there 
is not the hideous distortion of feature 
observed in epilepsy, nor is there the 
dilatation of the pupil; the eyelids may 
quiver, and the eyeballs may be turned 
up, but there is no divergent strabismus, 
nor is there the wide-open eye. Ex- 
amined carefully, the physician may ob- 
serve that the patient not only sees, but 
looks ; the eyes are often definitely turned 
towards objects or persons standing near, 
and then rolled up again towards the 
forehead: there is no bitten tongue, al- 
though there may be much foaming and 
spluttering with the mouth: the breath- 
ing is tumultuous and noisy, but there is 
no such absolute arrest of respiration as 
to cause asphyxia; and the irregular 
movements and noises that accompany 
the labored breathing may often be seen 
to be occasioned by the lips. The attacks 
last for an indefinite time, are followed by 
much apparent exhaustion, but not by 
real stupor. 
Wherever the attacks pass beyond the 
description here given, it is probable that 
something more than mere Hysteria ex- 
ists, and that the case borders upon the 
much more severe ailment known as epi- 
lepsy. In a few patients the two diseases 
coexist, and then the attacks bear some 
of the characters common to the two ele- 
ments ; but in the vast majority of cases 
it is comparatively easy to distinguish be- 
tween them. 
Mr. R. B. Carter, in an interesting 
book,1 has described the hysteric paroxysm 
under three phases, giving to them the 
terms "primary," "secondary," and 
" tertiary implying that in the first in- 
stance the attack is quite involuntary, 
and is the product of violent emotion ; 
that in the second it is reproduced by 
association of ideas ; and that in the third 
it is deliberately "got up" by the patient. 
There does not, however, appear to me to 
be sufficient reason for adopting these 
phrases, as I am sure that in many in- 
stances all that can be said of any of the 
tertiary paroxysms may be affirmed with 
equal accuracy of the very first attack. 
Hysterical Mania sometimes appears 
after an attack, and its features resolve 
themselves into an exaggeration of the 
condition already described as the "hys- 
teric state." The patient is unmanage- 
able, sometimes mischievous, and very 
often highly abusive; but generally is 
merely loquacious, unreasonable, and de- 
monstrative in regard of emotion, and the 
attack speedily subsides under judicious 
treatment. It, however, exhibits a great 
tendency to recur ; and hysteric patients 
sometimes become, for a time, maniacal 
without going through a paroxysm of 
convulsion. 
Hypochondriacal symptoms are met 
with, and are by no means rare, in cases 
of Hysteria ; but it is quite easy to sepa- 
rate the two diseases. 
Pathology. -Anatomical investiga- 
tion has failed to show the presence of 
any organic lesion which is either so con- 
stant or so prevalent in Hysteria, that it 
may be justly regarded as its cause. 
Pathological examination has been equal- 
ly unsuccessful in its attempts to explain 
the disease by a reference to the disturbed 
function of any one set of organs. It is 
common to find some derangement of the 
digestive, the assimilative, or of the re- 
productive systems ; but these may exist 
without Hysteria; and vice versa, that 
disease may be present when those bodily 
functions are healthily performed. There 
is, however, one thing common to all cases 
of Hysteria, and that is a perturbed con- 
dition of the nervous system. The essen- 
tial character of this morbid state is an 
exaggeration of involuntary motility, and 
a diminution of the power of the will; the 
emotional, sensational, and reflex move- 
ments are in excess, while the voluntary 
are defective. The outcome of such a 
condition is seen in the mode of life of the 
hysteric patient. The will is determined 
by anything rather than by judgment, 
while ideas, feelings, and fancies exert an 
undue influence. Sensations are often 
morbidly acute, are uncorrected by any 
careful discrimination, and thus they in- 
crease the evil. Reflex movements, which 
in health are under some control, are not 
only exaggerated in their individual in- 
tensity, as a part of the hysteric state, 
but, from the weakness of volition, are 
allowed to run such riot that they pass 
beyond all bounds of healthy influence. 
It has already been shown that the 
hysteric condition is somewhat analogous 
to that of the earliest period of decay, 
whether that be the result of age or of 
degeneration from disease. Hysterical 
symptoms are common enough in soften- 
ing of the brain, and also during the 
course of, or convalescence from, exhaust- 
ing diseases. They may break out sud- 
denly, from a loss of blood, of food, or of 
rest, and they may occur as the immedi- 
ate sequel of some violent shock, mental, 
moral, or corporeal. Whatever weakens 
the individual generally may bring about 
this state of nervous disturbance, may 
alter the relations of the several nervous 
functions; and this is, I believe, the true 
pathology of Hysteria, a disease which is 
more closely associated with affections of 
the nervous system than with those of the 
generative organs, although it is well 
known that the latter may and do exert 
a marked influence upon the former. 
The hysteric state is essentially one of 
mental perturbation; and it is brought 
1 On the Pathology and Treatment of Hys- 
teria, p. 43. PATHOLOGY. 
641 
into existence, if not inherited, by those 
conditions which are the most active in 
producing disorder of the mind : in the 
male sex by worry, anxiety, over-work, 
late hours, accidental injuries, and dissi- 
pation ; in the female sex by vexatious 
emotions, want of sympathy or success, 
disappointed and concealed affection, 
want of occupation, fear, and morbid con- 
ditions, or supposed morbid conditions, of 
the reproductive system. The latter are 
sometimes the coincidents, but I believe 
much more commonly the effects of Hys- 
teria than its cause. Their relation is by 
no means constant in existence, and is 
most variable in kind. 
It would appear that the nutrition of 
the whole nervous system is changed, but 
that the change is of such kind that it 
passes beyond our power of recognition, 
except in its physiological or pathological 
effects. We cannot see degeneration of 
tissue here, or too rapid a metamorphosis 
there; but we can witness the effects of 
such morbid processes, in movement, in 
secretion, and nutrition, and we can ob- 
serve some of the ulterior results of such 
changes, in emotion and sensation. 
The influences exerted by emotion upon 
secretion and nutrition have been well 
shown, in their relation to Hysteria, by 
Mr. Carter,1 and the inter-relations of 
physical, mental, and moral life have been 
very ably treated by Mr. Hovell in a more 
recent publication ;2 but the primary fact 
in that condition which we term Hysteria, 
would seem to lie behind all that is refer- 
red to in these considerations, and to con- 
sist in that special morbid change of the 
nervous centres, which either gives to 
emotion an undue influence, or removes 
the limitations of its action. There are 
divers links in the chain of causes and 
effects, but there is one link at which, in 
fixing upon the pathology of Hysteria, we 
must stop and say - all behind this is 
cause, all beyond it is symptom or effect; 
here is the one point which determines 
the hysteric result. Up to this link we 
find the causes of chorea, of epilepsy, and 
of insanity, together with and identical 
with those of Hysteria ; beyond it we find 
neither chorea, epilepsy, nor insanity, but 
what we term Hysteria: in that link, 
therefore, we must seek for and find, if 
we can, the essential fact of the disease. 
I do not say that we have found it; still 
we are much nearer its discovery than we 
were fifty years ago : but I think it better 
to state, in general terms, wherein this 
morbid condition lies, than to lose sight 
of that point, by regarding some outlying 
facts, and attaching undue importance to 
certain frequent lines of apparent causa- 
tion and effect. There is nothing to 
prove that the vaso-motor or sympathetic 
system of nerve-fibres is primarily at 
fault; on the contrary, it often appears 
that the secretions and the general nutri- 
tion are late in suffering; and that the 
earliest departure from health is to be 
found in the disturbed balance of mental 
and emotional operations. If it be held 
that every change in every organ and 
every function is, more or less directly, 
determined by a change in the vaso-motor 
nerves, Hysteria may be driven theoreti- 
cally into this "sympathetic" corner; 
but, when it is made to go there, it will 
find itself in company with almost every 
ill to which flesh is heir-with tubercle 
and corns, with cancer and ataxy. If the 
"vaso-motor system" furnishes the agency 
by which all departures from health find 
their expression, we have yet to discover 
the nature and cause of those special 
changes in its action which lead to these 
particular results. 
The most general expression that we 
can give to the pathology of the hysteric 
state is, perhaps, this, that it is a malnu- 
trition of the nervous system, so distri- 
buted that its higher functions are rela- 
tively impaired and subordinated to the 
lower-that there is diminished power of 
the former and increased activity of the 
latter. 
Every one knows that, in health, there 
are numberless processes which are quite 
familiar to the mind, but which appear 
very strange when described in technical 
language. A physiological or pathological 
discovery is sometimes nothing more than 
the translation into scientific terms of a 
"well-known saw ;" and what may now 
be said upon the pathology of Hysteria is 
little more than such translation. Slight 
emotional excitement, such as shyness, 
trifling vexation, or moderate pleasure, 
may flush the face, quiver the lip, and 
make the breathing "panting;" strong 
emotion, such as terror, intense anger, or 
disgust, may blanch the cheek, fix the 
jaw, parch the mouth, and hold the breath. 
Moderate distress may "find relief in 
tears ;" but when grief is deepest the eyes 
1 Op. cit. p. 5 et seq. 
2 Medicine and Psychology, p. 56, &c. The 
gist of Mr. Hovell's argument lies in the fol- 
lowing sentence : "The nutrition of the body 
is not affected, mental power is not impaired, 
although it may be suspended, innervation 
is deranged, for the generation of nerve power 
is feeble, and its distribution is irregular; 
but it is the sympathetic, the vaso-motory 
system, the moral power, that is at fault: 
either from exhaustion of the physical 
strength of the sensori-motor centres, or be- 
cause, perhaps most frequently, the purposes 
of life are in some respects disappointed, and 
the paresis of disappointment not only saps 
the strength, but, at the same time that it 
brings low the nervous system, also renders 
it peculiarly liable to irritable excitability 
from opposing and aggravating causes." P. 
70, op. cit. 
VOL. I.-41 642 
HYSTERIA. 
are dry. The postures of the various 
emotions are known, and have been 
studies for the artist in marble or on can- 
vas, and for the actor on the stage. If 
we express this physiologically, we say 
that emotions lead through certain nerve- 
tracks to the contraction or elongation of 
some muscular fibres ; that the vessels are 
dilated in the one instance, so that more 
blood than usual passes through the or- 
gans ; and are diminished in the other, so 
that the circulation is arrested ; in the 
former, occasioning an excess of secretion, 
in the latter, a defect: that the muscles 
are spasmodically fixed in one condition, 
and in another are relaxed ; but what we 
want to know is the primary fact leading 
to such changes, when they are unusual 
in degree or persistence, and morbid in 
kind. 
Some individuals, we say, have more 
" control over themselves," or more "pre- 
sence of mind," than others; that A never 
shows what he feels, while B never hides, 
and never can hide, anything ; and if we 
translate this into technical phraseology, 
it is but to say that the one is of " phleg- 
matic," and the other of "nervous tem- 
perament ;" that A is a stolid, resolute 
individual, and thatB is somewhat "hys- 
teric ;" but here again we do but throw 
the question one step backward. 
There is an old proverb to the effect 
that " it is the last straw that breaks the 
camel's back;" and if we put this into 
other terms, it often means but this-that 
an individual has for a long time gone on 
bearing what was too much to bear heal- 
thily, that he has struggled against it, 
•and by forced effort has made everything 
^appear quite tolerable or even easy; but 
at last he "breaks down" from some 
"shock," and then all the "wear and 
tear" comes out, and friends see that he 
had done or borne far too much before. 
Sometimes what is held to be "shock" is 
a mere trifle compared with the rough 
handling that had been previously en- 
dured without complaint; it is simply be- 
cause it, a mere "straw," fell upon the 
already overburdened soul that the great 
crash came, and that then-all power of 
resistance being gone, the "backbroken," 
as it were-the brave sufferer was pros- 
trate, crushed, gave way, and the pent-up 
tide he had kept back so sternly broke 
through destructively. 
In some there is weakness at the out- 
set, congenital, or acquired; in others 
there is weakness, but it is induced by 
long patience, vexation, care, or trouble, 
that have at last done their work, and a 
work which it may take years to undo. 
But here, again, we have yet to learn 
"why, out of a hundred individuals simi- 
larly exposed, one becomes hysteric, an- 
other epileptic, and a third maniacal. 
If we refer to the etiology of Hysteria, 
we shall see that all the facts point in one 
direction ; if we look to the symptoms, we 
shall see that they are partially explained. 
In the female sex, at certain ages and 
under certain conditions, Hysteria is most 
common, for it is but an exaggeration of 
that which constitutes the normal cha- 
racteristics of that sex ; in the male sex 
it is met with when circumstances have 
gradually converted males into the con- 
dition of the other sex; i. e.,when emotions 
have been so played upon that they have, 
at last, broken through the force of resist- 
ance, which held out for a long time 
bravely, but at length gave way. 
The essential fact of Hysteria, then, is 
the distorted balance between voluntary 
and involuntary power ; volition is defec- 
tive ; emotional, sensational, and reflex 
activity are in excess ; and this distortion 
may be brought about by the many and 
divers circumstances of age, sex, position, 
employment, and the like which have 
been enumerated in the section on etiol- 
ogy ; but the precise nature of the change 
which is the efficient cause of such distor- 
tion-i. e., the primary physical fact in the 
pathology of Hysteria-has yet to be dis- 
covered. 
Diagnosis.-If the symptoms already 
described be borne in mind, and the his- 
tory of each case be carefully considered, 
there is not much difficulty in the diag- 
nosis. A physician called in on an emer- 
gency may have, however, to distinguish 
Hysteria from several diseases which it 
simulates. 
From Epilepsy it may be separated by 
negative characters. There is neither 
the suddenness of attack, the absolute loss 
of consciousness, the dilated pupils, the 
complete asphyxia, the bitten tongue, nor 
the reckless injury of either the person or 
the clothes. The patient "looks about," 
the attack lasts longer, there is much 
sobbing and crying, much exhaustion, but 
no perfect stupor. The interparoxysmal 
state of the hysteric patient exhibits fea- 
tures not met with in epilepsy, and vice 
versd. [See Hystero-epilepsy, in this vol- 
ume.-H.] 
From various inflammatory affections, 
such as Peritonitis, Laryngitis, and Arth- 
ritis, hysterical symptoms may be distin- 
guished by a careful use of the ther- 
mometer, which fails to show any rise of 
temperature. Again, the tenderness of 
parts complained of may be seen to be 
ideal rather than real, and to bear rela- 
tion to the skin quite as much as, and 
often more obviously than, to the deeper 
tissues. When there is loss of voice, this 
has the characters already described; 
there is no attempt made to whisper 
loudly ; the failure is evidently not in the 
apparatus of voice, as a mechanical pro- 
duction, but in the will to put that ma- PROGNOSIS. 
643 
chinery into play. A laryngoscopic ex- 
amination will show that the throat is 
healthy, or is simply relaxed-the vocal 
cords being widely separated, and slight 
effort being made for their approximation. 
The pulse-respiration ratio will further 
show that although the breathing may be 
tumultuous, there is no real dyspnoea. 
Phantom tumors may be removed by the 
inhalation of chloroform, while palpation 
and percussion usually reveal the nature 
of their constituents. 
Organic diseases of the nervous centres, 
which are sometimes simulated by hys- 
teric paralyses and aneesthesije, may be 
excluded by the conditions already de- 
scribed, when detailing, in the- section on 
symptoms, the mode of their development. 
Usually the phenomena presented are in- 
consistent with the idea of any definite 
disease of either the cerebrum or the 
spine ; the paralyses are imperfect in de- 
velopment, vague in their distribution, 
and changing in their locality ; they are 
not accompanied by the alterations of 
nutrition, or of electric contractility or 
sensibility which are proper to other af- 
fections ; and the history of the case will 
usually reveal their true nature. The 
walk in hysteric paralysis has already 
been described ; but it is further to be 
observed that the patient does not look 
at her feet, as those who are ataxic do, 
but looks around about her to observe the 
effect of her performance. The ataxic or 
paraplegic patient tries to walk ; the hys- 
teric girl tries to show that she cannot 
use her limbs : if the former forgets him- 
self, he falls ; if the latter forgets herself, 
she walks. 
Neuralgia, when of hysteric origin, has 
not the real intensity of the genuine dis- 
ease, as may be proved by withdrawal of 
attention. There is also an absence of 
those "painful spots," which are present 
when Hysteria does not complicate the 
case. The distribution of pain described 
by hysteric patients is, moreover, often 
so wide of all relation to anatomy and 
physiology, that its true nature may be 
recognized. 
Prognosis.-"When once established, 
Hysteria is very difficult to cure, and this 
is true under all the conditions of causa- 
tion. The most difficult cases are those 
in which it is but an exaggeration of a 
constitutional defect, inasmuch as it is 
impossible to cure the malady without 
changing the individual, and this is by no 
means an easy task. If the hysteric 
habit be natural, or have become a "sec- 
ond nature" by long existence, the prog- 
nosis is pro tanto bad : if it be something 
quite unlike "the former self," or if it 
have been only recently developed, there 
is much room for hope. If the cause ex- 
ist in the patient, i. e., in the essential 
features of the individual character, com- 
paratively little can be done ; if it lie in 
external circumstances, much may be 
done, provided that those circumstances 
can be changed. If there be definite or- 
ganic disease, and this be of such a cha- 
racter that it is amenable to treatment, 
prognosis is so far favorable ; but if there 
be no such disease, and a fortiori if the 
general health be good, the prognosis is 
unfavorable. 
Hysteric symptoms, such as paralysis, 
aphonia, and the like, are often easily re- 
moved when they are of recent origin; 
but when they have existed for many 
months, the prognosis with regard to 
them is unfavorable. It is not, however, 
hopeless ; for in some cases, of even many 
years' duration, there has been amend- 
ment, and-but more rarely-cure. 
The prognosis in Hysteria depends, 
therefore, mainly upon these two things 
-the nature of the "cause," and the 
freedom with which treatment may be 
employed. No human being can cure, 
the physician can do but little for, one 
who is born hysteric ; i. e., for one whose 
disease is but an exaggeration, and some- 
times only a slight exaggeration, of her 
habitual, constitutional state. Education 
might have accomplished much in child- 
hood, but often when the physician is 
called in, the grooves of life are worn so 
deeply that he cannot change them, and 
all that is possible is to soften their sharp 
edges, or to retard the movement which 
he can neither stop nor guide. In such 
cases the prognosis is unfavorable. When 
Hysteria is an accident, is unlike the ear- 
lier promise of the individual, or when it 
is brought about by long, and at last un- 
endurable pressure from without, then 
there is much room for hope. When the 
treatment of the hysteric patient is 
cramped by the anxieties of friends-• 
limited, in this direction, and in that, by 
frightened, too sympathetic, or unwise 
relatives-the prognosis is unfavorable; 
but when the circumstances are such that 
the physician can control them all, much 
hope may be entertained. Upon these 
points, rather than upon the special cha- 
racter of the symptoms, the prognosis 
turns. When Hysteria is a disease, and 
the physician has given to him a carte 
blanche to treat it as he deems best, the 
patient may be cured : but when it is a 
constitutional peculiarity, and the phy- 
sician is checked at every turn by anxious 
friends, the case is hopeless, and might 
as well be left alone. 
In regard to all special symptoms, the 
prognosis is more favorable than it is in 
those diseases which Hysteria simulates ; 
but even here the general principles just 
stated are the most trustworthy guides in 
our attempts to forecast the future. 644 
HYSTERIA. 
Treatment.-The old copy-book max- 
im, "Prevention is better than cure," 
expresses but a small portion of the truth 
in regard to the management of Hysteria: 
prevention might be easy ; cure is often 
almost impossible. It is not within the 
scope of this work to describe generally 
the processes of a healthy education, but 
some things that are special must be said 
with regard to prophylaxis. 
Bearing in mind the pathology of the 
disease, it is highly important that its 
earliest indications should be recognized 
and combated. When there is a tendency 
to Hysteria in early life, these things are 
necessary :- 
1st. A strenuous effort to draw the per- 
son " out of himself," or " herself," and to 
develop the faculty of self-control. This 
should be done, not as an occasional or 
spasmodic effort, but as the business and 
prevailing arrangement of daily life ; and 
while it is done, and in order that it may 
be done, the predisposed person should be 
unconscious of the process. A child who 
is "peculiar," disposed to be taciturn, 
loquacious, "excited," or unduly gay ; or 
who is very readily "upset," and is "so 
sensitive" that parents and others are 
"afraid to tell her" this or that, "for 
fear that it should make her ill-one 
who is " impulsive," and disposed to find 
fault with herself without just ground; 
one who is " shy," and hides herself; one 
who is morose, and who thinks herself 
" misunderstood ;" or one who is retiring, 
and shuts herself out from the sympathy 
she craves for ; -- should be carefully 
watched, tended, and unconsciously guid- 
ed away from self, and into some line of 
feeling, thought, and action, which may 
interest the mind without fatiguing the 
body. The worst thing that can be done 
is that which makes the patient know and 
feel that she is thought to be "peculiar." 
Sometimes such treatment is gratifying to 
her and she likes it-it is easy, and it 
"seems kind" to give it-but it is radi- 
cally wrong. Anything that looks like 
harshness, rigid discipline with a view to 
improvement, or want of sympathy from 
want of " understanding her feelings," is 
shrunk from, or resented by, the patient, 
and is worse than useless. At the same 
time, all exhibitions of a want of self-con- 
trol should be checked, and much of this 
kind may be done in the nursery, and long 
before Hysteria is dreamt of. Kindness, 
firmness, and obvious recognition of " ten- 
der points," with judicious, sympathetic, 
and wise regard to them, may do much to 
avoid future evil; and sometimes the 
qualities of mind which will produce such 
treatment may be met with in a parent, a 
sister, or a governess. The physician 
should guide, in little details of daily life, 
those who have the management of such 
a child. The object is to make her feel 
that she is understood and cared for ; and 
the best mode of attaining this object is 
often indirect in its operation. The mind 
and the heart should be engaged in some 
healthy pursuit; interest should be awa- 
kened, and exercised in anything-it mat- 
ters not what-outside the individual; 
self should be lost sight of, and life made 
useful. 
2d. The bodily health should be most 
carefully regarded, and this without any 
admission or appearance of anxiety on 
the part of others. The points that re- 
quire attention are the following :-(a) 
.Diet, which should be sufficient, whole- 
some, and easy of digestion, avoiding too 
long an interval between meals, and ob- 
serving an especial regularity in the times 
at which they are taken, (b) Rest. The 
hours of sleep should be long, and those 
of rest or lying down not too long. Hys- 
teric girls, or those who are disposed to 
become such, are in the habit of reading 
at night and of lying in bed in the morn- 
ing. Such habits should be broken,-not 
roughly, for the sake of breaking them, 
and of "doing something disagreeable," 
but-by supplying a reason and motive 
for a different mode of life, (c) Exercise 
should be taken regularly, and in the open 
air, as much as possible without fatigue ; 
and here, again, the exercise should have 
some other apparent object than a mere 
piece of tedious hygiene, (d) Recreation 
should be ample and merry ; but all such 
things as precocious or preternatural ex- 
citements should be avoided, (e) Study 
should be systematic and disciplinary, but 
varied and interesting, and made to sub- 
serve some purpose which lies, obviously, 
outside of mere personal accomplishment 
or pleasure. (/) The various functions 
of secretion, excretion, and (if they have 
commenced) of menstruation, should be 
regulated ; and this, again, should be done, 
as far as possible, without any particular 
notice being taken of the fact that they 
may be unhealthy. 
3d. Some motive or purpose should be 
supplied which may give force, persistence, 
unity, and success to the endeavors of the 
patient. This is sometimes very difficult 
to manage ; but it is less difficult in early 
life and in predisposed persons than it is 
in those who are older and have already 
shown definite symptoms of the malady. 
Still, much may be done by those who 
have a little ingenuity in detecting cha- 
racter, and a great deal of perseverance 
and determination in carrying out their 
wishes. The patient should be led to feel 
that the object is in itself desirable ; she 
should never think that it is suggested for 
her own treatment or benefit. If she is 
urged on the former ground, she may do 
much ; if on the latter, she fails entirely. 
The hysteric patient is often most thank- 
ful for and happy in the idea that she is TREATMENT. 
645 
doing good to others, and she will take 
great pains to make her efforts successful 
and pleasing ; but she hates the notion of 
doing anything of such kind as a mere 
means of self-cure, thinks that the doctor 
who recommends them is grossly ignorant 
of her real wants, and that the friends 
who urge her onwards are singularly stu- 
pid or unkind in their advice. To " make 
an effort," simply because told to do so 
for her own sake, is sheerly detestable to 
the hysteric patient, and is sometimes as 
impossible as it is distasteful; but to exert 
herself, almost unconsciously, because a 
motive is supplied, is scarcely felt to be an 
effort. The patient does what she herself 
is surprised and pleased with, and derives 
great benefit from the process. 
When the symptoms of Hysteria are 
developed, the treatment should be con- 
ducted upon the principles already laid 
down with regard to prevention. There 
is, so far as I know, not one single drug 
which exerts any specific action on the 
disease ; but there are many medicines 
which may be used with advantage for 
the relief of associated disorders. These 
do not require any special notice here, 
further than to say that if the patient be 
ansemic, iron is useful; if deficient in gen- 
eral nervous tone, quinine, strychnia, and 
vegetable bitters may do good ; if there be 
indigestion with much flatulence, bismuth, 
charcoal, and alkalies, or mineral acids 
with light bitter infusions, may give relief; 
if there be constipation, mild aperients 
may overcome the difficulty; if there be 
menstrual derangements, they should be 
treated upon general principles. 
The whole list of anti-hysteric remedies 
-such as musk, castor, valerian, asafte- 
tida, and the like-appear to have this 
one property in common, that they do no 
good, and delay the real treatment of the 
case, which is not one of "nauseous 
gums," but of mental, moral, and social 
management. 
Painstaking appreciation of the patient's 
own feelings ; determinate assurance that 
the disease is a real thing, and no idle 
fancy; strenuous effort to help the patient 
in weakness, and to set her right when 
wrong ; fertility of resource in little things; 
a cheerful but not boastful, a sympathetic 
and calm, but neither condoling nor anx- 
ious, manner ; and a strong will, with pa- 
tient work and tact, may do very much, 
and may often cure. But the physician 
should see that he manages his patient, 
and that all that he has attempted to 
effect is not undone by frightened relatives 
or anxious friends. 
There are some drugs which are useful 
under special circumstances; and these 
are opium, or morphia, where there is 
loss of sleep, or persistent pain ; and the 
diffusible stimulants, where there is a 
great tendency to recurrent spasm. Mor- 
phia may be administered most effectually, 
for the relief of pain, by hypodermic injec- 
tion ; it may be given by the mouth, with 
light food, when there is want of sleep. 
Chloric ether, ammonia, and musk, often 
relieve the tendency to spasm; and in 
some cases Indian hemp has proved of 
service when other medicines have failed : 
in the large majority of cases, however, I 
have found Indian hemp of but little use. 
Asafbetida, in doses of thirty grains, three 
or four times daily, is of service in some 
cases. Bromide of potassium has appear- 
ed to me to be singularly useless in Hys- 
teria, failing to relieve either the attacks 
or the symptoms which exist between the 
periods of their recurrence. 
The attacks of hysteric convulsion may 
be arrested by a plan suggested by Dr. 
Hare-viz., that of forcibly preventing 
the patient from breathing for a certain 
time, by holding the nose and mouth. 
The effect of such constraint is to make 
the patient, when allowed to do so, "draw 
a long breath," this vigorous inspiration 
being usually followed by a relaxation of 
all spasm, and a disappearance of the fit. 
Some attacks are of such short duration, 
that there is neither occasion nor time for 
this mode of treatment; but when they are 
prolonged, I have seen it notably useful. 
Dashing cold water on the face and 
neck may sometimes succeed in doing im- 
perfectly that which Dr. Hare's treatment 
accomplishes effectually; but even cold 
water is not always at hand, and when it 
is-in addition to its other inconveniences 
in regard to carpets and dress-it often 
fails to do any good. 
A calm manner, the absence of all ap- 
pearance of alarm, and of either scolding 
or distressing sympathy,-all of which 
things the apparently unconscious patient 
observes much more accurately than do 
her frightened friends,-will sometimes 
bring a fit to a speedy end. 
Some special symptoms of Hysteria re- 
quire special treatment. Aphonia may 
often be cured by electricity; and the 
mode of application which has appeared 
to be the most useful is that of giving 
sparks to, or taking them from, the larynx. 
An ordinary plate or cylinder machine 
may be used for the purpose, and either 
the patient or the physician may be insu- 
lated, and the sparks taken from or given 
respectively by a brass knob. The inter- 
rupted current from a magneto-electric or 
volta-dynamic apparatus may be used so 
as to pass the shocks through the throat, 
or a shock may be administered from a 
charged Leyden phial. Under all these 
circumstances, the voice is sometimes in- 
stantaneously restored. But when Apho- 
nia has been of very long duration, and 
such measures fail to affect it, good may 
be done by directly galvanizing the vocal 
cords, in the manner proposed by Dr. 646 
ECSTASY. 
Morell Mackenzie. Further, I have 
known a strip of blister round the throat 
recall the voice when all means of electri- 
fying have failed. 
Paralyses are treated very successfully 
by Faradization, and by passive move- 
ments and frictions, employed by a well- 
instructed nurse. The electricity should 
be applied to the muscles affected, and 
also to the skin which covers them. I 
have, however, found no mode of treat- 
ing hysterical paralyses comparable in 
efficiency with that of placing narrow 
strips of blister completely round the af- 
fected limbs. This method of treatment 
has succeeded perfectly and rapidly, after 
all other plans have failed. 
Rigid Contractions may be relieved by 
the continuous galvanic current, but 
much more successfully by the inhalation 
of chloroform, and the adaptation of some 
apparatus to maintain extension when 
the effect of chloroform has subsided. 
Passive movements are also of much ser- 
vice in such cases. Drugs may-be taken 
in almost poisonous doses without reliev- 
ing the tonic spasm. 
The treatment of other symptoms must 
be conducted upon the general principles 
already laid down, and may be assisted 
by those local sedative measures to which 
allusion has been made. 
ECSTASY. 
By Thomas King Chambers, M.D., F.R.C.P. 
By intense concentration on one object, 
engaging only a few of the intellectual 
faculties, the mind is liable to lose tempo- 
rarily its sensitive and controlling power 
in respect to its other relations. In minor 
degrees this state is a matter of daily ex- 
perience with us all, and in minds of ave- 
rage strength it does not seem to go be- 
yond minor degrees. They do not wish 
or practise such intense concentration; 
they are able to do and feel all they want 
to do and feel without overtasking them- 
selves. But there are some, either natu- 
rally weaker, and so incapable of full feel- 
ing without concentration, or else desirous 
of a higher degree of emotion than they 
are healthily capable of; and in these a 
condition may be adduced allied in some 
respects to catalepsy, and in some to hys- 
teria-a condition certainly morbid, for it 
renders the patient unequal to the func- 
tions of social life, and is excited by causes 
which affect some and not others/ 
Sometimes the patient falls into a state 
of immobility, in which there is a passive 
reception of ideas, like that of the Mid- 
ianite prophet "falling into a trance, but 
having his eyes open," a state he evi- 
dently considered rarer than that of a 
mere dreamer of dreams. Hoffman1 de- 
scribes an ignorant peasant woman of 
twenty-four, after a fortnight's course of 
exciting sermons, remaining motionless 
for more than an hour; after which she 
gave a few sighs and returned to herself, 
having seen or heard nothing of what was 
going on about her, but having had ex- 
quisite revelations of the love of Christ. 
During forty days she had a hundred re- 
turns of the same state, which would al- 
ways be induced by a recitation of a few 
verses of the Scriptures concerning the 
love of God. During the fits the pulse re- 
mained quite natural. They were finally 
removed by a change of air and scene, 
after bleeding and stimulants had failed. 
The followers of St. Francis, in the days 
of faith, were often brought into these 
ecstasies by fasting, meditation, and ab- 
stinence from varied intellectual exertion. 
Nowhere is it so strikingly depicted 
as by the Tuscan artist Cigoli-a man of 
by no means lively fancy, for, except an 
Ecce Homo, he painted nothing well but 
ecstatic and starving Franciscans. So he 
is probably truthful. After visiting each 
Florentine gallery it is difficult to expel 
from one's memory these strange figures, 
of marble paleness, kneeling, but sunk on 
one side from exhaustion, the eyes open, 
the pupils fixed, the arms extended to 
embrace the beloved vision, the livid lips 
parted in smiles, showing the parched 
dark mouth, the breast heaving with de- 
light. It is necessary to add only one 
medical fact, derived from M. Sagar's ob- 
servation1 of a Capuchin in this state; 
namely, that the pulse was pretty strong. 
One main psychical difference between 
1 Quoted by M. Tissot, (Euvres, vol. xiii. 
p. 4. 
1 Medicina Rationalis, vol. iii. p. 50. ECSTASY. 
647 
this and catalepsy lies in the visions which 
are recollected afterwards with all the 
force of reality. In true catalepsy all 
memory of what is done during the fits is 
completely wiped away-a phenomenon 
which may assist in the detection of im- 
postors. 
A more common development of Ecs- 
tasy is where the sufferer feels "borne in 
upon him," a desire to communicate to 
others the feelings he is sensible of him- 
self, instead of reserving the experience 
till afterwards. The simplest instances 
of this are the scenes which take place 
from time to time in the Primitive Metho- 
dists' or " Ranters'" chapels. The con- 
gregation groan and respond to the feel- 
ings of the preacher, second his words 
with their own experience, and various 
members work themselves up into a state 
of excitement, repeating the last words of 
the sentence, "Salvation ! salvation !" or 
whatever else it may be, with continually 
increasing earnestness, till they end in 
shouting and sobbing. 
The next stage or form of Ecstasy is 
where the enthusiasm tries to express 
and exhaust itself in bodily movements. 
One of the most famous instances of this 
is the spasm of the Convulsionnaires de 
Saint Medard, a disease which was by 
neglect allowed to attain most formidable 
proportions in the last century. It owed 
its origin to the discussion of dogmas 
whose character one would never have 
expected to have stimulated feeling; 
namely, those which were in dispute be- 
tween the Gallicans and Ultramontanists 
on the occasion of the bull "Unigenitus." 
A popular Gallican deacon, named Paris, 
died in 1727, and was buried at St. Me- 
dard ; and on his grave people began to 
fall into convulsions, be affected with 
clairvoyance, preach, jump, spin round 
with incredible rapidity, run their heads 
against the walls, &c. &c. Of no avail 
was Louis the Fifteenth's proclamation, 
which some one parodied- 
"De part le Roi! Defense a Dieu 
De laire miracles dans ce lieu." 
In spite of it Convulsionism grew into a 
sect, and was at last only smothered by 
the French Revolution. 
A transition between this form and the 
last is exhibited in Revivalism ; and its 
reduction to a certain system and order is 
shown in the ceremonies of the Jumpers 
of New York and the Dancing Dervishes 
of Cairo. 
Sporadic cases of this Ecstasy not in- 
frequently occur in the experience of the 
promulgators of new or arousing doc- 
trine ; but judicious discouragement has 
usually prevented its becoming historical. 
We meet with it in the biographies of 
such men as Samuel Wesley and Edward 
Irving ; and a valuable lesson is to be 
learnt from their wise mode of dealing 
with it, especially the former. 
The mention made of this disease being 
used by dishonest or foolish people as a 
bond of union for religious sects, leads to 
a point in its history which constitutes 
the main interest it possesses for practical 
consideration. It is eminently communi- 
cable, especially in its more active, noisy, 
and ridiculous forms. 
There is not much worth reading in the 
Pastorals of Longus ; but one expression 
of his-j? "rwr dxwois " the conta- 
gion of the eyes"-is so picturesque and 
truthful that he deserves the credit of it. 
Through the eye instinctive imitation, or 
sympathy, directs the first intellectual 
and corporeal efforts of the infant, and 
makes him grow up in the image of his 
kind ; and, as Longus felt, it is by such 
means that two adult souls get bound into 
one. So also through the eye flashes in 
that morbid state in which a nervous 
malady fetters the normal powers of con- 
trol, binding them up as with an electric 
spasm, and allowing the lowest animal 
emotions to exhibit tliemselves. An initi- 
ative compliance, a voluntary surrender 
of the gates of the soul, is doubtless neces- 
sary at first: but with each yielding the 
energy is weaker, and this natural and 
healthy sympathy may pass into an actual 
disease of the mind, in which the power 
of the will is quite in abeyance. 
In this way, from the accidental eccen- 
tricity, convulsion, or insanity of often a 
single person, the strange spasmodic epi- 
demics of the Middle Ages arose. We 
can easily understand the disorganization 
which they produced among the lower 
orders, when we read that a few months 
after a new appearance of the "dancing 
mania" at Aix-la-Chapelle, on St. John's 
Day, 1374, there were as many as eleven 
thousand dancers in the streets of Metz. 
In this instance, at least, the outbreak 
took its rise in the scandalous midsum- 
mer revels, which had been handed over 
from paganism to the ascetic Baptist's 
festival, in spite of the protests of the 
Church from St. Augustine to Pope Boni- 
face. The origin was a disreputable one, 
so the dancers hastened to avoid the in- 
ference by placing themselves under the 
protection of St. Vitus, one of the four- 
teen "Helpers in need."1 For full 150 
years it was in Germany a most serious 
plague, of which a full history is given 
in Hecker's " Epidemics of the Middle 
1 Most travellers in Flanders and Germany 
are probably familiar with the shrines of the 
fourteen "Nothhelfer" or "Apotheker" saints, 
spiritual specialists, of whom one cures tooth- 
ache, another stone, another cancer. It is a 
curious fact that the regularly educated phy- 
sicians, St. Luke, St. Cosmo, and St. Damian,, 
are not among them. ECSTASY. 
648 
Ages." As a translation of that graphic 
description is published by the Sydenham 
Society, it is unnecessary to do more than 
refer to it those who are anxious to trace 
to its most disgusting results an extreme 
indulgence in uncontrolled sympathy. 
Spasmodic epidemics seem to have ap- 
peared in Italy about the same time as in 
Germany, but to have been for some time 
confined to Apulia. At the end of the 
fifteenth century they spread further, and 
coincident with the spread there seems to 
have been observed an increase in the 
numbers of the tarantula or ground-spi- 
der. The two facts became associated 
together, and a panic flashed like light- 
ning through the country that this crea- 
ture was communicating the disease by 
its bite. Of "tarantism" in Italy, pure 
fright was as potent an exciting cause as 
superstitious fanaticism had been of the 
"St. John's" or "St. Vitus's dance" in 
Germany. And for this reason it affected 
a higher and better educated class of 
society. Even a sceptical prelate did not 
find his freethinking a protection. Quin- 
zato, Bishop of Foligno, having allowed 
himself in joke to be bitten by a taran- 
tula, fell into the disease, and could only 
be cured in the undignified method adopt- 
ed by vulgar laymen. (Hecker.) He was 
obliged to kick off his shoes (such at least 
is the necessary prelude nowadays) and 
dance the tarantella. 
As an epidemic, tarantism has long dis- 
appeared, but sporadic cases are said still 
to occur, and hysterical women will per- 
suade their gossips that they have been 
bitten by the tarantula, and that they can- 
not get rid of their mental fidgets without 
an immoderate indulgence in the tradi- 
tional cure by dancing. 
Of the exciting causes of Ecstasy, and 
its allied spasmodic epidemics, the most 
common is perverted religious feeling, of 
which elaborate examples are given in the 
"New America" and other works of Mr. 
Hepworth Dixon. The reason is that, 
since the diffusion of Christianity, religion 
has a more powerful hold upon the emo- 
tions than anything else. But all histo- 
rians agree in attributing much influence 
also to venereal excitement; and in pre- 
Christian times, when in default of revela- 
tion men worshipped their incarnate pas- 
sions, we have from the pen of Sappho a 
description of a purely erotic ecstasy, 
which can never be paralleled again, in 
the case of tarantism it seems to have 
been cowardice which was the exciting 
cause. 
The history of the treatment of exag- 
gerated instances of this disease is instruc- 
tive to us, not from the likelihood that any 
of this volume's readers will be called upon 
to undertake it, but as a suggestive guide 
for the management of allied states, semi- 
mental, semi-corporeal, which are as com- 
monly, as it is rarely, under medical 
charge. Allusion is especially intended 
to two-chorea, the heir to the name, and 
in a diluted degree to the nature, of the 
mediaeval mad dancers who put them- 
selves under the protection of St. Vitus ; 
and to hysteria, which being more usual 
among women than among men, has ac- 
quired a name derived from a part of 
their bodies anciently supposed to produce 
the symptoms-a nomenclature often 
leading to bad practice. 
1. If taken in time, ecstatic and emo- 
tional exhibitions are capable of being for- 
cibly repressed. For example, in Unst, 
the most northerly of the Shetlands, an 
epidemic of convulsive fits occurring in 
sermon time began to prevail in several 
parish churches. At one of these, North- 
maven, the disease was cut short by a 
rough fellow of a kirk officer, who carried 
out a troublesome patient and " tossed 
her into a wet ditch." Nobody else 
caught it.1 From what scandalous scenes 
Europe might have been saved had the 
first dancers on St. John's eve been 
" tossed into a wet ditch !" 
2. A strict quarantine prevents infec- 
tion. In 1796 an epidemic convulsion 
spread to twenty-four persons in Angle- 
sea. Their landlord, Lord Uxbridge, 
consulted Dr. Haygarth, and by his ad- 
vice all communication with the afflicted 
persons was prevented, and the plague 
was stayed, as he records.2 
I have often had chorea and hysteria 
arrested in hospital wards on separating 
the patients thus diseased, who had been 
keeping up one another's malady by sym- 
pathy. 
3. Order, rhythm,designed consecutive- 
ness, and in short anything implying 
voluntary control, has a beneficial effect 
in this class of complaints. Doubtless 
when once Sappho had grown particular 
in winding up with a dactyle and spondee 
the pretty stanzas named after her, when 
Madam Guyon had learnt to be careful of 
her rhymes, and Saint Theresa had com- 
mitted her devotions to paper, all danger 
of contagious enthusiasm was past. But 
it is only an intellect of above the average 
capacity that can undertake to reduce it- 
self to order in this way. Those afflicted 
in Germany with the epidemic convul- 
sions before alluded to, took to dancing, 
evidently with an instinctive feeling that 
rhythmical movement was a relief to their 
morbid sensations ; but in that country 
the application of it as a mode of cure 
does not appear to have been turned to 
such good account by art as in Italy. The 
1 Edinburgh Med. and Surg. Journal, vol. 
iii. p. 439. 
2 Haygarth, "On the Imagination as a Cause 
and Cure of the Disorders of the Body." Bath, 
1801. IIYSTERO-EPILEPSY. 
649 
tarantellas I have seen performed in South 
Italy are very complicated figures, accom- 
panied by an amount of arm-waving, fin- 
ger-snapping, simultaneous wriggling, 
slapping of hands, bumping of backs, and. 
crossing one another's footsteps, that can 
only be accomplished by a strict adherence 
to time. And the time is marked by a 
tambourine or drum. These dances are 
probably much older than tarantism; 
but for the cure of it they became popu- 
lar, and from it they got their name. It 
is impossible to doubt that they had a real 
influence, even over those who undertook 
them unwillingly, as in the case of the 
sceptical bishop above alluded to. The 
peculiar features of them, to which I 
should attribute their usefulness, are the 
marked time and intricate figure, by which 
they are honorably distinguished from 
the senseless rotatory embrace now called 
dancing. 
I am sure I have seen decided benefit 
in hysteria from dancing reels, and there 
would probably be much more, if time 
were better marked and kept. 
In chorea, marching in timed step is ex- 
cellent practice for regaining the directing 
power over the limbs. In stuttering, 
which is a sort of chorea, spouting poetry 
before a looking-glass contributes much to 
the cure, 
[HYSTERO-EPILEPSY. 
By Henry Hartshorne, M.D. 
It has long been a familiar fact to most 
practitioners, that some cases of Hysteria 
simulate or approach Epilepsy so closely 
that their diagnosis requires a very care- 
ful estimation of the whole history of each 
case. Latterly, Briquet,1 and more espe- 
cially Charcot2 and Bourneville,3 have 
elaborately described and analyzed cases 
which are regarded by some pathologists 
as a combination of the two maladies ; al- 
though Villermay, Briquet, Tissot, Char- 
cot, and others, consider them rather as 
examples of exaggerated Hysteria. Lan- 
douzy, Saunders, Anderson,4 McLane 
Hamilton,5 and others, also, have record- 
ed cases having more or less resemblance 
to those of the SalpStriere. It appears 
probable that the two diseases may some- 
times be actually combined. In some 
cases Epilepsy is then the primary disor- 
der, Hysteria being engrafted upon it, 
generally by some powerfully disturbing 
emotional cause. In other instances, Hys- 
teria having previously existed, Epilepsy 
has been added, as it were, to it. Mar- 
riage, in some cases, seemed to be the 
immediately exciting cause. In others, 
the attacks (as in a case mentioned by 
Hamilton) coincided with the menstrual 
period. 
A personal history of a kind likely to 
predispose to psychical as well as corporeal 
functional disorders, is stated to have oc- 
curred in connection with each of the most 
typical cases. Some were prostitutes; 
others had suffered extreme fright (e. g., 
during the terrors of the Commune in 
Paris); or had been the victims of domes- 
tic tragedies. 
Preliminary symptoms of the attack are 
nearly always observable, through one, 
two, or three days. These are, palpita- 
tion of the heart, the "globus hystericus," 
noises in the ears, visual disturbances, 
and (ascertained by palpation) ovarian 
hgpercRsthesia. Strong pressure upon the 
affected ovary will sometimes arrest the 
attack. Charcot asserts1 that ovarialgia 
is an important part of these seizures; 
and calls attention to the not uncommon 
empirical resort to pressure upon the ab- 
domen, in convulsive affections of women, 
as long ago as the 16th century. Mercado, 
in 1513, advised abdominal frictions, and 
about the same time Monartes placed a 
large stone on the patient's belly during 
the seizure. Willits,2 in the 17th century, 
made a similar recommendation, which 
was, later, reviewed by Recamier and 
Negrier. But most remarkable was the 
secours afforded to the "Convulsionnaires 
de St. Medard," in the 18th century, dur- 
ing their paroxysms. Several methods 
[' Traits Clinique et Th^rapeutique de 
l'Hyst6rie, Paris, 1859.] 
[2 Lemons sur les Maladies du Systbme Ner- 
veux, Paris, 1872.] 
[3 Iconographie Photographique de la Sal- 
petribre (service de M. Charcot). Par Bourne- 
ville et P. Regnard, Paris, 1878.] 
[* Brit. Med. Journal, Feb. 8, 1879.] 
[® Nervous Diseases, &c., Philada., 1878.] 
[* Op. cit., Lecture XI ] 
[2 De Morbis Convulsivis, t. ii. p. 34.] 650 
IIYSTERO-EPILEPS Y. 
were employed : 1st, striking the abdomen 
repeatedly with a heavy andiron, or a 
large wooden pestle; '2d, the two fists of 
a man being thrust, with all his might, 
against the abdomen; 3d, three, four, or 
five persons together getting upon the 
body of the " convulsionnaire 4th, long 
bands being passed around the body, so as 
to compress it when they were drawn 
right and left. Charcot ascribes the ben- 
efit of all these measures to pressure upon 
hypersesthetic ovaries. 
For an account of the hystero-epileptic 
paroxysm itself, we cannot do better than 
to have recourse to a description, by an 
eye-witness, of one of Charcot's patients 
at the SalpStriere. Dr. Arthur Gamgee. 
of Owen's College, Manchester, thus nar- 
rates1 what took place in one of the demon- 
strations occurring during a visit in Au- 
gust, 1878, to Prof. Charcot's wards, made 
by himself, in company with Drs. Vir- 
chow, G. Stewart Turner, O. Liebreich, 
E. Hart, and others:- 
" Hystero-Epilepsy; Absolute Hemianoes- 
thesia with Hight-sided Ovarian Hyperes- 
thesia; Induction of the Hystero-Epileptic 
Seizure by Peripheral Irritation; its Arrest 
by Compression in the Hight Ovarian He- 
gion; Inhibition of Fits by continuous Ap- 
plication of Pressure.-The patient, a 
young woman of considerable vigor and 
intelligence, is apparently about twenty- 
two years of age, and is very frequently 
subject to the most characteristic hystero- 
epileptic attacks. These attacks had 
been exceedingly frequent on the day pre- 
ceding our visit, but had been inhibited 
by the systematic application of pressure 
to the right ovarian region, as will be 
more particularly mentioned in the sequel. 
They still continued to recur. 
"Professor Charcot pointed out that the 
hystero-epileptic seizure, besides occurring 
spontaneously, can usually be induced 
with ease by some modes of peripheral 
irritation. In the present case, for in- 
stance, by suddenly "gripping" the skin 
of the breast on both sides, about on a 
level with the fifth rib, and midway be- 
tween the anterior and posterior bounda- 
ries of the axilla, the patient instantly 
fell into the hystero-epileptic convulsion. 
The constancy with which the effect fol- 
lowed the cause was demonstrated over 
and over again to be absolute. 
"Although the various phenomena of 
the hystero-epileptic seizure are known to 
many readers through the writings of M. 
Charcot, it may be not uninteresting to 
describe them with all minuteness as they 
were presented before us by this patient. 
The attack may be conveniently divided 
into three or four stages. 
"The first stage followed the application 
of the peripheral irritation without the 
intervention of any perceptible latent pe- 
riod ; its features were the following: 
The head was thrown violently back- 
wards, the limbs and body became rigid, 
the respirations infrequent and stertorous; 
in a few seconds, the tonic spasms were 
succeeded by clonic spasms affecting the 
muscular system. A slight remission, 
Fig. 35. 
Hystero-Epilepsy, Stage of Rigidity. (Bournevilla.) 
lasting for a very few seconds, occurred, 
which was spoken of as a kind of entr'acte, 
and then commenced the second stage. 
The first may be termed the epileptiform 
stage. 
" The second stage was characterized by 
extraordinary movements affecting the 
whole trunk. The back being somewhat 
opisthotonically arched, the body was 
thrown with great violence and astound- 
ing rapidity alternately on to the occiput 
and heels. This stage, which, like the 
first, is of very brief duration, is denomi- 
nated the phase des grands mouvements; 
during its continuance occur the first hal- 
lucinations, to be afterwards referred to. 
The violent movements cease almost in- 
stantaneously, and then follows 
[' British Medical Journal, Oct. 12, 1878.] 651 
HYSTERO-EPILEPSY. 
Fig. 36. 
Hystero-Epilepsy. Stage of "grands mouvements." (Bourneville.) 
" The third stage, or stage of emotional 
attitudes (phase des attitudes passionelles). 
During this stage, the patient assumes 
successively the expression of face, the 
attitudes, and the gestures which portray 
varied emotions-intense and vivid. The 
varied emotional states will be distin- 
guished in the order in which they oc- 
curred by letters. 
"a. No sooner had the great movements 
Fig. 37. 
Hystero-Epilepsy, Period of Contortion. (Charcot.) 
ceased, than, raising herself into a sitting 
posture, with clenched fists and menacing 
expression, the patient presented the 
most startling picture of one threatening; 652 
CATALEPSY. 
but almost instantly the picture changed 
to 
"6. The whole expression and attitude 
portrayed cowering, abject fear. Of no 
longer duration than a. b was followed by 
stage 
"c. The patient now assumed an ex- 
pression of absolute beatitude. It is im- 
possible to describe the look of saintly 
happiness, as of one who realized the 
blessedness of heaven, which the patient 
presented. It was the expression which 
some of the old masters have impressed 
upon their saints and martyrs. 
"But now occurred a change no less 
striking than the preceding. 
"d. The expression of saintly happi- 
ness was succeeded by one of intense joy; 
the patient sees one whom she loves ; she 
beckons to him to come, to come quickly; 
he has come. . . . Then succeed ges- 
tures which stamp this as the phase of 
lubricity or the stage of the emotional atti- 
tudes. 
"e. Again fear takes possession of the 
patient; at first it is rats which she sees, 
and which she appears to fear the attack 
of, which evoke passionate exclamations 
of dread and disgust; then it is obviously 
the fear of some human being which op- 
presses her, and causes her to beg for 
mercy. 
"/. There is no longer fear. The pa- 
tient hears the strains of music ; she is 
pleased; she herself begins to hum the 
tune, but only for an instant, for 
" g. Her singing is followed by weeping, 
which is broken by reproaches addressed 
to her parents as the causes of her misery. 
This last phase (g) in the stage of passion- 
ate attitudes may be made to constitute a 
fourth stage, or a stage of recovery, in 
which hallucinations persist fora time." 
Other cases present different features. 
Sometimes the clonic stage is followed, as 
described by Bourneville, by throwing out 
the arms at right angles from the body, 
as in the position of crucifixion. 
Induction of "mesmeric" sleep, with 
insensibility to pain, and artificial som- 
nambulism, is readily effected in some 
Hystero-epileptic patients. In them, also, 
the extraordinary action of metals, mag- 
nets, and galvano-electric spirals has been 
observed and recorded, by Charcot, 
Bourneville, Westphal, Dumontpallier, 
Luys, and others, to which allusion was 
made on a previous page of this volume.1 
It is, as before said, the eminence of 
those who have witnessed these phenome- 
na, and brought them before the attention 
of the profession, that entitles them to re- 
spectful attention. Much care has been 
evidently taken to eliminate as far as pos- 
sible the element of deception. The 
transfer of hemi-ansesthesia from one 
side of the body to the other, under the 
influence (however explained) of metals, 
magnetic or otherwise, appears to have 
been clearly established. It remains, 
however, yet to be placed beyond doubt 
how much of this and the connected phe- 
nomena is due to physical, and how much 
to psychical impressions and communica- 
tions. In any case, the study of Hystero- 
Epilepsy is of great interest, as furnishing 
a comparatively new chapter in the an- 
nais of Hysteria, to which, chiefly, its 
characteristics must be referred.] 
CATALEPSY. 
By Thomas King Chambers, M.D., F.R.C.P. 
Name.--This word Catalepsy is derived 
from the Greek a "seizure" or 
" arrest." 
Definition.-Catalepsy is the name 
given to intermittent attacks of a suspen- 
sion, more or less complete, of sensation 
and voluntary power, without convul- 
sions, accompanied by a stiffening, gene- 
ral or partial, of the muscular system ; so 
that the parts affected retain for a period 
of variable duration the position in which 
they happen to be at the invasion of the fit. 
Description.-This is one of those 
pathological phenomena of whose anatom- 
ical cause we are entirely ignorant, and 
therefore it is best defined by its symp- 
toms, instead of committing ourselves to 
any vague theory of its nature. It is best 
to call "Catalepsy" any attack which ful- 
fils the conditions above named, and then 
we shall at once avoid all those discus- 
sions with which writings on the subject 
are laden about "true" Catalepsy and 
[' See article on Hysteria.] DESCRIPTION. 
653 
"false" Catalepsy, and the separation 
into symptomatic and idiopathic, which 
we have no warrant for making at all. 
It is as much Catalepsy, and the ultimate 
morbid state is essentially the same, 
whether it is followed by a disease with 
another name, or whether it is followed 
by restored health. 
The following account of a well-marked 
case by Dr. John Jebb describes the de- 
tails of Catalepsy more graphically and 
fully than any I have yet read. He 
says :*- 
"In the latter end of last year (viz., 
1781), I was desired to visit a young lady 
who for nine months had been afflicted 
with that singular disorder termed a Cata- 
lepsy. Although she was prepared for 
my visit, she was seized with the disorder 
as soon as my arrival was announced. 
She was employed in netting, and was 
passing the needle through the mesh, in 
which position she immediately became 
rigid, exhibiting in a very pleasing form 
a figure of death-like sleep, beyond the 
power of art to imitate, or the imagination 
to conceive. Her forehead was serene, her 
features perfectly composed. The pale- 
ness of her color, her breathing at a dis- 
tance being also scarcely perceptible, ope- 
rated in rendering the similitude to marble 
more exact and striking. The positions 
of her fingers, hands, and arms, were al- 
tered with difficulty, but they preserved 
every form of flexure they acquired ; nor 
were the muscles of the neck exempted 
from this law, her head maintaining 
every situation in which the hand could 
place it as firmly as her limbs. 
"Upon gently raising the eyelids, they 
immediately closed, with a degree of 
spasm. The iris contracted upon the ap- 
proach of a candle, as if in a state of vigi- 
lance ; the eyeball was slightly agitated 
with a tremulous motion, discernible when 
the eyelid had descended. 
"About half an hour after my arrival, 
the rigidity in her limbs and statue-like 
appearance being yet unaltered, she sang 
three plaintive songs, in a tone of voice 
so elegantly expressive, and with such 
affecting modulation, as evidently pointed 
out how much the most powerful passion 
of the mind was concerned in the produc- 
tion of her disorder, as indeed her history 
confirmed. In a few minutes afterwards 
she sighed deeply, and the spasm in her 
limbs was immediately relaxed. She 
complained that she could not open her 
eyes, her hands grew cold, a general tre- 
mor followed ; but, in a few seconds, re- 
covering entirely her recollection and 
powers of motion, she entered into a de- 
tail of her symptoms and a history of her 
complaints. 
"She informed me that she had no re- 
collection whatever of what passed in the 
fits ; that upon coming out of them she 
felt fatigued, in proportion to the time of 
their continuance ; and that they some- 
times lasted for five hours, though gene- 
rally for a much shorter period. 
"She further related, that the fits re- 
turned once or twice a day, sometimes 
more frequently ; but that she was never 
troubled with them in the night. She 
sometimes lost her sight and speech, the 
power over her limbs and her intellectual 
faculties remaining unimpaired. The fits 
frequently attacked her without any pre- 
vious warning ; at other times, a flutter- 
ing at her stomach, and a fixed pain at 
the top of her head, occupying a part she 
could cover with her finger, announced 
their approach. 
" Hysterical risings in her throat, ap- 
pearance of fire, pains in her eyes, and 
not infrequently in her teeth, flatulence, 
a sense of weight in her stomach after 
eating, with convulsive motions in the 
region of that organ, were superadded 
symptoms of which she much complained. 
"Iler disorder was evidently exaspe- 
rated at the approach of the catamenia, 
which were constantly present at the reg- 
ular period. She was always much agi- 
tated previously to a storm of thunder, 
and every material alteration of the 
weather produced a sensible effect. 
"After she had discoursed for some 
time with apparent calmness, the univer- 
sal spasm suddenly returned. Her fea- 
tures now assumed a different form, de- 
noting a mind strongly impressed with 
anxiety and apprehension. At times she 
uttered short and vehement exclamations, 
in a piercing tone of voice, expressive of 
the passions that agitated her mind, her 
hands being strongly locked in each other, 
and all her muscles, those subservient to 
speech excepted, being affected with the 
same rigidity as before. 
"During the time of my attendance 
similar appearances were frequently ex- 
hibited. 
" I was informed by the family of many 
particularities in the access of the dis- 
order, all denoting its instantaneous effect 
upon the nervous system. She once was 
seized in my presence while drinking tea, 
and became universally rigid at the in- 
stant she was advancing the tea-cup to 
her mouth. Her tears sometimes flowed 
copiously, while every internal, as well as 
external, sense seemed entirely locked up 
in sleep. 
"I will now proceed to describe the 
progress of the disorder, and the mode of 
treatment, before she was entrusted to my 
care. 
" It appears that for many years before 
1 Appendix to Select Cases of the Disorder 
commonly called the Paralysis of the Lower 
Extremities, by John Jebb, M.D., F.R.S. Lon- 
don, 1782. CATALEPSY. 
654 
the access of the cataleptical symptoms, 
she had suffered much from violent head- 
aches, particularly that species of head- 
ache termed clavus hystericus. Iler 
spirits were easily discomposed. Her 
fingers, upon touching cold substances, 
would frequently lose their natural heat 
and feeling. Iler habit of body had been 
uncommonly costive, but of late her 
bowels were much disturbed by every 
kind of laxative. Her nervous complaints 
were always particularly troublesome at 
the approach of rain and after a sleepless 
night. 
" Her disorder commenced with hys- 
teric fits; to these succeeded a delirium 
of several days' continuance, attended 
with slight shiverings, but no other sign 
of fever; the Catalepsy followed next in 
order, which at first affected her with 
only single fits, at a week or fortnight's 
interval; these gradually advanced in 
strength and frequency until by her own 
sufferings, and her sensibility on account 
of the anxiety of her friends, she was re- 
duced to the most pitiable distress." 
Then follow details of the treatment 
advised by Dr. Jebb, which was judicious 
and successful. An opium plaster to the 
epigastrium did good, but the last and 
longest continued prescription consisted 
of bark, gentian, and tincture of lavender, 
which she went on with till quite well. 
This exceedingly well-drawn-up de- 
scription makes one regret that the ac- 
complished author had not continued to 
apply his pen to depicting the eternal 
truths of nature, instead of wasting it 
upon theological and political advocacy. 
It renders needless the repetition of stock 
cases which usually illustrate the subject. 
Causes.-The most common exciting 
cause of Catalepsy seems to be strong 
mental emotion. When Covent Garden 
Theatre was last burnt down, the blaze 
flashed in at the uncurtained windows of 
St. Mary's Hospital. One of my patients, 
a girl of twenty, recovering from low 
fever, was woke up by it, and exclaimed 
that the day of judgment was come. She 
remained in an excited state all night, 
and the next morning grew gradually 
stiff, like a corpse, whispering before she 
became quite insensible that she was 
dead. If her arm was raised, it remained 
extended in the position in which it was 
placed for several minutes, and then 
slowly subsided. The inelastic kind of 
way in which it retained its position for 
a time, and then gradually yielded to the 
force of gravity, reminded one more of a 
wax figure than of the marble, to which 
Dr. Jebb compares it. A strange effect 
was produced by opening the eyelid of 
one eye ; the other eye remained closed, 
and the raised lid after a time fell very 
slowly, like the arm. A better superficial 
representation of death it is difficult to 
conceive. The pupils, however, contracted 
sluggishly under the influence of light; 
and the pulse could be felt beating softly 
at both heart and wrist. She came round 
again by degrees in the course of the 
morning, and had no relapse ; nor had 
she any manifestations of ordinary hys- 
teria during her stay in the hospital, I 
believe. 
Less acute but more long-continued 
mental emotion will sometimes cause it. 
The same year as that in which the last 
case occurred, I was attending for men- 
orrhagia from relaxed fibre a young wo- 
man, aged twenty-two or twenty-three, 
who had been a governess in a family I 
was acquainted with. She was of an 
affectionate disposition, and 'had been 
rather coldly treated-"misunderstood," 
as it is called. The menorrhagia, too, had 
pulled her down a good deal, and forced 
her into involuntary idleness. One morn- 
ing when 1 called to see her, she was in 
bed, unable to move, and scarcely capable 
of articulating. She said she was just 
recovering consciousness, but all the limbs 
were partially stiff, and the neck and 
back quite so, as appeared by raising her 
up with the hand at the back of the neck, 
when the body remained straight, resting 
on the heels. This state soon passed off, 
even while I was in the room. But the 
next morning I found her partially affected 
in the same way ; the left side was rigid, 
and especially the left arm, which re- 
mained stretched out at an angle when so 
placed.1 I observed that when I bent the 
arm, the deltoid contracted as it does 
when flexion is made by voluntary effort. 
She then told me that, though quite in- 
capable of moving the limb of her own 
unassisted will, she thought she could do 
so if I hade her very strongly. And such 
proved to be the fact ; for, on my rating 
her soundly and ordering her to get up, 
she at last obeyed. I explained to her 
what I believed to be the nature of the 
disorder, namely, a broken connection (to 
speak metaphorically) between the will 
and the nervous system; and that she 
must rejoin this broken link by painful 
exertion and violent determination. She 
had no further relapse. 
In both these cases I convinced myself 
carefully that there was no deception. 
Catalepsy is sometimes very brief and 
sudden. I have a young lady now under 
my care, for non-assimilative indigestion, 
of whom I received the following accounts 
from a mother of more than ordinary in- 
telligence and powers of observation. She 
said that her daughter was fond of read- 
ing aloud, aud that sometimes in the mid- 
1 M. Tissot mentions a similar case of par- 
tial Catalepsy affecting the arms in a man. 
(OEuvres, tom. xiii. p. 56.) CAUSES. 
655 
die of a sentence the voice would sud- 
denly stop, a peculiar stiffness of the 
whole body would come on and fix the 
limbs immovably for several minutes. 
Then it would relax, and the reading 
would be continued at the very word it 
stopped at, the patient being quite un- 
conscious that a parenthesis had been 
snipped out of her existence, or that aught 
strange had happened. She grew much 
better under tonic and restorative treat- 
ment, and gradually ceased to have these 
singular attacks; but after about a 
month's interval, as she was one evening 
engaged in playing a round game of cards, 
she suddenly went off' into a regular epi- 
leptic fit, which was followed by sleep, 
and she did not recover consciousness till 
the next morning. This fit could be ac- 
counted for by certain errors in digestion, 
and she has had no recurrence of it, or of 
the Catalepsy, though four months have 
passed over. So I hope it was epilepsy of 
an intercurrent or curable sort. 
But sometimes the epilepsy preceded by 
Catalepsy is of a more serious sort. I re- 
member a much-respected lecturer in this 
metropolis, in whom the petit mal of epi- 
lepsy assumed this form. He used to be 
attacked sometimes in the middle of a 
sentence, with his hand wielded in de- 
monstration before his class. He would 
remain perfectly stiff for a minute or so, 
with mouth open and arm extended, and 
then resume his sentence just where he 
had dropped it, quite unconscious that 
anything had happened. • After a time 
the seizures assumed the more usual and 
more fatal form. 
This sort of short attack is not, how- 
ever, always the precursor of anything so 
serious. Nor, if traceable to a material 
cause, is that cause necessarily in the 
brain. Van Swieten tells a story of a 
woman, forty years of age, who was roast- 
ing chestnuts in the frying-pan, and kept 
continually stirring them lest they should 
be too much scorched; in doing which, 
she was seized with a true Catalepsy. As 
Van Swieten lived hard by, he was im- 
mediately called in; in his presence she 
suddenly vomited two live worms, and 
forthwith proceeded with her cookery, 
quite unconscious of what had happened. 
She had no relapse.1 
Other cases are of much longer dura- 
tion. The death-like state may last for 
days. It may be mistaken for real death, 
and treated as such. In the old pre- 
Christian times we do not hear of this, 
though it was a sort of thing that would 
appeal strongly to the feelings and me- 
mory. No Sadducee seems to have sug- 
gested Catalepsy to discredit the real re- 
surrections recorded in the Gospels,1 and 
the fear of being accidentally buried alive 
is never alluded to by the classic writers, 
though so picturesque and so capable of 
poetical treatment. Any cases of appa- 
rent death that did occur were burnt, or 
buried, or otherwise put out of the way, 
and were never more heard of. But after 
the establishment of Christianity, tender- 
ness, sometimes excessive, for the remains 
of departed friends took the place of the 
hard heathen selfishness. The dead were 
kept closer to the congregations of the 
living, as if to represent in material form 
the dogma of the communion of saints. 
This led to the discovery that some per- 
sons, indeed some persons of note (amongst 
others, Duns Scotus the theologian, at 
Cologne), had got out of their coffins, and 
died in a vain attempt to open the doors 
of their vaults. 
Others were more fortunate. Those 
who have visited the Lutheran cathedral 
at Magdeburg, have probably not failed 
to notice a quaint monument to the Frau 
von Asseburg. There is her effigy on it 
in stone, kneeling with her husband, and, 
in the style of the period, a goodly line or 
sons on one side and daughters on the 
other support the pair. The inscription 
relates how that this noble lady was, after 
her marriage, supposed to be dead, and 
placed in the family vault. Luckily the 
entrance was left unclosed that night, for 
she rose up, returned to her home and 
husband, and bore all this fair family after 
her strange experience of the tomb. 
Such events caused no slight panic at 
the time, and probably led to the custom, 
still kept up in many parts of Germany, 
of fastening a bell-pull to the hand of a 
corpse when laid in the public mortuary. 
Some cases of resuscitated cataleptics 
have even occurred in modern times, ac- 
cording to the statement made by Arch- 
bishop Donnet to the French Senate last 
spring. 
Catalepsy may be a premonitory symp- 
tom of other diseases. Epilepsy has al- 
ready been mentioned. De Haen relates, 
in a clinical lecture, a case he saw of a 
child of twelve, who began by being cata- 
leptic, and ended by reciting the metrical 
Protestant version of David's Psalms, say- 
ing her catechism with proof texts, and 
1 Had he done so, it would have heen a 
telling argument for the Council and the 
Scribes ; but it would have small weight with 
an experienced physician now, nor would it 
make the miracle any the less in his eyes. 
He would know that it is quite as supernatu- 
ral to detect a cataleptic in a funeral-train 
accidentally met at the city gate, or in one 
who had lain three days in a tomb completely 
rolled up in mummy cloth, as it is to raise 
the dead. 
1 Van Swieten's Commentary on Boerhaave 
§ 1040, vol. x. p. 170. 656 
CATALEPSY. 
preaching a sermon on adultery.1 And 
in several other stock cases, somnambu- 
lism seems to have been a complication. 
Marx saw a girl who became cataleptic 
from being frightened at a fire (like my 
patient at St. Mary's), and afterwards 
went out of her mind.2 In Goebel's case 
of a young soldier, Catalepsy complicated 
the invasion of melancholia.3 Sauvages 
says he saw an old man in the hospital at 
Alais, in whom Catalepsy alternated with 
quartan fever.4 
Catalepsy seems to be sometimes volun- 
tary, or at least capable of being brought 
on by very little external aid. Of this, 
St. Augustine gives an instance within 
his own knowledge :- 
"There was a certain presbyter of the 
name of Restitutus in a parish of the dio- 
cese of Calami, who, when he pleased (and 
he was often asked to do it by those w ho 
wished to have ocular demonstration of 
the strange fact), just by having a noise 
made like as of somebody crying, used to 
convey himself out of the influence of sen- 
sation, and lie like a corpse. So that not 
only was he insensible to people pinching 
and pricking him, but sometimes fire had 
been brought and he burnt with it, with- 
out any sense of pain, except from the 
wound afterwards. The body seemed to 
be motionless, not in consequence of any 
voluntary effort, but from want of sensa- 
tion, as was made the more probable by 
the absence of any appearance of respira- 
tion, as in a dead body: yet people's 
voices, if they spoke out very clear, he 
said afterwards he could hear as if they 
were a long wray off."5 
Persons liable to this form in various 
degrees lose, by yielding to it more and 
more, their power of voluntary control, so 
that exhibitions of it are easily brought 
on by others who assume an influence 
over them. They are told in a positive 
manner that they cannot raise their limbs, 
cannot open their eyes, cannot feel, and 
they really seem to lose temporarily mo- 
tion, sight, sensation. Mesmer turned 
this artificial production of disease to 
profit (his owrn), and it has been largely 
experimented upon of late years. But 
the unfortunate subjects of it have brought 
to their masters so much "gain by their 
soothsaying," that deception has largely 
adulterated the real phenomena, and it is 
difficult to find a genuine patient. For 
this reason I thought it preferable to 
quote a case from a writer of unimpeach- 
able shrewdness and honesty, and far 
from credulous, though destitute of the 
light of modern science, than to detail the 
experience of our own generation. 
In the artificial disease and in the natu- 
ral, somnambulism (clairvoyance) is a fre- 
quent complication, as appears from sev- 
eral cases cited by Tissot. (CEuvres, tom. 
xiii.) 
It was not a groundless idea to suggest 
that, as we employ counter-irritants to re- 
lieve an internal unmanageable inflam- 
mation by one which is under our control 
and less injurious, so hysteria might be 
cured by inducing in its place an allied 
malady more subject to our will. But 
harm seems to be done by it, and probably 
only a limited number of the English race 
have a suitable diathesis.1 
Both in the natural and artificial dis- 
ease there is exerted a very different in- 
fluence over the patient by different indi- 
viduals. The sight of l)r. Jebb's face 
seems to have acted like the Gorgon's 
head in reducing his patient to instanta- 
neous marble. My own experience is 
quite the reverse. Strange nervous phe- 
nomena always seem to be frightened 
away or subside into commonplace at my 
presence, and so perhaps my report of 
them is printed in less bright colors than 
the subject admits of. 
Natural Catalepsy seems to become less 
frequent, or, at all events, the symptoms 
less marked and strange, as the world 
grows older. Some are even getting scep- 
tical about its existence, and doubt the 
propriety of retaining it on our list of dis- 
eases. But even if it should be as extinct 
as the dodo or the great auk, this insult 
is uncalled for'. The circumstances which 
surround the human race, especially when 
sick, are so altered, that it would be won- 
derful if some of the phenomena exhibited 
in pathological conditions were not altered 
too. Read the treatment adopted in 
many of the cases of Catalepsy quoted by 
the systematic writers. Take, for in- 
stance, that which M. Sauvages commu- 
nicated to the Academic des Sciences,2 
where intermittent attacks of the disease 
occurred from time to time during several 
years. Though the patient was pale with 
a weak pulse, and though the blood could 
scarce be got to flow from the veins, yet 
she was bled, once from the arms, many 
times from the feet, and seven times from 
the neck. She had five or six repetitions 
of purgative medicine, not to mention 
1 Re Haen, Ratio Medendi, vol. i. cap. 
xxxiii. 
2 Marx, Re Spasmis, § 61. 
3 Re Catalepsi, autore Theophilo Goebel. 
(A Berlin inaugural thesis, 1818.) 
4 Memoires de l'Academie Royale des Sci- 
ences, &c., 1742, last page. 
6 Augustine, Re Civitate Rei, lib. xiv. cap. 
xxiv. 
1 Those who wish to pursue the subject of 
mesmerism will find it treated of with the 
broad views of a non-specialist by Feuchter- 
sleben in his Medical Psychology, translated 
by the Sydenham Society. 
2 Memoires de I'Acadtfmie Royale des Sci- 
ences, AnnSe 1742, p. 409. CAUSES. 
657 
bouillons aperitives, stomachic opiates, and 
twenty tepid baths, before they thought 
of giving her iron, which wrought a cure 
sooner than one could have expected. I 
lighted accidentally on another case com- 
municated to the same scientific body by 
M. Imbert, in 1713.' It is that of the 
driver of the Rouen diligence, aged 45, 
who fell into a kind of soporific Catalepsy 
on hearing of the sudden death of a man 
he had quarrelled with. It appears that 
"M. Burette, under whose care he was 
at La Charite, made use of the most 
powerful assistances of art1-bleeding in 
the arm, the foot, the neck, emetics, pur- 
gatives, blisters, leeches," &c. At last 
somebody "threw him naked into cold 
water to surprise him." The effect sur- 
prised the doctors as much as the patient; 
it is related with evident wonder how 
that " he opened his eyes, looked stead- 
fastly, but did not speak." His wife 
seems to have been a prudent woman, for 
a week afterwards she " carried him 
home, where he is at present: they give 
him no medicine; he speaks sensibly 
enough, and mends every day." 
Again, the "dame de Vesoul," whom M. 
Tissot justly calls " la cataleptique par ex- 
cellence," so characteristic were the phe- 
nomena, was attacked during Lent, when 
she had been starving herself in order to 
give alms to the poor, and was also wor- 
ried by a lawsuit which had brought her 
to Besangon. Yet she was bled in the 
foot. Fortunately, after three days, her 
friends took her home to Vesoul. What 
happened then the reporter says was 
quite as wonderful as her illness,2 namely, 
that she had no more medical treatment, 
and yet got well without a relapse. I 
cannot feel the same wonder, for I feel 
sure that the "powerful assistances of 
art"-bleeding, blistering, starving, purg- 
ing, coddling, sympathizing, and admir- 
ing- would have converted any of the 
cases under my charge into equally mag- 
nificent specimens of a long-continued in- 
termittent disease. 
But the fact of its being partly pro- 
duced by art does not make Catalepsy a 
bit less of a reality, for the same may be 
said of all preventible diseases. 
Besides the effect of treatment, it is 
likely that the unrestrained manners and 
want of mental control peculiar to the 
barbarous ages of all nations, would ren- 
der mediaeval Europe liable to exaggerated 
exhibitions of all physical defects. And, 
as physical defects are indubitably hered- 
itary, the national temperament would 
be thereby affected. As an example of 
what is alluded to, take one scene from 
early English history, and conceive it 
happening in the present day. Fancy 
four members of the Queen's Privy Coun- 
cil calling after lunch on a refractory 
archbishop who had voted against the 
Ministry that had appointed him, with 
the intention of showing him the error of 
his ways. Fancy them scolding and blas- 
pheming " by God's wounds," giving him 
the lie, "jumping up and leaping about," 
" throwing about their arms," "twisting 
their gloves," "raving like madmen." 
Fancy him, red in the face, defying them, 
rushing after them to the door, calling 
one his lackey, and another "a pimp." 
Yet this is only a part of the want of re- 
straint shown by both parties when Regi- 
nald Fitzurse, William de Tracy, Hugh 
de Morville, and Richard Brito called on 
Archbishop Becket on the afternoon of 
December 29th, 1170.1 The mere fact of 
the murder, with the nauseous details of 
how Tracy picked out the brains with his 
sword, is not half so strange as such a 
scene. How many generations does it 
take to produce descendants of such men 
free from nervous disorders ? 
The deficient vitality of which Catalep- 
sy is a manifestation occupies that puz- 
ling part of the circle of life which lies 
between spirit and matter. We know so 
little about the chain which connects the 
two, that its links are reckoned by us as 
few and short, and we have no names for 
them. Yet when we see the varied phe- 
nomena produced by breaches in the con- 
nection, we are led to feel our ignorance 
of the subject, and to conjecture that 
these abysses of incertitude veil a long list 
of vital functions. 
In default of names for even the normal 
functions of this department of life, we 
must not expect an accurate nomenclature 
for their aberrations from health ; and the 
most we can do in attempting to classify 
them, is to observe how near their origin 
lies to one or the other extremity of the 
series of vital acts which are interfered 
with-what relations their phenomena 
bear on the one hand to mind, and on the 
other to body. We shall thus have a 
natural order with pure insanity at the 
one end, and epilepsy traceable to organic 
lesion at the other. In the middle will lie 
ecstasy, Catalepsy, and hysteria, with 
many a blank between for the anonymous 
transitional forms. I do not think we can 
spare any of these names, and instead of 
clubbing them together, as some would 
fain do, under the common head of "hys- 
teria," it would appear more useful to 
divide that disease, according as its emo- 
tional, anaesthetic, hyperaesthetic, or con- 
vulsive phenomena are most prominent. 
1 Martin's Memoirs of the Academy of Sci- 
ences at Paris, vol. iv. p. 360. 
2 "Ce qui ne surprendra pent-Stre pas 
moins que sa maladie." (Tissot, (Euvres, 
tom. xiii. p. 16.) 
VOL. I.-42 
1 Hook's Archbishops of Canterbury, vol. 
ii. p. 497. 658 
somnambulism and allied states. 
I say it would be useful to make a main 
point in each individual case whether the 
malady is most related to deviation from 
mental or bodily health; for I feel con- 
vinced it is only by this observation that 
we can avoid such disappointment as leads 
many to look upon hysteria, for example, 
as an opprobrium medicinoe which makes 
them feel the same sort of anger against 
it as is roused by moral guiltiness, and 
disposes them rather to punish than to 
cure the patient who has thwarted them. 
Treatment.-As to the treatment of 
Catalepsy, it is probable that valerian and 
ammonia, administered in draught or 
enema, whichever is most convenient, 
together with a modification of what cured 
the Rouenese stage-coachman, namely 
shower-baths, will accomplish all that is 
wanted in the way of medicine for the 
slighter cases likely to come under treat- 
ment in the present day. In longer con- 
tinued cases Dr. Jebb's prescription of an 
opium plaster to the epigastrium, with 
tonics to the mucous membranes, is ra- 
tional practice; for Catalepsy seems to 
depend much on the mucous membrane 
of the stomach, as is the case with its 
sister malady, hysteria. But I would 
strongly urge upon all who have the 
charge of these and similar mental, semi- 
corporeal manifestations, to take the hint 
given me by the second patient, and try 
to acquire (surely it is to be acquired 
by trying) the habit of command. Let 
them exercise it in the direction of sup- 
plying the deficient will, not of paralyzing 
it, of demesmerizing instead of mesmer- 
izing their patients, and it is astonishing 
how much pharmacopoeial medication will 
be saved to both parties. 
Catalepsy may be sometimes feigned. 
For its detection the most cruel means 
appear sometimes to have been adopted 
by our forefathers, such as burning, pinch- 
ing, cutting, putting into coftins, and 
otherwise frightening the supposed im- 
postors. A caution is therefore needed, 
that the trial of these methods would in 
England very properly subject the experi- 
menter to legal proceedings, the more so 
as they are quite useless, and prove no- 
thing. No malingerer could successfully 
feign the peculiar wax-like yielding re- 
sistance of a cataleptic muscle, and ought 
to be immediately detected by a medical 
man. If a doubt is felt, some expedient 
may be tried like that of Dr. Marx. Ob- 
serving that really cataleptic limbs finally, 
though slowly, yield to the force of gravity 
and fall by their own weight, he attached 
a heavy body to the extended hand of a 
suspected imposter. She bore it up with- 
out moving ; the intention of the experi- 
ment was explained, and she confessed 
her fraud.1 
The points intended to be made con- 
cerning Catalepsy are these :- 
1. That it is a rare pathological condition 
of mind and body, allied in its causes to 
hysteria, but not so apt to become chronic. 
2. That it is not dangerous in itself, 
though it may be the precursor of danger- 
ous disease. 
3. That it may be artificially produced, 
but is not easy to feign. 
4. That the treatment, moral and phy- 
sical, should be conducted on the same 
principles as the treatment of hysteria. 
SOMNAMBULISM AND ALLIED STATES. 
Thomas King Chambers, M.D., F.R.C.P. 
Somnambulism is a slumber so mor- 
bidly profound that resisting spontaneity 
is lost, and the obscure images, known as 
ordinary dreams, are able to exert a mo- 
tor power. " Sleep-walking, " where even 
the intricate concatenated motions neces- 
sary to preserve the body's balance are 
performed, is the most striking and dan- 
gerous exhibition of this state, and there- 
fore has given a name to the disease ; but 
it differs in degree only from sleep-talking, 
sleep-eating, and a form of nocturnal in- 
continence of urine and of spermator- 
rhoea. That it is not a partial waking is 
shown by the difficulty always found in 
fully waking a somnambulist, and also by 
the bewilderment and slow return of 
consciousness afterwards. This bewilder- 
ment, moreover, is often followed by head- 
ache and a clamminess of the mouth, just 
like that of the condition known as " the 
intoxication of sleep" in those who have 
slumbered too heavily and too long. 
Again, decided somnambulists are en- 
tirely ignorant of what they have been 
doing during sleep : whereas dreams which 
1 Marx, De Spasmis. Halae, 1765, § 19. SOMNAMBULISM AND ALLIED STATES. 
659 
occur during a partial waking are always 
remembered more or less. Again, the 
automatic acts done during partial waking 
are very short, have no continuity, and 
quickly end in a decided condition; 
whereas the acts of the somnambulist are 
consecutive one upon another. It seems 
impossible, therefore, to agree with Drs. 
Symonds, Hartmann, and others, who 
have regarded it as an incomplete sleep. 
Still less can we agree with the super- 
stitious awe which would represent it as 
an exalted state, in which the soul is freed 
from the trammels of the corruptible car- 
case. It is in truth a lower life, in which 
" the sceptre of reason is surrendered to a 
physically-directed fancy." (Feuchter- 
sleben.) Instead of nearing the angels, 
man thus approaches temporarily the na- 
ture of ill-bred horses who refuse to lie 
down in their stalls, birds who roost stand- 
ing on one leg, and gorged dogs who- 
"Weary with the chase, 
Lie stretch'd upon the rushy floor, 
And urge, in dreams, the forest race 
From Teviotstone to Eskdale Moor." 
This morbid sleep usually arises in the 
first instance from eating too much. Per- 
haps the overloaded stomach presses on 
the solar plexus, and produces a partial 
paralysis in the coats of the arteries, and 
so in the cerebral circulation. The ex- 
planation is the more probable, because 
sleeping with the head too low is another 
predisposing cause, whose action would 
be on the brain. 
Strong mental emotion, excessive exer- 
tion of the intellect, violent grief, love, 
&c., probably act in the same way ; 
namely, by arresting digestion and causing 
a weight at the stomach. 
When, however, the habit is once estab- 
lished, it is persisted in even after the 
gluttony or emotion has been discon- 
tinued. In this it follows the rule of all 
morbid states of the nervous system, 
which are peculiarly apt to be retained in 
spite of the removal of their causes. 
It is most common in youth, and at 
about the age of puberty. Then the 
sexes are equally subject to it; but later 
in life it seldomer attacks men than 
women. 
Somnambulism is sometimes heredi- 
tary. A young lady, about whom I have 
been consulted a few times this summer, 
will often (sometimes two or three days a 
week) go off in the evening into a pecu- 
liar dreamy state. She talks and answers 
questions, though after an interval, walks 
about the house, goes to bed, remains 
quiet at night, and sometimes recovers 
her ordinary condition on waking : but 
sometimes her mother will go into her 
room and find her dressing in a vague, 
dreamy way. After a while she will 
stare, stretch herself like a person waking 
from sleep, and resume her natural lively 
manner. Her memory is always quite 
blank as to anything said, seen, or done 
during this condition. She has never had 
any hysteric or epileptic fits. Such are 
the symptoms, and her father asked me 
what name I should give to the disease. 
I hesitated at first, and then said that 
some might call it perhaps catalepsy, but 
that the more proper name was Somnam- 
bulism. That was curious, he observed, 
for his mother had been afflicted with 
what was called both catalepsy and Som- 
nambulism, and he had heard it was in 
the family. I have also recently under- 
stood that a younger sister of my patient 
is falling into the same state, but I have 
not seen her. This lady had occasionally 
got out of bed when in her unconscious 
state, but it happened so seldom that no 
alarm on that score was expressed by the 
family. 
Somnambulism is inconvenient to other 
people from the fright it causes, and dan- 
gerous to the patient from the awkward 
positions it puts him in when unprotected 
by reason. But it is by no means incon- 
sistent with a fair condition of general 
health. It is, for instance, not unfrequent 
amongst boys and girls at school who 
bodily and mentally are quite equal to 
their companions. 
At schools accidental accesses of it are 
liable to be fostered into a habit by the 
patients' room-fellows talking to them, 
and otherwise " drawing them out," when 
in this state. 
Like epilepsy, and indeed all diseases of 
the nervous system, it is apt to become peri- 
odical. Some persons will walk or talk, or 
wet their beds, &c., once a fortnight, week, 
or month, and so on with great regularity. 
That does not arise from an accumula- 
tion of secretion or excitability; for at 
first, and while the original cause is pre- 
dominant, several attacks occur often 
close together in succession, and then 
cease. It is rather an evidence of the 
weakness becoming constitutional, after 
the original cause has been removed. 
Somnambulism has in some rare cases 
alternated with catalepsy, of which M. 
Sauvages has recorded an instance. (See 
Catalepsy.) More generally, it alternates 
with a normal state. 
There are cases recorded where the 
somnambulistic sopors have been so fre- 
quent and so long, that there is as much 
of a sleeping as there is of a waking condi- 
tion, and thus has arisen the singular phe- 
nomenon called "double consciousness." 
Trains of thought are carried on from one 
attack to the next, though in the normal 
interval the mind is quite unconscious of 
them. A remarkable instance of this is 
recorded by Dr. Dewar, in the "Transac- 
tions of the Royal Society of Edinburgh," 
vol. ix. p. 365. A servant maid began by 660 
SOMNAMBULISM AND ALLIED STATES. 
being subject to attacks of extreme sleepi- 
ness : then in these sleeps she began to be 
talkative. Soon there appeared more 
method in what she said : she personated 
an episcopal clergyman, went through the 
baptismal service for three children, and 
delivered an extempore prayer. Another 
time she was a jockey at Epsom, and 
rode round the kitchen on a stool. On 
awaking, all these pranks were quite for- 
gotten, but in the succeeding fit she re- 
membered all that occurred. Thus, one 
night a villain indecently assaulted her 
when somnambulistic. On the morrow 
the insult was forgotten, but shortly after- 
wards she had a fresh attack and told her 
mother of it. She got well after an emetic 
and the return of the catamenia, which 
had been absent. 
Dr. Abercrombie adds two more cases 
related to him by non-medical persons, 
and for that reason (probably) accompa- 
nied by more wonderful phenomena. (On 
the Intellectual Powers, Pt. III., sect. iv. 
§ 2, II.) In principle these phenomena 
are quite in analogy with healthy dreams, 
which scarcely ever take cognizance of re- 
cent facts of the waking state. For ex- 
ample, in my own dreams, though I had 
the misfortune to lose a leg two years ago, 
I always seem to walk about as in youth. 
And I certainly remember a room-fellow 
at school who used to talk in his sleep on 
a class of subjects he never mentioned by 
day, and who seemed to recollect when in 
the same state next night that he had 
spoken of them before. But that an edu- 
cation should be carried on, and languages 
acquired, during somnambulism, as some 
strange stories record, is hard to credit. 
Possibly some confusion existed in the 
minds of the observers, and they mistook 
the waking for the sleeping state. 
Somnambulistic phenomena have some- 
times accompanied the artificial catalepsy 
of the mesmeric trance. They are called 
" clairvoyance, " not that the patients see 
particularly clearly, but that the common 
sensorium is very receptive of those slight 
suggestions which it would neglect at 
other times, when its attention is occupied 
with the external world ; and so they ap- 
pear to careless observers to see with the 
tips of their fingers, the epigastrium, &c., 
when their eyes are closed. Singular ex- 
hibitions are thus produced. But with 
practice this rapid obedience to slight 
suggestion is soon acquired by even stupid 
people ; so that jugglers have no difficulty 
in obtaining sham cases for shows, by no 
means easy of detection. This prevents 
the investigation of the subject by scienti- 
fic persons. 
Treatment.-1. The patient must be 
removed from the company of those who 
would be disposed to foster into a habit by 
experiment the recent establishment of 
the disease. This applies particularly to 
young persons at school, and those brought 
under the dominion of mesmerizers. 
2. The patient must be prevented from 
falling into that morbidly deep sleep in 
which the special phenomena of the case 
are produced. This can be accomplished 
by waking them up once or twice in the 
night, before they begin to walk, talk, or 
do other unseemly acts. It may be done 
with great advantage during tlie second 
hour of sleep in cases of simple sleep- 
walking and of bed-wetting. 
A young lady under my care who used 
to rise and make water on the floor with- 
out being aware of it, was relieved by this 
means. 
M. Trousseau1 knew a wealthy and 
beautiful girl, from whose feet wooers had 
been driven away by an incontinence of 
urine occurring nightly. At last the im- 
pediment to marriage was overcome by a 
hero. M. Trousseau cynically calls him 
" un individu sans fortune," implying that 
the girl's purse was her only attraction ; 
but poetic justice requires a better motive 
for an act so richly rewarded ; for. like the 
knight of whom the "Wif of Bath" tells, 
he found her " bothe faire and good," 
when expecting, like him, the latter only; 
the disgusting affliction vanished straight 
away- 
"And thus they live unto hir lives ende 
In parfit joye"- 
at least they have the chance of doing so. 
Doubtless it was the prevention of over- 
profound sleep which cured her. 
Some years ago a foolish young man 
from the country brought for my opinion 
an instrument which he had purchased of 
an advertising quack, designed to cure 
spermatorrhoea by compression of the ure- 
thra and prostate. The disease in his 
case, being purely imaginary, was of 
course incurable ; but I should not won- 
der if the plan had been found useful, act- 
ing as an obstacle to morbid sleep. How- 
ever, it would require careful medical 
superintendence. 
A clergyman (who corresponded with 
me anonymously, and therefore I can say 
nothing of his general health) took by my 
advice, unsuccessfully, several remedies 
for spermatorrhoea, till he suspected that 
he abused himself during sleep; he tied 
his hands by a string to the bedpost, was 
awakened several times a night, and 
cured. 
Another patient, troubled with really 
involuntary emissions, cured himself by 
having an alarum which he set so as to 
wake him occasionally in the night. 
Other attacks of spermatorrhoea I have 
found to take place during the abnormally 
heavy morning doze which lazy people 
1 Clinique Medicale. Le?on LX. sunstroke: history. 
661 
indulge in after they have really had 
enough rest-the intoxication of repose. 
These patients should be told to get up 
and dress immediately after their first 
waking. It soon cures them. 
3. Care should be taken that the head 
lie high in the bed, and that the body be 
not covered with too great a weight of 
clothes. 
The son of an old and intimate friend of 
mine used to suffer when a child from in- 
continence of urine. Soon after puberty 
this inconvenience ceased, and has not 
returned. But at eighteen he has come 
to me complaining of seminal emissions, 
which have occurred on a few occasions 
more than once in a night. On inquiry, 
he said that on waking up after a defile- 
ment he had often found his head right 
under the bolster. He was advised to be 
careful in keeping a good hard pillow well 
down under the shoulders, and he has not 
suffered since. 
4. Though prevention by means of 
keeping off too profound sleep is desirable, 
yet patients should not be wakened when 
walking, or in any other unnatural pos- 
ture. They should be led back quietly to 
bed 
"Donee discussis redeant erroribus ad se." 
Otherwise the fright is dangerous, espe- 
cially to hysterical persons. 
5. Light meals and digestible food are 
essential, and special expedients should 
not be trusted in till the general health 
has been brought up to the average. 
SUNSTROKE. 
By W. C. Maclean, M.D. 
Definition.-A disease of the nervous 
system, excited by heat, sometimes fol- 
lowing exposure to the direct rays of the 
sun, particularly when to heat is added 
the pressure of tight and unsuitable cloth- 
ing and accoutrements, or both; more 
frequently occurring when the above con- 
ditions combine with exhaustion, induced 
by great fatigue in hot weather, or from 
the effects of high temperature, night and 
day, on men breathing the vitiated air of 
crowded barracks or ships. 
The affection is generally preceded by 
premonitory symptoms, such as thirst, 
heat, and dryness of skin, vertigo, conges- 
tion of the eyes, frequent desire to mictu- 
rate, followed by syncope, often instantly 
fatal (the cardiac variety of Morehead), 
or by insensibility and stertorous breath- 
ing, with or without convulsions (the 
cerebro-spinal variety of the same author). 
In both varieties the mortality is high, 
and unexampled congestion of the lungs 
is the most common morbid appearance 
observed after death. 
Synonyms. - Insolation ; Sun-fever ; 
Coup de Soleil; Calenture; Heat-apo- 
plexy ; Ictus solis ; Erythismus tropicus. 
The first is the name by which the affec- 
tion is designated in the official classifica- 
tion of diseases in use in the British army. 
History.-Sunstroke has been known 
and recognized as a dangerous disease 
from early times. Fatal examples of it 
are recorded by the sacred writers, and 
these have been referred to by most mo- 
dern authors who have written on the 
subject. It is worthy of note that one of 
the blessings promised to those who shall 
be partakers of the better life that is to 
come, is, "that the sun shall not light 
upon them, nor any heat,"-a promise 
full of meaning to the inhabitants of the 
"dry and thirsty land" to whom it was 
first made. 
Men of European birth who become 
sojourners in Hindostan are hardly more 
solicitous to protect their heads from the 
direct rays of the sun than are the various 
races who are children of the soil. In 
China, on the other hand, the inhabitants 
expose their closely shaven heads to the 
hottest sun with apparent impunity.1 
But when so doing they generally make 
vigorous use of their fans, as if they at- 
tached more importance to having a free 
current of air about their faces, than to 
protecting their heads from the sun's 
rays. Sportsmen in India constantly ex- 
pose themselves in the hottest weather 
when in pursuit of game. Those who use 
1 I have recently, however, seen an account 
of an epidemic of insolation, which attacked 
one of our trading ports in China, after many 
days and nights of unusually high tempera- 
ture. The mortality was high, and by no 
means confined to the European community. SUNSTROKE. 
662 
reasonable precautions, who protect the 
head and spine by a head-dress adapted 
for the purpose, wear loose clothing of a 
suitable material, and abstain from stim- 
ulants, rarely suffer from Sunstroke.' 
[The same is true of those who play 
cricket and base-ball in the United States; 
where the temperature in July and 
August is sometimes very nearly as high 
as in India.-H.] 
On the other hand, as will be shown 
further on, men who are made to undergo 
fatigue under a hot sun, dressed as British 
soldiers used to be in such circumstances, 
in tight-fitting clothes, and encumbered 
with heavy and badly-adjusted accoutre- 
ments, wearing a head-dress which not 
only gave no protection, but concentrated 
the sun's rays on their heads, suffered 
from insolation in great numbers in a most 
fatal form. 
Sunstroke, if we are to judge from the 
older medical returns of the Indian army, 
was not a frequent or a fatal disease. 
Even in the eight years ending 1853-4, as 
appears from Dr. Hugh Macpherson's in- 
structive analysis of later Bengal medical 
returns, only thirty-eight cases are record- 
ed. This would be very puzzling if we 
did not know that a great many cases, 
which would now be entered without hesi- 
tation under the head of insolatio, were in 
those days "returned" under the heads 
of continued or remittent fevers; while 
those proving quickly fatal, with insensi- 
bility, convulsions, stertorous breathing, 
and such-like symptoms, were considered 
to be cases of cerebral apoplexy, and reg- 
istered accordingly. 
For example, in the case of the two 
wings of H. M. 13th Regiment, referred 
to by Martin, which marched, after some 
very ill-judged exposure and drilling in 
the sun, from Nuddea to Berampore in 
the midst of the hot weather, the men 
suffered terribly. As the result of one 
march, " the day closed with a sick-list of 
sixty-three, and eighteen deaths," all of 
which appear to have been registered as 
cases of apoplexy. It is certain from the 
description left by the medical officers, 
that the cases would in the present day 
be considered to have no pathological re- 
lation to apoplexy, yet Dr. Henderson 
was at a loss "whether to consider them 
cases of remittent fe 7er or apoplexy." 
(Martin.) The symptoms were clearly 
those of insolation. Many other examples 
of a like kind could be given. 
The following are some of the best his- 
torical instances of insolation occurring in 
the field and in barracks ; they have been 
brought forward in more or less detail by 
nearly all recent authors on the subject, 
and for the last five years I have used 
them in my lectures in illustration of the 
different forms of this affection. 
In May, 1834, the 68th Regiment, 
quartered in Fort St. George, Madras, at- 
tended the funeral of a general officer. 
The regiment paraded in full dress at an 
early hour in the afternoon in one of the 
hottest months in the year, their tight- 
fitting coats buttoned up, their leather 
stocks, as stiff and unyielding as horse- 
collars, round their necks, heavy cross- 
belts so contrived as to interfere with 
every movement of the chest, heavy sha- 
koes" on their heads, made of black felt, 
mounted with brass ornaments with wide 
flat circular tops, ingeniously contrived to 
concentrate the sun's rays on the crown 
of the head, and without protection in the 
way of a depending flap for the nape of 
the neck. So dressed, the men marched 
for several miles. Before the funeral pa- 
rade was over, the soldiers began to fall 
senseless-one died on the spot, two more 
in less than two hours. Men suffering 
from insolation in various degrees were 
brought into hospital all that night and 
part of next day. The cases that did not 
prove fatal, although their real nature 
was correctly understood by Dr. Russell, 
acting surgeon of the regiment, were all 
registered as cases either of continued or 
ephemeral fever. The symptoms in the 
fatal cases were thirst, excessive heat of 
skin, extreme prostration, immediately 
followed by gasping respiration, coma, 
stertor, lividity of the face, and death. 
After death no morbid appearance was 
found in the brain, but in the lungs of all 
there was extreme congestion. There 
lingers a tradition of this parade in Ma- 
dras to this day. 
The 63d Regiment suffered in the same 
way, at the same place, and under cir- 
cumstances precisely alike. (Martin: 
Influence of Tropical Climates.) 
Of the next example the writer of this 
article was an eye-witness. The 98th 
Regiment joined the expeditionary force 
under Lord Gough in China in 1842. The 
regiment came from England in the 
BeUeisle, an old 74-gun ship, and suffered 
from overcrowding. On the 21st of July, 
the 98th took part in the attack on Chin- 
Kiang-Foo, the final military operation of 
the war. The men were dressed precisely 
as already described in the case of the 
68th Regiment. In this condition they 
1 Staff-surgeon Becker informs me that 
while on active service in China, a sudden 
order was given for a movement in the heat 
of the day. One commanding officer opened 
the canteen before the men marched ; by way 
of precaution they partook freely of spirits. 
The effects of this injudicious measure were 
soon apparent: the men who thus indulged 
suffered twice as much from Sunstroke as 
those who did not. On this occasion also it 
was noted that a large proportion of the vic- 
tims had heart disease, in one or other of the 
forms I have elsewhere shown to be so com- 
mon in the army. HISTORY. 
663 
had to take possession of a steep hill ex- 
posed to the fierce rays of the sun shining 
out of an unclouded sky. A ^reat many 
men were struck down by the heat, about 
fifteen died on the spot, falling on their 
faces, as Dr. Parkes, on the authority of 
another eye-witness, has correctly de- 
scribed (Practical Hygiene); they gave a 
few convulsive gasps, and died before 
anything could be done for their relief. 
The best history of an outbreak of inso- 
lation with which the writer is acquainted 
is that given by Dr. Barclay, of the 43d 
Light Infantry, and published in the sec- 
ond number of the Madras Quarterly 
Journal of Medical Science. The 43d Regi- 
ment performed one of the most extra- 
ordinary marches on record, having 
marched from Bangalore, in the Deccan, 
to Calpee, in Central India, a distance by 
the route taken considerably exceeding 
eleven hundred miles. The exigencies 
of the public service at that time (1857-58, 
memorable as the years of the mutiny in 
Bengal) were such, that this march, with 
the exception of a few brief halts at sta- 
tions by the way, was made continuously, 
and a great portion of it was accomplished 
during the hottest season of the year. 
The men were exposed to a very high 
temperature by night as well as by day. 
Dr. Barclay, while in a valley at the 
foot of the Bisramgunge Ghat, observed 
the thermometer at 118° Fahr, in the 
largest tents during the day, 127° in the 
smallest, and on one occasion he observed 
it at 105° at midnight. This prolonged 
exertion and continuous exposure to ex- 
cessive heat by night as well as by day, 
exceeded the limits of human endurance. 
When they reached Nagode, " the indi- 
cations of exhaustion in the altered looks 
of the men, their loss of flesh, and their 
evidently failing strength, were so obvious 
that they forced themselves on the obser- 
vation of every one." But further on, on 
the march from Ilumeerpore to Calpee, 
Dr. Barclay records, "There was scarcely 
a man in the regiment whose strength 
was not reduced to a level with that of a 
child." 
It is remarkable that no case of insola- 
tion occurred until the 28th of April, i. e., 
until the 43d had marched 9G9 miles- 
until, in fact, the signs of exhaustion, first 
noted by Dr. Barclay, were apparent. 
From that date they increased in fre- 
quency. When at the foot of the pass, 
named above, cases " were brought to the 
hospital tents at every hour of the day 
and night, and although a large propor- 
tion of them recovered, two officers and 
eleven men were buried under one tree in 
the neighborhood of the camp." (Dr. 
Barclay on the Natural History of Inso- 
lation;) 
Boudin relates a terrible example of the 
effects of heat on a body of Belgian sol- 
diers on the line of march, which may be 
fairly taken as a striking instance of the 
evil consequences of tight clothing and 
accoutrements under exertion in a high 
temperature. On the 8th of July, 1853, 
a body of men, 1200 strong, marched from 
Beverloo to Hasselt. They started at 
eight o'clock in the morning. Only 500 
reached Hasselt in the evening. Nine- 
teen perished en route, and a great num- 
ber in a state of furious delirium were 
taken to hospital. I do not think that 
anything so disastrous as this occurred 
during the unavoidable exposure of Brit- 
ish soldiers to the fierce heat of the sun in 
Central India, in the years of the Mutiny, 
1857-58. It is remarkable that the tem- 
perature on this occasion did not exceed 
33° or 35° Centigrade. M. Boudin adds, 
that two well-known Egyptian astrono- 
mers, MM. Mahmoud and Ismael, who 
were in Brussels on that day, assured M. 
Quetelet that they suffered as much from 
a temperature of 30'7° C. in that city as 
in Cairo under a temperature of nearly 
50° C. : " Nmtvelle preuve de la necessite de 
tenir compte de la qualite de la temperature. " 
But, as has been said, insolation occurs 
in barracks as well as in the field. The 
two best and most carefully observed ex- 
amples of this form of the affection are 
those recorded by Dr. Butler, of the 3d 
Light Cavalry, at Meean Meer, and by 
Mr. Longmore, then surgeon of the 19th 
Regiment, stationed at Barrackpore, in 
Lower Bengal, and both published in the 
Indian Annals of Medicine. 
Dr. Butler records that his men had not 
been overworked or fatigued, but at a 
time when the heat was excessive (102° 
in the shade) they were overcrowded. 
"Assuredly," says Dr. Butler, "those 
barracks most crowded, least ventilated, 
and worst provided with punkahs and 
other appliances to moderate excessive 
heat, furnished the greatest number of 
fatal cases." 
Mr. Longmore's evidence on the same 
point is most important. Out of sixteen 
cases thirteen occurred in barracks or in 
hospital, and Mr. Longmore notes that 
one-third of his cases, and nearly half the 
deaths, " occurred in one company of the 
regiment quartered in the barrack which 
was manifestly the worst conditioned as 
to ventilation, and, indeed, in every sani- 
tary requirement." 
Mr. Longmore remarked also that " the 
patients seized in hospital were lying in 
two wards on the leeward side, and from 
circumstances of situation the warmest 
and most confined." 
Insolation has frequently been observed 
on board ship, but almost always under 
conditions similar to those in barracks ; 
that is, where overcrowding and impure 
air are added to the influence of excessive 
heat. Insolation is not uncommon on 664 
SUNSTROKE. 
board the mail steamers in the Red Sea in 
the hot months of August and September; 
it has been observed that most of the cases 
occur while the sufferers are in the hori- 
zontal position in ill-ventilated cabins. 
III. Bassier, Surgeon in the French 
Navy, reports (Dissertation sur la Calen- 
ture) that in the month of August, 1823, 
the man-of-war brig Le Lynx, cruising off 
Cadiz, had eighteen cases of insolation, 
out of a crew of seventy-eight men. The 
heat was excessive (" 33 a 35 degres Cent. ") 
and much aggravated by calms. In this 
case the ship was overcrowded : " le bati- 
ment, tres petit, offrait peu d'espaw pour le 
coucher de V equipage. 
M. Boudin (Statistiques Medicales) 
quotes from the same author the case of the 
French man-of-war Duquesne. This ship, 
while at Rio Janeiro, had a hundred cases 
of insolation, out of a crew of six hundred 
men. Most of the men were attacked, 
not when exposed to the direct heat of the 
sun, but at night when in the recumbent 
position-that is, when breathing not only 
a hot and suffocating, but also an impure 
air. 
[An important fact is, that heat-stroke 
is very much more common in cities than 
in the open country. Tokio has had 100 
cases in a single day; New York, 60; 
Philadelphia, 20. By the statistics of the 
New York Board of Health it has been 
shown that, when the thermometer is 
over 90° Fahr, the number of cases of 
heat-stroke is not exactly proportional to 
the maximum or average of daily temper- 
ature. The existence of another factor 
may be here suspected; probably, the 
condition of the atmospere in regard to 
humidity, electricity, or pressure.-II.] 
Etiology.-I have already remarked, 
that men will bear a high temperature in 
the open air with comparative impunity, 
provided (a) that it is not too long contin- 
ued, (6)that the dress be reasonably adapted 
to the temperature, (c) that the free move- 
ment of the chest be not interfered with. 
As already remarked, British sportsmen 
in India often pursue their exciting 
amusement in the hottest weather; but 
as they are careful to dress suitably, they 
seldom suffer from insolation. 
It will be remarked, that in all the ex- 
amples of insolation in the direct rays of 
the sun given above, the sufferers were 
soldiers dressed and accoutred precisely 
as men ought not to be in the circum- 
stances in which they were placed. 
Dress and accoutrements, then, are 
powerful aids to high temperature. 
The case of the 43d Light Infantry, as 
related by Dr. Barclay, brings out an- 
other predisposing cause, which appears 
to exercise a powerful influence, viz. ex- 
haustion, the result of prolonged exertion. 
This appears to act in various ways. 
First, there is a great waste of tissue, for 
a time,-that is, so long as the functions 
of the skin, lungs, bowels, and kidneys 
continue in tolerable activity, the blood is 
maintained in a state probably not far 
from its normal condition. But as exer- 
tion continues under a temperature sel- 
dom falling below 90° or 92° Fahr., and 
often reaching, as we have seen, 100°, 
107°, and sometimes 118°, in a well-made 
tent, the function of the skin ceases, and 
the result of this must be not only the loss 
of the cooling effect of evaporation, but 
also blood impurity. Again, all observers 
note that under such circumstances, ob- 
stinate constipation of the bowels is a 
constant condition, still further promoting 
this impure condition of the blood. But 
not only may we reasonably suppose that 
the blood must be in an abnormal condi- 
tion from the above causes; it is very im- 
perfectly replenished by healthy, well- 
digested food. "The appetite," says Dr. 
Barclay, " gradually failed, and a feeling 
of nausea was generally complained of, 
the sight of food often exciting loathing." 
In other instances there was nearly 
complete anorexia. It may be supposed 
that the activity of the kidneys may, to 
some extent, compensate for the lost func- 
tion of the skin and the impaired eliminat- 
ing action of other organs. But not to 
dilate on the fact that frequent micturi- 
tion, although a common, is by no means 
an invariable symptom in the premonitory 
stage of insolation, is it not possible that 
the inability to retain urine in the blad- 
der is quite as much due to its quality as 
its quantity ? "I cannot hold my 
water," was the almost invariable com- 
plaint of Dr. Barclay's men; and Mr. 
Longmore carefully noted the same thing 
in his cases. 
Dr. Obernier is of opinion that although 
the secretion of urine is in excess at the 
beginning of a march, the quantity is les- 
sened by prolonged exertion, doubtless 
because the blood has lost much of its 
water through profuse perspiration ; and 
he states that suppression of urine often 
precedes Sunstroke. "Now, suppression 
of urine means retention of urea in the 
blood," and accordingly in two cases of 
Sunstroke Dr. Obernier found urea in ex- 
cess of the normal quantity in the blood. 
Yet the same author declares that in his 
experiments on animals subjected to the 
effects of heat until they exhibited signs of 
Sunstroke, he " could not discover a trace 
of urea in their blood." 
If we look again to the cases quoted as 
occurring in barracks and ships, it will be 
seen that another cause besides heat was 
in operation. In all the examples given 
of insolation in barracks, the observers 
have noted the ill-ventilated, overcrowded 
condition of the places where the majority 
of the cases occurred. Many of the small ETIOLOGY. 
665 
bungalows occupied by officers in military 
stations in India, are quite as hot as any 
barrack-room, yet nothing is more rare 
than to see officers affected with this form 
of insolation. In the French ships, over- 
crowding and imperfect ventilation, with 
their necessary consequence, impure air, 
were noted by the surgeons who reported 
the cases. 
It is then evident, from the above facts, 
and from many more of the same kind 
that might be adduced, that the pressure 
of tight and unsuitable clothes and accou- 
trements, excessive fatigue, with all its 
consequences, and the impure air of ill- 
ventilated barracks and ships, are power- 
ful predisposing causes of insolation. 
[Another obviously predisposing cause, 
in the cities of the United States, is intem- 
perance. A large proportion of the victims 
of insolation are those who drink freely, 
whether actually drunkards or not. In 
1878, when a considerable number of 
deaths from Sunstroke occurred, a sort of 
panic in regard to the agency of alcohol 
and over-exertion in its promotion was 
started by the public press. Whether this 
had a beneficial effect or not, it happened 
that on the hottest day (IGth) of July, 
1879, with the thermometer 100° in the 
shade in some places in Philadelphia, no 
cases of heat-stroke were there reported. 
-II.] 
But it cannot be doubted that heat, and, 
speaking generally, heat long continued, 
is the true exciting cause of this formida- 
ble affection. The recently published ob- 
servations of Dr. Obernier, of Bonn, put 
this opinion beyond doubt. Fick, a Ger- 
man physiologist of reputation, maintains 
that under the controlling influence of 
radiation and evaporation through the 
lungs and skin, the temperature of the 
blood in man is always the same.1 But 
Obernier's experiments confirm the 
opinion urged in this article, viz. that, if 
through any cause the cooling effect of 
the above processes be interrupted, "as 
by warm and tight clothing, by an elevated 
temperature of the outer air, by exposure 
to direct sunshine, or the overheated at- 
mosphere of the engine-room, or even the 
forced deprivation of cold water: the effect 
is an accumulation of heat in the body, 
and an injurious if not fatal action of this 
heated blood on the nervous system and 
through it on the heart." 
The observations of physiologists have 
shown that the human body produces four 
times as much heat under considerable 
muscular exertion as during sleep. Ober- 
nier's exact experiments prove that the 
temperature of a man walking for half an 
hour increased by |° Cent, or 0-9° Fahr. 
After two hours' walking in sunshine, his 
temperature rose 3'6° Fahr. If exertion 
be continued in a hot atmosphere, or with 
the clothing so often adverted to in this 
article, or without the use of cold water, 
until the cooling processes of radiation and 
evaporation fail, " then the action of the 
heart grows weaker and weaker, the lesser 
circuit of the blood becomes overcharged, 
the venous vessels of the head grow tur- 
gid and sensibly expand ; these symptoms 
develop gradually, but the resulting dis- 
ease-Sunstroke-makes its appearance 
suddenly. " Obernier offers no opinion on 
the question whether or not nerve tissue 
undergoes any change of structure under 
heat. At this point the observations and 
experiments of Kiihne, recorded in the 
second edition of Ludwig's Physiology, 
are full of interest.1 This physiologist 
found that after exposing frogs to a high 
temperature, an electric current could 
with difficulty be transmitted along their 
nerves; at first it was lessened, and 
finally stopped altogether. 
Other experiments by the same ob- 
server demonstrate that if the heat in any 
vertebrate animal exceeds 113° of Fahr., 
coagulation of the albuminous principle 
in the muscular system at once takes 
place. 
[Similar investigations, by II. C. Wood 
and others, have added nothing of much 
importance to the above results. It 
appears certain that when a tempera- 
ture a few degrees above 100° Fahr, is 
reached in the human body, the normal 
conditions of the muscular and nervous 
tissues and of the blood are all in danger 
of alteration. This becomes more or less 
serious according to the extremity of heat 
attained, and also according to the vital 
energy of the system at the time. Fa- 
tigue, intemperance, perhaps the depress- 
ing influence of humidity, and certainly 
that of the foul atmosphere of ships, bar- 
racks, or large cities, by lowering vital 
resistance, may promote the production, 
by heat, of disorganization of nerve-cor- 
puscles, sarcous elements, or of the blood. 
Either of these, if carried to a consider- 
1 My friend Staff-surgeon Becker will short- 
ly publish a series of most interesting obser- 
vations on his own temperature on a voyage 
to India. Dr. Becker lived as much as pos- 
sible on a uniform diet, which he weighed 
exactly, and ascertained the amount of urine 
excreted daily. He took his temperature 
with unfailing regularity eleven times in 
twenty-four hours. Every tenth day he 
fasted, and took his temperature every hour. 
The temperature in the external air was also 
carefully registered. The chart shows that 
the temperature of the observer rose or fell 
one degree with every twenty degrees of rise 
or fall of that of the external air. The dis- 
turbance on the days of fasting was very 
marked, the temperature invariably falling, 
and not recovering for many hours after food 
was resumed. 
1 Ludwig's Physiologie, vol. ii. p. 732. 666 
SUNSTROKE. 
able extent, may cause death. The capa- 
city of the body to endure with safety ex- 
posure to an external temperature much 
above 100° Fahr, is due to the protective 
effect of cutaneous transpiration and 
evaporation. The sun temperature of 
New York and Philadelphia is often as 
high as 132°. I found it on one occasion in 
Maryland, 135°. Livingstone, in African 
deserts, found it 136°. But the hot-air 
bath is often taken as high as 150°-250° ; 
and Chabert, the " Fire-king," is reported 
to have gone, specially protected, into an 
oven heated to 600° Fahr.-II.] 
There is no agreement among observers 
as to the effects of extreme dryness or 
moisture in increasing or diminishing the 
effects of heat. Insolation has been ob- 
served in both conditions. In the case of 
the 43d Regiment, the hot, dry land winds 
were blowing. Mr. Longmore also notes 
the extreme dryness of the air at Bar- 
rackpore during the outbreak there ; and 
in all the examples given, the disease dis- 
appeared with the first heavy fall of rain, 
attended with a rapid fall in tempera- 
ture. On the other hand, Dr. Baxter, of 
the 93d Highlanders, who gives four cases 
of Sunstroke observed at Sealkote, con- 
siders that Sunstroke is much more likely 
to occur when the atmosphere "is largely 
impregnated with watery vapor." (Dub- 
lin Quart. Journal of Med. Science, No. 
81, Feb. 1866.) 
Mr. Naylor also is of opinion that 
cloudy days, with " a moist condition of 
the atmosphere," favor the occurrence 
of insolation (Morehead's Clinical Re- 
searches). Exact observations on this 
point, with the wet and dry bulb, are 
much required. 
It would appear that a hot and moist 
condition of the air is most favorable to 
the production of insolation in barracks, 
because not only does such a condition 
diminish the cooling effect of the evapora- 
tion from the skin, but interferes with the 
artificial means used to reduce the tem- 
perature of the overheated rooms. 
Duration. - The disease may prove 
fatal, as we have seen, in a few minutes, 
or the symptoms may last from one to 
forty-six or forty-eight hours. 
Termination.-The disease terminates 
either in death or recovery, which may be 
complete or partial, certain sequels in a 
considerable number of cases appearing. 
These are persisting headache, the pain 
being either fixed or shifting ; a chorea- 
like affection of the muscles, generally 
those of the forearm and hands ; epilepsy, 
particularly in those who have suffered 
from this disease in youth, or who have a 
hereditary tendency to it. In some cases 
mental weakness, which may prove per- 
manent, follows Sunstroke. In one ex- 
ample, that of an officer of distinction, 
who lost his hunting-cap while pursuing 
a wild hog at speed, and in the eagerness 
of the chase rode for miles bare-headed, 
Sunstroke was the result; from that 
hour his mind was affected, and complete 
recovery never took place. 
Symptoms.-Dr. Morehead has divided 
Insolation into three varieties-the Car- 
diac, the Cerebro-spinal, and the Mixed. 
In the present state of knowledge this 
classification is useful, and it certainly 
appears to be founded on correct pa- 
thology. 
In the Cardiac variety, although it is 
probable that the sufferer is himself con- 
scious of some premonitory symptoms, 
there is seldom time for their full develop- 
ment so as to attract the attention of by- 
standers before the patient falls, gasps, 
and in some severe cases expires before 
there is time to do much, or anything, for 
his recovery, death taking place by syn- 
cope. This is the form most frequently 
seen in men exerting themselves in the 
heat of the sun when dressed and accou- 
tred as were the soldiers of the 98th Regi- 
ment at Chin-Kiang-Foo, or at the funeral 
parades at Madras above described. 
In the so-called Cerebro-spinal cases, 
premonitory symptoms generally give no- 
tice of the coming danger. These are 
heat of skin-this is never absent; the 
heat is attended with extreme dryness, 
and is remarkably ardent and stinging, 
exceeding that of the worst form of re- 
mittent fever, which is sometimes as high 
as 107° Fahr.-giddiness, congestion of 
the eyes, extreme debility, nausea, and 
frequent desire to micturate. This last 
symptom is much insisted on by Long- 
more, and Dr. Barclay says that " I can- 
not hold my water" was often the first 
complaint made by many of his patients. 
It is a notable thing that headache is by 
no means a common symptom ; it does 
not appear to have been complained of in 
a single instance in Dr. Barclay's cases. 
Again, a wild shout of laughter, or an 
attempt to escape in terror from some 
imaginary enemy, sometimes precedes the 
more serious symptoms, to be presently 
described. 
M. Bassier, in the case already referred 
to of the French man-of-war at Rio 
Janeiro, mentions that the utmost diffi- 
culty was experienced in preventing the 
men from throwing themselves into the 
sea: "Ils devenaient incoldrents dans leur 
discours, poussaient des curis, nienaqaient de 
geste et de regard, entraient en fureur, et 
semblaient mettre tons lews soins adecouvrir 
une issue qui leur permit de s'elancer a la 
mer."1 On one occasion I saw a man in 
1 Frenchmen under the influence of insola- 
tion seem strongly impelled to self-destruc- 
tion. 
Boudin relates that in 1836, " pendant une DIAGNOSIS - PATHOLOGY. 
667 
this condition suddenly possess himself of 
the arms of a sentry to defend himself 
from an imaginary enemy. 
It is not by any means always that we 
have an opportunity of seeing the above 
premonitory symptoms. Where men in 
barracks are sensible of the approach of 
any of them, they generally assume the 
recumbent position, and in that state pass 
into a state of coma, the attention of their 
comrades being first called to their con- 
dition by their stertorous breathing. 
After a longer or shorter continuance 
of the above symptoms, the patient be- 
comes insensible ; the heat and dryness of 
the skin augment; the respiration be- 
comes hurried, noisy, labored ; the pupils 
contract, and are quite insensible to light; 
the conjunctive become more congested, 
" pinky" (Barclay); the heart acts tumul- 
tuously ; the pulse in men in asthenic 
condition being at first rapid, but distinct, 
but as the case progresses unfavorably, 
becoming compressible, feeble, and irregu- 
lar ; convulsions are frequent, but not in- 
variable : sometimes they appear early, in 
other cases they immediately precede 
death. 
Dr. Barclay expressly says, that "in a 
large proportion of cases, from the com- 
mencement of the attack to its termina- 
tion in death, the patient never moved a 
limb or even an eyelid." 
In the Mixed form of Morehead, the 
symptoms partake of both varieties, and 
the fatal event is brought about partly 
by coma, partly by syncope. 
Diagnosis.-The diseases with which 
this affection appears to have been con- 
founded are cerebral apoplexy, and various 
forms of fever, such as ardent continued 
fever, and even some of the graver forms 
of remittent. With the first named it has 
no pathological relations at all, and it is 
to be regretted that the term "apoplexy" 
continues to be appended to any of the 
names in use to distinguish this disease. 
In both apoplexy and the cerebro-spinal 
variety of Sunstroke, there is coma ; but 
the pulse in apoplexy is slow, generally 
full, sometimes intermitting. In Sun- 
stroke it is quick and sharp. In apoplexy 
the breathing is slow, irregular, and ex- 
plosive in expiration; in Sunstroke it is 
rapid, noisy, but not explosive. In apo- 
plexy the pupils are usually dilated, or 
one is more so than the other; in Sun- 
stroke both are contracted, and the con- 
junctive are deeply congested. The skin 
in apoplexy is not hot, and is often cold 
and moist; in Sunstroke it is always, 
except in some rare examples of the car- 
diac variety, very hot and excessively dry. 
Paralysis (hemiplegia) is the almost 
invariable result of cerebral hemorrhage ; 
it never follows immediately on Sunstroke, 
and is rare even as a sequel of that affec- 
tion. 
From ardent continued fever, the pre- 
monitory symptoms already enumerated, 
more particularly the frequent micturi- 
tion, and the early supervention of insen- 
sibility, will distinguish it. The above, 
with the history of the case, ought to 
suffice to distinguish it from the hot stage 
of remittent fever. 
Pathology.-On one point, at least, 
all modern pathologists are agreed, viz., 
that the superheating of the blood which 
precedes and accompanies Sunstroke, has 
a depressing and not a stimulating effect 
on the nervous centres ; and as the gen- 
eral recognition of this has had a powerful 
effect in leading to a more rational form 
of treatment, it is a decided step in ad- 
vance. 
The opinion given by Dr. Morehead, 
that the sthenic constitution of the newly- 
arrived European predisposes to the cere- 
bro-spinal variety of insolation, must, I 
venture to think, be taken with some 
qualification. Without doubt it was this 
variety that prevailed most in the 43d 
Light Infantry; yet, from Dr. Barclay's 
description of the miserable condition to 
which his men were reduced before the 
disease appeared among them, they were 
in anything but a sthenic condition. On 
the other hand, the men of the 63d Regi- 
ment at Madras, and the 98th at Chin- 
Kiang-Foo, fresh from Europe, were in 
the very opposite condition; yet it is 
clear, from the description given of the 
symptoms, that they suffered from the 
cardiac variety. It appears to me that 
the constriction of the men's chests by 
tight coats, the pressure of their unyield- 
ing stocks and accoutrements, had much 
to do in determining the particular symp- 
toms-an opinion strengthened by all that 
I have learned from a careful study of the 
effects of dress and accoutrements on the 
organs of circulation and respiration, and 
by the revelations of the committee ap- 
pointed to investigate this subject. At 
Chin-Kiang-Foo, the soldiers of the 18th 
Royal Irish, the 49th, and 55th Regiments 
were quite as much exposed to the sun as 
the 98th ; they did not suffer from insola- 
tion, but they marched and fought with- 
out stocks, and with their jackets open. 
I am also strongly impressed with the 
opinion that blood impurity, induced by 
the vitiated air of overcrowded barracks, 
tents, and ships, powerfully aids heat in 
bringing about that condition of the ner- 
expedition du G^n^ral Bugeaud dans la pro- 
vince d'Oran, on a pu compter en quelques 
heures, 11 suicides et 200 homines atteints 
de congestion c^r^brale, sur un colonne de 
quelques milliers d'homines." 668 
SUNSTROKE. 
vous centres which leads to the develop- 
ment of the terrible symptoms of insola- 
tion. Were it not so, the high temperature 
so often observed in the small houses and 
tents, particularly of many junior officers, 
would make this disease more common 
than it is among them. 
[There appears to be practical impor- 
tance in the distinction between two 
classes of cases, which may be respectively 
designated as heat-apoplexy and heat- 
collapse. The former is most likely to 
occur under direct exposure of the head 
to the rays of the sun; a genuine Sun- 
stroke. It is most often met with, also, 
in persons of a rather plethoric habit, or 
inclined to determination of blood to the 
head. Heat-collapse, on the other hand, 
is quite as likely to take place in persons 
who are fatigued, or whose vitality is 
low, in the shade, at a high temperature ; 
or, as in China and India, even at night. 
In the first, heat-apoplexy, there is stupor, 
with fulness of the vessels of the head and 
neck, and a full, sometimes slow, pulse. 
The second, heat-collapse, is much more 
common, and is marked by all the signs 
of exhaustion, as above described ; with a 
rapid and feeble, often irregular pulse, 
breathing accelerated or labored, face 
rather pallid than flushed, and vessels not 
distended. In this state, the patient may 
be conscious almost to the moment of 
death. As above said, however, mixed 
cases are numerous.-II.] 
Morbid Anatomy.-The blood is in- 
variably found in the same condition as 
after death from lightning, or blows on 
the epigastrium-that is, fluid. 
When death occurs so quickly as it gen- 
erally does in this affection, there is really 
no time for much organic lesion; some 
congestion of the cerebral vessels is a 
common, but by no means an invariable, 
appearance. 
The most common condition in all varie- 
ties, but more particularly in the cardiac, 
is congestion of the lungs, with distension 
of the right heart. This congestion is 
more complete in this than in any other 
disease. 
Mortality.-If Sir Charles Napier is 
correct in the statement he makes in a 
letter published in his Life, that out of 
forty-four cases of Sunstroke which oc- 
curred at Nussurpoor on the 15th of June, 
1843, forty-three proved fatal, this is the 
highest mortality on record. 
Dr. Barclay only included severe and 
well-marked cases in his table, and his 
death-rate was 42-734 per cent. 
Dr. Butler's at Meean Meer was 43-3 
per cent. 
Dr. Morehead gives the following 
table 
Treated. Death*. 
Mr. Hill's collected cases . . 504 259 
Dr. Taylor's, Gazeepore . . 115 16 
Mr. Longmore's, Barrackpore 16 7 
Mr. Lofthouse, 14th Light Dra- 
goons 80 10 
Dr. Simpson, 71st Regiment . 89 24 
Mr. Ward, 3d Bombay E. Regi- 
ment 25 6 
Mr. Ewing, 95th Regiment . 60 17 
Sir Hugh Rose and Dr. Stuart, 
25th Regiment .... 200 
Field Hospital, Hansi ... 29 10 
Prognosis. - The most unfavorable 
signs are prolonged and complete insen- 
sibility, without movement (this is a 
much more unfavorable symptom than 
occasional convulsions) ; intense heat of 
skin, persisting notwithstanding the free 
use of the douche ; increasing congestion 
of the eyes; tumultuous action of the 
heart; failing pulse ; lividity of hands 
and feet. 
If convulsions appear after such symp- 
toms have been present for some time, 
they indicate the near approach of death. 
Prophylaxis.-1st, In barracks. The 
measure now about to be carried out in 
the construction of barracks in India, viz., 
having dormitories in which not more 
than from ten to fifteen men can be ac- 
commodated, will do more to diminish 
the frequency of barrack insolation than 
any single remedy with which I am ac- 
quainted. 
Meanwhile, I cannot too strongly insist 
on the propriety of at once pitching a 
sufficient number of tents for dormitories, 
whenever the night temperature rises to 
90°, so as to diminish, by at least one- 
half, the number of men in barracks 
during the night. The manner of cooling 
both tents and barracks is so well under- 
stood in India, that it is useless to insist 
upon it here. 
In future, troops in India are never 
likely to be drilled in a hot sun, or pa- 
raded to attend military funerals in heavy 
marching order at 3 P.M. Even in that 
"military hothouse" Madras, where such 
customs " lingered long and latest died," 
it is to be hoped they will never more be 
heard of. 
As a rule, save under the presence of 
real military necessity, European troops 
are not likely to be moved during the hot 
weather ; and where such a cruel neces- 
sity exists, the terrible lessons taught 
during the Mutiny are not likely to be 
forgotten.1 When troops of necessity must 
1 Dr. Obernier lays it down as a rule that 
when the thermometer in the shade marks 
from 86° to 88° Fahr, all marching of troops, 
if for practice only, ought to be avoided. 
According to the same authority, a man TREATMENT. 
669 
march in hot weather, they should do so 
in as "open order" as military reasons 
will allow, and frequent halts should be 
called to allow the overheated bodies of 
the men to cool. This point is much in- 
sisted on by Marshal Ney, doubtless from 
observation of its necessity. 
The necessity for light clothing, suit- 
able protection for the head, neck, and 
spine, is now well understood and provid- 
ed for by existing regulations. 
At such times it will be good economy 
to engage an extra number of water- 
carriers, so that a never-failing supply 
shall be at hand, not only for drinking, 
but for douching purposes. I cordially 
assent to the practical suggestion urged 
by Dr. Barclay, that the hospital tents 
used on such occasions should be the best 
that can be made, and should be furnished 
with the best appliances, to maintain as 
low a temperature as possible. If a patient 
suffering from insolation can quickly be 
brought into an hospital tent 15 or 20 
degrees cooler than the one from whence 
he lias been taken, his chance of life will 
be immediately increased. Nor is it ne- 
cessary to say much on the good effects of 
temperance. 
It is to be hoped that the day is not 
distant when the spirit ration will be a 
thing of the past. 
Treatment.-In the days when inso- 
lation was commonly mistaken for cere- 
bral apoplexy, the lancet was usually the 
first resource. The mortality even now, 
under a mode of treatment more in ac- 
cordance with sound pathology, is often 
exceedingly high ; but when blood-letting 
was the rule, recovery was the rare ex- 
ception. 
A few years ago, in an outburst of inso- 
lation on board one of the mail steamers 
in the Red Sea, this was the mode of 
treatment pursued. A fatal issue resulted 
in every case. 
During active service in the presence of 
the enemy, an officer of rank had Sun- 
stroke. The assistant-surgeon in medical 
charge of the battery where this happened 
had the sufferer instantly removed to the 
nearest shade, stripped him, used the 
douche freely, and had the satisfaction to 
see his patient revive and consciousness 
return. An official superior, "an older, 
not a better" physician, unhappily coming 
up at this critical moment, insisted on 
opening a vein ; a few ounces of blood 
trickled away and so did the life of the 
officer. Mortal syncope immediately fol- 
lowed the operation. 
It is needless to insist on this point, for, 
as Dr. Morehead has observed, "there is 
now great unanimity of opinion" on the 
treatment of Sunstroke, and by universal 
consent the lancet has no place in it. 
At the earliest possible moment let the 
sufferer be carried to the nearest shade, 
stripped, and assiduously douched with 
cold water over head, neck, and chest. If 
this be effectually and quickly done, the 
powerful impression on the cutaneous 
nerves will soon re-establish respiration, 
at first by gasps and catches, soon in a 
more regular and tranquil manner. It 
will also reduce the heat of skin. It 
may require to be done again and again ; 
in hospital it may be necessary to envelop 
the patient in a wet sheet, and to apply 
the fan or pankah over him vigorously 
until the skin is reduced to a more natural 
temperature-a measure, however, requir- 
ing to be done under medical supervision. 
The patient should be encouraged to 
drink freely, and if vomiting follows, this 
will often aid in relieving the congestion 
of the lungs. The douche used as above 
described is a powerful remedy, and, as 
Dr. Abercrombie long since pointed out, 
it may be abused, particularly if it is ap- 
plied too long to the shaven head. More- 
head has also well cautioned us against 
its prolonged use in a routine way, when 
the skin is cold and clammy, and the res- 
piration sighing - under such circum- 
stances we must restrict ourselves to 
dashing water over the face and chest. 
When the heat of the skin is excessive we 
may avail ourselves, if ice is at hand, of 
Dr. Parkes's suggestion, and give an 
enema of ice-cold water. We should also 
apply ammonia, with the usual caution, 
now and then to the nostrils. The bowels 
being always constipated, the sooner they 
are relieved the better, by the use of pur- 
gatives and enemata. If the skin refuse 
to act, even after the free use of the 
douche, and maintains its high tempera- 
ture, a trial may be given to Warburg's 
Tincture, the most powerful sudorific with 
which I am acquainted.1 The occurrence 
of moderate diarrhoea seems to favor re- 
covery. Support and a judicious use of 
stimulants must not be neglected. 
If sensibility be not restored and main- 
tained by the douche, a blister should be 
applied at once to the nape, and, if need 
be, to the shaven head. There is much 
unanimity as to the good effects of this 
measure. 
The late Sir James Simpson, of Edin- 
burgh, long ago taught us how invaluable 
the inhalation of chloroform is in the con- 
vulsions of children depending on cerebral 
irritation. In India I have saved the 
lives of many by acting on this advice. 
Dr. Barclay in like manner found chloro- 
engaged for an hour in foot-racing, the tem- 
perature of the air being 61° Fahr., expe- 
riences a rise in temperature of 5° even when 
perspiring profusely. 
1 Vide article Remittent Fever, vol. i. p. 
365. 670 
ALCOHOLISM. 
form inhalation useful "in the convulsive 
form of the disease, attended with ex- 
treme nervous irritability," - a class of 
cases in which, he adds, "the douche is 
inadmissible from the agony it occasions. " 
In some instances life was saved by this 
remedy; in all it was prolonged. 
[Dr. A. R. Hall, in India, reported 
beneficial results from the hypodermic in- 
jection of sulphate of quinia. In 1868, 
Dr. II. Norris, at the Pennsylvania Hos- 
pital, treated successfully four cases of 
heat-stroke by the hypodermic injection 
(a quarter of a grain at a time) of sul- 
phate of morphia.-II.] 
Treatment of the Sequelae of 
Sunstroke. -Although by careful and 
judicious treatment many recover from 
the immediate effects of Sunstroke, con- 
siderable numbers are incapacitated by it 
for service in India, or in any hot climate, 
without at least a more or less prolonged 
stay in a cold climate. This is precisely 
what we see after concussion. Out of the 
large number of cases of concussion I 
have seen in India from falls from horse- 
back, I have hardly seen one make a 
complete recovery without a visit to Eu- 
rope. 
Persistent headache is one of the most 
common sequels to Sunstroke. 
At Netlcy during the invaliding season 
we are never without such cases, and 
very obstinate and intractable some of 
them are. When the pain is fixed, coun- 
ter-irritation to the nape is recommended. 
I have seldom seen it of much use. I 
have seen this troublesome symptom fol- 
low Sunstroke in this country, and be 
quite as intractable and obstinate as after 
insolation in India. A lady bathing at 
Cowes had a slight " stroke" of the sun ; 
she did not lose consciousness. For more 
than a year after the occurrence this lady 
(who was under my observation) suffered 
from headache as severely as any of our 
invalids from India sent home after Sun- 
stroke in its gravest forms. Of late I 
have been more successful with the bro- 
mide of potassium than with any other 
remedy. It is far, however, from being a 
specific, often it fails entirely, as it did 
very notably in the case just recorded. 
Great attention to the functions of the 
skin forms an essential part of the treat- 
ment in all the varieties of the sequelae 
of Sunstroke, for it is impaired in all. 
Frictions, bathing, exercise in the open 
air, are essential. When the headache is 
not fixed, but shifting, it will often be 
found to depend on a weak condition of 
the digestive organs, and careful treat- 
ment suited to the peculiar features of 
each individual case is required. 
In epilepsy following Sunstroke the 
prognosis is generally favorable. The fits 
usually subside on the patient being re- 
moved to a temperate climate. 
ALCOHOLISM. 
By Francis Edmund Anstie, M.D., F.R.C.P. 
Definitton.-A disease of the general 
nervous system, induced by continued ex- 
cesses in the use of alcoholic liquors. It 
manifests itself usually in a chronic, but 
occasionally in an acute form. Its charac- 
teristic phenomena are muscular tremor 
and progressive muscular weakness, in- 
somnia, hallucinations of sight and (less 
commonly) of hearing and smell, busy de- 
lirium, diminished or deranged intellectual 
and moral force, together with dyspepsia, 
slight jaundice and morning vomiting. 
In advanced cases there are also paralysis 
of sensation or motion, or both, convul- 
sions, epilepsy, dementia, and general de- 
generation of the tissues of the body. 
Tendency to death slight when the origi- 
nal cause of the malady can be removed. 
The fatal result is either produced by ex- 
haustion from protracted acute delirium, 
or slowly brought about by progressive 
degeneration of the nervous centres, or of 
some important organ of nutrition. 
Synon yms. -Alcoholismus chronicus, 
Delirium tremens, Delirium potatorum, 
Mania potatorum, Ebrietas, Chronic alco- 
holic intoxication, Trunksucht, &c. &c. 
These various names obviously apply to 
various aspects of the disease accordingly 
as it occurs in the acute or the chronic 
forms, between which there was formerly 
no sufficient distinction made. 
History.-The "history" of Alcohol- 
ism, to use the expression in its proper 
medical sense, is simply the story of the 
excesses of each individual patient as re- ETIOLOGY. 
671 
gards the daily allowance of alcohol, the 
duration of intemperate habits, and the 
kind of liquor taken, especially as regards 
its degree of concentration. 
Etiology.-This part of the subject is 
extremely complex. The simplest portion 
of it is that which refers to the exciting 
causes, and it will be best to dispose of 
this first. 
1. The exciting causes of Alcoholism can 
be better appreciated at the present time 
than formerly, because our increased 
knowledge of the physiological action of 
alcohol has enabled us to explode some 
errors of theory which were almost uni- 
versal in medical writings and popular 
belief about the disease. The prime 
source of these errors was the general 
tendency to notice only the more acute 
nervous affections which are caused by 
alcoholic excess-namely, delirium tre- 
mens, maniacal excitement, and terrify- 
ing hallucinations (horrors). These phe- 
nomena had been observed to occur fre- 
quently, and were believed to occur 
always in consequence of a temporary 
abstinence from drink after a course of 
excessive indulgence. This presumed se- 
quence of cause and effect fitted exactly 
with the classical denomination of alcohol 
as a "stimulant," a member of an ideal 
class of medicaments which possessed the 
peculiar property of exciting vital function 
in such a manner that after a longer or 
shorter period a " recoil" was inevitable, 
under which the forces of life were reduced 
below their natural level. The great 
feebleness which was observed to charac- 
terize the acute delirium of drunkards was 
supposed to be due to this kind of exhaus- 
tion from the withdrawal of an accustomed 
stimulus. 
At present our ideas are very different. 
In the first place it has been abundantly 
shown by various writers, of whom Ware1 
was the earliest, that abstinence from 
drink by no means always, or even most 
frequently, precedes the outbreak of deli- 
rium tremens or of alcoholic mania: on 
the contrary, these accidents commonly 
overtake the patient in the midst of his 
excesses. Secondly, alcohol, in doses 
which singly are capable of producing 
drunkenness, and frequently repeated may 
bring on acute delirium, &c., has been 
proved to be a true narcotic poison, of the 
same class as the so-called anaesthetics, 
chloroform, and sulphuric ether. Given 
in these large doses, its influence is entirely 
in the direction of paralysis-suspension 
of nervous activity; and this suspension 
of nervous activity (increased by other 
sources of deficient vital power, which we 
shall have to notice as incidental to the 
circumstances of the chronic drunkard) is 
itself a sufficient explanation of the ner- 
vous debility which brings about the 
delirious crisis. And thirdly, the modern 
researches which have enabled us clearly 
to identify a chronic alcoholic intoxication, 
often reaching over a period of many 
months or years, have revealed the fact 
that in the multitudes of instances the 
acute attack merely exhibits in full de- 
velopment symptoms which had been 
partially recognizable for a long time 
previously. 
It may now be taken for certain that 
the phenomena of which we have to treat 
under the denomination of Alcoholism, 
are due in the first place to the direct 
action upon the nervous system of a blood- 
supply charged with a high percentage of 
alcohol. If we surround a living nerve 
(partially dissected from its connections) 
with alcohol of a certain strength, we find 
that it becomes paralyzed-i. e., incapable 
of transmitting impressions-through its 
affected part; while a very weak mixture 
of alcohol and water is incapable of pro- 
ducing this effect. Similarly, if an animal 
absorb into its circulation a certain quan- 
tity of alcohol within a given time, the 
nervous centres and the peripheral nerves 
become (though in less degree) paralyzed. 
That this effect is, at least in part, due to 
direct action of strong alcohol upon the 
nervous tissue can hardly be doubted, con- 
sidering the analogy of the well-ascer- 
tained local effect in the above experi- 
ment : there is, however, a co-operative 
cause of no small importance ; namely, it 
has been ascertained by the researches of 
various observers that the impregnation 
of the blood with large quantities of alco- 
hol interferes with its absorption of oxy- 
gen : it thus becomes unfitted to support 
healthy nervous functions. Under these 
combined influences the nervous tissues, 
and particularly those of the central or- 
gans, become more and more unfitted for 
the performance of their proper functions: 
and this change progresses with a rapidity 
proportionate to the strength and fre- 
quency of the alcoholic influence. It is 
counteracted only by one circumstance- 
the elimination of portions of the alcohol 
from the system, which goes on by the 
medium of all the excreting glands, but 
more especially by the kidneys, the skin, 
and the lungs. Upon the activity of these 
organs in performing this task probably 
depends, cocteris paribus, the impunity of 
the drinker from the ill effects of the poi- 
son upon his nervous centres. Thus it 
comes to pass that the occupation and 
many surrounding circumstances of the 
drinker modify his symptoms in an im- 
portant manner, as will be noticed more 
particularly under the head of Predispos- 
ing Causes. 
It is necessary here to recall the prin- 
1 Remarks on the History and Treatment of 
Delirium Tremens. Boston, 1831. 672 
ALCOHOLISM. 
cipal facts which are known with respect 
to the action of alcohol upon the organ- 
ism. This substance is easily absorbed 
from the stomach, especially when that 
viscus is empty. If the dose be moderate 
and the administration well-timed, the 
effect upon the nervous system is simply 
that of a restorative stimulant. Sensa- 
tions of fatigue are dispelled, the mind 
works more freely, a healthy sense of 
warmth is diffused through the body, and 
the arterial system acquires an increased 
tonicity if it was hitherto deficient in that 
quality. The latter fact, which is due to 
the influence of the remedy upon the sym- 
pathetic nerves, is capable of being de- 
monstrated in a very interesting and con- 
vincing manner. The sphygmograph of 
M. Marey has the power of accurately 
representing, by its registration of the 
pulse-wave, the degree of arterial tonicity 
present; and by tins unfailing test it ap- 
pears that the small vessels, when relaxed 
in a condition of fatigue, are brought, by 
a moderate dose of alcohol, to a proper 
tension, from which they suffer no recoil. 
If, on the contrary, the dose has been im- 
moderate, or administered at a time when 
it was not required, the pulse-waves give 
a precisely opposite indication - that, 
namely, which proves that arterial relaxa- 
tion has occurred ; and simultaneously 
with this the pulse becomes abnormally 
quick. At the same time other symptoms 
of a paralytic nature are observed, con- 
fined in the first instance to the spinal 
nerves and to the fifth cranial nerve. The 
former show their weakness by the occur- 
rence of slight feelings of numbness, and 
an impairment of muscular sense in the 
extremities ; the latter indicates its affec- 
tion by the occurrence of slight numbness 
of the lips. The vaso-motor fibres of the 
fifth nerve discover their partially palsied 
condition by flushing of the face, conges- 
tion of the conjunctivae, and lachryma- 
tion. The cerebral hemispheres next give 
notice of the alcoholic influence by the 
occurrence of intellectual confusion, and 
the hypoglossi becoming simultaneously 
affected, the muscular movements of the 
tongue become difficult, and articulation 
is impeded. The further stages of drunk- 
enness consist in more or less noisy or 
sentimental delirium, passing gradually 
into coma; palsy, more and more com- 
plete, of voluntary motion and sensation ; 
the medulla oblongata is palsied, and 
breathing ceases ; and, last of all, the or- 
ganic nerves of the heart become incapable 
of performing their functions, and cardiac 
life ceases. During all this process the 
secreting glands are affected, but in vary- 
ing degrees : the kidneys in particular are 
singularly little acted on in some cases, 
and very strikingly in others ; and the 
diuresis, which is the result of the latter 
condition, is the best safeguard against 
fatal results, as it involves a large elimi- 
nation of alcohol. MM. Lallemand, Du- 
roy, and Perrin were the first observers 
who clearly proved the elimination of un- 
changed alcohol, and the phenomena ap- 
peared to them so striking that they con- 
cluded, too hastily, that the whole amount 
of any dose of alcohol taken into the sys- 
tem was thus eliminated by one or other 
secreting surface. The facts adduced by 
these authors do not, however, justify any 
such inference. I have repeated their ob- 
servations with much care and especial 
attention to the dose administered - a 
point singularly neglected by MM. Lalle- 
mand, Duroy, and Perrin. The result of 
these observations is, that a moderate 
dose (e. g. a pint of light beer or a glass of 
sherry) produces very slight effects in the 
way of elimination, which last over a 
few hours only, and cannot be reasonably 
supposed to represent the elimination of 
more than a small fractional part of the 
alcohol imbibed. On the contrary, when 
a dose has been taken sufficient to pro- 
duce more or less profound intoxication, 
alcohol is so copiously eliminated by skin, 
lungs, and kidneys, especially the latter, 
that there is some reason to think that as 
much as from a fourth to a third of the 
dose taken leaves the body in an un- 
changed condition within the course of 
forty-eight hours. Even in this instance, 
however, there is no sufficient reason to 
suppose that all the alcohol leaves the 
body in an unchanged form ; indeed there 
are the strongest reasons for thinking the 
reverse. It is true that the intermediate 
compounds, between alcohol on the one 
side, and carbonic acid and water on the 
other, which would represent the stages 
of transformation of the former into the 
latter, have not yet been satisfactorily 
proved to exist in the organism after a 
dose of alcohol has been taken; but in 
truth nothing like an efficient search has 
yet been made for them. The researches 
of Lallemand show us that elimination 
may go on for a period of forty-eight 
hours, and my own experience appears to 
indicate with certainty that not a trace of 
elimination of unchanged alcohol can be 
detected at a later date than this. But 
this is entirely contrary to what we know 
of the behavior of those poisonous sub- 
stances which are wholly eliminated in an 
unchanged form, especially when, like 
alcohol, they are of a low diffusive power. 
According to the analogy drawn from 
such cases, alcohol, were it entirely elimi- 
nated in an unchanged form, ought to be 
traceable by the delicate chromic acid test 
in all the secretions for a period not of 
two days, but of two weeks or more, from 
the time of its ingestion. Probabilities 
are therefore greatly against the total 
elimination of alcohol in an unchanged 
form, even from the chemical point of ETIOLOGY. 
673 
view; and to conclude this part of my 
subject, I may say that probabilities are 
converted into what most persons will be 
inclined to consider certainties, when the 
remarkable physiological influence of alco- 
hol in supporting vital power is taken into 
consideration. But as I have dwelt fully 
on these matters elsewhere, it is unneces- 
sary to repeat facts which would take up 
a great deal of space in the telling.1 
The exciting causes of Alcoholism may 
be understood, then, to be the repeated 
direct action of blood strongly impregnated 
with alcohol on the tissue of the nervous 
centres and branches, rendering them 
physically incapable of the due perform- 
ance of their functions, and the influence 
of an insufficiently oxygenated blood- 
supply consequent on a morbid condition 
of the blood-corpuscles. 
2. The predisposing causes of the disease 
are much more complicated. They should 
be divided, in the first place, into (a) those 
which are occasional, and (6) those which 
are constant. 
(a) The occasional predisposing causes 
include those external circumstances 
which expose persons to the temptation 
of drink, and those internal sensations, 
produced by temporary illness, which 
bias them in a similar .direction, or, by 
weakening the nervous system, render 
the effects of drink more sensibly felt. 
Occupation is an important influence. 
For instance, a large number of cases pre- 
sent themselves at the hospital which are 
directly traceable to the frequent presence 
of the temptation, as in the case of work- 
men at breweries and distilleries, and 
potmen and waiters at taverns. In a 
higher grade of life, public-house keepers 
and the clerks and travellers for wine and 
spirit merchants, are especially liable to 
Alcoholism. There is, however, by no 
means such a preponderance of cases due 
to this direct temptation as might be sup- 
posed. A very large number of patients 
come from the classes whose business ex- 
poses them greatly to the inclemency of the 
weather; thus cab-drivers, coal-porters 
(especially the workmen who lade the 
river barges), and hawkers are very com- 
monly large drinkers; they very frequently 
become the subjects of Alcoholism, and 
would be still oftener affected in this way 
were it not for the assistance to elimina- 
tion which their outdoor life renders. 
Monotony of occupation is also highly 
predisposing, especially when combined 
with much confinement in close rooms. 
Amongst occupations of this kind there 
are none which have furnished me with 
so many and such serious cases as the 
trades of shoemaker and barber. The 
want of active outdoor exercise, of course, 
represses elimination, and much increases 
the evil. I have seen few more desperate 
cases of Alcoholism than some which 
have occurred in barbers who have been 
habitually confined to miserably small 
shops, and at the same time have earned 
enough money to pay for a great deal of 
drink. 
Depressing Mental Influences are powerful 
predisposers to drinking habits ; and be- 
sides this, they directly increase the lia- 
bility of the nervous system to be affected 
with symptoms of Alcoholism, in virtue 
of their weakening operation upon it. 
There is a vulgar notion that drink is the 
simple and uncomplicated cause of the 
greater number of crimes committed by 
the poor. The truth is, that, in recog- 
nizing the indisputable fact that drunken- 
ness is often followed by crime of a worse 
kind, people are apt to overlook large 
portions of the history of the criminal, 
and especially the wretched poverty in 
which he is usually reared. The demoral- 
izing influence of this poverty is the cen- 
tral fact on which we ought to concentrate 
our attention ; it is a common cause 
of general reckless behavior, of which 
drunken habits are only a part, although 
they doubtless render the commission of 
fresh crimes more probable. The same 
recklessness of despair has often been seen 
1 The reader is referred for ampler informa- 
tion to the papers of M. Baudot, in the Union 
Medicale for 1863, and to my work on "Stimu- 
lants and Narcotics." (London, 1864.) 
Since this article was written and in type 
I have had time to make new researches, 
which enable me greatly to strengthen my 
statement as to the comparatively trilling ex- 
tent to which alcohol is eliminated from the 
body in an unchanged form. With the as- 
sistance of my friend and colleague, Dr. Du- 
pre, I have made experiments on a large 
scale, and with increased care, which prove 
indisputably that when alcohol is taken in 
non-intoxicating doses, the total elimination, 
in the twenty-four hours, only amounts to a 
fraction (generally a small one) of a grain for 
the kidneys, and even smaller quantities for 
the lungs and skin. Even in cases of intoxi- 
cation I now believe that a very much smaller 
proportion of unchanged alcohol is excreted 
than I had supposed, and enormously less 
than MM. Lallemand, Duroy, and Perrin had 
represented. The total period during which 
any elimination goes on is also proved to be 
much shorter than had been previously sup- 
posed. 
By a curious coincidence, it happened that 
a German observer, Dr. Schulinus, was in- 
vestigating the same question simultaneously 
with myself. His results, obtained from a 
very elaborate and careful series of experi- 
ments, closely correspond with my own. Dr. 
Schulinus' paper will be found in the Arch, 
d. Heilkunde for 1866. My own observations, 
which were made in ignorance of the German 
researches, are included in my lectures at 
the Royal College of Physicians, which ap- 
pear in the Lancet of July, August, and Sep- 
tember, 1867.-F. E. A. 
vol. i.-43 674 
ALCOIIOLISM. 
to produce intemperance in drink, where 
poverty had no share in its origin. In 
the higher classes we not unfrequently 
see men who have failed in some cherished 
speculation, or women who have lost the 
only object which they cared about in 
life, take to drink with an almost insane 
vehemence, although they may never have 
shown any such tendencies before. It is 
not that there is any particular tempta- 
tion in the taste of the drinks to which 
they have recourse, for it is a fact that 
even the most refined and delicate women, 
when they take to these practices, alto- 
gether neglect the really fine-flavored 
alcoholic compounds : they do not drink 
wine, for instance, but brandy, or some 
equally coarse and strong spirit. In truth, 
it is an accident which leads them to se- 
lect alcohol: under other circumstances 
they would take opium or hashish, or any 
other intoxicant which came conveniently 
to hand, or they would plunge into the 
indulgence of some special vice which 
promised them excitement. They merely 
wish for oblivion. And this is the very 
motive which drives the poor in many 
cases to drunkenness, and which simul- 
taneously inclines them to commit other 
rash and criminal acts; the wish to es- 
cape, in any direction possible, from the 
hideous dulness of a life which is one 
monotonous pain. Starvation-actual se- 
vere deprivation of food-cannot be an 
active predisposing cause of drunkenness; 
fbr the opportunity of getting liquor is cut 
off by the extreme degree of poverty which 
brings about such a state of things : it is 
rather the sense of embarrassment and 
misery, consequent on the difficulty or 
impossibility of paying debts, that is 
common in the lowest ranks of the middle 
class, which prompts to drinking habits. 
The influence of various forms of dis- 
ease in predisposing patients to Alcoholism 
is twofold. In the first place, there are 
many conditions of chronic weakness and 
suffering which are susceptible of great 
relief, when they are at their worst period 
of aggravation, by the use of alcohol; and 
this fact, accidentally learned by the suf- 
ferer, is from ignorance often perverted. 
The diseases of this class which are the 
most important are the whole group of 
neuralgise, the depression and faintness 
attending the menstrual period of some 
women, and the debility and low spirits 
which often distress nursing mothers. 
Under the influence of such disorders 
patients are extremely apt to use alcoholic 
drinks recklessly, and the foundation of 
drunken habits is thus laid. This subject 
is so important that I may be excused for 
dwelling on it, at the risk of a digression, 
because it is scarcely possible in a very 
few words to convey my meaning without 
danger of being misunderstood. It is 
frequently charged upon those physicians 
who recommend alcoholic stimulants in 
disease, that they are encouraging patients 
to indulge in one of the strongest tempta- 
tions to drunkenness. This accusation is 
entirely unjust, if applied to those who 
administer the remedy on scientific prin- 
ciples. I have endeavored to show else- 
where, that it is the use of doses which 
are large enough or ill-timed enough to 
produce symptoms of narcotism that can 
alone implant in the patient that craving 
for drink which forces him against his 
will to indulge, with constantly increasing 
intemperance, in the abuse of alcoholic 
liquors. But the ignorance of the layman 
who attempts to regulate his own medi- 
cinal use of alcohol frequently leads him 
to confound two radically distinct modes 
of operation, by either of which this sub- 
stance may be made to relieve pain and 
nervous depression or restlessness. The 
use of such moderate quantities as fall 
short of producing any, even the earliest, 
of the intoxicative symptoms which have 
been already described, while it frequently 
relieves the patient's distress, leaves no 
disastrous after depression or craving, 
but simply restores the nervous system to 
its healthy state. But pain, and various 
other forms of malaise, may also be re- 
lieved by the use of true narcotic or intox- 
icant doses which paralyze the nervous 
system for a time ; and it is this kind of 
temporary relief which involves depres- 
sion, and a sense of craving for stimulants 
during the period in which the drinker is 
recovering from his narcotic stupefaction. 
It is this wasteful misuse of alcohol, in 
the absence of scientific knowledge, which 
becomes a predisposing cause of drunken- 
ness in the case of patients affected with 
the class of maladies to which I have now 
referred. 
One special variety of chronic tempta- 
tion to drink, depending on temporary 
bodily conditions, deserves more notice 
than it has yet received, but can be only 
briefly indicated here. I refer to the in- 
fluence of the sexual orgasm which dis- 
tresses particular individuals of both sexes 
(but especially females) in whom the de- 
velopment of puberty takes place in a 
difficult or irregular manner. The symp- 
toms with which young females are af- 
fected under these circumstances are 
commonly treated (as " hysterical") by 
various household remedies, which con- 
tain more or less alcohol, such as sal-vol- 
atile, eau-de-Cologne, and various warm- 
ing tinctures. These remedies are often 
swallowed in most improper and unneces- 
sary quantities ; and there is too much 
reason to believe that in this way the 
foundation of secret drinking is not un- 
frequently laid. 
(b) There is another kind of predispos- 
ing cause, which is constant in its operation, 
and which is probably at least as influen- SYMPTOMS. 
675 
tial, both in producing alcoholic excess 
and in aggravating its ill effects, as any 
of these occasional causes which have 
been enumerated-viz. a peculiar inherit- 
ed constitution of the nervous system. In 
the course of a large experience of Alco- 
holism among the hospital out-patients, I 
have been greatly struck with the number 
of drinkers who have informed me that 
their relations, either on the paternal or 
the maternal side, have also been given 
to drink. And a still larger number are 
found on inquiry to come of families in 
which some nervous disorders (especially 
insanity, epilepsy, and neuralgia) have 
been markedly prevalent. The doctrine 
of the hereditary transmission of a neu- 
rosis,- which, according to the special 
pressure of external circumstances, may 
take the form either of intellectual insan- 
ity, of emotional impulsiveness combined 
with moral weakness, or, on the other 
hand, of convulsive or neuralgic affec- 
tions,-has been much insisted upon by 
recent alienist writers, and especially 
by Moreau in his very able treatise on 
" Psychologic Morbide. " My own expe- 
rience has led me to a firm conviction that 
particular causes of nervous degeneration 
affecting individuals do very frequently 
lead to the transmission, to the offspring 
of those persons, of an enfeebled nervous 
organization which renders them pecu- 
liarly liable to the severer neuroses, and 
which also makes them facile victims of 
the temptations to seek oblivion for their 
mental and bodily pains in narcotic indul- 
gence. I believe that things often work 
in a vicious circle to this end ; and that 
the nervous enfeeblement produced in an 
ancestor by great excesses in drink is 
reproduced in his various descendants 
with the effect of producing insanity in 
one, epilepsy in another, neuralgia in a 
third, alcoholic excesses in a fourth, and 
so on. Among the higher classes, where 
it is easier than in the case of the poor to 
obtain tolerably complete family histories 
extending over two or three generations, 
careful inquiry elicits facts of this kind 
with surprising frequency. So strong is 
the impression left on my mind by what I 
have observed in this direction, that I am 
inclined to believe that the great majority 
of the most inveterate and hopeless cases 
of alcoholic excess, among the higher 
classes, are produced by two factors, of 
which the least important is the circum- 
stance of external momentary temptation 
in which the patient has been placed, 
while the more momentous and weighty 
cause is derived from an inherited nervous 
weakness which renders all kinds of bodily 
and mental trouble specially hard to be 
borne. It need hardly be remarked that, 
in this view of the case, the fatal rapidity 
with which habits of intemperance exag- 
gerate themselves is only what might be 
expected, seeing that the nutrition of the 
nervous centres would be still further im- 
paired by each successive indulgence in 
poisonous doses of alcohol, and the power 
of moral resistance to feelings of depression 
and misery would be proportionately weak- 
ened. 
Symptoms.-The symptoms of acute 
Alcoholism are in general well known, 
and there is little difficulty is understand- 
ing their access and the order of their 
succession. What is far less generally 
understood is the slighter and more 
chronic form of Alcoholism which, in the 
majority of cases, precedes by a consider- 
able time the occurrence of the delirious 
affection. Accordingly, it will be well to 
commence with the description of this 
chronic disease, since its characters may 
be properly considered as representing the 
earlier stages of a great constitutional 
malady. 
(a) Symptoms of Chronic Alcoholism.- 
It is upon the motor nervous system that 
the influence of chronic excess is first dis- 
cernible in the largest number of cases. 
Of an extremely large number of patients 
who present themselves at the out-patient 
department of Westminster Hospital suf- 
fering from this disease, certainly more 
than two-thirds, upon careful analysis of 
their complaints, state that a muscular 
inquietude, which might or might not 
amount to actual tremor, was the first 
disagreeable symptom which they noticed. 
In cases of gradual access the affection at 
first may amount to no more than an in- 
ability to keep the limbs of the body still 
without a special effort of attention-the 
exercise of the will being sufficient to 
render the muscles perfectly steady. The 
degree of motor disturbance is distinct 
from and independent of the peculiar 
mental restlessness to be presently no- 
ticed as arising somewhat later, although 
the occurrence of the mental affection 
very much aggravates the tendency to in- 
voluntary movement. This distinction is 
noticeable in relation to the nocturnal 
state of the patients. Long before the 
occurrence of terrifying dreams, of noc- 
turnal delirium, or of hallucination-even 
before there is conscious nocturnal dis- 
turbance of the mind at all-the patient 
feels an inability to sleep which appears 
to depend on the condition of the motor 
nervous system. Repeatedly I have been 
assured by persons suffering from the 
slighter degrees of Alcoholism that they 
go to bed with a sense of at least average 
drowsiness, but an invincible disposition 
to turn restlessly from side to side in the 
bed entirely prevents them from getting 
any sleep. 
It is not very often that a patient asks 
for advice at the early stage of the dis- 
ease, which is represented by the pres- 676 
ALCOHOLISM. 
ence of the above symptoms only. More 
commonly he does not come under medi- 
cal notice till the motor disorder has 
reached a further stage ; and his com- 
plaint is now, probably, that he suffers 
from persistent muscular tremor. This 
symptom develops itself first in the ex- 
tremities. Magnus Huss declares that it 
always appears earliest in the hands ; but 
it is probable that this is a mistake, for 
in a majority of the cases which have 
come under my care the lower extremi- 
ties were first affected ; while it is less 
easy to detect tremor of the lower than of 
the upper extremities, and the former 
often escapes notice for some time after 
its commencement. Huss notes correctly 
the fact that even in the stage of persistent 
alcoholic tremor the patients can at first, 
by a strong effort of the will, restrain 
their movements for a time, but on the 
cessation of the effort the tremulousness 
is ordinarily worse than ever. A very old 
and general observation is to the effect 
that the tremor of Alcoholism is almost 
invariably worse in the 'morning, and it 
has been usual to assign as the reason for 
this, that the accustomed stimulus of al- 
cohol has been withheld for some hours. 
The statement is plausible, because it is 
the fact that a glass of beer, or wine, or 
brandy, taken under these circumstances, 
will at once diminish the unsteadiness of 
the muscles: but another fact may be 
mentioned which strongly opposes the 
theory-viz. that common foods, such as 
bread and milk, or broth (if the stomach 
be not too much irritated to digest them), 
will answer precisely the same purpose. 
In truth, the excessive morning tremor of 
the chronic toper is due chiefly to ex- 
haustion from failure to get sleep. What 
sleep he has had has been of an unre- 
freshing kind, and a complete condition 
of nervous prostration naturally results, 
from which he can only be rallied bjr food 
or drink. 
Coincidently with the establishment of 
persistent muscular tremor, and some- 
times earlier than this, certain cerebral 
symptoms present themselves. One of 
the commonest of these is a buzzing or a 
rushing sound in the ears, which is fre- 
quently, though not always, accompanied 
with dull diffused headache. Vision is 
also affected, with varying degrees of 
severity, the most trifling symptoms being 
the appearance of muscce volitantes, or of 
"clouds" before the eyes. Flashes of 
light are a more serious phenomenon, 
and their occurrence at night, just before 
the patient drops into his first uneasy 
half-slumber, is frequently the immediate 
precursor of the more definite visual hal- 
lucinations. Momentary attacks of ver- 
tigo are common. By this time the pecu- 
liar alcoholic insomnia is fully developed 
in the great majority of cases : the patient 
tosses from side to side during nearly the 
whole night, getting only broken snatches 
of sleep, and these almost always at- 
tended with disturbing, ana often with 
frightful, dreams. 
The mental condition is now usually 
such as to distress the patient and to im- 
press the medical observer who sees the 
case for the first time. Its chief feature 
is the uncertainty of purpose which the 
sufferer displays: independently of any 
fixed delusion, or even of a distinct feeling 
of terror, there is a mental inquietude 
which makes it impossible for him to set- 
tle to any ordinary occupation, or to com- 
plete the tasks which he begins. To this 
is added either violent temper or a feeling 
of dread which may be vague and unac- 
countable, or (in bad cases) may arise 
from actual delusions, such as the belief 
that an enemy is constantly lying in wait 
to inflict an injury, &c. This sort of de- 
lusion is not to be confounded with another 
kind, which consists in a vivid apprehen- 
sion by the patient that he is in danger of 
falling down a precipice even when he is 
walking on firm ground in broad daylight, 
and which seems to me to be connected 
with rapidly progressing impairment of 
muscular co-ordination. Cases which dis- 
play the latter feature are commonly of a 
dangerous type, and, unless energetically 
treated, pass rapidly to a hopeless condi- 
tion as to recovery. The sensation as 
described to me is not like that of ordi- 
nary vertigo, or of fainting; it resembles 
the disagreeable nightmare which every 
one has experienced on first falling asleep 
after an indigestible supper, or, still more 
closely, the hideous feelings which some 
persons (myself among the number) suffer 
from under the action of a large dose of 
Indian hemp. But it is not usually found 
among the earlier symptoms of Alcohol- 
ism. 
The above is a fair description of the 
nervous symptoms under which the pa- 
tient commonly suffers when he first ap- 
plies for relief. The disorders of common 
sensation which are frequently produced 
by alcoholic excess are, in my experience, 
usually later in their advent. When the 
patient comes under notice, he may pre- 
sent either of several conditions as regards 
his outward appearance. There is not 
often, at this early stage, any very great u 
emaciation, even in the case of habitual 
spirit-drinkers; but there may be every 
degree of fatness, from the unwieldy bulk 
of the country publican, who chiefly fud- 
dles himself with beer, to the slight frame 
of the London hairdresser, who too often 
makes away with two or three quarterns 
of gin or rilm daily. It is a great mistake, 
however, to push so far, as is often done 
in descriptive works, the contrast between 
the respective influences of spirit-drinking 
and beer-drinking. The haggard wretches SYMPTOMS. 
677 
whose portraits Hogarth has drawn in his 
picture of "Gin Lane" are emaciated to 
that degree quite as much from utter 
want of all the comforts of life as from 
the direct influence of spirit-drinking; 
and, in fact, one sees, in the classes whose 
circumstances are a shade more easy, 
plenty of gin-drinkers who (living chiefly 
on gin) have a good allowance of fat, if 
not of muscle. The countenance of the 
drinker (whether of spirits or beer) usually 
presents two remarkable features in con- 
junction, viz., great flabbiness of the mus- 
cles of expression, and red, watery eyes; 
the conjunctivae are also very generally 
more or less jaundiced. To this is often 
added redness of the nose and cheeks, and 
an eruption, resembling acne rosacea, 
around the nose and the mouth. On in- 
quiry we learn that, besides the already- 
described nervous symptoms, the patient 
suffers from morning vomiting, or at least 
nausea. This is nearly always the case, 
but there may be any amount-or no 
amount-of general symptoms of gastric 
or intestinal irritation, except this one 
symptom; and the tongue, in correspond- 
ence with these variations, may be in 
nearly any state, from perfect cleanness 
and moistness to dry red glaziness or thick 
yellow furring: the latter is its more com- 
mon condition, especially at the back part. 
The morning vomiting is in my opinion 
not a mere dyspeptic disorder, but a true 
part of the nervous phenomena of receding 
narcosis. One symptom, which it is not 
easy to explain, but which nearly always 
exists, even where there are no signs of 
dyspepsia, is a peculiar foul breath-smell, 
which it is impossible to describe, or to 
mistake when once it has been smelt. It 
is quite unlike the odor of the alcoholic 
liquor itself, and may be separately dis- 
tinguished even when the latter is also 
present. 
Considering the enormous quantities of 
spirituous liquors which are drunk by 
many of the patients who apply for relief 
from the consequences of chronic Alcohol- 
ism, it would be natural for the reader 
.who holds the usual opinion as to the ori- 
gin of cirrhosis of the liver to expect that 
serious symptoms, produced by the latter 
disorder, must often complicate cases of 
the former. The case, however, is far 
otherwise, in my own experience. Of an 
immense number of patients in whom the 
nervous disorder has been clearly identi- 
fied, I have only seen thirteen cases in 
which the symptoms of cirrhotic disease 
called for any special treatment, although 
a certain degree of cirrhosis was doubtless 
present in many of the others ; and I can- 
not avoid the conclusion that some very 
powerful element, over and above the in- 
fluence of alcoholic excess, is needed to 
produce the severe type of that disease. 
To a less, but still a remarkable extent, 
the same observation holds good for kid- 
ney disease of the degenerative kind. 
With regard to these disorders, I am con- 
vinced that other depressing influences 
must bear a large share of the blame or- 
dinarily attributed to alcohol. How is it 
possible to form any other opinion, when 
of the multitudes of drinkers whose kid- 
neys must be daily traversed by blood 
containing large quantities of alcohol, so 
few present any characteristic change of 
the urine, or other recognizable symptoms 
of renal mischief? Be this as it may, it 
is certain that renal, and still more he- 
patic, complications are very rarely the 
source of serious embarrassment in the 
treatment of chronic Alcoholism of the 
ordinary type which is indicated by such 
a group of nervous symptoms as is above 
described. 
Not to anticipate unduly what will 
have to be said under the head of Prog- 
nosis, it may be stated here that the form 
of the disease which we have so far con- 
sidered, is decidedly curable, tending in 
fact to right itself on the simple adoption 
of a plan of complete abstinence from the 
exciting cause of the mischief, combined 
with a nourishing and supporting diet, 
unless in the rare instances where sundry 
complications, which may fairly be called 
accidental, happen to receive a dangerous 
development. These complications arise 
out of the local irritant action of the more 
concentrated alcoholic liquors on the gas- 
tro-intestinal mucous membrane or on the 
air-passages, and will now be described. 
The irritant effects of alcohol on the 
alimentary canal are chiefly seen in the 
case of spirit-drinkers, and more particu- 
larly in those who drink spirits neat, or 
highly concentrated. Beer-drinkers do, 
indeed, often suffer from a simple form of 
dyspepsia, and there is little doubt that 
slow degenerative changes are usually set 
up in the stomachs of these patients ; but, 
except in the case of enormous habitual 
excesses, the dyspepsia is a transient phe- 
nomenon which rapidly disappears on the 
adoption of a rigid plan of abstinence to- 
gether with a simple medicinal treatment. 
The more concentrated alcohols, however, 
when used for any length of time, may set 
up a formidable irritation which produces 
intense congestion of the stomach or the 
intestines, or both : in short, a greater or 
less portion of the tract in which the radi- 
cles of the portal veins take their rise is 
subject to severe engorgement. Perhaps 
the most serious consequence of such an 
action is the occurrence, which we now 
and then witness, of profuse hemorrhage 
from the stomach or bowels. According 
to what I have seen, this is rare. I have 
not met with a dozen cases of this kind 
altogether : two of these-one a case of 
htematemesis, and the other of intestinal 
hemorrhage-occurred in the same week, ALCOHOLISM. 
678 
in the practice of Westminster Hospital, 
quite lately. It is a frequent thing, how- 
ever, for drinkers to be affected with hem- 
orrhoids, from which more or less bleeding 
takes place. 
Great numbers even of the heaviest 
drinkers never develop any further specific 
symptoms of Alcoholism than those which 
have been already described, and their 
vicious habit, if it shortens their lives, does 
so chiefly by impairing their general nu- 
trition, and thus rendering them less able 
to resist the attacks of intercurrent acute 
disease, and at the same time more pre- 
disposed to constitutional maladies, such 
as gout for instance, to which they may 
chance to have a hereditary bias. Others 
suffer from attacks of delirium tremens 
(to be presently described), once and 
again. But in many other drinkers the 
nervous symptoms, still preserving a more 
or less chronic type, assume a far more 
serious development; and we have now 
to speak of these more extreme develop- 
ments of chronic Alcoholism. 
Of the earliest symptoms which indi- 
cate a dangerous degree of nervous de- 
generation, the occurrence of marked sen- 
sory paralysis is one of the most frequent. 
Unlike the corresponding affection of the 
motor nerves, sensory paralysis is most 
commonly exhibited in a slight degree in 
the upper extremities before it appears in 
the lower. The occurrence of any con- 
siderable degree of sensory palsy in the 
lower limbs is a sign of grave import: the 
patient so affected, unless he be induced 
at once to adopt a proper abstinence, and 
an appropriate medical treatment, is al- 
most certain very quickly to experience 
some serious organic lesion of the brain. 
Simultaneously with the occurrence of a 
considerable degree of sensory paralysis, 
there is usually a great development of 
the muscular tremor, which, in several 
cases which I have seen, approached 
closely to the type of paralysis agitans. 
The mental powers are by this time usu- 
ally affected in a marked degree-the 
most common mental condition being one 
of general intellectual enfeeblement and 
moral degradation, marked by cowardice 
and untruthfulness. At this point the 
progress of the case may diverge in either 
of several directions. In patients whose 
family history is strongly marked with 
the taint of insanity, a tendency to suicide 
is often developed, or else the sufferer 
sinks rapidly into a state of confirmed and 
incurable dementia. In others the func- 
tion of muscular co-ordination is inter- 
fered with to a degree which makes the 
case resemble, at first sight, the affection 
known as Locomotor Ataxy. In others 
there occurs a sudden break-down of ner- 
vous fibres in the corpora striata, or optic 
thalami, which produces a stroke of hemi- 
plegic paralysis. In others, along with 
some symptoms of mental alienation, a 
general motor palsy is so distinctly ob- 
served as strongly to suggest the idea of 
commencing general paralysis of the in- 
sane. In others the rupture of a cerebral 
artery leads to an effusion of blood and 
the sudden occurrence of an attack resem- 
bling ordinary apoplexy. In others, again 
(but this is a very small class), the patient 
suffers attacks of convulsions indistin- 
guishable from those of simple epilepsy. 
Epileptic attacks, occurring in this way, 
as a symptom of a very advanced stage of 
the nervous degeneration developed by 
chronic Alcoholism, are broadly distin- 
guished, in a clinical and prognostic point 
of view, from the much commoner attacks 
of epilepsy in a subject known to be pre- 
disposed to or actually affected with that 
disease, as a mere consequence of a some- 
what unusual alcoholic excess : the latter 
are of comparatively slight consequence, 
while the former indicate an altogether 
hopeless phase of alcoholic degeneration 
of the nervous centres. They are almost 
always accompanied by an advanced de- 
gree of dementia. 
(b) Symptoms of Acute Alcoholism.-If 
we set aside the case of common drunken- 
ness, as being rather an instance of nar- 
cotic poisoning, to be dealt with by toxi- 
cologists, than a morbid affection coming 
under the definition which we have placed 
at the head of this article, we may de- 
scribe the symptoms of acute Alcohol- 
ism as presenting themselves under four 
principal forms-namely, Delirium Tre- 
mens, Acute Mania from drink, Acute 
Melancholia from drink, and Oinomania. 
1. Delirium Tremens.-The clinical his- 
tory of this disease was much misunder- 
stood in former times. It used to be be- 
lieved that in the majority of cases the 
delirious affection was produced, not by 
the direct poisonous action of alcohol upon 
the nervous system, but by the circum- 
stance of an habitually intemperate per- 
son's leaving off the use of his accustomed 
potations. As a matter of fact it had fre- 
quently been observed that a sufferer from 
delirium tremens had ceased to drink for 
one, two, or three days before the access 
of his more acute symptoms, and the ex- 
haustion caused by* the loss of his ordi- 
nary stimulant was supposed to produce 
those symptoms. Dr. Ware, of Boston 
(1831), was one of the first writers who 
pointed out that this statement includes a 
fallacy of observation. From an analysis 
of 100 cases, he proved that the cessation 
of drinking, where this occurs, is in fact 
produced by a feeling of revulsion to 
strong liquors, which is a part of the early 
symptoms of the acute disease in many 
cases; and, on the other hand, that very 
many patients do not leave off drinking at 
all, but the delirious attack supervenes in 
the midst of a debauch. This observation SYMPTOMS. 
679 
has been confirmed by Dr. Gairdner, and 
many other excellent writers, and at 
present the classical theory of exhaus- 
tion from withdrawal of an accustomed 
stimulus has but few upholders. [Sur- 
geons are familiar with the occurrence 
of delirium tremens in intemperate per- 
sons who have suffered severe injuries, 
or have undergone amputation or other 
severe operations. It is reasonable to 
suppose that this may be due to the con- 
tributive or exciting causative action of 
surgical shock, and not to the withdrawal, 
under treatment, of their accustomed ex- 
cessive stimulation. Yet it is hard not to 
think, that in these, and some other cases 
of suddenly enforced abstinence, this with- 
drawal does have something to do with 
bringing on the attack.-II.] 
The first warning of the approach of 
delirium tremens is ordinarily given by 
the occurrence of complete insomnia. 
The patient may have long indulged to 
excess in drink, or he may be quite a 
novice in intemperance, but in any case a 
greater debauch than usual has commonly 
been perpetrated ; and the sufferer finds 
himself quite unable to obtain any sleep, 
or at most can only gain short snatches of 
slumber, disturbed by horrifying dreams 
and visions: and during his waking mo- 
ments, even in broad daylight, he suffers 
from hallucinations of sight which com- 
monly take the form of disgusting or ter- 
rifying objects, such as snakes, insects, 
monsters, or of armed men pursuing him 
with threatening gestures. More rarely 
he hears voices denouncing threats, or 
mocking him : occasionally he experiences 
delusive sensations of disgusting smells. 
Often the occurrence of distinct visual 
hallucinations while the patient is awake 
is the first sign of the passage from 
chronic Alcoholism (which may have 
lasted for months or years, with a vary- 
ing degree of insomnia, and perhaps with 
habitually distressing dreams) to the 
acute affection. During the first day or 
two days the patient is in an extraordi- 
narily depressed state, with slow and 
feeble pulse, cold extremities, and a pro- 
fuse sweating. The mental state is one 
of great anxiety, but there are usually no 
real delusions: even where visual halluci- 
nations are present, the patient can by an 
effort of the will recognize them as such, 
and momentarily banish them from his 
sight. During all this time there is so 
complete an absence of appetite, in the 
great majority of cases, that no food, or 
scarcely any, is taken, and this circum- 
stance probably mainly conduces to pre- 
cipitate the onset of the second stage. 
In this the mere anxiety and nervousness 
is exchanged for incoherence of speech 
and wild excitability of manner, which 
sometimes takes the shape of causeless 
anger (though even then nearly always 
mixed with cowardice), and sometimes 
of great terror, which the sufferer often 
accounts for by pointing to imaginary 
terrific shapes which seem to people the 
room, and which he is constantly seeking 
to push aside with a restless motion of his 
hands. lie talks incessantly, in a ram- 
bling fashion. Even when his terror or 
his anger is at its height he can generally 
be momentarily restrained by the influ- 
ence of any onlooker who addresses him 
in a firm and determined manner, and 
may even be reasoned temporarily out of 
his hallucinatory i maginations. The pulse 
has now become quick (from 100 to 130 or 
140 a minute): it is sometimes small and 
thready, sometimes soft and voluminous : 
but in every case which I have examined 
it gives a tracing, by the use of Marey's 
sphygmograph, in which the form of the 
pulse-waves closely resembles that which 
is observed in fevers and inflammations 
of a typhoid type, and is especially re- 
markable for tlie prominence of the phe- 
nomenon called dicrotism. " The an- 
nexed tracings will give a more accurate 
idea of the quality of the pulse than any 
description of the sensations which it 
communicates to the finger :- 
Muscular tremor, which, from its strik- 
ing prominence in many cases, has given 
the disease its name of delirium tremens, 
is by no means universally present. 
According to Craigie, whose observations 
on this point I believe to be correct, they 
are usually observed in the cases of con- 
firmed dram-drinkers ; and in many in- 
stances I have found on inquiry that they 
were only an exaggeration of a tremu- 680 
ALCOHOLISM. 
lousness of the extremities which had 
already existed for months or for years. 
But even when the characteristic tremu- 
lous movement of the arms and hands is 
not present there is a constant restless- 
ness ; the patient shifts constantly in the 
bed, and will get out of it twenty times in 
an hour if he be permitted to do so. The 
eyes are in almost constant movement; 
the pupils are usually, though by no 
means always, dilated. The temporal 
and carotid arteries throb violently in 
most cases ; very often the face is flushed, 
but sometimes it remains deadly pale ; 
nearly always there is much sweating, 
which is obviously due, in great part, to 
the constant muscular movements. The 
tongue is protruded, on the request of the 
physician, with an almost choreic jerk. 
It almost always trembles; usually it is 
covered with a yellowish fur, but it may 
be clean, red, and glassy on the one hand, 
or brown, dry, and cracked on the other. 
It is usual to assign a limit to the 
second stage (which may last one, two, 
or several days) at the period when the 
patient first falls into continuous slumber ; 
and no doubt the classical descriptions 
which assign this as the critical event to 
which convalescence may be expected to 
succeed, find a considerable superficial 
justification in clinical facts. But, in 
common with some of the most careful 
observers, I believe that to be a very erro- 
neous and mischievous opinion which 
ascribes to a few hours' sleep anything 
like a distinctly curative power. It is 
true that in many, perhaps most, instances, 
the patient awakes, after his first sleep of 
considerable duration, in a condition of 
comparative convalescence. But, on the 
other hand, numerous cases have been 
observed in which the patient has sunk 
into profound slumber for many hours, 
and has awakened as delirious as ever, or 
in a state of complete prostration, which 
has rapidly terminated in death. Inter- 
esting considerations will be brought for- 
ward on this point, under the head of 
Prognosis, particularly with regard to the 
condition of the pulse, and the amount of 
success which has attended the efforts of 
the attendants to get the patient to take 
nourishment. In fact, the occurrence of 
sleep, even of considerable duration, 
marks with accuracy the commencement 
of convalescence only where we find the 
patient, on waking, clear in his intellect, 
free (or nearly so) from hallucinations, 
and with a pulse greatly reduced in fre- 
quency and yielding a sphygmographic 
trace such as will be presently described. 
The stage of convalescence, once estab- 
lished, presents nothing particularly 
worthy of description. But instead of 
sleep occurring at all, the patient may 
pass from mere delirium into a comatose 
condition, with muttering delirium, eyes 
open, staring, and fixed, restless move- 
ments of the limbs more marked than 
ever, picking at the bed-clothes, or possi- 
bly profound stertorous coma, or violent 
convulsions, these symptoms being fol- 
lowed speedily by death. In other cases 
the patient, in the midst of violent deli- 
rium, with great excitability, suddenly 
collapses, as it were; the pulse becomes 
hurried, intermittent, and thready ; the 
features pinched and ghastly, the breath- 
ing gasping, and death ensues in a minute 
or two, sometimes even in a few moments. 
2. Acute Mania from drink presents 
symptoms which, though semetimes puz- 
zlingly like those of simple delirium tre- 
mens, can usually be discriminated from 
the latter. The patient, who (invariably, 
as far as my experience goes) possesses 
some hereditary predisposition to in- 
sanity, is seized, in the midst of a drink- 
ing bout most commonly, with active 
maniacal delirium of a violent kind, and 
frequently displays a marked tendency to 
homicidal acts. In most of the cases 
which I have seen the whole aspect of 
the countenance and manner of the pa- 
tient is different from that of delirium 
tremens, and there is comparatively little 
of the busy tremulousness of the hands so 
often seen in the latter disease. I believe 
that cases which are attended with posi- 
tive intellectual delusion are nearly always 
of this, or else of the melancholic kind. 
The pulse, whatever its degree of appa- 
rent strength or weakness, as tested by 
the finger, is seldom so markedly dicrotous 
as in delirium tremens. [A modification 
of this kind of attack occurs in rare in- 
stances, to which the name of alcoholic 
phrenitis or inflammatory delirium may be 
applied. I have seen but one case of it; 
but the same man had been two or three 
times similarly affected, as I learned from 
his previous medical attendant. After a 
hard drinking spell, he became delirious; 
with very little tremor, a hot head, skin 
generally of a high temperature, pulse 
rather rapid, full, and strong. Acting upon 
information received of his other attacks, 
I took several ounces of blood from his 
arm.1 This, with a saline cathartic, was 
followed by improvement in all his symp- 
toms, and recovery within a week. Alto- 
gether exceptional as such cases are, it is 
well to be aware that they are possible.- 
II.] 
3. Acute Melancholia from drink pre- 
sents the usual characteristics of melan- 
cholia from any other cause, but is 
marked by a special tendency to suicidal 
acts. The influence of a sound, pro- 
tracted slumber, which in mania from 
[■ It is proper to say, that, agreeing with 
the general principles of Dr. Anstie's article, 
I have never taken blood in any other case of 
delirium from alcoholism.-H.] DIAGNOSIS. 
681 
drink is usually very beneficial, is far less 
so in melancholia from the same cause, as 
far as my limited experience goes. 
4. Oinomania.-The fourth variety of 
acute Alcoholism is that curious affection 
which Roesch was the first to describe 
with precision, and which is now com- 
monly called oinomania. It is, in truth, 
rather a variety of constitutional insanity 
than of alcoholic disease ; but as the out- 
breaks owe many of their characteristic 
symptoms to the influence of drink, the 
disorder requires notice in a treatise on 
Alcoholism. The sufferers from oinoma- 
nia are, I believe, usually descended of 
families in which insanity (and often in- 
sanity of the same type) is hereditary. 
Patients of this class very commonly, 
though not always, display their tenden- 
cies early in life; sometimes, indeed, on 
the very first occasion on which the op- 
portunity for the free use of strong drink 
presents itself. It should be clearly un- 
derstood that the term "monomania," 
which is often applied to the disease, very 
imperfectly describes the condition of the 
victims. Closer investigation of their 
mental state will usually discover the fact 
that they are liable to periodical recur- 
rences of causeless exultation and bursts 
of self-confidence on trifling occasions ; 
they then display great obstinacy, and a 
marked excitement of the animal passions 
generally: indeed the commencement of a 
drinking bout is often accidentally pre- 
cipitated by the circumstances of tempta- 
tion in which they are placed by loose 
company. Under the influence partly of 
an uncontrollable impulse, and partly of 
intoxication, they will perform truly in- 
sane acts; they take useless and purpose- 
less journeys to remote places, or they 
lose their usual sense of decency, and ex- 
pose themselves to disgrace by public acts 
of a degrading character. They exhibit 
symptoms which in many respects resem- 
ble those of simple delirium tremens, 
though there is usually a marked absence 
of that anxious terror which is almost 
always present in the latter complaint, 
and also a far less decided incapacity to 
sleep; indeed, there is sometimes very 
little insomnia. After lasting for a few 
days, a week, sometimes even a month or 
six weeks, the attack seems to wear itself 
out, as if rhythmically; and the patient 
generally recovers very rapidly his usual 
health, though he suffers " horrors" for a 
day or two. The condition of these pa- 
tients in the intervals between these at- 
tacks is very different from that of the 
ordinary confirmed sot. Very often they 
live perfectly sober and chaste lives, and 
are even remarkable for active and intel- 
ligent management of their affairs. But 
this condition only lasts for two or three 
months, or six months, or at most a year, 
and then the old symptoms recur, and the 
patient is uncontrollably hurried into ex- 
cesses of the most violent kind. Very 
rarely indeed is a sufferer from this dis- 
ease really cured ; it usually recurs with 
increasing frequency throughout life, and 
frequently ends in declared and perma- 
nent insanity. 
[It seems to be more generally admit- 
ted by the profession in America than in 
Great Britain, that uncontrollable intem- 
perance constitutes a form of insanity in 
a large number of instances. Opinion is 
divided, however, here as well as abroad, 
as to whether the drinking habit alone is 
to be credited, in most cases, with the 
production of oinomania (or methomania, 
a better term) as an affection in which 
the will is overborne by the morbid im- 
pulse to drink liquor. Some consider that 
either insanity or a predisposition to it 
existed before ; of which the methomania 
is only a partial manifestation. My own 
conviction, from observation, is, that 
long-continued intemperance very often 
does induce, in persons otherwise sound 
in mind, a condition, mental and physical, 
in which, with opportunity and the ab- 
sence of restraint, it is impossible for 
them to resist the tendency to take alcohol 
in excess. This may be most properly 
called methomania.-H.] 
Diagnosis.-The diagnosis of alcoholic 
diseases of the nervous system is not un- 
frequently surrounded with difficulties, 
especially in the case of the chronic 
forms. Chronic Alcoholism produces ner- 
vous symptoms which are particularly 
liable to be confounded with the follow- 
ing diseases : 1, chiefly with commencing 
general paralysis; 2, with paralysis agi- 
tans; 3, with lead-poisoning; 4, with 
locomotor ataxy; 5, with hemiplegia or 
paraplegia from ordinary softening of the 
brain or spinal cord ; 6, with epilepsy ; 7, 
with senile dementia; 8, with hysteria; 
9, with the nervous malaise associated 
with some forms of dyspepsia. The gen- 
eral group of leading symptoms whose 
presence enables us to affirm the diagnosis 
of chronic Alcoholism rather than that of 
any of these diseases is as follows : The 
patient suffers from restlessness of mind 
(without delusions), insomnia, muscular 
fidgetiness, or actual tremor, morning 
vomiting; and presents flabby features, 
and watery eyes, and slight jaundice of 
the conjunctivae. These symptoms make 
the diagnosis highly probable. If to them 
is added the occurrence of vertigo, mus- 
cae volitantes, and terrifying dreams, it is 
greatly strengthened ; and it is raised to 
the point of certainty, in my opinion, if 
there be also actual visual or auditory 
hallucinations in the form of visible 
shapes of men, beasts, &c., or audible 
voices. Indeed, the concurrence of dis- 
tinct visual or auditory hallucination with 682 
ALCOHOLISM. 
only four other of the above-mentioned 
symptoms-viz., insomnia, morning vom- 
iting, muscular tremor, and causeless 
mental restlessness-would of itself very 
nearly persuade me of the existence of 
alcoholic poisoning. Cases of commenc- 
ing general paralysis (the most embar- 
rassing counterfeits of the disease) may 
nearly always be distinguished by the 
presence of mental exaltation, the condi- 
tion of the toper being uniformly one of 
mental depression, on the whole. The 
very rare cases of general palsy which do 
not display mental exaltation are wanting 
in the other features of Alcoholism, unless 
indeed when drink has been the exciting 
cause. As far as I have seen, chronic 
alcoholic poisoning always produces three 
or four of the leading symptoms which I 
have mentioned as specially diagnostic; 
and where an acne-like eruption of the 
face is also present, this settles it. The 
diagnosis of the acute forms of Alcohol- 
ism is usually far less difficult. We can 
generally get at a knowledge of the pa- 
tient's mode of life in these cases ; whereas 
the chronic toper is very commonly, espe- 
cially if a woman, most cautiously and 
skilfully reticent and deceitful, and often 
conceals her habits even from her nearest 
relations. A case of considerable diffi- 
culty may arise in the distinction between 
delirium tremens and some forms of acute 
mania not caused by drink. The exist- 
ence of delusions, not mere terrors, should 
bias us in favor of the diagnosis of mania, 
as should also the tendency to commit 
particular acts of violence, and especially 
lustful propensities ; while the predomi- 
nance of hallucination, especially when 
combined with terror of mind, tremor, 
and busy delirium, should predispose us 
to recognize delirium tremens. For the 
means of diagnosis between the different 
forms of acute Alcoholism the reader is 
referred to what has already been said 
under the heading of symptoms. 
Prognosis.-The prognosis in chronic 
Alcoholism, except in its more advanced 
forms, which are marked by the occur- 
rence of serious paralytic or convulsive 
symptoms, or by considerable mental im- 
pairment, is highly favorable as regards 
recovery from the immediate symptoms. 
Mere abstinence, combined with simple 
but energetic treatment, to be presently 
described, will suffice in such cases to pro- 
cure a rapid removal of all the unpleas- 
ant symptoms. Unfortunately, too many 
patients are biased by long habit, by 
hereditary constitution, or by the dis- 
mally depressing circumstances of their 
daily life, in a way which renders their 
return to intemperance indefinitely prob- 
able. When once the more serious symp- 
toms-such as paralysis, or epilepsy, or 
extreme and persistent muscular tremor 
•-have occurred, cure, even for a time, is 
far more difficult, and the moral degrada- 
tion of the patient, especially if a female, 
is so great as to allow small hope that 
abstinence will be observed. 
In delirium tremens the main elements 
of prognosis are the occurrence or non- 
occurrence of sleep before the patient is 
very much exhausted, the condition of 
the pulse as tested by the sphygmograph, 
and the degree of success which attends 
the physician's efforts to get nourishment 
into the system. Sleep, as already re- 
marked, is not of itself curative. The 
disease, in proportion to its original viru- 
lence, has a course of longer or shorter 
duration to run : this depends in great 
measure on the quantity of the poison 
taken, the sufficiency of the assimilative 
processes, the original strength of the 
constitution, and the degree in which it 
can be supported by well-assimilated food. 
Thus the prognosis is bad in the extreme 
when the dose of poison has been very 
large, the patient's constitution feeble, 
his powrers of assimilation weak, and, in 
addition to this, disease of the glandular 
organs (especially of the kidneys) exists. 
Such a case is well-nigh hopeless. Almost 
equally bad is that in which any severe 
degree of pneumonia complicates the mal- 
ady. The test, however, of the patient's 
chances which more than any other I am 
inclined to value, is the indications given 
by Marey's sphygmograph. In propor- 
tion as the pulse shows a tendency towards 
the normal form indicated by this tracing 
are the chances good. On the contrary, such a pulse as the following 
offers the extreme type of that typhoid form 
which is of most evil augury. This latter 
tracing was taken from a man, aged 40, 
who, after remaining for nearly a week in 
the delirious stage, fell into a sound sleep, 
which lasted for six or seven hours, awoke COMPLICATIONS. 
683 
apparently so much improved as to his 
nervous symptoms, that a somewhat con- 
fident opinion was pronounced in favor of 
his recovery. I augured the worst from 
the pulse-tracing ; and in fact the patient 
sank rapidly, about twenty-four hours 
later. A somewhat extensive experience 
of this means of prognosis enables me to 
recommend it with much confidence. 
Mere rapidity of pulse counts as nothing 
in gravity, in my opinion, in comparison 
with the obstinate maintenance of the 
typhoid form of pulse-wave. 
It is almost needless to remark that the 
circumstance of an attack being the first 
of the kind which the patient has suffered, 
renders it much less dangerous to life, as 
a general rule, than a second, a third, or 
a fourth would be ; but there are import- 
ant exceptions and qualifications to this 
law. Thus it may happen that a first at- 
tack of delirium tremens seizes a patient 
who has passed the line of middle age, 
and whose nervous system has been al- 
ready much enfeebled by chronic disease 
or bad feeding, but who has never till re- 
cently indulged to excess in drink. Such 
an individual runs a great danger of sink- 
ing under the first acute attack ; and the 
reason of this may be partly found in the 
feebleness of his system, and partly in 
the circumstance that his eliminating or- 
gans, especially his kidneys, have not 
become habituated to the irritation sud- 
denly thrown upon them by blood con- 
taining large quantities of unchanged 
alcohol. The same embarrassment of 
eliminating organs suddenly charged with 
unaccustomed alcohol is doubtless the 
cause that a young man's first debauch 
(such at that of a young sailor, e. g., put 
on shore after his first voyage) so often 
causes an attack of delirium tremens; but 
here the constitutional strength usually 
enables the patient to bear up till the 
natural process of cure has time to be 
accomplished. 
The prognosis both of acute mania and 
of acute melancholia from drink is de- 
cidedly good, at any rate on the occasion 
of first attacks, and provided that the 
affection is promptly treated. The prob- 
ability of the case passing into one of con- 
firmed insanity is of course progressively 
increased on the occasion of each succes- 
sive acute attack. 
The prognosis of oinomania is in one 
way very hopeful, in another almost en- 
tirely hopeless. The attacks of the acute 
affection may recur any number of times 
without any serious result: the patient, 
after a variable number of hours, days, or 
weeks, returns to his sober senses, and re- 
sumes his usual course of life. The hope- 
lessness of the case lies in the taint of in- 
sanity which almost always lies at the 
foundation of the complaint, and which 
makes it almost impossible that the pa- 
tient can effect a thorough reformation of 
his habits. However virtuous his inten- 
tions may be, and however strongly he 
may be urged by every consideration of 
prudence, or affection for those whose in- 
terests may depend upon his conduct, it 
appears as if he were impelled by a really 
irresistible force to yield himself, at cer- 
tain intervals, to the temptation of drink. 
When the outbreaks become, as they 
usually do in the end, greatly more numer- 
ous than at first, there is reason to appre- 
hend the speedy supervention of confirmed 
insanity. 
Complications.-Of the complications 
of chronic Alcoholism it would be impos- 
sible to speak in detail, on account of 
their great number and variety. The 
only point to which I think it necessary 
to direct attention, is the question of the 
comparative liability of drinkers and of 
sober persons to phthisis. It appears cer- 
tain, from the most careful statistics, and 
especially from those recently collected by 
Dr. Sutton, that the liability of drinkers 
to the ordinary forms of phthisis is con- 
siderably less than that of temperate 
people. On the other hand, every phy- 
sician has now and then observed cases, 
which may be classed as "galloping con- 
sumption, " which have occurred in per- 
sons who have been leading drunken 
lives, and which arrive with great rapidity 
at a fatal termination. I believe these 
victims of acute phthisis from drink are 
always descended of tuberculous fami- 
lies ; and I think it likely that the start- 
ing-point of the actual tubercular deposit, 
is to be found in continuous paralysis or' 
semi-paralysis of the " nutritive" fibres 
contained in the pulmonary branches of 
the pneumogastric nerve, which is kept' 
up by the patient's drinking habits. 
Of acute Alcoholism, the only compli- 
cation of which I shall separately speak 
is that of pneumonia. Nothing is more 
insidious than the occurrence of pneu- 
monia in a subject whose nervous system 
is deeply poisoned with alcohol. A cru- 
cial instance of this occurred in the per- 
son of a patient who died in King's Col- 
lege Hospital many years ago, without its 
being suspected that anything more than 
delirium tremens was amiss, but whose 
right lung proved, on post-mortem ex- 
amination, to be hepatized from apex to 
base. In this case there was no cough, 
no expectoration, no pain in the chest, 
and only so much frequency of breathing 
as seemed sufficiently accounted for by 
the restless muscular movements of the 
patient. It is most important, in every 
case of delirium tremens, that the chest 
should be periodically examined with 
care. ALCOHOLISM. 
684 
Pathology.-The pathology of Alco- 
holism naturally divides itself into three 
portions. The morbid influence which 
the poison exerts is of three kinds : in the 
first place, it acts as a local irritant (when 
highly concentrated) upon the mucous 
membrane of the stomach and the ali- 
mentary canal generally ; and in the sec- 
ond place, after absorption, it affects the 
rate of movement amt the vitality of the 
blood, and as a consequence of this im- 
pairs the nutrition of every organ of the 
body. And thirdly, it is clear that the 
nervous centres, independently of the ill 
effects on their nutrition of the blood- 
changes, have a certain chemical attrac- 
tion for alcohol, which accordingly is 
found to accumulate in their tissues. 
In the alimentary canal, and particu- 
larly in the stomach, the local effects of 
habitual large doses of concentrated al- 
cohol are seen in permanent congestion of 
the bloodvessels, exaggerated or vitiated 
secretions from the gastric glands, and 
ultimately a degenerative change in the 
structure of the submucous tissues, which 
consists in the disappearance of charac- 
teristic secreting structures, and the hy- 
pertrophic exaggeration of fibrous tissue. 
Absorbed into the blood in large propor- 
tions, alcohol increases largely the amount 
of fatty matters in that fluid, and promotes 
congestion of certain important organs. 
The congestion of the lungs, liver, kidneys, 
&c. seems to be partly due to altered 
chemical relations between the blood and 
the tissues of those organs, and partly to 
a paralytic action of the alcohol upon the 
vaso-motor nervous system. It is by this 
latter action that I am inclined to account 
for the abnormal production of sugar in 
the liver, which has been experimentally 
observed by Bernard and Harley to follow 
the introduction of concentrated alcohol 
into the portal vein, and also for a largely 
increased excretion of water from the 
kidneys, which is one of the most in- 
variable consequences of large doses of 
alcoholic liquors. It is indeed doubtful 
whether the degenerative changes which 
result from prolonged alcoholic poisoning 
are not in great part due to the direct 
chemical influence of alcohol upon the 
nervous tissues. The characteristic 
changes which have been observed in the 
brain, medulla oblongata, &c. of confirmed 
drinkers, consist essentially of a peculiar 
atrophic modification, by which the true 
elements of nervous tissue are partially re- 
moved, the total mass of nervous matter 
wastes, serous fluid is effused into the 
ventricles and the arachnoid, while simul- 
taneously there is a marked development 
of fibrous tissue, granular fat, and other 
elements which belong to a low order of 
vitalized products. Essentially similar 
changes are observed in the lungs, the 
liver, the kidneys, the heart, and the 
larger arteries, which (after the nervous 
centres) are the most frequently affected. 
The cranial bones are also thickened by 
a deposit which is not of the nature of a 
true hypertrophy, for the bones lose much 
of their original texture, and become 
dense, almost porcellanous. There is 
much in these changes which reminds us 
forcibly of the effects on nutrition of tis- 
sues produced experimentally by Schiff 
and Mantegazza by the section of com- 
pound nerves, such as the fifth cranial, 
and the sciatic and crural of the lower 
limb ; and suggests the idea that in al- 
coholic poisoning the starting-point (or at 
least one starting-point) of degenerative 
tissue-changes may consist in paralysis of 
those nervous branches which preside 
specially over nutrition, the distinct 
character of which has been so well 
pointed out by Brown-Sequard.1 
It is highly probable, however, that a 
considerable portion of the degenerative 
influence of the continued excessive inges- 
tion of alcohol is due to a chemical inter- 
ference with the natural course of oxida- 
tion of the blood and tissues. Notwith- 
standing all that has been urged in favor 
of the view that alcohol is not transformed 
within the body, the balance of evidence 
is strongly in favor of the belief that a 
considerable portion of every dose of alco- 
hol which is ingested does undergo oxida- 
tion in the system, and that to the diver- 
sion from its ordinary purposes of the 
inspired oxygen must be ascribed the 
diminished activity of elimination of car- 
bonic acid, of urea, of chlorine, and of the 
acids and bases of the urine, which un- 
doubtedly does occur in the subjects of 
alcoholic poisoning. 
Treatment.-1. The treatment of the 
chronic form of Alcoholism varies accord- 
ing to the stage of the disease which has 
been reached. In that large majority of 
the cases which come under our notice, in 
which the patient merely complains of 
nervousness, of inability to sleep, of mus- 
cular tremor, and perhaps of the slighter 
forms of visual hallucination, together 
with some dyspepsia and with morning 
vomiting, the treatment required is ex- 
tremely simple. One has only to insure 
that the patient practises a proper absti- 
nence from drink-to insist upon his tak- 
ing a diet as rich in nitrogenous matters 
as may be, but at the same time such as 
his digestive system can appropriate- 
and to administer certain tonic medicines; 
and in nearly every case we may count 
upon a rapid disappearance of the un- 
1 Vide Lancereaux, Archives Gen., Oct, 
1865, for a full account of the Morbid. Anato- 
my of Alcoholism. TREATMENT. 
685 
pleasant symptoms of which he has com- 
plained. With regard to the first item, 
the prescription of abstinence from drink, 
a good deal of difficulty may arise, and 
there is room for difference of opinion as 
to the expedient course. I wish to ex- 
press the decided opinion that complete 
abstinence may always be carried out 
without any immediate danger to life or 
health, if proper care be taken to substi- 
tute a substantially nourishing diet. The 
danger of pursuing this course is not a 
physical but a moral one: all kinds of 
pledges which, as it were, bind the indi- 
vidual, have a tendency to lessen the force 
of such notions of personal responsibility 
as he may retain; he is apt to rest his 
confidence on the oath or formal resolu- 
tion, which he has taken, instead of teach- 
ing himself the virtue of self-restraint, as 
he would have to do if he were to accus- 
tom himself to the moderate use of alco- 
holic liquors. This is a question, how- 
ever, which must be left to the practi- 
tioner's judgment in each case. The 
administration of a highly animalized diet 
is often a matter of difficulty at first, 
owing to the feebleness of the digestive 
powers, which renders the use of solid 
meat impossible, and even that of soups 
very difficult. Under these circumstances 
the greatest possible benefit may be de- 
rived from the administration of some of 
the better so-called "concentrated" pre- 
parations of meat, more especially Gillon's 
beef-juice, and a solid extract from this 
which is prepared by Messrs. Bell, of Ox- 
ford Street, as also the better specimens 
of the extractum carnis of Liebig. [ I have 
found to answer very well, a strong home- 
made beef soup ; with the fat carefully 
removed, and a good seasoning of cayenne 
pepper.-II.] Without entering into the 
vexed question of the exact nutritive value 
of these preparations, there can be no 
doubt that they are powerfully reviving 
to an exhausted nervous system, and that 
simultaneously with the general improve- 
ment which they produce, the digestive 
organs become strengthened to deal with 
more bulky forms of animal food. The 
direct medicinal treatment of chronic 
Alcoholism in its milder forms is very 
simple. The presence of dyspeptic symp- 
toms, unless they are very aggravated, 
and there is reason to believe that serious 
organic changes in the abdominal viscera 
have taken place, ought not to distract 
our attention from the main object of 
fortifying the nervous system ; for with 
the observance of a proper abstinence 
from their exciting cause they will rapidly 
subside. The nervous tonic in which, 
after a great many trials of different 
remedies, I have come to repose the 
greatest confidence, is quinine in one-grain 
doses two or three times a day. It should 
be given from the very first, if possible ; 
and this may be done, even when the 
stomach is very irritable, by administering 
the remedy in effervescence, with bicar- 
bonate of potash and citric acid. The 
symptoms which most of all distress the 
patient, in the majority of cases, are the 
persistent wakefulness and the tendency 
to visual hallucinations or to appearances 
of black specks, flashes of fire, &c., before 
the eyes : the insomnia is also, of course, 
a great obstacle to that repair of the ner- 
vous energy without which recovery is 
impossible. But it would be a mistake to 
suppose that soporific narcotics, in doses 
which in a comparatively healthy patient 
would produce a stupefying effect, are 
well adapted to relieve this wakefulness : 
on the contrary, they generally aggra- 
vate the nocturnal restlessness, besides 
seriously impairing the general health. 
Nothing has been more marked, in my 
experience, than the superior efficacy of 
direct tonics, and especially of quinine, in 
producing that nervous tranquillity which 
makes sleep possible. When these medi- 
cines prove insufficient, I have found a 
remedy, which has been recommended by 
several authors, very useful-namely, sul- 
phuric ether, either given in half-drachm 
doses three times a day, or a single dose 
of one drachm at bedtime. A good addi- 
tion to such a night-draught is half a 
drachm of tincture of sumbul. 
Another remedy, which has proved very 
successful in the hands of my friend and 
late colleague, Dr. Marcet, is the oxide of 
zinc, which, according to that author, has 
a powerful effect in inducing sleep. He 
recommends it to be used at first in doses 
of two grains twice daily, but this quan- 
tity may be progressively increased, if 
necessary, until ten, twenty, thirty grains 
daily, or even larger quantities, are taken. 
I have given this medicine very patient 
trials, both in the smaller and in the larger 
doses, and I cannot say that I have been 
so favorably impressed by its action ; and 
on the whole I am inclined to think that 
in the majority of cases quinine acts much 
more satisfactorily. It must also be 
borne in mind, as Dr. Marcet himself ad- 
mits, that in certain subjects, especially 
the anaemic and the chlorotic, the con- 
tinued administration of zinc is observed 
to produce a prejudicially depressing 
effect on the constitution. Nevertheless 
there is no doubt that oxide of zinc occa- 
sionally proves a valuable remedy. I 
think it should not be administered in 
larger quantities than at most six grains 
daily ; and I concur with Dr. Marcet in 
the recommendation that it should be 
given shortly after a meal, as it otherwise 
sometimes occasions nausea. 
A much more effective remedy than 
zinc appears to be the bromide of potas- 
sium in ten- or twenty-grain doses three 
times a day. Although I have not yet 686 
ALCOHOLISM. 
had the opportunity of trying this medi- 
cine so extensively as I should wish, the 
results obtained have been very good. 
In several instances it has at once re- 
moved distressing wakefulness, dreams, 
and visual hallucinations. It is occasion- 
ally impossible to give this drug, how- 
ever, from its exciting gastric irritation. 
Now and then we find that sleep is not 
to be obtained by any of the remedies 
above mentioned, and we are driven to 
the use of some of the more recognized 
hypnotics. Of these one of the most 
effectual is the extract of Indian hemp; it 
should be given in small doses; from a 
quarter to half a grain of a good extract 
is quite sufficient, and a larger quantity 
is more likely to do harm than good to 
the majority of patients. Opium, if given 
at all, should be administered in the form 
of morphia, hypodermically injected; one- 
tenth to one-quarter of a grain is suffi- 
cient. But a medicine which is quite as 
effectual in many cases is good bottled 
stout given in one single dose of half a 
pint at bed-time. 
In the more advanced cases of chronic 
Alcoholism, where the nervous centres are 
undergoing serious degenerative changes, 
as evidenced by the occurrence of para- 
lysis, epileptiform convulsions, or grave 
mental deterioration, further remedial 
measures are required. Of these the two 
which have yielded me by far the most 
satisfactory results are cod-liver oil, and 
phosphorus in the form of the hypophos- 
phites of soda or lime. Cod-liver oil, to 
be really of use, must be continued in 
tolerably full doses over a long period. 
Employed for so long a time as three or 
six months without intermission, I have 
seen it produce striking benefit even in 
advanced stages ; and in some instances 
where it failed to produce anything like a 
cure, it caused great amendment of the 
most serious symptoms. The hypophos- 
phites in five- and ten-grain doses, three 
times a day, have been particularly valua- 
ble, in my hands, in the treatment of 
cases which were distinguished by com- 
mencing paralysis of sensation. In one 
case which was marked by epileptic con- 
vulsions, with much impairment of the 
mental faculties, the combined use of cod- 
liver oil and bromide of potassium pro- 
duced very beneficial effects. Another 
class of cases, those in which the predo- 
minant symptom is a very considerable 
degree of muscular tremor, are often 
greatly benefited by strychnia. Very 
small doses only are to be "used ; it is well 
to commence with the j^th of a grain, 
and increase this to not more than the 
3'2d of a grain, three times daily. Doses 
much larger than this have invariably 
seemed to do decided harm, especially in- 
creasing the tendency to vertigo, visual 
hallucinations, and noises in the ears. 
2. The treatment of Acute Alcoholism, 
(a) Delirium tremens is a malady the 
treatment of which has experienced seve- 
ral changes correspondingly with the pro- 
gress of accurate clinical observation. In 
former times-indeed a very few years 
since - the notion universally prevailed 
that the delirious symptoms were owing 
to the exhaustion which was chiefly kept 
up by want of sleep ; and, consequently, 
that the production of continuous sleep 
for several hours was the sole and all- 
important means of cure. It was there- 
fore the custom to ply the patients with 
larger and larger successive doses of 
opium, with a view of drowning the deli- 
rium in narcotic stupor. Great mischief 
arose from this wide-spread belief and 
practice. In the first place, it has often 
happened that the patient, without ever 
sleeping at all, has passed first into a con- 
dition of coma-vigil, next of stertorous 
breathing, and at last sunk, fairly poisoned 
with opium. Again, a fact which was 
disregarded by the earlier authorities was 
this, that, without exerting any poisonous 
action upon the centres of consciousness, 
opium occasionally spends almost the 
whole of its depressing force upon the vis- 
ceral nerves. A minor consequence of 
neglecting this fact was, that the patient's 
chance of assimilating food was often en- 
tirely ruined by the paralyzing action ot 
the drug upon the digestive organs : a 
much more serious one was the accident 
which has doubtless often happened, and 
which occurred in cases within my know- 
ledge-namely, the rapid induction of a 
cardiac paralysis, the patient (without 
any cerebral signs of poisoning whatever) 
suddenly becoming ghastly pale, the pulse 
fluttering and coming to a standstill within 
a few moments. One such example was 
particularly striking, as it immediately 
followed two large doses of opium, which 
had been given"in the vain hope of pro- 
curing sleep; the second dose was equally 
inefficacious as a soporific with the first, 
but its deadly effect upon the circulation 
could not be mistaken. 
The idea that patients in delirium tre- 
mens require to be narcotized into a state 
of repose, may now be said to be aban- 
doned by those best qualified to speak on 
the subject. In truth, the condition of the 
brain requires that sort of treatment which 
shall fortify and stimulate its functions. 
I have already argued at length, in an- 
other work, that every stimulant, when 
given in such restricted doses as alone de- 
serve that name, is a promoter, but not 
an exhauster, of function, and that the 
idea of any depressive recoil following its 
action is purely fictitious. There are, 
accordingly, a great number of remedies 
of which the larger doses are narcotic, and 
the smaller stimulant, which in the latter 
form are capable of giving more or less TREATMENT. 
687 
relief to the symptoms of delirium tre- 
mens. It is not worth while to enumerate 
all these. The typical member of the 
group of stimulants is simple, easily di- 
gested food ; and the successful treatment 
of delirium tremens, in nine cases out of 
ten, depends on the regular and continu- 
ous supply of suitable nutriment, whereby 
the functions of the nervous system are 
supported during the struggle towards re- 
covery. The principal kinds of food 
which are desirable are milk, soup, or 
strong broth with bread in it (and given 
very hot), the concentrated meat-foods 
already recommended under the head of 
Chronic Alcoholism, and raw eggs beaten 
up. The necessity for the administration 
of some nutriment of this kind is impera- 
tive ; and if the stomach be at first too 
irritable or the anorexia too complete to 
allow of feeding by the stomach, it must 
be given in the form of enemata, so as not 
to lose a day, nor even a few hours. 
It should be observed, however, that 
there are two classes of patients, in one of 
whom it is, and in the other it is not, de- 
sirable to employ some preparatory treat- 
ment of an eliminative kind. The value 
of purgatives has been recognized by many 
writers. They are eminently suitable to 
those cases in which a young and some- 
what robust person has brought on deli- 
rium by drinking a very large quantity of 
spirits ; in such instances a dose or two of 
medicine, producing free watery evacua- 
tions, effects a wonderful improvement (no 
doubt bv ridding the alimentary canal of 
much of the alcohol which it has taken 
in). Where the strength of the patient is 
sufficient to allow of this plan being safely 
carried out, it will be found that the sub- 
sequent assimilation of food is rendered 
more easy and rapid, and that the stage 
of convalescence is comparatively soon 
attained. But in debilitated subjects it is 
far better not to attempt any forced in- 
crease of the eliminative processes, but to 
commence at once with the administra- 
tion of the more easily digested foods in 
small quantities frequently repeated. The 
irritation of the stomach may be combated 
by the administration of ice, and of small 
quantities of soda-water and other aerated 
drinks, and one of the best modes of com- 
mencing the necessary feeding is by ad- 
ministering milk, mixed with one-third its 
bulk of lime-water, at frequent intervals. 
Everything is to be hoped for a patient 
who has been well supported by food from 
the early stages of the attack. 
Of late years an important question has 
been raised concerning the therapeutic 
value of digitalis in delirium tremens. 
The practice, introduced by Mr. Jones of 
Jersey, of administering very large doses 
of tincture of digitalis (from half an ounce 
to an ounce and even more), was a start- 
ling innovation on the traditional practice 
in the use of this drug ; such doses having 
formerly been universally regarded as 
dangerously poisonous, and calculated to 
produce fatal depression of the circula- 
tion. It has been proved, beyond doubt, 
that in a large number of cases these doses 
are at least harmless, and the testimony 
of a good many observers has now appa- 
rently established the fact that the deli- 
rium may frequently be quieted, and sleep 
obtained, by the employment of digitalis 
in this manner. It must be owned, how- 
ever, that the question still remains in a 
very unsatisfactory position. The great 
majority of the cases have been treated 
with the tincture, and not with any simple 
preparation of digitalis: that is to say, 
the patients have, in fact, received half- 
ounce or ounce doses of proof spirit over 
and above the drug intended to act upon 
the disease. But it is well known that 
alcohol, in common with all the stimulant 
class of remedies, has often a beneficial 
influence in states of low delirium. In 
the presence of the very conflicting state- 
ments on the action of digitalis which 
have been published by different writers, I 
have endeavored to clear the matter up by 
employing a strong infusion instead of the 
tincture ; but it is unfortunately impossi- 
ble, in many cases, to get the patients to 
take the remedy in this shape, and I have 
thus been hindered from effectively carry- 
ing out the experiment. The powder, 
given in pills, would be a better form. 
Brom the observation of a few cases 
treated with digitalis, in one form or an- 
other, which have been under my own 
treatment or that of friends, I have been 
led to the provisional conclusion that in 
all probability a large number of the re- 
ported successful cases have either been 
instances of a spontaneous favorable ter- 
mination of the disease, or have been 
slightly helped towards their happy issue 
by the alcohol which is contained in the 
tincture ordinarily employed. This con- 
sideration leads us naturally to consider 
the very important question-whether 
alcoholic liquors should or should not be 
used in the treatment of delirium tre- 
mens. 
I am inclined to think that the moral 
argument has great weight here. In all 
cases, and more especially in first attacks, 
the subjects of which, we may hope, are 
not irremediably debased by drunken 
habits, it appears to be incumbent on us 
to use the time of sickness as an opportu- 
nity for possible reformation, unless alco- 
hol were necessary. It would, therefore, 
seem to be our duty to commence the work 
by giving the patient's system an entire 
rest from the action of alcohol during the 
period for which he is under our authori- 
tative guidance. In young subjects, there- 
fore, and in first attacks, it is proper to 
abstain altogether from the use of alcohol. 688 
ALCOHOLISM. 
It is more difficult to carry out this plan 
with older patients, and with those who 
have been for a long time accustomed to 
depend upon strong drinks for a large 
part of their ordinary nutrition. In every 
case, however, I think it is our duty to 
abstain as long as possible from the use 
of alcohol, and before resorting to a treat- 
ment of such doubtful propriety, we 
ought to try less harmful narcotic stimu- 
lants. Opium and Indian hemp fulfil the 
indications which we require, under these 
circumstances, better than any others of 
their class. Opium should never be ad- 
ministered by the stomach, but always in 
the form of morphia hypodermically in- 
jected, in the dose of one-tenth to one- 
fourth or one half grain. Where there is 
any reason, from the quality of the pulse, 
to believe that the circulation is much en- 
feebled, Indian hemp, in doses of a quar- 
ter to half a grain of good extract, is a 
less objectionable remedy, and I have 
seen it produce excellent effects. 
A very important question is the pro- 
priety or otherwise of employing the in- 
halation of chloroform, in order to quiet 
the patient sufficiently to enable him to 
sleep : on this matter there has been the 
greatest difference of opinion. My own 
experience of this remedy may be summed 
up as follows :-In the first place, I have 
known from personal friends of two cases 
(and many others have been recorded) in 
which the patient died suddenly, from 
cardiac palsy, while the inhalation was 
proceeding. Secondly, I do not believe, 
though I have frequently tried it, that the 
action of small doses of a weak atmo- 
sphere of chloroform (such as would be 
free from the danger of producing cardiac 
palsy) is sufficient to induce sleep, or even 
to greatly induce the patient's agitation, 
in the majority of cases. And lastly, re- 
membering how few persons possess a 
high degree of skill in exactly graduating 
the dose of chloroform-vapor, it appears 
undesirable that it should come into gen- 
eral use in delirium tremens. For it is 
certain that the evil effects of a narcotic 
depression of the heart's action are much 
more serious in the case of this disease 
than of many other complaints. Given 
internally, in doses of twenty to thirty 
minims (or an equivalent amount of chlo- 
ric ether), chloroform is less dangerous, 
but, as far as my experience goes, not 
more successful. Other practitioners, 
however, have met with more success in 
its use, and some have pushed it to much 
larger doses; but considering that forty- 
five minims taken internally by a healthy 
man has been known to produce full anses- 
thesia (though this is usually too little to 
produce such an effect), it is not advisable 
to run the risk of larger doses than I have 
named. 
has only lately become the subject of at- 
tention in respect to delirium tremens, 
will prove one of the best of all the auxili- 
ary means for quieting nervous agitation 
and hastening the advent of convales- 
cence. I refer to the bromide of potas- 
sium. 
In twenty-grain doses repeated every 
two hours the bromide succeeds, in a large 
number of cases, in calming the nervous 
agitation and procuring really refreshing 
sleep; it should be pushed till as much 
as two drachms have been taken in con- 
secutive doses, if sleep is not procured 
before ; but very commonly not more than 
three or four doses are required. As soon 
as the patient wakes out of sleep the ad- 
ministration should be resumed. My own 
experience is now sufficient to assure me 
that this treatment is incomparably more 
effective as well as more safe than the use 
of opium. It is more especially fitted for 
young and vigorous patients however, and 
especially to those who, while preserving 
considerable muscular power, have so 
injured their nervous centres by large ex- 
cesses as to induce epileptiform tendencies. 
A second remedy has lately been dis- 
covered, which appears to me to exactly 
fill the place of an appropriate remedy for 
those cases for which the bromide is not 
suitable-I mean the hydrate of chloral. 
Given in twenty-grain doses repeated at 
an hour's interval, chloral appears to me 
to act in a manner superior to that of any 
drug which has been used in delirium tre- 
mens. It is rarely that more than three 
doses are required to produce calm and 
refreshing sleep. 
A remedy which has been used with 
great success in many cases, and with 
most unfortunate results in others, is tar- 
tar emetic. The handling of this drug in 
delirium tremens is an extremely difficult 
thing, for it requires much judgment to 
decide whether the constitutional strength 
of the patient is sufficient to support its 
undoubtedly depressing effects. I venture 
to believe that the directions, so often 
given, to employ antimony in cases which 
are distinguished by "active" delirium, 
with a bold and threatening (instead of a 
timid) expression of countenance, con- 
gested conjunctivae, &c. are quite worth- 
less. Such symptoms afford no measure 
of the patient's real strength, nor are they 
any warrant for the use of antimony ; for 
this remedy must be given in considerable 
doses, if it is to do any real good: from 
a quarter to half a grain should be given 
three or four times, at intervals of one or 
two hours. When a favorable effect is 
produced, it is always accompanied (and 
I believe caused) by an increased secretion 
from the kidneys, or by profuse sweating, 
by which probably the elimination of al- 
cohol is favored. Scantiness of either or 
both these secretions is therefore the true 
In all probability another remedy, which TREATMENT. 
689 
indication for antimony. But it is neces- 
sary, even when these indications exist, 
to form a very accurate judgment of the 
strength of the circulation, and this, if we 
trust to the finger's estimate of the radial 
pulse, is most difficult. Fortunately, the 
use of Marey's sphygmograph will enable 
us to form a far more correct opinion than 
was formerly possible on this point. The 
symptoms which indicate a dangerous 
action of tartar emetic are faintness, cold 
sweating, and intermittence or irregular- 
ity of the pulse: the latter symptom 
should be carefully looked for with the 
help of the sphygmograph, which may de- 
tect it when the finger could not. If the 
first dose produces even a slight irregu- 
larity of cardiac rhythm, the medicine 
should be at once suspended. I wish to 
express the decided opinion that bromide 
of potassium and chloral are practically 
the only drugs we need ever employ in 
delirium tremens. [It may be believed, 
however, that some practitioners will not 
give up their confidence, based on experi- 
ence, in the value of moderate doses of 
opium, at least given at night, in average 
cases. Alcohol, also, in diminishing quan- 
tities, does seem to aid in the cure of the 
feebler cases. If a man has been drink- 
ing a quart of whiskey daily up to the 
time of his attack, a pint or a quart of ale 
or porter will be to him only a mild tonic 
beverage, aiding his digestion. The popu- 
lar idea of '' tapering off" is not altogether 
devoid of scientific as well as clinical 
foundation. 
The prolonged warm or hot bath will 
sometimes do a great deal of good in de- 
lirium tremens. Also, in cases of very 
obstinate insomnia, the application of a 
blister to the back of the neck may have 
the happiest effect.-II.] 
The treatment of the complications of 
delirium tremens hardly requires any spe- 
cial remark, except perhaps as to the 
complications of pneumonia. It is of course 
necessary, as a general rule, to be specially 
careful to avoid unnecessarily depressing 
treatment of affections the original cause 
of which is the action of a depressing 
narcotic poison such as alcohol: but this 
rule is of twofold importance in the case 
of pneumonia supervening in acute Alco- 
holism. I am satisfied that I have seen 
the life of a patient sacrificed by the ad- 
ministration of two or three consecutive 
quarter-grain doses of tartar emetic, under 
the idea that this treatment was specific- 
ally indicated by the affection of the lung. 
Tartar emetic, blood-letting, both general 
and local, purgatives, and every other 
depressing treatment, are to be utterly 
proscribed in alcoholic pneumonia, an 
affection which is attended with much 
greater debility, especially of the heart, 
than its superficial symptoms would ap- 
pear to indicate. The sphygmograph is 
very useful as a test of the real condition 
of things. 
One important branch of the treatment 
remains to be briefly noticed. It is in all 
cases most highly desirable that a skilled 
attendant should be procured, and in cases 
where the patient is at once violent and 
of considerable strength, two trained per- 
sons, with experience of the treatment of 
lunatics, should be placed in constant at- 
tendance. It is scarcely necessary to say 
that the utmost violence of a patient should 
never induce us to employ bandages or the 
strait-waistcoat, if it be anyhow possible 
to secure sufficient nursing assistance. 
(&) The treatment of acute mania from 
drink is a subject which belongs properly 
to the department of mental disease, and 
(c) The treatment of alcoholic melan- 
cholia is in the same position, as is also 
(d) The treatment of oinomania. 
[On the last subject, however, it may 
be well to advert to some principles estab- 
lished by experience. Many persons, 
habituated to excessive drinking, becom- 
ing incapable of resisting their craving 
for liquor while it can be obtained, can be 
cured only by withdrawal to a secure 
place at a distance from all opportunities 
of indulgence. Inebriate retreats or asy- 
lums have been established for this pur- 
pose ; and those at Boston, Philadelphia, 
Binghamton, Chicago, and elsewhere have 
now been sufficiently long in existence for 
a fair judgment to be arrived at in regard 
to their utility. 
About 30 per cent, of all admitted to 
these institutions have been reported 
cured, after retirement for periods vary- 
ing from three months to a year or longer. 
Permanence of cure is, in such cases, 
more indeterminable than in cases of or- 
dinary insanity, as so much depends upon 
the will of the individual. A methoma- 
niac may be said to be cured, when he 
has recovered the power to continue ab- 
stinent while at full liberty, if he chooses 
to do so. But he may not so choose ; and 
then his cure has been in vain, however 
real it has been in itself, medically or 
therapeutically considered. 
The plan oi management at such re- 
treats is essentially like that of the best 
hospitals for the insane ; only with less 
need of apartments and inclosures for 
confinement of their inmates. Occupation, 
exercise, and wholesome diversion, by aid. 
of garden or farm work, or various arts, 
etc., with books, lectures, religious ser- 
vices, conversations, and excursions, make 
up the " moral treatment." Medically, 
the therapeutics most required will be, the 
use of tonics and calmatives to the ner- 
vous system. Iron, cod-liver oil, quinine, 
valerian, assafoetida, and the bromides 
(of potassium, sodium, or ammonium, at 
the option of the adviser) will be the only 
drugs likely to be called for; unless un- 
vol. i.-44 690 
VERTIGO. 
usual insomnia may for a ■while demand 
the employment of hydrate of chloral at 
night. A nourishing diet, with abundance 
of animal food in most cases, will be of 
great importance. More free use of stim- 
ulating condiments, as mustard and pep- 
per, will be suitable with these than with 
any other class of patients. Bathing, 
particularly the cool (with the strongest, 
the cold) shower bath, is also to be re- 
commended ; its effects, however, being 
watched carefully in each case. 
Six months ought to be the shortest 
period of retirement. A year will be 
better, to promote a secure recovery. The 
great difficulty is to obtain this prolonged 
seclusion. Legislation is necessary, and 
to some extent has been effected in a few 
of the United States, providing for the 
committal, upon proper evidence, and in 
due form, of persons rendered, by metho- 
mania, incapable of taking care of them- 
selves, to suitable institutions ; precisely 
as the same thing is done for other varie- 
ties of insanity. 
Two extreme views are still in conflict 
upon this subject: that of those who 
regard drunkenness as only and always a 
vice, to be visited by severe punishment 
and outlawry from society; and that of 
others, who consider it merely a form of 
insanity. Actually, it begins almost al- 
ways as a more or less vicious excess, the 
culpability of which depends upon a va- 
riety of circumstances. After long indul- 
gence, however, it becomes a psycho-phy- 
sical disease ; as positively as if it had its 
origin only in material conditions. A 
prominent fact, of great practical conse- 
quence, is, that the tendency to it becomes 
hereditary. Certain families are well- 
known to exhibit exceptional proclivity to 
habits of intemperance. Among the evils 
of Alcoholism, this is not one of the leasts 
and to it may be added the very frequent 
predisposition of the children of drunkards 
to cerebro-nervous disorders, leading in 
many instances to their early death.-II.] 
In order to give as much continuity as 
possible to my description of the diseases 
grouped under the term "Alcoholism," I 
have purposely avoided long digressions 
upon the views held by other writers, and 
have made comparatively few quotations 
of their writings. But in order that the 
reader may have an opportunity of com- 
paring this article with the teachings of 
other modern writers, I subjoin the fol- 
lowing list of the principal works which 
are now looked upon as possessing author- 
ity on this subject:- 
Sutton, Tracts on Delir. Trem., &c.: Lon- 
don, 1813. Roesch, Papers in Ann. d'Hy- 
giene, t. xx. 1838. Payer, Memoire sur le 
Delir. Trem.: Paris, 1819. Ware, John, Re- 
marks on the History and Treatment of Delir. 
Trem.: Boston, 1831. Peddie, Dr. J., On the 
Pathol, of Delir. Trem. and its Treatment 
without Stimulants or Opiates: Edinburgh, 
1854 (pamphlet). Laycock, Dr., Pathology 
and Treatment of Delir. Trem. : Edin. Med. 
Journ. vol. iv. 1858-9. Huss, Magnus, Chron- 
ische Alkohols-Krankheit (German Edit.): 
Leipzig, 1852. Marcet, Dr., On Chronic Al- 
coholic Intoxication, Second Edition: London, 
1863. Carpenter, Dr., Use and Abuse of Al- 
coholic Liquors : London, 1850. Various pa- 
pers by Dr. G. Johnson, in the Lancet. 
VERTIGO. 
J. Spence Ramskill, M.D. 
Definition.-The sensation of mov- 
ing, or the appearance of moving objects, 
without any real existence of movement. 
Description.-Vertigo may present 
two forms: in the one the patient com- 
plains of giddiness in himself, external 
objects remaining stationary, in the other 
external objects assume various abnormal 
positions: for example, articles of furniture 
in the room, or patterns of paper on a wall, 
seem to chase each other round the apart- 
ment; or, in rarer cases, the vehicles in the 
street appear upside down, or the pave- 
ment undulates, or feels elastic. On at- 
tempting to walk, the patient may feel 
himself drawn or impelled forwards, side- 
wards, or backwards, and he can only 
prevent himself obeying the impulse by a 
strong effort of volition. Minor degrees 
of disturbed balance, and the commonest 
sense of uncertainty of gait demand the 
same exercise of volition, for there is in 
all cases a perpetual fear of falling down 
or of rude contact against other persons 
or against surrounding objects. In slight 
cases Vertigo occurs only on movement; 
in severe ones, when at rest also, and 
even during sleep. 691 
PROGNOSIS - STOMACHAL VERTIGO. 
With both forms of Vertigo we occa- 
sionally find perversions of the special 
senses. Patients complain of mistiness 
of vision, of being unable to see more than 
half an object, or of one half being out of 
all proportion to the other half, of exag- 
geration in size of an object, of deafness, 
or of hypereesthesia of the sense of hear- 
ing, the noise of passing vehicles assuming 
the intensity of thunder, or of metsesthe- 
sia or a perverted sense, ordinary loud 
sounds appearing clear, but soft and dis- 
tant. In a distinct variety of Vertigo 
there is real deafness of one or both ears. 
Associated with these functional disor- 
ders there are complaints of tinnitus 
aurium, a noise of pumping water, of in- 
termittent pulsations of fluids, of the hiss- 
ing of a tea-kettle, of the noise of ma- 
chinery, in fact of many kinds of noises 
which defy and escape description; most 
commonly the noises are permanent, al- 
though they may vary in intensity whilst 
the Vertigo is intermittent, yet the noises 
are loudest during the vertiginous attack. 
Prognosis.-It may be taken as a rule 
that in Vertigo unconnected with visceral 
disease, and in persons under the age of 
fifty, there is not much danger to life, nor 
from what is most usually dreaded, viz., 
paralysis. Sudden and violent attacks of 
an intermittent character are unusually 
eccentric in origin, whereas a constant 
sense of uncertainty in movement, and a 
susceptibility to the induction of giddiness 
from the movement of passing objects, 
especially if combined with a cloudiness 
of intelligence, or rather a want of the 
usual clearness, indicates usually a centric 
disturbance. When, however, a severe 
attack occurs, without any palpable cause, 
to a person after the climacteric has been 
reached, a cautious prognosis must be 
given, and the more so if it be associated 
with vomiting, or constant nausea, ting- 
ling of extremities, the sense of pins and 
needles in one hand or foot, or of neural- 
gia of a group of muscles, or of those of 
one limb. The just fear in such a case is 
the fear of impending apoplexy. A dis- 
covery of dilated heart, of valvular disease 
of that organ, of degeneration of kidneys, 
with the presence of albumen in the urine, 
will make the prognosis more serious still. 
Organic disease apart, Vertigo has been 
known to exist during a long life, and 
indeed, unless some other suggestive 
symptoms are superadded, it cannot be 
considered a dangerous disease. In fact, 
the longer the complaint has existed in 
any given case, the less dangerous it ap- 
pears to be. 
Etiology.-The direct proximate cause 
of all Vertigo appears to be a disordered 
cerebral circulation; whereby, on the one 
hand, the special senses convey a false 
impression to the sensorium, or, on the 
other, a faulty co-ordination of muscular 
action is induced. 
Of remote causes, it seems probable that 
any acute disease, or any sudden perver- 
sion of function of any important viscus 
on the body, may cause Vertigo, either 
directly or by reflex action. Thus we 
find stomachal vertigo as the commonest 
of all forms of the complaint, excepting 
only the invasion of all, or almost all, 
acute inflammatory diseases, the exanthe- 
mata, &c.; next, poisoning of blood, 
whether by disease, as from cachtemia, ex- 
cessive smoking, intoxication, or paludal 
poison ; then organic disease of heart, of 
right or left side, after such disease has 
reached a certain point, which acts by 
altering the cerebral circulation in a two- 
fold manner. In like manner the sup- 
pression of a long-accustomed hemorrhage 
acts, whether it be in the form of epis- 
taxis, bleeding from haemorrhoids, or pro- 
lapsus ani, or from the menstrual flow 
ceasing too suddenly. 
The rapid suppression of an extensive 
chronic cutaneous eruption is an acknowl- 
edged common cause, and it is explicable 
on the same principle. 
Varieties.-The varieties of Vertigo 
may be practically divided into eccentric 
forms, or those arising from functional 
disorder of any viscus or viscera in the 
body ; or centric, from organic disease in 
the brain itself, or by blood-poisoning. 
There is a third variety, important enough 
to demand separation from these groups. 
I have called it essential Vertigo. It is 
not associated with any other head symp- 
toms, and there is no appearance of de- 
praved general nutrition. It occurs mostly 
in persons about thirty years of age, and 
is a rare form of the disease, as compared 
with Vertigo arising from other demon- 
strable eccentric causes. In other re- 
spects, a patient suffering from it will de- 
clare himself in perfect health. In all the 
cases I have seen, the complaint has been 
associated with a decidedly weak heart, a 
feeble small pulse, and with symptoms I 
take to indicate a dilated right ventricle. 
Another characteristic may be said to be 
this, that it is not materially improved by 
remedies, unless these are accompanied 
by rest and freedom from anxiety of every 
kind. 
Stomachal Vertigo. - The most 
common and most tractable eccentric 
variety arises from disorder of stomach, 
or of functional derangement of the liver 
and upper part of the alimentary canal. 
It often occurs suddenly in the middle of 
the night, or without any warning at any 
period of the day, and in a state of appa- 
rent robust health. From its violence it 
suggests the idea of imminent danger. VERTIGO. 
692 
The following case may be taken as a 
type : A merchant, some three hours after 
breakfast, after transacting some business 
of an exciting character, was quietly walk- 
ing from a neighboring office to his own, 
when he was suddenly seized with violent 
Vertigo. He reeled and immediately 
laid hold of an adjacent gas pillar ; he 
felt sick. Resting a few minutes, he felt 
the giddiness subsiding, and tried to walk; 
but with the first step the Vertigo re- 
turned in greater violence, accompanied 
by a strange tightness of scalp. He 
asked a passer-by to assist him, and with 
the help of this second person managed, 
reeling or rolling, to reach his office, a 
distance of a few hundred yards. Seated 
in his chair, the symptoms gradually sub- 
sided ; and in a few hours, after a free 
evacuation of the bowels, he was free 
from the Vertigo, but he felt weak and 
shaken, and complained of a heavy dif- 
fused headache. From a very careful 
examination these facts were elicited. 
The Vertigo seemed to be of both forms 
described at p. 690. He felt giddy in 
himself, and his legs were feeble, but the 
objects in the streets were also strange. 
The shop windows seemed moving for- 
wards, passers-by were racing after each 
other, the ground felt to his feet uneven, 
billowy, as if elevated and depressed, and 
he felt constrained to lift his feet over the 
apparent elevations. Yet he was dis- 
tinctly conscious of this illusion, and tried 
to conceal it. The headache occupied the 
entire head; it was not acute ; it gave the 
sensation of weight rather than of pain ; 
it was not more frontal than vertical and 
occipital in its seat. There was no dis- 
coverable disorder of stomach or of any 
individual viscus, and, beyond the sudden 
attack of diarrhoea, nothing to suggest 
disorder of the abdominal viscera. He 
attributed the attack, and probably cor- 
rectly, to having eaten very heartily a 
breakfast of which sausages and Devon- 
shire cream formed a part, and to a hasty 
and very imperfect habit of mastication. 
During the ensuing month this patient 
had five separate attacks of the same 
violence, but without the same disturb- 
ance of bowels, and without being able to 
discover any cause, most assuredly not in 
the matter of diet, in which he had be- 
come exceedingly careful. Yet he was 
completely and permanently cured by the 
remedies adopted for stomachal Vertigo. 
As a matter of fact, it is very rare to find 
any positive signs of stomach disorder in 
these cases. They are named stomachal 
because remedies addressed to the stomach 
cure, and cure readily and quickly. With 
respect to the kind of Vertigo experi- 
enced, it does not, exclusively, take either 
of the two forms ; it assumes both charac- 
ters in some individuals. However, it is 
often so entirely connected with the ap- 
pearance of external objects to the patient's 
eye, that the internal sense of giddiness 
is with difficulty made manifest. Curiously 
enough, it is rarely that patients complain 
of exaltation or defect of hearing, or of 
tinnitus aurium, although both these 
complaints are very common in the chronic 
stomachal forms of Vertigo. The ra- 
tionale of the symptoms would appear to 
stand thus : Digestion progresses satisfac- 
torily up to a certain point, when, owing 
to some temporary cerebral excitement, 
perhaps of transacting business or of deep 
thought, the process is suspended, an 
irritation is conveyed to the bloodvessels 
of the brain, vid the splanchnic or pneu- 
mogastric nerves, and a disorder of circu- 
lation and of brain nutrition follows, with 
a corresponding disorder of function of the 
particular parts of the brain affected. 
Like causes produce like effects; and, 
moreover, in disorders of the nervous sys- 
tem it seems that a perversion of function, 
once induced, is easily reinduced, and by 
slighter causes. Hence it is not surprising 
that, if a patient has suffered from this 
acute stomachal form of Vertigo once, he 
will be subject to recurrent attacks. 
Chronic stomachal Vertigo is of very 
common occurrence, and one often sup- 
posed to indicate the commencement of 
congestion, of organic disease of brain, of 
minute tissue change, premonitory of 
softening, or of threatening apoplexy ; and 
the treatment which has been adopted 
under such erroneous diagnosis has only 
served to render the Vertigo permanent. 
Patients in this form of disease do not 
usually complain of the common symp- 
toms of dyspepsia. There is never any 
acute pain referred to the stomach after 
food; often there is a slight weight, a 
somewhat tender epigastrium, only, how- 
ever, felt on deep pressure, evidences not 
so much of a perverted as of a slow diges- 
tion. Complaints are sometimes made of 
a pain radiating from the stomach to the 
back, to the cardiac region, or to a gen- 
eral undefined uneasiness about the entire 
epigastric region. Rarely can more than 
this be made out by a most careful cross- 
examination of the patient's stomachal 
symptoms. In the lower ranks of life, 
however, such as we find in hospital 
practice, we meet with all sorts of com- 
plications ; but that the symptoms apper- 
taining to the stomach are not urgent may 
be inferred from the fact that patients do 
not seek advice for their relief, but for the 
Vertigo, and some steadily refused to 
admit there could be any disorder of the 
stomach, when remedies addressed to 
that organ afterwards cured the Vertigo. 
Additional symptoms of functional dis- 
ease of other organs are, of course, in 
such a class of patients common, but they 
are found to be independent of, and to 
have little influence on, the Vertigo. 693 
ESSENTIAL VERTIGO. 
[There is excellent reason for believing 
that disorder of the liver has a part in the 
production of Vertigo in some cases. It 
is not uncommon to find an attack of diz- 
ziness associated with a yellowish tongue, 
bitter taste in the morning, and yellow- 
ness of the conjunctiva. Here chokemia 
may be inferred ; or, as it is preferably 
designated by Dr. A. Flint, Jr., on the 
basis of his elaborate investigations, cho- 
lesterwmia; the ingredients of the bile, 
especially cholesterin, being present in 
excess in the blood, and affecting the 
brain with Vertigo as a symptom.-II.] 
Very usual combinations of symptoms 
run thus: Vertigo, pyrosis, leucorrhoea. 
Vertigo, menorrhagia, leucorrhoea, ano- 
rexia. Vertigo, weight of the entire head ; 
relieved after food. Vertigo, vertical 
headache, nausea both before and after 
food. Vertigo, clavus, obstinate consti- 
pation, amenorrhoea. Vertigo progres- 
sive, weakness of sight, formicatio. Ver* 
tigo, tinnitus aurium, and partial deafness. 
In all these combinations the collateral 
diseases may be cured, and yet the Ver- 
tigo remains. There are several points 
of interest connected with chronic sto- 
machal Vertigo which serve as a means 
of diagnosis from the graver forms of it. 
Thus it is never associated with loss of 
consciousness. There are intervals of 
hours in which the patient is perfectly 
free from it. It is made worse by excite- 
ment, by long fasting, and almost always 
the severe attacks occur when the stomach 
is empty. A stimulus in the form of wine 
or brandy relieves it; so also does food 
taken in small quantity. Closing the 
eyes to exclude objects in motion often 
relieves. During the attack a steady gaze 
on some fixed object mitigates the inten- 
sity of the sensation of giddiness. It is 
right to say that closing the eyes and the 
steady gaze are not invariably productive 
of relief, although subsequent treatment 
may prove Vertigo to have been sto- 
machal. 
In some cases the giddiness is slight, 
but almost constant; then it is usually 
associated with tinnitus aurium. More 
commonly it will occur several times 
daily, lasting from a few minutes to an 
hour, varying in degree, and accompanied 
by a singular general heaviness of the 
head, and a sense of heat at the vertex, 
which latter becomes aggravated when 
the Vertigo ceases. With respect to the 
peculiar form of Vertigo, no special con- 
clusions serving the purpose of diagnosis 
can be drawn. Almost always uneven- 
ness of the ground is spoken of, or an illu- 
sive opening of the ground under the 
feet. Objects race in the eye of the be- 
holder, and the patient feels going round 
with the objects he looks at when confined 
to a limited space, as in a small bedroom. 
There are two varieties of chronic sto- 
machal Vertigo which resist ordinary 
treatment. I allude to those forms com- 
plicated with, in some cases caused by, 
changes of tissue and alterations of the 
structure of the minute arteries, such as 
are known to occur in the persons of hard 
drinkers, or in those who have suffered 
from delirium tremens, and also in those 
who have suffered from latent or slight 
and irregular gout. It is in these cases 
we find the rarer forms of vertiginous per- 
ception,-as, for instance, when objects 
in the street or in the room appear turned 
upside down. In such persons vertigi- 
nous perceptions and movements last for 
days, and are often so severe as to confine 
the patient to bed, incapable of the slight- 
est movement in the upright position 
without assistance. Nausea and disin- 
clination for food are the only stomachal 
symptoms present. 
Vertigo of the Aged is often stom- 
achal, but equally often has no reference 
to that organ. As years are added, arte- 
ries become atheromatous, and otherwise 
diseased and obstructed, the circulation 
in the brain becomes irregular, we may 
have congestion in one place and anaemia 
in the other-a varying condition, abun- 
dantly sufficient to explain the frequent 
slight attacks of Vertigo in the aged. 
The essential condition of the brain is 
always one of anaemia. (Maclagan.) It 
is to be remembered that the prognosis 
is always more or less unfavorable when 
Vertigo has commenced only in old age, 
on account of the known pathological con- 
dition of the nerve centres. 
Essential Vertigo.-Some remarks 
have already been made on this variety. 
The following case will best illustrate its 
characteristics : A gentleman, aged thirty- 
four, of considerable energy of character 
and great bodily vigor, has for three 
years suffered from almost constant, for 
the last two years quite constant, Vertigo. 
He is in comfortable circumstances, and 
has been very free from the ordinary anx- 
ieties of life. He has led a temperate 
country life, and has never had syphilis, 
gout, or rheumatism. Excepting the 
Vertigo, he has enjoyed excellent health. 
He says the giddiness came on gradually, 
and was at the commencement so slight 
that he can hardly fix the time of its first 
appearance. In kind it was subjective. 
At first, he found himself giddy on dressing 
in the morning ; he felt as if he had taken 
too much wine overnight, and his legs 
were weak, and his gait unsteady. After 
breakfast he was well. The attacks be- 
came more prolonged, and occurred at 
various periods in the day ; and now he is 
rarely free from a sense of uncertainty 
rather than positive giddiness. Occa- 
sionally he becomes worse, and is obliged 694 
VERTIGO. 
to sit down to prevent falling. He has no 
confusion or muddiness of intellect, has 
never lost consciousness, has no complaint 
of headache, dyspepsia, or disorder of any 
other kind. After many examinations, I 
have not been able to discover even func- 
tional disorder in any of the abdominal 
viscera. He has a soft, small, compressi- 
ble pulse. The impulse of the heart is 
not visible ; the area of dulness enlarged 
laterally to the right; the sounds are 
feeble, close to the ear, and too clearly 
audible to the right of the sternum. This 
patient has undergone a variety of medi- 
cal treatment in the hands of various 
practitioners, including strychnine, which 
was pushed to the verge of producing in- 
voluntary spasms in the limbs. He has 
tried the hydropathic treatment, has 
passed a season at Vichy, but has not 
been able to find the slightest benefit. 
Very careful diet has not altered his con- 
dition, but excesses of any kind make him 
worse. Although there is no evidence of 
valvular disease, yet I cannot help con- 
necting the feeble heart, and perhaps en- 
larged right ventricle, with a disordered 
cerebral circulation, which is itself the 
proximate cause of the Vertigo. I have 
met with two cases of this kind which 
were apparently hereditary. The father 
of one of them is now seventy-one years 
of ag ; he suffers from spasmodic asthma, 
and has been the victim of Vertigo for 
the past thirty-five years. 
Vertigo from Overwork ranks 
next in frequency to the stomachal va- 
riety. It occurs in young persons who 
are underfed as well as overworked, as in 
some sempstresses; in the middle-aged, 
who to spare diet add various irregulari- 
ties, as well as in the temperate and well- 
fed, who are constantly subject to mental 
anxiety and excitement. The attacks of 
Vertigo are of short duration, occur at 
intervals of some hours or days, after pro- 
longed exertion, or poorer diet than usual; 
it is only a sense of the abnormal appear- 
ance of external objects at first, and oc- 
curs only on movement; it becomes more 
frequent, and then assumes, in addition, 
the character of an internal feeling of diz- 
ziness ; the recumbent position always re- 
lieves, but does not even temporarily cure 
it. It is often complicated with stomach 
disorder, as anorexia, rarely nausea, with 
constipation, and in the female sex with 
menstrual irregularities. But the simple 
stomachic remedies do not remove, they 
scarcely mitigate, the Vertigo. Patients 
complain of a want of clearness of intel- 
lect, an incapability of sustained mental 
exertion, together with occipital heavi- 
ness or headache. In the worst cases, 
irritability of temper, restlessness, a sense 
of impending evil, and more rarely insom- 
nia, are added, Sometimes the Vertigo 
is so easily induced by the appearance of 
objects in motion, that the patients are 
unable to go into the streets. In such 
cases there are functional ailments of 
other organs, palpitations, and lumbar 
pains, accompanied by the passing of 
phosphates in the urine. Oxaluria is a 
not unfrequent complication. Indeed, 
there is a general lowering of vitality, a 
universal deprivation of nutrition, and 
corresponding diminution of power, of 
which the Vertigo is only one of the ex- 
ponent symptoms. This is the form of 
Vertigo which most often amongst busi- 
ness men precedes softening of the brain. 
Vertigo from irritation of the auditory 
nerve has been noticed by my late col- 
league, Dr. Brown-Sequard. lie men- 
tions, in his Physiology of the Nervous 
System (p. 195), this result produced by 
injecting cold water into the ear, and also 
by the topical application of nitrate of 
silver; and he suggests that such appli- 
cations act in a reflex manner on the 
bloodvessels, producing temporary anae- 
mia and a disordered circulation and nu- 
trition of the brain, resulting in the pro- 
duction of Vertigo. 
Meniere, in 1841,* established before 
the Academy of Medicine in Paris, that 
certain affections of the ear produced a 
series of symptoms closely resembling 
those attending disease of the brain, as 
Vertigo, dulness, uncertain walk, occa- 
sional circus movement, and even falling 
down, accompanied also by nausea, vom- 
iting, and syncope. He gives also a case 
of a young girl who, travelling one cold 
night in winter during menstruation, was 
seized with sudden and complete deaf- 
ness. Her chief symptoms were continual 
giddiness and irrepressible vomiting, pro- 
duced by the slightest movement. She 
died on the fifteenth day; yet no trace of 
disease was to be found in the brain, cere- 
bellum, or spinal cords. The semicircular 
canals only exhibited traces of disease; 
they were filled with reddish plastic 
lymph. Other cases are on record, by 
French authors, of a similar kind, some 
having associated with the Vertigo dys- 
sesthesia; that is to say, the slightest 
noise producing positive and even severe 
pain in the affected and deaf ear. It is 
remarkable that such cases may terminate 
fatally, without presenting one single 
symptom of feverish reaction, and with- 
out any extension of disease to the brain 
(Trousseau). It is well known that Ver- 
tigo in animals may be produced by punc- 
ture of the semicircular canals, as well as 
by wounding various parts of the base of 
the brain. Further information will be 
found in Dr. Brown-Sequard's Physiology 
1 Bulletin de l'Academie de M^decine, vol. 
xxvi. p. 241; Gazette Medicate, 1861, vol. 
xvi. pp. 88, 239, 597. TREATMENT. 
695 
of the Nervous System, and in the works 
of Schilf, Flourens, Magendie, and Claude 
Bernard. These are, however, matters 
rather of physiological than medical inte- 
rest. Cases of vertiginous movements 
arising from disease of brain are common, 
such as a tendency to gyrate, to fall for- 
wards, to one side, or backwards; but we 
are not able in the present state of sci- 
ence to draw accurate conclusions as to 
the seat or nature of the disease, unless it 
be one of a group of symptoms involving 
paralysis, or having other special marks 
of disease in a particular locality. Ver- 
tigo accompanies, to a greater or less de- 
gree, almost every organic disease of the 
brain, and every acute affection of this 
organ. Its value as a sign of disease 
clearly depends on its association with 
other symptoms ; and it can only be prop- 
erly appreciated in connection with a 
study of those diseases of which it forms 
a minor part. 
In a large number of hospital cases 
there is the association of Vertigo on 
movement with tinnitus aurium and par- 
tial deafness. The tinnitus and deafness 
appear first, and the Vertigo follows. I 
have never been able to trace anything 
like suddenness in the invasion of these 
symptoms; their accession is always 
gradual, and unassociated with pain in 
or about the ear, or with symptoms of 
fever. Persons in fair average health, and 
without any stomach or other obvious 
disorder, suffer most. There seems to be 
some mischief of a very slow kind going 
on, perhaps in the semicircular canals 
connected with the circulation, analogous 
to the more acute cases recorded by Me- 
niere. The occasional value of counter- 
irritation, and of iodide of potassium and 
of small doses of mercury, confirms this 
view. 
Treatment.-Stomachal Vertigo, in 
its acute and chronic forms, often yields 
to a very simple method of treatment. 
This consists in the exhibition of alkaline 
remedies and of alterative aperients con- 
tinued steadily for some weeks, to be fol- 
lowed by bitters, and especially by the 
use of nux vomica or strychnia. The 
alkaline treatment is to be used after 
meals, so as to neutralize any formation 
of acid, and to excite a freer secretion of 
gastric juice; the tonics to enable the 
stomach and bowels below to perform 
completely their functions. [Magnesia 
answers an excellent purpose in acute 
cases.-H.J Stomachal Vertigo of the 
severest kind yields most readily to the 
influence of these remedies. At the same 
time food is to be taken in small quantity, 
to be carefully masticated, at regular pe- 
riods ; and, for drink, Vichy water mixed 
with a small quantity of brandy acts most 
efficiently. All kinds of malt liquors are 
to be forbidden, whilst general hygienic 
measures are to be adopted. The splash 
bath in the morning, early retiring to 
rest, sleeping on a mattress in a large airy 
bedroom, are great adjuvants to the treat- 
ment. Freedom from the cares and anx- 
ieties of business are not less necessary. 
In all varieties of Vertigo it is wise to 
commence the treatment as if the case 
were stomachal, not simply because the 
case may turn out one of this variety, but 
because stomachal disorder may compli- 
cate any variety of the malady. The 
chronic forms of the complaint are more 
difficult of cure, but the same principles 
apply, and the treatment must be varied 
according to the peculiarities of the indi- 
vidual case, always remembering, how- 
ever, that it will be wise to attack and 
remove the complications which are asso- 
ciated with it, before making a special 
treatment of the Vertigo. In more ob- 
stinate forms of disease connected with 
tissue degeneration, intemperance, or 
with chronic gout, measures adapted to 
these several conditions will of themselves 
relieve the Vertigo, and prepare the way 
for the restoration of tone and improve- 
ment of nutrition, on which any hope of a 
great amelioration or cure must depend. 
| When the attack is attended by a yellow 
fur upon the back part of the tongue, 
with a bitter taste on rising in the morn- 
ing, and a yellowish tinge of the conjunc- 
tiva, it is a matter of frequent experience 
to find the use of a few grains of blue 
mass followed by improvement. The 
dose need not be larger than two grains, 
at bedtime, for two or three nights in suc- 
cession.-H.] 
The Vertigo of the aged demands wine, 
and any plan of treatment which the case 
may demand must be associated with 
stimulants, unless (a very rare occurrence) 
the Vertigo be premonitory of menin- 
gitis, and is accompanied by heat of the 
scalp and some congestion of the conjunc- 
tiva. A most effective combination for 
Vertigo of the aged consists in very small 
doses of the bichloride of mercury, with 
tincture of iron and cantharides. In Ver- 
tigo from overwork, in the well-fed there 
are usually present restlessness, insomnia, 
depression of spirits, and a vague feeling 
of unhappiness or impending evil, for the 
relief of which I have found great help in 
bromide of ammonium, given in an effer- 
vescing form, with the addition of casca- 
rilla. Amongst the poor, where scanty 
food accompanies overwork, this remedy 
is not of such value ; we shall gain more 
from measures calculated directly to im- 
prove nutrition, and from slight stimu- 
lants frequently repeated. Brandy or 
wine, under these conditions, is a better 
tonic for a time than bark or quinine, 696 
CHOREA. 
which will be found most appropriate 
afterwards. The solutions of the hypo- 
phosphites are also especially valuable. 
Essential Vertigo is most benefited by 
a long course of citrate of iron and strych- 
nia, given in an effervescing form, alter- 
nating month by month with tincture of 
larch and small doses of digitalis. The 
local application of belladonna does good, 
although there may be neither pain nor 
palpitation to suggest its use. I believe 
it is a direct tonic to the muscular tissue 
of the heart, in which respect it resem- 
bles the preparations of larch, and per- 
haps also of digitalis. The usual con- 
ditions of rest, freedom from care and 
anxiety, are, of course, as essential as in 
the other varieties of the disease. The 
treatment of Vertigo arising from grave 
disease of brain, from softening of its 
structure, from aneurism, or tumor, must 
be involved in the treatment of these 
diseases. 
CHOREA. 
By C. B. Radcliffe, M.D., F.R.C.P. 
Chorea is the disease known as St. 
Vitus's dance in this country, as the 
dance of St. Guy in France, and as the 
dance of St. Weit in Germany, St. Guy 
being the name which is the French 
equivalent of St. Vitus or St. Weit. It 
is chiefly characterized by irregular clonic 
movements of the voluntary muscles, and 
by weakness more or less approaching to 
paralysis in the same parts. 
1. Symptoms.-Chorea is sketched for 
the first time in the writings of the Eng- 
lish father of medicine. "St. Vitus's 
dance," says Sydenham, " is a sort of con- 
vulsion which attacks boys and girls from 
the tenth year until the time they have 
done growing. At first it shows itself by 
a halting, or rather an unsteady move- 
ment of one of the legs, which the pa- 
tient drags. Then it is seen in the hand 
of the same side. The patient cannot 
keep it a moment in the same place; 
whether he lay it upon his breast or any 
other part of the body, do what he may, 
it will be jerked elsewhere convulsively. 
If any vessel filled with drink be put into 
his hand, before it reaches his mouth he 
will exhibit a thousand gesticulations like 
a mountebank. He holds the cup out 
straight, as if to move it to his mouth, 
but has his hand carried elsewhere by 
sudden jerks. Then, perhaps, he con- 
trives to bring it to his mouth ; and if so, 
he will drink the liquid off at a gulp, just 
as if he were trying to amuse the specta- 
tors by his antics." 
The symptoms of the fully developed 
disorder, as the following case will serve 
to show, are marked enough and charac- 
teristic enough. 
Case.-Mary C , aged 11, admitted 
into the Westminster Hospital, under the 
care of the writer, on the 12th of March, 
1864. 
She is suffering from pains in the limbs, 
slight feverishness, and some tenderness 
and fulness in the right wrist, the pains 
in the limbs being chiefly in the right 
arm. The day before, she got drenched 
to the skin in a showrer, and wras obliged 
to remain in her wet clothes for some 
time. She is a bright-faced, good-look- 
ing, exceedingly pale child, the reverse 
of dull and stupid in every way, never 
strong, but never ill, except with severe 
convulsions M'hen cutting her first teeth. 
Her mother had four or five epileptic fits 
about the time of puberty. 
March 14.-The pains in the limbs are 
better ; but the tenderness and swelling 
of the wrist have somewhat increased in 
the right wrist, and extended to both the 
ankles. The pulse is 100, and slightly 
irregular ; the action of the heart is a 
little excited, and there is a slight systolic 
bruit at the apex. The skin is moist, and 
the perspiration has a sourish smell. The 
appetite has gone altogether, and there is 
some thirst. The medicine ordered con- 
tains iodide of potassium and bicarbonate 
of potass. 
March 20.-The fulness and tenderness 
of the joints have disappeared, and so have 
the thirst and want of appetite; but the 
cardiac murmur is more, rather than less, 
marked. Ordered to get up, and to have 
cod-liver oil. 
March 27.-She has just been greatly 
frightened by seeing a patient close by die 
suddenly, and is now crying and sobbing 
bitterly. Previously to this she had been 
playing with another child in the ward, 
and was to all appearance quite well. SYMPTOMS. 
697 
March 29.-A marked change has taken 
place since the last visit. There is now 
great restlessness, and impatience, and 
fretfulness, with curious wriggling, fidgety 
movements in the right arm. Her sleep 
has been much disturbed, and twice in the 
night she got up and went to the sister, 
crying and saying she was frightened. 
Four ounces of wine were ordered. 
March 30.-The restlessness is much 
increased ; but, instead of impatience and 
fretfulness, there is now evident dulness 
and listlessness. The right arm is con- 
tinually jerking about, and in attempting 
to walk the right leg both jerks and drags. 
Though right-handed, the left hand is 
used in feeding, and on inquiry it is found 
that the right hand is useless for this pur- 
pose. The speech is thick. All the joints 
feel strangely loose. There is some diffi- 
culty in swallowing, and the food is rolled 
about in the mouth some time before dis- 
posing of it in the usual way. The fea- 
tures twitch and twist a little, but not 
much, the tongue is put out and kept out 
without difficulty, and it is not particularly 
unsteady. All the disordered movements 
are much increased by trying to be still, 
and during fits of crying and fretting, 
which fits are not uncommon. The pulse 
is quick and small, the hands are cold and 
rather damp, and there is a constant wish 
to huddle over the fire; the bowels are 
very sluggish; the urine is neutral, and 
rapidly becomes offensive. Ordered to 
have hypophosphite of soda and cod-liver 
oil thrice daily, and a single dose of castor 
oil. 
March 31.-The restlessness is much 
increased, and the tossings and jerkings 
have become almost general. Standing 
and walking are barely possible, partly 
from the jerks and tossings of the limbs, 
but chiefly from the weakness of the right 
leg. The grasp of the right hand is also 
much weaker than that of the left. The 
right foot is a little more sensitive to 
pinching than the left. The features are 
almost continually being twisted into the 
oddest grimaces, but when at rest they 
are so wanting in expression as to give 
the idea of extreme silliness. Indeed, the 
expression is so changed as to make it 
difficult to identify the patient as the 
bright-faced, intelligent girl she was when 
admitted into the hospital. The speech 
is quite inarticulate, her only question or 
answer being " um," with a snort. Saliva 
dribbles from the mouth, and even food, 
w'hich she can only now get by being fed, 
is scarcely kept from falling out of the 
mouth. Mastication and swallowing are 
both matters of much difficulty. The 
tongue is unsteady, but it can be put out 
and kept out by an effort. The pupils are 
dilated and sluggish-the left especially. 
The pulse is quick and weak, but not 
irregular; the hands are cold and moist. 
The movements are suspended during 
sleep, but sleep itself is only in compara- 
tively short catches. The same medicines 
to be continued, with brandy and milk at 
short intervals, in addition four ounces of 
brandy being given in the twenty-four 
hours. 
April 5.-No very material improve- 
ment. The grasp of the right hand a 
little stronger perhaps, and the right leg 
dragging and jerking not quite so much. 
April 14.-A marked improvement. 
The gait is much more firm and steady ; 
the features are less vacant and less dis- 
composed ; the sleep is comparatively 
sound; the appetite is better; the hands 
are warmer; the pupils are now fairly 
sensitive and equal in size, but the speech 
remains inarticulate, and the child has 
still to be fed. No change in the treat- 
ment. 
April 21.-The irregular movements of 
the arms and legs are nearly at an end ; 
the features are comparatively at rest, 
and the expression of intelligence has re- 
turned ; the speech is distinct now, but 
the voice is low, and the articulation slow; 
the gait is slouching, but there is no drag- 
ging in the right leg; the power of self- 
feeding has returned, though the left hand 
is still made use of rather than the right, 
and the sleep is sound and refreshing. No 
change in the treatment. 
May 1.-Nearly well. 
May 14.-Discharged well, except that 
there is still a systolic bruit at the apex of 
the heart. 
In this case the salient points are, the 
age and sex, the movements, the paraly- 
sis, the numbness, the dulness and listless- 
ness, the relations to rheumatism and 
heart-disease, the absence of fever, and 
the neutral urine ; and the noticing of 
each of these points in turn will serve to 
bring out the general features of chorea 
in its ordinary form. 
Age and Sex.-Sydenham states that 
chorea, for the most part, attacks children 
between the tenth and fourteenth year of 
their age, who have not reached the time 
of puberty. Sir Thomas Watsou considers 
these limits to be too narrow, and extends 
them to the period of the second dentition 
on the one hand, and to that of puberty 
on the other; nay, he extends them still 
wider, for he states that now and then, 
but only exceptionally, cases occur as 
early as 4 or 5, and as late as 20 or 25 
years of age. Up to nine years of age the 
two sexes appear to be equally liable ; 
after this age females become much more 
liable than males, in the proportion of 
nearly 5 to 2. 
Of 422 cases treated as out-patients at 
the Children's Hospital in Great Ormond 698 
CHOREA. 
Street, and tabulated by Dr. Hillier, the 
numbers of each sex at different ages were 
as follow:- 
ing movements which are looked upon as 
characteristic. Thus, in the case which 
has been cited as a text, the tongue was 
not put out with a sudden jerk after a 
pause, and retracted with equal sudden- 
ness, after the manner which is described 
as specially characteristic of Chorea; and 
most certainly this case is by no means 
exceptional in this respect. 
Paralysis.-Want of muscular power is 
shown by the readiness with which the 
patients become tired, and by the slow- 
ness with which they recover from fatigue, 
as well as in the soft, flaccid, and wasted 
condition of the muscles when the disease 
has continued for some time. But this is 
not all which may be noticed, especially 
in those patients in which the choreic 
movements are confined to one side ; for, 
in these cases, there is usually a want of 
power in the affected muscles which must 
certainly be spoken of as a slight degree 
of paralysis. This want, as Sydenham 
said, "often shows itself by a halting, or 
rather unsteady movement of one of the 
legs, which the patient drags:'1'1 or still 
more frequently, it may show itself in the 
helpless way in which the arm almost im- 
mediately falls when it is held out, for it 
is easy to see that this falling is a pheno- 
menon which has much more to do with 
paralysis than with choreic movement. 
As positive evidences of paralysis, must 
be reckoned the loss of speech, the loss of 
facial expression, the loss of the power of 
swallowing, the inability to use the hands 
for the purposes of feeding, the looseness 
of the joints, all of which symptoms were 
present in a marked degree in the case 
which has been given, and one or other 
or all of which, in a greater or less degree, 
are usually present in all cases. Para- 
lysis, indeed, is seen to be a marked fea- 
ture in Chorea, if only the attention is not 
allowed to be entirely absorbed by the 
contemplation of the movements ; and in 
some extreme cases it may be so marked 
as to lead to incontinence or retention of 
urine, or to involuntary stools. Usually, 
also, the muscles which are most affected 
by the movements are those which are 
most paralyzed. Nor is the connection 
of Chorea and paralysis altogether out of 
order ; for in many cases of paralysis pro- 
perly so called, the paralyzed parts are 
affected by movements which, without 
question, are not remotely akin to those 
of Chorea. 
Numbness.-This symptom is sufficiently 
marked in many cases to be detected with- 
out difficulty, especially in the parts in 
which the movements are most marked, 
but it is never as prominent a symptom 
as in hysteria ; and the same remark ap- 
plies to the opposite condition of over- 
sensitiveness. Trousseau says that numb- 
ness, when present, is usually accompa- 
nied by tingling. - 
Males. Females. Total. 
From 3 to 6 months . . 
1 
2 
3 
< « 
6 " 
12 
44 
1 
4 
5 
<< 
12" 
18 
ll 
1 
1 
2 
CC 
18" 
24 
ll 
1 
3 
4 
44 
2 years to 3 years . 
3 
3 
6 
ll 
3 
ll 
4 
4 4 
6 
5 
11 
<< 
4 
ll 
5 
ll 
4 
16 
20 
<4 
5 
ll 
6 
ll 
7 
23 
30 
ll 
6 
ll 
7 
44 
18 
30 
48 
4 4 
7 
4 < 
8 
ll 
17 
34 
51 
ll 
8 
ll 
9 
44 
17 
41 
58 
44 
9 
ll 
10 
<4 
23 
57 
80 
44 
10 
ll 
12 
44 
23 
81 
104 
Total 
122 
300 
422 
At the Children's Hospital patients are 
not admitted above the age of 12, so that 
these statistics do not include cases from 
12 to 15 years of age-that is, about the 
age of puberty ; but judging from other 
statistics, as Dr. Hillier says, " it does not 
appear that the period of puberty is more 
prone to the disease than the period be- 
tween the second dentition and puberty." 
Thus, of 100 cases occurring at all ages, 
and tabulated by the late Dr. Hughes in 
the Guy's Hospital Reports, 29 were be- 
tween 12 and 15 years of age, 9 being 
males and 20 females ; at 15 years of age 
there were 5 females and 1 male. After 
puberty, chorea is comparatively rare. In 
96 cases, of which the statistics are given 
by Dr. Ogle, 19 were above 15-the ages 
being 2 at 16, 6 at 17, 2 at 18, 1 at 19, 2 
at 20, 2 at 21, 1 at 23, 1 at 24, 1 at 26, 
and 1 at 43 ; and of these 19,16 (including 
the one at 43) were females. And of 17 
cases of chorea during pregnancy which 
proved fatal, which cases form the basis 
of an excellent paper by Dr. Barnes on 
chorea in pregnancy, the ages range be- 
tween 17 and 24, with one exception, in 
which the age was 47. 
The Movements.- These are the most 
characteristic feature of Chorea. They 
are clonic spasms, unattended by pain, 
and, as Dr. Hillier says, "something like 
the restless movements of a child put out 
of temper." Usually they are more 
marked on one side of the body than on 
the other, and at first they may be con- 
fined to one side. Not unfrequently they 
make their appearance first in one arm, 
then in the leg of the same side, then in 
the face, then in the arm and leg of the 
other side. They are always increased by 
any attempt to exercise the will, or under 
any emotional excitement: and they are, 
for the most part, put a stop to by sleep. 
As a rule, it is enough to see the move- 
ments to recognize at once the nature of 
the disorder ; and some of the movements 
of the face are very characteristic. Still 
it does not do always to reckon upon find- SYMPTOMS. 
699 
Fulness and Listlessness.-The vacancy 
of expression resulting from the semi- 
paralyzed condition of the features, which 
may be so extreme as to suggest the idea 
of idiocy, must not be taken as the gauge 
by which to measure the mental condition 
of the patient. Matters mentally are cer- 
tainly not so bad as they look ; still there 
is always more or less dulness and list- 
lessness-dulness and listlessness rather 
than fretfulness, and undue excitability, 
as in the ordinary hysterical condition. 
It is to be remembered, also, that the 
children attacked by Chorea are com- 
monly distinguished by vivacity and rest- 
lessness of disposition. 
Rheumatism and Cardiac Diseases.-In 
his excellent digest of 300 cases of Chorea, 
occurring in Guy's Hospital, the late Dr. 
Hughes ascertained that, "out of 104 
cases in which special inquiries were 
made respecting rheumatic and heart 
affections, there were only 15 in which 
the patients were both free from cardiac 
murmur, and had not suffered from a 
previous attack of rheumatism." Nor is 
it possible to get over this fact by imagin- 
ing that the pains of the supposed rheu- 
matism may have been simply neuralgic, 
and the cardiac murmur merely antemic, 
for in 11 out of 14 cases of death from 
Chorea recorded in this paper, there were 
actual vegetations upon the cardiac valves. 
Dr. Romberg says, "The rheumatic pre- 
disposition, noted by English medical 
men, was rarely traceable in the cases 
presenting themselves to my observa- 
tion;" but this opinion is not that of 
other German writers. Dr. West, who 
once had doubts as to the frequency of 
the connection between rheumatism and 
Chorea, now believes that the rheumatic 
diathesis is a powerful predisposing cause 
of Chorea. M. Rogers says, "The coin- 
cidence of Chorea and rheumatism is so 
common a fact, that it ought to be re- 
garded as a pathological law, just as much 
as the coincidence of heart disease and 
rheumatism;" and again, "The child 
affected with rheumatism is, after a 
longer or shorter interval, threatened 
with Chorea ; and the child affected with 
Chorea is sooner or later menaced with 
rheumatism." It may also, as Dr. Tuck- 
well points out, explain why it is that in 
adults rheumatism and Chorea do not go 
together as they do in earlier life, that in 
earlier life rheumatism is far more fre- 
quently complicated with heart disease. 
"The younger the patient," as Dr. Hil- 
lier remarks, "the more frequently is 
rheumatism accompanied by endocardi- 
tis." Cardiac disease is also very com- 
mon in Chorea. Thus, in 37 cases of 
which notes were taken by Dr. Hillier, 
there was probably organic disease of the 
heart in 25, and of functional derange- 
ment in 4, whilst in 8 only was there no 
sign of cardiac disturbance. Heart dis- 
ease, however, does not necessarily point 
to rheumatism in children. On the con- 
trary, it may follow scarlet fever or 
measles, and in some cases it may come 
on without any obvious reason. But, be 
the cause of the heart disease what it 
may, heart disease is a common accom- 
paniment of Chorea, in the refractory 
cases especially. 
Absence of Fever.-Fever does not figure 
among the necessary symptoms of Chorea. 
In fact, Chorea is essentially a fevcrless 
malady. Not unfrequently, also, there 
are signs which point to a condition of 
circulation the very opposite to that which 
is met with in fever, such as coldness and 
clamminess of the hands, a disposition to 
chilblains if the weather be at all cold, 
pastiness or puffiness of certain parts or 
the skin, ansemic vascular murmurs, and 
the rest. In some instances, it is true, 
the temperature is increased; but such 
increase, according to my experience, is 
only met with in mixed cases of Chorea, 
where delirium is a marked feature, and. 
where the movements point to delirium 
rather than to Chorea, and then only ex- 
ceptionally, and therefore it may have 
nothing to do with the Chorea. More- 
over, increase of temperature is not always 
a sign of fever in the ordinary sense of 
the word, for it is a fact, not unfrequently 
verified, that the temperature often rises 
remarkably in the moribund state, and 
that for some time after death the corpse 
may give a disagreeably hot sensation to 
the touch. Nor is an argument to the 
contrary to be found in the relation of 
Chorea to rheumatism. Chorea may oc- 
cur before or after rheumatic fever, but 
not along with rheumatic fever. This is 
the plain fact. Indeed, the very connec- 
tion of Chorea with rheumatism, when 
properly understood, may be only one 
other proof that Chorea is associated with 
a state of wanting vigor and activity in 
the circulation, for most assuredly a weak 
circulation and a lymphatic habit gener- 
ally is the state of things which is likely 
to be present in persons who are prone to 
rheumatic fever. Moreover, it not un- 
frequently happens that the symptoms of 
Chorea are suspended by the accidental 
development of scarlet fever or some other 
febrile disorder, and that they return 
again when the state of feverishness 
passes off'. 
Neutral Urine.-In the case which serves 
as my text the urine was neutral, and 
readily becoming offensive ; and so far as 
my experience goes, this is the case gen- 
erally. In some cases, however, the urine 
seems to be of unusually high specific 
gravity, as has been shown, first of all by 
Dr. Walshe, and afterwards by the late 700 
CHOREA. 
Dr. Todd and by Dr. Bence Jones. In a 
case of acute Chorea, of which Dr. Walshe 
fives the history in detail, lithates were 
eposited in large quantities during the 
first few days, then urea was found to be 
present in great excess, then oxalates 
made their appearance, and last of all 
there was a copious precipitation of oxa- 
lates ; and in another case, given in the 
Clinical Lectures of Dr. Todd, the specific 
gravity of the urine was never below 
1'019, and often as high as 1'030 or even 
1'035, and as a rule urea and oxalate of 
lime, but especially lithates of ammonia, 
were present in considerable excess. The 
state of the urine requires to be more 
carefully inquired into. In two cases I 
found, for a short time only, some excess 
of urea, and a thick deposit of lithates on 
cooling; but this state of things soon 
changed, and what I noticed chiefly was 
the rapidity with which the urine lost its 
acidity, and threw down phosphates. 
The case of Chorea which has served 
as the text for these comments is a little 
more marked in its symptoms than the 
average of cases. Usually, indeed, the 
speech is thick and confused, not lost, and 
the use of the hands is not so completely 
taken away. Usually, also, paralysis is a 
less prominent phenomenon. The symp- 
toms are, in fact, infinitely varied; and 
as they are toned down on the one hand, 
or exaggerated on the other, Chorea may 
be a most trifling disorder or a very grave 
malady. In its most trifling form Chorea 
may be nothing more than a grimace, or 
a shrug of the shoulders, or a catch in the 
speech, or some other odd or awkward in- 
voluntary movement, which in many in- 
stances appears to be little more, or no 
more, than an unchecked bad habit. In 
its gravest form, on the contrary, few dis- 
eases are more distressing to witness-the 
patient tossing ceaselessly to and fro, un- 
able to walk or even stand, turning, writh- 
ing, dashing about, and only kept in bed 
by being strapped down or fenced in; 
without speech, perhaps with the lips torn, 
chapped, and bleeding, by being, in spite 
of all we can do to prevent it, continually 
drawn into the mouth and munched be- 
tween the teeth, which themselves, in 
some instances' are actually ground down 
and even forced from their sockets ; with 
the elbows and hips and other prominent 
points made raw by constant rubbing 
against the bedding-a sight which is 
forced upon one, for no care can keep the 
bedclothes in their place-sometimes rav- 
ing, and never sleeping, until death comes 
to the rescue. Once seen, indeed, it is 
not easy to forget a scene so sad as that 
presented by Chorea in its gravest form, 
a scene than which there is none sadder 
in the whole range of diseases, hydro- 
phobia itself not excepted. 
2. Exceptional Forms of Chorea. 
-Allied more or less closely to Chorea in 
its severest form is a disease which was 
first described by Dr. Dubini, of Milan, 
about twenty years ago, under the name 
of electric chorea. This disease seems to 
be peculiar to certain districts of Lom- 
bardy. Its symptoms are :-(1) Certain 
choreic or convulsive shocks in the limbs, 
repeated with a certain regularity of 
rhythm, persisting with scarcely any in- 
termission for days, or even weeks, and 
followed by paralysis, and, it may be, 
atrophy of the affected parts ; (2) certain 
tonic convulsions of great violence, affect- 
ing the muscles in which the choreic con- 
vulsions are manifested, and occurring in 
not unfrequent paroxysms; (3) epilepti- 
form attacks, sometimes general, some- 
times partial; (4) certain head-symptoms, 
such as cephalalgia, delirium, and coma. 
One or the other of these groups of symp- 
toms may be predominant in different 
cases. Electric chorea may be either 
acute or chronic, and in either case its 
termination is almost always in death. 
As a rule, it begins quietly, and is in no 
great haste to assume its serious charac- 
ters. As a rule also, a delirium, lasting 
for some days, and ending in coma, ushers 
in the fatal termination; but not unfre- 
quently death is brought about more 
speedily and suddenly in an epileptic 
paroxysm. The electric shocks which 
form so conspicuous a feature in the dis- 
order, occur very frequently, as often as 
thirty, sixty, or a hundred times in the 
minute, and they are often, if not always, 
accompanied by feelings of pain, tingling, 
or cramp in the same parts, by vertigo, 
and by humming or singing sounds in the 
ears. At first the digestive organs are 
but little affected, but after a time the 
appetite fails, and gastralgia and frequent 
vomiting add to the distress. Fever, 
indeed, is not seldom present. The mean 
duration of the disease is from forty to 
seventy days, if we except a few acute 
cases in which death happened in a few 
days with urgent cerebral symptoms. 
Electric chorea was the name chosen 
for this disease by Dr. Dubini; typhus 
convulsivo-cerebralis was the name selected 
by Dr. Frua, a colleague of Dr. Dubini's 
in the great hospital in Milan, who saw 
many cases, and whose description of the 
disease immediately followed that of this 
last-named physician ; and myelitis convul- 
siva was the name made use of by Dr. 
Ilbrtel, in his account of the disorder. 
This difference of nomenclature shows 
how differently various observers were 
struck by what they saw, and proves, at 
the same time, what is plain from their 
description, that electric chorea has not, 
perhaps, the strictest claim to be admitted 
into the category of choreic affections. 
St. Vitus's dance, however, is the very EXCEPTIONAL FORMS OF CHOREA. 
701 
Proteus of diseases, and many strange 
maladies have to be passed in review 
before the description of all its various 
forms is complete. 
The disease to which the name of St. 
Vitus's dance was originally given was of 
an epidemic character. It broke out at 
Strasburg in 1418, close upon the heels of 
the black death. It was, in fact, a fresh 
outbreak of a dancing epidemic called the 
dance of St. John, which made its appear- 
ance at Aix-la-Chapelle in the summer of 
1374, and then spread like wildfire over 
the whole of Germany and the countries 
to the northwest. This dance of St. 
John appears to have been characterized 
chiefly by paroxysms of extravagant danc- 
ing and leaping and howling and scream- 
ing. In some cases the head was filled 
with ecstatic visions in which St. John 
was a prominent object; in others the 
most frantic excitement was produced by 
certain sights or sounds. Sometimes the 
dancing movements were ushered in by 
symptoms of an epileptiform character: 
usually they were accompanied and fol- 
lowed by the most distressing flatulency : 
almost always they were carried on until 
they came to an end from sheer want of 
strength. For nearly two hundred years 
society was disorganized by persons suf- 
fering from this demoniacal disorder, and 
by rogues who simulated it for sinister 
purposes. Dr. Hecker tells us that the 
feast of St. John the Baptist was always 
held as a day of wild revelry ; and that at 
the time when this strange malady made 
its appearance, the Germans were in the 
habit of mixing up with this Christian 
ceremonial an ancient pagan usage-the 
kindling of the ''nodfyr." It was the 
custom on these occasions to leap through 
the flames of this fire, and to consider 
that a year's immunity from the disease 
was gained in this way ; and in this leap- 
ing run mad, Dr. Hecker thinks, we have 
the origin of the dance of St. John. 
In its main characteristics the dance of 
St. Vitus does not appear to have differed 
from the dance of St. John. The differ- 
ence of name was owing to this-that at 
the first appearance of the disease in 
Strasburg, the sufferers, real or pretended, 
were so numerous that the city authorities 
divided them into companies, and appoint- 
ed persons whose duty it was to conduct 
them to the chapels of St. Vitus near 
Zabern and Rotenstein, as well as to pro- 
tect and restrain them by the way. They 
were taken to these chapels in consequence 
of a legend, invented conveniently for the 
occasion, which represented that this St. 
Vitus, when suffering martyrdom under 
Diocletian, A. d. 303, had, in answer to 
prayer, received power to protect from 
the dancing mania all those who observed 
the day of his commemoration and fasted 
upon its eve. At any rate to the shrine 
of St. Vitus these people went, and there 
priests were ready to sing masses, and to 
perform other services fitted for the occa- 
sion ; and thus the name of the disorder 
became changed from the dance of St. 
John into the dance of St. Vitus. 
Attention was first prominently directed 
to these two dances, at the times which 
have been mentioned, but there is good 
reason to believe that they had been 
known a long time previously. 
At the beginning of the sixteenth cen- 
tury, a change had taken place by which 
these disorders had become less unlike 
disorders which are now classed under 
the head of chorea. This is evident from 
the description given by Paracelsus and 
other competent observers. At this time 
these maladies were characterized by fre- 
quent fits of hysterical laughing or cry- 
ing, by odd movements, and now and 
then by fits of dancing, but not by the 
howling or screaming or mental delusions 
or distressing flatulency of former days. 
In some instances, also, the propensity to 
dance was not irresistible. Still, now 
and then the disorders in question ap- 
peared in their old form, and Dr. Hecker 
tells us that so late as 1623 some women 
were in the habit of paying a yearly visit 
to the chapel of St. Vitus, in the terri- 
tory of Ulm, in order that a dance at the 
altar there might save them from dancing 
elsewhere against their will, until the 
same time next year. 
Almost contemporaneously with the 
dance of St. Vitus, a dancing malady, 
called tarantism, appeared at Apuleia, and 
spread from thence with great rapidity 
over the rest of Italy. This malady was 
attributed to the bite of a tarantula, or 
ground-spider, common in the country; 
but it is more probable that undue fears 
as to the evil consequences of the bite- 
fears arising easily in the gloomy and de- 
spondent temper of the times-had more 
to do in causing the malady than the bite 
itself. Those who were bitten remained 
dejected and stupefied, or else, becoming 
greatly excited, went about laughing, 
singing, or dancing. In any case, they 
were utterly unable to restrain themselves 
if acted upon by music of a certain kind. 
A bacchantic furor was excited by the 
first notes, and as the performance went 
on they would dance, and leap, and shout, 
and scream, until they fell down from 
sheer exhaustion. Some colors appear 
to have excited them, others to have 
calmed them. Some had a strong dispo- 
sition to rush into the sea; many were 
carried away by strong sensual passions 
into deplorable excesses. Some, again, 
were tormented by the flatulent distress 
which was a symptom in the dance of St. 
John. In this malady, music was looked 
upon as the only remedy, and the country 
everywhere resounded with the merry 702 
CHOREA. 
notes of the tarantella. The favorite in- 
struments were the shepherd's pipe and 
the Turkish drum. It was supposed that 
the poison of the tarantula was diffused 
over the system by the exercise of the 
dancing, and expelled along with the per- 
spiration. It was customary for nume- 
rous bands of musicians to traverse the 
length and breadth of the land during the 
summer months, and the seasons of danc- 
ing at the different places were called 
"the women's little carnival," "carna- 
valetto delle donne," for it was the 
women, more especially, who conducted 
the arrangements, and defrayed the ex- 
penses. Tarantism continued in Italy 
long after the dance of St. Vitus had died 
out in Germany ; indeed, the epidemic 
can scarcely be said to have been at its 
height until the middle of the sixteenth 
century. 
It would seem also that the tigretier or 
dancing mania of Abyssinia, a malady 
occurring most frequently in the Tigre 
country, is, in some respects, not unlike 
the ancient dances of St. Vitus and St. 
John. Beginning with violent fever, this 
malady soon turns to a lingering sickness, 
in which the patient becomes reduced to 
the last degree of emaciation and ex- 
haustion. This sickness may continue 
for months, and end in death if the pro- 
per cure be not sought after. The first 
cure, which is also the cheapest, is one in 
which a priest ministers. It is a kind of 
water cure, with a blessing superadded. 
If this fail, the aid of music is appealed 
to, and arrangements are made for a pro- 
longed performance. The place chosen 
generally is the market-place. Under the 
influence of the music the patient soon 
bestirs herself, and begins to leap and 
dance in the maddest manner possible, 
and, having begun, she goes on in the 
same way until the day is nearly, and the 
musicians altogether, spent, and then she 
starts off, and runs until her legs refuse to 
carry her any further. Then a young 
man who has followed her fires a gun over 
her head, and, striking her on the back 
with the flat of a broad knife, asks her 
name, when, if cured (she had never ut- 
tered this name during her strange ill- 
ness), she repeats her Christian name. 
After this she is re-baptized, and consid- 
ered convalescent. The account of this 
extraordinary affection is by Mr. Na- 
thaniel Pearce who lived nine years in 
Abyssinia, who saw what he describes, 
and who published the story about thirty 
years ago. 
A place in this strange category of dis- 
orders must also be conceded to those ex- 
travagant leapings and dancings which 
have been met with at various times 
among certain sects of religious enthusi- 
asts-the jumpers of this country and 
America, the "convulsionnaires" in 
France, and the victims of "leaping 
ague," who some time ago startled and 
shocked the grave people of Scotland. 
These latter enthusiasts complained of 
pains in the head and elsewhere, and soon 
afterwards they began to suffer at certain 
periods from fits of convulsion and fits of 
dancing. At these times they acted in 
the maddest W'ay, distorting their bodies, 
springing to a surprising height, or run- 
ning with amazing velocity until they fell 
down exhausted. When confined in cot- 
tages, a favorite practice was to leap up 
and swing about among the beams sup- 
porting the roof. The effects of music do 
not appear to have been tested. 
The time for a general visitation of 
maladies such as these would appear to 
have passed by, at least in this country ; 
but there are still to be met with, now 
and then, isolated cases which have some 
claim to be included in the same category 
■-cases distinguished by involuntary leap- 
ing, turning, or rushing backwards, for- 
wards, or sideways. One of these, often 
quoted before, is recorded by Mr. Kinder 
Wood; and this, with two which have 
fallen under my own observation, may 
serve as illustrations. 
Mr. Kinder Wood's patient was a young 
married woman W'ho had suffered for 
some time from headache, nausea, quick 
involuntary movement of her eyelids, and 
various contortions of the limbs and 
trunk. The paroxysms themselves were 
not always of the same kind. At one 
time she would be violently and rapidly 
hurled from side to side of the chair in 
which she might happen to be sitting, or 
else, suddenly gaining her feet, she would 
go on jumping or stamping for a while, or 
she would rush round and round the room 
and rap with her hand each article of 
furniture that lay in her course. Or she 
would spring aloft many times in succes- 
sion, and strike the ceiling with the palm 
of her hand, so that it became necessarv 
to remove some nails and hooks which 
had done her an injury. Or she would 
dance upon one leg, with the foot of the 
other leg in her hand. These movements 
always began in the fingers, and the legs 
were not affected until the arms and 
trunk had been first seized upon. No- 
ticing a rhythmical order in some of her 
movements, as if they were obedient to 
the memory of some tune, a drum and 
fife were procured, and the result of play- 
ing upon these instruments was, that she 
immediately danced up to the musicians 
as closely as she could get, and continued 
dancing until, missing the step, she sud- 
denly came to a standstill. On another 
occasion a continuous roll of the drum at 
once put a stop to the dancing movements. 
Afterwards, the drum was used in this 
manner with the happiest results, and at 
the end of a week these movements may EXCEPTIONAL FORMS OF CHOREA. 
703 
fairly be said to have been stopped and 
cured in this way. Unfortunately, how- 
ever, the drum and the fife were alike found 
to have lost the power on two subsequent 
occasions when the dancing recurred. 
These strange paroxysms were generally 
accompanied by some headache and nau- 
sea, and followed by a feeling of great 
weakness and exhaustion, but the patient 
was always able to go about her household 
duties in the interval. 
A young lady, between twelve anti 
thirteen years of age, who had suffered 
for about three years from a choreic 
practice of "making faces," and bobbing 
her head forwards in a curious manner, 
was the patient in one of my cases. About 
three weeks before the date of my first 
visit (24th June, 1857) she suddenly be- 
gan to suffer from the paroxysms which 
have now to be described, and a few 
months previously she had suffered for 
some weeks in a similar manner. In one 
of these paroxysms she would sink or rise 
into a sitting posture, with her legs folded 
under her, and then her head would be 
agitated by a violent, alternating, semi- 
rotatory movement, until the hair would 
stream out horizontally on all sides, like 
the strands of a mop when twirled over 
the side of a vessel. Then followed a 
movement in which the whole body was 
thrown round and round by a succession 
of rapid vaults. In making these vaults, 
the hands were placed upon the floor or 
bed, and the arms used as a kind of leap- 
ing-pole ; and except at the instant of 
swinging round, when the feet and legs 
were thrown horizontally outwards, the 
half-sitting, half-kneeling posture was 
never abandoned. The movements of 
alternating semi-rotation of the head, and 
of circumvolution of the whole body, oc- 
curred separately and without any order, 
and lasted from a few minutes to half an 
hour. At their worst the paroxysms 
were only separated by short intervals ; 
and it is difficult to say whether the move- 
ments themselves or the state which fol- 
lowed-a state in which the patient lay 
panting, dripping with sweat, and ex- 
hausted to the last degree-were most 
distressing to witness. Paroxysms such 
as these occurred several times a day dur- 
ing the first fortnight of my attendance, 
and then ceased suddenly. After this the 
patient rapidly improved in general health, 
and the choreic twitchings of the muscles 
of the face and the bobbings of the head 
became much less frequent. This im- 
provement, however, was only temporary, 
and at the end of three months the fits 
returned, though in a modified form, and 
much less frequently. At this time, in- 
deed, the alternating semi-rotatory move- 
ment of the head did not return, and the 
movement of circumvolution was varied 
by other movements. Thus, instead of 
turning, the patient would at times make 
a succession of leaps in a straight line, so 
that it was necessary to run in order to 
prevent her from rushing out at the foot 
of her bed ; and now and then, after fall- 
ing back exhausted at the end of such a 
paroxysm, she would roll over and over 
sideways for three or four times. During 
these strange attacks there was not the 
least trace of stupor, and she would often 
complain of pains in her head, or of being 
excessively tired even while the muscular 
disturbance was at its height. In some 
instances after the relapse, however, her 
mind was in a rapt or entranced state, 
and now and then words escaped which 
showed that she was absorbed by some 
alarming dream or vision. At those 
times the eyes had a fixed stare, and the 
cheeks were somewhat flushed. After 
the paroxysm she would be for some time 
in an intensely nervous and excitable 
state, starting at the slightest noise or the 
gentlest touch, and now and then bobbing 
her head with much violence; or if the 
mind had been entranced while the move- 
ments were going on, this state would 
continue for some time, and then pass off 
with a succession of sighs. Ordinarily, 
however, the mind was perfectly clear, 
and the first moment of rest was occupied 
in complaining of the feeling of headache 
and fatigue from which she suffered. In 
the intervals, the patient was nervous 
and excitable, but in every respect an 
acute, clever, accomplished, amiable girl. 
At these times her principal complaint 
was of a dull pain across the top of the 
head, or of a feeling of tingling in the 
back and limbs. In this case, the pulse 
was quick and weak, the hands and feet 
were habitually cold, chilblains were 
scarcely absent in summer, ansemic sounds 
were audible in the heart and great ves- 
sels, the appetite was very defective, and 
the digestion sluggish. There were no 
worms or any other evidence of derange- 
ment in the alimentary canal beyond a 
slight disposition to tympanitic distension 
of the abdomen. Nor was there the 
slightest evidence of uterine derangement; 
indeed, in this point of view, the patient 
was a mere child. Recovery was tedious, 
and more than once interrupted by a re- 
lapse, but it was complete in the end ; so 
complete that there was no relapse when 
menstruation was established about twelve 
months later. 
The next case is that of a young gentle- 
man, Mr. E , set. 22, who came up 
from the country, about six years ago, 
to consult me for what he considered to be 
epileptic attacks. These attacks he had, 
but he also had other attacks, for the sake 
of which I now refer to the case. In the 
first place, he had a curious pursing up of 
the mouth, attended with frequent shrug- 
gings of the right shoulder, and frequent 704 
CHOREA. 
tossings out of the right leg ; in the next 
place, he had attacks of shuddering, which 
were so violent as to shake things out of 
his hand, or to pitch him bodily out of the 
chair in which he might be sitting, or even 
out of the bed in which he might belying; 
in the third place, he had what he called 
a " fit of turning." He had scarcely told 
me this story, when, after two or three 
shudders, as if a shock of electricity had 
been passed through him, he get up from 
the chair on which he was sitting, and be- 
gan to turn slowly on his heels upon the 
hearthrug. He turned round and round 
in this way perhaps twenty times and 
then sat down. Before getting up from 
the chair he told me not to be surprised at 
■what I saw, and begged me not to attempt 
to stop him. He said, moreover, that the 
impulse to turn was not altogether irre- 
sistible, but that he could not resist the 
impulse successfully without being much 
agitated afterwards. This gentleman had 
gained honors at college, and there was no 
reason to conclude that his mental powers 
were at all impaired. He had suffered for 
sometime from vertigo, and nowand then 
from headache, but never distressingly so. 
His pulse was 60, and weak, and during 
one of the paroxysms which I have de- 
scribed it fell full 10 beats, and became 
much weaker. I noticed, also, that the 
breathings were slow and embarrassed, and 
that he drew several long breaths in suc- 
cession as soon as the paroxysm was over. 
It is also customary to regard as varie- 
ties of Chorea those distressing and not 
very uncommon cases in which the head 
is affected by semirotatory, oscillatory, 
bowing, or bobbing movements. These 
movements are very varied in character 
and degree: they may be combined in 
various ways; and not unfrequently one 
kind changes into another in no very regu- 
lar or intelligible order. The contractions 
giving rise to these movements may take 
place suddenly or gradually; very often 
they recur with monotonous regularity so 
long as the patient is awake ; in some in- 
stances they may now and then be sus- 
pended for a time by a strong effort of the 
will, or by holding the head firmly between 
the hands: not unfrequently they are ac- 
companied by muscular contractions else- 
where, especially when the patient begins 
to be worn out by want of sleep and annoy- 
ance, and in some degree by bodily suffer- 
ing also, for, after a time, the muscles 
affected become very sore, especially about 
their insertions, and the contraction is at- 
tended with a good deal of pain. 
Nor does this exhaust the list of affec- 
tions which have or are supposed to have 
some relationship to Chorea. On the con- 
trary, it remains to mention certain move- 
ments which are, often at least, little more 
than bad habits or awkward tricks, such 
as semi-uncontrollable grimacings, wink- 
ings, and other movements, which are 
sometimes spoken of as tics-non-doulou- 
reux. Nay, even stammering, stuttering, 
giggling, sneezing, and some forms of hys- 
terical coughing, are not excluded, nor 
yet the convulsive shakings which are 
often seen in certain paralyzed parts, or 
the jerks and starts which are not unfre- 
quently met with in connection with epi- 
lepsy. In fact, the term Chorea is of the 
widest and loosest significance; for it is 
scarcely too much to say that it is made 
to include every form of disorderly in- 
voluntary movement, partial or general, 
which has not altogether the specific cha- 
racters of tremor proper, or convulsion 
proper, or spasm proper. 
3. Pathology.-During the last two 
years Drs. Hughlings Jackson, Broadbent, 
Tuckwell, Ogle, Barnes, and others, have 
done much to elucidate the pathology of 
chorea ; the investigations of Dr. Kirkes, 
made four or five years previously, serving 
as the starting-point to these new in- 
quiries. 
Dr. Kirkes was of opinion that "Chorea 
is the result of irritation produced in the 
nerve-centres by fine molecular particles 
of fibrin which are set free from an in- 
flamed endocardium, and washed by the 
blood into the cavities of these centres 
but he did not venture to fix upon the 
precise seat of the mischief thus done in 
these centres. He merely pointed to the 
vegetations on the valves of the heart 
which he believed to be constantly present 
in fatal cases of Chorea, and to the signs 
of heart disease during life in these and 
other cases, and drew his conclusions. 
Adopting this theory of embolism, Dr. 
Hughlings Jackson goes further than Dr. 
Kirkes had done, and attempts to prove 
that the plugging of the vessels, which he 
regards as the cause of Chorea, is in the 
nerve-tissue forming the convolutions near 
the corpus striatum-a part supplied by 
branches of the middle cerebral artery; 
and that the tissue is thereby not de- 
stroyed, but rendered unstable from under- 
nutrition resulting from a diminished sup- 
ply of blood. And, without doubt, the 
clinical evidence adduced in favor of this 
view is very cogent. Taking Chorea of 
one side of the body, hemichorea, as the 
simplest form of Chorea, and putting it 
side by side with hemiplegia, the result of 
embolism, good reason is found for believ- 
ing that the disorder of movement and 
the palsy both point to the region of the 
corpus striatum as the seat of mischief. 
If this be the seat of mischief in hemi- 
plegia, why not in hemichorea ? The 
muscles most moved in hemichorea are 
those most palsied in hemiplegia. In 
hemichorea, as in hemiplegia, the arm, as 
a rule, is more affected than the leg. In 
right hemichorea, as in right hemiplegia, PATHOLOGY. 
705 
the speech is generally very much affected. 
Again, hemichorea is always more or less 
mixed up with, and sometimes ends in, 
hemiplegia; and, on the other hand, 
hemiplegia from various causes is not un- 
frequently attended by chorea, or move- 
ments of some kind or other. The fact 
that the face is involved in chorea shows 
that the seat of the disorder must be above 
the spinal cord. The facts which have 
been instanced point to the convolutions 
near the corpus striatum, rather than in 
any other part of the brain, as the part 
affected. In this way Dr. Jackson rea- 
sons, and reasons to good purpose; for 
most assuredly the difficulties which beset 
any attempt to localize the choreic lesion 
in the nerve-centres are not a little simpli- 
fied by thus insisting upon the clinical 
relations between hemichorea and hemi- 
plegia, as a ground for believing that the 
region of the corpus striatum is the part 
affected in both disorders. 
Dr. Broadbent also accepts the same 
doctrine of embolism up to a certain 
point, and, not knowing that any one had 
gone before him, travels by the same way 
to the same conclusion as that which Dr. 
Hughlings Jackson had arrived at only 
just before. He is, however, inclined to 
localize the seat of the cerebral mischief 
in chorea in, rather than near, the sen- 
sori-motor ganglia, and he looks upon 
embolism of the fine vessels of these gan- 
glia only as the chief cause of Chorea. As 
with paralysis, so with Chorea, he believes 
that the symptoms point to the seat of the 
mischief, not to its nature; and that, be- 
sides embolism, hemorrhage, softening, 
irritation, and other causes, may figure 
among the causes of Chorea; the differ- 
ence between the mischief causing Chorea 
and that causing paralysis being this- 
that in the one case it is impairment of 
function only, and in the other case abo- 
lition of function-a view which is also 
insisted upon by Dr. Hughlings Jackson. 
In addition to embolism as a cause of 
Chorea, Dr. Broadbent instances local 
innutrition, reflex action from peripheral 
irritation, and direct action upon the sen- 
sori-motor ganglia, from shock, &c. He 
shifts his ground, in fact, considerably, 
from embolism as a cause, but at the 
same time he refers to the discovery by 
Dr. Bastian of the proximate cause of the 
delirium of febrile diseases in embolism 
by altered and cohering white blood-cor- 
puscles, as bringing some of the causes 
which might be referred vaguely to local 
innutrition or blood disease within the 
category of the cases caused by embolism. 
Much evidence to the same effect, at 
least so far as showing that the condition 
of the heart is favorable to embolism, is 
also supplied by Drs. Ogle and Tuckwell, 
though Dr. Ogle himself is not in favor of 
this theory of embolism. 
Dr. Ogle reports sixteen cases of fatal 
Chorea occurring at St. George's Hospital 
since 1841, and all taken from the hospital 
books. In ten of these, fibrinous bands 
were present on the cardiac valves; and 
in eight of these ten, their seat was on 
the auricular surface of the mitral valves. 
In another case also, not included in 
these ten, the carotid artery was plugged 
up. Dr. Tuckwell has witnessed five fatal 
cases, in all of which the valves of the 
heart were affected in the same way-a 
way so constant as to lead him to speak 
of hearts thus altered as choreic hearts, 
the peculiarity being In the presence on 
the auricular aspect of the mitral valves, 
along the free margin of each cusp, of a 
line of numerous, bright, clustering, 
warty vegetations, some as large as a 
pin's head, others so minute as to be just 
visible to the naked eye, and that only in a 
certain light, but shining like little white 
beads when slightly magnified, which 
bodies might be easily detached by lightly 
brushing the part with a camel-hair brush 
or with the tip of the finger, and some of 
which had been detached, and were cling- 
ing to the chordae tendineae of the valve, 
ready to pass into the circulation at the 
next contraction of the heart. In order 
to find these evidences of valvular dis- 
ease, as Dr. Tuckwell points out, it is not 
enough to open the heart in the ordinary 
manner, and look at the mitral valve from 
below: for, looked at in this way, the 
valve may appear quite healthy. It is 
necessary to slit up the left auricle and 
look at the valve from above; and be- 
cause this is not always done, no doubt 
the disease has been often overlooked 
when it only wanted looking for to be de- 
tected. [Dr. Dickinson has reported au- 
topsies of 22 cases of fatal Chorea, in 17 
of which recent vegetations were found 
on one or more of the valves of the heart. 
-H.] 
The appearances met with, after death, 
in the nervous system, are more difficult 
to explain in accordance with, what has 
been already said. In a few instances 
only do they tend to confirm the notion of 
the choreic lesion being caused by embol- 
ism, and localized in the region of the 
sensori-motor ganglia. In one of two 
fatal cases, of which Dr. Tuckwell gives 
the details, mania was the most promi- 
nent symptom during life, and the post- 
mortem examination discovered an exten- 
sive red softening of the convolutions- 
"a consequence of embolism;" and in the 
other, in which there was no mania or de- 
lirium, there was no superficial softening 
of the gray matter, but a deeper seated 
softening of the right, and in a less degree 
of the left hemisphere, in that part which 
lies outside and beneath the sensori-motor 
ganglia, without any recognizable evi- 
dence of embolism, the corpus striatum 
vol. i.-45 706 
CHOREA. 
and optic thalamus lying, as it were, em- 
bedded in a nest of softened cerebral mat- 
ter. Dr. Tuckwell also cites a case of 
embolic hemiplegia, with choreic move- 
ments supervening upon the paralysis, in 
which the same parts were found softened 
after death. 
" In the beginning of May, I860, a girl, 
aged 19, was admitted into St. Bartholo- 
mew's Hospital, under Dr. Burrows, with 
complete hemiplegia of the left side, and 
a loud musical systolic murmur at the 
apex of the heart. The diagnosis made 
was ' plugging of some cerebral vessel by 
fibrin detached from a diseased mitral 
valve.' Within a fortnight from the time 
of her admission, while the paralysis of 
the left side was steadily improving, the 
right side became paralyzed, and both 
the right and left sides became affected 
with well-marked Chorea. On May 27, 
double pneumonia, involving the right 
more than the left lung, came on ; and 
she died on May 29. The post-mortem 
examination was made by Dr. Harris, 
and I took down the following from his 
dictation:-The brain was found healthy 
at all points except at the under part of 
the middle lobe in either hemisphere, 
where there was a well-marked patch of 
softening, about as large as a hen's egg, 
larger in the left than in the right hemi- 
sphere. The brain tissue at the softened 
part had a reddish-yellow tinge, more 
marked on the left than on the right side. 
The middle cerebral artery, on either 
side, at about its third division, was 
found obstructed, at an angle of bifurca- 
tion, by a firm fibrinous deposit. The 
heart had its left ventricle hypertrophied, 
and the auricular surface of its mitral 
valve studded with numerous warty 
growths. The right lung was partly in 
the first, partly in the second stage of 
pneumonia. The upper lobe of the left 
lung was in the first stage of pneumonia. 
There were no deposits in the liver, 
spleen, or kidneys." 
Dr. Bastian also refers to a fatal case of 
bilateral Chorea, with delirium, of which 
he promises to give the details presently, 
in which embolisms, consisting of masses 
of irregular shape and size, and evidently 
made up of an agglomeration of white 
blood-corpuscles, had led to ruptures and 
obliterations of small vessels throughout 
the corpora striata and the course of the 
middle cerebral arteries generally. So far 
the appearances in the nervous system 
after death from Chorea agree with the 
premises, but not so what remains to be 
stated. Thus, in fourteen cases of deaths 
from chorea, collected by the late Dr. 
Hughes, the brain was quite healthy in 
four, and only congested in three cases, 
while of the remaining seven cases the 
particulars are these :-In the first, serous 
effusion beneath the arachnoid and into 
the ventricles, slight effusion of blood be- 
neath the right cerebral hemisphere, soft- 
ened brain ; in the second, arachnoid 
opaque, brain dark and soft; in the third, 
pia mater watery, cineritious matter, red, 
soft, and partially adherent; in the fourth, 
brain soft and vascular, much fluid in 
ventricles ; in the fifth, arachnoid opaque 
in parts, cerebrum vascular, left thalamus 
rather soft; in the sixth, dura mater ad- 
herent very firmly to calvarium, more 
opaque than natural, cerebral vessels 
turgid ; in the seventh, blood effused into 
arachnoid, fornix and edge of third ven- 
tricle soft, red, and tumid, brain softened. 
In the same fourteen cases, the spinal 
column was not opened in six: of the 
remaining eight, the cord and its mem- 
branes were quite healthy in three, and 
only a little congested in one ; and of the 
four others, the particulars are these:- 
In the first, fresh adhesions of the arach- 
noid, gray matter dark; in the second, 
vessels rather large and numerous, serous 
surfaces opaque, old adhesions of the 
membranes, especially posteriorly ; in the 
third, medulla slightly softened, rachidian 
fluid opaque, yellow, and densely coagu- 
lable by heat; in the fourth, softening of 
the cord opposite the fourth and fifth 
dorsal vertebrae. Nor is the information 
supplied by Dr. Ogle in the paper already 
referred to less vague, for the sum of it is 
only this-that the brain or cord, one or 
both, were more or less congested in six 
cases, that the central parts of the brain 
were much softened in one, and that the 
cord was softened in one and otherwise 
affected in another. Very possibly a dif- 
ferent result might have been arrived at 
if these cases had been examined with 
special reference to the condition of the 
sensori-motor ganglia, especially if more 
men like Dr. Bastian were concerned in 
the investigation. As it is, all that can 
be said is that the facts of morbid an- 
atomy do not supply much support to the 
notion that the choreic lesion is caused by 
embolism and localized in the sensori- 
motor ganglia. There is nothing in the 
facts to contradict the notion that the 
choreic lesion may begin in the sensori- 
motor ganglia ; there is something to show 
that all parts of the nervous centres may 
become affected in the end-the cord as 
well as the brain. No doubt, as Dr. 
Reynolds remarks, the symptoms of Cho- 
rea point from, rather than to, the cord. 
No doubt the spasm should be tonic rather 
than clonic, as it is in Chorea, if the cord 
were specially at fault in chorea. No 
doubt the cessation of the spasm of chorea 
in sleep points to the brain, which does 
sleep, away from the cord, which does not 
sleep. Nor are these the only reasons 
which point away from the cord ; but the 
fact remains that after death from Chorea 
the cord is often found to be affected, and PATHOLOGY. 
707 
also that a particular part of the cord, the 
posterior columns, is especially affected in 
a disease which agrees with Chorea in this, 
that it is marked by inco-ordination of 
movement, namely, locomotor ataxy. 
[The order of succession of the symp- 
toms in some cases, where Chorea follows 
articular rheumatism, makes it not im- 
probable that a subacute rheumatic me- 
ningitis may occur, bringing on the attack 
of Chorea by cerebro-spinal irritation. 
More acute and violent manifestations of 
cerebral rheumatism are, although un- 
common, familiar to most physicians.-II. ] 
Neither do the teachings of experimental 
physiology help much towards exactly 
localizing the particular mischief which 
operates in the exceptional cases of Chorea. 
These teachings show that movements of 
a rotatory character may originate in 
various parts of the nervous system-in 
the thalami optici, corpora quadrigemina, 
crura cerebri, pons Varolii, crura cere- 
belli, in certain parts of the medulla ob- 
longata, and also in the upper portion of 
the spinal cord; that choreic agitation 
may be caused by slicing away the cere- 
bellum, and by puncturing one of the 
corpora quadrigemina ; that the removal 
of the encephalon in front of the thal- 
ami optici may result in an impulse to 
go forwards; and that a deep wound in 
the cerebellum may be attended by an 
impulse to go backward. " The parts 
injured," says Dr. Brown-Sequard, "seem 
to be quite different from those employed 
in the transmission of sensitive impres- 
sions or of the ideas of the will to the 
muscles, at least in the medulla oblongata 
and pons Varolii. They constitute a very 
large proportion of these two organs, per- 
haps three-fourths of the first one : they 
are placed chiefly in the lateral and pos- 
terior columns of these organs : they seem 
to contain most of the vaso-motor nerves, 
by which, directly, or through a reflex 
action, they may act on other parts of the 
nervous system ; and they can give rise 
to spasm on the same side of the body-a 
fact which shows that many of their fibres 
do not decussate." Moreover, another 
lesson to be learnt from experimental 
physiology is, that rotatory movements 
may have their starting-point in a nerve 
at a distance from the nervous centres. 
Thus, Dr. Brown-Sequard has made a 
rabbit turn or roll towards the injured 
side by puncturing the expansion of the 
auditory nerve within the ear ; and M. 
Flourens has produced similar movements 
in a pigeon, by simply tying a bandage 
over one of its eyes. It would seem, 
indeed, as if the parts of the nervous 
centres which are concerned in the pro- 
duction of choreic movements may be 
affected from a distance by reflex action. 
Nor is this to be wondered at. seeing that 
there are facts without number which 
show that distant parts of the nervous 
system are continually being affected by 
reflex action, and that the varied conse- 
quences of a particular injury are only to 
be accounted for by supposing many of 
them to be reflex phenomena. Indeed, 
there is no lack of instances to show that 
any part of the nervous system may act 
on any other part, and the exact localiza- 
tion of many disorders of the system is a 
difficult if not hopeless task, for the simple 
reason that any given lesion in any part 
may be attended by a wide range of symp- 
toms depending upon sympathetic dis- 
order set up in other parts. 
At first sight it may be supposed that 
the pathological facts which have been 
given, favor the idea that inflammation of 
the brain or spinal cord, one or both, has 
to do with the production of Chorea ; but 
a moment's reflection is sufficient to dis- 
pose of this supposition. It is plain, in 
fact, that this inflammation cannot be re- 
garded as essential to the Chorea, for in 
some of the cases there are no traces of 
inflammation. This inference is inevita- 
ble. Moreover, the clinical history of 
these very inflammations, apart from 
Chorea, leads to the same conclusion, for 
the symptoms of these inflammations are 
not those of Chorea. There are also on 
record many cases in which inflammation 
in other parts, as in the lungs, has been 
developed in the course of Chorea, and in 
which the choreic symptoms have been 
suspended during the inflammation. The 
case, indeed, is one which seems to justify 
the inference that the Chorea is connect- 
ed, not with inflammation, but with a 
state which may issue in inflammation. 
The case is one in which all seems to be 
explained if it be supposed that the Cho- 
rea is connected with irritation, not with 
inflammation-with the state, that is to 
say, which precedes inflammation always, 
and which may or may not issue in in- 
flammation. In this way, then, the cases 
which have been given, in which the 
traces of inflammation are absent after 
death, must be looked upon as cases in 
which the Chorea proved fatal before irri- 
tation issued in inflammation, and the 
cases in which the signs of inflammation 
were present, as cases in which before 
death the irritation had issued in inflam- 
mation. Nor is there anything contra- 
dictory to this conclusion in the clinical 
history of the cases of which the post- 
mortem appearances were those of inflam- 
mation, for there is nothing in this history 
to show that this inflammation may not 
have occurred very shortly before death, 
and that the true choreic symptoms may 
not have disappeared as the true symp- 
toms of inflammation made their appear- 
ance. 
And, certainly, there is little reason 
for connecting Chorea with fever. On 708 
CHOREA. 
the contrary, there appear to be good 
grounds for believing that the maxim of 
Hippocrates holds good here as in other 
cases-febris accedens solvit spasmos. At 
any rate, there are many cases on record 
of measles, scarlet fever, rheumatic fever, 
nr some other fever, being developed dur- 
ing the course of Chorea, and in which 
the choreic symptoms have been sus- 
pended during the fever. I have met 
with seven such cases. Indeed, so far as 
I have had the opportunity of judging, 
the constant rule appears to be, that the 
Chorea is aggravated in the initial stage 
of the fever-that is, in the cold stage, or 
stage of irritation-and suspended more 
or less completely when the stage of re- 
action, or hot stage, is established; and 
that, in relation to rheumatic fever, the 
place of Chorea is either before the fever 
(often a long time before) or after the fever 
(often a long time after). 
The history of Chorea in relation to in- 
flammation and fever, indeed, so far as I 
can see, would seem to be like that of dis- 
orders which are more or less akin to 
Chorea-namely, tremor,1 convulsion, and 
spasm in their various forms. For what 
is this history ? In an attack of com- 
mon trembling, the circulation is greatly 
depressed, and the pulse does not recover 
itself until this paroxysm is over; and in 
paralysis agitans the paleness and chilli- 
ness of the surface of the body, and the 
decided relief afforded by wine, tell a sim- 
ilar story. In delirium tremens the cold 
perspirations, the quick and fluttering 
pulse, the moist and creamy tongue, are 
all significant facts. The initial rigor of 
fever, moreover, is coincident with defec- 
tive surface-warmth, miserable pulse, 
sunken countenance, blueness of nails, 
cutis anserina, and other signs of vascular 
collapse, and subsultus goes along with 
the most utter prostration of the powers 
of the circulation. And in mercurial tre- 
mor, an inference as to the real state of 
the circulation may be drawn from the 
fact that the subjects of this disorder are 
not unfrequently in the habit of resorting 
to gin and other stimulants for the pur- 
pose of making themselves steady. There 
even appears to be something uncongenial 
between tremor and an excited state of 
the circulation. The state of the circula- 
tion in the delirium of which trembling is 
the distinctive feature-delirium tremens 
■-is quite different from the state of the 
circulation in the delirium in which there 
is no trembling. In the latter case-in 
the delirium of acute meningitis, for ex- 
ample-the skin, especially the skin of the 
head, is hot and dry, not cold and damp; 
the pulse is hard and strong, not weak 
and fluttering; the tongue is parched and 
brown, not moist and creamy-the condi- 
tion is one, in fact, of high fever, and not 
one which, as in delirium tremens, is 
more akin to collapse than to high fever. 
And it is not less certainly a fact, that 
delirium tremens loses its characteristic 
trembling if acute head-symptoms and 
high fever make their appearance in the 
course of the disorder. Moreover, it must 
be borne in mind, as pointing to the same 
conclusion, that the initial rigors of fever 
disappear pari passu with the establish- 
ment of the vascular reaction of the hot 
stage, and that they return in the form of 
subsultus when the state of reaction has 
died out, and the patient is left utterly 
prostrate and helpless. 
Again, there is reason to believe that 
spasm is associated frequently with a de- 
pressed state of circulation. During the 
attack of catalepsy, the appearance of the 
patient is very like that of a corpse, and 
it may even be necessary to apply the ear 
to the chest to know of a certainty that 
the heart continues to beat. In tetanus, 
as all are agreed, there is no fever ; and 
in the tetanus arising from strychnia, as 
Dr. Harley has shown, one effect of the 
poison is to prevent the blood from be- 
coming properly oxygenated. In cholera 
the cramps are coincident with a state of 
almost pulseless collapse. In hydrophobia 
the condition of the circulation is as far 
removed from feverish excitement as in 
tetanus. And, certainly, a similar infer- 
ence may be drawn with respect to the 
state of the circulation in cramp in the 
leg and elsewhere, for these seizures are 
met with, not in strong persons, but in 
those who are weakly, and especially in 
those who are elderly as well as weakly. 
Nay, there is reason to believe that spasm 
in its various forms is antagonized rather 
than favored by an excited state of the 
circulation. In tetanus it appears to be 
the rule for the spasm to gain ground al- 
most in exact proportion to the degree in 
which the pulse loses its true power. In 
hydrophobia it would seem as if the same 
law held good, for on analyzing the his- 
tories of a considerable number of cases, 
I find that there was less agitation, less 
convulsion, less spasm, where the circula- 
tion was less depressed than it is in the 
ordinary run of cases. Nor is a different 
conclusion to be drawn from the history 
of spasm as it is set forth in whooping- 
cough. For what is the fact ? The fact 
is simply this-that the whoop, which is 
the audible sign of the spasm, does not 
make its appearance until the febrile or 
catarrhal stage has passed off; that it dis- 
appears if pneumonia, bronchitis, or any 
other inflammation be developed in the 
course of the malady ; and that it returns 
when the inflammation has departed. 
And most assuredly there • is no clinical 
evidence to show that convulsion is asso- 
[* Choreic movement is, however, a phe- 
nomenon very different from tremor.-H.] CAUSES. 
709 
ciated with an over-active condition of 
the circulation. In the fevers of infancy 
and early childhood, especially in the ex- 
anthematous forms of these disorders, 
convulsion not unfrequently occupies the 
place which belongs to rigor in the fevers 
of youth and riper years. It occurs in the 
cold stage of the fever, when the powers 
of the circulation are greatly depressed in 
every way ; and it is confined to this 
stage, except in those cases in which there 
are certain brain and kidney complica- 
tions, when it may also take the place of 
subsultus, or rather of death itself, for 
when it occurs at this time the patient 
has all but ceased to strive in the " struggle 
called living." Nay, I am even disposed 
to think that there is something altogether 
uncongenial between convulsion and the 
hot stage of the sympathetic fever con- 
nected with inflammation, for it is a fact 
not unfrequently verified that fits of com- 
mon epilepsy are often suspended for the 
time by causes which give rise to a state 
of sympathetic fever in the system. For 
example, I can call to mind four or five 
cases of epilepsy, in which high sympa- 
thetic fever was set up by a burn or other 
injury inflicted during a fit, and in which 
fits, which were of daily occurrence be- 
fore the accident, and which recurred with 
the same degree of frequency afterwards, 
were altogether suspended so long as the 
fever continued. Nor is a contrary con- 
clusion to be deduced from the history of 
the convulsion connected with teething, 
with worms, or with any other condition 
in which what is called " morbid irrita- 
bility" is the prominent characteristic; 
for it is found, not only that fever is al- 
most entirely foreign to the state of 
"morbid irritability," but also that con- 
vulsion, when it does occur, is associated 
with seasons of decided vascular depres- 
sion. In a word, the result of bed-side 
study has been to convince me that the 
true place of convulsion, in connection 
with any form of febrile disorder, is in the 
cold stage before the hot stage, or in the 
cold stage after the hot stage, and not in 
the hot stage itself; that, in fact, there is 
something uncongenial between convul- 
sion and an excited state of the circula- 
tion. And so also with ordinary epilepsy, 
the general history of the disorder appears 
to be that the convulsion is antagonized 
by an excited state of the circulation 
rather than favored by it. 
As it seems to me, then, there is no- 
thing unintelligible in the fact that Cho- 
rea, instead of being connected with a 
state of inflammation and fever, is con- 
nected with a state which must be looked 
upon as the very opposite of inflammation 
and fever. As it seems to me, indeed, 
there is nothing in this part of the history 
of Chorea but what was to be expected 
from the history of tremor, convulsion, 
and spasm in their various forms. Nay 
more, the antagonism between chorea and 
inflammation or fever is, as it seems to me, 
nothing but what is necessitated by the 
physiological as well as by the pathological 
history of muscular contraction. But these 
are topics upon which I may not dilate 
further in this place, and I therefore bring 
my remarks under the present head to a 
close, by simply saying, that those who care 
to know more of what I think on this sub- 
ject will find the latest statement of my 
views in a book about to be published 
under the title of " The Dynamics of 
Nerve and Muscle." 
4. Causes.-" The patients who suffer 
from Chorea," says Dr. Hillier, " are very 
impressible and emotional, and very liable 
to derangements of the nervous system." 
Often too, as in the case which has been 
given as an example of the disease, where 
there were fits at the time of teething, 
they have suffered from some other de- 
cided disorder of the nervous system, and 
quite as frequently ; as also is illustrated 
in the case in question, where the mother 
had epilepsy at the time of puberty, an 
inherited disposition to disorder of the 
nervous system may be suspected. Thus, 
out of 48 cases in which I have inquired 
into the family and personal history of 
the patients, I find 27 cases in which 
father or mother, or brother or sister, had 
been, or was, subject to epilepsy, pa- 
ralysis, apoplexy, hysteria, Chorea, or in- 
sanity ; and 11 in which the patient had 
had infantile convulsions, Chorea, or epi- 
lepsy. As in hysteria, it might be ex- 
pected that sympathy and imitation would 
figure among the causes of Chorea ; but 
this anticipation does not appear to be 
borne out by the facts. " The disease," 
says Dr. Hillier, "is never induced by 
the assemblage of several choreic patients 
in a ward of children, nor does it appear 
that the symptoms are in any way aggra- 
vated by mutual association." Fright, 
on the other hand, is without question a 
frequent cause ; it is distinctly stated to 
be the exciting cause in 31 out of 56 cases 
collected by Dufosse and Bird, in 34 out 
of 100 cases reported by Hughes, in 9 out 
of 31, and in 9 out of 38, related by Dr. 
Peacock and Dr. Hillier respectively. 
Still it is certain that in many of these 
very cases the debut of the choreic symp- 
toms is so long deferred as to make it dif- 
ficult to believe that fright has had very 
much to do as an exciting cause, and not 
unfrequently also a doubt as to the opera- 
tion of any sudden exciting cause is sug- 
gested by the very slow development of 
the choreic symptoms. Indeed, when 
the matter is strictly inquired into, but 
few cases are to be met with in which the 
patient was at once suddenly sent into a 
state of Chorea from any cause, emotional 710 
CHOREA. 
or other. Some special cause of irritation 
may also be suspected in some cases, as 
worms in the intestines, a foetus in the 
uterus, and especially unnatural irritation 
of the sexual organs ; but here again the 
evidence is less conclusive than it might 
be supposed to be. One or two cases are 
on record in which choreic symptoms have 
ceased almost abruptly on the expulsion 
of a tape-worm by a vermifuge. Chorea 
in pregnancy has also been found to cease 
on delivery. Still it may be questioned 
whether Chorea in pregnancy is always 
true Chorea, and whether an altered state 
of the blood rather than irritation may 
not be the true cause in those cases where 
there is no good reason to be in doubt as 
to the nature of the disease ; for in preg- 
nancy there is a hyperplastic state of the 
blood which may favor embolism, from 
the direct deposit of white corpuscles in 
the minute vessels, as is pointed out by 
Dr. -Bastian, if not by the floating into 
these vessels of minute vegetations de- 
tached from the cardiac valves. In 5 out 
of 16 cases of fatal Chorea reported by Dr. 
Ogle there were " proofs of congestion and 
other graver lesions of the genital sys- 
tem and most certainly I have in not a 
few cases found reason to know or suspect 
the existence of practices which might lay 
the foundation of such congestion, and 
give rise to any amount of irritation, and 
this too in cases where the age of the pa- 
tient might be supposed to be a suflicient 
contradiction to the notion. Again, the 
causes of Chorea and rheumatism would 
seem to be closely allied, if not identical. 
"Chorea," says Dr. Tuckwell, "is a dis- 
ease which is common among the poor 
and ill-nourished, rare among the rich and 
well-favored ; and exactly the same holds 
for rheumatism." Chorea also resembles 
rheumatism in being more common in 
damp and cold than in warm and dry cli- 
mates. At the same time, season does 
not seem to influence the development of 
Chorea very much. Thus, in 27 cases 
given by Dr. Hillier, 13 occurred in the 
six winter months and 14 in the six sum- 
mer months-viz., 2 in January, 5 in Feb- 
ruary, none in March, 3 in April, 2 in 
May, 4 in June, 2 in July, 0 in August, 2 
in September, 1 in October, 3 in Novem- 
ber, and 2 in December. 
5. Diagnosis.-In a well-marked form, 
Chorea cannot well be confounded with 
other maladies. It does not even suggest 
the idea of hysteria, and therefore there 
need be no confusion on this score. Nor 
need Chorea be confounded with inflam- 
matory diseases of the brain and spinal 
cord. In the more aggravated cases there 
is, I believe, a tendency to run on into 
one or other of these diseases, and the 
moment of transition may not always be 
easily definable : but, as a rule, the acces- 
sion of the new disease will be indicated, 
not by the aggravation, but by the cessa- 
tion of the choreic symptoms proper, and 
the substitution for them of delirium, pain 
in the head, convulsion, paralysis, numb- 
ness, pain in the back increased by move- 
ment, and others, in groupings which will 
leave no doubt as to what their true mean- 
ing must be. I have seen two cases of 
Chorea in children which ended in cere- 
bral meningitis, and in which the choreic 
movements ceased when convulsion and 
delirium made their appearance; and I 
have seen one case of severe Chorea in a 
youth which ended in inflammatory dis- 
organization of a considerable portion of 
the spinal cord, and in which the choreic 
symptoms did not continue after the de- 
velopment of the numbness, paralysis, 
and other symptoms of myelitis. Indeed, 
it may be stated broadly that the symp- 
toms of Chorea are not the symptoms of 
acute inflammatory affections of the sub- 
stance of the brain and spinal cord, or of 
their meninges. Delirium is reckoned 
among the symptoms of acute Chorea in 
some cases. But I am very much dis- 
posed to believe that the case has changed 
from Chorea to some other disease of the 
brain, not always inflammatory, of course, 
when delirium makes its appearance ; and 
that this case will be spoken of, not as 
Chorea, but as a consequence of Chorea, 
when more is known of the diagnosis of 
diseases of the nervous system, and when 
greater exactness of nomenclature is at- 
tained to. Nor need Chorea be con- 
founded with any chronic affection of the 
membranes or substance of the brain or 
cord, the points of difference to be noted 
being always more numerous than the 
points of resemblance. In locomotor 
ataxy the disorderly movements are 
mostly in the legs, and in these parts 
only when attempts are made to stand or 
walk ; whereas in Chorea the movements, 
which are chiefly in the upper part of the 
body, though aggravated by any attempt 
to use the will, continue at all times with 
little ox- no intermission so long as the pa- 
tient is awake. In Chorea also there are 
none of the severe neuralgic pains which 
are so characteristic of locomotor ataxy. 
Again, Chorea is emphatically what loco- 
motor ataxy is not-a disease of child- 
hood. The history of Chorea is also suf- 
ficiently distinct from that of the jerks 
and shocks attending epilepsy and paral- 
ysis agitans. In the former case I have 
sometimes seen movements so repeated, 
and so like those of Chorea, that a mis- 
take might have been possible if the fact 
of the fits had been overlooked ; but usu- 
ally the movements attending epilepsy are 
jerks and shocks, separated afterwards by 
wide intervals and extending over a long 
period, and not at all choreic in them- 
selves. The history of paralysis agitans, 711 
PROGNOSIS-TREATMENT. 
let alone the age of the patient, is suffi- 
ciently distinctive. And so is the history 
of those cases of paralysis complicated 
with choreic movements, in which paral- 
ysis is the primary disorder, and which 
may be spoken of as a sort of local paral- 
ysis agitans; for this history points to 
previous brain disease in a way not to be 
mistaken, and to a time of life which is 
in itself inconsistent with the idea of 
Chorea. In fact, it is scarcely possible to 
confound ordinary Chorea with any dis- 
order of the bain or cord, acute or chronic, 
if only moderate care be used in the diag- 
nosis. And this is all that need be said 
under this head; for with respect to the 
exceptional forms of Chorea, general or 
partial, it is more than probable that they 
ought to be taken out of the category of 
Chorea and placed with hysteria, or re- 
ferred to some special disease or disorder 
of the brain or cord. 
6. Prognosis.-The natural tendency 
of Chorea is, without doubt, towards re- 
covery. Sooner or later, as a rule, the 
patient gets well; and too often, as it 
would seem, the treatment deserves very 
little credit for this result. The mean 
time occupied in recovery, according to 
See, is 69 days, or a trifle under 10 weeks; 
and Dr. Hillier, basing his calculations on 
30 cases treated by himself, arrives at the 
same conclusion, the longest time occu- 
pied by these cases in recovery being 28 
weeks, the shortest two weeks, and the 
mean 10 weeks. The disposition to re- 
lapse is considerable, and usually primary 
attacks are more protracted than relapses. 
Now and then, in the proportion of six 
per cent, according to See, Chorea takes 
an acute form, and is rapidly fatal. Local 
chorea, as exhibited in the muscles of the 
neck at least, is notoriously obstinate; 
and instead of wearing itself out, it is 
more likely to go on year after year until 
the patient is worn out by it. How far 
the occurrence of Chorea implies a ten- 
dency to other disorders of the nervous 
system, especially to epilepsy, is a ques- 
tion which has not yet been fully enter- 
tained, and I cannot supply an answer 
from actual statistics. But this I may 
say-that I have frequently met with epi- 
leptic patients who were choreic at one 
period of their life, and that the impres- 
sion left on my mind from what I have 
seen is, that the chances of Chorea being 
followed, sooner or later, by some other 
disorder of the nervous system are too 
much made light of. 
7. Treatment.-Nothing can be more 
perplexing than the statements made by 
various authorities respecting the efficacy 
of remedial agents in the treatment of 
Chorea. Few voices, it is true, are now 
raised in favor of the old-fashioned anti- 
phlogistic ways of treatment, in which 
bloodletting and purgatives and low diet 
figured so conspicuously ; but beyond this 
all that is uttered seems to be dictated by 
the spirit of contradiction or scepticism. 
Indeed, so little unanimity of opinion is 
there respecting the treatment which 
ought to be pursued in Chorea, that the 
only course is for each one to glance at 
the principal remedial agents recom- 
mended, to weigh the statements made 
respecting them as well as he can, and to 
take upon himself the responsibility of de- 
ciding upon his own course of action. 
Sir Thomas Watson considers that the 
most suitable medicine in cases of Chorea 
is, as a rule, some preparation of iron; 
and this verdict is accepted by the great 
majority of English practitioners in medi- 
cine. Dr. Elliotson says that he cured 
forty cases in succession by the use of full 
doses of sesquioxide of iron, the time spent 
in the cure varying from six to eight 
weeks. I have not used iron much in the 
treatment of Chorea, and I have not seen 
it used to any great extent by others. 
Not unfrequently, however, I have known 
a person using this agent go on for a while 
with it, and then discontinue its use, ap- 
parently as if he were not satisfied that 
all the good was being done which ought 
to be done. Of the several preparations 
of iron which have been recommended, I 
am disposed to believe most in the syrup 
of the iodide, the use of which was first 
suggested by the late Dr. Barlow, of Guy's 
Hospital. I have certainly seen several 
cases in which the use of this preparation 
seemed to be followed by unequivocal evi- 
dence of improvement; but, on reflection, 
I find it difficult to refer this change for 
the better to the iron altogether, or even 
to the iron chiefly. On the contrary, I 
am disposed to think that the iodine is 
entitled to a fair share of the credit, to 
say the least; and that the iodine in the 
doses usually given is stimulating or re- 
storative in its action rather than altera- 
tive, in the sense in which it is usually 
supposed to be alterative. I fancy, also, 
that there is a growing doubt as to the 
efficacy of iron in cases of Chorea, and 
that many would now be disposed to agree 
with the late Dr. Hughes, who says only 
that iron has been administered in num- 
bers of the cases of Chorea recorded in 
his admirable report, and that it has 
"sometimes succeeded where zinc has 
failed." 
Zinc is given very largely in the treat- 
ment of Chorea. In the cases of Chorea 
occurring in Guy's Hospital, the late Dr. 
Hughes says that "zinc in the form of 
sulphate has been the most frequently 
employed as a remedy, and has generally 
been most successfuland forty-five cures 
out of sixty-three cases, or five in seven, 
are credited by him to this medicine. Dr. 712 
CHOREA. 
Barlow says, " In ordinary cases, the ex- 
hibition of purgatives to keep the bowels 
freely open, and the sulphate of zinc in 
doses gradually increased from a grain to 
even fifteen or twenty grains, or even 
more, will effect a cure. When, however, 
the sulphate has been used in these large 
doses, its sudden discontinuance seems to 
be felt by the system, and a return of the 
symptoms ensues. The best rule, there- 
fore, for its exhibition is as follows:-"the 
bowels being kept open, the sulphate of 
zinc should be given in doses commencing 
with a grain three times a day, and in the 
case of a child about twelve years old the 
quantity should be increased by the addi- 
tion of a grain daily, until the medicine 
causes sickness, or there is an obvious 
diminution of the choreal movements. In 
the former case the dose should be dimin- 
ished by at least one-half, and so con- 
tinued for several days, with a view to 
establishing a tolerance ; but if, on the 
other hand, there be a marked improve- 
ment, it should be no further increased, 
but continued without alteration until 
either the improvement ceases-in which 
case it should be again gradually increased 
-or the disease has altogether subsided. 
Whenever the latter is the case, we ought 
to diminish the dose day by day, rather 
than discontinue it suddenly, as by follow- 
ing the latter course we have less reason 
to dread a relapse." In continuation of 
these remarks, Dr. Barlow adds, "In 
some cases, however, especially those in 
which there is considerable anaemia, the 
iron seems to have more control over the 
disease than has the zinc, though these 
cases are rather exceptionable ones. ' ' The 
late Dr. Bright tells us that he found the 
sulphate of zinc answer where the car- 
bonate of iron had failed, and that where 
iron succeeds, there the zinc had done no 
good ; and Sir Thomas Watson, who re- 
peats this statement of Dr. Bright, leaves 
us to infer that these words express his 
own experience in the matter. 
Arsenic is another favorite medicine in 
the treatment of Chorea, especially in 
Great Britain and Ireland. Thomas Mar- 
ten was the first to recommend it, now 
sixty years ago ; and since his time it has 
been very extensively used. Dr. Rom- 
berg, speaking of the various remedies 
recommended, and alone deserving confi- 
dence as capable of arresting the disease 
in a short space of time, says, "The fore- 
most among those an experience of seve- 
ral years has taught me to be arsenic." 
Dr. Begbie also writes, "In an experi- 
ence of nearly thirty years I have never 
known arsenic fail." Nor would it be at 
all difficult to cite other authorities to the 
same effect. Dr. Begbie gives five drops 
of Fowler's solution twice a day, an hour 
after a meal, and adds a drop to the dose 
every day until the specific effects of the 
mineral upon the system are observable, 
and then he suspends the treatment for a 
while. He goes on with the medicine, 
that is to say, until he is warned to stop 
by itching and swelling of the eyelids, by 
redness of the conjunctivae, by a white, 
silvery appearance of the tongue seldom 
accompanied by tenderness, and by nau- 
sea and uneasiness at the pit of the sto- 
mach. I have often used arsenic in the 
treatment of Chorea, and I have great 
faith in its efficacy as a medicine in the 
malady. At the same time I have often 
abandoned its use in consequence of the 
gastric disturbance which, do what one 
will to prevent it, was set up by it. It 
seemed, indeed, as if in these cases the 
stomach would not tolerate the medicine 
in doses large enough to produce a suffi- 
ciently rapid action in the cure of the 
disease. It did not follow, however, that 
this intolerance of the stomach was a suf- 
ficient reason for abandoning the arsenic 
in these cases, for the stomach is not the 
only channel by which this medicine could 
have been introduced into the system. 
Failing the stomach, indeed, the hypo- 
dermic or endermic method might have 
been tried, and that too, I have now rea- 
son to believe, with many chances of ad- 
vantage to the patient. The case which 
suggested to me the hypodermic use of 
arsenic was that of a patient in the West- 
minster Hospital (Hallett Ward), Marga- 
ret S by name. This patient had suf- 
fered for nine years from a distressing 
choreal affection of certain muscles of the 
neck, by which the head was continually 
kept turning and bobbing. At different 
times various modes of treatment had been 
tried, including the hypodermic injection 
of morphia and atropine, without the 
least benefit. When first admitted under 
my care, and for the three weeks follow- 
ing, I gave her bromide of potassium and 
morphia, my chief object being to procure 
sleep and alleviate pain in the neck ; for 
the muscles in the neck, which were the 
seat of the morbid movements, were very 
tender in many places, and the move- 
ments themselves attended with much 
pain; but harm, rather than good, seemed 
to be done by these means. The idea of 
injecting arsenic hypodermically occurred 
to me on the 12th of January, 1866, and 
was carried out on the same day. Fow- 
ler's solution was chosen, and the part 
selected was the most tender point over 
the contracting muscle. Three minims 
were injected on the 12th, TT[v. on the 
15th and on the 27th, Hlyj. on the 19th, 
mvuj. on the 22d, TH vij. on the 25th, and 
again on the 29th, 1T|viij. on February 1st, 
TITix. on the 3d, TT[x. on the 6th, Ulxj. on 
the 8th, Tffxij. on March 1st, and again 
on the 10th, THxiij. on the 12th, TH xiv. on 
the 14th. On the 21st the patient left the 
hospital almost well. Before the fourth TREATMENT. 
713 
injection was practised, a marked change 
for the better had taken place ; before the 
eighth the choreal movements were al- 
most at an end, and the change for the 
better had gone on steadily progressing 
from the beginning. Between the eighth 
and the ninth injection there was an in- 
terval of three weeks1 - the injections 
being suspended on account of tlie local 
irritation and inflammation which they 
had set up. When the patient left the 
hospital there was some stiffness in the 
muscles which had been the seat of the 
disturbance, by which the head was 
slightly twisted, and the voluntary move- 
ments of these muscles were not free; but 
every day there was a change for the bet- 
ter in these respects. In the hospital, the 
only treatment associated with the injec- 
tions was a gymnastic one, the patient 
being made to move her head from side to 
side, and backwards and forwards, in time 
with a slowly moving pendulum, together 
with an occasional dose of morphia at bed- 
time, the drug being given less on account 
of the malady in the neck, though pain 
in this region was still complained of at 
night, than on account of a distressing 
habit of sleeplessness. Two months have 
now elapsed since the patient left the hos- 
pital. She occasionally presents herself 
for inspection, and her state continues 
very much the same as it was, just one 
step from being quite well, and not bad 
enough to make her wish to have the in- 
jections repeated. She goes on exercising 
the muscles of the neck with the pendu- 
lum, and having them shampooed, and 
for medicine she has now and then had 
some cod-liver oil. In this case the object 
in introducing the arsenic hypodermically 
was, not to escape gastric irritation, but 
to produce some local change in the nerves 
of the parts which were the seat of the 
disorder, as well as to bring about some 
more general change in the system. I 
have employed, with results more or less 
satisfactory, the hypodermic injection of 
arsenic in several analogous cases, and 
also in certain cases of neuralgia, epi- 
lepsy, and other affections of the nervous 
system ; and thus the case which I have 
given is not the only case which furnishes 
to my mind reason for believing that this 
mode of treatment may be of use in the 
treatment of certain cases of Chorea. I 
have also used arsenic endermically as 
well as hypodermically in a few cases of 
Chorea. In order to this I have dropped 
from fifteen to twenty drops of Fowler's 
solution upon lint moistened with water, 
and applied this, under oil-silk, night and 
morning, to a raw blistered surface. This 
application gives rise to considerable local 
irritation; indeed, it generally, before the 
week is over, has the effect of covering the 
blistered surface with a thin, dry eschar, 
and of causing a zone of angry pimples to 
crop up in the skin immediately surround- 
ing the part which has been blistered. 
Owing to this irritation, indeed, it is gen- 
erally necessary to make pauses in the 
treatment after going on for six or seven 
days at a time. " As yet, however, I have 
little practical experience of the effects of 
this mode of treatment in actual cases of 
Chorea. I have tried it in two cases of ave- 
rage severity, in one of which the patient 
was well in twenty-eight days, in the other 
in thirty-two days ; and this is all that I 
can say respecting it, except this, that as 
with the hypodermic method before men- 
tioned, so also with this, 1 have given it a 
trial in certain cases of neuralgia and epi- 
lepsy, and that the results arrived at in 
these cases lead me to hope that this 
mode of giving arsenic may prove to be 
a not unimportant addition to the arma- 
menta therapeutica. With respect to the 
comparative merits of the hypodermic and 
endermic methods of introducing arsenic 
into the system I cannot yet speak. I in- 
cline to give the preference to the former 
method, both as least distressing to the 
patient and as most efficacious; but I 
have, as yet, no sufficient practical expe- 
rience to justify the expression of a defi- 
nite opinion. 
During the last twenty-five years strych- 
nia has been employed somewhat exten- 
sively in the treatment of Chorea, espe- 
cially in France. Dr. Trousseau was the 
first, or among the first, to do this, and 
after an experience of a quarter of a cen- 
tury he is still disposed to give the prefer- 
ence to this practice. The preparation 
employed by this physician is a syrup of 
the sulphate of strychnia, made by dissolv- 
ing 3 grains of the sulphate in pX of simple 
syrup ; and the manner of giving it, which 
is peculiar, is as follows:-In children 
from five to ten years of age, the treat- 
ment is commenced by giving a teaspoon- 
ful of this syrup (containing 5'gth of a grain) 
twice or thrice a day-one dose in the 
morning, another in the evening, and the 
third, if there be a third, at noon. On 
the next day these doses are repeated. 
On the following days, each day an addi- 
tional teaspoonful of the syrup is given 
until six teaspoonfuls are given, care be- 
ing taken to distribute these four, five, or 
six doses at equal intervals through the 
day. Having arrived at this point, if the 
1 Up to the eighth injection undiluted 
Fowler's solution was used ; when the injec- 
tions were resumed, and after this time, this 
solution was diluted with an equal quantity 
of water. In other cases, also, where the 
same mode of treatment has been carried out, 
I have employed a mixture of equal parts of 
this solution and water, for I found that the 
solution diluted to this extent produced very 
much less local irritation than the undiluted 
Fowler's solution. 714 
CHOREA. 
physiological effects of the dosing are not 
yet produced, dessertspoonful doses are 
substituted for teaspoonful, and the same 
rule is observed with these larger doses as 
with the smaller. Beginning with two or 
three dessertspoonfuls in the course of the 
day, and giving three on the next day 
also, the doses are increased by a dessert- 
spoonful each day, until six dessertspoon- 
fuls are taken in the course of the day, 
care as before being taken to distribute 
these doses, few or many, with intervals 
between them as wide as possible. If the 
desired effect be not yet produced, a still 
bolder practice is pursued, and a table- 
spoonful of the syrup is substituted for one 
of the desertspoonfuls ; and you are to go 
on, still augmenting, but in a way which 
is not very clearly laid down. "En aug- 
mentant progress!vement, " M. Trousseau 
says, "avec la meme prudence, avec la 
precaution essentielle de distribuer le 
medicament a des intervalles sensible- 
ment egaux dans le courant de la joumee, 
vous arrivez a. donner aux enfans de cinq 
a six ans 50, 60,80 et jusqu'a 120 grammes 
[5 grammes go to the teaspoonful] 25 
milligrammes de sirop; 3, 4, jusqu'a 6 
centigrammes de sulfate de strychnia." 
In persons older than ten years, Dr. 
Trousseau begins with large doses, with 
dessertspoonfuls in place of teaspoonfuls, 
and goes on until he reaches 200 grammes 
of the syrup-a quantity containing no 
less than 10 centigrammes, or 1| grain, of 
the active principle. The object is to pro- 
duce the full physiological effects of strych- 
nia, and to maintain them for a while, 
and the duration of the treatment is said 
to be thirty-three days for girls and 
seventy-four days for boys. When the 
medicine begins to tell upon the system, 
the symptoms are, twenty minutes after 
taking it, or thereabouts," slight stiffness 
in the jaw or neck, some headache, con- 
fusion of sight, and giddiness, and some 
disagreeable "demangeaisons" in the 
parts of the skin covered with hair. 
Afterwards as the system becomes more 
deeply impressed, the stiffness extends 
from the jaw and neck to the limbs and 
elsewhere, especially to the limbs most 
affected with Chorea, which limbs are also 
in all probability more or less paralyzed, 
the itching of the skin is no longer con- 
fined to the hairy parts, and painful jerks 
or shocks, or still more obvious tetanic 
symptoms, make their appearance. The 
tolerance of strychnine varies not only in 
different individuals, but in the same 
individual at different times, so that the 
dose which was not more than enough one 
day may be poisonous the next. In fact, 
the treatment is one which requires to be 
most carefully watched, and which can- 
not well be watched with comfort, especi- 
ally by the friends of the patient, however 
enlightened or forewarned they may be. 
Another heroic treatment for Chorea, 
which has found some favor in France, is 
that by tartar emetic. Laennec has left on 
record three cases of Chorea treated by 
large doses of this medicine, and others 
have tried the same method with results, 
as they seem to think, more or less satis- 
factory, especially MM. Boulay, Gillette, 
and Henri Roger. M. Gillette's method, 
which is that adopted by M. Roger, is to 
give the antimony for three days^ to with- 
hold it for three or five days, and again to 
give and withhold it for the same period, 
as often as may be necessary, if the symp- 
toms have not yielded to the medication 
of the first three days. On the first day 
of the first triple series of days, the dose 
given in the twenty-four hours is from 20 
to 25 centigrammes (1 centigramme is = 
T5, or nearly |th of a grain). This dose 
is doubled on the next day, and tripled on 
the third day; then the patient is allowed 
to rest from three to five days. On begin- 
ning again, if this be necessary, the dose 
given on the first of the three days, which 
is to be doubled on the next day, and 
tripled on the day following, is 5 centi- 
grammes larger than that used on the day 
in which the treatment was commenced. 
If this be not enough, after waiting again 
for from three to five days, the dose for 
the first of the three days is 5 centi- 
grammes larger than that used on the first 
of the last series of three days, for the 
second day the dose is doubled, and for 
the third day the dose is tripled ; so that, 
if the dose given on the first of these three 
days was 30 centigrammes, the dose on 
the last of these three will be 90 centi- 
grammes, or nearly 14 grains I In the 
majority of cases we are told the first 
doses are followed by nausea and vomit- 
ing of a glairy matter, but these symp- 
toms soon pass off, and complete tolerance 
is established, especially if care be taken 
to withhold as much as possible all dietetic 
drinks. We are told also that diarrhoea 
is uncommon, that constipation is not un- 
common; that the pulse becomes slower, 
that the skin moistens, and that the gen- 
eral health improves. Indeed, Dr. Bour- 
guignon, speaking of certain children, pa- 
tients of M. Gillette, under this mode of 
treatment in the Hopital des Enfans 
Malades, at Paris, says: "Les enfans ne 
sont nullement abattus, ils conservent leur 
gaiete. " Dr. Bourguignon, who isstrongly 
in favor of this treatment, tells us also 
that in ten cases-whether in M. Gillette's 
practice, or in his own, he does not say- 
the patients got well in sixteen days, as an 
average, the shortest time being four days, 
the longest twenty-four. 
Iodide of potassium is another remedy 
which has been tried somewhat exten- 
sively in the treatment of Chorea, and to 
a less extent so has bromide of potassium. 
This iodide was supposed to be indicated TREATMENT. 
715 
by the probable existence of a rheumatic 
or lymphatic predisposition in the patient, 
or by the actual presence of some menin- 
geal irritation or inflammation, and these 
indications have been carried out fully 
and frequently ; but the practical results 
of this treatment, so far as I know, are 
unsatisfactory. Nor is a different opinion 
to be expressed with respect to the bro- 
mide. I have tried this medicine in sev- 
eral cases, and tried it fully, and from 
what I knew of its strange efficacy in epi- 
lepsy I was strongly prejudiced in its 
favor; but the result, as I have said, is 
that the bromide appears to be no more 
justly deserving of confidence than the 
iodide. 
As might be expected, opium is a medi- 
cine which has not been overlooked in the 
cases in question, especially in the severer 
cases. As in tetanus, there appears to be 
a remarkable tolerance of this medicine 
in Chorea, and in several cases enormous 
doses have been given ; indeed, in any 
case it appears to be necessary to give 
large doses, in order to procure what may 
be supposed to be the object in view, that 
is, sleep. I have seen opium employed in 
five very severe cases of Chorea, largely, 
and from what I saw in these cases I am 
not wishful to see the experiment re- 
peated. I am speaking now of the free 
use of opium by itself, and not of opium 
in moderate dose along with other agents, 
with the free use of alcoholic stimulants 
especially. This, I believe, is quite a dif- 
ferent matter. Nor does there appear to 
be sufficient reason for supposing that 
other narcotics, not excepting cannabis 
indices are more to be trusted than opium 
in cases of Chorea. 
The inhalation of chloroform or ether has 
been had recourse to in many severe cases 
of Chorea. I have seen three such cases 
in which chloroform was used in this 
way, and my impression was that harm, 
not good, was the result. I believe, also, 
that harm rather than good is likely to be 
done in these cases, unless alcohol is 
given in sufficient quantities before the 
inhalation. If this be done, the patient 
may remain asleep for some time, and 
awake the better; if this be not done, 
there is great danger, so far as my expe- 
rience of the use of chloroform inhala- 
tions is concerned, of the patient waking 
almost immediately, and of being more 
unnerved and more agitated than he was 
before he was put to sleep. At the pres- 
ent time I am in attendance upon a case 
of Chorea, attended with much sleepless- 
ness, until the practice was adopted of 
giving at bedtime a few whiffs of chloro- 
form after a glass of hot negus. The 
chloroform had been tried for four nights 
without the negus, and harm rather than 
good had been the result. It has now 
been tried with the negus for a week, and, 
as it would seem, with unmistakable ad- 
vantage. Nor is this an isolated case. 
Antispasmodics, such as camphor, ether, 
valerian, assafoetida, and musk, have been 
tried extensively, and the general verdict 
appears to be that they are not useless. 
I am disposed to place considerable con- 
fidence in camphor, and also in ether; in 
camphor especially. I often give very 
generally this last-named medicine dis- 
solved in cod-liver oil, and my impression, 
from what I have seen, is that this addi- 
tion to the oil is a decided advantage to 
the patient. 
Turpentine has been given for various 
reasons in Chorea-as an anthelmintic 
and purgative chiefly. At one time I 
gave it rather as a general stimulant, and, 
as it seemed, with benefit to the patient. 
I then tried mineral naphtha with the 
same view, and came to the conclusion 
that this medicine was more pleasant than 
turpentine, less trying to the system, and 
not less efficacious. During the last six 
or eight years, however, I have rarely 
given either one or the other of these 
medicines, and one chief reason for this 
seems to be that I have gradually come to 
prefer the treatment of which I have to 
speak in a few moments. 
Ammonia is also a remedy which has 
some good claim to be mentioned in the 
present place. I have tried the sesqui- 
carbonate in several cases, singly and in 
combination, and the trial has been to 
my mind eminently satisfactory. I am, 
for example, at present seeing a little 
choreic boy who had been for three weeks 
treated, without any benefit, with sulphate 
of zinc, and who has wonderfully im- 
proved during the last three days, by 
leaving off the zinc, and by substituting 
sesquicarbonate of ammonia in five-grain 
doses every three hours. In other re- 
spects there was no change in the treat- 
ment, and the patient is too young to 
allow it to be supposed that he was af- 
fected beneficially by the change of the 
practitioner. 
For various reasons, theoretical and 
practical, the free use of alcoholic drinks 
has long seemed to me to be the founda- 
tion of a rational plan of treatment in 
Chorea, and the larger experience of the 
last few years has only served to confirm 
me in this opinion. I have seen enough 
to know that, as a rule, the change for the 
better is unmistakable when, after the 
carrying out of a contrary mode of prac- 
tice, alcoholic drinks are given with a 
liberal hand. I have notes of three cases 
of great severity, where rapid amendment 
was brought about by giving, at frequent 
intervals, an egg beaten up with a large 
glass of sherry or with an equivalent dose 
of brandy, and I verily believe that this 
plan would rarely fail if carried out in 
time- if carried out, that is to say, before 716 
CHOREA. 
the nervous system had become thor- 
oughly exhausted and broken down, as it 
does do in the end. Indeed, in a bad 
case, where a dangerous degree of sleep- 
lessness had to be dealt with, there is 
nothing in which I should have more con- 
fidence than in the free use of alcoholic 
drinks. I should look upon these means 
properly, that is freely, used, as the natu- 
ral means of procuring sleep and all the 
beneficial consequences of sleep. I should 
be afraid of attempting to attain the same 
end by the use of medicines more or less 
analogous to alcohol in their action, be- 
cause these medicines would all of them 
be more likely to disturb the action of the 
stomach, and so interfere with the re- 
storation of the system by food. And for 
the same reason I should even be almost 
afraid of giving small doses of opium with 
the view of conciliating sleep, though I 
have no doubt that the proper dose of this 
drug at the proper time, in conjunction 
with the proper dose of alcohol, might be 
very satisfactory practice. In a word, I 
cannot but think that it is a perfectly 
rational way of dealing with severe cases 
of Chorea to push alcoholic drinks until 
they produce drowsiness-until, that is to 
say, they exercise a decidedly sedative 
action upon the system. At any rate I 
have carried out this idea in more than 
one case of the kind with what seem to 
me to be very satisfactory results. 
In bad cases of Chorea, as a matter of 
course, the recumbent position is a neces- 
sary part of the treatment; and in cases 
of ordinary severity my own impression is 
that the patient would improve more 
rapidly if he were kept longer in bed. 
Indeed, it surely stands to reason that 
rest, properly used, is a right means of 
remedying a state of muscular disorder, 
in which muscular fatigue is an unmis- 
takable element. Nay, it is not too much 
to imagine, that the persistency of many 
cases of Chorea may be not a little owing 
to the patient being allowed to be up and 
fidgeting about when he ought to be in 
bed. 
Exercise, on the other hand, properly 
used, cannot well be dispensed with as a 
means of treatment in Chorea. In ordi- 
nary cases, indeed, it is difficult to over- 
rate the importance of suitable gymnastics 
as a means of cure. This is no new idea. 
Darwin insisted upon it long ago; and 
from what has been done in this direction 
since his time, especially by Ling and his 
successors in the practice of the so-called 
"movement cure," it is perhaps not too 
much to say that Chorea may be one of 
the consequences of neglecting gymnastics 
as a means of education in children. Cer- 
tain it is, that ordinary cases of Chorea 
get better rapidly-the average duration 
of the period of treatment being sixty 
days-under a properly arranged course 
of gymnastics, with little or nothing else. 
The practice of M. See, at the Hopital 
des Enfans Malades in Paris, may be 
cited in support of this statement; and it 
would not now be difficult to find corrobo- 
rative passages in the practice of others. 
For myself, I should think that I was 
omitting an important duty if I did not 
prescribe the use of some suitable exer- 
cise for a patient suffering from Chorea- 
the use of a skipping-rope or trapeze, if 
nothing else. Dancing has long been a 
favorite idea with me as a means of exer- 
cise in cases like these ; and so have calis- 
thenics regulated by music. More than 
one choreic patient I have known to be 
cured by learning to dance, and I think 
that music might be employed with advan- 
tage now, as it was in the case of the 
tarantula dance of old, in quieting severe 
cases of Chorea, anomalous or not. In- 
deed, there is more than one case on re-> 
cord in which music has been so employed. 
It may be supposed also that music will 
help the choreic patient in his gymnastic 
efforts in the same sense as that in which 
it nerves the acrobat to the performance 
of his wonderful feats. In a word, it is 
not necessary to think long before it must 
become self-evident that orderly move- 
ments, be they those of dancing, calis- 
thenics, or more special gymnastics, and 
be they regulated by music or not, are 
natural remedies for disorderly move- 
ments such as are met with in ordinary 
cases of Chorea, and that a very impor- 
tant means of cure is neglected if they are 
not provided. Indeed it is to be hoped 
that the time is not far distant when a 
suitable gymnasium will be considered as 
much a part of the proper fittings of a 
hospital as the dispensary, and when 
medical men more generally will be alive 
to the importance of suitable gymnastics, 
not only as an educational, but also as a 
curative measure. Surely there is a lesson 
to be learnt from the results of the carry- 
ing out of the "movement cure,"-a 
lesson which the practitioners of orthodox 
medicine are not justified in continuing 
to decline to learn because it happens to 
have heterodox belongings I 
Baths, of one kind or another, have 
been extensively employed in the treat- 
ment of Chorea. In this country the 
cold shower bath has been the favorite mode 
of bathing, and there are some good 
grounds for this preference. Part of the 
good result is ascribed to the shock ; part 
-a greater part, perhaps-to the reaction. 
Still there are, unquestionably, many 
cases in which the shock is not tolerated, 
and where reaction is not easily estab- 
lished-cases in which the patient is ren- 
dered worse rather than better, so far as 
the Chorea is concerned, with the addi- 
tional disadvantage of a bad cold, or 
actual rheumatism, or some other evil. TREATMENT. 
717 
And these latter cases are by no means 
uncommon. Nay, it may even be sus- 
pected that all cases would come into this 
category if care were not exercised more 
or less. The same remarks apply also to 
cold plunge baths, and to other forms of 
cold baths. With respect to hot baths and 
to warm baths, the case is very different. 
A hot bath at bed-time has often seemed 
to me to have a marked calmative influ- 
ence. I am also disposed to think that a 
good part of the benefit ascribed by M. 
Baudelocque to sulphur baths (each bath 
contains about four ounces of sulphuret of 
potassium) is to be ascribed to the high 
temperature of the water, or, at any rate, 
to this in conjunction with the counter- 
irritation set up by the action of the sul- 
phuret upon the skin. The fact appears 
to be that baths of one kind or other are 
not sufficiently recognized as a means of 
cure, not only in Chorea, but in many 
other cases of disease, by the orthodox 
practitioners of medicine. With baths, 
indeed, it is very much as it is with 
"movements" as a means of cure, and 
hydropathy, like kinesitherapy, has a 
lesson to teach, which medical men ought 
to set themselves to learn if they would 
be fully provided with the means by 
which to contend successfully against dis- 
ease. 
Electricity is another agent which re- 
quires a passing mention in this place, 
though all that can be said respecting it 
is, that as yet there appears to be little or 
no reason for placing any confidence in it 
as a means of treatment. Whether this 
will be always the case-whether there 
are not modes of using electricity which 
will have the effect of quieting choreic and 
analogous movements (so long, at any 
rate, as they are used)-remains to be 
seen. I suspect that there are such modes, 
and that they will be beneficial, and that 
too not a little, in the case in question, 
but I have not yet the facts to justify the 
expression of a belief on the subject. 
For the last seven years I have employed 
cod-liver oil in many cases of Chorea, and, 
so far as I can judge, 1 have good reason 
to be satisfied with the results. In adopt- 
ing this practice my main object was to 
restore nerve-tone by improving the nutri- 
tion of nerve-tissue. I remembered that 
fatty matter was an essential ingredient 
in nerve-tissue; and, remembering this, 
I came easily to the conclusion that one 
natural way of attaining to the end in 
view was to take care that the food con- 
tained a sufficient amount of fatty and 
oily matter. Without a due supply of 
these matters, I reasoned, the nerve-tissue 
must be of necessity starved-that, in 
fact, to withhold these matters, or to supply 
them in insufficient quantity, would be as 
great a mistake in cases where the object 
was to improve the nutrition of the nerves, 
as it would be to withhold lean meat in cases 
where the object was to get more muscle. 
I. argued in this manner, and be the theory 
right or wrong I think, as I have said, I 
have no reason to be dissatisfied with the 
results of putting it in practice. 
For the last seven years also I have 
used phosphorus in the majority of cases 
of Chorea in which I have used cod-liver 
oil, and for the same reason. I asked 
myself whether the fact that phosphorus 
is present in large quantity in the great 
nerve-centres, and that the amount of 
this ingredient seems to have some direct 
relation to the activity of the nervous 
functions, being as much as 2 per cent, in 
adult life, and below 1 per cent, in infants 
and idiots, might not show that phospho- 
rus is specially indicated as food for a 
weak nervous system-as much indicated, 
perhaps, as iron in cases where there is a 
deficiency of red-corpuscles in the blood ; 
and this question once put seemed to re- 
quire an answer in the affirmative. " In 
small doses," says Dr. Pereira, "phos- 
phorus excites the nervous, vascular, 
and excretory organs. It creates an 
agreeable feeling of warmth in the epigas- 
trium, increases the fulness and frequency 
of the pulse, augments the heat of the 
skin, heightens the mental activity and 
the muscular powers, and operates as a 
powerful sudorific and diuretic. " In large 
doses, without doubt, phosphorus is a 
caustic poison; in proper doses, it pro- 
duces the very changes that are to be 
desired in cases of Chorea and analogous 
forms of convulsive disorder. In proper 
doses and properly watched, it is quite 
innocent in its action, and may be very 
beneficial. Of this I am confident. The 
forms in which I first gave phosphorus in 
Chorea were the phosphorated oil of the 
Prussian Pharmacopoeia and the ethereal 
tincture of the French Codex (forms con- 
taining 4 grains of phosphorus in the fluid 
ounce), but lately I have preferred the 
hypophosphites, especially the hypophos- 
phite of soda, for the simple reason that 
these salts, which were originally recom- 
mended by Dr. Churchill of Paris as spe- 
cifics in phthisis, are infinitely less nause- 
ous than the oil or tincture, and not less 
efficacious. I have given for some time 
from 5 to 8 grains, three times a day, of 
the hypophosphite of soda to children, in 
cases of Chorea, without any harm cer- 
tainly, and, as I think, with unmistak- 
able benefit, and I have not yet found any 
reason to change this practice for another. 
In an ordinary case of Chorea, the plan 
of treatment which I have now adopted 
as a rule for some time is to give cod-liver 
oil in conjunction with hypophosphite of 
soda, making the draught containing the 
latter salt the vehicle for the administra- 
tion of the cod-liver oil. With these 
medicines, according to circumstances, I 718 
PARALYSIS AGITANS. 
have associated camphor or ammonia, 
one or both, adding the sesquicarbonate 
of ammonia to the draught containing the 
hypophosphite, and dissolving the camphor 
in the cod-liver oil. I have found that this 
latter solution is an excellent way of giv- 
ing the camphor, and also that the cam- 
phor masks the taste of the oil not a little, 
and makes the stomach more tolerant of 
it. I have not kept notes of all the cases 
which I have treated in this manner, but 
I think I am quite within bounds when I 
say that the number now amounts to 
upwards of sixty, and that the average 
duration of the treatment was under one 
month. 
I may also add that I have in three or 
four cases given arsenic along with hypo- 
phosphite of soda and cod-liver oil, and 
that the result, to say the least, was not 
such as to discourage a continuance of the 
practice. 
If there be any special sources of irrita- 
tion, as worms or carious teeth, these of 
course must be met and dealt with. If 
the agitation be so great that there is 
danger of the skin being excoriated, or of 
the patient falling out of bed, properly 
padded sides must be fixed to the bed- 
stead, or it may be expedient to encase 
the body and limbs of the patient in cot- 
ton-wool. If the affection be confined to 
certain muscles of the neck or elsewhere, 
it may be expedient to use hypodermic 
injections of arsenic, as in the cases related 
in the text, to divide a nerve, as has just 
been done by Mr. Campbell De Morgan, 
or to use the actual cautery. If there be 
a morbid mental condition, as there too 
often is, moral means of treatment must 
not be neglected. In fact, each case of 
Chorea must be looked upon from a special 
as well as from a general point of view, 
and the success of the treatment will, in 
many instances, if not in all, depend upon 
the skill with which special means can be 
combined with those general means of 
which I have spoken, and upon which I 
have prosed at greater length than I ought 
to have done. 
PARALYSIS AGITANS. 
By William Rutherford Sanders, M.D., F.R.C.P. 
Synonyms.-Paralysis tremens, trem- 
ula, jactitans, palpitans ; Tremor artuum, 
T. coactus ; Scelotyrbe festinans, sen Fes- 
tinia (Sauvages); Synclonus tremor, S. 
ballismus (Mason Good); Schiittelahmung, 
Schiittelkrampf, Zittern; Tremblement 
senile, Tremulence paralytique progres- 
sive ; Chorea senilis, Ch. festinans; Pseu- 
do-chorea, Pseudo-paralysis agitans; Dys- 
taxia agitans; the Trembles, &c. ; the 
Shaking Palsy (Parkinson). 
Definition. - Idiopathic Paralysis 
Agitans consists of involuntary tremulous 
or shaking motions of the limbs, head, or 
trunk of the body, which takes place even 
when the parts are supported and unem- 
ployed. The voluntary movements are 
preserved, but their vigor is lessened in 
the affected parts. In certain, usually 
advanced, cases, there is a disturbance of 
equilibrium ; most commonly a disposition 
to stoop, or bend the body forwards, and 
to pass, in locomotion, from a walking to 
a running pace. The senses and intellect 
are unimpaired. 
The definition includes these principal 
characters : 1st, The shaking or tremors, 
of a spasmodic kind, which occur even 
when the parts are not in use (Tremor 
coactus, palpitatio, jtaipos, agitatio, jacti- 
tatio, quassus); 2d, The diminished mus- 
cular power (Paralysis, paresis, pseudo- 
paralysis) ; 3d, The disturbed equilibrium, 
shown usually in the tendency to stoop 
and to move forwards with accelerated 
speed (Scelotyrbe festinans, festinatio, 
procursus). Of these characters the 
clonic tremors or shaking are the most 
constant and distinctive. The paralysis, 
on the other hand, is of a peculiar kind. 
As here employed, the term does not 
mean cessation or interruption of volun- 
tary motion, which, on the contrary, per- 
sists ; but it is intended to designate both 
the imperfection of the movements, which 
results from the interference of the tremors, 
and also the impaired strength and the 
slowness of muscular action, which are 
usually observed in the tremulous parts. 
Some writers, objecting to call this condi- 
tion paralysis (a name apt to mislead), 
have spoken of it as "apparent but not 
real paralysis," or "paresis," or " pseudo- 
paralysis," or "dystaxia." Lastly, the 
disturbance of equilibrium does not always 
occur: it is often late in appearing, and 
it serves chiefly to mark a special form or DEFINITION. 
719 
an advanced stage of the affection. Never- 
theless, in fully developed examples of 
Paralysis Agitans, all these symptoms, 
the tremors, paralysis, forward stoop, and 
accelerating walk, are associated together; 
as Parkinson expressed it, there is a com- 
bination of Tremor coactus and Scelotyrbe 
festinans.1 
Historical Notice.-From the definition, 
as explained, it will be apparent that the 
older descriptions of Paralysis Agitans 
are to be sought less in the history of 
palsies than in that of spasmodic nervous 
diseases. In fact, Paralysis Agitans has 
been overlooked principally from being 
confounded, 1st, with tremors in general; 
2d, with chorea; 3d, with cases of motor 
palsy (hemi- or paraplegia) complicated 
with spasmodic and tremulous move- 
ments. 
1st. As a symptom, tremors early at- 
tract attention. They were briefly no- 
ticed by Hippocrates and Celsus, while 
by Galen and succeeding writers their 
kinds, their causes, and their value as 
prognostic signs were fully discussed. At 
length, nosologists established the genus 
Tremor, dividing it into species, in some 
of which tremor was still regarded as a 
symptom merely, while in others it was 
recognized as a substantive or idiopathic 
disease. Accordingly, well-marked cases 
of simple Paralysis Agitans are found in 
many of the older authors,2 by whom they 
are sometimes alluded to, sometimes de- 
scribed with graphic details, in illustra- 
tion of the pathology of tremor or as ex- 
amples of a distinct species of disease. 
Less notice was taken of the disposition 
to stoop and hasten onwards. The earliest 
mention of this curious symptom is prob- 
ably made by Gaubius; it was first par- 
ticularly described by Sauvages under the 
name of Scelotyrbe festinans. But Sau- 
vages did not connect it with tremors; 
he, indeed, had seen only two cases of it. 
It is certain that the combination of per- 
sistent tremors and hurrying gait had not 
been recognized, and no adequate de- 
scription of Paralysis Agitans existed 
previous to Parkinson's "Essay on the 
Shaking Palsy in 1817." His account 
still remains the standard authority. Suc- 
ceeding authors have, in general, simply 
quoted it, or have (especially French 
writers) overlooked the disease altogether. 
Accordingly, although Parkinson drew 
attention to the imperfection of our 
knowledge, the original contributions 
made since his time have been few and 
fragmentary. A list of references will be 
found at the end of this article. 
2d. In regard to the confusion of Pa- 
ralysis Agitans with chorea, it must be 
remembered, that convulsive diseases 
have been imperfectly discriminated, ow- 
ing partly to the difficulty of their pa- 
thology, partly to the superstitions with 
which they have been associated. The 
disease now commonly called chorea was 
not so named originally, nor was it con- 
founded with true St. Vitus's dance ; it 
was regarded merely as a kind of convul- 
sion (motus convulsivus) or species of epi- 
lepsy (epilepsia gesticulatoria), till near 
the end of the 17th century.1 About that 
period, Sydenham, in the brief description 
which fixes the characters of the disease, 
unfortunately named it " Chorea Sancti 
Viti," a misnomer which it has since 
commonly retained, with the effect of con- 
founding it with the dancing mania, from 
which it is quite distinct.2 While older 
authors therefore may have described 
cases of Paralysis Agitans among the 
motus convulsivi extraordinarii (just as 
some authors have given definitions ap- 
plicable to it under the name hieranosos),3 
it is only in recent times that Paralysis 
Agitans has been confounded with what 
is at present known as chorea. This con- 
fusion is due partly to a certain similarity 
in the diseases, partly to the unsettled 
state of medical nomenclature. Ordinary 
cases of the shaking malady are widely 
distinct from common chorea; but cer- 
tain extreme forms occasion a violent ir- 
regularity of movement, resembling in a 
great degree the gesticulations of that 
disease; so much so, that it has been 
proposed to regard Paralysis Agitans as 
a more intense form of chorea,4 and cases 
of Paralysis Agitans have been recorded 
under the title St. Vitus's dance.5 Some 
cases even exhibit a combination of Pa- 
ralysis Agitans and chorea.6 Moreover, 
while the common gesticulatory chorea is 
well known, there are other rarer forms, 
of irregular and uncontrollable spasmodic 
movements, as yet imperfectly studied 
and classified, to which the term chorea 
is usually applied : such are the rotatory 
or spinning-top chorea, the saltatio or 
leaping ague, malleatio, &c. In some 
1 Roth. 
2 Authors distinguish the common chorea 
of Sydenham as chorea minor, the dancing 
mania as chorea major, choreomania, or tar- 
antismus. By chorea or St. Vitus's dance, 
however, Sydenham's disease is now always 
meant, the tarantism from its rarity being 
left out of account. 
3 Linmeus, Gen. Morb., Upsal, 1763, p. 17, 
No. 144: " Hieranosos, Byting, Corporis agi- 
tatio, continua, indolens, convulsiva, cum 
sensibilitate." Also Vogel and Macbride. 
4 Eisenmann, remark on Dr. Haas's case, in 
Canst. Jahrb. 1852, iii. 92. 
5 Trousseau, case in 1843. See references. 
6 Maclachlan. 
1 Parkinson seems to consider the festina- 
tion as essential to Paralysis Agitans, but it 
cannot be so regarded. 
2 Sylvius, Bonet, Juncker, Van Swieten, 
Sauvages, &c. 720 
PARALYSIS AGITANS. 
respects, therefore, it is not altogether 
inappropriate to designate Paralysis Agi- 
tans as a species of abnormal chorea ; 
hence some recent authors employ the 
terms chorea senilis and chorea festinans 
for Parkinson's disease. The objection 
to such names is, that they tend to con- 
found Paralysis Agitans with the ordinary 
St. Vitus's dance, from which it is en- 
tirely different. 
3d. Lastly, the term Paralysis Agitans 
or shaking palsy has been applied, both 
before Parkinson's essay and since, to 
cases of ordinary motor paralysis (hemi- 
and paraplegia) complicated with tremors 
-a complication not uncommon bQth in 
diseases of the brain, and especially in 
certain cases of chronic myelitis and of 
locomotor ataxia. Etymologically the 
name of shaking palsy belongs perhaps to 
these, rather than to Parkinson's disease, 
but time has consecrated his use of the 
term. Parkinson's malady is Idiopathic 
Paralysis Agitans, in which the tremors 
or shaking are the chief and earliest 
symptom, and the paralysis entirely sub- 
ordinate and peculiar, true hemi- or 
paraplegia being rare complications: 
while, in the cerebral and spinal affections 
just referred to, the loss of motion (akine- 
sia) or sensation (anaesthesia) is the main 
feature of disease, and the tremors and 
spasmodic agitations are only concomi- 
tants (i. e. the Paralysis Agitans is Symp- 
tomatic). Hence the latter class of cases 
should be styled, not Paralysis Agitans, 
but hemi- or paraplegia, or spinal or 
cerebral disease complicated with Paralysis 
Agitans: i. e. with spasmodic tremors. 
This distinction, which is essential for the 
accurate definition of Parkinson's dis- 
ease, has often been overlooked, and re- 
quires, therefore, to be specially insisted 
upon. 
In the following description of Paralysis 
Agitans, besides some allusion to tremors 
generally, it is proposed for the sake of 
distinctness to recognize certain subdivi- 
sions of the disease, which experience ac- 
cumulated since Parkinson's essay seems 
to require. 
Divisions. - Idiopathic Paralysis Agi- 
tans is divided into I. General (includ- 
ing the bilateral and unilateral), and II. 
Local. 
I. General Idiopathic Paralysis Agitans 
presents certain forms or varieties import- 
ant to distinguish, as regards prognosis 
and cure:- 
A. Senile forms. Paralysis Agitans 
senilis, occurring in advanced life, above 
fifty or sixty ; usually incurable and with 
fatal tendency from senile decay : divided 
into 1st, Simplex, and 2d, Festinans or Pro- 
cursoria. Varieties, Unilateralis or Hemi- 
plegica and lietrograda. 
B. Non-senile forms, occurring under 
fifty, without fatal tendency, sometimes 
curable. 1st, Paralysis Agitans non-senilis, 
simplex (i. e. sine festinatione), including 
also hysterical and reflex Paralysis Agi- 
tans, &c. 2d, Paralysis Agitans toxica, 
including, chiefly, tremblement metal- 
lique, mercurial palsy, &c. 
The curable forms have been supposed 
to be Functional; the incurable, Organic. 
It will be necessary to describe the 
senile forms in detail, as they are much 
the most frequent; a shorter notice will 
suffice for the others. 
Description.-I. A. Idiopathic Paral- 
ysis Agitans senilis. 1st, simplex, when 
attended by the signs of senile decay 
only; 2, festinans, or procursoria, &c., 
when the disturbance of equilibrium is 
also present. These two forms will be 
described together. 
Symptoms and Course.-Onset usually 
gradual; course slow, progressive, liable 
to be arrested at different stages; dura- 
tion protracted, associated with senile de- 
cay. Several stages may be recognized. 
1st Stage. Commencement. - The first 
symptoms are usually so insidious that 
the patient cannot tell precisely when 
they began. A sense of weakness and a 
disposition to tremble is felt in some part, 
most frequently the hand or arm, some- 
times the leg or head. The tremors, at 
first slight and occasional, gradually in- 
crease ; and at an uncertain period, sel- 
dom less than a year, the corresponding 
parts of the opposite side, more rarely the 
other limb of the same side, become affect- 
ed. The tremors and muscular debility 
seldom extend beyond the arms during 
the first two years, which period may be 
said to comprise the first stage. Except 
for the inconvenience arising from the 
unsteadiness of the hand in writing or 
other manipulation, the patient would 
not consider himself the subject of dis- 
ease. At this period, probably, remedies 
might be applied with success. In a few 
cases, instead of the ordinary gradual ap- 
proach, the tremors have come on rapidly 
after a fright or exposure to cold. 
2d Stage. Generalization of the Tremors. 
-Some time after the hands and arms 
have been affected, one of the legs, usu- 
ally that on the side first attacked, begins 
to tremble and is more easily fatigued; 
and in a few months the other leg be- 
comes similarly tremulous and weak. 
Walking becomes a task requiring con- 
siderable attention. The legs feel heavy 
as lead, and are not raised to the height 
or with the promptitude which the will 
directs, so that care is necessary to pre- 
vent frequent falls. At a later period, 
usually some years after, the tremors ex- 
tend to the head, and finally to the whole 
body. The tremors of the limbs are usu- 
ally in the direction of flexion and exten- 
sion, sometimes of rotation, sometimes of DESCRIPTION. 
721 
ab- and adduction (so that patients have 
had their knees padded to prevent them 
knocking together). In the head1 and 
neck the movements are more commonly 
lateral (shaking negatively), then vertical 
(nodding). The lower jaw is affected with 
vertical, rarely lateral motions; and the 
tongue is tremulous, impeding speech : in 
many cases, however, these parts are not 
affected till near the end of the disease. 
The larynx is little, if at all, affected. 
Deglutition does not suffer till near the 
close. The muscles of the eyeballs and 
eyelids, and the facial muscles of expres- 
sion, are nearly always exempt from tre- 
mors.2 The thorax and trunk are later 
and less affected than the limbs, or head, 
or neck. Appearing chiefly during a gen- 
eral paroxysm of tremors, the spasmodic 
action of the respiratory muscles occa- 
sions a peculiar panting of the breathing 
and a jerking interruption of speech. As 
the tremors last, and become general over 
the body, they increase in intensity ; from 
mere vibrations they become violent con- 
vulsive agitations. The limbs are jerked 
to and fro as if by the action of springs 
or by rapid shocks of electricity. 
From the beginning, and throughout 
the whole course of the disease, mental 
emotion or agitation excites an attack of 
tremors, or greatly aggravates them ; rest 
and quietude diminish or stop them. In 
general, a slow, firm, voluntary act, or the 
grasp of a heavy body,3 stops the tremors 
for a time, and any change of posture has 
the same effect, affording the patient con- 
siderable relief. Parkinson mentions an 
artist, who, while his arm and hand were 
palpitating strongly, would seize his pen- 
cil, with the effect of instantly suspend - 
ing the tremors and allowing him to use 
it for a short period.4 On the contrary, 
when the limbs are quiescent, a voluntary 
movement usually starts the tremors, 
which continue for some time afterwards. 
The attacks of tremors are at first of short 
duration, and separated by intervals of 
complete immunity; they become more 
severe and the intermissions shorter as 
the disease proceeds. In certain exam- 
ples the paroxysms have lasted so long as 
ten to forty minutes, and were followed by 
fatigue like that produced by violent mus- 
cular exercise.1 The tremors cease en- 
tirely during sleep. 
Parkinson does not seem to have noticed 
that frequently, in addition to the tre- 
mors, there occur tonic spasms (rigidity 
or contraction) of the muscles in the parts 
affected. The fingers or toes or the whole 
limb become rigidly flexed or extended. 
These cramps last for some minutes, and 
return at intervals; they are sometimes 
painful and followed by a sense of fatigue. 
They occur chiefly during the day, but 
sometimes in the night also. In a case 
recently observed by the writer startings 
of the limbs took place during sleep, in 
the form of powerful flexion of the knees, 
by which the legs were suddenly drawn 
up. On the relaxation of the spasms, the 
limbs were slowly let down to their pre- 
vious position without awakening the pa- 
tient. 
Local deformities also sometimes result. 
From the hands being kept constantly 
supported to stay the tremors, the fingers 
become dislocated backwards on the meta- 
carpals so as to form an angle with the 
back of the hand.2 Sometimes the dis- 
tortion is lateral; in a case lately seen 
the fingers were bent obliquely to the 
radial side, owing probably to the clonic 
and tonic contractions being more power- 
ful in that direction. These deformities 
must not be confounded with the effects of 
rheumatism. 
[A not uncommon symptom is a sense 
of great heat of the body; causing the 
patient to throw off the bedclothes, &c. 
This sensation is shown by the thermome- 
ter to be subjective only ; there being no 
real excess of temperature.-H.l 
3d Stage. Disturbance of Equilibrium.- 
The occurrence of this symptom is varia- 
ble : sometimes it appears early, while 
the legs are becoming tremulous; some- 
times it is deferred for ten or twelve years 
or more after the tremors ; in many cases 
it is entirely absent (Paralysis Agitans 
simplex). It is therefore less a stage than a 
peculiar feature characteristic of one form, 
or of a special extension of the disease ; 
its presence should accordingly always be 
indicated by some additional term, such 
as festinans or procursoria. 
Owing to deficient power in the extensor 
muscles of the back, the patient becomes 
less able to preserve the erect posture ; he 
bends forward while sitting, still more 
while standing. In walking, the centre 
of gravity being displaced forwards, while 
the legs can only be moved slowly, stiffly, 
and with some degree of spasmodic jerk- 
ing agitation, he is in constant danger of 
falling ; he stumbles over small obstacles 
in his path, and by taking short hurried 
steps he is impelled from a walk to a run, 
[* Erb and others assert that the head is 
seldom or never affected in Paralysis Agitans, 
although it is in cerebro-spinal sclerosis. See 
Erb on Multiple Sclerosis, Ziemssen's Cyclo- 
psedia, vol. xiii.-H.] 
2 In Oppolzer's remarkable case the tremors 
are reported to have extended to the muscles 
of the face ; also in a few other cases. 
3 A patient we saw lately holds a smooth- 
ing-iron to keep his hand still; another 
steadies it by seizing a chair. 
4 Tebert refers to a similar instance. 
vol. i.-46 
1 Trousseau, Clin. Med. Ibid. 722 
PARALYSIS AGITANS. 
till he has difficulty in stopping himself. 
Persons in an early stage of this condition 
can sometimes march slowly with long 
measured strides, quite well; but so soon 
as they resume their shuffling gait, they 
must quicken their pace to avoid falling. 
There is no vertigo, as in cases of precipi- 
tancy from tumors or injuries of the cere- 
bral peduncles and adjoining parts. The 
forward running is the usual form of this 
curious symptom, which has not yet been 
much studied, but exceptional varieties 
occur. Thus Romberg met with an oppo- 
site disturbance of balance. " Two pa- 
tients, aged sixty, felt a constant desire to 
walk or fall backwards, and therefore car- 
ried the head strongly bent forwards; 
one of them in order to stand, separated 
his legs widely, at the same time cross- 
ing his arms on the back, with the view 
of offering some resistance to the over- 
powering tendency to move backwards" 
(Paralysis Agitans retrograda). Graves 
mentions a patient who had to be 
balanced to and fro before starting, and 
who, if arrested in his forward move- 
ment, immediately began to hurry back- 
wards and could not stop himself. No 
case is recorded of a disposition to fall or 
move sideways.1 There is a less degree 
of this symptom in which the patient 
stoops and shuffles in his walk, but has 
not the true festination. 
4th Stage. Disease fully established.- 
When the tremors have become general, 
violent, and of frequent recurrence, the 
patient experiences great inconvenience, 
which increases with the progress of the 
disease. The limbs cannot execute the 
directions of the will in the common 
offices of life. The patient is unable to 
write or perform any manipulation : he 
cannot hold a book to read, and has the 
utmost difficulty or isquite unable to clothe 
or feed himself. Raising a glass of water 
to the lips is impossible; the fluid is spilled 
and the glass knocked to and fro against 
the mouth. Patients deprived of assist- 
ance, in order to allay their thirst, have 
lapped up fluids with the tongue, like the 
lower animals. It is painful to witness 
the struggles which the patient makes to 
control the agitation of his body and effect 
some desired movement; the more he 
tries the more extravagant the jactitations 
become. To increase his distress, parox- 
ysms of tremors now often arise during 
rest; indeed, at times, the tremors be- 
come almost constant, with frequent 
aggravations. Commencing for instance 
in one arm, the wearisome agitation is 
borne until beyond suflerance, when by 
suddenly changing the posture it is for a 
time stopped in that limb, but commences 
generally in less than a minute in one of 
the legs or in the arm of the other side, 
often spreading over the whole body. 
Harassed by the tormenting round, the 
patient has recourse to walking, to which 
lie is partial, both on account of the relief 
afforded by change of posture and because 
his attention is diverted from his unpleas- 
ant feelings by the care and exertion re- 
quired for its performance. But if the 
procursive tendency has appeared, this 
relief is denied. The propensity to lean 
forward becomes invincible. Forced to 
step on the toes and fore-part of the feet, 
while the upper part of the body is thrown 
forwards, he is irresistibly impelled to 
take quick and short steps, and to adopt 
unwillingly a running pace, in order to 
avoid failing on the face.1 On some days, 
however, the tremors are less severe ; and. 
the patient is always relieved by intermis- 
sions during the day and complete cessa- 
tion of the tremors during the night. The 
disease, even at this stage, sometimes 
undergoes remissions for some weeks or 
months, during which the tremors greatly 
abate : unfortunately a relapse occurs and 
the disease resumes its progressive course. 
5th. Advanced and Final Stages.-Hith- 
erto the jactitations have been suspended 
at intervals during the day, and have 
ceased entirely at night. But in this stage 
tremors of the limbs occur even during 
sleep, and increase till they awaken the 
patient, often with much mental agitation 
and alarm. In addition, signs of failing 
strength and physical decay, which had 
previously appeared, rapidly increase. 
Unable to convey food to the mouth, the 
patient must be entirely fed by others. 
The bowels, previously torpid, require 
powerful stimulating medicine or mechan- 
ical aid for their relief. The trunk be- 
comes permanently bowed, and the whole 
muscular power fails. The patient walks 
with great difficulty; a stick no longer 
suffices; he requires an attendant, who, 
walking backwards before him, prevents 
his falling forwards by the pressure of his 
hands against the fore-part of his shoul- 
ders. His words are scarcely intelligible, 
and the memory and intellect are weak- 
ened. The actions of the tongue and 
pharynx are so hindered by enfeebled 
action and perpetual agitation that the 
food can hardly be masticated or swal- 
lowed ; the saliva mixed with particles of 
food continually drains from the mouth. 
1 Sauvages relates of a painter, aged 50, 
that he was not only impelled forward in 
walking, but could not turn right or left till 
he stopped himself against an obstacle, sup- 
ported by which he turned his body gradually 
round and then hurried straight on anew. 
This is given as Scelotyrbe festinans, without 
any mention of tremors; but similar conditions 
have been observed in Paralysis Agitans. 
1 In the words of Trousseau, "Il s'qp va 
trotillant, sau tillant,-il est oblige de courir, pour 
ainsi dire, apres lui-meme." DESCRIPTION. 
723 
Finally, amid increasing general debility 
and diminished voluntary power, the tre- 
mors become more vehement, and seldom 
cease for a moment. When exhausted 
nature seizes a small portion of sleep, the 
motions become so violent as to shake the 
bed-hangings, and even the floor and 
sashes of the room. The chin is bent 
down upon the sternum; the power of 
articulation is lost; the slops with which 
he is fed trickle continually from the 
mouth. The urine and feces are passed 
involuntarily ; bed-sores form ; and at the 
last constant sleepiness, and other marks 
of extreme exhaustion, usher in the fatal 
termination. 
The senile forms of the Paralysis Agi- 
tans, as just described after Parkinson, 
represent, it should be observed, the most 
aggravated examples of the disease. And 
the subject of it being advanced in years, 
the effects of senile decay are necessarily 
mixed up with the other symptoms. In- 
deed, this kind of Paralysis Agitans seems 
to induce and to terminate in general 
failure of the system. But the course of 
the senile disease is not always so deplor- 
able. Many cases of the simple or non- 
procursive form remain stationary for an 
indefinite period, and never reach the 
ultimate stages.1 A few exceptional cases 
have been cured. The procursive Paralysis 
Agitans also occasionally exhibits an ar- 
restment, or, at least, extreme protraction 
of its course. The fatal forms seldom 
occupy less than ten years. At the same 
time, Parkinson's account, drawn directly 
from nature, represents, without exagger- 
ation, the slow, continual progress and 
the fatal results of the senile Paralysis 
Agitans in its. full development. 
One very important fact, observed in 
nearly all cases of Paralysis Agitans, is 
that the cutaneous sensibility is not af- 
fected, either in regard to pain, touch, or 
temperature. The sensory powers, in- 
deed, persist remarkably even amid the 
general failure of nervous energy in the 
later stages of the disease. 
The Unilateral2 or " Hemiplegic" va- 
riety of Paralysis Agitans, first noticed 
by Marshall Hall, presents no essential 
difference from the bilateral (paraplegic) 
disease, just described. The limbs on one 
side are agitated with violent chronic 
tremors, while those on the opposite side 
are entirely unaffected, or exhibit only a 
slight and occasional tendency to tremble. 
The affection is not less severe than the 
bilateral, into which it probably passes. 
There is no complete case of this form, 
from beginning to end, on record. In one 
instance, lately under observation,1 there 
was no disturbance of equilibrium, no 
festination, and it does not appear that 
this symptom has been met with in the 
unilateral disease. The progress is, pro- 
bably, the same as in the other senile 
forms. 
To sum up: Paralysis Agitans senilis 
occurs in advanced lite, past fifty, usually 
past sixty years of age ; it is combined 
with and appears to hasten senile decay. 
Two forms of it are distinguished, the 
Simple and the Procursive (festinans) : it 
is usually very protracted, lasting ten 
years or more, and is, with rare excep- 
tions, incurable. 
We pass now to those forms of the dis- 
ease which occur earlier in life. 
I. 11. Non-senile forms of Paralysis 
Agitans, occurring under fifty, without 
fatal tendency, and sometimes admitting 
of cure. They are much rarer than the 
senile forms of the disease. 
1st. Paralysis Agitans simplex, non-seni- 
lis (sine festinatione).-This form resembles 
the senile disease in regard to the tremors, 
differing chiefly by the absence of the 
signs of senile decay. The jactitations 
affect the same parts, the limbs, head, and 
trunk, exempting the muscles of the eye- 
ball, and usually also the facial muscles of 
expression.2 They come on in paroxysms 
excited by attempts at voluntary move- 
ments, or by mental emotion ; they sub- 
side or disappear during rest, and they 
cease entirely during sleep. In severe 
cases they are extremely violent. The 
limbs and the whole body quiver and 
shake convulsively in the most extrava- 
gant manner. The patient cannot stand 
without support; in walking he jerks and 
staggers as if moved by broken springs, 
and is like to be pitched to the ground at 
every step. He cannot dress or feed him- 
self; if his limbs are approximated, they 
knock against each other ; and if his hand 
1 Dr. Maclachlan, out of a large number of 
instances among the inmates of Chelsea Hos- 
pital, found that the affection often had little 
or no influence in shortening life. None of 
his cases had occurred below 55, the majority 
between 65 and 70, yet in many the disease 
lasted upwards of 30 years. An in-pension- 
er, in his 107th year, had been affected since 
he was 60.-Page 213. 
2 "Uni-" and "bilateral" are preferable 
to "Jiemi-" and "paraplegic," being less apt 
to lead to confusion with ordinary motor pa- 
ralysis. 
1 Patient of Dr. Warburton Begbie, to whom 
the writer is indebted, for an opportunity of 
examining it. 
2 Marshall Hall mentions a male, aged 28, 
with Paralysis Agitans of right arm and leg, 
who presented a ' ' peculiar rocking motion of 
the eyes, and a degree of stammering and de- 
fective articulation." Certainly, however, 
tremors of the oculo-motor muscles are very 
rare in Paralysis Agitans; singularly so, since 
nystagmus by itself is not uncommon 724 
PARALYSIS AGITANS. 
is brought near the chest or the face, it 
strikes upon them in a series of quickly 
repeated blows. When the shaking arises 
unexpectedly, the patient may hurt him- 
self, knocking his head against a wall, &c. 
Il is rare, however, for the tremors to 
exhibit such extreme vehemence; more 
commonly they exist only to the extent 
of rendering the execution of regular 
movements impossible, interfering com- 
pletely with the patient's usefulness. It 
is further observed that, although some- 
times as severe, or more so, than in the 
senile forms, the tremors are less continu- 
ous and never occur during sleep, although 
they may come on as soon as the patient 
awakes or turns in bed. The special 
distinctions of the non-senile Paralysis 
Agitans are therefore : 1st. There is no 
disturbed equilibrium; no disposition to 
fall or hasten forwards or backwards.1 2d. 
The diminution of voluntary muscular 
power is slight; sometimes none is obser- 
vable. Tested by the grasp of the hand, 
by the dynamometer, or by the ability to 
lift weights or bear burdens, the muscular 
force is often found equal to the normal 
standard; sometimes the shaking arm 
appears stronger than the sound one. Yet 
the patient himself usually complains of 
diminished strength, and he has less ability 
to sustain prolonged exertion. If the 
disease progresses, the muscular debility 
increases. This is an important sign, for 
increasing muscular weakness is of unfa- 
vorable prognosis. 3d. There is no fatal 
tendency. The affection is extremely ob- 
stinate, often incurable, but the general 
bodily health is not impaired, and the 
duration is indefinite if no complication 
supervene. A patient, lately seen, aged 
sixty-six, was first affected at twelve 
years of age; the tremors have entirely 
unfitted him for labor during his whole 
life; yet even now bis appetite and bodily 
health are excellent. Similar cases are 
not very rare ; but, being regarded as ex- 
amples of incurable infirmity,2 they were 
not brought under the notice of the phy- 
sician, and probably suffer irremediably 
from neglect of care at the earliest stages. 
4th. Occurring in middle life (twenty-five 
to fifty), however formidable in appear- 
ance, it is susceptible of amelioration, and 
sometimes of cure. A case was cured by 
Elliotson by the use of carbonate of iron 
(1827), and several examples of recovery 
have been recorded under different meth- 
ods of treatment.3 Others, however, have 
resisted treatment altogether. To account 
for the fact that some cases are curable 
while others are not, it has been supposed 
that the former are functional and the lat- 
ter organic. 
To the slighter and more curable forms 
of Paralysis Agitans belong the Hysterical 
Paralysis Agitans, which exhibits the 
usual tremors (sometimes an approach to 
the festination), and is accompanied by 
hysterical symptoms and usually some 
disorder of the general health. Though 
often obstinate, it is entirely free from 
danger, and is usually cured when the 
general hysterical condition is removed by 
judicious treatment. 
The Intermittent Paralysis Agitans, in 
which tremors of the limbs, lasting five to 
six minutes, recur twice or thrice in an 
hour, appears frequently to depend on 
intestinal worms in young subjects, or is 
a variety of the hysterical or reflex forms. 
It is curable.1 
Beflex Paralysis Agitans may depend 
upon disordered primse vise, and be cured 
by appropriate remedies (Sauvages, Tre- 
mor a saburra). Perhaps derangements 
of other internal organs may exert a simi- 
lar effect; as also external wounds and 
injuries. An interesting case, caused by 
the latter, was observed by Dr. Door, and 
related by Dr. Haas (1852). A healthy 
girl of nineteen received a splinter under 
the nail of her right thumb, on the extrac- 
tion of which violent pain, and soon after 
Paralysis Agitans, came on in the right 
leg, subsequently spreading to the right 
arm and the whole body. The tongue 
and speech became affected; the general 
health suffered; the face had a stupid 
expression ; and she dragged the legs in 
walking. She recovered completely. 
Lastly, it appears from the important 
cases described by Dr. Hennis Green (a 
few similar to which are mentioned in 
older authors) that nervous tremor of the 
nature of Paralysis Agitans may occur in 
children (age, eleven to thirteen), and is 
in them speedily curable. Of the three 
cases which he reports, two recovered in 
about a month ; the third died of pulmo- 
nary consumption, and no trace of lesion 
was found in the brain and spinal cord. 
The non-senile Paralysis Agitans is 
particularly apt to be mistaken for cho- 
rea ; it sometimes assumes the unilateral 
form. 
Reynolds ; Handheld Jones ; Sanders, case of 
dystaxia or Pseudo-paralysis Agitans. This 
patient, after a year, was able to return to 
light work, the tremors having nearly ceased. 
Dr. Alexander Turnbull, R. N., has recently 
communicated to the writer two cases which 
came on after ague at Panama-the one re- 
covered after a year, the other was still un- 
der treatment. 
1 See Gowry's case. 
1 At least no case of non-senile Paralysis 
Agitans, accompanied by festination, is known 
to the writer. 
2 Often objects of charity, or paupers in 
and out of workhouses. The disease, how- 
ever, affects the rich as well as the poor. 
8 Trousseau, case of St- Vitus's dance 
(properly Paralysis Agitans) in 1843; Russell CAUSES. 
725 
2d. Paralysis Agitans Toxica.-Various 
poisons occasion debility and tremors. 
When these symptoms arise from the 
abuse of alcohol, tea, coffee, tobacco, or 
opium, they rarely occur except when the 
parts are used, and hence are simple 
tremors only; but if they take place also 
during repose, they belong to this sort of 
Paralysis Agitans. A strongly marked 
and very characteristic form of the cura- 
ble Paralysis Agitans is brought on by 
inhaling fumes of mercury, and, though 
less frequently, by certain other metallic 
poisons (tremor metallurgorum-tremble- 
ment mercuriel). This will be described 
elsewhere. (See Tremblement Metal- 
lique.) 
The other kinds of tremor mentioned 
by medical writers are either unimportant 
or symptomatic of other diseases; they 
present an interest, as related pathologi- 
cally to the morbid condition probably 
existing in idiopathic Paralysis Agitans. 
Such are the tremors from bodily weak- 
ness and mental emotion : tremor senilis, 
which is evidently closely allied to and 
may pass into Paralysis Agitans senilis ; 
febrile tremors and rigors (attended by a 
sense of cold, which is never present in 
Paralysis Agitans), analogous probably 
to the toxic forms of Paralysis Agitans ; 
tremor or subsultus tendinum, which ex- 
hibits the same spasmodic jerking of the 
muscles as Paralysis Agitans ; lastly, the 
tremors in diseases of the brain and spinal 
cord (hydrocephalus, parasites in cere- 
brum, myelitis, ataxia, tumors, &c.) are 
symptomatic, and, as previously explain- 
ed, distinct from idiopathic Paralysis 
Agitans. 
II. Local Paralysis Agitans attacks a 
single part, most frequently the head and 
neck, or the arm, or the lower jaw, and 
remains limited to the region affected. 
The tremors occur occasionally, seldom 
constantly, during the day ; they cease at 
night; they are excited or aggravated by 
exertion or emotion. Usually free from 
danger, local Paralysis Agitans is re- 
garded, like the spasmodic tics, as an in- 
firmity or bad habit rather than a disease. 
It is at the same time very obstinate, in 
fact usually incurable. It is important to 
distinguish the idiopathic Paralysis Agi- 
tans which continues local from that which 
is the precursor of the progressive general 
disease, or which may be symptomatic 
of a tumor or other lesion of the nerve 
centres. At first the distinction may be 
impossible ; but the history and course of 
the affection determines the diagnosis. 
Whenever the tremor has continued for 
some time unattended by any concurrent 
serious symptoms and strictly confined to 
one part, experience warrants the convic- 
tion that the morbid action has been ex- 
hausted in a circumscribed area, and that 
no extension of the disease need be feared. 
It is, indeed, singular that after a few 
years the local exhibits no tendency to 
pass into the general disease. 
A few remarkable cases have occurred 
of Paralysis Agitans restricted to the 
lower jaw and tongue ; in some distress- 
ing instances all remedies proved unavail- 
ing. The pathology has not been ascer- 
tained, and probably the severer cases 
were not idiopathic, but were symptomatic 
of some grave disease of the nerve centres. 
Of the latter kind an interesting case is 
recorded recently by Leyden, in which 
Paralysis Agitans of the right arm was 
found associated with sarcoma in the left 
optic thalamus. The more serious symp- 
tomatic kinds are distinguished from the 
idiopathic by the more dangerous cha- 
racter of the symptoms, among which are 
the signs of centric nervous lesion, such 
as motor and sensory paralysis, &c. In 
respect of pathology and treatment, the 
local resembles the general Paralysis Agi- 
tans. 
Causes. - These are frequently ob- 
scure, but it is probable that conditions 
productive of debility or atrophy of the 
motor nerve centres occasion the idio- 
pathic Paralysis Agitans. The results of 
experience are as follows: Predisposing 
Causes.-1. Age is of primary importance, 
both in causing the disease and aggra- 
vating it. 2. Hereditary and parental in- 
fluence is indicated in some cases.1 3. 
The male sex is almost exclusively the 
subject of general Paralysis Agitans ; the 
hysterical forms and local tremors of the 
head being met with in the female. Ex- 
citing Causes.-1. Violent muscular exer- 
tion is a frequent cause, as also-2. Inju- 
ries, especially falls; also wounds, &c. 
3. Excessive mental exertion, and parti- 
cularly-4. Violent emotions, as terror or 
fright, which have sometimes produced 
the disease suddenly. 5. Venereal ex- 
cesses have been alleged. 6. Exposure to 
cold and wet, as lying on damp ground, 
especially when giving rise to-7. Rheu- 
matism, which was noted by Parkinson, 
and has a decided causal relation to Para- 
lysis Agitans ; also-8. Ague.2 In certain 
cases Paralysis Agitans appears to have 
followed-9. Fever (typhoid and various 
exanthemata) and-10. Syphilis. 11. In- 
testinal worms sometimes give rise to it 
in young subjects, occasionally modified 
' Sauvages: " Mulier gravida, quse maritum 
subito peremptum exhorruerat, genuit filium 
tremore miserando correptum." Most knew 
a whole family in which it was hereditary. 
Lebert refers to females who, in successive 
generations, being otherwise in good health, 
presented tremors of the head at the climac- 
teric age. 
2 Romberg, Maclachlan, Turnbull. No re- 
lation to gout has been alleged. PARALYSIS AGITANS. 
726 
into a periodical or intermittent type. 12. 
Disordered primse vise (tremor a saburra). 
13. Suppressed itch will hardly now be 
admitted.1 14. Alcohol, opium, tobacco. 
15. Certain poisons, particularly mercurial 
vapors, cause the Paralysis Agitans toxica. 
While these are the causes of the idiopathic 
disease, the symptomatic Paralysis Agi- 
tans, as already stated, may occur, com- 
bined with other characteristic signs of 
nervous disease, in various lesions and 
tumors, &c., of the brain and spinal cord. 
Diagnosis.-Idiopathic Paralysis Agi- 
tans is sufficiently characterized to be of 
easy recognition; but its relations to al- 
lied affections are important. 1st. It is 
distinguished from the other species of the 
class tremors, because in Paralysis Agi- 
tans the trembling occurs not only during 
action, but even when the parts are not 
in use and are supported (spasmodic, 
tremor coactus). Tremor senilis, which 
most resembles it, may pass into Paralysis 
Agitans, when the tremors which begin 
during action continue after it has ceased: 
the tremors usually at the same time in- 
crease in intensity from trembling to jac- 
titation. 2d. The different kinds of Para- 
lysis Agitans are distinguished: the simple 
senile form by occurring in advanced life, 
by its progressive course, association with 
general decay of the system, and fatal 
issue; the procursive (festinans) senile form 
presents in addition the disturbed balance 
in locomotion ; the simple non-senile form 
occurs in middle age or under, is often 
stationary in its progress, may be amelio- 
rated or cured, and is not accompanied by 
disordered equilibrium ; the hysterical, re- 
mittent, reflex forms, and that occurring in 
children, &c., are known by their special 
circumstances; the toxic Paralysis Agitans 
is recognized by the cause, and by the 
concomitant effects of the poison-in the 
mercurial tremors the tongue and mouth 
are usually and early attacked, which is 
not the case in ordinary Paralysis Agi- 
tans. 3d. The relations to common 
chorea, both of difference and resem- 
blance, are instructive. Chorea occurs 
chiefly in the young before puberty; Para- 
lysis Agitans attacks the middle-aged, 
and especially the old. The gesticulations 
in chorea are jerking, irregular move- 
ments, changing frequently, and dissimi- 
lar on the two sides ; the tremors or jac- 
titations in Paralysis Agitans consist of 
to-and-fro oscillations of the part, due to 
the brief alternate action of antagonist 
muscles ; they continue long unchanged, 
and are usually the same on the two sides. 
Chorea specially attacks the female, Para- 
lysis Agitans the male sex. With atten- 
tion, therefore, the diseases are not diffi- 
cult to distinguish. But their points of 
resemblance are striking. Both consist 
of involuntary, spasmodic movements, 
rapidly repeated, and not under the con- 
trol of the will, while the voluntary motor 
power persists in the affected parts, al- 
though it is often enfeebled, the debility 
sometimes amounting to paralysis.1 Both 
are often caused by fright, and by rheu- 
matism (although no relation seems to 
exist between Paralysis Agitans and heart 
disease); in both, when fatal, no visible 
lesion may be discovered. On the other 
hand, chorea is nearly always curable in a 
comparatively short period ; while Para- 
lysis Agitans, although susceptible of cure 
in younger individuals, is a peculiarly ob- 
stinate disease, and is incurable in old 
persons, in whom it associates itself with 
senile decay. 4th. The irresistible move- 
ments forward or backward in Paralysis 
Agitans present great affinity to the like 
symptoms met with in "leaping ague," 
and certain forms of tarantism and ab- 
normal chorea, and which are also ob- 
served in connection with lesion of the 
cerebral peduncles or other parts of the 
encephalon.2 But these affections are not 
usually attended by tremors, and the his- 
tory and special concomitant symptoms 
are sufficiently distinctive. The differ- 
ence of Symptomatic from Idiopathic 
Paralysis Agitans must always be kept in 
view. 5th. The same remarks apply to 
the discrimination of idiopathic Paralysis 
Agitans from certain cases of locomotor 
ataxia and chronic myelitis, &c.-affec- 
tions which it often closely resembles in 
the progressive character of the symp- 
toms, and in the spasmodic nature of the 
movements. But these spinal diseases 
are, in addition to their clinical history, 
especially distinguished by the presence 
of decided motor, and mostly also of sen- 
sory paralysis ; while in idiopathic Para- 
lysis Agitans the sensibility is remarkably 
exempted, what is there called paralysis 
being only a failure of vigor. The diag- 
nosis is very important, and only difficult 
because the occurrence of tremors as a 
complication in various organic nervous 
diseases may mislead, if the difference of 
Symptomatic from Idiopathic Paralysis 
Agitans be not attended to. 6th. In a 
similar manner, Paralysis Agitans is dis- 
tinguished from beriberi, raphania, &c. 
1 Both are sometimes unilateral. 
2 Marshall Hall remarks the similarity of 
certain symptoms in Paralysis Agitans to the 
effects observed by Serres in diseases of the 
tuber annulare and tubercula quadrigemina. 
The irresistible movements-forward, back- 
ward, lateral, whirling, rolling, somersault, 
&c.-in experimental lesions of the brain in 
animals (Fodera, Magendie, Flourens, &c.) 
have thrown much light on the subject. 
1 Mentioned by Canstatt. 727 
PATHOLOGY and morbid anatomy. 
Complications. - These are rare in 
idiopathic Paralysis Agitans ; the health 
usually continuing good till senile decay 
begins. Apoplexy, hemi- and paraplegia 
sometimes occur, but not often. Common 
chorea has, in some cases, been found 
associated with Paralysis Agitans usu- 
ally, however, the disordered move- 
ments called chorea have been only exag- 
gerated examples of the shaking disease. 
On the other hand, as already remarked, 
symptomatic Paralysis Agitans may com- 
plicate many diseases of the brain and 
spinal cord. 
Pathology and Morbid Anatomy. 
- Tremors are generally admitted to be a 
sign of weakness in the nerve centres, and 
are ascribed to defective and interrupted 
discharge of nervous stimulus. But two 
kinds of tremors have been distinguished:2 
first, simple or passive tremors, which oc- 
cur during a voluntary act, and cease with 
it, being evidently due to want of power 
only (rpoyoi); second, spasmodic, clonic, 
or active tremors, which take place even 
during rest when the parts are supported 
and unemployed ftaxyos, tremor coactus, 
palpitatio): these are short, alternate, 
clonic convulsions of antagonist muscles, 
and imply some irritation in the motor 
nerve centres. Although these two kinds 
are allied and pass the one into the other, 
yet the distinction is important, and fur- 
nishes the ground of diagnosis ; the spas- 
modic, not the passive tremor being cha- 
racteristic of Paralysis Agitans. The dis- 
turbance of equilibrium is no doubt owing 
to an affection of a different part of the 
nervous system from the tremors, since 
these may exist, even generalized, with- 
out it. The cerebral or cerebellar pedun- 
cles or the pons Varolii, are most probably 
the seat of lesion. But while the locality 
is different, the association with tremors 
shows that the morbid action is probably 
the same in both. The general opinion is 
that the tremors are due to an affection of 
the spinal cord, the disturbed equilibrium 
to an extension of the morbid action 
within the cranium. Hence some wri- 
ters speak of Paralysis Agitans Spinalis, 
consisting of tremor and muscular de- 
bility, and Paralysis Agitans Cerebralis, 
in which the disturbance of equilibrium 
is superadded.3 There is no vertigo nor 
distortion of the eyeballs, as in lesion of 
the base of the encephalon. The dis- 
turbed equilibrium seems due to weak- 
ness of one set of muscles (e. g., extensors), 
and perhaps spasmodic action of their 
antagonists (i. e., flexors). 
Morbid Anatomy, which formerly gave 
only negative, has lately afforded indica- 
tions of positive results. The facts are as 
follows :- 
1st. In many instances of idiopathic 
Paralysis Agitans no lesion of the cere 
bro-spinal axis can be discovered by our 
present means of investigation. In these 
cases, therefore, the disease may be re- 
garded as functional or dynamical; and it 
may be presumed to depend, (a) on im- 
paired generation of nerve energy, due to 
some unknown conditions ; (b) alteration 
of vascular supply, either congestion, or, 
as late researches on the pathology of con- 
vulsions suggest, anaemia, i. e., deficient 
or interrupted vascular supply possibly 
also an oedematous condition of the nerve 
centres might cause the symptoms; (c) 
molecular physical or chemical changes, 
which we may certainly assume in the 
toxic forms (mercurial tremors). The 
functional are especially the curable forms 
of the disease. 
2d. In more inveterate, especially senile 
cases, Paralysis Agitans appears to de- 
pend on a discoverable lesion ; namely, 
an atrophic condition of the spinal cord, 
pons Varolii, crura, or medulla oblongata 
{atrophic or organic Paralysis Agitans). 
This atrophy has been found in several 
careful dissections, and it certainly coin- 
cides with and would explain the chief 
features of the disease-namely, its ob- 
stinacy or incurability, without immediate 
danger to life ; the progressive course; 
the impaired strength and muscular de- 
bility (paralysis); the occurrence in old 
age, after violent exertion and emotion, 
under conditions of premature senility, 
&c. In addition to simple atrophy, with 
serous accumulations, autopsies have re- 
vealed in different parts of the spinal 
cord, medulla oblongata, and pons an in- 
durated condition (sclerosis), with patches 
of gray or gelatinous degeneration, due 
to the new formation of connective tis- 
sue, which compresses and atrophies the 
proper nerve structures.2 Since a similar 
condition, involving extensively the pos- 
terior columns of the cord, is the chief 
lesion found in progressive locomotor 
ataxia (tabes dorsalis), some relation is 
established between it and Paralysis Agi- 
tans.3 It is curious that Parkinson (from 
the report of a case not seen by himself) 
drew attention to the induration and en- 
largement of the upper part of the me- 
dulla spinalis, oblongata, and pons, as 
the probable morbid condition in Paraly- 
sis Agitans, and supposed it might be 
due to simple inflammation, or rheumatic 
1 Marshall Hall, Kussmaul and Tenner, 
Brown-S^quard, &c. 
2 Bamberger, Skoda, Oppolzer, Lebert, &c. 
3 Also with tetanus, probably chorea, and 
with progressive paralysis of the Insane. 
See Rokitansky, Ueber Bindegewebs-Wuche- 
rung im Nervensysteme. Wien, 1857. Cru- 
veilhier, &c. 
1 Maclachlan, p. 216. 
2 Distinction first clearly drawn by Sylvius, 
previously indicated by Galen. 
3 Remak. 728 
PARALYSIS AGITANS. 
or scrofulous affection of the nervous sub- 
stance or membranes. The sclerotic 
atrophy does not seem to be of inflamma- 
tory origin, although, according to Ro- 
kitansky, it is preceded by congestion. In 
the early stages, there may be softening 
instead of induration. Rheumatic ami 
other morbid diatheses may probably dis- 
pose to it. Degeneration of the blood- 
vessels may possibly be connected with 
it.1 The pathogenesis of atrophy of the 
nerve centres, however, has not yet been 
fully investigated; and, although highly 
probable, it cannot yet be positively 
affirmed, that Paralysis Agitans depends 
upon atrophy, simple or sclerotic, of cer- 
tain parts of the cerebro-spinal axis. In 
regard to symptomatic Paralysis Agitans, 
the tremors are ascribed to the atrophy 
of the nerve substance surrounding the 
tumor or other principal lesion. 
But whether the disease be functional 
or organic (atrophic) in its nature, it 
clearly affects the motor centres only, ex- 
empting the sensory and the intellectual; 
and, further, the morbid state of the 
nerve centres implies not only diminished 
power, but some condition of spontaneous 
irritation, giving rise to the spasmodic 
jactitations even during rest. Probably 
the degenerative molecular changes in 
the nerve structures may occasion a dis- 
turbed equilibrium and consequent irregu- 
lar discharge of nerve stimulus. The 
morbid process is presumed to begin usu- 
ally in the cervical portion of the spinal 
cord, since the arms are apt to be first 
affected, and the disease presents the bi- 
lateral type. But the occurrence of the 
unilateral form, as well as the fact that 
the limbs are much earlier affected than 
the trunk, shows that the possibility of 
the cerebral centres of motion being 
sometimes attacked should not be over- 
looked. The disturbed equilibrium prob- 
ably ensues when the parts in the vicinity 
of the pons Varolii are involved, and the 
extension to the medulla oblongata is in- 
dicated by the impaired speech, degluti- 
tion, &c., which supervene in the ad- 
vanced stages of the disease. 
[Since this article was written, the 
distinction urged by Charcot has been 
generally accepted, between Paralysis 
Agitans and disseminated (multiple, 
cerebro-spinal) sclerosis. Of the two 
kinds of tremor above described, which 
may be called, the one passive and perma- 
nent, and the other volitional, the former 
is peculiar to Paralysis Agitans; the 
latter occurs in disseminated sclerosis. 
That is to say, in the first named disorder 
there is trembling at all times, whether 
the patient be moving or reclining, so 
long as he is awake. In the second dis- 
ease, tremor occurs only when some mus- 
cular action is attempted; then the move- 
ment of the muscles used becomes irregu- 
lar, with a coarser tremulousness than in 
shaking palsy (see Multiple Sclerosis, 
under Induration, in this volume). 
Charcot analyzes1 the morbid appear- 
ances of the cases above referred to, re- 
ported by Bamberger, Lebert, Skoda, 
Parkinson, and Oppolzer; and believes 
that some of them were examples of dis- 
seminated sclerosis, not of Paralysis Agi- 
tans. Yet, in Charcot's account of dis- 
seminated sclerosis, it is admitted that 
morbid anatomy has not made clear what 
location of disease explains the trembling 
which is one of its characteristic symp- 
toms. Erb,2 also, observes, that the two 
kinds of tremor, in some cases, "exist 
side by side." This pathologist, while 
preferring to regard such a combination 
as indicating the presence of two differ- 
ent diseases, rather than as evidence of 
the non-essentiality of the distinction be- 
tween them, adds: "We must wait for 
more accurate observations, however, be- 
Fig. 38. 
The writing hand. Habitual attitude of the hand 
at a somewhat advanced stage of Paralysis Agitans. 
(Charcot.) 
fore passing finally on the correctness of 
this view." 
Fig. 39. 
1 In Skoda's ease the nerve elements were 
destroyed in some parts of the brain, the 
pons, and medulla, by embryonal connective 
tissue; the vessels were obliterated; the muscles 
were in a state of fatty degeneration; the 
neurilemma of the nerves of the upper ex- 
tremity was thickened. The thickened neu- 
rilemma has been observed in other cases. 
Digital deformation, simulating that of primitive 
chronic articular rheumatism. (Charcot.) 
Ill three cases examined post-mortem by 
Charcot,3 the appearances common to all 
[' Lectures, &c., Leet, v.] 
[2 Ziemssen's Cyclopaedia, vol. xiii. Multi- 
ple Sclerosis.] 
[3 Joifroy, Soci^te de Biologie, 1871.] TREATMENT. 
729 
were the following : a, obliteration of the 
central canal of the spinal cord by pro- 
liferation of the epithelial elements which 
line the ependyma ; b, proliferation of the 
nuclei which surround the ependyma ; c, 
pigmentation of nerve-cells, most marked 
in Clarke's (posterior gray) columns. Two 
of the cases had also a multiplication of 
amyloid corpuscles; one, a sclerosed 
patch on the posterior surface of the bul- 
bus rachidicus.1 The language of Charcot 
appears to be still appropriate: "The 
special lesion of Paralysis Agitans re- 
mains to be discovered."-H.] 
Should future researches confirm the 
results above indicated, there would then 
exist a secure basis of morbid anatomy 
for the distinctions which authors have 
indicated clinically, of idiopathic Paraly- 
sis Agitans into functional and organic : 
the latter with, the former without, 
atrophy of the nerve centres; the latter 
mostly incurable, the former admitting of 
cure. 
The Prognosis is unfavorable, but de- 
pends upon the age of the patient and 
the particular form of the disease. When 
fully established, idiopathic Paralysis 
Agitans is an obstinate,2 and in the aged, 
with rare exceptions, an incurable dis- 
ease. But, unless mixed with signs of 
senile decay, Paralysis Agitans does not 
endanger life, and its course is often in- 
definitely protracted. As a rule, it is ob- 
stinate in proportion to the age of the 
subject, and is fatal only in the old. The 
distinction of curable and incurable, 
functional and organic (atrophic), has 
been already sufficiently indicated. It 
need only be added that mere violence of 
the jactitations is no evidence of incura- 
bility ; slight tremors are frequently the 
most obstinate ;3 it is the persistence of 
tremors during absence of voluntary 
effort, and especially during sleep, the oc- 
currence of disturbed equilibrium, and 
symptoms of senile decay which are of 
serious import. Disturbed equilibrium is 
apparently incurable in itself, as well as 
of bad augury for the disease generally. 
The supervention of convulsions, apo- 
plexy, motor or sensory paralysis, indi- 
cates more immediate danger to life. 
In the Registrar-General's Reports for 
England and Wales, from 1855 to 1863 
inclusive, 205 deaths from Paralysis Agi- 
tans are recorded, 129 being males, and 
76 females; on an average about 14 males 
and 8 females annually. Of these 205, 
189 were above 55 years of age; nearly 
half, viz., 91, occurring at 65 years ; only 
16 below 45 years, one death taking place 
at 20 years. It may be doubted, how- 
ever, whether the cases fatal below the 
age of 45 were true idiopathic Paralysis 
Agitans ; more probably they were exam- 
ples of spinal or cerebral disease accom- 
panied by tremors, i. e., by symptomatic 
Paralysis Agitans. 
Of the Modes of Termination, the prin- 
cipal in the senile disease is by general 
decay of the system. Sometimes life is cut 
short by the intercurrence of the usual 
diseases of old age. Trousseau states 
that in three cases which he traced to 
the end the patients all died of pneumonia. 
The non-senile forms of Paralysis Agitans 
are not known to have any special mode 
of termination. 
Treatment.-The modes of treatment 
and remedies employed are numerous, but 
few have been attended with success. 
Allowance must be made for the form of 
the disease; the senile being mostly in- 
curable, the non-senile obstinate, but sus- 
ceptible of relief or cure. The physician 
must keep in mind the propriety of ab- 
staining from remedies in inveterate 
cases, after a fair trial has been given to 
them: a fruitless perseverance would 
only injure the general health and excite 
false hopes. At the same time, general 
hygienic measures are always beneficial, 
and by their means alone, the symptoms 
may be alleviated, and life prolonged to 
advanced age. 
The methods of treatment are:- 
1. Antiphlogistic.-This used to be com- 
monly practised on the supposition of the 
congestive or inflammatory nature of the 
affection of the spinal cord. In some 
cases, in an early stage, it seems to have 
done good; purgatives, indeed, in judi- 
cious moderation, are useful in all cases, 
and they cure the forms depending on 
disordered primje vise (tremor a saburra). 
The means employed were: Venesection 
general or local, purgatives, diaphoretics, 
mercury, blisters, setons, cauteries actual 
and potential, moxas, &c., to the spine; 
frictions, stimulant embrocations, hot 
baths, &c. In the majority of cases, how- 
ever, this practice did no good or did posi- 
tive harm. The treatment now preferred, 
especially in chronic cases, is- 
2. Tonic, general and nervine. Hygi- 
enic regimen, nutritious but not stimu- 
lating diet; little wine ; rest or moderate 
f1 Bulbe rachidien, the lower part of the 
medulla oblongata.] 
2 "Morbus valde pertinax," Juncker. Com- 
paring it with apoplexy and motor palsy, &c., 
he says it is inferior to them in danger to life, 
but equals them in reference to treatment. 
3 Dr. Russell Reynolds, in a letter, June 1, 
1865, says: "From what I have seen of a 
large number of cases, I am led to believe 
that there is a most important difference be- 
tween those cases in which there is trembling 
only and those in which there is clonic alter- 
nate spasm. In the latter the prognosis is 
very much more favorable than in the for- 
mer." The age of the patient and stage of 
the disease being, of course, taken into ac- 
count. 730 
PARALYSIS AGITANS. 
exercise, light gymnastics. Excessive ex- 
ertion is injurious, and many cases of sim- 
ple Paralysis Agitans are aggravated by 
the patients when poor being compelled 
to work, or, when rich, endeavoring by 
forced exercise to overcome the debility 
in which they suppose their disease exists. 
Subcarbonate of iron has been a noted 
remedy in consequence of Elliotson hav- 
ing cured cases by it in persons under 50; 
it failed in older patients. Quinine, zinc, 
arsenic, nitrate of silver, chloride of gold ; 
strychnine, which has apparently cured 
some, and failed in other cases; ergot, 
said to have been beneficial; iodine and 
bromide of potassium, balsams, oil of tur- 
pentine, sarsaparilla, quassia, colchicum, 
&c.; Iceland moss; mineral-waters, sul- 
phurous or chalybeate ; sea or mountain 
air, the milk cure, &c. 
3. Narcotics and Calmants. - Opium, 
belladonna, henbane ($ss of Tinct. thrice 
daily, used successfully in functional Pa- 
ralysis Agitans by Dr. Handfield Jones); 
stramonium ; chloroform stops the tremors 
at the time, but does not appear perma- 
nently beneficial; ether, musk, camphor ; 
veratrin, externally or internally, reported 
successful in a case by Volz; valerian and 
valerianate of zinc; Calabar bean, tried 
without success by Dr. J. W. Ogle. 
4. Baths have been much resorted to, 
sometimes with success, often without 
effect. Warm sulphur baths, especially 
of liver of sulphur, has been specially 
recommended. Simple warm baths with 
cold douches (Romberg). Vapor baths, 
Russian baths, and baths of gelatine, fir- 
tops, mud, even animal baths, have been 
used in Germany. The water-cure, cold 
affusions; sea-bathing, which rendered 
one case stationary (Lebert); brine baths, 
ice baths, first tepid, gradually made 
colder. It should be remembered that 
some of these, especially the cold-water 
cure, are not free from danger, and require 
proper caution in old persons ; sometimes 
they aggravate the disease. 
5. Electricity and Galvanism.-Partially 
successful in previous experience, elec- 
tricity was found to produce no improve- 
ment in four cases observed by Gull. The 
interrupted galvanic current appears also 
to have been of little service; but the con- 
tinuous current recommended by Remak 
proved successful in his hands with a pa- 
tient aged 60, and others were benefited 
by it. In a man, aged 57, the disease, 
well marked though recent, was cured in 
this manner by Dr. Russell Reynolds. 
After five applications of Pulvermacher's 
chain of 120 links, daily, for one hour, 
the spontaneous jactitations completely 
ceased; the same treatment, continued 
every second day, completed the cure in 
about a month. In other instances, this 
means has not produced such favorable 
results, but it deserves a persevering trial 
in all cases. 
On the whole, good hygienic rules, at- 
tention to any special indications, gouty, 
rheumatic, &c.; regulation of the primse 
vise; the administration separately or 
combined of general and nervine tonics, 
and calmants, and the judicious use of 
the continuous galvanic current, are the 
measures chiefly to be recommended. 
Depletion and counter-irritation are sel- 
dom required, and would in most cases 
be highly injurious. Time must in all 
cases be allowed, for the affection is ob- 
stinate. In the confirmed senile forms, 
we may be satisfied with arresting or 
mitigating, but must not expect to cure 
the disease. 
References in chronological order. When 
marked °, the originals were not obtain- 
able. 
Hippocrates, Coan prognost. and Prorrhet., 
Ed. Kiihn, i. pp. 159, 161, 246, 288; Epidem. 
iii. § 3, 4th case, p. 298, &c. Celsus, lib. iii. 
c. 27, and lib. i. c. 9. Galen, on Tremor, 
Palpitation, Convulsion, and Rigor, Ed. Kiihn, 
vii. 584; Scelotyrbe, Definitions, xix., 427, § 
293. Oribasius (a. d. 360), Ed. Bussemaker 
and Daremberg, iii. 209, On Trembling (from 
Galen). Paul jEgineta (6th or 7th century), 
Book iii. sect 21, On Trembling, Syd. Soc. 
transl. i. 407. Diemerbroeck (1652) Disp. de 
Paral. et Tremore. Tulpius, Obs. Med. i. 12, 
Tremor periodicus, 1672. Sylvius de la Boe, 
Op. Med., Ed. Alt. 1680; Prax. Med. 1. i. c. 
42, p. 291 ; De Spirit. Animal, per nervos. 
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On Stupor, Torpor, Tremor, &c. Obs. 6-11, 
pp. 346-9. Juncker, Conspect. Med. 3 Ed. 
1737, Tab. 115; De Tremore artuum, p. 886. 
Gaubius, Inst. Path. Med. 1758, Spasmus, § 
751; Paralysis, § 757. Van Swieten, Com- 
ment. 2d Ed. 1749, ii. § 627, Tremor febrilis; 
cases of Paralysis Agitans at p. 181, Vidi in 
hac urbevirum, &c. Sauvages, Nosol. Meth., 
Ed. ult. 1768, i. p. 557, § xiv. Tremor, and 
p. 590, 4 xxi. Scelotyrbe, festinans et insta- 
bilis. Linnaeus, 1763, Gen. Morb. 144, Hiera- 
nosos. ° Vogel, Def. Gen. Morb. 1764, Hiera- 
nosos. Macbride, Theory and Pract. of Physic, 
1772, pp. 558-9, Hieranosos. Sagar, Syst. 
Morb. Sympt. 1779, Tremor, pp. 430-2. Cul- 
len, Synops. Nosol. Meth. 1785, Gen. 43, Pa- 
ralysis-Tremor. Kirkland, Comment, on Apop. 
and Parol. Affect. 1792, pp. 102 and 122. 
Heberden, Comment., Ed. Alt. 1807, c. 91, De 
Tremore, p. 371. Parkinson, Essay on the 
Shaking Palsy (Paralysis Agitans), London, 
1817. Art. Scelotyrbe in Diet, des Sc. Med. t. 
1. pp. 134, 1920. Cooke, Nerv. Diseases, 
1821, ii. p. 207. Mason Good, Study of Med. 
2d. Ed. 1825, iv. Synclonus Tremor, p. 458, 
and Syncl. Ballismus, p. 473. Elliotson, 
Med.-Chir. Trans, xiii. p. 240, 1827 ; Lancet, 
June 4, 1831, p. 290; Ryan's Lond. Med. and 
Surg. Journ. 1832, ii. 605; Lond. Med. Gaz. athetosis. 
731 
xi. p. 532, Jan. 1833; Prin. and Pract. of 
Med. by Rogers and Lee, 2d Ed. 1846, ch. xi. 
p. 689. Cruveilhier, An. Path. t. ii. 32, 
Liv., Pl. 2, fig. 3, p. 19, 1829. Gowry, Case 
of Par. Agit. Intermittens (cured), Lancet, 
1831, p. 651. Todd, in Forbes' Cyc. of Pract. 
Med. 1834, iii. 259, and Clin. Leet. 2d Ed., 
Leet. 45, p. 764, &c. Most, Encyc. d. Med. 
Prax. 1837, ii. 555. Gibson, on Spin. Irrit. 
case 5, Lancet, ii. 1838-9, p. 568. Romberg, 
Nerv. Diseases, 1st Ed. 1840; 3d, 1857; Syd. 
Soc. transl. 1853, ii. 233. Marshall Hall, 
Dis. and Derange, of Nerv. Syst. 1841, p. 320. 
Thompson, Secale cornutum in Chorea, Par. 
Agit. &c. Lancet, Jan. 29, 1842, p. 616. 
Graves, Clin. Med. 1843, 1st Ed. p. 714; El- 
len Davis's case, &c. Canstatt, Pathol, or 
Handb. der Med. Klinik, 3d Ed. Bd. iii., 1 
Abth. pp. 441-5, 1843. ° Trousseau, Des. 
Prep, de Noix vom. dans la Danse de St. Guy, 
Journ. de Med. par Beau, June, 1843, p. 161, 
reported as Par. Agit. in Canstatt's Jahrb. 
1843, Bd. ii. p. 99, § 35. Watson, Prin. and 
Pract. of Phys. Leet. 38, 1st Ed. 1843. Hen- 
nis Green, cases of Nervous Tremor in Chil- 
dren, Prov. Med. Journ. No. 178, Lond. Feb. 
24, 1844. °Volz, in Heidelb. Annal. xii. 2, 
1846, reported in Schmidt's Jahrb. liii. 37. 
°V. Brunn, Chron. Zittern, in Caspars Wo- 
chensch. No. 40, rep. in Canstatt's Jahrb. 
1846, ii. 70. ° Rudder, Chorea with Parox. 
of Scelotyrbe, Ann. Soc. Med. de Gand, 1848, 
ii. rep. in Canst. Jahrb. 1848, ii. 48. Roth. 
Hist, de la Musculation irresistible on Choree 
Anormale, Paris, 1850. ° Basedow, Stabili- 
tats-neurosen. Casp. Wochensch. No. 33, 
rep. in Canst. Jahrb. 1851, iii. 79. ° Seitz, 
Deutsche Klinik, No. 46, and 0 Haas, Nassau 
Med. Jahrb. Hft. ix. rep. in Canst. Jahrb. 
1852, iii. 92. Gull, Value of Electricity as a 
remedial agent, Guy's Hosp. Rep. 2 Ser. viii. 
134-6. Paget, case of involuntary tendency 
to fall precipitately forwards, with remarks, 
Med. Times and Gaz. Feb. 24, 1855. 0 Bam- 
berger, Beob. ub. Hirnkrank, in Verhand, 
d. phys. Med. Gaz. z. Wurtzb. Bd. vi. 283, 
rep. in Canst. Jahrb. 1855, iii. 73. Hasse, 
in Virch. Handb. d. Spec. Path. u. Ther. 
1855, Bd. iv. 1 Abth. pp. 301 and 306-7. 
Russell Reynolds, Diag. of Dis. of Brain, &c. 
1855, p. 163; Case of Par. Agit. removed by 
continuous Galv. current, Lancet, Dec. 3, 
1859, p. 588. Remak, Galvano th^rapie, 
Berlin, 1858, pp. 219, 248, 447. Copland's 
Med. Diet. 1858. Cohn, Beitrag. z. Lehre 
der P. Agit. Wien Wochensch. Nos. 18-26, 
rep. in Canst. Jahrb. 1860, iii. 73. 0 Oppol- 
zer, remarkable case of P. Agit. with Autop- 
sy, Spital-Zeit. Nos. 17, 18, rep. in Canst. 
Jahrb. 1861, iii. 78; also quoted fully in 
Trousseau, Clin. Med. 2d Ed. ii. 219; also 
°Oppolzer in Wien. Med. Zeit. 1862, No. 52, 
rep. in Canst. Jahrb. 1863, iii. 39. 0 Stofella, 
case of P. A. with Autopsy, Wien Wochensch. 
xvii. 37, 1861, rep. in Schm. Jahrb. 113, p. 
39, and in Syd. Soc. Yearbook, 1862, p. 82. 
° Skoda, in Wien. Med. Halle, iii. 13, 1862, 
rep. in Schm. Jahrb. 119, p. 294, and in Syd. 
Soc. Yearbook, 1863, p. 100. ° Alfred Louis, 
De la Tremulence paralytique progressive, 
Strasb. 1862, rep. in Canst. Jahrb. 1862, iii. 
66. Lebert, Handb. d. Pract. Med. 1863, ii. 
590. Maclachlan, Dis. and Infirm, of Ad- 
vanced Life, 1863, p. 212. Leyden, case of 
P. Agit. of right arm, with develop, of Sarco- 
ma in 1 Opt. Thal. Virch. Arch, xxix, p. 202, 
1864. Handfield Jones, Functional Nerv. 
Disorders, 1864, 263. Topinard, De l'Ataxie, 
Loc. Prog., forme Paral. Agit. pp. 103, 114, 
117, &c. Paris, 1864. Trousseau, Clin. Med. 
2d Ed. ii. 213. Sanders, case of Dystaxia or 
Pseudo-paral. Agitans with remarks, Ed. 
Med. Journ. May 1865, p. 987. J. W. Ogle, 
Calabar bean in Par. Agit., Med. Times and 
Gaz. 1865, ii. 256. 
[ATHETOSIS. 
By Henry Hartshorne, M.D. 
This term (from without fixed 
position) was first applied by Dr. Ham- 
mond, in 1871, to an affection of which 
he reported two cases in his work upon 
Diseases of the Nervous System. The 
characteristic symptom is a constant, in- 
voluntary, and more or less regular move- 
ment of the fingers or toes, on one side 
or both. As an occasional phenomenon, 
Charcot had noticed this in 1853, and 
Heisse in 1860. 
Charcot, however, regards it as a variety 
of chorea, following hemiplegia ; corre- 
spending, therefore, in part, with what 
S. Weir Mitchell has designated as post- 
paralytic chorea. In some of the cases re- 
ported, however, no paralysis whatever 
has existed.1 
Oulmont published an account of his 
study of several cases in the Salpetriere.2 
Other cases also have been reported; 
among the latest of which are one in the 
[' London Med. Record, March 15th, 1879.] 
[2 Etude clinique sur l'AthGtose, Paris, 
1878.] 732 
WRITERS' CRAMP. 
Revue Med. Tr. et Etr anger e, January, 1879, 
and another in the London Lancet, March 
15, 1879. In the last-named instance, 
and at least once previously, post-mortem 
examination has been made. 
The following is the description given 
of the phenomena in the last case, which 
was under the care of Dr. Sturges, in the 
Westminster Hospital, London :- 
" The movements referred to were con- 
fined to the left side, and almost exclu- 
sively to the upper extremity. They were 
continuous and involuntary. When the 
hand was extended with the palm down- 
wards, the index and middle fingers were 
slowly and gradually flexed, the ungual 
phalanges being first bent, then the mid- 
dle, and finally the proximal. The thumb 
was also adducted, and either closed over 
the first phalanx of the index finger, or 
passed under the index and middle fingers, 
so that the ungual phalanx protruded be- 
tween the middle and ring fingers. The 
hand was then supinated, the fingers again 
extended and the thumb abducted. Pro- 
nation of the hand completed the cycle. 
This was the type of the movement, but 
it was subjected to some variation, and 
there was at times great irregularity. 
When the fingers were flexed consider- 
able force had to be exerted to extend 
them, but the forcible extension did not 
increase the subsequent involuntary move- 
ments. Patient had always to keep his 
nails short, or they would indent the palm 
of the hand. He was able by a great 
effort to partly control the movement, but 
his power in this respect was very slight. 
On requesting him to close his hand, the 
fingers being at the time extended, he 
was unable to do so, and the effort, al- 
though directed exclusively to the left 
hand, often resulted in the unconscious 
closure of the right. The only time the 
hand was really quiet was during sleep. 
The movements were ordinarily so con- 
stant and so little under the control of the 
will that the patient was not able to use 
his left hand for any of the ordinary pur- 
poses of lifting ; even his food had to be 
cut up for him." 
In this case there had been two fits dur- 
ing infancy, followed by hemiplegia of the 
left side, which, however, disappeared be- 
fore the age of ten yearst, and did not 
return. The man died of phthisis in the 
hospital, and a careful autopsy was made. 
The whole right hemisphere of the brain 
was found to be distinctly smaller than 
the left. Atrophy of some of the convo- 
lutions had occurred, especially those of 
the frontal and parietal lobes. The whole 
of the gray substance of the right corpus 
striatum, and nearly all of its white sub- 
stance, was destroyed. The optic thala- 
mus, arteries and membranes of the brain, 
and the spinal cord, were healthy. 
Oulmont has dwelt especially upon 
what he conceives to be the important dif- 
ference between double or general Athe- 
tosis, and that which is unilateral, hemi- 
athetosis. The latter, when there is motor 
hemiplegia, occurs nearly always on the 
paralyzed side. In the majority of cases, 
there is also hemiansesthesia of the same 
side. Permanent contraction, rigidity, 
atrophy, and laxity of the articular liga- 
ments, may exist, as post-hemiplegic 
sequelse, not necessarily connected with 
the Athetosis. This disorder is compared 
by Oulmont to hemichorea, and referred 
to a probable cerebral lesion, in the neigh- 
borhood of the fibres in front and outside 
of the sensory bundles at the lower part 
of the corona radiata (of Reil). 
Gowers and McLane Hamilton1 refuse 
to admit that there is clinical or patho- 
logical reason for separating Athetosis 
from other symptomatic or secondary 
affections of disordered movement, chiefly 
hemiplegic in origin. Notwithstanding 
its occasional independence of paralysis 
(as above seen), its place in nosology, at 
present, appears to be rather that of a 
symptom than of a disease ] 
WRITERS' CRAMP. 
J. Russell Reynolds, M.D., F.R.S. 
Definition.-A chronic disease, char- 
acterized by the occurrence of spasm 
when the attempt is made to execute spe- 
cial and complicated movements, the re- 
sult of previous education ; such spasm, 
not following muscular actions of the 
affected part when these special move- 
ments are not required. 
The term "Writers' Cramp" is bad in 
one respect, because the symptoms it de- 
f1 Nervous Diseases, p. 92.] 733 
SYNONYMS-SYMPTOMS. 
notes do not belong exclusively to the act 
of writing ; it is good, and therefore re- 
tained in this " System of Medicine," be- 
cause it points to the most frequent form 
in which the disease is exhibited, and be- 
cause it has already passed into general 
usage. 
A disease pathologically similar to 
Writers' Cramp may be found in the 
artist, and may prevent him from paint- 
ing in oil; it may occur in the violinist or 
the pianist, and hinder the musical per- 
formances of either; it may be 
met with in the seamstress, or 
the smith, or the milkmaid, and 
may limit or destroy their powers 
of work. Wherever it is found it 
shows the same general features, 
expressed in the definition, viz. a 
limitation by spasm of a particu- 
lar kind of movement, and of that 
movement only. 
Synonyms.-Scriveners' Palsy; 
Mogigraphie ; Schreibekrampf; 
Crampe des Ecrivains ; Schuster- 
krampf; Melkerkrampf. 
Symptoms.-A slowly develop- 
ed difficulty in executing a par- 
ticular movement, such as that of 
writing or playing on a musical 
instrument, other movements of 
the same limb being perfectly 
easy of performance. Usually the 
patient feels at first some undue 
weariness after long exertion, a 
stiffness of the fingers, or an un- 
steadiness and uncertainty of 
movement, all of which immedi- 
ately disappear on giving up the 
exertion. If writing, a man feels 
that his pen does not do what 
he intended that it should ; that 
his handwriting looks unnatu- 
ral ; that he has to hold his pen 
more tightly than before, in order to keep 
it between his thumb and fingers; that 
it starts from its place, and often is 
pushed, by his first finger, over the nail 
of his thumb, and that he has some diffi- 
culty in getting it back to its place. A 
pianist makes blunders in striking chords, 
the fingers falling on keys they were in- 
tended to avoid : the violinist cannot con- 
trol the movements of his left hand,-or 
can do so only by a painful effort,-the 
fingers running together and feeling stiff: 
the seamstress cannot ply her needle, but 
pricks her fingers, and makes her stitching 
irregular. In one case, under my own 
care, the bricklayer could not use his 
trowel. 
At first the difficulty is slight, and may 
be overcome by strenuous effort; but, 
after a little time, if the attempt to con- 
tinue or repeat the movement be persisted 
in, there is distinct cramp, jactitation, or 
tremor of the hand, and the particular 
performance is quite impossible. Other 
things may be done, but that one thing 
with regard to which the difficulty was 
first felt cannot be effected properly by 
any amount of exertion. A patient may 
not be able to write, and yet may feel no 
difficulty in fingering either the piano- 
forte or the harp. 
The accompanying woodcut represents 
four different attempts made by one of my 
patients to write his name- 
Fig. 40. 
The moment that the attempt is given 
up the patient feels nothing abnormal; 
but the moment that he tries again to per- 
form this special act the difficulty returns 
and increases. Sometimes the special 
symptoms are made worse by any exer- 
tion of the arm. 
The cramp-movements, at first limited 
to the thumb and fingers, are sometimes 
avoided by the writer who adopts me- 
chanical devices which leave them at rest, 
but make it possible to perform the act of 
writing by using only the muscles of the 
wrist and forearm; as soon, however, as 
he has trained himself to write in this 
awkward manner, the muscles of the fore- 
arm take on a spasmodic movement, and 
he is no better off than before. In one 
case, which I have recently seen, the pa- 
tient could manage to write a few words 
by moving only the muscles of his arm 
and trunk-his pen was directed by the 734 
WRITERS* CRAMP. 
muscles of his back and arm, the latter 
being pressed closely against his side ; 
but, after a few seconds, spasm occurred 
in these, the whole body was contracted, 
the head being drawn downwards to the 
right shoulder, and the trunk contorted so 
as to render it concave on the right side. 
In several cases that I have known the 
sufferers have taught themselves to write 
with their left hands, to do this with ease, 
rapidity, and neatness ; but, shortly after 
having acquired the art, the left hand has 
become affected in a similar manner, and 
its writing-power has been limited more 
rapidly than was that of the other limb. 
When the disease has existed for some 
time, the attempt to write often becomes 
painful; there is a feeling of "cramp," 
and much general distress, accompanied 
by spasmodic movements in the neck, and 
sometimes in the limbs not especially en- 
gaged in the effort; and yet, apart from 
the attempt to write, there is no spasm 
and no inconvenience. 
After long persistence of the cramp 
there is sometimes feebleness in the gen- 
eral movements of the limb,-the grasp is 
not so firm as it used to be ; but such 
quasi-paralysis is the exception, and not 
the rule. 
In some cases the spasmodic movements 
have not been so closely limited, as they 
are in the majority, to the attempted per- 
formance of a special act; those move- 
ments which require no fine adjustment 
may be performed with force and pro- 
priety, but others-needing delicate co- 
ordination-may be difficult or even im- 
possible. There has been tremor, or 
choreiform agitation of the limb, more or 
less persistent during the day, even when 
no voluntary effort is being made, but 
ceasing at night, during sleep, or after 
prolonged rest in one position. 
There are-in some individuals, but not 
in all-abnormal sensations in the affected 
limb; and these may be noticed before 
any cramp appears. They may be in- 
creased by exertion, but do not entirely 
depend upon it. They are vague in cha- 
racter, such as a "feeling of weight," or 
of "tightness," "numbness," or "cold- 
ness ; " a pain, but more often a "some- 
thing not quite pain going up from the 
hand to the back." In some cases there 
has been actual anaesthesia of the fingers, 
and an "aching in the spine."1 There is 
nothing peculiar to the disease now men- 
tioned in the sensations that I have heard 
described, when description was possible, 
except this, that the attempt to control 
the spasm augmented the distressing or 
uneasy feelings. 
In the majority of cases the special 
cramp exists by itself; but in a few it is 
associated with other disturbances of the 
nervous system. Those which I have met 
with have been torticollis, occasional stra- 
bismus, stammering, and palpitation of 
the heart, with some distress about the 
cardiac region, over and above the mere 
fact of increased force or frequency of beat. 
The general health in some of the most 
typical cases has been excellent, and the 
physical strength equal to and even be- 
yond the average. In a few individuals 
there have been weakness, a " nervous 
temperament," and some anemia with 
impaired digestion and nutrition ; but in 
no one has there been witnessed any 
modification which is not consistent with, 
and frequently encountered in, other dis- 
eases. 
Etiology.-Age. Early life appears 
to be exempt; I have not met with a 
single case in which the symptoms ap- 
peared before the age of thirty. Sex. The 
male sex is much more liable to suffer 
than the female. Occupation. It is com- 
monly held that the disease is caused by 
excessive exertion, but there are reasons 
for doubting the correctness of this state- 
ment. Thousands of individuals write, 
work, milk, or play musical instruments 
to the highest degree that is possible, 
without suffering from the least inconve- 
nience of the kind now described ; and, on 
the other hand, many cases occur in which 
there has been no excessive strain upon 
the muscles in the performance of these 
special acts; and, indeed, in some quite 
characteristic examples of the malady, 
there has been less than the usual amount 
of writing performed by gentlemen of the 
age and professions of my patients. It 
may then be convenient, but it is not 
scientific, to refer this form of cramp to 
over-exertion of a special kind. 
Worry of mind and anxiety have been 
present in many cases before the outbreak 
of the symptoms, but so they have been 
in many other forms of nervous disturb- 
ance quite different from this ; and in some 
persons affected with Writers' Cramp there 
has been nothing of the kind to which the 
patient or others could refer the symptoms. 
I have known the symptoms of Writers' 
Cramp to occur in one who had been much 
interested in their appearance in a friend. 
An injury to the arm has been supposed, 
in some cases, to have originated the dis- 
ease. 
Diagnosis.-Scarcely anything need be 
added to the description already given. 
The special character of the difficulty is 
the diagnostic mark of true Writers' 
Cramp. A man may be unable to write 
from lead poisoning. But the presence of 
paralysis rather than spasm ; the singling 
out of certain muscles not only for weak- 
ness, but for loss of nutrition and of irri- 
1 Solly, on Scriveners' Palsy; Lancet, Jan. 
28, 1865. PROGNOSIS-PATHOLOGY. 
735 
tability to electricity in the induced form; 
the equal affection of the two upper ex- 
tremities, although, when slight, it may 
be shown more conspicuously in the hand 
which writes, and has been educated to 
perform other complex movements ; the 
presence of a blue line on the gums, and 
the general history of saturnine intoxica- 
tion,-are sufficient to establish the diag- 
nosis. 
Wasting Palsy, which often commences 
in the muscles of the thumb, may be 
known by its characteristic feature, 
"■wasting," and needs only to be men- 
tioned in order to be distinguished from 
Writers' Cramp. In wasting palsy the 
loss of power is in direct proportion to the 
loss of nutrition ; in Writers' Cramp, it is 
the spasm which interferes with the par- 
ticular movement that is required. 
Local Paralysis.-A few weeks ago a 
gentleman was sent to me with supposed 
" Scriveners' Palsy." He had been read- 
ing and writing much, and on one even- 
ing sat reading for some hours "in a 
draughthis hand was weak, and on the 
following day he could not write. There 
was when I saw him nearly complete 
paralysis of the right hand and forearm, 
and the electric irritability was almost 
extinct, but in the course of a fortnight 
the power had returned, and the patient 
was well. The extent of the paralysis 
and the absence of spasm were the dis- 
tinctive marks. Several cases of this 
kind have come before me, and have been 
thought to be examples of Writers' 
Cramp ; but the fact of their having been 
mistaken for the latter is enough to put 
any one on his guard against a repetition 
of the error. 
Prognosis.-If the case be seen when 
the symptoms have existed for only a 
short time, relief may be confidently ex- 
pected, provided that rest can be given. 
If the symptoms have existed for many 
months, or if rest be impossible, the prog- 
nosis is extremely unfavorable. There is 
scarcely any malady which has resisted 
more obstinately all kinds of attempts- 
well-directed and ill-directed-which have 
been made for its cure. Many who were 
seriously threatened with Writers' Cramp 
are now free from the malady because 
they rested ; many who could not and did 
not rest, are now, in the present state of 
therapeutics, incurable. 
Bearing in mind what has been said 
with regard to the extension of the disease 
into other regions of the nervous system, 
some caution is required in stating the 
general prognosis of such cases, but, in 
the vast majority, it may be confidently 
expected that no such extension will 
occur. When there are signs of disease 
already present in other directions, such 
as strabismus, torticollis, weakness of the 
corresponding leg, and the like, the prog- 
nosis should be extremely guarded. 
Pathology. - The exact locality of 
disease, and the precise nature of the 
change which constitutes it, have not 
been yet demonstrated with regard to 
Writers' Cramp. Its closest clinical 
affinities are with stammering, spasmodic 
wry-neck, and histrionic spasm, or " mus- 
cular tic" of the face. Analogous mala- 
dies, but moving in a yet wider range, 
are sometimes encountered, such as cer- 
tain forms of rotatory movement, of 
chorea, and of locomotor ataxy ; and be- 
yond these there are anomalous cases, 
which every physician occasionally meets 
with, but does not know how to designate. 
One patient cannot make the attempt to 
walk without performing, or running in 
danger of performing, sundry rotatory 
movements, which terminate in a fall: 
another, a hard-working clergyman, can 
only speak, though he has the voice of a 
Stentor, when on a level with his audience ; 
and this not from any fear, or shyness, or 
sham, but from definite aphonia. Some 
of the spasmodic movements induced in 
frogs by injury to the auditory nerve are 
of similar character ;* and the experiments 
of Magendie, Flourens, Longet, and 
Schiff afford further illustrations of analo- 
gous disturbances in the physiology of 
motion. 
In order to understand Writers' Cramp, 
it is necessary to remember what is, phy- 
siologically, involved in the education of 
the muscles to perform complicated acts, 
such as those of writing, speaking, or 
playing on musical instruments. The 
will does not pick out the muscles which 
are to be brought into play to hold a pen; 
it simply directs itself to the result. The 
boy who plays at marbles directs his 
movements in the same manner, and 
with as much accuracy and nicety, as the 
professor of anatomy directs his when he 
is writing a description of the muscles of 
the hand. The combination or co-ordina- 
tion of muscular contractions is determined 
by the will, but is affected by another 
agency. Each is conscious of a wish to 
do a certain thing, and of a will to do it, 
but a knowledge of the mode in which the 
movement is brought about does not help, 
and may sometimes hinacr, its produc- 
tion. Experimental physiology and clin- 
ical pathology combine to teach us that a 
certain portion of the nervous system, the 
cerebellum, has the power of effecting the 
co-ordination that is required ; and they 
also unite in proving-what is often lost 
sight of-that this co-ordinating faculty 
is guided by sensations, and can act effi- 
1 Brown-S^quard, Lectures on the Physi- 
ology and Pathology of the Central Nervous 
System, p. 194. 736 
writers' cramp. 
ciently only when they are normal in 
kind and intensity. The production of a 
movement such as writing is therefore a 
very complicated process, requiring for its 
efficient performance the integrity of a 
great number of different parts : viz., that 
of the will and its immediate exponent in 
the cerebral hemispheres; that of the 
nerve-fibres between it. and the muscles, 
together with that of the ganglia which 
exist on certain nerve-trunks ; that of the 
muscles themselves ; that of the cerebel- 
lum, as the centre of co-ordination, also 
that of all the "sensory" nerve-fibres 
which place it in relation with the organs 
of special sense and with the muscles 
themselves ; and, lastly, integrity of the 
organs of sense, so that they, at the peri- 
pheral expansion of their special nerves, 
can receive impressions in a normal man- 
ner. It must be remembered, also, that 
not only the fact but the degree of con- 
traction is under the control and guidance 
of the same organs or parts of organs. 
Failure in any one portion of this appa- 
ratus interferes with the production of the 
movement that is required ; and the kind 
of failure is determined by the locality of 
the lesion ; or, in other words, by the na- 
ture of the process or function which is 
lost or disturbed. If the contraction of a 
muscle be acutely painful, the man cannot 
write, the act would be impossible in 
some cases of rheumatism ; if the muscle 
be wasted, it cannot be put into the same 
amount of contraction as in health; if the 
skin have lost its sensitiveness, all fine 
movements are awkwardly performed, 
and the finest are rendered impossible; 
they may be partially guided by the eye, 
but the guidance is defective for the most 
complicated acts ; if the motor nerve be 
damaged, the muscle is pro tanto palsied ; 
if the sensory nerves be injured, sensation 
is defective ; if the sense of muscular con- 
dition be in abeyance, the power to control 
either the kind or force of contraction is 
without its guide : but locally, i. e., so far 
as that limb is concerned, all other nerve, 
muscular, and sentient properties may be 
intact, and yet spasm or paralysis, or 
both, are present. If the will be deficient, 
and this from any cause, there is palsy, or 
irregular movement; if the fibr.es coming 
between it and the nerve-trunks be in- 
jured, there is paralysis in the ordinary 
sense of the word ; if the cerebellum be 
diseased, there is loss of co-ordination, 
while power and sensation persist; if the 
spinal cord be injured, there may be, in 
relation to the nature and locality of the 
injury, almost any one of the conditions 
that have been enumerated. 
In true Writers' Cramp, the will, the 
co-ordinating power in all directions but 
in one, the motor power, the muscular 
nutrition and activity, as well as the sen- 
sorial faculties, are uninjured ; the indi- 
vidual is, or may be, " well" in all respects 
but one. A particular kind of movement 
is interfered with, by the occurrence of 
irregular and spasmodic, instead of regu- 
lar and co-ordinated, contractions. It 
must be carefully remembered that the 
malady is special; the muscles which can- 
not be made to write can be controlled so 
as to fasten the most tiresome buttons, 
carve the toughest of pheasants, or pull a 
heavy boat. The pianist cannot play on 
the pianoforte, but he can write as well as 
ever; the bricklayer cannot use his trowel, 
but he can do everything else that he 
wants to do ; and in order to understand 
this, we must revert to what is included 
in education, and what confers the dex- 
terity which comes of special practice. 
Many movements are "automatic;" we 
adopt them without education and with- 
out effort; others are the result of labori- 
ous "practice." It would seem that the 
body is naturally endowed with certain 
paths or lines of nerve-action, along which 
all moves easily. The instinctive move- 
ments of the child or of the animal are 
examples of the mode in which, along 
these lines, impressions from without pass 
readily, and become converted into motor 
impulses, which are, in their turn, con- 
veyed to muscles, which contract, and so 
perform these instinctive acts. But the 
process of education, so far as the per- 
formance of writing, playing, stitching, 
&c., is concerned, consisted in the fre- 
quent repetition, by an act of the will, of 
certain forced and complicated move- 
ments. The repetition makes them easy, 
until at length they are executed without 
effort, and almost unconsciously. It would 
seem that, by this education, new paths 
are forced, so that what was once difficult 
and required attention becomes day by 
day more easy, and at last "secondarily 
automatic." It cannot be doubted that 
some changes take place in the nutrition 
of the parts through which these lines of 
nerve-action run; and that their education 
involves structural alteration in the or- 
gans. The perfection with which compli- 
cated movements are performed in the 
lower animals appears to be associated 
with great keenness and remarkable de- 
velopment of the organs of sense ; and in 
man a similar relation may be observed. 
No man writes well who has not keen 
sight and a quick sense of touch ; no man 
plays well on the violin who has not an 
acute ear, and a delicate power of feeling 
in his fingers. In all instances of educated 
movement some "sense" is needed, and 
is an important element in the process by 
which the result is obtained. 
In the present state of science it is not 
possible to say, for every act, what part 
of the nervous system is especially engaged 
in this educational development ; but it 
seems probable that the association of CONVULSIONS. 
737 
movement is effected by ganglia which 
are common to fibres passing through dis- 
tinct but contiguous nerve-trunks, and 
that it is owing to some nutrition-change 
in them-the result of persevering and 
forced effort-that the perfection of move- 
ment is produced ; associations at first 
caused by the will, are at last produced 
unconsciously. What happens, then, in 
such maladies as Writers' Cramp, is a 
perverted nutrition of these parts; a 
worn-out activity, or a degeneration which 
may arise without over-exertion, and de- 
stroy all that had been previously 
achieved.1 Neuromata have existed in 
the arms of some patients. The disease, 
as it has been shown, passes readily from 
one side of the body to the other ; and it 
must be carefully borne in mind that co- 
ordination of movement is a most complex 
process, requiring integrity of sensation 
as well as of motor nerve and of cerebel- 
lum. The real mischief may be some 
want of limiting and guiding influence 
ordinarily coming, through sensation, 
from external impressions. The spasm 
which occurs is very like that which Mr. 
Lockhart Clarke describes as taking place 
in the legs of ataxic patients who cannot 
regulate the force of their muscular con- 
tractions. 
Treatment.-In an early stage abso- 
lute rest may do much ; in a later stage 
it may accomplish something; but I know 
of nothing else which can be called a 
therapeutic agent. I have tried every 
form of general and nervine tonic, of sed- 
ative, and of local application, but no one 
of them has been of the least specific 
value. I have used hypodermic injec- 
tions of morphia, atropine, and of arse- 
nic, and have found them incompetent to 
cure the disease. The hypodermic injec- 
tion of morphia appears sometimes to re- 
lieve the spasm for a certain period, and 
I have seen the writing become steadier 
within five minutes of the application, 
and increase in precision for half an hour, 
but the effect has then, or soon after- 
wards, passed away, and a frequent repe- 
tition of the process has been without any 
permanent result. It has, unfortunately, 
happened that several patients in whom I 
have used morphine hypodermically pre- 
sented an intolerance of that medicine. 
I have employed galvanism and electricity 
in all their forms, and have seen no good 
results. But in many cases perfect rest 
has removed the symptoms, and it alone 
seems worthy of being regarded as a 
means of cure. 
Mechanical contrivances for holding the 
pen may render occasional writing possi- 
ble, but they do not affect the disease; 
and persistence in their use has been fol- 
lowed by an extension of the malady to 
the muscles of the forearm and arm. 
CONVULSIONS. 
By J. Hughlings Jackson, M.D., F.R.C.P. 
It cannot be kept too much in mind 
that Convulsion is a symptom, not a dis- 
ease. But it is the most striking member 
of the series of symptoms in which it oc- 
curs, and in many cases the only one 
about which we have definite knowledge. 
In other words, although we always be- 
lieve a Convulsion to be symptomatic, we 
too often know very little of the condition 
of the system of which it is one of the 
symptoms; and this even after post-mor- 
tem examinations. Let us glance at the 
circumstances with which Convulsions 
may occur. 
Convulsions occur in association with 
organic changes in the nervous system of 
the most varied kinds ; for instance, with 
cerebral hemorrhage, and with intracra- 
nial tumors. They follow injuries to the 
head, either immediately or remotely : 
immediately (within a few hours), as when 
a blow leads to meningeal hemorrhage; 
and remotely (after weeks or months), 
when diseased bone, the consequence of a 
blow, causes cerebral abscess. They will 
occur in a healthy but parturient woman 
after severe loss of blood. They occur 
with diseased kidney. They come on as 
indirect results of syphilis, as in cases of 
gummatous tumors in the hemisphere. 
In children they are often associated with 
rickets. Some believe that Convulsions 
may be the results of disturbances of 
parts of the body at a distance from the 
central nervous system, the result of ec- 
' Some of these points in the pathology of 
Writers' Cramp have been ably treated by 
Mr. Solly, in the Lectures already referred to 
in the Lancet of 1865. 
vol. i.-47 738 
CONVULSIONS. 
centric irritations, such as the irritation 
occurring with dentition, or the irritation 
of worms. Finally, there are a large 
number of cases of convulsive seizures 
which (for want even of that approxima- 
tive knowledge we have of such causes of 
fits as are mentioned above) we are obliged 
to speak of as essential, eclamptic, epilep- 
tic, or epileptiform. When we consider 
further that the symptom occurs at all 
ages and in many diseases, that there are 
many varieties in part of the body affected 
by spasm-it is unilateral or general- 
many degrees in severity-there may be 
local spasm without lost of consciousness, 
or general convulsion with profound coma 
-and in times of recurrence-there may 
be one fit a week, or fifty in a day-we 
arc forced to the conclusion that we can 
only speak of Convulsion as a symptom. 
1'116 only things we can safely affirm of 
the symptom are certain truisms. It is 
the phenomenon of an occasional discharge 
of nerve tissue (no doubt of gray matter). 
It points not to destroying lesions, but to 
unstable nerve tissue - to "functional" 
changes. But the most careful study of 
the symptom (the paroxysm) tells us 
nothing of the pathological process by 
which such changes of instability are 
brought about; does not, for instance, 
enable us to say whether these changes 
are the result of "irritation," of tumors, 
of uraemia, or whether they are not mi- 
nute changes (epileptic) to the pathology 
of which we have no clue. But clinical 
study of the circumstances under which the 
symptom occurs, tells us very much. Al- 
though it rarely leads us to a knowledge 
of the pathological condition of the ner- 
vous centres, it gives valuable information 
as to the treatment of the patient, and 
for the purposes of prognosis. There is a 
practical convenience in studying this 
symptom separately. Indeed, we are 
forced to this narrow study, as it is very 
often our only "way in" to a case; and 
its distinct consideration will not be hurt- 
ful if we use it as a point about which to 
group not only our positive knowledge 
for present action, but also, if such a 
phrase may be permitted, our positive 
ignorance for future research. 
I will try to show what meaning we can 
give to this symptom under various cir- 
cumstances ; how we should investigate 
the condition of our patient who presents 
it, and what we should try to do for 
him. It may be well to say that I have 
only to consider epilepsy so far as diag- 
nosis is concerned. It is justifiable to 
sacrifice some exactness to convenience 
by dividing the subject into (1) Convulsions 
in infants and young children, and (2) 
Convulsions in persons above seven years 
of age. 
Convulsions in Children. 
Convulsions may occur at any age, and 
this remark applies not only to general 
Convulsions but also to most kinds of con- 
vulsive movements. Still, Convulsion is 
par excellence the nervous symptom of in- 
fants and young children.1 The tendency 
to Convulsions gradually decreases with 
increasing years. The following quotation 
from West shows this:-" In proportion as 
the brain increases in size, and its struc- 
ture acquires perfection, and its higher 
functions become displayed, Convulsions 
grow less and less frequent, until, from 
the tenth to the fifteenth year, they cause 
less than three percent., and above fifteen 
less than one per cent, of the deaths from 
diseases of the nervous system." The 
first line in the accompanying table (Dr. 
West adds in a footnote) shows the pro- 
portion per cent, of deaths from diseases 
of the nervous system at different ages, to 
the deaths from all causes at the same 
ages in the metropolis ; and the second 
line the proportion borne by deaths from 
Convulsions, to deaths from diseases of 
the nervous system in general:- 
Under 1 year. 
From 1 to 3 
years. 
From 3 to 5 
years. 
Total under 5 
years. 
From 5 to 10 
years. 
From 10 to 15 
years. 
Total above 
la years. 
30-5 
18-5 
17-6 
24-3 
15-1 
10-6 
10-4 
73-3 
24-9 
17-8 
54-3 
9-9 
2-4 
•8 
West says: "In a large proportion of 
cases of Convulsion in the infant, Convul- 
sions answer to delirium in the adult 
and Trousseau says that there are chil- 
dren who have Convulsions as easily as 
some have delirium or even dreams. 
We shall then, as a preliminary, speak 
briefly of the physiological peculiarities of 
the child's nervous system. We may 
affirm of it two things. (1) It is unde- 
veloped. Besides the obvious fact that 
the infant has to acquire such movements 
as those of walking and talking, there is 
1 Meigs and Pepper write: " During the 
five years from 1844 to 1848 inclusive, 1729 
children under fifteen years of age died in 
this city (Philadelphia) of convulsions, 
whilst, during the same time, 1611 died of 
infantile cholera, 1060 of marasmus, 1041 of 
dropsy of the brain, and 772 of pneumonia, 
showing that eclampsia was the cause of a CONVULSIONS IN CHILDREN. 
739 
evidence from the special nervous dis- 
eases of children, that the parts of the 
young nervous system are not knit to- 
gether as closely as in the adult-incom- 
plete neurifi cation analogous to incomplete 
ossification. The child is the subject of 
certain limited palsies and limited spasms 
which do not occur in the adult. Indeed, 
there is a form of talipes varus, Dr. Little 
tells us, which is always congenital. • " In- 
fantile paralysis" never occurs in adults. 
After hemiplegia in childhood, a well- 
known contraction (spastic rigidity) often 
sets in which does not follow hemiplegia 
in adults (p. 742). And lastly, coming 
near to our immediate topic, spasm of 
the glottis is a convulsion of a certain 
limited region which is rarely met with 
after the age of three or four years. Then 
there are minor symptoms which are 
almost peculiar to children, e. g. carpo- 
psedal contractions. As regards the last 
two symptoms, there are the significant 
exceptions that they occur in hysterical 
women. 
(2) The nervous system is developing. 
It is in a state of active change. Its nu- 
trition will be in considerable excess of its 
expenditure, whilst in adults the two will 
be more evenly balanced. For this reason 
the child's nervous tissue will naturally be 
more unstable than is that of the adult. 
It will more easily discharge from a slight 
cause, or, to use a common expression, it 
is more excitable. It is believed too that 
the equilibrium of the child's nervous sys- 
tem is more often upset by nerve-trans- 
mitted irritations than that of the adult is. 
Hence very severe convulsions are ascribed 
to irritation carried by the fifth nerve from 
the gums during dentition, or to the irri- 
tation of worms. The child's nervous 
system is even believed by some to be 
naturally so unstable that eccentric irrita- 
tions so very local as those just mentioned 
will produce a general convulsion in a 
healthy child, i. e. will determine a sudden 
and excessive discharge of nervous tissue 
which is only physiologically unstable. 
Others will qualify this opinion by the 
supposition that the nervous system, or 
some part of it, is pathologically unstable 
prior to the action on it of the transmitted 
irritation. Thus the late Dr. Hillier 
says (I italicize some words); "It is very 
doubtful whether in a healthy child these 
causes can produce convulsions at all; in 
a predisposed subject they no doubt often 
excite them." 
The above are physiological differences. 
Disease finds the child's nervous system 
undeveloped, and it finds it developing. 
But, so to speak, the attacking disease 
itself has peculiarities, at all events nega- 
tive peculiarities. A child is much less 
likely to suffer from gross lesions in the 
brain, such as hemorrhage, syphiloma, 
and other new growths ; he is less likely 
to suffer from uraemia excepting from 
acute changes of the kidney, especially of 
scarlatinal origin; or, putting it more 
simply, we usually discover no pathologi- 
cal changes in the nervous system of a 
child who has died of Convulsions. Wilks, 
speaking of diseases of children, says: 
" We meet with a large number of cases 
where the post-mortem appearances are 
absolutely nothing ; and where, indeed, we 
could scarcely expect to find it otherwise. 
We allude especially to cases of Convul- 
sions in children where no morbid changes 
are discovered ; and when we consider 
that a child may have several convulsive 
attacks and speedily recover, which only 
a degree more severe shall prove fatal, it 
is clear that no very great change could 
occur in an organ which would have per- 
fectly recovered itself had the fit been only 
one degree less in severity." Whilst it is 
true that, as a rule, no pathological 
changes are discoverable, we must not in- 
fer that pathological changes do not exist; 
the probability is that there are minute 
changes. Nor must we infer from com- 
plete recovery from a convulsion, or a 
series of convulsions, that there are no 
pathological changes. Adults recover 
even from hemiplegia, which subsequent 
post-mortem examination shows to have 
been due to obvious although very limited 
destroying lesions - small clots, for in- 
stance. Therefore recovery from Convul- 
sions is no certain sign that there was no 
real impairment of structure. It is a sign 
only that no wide breaking up of structure 
has happened. There must certainly be 
local changes in those cases of Convulsions 
in which hemiplegia follows, however 
temporary it may be, since local symptoms 
of necessity imply local lesions. Still this 
is only a necessary inference, as we rarely 
discover any changes even in these cases. 
Nay, even in those rare cases where we 
find gross disease, a tumor for instance, 
we do not discover the minute and second- 
ary changes on which the discharge pro- 
ducing the Convulsion depends. We must 
not say that the tumor was the direct 
" cause" of the Convulsion, but that it led 
to secondary changes in nervous tissue on 
which the Convulsion depended, and these 
secondary changes are inferred, not de- 
monstrated. 
It is true that there are found at exami- 
nations after death from Convulsion abnor- 
mal quantities of serum and blood in the 
head, but these differences are quite as 
larger number of deaths than any other of 
the diseases just mentioned. It must be 
recollected, however, that a very large num- 
ber of these cases ought, beyond doubt, to 
have been returned under other titles, as 
many of them must have been a mere result 
of organic disease of the cerebro-spinal axis, 
and of other acute local or general diseases." 740 
CONVULSIONS. 
likely to be results of the fits as their 
causes-the results of the sudden interfer- 
ence with respiration. Effusion of serum 
and congestion of the brain have not been 
shown, either in adults or in children, to 
have much to do in producing sudden and 
severe cerebral symptoms of any kind. 
Of course those cases in which, possibly 
from obstruction to the vein of Galen, as 
by tumors of the vermiform process of the 
cerebellum, there is immense effusion into 
the cerebral ventricles, are not in ques- 
tion. 
To resume, we know nothing of the 
causes of Convulsions in children in the 
sense of knowing what the pathological 
changes are. This is so, however much 
we may narrow our consideration to 
groups "of cases, either to those which 
occur singly and at intervals over a period 
of months or years, and which are often 
called epileptic, or to those in which the 
fits occur in considerable number for a 
limited period, and are often called 
eclamptic. 
After these general remarks on the 
symptom Convulsion as it occurs in chil- 
dren, we have to consider what meaning 
we can give it in particular cases. Our 
task is twofold. We have first to note 
carefully the kind of paroxysm. For in- 
stance, is the Convulsion one-sided ? Is 
it followed by hemiplegia ? Secondly, to 
investigate the child's general bodily health. 
For instance, is he rickety ? Is there 
bronchitis ? Is there irritation from den- 
tition ? 
Paroxysm. 
Convulsions occur in all degrees. The 
Convulsion may be a twitching or clench- 
ing of the hands only, or an occasional 
grim smile in sleep, or the spasm may be 
general and so severe that the child dies 
of the paroxysm, even of the first. At- 
tacks of slight occasional spasm, be it of 
one finger, have the same general signifi- 
cance as a severe convulsion has. They 
are both Convulsions, the proof being that, 
as in adults, we have very often first the 
local and quasi-trivial spasm, and later, a 
general convulsion. Each of them is a 
sign that there is an abnormal discharge 
of the nervous system or of some part of it. 
But the effect of the severe and of the 
slight discharges is different. We have 
to consider very carefully not only the 
"cause" of the convulsion, but also what 
effect single and repeated paroxysms pro- 
duce on the child. The slight and partial 
fits do no harm, or little harm, for they do 
not spread to the respiratory muscles, and 
thus, as it were, they do not retaliate on 
the nervous system which "began it" by 
congestion of the brain, and they are too 
slight to exhaust the child by abnormal 
exercise of the muscles convulsed. Fur- 
ther, it is usually held that fits so slight 
and so partial point to slight and usually 
to transient causes, and that they often 
disappear when we obviate some condition 
of ill-health, such as wrong feeding and 
diarrhoea, or when we lance gums swollen 
during the eruption of teeth. But even 
granting that these slight symptoms sig- 
nify that the nervous system is but slightly 
disturbed, or that they usually directly re- 
sult from some removable condition, and 
that the seizure does little harm to the 
patient, they still demand serious con- 
sideration, for two reasons. In the first 
place, we think ill of that nervous system 
which is upset ever so little by slight 
causes, such as over-eating, and we have 
anxieties that if the child be afterwards 
exposed to severer exciting causes, such 
as fright, exhausting diarrhoea, &c., very 
severe convulsions may occur. Another 
reason for careful attention to slight 
spasms is, that they may not disappear 
under treatment, or that they disappear 
for a time only, and that they are often 
the premonitory symptoms of severer con- 
vulsions, the paroxysms of which will do 
much harm to the child by interfering 
with respiration and, when frequently re- 
peated, by exhausting him. Therefore, 
although in strictness these slight symp- 
toms are themselves miniature convul- 
sions, it is convenient to consider them, 
along with other symptoms, as warnings. 
But it must be remarked that, like an 
adult, a child may be suddenly attacked 
by a severe convulsion in the midst of 
what seems to be perfect health. He may 
die in the first fit, or we may see him soon 
after the seizure playing about as if no- 
thing unusual had happened. 
Premonitory Symptoms.-It is pro- 
per to mention, to begin with, that Trous- 
seau states that there are no premonitory 
symptoms. "Nothing," he says, "fore- 
tells the invasion of the attack ; and, for 
my part, I have never observed the pre- 
monitory signs spoken of by Bracket, and 
repeated after him by others." Most au- 
thors, however, admit that there usually 
are warning symptoms. There are often 
symptoms before there is any local twitch- 
ing, such as peevishness, want of sleep, 
and sleepiness. These symptoms show 
that the child's nervous system is suffer- 
ing, but they cannot, of course, be taken 
as evidence that the illness is one in 
which the symptom Convulsion will be 
the sole or even the most striking event. 
In the child, as in the adult, want of 
sleep is associated with drowsiness. Adult 
patients will sometimes say what very 
young patients are not likely to tell us, 
that they always feel sleepy and never 
sleep soundly. Children who are about 
to have Convulsions will sleep with their PREMONITORY SYMPTOMS. 
741 
eyes partly open; their mouths will 
twitch; they will start in their sleep, 
grind their teeth, and may have night 
terrors. In the day they are dull, heavy, 
and peevish. When any twitching occurs 
on one side of the face or in one limb, or 
in both limbs of one side, however slight 
the cause, let us say over-eating, which 
seems to excite it, we fear the nervous 
system is seriously implicated, and that 
severe convulsions are setting in. When 
the slight symptoms occur during waking, 
especially if now and then a vacant look 
points to some loss of consciousness, how- 
ever transient it may be, we fear severe 
convulsions are at hand. I may here 
quote, as a summary of the occasionally 
insidious march of the symptoms, what 
Churchill says of fits of dentition: "I 
have frequently observed a sort of grada- 
tion from simple irritation and restless- 
ness to starting, surprise, wildness of 
look, partial or local convulsive move- 
ments, and, lastly, general convulsions." 
Having spoken of partial or slight fits 
ancl incidentally of premonitory symp- 
toms, we now come to consider varieties 
of severer convulsions. It is not denied 
that we may have any kind of occasional 
spasms in children, but we choose three 
types. It is a very important matter to 
note the variety of Convulsions, especially 
for prognosis : 1. Laryngismus Stridulus ; 
2. Unilateral Convulsions; 3. General 
Convulsions. 
Laryngismus Stridulus.-A certain kind 
of Convulsion is called laryngismus stri- 
dulus because the muscles of the larynx 
being attacked by spasm, a noise results 
during inspiration from narrowing of the 
glottis. It is not a laryngeal disease, al- 
though one of its names, "false croup," 
seems to imply that it is. There is no 
continued fever in laryngismus. It is 
Convulsion affecting the muscles of res- 
piration. Dr. Gee, in a most able article, 
very rich in clinical observations (Con- 
vulsions in Children, St. Bartholomew's 
Hospital Reports, vol. iii.), remarks : " In 
laryngismus (convulsion interne) we have 
a disease closely allied to epileptiform 
convulsion. Out of fifty cases of laryn- 
gismus of which I have notes, nineteen 
had had eclamptic fits. " Niemeyer treats 
of it under the head of Nervous Diseases 
of the Larynx (Spasm of the Muscles of 
the Glottis). The larynx is found to be 
quite normal post-mortem. The obtru- 
sive symptom, the crowing noise, is due 
to spasm of the glottis, but in many cases 
the muscles of the chest and abdomen, as 
well as those of the larynx, become in- 
volved. 
The alliance of the laryngeal spasm- 
the local convulsion-with general con- 
vulsion is further shown by the fact that 
not infrequently the child has first laryn- 
gismus and then general convulsion. Oc- 
casionally we find in the intervals of the 
fits tonic spasm of the hands and feet- 
carpo-pedal contractions. 
Yet it has certain peculiarities beyond 
those of limitation of range of the spasm. 
Age is one of the most important of these. 
Dr. West compares attacks of laryngismus 
to hysterical attacks, and remarks that 
both occur when processes of development 
are active. Out of thirty-seven cases of 
laryngismus, thirty-one, he tells us, oc- 
curred betwixt the ages of six months 
and two years. Vogel1 says, " The age 
at which the disease occurs, fluctuates be- 
tween one-half and three years ; that is 
to say, it makes its appearance with the 
eruption of the first tooth, and disappears 
with that of the last." Niemeyer says 
that spasm of the glottis occurs almost 
exclusively during childhood, and espe- 
cially in the first year of life. It is most 
frequent during the period of the first 
dentition. lie makes a remark which is 
of considerable interest in connection 
with the one quoted from West: " Among 
adults none but hysterical persons suffer 
from spasm of the glottis, and those only 
exceptionally." Mackenzie, in his work, 
" Nervo-muscular Affections of the 
Larynx," treats of laryngismus under the 
head of Spasm of the Adductors of the 
Vocal Cords, and says that hysterical 
cases (in adults) are by no means infre- 
quent. The observation of these cases is 
of very great interest, because in the 
adult the condition of the vocal cords in 
the attack can be seen, and we may plau- 
sibly infer that the condition of the glottis 
is similar in the laryngoscopy of children. 
Mackenzie writes of adults: " With the 
laryngoscope the vocal cords can be seen 
on inspiration to be spasmodically ap- 
proximated. They may separate widely ; 
but, instead of remaining apart for a few 
seconds, they are instantly and spasmodi- 
cally adducted to the median line, or even 
beyond it, that is, against one another." 
Another peculiarity is, that boys are much 
oftener the subjects of this disease than 
girls, " a fact almost all authors admit" 
(Vogel). Of Gee's (op. cit.) forty-eight 
cases, thirty-four were males. Mackenzie 
(op. cit.) says, "The greater liability of 
the male sex, which occurs in other laryn- 
geal diseases, holds good here." 
The most striking feature of the disease 
is the crowing noise the child makes. 
This noise often begins insidiously, but 
there is great difference in this respect. 
The crowing noise is most frequently ob- 
served when the child awakes from sleep, 
and is very often noticed for the first time 
1 A Practical Treatise on Diseases of Chil- 
dren. By Alfred Vogel, M.D. (Translated 
bv H. Raphael, M.D.) Appleton & Co., New- 
York. 742 
CONVULSIONS. 
in the night. After several attacks of the 
crowing, which is generally at first occa- 
sional, and produces little inconvenience, 
very often exciting no alarm in the child's 
friends, a severe paroxysm may come on. 
A slight crowing noise may become al- 
most continuous in the child's ordinary 
respiratory movements, and a severe at- 
tack may come on in the midst of this 
warning. The convulsion may be, it is 
believed, at first no more than spasm of 
the laryngeal muscles-a laryngeal con- 
vulsion ; but in many cases the whole 
system of respiration is involved in the 
spasm, and sometimes the limbs - the 
convulsion becomes general. The severe 
attack is paroxysmal, and while the pa- 
roxysm is on, respiration is much impeded 
-sometimes indeed being quite, for a 
short time, suspended, as in severe con- 
vulsion in the adult. At the climax the 
face is flushed, the eyeballs start, the 
veins of the neck are distended, and the 
face wears an aspect of exquisite distress. 
The sign that this stage of danger is pass- 
ing is a crowing or whistling noise made 
by air entering the now only narrowed 
glottic aperture. As before said, general 
convulsion may supervene. In the inter- 
vals, as in the other forms of Convulsion, 
if the attacks be not frequent, the child 
may be quite well, or only fatigued and 
peevish. If they are frequent (and they 
may occur thirty times a day), the child 
may be exceedingly exhausted, almost 
comatose. Occasionally, although this is 
a rare occurrence, the cnild may die in an 
attack, even in the first attack, just as 
now and then an adult may die in an epi- 
leptic attack. Nay, according to Nie- 
meyer, in rare cases spams of the glottis 
in hysterical adults produces death by 
suffocation. 
Without underrating the importance of 
studying particular convulsive seizures, 
due to spasm of certain groups of muscles 
which have especially important duties, 
we must, as regards treatment, consider 
the more general question of the state of 
the child's health or nervous system, 
which permits occasional spasm of mus- 
cles anywhere, whether these be of the 
limbs, of the thorax, or of the larynx. 
The inference is that the causes which 
give rise to laryngismus are essentially 
similar to those which give rise to other 
varieties of Convulsion. (See p. 744.) It 
is convenient, however, to say a few words 
here on causation. 
The general belief is that this form of 
Convulsion is oftener than other varieties 
of Convulsion determined by the irritation 
of dentition, a belief which the facts as to 
age seem to justify. I say "seem," be- 
cause the eruptions of the teeth are no 
doubt to be considered as marks of stages 
of development of the whole system, just 
as the occurrence of menstruation is later 
in life. Further, there is another fact of 
yery great importance never to be lost 
sight of, viz., that, as Jenner, Elsasser, 
and Gee have pointed out, children the 
subjects of laryngismus are usually, almost 
always, rickety. Forty-eight out of Gee's 
fifty cases were unquestionably rickety, 
and in the two exceptional cases there 
was laryngeal catarrh. 
We must at least modify the inference 
as to the influence of dentition, and say 
that the irritation of dentition produces 
laryngismus in rickety children. In none 
of Gee's cases (op. cit.) was there any 
reason to believe that the teeth bore any 
part in the causation of the fits. In ac- 
cordance with these facts and opinions, 
whilst we must certainly endeavor to re- 
move every source of eccentric irritation, 
we must also treat the child for rickets as 
well. "Laryngismus, when treated as if 
wholly dependent on the rickets, even if 
it be not so in fact, ceases to be a serious 
disease" (Gee). 
Laryngismus has been attributed to en- 
largement of the thymus, but this view is 
not now entertained, one very good rea- 
son being that post-mortem examinations 
show that in many instances there is no 
enlargement of this organ. Moreover, in 
cases where a large thymus has been 
found there has been no laryngismus. 
Unilateral Convulsions and Hemiplegia. 
-The Convulsions are limited to one side, 
or they affect one side first and chiefly. 
In such a fit, if it be severe, the face, arm, 
and leg of one side are in spasm; the head 
and both eyes turn to the same side, and 
next the chest becomes fixed. When se- 
verer still, the other side of the body be- 
comes affected in the same way as the 
first, but to a less extent; the spasm may 
return to the side first affected. In this 
class of fits the spasm may be, for a while, 
very limited, e. g. a few jerks of the head 
to one side, or to spasm of one side, or it 
may be sometimes limited, and may at 
other times affect the whole of one side, 
or spread over the whole body. When 
the spasm is very limited, to the arm for 
instance, or even, when slight in degree, 
to one side of the body, there may be no 
loss of consciousness. The sources of 
danger to life from the paroxysm in this 
and in other forms of Convulsion are 
either that the spasm may fix the respira- 
tory muscles, or that the frequency of the 
attacks may severely exhaust the child. 
It is important to note this kind of Con- 
vulsion, because it is the one which is 
often followed by hemiplegia. We shall 
therefore anticipate what has to be said 
of the sequelae of fits so far as this symp- 
tom is concerned. We should always 
carefully examine the child's limbs, after 
as well as during a fit ; and when the fits 
of this kind are frequent, we may find the PREMONITORY SYMPTOMS. 
743 
arm and leg of one side paralyzed. If, 
however the child be deeply insensible, we 
may not be able to determine this, just as 
we cannot determine the existence of 
hemiplegia in some cases of cerebral he- 
morrhage in adults so long as the patient 
is very deeply comatose. We may first 
find out that the patient is paralyzed 
when he is recovering from the "status 
epilepticus." I believe hemiplegia is 
common, but the palsy usually passes off 
quickly. This is precisely what occurs so 
often in adults. We frequently see uni- 
lateral convulsions, or more strictly con- 
vulsions beginning unilaterally, in adults, 
followed by transient hemiplegia-the 
epileptic hemiplegia of Dr. Todd. How- 
ever, the palsy in children sometimes does 
not pass off; and if it remains for many 
days after convulsions have ceased, and if, 
above all, it remains so long after but one 
severe convulsion in a child otherwise 
seemingly healthy, it is very likely to be 
permanent. The palsy may be only a little 
weakness, or there may be complete im- 
mobility. In most cases the leg at all 
events recovers so far that the child can 
walk. As the child grows up, the condi- 
tion is often a mixture of palsy and 
spasm. There is either "contracture" 
or "spastic rigidity" of the hand and 
foot-the foot suffering very much less 
than the arm. More rarely the face suf- 
fers too in the same way. As the child 
grows up the paralyzed parts are smaller 
than those of the other side, the bones as 
well as the soft parts ; the scapula is fre- 
quently strikingly smaller on the para- 
lyzed side. The condition is not like that 
of limbs affected by infantile palsy. The 
muscles respond to the interrupted cur- 
rent, and when there is much spastic 
rigidity, the arm, although shorter than 
the sound limb, may be thicker. Here 
we may say a few words as to the cause of 
this symptom. 
In the first place, unless the child's ner- 
vous system is altogether different from 
that of the adult, the symptom points to 
disease of the opposite side of the brain. 
(Vide infra on Convulsions in Adults.) 
But such a symptom does not of course 
point to any particular pathological 
change.1 It is rare to find atrophy of the 
optic nerves in hemiplegic children, and 
this is some evidence that there is no 
gross lesion, such as tumor, tubercle, &u. 
The changes are probably minute. The 
causation of the symptom cannot be clearly 
discussed. But this issue may be raised : 
Is it the result of the very same changes 
which caused the Convulsion, or is it the 
result of damage to the brain in the parox- 
ysm, e. g. to excessive congestion, or even 
rupture of vessels from sudden stoppage 
of respiration ? I have no doubt it is 
owing to the first cause. 1. Because the 
rule is that the spasm has been on the 
side afterwards paralyzed, or has begun 
on that side and affected it chiefly. 2. 
Because in the epileptic hemiplegia of 
adults, in whom we do sometimes find 
gross changes, syphiloma for instance, we 
find the disease in the cerebral hemisphere 
opposite the side of the body, first con- 
vulsed and afterwards paralyzed. To 
this may be added the argument that 
general congestion of the brain is not 
likely to lead to so local a symptom-to 
paralysis of one side of the body. The 
fact that the hemiplegia is often transient 
does not show that there have been no 
local changes, because in adults, hemiple- 
gia, after a convulsion, is often transient, 
even when there is organic disease of the 
brain,-syphiloma for instance. 
The Convulsions are general.-It is not 
meant that the Convulsion affects both 
sides together, nor both sides quite equal- 
ly, but that both sides are nearly equally 
affected, and nearly at the same time. 
The chief point here is to consider the 
condition of the thorax in the paroxysm. 
A long stoppage of respiration is the' 
worst symptom we can witness, and when 
a child dies in a fit he is no doubt killed 
by the prolonged fixation of his thorax. 
In some of these cases the limbs seem to- 
be comparatively little affected, although 
all four are somewhat affected. The 
older the child, the more the limbs and 
the less the chest suffer. These fits vary 
much in degree of severity. If slight, the 
child may, as in other varieties of Convul- 
sions, seem quite well shortly after. If 
severe he may remain exhausted and ap- 
pear dull only ; if very severe, he lies in 
deep coma. The frequency of the fits 
modifies his condition. He may have a 
second fit before he has recovered from 
the effects of the first, or as the nurse will 
say, "in and out of fits all day long." 
The child may have an attack and never 
suffer again. He may die in his first fit. 
It is not very uncommon for a fit to occur 
in a child who is seemingly quite well. 
He is suddenly convulsed, and may as 
soon as the fit is over go to play again as 
if nothing unusual had happened. It is 
to be insisted on that, however well a 
child may seem before and after a convul- 
sion, we cannot be sure that he will not 
1 I have made an autopsy on the body of a 
young woman, twenty-two years of age, who 
had been hemiplegic in the left side, after 
one series of fits, since the age of about three 
years, and subject to frequent convulsions 
from the age of five or six. The right cere- 
bral hemisphere was much smaller than the 
left, and the left arm and leg were smaller 
than the right arm and leg. I found, how- 
ever, no disease beyond what the unilateral 
atrophy implies. I have to thank my friend 
Mr. Norton for permission to see this patient. 744 
CONVULSIONS. 
have more. He probably will. Next 
day or next week he has another, and 
then perhaps thirty in the day. From a 
rapid succession he suffers in two ways : 
1. The respiratory function is much in- 
terfered with, and it is suddenly interfered 
with. 2. There is very great exhaustion 
from the severe muscular " exercise, " and 
want of sleep. These things will be par- 
ticularly referred to under "Treatment." 
Sequels. - The chief sequelte may 
with great looseness be arranged as, (1) 
Paralysis ; (2) Amaurosis ; (3) Defects of 
Speech and Disorders of Mind; (4) Squint- 
ing; (5) Paralysis of cranial nerves. There 
are of course other defects after Con- 
vulsion : loss of smell, loss of hearing, and 
unsteadiness of gait. These, however, 
are less common; they have different sig- 
nificance, being more accidental than the 
other defects I have named, and often de- 
pend on organic disease. 
(1) Now children are subject to two 
kinds of paralysis, one of which almost 
deserves the name of essential, and is 
well enough recognized when called In- 
fantile Palsy. The other, which will oc- 
cur at any age, namely hemiplegia, is the 
form of paralysis which most frequently 
follows Convulsion, and has been already 
considered. (2) Amaurosis will be con- 
sidered elsewhere : it is a rare sequel of 
Convulsion in children. If we find double 
optic neuritis, or double optic atrophy, we 
fear there is a gross intracranial lesion, 
such as tumor, a lump of tubercle, &c. 
Recovery from a condition very like that 
occurring from meningitis does not con- 
tra-indicate the existence of gross organic 
disease, if there has been double optic 
neuritis. Atrophy of the optic nerves 
occurs with fits owing to chronic hydro- 
cephalus. Under any circumstances we 
can do nothing for Amaurosis from atro- 
phy of the optic nerves. (3) With loss of 
speech we may take in mental defects, 
because in children the two things often 
go together. (Deaf-mutism is not consid- 
ered here. If deafness occurs from any 
cause before speech has been acquired, 
mutism is the result.) After attacks of 
Convulsion, children are liable to lose 
their speech, and this loss occurs without 
any notable lack of power in the articu- 
latory muscles. The proof of this is that 
the child eats and swallows well, &c. 
After a while, a few months or a few 
years, he begins to utter some word or 
syllable, e.g. "do, do," "ta, ta," "mam, 
mam," and he utters such syllables very 
distinctly. This loss may be temporary 
or it may be permanent. There is rarely 
hemiplegia along with loss of speech in 
children, or at all events rarely persistent 
hemiplegia. Sometimes after Convulsion, 
before speech is acquired, the child never 
learns to talk. If the child is only begin- 
ning to talk when the fits occur, loss of 
so recent an acquirement is usually only 
temporary. 
In most of the cases I have seen where 
the loss of speech is permanent, the chil- 
dren are spiteful, vicious, and they have 
nearly always uncontrollable tempers. 
Children may be left after Convulsion in 
this general condition without loss of 
speech. These are, I think, the saddest 
cases in the whole range of our practice. 
Trousseau says that idiocy very often 
supervenes on infantile Convulsion. But 
the condition of speechless children is 
often worse than mere imbecility. There 
are many varieties of this sad mental con- 
dition, from some vulgar coarseness of 
mind to a total absence of decency. No 
purely medical treatment is of any avail. 
In many cases a false sentiment induces 
the parents to let the enfeebled mind grow 
as it lists rather than put their child to 
the annoyance of vigilant discipline. In- 
deed sometimes a fond mother not unna- 
turally mistakes a kind of animal vivacity 
for cleverness, and will not be persuaded 
that her child is much different from 
others, even when he cannot or will not 
dress himself or cut his food. Strenuous 
efforts must be made to teach the child to 
talk, for Dr. Langdon Down tells me that 
idiots who have come under his care 
speechless have been taught to speak. 
Very strangely, the worst of such patients 
even when speechless have often a good 
ear for music, and will hum or sing tunes 
correctly. This is not an important sign 
of mental power. Dr. Down tells me 
that idiots often can sing. The younger 
the child, the more likely is loss of speech 
to be attended by general mental deterio- 
ration. I do not know how it is that 
there is loss of speech after some convul- 
sions and not after others. It is not, I 
believe, the result of the Convulsion, but 
is another result of the disease in the 
brain, be it what it may, which gives rise 
to, or permits, the Convulsion. Loss of 
speech is indeed a rare sequel of Convul- 
sions, and will occasionally attend a sim- 
ple attack of hemiplegia- i. e. simple in 
the sense that it is unaccompanied by 
Convulsion, or other evident symptoms. 
I may just observe that the association of 
defects of speech with symptoms pointing 
to disease of the left hemisphere is not so 
striking as it is in adults, but it will be 
found that they more often occur with 
Convulsion and paralysis of the right than 
of the left side of the body. 
(4) Squinting has long been considered 
a common symptom of affection of the 
nervous system in childhood. But Helm- 
holtz has shown that the most frequent 
cause of strabismus is a congenital defect 
in the eyeballs. It is found in those 
whose eyes are hypermetropic. Of course 
a child may have strabismus, as an adult THE CAUSES OF CONVULSIONS. 
745 
may, from paralysis of one or more of the 
muscles moving the globe. It is generally 
held, however, that strabismus, when a 
nervous symptom, is a result of spasm of 
muscles. Yet neither paralysis nor spasm 
of one muscle-for instance, of one inter- 
nal or of one external rectus-will pro- 
perly account for the common form of 
strabismus. The kind of strabismus we 
meet with in children during or after Con- 
vulsions is not found during nor after 
Convulsions in adults. The presumption 
is that this difference is owing to differ- 
ences in the development of the nervous 
system of the child and the adult. 
(5) If the whole of the muscles sup- 
plied by any one of the cranial nerves 
are paralyzed during or after Convulsions 
in a child or in an adult, we are certain 
that there is disease of that nerve trunk, 
or of the part of the nervous system 
where the nerve issues. In these cases 
we are usually able to infer that there is 
organic disease. We should especially 
inquire for evidence of syphilis. 
The Causes of Convulsions. 
We have considered the several kinds 
of paroxysm, and now we have to speak 
of the diagnosis in cases in which a parox- 
ysm of any kind occurs, or, as it is usu- 
ally said, on the " causes" of Convulsions. 
However, we have already seen that we 
know scarcely anything of the pathology 
of children's Convulsions; we do not 
know what is the change in the nervous 
system which produces this symptom, be- 
cause in most cases the brain appears 
healthy post mortem. It is scarcely fair, 
therefore, to use the word "cause." We 
can, however, group cases according to 
certain circumstances, and the following 
list will show, better than any exposition 
can, the limited way in which the word 
"cause" is to be used with reference to 
Convulsion. It is needless to say that the 
arrangement is a very arbitrary one, but 
it is convenient as guiding us in prognosis 
and treatment. We shall find that many 
a case will refuse to be placed altogether 
under one of the headings. For this rea- 
son it is impossible to discuss the points 
raised under each of the five following 
headings, quite separately from those 
raised under the others. When called to 
a case of Convulsion, we may find- 
1. That an acute illness is setting in, 
as, for instance, an exanthem or acute 
cerebral disorder. 
2. That the Convulsion is one of a 
series of symptoms, the result of organic 
disease of the brain or of its membranes, 
such as tumor, abscess, syphilis, &c. 
3. That the fit is part of some chronic 
condition of ill-health, such as rickets, 
exhaustion and emaciation with diarrhoea. 
4. That the child is suffering from some 
slight and temporary thing, such as an 
overloaded stomach, perhaps diarrhoea, 
the irritation of worms, or the irritation 
of teeth. 
5. That the fits are of a kind which, for 
want of better knowledge, we are obliged 
to call essential, eclamptic, or epileptic. 
(1.) There are symptoms of fever. 
Here we should fear that some acute ill- 
ness, as pneumonia, smallpox, or scarlet 
fever, is beginning, of which the Convul- 
sion is, if not the first, yet the first prom- 
inent symptom. It scarcely comes in my 
way to do more in this paper than urge 
the recognition of these rarer possibilities 
in the crowd of more probable causes. I 
must refer to special articles on the acute 
diseases of children. We should always 
make investigations for many acute dis- 
eases when there is heat of skin. The 
chest should be examined as a matter of 
routine, as not very rarely a child is first 
found by its parents to be ill when a Con- 
vulsion occurs, although when we exam- 
ine we discover that there is bronchitis, 
or even that one pleural cavity is full of 
fluid. The history of scarlet fever in 
other members of the family would be a 
most important guide, and we must never 
fail to make inquiries for it, however sud- 
denly the fit may have come on in the 
most robust child. Dr. West mentions a 
case, no doubt scarlatinal, in which Con- 
vulsions succeeded by coma destroyed in 
a single day a healthy boy two years of 
age. We should in all doubtful cases 
examine the urine. The presence of 
blood in the urine would help us to deter- 
mine whether the fits were or were not 
the result of masked scarlet fever. We 
require more observations on the condi- 
tion of the urine in convulsive seizures 
soon after the attacks. Sir James Simp- 
son has found albumen in the urine of a 
child three days old who suffered from 
Convulsion. 
Feverish symptoms may he thought to 
point to causes which primarily affect the 
head itself, tubercular meningitis for in- 
stance. The difficulty in diagnosis is 
only likely to occur in cases where Con- 
vulsion is the first symptom, or, in more 
strictness, the symptom for which we are 
consulted. It is to be remarked, however, 
that Convulsion is rarely one of the symp- 
toms of the invasion of tubercular menin- 
gitis, and when it is we usually find that 
the child has for weeks, without obvious 
cause, been getting thin, listless, and 
peevish-that in reality he has been ill 
for some time. Moreover, facts as to age 
will often help us in the diagnosis of many^ 
of these cases. Tubercular meningitis' 
rarely attacks children under two years, 
and very rarely indeed under one year of> 
age. It is well to remark here that we 
must not mistake the status epilepticus- 746 
CONVULSIONS. 
the condition resulting from a quick suc- 
cession of fits-for meningitis. If the 
' convulsions be very numerous, the illness 
beginning by a convulsion, the disease is 
very unlikely to be meningitis. 
L (2.) Then it is possible that the Convul- 
sion may be a symptom of organic disease, 
e. g. tumor. Such cases in children are 
very rare. There is usually a history of 
severe headache and urgent vomiting for 
weeks or months before the Convulsions, 
without any previous rapid emaciation to 
lead us to suppose there is tubercular 
meningitis. Moreover the symptoms are 
capricious, the headache and vomiting 
often ceasing for days. When these symp- 
toms are not urgent we may be first con- 
sulted for a convulsion; we see cases 
occasionally in which a convulsion occurs 
from tumor of the brain in a child whose 
symptoms had been primarily so slight 
as not to prevent his going about, the 
severe headaches being put down by the 
child's friends to " biliousness," &c. In 
these cases we can only decide by consider- 
ing the general evidence. The urgent, 
purposeless, often bilious, vomiting, pos- 
sibly existing with clean tongue, and not 
infrequently with good appetite at inter- 
vals, days of comparative freedom from 
marked symptoms, point to the diagnosis 
of tumor. But the most conclusive evi- 
dence is the presence of double optic 
neuritis. If with headache, vomiting, 
and convulsion there is double optic neu- 
ritis, we may be almost certain that there 
is cerebral tumor. Double optic neuritis 
is rare under seven years of age, and very 
rare under five. 
In all cases in which there is or has 
been discharge, especially offensive dis- 
charge, from the ear, especially when 
there is also pain in many branches of the 
fifth nerve ; above all, if palsy of the por- 
tio dura nerve comes on, we should fear 
one of two things: (1) cerebral or cere- 
bellar abscess, or (2) meningitis. It is 
not part of my task to enter fully into the 
diagnosis of these two conditions. We 
must not decide unless there are general 
symptoms also, e. g. increase of tempera- 
ture, constipation, vomiting, and stupor, 
for discharge from the ear is not infre- 
quently attended by chronic convulsions 
occurring at intervals for years (epilepsy), 
and the fit we are consulted for may be 
the first of such a series. What the con- 
nection of the ear disease with the fits in 
these chronic cases is we do not know, 
unless we adopt the explanation that they 
depend on irritation starting from the 
ear. The frequent repetition of fits, even 
twenty or thirty in twenty-four hours let 
us say, does not make us incline to the 
diagnosis of abscess or meningitis, because 
it is not at all uncommon for Convulsions 
both in children and adults to occur in 
batches when there is no ear disease and 
no evidence of organic disease in the 
brain. The stupor which is produced by 
a succession of tits is of little moment, 
comparatively speaking, unless there has 
been before the advent of the fits severe 
pain in the head and vomiting, and unless 
the respiration and pulse be irregular. 
It is possible that the Convulsions may 
be owing to congenital syphilis; but we 
cannot so conclude unless, besides a clear 
history of syphilitic taint, there are such 
symptoms as palsies of cranial nerves, or 
paraplegia. The existence of hemiplegia 
with a mere history of syphilitic taint 
would not warrant the diagnosis. Of 
course if signs of active syphilis be pre- 
sent, especially nodes, and especially if 
the patient be above three or four years 
of age, we should treat foi' syphilis. In- 
deed, in chronic cases at all events, if the 
patient's brothers or sisters show signs of 
inherited taint, we should give iodide of 
potassium. 
(3.) If we found the child emaciated 
(there being now, we are supposing, no 
signs of acute mischief and no signs of 
organic disease), or if he had diarrhoea or 
dyspepsia, we should hope that the fit was 
but a sign that the nervous system was 
temporarily suffering with the rest of the 
body, and that it would cease to sutler 
when the child was brought back to good 
general health. Convulsions not infre- 
quently occur in infants improperly fed. 
In these cases there is often dyspepsia and 
diarrhoea, there is a big belly with general 
emaciation. The convulsions are then 
often ascribed to irritation from cutting 
the teeth, or, especially when there is diar- 
rhoea, to the irritation of the intestinal 
canal. (The diarrhoea itself is sometimes 
ascribed to eruptions of the teeth.) These 
causes may have something to do in pro- 
voking the fit, but they cannot, I think, be 
solely to blame for it. Yet there can be 
no doubt as to the propriety of helping a 
tooth through if the gum be tense, swollen, 
or red ; but to lance the gums as a matter 
of routine is not good practice. I have no 
belief that such irritations are the sole 
causes of fits ; but I will now only depre- 
cate exclusive attention to these supposed 
sources of eccentric irritation. If fits do 
sometimes cease when a vermifuge brings 
away worms, or when the gums are lanced, 
we know that in many cases they often 
continue when the system is freed from 
such cares, or at least when we have done 
all we can to get rid of them. I think 
with young practitioners, such "causes" 
are held to explain the occurrence of the 
fit so thoroughly that they keep in the 
background the evidence the child's gene- 
ral state will afford. We are, to say the 
least, unauthorized to ascribe children's 
illnesses solely to the irritation of teeth 
and the like, unless we have most thor- 
oughly considered all other possible causes. 747 
THE CAUSES OF CONVULSIONS. 
Above all, we must negative the existence 
of rickets. In Gee's article, several times 
referred to, the frequent, almost constant, 
association of Convulsion, including laryn- 
gismus, with rickets, is insisted on. He 
notes seventy-three cases of Convulsion, 
and of these fifty-six were dependent on 
the "general condition" of the child. 
These fifty-six cases were, he tells us, of 
that kind commonly called, par excellence, 
cases of essential Convulsions (eclampsy). 
"Now, of sixty-one eclamptic children, 
fifty-six were rickety. Saying this I fear 
that I shall incur the charge of exaggera- 
tion. It is necessary to explain that my 
experience is wholly derived from the 
children of the poor." He tries to show, 
and I think he shows conclusively, "that 
the existence of a constitution leading to 
rickets is the most important fact in the 
kind of Convulsion [that depending on the 
general condition of the child] in ques- 
tion." And even when no other causes 
are obvious, we must not infer that the 
relation between teething and Convul- 
sions is one solely of irritation transmitted 
from the gum to some part of the child's 
nervous system. The coming through of 
a tooth must be thought of as an outward 
mark of a certain constitutional progress 
in development, as the occurrence of men- 
struation is later in life. It is far better 
to acknowledge that very often we cannot 
find out what causes a fit than to put it 
down to an orthodox cause for the want 
of a more real one.1 
When diarrhoea is severe the child is 
often emaciated, and the fit is more likely 
to be due to exhaustion than to eccentric 
irritation starting from the intestinal 
canal. We should not adopt routine 
efforts at clearing out the bowels to get 
rid of " undigested irritating" matters. 
In most of these cases the child has been 
improperly fed, and careful dieting is of 
very much more moment than immediate 
treatment of the diarrhoea by drugs. A 
child is at once overworked and underfed 
when it has to take into its stomach large 
masses of food which it cannot properly 
digest. We must certainly not consider 
the most violent convulsion in a child who 
is thin or who has exhausting diarrhoea 
as a result of " congested brain." There 
may be stagnation of blood in the head, 
the result of the paroxysm, but not any 
"active" process requiring antiphlogistic 
treatment. We do not know what the 
intracranial changes are which cause tits, 
and we have no evidence that cerebral 
congestion occurs before the attacks. We 
have plenty of proof, from disease and 
from experiments on animals, that Con- 
vulsions will follow anaemia; but as in 
these instances the anaemia is sudden, per- 
haps the facts are not quite to the point. 
We have, however, clinical evidence that 
they occur in feeble children and in the 
course of exhausting diseases. Since the 
days when antiphlogistic measures were 
so freely resorted to in children's dis- 
orders, "we have learned," Vogel says 
(op. cit. p. 385), "that pale anaemic chil- 
dren are as liable to be attacked by Con- 
vulsions as robust and plethoric ones." 
Beyond question the violence of fits and 
their frequent repetition are not the clinical 
signs of active changes in the head. Heat 
of skin and vomiting, headache, and irre- 
gular pulse are the real signs of acute 
changes in the head-encephalitis and 
meningitis. But since the brain may be- 
come much congested as a consequence of 
the fits when they are severe and fre- 
quently repeated, it is intelligible that 
some advantage may follow the applica- 
tion of leeches by a reduction of the con- 
gestion, although there is no inflammatory 
process to relieve. I say again that severe 
and repeated Convulsions are not the 
signs which should make us deplete gene- 
rally, apply blisters, or give purgatives 
largely. Treatment of this sort is admit- 
tedly a most fatal mistake in those cases 
where the fit is but one sign of starvation, 
as it undoubtedly is in many cases of diar- 
rhoea, and in cases of wrong feeding. 
(4.) It does occasionally happen that a 
child is attacked by Convulsions when in 
apparently good health. But before con- 
cluding that a child is in good health we 
must, I repeat, consider very carefully 
whether or not there are signs of rickets, 
and we "must bear in mind that active 
rickets and the preservation of a large 
amount of fat are by no means incompat- 
ible." (Gee, op. cit.) 
These are the cases in which it is plaus- 
ible that the convulsion is the result of 
some temporary cause, such as over-eat- 
ing ; of some removable cause, such as the 
irritation of teeth during dentition ; or of 
some sudden excessive mental disturbance, 
such as fright. I consider it very doubtful 
whether any of these so-called "causes" 
1 "Much eclat has lately been made in Eng- 
land and France with the scarification of the 
gums. Some recommend a crucial incision ; 
others, the removal of the whole cap which 
covers the head of the tooth. But, as an ad- 
monition, it is premised in all the reports 
and laudation, that the tooth has to be very 
near eruption, otherwise the scarification will 
be of no benefit. I have frequently performed 
this operation, but have always found that 
the lancinated wounds of an inflamed mucous 
membrane heal very badly, and ulcerate for 
a long time; that the nervous symptoms con- 
tinue notwithstanding, till ultimately artifi- 
cial or spontaneous diarrhoea supervenes. 
Indeed, if we have to wait until the tooth is 
' very near' breaking through, then the pro- 
cess is in fact near its end, and any other 
simple remedy is as efficacious as this, which 
is attended by a considerable amount of 
pain." (Vogel, Raphael's Trans, p. 107.) CONVULSIONS. 
748 
induce fits in children whose nervous sys- 
tems are healthy beforehand. But it is 
very likely that they are exciting causes 
when it is not healthy. I have twice made 
autopsies on children who have died in 
fits after a meal, and in each case the 
stomach was full of food. In one case the 
child had had fits before, but none for three 
months before the fatal seizure ; in the 
other the fit which the child died in 
was the first. If then we find that a child 
has had a fit soon after a meal which we 
have good reason to believe was large- 
say a basinful of soup-we should give an 
emetic. If we find that a tooth is coming 
through, we may justifiably lance the 
gum. But when we have done this we 
must bear in mind that a nervous system 
which has given way from such temporary 
and comparatively slight exciting causes, 
will be very likely to fail again when 
again tried by indiscretion in feeding or 
by eruption of teeth later in the dentition 
period. Indeed, we must, I think, con- 
clude that the nervous system of a child 
cannot be healthy if a slight and tempo- 
rary cause produces a convulsion, however 
healthy the child may look. We often 
find that the fits recur when we have done 
all we can to remove supposed sources of 
irritation. There are great differences of 
opinion with regard to the influence of den- 
tal irritation. Vogel says (op. cit. p. 387): 
"Eclampsia, originating from dental irri- 
tation, belongs to the serious forms, and 
often leaves behind it partial paralysis 
and imbecility." Meigs and Pepper, in 
their most valuable work on Diseases of 
Children, say : " As a general rule, the 
convulsions which depend solely on the 
process of dentition are slight, and last 
but a short time. In all the instances 
that we have seen in which this was the 
only cause to be detected, the attack was 
of this nature." 
(5.) We will now consider cases in 
which Convulsion attacks healthy children 
without obvious cause of any kind, and 
cases in which they continue when we 
have removed all temporary sources of 
irritation. Once more having regard to 
the important researches of Elsasser, Jen- 
ner, and Gee, I would urge the considera- 
tion whether in these cases the " healthy" 
child is not rickety, although often slightly 
so. It is to be remarked that a child may 
suffer fits from blows on the head, and 
occasionally we see patients who have 
Convulsions after severe blows, followed 
by indentation of the skull. These cases 
it is not my task to consider. We are 
sometimes told by the friends of our little 
patients that palsy or convulsion followed 
an injury, but on inquiry we find there is 
not a shadow of evidence of a blow or a 
fall having occurred. The friends suppose 
very naturally that a fit must have a 
cause, and if their child has a convulsion 
in the midst of seeming good health, they 
infer that the child has had a fall. When 
we find a child the subject of Convulsions 
for which we discover no cause, or infer 
none from the condition of the teeth, 
bowels, and general health, we think of 
the terms eclampsia and essential. I do 
not, however, use these terms, for I know 
no means of distinguishing betwixt an 
epileptic fit in a child and an eclamptic fit. 
The practical point is this, and it is occa-" 
sionally put to us by the child's friends : 
Is it epilepsy ? I take this to mean : Is 
the illness one which will quickly, in days 
or weeks, run a course to death or to per- 
manent recovery, or will the child recover 
from the fit or series of fits, but be liable 
to occasional attacks of convulsions for 
years or for life ? This seems to me to be 
the practical question. Now, when we 
see a child in his first fit, we certainly can- 
not tell, whatever the age may be. The 
paroxysm is the same in all cases of gen- 
eral Convulsion. There seems to be great 
unanimity among authors that the eclamp- 
tic fit is quite like that of epilepsy. Nie- 
meyer speaks of eclampsia as acute epi- 
lepsy. Vogel says it is impossible to 
distinguish the paroxysm of eclampsia from 
that of epilepsy. Then epilepsy will occur 
at any age. Vogel (op. cit. p. 411) states 
that Beau found, out of two hundred and 
eleven epileptics, that the disease was 
congenital in seventeen cases, and that it 
occurred from birth to the age of six years 
in twenty-two cases. Nevertheless, Vogel 
says, "Young children in general rarely 
suffer from true epilepsy, as we might ex- 
pect, if the more frequent eclampsia be 
regarded as a distinct disease." And he 
adds : " Eclampsia is easily distinguished 
from the disease under consideration (epi- 
lepsy), by the fact that it almost always 
occurs at the breaking out of an acute 
affection only ; that the general condition 
of the patient, after the termination of the 
Convulsions is not restored : and that it 
is often fatal, while epileptic attacks are 
almost always devoid of danger." I sub- 
mit that at the best we can only deal in 
probabilities. The older the child the 
more seemingly causeless the fits, the 
slower the succession-say a fit every 
other day, or fits scattered at irregular 
intervals of days or weeks-and perhaps 
we may say the less rickety the child the 
more likely are the fits to be epileptic, i. e. 
the more likely is the child to continue for 
years or for life subject to fits. But I am 
convinced that we can give a prognosis in 
no case with anything like certainty. I 
do not exempt cases where a child has had 
one fit during the eruption of a tooth or 
during an exanthem. We can only say, 
even in these cases, that the child is very 
unlikely to suffer again. If the child be PROGNOSIS - TREATMENT. 
749 
partially hemiplegic after a seizure, he is 
very likely to suffer from Convulsions later 
in life. 
' Epileptic fits in adults not rarely date 
from Convulsions in infancy. The con- 
nection is shown now and then by strag- 
gling fits at intervals of months or years, 
or by uninterrupted continuity of attacks 
at fairly regular periods. I have no facts, 
and I know of none on record, to show 
how many children keep well after get- 
ting through an illness with severe Con- 
vulsions, but I am certain that attacks in 
infancy-from one which attracted little 
attention, " we thought," says the mother, 
"it was only the teeth," to a whole batch 
-are occasionally followed by epileptic 
fits near the age of seven, fourteen, or 
twenty. 
In reference to this question, it is im- 
portant to ask if the child's near relatives 
have had nervous symptoms. Every med- 
ical man can relate instances of fits, or of 
other symptoms of cerebral disease in dif- 
ferent members of one family. I have 
had under my care a girl of eleven years 
of age, who has had fits from the age of 
six months. Iler sister, three years of 
age, had had them from the age of one 
week: another sister, aged ten, from the 
age of four years; and a fourth, also a 
girl aged eight, from six years. Instances 
so striking are rare. The fact that seve- 
ral of the child's relatives have had hemi- 
plegia or Convulsions from embolism, clot, 
syphilis, &c., has no bearing whatever on 
the question. If the child's brother, or 
sister, or mother had Convulsions in 
childhood, the evidence is perhaps 
stronger; but I confess that I have very 
little faith in the hereditariness of such 
symptoms as epilepsy or Convulsions. 
The occurrence of Convulsions in several 
of one family may be because they all 
suffer from rickets. We may believe that 
a " nervous temperament" is transmitted, 
but if so, there will be a predisposition to 
many nervous affections, and not to one 
symptom only. At the best it is very 
difficult to obtain certainty as to heredi- 
tariness, as Convulsions are so very com- 
mon in children, and occur, it is presum- 
able, from numerous pathological pro- 
cesses. 
Prognosis. 
The prognosis of a symptom with so 
uncertain a meaning must, of course, be 
very uncertain, and much has been inci- 
dentally said on prognosis. Here may be 
excluded from consideration the attacks 
which precede or occur in the course of 
acute disease. The writers of other arti- 
cles will speak of seizures so occurring. 
When a child has had a fit, and appears 
to be in good health again, the question 
as to the cause of the fits, with a view to 
forecast the child's future, becomes again 
urgent. If there is clear evidence of some 
source of irritation, and we have got rid 
of it, we may hope the child will keep 
well; but I have already spoken of the 
uncertainty of our hopes in this respect. 
By far the most important question in 
prognosis is whether or not the child is 
likely to get through an attack or a series 
of attacks of acute Convulsions with life. 
In the first place, a single attack may be 
fatal, but this is a rare event. Wilks re- 
lates two striking instances of rapid death 
with Convulsions. One was a small, deli- 
cate child, six weeks old, who was seized 
suddenly with diarrhoea and Convulsions, 
and died in a few hours. The other pa- 
tient was a child four years old, strong 
and healthy, who died soon after being 
brought to the hospital. In neither case 
was anything wrong found with the brain; 
but in the child four years old the stomach 
was distended with food. I have men- 
tioned two cases of a like kind. Such 
cases, however, are rare. The consider- 
ation of less acute seizures is more im- 
portant. We have no generalizations, 
and can only deal in generalities. The 
younger the child, the more likely is the 
result to be fatal. The more frequent or 
violent the seizures, the more profound 
the coma; and the worse the state of 
health in which the fits began, the more 
likely is the child to succumb. To con- 
sider the manner in which fits are likely 
to bring about death, is the important 
matter. This will be considered with the 
treatment, to which I now come. 
Treatment. 
It would not be correct, as I have re- 
marked, to speak of any purely rational 
treatment of a single symptom, as it 
means things very different. Our treat- 
ment is nearly altogether empirical. And, 
of course, we exclude entirely from pres- 
ent consideration cases in which Convul- 
sion occurs in such diseases as scarlet 
fever, meningitis, &c. Even an empirical 
treatment of Convulsion would not be jus- 
tifiable in these instances. Our thoughts 
or treatment go hand-in-hand with our 
investigations into the cause. Principles 
of treatment apply to Convulsions of all 
degrees, from rolling of the eyes to com- 
plete seizures. 
If we find the child in a fit, we can do 
little during the paroxysm. We should 
see that every part of its dress is loosened, 
that it has a plentiful supply of pure air, 
and we should direct that it be laid down 
and kept quiet. Vogel says that by 
sprinkling the face and exposed chest 
with cold water, wre may succeed in in- 
ducing deep spasmodic inspiration, by 750 
CONVULSIONS. 
which the danger of suffocation at least 
is lessened. 
Then as to general treatment, in the 
intervals of the paroxysms. I begin with 
what may be called attention to imme- 
diate circumstances. We undress the 
child, and it is possible we may find that 
a pin or a needle is sticking in some part 
of the body, even in the child's head, 
penetrating the brain. A needle has 
been found in the liver of a child who 
died of Convulsion (see Trousseau's Clin- 
ical Medicine, vol. i. p. 343, Bazire's 
translation). Trousseau believes that 
blisters and mustard plasters are often 
the causes of fatal Convulsions. 
If we find that the fit came on after 
''eating, we should give an emetic of ipe- 
cacuanha. If a gum be swollen and 
tense, we may properly use the lancet. 
We should inquire after the state of the 
child's bowels ; if they are constipated, 
we should give a purgative. But none of 
these things must be done as matter of 
routine. The presence of diarrhoea, es- 
pecially, with tenesmus and expulsion of 
little but mucus, may show that there is 
irritating matter in the intestinal canal, 
and it is then proper to give a dose of cas- 
tor oil. This must be, however, only to 
make a starting-point for careful dieting. 
The presence of abdominal pain and con- 
stipation in robust children may lead to 
the suspicion of retained feces. Diar- 
rhoea, which is-paradoxical as it may 
seem at first glance-sometimes a sign of 
constipation, would not prevent the mod- 
erate administration of purgatives or 
enemata. For a child at the breast, an 
enema of an ounce of warm water or of 
thin gruel may be administered ; at one 
year, two ounces. Very likely the diar- 
rhoea is due to wrong feeding, and to diet 
the child would then be the most impor- 
tant thing to attend to. When the mo- 
tions are very frequent, and if the child 
be thin and weak, we may try to check 
the diarrhoea by astringents, if proper 
dieting does not arrest it. 
Warm baths are frequently used, and, 
when there is no great heat of skin, and 
no thoracic complication, the child may 
be put in a bath at the temperature of 
about 96° Fahr, for from five to ten min- 
utes. Under any circumstances the feet 
and legs may be immersed in warm water. 
Then mustard plasters - a mixture of 
mustard and flour-may be applied to the 
calves of the legs for five, ten, or fifteen 
minutes. 
When we have done all that immediate 
investigation prompts; when we have 
attended to the bowels, lanced the gums, 
ordered proper food, the Convulsions may 
persist, and may even increase in num- 
ber and in severity. We are thus urged 
to do something more. 
There is in attacks of Convulsion a ten- 
dency to (1) death by exhaustion, from 
the frequency of the fits and want of 
sleep ; (2) death from asphyxia, from sud- 
den and prolonged fixing of the chest 
walls, anti from slow congestion of the 
lunes. The latter is often rather a way 
of dying than a cause of death. Adults 
die from convulsive seizures in each of 
these two days. 
1. If the child were much exhausted by 
frequent fits, or if he wrere weak to begin 
with ; if he were thin, if he had long had 
diarrhoea, wTe should look most carefully 
to his support: we should prescribe beei- 
tea or juice of meat in abundance. Nor 
should we hesitate to give stimulants. 
The circumstances that would guide me 
most on this point would be the great fre- 
quency of other abnormal muscular ac- 
tions. 
The main object in treatment of disor-i 
dered function of the brain in general, 
e. g. sleeplessness, delirium, and frequent, 
slight Convulsions, is to produce sleep, 
and to accomplish this wre should give nu- 
triment liberally ; and if this fails, stimu- 
lants freely. I have already spoken of 
the importance of recognizing that violent' 
or frequent Convulsions do not depend on 
inflammatory changes. If the beef-tea or 
juice of meat were vomited, I should give 
milk with a little ice, and inject the tea and 
the juice. 
Affusion with cold water has been ad- 
vised, but this I should not adopt unless 
the child was robust. Of course I speak 
of cases in which there is no general 
fever, and no sign of inflammation of the 
membranes. A thin, delicate child I 
should keep warm. Vogel, however, says 
that affusions of the head with cold water, 
performed every hour or two, are useful 
against all Convulsions in children (op. 
cit. p. 107). 
Then as to drugs. Antispasmodics 
have been given, but I think the best an- 
tispasmodics are nutrients and stimulants 
when these can be taken and digested. 
It is of course comparatively easy to get- 
drugs into the stomach, but they may be 
vomited. It may then be desirable to 
give an enema of asafoetida, e. g. 20 to 
30 minims of the tincture in an ounce of 
warm milk. In all cases-Convulsions in 
exanthematic and other acute diseases 
excepted-I should give bromide of po- 
tassium in large doses, by enemata, if 
necessary, if the fits were frequent, or if 
they continued several days. A mixture 
containing hyoscyamus, two or three drops 
for the age of six weeks, may be given 
with peppermint water. The great point, 
however, is, I repeat, to get the child to 
sleep, and to do this it is, I think, justifi- 
able, simple nutrients failing, to give stim- 
ulants freely. I should, however, be most 
wishful to give as much nutriment and as 
little stimulant as possible. Nor, of TREATMENT. 
751 
course, should I give wine because a child 
had a fit, but only when the child was 
feeble to begin with, or was exhausted by 
the frequency of the attack, wearied too 
from imperfect sleep, and perhaps starv- 
ing because the friends had not given 
enough nutriment before we were called. 
I should not give stimulants if the ther- 
mometer showed a great increase of tem- 
perature. Supposing nutrients and stim- 
ulants and the drugs mentioned were 
taken and retained, and failed to stop the 
Convulsions and to procure sleep, I should 
then venture to give narcotics. In no 
case should I prescribe narcotics except 
when I had ascertained that the child had 
previously taken nutrients and stimulants, 
or unless the child was fairly vigorous to 
start with. In no case, at any age, would 
I give opiates, when there was great ex- 
citement without vigor. It is as hurtful 
to give opium at this extreme, as in the 
condition of brain which occurs with gen- 
eral febrile states, and which condition is 
supposed to be due to congestion. Nor 
wo aid I give the narcotic more than once 
in twelve hours, and then I should give a 
decided dose. e. g. a quarter of a grain of 
Dover's powder under the age of three 
months; half a grain to a year, and a 
grain to a year and a half. Chloroform 
has been used by Sir James Simpson, and, 
when the above ascending series of reme- 
dies-nutrients, stimulants, bromide of 
potassium, and opiates-have failed, this 
may be tried. Dr. West says : " In cases 
where depletion is inadmissible, where the 
Convulsions are not obviously due to or- 
ganic disease of the brain, while they are 
both severe in their character and are re- 
turning with frequency, the inhalation of 
chloroform sometimes altogether arrests 
them." It is also, he says, of service in 
Convulsions of a more chronic kind. He 
tells us, however, that its effects are eva- 
nescent ; he adds, that he has never seen 
mischief from its use. " It requires the 
constant presence in the house of some 
one competent to administer it. " [It is a 
matter of universal testimony that ether 
is safer for inhalation than chloroform. 
Ether has been largely employed in Ame- 
rica in the treatment of Convulsions. The 
remarks just made concerning the admin- 
istration of chloroform apply equally well 
2. Now I come to speak of the cases 
where the severity of the individual fits 
threatens death by asphyxia, or when 
from the breathing we fear the blood is 
largely delayed in the lungs. When Con- 
vulsions occur in robust children, bleed- 
ing is sometimes advised for them. It is 
a remedy which has been urged by many 
writers, but does not seem to me-t speak 
very respectfully-to be likely to be of use; 
but I have never tried it in any form, 
either by leeches or otherwise. For I 
have no faith whatever that Convulsions 
depend on any increase of nutritive 
changes that we can arrest by taking 
blood. There is in children's Convul- 
sions no certain evidence as to the patho- 
logical condition of nervous organs. It 
is, however, often evident enough in 
robust adults, as when epileptiform seiz- 
ures follow on blows, and on tearing up 
of the brain by mechanical injury, or the 
irritation of tumor, that bleeding could do 
no good-no good by acting on the cere- 
bral circulation. But it would, I think, 
be good practice to relieve the venous sys- 
tem when, after repeated fits, the circula- 
tion is becoming embarrassed by great 
congestion of the lungs. Death seems, in 
these cases, to result from pulmonary con- 
gestion. Indeed, I think we neglect to 
bleed as often as we ought to do, on the 
principle Markham has laid down. I 
should be entirely guided by evidence 
from the color of the lips and the state of 
respiration, and not by the heat of skin or 
by shivering. However, difficulty of the 
respiration so great as these signs imply 
would mark the advance of a fatal issue, 
and our treatment could only, I fear, be 
expected to delay it: when I did deplete, 
it would be by leeches only. 
I have just spoken on the supposition 
that the fits are frequent and are running 
a rapid course, and are tending towards 
death by exhaustion or by asphyxia ; but 
if the fits come on at intervals, as once 
every day, or once a week, and if from in- 
ability to discover what they really did 
mean, i. e. if unassociated with debility, 
irritation of teeth, &c., we were obliged 
to class them as epileptic or essential, I 
should adopt the same treatment as for 
epilepsy in the adult, supposing of course 
all general indications fulfilled. I should 
give bromide of potassium, a quarter of a 
grain under six weeks, half a grain under 
three months, a grain above, and a grain 
additional for every year. Indeed, the 
bromide is a most useful drug in chronic 
convulsions from any cause, and in most 
cases - excepting temporary and acute 
states like uraemia-I should prescribe it 
when other remedies failed, whatever was 
the state of the child. Since, however, 
there is manifestly an association of Con- 
vulsions with rickets in very many cases, 
it is well to treat the child for this condi- 
tion in all chronic cases. I shall therefore 
conclude what I have to say on the treat- 
ment of Convulsions by the following quo- 
tation from a paper on rickets, by Gee (St. 
Bartholomew's Hospital Reports, vol. iv. 
p. 79):-" Treatment. This must be radi- 
cal. And in cod-liver oil we possess a 
pharmaceutical agent worthy of a place 
beside iron, Peruvian bark, and mercury. 
We ought to lose no time over the symp- 
toms of rickets ; slight catarrh, diarrhoea, 
paleness, a tendency to fits, these will all 752 
CONVULSIONS. 
disappear under cod-liver oil. Give ex- 
pectorants, purgatives, styptics, and the 
rickets will increase under our eyes ; nay, 
occasionally it will even develop de novo 
while a child is being treated for coughs, 
deranged bowels, and other apparently 
simple disorders. " t 
Convulsions in Adults. 
It is a matter of exceeding great diffi- 
culty to write on the subject of Convulsion 
in the adult. We may arrange Convul- 
sions as they are local or general, as they 
are acute or chronic, as they depend on 
acute states, such as uraemia, on organic 
disease, such as tumor, or on changes 
which we infer to be functional. I shall 
follow the course adopted in treating of 
Convulsions in Children. I shall speak 
first of the varieties of the paroxysm, and 
then of the causes of the seizures. 
There are no doubt innumerable varie- 
ties of paroxysm, but for clinical purposes 
we may arrange most of them in one of 
two classes. 
Class I. The Convulsion begins uni- 
laterally, and begins deliberately. In this 
kind of seizures consciousness is not al- 
ways lost, and when it is, it is lost after 
the spasm has begun. 
Class II. The fit begins either without 
any warning or by a very vague one, such 
as a strange feeling in the head (" giddi- 
ness," "swimming," &c.), or by a sensa- 
tion at or near to the epigastrium which 
is variously called "sinking," "faint- 
ness," "sickness," "fear," and some- 
times by children "stomach-ache." In 
these cases the spasm is more contempo- 
raneous, i. e., it affects the two sides of the 
body more nearly at the same time, and it 
affects them more equally. In this class 
of cases loss of consciousness is the first 
symptom, which occurs very quickly after 
the first warning. 
It is not pretended that there is an 
absolute distinction, for in the first class 
the spasm, in severe cases, spreads all 
over the body. In the second class it is 
not usually, probably never is. strictly 
equal on the two sides. Nor is it strictly 
contemporaneous; one side almost always, 
if not always, suffers not only more but 
sooner than the other. Moreover we often 
do not witness the fit, and we may be un- 
able to learn how it began and how it 
affected the patient. Fits of the first 
class are almost always chronic. Those 
of the second also are mostly chronic (epi- 
leptic), but frequently acute ; they may- 
be symptoms of uraemia, cerebral hemor- 
rhage, &c. In handling the subject clini- 
cally we must arbitrarily put in the second 
class cases in which we can only learn 
that the patient has had a severe convul- 
sion. In strictness, Class II. is merely a 
grouping of cases which agree in that 
Convulsion is the most prominent symp- 
tom. We must make a provisional ar- 
rangement for clinical purposes, and the 
above distinction is at least convenient in 
practice. 
The paroxysms of the first class only 
need be described at length. These fits 
are far simpler than those of the second 
class. The patient can tell us more about 
them ; we can, when present at a fit, ob- 
tain a clearer idea of what takes place, 
because the progress of the Convulsion is 
more deliberate than that of the second 
class. It is for this reason that I speak 
at most length on the "causes" of Con- 
vulsion, after describing the peculiarities 
of the paroxysm and its sequelae in this 
class. 
Class I. The Convulsion begins 
Unilaterally. 
Onset.-The patient or his friends tell 
us that he is subject to fits beginning by 
" working" in the hand, or in the face, or 
in the leg ; sometimes there is a local sen- 
sation, often named an aura, before there 
is visible movement. The rule is, that in 
these cases the spasm starts in the very 
same place in each seizure. For instance, 
one patient's fits will always begin in 
his right index finger, another patient's 
always in his right great toe. The excep- 
tions occur chiefly in cases of syphilitic 
disease of the brain. Taking a large num- 
ber of cases, there is an order of frequency 
of onset to be stated. The spasm begins 
most frequently in the hand (usually in 
the index finger and the thumb), less 
often in the side of the face and tongue, 
and rarely in the foot. 
Range (Fits partial or general).- In the 
severest fit the spasm first spreads over 
the side it begins in, then extends to the 
trunk, and then to the face, arm, and leg 
of the other side. It is important to ob- 
serve that the spasm may stop at any 
stage. There are all degrees, from a 
slight twitching of one finger to general 
and severe convulsion. In other words, 
these fits may be partial or general. More- 
over, the same patient may on one occa- 
sion have a fit limited to the hand or arm, 
during which he is quite conscious, and 
on another occasion the spasm may 
spread all over his body; he will then 
become insensible and may bite his 
tongue. The importance of studying the 
partial fits is that sometimes they occur 
for months before a severe fit. A few 
minutes' steady cramp-not " live blood," 
tremor, fidgets, or irregular jerks of a 
choreal kind-on one side of the face, in 
one hand, or in one foot, demand almost 
as serious consideration in prognosis as a 
severe fit does ; for a patient who has such CONVULSIONS IN ADULTS. 
753 
local spasm will probably suffer from 
severe convulsions. 
Ligature.-These are the cases of "epi- 
lepsy" in which the fit may often be 
stopped by tying something round the 
limb above the part in which the spasm 
begins (or in which some abnormal sensa- 
tion (aura) appears), by unclenching the 
closing hand, or by briskly rubbing it. 
As Brown-Sequard has insisted, such pro- 
cedures are as successful in cases of or- 
ganic disease of the brain, syphiloma for 
instance, as in cases where there is no 
evidence of such kind of disease. The 
patient or his friends may often arrest 
the progress of fits of this kind. We hear 
patients remark to this effect, "If I can 
get the hand open, I have no fit." I am 
convinced from what I have seen in 
Brown-Sequard's practice that a garter of 
blister above the part in which the fit 
begins will keep off fits of this kind. Dr. 
Buzzard has recently written an import- 
ant paper on this method of treatment in 
the " Practitioner" for October, 1868. In 
a few, but in very few cases, there is his- 
tory of injury to the part in which the 
spasm begins. 
Duration of the Attacks.-The duration 
of the attack varies much. It may last 
even ten minutes, but in such cases the 
spasm is long in spreading to the muscles 
of the thorax. 
Consciousness.-These are the cases of 
Convulsion in which there is often no loss 
of consciousness whatever. The patient 
does not lose his consciousness when the 
fit is partial; the whole of one side may 
be involved in spasm without any insensi- 
bility, but the rule is that consciousness 
is lost at an earlier stage. For instance, 
when the fit begins in the hand, con- 
sciousness is usually lost when the spasm 
has largely involved the face, and when 
the head begins to turn. When it starts 
from the foot, consciousness is usually lost 
when the spasm or abnormal sensation 
reaches the body. There are in these 
seizures all degrees of impairment of con- 
sciousness, if such a phrase be permis- 
sible. The patient may assert that in 
some of his attacks he is conscious, but 
may qualify his statement by adding that 
he does not know people about him or 
where he is ; at another time he may be 
profoundly comatose. 
Affections of Speech {Epileptic Aphasia)} 
-In certain of these seizures the patient 
loses his speech without losing his con- 
sciousness. This is not to be confounded 
with petit mol. It most often occurs when 
the fit begins on the right side of the face 
and tongue. Occasionally there is only 
disorder of speech. Temporary loss or 
defect of speech is often observed even in 
cases where the spasm is limited to the 
right cheek and tongue. The patient may 
consult us because he occasionally sud- 
denly loses his speech for a few minutes ; 
for instance, he goes to a shop, and on 
trying to give an order finds that he can- 
not talk, or he talks so badly that he is 
supposed to be drunk. We mostly hear 
that there is local spasm of the right 
cheek at the same time. (We rarely get 
any facts about writing in this condition ; 
this part of the subject is too complex for 
consideration here.) It is hard to de- 
scribe the defect of speech which some- 
times follows these seizures. The defect 
is not, I think, quite like the defects of 
speech which are the result of small de- 
stroying lesions such as small clots, lim- 
ited softening from embolism, &c. There 
is very much hesitation ; the patient slurs 
his words and mumbles. I use the word 
defect, because there is never, so far as I 
have observed, permanent loss of speech 
(complete inability to utter words) after 
a convulsion beginning by deliberate spasm 
in the face or hand. If an adult does not 
talk at all for several days after a "fit," 
especially if he expresses himself quite 
well in writing, we should suspect malin- 
gering. If there be loss of voice with or 
without loss of speech after a "fit," pre- 
tence or hysteria is almost certain. 
Epileptic Hemiplegia.'-These are the 
cases of Convulsion in which there is so 
often hemiplegia-epileptic hemiplegia of 
Dr. Todd. Sometimes hemiplegia follows 
such seizures, and sometimes it does not. 
The presumption is that when the spasm 
is very severe-severe in degree that is, 
not necessarily, although usually exten- 
sive in range also-there is palsy. Thus 
much, however, is certain, that a patient 
who has fits of this kind (at all events 
when the spasm begins in the hand) can 
never be considered safe from hemiplegia. 
In very many cases the palsy is trifling, 
such a " numbness," for instance, as pre- 
vents the patient picking up a pin, 
although he may strike the table pretty 
strongly; occasionally there is perfect* 
paralysis. The palsy always affects the 
side in which the fit begins; and when 
there is complete hemiplegia, the hemi- 
plegia is quite like that produced by plug- 
ging of the middle cerebral artery. When, 
however, the spasm is limited in range, 
the consequent palsy is limited in range. 
If the arm only be affected by severe 
spasm, the arm only is palsied when the 
1 "There is a peculiar class of cases of 
epileptic hemiplegia, in which the exciting 
cause of the epileptic fit at the same time 
damages or greatly injures voluntary power 
and speech." (Todd, "Nervous Diseases," 
Leet, xv.) 
1 I use the words "perfect" and "imper- 
fect" to express degrees of loss of power, and 
the words "complete" and "incomplete" to 
express differences in range of the paralysis. 
vol. i.-48 754 
CONVULSIONS. 
fit is over; if the leg only, the patient 
drags it, but uses his arm well. Thus it 
happens that we may have complete palsy 
of the arm following a convulsion in which 
there had been no loss of consciousness 
whatever. Whether the palsy be com- 
plete in range or perfect in degree, it 
passes off in the vast majority of cases, 
and according to the degree of palsy, in 
hours, days, or weeks-perhaps, however, 
leaving a little numbness-the patient 
may afterwards speak of his "weak side." 
Unfortunately, since the patient will 
doubtless continue subject to convulsive 
seizures of a like kind, we shall be obliged 
to admit that he will probably have the 
palsy again. Indeed he may have an- 
other fit even before the palsy from the 
former one has had time to pass off. 
More rarely hemiplegia is the first symp- 
tom, and Convulsion of the kind I de- 
scribe occurs after or during recovery. 
The Convulsion affects first and chiefly 
the side paralyzed. Since this order of 
events usually happens in cases where 
there is valvular disease of the heart, I 
suppose there is in these cases embolism 
of some part of the district of the middle 
cerebral artery. 
Frequency.-In this class of cases the 
fits vary in frequency. They are, I think, 
more irregular in this respect than chronic 
convulsions of other kinds. The patient 
may have one a week, one a month, or he 
may have thirty or forty, nay literally 
hundreds, in a few days. When the fits 
are very frequent, the patient is usually, 
if not always, hemiplegic and deeply 
comatose. There is the "status epilcp- 
ticus." It will be observed that in the 
paroxysms the spasm still affects first and 
more strongly the side already paralyzed. 
The signs of danger in the status epilep- 
ticus are not so much the number of fits 
or the degree of palsy-the frequency of 
the fits, of course, adds much to the 
gravity of the case-as increase of tem- 
perature, abnormal respiration, and irreg- 
ular pulse. 
Causation.-A convulsion implies dis- 
charge of unstable gray matter. We have 
then three directions of investigation in 
these cases: (a) the seat of the changes 
in gray matter ; (&) the pathological pro- 
cesses by which these changes are brought 
about; (c) the circumstances which favor 
the discharge (exciting causes). 
(a) Seat of Lesion.-The probability is 
that in many cases we should discover no 
lesion post mortem. Although we must 
admit that gray matter is in an abnormal 
condition (because it discharges on slight 
provocation, and because it discharges 
abundantly), we must admit also that 
this abnormality does not involve any 
•great alteration of structure. If it were 
much altered, even disorderly functions 
would not be possible. We are therefore 
not likely to discover the changes in the 
gray cells to which exaggeration of their 
normal function-to store up and expend 
force-is due. Niemeyer (op. cit.) says, 
"Experience teaches that the lesions from 
which abnormally active impulses pro- 
ceed are insusceptible of anatomical de- 
monstration."1 Since increase of func- 
tion, even in disease, implies increased 
nutrition, we infer that the gray cells 
affected in Convulsions store up force in 
large quantity, and reach a high degree 
of tension. Further, since they discharge 
on slight provocation-possibly even in 
periodical normal changes in 'the body, 
when by continuous nutrition a certain 
degree of tension is reached-we must 
suppose they are in a state of highly un- 
stable equilibrium. Instability, "in this 
article, is made to include two things- 
high tension and very unstable equilib- 
rium. But admitting that we cannot, or 
have not, yet discovered the change which 
permits this duplex condition, we have 
ground for inference as to the position of 
the changes of instability. 
In some cases we discover gross changes. 
(For convenience we shall suppose the 
gross change to be, as it often is, a syphi- 
litic nodule.) The gross change affects 
the cerebral hemisphere2 opposite the side 
of the body in which the spasm sets in. 
Moreover, in all the autopsies I have seen 
the disease has been in the region sup- 
plied by the Sylvian artery, and has af- 
fected convolutions-parts rich in gray 
matter. But the nodule we find is of 
course not the direct cause of the seizure 
-the seizure is the result of a discharge 
of gray matter, and the nodule is an over- 
growth of connective tissue. In other 
words, the changes in gray matter on 
which the Convulsions depend are sec- 
ondary to the nodule. Now, at least two 
views may be held as to the seat of these 
secondary changes. The view generally 
adopted is that they are in the medulla 
1 "The proximate cause of convulsions is 
an abnormal increase in the nutritive changes 
of the nervous centres." (Russell Reynolds 
"On Epilepsy.") 
2 Wilks says ("Pathology of Nervous Dis- 
eases," Guy's Hospital Reports, 1866) "that 
the morbid conditions which we find to give 
rise to epileptiform convulsions are remarka- 
bly uniform. They all point to the presence 
of local irritation of the surface [of the 
brain]." Speaking of a case of epileptic con- 
vulsions in a patient who had tumor in the 
pons Varolii-a case which had been sup- 
posed to confirm Schroder van der Kolk's 
"supposition that the cause of epilepsy is 
seated in this part"-he says, "I have no 
hesitation in saying that for one such case 
fifty might be found in which the marked 
changes producing these symptoms occupy 
the surface [of the brain]." CAUSATION. 
755 
oblongata; and that they are the result of 
an "irritation" starting from the nodule, 
or rather from its neighborhood. Another 
view is, that the gray matter changed is 
near the tumor itself, or in its vascular 
territory at least. Arguments in favor of 
the latter view are, chiefly, first, that the 
muscles first and most affected in the 
seizures are those most and longest af- 
fected in hemiplegia due to the disease of 
the corpus striatum; secondly, that the 
epileptic hemiplegia, when complete, is 
quite like that which results from plug- 
ging of the middle cerebral artery. Other 
reasons could be given. The occurrence 
of temporary defect of speech in certain 
of the seizures (vide p. 753) is of some 
value in localizing. It may, however, be 
said that disease of certain convolutions 
often causes no symptoms at all, and 
therefore that when Convulsions occur 
along with, they cannot depend on, changes 
in the convolutions. The word disease is, 
however, here used vaguely. It is true, 
as every surgeon knows, that much of the 
convolutions may be destroyed without the 
supervention of symptoms. The patient 
can do without certain parts of his brain, 
but if much of its gray matter be very un- 
stable, he must have symptoms, for it will 
discharge strongly, and of necessity put 
muscles in disorderly movement. It may 
be asked, How is it, if the patient can do 
without the part which discharges, that 
there is sometimes hemiplegia ? The 
explanation is admittedly speculative. 
The hemiplegia comes on after the parox- 
ysm. Suppose the fit to begin by dis- 
charge of unstable gray matter in a cer- 
tain convolution, the violent impulse thus 
originated will probably discharge lower 
and yet related centres of healthy gray 
matter. At all events, the nerve fibres 
to the muscles, and the muscles them- 
selves, are suddenly in excessive function. 
I suppose, then, that the hemiplegia re- 
mains until the normal conditions of these 
suddenly overworked parts have been 
slowly restored by nutrition. Wilks (op. 
cit.) says the paralysis follows by "an in- 
hibitory action. " 
As my plan, however, is chiefly clini- 
cal, I have discussed the question of 
position very briefly. It suffices for the 
discussion of the next question to admit, 
as we must, that there are changes of 
gray matter in some part of the nervous 
system. 
(5) The Pathological Process. - The 
changes of instability may no doubt be 
brought about in many ways; but we 
shall limit ourselves to these questions: 
" Are the changes the secondary results 
of gross organic disease-tumor, for in- 
stance-or are they minute changes, often 
inferable, rarely, if ever, discoverable ?" 
If there are symptoms pointing to gross 
organic disease, we fear that the patient 
will die of that disease ; if there are not, 
our fears are of a different kind, viz., that 
he will be subject to fits for years or for 
life, or, as it is often said, will be an epi- 
leptic. The first question then is, Is there 
gross organic disease ? 
If for no other reason than to econo- 
mize space, it is well to consider first the 
symptoms which show that there is gross 
organic disease of any kind ; and next, to 
consider the evidence by which we infer 
its particular nature-whether, for in- 
stance, it be syphilitic or not. Before 
beginning our task, it may be well to 
point out that certain symptoms which 
young practitioners sometimes rely on are 
not to be relied on, either for or against 
the diagnosis of gross organic disease. 
Tongue-biting is of no value in the 
diagnosis of the cause of any kind of con- 
vulsion : it is only a sign of severe con- 
vulsion. It occurs in cases of the first 
class described, if the fit be general and 
severe, and does not occur if the fit be 
partial and slight. It occurs in severe fits 
from ursemia, cerebral hemorrhage, tu- 
mor, &c. Nor does the condition of the 
pupils during the fit furnish any evidence 
in diagnosis. Very great inequality of 
the pupils after the fit would point to or- 
ganic disease. In these cases there may 
be, as has been remarked, no loss of con- 
sciousness when the fit is limited in range. 
It was said by the late Dr. Bright that 
absence of insensibility in convulsive seiz- 
ures is some evidence that the lesion is 
organic. With very great deference, I 
must say I cannot accept this view. If 
we were to judge by post-mortem evidence 
alone, we might draw the conclusion ; but 
we see patients who have convulsion 
without loss of consciousness, who not 
only show no signs of organic disease, but 
who, except for their seizures, seem to 
be in good health. Post-mortem exami- 
nations, in cases where there has been no 
evidence of organic disease, are very rarely 
had. I have not yet seen one. The fact 
that the fit is partial, let us say limited 
to the arm, the transitoriness of epileptic 
hemiplegia, the absence of fits for months, 
do not negative the existence of gross 
organic disease. It is to be especially in- 
sisted on that quick recovery from epi- 
leptic hemiplegia is of no value whatever 
in negativing organic disease, tumor for 
instance. The signs I have mentioned 
are of no value for or against the diag- 
nosis of gross organic disease in this class 
of convulsions. 
The evidence which warrants the diag- 
nosis of gross organic disease in cases of 
Convulsion is of a different kind. We 
have carefully to distinguish betwixt the 
symptoms which are owing to local de- 
struction of the nervous system and those 
owing to changes diffused in nervous 
masses about the destroying agent-the 756 
CONVULSIONS. 
results of the irritation it excites. For 
instance, a certain form of hemiplegia is 
owing to the destruction of fibres and 
cells of the corpus striatum by, let us in- 
stance, a clot. This symptom is special 
to the part injured ; injury to no other 
part produces it. Again, it is primary, 
for it comes on at once, from destruction 
of nerve fibres there seated. But, next, 
the patient suffers headache ; his temper- 
ature rises, his pulse and his respiration 
become irregular. Such symptoms may 
be called general, because they do not 
point to disease in any one part of the 
encephalon, and they may be called sec- 
ondary because they do not come on at 
once, but are indirect results of the irri- 
tation of the clot as a foreign body-of a 
local encephalitis. Hence we see that 
whilst the nature of the lesion matters 
little or nothing so far as the production 
of such special and primary symptom as 
hemiplegia is concerned-it suffices that 
nerve-fibres in the corpus striatum are by 
any means destroyed-it matters very 
much with regard to the general or sec- 
ondary symptoms. The encephalitis in 
cases of clot is often a rapid process, but 
the same distinction is to be made in 
cases of tumors, syphiloma, abscess, and 
other kinds of gross organic disease. But 
it frequently happens that tumors, syphi- 
litic disease, &c., occur in regions of the 
brain-in the cerebrum and cerebellum- 
large parts of which may be destroyed 
without the production of any special 
symptoms-without hemiplegia or obvious 
mental defect. In other words, the pa- 
tient does not suffer because the tumor 
has destroyed a certain part of his brain. 
He begins to suffer when a local encepha- 
litis is excited by the destroying agent. 
And as this encephalitis does not always 
occur, he may have no symptom what- 
ever from cerebral tumor. 
What is the evidence which shows a 
patient the subject of a convulsion to 
have gross organic disease within the cra- 
nium ? The symptoms which show there 
is organic disease within the cranium, not 
in these cases only, but in any cases-in 
cases of palsies of cranial nerves, hemi- 
plegia, &c.-are such as severe headache, 
urgent vomiting, and double optic neuritis. 
The pain in the head has no value in diag- 
nosis if it be the temporary sequel of a 
severe fit, or of a scries of fits. We must 
be satisfied that the patient's "headache" 
is really pain, and not "confusion," "gid- 
diness," " weight on the top of the head," 
&c. Nor can we lay stress on it as evi- 
dence unless it be intense, and unless it 
has lasted for some days or weeks. We 
can sometimes judge of its intensity by the 
patient's manner and by his expressions, 
lie gives up work ; he may remark, " it 
is not a common headache." He is said 
by his friends to " rave," and sometimes 
it is reported that he "knocks his head 
against the wall." The headache is of 
more value in diagnosis if it occurs in un- 
usual places. If it be at the back of the 
head shooting forward, or on one side-I 
do not refer to nodes nor to neuralgic pain 
extending into the face-gross disease is 
likely. The vomiting is urgent, it is pur- 
poseless and capricious sometimes, for in- 
stance, occurring only at night or in the 
morning. The vomit is frothy "like 
phlegm," the patients sometimes say; and 
if there be very much retching, as there 
usually is, it is greenish or yellowish. The 
tongue may be quite clean, and the appe- 
tite may be good. Vomiting is not al- 
ways present. When symptoms so well 
marked have lasted for several weeks, we 
suspect that the convulsion is the result 
of gross disease. We may, I think, be 
quite certain if there is also paralysis of 
the whole of any one motor cranial nerve. 
If there be double optic neuritis as well, 
or its usual sequel, double optic atrophy, 
we may be almost absolutely certain. 
Let us suppose we have satisfied our- 
selves that there is a gross lesion of some 
kind, we have now to find out what is its 
particular nature. We may, I believe, 
exclude clot in nervous centres as a cause 
of chronic seizures of this kind. No doubt 
effusion of blood on the surface of the 
brain would produce fits of this kind, and 
in all cases we should inquire carefully for 
history of injury to the head, and seek for 
evidence of chronic renal disease, the two 
chief conditions under which meningeal 
hemorrhage occurs. I have only twice 
known albuminuria to occur with fits of 
this variety, and there is, I think, no war- 
rant for the supposition that unemia has 
anything to do with their causation. It 
is true that Convulsions called uraemic- 
after scarlet fever, for instance-are often 
unilateral, but as far as I know these 
seizures do not begin by a very deliberate 
spasm in one side. When they do, their 
real nature may be inferred by examining 
the patient's heart, urine, &c. 
The gross organic disease may no doubt 
be of many kinds, but practically the 
point we wish to determine is, Is it syphi- 
litic, or is it some other kind of new 
growth ? It is needless to mention that 
when other symptoms of syphilis are pre- 
sent, such as nodes, the diagnosis of 
syphilis is almost certain, and needless to 
urge in all cases of this kind a very care- 
ful investigation for evidences of syphilis, 
such as scars on the skin, holes in the 
palate, white marks on the tongue. It is 
only necessary to speak of cases in which 
such decisive evidence is not to be had. 
In the first place the gross disease is fre- 
quently syphilitic. It is so with the very 
rarest exceptions when there is also double 
optic neuritis. It is next to certain that 
there is syphilitic disease if the patient CAUSATION. 
757 
has Convulsions of this kind along With 
complete palsy of the whole of any motor 
cranial nerve ; for one great diagnostic 
mark of syphilis is that it produces random 
associations of symptoms. The evidence 
is clearer if the motor cranial nerve para- 
lyzed be on the same side as that on which 
the Convulsion begins, and on which there 
may be epileptic hemiplegia, because we 
are sure then that there are two lesions. 
(The facial paralysis, which is part of 
epileptic hemiplegia, is not of course in- 
cluded in the expression palsy of a motor 
cranial nerve, because it is not owing to 
disease of a nerve trunk.) If there is palsy 
of any nerve trunk, e. g. of the radial, 
palsy of one leg, or paraplegia, the great 
probability is that these symptoms and 
the Convulsions are owing to syphilis. 
Still there may be some other kind of 
new growth, but this is very rare in cases 
of Convulsion of the class described, and 
rarer still when the Convulsion is attended 
by any of the other symptoms mentioned 
in the preceding paragraph. In some 
cases the recovery of the patient from local 
palsy, let us say of the third nerve, by 
iodide of potassium will make the diag- 
nosis pretty certain. In other cases the 
length of time, e. g. many months or 
several years, the symptoms had lasted, 
would point to syphilis. There can be no 
doubt that we should treat for syphilis. 
Fits of this kind occasionally follow 
blows on the head. In these cases we 
should carefully inquire for evidence of 
syphilis, as syphilitic disease of the brain 
is frequently "lighted up" by injuries. 
In some cases there is a depression of the 
skull on the side opposite the side of the 
body in which the fit begins. 
Suppose now that there is no evidence 
of gross organic disease of any kind. In 
the vast majority of cases we can get no 
further, we can only infer that there are 
not gross changes in the brain, and as a 
corollary that the patient will not soon 
die, but will continue subject to fits. In 
a few cases there will be found evidence 
which will warrant the supposition that 
the plugging of small arteries of the Syl- 
vian region is the cause of the pathological 
change.1 It is certain that patients, the 
subjects of valvular disease, have seizures 
of this kind after or during recovery from 
hemiplegia. Yet although I have made 
post-mortem examinations of patients, the 
subjects of valvular disease, who have had 
Convulsions, I have had no post-mortem 
examination of one whom I knew to have 
had fits of the kind described. My sup- 
position is that patients who have " epi- 
leptic fits" from intracranial aneurism 
suffer really from local embolism, and that 
when the aneurism is of the middle cere- 
bral artery, or of some large branch of this 
vessel, the seizures will be of the first class. 
It is, however, held by some that the fit 
depends on irritation by the aneurism. 
Mr. Callender (St. Bartholomew's Hos- 
pital Reports, vol. iii. 1867) has made the 
very important observation that the "epi- 
leptic attacks belong to aneurism of the 
middle cerebral artery." 
(c) Exciting Causes of the Paroxysm.- 
Some patients who are subject to fits of 
this kind are otherwise in very good 
health. Such cases are sometimes sup- 
posed to be owing to some very general 
cause. A patient who in the midst of 
good health has had a severe convulsion 
is naturally most anxious that his fit 
should be attributed to some very general 
and removable cause, and will dwell much 
on such facts as that he had taken some- 
thing that had disagreed with him, or that 
he was in a close room, or will say that 
he was "bilious," or worried by anxiety 
the day it happened. Dyspepsia, over- 
work, fright, and the like, may be admit- 
ted to be factors in causation. I cannot, 
however, conceive that any such general 
conditions can alone produce fits which 
time after time begin in one hand and 
even in the very same finger even for 
months and years. In other words, I 
cannot conceive that they alone can de- 
termine the discharge of healthy nervous 
tissue in some particular locality. I class 
them as exciting causes, believing that 
there is some central change as well. 
Whatever view may be held, there is for 
therapeutical purposes a complete agree- 
ment that we should try to remove all 
such causes. We may find that the pa- 
tient is dyspeptic. It is, I think, quite 
certain that in some cases the paroxysm 
frequently comes on when the patient is 
flatulent. So, although we may differ as 
1 The inference is not that each fit or each 
series of fits depends on separate pluggings. 
It is true that sudden plugging of the middle 
cerebral artery, or perhaps of some large 
branch, may lead to a severe convulsion in a 
patient whose nervous system was previously 
healthy, but in these cases there is persistent 
hemiplegia after a fit. If a smaller branch 
be plugged and perhaps slowly occluded, the 
hemiplegia passes off or diminishes greatly, 
and, as before said (p. 753), occasionally the 
patients become subject to convulsion begin- 
ning in some part of the region previously 
paralyzed. The hemiplegia depends on de- 
struction of nerve fibres, the occasional spasm 
depends on instability of gray matter. It is 
evident enough that plugging will lead to 
destruction (softening even to diffluence) of 
fibres and cells, but it is not sufficiently borne 
in mind that plugging of small vessels may 
lead also to increased quantity of blood be- 
yond the plug, and thus to altered nutrition 
and instability. At autopsies on patients 
who have died of or with plugging of the 
middle cerebral artery, whilst we find soften- 
ing of part of the corpus striatum, we find 
also at the periphery "red softening." 758 
CONVULSIONS. 
to the way in which dyspepsia is connected 
with the seizure, there is no question that 
to treat the dyspepsia by careful dietary 
and by medicine is a matter of the very 
greatest importance. (See Dr. Paget, of 
Cambridge: Lectures on Gastric Epilepsy, 
Lancet, 1868.) 
These seizures, like other convulsive 
attacks, and other nervous symptoms, 
sometimes follow fright. The first fit of 
a series evidently depending on organic 
disease may follow fright so closely that 
we are driven to believe there is some re- 
lation betwixt the two things. I imagine 
that the fright merely determines the pa- 
roxysm which some other cause would 
afterwards determine. There is nervous 
tissue in a state of highly unstable equi- 
librium, which will surely discharge soon 
from some provocation, and now and then 
fright is that provocation. As no special 
point of treatment is involved, and as the 
discussion of such causes belongs rather 
to epilepsy, nothing further need be said 
here. 
As to local irritation by worms, teeth, 
&c., all that need be said here is that we 
should try to remove these sources of irri- 
tation. Then possibly the part of the 
nervous system diseased, ceasing to be 
worried by such eccentric irritations, may 
cease to discharge. 
Class II.1 
Let us now suppose the patient's fit to 
be one of the second class. These cases 
cannot be considered on the same plan as 
those of Class I.; the paroxysms are too 
sudden, and the conditions under which 
they occur are too numerous and complex. 
In chronic cases of this class the same 
reasoning as toposition, nature of change, 
and exciting cause will to a very great 
extent apply. We shall include in this 
class those cases of which we obtain no 
history of the mode of onset of the fit. 
For instance, we find the patient coma- 
tose, and we only learn that he has had a 
convulsion. It is then that the question 
arises, Is the fit epileptic? This is the 
great question when we see a patient in 
or soon after his first convulsion. But 
since we may find him hemiplegic, it will 
be best to use the expression epileptiform, 
and modify the question thus, Does the 
fit depend on a state of the brain or sys- 
tem which is such that the patient will 
recover from the fit in all probability to 
suffer similarly again and again for months 
or years, or is it owing to such causes as 
cerebral hemorrhage, tumors, uraemia, 
&c., which will soon lead to a fatal result? 
In the first place, the phenomena of the 
convulsion-it does not begin by deliberate 
aura in one limb-the nature of the pa- 
roxysm, stertor, coma, tongue-biting, fur- 
nish no reliable evidence. Cases of apo- 
plexy from cerebral hemorrhage are now 
and then diagnosed as cases of epilepsy, 
because the apoplectic condition was ush- 
ered in by a fit of an "epileptic character. " 
It is to be insisted on that neither the 
kind of convulsion nor its repetition are 
signs serving in the diagnosis of the nature 
of the lesion. Neither enables us to say 
whether the fit is epileptic or not. Nev- 
ertheless it is freely admitted that in most 
cases we are right in the prediction we 
make. Although it is difficult to make a 
diagnosis, it is easy to guess. If we are 
called to a young man who has had a se- 
vere fit and who is not paralyzed after it, 
and if we find that he has recovered or is 
recovering consciousness, we shall be 
right in the great majority of cases if we 
say, without any further medical exami- 
nation, that the fit is one of epilepsy, and 
not one of uraemia, cerebral hemorrhage, 
&c. But it is not necessary even to see 
the patients to make diagnoses which 
shall be generally right. And when we 
hear that a patient has been long subject 
to fits, from each of which he quickly re- 
covered, or if we hear that he has had 
attacks of petit mal only before the con- 
vulsion, we shall be right in nearly all the 
cases when we make the diagnosis of epi- 
lepsy. But even under these circum- 
stances the practitioner will be wrong 
now and then. For instance, there may 
be chronic renal disease, notwithstanding 
the patient has had fits of an "epileptic 
character" months before. Again, the 
former fits may have been due"to aneu- 
rism of one of the larger cerebral vessels, 
and the fit we are called to may be owing 
to rupture of that aneurism. The former 
fits may have been owing to tumor, and 
the one we are called to may be the result 
of fatal hemorrhage from that tumor. 
These are rare cases, but we are sure to 
meet with them now and then. If we do 
not consider these rare possibilities, we 
may make very painful blunders. 
I repeat that a routine diagnosis of epi- 
lepsy in young people who have a convul- 
sion will rarely be wrong, because such 
Convulsions are nearly always epileptic. 
And those who do not examine the urine 
unless the patient be dropsical, and who 
content themselves by saying in cases of 
death by Convulsion that the patient 
"died of an epileptic fit," and make no 
post-mortem examination, will not be 
aware that this diagnosis is sometimes 
grossly wrong. 
In what follows, in order to encounter 
fully the difficulties of diagnosis which 
actually do occur, and because I have only 
to do with the most commonly occurring 
seizures (epileptic) in diagnosis, I will 
suppose that we are called to a person in 
1 See page 752. CEREBRAL ANEURISM. 
759 
his first fit, or first series of fits, and only 
incidentally notice what bearing on our 
diagnosis the fact of the previous occur- 
rence of fits has. There is no position 
more embarrassing than that we are in 
when called to a patient in his first fit. 
As before said, it is easy to be generally 
right. 
We will consider some of the recognized 
causes of Convulsion, or, it may be safer 
to say, the known conditions under which 
they arise. It will be well first to remark 
however, that when we are called to a 
patient who has " died in a fit," we must 
ask if the patient were eating when the 
fit came on. Dr. Lalor has written a 
valuable monograph on death by choking 
in epileptic attacks, and I could relate a 
case in which I feel convinced that death 
was thus caused, although the larynx was 
not examined post mortem. 
lienal Disease (Urcemia).-In all cases 
of Convulsion we must examine the urine, 
however young the patient may be, and 
however healthy he may look, and not- 
withstanding that he has had fits de- 
scribed as epileptic on previous occasions. 
This examination is still necessary when 
the patient has recovered consciousness 
by the time we reach him. None of the 
above circumstances negative uraemia, 
nor is the quick repetition of fits of value 
in diagnosis. The fact that the patient 
has had no dropsy does not influence us. 
We must, I repeat, examine the urine. 
If it be smoky ; if there be scarlet fever in 
other members of the patient's family; 
above all, if the patient be the subject of 
scarlet fever, we conclude almost with cer- 
tainty that there is uraemia. I say almost, 
because now and then Convulsions in 
scarlet fever are followed by a liability to 
Convulsions for life. As we sometimes 
say, "some cases of epilepsy date from 
scarlet feveroccasionally they leave 
persistent hemiplegia. It is hard to be- 
lieve that there can have been uraemia 
only in these cases. Since endocarditis 
occurs now and then in scarlet fever, and 
since plugging of the middle cerebral ar- 
tery will cause Convulsions, it is as likely 
that there is embolism as uraemia. 
Cerebral Hemorrhage.-The mere pres- 
ence of albumen, however, does not lead 
us to declare that there is uraemia. In a 
patient past middle age there may be 
cerebral hemorrhage. If there be hemi- 
plegia with deep and continuing coma, we 
diagnose hemorrhage, and we do this not- 
withstanding that the patient is young- 
say twenty-and notwithstanding that he 
was "quite well before the fit." If there 
be no hemiplegia, and if the patient be 
young, the inference is very strong that 
there is uraemia, and not clot. But, as 
will be mentioned in the article on Apo- 
plexy, a general convulsion followed by 
deep coma and universal powerlessness, 
in a patient whose urine is albuminous, 
may be owing either to very large hemor- 
rhage into the cerebrum, into the lateral 
ventricles, or into the pons Varolii, or it 
may be owing to uraemia. We cannot 
rely on stertor, kind of coma, repetition 
of convulsion, or increase of temperature, 
although rapidly increasing stertor, rap- 
idly deepening coma, are signs in favor of 
the diagnosis of hemorrhage. It is the 
ingravescence of these symptoms, after the 
convulsion, which favors hemorrhage. 
We will now suppose that there is no 
albuminuria.1 
Cerebral Aneurism.-Dr. John W. Ogle 
and Dr. Murchison have pointed out that 
epilepsy (i. e. fits at intervals, like those 
usually called epileptic) occurs in patients 
the subjects of aneurism of large cerebral 
arteries. Such aneurisms will occur in 
young people, and therefore the question 
of age has no bearing on diagnosis. There 
is nothing special, so far as has yet been 
determined, in the kind of convulsion; 
there are, indeed, no symptoms which 
are characteristic of cerebral aneurism. 
There may be no symptoms at all, or none 
sufficient to send the patient to a doctor, 
until the fatal ones from rupture of the 
aneurism. We cannot therefore be cer- 
tain whether a patient's fits are the re- 
sults of cerebral aneurism or not. If, ex- 
cluding albuminuria, syphilis, and other 
causes to be afterwards mentioned, we 
have reason to believe that there are 
vegetations on the heart's valves, we may 
surmise that the fits are owing to cerebral 
aneurism or (vide supra) to local embolism 
in connection therewith.2 
We can occasionally diagnose that a 
fatal seizure is owing to rupture of a cere- 
bral aneurism, and this is an important 
matter in a medico-legal point of view. 
If a young patient has had Convulsions 
now and then for months or years, and if 
after one severe fit he is more profoundly 
comatose than usual, with great stertor, 
and if he continues so for some hours, 
rupture of a cerebral aneurism is proba- 
ble. It is all the more likely if the patient 
has been hemiplegic. If the patient dies 
in the fit in a few minutes or in half an 
hour, we are more certain, because we 
know that it requires a large and, what is 
more important, a sudden hemorrhage to 
kill quickly.3 We are more sure still if 
1 Occasionally when there is chronic renal 
disease, we discover no albumen in the urine, 
and it is said that occasionally, after a severe 
convulsion, albumen appears in the urine in. 
consequence of that convulsion. I do not see 
how we can avoid mistakes in these cases. 
2 See Dr. Gull on Cerebral Aneurisms, 
Guy's Hosp. Rep., vol. v. (3d series). 
3 It is not, of course, said that rupture of 
aneurism of the large cerebral vessels always 
kills suddenly or quickly, nor always by 
Convulsion. Rupture leads to death slowly. 760 
CONVULSIONS. 
the patient is known to be the subject of 
valvular disease of the heart, or if he has 
had rheumatic fever. Dr. J. W. Ogle 
and Dr. Church have shown, and my ex- 
perience bears out their conclusions, that 
aneurism of the larger cerebral vessels 
frequently occurs along with vegetations 
on the heart's valves. 
Embolism.-Embolism of the middle 
cerebral artery sometimes, although rare- 
ly, produces severe convulsions. It is 
followed by hemiplegia. The modes of 
onset of symptoms from plugging vary 
much. They sometimes come on sud- 
denly and sometimes deliberately, accord- 
ing, the presumption is, as the vessel is 
slowly or suddenly plugged. Again, the 
degree of the symptoms varies. There 
may be no loss of consciousness, and the 
hemiplegia may be transitory. This is so 
when the branch occluded is small. If a 
patient the subject of valvular disease 
becomes hemiplegic after a severe convul- 
sion, it is considered to be almost certain 
that there is sudden plugging of the main 
trunk or of a large branch of the middle 
cerebral artery : it is not quite certain. 
The convulsion and consequent hemiple- 
gia may be owing to rupture of a large 
aneurism of this vessel. Aneurism of the 
middle cerebral artery usually ruptures so 
that the blood is poured out external to 
the brain, and the patient dies quickly 
because the blood gets out in large quan- 
tity, and, what is more important, with 
great rapidity. But occasionally it rup- 
tures so as to break up the motor tract, 
corpus striatum, nor thalamus, and will 
then, so to speak, imitate common cere- 
bral hemorrhage. If then a patient, espe- 
cially a young patient whom we know to 
be the subject of valvular disease of the 
heart, becomes hemiplegic after a convul- 
sion, we must take this rarer possibility 
into consideration. 
If the coma be very deep, if it deepens, 
or, generally speaking, if the patient 
quickly gets worse, rupture of an aneur- 
ism is at least as likely as embolism. 
With all our care we shall be wrong now 
and then, as patients sometimes die in a 
few days in an apoplectic manner, from 
plugging of the middle cerebral artery. 
(See also Art. Softening.) 
Tumors. -If the patient, especially if he 
be a young and healthy-looking man, 
have had for weeks or months severe pain 
in the head, vomiting, &c., there being 
no albuminuria,-above all, if there be 
also double optic neuritis,-a tumor of the 
brain is probable. Although headache is 
one of the symptoms of cerebral aneurism, 
cerebral aneurisms rarely if ever cause in- 
tense and persistent headache. 
Here I must refer to the evidence stated 
in more detail (p. 758). But in this con- 
nection one further fact is to be mentioned, 
viz., that a patient may have occasional 
convulsions for weeks or months from 
the " irritation of a tumor," and may die 
after one severe convulsion, or several 
quickly recurring convulsions, due to 
large hemorrhage from that tumor. If, 
then, we find a patient whom we infer to 
be the subject of cerebral tumor who has 
been seized with convulsions much more 
severe than usual, and if he becomes un- 
usually deeply comatose, and if the coma 
deepens, especially if there be no further 
convulsion, we fear large hemorrhage 
from the tumor.1 
' Syphilis.-As before said, if the con- 
vulsion be of the first class, and if there 
be signs of organic disease, there is usually 
syphiloma of the brain : but if the con- 
vulsion be general, or if we know nothing 
of its mode of onset, we must infer from 
the evidence of present syphilis. If there 
be such demonstrative evidence as nodes, 
&c., or a clear history of recent syphilitic 
changes in any part of the body, our 
diagnosis is practically certain. If there 
is not such evidence, we may judge from 
the history of a random succession of 
nervous symptoms, such as palsy of a 
cranial nerve, followed by hemiplegia or 
paraplegia, or from the previous disor- 
derly association of nervous symptoms, 
showing several lesions, e. g. palsy of the 
third or fifth, or portio dura with hemi- 
plegia of the same side. When, however, 
such symptoms are of recent date, they 
may be still rarely owing to tumor. We 
must, however, always in these cases 
treat for syphilis. 
Abscess.-Again, it is possible that there 
may be cerebral abscess. If we are to 
ignore this possibility altogether, we shall 
very rarely err, as cerebral abscess is very 
rare. I have, however, more than once 
been consulted for Convulsion which 
turned out to be owing to cerebral ab- 
scess. There are no certain points in 
diagnosis except the presence of bone dis- 
ease in some part of the cranial wall, most 
often the bones of the ear, occasionally at 
the vertex. If the only evidence there is 
be that the patient a week or month ago 
received a severe blow on the head, the 
fit may be owing to syphilitic disease of 
the surface of the brain. It probably is, 
if the fit begins deliberately, and if there 
be epileptic hemiplegia. Syphilitic dis- 
ease of the brain not infrequently follows 
blows on the head. If, however, there be 
no evidence of syphilis, no palsy of any 
cranial nerve-excepting amaurosis from 
if the rupture of the aneurism is small, or if 
the blood, as when the aneurism is far in the 
Sylvian fissure, can only get out slowly. 
1 Of course it is not to be implied that 
hemorrhage from cerebral tumor necessarily 
leads to Convulsions, any more than ordinary 
cerebral hemorrhage does. TREATMENT OF CONVULSIONS IN ADULTS. 
761 
double optic neuritis, which is scarcely to 
be called palsy of a cranial nerve,-if we 
find that there is a "putty" tumor on the 
scalp, abscess is probable, and very pro- 
bable if there be hemiplegia after the 
Convulsions. Occasionally, as is well 
known, a patient suffers from cerebral 
abscess without any symptoms at all, or 
any obvious symptoms. Occasionally 
after a period of latency it breaks into the 
lateral ventricle : then the symptoms are 
quite like those of hemorrhage into the 
lateral ventricles, and we can only make 
the diagnosis of what has occurred from 
evidence of blows, disease of the bones of 
the ear, of the nose, &c. If there be no 
history, and if we find no evidence of 
disease of bone, we caunot make a diag- 
nosis. 
Epilepsy.-Supposing now that we can 
negative the above causes, we conclude 
that the patient has had an epileptic fit. 
By this we mean that he has had a con- 
vulsion which does not depend on an 
organic lesion, or on an acute state like 
uraemia, or on a sudden quasi-accident 
like hemorrhage. We infer that he will 
quickly get into his usual health, but that 
he will in all probability have fits of a like 
kind again and again for years. We say 
probably, because now and then he does 
not suffer again, and it not infrequently 
happens that after the first fit or the first 
series of fits he has an interval of good 
health for many months. 
Death in Convulsions. 
Now and then, however, a patient dies 
in a convulsion, and we discover nothing 
post mortem which we can suppose to have 
been the cause of the fit. Of course there 
is something overlooked, and we should 
always search every organ of the body with 
great care in these cases. When the pa- 
tient is known to have had fits of a like 
kind before, we may say that he died in 
an epileptic fit ; but when it is his first fit, 
this nomenclature does not conceal the 
bald fact that a patient seemingly healthy 
has a convulsion the cause of which we 
cannot make out, even after post-mortem 
examination. He dies in it, we surmise, 
because it has been unusually severe, res- 
piration, and probably the heart's action, 
having been suspended too long for re- 
covery. The point that chiefly concerns 
us here is that such modes of death are 
well recognized, and do not indicate either 
violence or the administration of poison. 
Treatment of Convulsions in 
Adults. 
Obviously enough, treatment will vary 
so much in different cases that most of | 
what has to be said will be found in the 
articles Uraemia, Cerebral Hemorrhage, 
Embolism, and Epilepsy. Indeed, I wish 
only to say a word on the treatment of 
Convulsions due to syphilis. In these 
cases we treat for syphilis, but in chronic 
cases, at least, this treatment is not of so 
great service, so far as removing the symp- 
toms goes, as from superficial considera- 
tions we should expect. The bromide of 
potassium is of more service than the 
iodide in keeping off fits. 
[Puerperal eclampsia is not alluded to 
in this article. Its full discussion belongs 
to works on Gynaecology. A few words, 
however, upon it may not be inappro- 
priate here. 
Convulsions duriny pregnancy may be 
either uraemic, reflex, or apoplectic. Pres- 
sure of the distended uterus upon the re- 
nal veins may interfere with the normal 
condition and action of the kidneys. Of 
this state of things albuminuria is an ad- 
monitory sign. When it amounts to such 
a degree as to produce marked uraemia, 
Convulsions may follow. If parturition 
be safely accomplished, the Convulsions 
disappear with the uraemia. 
In women having excito-motor irrita- 
bility greatly developed, there may be, 
in the absence of uraemia, Convulsions 
from irritation of the gravid uterus, act- 
ing reflexly. Here, also, delivery results 
in the cessation of the tendency to eclamp- 
sia. 
A plethoric state exists during preg- 
nancy in some women, predisposing to 
cerebral congestion.1 Either before, dur- 
ing, or after delivery, one concomitant of 
this condition may be Convulsions; whose 
prognosis is always very serious. A fatal 
termination is least apt to occur in the 
utero-retlex cases; it is most frequent in 
the apoplectic. Signs of this form are, 
deep flushing of the face, distension of the 
vessels of the neck and head, full, some- 
times slow, pulse, and stertorous respira- 
tion. 
Treatment.-If, during pregnancy, a 
woman known to have good vigor of sys- 
tem, with a full pulse, warm skin gene- 
rally, and hot head, is attacked with Con- 
vulsions, it is good practice to draw blood 
from the arm. About ten ounces will 
usually be enough ; if the pulse be quickly 
reduced, less will do. An enema of cas- 
tor oil, soap, and warm water may be ad- 
ministered. A large sinapism should be 
applied to the back, and cold water to the 
head. If the convulsion be prolonged, the 
[' The opinion of Cazeaux and Traube, 
that,"instead of plethora, there is hydraemia 
in such cases, is not likely to be correct. 
That of Frank, Munk, and others, that the 
symptoms are due to high arterial tension, 
has more to sustain it. This may explain 
the symptomatology of many cases.-H.] 762 
EPILEPSY. 
patient may be placed in a warm bath. 
After this, should further treatment be 
called for, inhalation of ether or chloro- 
form may be suitable as a last resort. 
When the convulsions are evidently 
utero-reflex, not uraemic, nor accompanied 
by apoplectiform congestion of the brain, 
bleeding is out of place. Sinapisms to the 
back and limbs, and the warm bath, will 
be proper, and the use of ether or chloro- 
form by inhalation may be earlier resorted 
to. Nitrite of amyl (a few drops, by in- 
halation) has been employed in some such 
cases with benefit. When the convul- 
sions show a tendency to repetition, bro- 
mide of potassium may be used, or hy- 
drate of chloral may be given in twenty 
or thirty-grain doses ; or morphia may be 
administered by hypodermic injection. 
Either of these remedies will require 
close watching of their effects upon the 
patient.-II.] 
EPILEPSY. 
By J. Russell Reynolds, M.D., F.R.S. 
Definition.-Epilepsy is a chronic 
disease of which the characteristic symp- 
tom is a sudden trouble or loss of con- 
sciousness, this change being occasional 
and temporary, sometimes unattended by 
any evident muscular contraction, some- 
times accompanied by partial spasm, and 
sometimes by general convulsion. 
The two elements probably present in 
every case of Epilepsy are diminution of 
intelligence and excess of muscular con- 
traction ; and these two elements may 
exist in almost every variety of combina- 
tion, and be developed to any degree of 
intensity. The latter element is not al- 
ways seen to exist; there may be no spasm 
of the facial muscles, not the slightest 
change in the expression of countenance; 
or the face may become dull in aspect, or 
pale in color, but consciousness is, for the 
moment, in absolute abeyance. There 
are reasons for thinking, as will be shown 
hereafter, that this loss of consciousness 
depends upon spasm affecting the vessels 
of the pia mater, but such spasm is hid- 
den from our eyes. The former element, 
loss of consciousness, is that which is 
essential to our idea of Epilepsy ; without 
its occurrence, no convulsion, however 
severe, should be regarded as epileptic; 
when it does occur, as a paroxysmal event, 
and with a chronic history, the case is one 
of Epilepsy, although no other symptom 
may be present. 
There are two classes of errors into 
which authors have fallen with regard to 
the use of the word Epilepsy. The older 
mistake was to apply the term to every 
case in which there were convulsions ap- 
pearing in a certain form, called "epilep- 
tic," "epileptoid," or "epileptiform;" 
the modern error is to use the word to 
denote a paroxysmal-i. e. occasional and 
sudden-loss or diminution not only of 
consciousness but of any function of any 
organ; or, indeed, sometimes to denote 
anything, or any condition, which occurs 
in a paroxysmal manner. The former 
led to the association, under one name, of 
diseases differing so widely from each 
other as tumor of the brain, Bright's dis- 
ease of the kidney, intestinal entozoa, 
lead poisoning, and almost every form of 
malady: the latter might lead to the 
placing in one common group, and calling 
by one common name, such diseases as 
amaurosis from dyspepsia, stammering, 
deafness, paralysis, or asthma. The for- 
mer tendency led to the production of 
such words as renal epilepsy, sympto- 
matic and sympathetic epilepsy, toxsemic 
epilepsy, and the like : the latter has con- 
duced to the coinage of such terms as epi- 
lepsy of the retina, acoustic epilepsy, and 
so forth. 
There is, I think, a radical and very 
mischievous mistake in both of these 
modes of using words; the error is similar 
in the two, as far as regards its principle, 
but it differs in the detail of its develop- 
ment. The older authors exaggerated 
the importance of the form of a group of 
symptoms - convulsive - occurring in a 
number of organs, and common to many 
widely different diseases; the modern 
have exalted into undue prominence the 
pathological significance of one element 
out of this group of symptoms-viz., ar- 
rest of function-which single element 
may occur in many diverse organs of the 
body. By such a term as " renal epilepsy" 
was meant a disease resembling Epilepsy 
in its outward form, but dependent upon, 
not an unhealthy condition of the nervous 
centres, but on an irritation of the kidney, 
or an altered blood-state which kidney- causes of epilepsy. 
763 
disease might have determined : by such 
words as " retinal epilepsy" something 
very different is intended, viz., a malady 
showing itself only in the retina, in which 
a change takes place, supposed to be 
analogous, in its intimate pathology, to 
that occurring in the brain in Epilepsy. 
In the one Epilepsy merely means con- 
vulsion ; in the other it merely means ar- 
rest of function; and the objection I enter- 
tain to such use of terms is based upon 
the fact that, however widely different 
individual cases of Epilepsy may be, they 
do yet belong to and constitute a group 
which has a definite clinical history, and 
has had it for some hundreds of years. If 
good reason can be shown for getting rid 
of the word "epilepsy," I should rejoice 
to lose it from our nosology; but so long 
as the word is retained at all it should 
have a definite and intelligible meaning. 
Renal asthma would be a term as patho- 
logically correct as "renal epilepsy;" 
dyspnoea of the fingers as justifiable as the 
expression "epilepsy of the retina." 
Synonyms.-No useful end would be 
served by enumerating all the names by 
which this disease has been described, in- 
asmuch as many of them have fallen into 
complete disuse. The most important 
are the following :- 
Epilepsy (English); 1'Epilepsie (French); 
Fallsucht (German); Mal Caduco (Ita- 
lian) ; Epileptica passio, Morbus sacer, 
M. comitialis (Latin) ; 'Erta^a, 'ExiX^^s 
(Greek). 
Natural History.-1. General 
Prevalence of the Disease.-Epi- 
lepsy is spoken of as a very common affec- 
tion. Niemeyer states that in every 
thousand individuals there are to be 
found six epileptics.1 Such statement 
cannot, I think, be true with regard to 
Epilepsy in this country ; for among 1820 
invalids, whose cases were recorded by 
myself as out-patients of the Westminster 
Hospital, there were only seven epileptics; 
and but thirty-four whose diseases could 
by any possibility be confounded with 
Epilepsy. It must be observed further, 
that Niemeyer is speaking of individuals 
generally, and that the results of my own 
examination at the Westminster Hospital 
are obtained from a small class of indivi- 
duals, viz., those who are ill. 
The proportion of true Epilepsy to other 
diseases of the nervous system has been 
found to be about 7 per cent. 
2. Causes of Epilepsy.-(a) Predis- 
posing Causes.-Hereditary taint has been 
found to exist in rather less than one- 
third of those cases which have fallen 
under my care, and have been carefully 
examined on this point.1 It is not in- 
tended by this statement to affirm that 
true Epilepsy has existed in the parents 
of one-third of the cases ; but that some 
disease of the nervous system, more or 
less closely allied to that under considera- 
tion, has been present in either the 
parents, the grandparents, the aunts, 
uncles, brothers, or sisters; that there 
has been a family proclivity to nervous 
disorder, in one case showing itself by 
idiotcy, in another by mania, in a third by 
convulsions, and so forth. I have found 
only 12 per cent, of epileptics giving a dis- 
tinct history of Epilepsy in other members 
of their families ; a number which is very 
near to that stated by Dr. Sieveking, and 
not far removed from that given by M. 
Delasiauve. 
It has been said that the disease is more 
frequently transmitted on the fathers' 
than on the mothers' side,2 but the re- 
verse of this proposition has been found 
to obtain in cases examined by myself. 
Of 130 epileptics, I found 80, or 61'06 
per cent., who asserted the entire absence 
from their families of any predisposition 
to nervous disease ; and 8 individuals, or 
6'10 per cent., who were in some uncer- 
tainty as to the health of important rela- 
tives. These patients were derived from 
all classes of society; and I have no means 
of determining the question, on a scale 
sufficiently large to be satisfactory, 
whether Epilepsy is more commonly 
found to be hereditary in the upper, the 
middle, or the lower classes. Several ele- 
ments of doubt enter into the solution of 
this question, the most important of which 
is the greater difficulty that is encountered 
in obtaining accurately the facts which 
belong to the latter. Hospital patients 
often know but little of their antecedent 
or even collateral relations. Among the 
upper classes there is not rarely a studious 
concealment of what are regarded as pre- 
judicial family conditions. The middle 
classes are not only more accurate than 
the former, but more free than the latter; 
and, judging from what I have gathered 
1 In a careful paper by Messrs. Leech and 
Fox, in vol. i. of the Manchester Medical and 
Surgical Reports, p. 198, the proportion of 
those epileptics in whom hereditary taint 
was traceable was somewhat higher, viz., 
36-8 per cent. These observers compare with 
each other epileptics and non-epileptics, and, 
having obtained particulars with regard to 
the health of a large number of the relatives 
of each group, show that the relatives of epi- 
leptic patients were found to suffer from 
"some form of nervous disease" in larger 
proportion than were those of non-epileptic 
individuals. 
2 Esquirol. Des Maladies Mentales, tom. 
i. p. 406. 
1 Niemeyer, Handbuch der speciellen Pa- 
thologie, p. 637. EPILEPSY. 
764 
from them, as they shade off on either 
side-above them and below-I should be 
of opinion that hereditary taint is more 
frequently discoverable in the better con- 
ditions of life than in the pooler. It is 
not intended that there are absolutely a 
larger number of hereditary epileptics 
among the former than the latter; but 
that, of an equal number of epileptics in 
the two extremes of society, a larger pro- 
portion will furnish evidence of hereditary 
taint among the rich than among those 
who are in want. This is probably due 
to the fact that the latter class are ex- 
posed more frequently and more severely 
than are the former to the most active de- 
termining causes of the disease, viz., 
anxiety, alarm, and want. With regard 
to the hereditary transmission of Epilepsy, 
as indeed with regard to the causation of 
all diseases by supposed hereditary taint, 
it must be remembered that, inasmuch as 
the large majority of cases owe their 
malady to other causes than inherited 
tendency, a certain number of those 
whose parents exhibit a like affection to 
their own may have become morbid inde- 
pendently of any hereditary taint. It is 
well known that many of the children of 
epileptic parentage are free from the dis- 
ease, and it is quite clear that many epi- 
leptics, descended from epileptic stock, 
have been exposed to causes of the malady 
which would, of themselves, have been 
held sufficient to have induced the malady 
independently of any constitutional taint. 
It is, therefore, of practical importance 
not to assume too readily the operation of 
this cause, and hence to neglect an exami- 
nation into other conditions. In the 
largest and most correct sense of the word, 
the etiology of Epilepsy is advanced but 
little by the discovery of hereditary taint; 
the causation may be thus thrown back- 
wards, but it is not explained. 
Sex.-Little that is of value can be 
shown with regard to the influence of 
sex as a predisposing cause of Epilepsy. 
Practically, the two sexes appear to be 
about equally affected ; and the different 
statements that have been made by va- 
rious authors-some of whom represent 
the male sex, others the female sex, as 
the more liable to the disease-may prob- 
ably be accounted for by other circum- 
stances than that supposed, viz. a special 
sexual predisposition. The relative num- 
ber of female epileptics who are out-pa- 
tients of hospitals may be determined by 
the hours at which the physicians make 
their visits, or by other conditions which 
have to do with the social position of the 
applicants, and which may render it 
easy, difficult, or almost impossible for 
either the one or the other sex to attend. 
Similar degrees of fallacy, although 
different in kind, may influence the re- 
sults obtained from private practice. The 
facts of a physician's age, and single or 
married condition, for example, might 
exert an influence upon the relative num- 
bers of his male and female patients too 
great to be counterbalanced by proclivity 
to Epilepsy inherent in either sex. 
Again, the statistics gathered from asy- 
lums are liable to disturbing causes so far 
as etiology is concerned. In proportion 
to the amount of disease a larger number 
of males than females find their way into 
public asylums. The reason for this is 
obvious, viz. that men are prevented from 
doing their special work in the world by 
an amount of disease which need not 
deter women from performing their do- 
mestic duties. Yet further, the statistics 
furnished on this point by some authors 
are complicated by limitations as to age, 
and by the fact of more or less clearly 
pronounced insanity of mind. 
Little, then, that is definite can be 
stated on the influence of sex, as a predis- 
ponent to Epilepsy ; and it seems to me to 
be the wisest course at present to leave the 
question open for further investigation. 
Age.-The influence of age in the pro- 
duction of Epilepsy is strongly marked. 
This is shown in the following short table 
of cases collected by myself:- 
Age at commencement. 
Males. 
Females. 
Total. 
Under 10 years • . •» 
10 
9 
19 
Between 10 and 20 years 
66 
40 
106 
Between 20 and 45 years 
25 
20 
45 
Over 45 years . . . . 
1 
1 
2 
■ 11 1 
■ ■■ 1 
102 
70 
172 
The most important fact to be recog- 
nized in the above summary is the great 
frequency with which Epilepsy com- 
mences between 10 and 20 years of age- 
i. e. at a period of life embracing the pro- 
cesses of the second dentition and of the 
establishment of puberty ; and, without 
going much further into detail, it may be 
stated in addition, that by far the larger 
number of the group showed their first 
symptoms of the disease between the 
ages of 13 and 17 years, inclusive. Fur- 
ther, that there is a comparative immu- 
nity from the commencement of the dis- 
ease between 25 and 35, the greater pro- 
portion of cases forming the third group 
having been seized by the disease at or 
about the age of 40.1 
1 For further information on these points 
the reader is referred to Hasse, in Virchow's 
Handbuch, Ister Abth. 4ter Bd. p. 264; 
Reynolds on Epilepsy, p. 126; Leuret, Archiv. 
Gen. de Med. 4me Serie, 1843, t. ii. ; Sieve- 
king, Med.-Chir. Trans., vol. xl. p. 158; 
Herpin, Du Pronostic, &c., p. 332, Leech and 
Fox, in Manchester Medical and Surgical Re- 
ports, p. 199. It is, however, to be remem- 
bered that in the case of some of the authors 
referred to care has not been taken to separate 
Epilepsy from other convulsive diseases. CAUSES OF EPILEPSY. 
765 
When there is a marked hereditary 
taint as a predisposing cause of Epilepsy, 
the disease is found to develop itself some- 
what earlier than under other circum- 
stances. The difference, however, is not 
so great as that which is to be observed 
in regard of some other maladies which 
are held to be hereditary. The difference 
may be fairly represented in the following 
table:- 
which category of causation some cases 
should be placed ; as, for example, those 
in which the fits have been referred to 
either falls or blows, inasmuch as it is 
possible that such accidents may have 
operated through the mind by alarm or 
fear, rather than through the body by the 
merely physical process of concussion or 
laceration. I have .'placed such cases in 
those groups to which they had been as- 
signed by the patients or their friends at 
the time that the disease began. 
The following table exhibits the relative 
frequency of the several kinds of causes to 
which I have referred :- 
Nature of Cause. Number of Cases. 
I.-Psychical; such as fright, 
grief, worry, overwork 29 
II.-Eccentric irritation ; den- 
tition, indigestion, ve- 
nereal excesses, dysen- 
tery, &c 16 
III.-General organic changes; 
fatigue, pregnancy,mis- 
carriages, rheumatic fe- 
ver, scarlet fever, diph- 
theria, pneumonia. . 9 
IV.-Physical influences; blows 
on head, falls, insola- 
tion, cuts 9l 
63 
Besides these sixty-three cases, I have 
the records of sixty-one cases in which no 
cause could be assigned ; the patients or 
their friends either asserting their absolute 
inability to make any reasonable conjec- 
ture on the matter, or hazarding some 
explanation which was utterly nonsensical. 
It is important to know that of these sixty- 
one, there were forty-three individuals 
who, after examination and cross-exami- 
nation, and suggestion, could give neither 
to themselves nor to me any clue to the 
solution of the mystery. Of 124 cases, there- 
fore, sixty-three, rather more than the 
half, supposed that they could explain the 
causation of their malady ; forty-three, or 
34 per cent., asserted their utter inability 
to do so; while twenty-nine, or 23 per 
cent., referred their attacks to mental or 
emotional disturbance. 
The frequency with which mental or 
emotional disturbance has been shown to 
be the cause of Epilepsy is such that it 
requires some further notice. The most 
common conditions that I have witnessed 
are those of continued anxiety and pro- 
longed rather than intense alarm. I have 
in a very few instances found that an 
over-strain of the mental powers has been 
followed by Epilepsy, but in almost every 
one of these cases there has been consid- 
erable anxiety, as well, and it, I believe, 
Hereditary. 
Non- 
hereditary. 
Commencing under set. 15 83'33 
46'15 
above " 16'66 
53'82 
It has appeared, further, that when 
Epilepsy is hereditary it shows itself at an 
earlier age among girls than among boys. 
The difference is not great, and Messrs. 
Leech and Fox have arrived at an oppo- 
site result.1 
(6) Accidental or Exciting Causes.-Pa- 
tients and their friends often exhibit a 
very great anxiety to refer the outbreak 
of Epilepsy to some external condition, 
which they may speak of as its cause ; 
and, in doing so, they occasionally attach 
undue importance to trivial circumstances. 
There is a natural reluctance to admit the 
presence of constitutional or hereditary 
taint, and an eagerness to find excuses 
for the poor sufferer, in the fact of his 
having been exposed to some extraordi- 
nary disturbance from without. In this 
way we may in some measure account for 
the wideness of the range of conditions to 
which the production of Epilepsy has been 
referred. It is so difficult to conceive that 
a disease having such strongly marked 
features as those of the epileptic paroxysm 
can lurk in an apparently healthy frame 
-that all the essential conditions of so 
terrible a malady may be present and yet 
give no sign-that many find an explana- 
tion of the outburst in some externally 
disturbing cause which they can appre- 
ciate, and ignore the operation of those 
internal conditions which had hitherto 
escaped their notice, or had been regarded 
from a different point of view. 
It is important to classify the causes to 
which Epilepsy has been referred, and I 
have done so by distributing them into 
four groups: placing in the first, those 
which operated through the mind or the 
emotions, such as fright, grief, worry, and 
the like ; in the second, those which acted 
through the reflective centre, such as ec- 
centric irritations; in the third, those 
which produced their effect through 
changes in the general health, such as 
those which may be occasioned by preg- 
nancy, by acute specific, or other dis- 
eases ; and in the fourth, those which may 
be regarded as acting physically, such as 
insolation, mechanical injury, and the 
like. It is difficult to determine into 
1 Messrs. Leech and Fox found a much 
larger proportion of cases falling under this 
category. Op. cit. p. 206. 
* Op. cit. p. 202. 766 
EPILEPSY. 
has been the more efficient factor of the 
malady. Women and girls have much 
more frequently than either men or boys 
referred their attacks to emotional dis- 
turbances ; the proportion being 36 per 
cent, of females, and 13 per cent, of males. 
The period at which the first attack has 
occurred after an individual has received 
some great mental shock varies widely ; 
the lit may take place at the moment of 
alarm, or it may follow after an interval 
of hours, days, or weeks. 
With regard to eccentric irritations, it 
must be remembered that in the list given 
above cases of "convulsions" are not 
enumerated. Both the first and the 
second dentition, and even the cutting of 
the " wisdom teeth," may be attended by 
convulsions, which in the large majority 
of cases disappear as soon as the source 
of annoyance has been removed. In a 
few rare cases, however, the processes 
referred to have appeared to cause genu- 
ine Epilepsy, and it is to these rare cases 
that reference is made. It is curious to 
know that in not more than half of the 
cases of Epilepsy can it be ascertained 
that "fits" have occurred during infancy; 
and it is a still more interesting fact that 
epileptic women appear to exhibit no high 
degree of proclivity to puerperal convul- 
sions. Dr. Tyler Smith states that puer- 
peral convulsions occurred only twice in 
fifty-three deliveries of fifteen epileptic 
women and so far as my own experience 
extends, it is exceedingly rare, and indeed 
almost unknown, for epileptic women to 
suffer from their attacks during or imme- 
diately after labor. 
Among the second group of causes ap- 
pears one to which, I believe, far too great 
an amount of importance has been attach- 
ed, viz. excessive venery or masturbation. 
It is very common to hear suspicions ex- 
pressed upon this point; much more com- 
mon, I think, than to hear any such 
statement of facts as should prove that 
Epilepsy and masturbation have any spe- 
cial character or frequency of relation to 
one another. The one is a tolerably pre- 
valent disease, the other a very widely 
distributed vice. There are multitudes of 
epileptics with regard to whom no such 
suspicion could ever be entertained ; and 
there are, it is to be feared, much larger 
multitudes of masturbators who have 
never become epileptic. When, therefore, 
we find the two elements combined in the 
same individual, it is necessary to observe 
some caution in our attempt to interpret 
their relations. It is, I believe, sufficiently 
well proved to be regarded as a fact that 
the vice referred to is liable to induce 
various disturbances in the health, and 
that the major part of these is brought 
about by, and is exhibited in, the altered 
functions of the nervous system ; but what 
it appears to me is yet wanting in proof is 
the special relationship of Epilepsy to this 
particular wickedness or weakness. Again 
and again it has occurred to me to see 
cases of vague and various nervous de- 
rangements which might be fairly inferred 
to be the result of masturbation ; but it 
has in only an exceedingly small number 
of cases of Epilepsy been possible for me 
to establish the existence of such relation. 
There can, I think, be no doubt what- 
ever as to the existence of an intimate asso- 
ciation between various forms of nervous 
malady and either various abnormal con- 
ditions of the sexual organs, or unnatural 
circumstances attending upon their exer- 
cise ; but, as yet, the nature of that asso- 
ciation is, I believe, and as undoubtedly, 
unexplained. Sometimes sexual excess, 
and sometimes the reverse ; now great 
emotional involvement, and now the en- 
tire absence of all sympathy ; at one time 
exuberant enjoyment, and at another dis- 
appointment or disgust, are conditions 
met with in epileptics, and in all forms of 
many sorts of disease; but, so far as I 
know, neither one of those conditions is 
more frequent than another in the history 
of epileptics. I have known cases in 
which morbid libidinousness occurred in 
epileptics, but only long after the develop- 
ment of the disease; and on the other 
hand I have met with cases where the 
sexual propensity had become diminished, 
or even extinct, after the occurrence of 
the attacks, and this without any pre- 
vious excess in its gratification. 
In endeavoring to determine this ques- 
tion, which is of considerable etiological 
interest, it would be undesirable to omit 
notice of the striking effects which have 
been observed to follow the administra- 
tion of bromide of potassium in cases of 
Epilepsy. It cannot be doubted that this 
medicine is highly valuable in diminish- 
ing the number of attacks and the only 
point of interest to us now is to ascer- 
tain whether its modus operandi is such 
that it either countenances or discoun- 
tenances the prevalent belief with re- 
gard to the etiological question under 
consideration. When this medicine was 
first introduced by Sir Charles Locock,2 it 
was recommended as being of especial 
service in those cases of Epilepsy in women 
in which the attacks occurred only during 
the menstrual period ; and since that time 
it has been very generally received that 
bromide of potassium possesses strong 
antaphrodisiac properties, and that its 
1 See p. 780 on Treatment, Dr. S. W. 
Duckworth Williams' Paper "On the Efficacy 
of the Bromide of Potassium in Epilepsy and 
certain Psychical Affections," also a paper by 
the editor in "The Practitioner." 
2 See Lancet, May 20, 1857, vol. i. p. 528. 
1 Lancet, 1849, vol. xxiv. p. 644. SYMPTOMS. 
767 
utility in Epilepsy is to be accounted for 
by its special action upon the generative 
organs. From the very first I saw rea- 
son to doubt this mode of explanation,1 
and much enlarged experience has,' from 
my own mind, removed all doubt what- 
ever upon the point, and produced a set- 
tled conviction that bromide of potassium, 
when given in such doses as to be of ser- 
vice in Epilepsy-viz. from 10 to 30 grains 
either three or four times daily-exerts no 
recognizable influence upon either the 
sexual propensity or power. It is not 
asserted that doses might not be given so 
large as to exert such influence, but that 
where decidedly remedial effects have 
been produced in Epilepsy, their produc- 
tion has not been attended by any change 
in the generative functions. Dr. Duck- 
worth Williams2 says: "I have tried it 
(KBr) in every variety of uterine affec- 
tion that has come within my reach, in- 
cluding nymphomania, satyriasis, menor- 
rhagia, amenorrhoea, dysmenorrheea, &c. 
&c., but without perceiving the least bene- 
fit accrue." Dr. Williams mentions cases 
in which the patients, in spite of their 
taking the medicine, "persisted in their 
bad habits, and their sensuality became 
if possible more confirmed" (p. 17) ; and 
his experience on this matter is in entire 
accordance with the results of my own 
observations. We cannot, therefore, sup- 
port tlie prevalent creed in regard of one 
mode in which Epilepsy is produced by 
facts gathered from the treatment of that 
disease by bromide of potassium. 
To what degree the view to which I 
refer is supported by the observations of 
Mr. Baker Brown,3 must depend partly 
upon the therapeutic results of this mode 
of treatment, and partly upon the inter- 
pretation which must be given to the 
alleged facts. On the former point the 
evidence is unsatisfactory, being gathered 
from a small and too exclusive selection 
of cases ;4 on the latter point some mis- 
conception is possible. Considered etio- 
logically, we want to know the proportion 
of cases in which the particular cause to 
which Mr. Brown refers had been in ope- 
ration, but upon this point we are not 
furnished with any evidence whatever, 
inasmuch as in all the cases he records 
not only was irritation of the pudendal 
nerves believed to exist, but a certain kind 
of operation was performed. It would, I 
think, be pushing much too far the infer- 
ence to be drawn from Mr. Brown's little 
book, to assert that his opinion is that 
every case of Epilepsy is produced in the 
manner described. What we want to 
know is the number of cases of Epilepsy 
in which Mr. Brown entertained no such 
suspicion, and, still further, the number 
of cases in which, having entertained it 
and acted upon it, the result was unsatis- 
factory. As to the interpretation of the 
facts that are stated, there is this to be 
borne in mind, that so far as I can under- 
stand Mr. Brown's theory, it is not that 
in such cases there have been of necessity 
immodest wishes, excessive sensuality, or 
irregular practices, but that there has 
been a morbid condition of irritability of 
a certain nerve, and that this has been 
taken away by the removal of the peri- 
pheral termination of the nerve. Refer- 
ring for future consideration the question 
of the therapeutic propriety or desirability 
of the operation of clitoridectomy,1 all 
that is necessary to say now is that-in 
the absence of any definite statement of 
Mr. Brown upon the question of propor- 
tion as described above-my own expe- 
rience would lead me to believe that the 
cause he refers to is of very rare and very 
exceptional occurrence. 
In another work2 I took some pains to 
show how extremely rare it was to meet 
with a case of Epilepsy in which no 
causative conditions could be discovered. 
Although in one person we might find no 
predisposing cause, and in another no ex- 
citing cause, in only one-eighth of the 
cases was there an absence of both. In 
seven-eighths, either one, two, three, or 
more causative conditions of disturbance 
were present and were recognized. 
The proportion, therefore, of cases of 
Epilepsy in which the causation of the 
disease is placed beyond explanation by 
our present knowledge of pathology is not 
greater than that which we meet with in 
many other chronic diseases, and is far 
less than that which is admitted to exist 
in several. There is some mystery in the 
causation of almost all diseases ; and I do 
not think that it is greater in the case of 
Epilepsy than in that of many others with 
regard to which we think ourselves on 
easy terms with the science of pathology. 
3. Symptoms.-It will be convenient 
to consider those which occur in, and con- 
stitute a paroxysm of Epilepsy, separately 
from such as may be observed during the 
intervals of attack. We have, therefore, 
to describe, first- 
The Paroxysmal Symptoms, or features 
of the attack. In most characteristic cases 
of Epilepsy there is an entire loss of con- 
sciousness in conjunction with a peculiar 
series of involuntary muscular move- 
ments ; but, on the one side of these typ- 
ical cases, we see epileptics in whom the 
loss of consciousness is alone obvious, 
1 See Author, on Epilepsy, p. 332. 
2 Loc. ant. cit. p. 16. 
3 On Certain Forms of Insanity, Epilepsy, 
Catalepsy, and Hysteria in Females 
4 See Treatment, p. 781. 
1 See p. 781. 
2 Author, on Epilepsy, p. 2G1 768 
EPILEPSY. 
and, on the other, individuals exhibiting 
certain highly marked spasmodic phe- 
nomena, and only very slight or even im- 
perceptible obscuration of the mind. It 
is necessary, therefore, to classify cases, 
in order to render description possible, 
and it is proposed to do so by dividing 
them into four groups, which may be tiius 
distinguished : First, those in which there 
is loss of consciousness without evident 
spasm ; second, those in which such loss 
of consciousness is accompanied by local 
spasmodic movement; third, those in 
which it is attended by general tonic and 
clonic convulsion, following a particular 
order ; and fourth, those in which general 
or partial convulsion occurs without com- 
plete loss of consciousness. The first and 
second forms may be termed "epilepsia 
mitior," or "le petit mal;" the third 
form "epilepsia gravior," or "le haut 
mal;" and the fourth "epilepsia abor- 
tiva," or irregular Epilepsy. 
(a) Epilepsia Mitior, or Le Petit Mal," 
without evident Spasm.-All that occurs 
and can be positively attested in cases of 
this description is a sudden, temporary, 
but absolute arrest of both perception and 
volition. The individual so attacked 
loses consciousness for two, three, or 
more seconds; and may after that or a 
longer period resume his sentence or em- 
ployment perfectly unaware that anything 
abnormal has happened. 
Sometimes there is slight loss of bal- 
ance-the patient, if standing or walking, 
leans to one side, or staggers, but does 
not fall; sometimes there is pallor of the 
countenance followed by slight flushing; 
sometimes the latter without the former ; 
sometimes there is slight dilatation of the 
pupil, and an absence of the expression 
of " looking at anything ;" sometimes an 
irregularity and faltering of the pulse; 
but often, as I can testify from repeated 
observations, there is not any one of the 
physical changes I have mentioned; the 
patient's mind becomes a blank for a few 
seconds, and that is all that can be ob- 
served. 
These seizures are often regarded as 
"faintings," and are described by pa- 
tients under various terms, such as 
"blanks," "forgets," "faints," "sensa- 
tions," "absences," "darknesses," &c. 
&c. 
Occasionally these slight attacks are 
preceded by vertigo; the patient thinks 
he shall fall, and so lies down to avoid 
doing so: sometimes he staggers and 
grasps an object for support; but, much 
more commonly, he simply ceases to per- 
form any act requiring volition-he stops 
speaking or writing; but the automatic 
movements of standing or sitting, and the 
secondarily automatic movements of rid- 
ing, walking, or holding an object, are 
maintained. 
Sometimes the attack is followed, for a 
few seconds or for a longer period, by an 
obscured or altered state of intelligence; 
the patient speaks in reply to what is 
asked of him, but in half an hour after- 
wards is found to have entirely forgotten 
what was said to him or by him. In 
more rare cases the mind is dull, or alter- 
ed from its habitual condition for a period 
of some hours, the patient being low- 
spirited, or suspicious, and apparently 
laboring under some delusion which he 
afterwards forgets. In this condition he 
may be listless ; or he may do some odd 
things which he cannot afterwards ac- 
count for or even recollect. 
(&) Epilepsia Mitior with evident Spasm. 
-This is more common than the preced- 
ing, which it resembles exactly so far as 
the mental condition is concerned. The 
extent and locality of the spasm differ 
widely in different cases, and also in the 
same individual at different times. There 
may be only slight strabismus, or draw- 
ing of the mouth, partial turning of the 
head to one side, or some movement as of 
swallowing or attempts at getting some- 
thing from the mouth; or, on the other 
hand, there may be slight momentary 
rigidity of the whole body. Sometimes 
the patient fixes his chest walls, and ap- 
pears to "hold his breath; sometimes he 
does some curious thing, such as stoop 
down to peep under a sofa, lie down and 
pull off his cravat, jump from his chair 
and walk quickly half-way across a room ; 
but in any or all of these apparent at- 
tempts to do something he is suddenly 
arrested by the loss of consciousness, 
which is often absolute. Occasionally 
peculiar actions are performed after an 
attack of " le petit mal;" but it has never 
occurred to me to find an epileptic who 
could tell me why he did these things, or 
who could even remember that he had 
done them. 
As to the locality of the muscles af- 
fected, it would appear that those of "ex- 
pression" and of respiration are by far the 
most frequently involved. There is no 
evidence to show that either "trachelis- 
mus,"1 or "laryngismus," or "phlebis- 
mus" occurs with anything like such fre- 
quency as to make them of any value in 
the interpretation of the epileptic parox- 
ysm : although it is quite clear that the 
former may exist to such a degree as to 
occasion duskiness of the face. 
The spasm in "le petit mal" is never 
violent; and it is only of short duration. 
It is tonic in its character, and painless to 
the patient, and the vascular changes 
which may be observed are of the same 
variable degree and kind as those enume- 
1 Marshall Hall, "Memoirs on the Neck as 
a Medical Region," 1849. SYMPTOMS. 
769 
rated in the previous section. Patients I 
sometimes have warning sensations of 
these attacks, and I have known more 
than one instance in which there was a 
highly marked and most painful "aura 
epileptica." 1 
The most common combination and de- 
gree of symptoms may be thus described, 
-a feeling of giddiness, faintness, or dis- 
comfort ; slight twisting of the neck, with 
anxious, lachrymose expression of the 
face, dilatation of the pupils, and pallor; 
accompanied, or quickly followed, by en- 
tire loss of consciousness, which lasts for 
two or three seconds; the patient "be- 
coming himself again" after making a few 
sighing sounds, but feeling faint and be- 
wildered, and often perspiring freely. 
(c) Epilepsia Gravior, or " Le Haut 
Mal."-This, the ordinary form of Epi- 
lepsy, is in the vast majority of cases 
characterized by complete loss of con- 
sciousness, and a peculiar combination 
and series of spasmodic movements. In 
very rare instances we have the latter 
element without the former; the more 
common and much larger group shall be 
described first, and it will be convenient 
to enumerate separately the premonitory 
symptoms, those of the attack, and the 
immediate sequelae or after-symptoms. 
Premonitory symptoms are sometimes 
absent altogether; in certain cases they 
are of regular occurrence, being in the 
same individual invariable in character, 
while in another set of cases they are 
sometimes absent and sometimes present, 
and are more or less variable in their fea- 
tures. Their duration may be almost 
momentary, it may extend to several 
minutes, or, but very rarely, to hours, or 
even days. When of long duration, the 
prodromata are diminished in specialty 
and in intensity ; and consist, as far as I 
have seen, in some mental change, or in 
some alteration of the general appearance. 
Thus, there may be an exaggeration of 
any habitual condition of the mind or 
spirits; the patient becoming, to an un- 
usual degree, depressed, morose, or taci- 
turn ; or, on the other hand, lively, irri- 
table, and excited. I have known several 
instances in which an undue flow of 
spirits, and an emphatic frivolity and ex- 
pression of "feeling remarkably well," 
have almost invariably preceded the epi- 
leptic paroxysms. Such sensations have 
occurred in those patients whose attacks 
were not of very frequent repetition. It 
is very difficult to describe those changes 
in general appearance, or in "the looks" 
of a man, which friends recognize as pre- 
monitory of an attack. Generally, I be- 
lieve, they depend upon an alteration in 
the color of the skin, and some want of 
fineness in the outline of the features. 
The face becomes less red, more yellow, 
and somewhat dusky in tint, and there is 
a certain puffiness which, without altering 
in kind, diminishes in force its habitual 
expression. It is said, " He seems quite 
himself, but he does not look so; he is 
sharp enough, but looks stupid; and we 
know that an attack is coming on. " There 
is no oedema, but there is a partial oblit- 
eration of the lines which make up "ex- 
pression." 
Those symptoms which immediately pre- 
cede the seizures are widely different in 
character, variability, intensity, and dura- 
tion. They may occur in the mind, the 
sensations, the muscular system, or the 
general bodily condition. 
The mental prodromata are of many 
kinds: in some cases there is a distinct 
idea, never spontaneously presenting itself 
at any other period, and one which in its 
character and bearing is perfectly remem- 
bered afterwards ; while in others there is 
a vague notion, recognized to be the warn- 
ing of an attack, but of such indistinct 
character that only the fact of having en- 
tertained it is remembered. One gentle- 
man told me that just as an attack was 
coming on he always thought, "This is 
what I had foreseen, I knew it would 
come on here, I ought to have avoided it 
by remaining away," and this, although 
there had not been the remotest suspicion 
beforehand that an attack was imminent, 
or that the circumstances about to be en- 
tered upon would be likely to induce it. 
Much more common is a vague feeling of 
fear, which is horrible enough, but hap- 
pily of only short duration. 
Sensorial changes are by no means un- 
common, and they are of every kind, de- 
scription, and indescribability. By far 
the most common is a "painful feeling," 
sometimes said to be "most painful," or 
"horribly painful and distressing," but 
which, yet, the patient says-when mi- 
nutely questioned-is not "pain," in the 
ordinary sense of the word. It would 
seem to be some condition of sensation 
which is intensely distressing, but which 
is unlike what we mean by smarting, 
burning, aching, &c. &c. Patients some- 
times say that "it is in the head," and 
yet it is not " headache ;" that it is in the 
epigastrium, and yet it is not "stomach- 
ache." In some cases the sensation is 
always in either the head, the epigastrium, 
or lower thoracic region, the lower ab- 
dominal region, or the limbs. These are 
stated in the order of frequency, as they 
have occurred to me. In a large number 
of individuals, however, the sensation- 
which is sufficiently distinct and consist- 
ent for them to know that an attack is 
coming-is so vague that they cannot 
assert whether it is in the head, chest, 
abdomen, or limbs. Sometimes there are 
1 Infra. 
VOL. I.-49 EPILEPSY. 
770 
hallucinations of the special senses; one 
patient told me that he always heard "an 
infernal noise, something like that outside 
a booth at a country fair;" another that 
he had "a vision of a hideous donkey." 
It would be waste of space to enumerate 
further these prodromata. 
Premonitory symptoms may occur in 
the form of tremor, twitching, tonic 
spasm, or co-ordinated movements, such 
as turning round, running some distance, 
&c. ; or they may appear as partial paral- 
ysis of one or more limbs. The latter is 
stated to be more common in old people.1 
The term epileptic "aura" has been 
sometimes used, very vaguely, to describe 
any premonitory symptom of which the 
patient could give an account; but, when 
more strictly limited in its meaning, it 
has been used to express a sensation of 
blowing, or of something analogous there- 
to, which, commencing in the periphery, 
passed upwards to the head, the patient 
becoming insensible when it had reached 
this point. Passing over for the present 
the pathological interest attaching to the 
interpretation of the so-called aura, it 
may be now stated broadly that anything 
characteristic of Epilepsy, in the second 
or limited sense of the word "aura," is 
rare, but that when such premonitory 
symptom does occur, it varies in charac- 
ter in different individuals; in one class 
there is a pain in the limbs, which "runs 
up them towards the headin another 
there are some twitching movements, and 
"the leg draws up," or "the arm be- 
comes contracted and in a third there 
is some vague uneasiness about the hypo- 
gastric or epigastric regions, which " goes 
up through the chest." One peculiarity 
attaching to these symptoms is the facility 
with which they may sometimes be re- 
moved, and the attack averted. Pain 
may be stopped by rubbing, or by the 
pressure of the hand, or of a ligature; 
contractions may be undone by forcible 
extension of the limb ; and the uneasiness 
in the abdomen may be removed by a 
cordial draught.2 The duration of the 
aura is very variable, viz., from a few 
seconds to several minutes ; sometimes the 
feelings "come, and go again," for hours, 
being arrested many times in the manners 
I have mentioned, but at last, as the pa- 
tients say, "slipping by," and being fol- 
lowed by the fit. 
There are, further, premonitory symp- 
toms in the vascular system, and in the 
secreting organs, such as alterations in 
the color of the face, or of the fingers, a 
redness or duskiness of the lips, a blue 
color of the gums, an excessive salivation, 
a change in the nature of secretions but 
these are of rare occurrence, and of sucli 
variable character that the mere fact of 
their existence is all that need be stated 
here. 
The relative frequency of the different 
classes of premonitory symptoms, so far 
as I have been able to ascertain, may be 
represented thus:- 
Mental and emotional . 11T per cent. 
Sensational 19 8 " 
Motorial 8'6 " 
Vascular and secretory . 3'7 " 
Prodromata were declared, positively, 
to be absent in 40'7 per cent.,2 whereas 
information was "doubtful" in regard of 
16 per cent. The most common precur- 
sory sensation was vertigo; there was 
little difference to be observed between 
the relative liability of the two sexes to 
any one form of "warning." 
Actual Symptoms of the Attack.-For the 
purposes of description it is desirable to 
divide the epileptic paroxysms into three 
stages. 
In the first stage of the attack there are 
the following phenomena, which occur- 
not successively, as they are necessarily 
represented in writing, but simulta- 
neously, or with only slightly varying 
order:- 
Loss of consciousness, i. e. of perception 
and volition. 
Tonic contraction of the muscles 
throughout the body, with some excess of 
power on one side, or in one direction. 
Impeded or arrested respiration, with 
or without a crying noise. 
Pallor, redness, or duskiness of face ; 
either the one or the other, often the one 
succeeding the other in the order they are 
mentioned. 
Dilatation of the pupils of the eyes. 
Natural, weak, or imperceptible radial 
pulses, with throbbing carotids and dis- 
tending veins. 
This stage lasts from two or three to 
thirty or forty seconds. 
The loss of consciousness is usually 
sudden and complete; the patient falls 
down, or is, as it were, "thrown down" 
in a moment, with or without warning; 
but even when the warning occurs, so 
that he may change his position, or call 
attention to his wants, habitually the 
passage from consciousness to uncon- 
sciousness is abrupt, and the loss abso- 
lute. Sensation is, at the same time, in 
abeyance ; although some reflex acts may 
be excited. 
1 Tissot, Traits de 1'hpilepsie; (Euvres, 
tome vii. p. 131. 
2 See cases recorded by Author, op. cit. p. 
92. 
1 Romberg, Manual, Syd. Soc. Transl. vol. 
i. p. 198. 
2 Messrs. Leech and Fox give a smaller 
proportion. Op. cit. p. 218. SYMPTOMS. 
771 
The tonic spasm of the muscles is pecu- 
liar, and it may precede the loss of con- 
sciousness. The patient usually appears 
to be straining round towards one side, as 
if striving to look over and behind one of 
his shoulders. The muscles of the face 
and front of the neck are those which 
most frequently mark the onset of the 
paroxysm.1 The eyeballs, the head, the 
arms, and the trunk, turn and twist 
round, so as to give the impression I have 
mentioned. There is universal strain, 
but not actual equilibrium. Every limb 
is rigid, every muscle is at work; but 
some one set of muscles in each limb 
proves slightly stronger than its opposing 
set; and the limbs pass slowly, in a stif- 
fened manner, and sometimes with slight 
jerking movements, from the positions 
that they occupied before the attack com- 
menced. The head, neck, and trunk 
share in a similar movement, and its 
direction is usually uniform in the indi- 
vidual epileptic. 
Respiration is arrested, the patient ap- 
pearing just like a man forcibly "holding 
his breathand in nearly half of the cases 
which have fallen under my own observa- 
tion, the stoppage of the breathing has 
been so complete that no sound whatever 
has escaped from the mouth. In a certain 
number of individuals the respiration pro- 
ceeds without actual interruption, but its 
movements are diminished in force; 
whereas in a very small number there is 
no change whatever. 
In an uncertain proportion of cases 
there is the "epileptic cry," a peculiar 
and hideous sound, of which there are 
two distinct varieties. Some individuals 
utter a yell at the very commencement of 
the attack, and just before there is the 
peculiar holding of the breath I have de- 
scribed. Others do not "cry," but emit 
a groaning sound, which is, as it were, 
squeezed out of them by the quasi-tonic 
contraction of the muscles of the chest. 
There is, in fact, in regard of respiratory 
movement, a condition analogous to that 
observed in the limbs and trunk, viz., that 
of strain, but of imperfect equilibrium. 
As in the limbs there is a stiffened move- 
ment, from the fact that one set of mus- 
cles overcomes its opponents, so in the 
chest, sometimes a slow expiration, some- 
times an inspiration is performed, and 
with either of these there may be a groan- 
ing sound. Usually there is but one 
sound-either a yell or a smothered groan; 
there is no repetition of either the one or 
the other.2 
Pallor of the face is observed immedi- 
ately before, and at the very onset of the 
attack in many ; it is not present in all; 
and it occurs more certainly and more 
notably in females than in males. In other 
instances the face remains absolutely un- 
changed in regard of color, whereas in a 
larger number there is suffusion of a florid 
dull red, or dusky hue. Messrs. Leech 
and Fox found pallor to exist in only 38 
per cent, of their eases, whereas duskiness 
was "very marked and present all through 
the fit" in 53 per cent.1 
Dilatation of the pupil occurs, and, so 
far as I have seen, invariably, at the onset 
of the attack. In one case, however, I 
witnessed a momentary contraction before 
dilatation commenced. 
The pulse, as felt at the wrist, is usually 
small, and is sometimes quite impercepti- 
ble ; but in several cases that I have ob- 
served there has been no change whatever 
in either the force or rapidity of its beats. 
When it has been imperceptible, there has 
been highly marked tonic spasm of the 
limbs; and often at the same time the 
heart may be seen, felt, and heard to be 
acting, and that even forcibly, and there 
is obvious throbbing of the carotid ar- 
teries. 
In the second stage of the attack there 
are the following symptoms :- 
Persistent unconsciousness. 
Clonic convulsion. 
Laborious breathing, with gurgling, 
foaming, and the like. 
Darkness of face, and body generally, 
with cold and often profuse sweating. 
Oscillation of the pupils. 
Throbbing, labored pulse, and palpita- 
tion of heart. 
This second stage may last from a few 
seconds to five or ten minutes, its features 
gradually passing into those of the third 
stage. The transition from the first to the 
second stage is abrupt, and is determined 
by what may be termed the "letting go" 
of the breath which had been "held" be- 
fore. 
Clonic spasms are, more or less, uni- 
versal ; often they begin in the extremi- 
ties, and are more highly marked on one 
side of the body than on the other. The 
jaws are champed together, the tongue is 
bitten, the limbs are thrown about, the 
bladder, rectum, and vesiculse seminales 
may be evacuated ; there are rumbling 
noises in the intestines, hiccup, and vomit- 
ing. The eyeballs are rolled outwards, 
and in every direction but that which is 
natural, and the aspect is as hideous as 
can be conceived. 
Respiration is violently and convulsively 
performed ; the diaphragm may be felt 
through the abdominal walls ; the chest 
heaves; the alee nasi are forcibly dilated ; 
1 In twenty-four of forty-two cases. Leech 
and Fox, op. cit. p. 222. 
2 I state this as the result of special atten- 
tion to this point, as in a singular case, oc- 
curring many years ago, the question of the 
possible number of "cries" an epileptic 
might make assumed some importance in a 
medico-legal inquiry. 
1 Op. cit. p. 224. 772 
EPILEPSY. 
and the patient is in the condition of one 
who has made a most violent effort, and 
is now "out of breath. " Mucus is heard 
rattling in the trachea, and is often blow n 
out of the mouth, bloody from the bitten 
tongue or cheek. There is obviously 
great excess of secretion, and much of the 
distress of the sufferer appears due to his 
want of power to get rid of it. 
Duskiness or lividity of the surface ap- 
pears to increase, and it reaches its maxi- 
mum just as the clonic spasms begin to 
abate in their severity, and the second 
stage passes into the third. The sweating 
is often excessive, and in some cases has 
been observed to have a peculiarly fetid 
odor. 
The pupils vary from contraction to 
dilatation, and back again, not, however, 
becoming so widely dilated as they were 
at the onset of the seizure ; and they are, 
to some extent, influenced by exposure to 
light. 
The veins are greatly distended, espe- 
cially those of the throat; the heart beats 
tumultuously; friends of patients say, 
" It seems as if it would beat through the 
chest;" the carotids throb, and the ar- 
terial pulsation every where is violent, and 
the vessels are full. 
In the third stage, there are many of 
the phenomena of the second, out of which 
it is gradually developed,-that which 
marks its arrival being the partial return 
of sensation, consciousness, and voluntary 
power. 
The movements now witnessed are not 
wholly meaningless ; the patient makes 
an attempt to change his position, or to do 
something, his efforts often, however, be- 
ing frustrated by some violent spasm ; he 
"looks" at those around him, with a be- 
wildered, suspicious, or sad expression; 
still there is "expression ;" and he may 
make some attempt to speak ; the respira- 
tion becomes less unruly, he can clear his 
throat; the pupils are contracted, but he 
can see; the conjunctivae are injected, 
and there are often petechiae on the fore- 
head, the temples, behind the ears, and in 
the eyelids; the pulse is variable; there 
is a jaded, exhausted state, and the pa- 
tient seems tired and disposed to sleep. 
This third stage may last from a few 
seconds to ten minutes, when the " after- 
stage" of stupor sets in. Often there is 
a confused mental condition, with occa- 
sional involuntary movements, lasting for 
several hours : often the patient recovers 
rapidly, and goes on with what he was 
doing before the attack occurred. There 
is, indeed, almost every degree of severity 
in the seizure ; sometimes all the symp- 
toms I have mentioned being passed 
through in a far shorter time than it takes 
to describe them ; sometimes each stage 
being prolonged, and the patient passing 
gradually into a condition of stupor, from 
which he awakes, even after many hours, 
jaded and " beaten," and from which it 
takes several days for him to recover. 
Vomiting often follows the attacks in 
many individuals ; in some it is a constant 
sequence. Large quantities of pale urine 
are secreted in the majority of cases; 
both the urinary water and the amount 
of urea are increased; and deposits of 
uric acid and of urates may be discovered. 
I have, however, failed to find either 
sugar or albumen in the urine of those 
epileptics who were not affected by either 
diabetes or Bright's disease. 
The after-sympUrms of an epileptic pa- 
roxysm vary widely in character, severity, 
and duration. There is usually lassitude 
and stupor, w ith headache. It is difficult 
to rouse the patient, and, if awaked, he 
is often peevish and irritable, and some- 
times suspicious. The sleep is usually 
tranquil, but occasionally disturbed, as if 
by dreams. There is commonly stertor, 
coming and going, guttural in tone, and 
unlike the noise made by mucus, rattling 
in the trachea, during the second stage. 
The muscular condition is that of relaxa- 
tion, occasionally interrupted, for a mo- 
ment, by clonic spasm or fibrillar contrac- 
tion. This stupor may last, if the attack 
has occurred in the evening, throughout 
the night, passing insensibly into ordinary 
sleep. But when the seizure has taken 
place in the daytime, its average duration 
lias been one hour. It has not appeared 
to me to bear any constant relation to the 
severity of the attack as measured by the 
violence of convulsion. It is often absent 
in lunatics who are subject to Epilepsy ;* 
but Messrs. Leech and Fox show that 
there is some relation to be observed be- 
tween the interparoxysmal and the post- 
paroxysmal mental state. When the 
post-paroxysmal symptoms are absent or 
slight, 38'7 per cent, are in the first men- 
tal class ; whilst of those in whom these 
symptoms are slight, only 18'1 per cent, 
are free from interparoxysmal mental 
change.2 
M. Voisin states that epileptic fits pro- 
duce changes in the sphygmographic 
tracings of the pulse, which last for 
several hours after the attacks, viz. as- 
cending lines of great height and well- 
marked dicrotism.3 
(d) Epilepsia Abortiva, or Epilepsia 
Gravior without complete loss of Conscious- 
ness.-It is for the sake of practical con- 
venience, rather than because it is strictly 
speaking pathologically correct, that the 
1 Dr. Bucknill, Asylum Journal, for Octo- 
ber, 1855. 
2 Op. cit. p. 229. 
3 Ann. d'Hygiene, xxix. p. 358, quoted in 
Syd. Soc. Biennial Retrospect, 1867-8, p. 
471. SYMPTOMS. 
773 
class of cases now to be described are 
mentioned in this place. Names, as em- 
ployed in the science of medicine, are 
useful modes of recognition, and not ex- 
haustive descriptions of the maladies they 
denote. We must give names to the dis- 
eases we describe ; we must define what 
we denote by the names we use ; yet, in 
so doing, we draw, besides the necessary, 
some artificial lines; and it is occasion- 
ally the least of many evils to overstep 
them. 
The attacks to be described are almost 
excluded by our definition of Epilepsy, 
yet they so closely resemble that disease 
in all their own features, that they find a 
more fitting place in this portion of a Sys- 
tem of Medicine than they could find 
elsewhere. They are closely related pa- 
thologically, and we find in their position 
here an example of the general principle 
of terminology employed in this work, 
and no departure from its spirit. 
Abortive attacks of Epilepsy have been 
described by Dr. Prichard (Treatise on 
Diseases of the Nervous System, p. 91); 
M. Doussin Dubreuil (De 1'Epilepsie en 
general, p. 16); Schr. van der Kolk (Pa- 
thology of the Medulla Oblongata, Syd. 
Soc. Transl., p. 211); Maisomieuve (Re- 
cherches et Observations sur 1'Epilepsie, 
p. 22); Dr. Radcliffe (Epilepsy and other 
Convulsive Affections, p. 161) ; Ilerpin 
(Du Pronostic et du Traitement de 1'Epi- 
lepsie, p. 429); Messrs. Leech and Fox 
(op. cit. 226) ; and M. Brown-Sequard has 
detailed the occurrence of similar phe- 
nomena in animals (Journal de Physiolo- 
gic, tome i. p. 474). Several cases of 
seizures of an abortive character have 
fallen under ray own observation ; and 
what is to be said about them will occupy 
but little space. There has been sudden 
tonic spasm of the face, neck, and chest, 
accompanied by arrest of respiration, and 
followed by clonic convulsion, having the 
general form of an ordinary epileptic pa- 
roxysm ; and yet there has been either no 
interference with consciousness, or only 
such slight obscuration as to be at first 
completely denied by the patient. Such 
paroxysms may occur, at intervals, for 
many years ; they may take place in those 
who are subject to ordinary epileptic at- 
tacks ; or they may exist in connection 
with other signs of disease in the nervous 
centres. 
(a) Mental Condition of Epileptics.-A 
prevalent belief is that some form or de- 
gree of mental deterioration is necessarily 
associated with Epilepsy. The result of 
inquiry upon this point is to show that 
there is no such "■necessary" relation. 
The general belief is, however, to be ac- 
counted for partly by the strong impression 
which some notable cases of mental failure 
have made upon the minds of those who 
witnessed and recorded them, - such 
strong impression being followed by an 
undue inference,-and partly by the fact 
that the words Epilepsy and Epileptic 
have been made to include every form of 
disease of brain, spinal cord, or other 
organs, and also every variety of that 
multiform derangement which we call 
"insanity of mind" which might be as- 
sociated with fits. It is desirable, again, 
to assert that this article refers only to 
such cases as constitute Epilepsy proper ; 
and that the statistics upon which my re- 
sults are based, can only with a double 
injustice be compared with those deriv- 
able from lunatic asylums. A patient 
may be epileptic and a lunatic : he may 
be epileptic and asthmatic; but there are 
some epileptics whose minds are as healthy 
as their lungs : and, so far as the natural 
history of Epilepsy generally is concerned, 
it is a mistake to derive it from compli- 
cated cases. 
The mode in which I have endeavored 
to answer the question, -what is the ac- 
tual mental condition of epileptics during 
the intervals of their attacks ?-has been 
the following. I have divided epileptics 
into four classes: in the first there are 
placed those in whom, neither by the pa- 
tients themselves, by their friends, nor by 
myself, could there be detected any devi- 
ation from mental health; such individuals 
had "nothing the matter with them," 
but exhibited for their station in life and 
educational advantages the full average 
amount of intellectual vigor and cultiva- 
tion. The second class consists of those 
who presented that slight defect of mem- 
ory which is limited to the occurrence of 
recent and trifling events, the memory for 
those long since past being intact; and 
in those who formed this group, sucli im- 
pairment of memory was the only depart- 
ure from mental health. In the third 
class are those cases which present, in 
addition to the loss of memory described, 
some diminution of the power of appre- 
hension. Such patients are dull in ac- 
quiring new ideas, and often receive in- 
correct or imperfect and confused notions 
of what is brought before them. The 
fourth class includes those who, in addi- 
tion to the failures exhibited by the pre- 
ceding groups, are habitually confused, 
and unable to follow cut any train of 
thought; people who seem to think little, 
but to be in a vacant, wandering state of 
The interparoxysmal symptoms of Epi- 
lepsy may be divided into those pertaining 
to the nervous system, and those not so 
related. The "nervous" phenomena 
exist in regard of mind, sensation, and 
motility, and they are of varying inten- 
sity, prevalence, and kind. The most im- 
portant are those which belong to the 
mental history, and they will be con- 
sidered first. 774 
EPILEPSY. 
mind, often idle, stupid, and indifferent, 
and sometimes almost or completely de- 
mented. 
Having determined upon this principle 
of arrangement, it is comparatively easy 
to answer many questions of interest with 
regard to epileptics, and to state the an- 
swers to such questions in numerical 
terms. This I have done in another 
work;1 and all that it is thought desirable 
to do now is to give some of these results, 
-and with them others based upon a 
wider range of facts,-without burdening 
the reader with a number of statistical 
details. 
In rather more than one-third of all the 
cases which I have examined there has 
been perfect (i. e. average) mental integ- 
rity ; in a little less than two-thirds, there 
has been some intellectual deterioration, 
but this has existed to a high degree in 
only a very small proportion. Women have 
been found to sutler more frequently and 
more severely than men ; and the com- 
monest form of failure is that of defective 
memory ; this faculty being diminished, 
especially in regard to recent and trifling 
events. 
It is of much interest to know the con- 
ditions which determine mental failure in 
the epileptic, and thus to avoid certain 
errors which are prevalent upon the sub- 
ject. The results of inquiry upon this 
point may be stated in the following pro- 
positions :- 
Hereditary taint is without influence. 
The age at which Epilepsy commences 
exerts a certain amount of influence, and 
to this effect-that the disease when ap- 
pearing late in life is more commonly 
associated with mental failure than it is 
under the opposite condition; and that 
the chances of mental failure are less 
when the attacks commence before the 
arrival at puberty than they are when 
Epilepsy is developed after that epoch. 
This statement is supported by the fur- 
ther statistics of Messrs. Leech and Fox.2 
Late rather than early Epilepsy is a pre- 
disponent to intelle< tual failure, and this 
whether we divide the cases at the tenth, 
sixteenth, or twentieth years, and whether 
we consider the two sexes together, or 
each sex separately. 
The duration of Epilepsy is, perse, with- 
out influence upon the mental condition 
of the epileptic. 
The amount of mental deterioration is 
not in direct proportion-but in inverse 
ratio-to that of muscular disturbance, as 
shown by the presence of tremor, or spasm, 
either clonic or tonic. 
The state of the "general health" does 
not account for that of the mind; the 
former may be good, and the latter bad, 
and vice versa; and, contrary to what 
would be expected, such relation is more 
usual than the coexistence of marked 
failure or integrity in both directions. 
The number of attacks does not deter- 
mine either the degree or the existence of 
intellectual change. 
Frequency of recurrence of the seizures 
is, however, associated with mental 
change ; but in such manner as to show 
that it is not the sole condition of such 
result, and that it is not even a necessary 
condition. 
The severity of the convulsive parox- 
ysm is without apparent influence, when 
such severity is judged of by the duration 
of subsequent coma. The form of the 
attack appears, however, to exert a con- 
siderable influence. Neither seizures of 
"le haut mal," nor those of "le petit 
mal," necessarily induce the change of 
which we are speaking ; but the mental 
deterioration of epileptics is much more 
clearly associated with the minor than 
with the severer seizures. 
The nature of the exciting cause, viz., 
its existence in the psychical or the mate- 
rial elements of life, appears to be without 
influence in the determination of mental 
change. 
(6) Sensorial Condition of Epileptics.- 
Headache and vertigo are the two forms 
of disturbance the most frequently com- 
plained of by epileptics. They exist, how- 
ever, to a high degree in only a small 
number of the cases ; and, when they do 
exist, have no special character which 
renders them of value in either diagnosis 
or prognosis. Headache is more frequent 
in females than males. The vertigo of 
epileptics is commonly of such kind that 
the patient rarely imagines that surround- 
ing objects are in motion, but rather that 
he is, himself, moving or turning round ; 
he feels as if he were doing so, and is un- 
steady in standing, or in his attempts to 
walk. 
The pupils are more commonly beyond 
than below the average size ; the special 
senses exhibit neither constant, preva- 
lent, nor characteristic change. 
(c) Condition of the Notorial System in 
Epileptics.-Some patients exhibit a trem- 
ulous state of the muscles, some, either 
with or without tremor, are affected by 
clonic spasm ; others present tonic spasm, 
or cramp; whereas many are quite free 
from either of these forms of altered mo- 
tility. In the majority of cases there is 
some kind of disturbance ; but in the 
greater number of this majority the 
amount of such disturbance is slight. 
The patient often says that he is "ner- 
vous," meaning by this that his hand is 
unsteady, or that the body is tremulous, 
or that ne feels as if they were so. 
It is often denied that any jerking of 
the muscles ever occurs; but the phy- 
sician may frequently discover that such 
1 Auct. op. cit. 
1 Op. cit. p. 212. RELATIONS BETWEEN THE SYMPTOMS OF EPILEPSY. 
775 
denial is incorrect. The amount of clonic 
spasm may be, therefore, very slight: it 
may, on the other hand, be very consider- 
able, assuming one or both of two general 
forms. There may be, more or less con- 
stant and considerable, choreiform move- 
ment ; and this may be observed not only 
when the patient is awake, but when he 
is asleep, and often with exaggerated 
force in the latter condition. There may 
be violent spasmodic shakings of the 
limbs or of the trunk ; occurring at irreg- 
ular intervals, but exhibiting an especial 
frequency of occurrence just as the pa- 
tient falls asleep. Such jactitations have 
proved excessively annoying in several 
cases, and have been so troublesome as 
to entail much ulterior distress from the 
loss of sleep that they have occasioned. 
Sometimes the jerk of muscles is so sud- 
den and so violent that the patient is 
thrown out of bed; or, if standing, is 
thrown down. 
Cramp, or tonic contraction, is com- 
paratively rare, and has apparently only 
an accidental relation to the disease. 
Messrs. Leech and Fox found it more fre- 
quent in occurrence than I have done (op. 
cit. p. 216). 
(d) Condition of the General Health.- 
There are no changes in the "general 
health" of epileptics to be observed with 
such sufficient frequency or specialty that 
they deserve to be reckoned among the 
characteristic features of the disease. 
Epilepsy may exist in every condition of 
the general health ; but among those who 
have been primarily poor, or who have 
become so owing to their disease, a low 
state of vitality is encountered. A simi- 
larly depraved condition may be found 
where the circumstances have been dif- 
ferent ; but such state is by no means 
necessarily present. Epileptics may be 
found in robust as well as in feeble 
health; but it is important to know the 
relative frequency of the one and of the 
other condition. 
Patients have been examined by myself 
in regard to their nutrition, temperature, 
and strength, and the general results of 
such inquiry are those stated above. But, 
further, cases have been divided into four 
groups, viz. : into, 1st, those exhibiting, 
in every particular, good health; the 
limbs being well nourished, of normal 
temperature, and of natural strength ;- 
individuals capable of enduring both ex- 
posure and fatigue, as well as any others 
of their age, sex, and social condition ; 
2d, those in whom some failure in one of 
the above particulars was noted ; 3d, 
those in whom a double deterioration was 
observed ; and 4th, those in whom there 
was deficiency in all three particulars. 
The result of such inquiry has been to 
show that more than one-half of the cases 
belonged to the first group; less than one- 
third to the second; less than one-tenth 
to the third ; and little more than one- 
hundredth to the fourth. The most fre- 
quent change has been defective tem- 
perature ; the least frequent, impaired 
nutrition. The pulse has exhibited no 
constant feature, either in frequency, 
force, or fulness. 
There is, according to my experience, 
an entire absence of any specific change 
in epileptics, so far as regards their func- 
tions of digestion, respiration, circulation, 
and secretion. 
If, as the result of this mode of inquiry, 
we regard epileptics as a whole, and put 
together all the results that have been 
obtained, we come to this important con- 
clusion, that in a certain number (12 per 
cent.) there is nothing, absolutely no- 
thing, abnormal to be discovered during 
the intervals of attack; that in nearly 
two-thirds of the cases some failure may 
be observed either in mind, motility, or 
general health ; and that in less than 
one-third there is marked alteration. 
It is then obvious that Epilepsy is a 
disease characterized only by its paroxys- 
mal symptoms, and having, in the present 
state of science, no special features by 
which it may be recognized during the 
intervals of attack. 
4. Relations between the Symp- 
toms of Epilepsy.-(a) Forms of Attack. 
-The severer seizure, Epilepsia gravior, 
is nearly twice as common as the milder, 
Epilepsia mitior ; and the former is much 
more frequently found by itself than is 
the latter. Hereditary taint seems to 
exert an influence in predisposing to the 
severer form of attack. The milder at- 
tacks, however, do not appear to take the 
place of the more severe, but to be found 
with especial frequency in those cases 
which exhibit a rapid recurrence of the 
latter, i. e. of Epilepsia gravior. The 
form of attack does not appear to be de- 
termined solely, or even notably, by the 
age at which the disease commences; 
but when Epilepsy is developed early in 
life, there is an increased proclivity to 
the attack in its milder form. Duration 
of the malady does not determine its form 
of seizure. 
(6) Frequency of Attacks.-In about one- 
seventh of the cases that I have examined 
the seizures have exhibited a mode of re- 
currence which has been termed "serial;" 
that is to say, that the patients suffer 
from two, three, or more attacks in one 
day, and then pass through a period of 
freedom lasting from one to several weeks; 
and this mode of recurrence is more fre- 
quent in the female than in the male sex. 
The series, groups, or, as they are often 
termed, "bouts" of the fits, usually oc- 
cupy one day only, and they are often 
limited to a period of twelve hours. 776 
EPILEPSY. 
It is rare, very rare, to find an accurate 
periodicity in Epilepsy ; but it is exceed- 
ingly common to observe that the recur- 
rence of attacks has some kind of relation 
to time, as marked by its natural division 
into days, and periods of seven days, or 
multiples of seven days. Thus a large 
number of epileptics have their seizures 
every day, every two weeks, three weeks, 
and four weeks; while only a much smaller 
number suffer at such irregular intervals 
as cannot be thus expressed. An almost 
identical number of patients state that 
they have attacks at each of the periods 
mentioned ; not meaning by that to say 
that there was always either perfect peri- 
odicity, or recurrence "to the day," but 
that, as a rule, every fortnight, three 
weeks, month, or day, there had been an 
attack. 
There are four times as many epileptics 
who suffer from their seizures more fre- 
quently than once a month than there are 
of those whose attacks recur at longer in- 
tervals. The return of attacks at monthly 
periods is rather more common in the male 
sex than in the female; and it is very rare 
to find the seizures limited to the time of 
the menstrual discharge. It is frequently 
noticed that they are more common during 
menstruation ; "but, on the other hand, 
many women whose attacks recur at 
monthly intervals, exhibit no marked 
proclivity to their recurrence while the 
catamenia are present. A high rate of 
frequency is more common among women 
than among men. 
The number of attacks in a given time 
ranges between very wide limits-from 
two to two thousand in a year; but half 
the cases are found to have a rate of recur- 
rence ranging from one attack in fourteen 
to one in thirty days. 
Great frequency of attack is not con- 
stantly associated with signs of motor dis- 
turbance, such as tremor, clonic spasm, 
and the like. 
Again, a high rate of frequency is not 
determined by an enfeebled state of the 
bodily health ; but, on the contrary, is 
observed in those whose general physical 
condition is up to the standard of health, 
whereas a low rate of frequency is found 
in those whose organic powers have under- 
gone marked deterioration. 
An early commencement of Epilepsy is 
commonly, but not necessarily, associated 
with a high rate of frequency in the at- 
tacks. As the disease continues it exhibits 
a tendency to increase in the frequency of 
its paroxysms; but duration is not the 
sole condition determining this result. 
(c) Morbid Motorial Phenomena are not 
found exclusively in those who exhibit an 
impaired state of the general health, but 
the one kind of derangement-marked by 
tremor, or clonic spasm-is commonly 
found in combination with the other, viz. 
diminution of temperature, or nutrition, 
or strength. 
The prolongation of Epilepsy is not 
necessarily associated with impairment of 
the physical condition ; but a high degree 
of the latter is often found in conjunction 
with a protracted duration of the disease. 
(d) Consequences of Epilepsy.- If Epi- 
lepsy were found to entail, of necessity, 
any definite changes in the health of its 
subject, in regard of either mind, motility, 
or general condition, we should expect to 
find that such changes bore a definite and 
direct relation to the time during which 
the disease had existed. On this point, 
however, the result of a careful examina- 
tion leads to the conclusion that duration 
is, per se, without effect, and that the de- 
monstrable "consequences" are nil.1 
5. Complications of Epilepsy.- 
These may exist in any organ of the body, 
but they have no such definite character, 
except when they are presented by the 
nervous system, as to require any special 
comment in this place. The most im- 
portant is- 
Epileptic Mania.-This complication oc- 
curs in about one-tenth of the cases, if we 
reckon all those degrees of such disturb- 
ance as may warrant the application of 
such name. Having occurred once in a 
particular individual, it is likely to appear 
again, and this is especially the case when 
several attacks have followed in rapid 
succession. 
The delirium is commonly but not uni- 
versally furious and dangerous; it is some- 
times ecstatic in form, sometimes dull and 
melancholic. It may appear in the form 
of preternatural gayety before the attacks, 
or in the intervals of their recurrence ; it 
may break out as violent excitement just 
as the patient is emerging from the sec- 
ond stage of the paroxysm. Sometimes 
the mania has preceded the convulsions, 
but this order of events is, comparatively 
speaking, rare. Epileptics occasionally 
have some premonition of their maniacal 
state-an indescribable feeling which 
leads them to place themselves under re- 
straint before the occurrence of the out- 
break. More commonly, however, there 
is no such warning, and the physician 
fails to discover any special reason for the 
attack. 
Meningitis in an acute, sthenic form, 
may follow epileptic paroxysms; but when 
it has done so, it has, in the majority of 
cases, been determined by some accidental 
injury inflicted by a blow or fall, which 
the patient has experienced in one of his 
attacks. 
Apoplexy is so rare a sequence of Epi- 
lepsy that it is mentioned simply for the 
purpose of stating this fact, because it- 
1 Auct. op. cit. p. 199 et seq. PATHOLOGY. 
777 
apoplexy-is one of the dangers often 
quite unnecessarily dreaded by both epi- 
leptics and their friends. 
Idiocy may be complicated by Epilepsy; 
but when the two conditions are found 
together, or are stated to coexist, the 
truth appears to be this, that the idiotcy 
has been congenital, and that the idiot 
has been "subject to fits." Abundant 
facts and reasons have been already fur- 
nished for the purpose of proving that the 
mode of regarding Epilepsy proper which 
would show that idiotcy is one of its fre- 
quent complications is fallacious, inasmuch 
as it widens the meaning of the word Epi- 
lepsy beyond what is pathologically cor- 
rect, or practically desirable. 
Convulsions, such as those attending up- 
on dentition or parturition, exhibit no 
special frequency of occurrence in epilep- 
tics. 
Paralysis is so rare an event that it may 
be regarded as having-like meningitis- 
an accidental, rather than essential, rela- 
tionship to the disease in question. 
Cyanosis is often accompanied by fits, 
and these have often assumed an epileptic 
character ; but cyanosis is a rare malady, 
and its mere mention as a complication is 
all that is necessary here. 
Pathology. - Anatomical investiga- 
tion has hitherto failed to give any ex- 
planation of Epilepsy; every kind of lesion 
has been discovered in every organ of the 
body; and, on the other hand, every organ 
and part of organ has been found in per- 
fect health. The observations of Wenzel,1 
those of MM. Bouchet and Cazauvielh,2 
and the later researches of Dr. Schroder 
van der Kolk,3 have shown the existence 
of disease in the pituitary body, in the 
white substance of the brain, and in the 
medulla oblongata ; but the changes that 
each of these authors has described have 
been found to be inconstant, and some of 
them quite exceptional. We must, there- 
fore, admit the disease to be what is 
termed "functional," using that word in 
the sense strictly defined in the first part 
of this volume.4 It is believed that "nu- 
trition" is changed, but that its alterations 
are too fine for detection by our present 
modes of examination. 
Bearing in mind all the facts of Epi- 
lepsy, and proceeding to their interpreta- 
tion by the aid of physiology, we arrive at 
the following conclusions :-5 
1st. That the seat of primary derange- 
ment is the medulla oblongata, upper 
portion of the spinal cord, and vaso-motor 
system of nerves. 
2d. That the derangement consists in 
an increased and perverted readiness of 
action in these organs ; the result of such 
action being the induction of spasm in the 
contractile fibres of the vessels supplying 
the brain, and in those of the muscles of 
the face, pharynx, larynx, respiratory 
apparatus, and limbs generally. 
By contraction of the vessels, the brain 
is deprived of blood, and consciousness is 
arrested ; the face is, or may be, deprived 
of blood, and there is pallor ; by contrac- 
tion of the muscles which have been men- 
tioned, there is arrest of respiration, the 
chest walls are fixed, and the other phe- 
nomena of the first stage of the attack are 
brought about. 
3d. That the arrest of breathing leads 
to the special convulsions of asphyxia, 
and that the amount of these is in direct 
proportion to the perfection and continu- 
ance of the asphyxia. 
4th. That the subsequent phenomena 
are those of poisoned blood ; i. e., of blood 
poisoned by the retention of carbonic acid, 
and altered by the absence of a due 
amount of oxygen. 
5th. That the primary nutrition-change 
which is the starting-point of Epilepsy 
may exist alone, and Epilepsy be an idio- 
pathic disease, i. e., a morbus per se. 
6th. That this change may be trans- 
mitted hereditarily. 
7th. That it may be induced by condi- 
tions acting upon the nervous centres 
directly, such as mechanical injuries, 
overwork, insolation, emotional disturb- 
ances, excessive venery, &c. 
8th. That the nutrition-change of Epi- 
lepsy may be a part of some general meta- 
morphosis, such as that present in the 
several cachexise, rheumatism, gout, syph- 
ilis, scrofula, and the like ; and further, 
that it may often be associated with 
change in the cortical substance of the 
hemispheres of the brain.1 
9th. That it may be induced by some 
unknown circumstances determining a 
relative excess of change in the medulla, 
during the general excess and perversion 
of organic change occurring at the periods 
of puberty, of pregnancy, and of dentition. 
10th. That it may be due to diseased 
action extending from contiguous portions 
of the nervous centres or their appen- 
dages.3 
1 Observations sur le Cervelet, &c., traduit 
par M. Breton. 
2 Archives G6n£rales de MMecine. 
3 On the Minute Structure and Functions 
of the Spinal Cord, Syd. Soc. Transl. 
* See p. 18 et seq. 
5 The reader is referred to the Author's 
Treatise on Epilepsy, chapter Pathology, for 
a full exposition of the views here stated 
propositionally, and also for complete refer- 
ence to the different authorities quoted in 
support of each proposition. 
1 See Dr. Wilks's paper in Guy's Hospital 
Reports, 1866. 
[2 Referring to the article preceding this, 
upon Convulsions (especially the part dealing 778 
EPILEPSY. 
11th. That the so-called epileptic aura 
is a condition of sensation or of motion de- 
pendent upon some change in the central 
nervous system ; and is, like the paroxysm, 
a peripheral expression of the disease, and 
not its cause. 
Diagnosis.-Bearing in mind all the 
features of this disease as they have been 
described and limited in the foregoing 
pages, it will be comparatively easy to 
distinguish Epilepsy from every other 
malady. 
The disease may be simulated, and when 
such is the case the fraud may be detected 
by the " over-acting" of the pretender, 
and longer duration of the paroxysm ; by 
the choice of locality for the purpose of 
display ; by the absence of those changes 
in color which have been described ; and 
last, but most certainly, by the absence of 
dilatation of the pupil. After the attack 
the sphygmograph may be employed in 
the manner adopted by M. Voisin. 
Syncopal Attacks often resemble those 
of "le petit mal;" and the latter may be 
mistaken for the former. There is, per- 
haps, a much closer analogy between 
them than is sometimes supposed. For 
practical purposes of prognosis and of 
treatment, the distinction will turn upon 
these points of difference; in Epilepsy loss 
of consciousness is sudden, absolute, and 
often without any sense of "faintness;" 
recovery is rapid, and there is no recollec- 
tion of the attack. 
Hysteria, when convulsive in form, dif- 
fers in the presence of some volition, some 
sensation, some power of directing move- 
ments. The attack is " got up, " or passed 
into, gradually; and is preceded by sob- 
bing, crying, laughing, and gesticulations: 
it continues sometimes for an indefinite 
period, and passes off through a stage of 
hysterical excitement.1 The history of 
the case before the attack, and after its 
occurrence, is that of hysteria; whereas 
in Epilepsy there is or may be nothing 
abnormal to be discovered. In the attack 
there is not the hideous distortion of the 
features, neither is there the meaningless 
eye, nor the dilated pupil, nor the bitten 
tongue ; respiration may be and generally 
is disorderly, but there is no marked 
asphyxia. After the attacks the patient 
is exhausted, but does not pass into stu- 
por; hysterical mania or paralysis may 
follow, but they have their own special 
features. 
Convulsions-such as those of teething, 
of worms, and the like-differ as widely 
from Epilepsy as attacks of bronchial ca- 
tarrh do from genuine spasmodic asthma. 
The presence of dyspnoea, cough, and ex- 
pectoration does not constitute a case of 
asthma; the loss of consciousness and 
convulsion does not constitute a case of 
Epilepsy. The real nature of the disease 
must be determined by those facts of its 
history which lie behind these symptoms, 
and determine its position in nosology. 
Convulsions may occur many times, and 
may sometimes pass into the disease we 
are describing; but they do not necessarily 
do this, and mere periodicity of recurrence 
is not the only mark of distinction between 
them. 
Convulsions are most frequently found 
during infancy, and especially so while 
the child is cutting its first set of teeth. 
It is rare for Epilepsy to date from so 
early a period. Usually febrile symptoms 
precede the attack, or there is some defi- 
nite source of irritation in the mucous 
membrane or secreting organs-e. g. den- 
tition, worms, indigestion, scybalae, cal- 
culi. The first occurrence of the convul- 
sion and its subsequent repetition may be 
traced to one or more of the irritations 
enumerated. The attacks cease on the 
removal of their "exciting cause:" and 
they differ from Epilepsy in the following 
features: Their invasion is less sudden, 
and the paroxysm is of shorter duration ; 
there is not absolute loss of consciousness 
at the onset of attack ; if perception, voli- 
tion, and sensibility are entirely removed, 
such removal is during the clonic spasm, 
and not at the beginning; there is little 
or no subsequent stupor, and no paraly- 
sis. 
The diagnosis of diathetic convulsions is 
based upon a recognition of the diathesis. 
At the onset of some of the exanthemata 
convulsions may occur, and assume an 
epileptic form, but they are to be distin- 
guished by the fact of their appearance in 
early life, the patient being usually under 
six years of age; by the presence of fe- 
brile disturbance, and of some exanthem, 
or some acute inflammatory change such 
as pneumonia or bronchitis. 
In "Bright's disease" of the kidney 
convulsions of epileptoid type may be the 
first symptoms which bring the patient 
under the notice of the physician. There 
will, however, be but little difficulty in 
establishing the diagnosis. There are 
marked and peculiar pallor, puffiness of 
eyelids or of ankles, and albuminuria. 
The attacks are followed, or have been 
with Unilateral Convulsions) for an admira- 
ble, though incidental, discussion of the 
above subject, it may be added that its au- 
thor, Hughlings Jackson, is regarded by re- 
cent writers as one of the pioneers in the 
study of the localization of brain-lesions and 
disorders, to which so much has been con- 
tributed since 1870, by Hitzig, Ferrier, Char- 
cot, Vulpian, Duret, and others. Later in this 
volume, a further consideration will be given 
to this subject, in connection with the article 
upon Cerebral Hemorrhage and Apoplexy.- 
IL] 
1 See article on Hysteria; [also, Hystero- 
Epilepsy.-IL] PROGNOSIS. 
779 
preceded, by drowsiness, listlessness, and 
a tendency to delirium; there are head- 
ache, vertigo, clonic spasm, alternating 
with marked rigidity of limb, great irrita- 
bility of the muscles on percussion, and 
often a highly characteristic state of the 
mental functions. The latter has these 
features : The patient lies in apparently 
profound coma, with some limbs relaxed, 
and others rigid or in clonic contraction, 
breathing heavily with a stertorous sound, 
which may be found to exist in the mouth, 
and not in the throat; but, from this 
state of apparently profound stupor, he 
may be readily aroused to do that which 
he is told to do, or to answer questions; 
and immediately afterwards he falls again 
into the state of stupor. His condition 
resembles somewhat that of a person poi- 
soned with opium. 
It is sufficient to mention such diseases 
as chronic alcoholism, lead-poisoning, syphi- 
lis, and rickets, in order to indicate the 
means by which, when they are attended 
by convulsions, the diagnosis may be es- 
tablished. 
Organic Diseases of the Nervous Centres 
may be distinguished from Epilepsy by 
the fact of their presenting symptoms 
over and above those proper to the latter. 
When conspicuous and persistent changes 
in the functions of the nervous system oc- 
cur during the interparoxysmal period, 
we may infer the existence of structural 
disease. Again, there is more marked 
impairment of the general health; and 
the signs of disordered nerve-function 
have a more rapid development than have 
those which may occasionally be observed 
in Epilepsy. Tumor of the brain exhibits 
its most characteristic feature in persist- 
ent, or paroxysmally exaggerated pain, 
limited to a particular locality, and ac- 
companied by local paralyses. Chronic 
softening may be diagnosticated by the 
gradual failure of mind, sensibility, and 
muscular power. Chronic meningitis may 
have a protracted history, but it is one of 
highly marked interparoxysmal change. 
There is irritability of temper, and, occa- 
sionally, delirium with loss of memory 
and impaired intellectual power : there is 
spasm alternating with local paralysis ; and 
there are alterations of the special senses, 
with headache and general malaise. 
The convulsions which occur in chronic 
cerebral diseases are not precisely like 
those of Epilepsy; there is less suddenness 
in their invasion, there is not the com- 
plete loss of consciousness, the convulsive 
movements do not pass through the sev- 
eral stages that have been described, but 
are irregular in their manner of develop- 
ment, protracted in their duration, and 
often limited to one side, or to one ex- 
tremity. There are not the asphyxial 
phenomena of Enilepsy, neither is there 
the subsequent stupor. 
Again, the ages at which intra-cranial 
diseases are developed differ from the 
prevailing age at which Epilepsy makes 
its appearance ; neither aneurism nor car- 
cinoma appears, as a rule, so early in life 
as does the disease under consideration; 
cerebral tubercle, when occurring in child- 
hood, has a history widely different from 
that of Epilepsy; and, lastly, each of 
these is attended by its own special dys- 
crasia, which may afford all that is needed 
to complete a diagnosis. 
Prognosis. - When the disease has 
been established for some time, and is 
recognized to be an idiopathic affection, 
the prognosis is unfortunately very unfa- 
vorable as regards perfect and permanent 
cure. When it is recent, much hope may 
be entertained. Cases of eccentric con- 
vulsions and of chronic meningitis, either 
syphilitic or simple, may be cured, and 
such are often spoken of as epileptic; but 
I do not include them in the present arti- 
cle : the remarks here made apply exclu- 
sively to Epilepsy proper. 
The general prognosis is framed upon 
several different considerations. Hered- 
itary taint is of unfavorable omen; 
whereas an early commencement of the 
disease is the reverse. The duration of 
the malady is of the highest importance ; 
the longer that it has lasted the greater 
is the difficulty and improbability of cure. 
Those cases in which the intervals be- 
tween the attacks are much prolonged 
are less amenable to treatment than are 
those which exhibit a more rapid recur- 
rence. Mental failure is of evil augury, 
but not to so high a degree as has been 
supposed. Some of the most obstinate 
cases are those in which the general 
health is good ; some of the most tracta- 
ble are those in which there is a disturb- 
ance which may be corrected. 
Next in importance to that of the prog- 
nosis of the disease as a whole, is the 
forecasting of the mental state, supposing 
that the disease itself cannot be cured. 
What conditions are there which would 
render mental failure probable ? The 
section on " natural history" supplies the 
answer to this query, but its results may 
be recapitulated here. Hereditary taint 
is without influence ; the female sex is of 
unfavorable omen; late commencement 
of the disease is a predisponent to intel- 
lectual failure ; mere duration is without 
influence ; an impaired state of the gen- 
eral health is of good rather than evil 
import; mere number of attacks is of no 
moment; rapid recurrence of seizures is 
indicative of danger; and attacks of " le 
petit mal" are more injurious than are 
the severer paroxysms. 
The danger to life is somewhat remote, 
and need scarcely be entertained. It is 
excessively rare for an epileptic to be 780 
EPILEPSY. 
killed by, or die in one of his attacks. 
Van der Kolk1 has shown that the dan- 
ger to life is greater in those eases in 
which the tongue is not bitten ; but I 
have no observations to prove either the 
correctness or the incorrectness of this 
opinion, as I have never yet known a case 
in which the attack proved fatal. 
Treatment.-There are two distinct 
elements to be regarded in the therapeu- 
tics of Epilepsy: the one is the diminution 
or removal of the condition which is the 
essential element in the disease; and the 
other is the mitigation of the paroxysmal 
symptoms when their removal cannot be 
effected. We have to direct the treatment 
of the disease and that of the attack. 
It has been already stated that many 
epileptics, during the intervals of their 
paroxysms, present no abnormal condi- 
tion; yet it is to be inferred that there 
must exist in them some departure from 
health, and the conclusion to which we 
have arrived is, that this departure con- 
sists in an undue readiness of action in 
certain portions of the nervous centres. 
Our object, therefore, is to control this 
over-readiness of action. For this pur- 
pose sedatives have been employed, and 
with success. It would be useless to at- 
tempt any estimate of the relative value 
of many of these agents, for there are no 
data sufficient for the purpose. Opium or 
morphia, conium, hyoscyamus, stramo- 
nium, belladonna, cannabis Indica, atro- 
pine, valerianate of atropine, selinum pa- 
lustre, cotyledon umbilicus, chloroform, 
and other medicines have been employed 
with good effect in some cases, and with- 
out any appreciable effect in others, and 
hitherto no principle has been evolved 
from either their failure or success. When 
the attacks have been of very frequent 
recurrence, I have found preparations of 
the solanaceaj useful in diminishing the 
number of seizures, but I have never 
known them to effect a cure. Opium, or 
some preparation of morphia, has been of 
service when the patient was restless at 
night, and was obviously suffering from 
the effects of loss of rest. Chloroform has 
delayed attacks while the patient was ac- 
tually under its influence, but has failed 
to prevent their subsequent recurrence. 
Dr. Murray has, however, been fortunate 
in the treatment of some cases by means 
of chloroform, and his observations are 
such as to warrant a further employment 
of this agent.2 Indian hemp has relieved 
headache and restlessness, but has not 
cured or notably relieved Epilepsy. 
The salts of zinc, and especially the 
oxide of zinc, have appeared to be of ser- 
vice in many cases; their action being 
obviously sedative. I have seen no good 
results from the sulphate of zinc given in 
heroic doses, and the good effects that 
have come under my own observation 
have been from oxide of zinc in doses of 
three or five grains given three times 
daily. The salts of copper and of silver 
have proved utterly useless in my own 
experience. 
Bromide of potassium, or some other 
salt containing bromine, is the one medi- 
cine which has, so far as I know, proved 
of real service in the treatment of Epi- 
lepsy. Undoubtedly it is "sedative" in 
its action; it lessens spasmodic move- 
ments, especially those of paroxysmal 
character, and sometimes insures sleep 
when vegetable sedatives, and among 
them opium, have failed. Bromide of 
potassium in small doses has appeared to 
be of little or no service, but in large 
doses it rarely fails to give some relief. 
Sir Charles Locock has the merit of intro- 
ducing this drug to the notice of the pro- 
fession in this country,1 and the testimony 
of all those who have had much expe- 
rience in the matter concurs to a remark- 
able degree as to its utility. Given in 
doses ranging from ten to thirty grains, 
three times daily, it has had these effects: 
In some cases it has completely cured the 
patient, and the cure has been permanent 
for years, and is so now. In others it has 
arrested the attacks so that none have 
occurred for periods varying from a few 
months to two or three years ; but, on the 
omission of the medicine, the seizures 
have returned. In such cases the attacks 
have again ceased on the re-administra- 
tion of the medicine. In a third series of 
cases it has diminished the frequency and 
severity of the seizures, but has not re- 
moved them altogether; the patients 
while taking the bromide have had one- 
half or one-third of the number to which 
they were habituated. Such patients 
have gone back to the old frequency of 
recurrence when the drug has been omit- 
ted, and have again improved when it 
has been re-administered. In a fourth,, 
but very much smaller number, the influ- 
ence of the drug has been good for a time, 
and has then appeared to cease; and in a 
fifth, and yet smaller proportion, it has 
been apparently without any appreciable 
effect. Still further, there are a very few 
cases in which the number of seizures has 
been increased by bromides. Dr. Duck- 
worth Williams has shown that it exerts 
much influence over those cases in which 
the attacks take place during the day, but 
that it is of little use in those patients 
whose seizures occur during the night.2 I 
have found that this is true to a certain 
1 Op. cit. p. 252. 
2 Medical Times and Gazette, April 8, 
18G5. 
1 Lancet, May 20, 1857. 
2 Op. cit. TREATMENT. 
781 
extent, but not to the degree described 
by Dr. Williams ; for in several instances 
KBr has been very useful when the fits 
were limited to the hours of sleep. It is 
possible that Dr. Williams's cases may 
have been, from the fact of their compli- 
cation with insanity, peculiar in this re- 
spect. Bromides appear less useful in 
growing girls and youths than in those 
who have reached adult age. 
It often happens that the administra- 
tion of five grains will diminish the fre- 
quency of attacks,' or prevent their oc- 
currence, for a period of weeks or months ; 
but that then, the medicine being still 
taken, the seizures revert to their previous 
rate of frequency. An increase of the 
dose is followed by a similar succession of 
events; a further increase by a second 
succession of temporary improvement and 
subsequent deterioration ; and so on, until 
a larger dose, of from thirty to forty 
grains, is administered three times daily, 
when the attacks cease altogether. 
It is not the mere administration of the 
drug, but its presence in certain quantity, 
that is necessary for a cure ; but the dose 
which shall prove curative is not deter- 
mined by either one of the following con- 
ditions : sex, age, duration of disease, 
frequency of attack, severity of attack, or 
form of attack. 
The number of cases in which it proves 
of no service, at any dose, is very small; 
and some of the cases which resist its ac- 
tion do not differ in any other obvious re- 
spect from those in which the bromide is 
highly efficacious. 
In an earlier part of this article I have 
given reasons for thinking that the mode 
in which KBr proves useful in Epilepsy 
is not by its diminishing either the sexual 
propensity, or power. It is positively 
curative of Epilepsy when given in doses 
which exert no influence whatever upon 
the generative functions. 
In some individuals the administration 
of KBr produces discomforts to which 
the term bromism has been applied. The 
most common of these is an acne-like 
eruption on the face, shoulders, and body 
generally ; the most important is a state 
of stupidity and partial aphysia. Drow- 
siness, dulness of apprehension, muscular 
weakness, and general lethargy are often 
met with ; and these symptoms may exist 
with varying degrees of severity, and be 
produced very easily in certain individ- 
uals. On the other hand, KBr may be 
given for many consecutive years, and in 
large doses, without producing any one of 
the discomforts that have been mentioned. 
It is easy to remove these symptoms by a 
discontinuance of the drug," and the tem- 
porary administration of a bitter infusion 
with a mineral acid ; and it is equally 
easy, and much more desirable, to pre- 
vent their occurrence, by omitting the 
medicine for one or two or even three 
days in the week. All the good effects of 
Br are thus secured, and its evils are 
avoided. 
Dr. Williams1 states some facts which 
would appear to prove that KBr does di- 
minish the force of the heart's action; 
but in my own experience this has not 
occurred to any such degree, or with such 
frequency, as to make me attach any im- 
portance to its occurrence. Bromide of 
potassium has arrested Epilepsy without 
producing any diminution of cardiac ac- 
tion ; and in all cases where there has 
been the least suspicion of such effect, the 
addition of chloric ether, or of tincture of 
cinchona, or indeed of any diffusible 
stimulant, has at once removed the 
threatened inconvenience. The bromide 
of sodium was suggested to me, some 
time ago, by my friend Dr. Ransom, of 
Nottingham, and I have now employed it 
in a large number of cases with perfectly 
satisfactory results. The dose is the same 
as that of KBr, but the NaBr has this 
advantage, that it may be taken alone, as 
common salt, with food, and when mixed 
with an equal proportion of NaCl would 
be quite unnoticed in the salt-cellar. 
Counter-irritation, and derivants, such 
as setons, issues, and the like, have ap- 
peared to me to be of signally little service 
in genuine Epilepsy, so that I have been 
led to the belief that those cases in which 
they have been said to be of great utility 
have been examples either of some other 
malady, or of some complication of the 
disease. 
As to diet and regimen, these things 
seem to me important: first that the pa- 
tient should eat digestible meals, with 
great regularity; and second that exer- 
cise, in the open air, should be taken as 
much as possible, short of fatigue. Many 
epileptics have been relieved from noctur- 
nal attacks by being made to sleep with 
the head and shoulders well raised, not 
by pillows, but by a simple contrivance 
which is placed under the upper half of 
the bed or mattress on which they lie. 
Baths used for the purpose of cleanliness 
are useful in Epilepsy as in many other 
diseases ; but I have seen more harm than 
good follow the employment of douche, 
shower, and sitz baths, when these have 
been administered in any manner or to 
any degree which exceeds that of pro- 
ducingcomfort to the individual. Warmth 
to the extremities, especially at night, is 
of great value ; the patient should never 
go to bed with cold feet, nor run the risk 
of their becoming cold during the night. 
Fires, hot water, hot-water baths, and 
woollen socks, may prevent much mis- 
chief. Sexual intercourse appears to me 
also to be one of those matters upon 
1 Op. cit. 782 
EPILEPSY. 
which the dictates of common sense are 
sufficient without any special direction 
from the physician. 
The mental state of the epileptic may 
be much injured by action upon one very 
common form of advice, viz. that the pa- 
tient should "do nothing." It is desira- 
ble to avoid over-exertion, worry, and 
undue excitement; but moderate mental 
exercise is of great utility ; and some defi- 
nite employment, carried to a point short 
of fatigue, should be enjoined as part of 
the treatment of those cases which are 
not complicated with cerebral excitement. 
It is impossible to pay too great an 
amount of attention to the " general 
health" of epileptics, but there is nothing 
special in regard to this matter. Cod-liver 
oil, quinine, iron, alteratives, and aperi- 
ents must be given in circumstances which 
would render their exhibition desirable in 
other forms of disease. 
Allusion has already been made to the 
operation of clitoridectomy, and reasons 
have been given for suspending judgment 
on the matter. Doubtless success has fol- 
lowed such treatment in some cases, but 
the results are, at present, too uncertain 
for the formation of a definite opinion, 
first as to the stability of the cure; sec- 
ondly as to the class of case in which the 
operation is justifiable ; and thirdly as to 
the therapeutic modus operandi of clitori- 
dectomy when it has appeared to be use- 
ful. It is not only possible, but highly 
probable, that an operation of severity 
equal to that of clitoridectomy might 
prove servicable in some cases of Epi- 
lepsy if it were performed on the back of 
the neck, the mouth, or the toes. A strong 
impression upon the mind, or a violent 
change in the body, such as the opening 
of an issue, the performance of trache- 
otomy, or the occurrence of an accidental 
burn, has often arrested the attacks. It 
is probable that clitoridectomy and cir- 
cumcision may, in some cases, act bene- 
ficially in a similar manner ; but it is ob- 
vious that, if they do, the form and local- 
ity of operation might be changed with 
advantage. So far as my own observa- 
tion extends, the cases are almost infi- 
nitely rare in which such an operation 
would appear to me to be allowable. 
The application of ice to the spine has, 
of late, been advocated with great ability 
by Dr. John Chapman ; and there appear 
to be many theoretical considerations war- 
ranting the employment of this mode of 
treatment. It is not my purpose to de- 
tail the theory upon which Dr. Chapman 
has acted, as it is fully explained in his 
own writings. I regret to say that such 
application has utterly failed to do any 
good in a very large number of epileptics 
for whom I have prescribed it. Ice has 
been applied in the manner recommended 
by Dr. Chapman, and has been persevered 
in for many months, without producing 
the smallest effect upon the frequency or 
severity of the paroxysms. In one case, 
at University College'Hospital, it was ap- 
plied both night and morning, without 
influencing the disease, and on more than 
one occasion the fits took place while the 
ice-bag was on the spine. In one instance 
it was followed by relief, but in this case 
the patient was taking at the same time 
bromide of potassium. For the purpose 
of testing its utility I have employed it in 
a number of cases without giving any 
medicine whatever, and the result has 
been absolutely negative ; it has done no 
harm, but it has done no good. It has 
appeared in several individuals to be of 
service in the first instance, but soon, in 
spite of its persevering application, the 
attacks have recurred with their usual 
frequency and severity. Patients have 
not complained of its application, but I 
have failed to find that it exerted any in- 
fluence upon their temperature, when this 
was tested by their own sensations, or by 
the thermometer applied to either the 
axillae or the extremities. 
The treatment of the attack is mainly of 
value when directed towards its preven- 
tion ; and there are several means by 
which some good may be accomplished. 
When an "aura" is present, the parox- 
ysms may sometimes be arrested by cau- 
terizing the surface from which the aura 
comes, or by applying pressure between 
the starting-point of the aura and the 
trunk. Sometimes the attack begins by 
a special form of contraction in particu- 
lar muscles, and its progress may be 
arrested by forcible extension of these 
muscles. Chloroform, or ammonia, if in- 
haled, will often prevent the seizures just 
at the moment of their onset; and in 
like manner a draught of wine, of sal- 
volatile and water, or of some other dif- 
fusible stimulant, will put off the attack. 
When patients have warning sensations, 
of sufficient duration for them to do any- 
thing, it is desirable that they should 
carry with them some little draught of this 
kind, which they may take at the moment 
of threatening. By such means a large 
number of fits may be averted. 
[Nitrite of amyl has been found to ex- 
ercise great control in this way in some 
cases. It is a powerful remedy; to be 
employed with much circumspection. A 
few drops only should be inhaled at a 
time ; the dose to be, after frequent repe- 
tition, very cautiously increased.-II.] 
Tracheotomy has been shown to be of 
no such real service in Epilepsy as to war- 
rant its recommendation. 
When the attack is once established, 
there is little that can be done beyond 
that of preventing the patient from injur- 
ing himself. Compression of the carotids 
may arrest or shorten the attack, but it muscular anaesthesia: symptoms. 
783 
does not cure the disease. It is possible 
that the pressure upon the nerve trunks is 
an important element in this mode of 
treatment. A piece of India-rubber may 
save the tongue from being bitten; a 
loose cravat may diminish the petechial 
discoloration of the face; and a strong 
arm may hinder the bruising of the ex- 
tremities. 
When the paroxysm is over the patient 
should be allowed to sleep, and should be 
placed with the head and shoulders raised. 
In some epileptics the mental symptoms 
are the most highly marked features of 
the interparoxysmal period, and to these 
attention must be mainly directed. In 
others the general health is greatly at 
fault, and in them the treatment must be 
turned towards its improvement. In a 
third class there is excessive motility of 
involuntary kind, and in such cases the 
vegetable sedatives are of marked utility ; 
but in all, the medicine which has proved 
most useful, in my own experience, is the 
bromide of potassium. 
MUSCULAR ANESTHESIA. 
By J. Russell Reynolds, M.D., F.R.S. 
Deetnttton.-A loss of the feeling of 
muscular action, attended by irregularity, 
sluggishness, and diminished force of vol- 
untary movement; but unattended by 
any necessary loss of cutaneous sensibil- 
ity or by distinct paralysis. 
Nomenclature.-The property which 
is diminished or lost, in the affection above 
defined, has been described under different 
names, of which the following are the 
more important:-" the muscular sense;" 
" le sentiment d'activite musculaire 
"le sens d'activite musculaire;" "la 
conscience musculaire "le sens muscu- 
laire ;" "le sens de la force;" "le senti- 
ment du mouvement;" " der Muskelsinn. " 
Symptoms.-The essential features of 
this condition are the following :-awk- 
wardness and clumsiness in performing 
certain voluntary movements, sometimes 
of the hand and arm, sometimes of the 
leg, sometimes of the face. The patient 
tries to do what he wishes, or is told to 
do, and succeeds in the attempt by look- 
ing carefully at his limb, and helping it 
with one of the others which is unaffected; 
but if not paying great attention, or mak- 
ing any great effort, he fails to effect the 
movement, lets objects fall out of his 
hands, knocks his legs one against the 
other, or in some other manner exhibits 
clumsiness and want of co-ordinating 
power. If placed in absolute darkness, 
or if the eyes are bandaged, he may be 
unable to execute any movement. The 
negative features are, that there may be 
no loss of cutaneous sensibility; the special 
senses may be intact; and there is no 
distinct paralysis. 
Movements instituted in the affected 
parts are less vigorous than is natural; 
the limbs are somewhat inert, and often 
hang idly by the side or are carried by 
some mechanical contrivance ; but they 
can be, by a strong effort, rendered almost 
as vigorous as in health, and the individual, 
after two or three awkward failures, may 
succeed in performing some complex act, 
provided that he thinks much about it 
and looks fixedly at what he is attempting 
to do. 
If the muscles are pinched forcibly be- 
tween the fingers, or if they are submitted 
to the electric current, they exhibit a 
diminution of sensibility. This has been 
well shown in a case lately under my 
care in University College Hospital; the 
patient did not know when the magneto- 
electric current was applied to the mus- 
cles of the right leg, although they could 
be seen to act quite vigorously. There 
was loss of cutaneous sensibility and of 
muscular power in the same limb, but 
electric irritability, although diminished, 
was preserved. As the voluntary power 
and the sensibility of the skin i-eturned, 
some electric sensibility returned also, but 
it was notably deficient long after the 
electric contractility was almost normal; 
the patient being scarcely conscious of an 
amount of actual contraction of the mus- 
cles induced by electricity, which amount 
could not be tolerated for a moment in 
the muscles of the unaffected limb. 
Without looking to see, the patient 
does not know the position of his limbs ; 
and even when he has voluntarily as- 
sumed any attitude or position, he swerves 
from it if his attention be directed to some 
other object than his own limbs. 784 
MUSCULAR ANESTHESIA. 
Minor degrees of this disturbance may 
often be observed in conjunction with de- 
finite but partial paralysis, in either a 
paraplegic or hemiplegic form. Such 
patients can only move their toes or lin- 
gers when they are looking at them ; and 
they do not know, if their eyes are closed, 
whether they are moving their extremi- 
ties or not, but, in perfect innocence, may 
ask the physician, to inform them. 
Commonly, Muscular Anaesthesia is 
seen in combination with other evidences 
of profound change in the nervous cen- 
tres ; but sometimes it exists, and that for 
a considerable time, alone. It may be, 
and often is, the precursor of paraplegia, 
and under such circumstances may be con- 
founded withataxy,spinal congestion, com- 
mencing myelitis, or softening of the cord. 
The following case affords a fair illus- 
tration of the malady :- 
A. B., female, at the age of 18 or 19 
years, "caught cold" during menstrua- 
tion, and soon afterwards felt "loss of 
power" in the legs and hands ; she stum- 
bled in walking, and found it very diffi- 
cult to dress herself. The symptoms 
became slow ly better, but occasionally re- 
turned ; and three years after their com- 
mencement she married, and at the time 
of my seeing her, eighteen months after 
marriage, had a. baby three months old. 
She walked into my room leaning upon 
the arm of a friend, but she stumbled, 
and nearly fell down in doing so ; her 
position in standing, when without sup- 
port from another person or a table, was 
that of inclination forwards, and she 
rocked about from side to side, and an- 
tero-posteriorly : when she attempted to 
walk she occasionally reeled, and did this 
especially when engaged in conversation. 
If told to make an effort to walk in a 
straight line, she looked carefully at her 
feet and managed to do so without much 
deviation. When standing with her heels 
together she maintained steadiness of 
position as long as her hand was on the 
table, or she was paying attention to her 
drill; but, in a moment, if her mind was 
distracted with conversation, she stag- 
gered, and caught at some object for sup- 
port. She told me that her hands were 
much better than they had been pre- 
viously ; but that still they were "very 
odd." It was, as I observed, difficult, 
and indeed impossible, for her to do sun- 
dry little things, such as putting a pin 
into her dress or taking it out, fastening 
or unfastening a button, without seeing 
either her fingers or the reflection of 
them in the glass. She found it impossi- 
ble, or very difficult, to play on the piano- 
forte, and, as she expressed it, she " could 
not fasten anything she could not see." 
Objects fell out of her hands when she did 
not look at them; when standing with 
support on both sides, but with the eyes 
closed, she could not raise either foot 
from the ground,-the sole of the foot 
seemed glued to the carpet. The cuta- 
neous sensibility was perfect; the electric 
contractility and sensibility were natural; 
there was no failure of general health, no 
tenderness of spine, no alteration in the 
special senses, no pain; and there were 
no symptoms of hysteria. All that was 
lost in this case was the sense of muscular 
condition and action. 
Causes.-Nothing definite is known 
with regard to these, beyond the frequent 
association of Anaesthesia Muscularis with 
hysteria. 
I once saw a marked case of Muscular 
and Cutaneous Anaesthesia which had 
been induced by exposure to cold. The 
symptoms in this instance were developed 
suddenly; but in other cases their com- 
mencement has been insidious, and their 
progress slow ; and it has been impossible 
to assign any rational cause for their pro- 
duction. In many they have followed a 
series of convulsions or other symptoms of 
hysterical character. 
Diagnosis. - From paraplegia gene- 
rally, whatever may be its cause, Muscu- 
lar Anaesthesia may be distinguished by 
the facts that power is not lost, and that 
forcible movements may be determined, 
although not directed with exactness. In 
ordinary paraplegia the awkwardness of 
movement is due to and proportioned to 
the want of power; in Muscular Anaes- 
thesia there is no such relation. More- 
over, the patient exhibits none of the signs 
of interference with those functions of the 
spinal centre which are speedily involved 
in all cases of paraplegia depending upon 
changes in the nutrition of the cord. The 
limbs do not waste, the skin undergoes no 
special alteration, the urine is not altered, 
and sensation in other directions is un- 
changed. 
From hemiplegia, indicative of those 
cerebral diseases which are usually ac- 
companied by paralysis of one side of the 
body, Muscular Anaesthesia is separated 
by considerations similar to some of those 
which have just been mentioned; but 
mainly by the absence of conformity of 
the case to the known types of cerebral 
lesion, by freedom from intellectual 
change, and by the limited distribution of 
the symptoms. 
Locomotor ataxy resembles Muscular 
Anaesthesia in its most striking symptom, 
viz. want of co-ordinating power ; and in 
many cases of the former there are symp- 
toms of the latter. It was present, for 
example, in 28 of 50 eases analyzed by 
Topinard but it was absent in 22 cases, 
1 De l'Ataxie locomotrice, p. 203; Paris, 
1864. 785 
PATHOLOGY-PROGNOSIS. 
and was but slightly marked in 8. The 
clinical history of locomotor ataxy is dif- 
ferent.1 There is not necessarily the 
special want which is the essential con- 
dition of Muscular Anaesthesia ; and in 
the latter there is an absence of pain in 
the limbs, of implication of the genital 
organs, and of affections of the eyesight. 
Hysterical patients often exhibit the 
phenomena of Muscular Anaesthesia ; in- 
deed it is one of the expressions of their 
malady ; and the only point of interest to 
ascertain is the degree to which this con- 
dition, the hysteric, may account for all 
the symptoms. The general course of the 
case usually affords the information that 
is required ; it would be unsafe to refer 
Anaesthesia Muscularisto hysteria, unless 
other symptoms of the latter disease were 
present; it would be unwise to suspect 
the existence of grave central lesion unless 
hysteria could be excluded. 
Pathology. - The present state of 
physiology with regard to the existence 
and nature of the muscular sense is so 
unsatisfactory that it would be quite idle 
to occupy much space in the discussion of 
its pathology. 
With regard to the existence of such 
sense there appears to be evidence similar 
to that which we possess in respect of 
other senses, viz. our consciousness of its 
existence. It is a matter of fact that we 
do know when, in what direction, and to 
what degree we contract our muscles. 
We guide our movements without looking 
at our limbs, we know where our extremi- 
ties are placed, we determine movements 
when we like, and apportion the amount 
of effort to the task set before us ; we 
guess at the weight of a body by the effort 
we make to raise it, and do not break an 
empty egg-shell if we hold it between our 
fingers in the dark. The patient with 
Muscular Amesthesia has lost the power 
or faculty which renders these adjust- 
ments of movement possible. The fact 
of the existence of a muscular sense may 
be regarded as established, and also that 
of its distinctness from all other modes of 
sensation. It is tolerably certain that the 
peripheral expansion of the muscular- 
sense nerves exists in the muscular tissue 
itself, and not in either the skin or the 
structures around the joints ; but beyond 
this point there is grave doubt even as to 
whether the fibres pass in the anterior or 
posterior roots of the spinal nerves. M. 
Trousseau2 admits the existence of mus- 
cular sensibility, but denies that of the 
sense of muscular activity ; and the most 
important fact upon which he bases his 
opinion is contained in the following 
words : " Lorsque, fermant les yeux, nous 
executons sans efforts un mouvement as- 
sez etendu, il nous est impossible, avec la 
plus severe attention, de sentir nos mus- 
cles se contractor; mais nous sentons le 
mouvement imprime aux leviers que la 
contraction des muscles met en jeu. Le 
fait est si vrai, que si nous interrogeons 
une personne fort intelligente, mais com- 
pletement etrangere aux notions anato- 
miques et physiologiques, et si nous lui 
demandons quel est le siege du mouvement 
d'extension et de flexion des doigts, elle 
le place exclusivement dans la main et 
jamais dans l'avant-bras. " This obser- 
vation is quite correct, but M. Trousseau's 
conclusion from it is, I think, erroneous. 
We do not see objects nor hear sounds in 
either our eyes or ears ; but involuntarily 
project these sensations, not into a distant 
part of our own body, but into space out- 
side ourselves. The senses of taste, smell, 
and of tact, we refer to something or 
somewhere just beyond the extreme peri- 
pheral expansion of the nerves which 
minister to those senses. We do not feel 
-or mentally recognize as such-the con- 
dition of our own nerves, but instinctively 
and of necessity feel and believe in some- 
thing outside ourselves, or objective, that 
presses on the skin; something not our- 
selves that we taste in our mouths ; some- 
thing not ourselves that we smell in our 
noses. It is well known that a patient 
who has lost his leg imagines that he feels 
pain in his amputated toes, and in this we 
have another illustration of the principle 
that the mind does not refer sensation to 
the spot which receives the impression 
which may occasion it. Because, there- 
fore, in the act of muscular movement 
our consciousness refers the sense of such 
movement to the extremity moved, and 
not to the moving organ, it is not proved 
that there is no sense of muscular ac- 
tivity ; on the" contrary, it is shown by 
this fact that the muscular sense obeys a 
law similar to that which we recognize in 
regard of other senses. For the existence 
of the sense we have the evidence of con- 
sciousness ; and for the absence of the 
sense, there is the testimony of disease. 
It matters, comparatively speaking, little 
for our present purpose to determine the 
exact nature or metaphysical relations of 
the property in question ; it is enough that 
in health there is a faculty which has been 
called "muscular sense,''and that in dis- 
ease this function is destroyed ; that such 
disease may exist alone, and that the 
name by which it is denoted is "Muscu- 
lar Anaesthesia." 
1 See article on Locomotor Ataxy. 
2 Article "Ataxie locomotrice progressive," 
Nouveau Dictionnaire de Medecine et de Chi- 
rurgie pratiques, tome 3me, p. 777. 
Prognosis.-The future of such cases 
cannot be predicted with certainty. It 
may be guessed at by regard to conditions 
vol. i.-50 786 
WASTING PALSY. 
other than those of the affection itself. If 
it be but one of many symptoms of that 
manifold disease called hysteria, the prog- 
nosis is that of the latter malady ; if it be 
associated with grave changes in other 
portions or functions of the nervous sys- 
tem, the nature of such ulterior symptoms 
must determine the prognosis. There is 
nothing special in the character of the 
symptoms of Muscular Anaesthesia, per 
se, which can form a satisfactory guide. 
Treatment.-Faradization of the af- 
fected muscles has proved of service, as 
has friction of the skin, and its electric 
irritation ; but there are no medicines that 
have been shown to exert any special influ- 
ence upon this variety of nervous disorder. 
WASTING PALSY. 
By William Roberts, M.D., F.I 
, M.D., F.R.C.P. 
Definition.-A chronic disease, con- 
sisting in a progressive atrophy of the 
voluntary muscles, independent of any 
antecedent motor or sensory paralysis. 
The disease attacks the muscles ingroups: 
in some cases it is partial, and limited to 
the extremities ; in other cases it is gene- 
ral, and implicates the muscles of the 
head, neck, and trunk. 
Synonyms.-Paralysis Atrophica; Pro- 
gressive Muscular Atrophy; Cruveilhier's 
Atrophy; Atrophie Musculaire Progres- 
sive (Fr.); Progressive Muskelatrophie, 
Progressive Muskel-lahmung (Ger.). 
History.-Cases of extreme wasting of 
the muscles of the upper and lower limbs, 
without loss of voluntary power, were 
published in this country, in the earlier 
decades of the present century, by Cooke, 
Bell, and Darwall; but the establishment 
of the affection as a distinct type of dis- 
ease is due to the labors of Cruveilhier, 
Aran, and Duchenne, in France, in the 
years 1851-53. The present writer col- 
lected all the information existing on the 
subject up to 1858, in an Essay published 
in that year.1 To this Essay the reader 
is referred for the earlier notices of the dis- 
ease. Since 1858 the pathology of Wast- 
ing Palsy has been elucidated by the in- 
vestigations of Gull, Lockhart Clarke, 
Luys, and others. 
Etiology.-The subjects of Wasting 
Palsy are mostly found among young 
adults and middle-aged individuals ; but 
children are not unfrequently attacked. 
The mean age of eighty-eight cases col- 
lected by me was thirty years-the young- 
est was only two years of age, and the eldest 
sixty-nine. The male sex is considerably 
more liable to the disease than the female 
(about six males to every one female). 
This disproportion probably depends, 
mainly, on the greater and more sustained 
muscular exertion which men's occupa- 
tions demand ; also on the greater expo- 
sure to cold and external violence of indi- 
viduals of the male sex. Women of the 
working-class - washerwomen, domestic 
servants, sempstresses, &c.-are seem- 
ingly not much less liable to Wasting 
Palsy than men employed in kindred oc- 
cupations ; but females belonging to the 
easy classes enjoy a remarkable immu- 
nity from this disease. It is, however, 
somewhat difficult to explain why cases 
arising from hereditary influence should 
occur more frequently among males than 
females. 
Partial or local muscular atrophy pre- 
vails mostly among handicraftsmen-me- 
chanics, masons, smiths, miners, needle- 
women, scriveners, laborers, and domestic 
servants. The subjects of general Wasting 
Palsy are found equally in every grade of 
life. 
The influence of consanguinity in the 
production of this disease has been marked 
in a number of instances. The present 
writer collected the history of ten families 
in which a tendency to Wasting Palsy 
prevailed. In four of these families the 
disease was confined to two brothers in 
each. Dr. Meryon's first described cases 
were four boys who had six healthy sis- 
ters. In another family mentioned by 
him, all the boys-namely, two-were af- 
fected, while the two sisters were healthy. 
A sea captain, whose history is related 
by Aran, had lost two maternal uncles 
and a sister by the same disease. In an- 
other instance, recorded by the same ob- 
1 An Essay on Wasting Palsy, by William 
Roberts, M.D. London, 1858. ETIOLOGY. 
787 
server, the patient's two aunts had died 
from general muscular atrophy; and, in 
a family known to Oppenheimer, two un- 
cles and a cousin were already deceased, 
while another cousin and two brothers 
still suffered from the same disease. Al- 
together these ten families included twen- 
ty-nine individuals affected with Wasting 
Palsy, and of these only four were females. 
Cases arising from hereditary influence 
present another well-marked feature-in 
nearly all of them the disease became 
generalized, and consequently tended to 
a fatal termination. 
As a rule, the subjects of Wasting Palsy 
have been persons of good physical devel- 
opment : in several cases the patients are 
reported to have been men of remarkable 
muscular power and activity; in a few 
instances-nearly all of which were asso- 
ciated with a hereditary proclivity to the 
disease-a certain weakness existed from 
early youth. 
The exciting causes of Wasting Palsy 
(excluding hereditary predisposition) may 
be ranged under three heads: namely, 
excessive muscular action, cold, and dis- 
ease or violence affecting the spine. In a 
considerable number of cases, however (36 
per cent.), no reasonable cause could be 
assigned for the breaking out of the dis- 
ease. 
Aran directs attention to the fact that 
the particular muscles which are neces- 
sarily in long-continued contraction in per- 
sons following certain mechanical trades 
(masons, milliners, shoemakers, smiths, 
&c.), are those which are first invaded 
and most deeply involved. In persons of 
this class the muscles of the shoulders, 
arms, and hands are first affected, and 
very frequently the atrophy is permanently 
limited to these parts. There are numer- 
ous exceptions, however, to this rule. 
Cases arising from cold (wearing of 
damp apparel, immersion of the limbs in 
cold water, rapid cooling of the perspiring 
surface, exposure to inclement weather) 
are marked by a train of neuralgic or so- 
called rheumatic pains in the affected 
parts, either at the onset of the atrophy, 
and ceasing when this has fairly set in, or 
continuing throughout its progress, and 
imparting a special character to the symp- 
toms. The invasion of the disease in this 
class of cases is often somewhat sudden, 
and accompanied by cramps and twitches 
of the muscles. 
In cases traceable to cold, the wasting 
is more apt to extend to the muscles of 
the trunk than in cases due to overwork. 
Of twenty-five cases attributed to over- 
work, eighteen were partial and only 
seven general; whereas, of the sixteen 
cases charged to the agency of cold, six 
were local and ten general. These two 
causes are often in operation together: 
the miners in my neighborhood, who work 
in damp or wet excavations, are frequent 
victims of Wasting Palsy. 
The connection of Wasting Palsy with 
injury or disease directly or indirectly 
implicating the spinal cord, has of late 
years attracted increasing attention ; and 
the interpretation of these cases has an 
important bearing on the pathology of the 
disease,as will be more particularly noticed 
hereafter. The history of some antecedent 
violence occurs too frequently in the re- 
ports of cases of Wasting Palsy to allow 
of its being set aside as a merely fortuitous 
circumstance, though the precise connec- 
tion between the injury and the subse- 
quent atrophy is often obscure. In a 
youth under my care at the Manchester 
Infirmary, who ultimately died from im- 
plication of the respiratory muscles, the 
first symptoms of atrophy in the ball of 
the right thumb occurred six months after 
the fall of a bale of cotton cloth on the 
nape of the neck. The immediate effects 
of the injury were confined to slight stiff- 
ness of the neck, and occasional pains 
extending down the arms. Valentiner 
records a case in which the first failure of 
health followed a fall on the back from a 
height of eight or ten feet: yet the atro- 
phy did not appear until six years after. 
Bergmann's patient' fell on his back from 
a horse, and lay for a while unconscious. 
From this time he suffered pain and stiff- 
ness in moving the head ; afterwards, and 
very slowly, a weakness in the shoulders 
came on, which ended in complete atro- 
phy of the muscles around the shoulder 
joints. In a remarkable case recently re- 
ported by Dr. Thudichum and Mr. Lock- 
hart Clarke, a gentleman, set. 54, suffered 
what he considered a slight injury. In 
jumping across a flower-bed for a wager, 
he came down heavily on his heels, and 
then fell backwards upon his head. He 
was stunned for a time, but gradually re- 
covered, and, after some days' confine- 
ment to his bed, appeared to be quite well 
again. It was, however, soon perceived 
that a great change took place in his hab- 
its. Having been extremely fond of manly 
sports and exercises-rowing, cricketing, 
riding on horseback, dancing, and the 
like-he discontinued to take part in any 
of these, although he continued to go 
every autumn to the Scotch moors for the 
purpose of shooting grouse. Five years 
after the above-mentioned accident, while 
engaged in this last-named sport, he per- 
ceived that his right leg had lost a part of 
its usual strength. From this time grad- 
ual atrophy and loss of power in the mus- 
cles crept over the patient, until at length 
death took place from failure of the re- 
spiratory muscles. Wide-spread degene- 
ration of the spinal cord was found after 
1 St. Petersburger Med. Zeitsch., p. 116. 
1864. 788 
WASTING PALSY. 
death. (Beale's Archives of Medicine, 
18G3.) 
In other cases, disease, manifestly pri- 
mary, of the spinal cord is followed by com- 
plete atrophy of certain groups of muscles. 
In a case published a few years ago in the 
London Medical lieview by the present 
writer, a young man suffered from acute 
general paralysis of all the muscles of the 
extremities, and of most of those of the 
trunk. The intellect was not affected. 
Gradually, in the course of months, the 
patient recovered the power of the mus- 
cles ; but after complete restoration of the 
remainder of the body, the intrinsic mus- 
cles of both the hands and feet passed into 
a state of total atrophy, and still con- 
tinue in the same condition. In the so- 
called essential paralysis of infancy and 
childhood-which is evidently of spinal 
origin-certain limited groups of muscles 
not unfrequently pass into a state of per- 
manent atrophy, while the remaining 
portions of the paralyzed members recover 
their mobility. 
Certain other exciting causes of Wast- 
ing Palsy are sometimes doubtfully men- 
tioned-namely, constitutional syphilis, 
venereal excesses, onanism, and antece- 
dent zymotic fevers. 
Symptoms.-The invasion of Wasting 
Palsy is always gradual, and the disease 
has usually been in progress some weeks 
or months before the patient discovers its 
existence. The first symptom perceived 
is a certain weakness in the affected mem- 
ber: the tailor finds he cannot hold his 
needle ; the shoemaker cannot thrust his 
awl; the mason fails to wield his hammer ; 
the gentleman experiences an awkward- 
ness in handling his pen, in pulling out 
his pocket handkerchief, or in putting on 
his hat. Some such incident calls atten- 
tion to the affected limb, which is then 
usually discovered to be more or less 
wasted and shrunken. 
The disease begins, in the great major- 
ity of cases, in the upper extremities, 
either in the ball of the thumb and hand, 
or in the shoulder-much more commonly 
in the former than in the latter. Some- 
times, however, it begins in the muscles 
of the neck, of the face, the tongue, in the 
thigh, the leg, or the foot. The extension 
or spread of the disease follows an erratic 
course. In the immense majority of cases 
the disease is permanently limited to one 
or a few groups of muscles in the upper or 
lower extremities; in other cases, and 
these are by far more formidable, the 
atrophy invades successively the voluntary 
muscles of the entire body, trunk and ex- 
tremities. The only muscles which, as 
yet, have not been known to be attacked, 
are those of mastication, and those which 
move the eyeball. When the atrophy is 
confined to certain regions of the extremi- 
ties, the life of the sufferer is not imper- 
illed ; but when the trunk is invaded, and 
the muscles of respiration participate in 
the disease, death by suffocation is the 
ultimate result. 
The wasting and disappearance of the 
muscles produce notable changes in the 
configuration of the body. The natural 
rounded contour of the limbs is replaced 
by an unsightly flattening; the bones 
stand out in unaccustomed distinctness, 
giving to the member the appearance of a 
skeleton clothed in skin ; but the skin 
itself, and the subcutaneous cellular tis- 
sue, undergo no change, and cannot be 
distinguished from the integuments of 
healthy parts. Certain distortions of the 
head, trunk, and extremities are also 
occasioned by the unequal wasting of op- 
posed groups of muscles-those less atro- 
phied overcoming the resistance of those 
more diseased. These changes of configu- 
ration are a marked feature of Wasting 
Palsy. The hand is frequently the seat 
of a very singular deformity-namely, the 
"claw-shaped" hand, or " main en griffe" 
of French writers. The palm is robbed of 
its muscular cushions ; flat planes or hol- 
lows occupy the sites of the thenar and 
hypothenar eminences ; the hollow of the 
hand is traversed by the visibly promi- 
nent diverging flexor tendons, which are 
stretched between the wrist and the bulg- 
ing bases of the fingers; the proximal 
phalanges are bent backwards, away from 
the hollow of the hand, while the middle 
and distal ones, inclined in an opposite 
direction, are in a state of continued semi- 
flexion. The back of the hand is hollowed 
out in long furrows, corresponding to the 
interosseous spaces, and the first joints of 
the fingers are pulled backwards, giving 
the hand a broken-backed appearance. 
Passing up the limb, the forearm is 
found flattened, or even hollowed, on its 
anterior and posterior aspects. When the 
shoulders are affected, the whole arm 
dangles powerlessly at the side; the round- 
ness of the shoulder has given place to a 
flattening, and the head of the humerus, 
the acromion, and the coracoid processes 
are plainly discerned through the thin 
covering of skin. If the serratus magnus 
be destroyed, the angle of the scapula is 
tilted upwards and inwards, and stands 
prominently out from the trunk. Corre- 
sponding deformities are witnessed when 
the lower limbs are invaded : the foot is 
distorted by the unequal involvement of 
its extrinsic and intrinsic muscles, and 
contractions of the toes on the sole, deflec- 
tions of the foot inwards, or of the heel 
upwards, are produced-interfering very 
seriously with the steadiness of progres- 
sion. 
But perhaps the most remarkable of all 
the anatomical changes are seen in the 
face, when the muscles of expression are COURSE AND DURATION. 
789 
destroyed. The face is veiled, as it were, 
by an impenetrable mask; no emotion 
changes its unvarying aspect-the expres- 
sion is always solemn, stolid, and un- 
moved. The muscles of the eyeball are, 
however, spared, and by their movements 
alone, in the later periods, the mind holds 
an imperfect communion with the exter- 
nal world. The oral and buccal muscles 
are usually invaded early, and the saliva 
dribbles over the lips. When the muscles 
of the neck are involved, the head falls 
forwards-the chin resting on the sternum 
-or, laterally, the head falling over on 
the shoulder. 
When the abdominal muscles are impli- 
cated, the lumbar curve is enormously ex- 
aggerated by the unopposed action of the 
erector spinse, and the belly projects in 
front, while the chest is thrown back as a 
counterpoise. The invasion of the lingual 
muscles leads to a falter in the speech, 
and to imperfect comminution of food in 
the mouth. The involvement of the 
laryngeal muscles produces a change in 
the voice, which loses its register, and is 
finally reduced to a monotone. When 
the diaphragm and intercostals are 
reached, violent suffocative fits of cough- 
ing are occasioned ; the play of the chest 
is at length so reduced that a slight addi- 
tional difficulty to respiration proves fatal. 
Dissolution is usually brought about by 
a bronchitic seizure; the air-tubes are 
speedily clogged with mucus, which no 
efforts of the patient can dislodge, and 
rapid asphyxia closes the scene. 
When the disease is partial in its ex- 
tension, it is observed that certain parts 
of the body, and certain groups of mus- 
cles, are much more obnoxious to its in- 
roads than others. The muscles of the 
trunk are less liable than those of the ex- 
tremities, and those of the lower extremi- 
ties are far less frequently affected than 
those of the upper. Of sixty-two cases of 
partial Wasting Palsy collected by me, the 
upper extremities were alone affected 
fifty-one times, the lower extremities 
alone five times, and the upper and lower 
together seven times. The right arm was 
much more frequently attacked than the 
left, and the hands oftener than the 
shoulders. As a general rule, it was 
found that when one limb was attacked, 
its fellow of the opposite side shared its 
fate ; that when the disease was unila- 
teral, the right side was more likely to be 
its seat than the left. 
One of the most striking characteristics 
of Wasting Palsy is the capriciousness of 
its line of attack. Scarcely two instances 
are exactly alike in the combination of 
muscles implicated-hence an almost in- 
finite variety of feature ; yet there are 
certain more common combinations. 
Among the most common cases are 
those in which the disease is confined to 
the hands, or to the hands and forearms. 
Not uncommon, likewise, are the cases in 
which the shoulder and upper arm of one 
or both sides are atrophied, while the fore- 
arms and hands remain healthy. 
Coincidently with the loss of substance 
in the muscular masses, there is necessa- 
rily a corresponding loss of power. Cer- 
tain less constant symptoms also some- 
times make their appearance-namely, 
fibrillary tremors, cramps, twitches, and 
diminution of electric contractility in the 
muscles. 
The loss of power corresponds, in the 
typical cases, very exactly to the grade of 
muscular atrophy, and gradually proceeds 
as the muscles diminish in bulk. In ex- 
treme cases absolute immobility of the 
limb, or part, is at length produced; more 
commonly the various movements are still 
capable of being performed, but with 
greatly diminished force. Not unfre- 
quently, however, this correspondence is 
not exact; and the loss of power exceeds, 
more or less considerably, what is due to 
mere atrophy of the muscular fibres. 
During the active stage of the disease 
the affected muscles sometimes exhibit 
curious vibratile tremors-fugitive wavy 
oscillations of the muscular fibres-which 
are visible under the skin, but do not pro- 
duce any movement of the limb, nor are 
they sensible to the patient. When ab- 
sent, they may occasionally be evoked by 
stripping the part or filliping the skin. 
These vibrations are sometimes the 
earliest symptom of a new advance of the 
disease into parts not yet affected. They 
disappear altogether when the atrophy 
has reached an extreme degree, or when 
its progress has been arrested. 
In uncomplicated cases the muscles of 
the wasting members respond to the elec- 
tric stimulus readily, and with a force 
corresponding to their bulk. As a rule, 
there is no alteration in the tactile sensi- 
bility of the affected limbs; but in rare 
cases there is a slight numbness of the 
skin, and not unfrequently the parts are 
highly sensitive to impressions of cold. 
In about half the cases there is more or 
less pain of a neuralgic character in the 
course of the nerves leading to the dis- 
eased muscles, or in the neighborhood of 
the muscles themselves. In some cases 
pain of an agonizing character is a marked 
feature of the complaint. 
The general health is usually quite un- 
affected, the intelligence is clear, and the 
functions of organic life are performed 
with their usual regularity, so long as the 
muscles of deglutition and respiration are 
spared. 
Course and Duration.-The course 
of Wasting Palsy is essentially chronic, 
and its duration uncertain. After de- 
stroying a certain group of muscles it may 790 
WASTING PALSY. 
be permanently arrested, or it may pro- 
ceed step by step until nearly all the volun- 
tary muscles are disabled. The atrophied 
muscles may be again restored by thera- 
peutical means to their original bulk : this 
is unfortunately not a very common ter- 
mination-more commonly the wasted 
parts are crippled for the remainder of 
life. When the disease is progressive, its 
advance is seldom continuous, but is 
rather marked by repeated pauses and re- 
commencements. The pauses may ex- 
tend over a few weeks or months, or even 
several years. In a case now under my 
care in the Manchester Infirmary, the dis- 
ease has started afresh in great intensity, 
after complete arrest for five years. In 
twenty-eight cases in which I was able to 
ascertain the continuance of the active 
process, the mean duration was thirty- 
eight months. Of these, four ended in 
recovery, thirteen in permanent arrest, 
and eleven in death. The cases which 
ended in recovery had a mean duration of 
fourteen months, those ending in arrest a 
mean duration of twenty-seven months, 
and those ending in death averaged a 
duration of more than five years. 
Cases which could be traced to the 
effects of over-exercise of the muscles, 
were nearly always found to terminate in 
permanent arrest after the destruction of 
one or more groups of muscles ; whereas 
cases which appeared to have arisen from 
exposure to cold, or from hereditary pre- 
disposition, showed a more decided ten- 
dency to a progressive course and a fatal 
termination. 
Diagnosis.-The partial form is liable 
to be confounded with paralysis from in- 
jury to a motor nerve, lead palsy, and 
malarious palsy. In all these there is a 
marked atrophy of the muscles ; and the 
affection may be confined to a narrow re- 
gion, around which are healthy muscles, 
offering a strong contrast to the decayed 
ones. 
Atrophy, resulting from injury to a 
nerve, is distinguished by the exact limi- 
tation of the wasting to the parts supplied 
by that nerve ; also, if the nerve be a 
mixed one, there is, or was, an accompa- 
nying loss of sensation. 
In lead palsy there is a comparatively 
sudden invasion: in a day or two-a 
week, or a fortnight, at most-the para- 
lysis is at its height; whereas in Wasting 
f'alsy the loss of power is excessively 
gradual. The precursory or concomitant 
phenomena distinctive of lead poisoning, 
seldom or never altogether fail-namely, 
colic, blue line on thft gums, tremblings, 
pallor, and other symptoms of saturnine 
cachexia. Duchenne states, that the 
electric contractility of the muscles is 
markedly diminished or altogether lost in 
lead palsy ; whereas, in Wasting Palsy, 
the muscles respond to the electric stimu- 
lus in a degree proportionate to their 
bulk. It will also be remembered that in 
saturnine poisoning the atrophy is dis- 
tinctly essential to the paralysis. 
From ordinary general paralysis of cen- 
tral origin, Wasting Palsy is distinguished 
by the dissecting character of its march. 
It attacks the muscles in separate groups 
-in detail, as it were-and does not dif- 
fuse its ravages uniformly over extensive 
regions or the entire body. It is very 
rare also that in general paralysis the 
wasting of the muscular masses bears any 
proportion to the loss of power. 
Extreme muscular atrophy sometimes 
follows infantile paralysis, and the distri- 
bution of the disease may resemble that of 
Wasting Palsy and produce ultimate re- 
sults indistinguishable therefrom. The 
cases are, however, totally different in 
their history. Infantile paralysis has al- 
ways a sudden invasion, and the wasting 
is subsequent to the loss of power. 
Morbid Anatomy. - The essential 
changes found in the bodies of persons 
who have died from Wasting Palsy are 
confined to the muscles, the spinal cord, 
and the nerves. 
The muscles of the affected regions are 
found wasted in various degrees. Some 
are only slightly atrophied, others more 
profoundly, while others again are re- 
duced to pale, thin, membranous strata, 
or are altogether destroyed, and can only 
be identified by comparing the origins 
and insertions of certain fibro-cellular 
bands, which are the vestigial representa- 
tives of the previously existing muscular 
masses. The color of the wasted muscles 
is changed to a pale red or rose, some- 
times with a buff or ochreous tinge, and 
not unfrequently streaks of adipose tissue 
run, in lines, between the fibres. Where 
there is much fatty change, the wasting, 
which is so conspicuous a characteristic 
of the disease, is less marked ; sometimes 
even the muscles are almost undiminished 
in bulk, but are transformed into masses 
of fat. This peculiarity has been observed 
only in the lower extremities. 
The difference in the degree of atrophy 
undergone by adjoining muscles, and 
sometimes even by different parts of the 
same muscle, is very remarkable. Scarcely 
any two muscles are affected in an equal 
degree. Side by side with a pale, almost 
filamentous remnant, may be found a 
muscle of full red color and undiminished 
bulk. One or two fasciculi of an affected 
muscle may survive in vigor after the 
destruction of the remainder. 
The decayed muscles have been exam- 
ined microscopically by Meryon, Galliet, 
Oppenheimer, Virchow, and others. Me- 
ryon describes the primitive fibres as com- 
pletely destroyed, the sarcous elements MORBID ANATOMY. 
791 
being diffused, and, in many places, con- 
verted into oil-globules and granular mat- 
ter ; while the sarcolemma was broken 
down and destroyed. Gailiet, who ex- 
amined the muscles in one of Cruveil- 
hier's cases, states that in those parts of 
the muscle which had retained a rosy 
hue, the primitive fibres had preserved 
their stri?e tolerably distinct, and between 
the striae were seen fine gray or brilliant 
molecules, resembling fat. In the com- 
pletely decolorized parts-those which to 
the naked eye appeared of a straw tint- 
there could still be recognized long cylin- 
ders, representing the primitive fibres. 
The sarcolemma was preserved, but the 
contained substance had lost its striated 
character, and was replaced by a uniform 
granular mass, presenting numerous mi- 
nute gray molecules mixed with fatty 
granules. In parts where the disease was 
still further advanced, the granular matter 
and its enveloping sarcolemma had entire- 
ly disappeared, and there remained only 
the fibro-cellular framework of the muscle, 
destitute of any true sarcous tissue. 
The condition of the spinal cord and of 
the spinal nerves has been examined in 
some thirty-five cases, of which thirty- 
four have been tabulated by Bergmann.1 
The results of the investigations have not 
been by any means uniform. In sixteen 
cases the cord and the nerves were pro- 
nounced healthy, and in six of these the 
parts were examined microscopically. In 
six cases the cord itself was found healthy, 
but there was marked atrophy of the ante- 
rior roots of a certain number of spinal 
nerves. In one case both the spinal cord 
and nerves were healthy, but there ex- 
isted disease of the medulla oblongata. 
In six cases the cord was found diseased 
when examined microscopically, though 
it appeared sound, or nearly so, to the 
naked eye. Lastly, in seven cases the 
cord appeared to the unaided senses pal- 
pably softened and disorganized. 
Atrophy of the anterior roots was first 
noticed by Cruveilhier, and was supposed 
by him to supply the key to the pathology 
of this disease. He thus describes the 
condition of these structures in the body 
of the showman Lecompte, who died from 
general Wasting Palsy of five years' du- 
ration : " The anterior roots of the spinal 
nerves are remarkably small compared 
with the posterior, and this inferiority of 
size is particularly great in the cervical 
region. The proportion between the two 
roots had become greatly changed. Ac- 
cording to my observations, in the normal 
state, the posterior roots compare with 
the anterior, in the cervical region, as 
three to one ; in the dorsal region, as one 
and a half to one ; and in the lumbar re- 
gion, as two to one. But here the pro- 
portion was as ten to one in the cervical, 
five to one in the dorsal and lumbar re- 
gions. Further, by plunging the cord 
into dilute nitric acid, I was able to ob- 
serve that a very large number of the an- 
terior cervical rootlets had been com- 
pletely reduced to their neurilemma, and 
appeared as gray filaments, which, search- 
ed with a strong lens, presented no trace 
of nervous tissue ; while, on the other 
hand, the anterior roots in the dorsal and 
lumbar regions had only suffered atrophy 
by emaciation. I was unable to trace the 
gray nervous filaments, or those simply 
atrophied, beyond the point where the 
anterior root joins the posterior; but I 
was able to establish the existence of atro- 
phy of the nerves as they were about to 
penetrate the muscles."1 A similar atro- 
phy of the anterior roots was found in ten 
other cases, either with or without discov- 
erable disease of the corresponding re- 
gions of the cord. In the great majority 
of the cases, however, the anterior roots 
were not perceptibly atrophied, and this 
leads directly to the inference that such 
atrophy is not an essential feature of the 
morbid anatomy of Wasting Palsy. 
The morbid anatomy of the spinal cord 
is confessedly a subject of great difficulty. 
Until recently only the coarser changes 
of consistence-softening or induration- 
were appreciated by pathologists; and 
even after the microscope had been 
brought in aid of the examination, it soon 
became apparent that very important 
changes in the structure of the cord 
might be overlooked, unless the observer 
possessed special skill and practice in this 
branch of inquiry. The positive results 
of Gull, Lockhart Clarke, and Luys, who 
may be regarded as experts in the exami- 
nation of the spinal cord, throw consider- 
able doubt on the trustworthiness of the 
negative results obtained by Meryon, 
Savory, Oppenheimer, Friedburg, and 
others, who failed to detect in the spinal 
cords of patients who had died from 
Wasting Palsy any appreciable changes 
of structure. 
Luys describes as follows the microsco- 
pical changes in the apparently sound cord 
of a man, aged fifty-seven years, who died 
of pneumonia, and who had been the sub- 
ject of advanced atrophy of the muscles of 
the left hand and forearm. There was 
also slight atrophy of the muscles of the 
right hand. The loss of power had cor- 
responded accurately with the degree of 
wasting. Five of the anterior roots com- 
ing off from the cervical enlargement of 
the cord were atrophied. The microscopic 
examination of the cord showed increase 
of the capillary vessels in the gray sub- 
stance at the level of the atrophied roots. 
1 St. Petersburger Medicinische Zeitschrift, 
Bd. vii., 1864. 
* Archives GSnerales, 1853. 792 
WASTING PALSY. 
The walls of the vessels were thickened 
and surrounded with a granular deposit, 
which extended into the gray substance. 
In the anterior gray cornua, at the point 
of exit of the anterior roots, there was an 
absence of nerve-cells, which were re- 
placed by granular deposit. Some of the 
nerve-cells of the anterior horns were in 
process of degeneration-brownish, and 
filled with dark granulations. These 
changes were found especially on the left 
side, and very slightly on the right side. 
The rest of the cord was healthy.1 
Dr. Gull gives an account of a man, 
aged forty-nine years, who" became the 
subject of Wasting Palsy after striking his 
head against a beam, whilst driving under 
an archway. Some months after this acci- 
dent he began to suffer pain from the occi- 
put down over the shoulders, and in about 
a year the muscles of the upper extremi- 
ties began to waste. Three years after 
the accident he was admitted into Guy's 
Hospital. He then presented a remark- 
able example of muscular atrophy, with- 
out actual paralysis. The upper extrem- 
ities were principally affected. The ex- 
tensors of the right hand, the muscles of 
the thumb, and the interossei were ex- 
tremely wasted. The wrist dropped. The 
muscles of the shoulder and arm, includ- 
ing the pectoralis major and minor, were 
much wasted ; but in a marked degree 
less so than those of the forearm and 
hand. Very slight diminution of sensa- 
tion. He could still lift the arm over the 
head. The left arm was similarly affected, 
but less than the right, so far as muscular 
atrophy was concerned-but there was 
numbness through the whole arm down 
to the fingers, accompanied with severe 
neuralgic pains. The trapezii, serrati 
postici superiores, rhomboidei, and all the 
long muscles of the neck and back were 
remarkably atrophied. The legs were 
wasted and weak, but the patient was 
able to walk. There was constipation 
and dribbling of the urine. He died with 
febrile symptoms and dyspnoea. 
Autopsy.-Sections of the cord exam- 
ined with the naked eye gave no distinct 
evidence of disease. There was a slight 
yellowishness of the posterior columns, 
and increased vascularity and thickening 
of the pia mater covering them. In these 
columns, especially in the right one, 
abundance of granule-cells were discov- 
ered with the microscope. The exudation 
was greatest in the middle and lower 
third of the cervical enlargement. The 
gray matter was hypersemic. There was 
no exudation into its tissue, nor into the 
anterior columns. The ventricle of the 
cord was enlarged and distended with 
delicate granular nuclei.2 
The limitation of structural changes in 
the cord to narrow tracts and spaces, with 
a healthy state of the intervening parts, 
and the absence of any alterations visible 
to the naked eye, are also strikingly illus- 
trated in the case of Dr. P., whose' spinal 
cord was subjected to an exhaustive ex- 
amination by Mr. Lockhart Clarke. 
Dr. P., set. 65, engaged in literary pur- 
suits, began to complain some five years be- 
fore his death of neuralgic pains in the ball 
of the thumbs of both hands, which before 
long extended to the forearms and arms. 
After some months there was marked 
weakness and wasting of the muscles of 
the thumbs and index fingers, which also 
became bent inwards towards the palms. 
The loss of power and volume in the 
muscles progressed steadily, accompanied 
with the most excruciating pains, until 
his death. The right hand and arm were 
more profoundly affected than the left. In 
the later periods of the disease the pains 
extended to the lower limbs. The right 
pupil was constantly larger than the left, 
but the movements of the two were 
normal. 
The cerebellum, pons Varolii, medulla 
oblongata, and spinal cord, were hardened 
in dilute chromic acid, and sent to Mr. 
Lockhart Clarke. He found nothing un- 
usual in the external aspect of the cord, 
neither were the anterior roots of its 
nerves, in any of the regions, smaller than 
usual to any appreciable extent. The in- 
terior of the cord, from the filum termi- 
nale through the whole of the lumbar and 
dorsal region, to the lower end of the 
cervical enlargement, presented no actual 
change of structure, either in the white 
or gray substance; but there was a con- 
siderable deposit of corpora amylacea 
round the central canal. In the cervical 
region, however, the case was different; 
for here there were decided evidences of 
morbid changes of structure in the pos- 
terior gray substance. These structural 
changes extended in a variable degree 
from the lower end of the cervical en- 
largement upwards to the third cervical 
nerves: they were more conspicuous at 
its upper than its lower part. Thin trans- 
verse sections of this part of the cord pre- 
sented to the naked eye no appearance 
that would excite suspicion of any lesion 
whatever; for the morbid portions, al- 
though numerous, were small and iso- 
lated. Under a low magnifying power 
the posterior gray substance was seen to 
be interspersed with a number of un- 
naturally transparent streaks, patches, or 
spots, of different shapes and sizes. Some 
of these spots were seen to interrupt the 
course of certain nerve-fibres which ex- 
tended from both the anterior and pos- 
terior cornua to the opposite side. In 
all the sections examined, it was around 
or at the side of the bloodvessels that the 
1 Gaz. M6d. de Paris, 1860. No. 32. 
2 Guy's Hospital Reports, 3d Series, vol. 
iv. p. 194. PATHOLOGY. 
793 
morbid appearances were most frequently 
found. The morbid spots were more 
numerous and extensive on the right side 
than on the left. The morbid spaces 
varied in shape, size, and relative posi- 
tion in the different sections.. In some 
they appeared as mere fissures or cracks, 
which, under a low power, might have 
been considered as the result of accident, 
if they had not been so uniformly found 
in only one portion of the gray substance, 
and more on the one side than on the 
other. But when a sufficiently high power 
was employed, it became at once evident 
that they were not merely vacant spaces, 
but composed of a substance which dif- 
fered entirely in its nature from that of 
the surrounding tissue. This substance 
had a delicate, transparent, and very fine- 
ly-granular aspect. The granules were 
more closely aggregated towards the cen- 
tre of the mass, but were generally so 
fine that they could not be distinctly seen 
under a magnifying power much less than 
400 diameters. Sometimes at the edges 
of these morbid spaces there seemed to be 
a kind of transition or degeneration of the 
surrounding nerve-tissue into the granu- 
lar substance of which they were com- 
posed. In some instances, the broken 
ends of nerve-fibres proceeding from the 
posterior roots were seen to project into 
the opposite sides of these spaces, across 
which there was strong reason to believe 
that they had once been continuous. 
The morbid appearances generally dis- 
appeared about the level of the third pair 
of cervical nerves ; in the middle third of 
the cervical enlargement they appeared 
to be more extensive than elsewhere, and 
they disappeared on approaching the dor- 
sal region. The sympathetic in the neck 
was also examined, and found normal.1 
The peripheral distribution of the nerves 
to the wasted muscles was in some cases 
found unaltered ; in other cases the nerves 
were found atrophied ; and in one in- 
stance, examined by Frommann,2 the 
nerves leading to the atrophied muscles 
contained fat-molecules and granular pig- 
ment. 
The sympathetic in the neck was found 
diseased in a case examined by Schnee- 
voogt.3 The ganglionic cord was found 
extensively affected with fatty degenera- 
tion. Two similar cases have more re- 
cently been communicated by Jacoud to 
the Societe Medicale des Ilopitaux.4 On 
the other hand, the sympathetic, in two 
other cases, examined by Landry and 
Bayldon,5 was found perfectly healthy. 
Pathology.-Although defective nu- 
trition of the muscles, ending in degene- 
ration and atrophy, is an invariable fea- 
ture of Wasting Palsy, it is evident that 
something more is necessary to the con- 
ception of the disease as a nos'ological 
entity. Muscles may be atrophied under 
a variety of pathological conditions, which 
are essentially distinct. Muscles may 
waste from want of use, as is witnessed 
in limbs which are temporarily kept im- 
movable by surgical appliances, or more 
permanently by anchylosis of the joints. 
A similar result follows severance of the 
connection between a muscle and its ner- 
vous centres, especially its spinal centres ; 
and, lastly, atrophy of muscle may follow 
metallic poisoning. In Wasting Palsy 
there is also muscular atrophy, and, so 
far as is known, the local changes are not 
essentially different from those occurring 
in the afore-mentioned cases ; and yet 
how widely different is the clinical signifi- 
cance of the fact! In order, therefore, to 
obtain any clear idea of the pathology of 
Wasting Palsy, it is absolutely necessary 
to consider circumstances which are ante- 
cedent to the mere atrophy. 
It must be borne in mind that the sev- 
eral vital endowments of a muscle may 
be struck with paralysis in their entirety, 
or singly, or in certain combinations. A 
muscle paralyzed by a cerebral lesion 
loses its voluntary power, but it retains 
its reflex functions and its power of self- 
nutrition, and does not become atrophied. 
Other cases are known in which the pecu- 
liar "muscular sense" is lost, with pre- 
servation of all the contractile and nutri- 
tive endowments. In Wasting Palsy, the 
muscle preserves its voluntary and reflex 
contractility, its muscular sense, and its 
sensitiveness to the electric stimulus ; but 
it loses its power of healthy nutrition, 
and becomes degenerated and atrophied. 
Pathologically, Wasting Palsy may be 
defined as an atrophic degeneration of 
certain groups of muscles, independent of 
any antecedent loss of mobility, or of any 
metallic poisoning. But the question 
immediately arises, whether the morbid 
process is primarily in the muscle itself, 
or in some part of the nervous system 
which controls its functions. 
The former opinion has been adopted 
by Aran, Duchenne, Friedberg, . Dr. 
Meryon, and others ; it was also advocated 
by the present writer in his Essay on the 
subject, published in 1858. It must, how- 
ever, be admitted that the additional 
facts observed since that epoch have 
tended materially to weaken this opinion, 
and to give support to the view that the 
primary lesion in Wasting Palsy exists in 
the spinal cord, or, at least, in some part 
of the nervous system. 
The principal arguments against a ner- 
vous origin of the complaint consisted in 
* Beale's Archives of Medicine. 1861. 
2 Deutsche Klinik. 1857. 
s Schmidt's Jahrb. 1857. 
' Nouveau Diet, de Med. et de Chir. Paris, 
1866. P. 48. 
5 See Author's Essay, p. 163, and Beale's 
Archives, 1861, p. 11. 794 
WASTING PALSY. 
the failure to discover, in several of the 
earlier post-mortem examinations, any 
palpable alteration in the spinal cord; 
and, secondly, in the want of correspon- 
dence between the range of muscles af- 
fected and the distribution of the nervous 
trunks. With regard to the former point, 
the multiplication of post-mortem exam- 
inations has very greatly increased the 
proportion of cases in which a lesion was 
discovered in the nervous system, and 
very much strengthened the suspicion 
that the earlier observations, in which the 
spinal cord was pronounced to be healthy, 
were not altogether trustworthy. The 
researches of Luys and Lockhart Clarke 
have demonstrated that profound changes 
in the substance of the cord may exist in 
detached and very limited areas, which 
might very easily be overlooked, seeing 
that it is exceedingly difficult to examine 
every individual section of the cord with 
the requisite care. Mr. Lockhart Clarke, 
speaking on this point, very significantly 
observes: "There may be very obscure 
structural changes in the gray substance 
of the cord, or perhaps only in the ganglia 
on the posterior roots of the nerves, that 
may affect the nutrition of the parts to 
which they are subservient, without in- 
terfering with the functions either of sen- 
sation or motion ; and in cases where the 
lesions occur in small isolated spots, the 
limitation of disease to particular muscles, 
or even to particular fasciculi of any one 
muscle, could be explained, I think, by 
the particular nerve-fibrils within the 
gray substance. " (Beale's Archives, 1861, 
p. 21.) 
The opinion, also, seems to be steadily 
gaining ground, that the nutrition of the 
muscles is placed under the control of a 
" Main en Griffe." (Roberts.)] 
special set of organic nerves, having up- 
ward connections with the sympathetic 
ganglia and the cerebro-spinal axis, which 
are by no means identical with the cen- 
tral connections of the motor nerve-fibres 
of the same muscles. 
Assuming the existence of such nutri- 
tive centres, all the clinical phenomena of 
Wasting Palsy, and the various findings 
of the post-mortem examinations, admit 
of easy explanation on the supposition 
that these centres, or some of their gangli- 
onic connections, are the primary seat of 
the disease. And the numerous associ- 
ations and complications of the disease 
can scarcely be accounted for on any other 
hypothesis. 
In considerably more than one-half of 
the cases now collected, and examined 
after death, actual disease was found in 
some part of the nervous system. This 
is a proportion which does not permit the 
assumption of a coincidence of two inde- 
pendent morbid processes. Some relation 
between the atrophy of the muscle and 
the disease of the nervous system must, 
I think, be admitted. Either it must be 
assumed that the disease of the muscle is 
capable of evoking disease of the cor- 
responding nervous centre, or the con- 
verse. And although the former supposi- 
tion is by no means a difficult one a priori, 
it stands on a very slender basis of fact. 
So far as I know, the only authenticated 
instance of the centripetal transmission 
of a morbid process along a nervous trunk 
is atrophy of the optic trunks after de- 
struction of the eye. With regard to the 
muscles, evidence of any such transmission 
has yet to be given ; the observations 
hitherto made, indeed, tend the other 
way. Schiff,1 who made resections both 
of mixed and of purely motor and sensory 
nerves, found no alteration in the central 
portions of the cut nerves even after the 
lapse of a year and three-quarters. Tiirck2 
also examined the central origins of the 
nerves and their vicinities, in withered 
and amputated limbs, without finding 
appreciable alteration therein. Nor are 
suppurative and cancerous affections of 
the muscles known to be capable of trans- 
mission along the nervous trunks to the 
nervous centres. 
The etiological conditions of some cases 
of Wasting Palsy, and the collateral phe- 
nomena in others, point also very strongly 
to a nervous origin. Several of the cases 
were sequential to falls or blows on the 
neck, or were associated with morbid 
growths in the spinal canal. In several 
1 Muskel-und Nerven-physiologie. Jahr. 
1859. P. 122. 
2 Zeitsch. der K. K. Gesellschaft der 
Aerzte in Wien. 1853. PATHOLOGY 
795 
well-marked cases of Wasting Palsy, also, 
motor paralysis, of undoubted central 
origin, affecting either the atrophied 
muscles or some other parts, preceded 
the atrophy. A strong impression was 
made on my mind by a case of this kind 
which fell under my notice four years ago. 
A young man was affected with acute 
paralysis of the voluntary muscles of the 
upper and lower extremities, unaccompa- 
nied by any wasting beyond what was due 
to general emaciation. After an almost 
total loss of motion for a period of three 
months, recovery set in, which, in the 
course of a few months, ended in com- 
plete restoration of the muscular power in 
all parts except the hands and feet. The 
muscles of these latter parts passed on to 
a state of characteristic atrophy, from 
which only partial recovery took place. 
Dumenil, Duchenne, and Trousseau have 
also published cases in which there ex- 
isted motor paralysis of the tongue with- 
out atrophy, combined with atrophy 
[Fig. 42. 
Branch of the median nerve for the 
Pronator teres 
Palmaris longus., 
Flexor carpi ulnaris. 
Flexor carpi radialis. 
■Flexor profundus digitorum. 
Flexor sublimis digitorum (middle 
and ring fingers) 
-Flexor sublimis digitorum. 
Ulnar nerve 
Flexor sublimis digitorum (index 
and little fingers) 
Deep branch of ulnar nerve _ 
Palmaris brevis 
-Flexor longue pollicis. 
-Median nerve. 
Abductor minimi digiti.. 
- Abductor pollicis. 
--Opponens pollicis. 
Flexor brevis minimi digiti. 
Oppouens minimi digiti .... 
Lumbricales (2, 3, and 4)., 
Flexor 'brevis pollicis. 
Adductor pollicis. 
Lumbricalis (1st). 
Ziemssen's Motor Points.] 
without paralysis (Wasting Palsy) of the 
upper extremities.1 It is easy to con- 
ceive that a morbid process in the motor 
centres may extend by continuity of tis- 
sue to contiguous nutritive centres (sup- 
posing such to exist), or, conversely, that 
disease of the nutritive centres may im- 
plicate motor or sensory centres in their 
vicinity, and so produce complicated clin- 
ical phenomena, analogous to those above 
mentioned, and which on any other sup- 
position are very difficult of rational 
explanation. 
The case-history of Wasting Palsy is 
rich in combinations of this sort. In the 
pure typical, uncomplicated cases-where 
atrophy of the muscles is unmixed with 
any degree of motor paralysis, or convul- 
sive movements, or with numbness, or 
neuralgic pains-it may be assumed that 
the morbid process is strictly limited to 
the nutritive centres in the cord, or to 
their connections in the sympathetic 
ganglia. In the complicated cases it may 
1 Bergmann, loc. cit. p. 88. 796 
WASTING PALSY. 
be assumed that the morbid process radi- 
ates into those contiguous parts of the 
cord which control motor and sensory 
functions. The question can only be 
finally elucidated by repeated accurate 
examinations of the spinal cord in com- 
plicated cases. 
[Of those who have more recently in- 
vestigated this subject, Jofi'roy, Hayem, 
and Charcot, assert the coincidence of 
Progressive Muscular Atrophy with de- 
generation of the anterior gray cornua of 
the spinal cord. Friedreich, Lichteim, 
and Cohnheim, however, have reported । 
cases in which no lesion either of the cord 
or nerves was found.-II.] 
Prognosis.-Wasting Palsy must be 
counted among the most intractable dis- 
eases ; and when it invades the muscles 
of the trunk, it almost always goes on 
sometimes very slowly, sometimes more 
rapidly-to a fatal termination. In the 
partial forms-when permanent limita- 
tion of the disease to one or two members 
is established-life may be regarded as no 
longer menaced, but the usefulness of the 
limb, if the atrophy be complete, is hope- 
lessly impaired. If remedial measures 
[Fig. 43. 
Supinator longus 
Extensor carpi radialis longior 
Extensor carpi radialis brevior 
Extensor communis digitorum. 
Extensor carpi ulnaris. 
Extensor indicis 
Extensor indicis and extensor ossis ) 
metacarpi pollicis $ 
Extensor ossis metacarpi pollicis 
Extensor minimi digiti. 
Extensor Indicts. 
Extensor secund! internodii pollicis. 
Extensor prim! internodii pollicis.. 
Flexor longus pollicis.. 
r i 
Dorsal interossei J 2 
I 3 
Abductor minimi digiti. 
Dorsal interosseus (4). 
Ziemssen'g Motor Points.] 
can be applied early, and persevered in, 
while the atrophy is still in progress, 
there is some prospect either that the ad- 
vance of the disease may be permanently 
checked, or even that partial or perfect 
restoration of the inj ured muscles may be 
effected. 
The gravity of the prognosis, in so far 
as the preservation of life is concerned, 
depends on the disease confining itself to 
the extremities, or extending its ravages 
to the muscles of the trunk. When the 
respiratory muscles are invaded, the fatal 
termination is not far distant. 
The probability of the disease becoming 
generalized is greatest when the origin of 
it can be traced back to hereditary pre- 
disposition. The same danger, though in 
a greatly inferior degree, is to be appre- 
hended when the disease has arisen from 
cold, and when the lower limbs are the 
first attacked ; also when the upper and 
lower limbs are both implicated. On the 
other hand, the prognosis is much more 
favorable when the disease is occasioned 
by overwork, and when it is confined to 
the hands and forearms. 
The longer the atrophy has existed, the 797 
PROGNOSIS. 
less is the prospect of recovery : if the siderable improvement in the condition of 
disease has become stationary for a year the muscles, but the danger to life has be- 
or two, there is no chance of any con- I come comparatively small. 
[Fig. 44. 
...Tensor fascia femoris (branch of su- 
perior gluteal nerve). 
...Tensor fascia femoris (branch of crural 
nerve). 
...Rectus femoris. 
« 
Vastus externus. 
... Vastus externus. 
Anterior crural nerve 
Obturator nerve 
Sartorius 
Adductor longus 
Branch of crural nerve to quadriceps 
extensor cruris 
Crureus 
Branch of crural nerve, to vastus in- 
ternus 
Ziemssen's Motor Points. 
Fig. 45. 
Inferior gluteal nerve for gluteus 
maximus 
Great sciatic nerve.. 
Long head of biceps. 
Adductor magnus. 
Semitendinosus. 
Semimembranosus. 
Short head of biceps. 
Posterior tibial nerve 
Peroneal nerve 
Gastrocnemius (external head). 
Soleus 
Gastrocnemius (internal head). 
Ziemssen's Motor Points.] 798 
WASTING PALSY. 
Therapeutics. - In projecting the 
treatment of a case of Wasting Palsy, 
the first necessity is to ascertain, as ac- 
curately as possible, the etiological cir- 
cumstances under which the disease has 
originated. The removal of these-sup- 
posing them to be still in operation-fol- 
lows as a matter of course. Mercury and 
iodide of potassium have been employed 
with success in cases where the disease 
depended on a syphilitic taint. If the 
disease has arisen from overtasking any 
set of muscles, these must be allowed to 
remain at rest. 
The direct treatment embraces the em- 
ployment of hygienic means-baths, me- 
thodical exercise, change of air, &c.-and 
the employment of galvanism and fric- 
tions to the affected muscles. Remak 
strongly advocates the use of the constant 
galvanic current applied to the spinal 
cord-especially the cervical portion. 
Thermal and sulphur baths have been 
highly recommended by a number of 
writers. Wetzlar has especially called 
attention to the beneficial effects of the 
waters of Aix-la-Chapelle. Cold baths 
are objectionable. 
The most effective remedy in Wasting 
Palsy is, undoubtedly, galvanism. Nu- 
merous observations attest its value when 
applied locally to the affected muscles. 
After a very considerable experience of 
its employment, I am convinced that it 
very rarely fails of some good effect when 
perseveringly applied. This effect is too 
often temporary : too often also it is found 
difficult to keep up the treatment with 
the requisite regularity for a sufficient 
length of time. In some cases marked 
improvement in the power and bulk of 
the muscular masses was witnessed ; in 
others, the disease, previously progres- 
sive, was brought to a standstill. In the 
case of a man, still under observation, 
suffering from atrophy of the muscles of 
the thighs and upper arms, and of the 
erectores spinse, which had been steadily 
progressive for twelve months, the daily 
application of the secondary current ar- 
rested the disease completely. The arrest 
has now continued for more than six 
years. 
Duchenne gives the following direc- 
tions for the employment of galvanism : 
"Every muscle ought to be faradized in 
a special manner, according as it has 
suffered more or less in its electric con- 
tractility and nutrition. Thus the more 
a muscle is atrophied and its contractility 
diminished, the longer it should be sub- 
jected to the stimulation, the more intense 
should be the current, and the more rapid 
its intermissions. And this strong cur- 
rent and quick intermissions are the more 
necessary, according as the sensibility of 
the muscle is more benumbed. But when 
the sensibility is seen to return, it is pru- 
dent to diminish the intermissions and 
abate the intensity of the current, and 
even to abridge the number of sittings, lest 
there be provoked unmanageable neural- 
gia, and, which sometimes has arisen, in- 
flammatory accidents. During the faradic 
treatment, I have excited the muscular 
sensibility, as much as possible, by rapid 
intermissions, inasmuch as I have found 
this the most effective means of reacting 
on the nutrition of the atrophied muscles. 
Sittings of too long duration fatigue and 
even exhaust the muscles, just as forced 
exercise induces atrophy, instead, like 
moderate exercise, of favoring nutrition. 
I believe that no sitting should be pro- 
tracted beyond fifteen minutes, at the 
[Fig. 46. 
Gastrocnemius 
(internal head) 
Soleus 
Flexor communis 
digitorum lon- 
gus 
Posterior tibial 
nerve 
Abductor pollicis 
most. I rarely give more than one min- 
ute to each muscle. To prevent weari- 
ness, and a bruised feeling, that sometimes 
follows the application of electricity, I 
pass rapidly over the muscles, taking care 
to return to each of them several times 
during the same sitting, so as to leave a 
short interval of repose between each 
excitation." 1 
The secondary symptoms-cramps and 
neuralgic pains-are most effectually sub- 
dued by warm baths, temporary rest in 
1 De 1'Electrisation localisee, p. 702. 
Ziemssen's Motor Points.] 799 
THERAPEUTICS. 
bed, and anodynes. The hypodermic in- 
jection of morphia has, in my hands, been 
followed by the happiest effects in reliev- 
ing the excruciating neuralgia which is 
not unfrequently associated with this dis- 
ease. One of my patients, thus afflicted, 
is in the habit of having half a grain of 
morphia injected early in the morning, 
when the pains are severe. Such an in- 
jection enables him to pursue his employ- 
ment through the day in comfort-a result 
which he fails to attain by any dose of the 
same remedy internally administered. 
[Fig. 47. 
Peroneal nerve. 
Gastrocnemius (external head) 
Soleus. 
Extensor communis digitorum 
longus. 
Peroneus brevis. 
Soleus. 
Flexor longus pollicis. 
Peroneus longus. 
Tibialis auticus.. 
Extensor longus pollicis. 
Branch of peroneal nerve for 
extensor brevis digitorum.. 
Dorsal interossei.... 
Extensor'brevis digitorum. 
Abductor minimi digiti. 
Ziemssen's Motor Points.] 
[Pseudo-hypertrophic Muscular Paralysis, 
after having been described by Costa and 
Gioga in Italy (1838), and Meryon in Eng- 
land (1852), was, in 1868, more definitely 
studied and classified by Duchenne. 
Many pathologists, in America as well as 
in Europe, have, since that time, reported 
cases. 
It occurs in children, up to the age of 
13 or 14, mostly in boys. No causes have 
as yet been made out; but its occurrence 
in several children of the same family, or 
nearly related to each other, has been 
established, especially by Poore.1 In 
thirty-seven instances, there were two or 
more of the same family thus affected. 
Hereditary transmission of the tendency 
to it appears to have been observed only 
on the mother's side ; that is to say, when 
the parents of children having it were not 
subject to it, examples have been found in 
the mother's family; her brothers, &c. 
The first well-marked symptom is mus- 
cular weakness of the lower limbs and 
back. This gradually increases. The 
child stands with the legs far apart, the 
shoulders thrown backward, and the belly 
forward. The toes point downwards, 
sometimes approximating talipes equinus. 
In the course of a few months some of the 
muscles of the lower limbs will be found 
to be enlarged ; and this gradually ex- 
tends to those of the trunk and upper 
extremities. Sometimes those of the face 
also are involved. 
The enlargement of the muscles of the 
calves of the legs, in many instances, gives 
an appearance like that of extraordinary 
[' N. Y. Medical Journal, June, 1875.] 800 
WASTING PALSY. 
strength; and yet the limbs are almost 
powerless for locomotion. In from one to 
three years, paralysis extends to nearly 
all the muscles of the body. An impair- 
ment of the mental faculties has been 
along with atrophy of the muscular fibres. 
It is altogether a degenerative, not a 
hypertrophic alteration that the muscles 
undergo. 
Fig. 48. 
Fig. 49. 
Pseudo-hypertrophic Muscle. (Charcot.) 
Several facts in the history of this dis- 
order point, in its pathology, to a nervous 
origin. 1. It is symmetrical, and pro- 
gressive upon both sides of the body alike. 
2. The intelligence is not unfrequently 
impaired. 3. It presents an analogy (not- 
withstanding that shrinking occurs in the 
one, and increase of bulk in the other) to 
progressive muscular atrophy ; in which, 
as above seen, lesions of the spinal cord, 
and sometimes of the sympathetic ganglia, 
have been demonstrated. Yet no satis- 
factory demonstration has been obtained 
of the association of Pseudo-hypertrophic 
Muscular Paralysis with morbid changes 
of the nervous system. 
The only treatment so far suggested as 
affording much prospect of advantage, is 
the use of electricity. Duchenne advised 
local faradization ; under which he re- 
ports two recoveries. McLane Hamilton1 
recommends massage; of which Bristowe8 
also expresses approval.-II.] 
Early stage of Pseudo-hypertrophic Paralysis. 
(Bristowe.) 
noticed in a number of cases. In this 
condition, unable to rise, from the position 
in which he is placed, the child may live 
for several years more: seldom to adult 
age. 
Sensation is not involved in this dis- 
ease ; neither are the functions of diges- 
tion, respiration, or circulation. At first, 
the electro-contractility of the muscles is 
unchanged ; at a late stage, it is gradually 
lost. 
Griesinger and Billroth, in 1865, first 
ascertained the presence of deposits of fat 
in the enlarged muscles of this affection. 
Duchenne and others have observed also 
the great increase of connective tissue, 
[' Nervous Diseases, &c., Philada., 1878; 
p. 275.] 
[2 Manual of the Practice of Medicine, 
American Edition, p. 1052.] METALLIC TREMOR : CAUSES. 
801 
METALLIC TREMOR. TREMBLEMENT 
METALLIQUE. 
William Rutherford Sanders, M.D., F.R.C.P. 
Synonyms.-Tremor Metallurgorum; 
Paralysis Agitans Metallica ; Rheumatis- 
mus Metallicus (Schbnlein); Metallic 
Shaking Palsy ; The Trembles. 
1st. Mercurial Palsy or Tremor ; Mer- 
curial Shaking Palsy; Mercurial Trade 
Disease ; Tremor ab Ilydrargyro ; Paral- 
ysis Agitans Mercurialis; Tremblement 
Mercuriel; Tremblement des Doreurs ; 
Mercurial-Zittern. 
2d. Lead Tremor or Shaking Palsy; 
Tremor Saturninus; Paralysis Agitans 
Saturnina ; Saturnines Zittern. 
Definition.-Metallic Tremor is a 
species of paralysis agitans, caused by the 
slow poisonous action of certain metals, 
particularly mercury and lead. It con- 
sists of spasmodic tremors with dimin- 
ished muscular power, occurring in vari- 
ous parts of the body. 
1. The Mercurial Tremor or Shaking 
Palsy, being the form best known and 
most important, will be first described. 
Causes.-Exciting.-The chief source 
of this disease is the inhalation of mer- 
cury in a state of vapor, this metal being 
volatile at nearly ordinary temperatures 
(68° to 70° Fahr.). By some authors this 
has been regarded as the only mode of 
origin ; but it is certain that the intro- 
duction of mercury by the skin, either in 
consequence of manipulating the metal, 
or of prolonged friction with mercurial 
ointment, has sometimes brought on the 
peculiar tremors ; and the same effect has 
also resulted, in a few instances, by ab- 
sorption, from the intestinal canal, of mer- 
curial preparations administered medici- 
nally. The principal sufferers from the 
disease are accordingly:-1st. The work- 
men employed in the quicksilver mines, 
especially when fire is used in the reduc- 
tion of the ores. 2d. Water-gilders (who 
plate with gold dissolved in mercury), 
looking-glass silverers, barometer makers, 
workmen in chemical manufactories, 
where mercurial preparations are made, 
button and toy gilders, furriers, and 
others whose business exposes them to 
contact with mercury.1 3d. Persons using 
mercury medicinally. In former times, 
the latraliptse, an inferior class of sur- 
geons, who practised as mercurial anoint- 
ers or rubbers, without protecting their 
hands, were frequently subject to tremors 
which sometimes proved incurable. A 
similar instance is recorded recently. 
Dixon, the anatomy porter of the Irish 
College of Surgeons, "who at one time 
rubbed in immense quantities of mercury 
for the cure of venereal among the Mo- 
hawks, or swells of the day," was subject 
for thirty years to mercurial stammering 
(psellismus mercurialis).1 Syphilitic pa- 
tients, after long courses of mercurial 
treatment, especially by friction, often 
suffered severely from the trembles.2 On 
the other hand, the internal use of mer- 
curial medicines alone very rarely gives 
rise to the tremors; nevertheless un- 
doubted examples of this kind have been 
observed even in recent times, both in 
venereal and in other cases.3 In the pre- 
sent day, there is little risk of tremors 
originating from excess in either the ex- 
ternal or internal medicinal use of the 
mineral, but the possibility must not be 
overlooked. 4th. Persons are sometimes 
accidentally exposed. In 1810, the Tri- 
umph, man-of-war, took on board a cargo 
of mercury, saved from a wreck. In con- 
sequence of the bladders bursting, in 
which it was held, the mercury spread 
through the ship, and in the space of 
three weeks " two hundred men were 
affected with ptyalism, ulceration of the 
mouth, partial paralysis in many in- 
stances, and bowel complaints."4 In 
1803, a fire broke out in the quicksilver 
mine at Idria, near Trieste, and about 
wall in Forbes' Cyc. Pract. Med. i. 151, 1833; 
Tardieu, Diet. d'Hygiene, 1852; Whitley in 
Sixth Report of Med. Officer of Privy Council, 
1863, p. 358. 
1 Mapother, Mercurial Trade Disease, Med- 
Press and Circular, i. 531, May 23, 1866. 
2 Hutten, De Morb. Gall.; Fernelius de 
Luis, Ven. Cur. c. vii. p. 234, 1656; Ramaz- 
zini, 1. c. 
* Colson, Arch. G6n. de Med. xv. 338, 1827;' 
Lancet, ii. 1838-9, p. 767. 
4 Burnett, Phil. Trans. 1823, Pt. ii. 402. 
The Phipps, schooner, which assisted, was 
similarly affected: Ed. Med. and Surg. Jour, 
vi. p. 513, 1813. 
1 Ramazzini, De Morb. Artif. caps. i.-iii. 
1717; Patissier, 1822; Thacrah, 1832; Dar- 
VOL. I.-51 802 
METALLIC TREMOR. 
nine hundred persons in the neighborhood 
were attacked with nervous tremblings.1 
Medico-legal questions have also risen as to 
the alleged deleterious effects of emanations 
from workshops where mercury was used.2 
In a few instances a single strong ex- 
posure has been known to cause the tre- 
mors ;3 but usually a prolonged and ha- 
bitual contact, for months or years, is 
required, under conditions which favor 
the development of the disease. 
Predisposing Causes. - The circum- 
stances which dispose to the disease or 
aggravate it, are:-1st. Bad ventilation ; 
2d. Cold and damp weather (hence the 
tremors are worse in winter, in conse- 
quence of the low temperature and close 
confinement); 3d. Defective cleanliness ; 
4th. Intemperance; 5th. Violent emo- 
tions (a fit of passion has sometimes orig- 
inated an attack of tremors suddenly); 
6th. Idiosyncrasies must be taken into 
account. Certain constitutions are more 
susceptible than others to the mercurial 
poison. The same exposure which in 
some individuals affects the mouth, pro- 
ducing salivation and ulcerations of the 
gums, without tremors, will, in others, 
cause tremors without salivation. 7th. 
The mode of application has considerable 
influence. As a rule, inhalation of mer- 
curial vapor is followed by tremors ; in- 
unction or internal medicinal use, by sali- 
vation. 
Description.-Previously noticed by 
several writers, and especially by De 
Haen,4 the tremulous mercurial disease 
has been most fully described by Merat,5 
as observed among the water-gilders of 
Paris. Less complete accounts have been 
given by various authors of the disease 
among workmen in other countries, and 
as it affects the quicksilver miners at Al- 
maden and Idria.6 
Symptoms. - 1st Stage. Simple Tre- 
mors.-The commencement is sometimes 
sudden, but most frequently the disease 
comes on gradually. The upper extremi- 
ties are nearly always first affected. The 
patient finds his hands and arms getting 
weak, unsteady, and less under control; 
they vacillate and tremble whenever they 
are used. He can do coarse work, but 
nothing requiring precision. The at- 
tempt to seize or hold anything increases 
the trembling. At the same time numb- 
ness or formication is sometimes felt in 
the hands or feet, and occasionally pains 
in the joints, particularly the thumbs, 
elbows, knees, or feet. These simple 
tremors are very common among quick- 
silver miners and water-gilders. They 
are not so severe as to prevent work alto- 
gether, and by judicious means they may 
be kept from increasing. 
2d Stage. Convulsive Tremors.-If the 
patient continues or increases the expo- 
sure, or becomes more susceptible to it, 
the trembling augments in intensity till 
it becomes convulsive or spasmodic in 
character. Muscular subsultus occasions 
vibration and jerking of the hands and 
arms. The tremor is easily excited either 
by exertion or emotion, and once begun 
cannot be stopped for some time. The 
voluntaiy acts also become spasmodic as 
well as tremulous, and are accomplished 
by interrupted violent starts, like the 
movements in chorea. In bending the 
arm, for example, the fiexion cannot be 
done by a single continuous contraction, 
but takes place by two or three jerks. 
The tremulous hand cannot be directed 
with precision, but is projected beyond or 
beside or away from the object; it soon 
becomes unfitted for work, and can 
scarcely convey food or liquids to the 
mouth. As Dr. Pope tells of a miner at 
Friuli, "he could not with both his hands 
carry a glass half full of wine to his mouth 
without spilling it, though he loved it too 
well to throw it away."1 The convulsive 
nature of the movements depends greatly 
on the predominance of the flexors over 
the extensors ; so that when a patient has 
seized an object, he often cannot let go 
his grasp. At this period, the patient is 
usually obliged to discontinue work, and 
after an interval of rest, steadiness may 
still be completely restored. But if he 
persist, or resume his employment too 
soon, the tremors become greatly aggra- 
vated, and extend by degrees over the 
whole body. The legs begin to shake, 
especially at the knees, and in walking 
they tremble and dance as if hung upon 
wires. The lips, tongue, and jaws are in 
tremulous vibration, and speech is hur- 
ried, staccato, and stammering, becoming 
at last unintelligible (psellismus mercu- 
rialis). The head oscillates, shaking, or 
1 Murray's Handbook to S. Germany, 9th 
edit. 1863, p. 400. 
2 Chevallier, Annal. d'Hygiene, xxv. 388, 
1848; Orfila, Toxicologie, 4th edit. 1843, i. p. 
593. 
3 Christison on Poisons, Merc. Tremor, 4th 
edit. p. 418, 1845. 
4 De Haen, Ratio Medendi, Pt. iii. c. 28, 
1761. 
5 Merat, M^m. sur le Tremblement des 
Doreurs,'&c.; Appendix to the Traite de la 
Colique Metallique, Paris, 1812; also in Diet, 
des Sc. Med. xxx. 232, 1818, and Iv. 521, 
1821; Bateman, Ed. Med. and Surg. Jour, 
viii. 376, 1812; Mitchell, Lend. Med. and 
Phys. Jour. 1831, p. 394; Bright, Med. Rep. 
ii. 495, 1831; Stokes, Ryan's Lond. Med. and 
Phys. Jour. v. 519, 1834; Lancet, ii. 1853, 
pp. 231 and 317; Med. Times, ii. p. 578, 
1853; Marshall Hall, Watson, Romberg, Val- 
leix, Falck in Virch. Handb. der Spec. Path, 
u. Ther. I. iii. 136, &c. 
6 Jussieu, Mem. de l'Acad. Roy. des Sci- 
'ences de I'Ann^e 1719, p. 357, &c. 
1 Phil. Trans, i. p. 21, 1665. SYMPTOMS. 
803 
nodding; and sometimes the features are 
distorted by spasmodic grimaces; the 
eyeballs alone are unaffected in their 
movements. Mastication is impeded. 
Finally, the tremulous subsultus appears 
in the muscles of the trunk, and the res- 
piratory movements are convulsive and 
attended with dyspnoea. Tonic spasms 
also occur in the affected parts, and are 
frequently attended by pains, to which 
the Spanish miners of Almaden give the 
name of "calambres," i. e., cramps. 
These pains are sharp and lancinating, 
and sometimes of intolerable intensity; 
they are not always in proportion to the 
muscular contraction.1 
When the tremors attain their greatest 
intensity, they amount to a kind of con- 
vulsion, and the patient presents a most 
pitiable aspect. In constant tremulous 
commotion, tottering, trembling, shaking, 
and stuttering, he is powerless to execute 
any combined movement; he cannot 
walk, or speak, or chew ; he dares not 
touch any object for fear of breaking it or 
letting it fall; on raising his agitated 
hand, with food to his mouth, he misses 
his aim and inflicts involuntary blows on 
his face. He must be fed and clothed like 
a child.2 Some unfortunates deprived of 
assistance, have been known to creep on 
all-fours, and seize food with the lips, 
like the lower animals. Unless in the 
very worst cases, however, whenever the 
body is supported, sitting or reclining, the 
tremors gradually subside, and soon cease 
altogether, and they do not return until 
excited in consequence of some voluntary 
movement or mental emotion. During 
sleep, they remain in entire abeyance. 
The patient is thus allowed time for re- 
pose and recovery. But in the most ad- 
vanced cases, the subsultus takes place 
even when the body is reposing, so that 
the involuntary shaking of the head on 
the pillow has prevented sleep.3 In the 
tremulous parts, the muscular strength is 
diminished (paresis), but there is no inter- 
ruption to the conduction of the stimulus 
of volition (paralysis). The sensibility is 
not impaired. 
Concomitant Symptoms.-The condition 
of the other functions, accompanying the 
disorders of the nervous system just de- 
scribed, indicates the presence of the mer- 
curial cachexia. At the beginning this is 
slight and unimportant. The skin ex- 
hibits a sallow, brown, or earthy tint; it 
is dry and sometimes rather warm ; the 
expression is sometimes animated, at 
other times languid ; there is little or no 
emaciation, which indeed does not appear 
till the disease is of long standing. The 
digestive functions are unimpaired ; there 
is no colic, the abdomen is soft and of ordi- 
nary volume, and the urinary and alvine 
excretions are natural. But as the tre- 
mors become more severe, the appetite 
diminishes, and it ultimately ceases alto- 
gether ; the tongue becomes white and 
pasty, but without bad taste, and gas ac- 
cumulates in the intestines. The respira- 
tory organs are natural, till dyspnoea and 
asthma arise, from the respiratory nerves 
being involved in the tremors. The pulse 
is usually at first strong and slow, as in 
metallic colic, but it may afterwards be- 
come small and weak 5 sometimes it is 
accelerated. 
But sooner or later signs of general 
mercurialism usually make their appear- 
ance, especially salivation, loose teeth, 
inflamed and ulcerated gums, aphthae, 
fetid breath and sweat, swelling of the 
parotids, and a pustular eruption over the 
body. These symptoms occur early, and 
are particularly obstinate in workmen 
who take their food in the workshops or 
mines, and who are not careful to use ab- 
lutions, and change their clothes and 
shoes. Attacks of excited circulation 
(erethism) are frequent in the early stages; 
and in the later, anaemia, emaciation, and 
great debility. If we except the cachec- 
tic symptoms just described, complications 
are rare in the course of mercurial tremors. 
The colic, which is sometimes observed, 
depends upon lead which is mixed with the 
mercury, or has been used along with it. 
3d Stage. Mercurial Tremors, with 
Affection of the Brain.-The tremors are 
not of themselves dangerous to life, but in 
the advanced stage they are often accom- 
panied by serious cerebral disorders, as 
headache, loss of memory, loss of con- 
sciousness, sleeplessness, delirium, epi- 
lepsy. These symptoms would soon end 
fatally were it not that generally their 
gravity compels the sufferer to desist from 
his employment; and by this fortunate 
interruption, recovery usually takes place 
even from this dangerous condition. In- 
deed, the disease when subjected to treat- 
ment is rarely fatal.1 Some inveterate 
cases prove incurable, or are succeeded by 
1 Tardieu, Diet, d'Hygiene, ii. 481, 1854, 
who quotes Roussel, Lettres Med. sur 1'Es- 
pagne, Union Med. for 1848-9 ; Ed. Monthly 
Med. Jour. Retrospect for 1848, p. 254. 
2 De Haen's description is graphic. Case 
2. " Deaurator, 25 annorum, horrendo artuum 
omnium, maxime superiorum . . . vex- 
atus . . . ita ut nihil laboris ultra per- 
ficere, ut nec comedere, bibereve solus, nec 
loquens amplius intelligi potuerit. Nutri- 
endus, vestiendus et infantis instar, alvum 
urinamque positurus, adjuvandus erat; dolo- 
rum cseterum immunis." It is satisfactory 
to add, "Virtute electrea trium septimanarum 
spatio adhibita, perfectissim^ convaluit, ita 
ut ipsi, sive in motu, sive in loquela, ne vel 
minimum quidem desit." (Loc. cit.) 
3 De Haen, loc. cit. case 7. 
1 See fatal case from "general failing of the 
vital powers." Lancet, 18'39-40, ii. p. 588, 
and Guy's Hosp. Rep., 1864, p. 175. 804 
METALLIC TREMOR. 
motor paralysis, but it is only in those 
instances where the noxious exposure is 
obstinately persisted in, notwithstanding 
repeated attacks of increasing severity, 
that death finally takes place, accompa- 
nied by symptoms of profound mercurial 
cachexia, and especially extreme maras- 
mus and exhaustion. 
But although mercurial tremor by itself 
is not directly fatal, and is a curable dis- 
ease when submitted to proper treatment, 
yet, under the circumstances in which 
workmen were placed till within a recent 
date, the effects of the mercurial poison, 
taken as a whole, were most disastrous, 
and the mortality in certain employments 
was excessive. " In Paris, in 1821, it is 
stated that the looking-glass manufac- 
turers could not remain at the trade above 
eight or twelve years. When necessity 
compelled them to persevere too long, 
their faces became pale, with an expres- 
sion of intoxication, their intelligence and 
memory gradually failed, they fell into a 
kind of idiotcy, and after lingering in this 
state for some years, they "died of con- 
sumption, or were struck with apoplexy.1 
In 1847, Dr. Sanderet reports that the 
trade of water-gilding at Besangon, where 
it was extensively carried on, was most 
injurious to health,2 the mortality among 
the workmen being enormous, and due 
chiefly to phthisis. Fortunately these 
trades, conducted under better hygienic 
conditions, or by means of new processes, 
are either entirely innocuous or are much 
less injurious at the present day. 
The condition of the quicksilver mines 
was, in ancient times, most dangerous.3 
At a comparatively recent date, when 
Jussieu visited Almaden, in 1719, he found 
that the free miners, who adopted proper 
precautions, preserved their health and 
lived like other men, but the convicts and 
slaves who took no care suffered severely, 
and fell victims to disease. In 1848-9, 
there were no slaves nor convicts in those 
mines; but it was observed that the native 
miners, who knew the risks and avoided 
them, were little affected, while the poor 
laborers from a distance, careless and dis- 
sipated, experienced the most disastrous 
effects. The average number of workmen 
was 3911; of these forty-eight were ' 'calam- 
bristes" (in the second stage of mercurial 
tremors), half of which number died within 
the year, and the other half remained unfit 
for work in the mines. Besides this, there 
were two deaths from accidents, three 
mutilations, and thirty-nine injuries more 
or less serious. And although many work- 
men do not fall victims to the mercurial 
poison, none of them entirely escape its 
action.1 At Idria, although the hygienic 
conditions of the place are in other re- 
spects highly favorable, it is stated that 
the whole population is subjected to the 
influence of mercury, not the workmen at 
the mines only. The annual mortality is 
120 out of 4500 inhabitants. The work- 
men exposed directly to the action of the 
metal suffer severely. In 1856,122 out of 
516 were seriously affected.2 Information 
is wanting in regard to the quicksilver 
miners in California and Australia. 
Course and Prognosis.-Mercurial 
Tremor is essentially a chronic and pro- 
tracted disease. It runs a uniform course. 
Once begun, if the exposure is persevered 
in, the symptoms gradually get worse ; 
the tremors become more intense, are ac- 
companied by spasms clonic and tonic, 
and spread over the whole body. But if 
the patient be removed from the exciting 
cause, exposed to fresh air, and placed 
under suitable treatment, amelioration 
soon begins, and, after a few weeks or 
months, perfect steadiness may be re- 
stored. The prognosis, therefore, is gene- 
rally favorable, provided the patient can 
avoid the contact with mercury. The 
prospect of cure, and the time required 
for it, will depend on the severity of the 
symptoms, and especially on their dura- 
tion previous to treatment, on the age of 
the patient, the presence of serious cere- 
bral symptoms, and the degree of mercu- 
rial cachexia which may accompany the 
tremors. The affection is most frequent 
probably in middle life (thirty to forty); 
it is more severe in old people. If taken 
at an early stage, twenty days may effect 
a cure, but in a confirmed case usually 
from two to seven months, sometimes a 
year or more, are required. When the 
tremors are spasmodic and generalized, 
the cure is tedious and imperfect, some 
tremor of the hands nearly always re- 
maining permanently. The upper ex- 
tremities, which are the parts earliest and 
most severely affected, resist cure the 
longest. It is seldom that the tremors 
are persistent and irremediable, and, as 
already stated, fatal results only ensue in 
consequence of general cachexia or phthi- 
• Burdin, Art. Tain, Diet, des Sc. MM. 
1821, liv. 276. 
2 "Une des industries des plus fatales & la 
sante." (Annal. d'Hygiene, 1847, xxxviii. 
457.) 
3 At Idria, in 1665, Dr. Pope says, "All of 
the miners in time (some later, some sooner) 
become paralytick and dye hectick." (Phil. 
Trans.) Also Dr. Edward Brown, in Phil. 
Trans. Dec. 13, 1669,. 
1 Tardieu, loc. cit. and Roussel. In the 
inclosure called Brutrones, where the fur- 
naces are situated, the animals which are 
allowed to graze there are liable to Mercurial 
Tremors. (Edin. Month. Med. Jour., Retro- 
spect for 1848, p. 255.) 
2 Med. Times and Gazette, xxxix. p. 616, 
1859, and Gaz. Hebd. PATHOLOGY AND MORBID ANATOMY. 
805 
sis or apoplexy, the effects of an unhealthy 
constitution, or of unpardonable neglect, 
or of obstinate persistence in exposure to 
the poison. 
After a first seizure relapses are fre- 
quent, and usually of increasing severity. 
If the patient, in spite of due care, is still 
subject to attacks, he ought to change his 
employment. Some constitutions, pecu- 
liarly sensitive to the poison, are unfit for 
any trade requiring the use of mercury. 
Diagnosis.- The symptoms and the 
cause distinguish Mercurial Tremor 
readily from other diseases. It could only 
be confounded, 1st, with chorea, or St. 
Vitus's dance, which it resembles in the 
jerking nature of the movements, but it 
differs by the presence of tremors; 2d, 
with idiopathic paralysis agitans, with 
which it is identical as regards the cha- 
racter of the irregular movements (viz. 
tremors and jerking), but it is distin- 
guished from it by the exciting cause 
(mercury), and by the concomitant symp- 
toms of mercurial poisoning. In addition, 
the speech (tongue and jaws) is much 
sooner, more invariably, and more cha- 
racteristically affected in the mercurial 
disease than in idiopathic shaking palsy. 
The loss of memory and consciousness, 
and other cerebral symptoms also, are pe- 
culiar to the mercurial disease. On the 
other hand, the irresistible tendency to 
walk or run forwards, which marks the 
paralysis agitans festinans, is not met 
with in the Mercurial Tremors ; the only 
disturbance of equilibrium in the latter is 
that which results from debility, tremors, 
and spasmodic jactitation.1 3d. It is not 
likely, with ordinary care, to be mistaken 
for delirium tremens, or alcoholism. 
Pathology and Morbid Anatomy. 
-The disease being rarely fatal, the in- 
formation in regard to the morbid anat- 
omy is scanty. In a recent case,2 Dr. 
Alfred Taylor found the brain and spinal 
cord, the muscles, lungs, heart, liver, and 
kidneys, in appearance quite healthy. On 
chemical examination of the brain, liver, 
and kidney, minute globules of metallic 
mercury were obtained, in largest propor- 
tion from the kidney. The spinal cord 
and medulla oblongata are doubtless the 
seat of the principal morbid action, just 
as in idiopathic paralysis agitans. The 
molecules of mercury entering probably 
into combination with the nervous sub- 
stance, seem both to irritate and partially 
to paralyze the nervous centres of motion, 
while they leave the apparatus of sensa- 
tion intact.1 The opinion which some 
authors entertain, that the morbid lesion 
has its seat in the muscles and not in the 
nerve-centres, is insufficient to account 
for the spasmodic and variable nature of 
the phenomena, and is inconsistent with 
the cerebral symptoms which ultimately 
become developed. 
The treatment is twofold, preventive and 
curative. 
Pretention is accomplished, 1st, by lim- 
iting the exposure to a short period at 
considerable intervals, or by adopting 
various contrivances which remove the 
mercury from contact with the operator. 
In the time of Pliny2 the workmen pro- 
tected their faces with masks of loose 
bladder skin, sufficiently transparent to 
admit of being seen through. Masks of 
glass were afterwards substituted. Sponges 
over the mouth, and various kinds of re- 
spirators, have also been proposed. But 
the chief improvement has taken place in 
recent times by the better construction 
and ventilation of the workshops, and by 
the introduction of Hues and chimneys, 
which carry off the mineral vapors by a 
powerful draught out of the apartment, 
while the workman is further protected 
by a glass sash interposed between his 
face and the stove where the mercurial 
vapors are disengaged. To D'Arcet's3 
draught chimney for this purpose the 
French Academy of Sciences, in 1816, 
awarded the prize founded by M. Ravrio, 
who had made his fortune as a manufac- 
turer of gilt bronzes, and was anxious to 
obtain some means for protecting work- 
men from the risks of the employment. 
Merat bears testimony to the efficacy of 
D'Arcet's chimney in warding off the 
tremors, to some extent. Similar flues 
and stoves have been used in this coun- 
try ;4 but none of these inventions have 
proved successful in entirely preventing 
the disease. 2d. On the part of the 
workmen, regular habits, personal clean- 
liness, change of clothes, frequent ablu- 
tions, and the practice of never eating in 
the mine or workshop, or with unwashed 
hands, are essential. Intemperance inva- 
riably predisposes to or aggravates the 
disease. Meisens observed that workmen 
1 Jussieu's idea of the pathology is curious. 
The tremors, he says, are "les tristes effets 
du sejour du sang dans les vaisseaux du cer- 
veau, devenus variqueux par le poids de 
quelques particules mercurielles, qui y ont 
s6journ£." (Loc. cit. p. 360.) 
2 Hist. Nat. xxxiii. 40. 
3 Memoire sur l'Art de dorer le Bronze; 
Paris, 1816. Diet, des Sc. Med. 1818, xxvii. 
p. 299. 
4 Darwall in Forbes' Cyc. Pract. Med. 1833, 
i. 157. 
1 De Haen's fourth case presented consid- 
erable disturbance of the balance in locomo- 
tion. "Adeo difficulter ingreditur, ut saepius 
humi concidat, dumque corpus pronando sus- 
tinere se nititur, vi quasi supinatur." (Loc. 
cit. p. 230.) 
2 Guy's Hosp. Rep. 1864, x. 176; Lancet, 
1839-40, ii. p. 589. 806 
METALLIC TREMOR. 
who used much salt with their food are less 
liable to suffer from Mercurial Tremors, 
and he also recommended the iodide of 
potassium as a powerful preservative. Of 
late years in this country Mercurial Tre- 
mor has greatly diminished in frequency, 
and under proper hygienic rules would 
probably cease altogether, at least in its 
more aggravated forms. Water-gilding, 
the most dangerous kind of mercurial 
trade, has been now almost altogether 
superseded by electro-plating, which is 
completely innocuous. Looking-glass sil- 
vering, when conducted in large well- 
ventilated apartments, with means for 
preventing the diffusion of the metallic 
dust, is also quite safe, if the workmen 
are employed only at intervals, and are 
careful and temperate. But when these 
conditions are not attended to, and espe- 
cially if the men are kept too continuously 
at work, slight tremors soon make their 
appearance, and severe cases occasionally 
happen.1 According to Dr. Whitley's 
report,2 the number of persons affected in 
England and Wales appears to be small, 
and the cases, for the most part, slight. 
The same statement may be applied to 
Scotland and Ireland. The condition of 
the quicksilver mines is probably still one 
of considerable danger to health and life. 
But full and accurate information is want- 
ing in regard to the amount of sickness 
and mortality among the miners, and the 
means used for their protection. 
The Curative treatment consists, first, in 
complete removal of the patient from his 
noxious employment; next, in change of 
dress, ablution, exposure to a free atmos- 
phere of moderate temperature, and the 
administration of a nutritious tonic diet. 
The objects of treatment then are, 1st, to 
eliminate the mercury from the system by 
the secreting organs. Sudorifics3 have 
been much used for this purpose : acetate 
of ammonia, Dover's powder, guaiac, sar- 
saparilla, sassafras, &c. Sulphur has been 
regarded by some as specific ; warm and 
vapor baths, or sulphurous baths, &c., are 
always employed. Neufchatel had a re- 
putation for the successful treatment of 
water-gilders' palsy, chiefly by means of 
vapor baths.1 Diuretics have become fa- 
vorite remedies, and especially the iodide 
of potassium, since Meisens2 brought evi- 
dence to show that this salt has the power 
of redissolving the mercury contained in 
the tissues and eliminating it by the urine, 
in which its presence may be detected 
chemically.3 The caution must be ob- 
served not to give the iodide so largely as 
to disengage an excess of mercury at once 
within the body. Various other diuretics, 
common salt, bitartrate of potash, &c., 
may be employed. Purgatives are also 
useful. 2d. Another indication is to 
soothe and strengthen the nervous sys- 
tem, by means of antispasmodics, narcotics, 
tonics, and stimulants. Steel and quinine, 
singly or in combination, are especially 
serviceable. Opium is useful. Nitrate of 
silver has also been recommended. Stim- 
ulants, particularly alcohol, wine, &c., ex- 
ert a powerful immediate effect in arrest- 
ing the tremors : hence workmen are apt 
to resort to them to steady their hands ; 
but when the immediate effect is over, 
they aggravate the tremors. The most 
beneficial stimulants are electricity and 
galvanism, which have afforded very satis- 
factory results.4 Dr. Haen's cases were 
cured, some of them rapidly, with elec- 
tricity as the only remedy applied. 
2. Lead Tremors; Tremor Saturninus; 
Paralysis Agitans Saturnina. 
Merat denied that any other metal than 
mercury could give rise to tremors, and, 
with few exceptions,5 other writers appear 
to be of the same opinion. In regard to 
artisans using lead, this view is probably 
correct; but the case is different with 
miners exposed to the vapors of the metal. 
Brockmann,6 in particular, from his ex- 
perience in the Harz Mountains, has de- 
scribed a species of lead tremors, which 
1 Sandaret, Ann. d'Hygi&ne, 1847. 
2 Annal. de Chimie et de Physique, 1845, 
xxvi. 215, and transl. in Brit, and For. Med.- 
Chir. Rev. for Jan. 1853, p. 217. 
3 Schneider of Vienna controverts the as- 
sertions of Meisens, Ed. Med. and Sur. Jour. 
1861-2, p. 394. 
4 De Haen, loc. cit. Gull, Guy's Hosp. 
Rep. 1853, viii. p. 136. 
5 Percival, Ed. Med. and Surg. Jour. 1813, 
ix. 62, ascribed tremors rather to lead than to 
mercury ! 
6 Die Metallurgischen Krankheiten der Ober- 
harzes, 1851, p. 282; Schonlein, Allg. und 
Spec. Path, und Ther. 2 Thele, p. 191 (St. 
Gallen, 1841) ; Falck, in Virch. Handb. d. 
Spec. Path, und Ther. ii. 1 Abth. 517-8, 1855. 
Wilson, in Edin. Essays Physical and Liter. 
2d edit. 1771, p. 517, in describing the disease 
called Mile-Reek among the miners at the 
Lead hills, mentions that the "extremities 
tremble and are convulsed." Sauvages, No- 
sol. Meth. 1768, p. 558, Tremor Metallur- 
gorum. 
1 See recent cases, Scott Orr in Glasg. Med. 
Jour. i. 37, May, 1866, and Mapother, loc. cit. 
Also Taylor, loc. cit. 
2 Sixth Report of Med. Officer of Privy 
Council for 1863, p. 22; and 1864, p. 358. 
3 Jussieu remarks (1719) that at the mines 
of Almaden the medical treatment differed 
from the usual practice then in vogue of 
purging and bleeding, and consisted simply 
in exposing the patients to the free air, and 
administering absorbents, as hartshorn, ivory, 
or crab's-eyes; and what is singular (he 
adds) the treatment succeeds almost always 
in temperate subjects and those who abstain 
from wine, whilst those who indulge perish 
without resource. (Loc. cit.) SYMPTOMS-TREATMENT. 
807 
affects the miners there, and which is 
almost identical with the mercurial shak- 
ing palsy, consisting, like it, of oscillating 
spasmodic contractions of the muscles, 
and consequent tremulous motion in vari- 
ous parts of the body. Uis account in- 
cludes two forms, the local (partialis) and 
the general (universalis), both the result 
of an affection of the nervous centres by 
lead. 
Symptoms.-1st. Tremor Saturninus 
partialis.-As a rule, the upper extremi- 
ties are alone affected. The arms and 
hands are in continual vibration, more or 
less, greatest when any powerful effort is 
made, or during emotion. With this there 
is often associated a peculiar nervous tre- 
mor of the lips (muse, orbic. oris) and 
angle of the mouth (levator anguli oris), 
like that observed when a shy sensitive 
person opens his lips. The local tremor 
usually follows violent and persistent at- 
tacks of lead colic, especially in highly 
nervous subjects, or in those exhausted 
by previous disease. It disappears mostly 
in a few days, but is apt to return when 
the exciting causes are renewed. Under 
very unfavorable circumstances, however, 
it may increase and extend into the gen- 
eral form of affection. 
2d. Tremor Saturninus universalis.-In 
this the tremors are not confined to the 
arms, but appear in the legs and muscles 
of the head and trunk. The patient pre- 
sents a peculiar and pitiful aspect. When 
at rest, his back is bent like an old man's, 
his head is bowed, and the chin falls upon 
the breast; in walking, the legs are ro- 
tated tremulously as in paralysis agitans. 
In advanced cases the jaws, and indeed 
all the muscles of the head and body, are 
the seat of the uncontrollable tremors 
which characterize the disease. 
Causes.-The general tremor never re- 
sults except from deeply-rooted lead-poi- 
soning. It is preceded by repeated out- 
breaks of the severer forms of the lead 
disease, and progresses hand in hand with 
the lead cachexia. All the causes of the 
cachexia predispose to it, and the ten- 
dency is increased by an excitable ner- 
vous constitution, together with lax fibre 
and weak muscular system. Age has no 
appreciable influence. The saturation of 
the system with lead is the only exciting 
cause of the disease. 
The Course of the general disease is 
chronic and very protracted. Months or 
tven years elapse before permanent im- 
provement takes place. Often a radical 
cure is impossible. Frequently, also, the 
tremor becomes associated with some 
form of anaesthesia, or ends in complete 
paralysis. 
The Prognosis is consequently almost 
always unfavorable. Only when the dis- 
ease is partial, and follows a violent colic, 
or an acute attack of convulsions, can a 
speedy favorable issue be anticipated. 
Under all other circumstances, lead tre- 
mor is a most serious affection, and is apt 
to be the precursor of more sudden and 
dangerous disorders, such as paralysis or 
cerebral disease. 
PATHOLOGY AND MORBID ANATOMY. 
-No specific lesion has yet been pointed 
out in the brain or spinal cord. The 
affected muscles have been found altered, 
but this is of subordinate importance. 
The pathology is doubtless analogous to 
that of mercurial tremor, and idiopathic 
paralysis agitans. 
The Diagnosis is sufficiently deter- 
mined by the symptoms of the lead ca- 
chexia which accompany the tremors, and 
by the absence of any source of mercurial 
poisoning. 
The Treatment must be directed to 
neutralize the lead poison, and to strength- 
en the nervous centres, which are the 
chief seat of the disease. The energetic 
employment of sulphur baths, cold water 
douches to the spine, and the internal use 
of nervine tonics, nux vomica, or strychnia, 
valerian, quinine, &c., are the appropriate 
means. Sudorifics, sarsaparilla, &c., have 
also been used, and Meisens recommends 
the iodide of potassium on the same 
grounds as in the case of mercury. Brock- 
mann states that he never concludes the 
treatment without the persevering use of 
baths of aromatic herbs, and the cold 
plunge bath, as well as the internal ad- 
ministration of chaly beates. In obstinate 
cases electricity and galvanism must be 
resorted to, but frequently without much 
success. The most essential part of the 
treatment consists in the removal of the 
patient from his unhealthy employment, 
and placing him in free pure air, with a 
nutritious animal diet, and a moderate 
allowance of good wine and beer. 
In poisoning with arsenic, zinc, or bis- 
muth, tremors frequently occur, but they 
only form part of a general group of symp- 
toms, and do not require particular de- 
scription in this article. B-PARTIAL DISEASES OF THE NERVOUS SYSTEM. 
1. Diseases of the Head. 
Simple Meningitis. 
Tubercular Meningitis. 
Chronic Hydrocephalus. 
a. Meningeal Diseases:- 
Meningeal Hemorrhage. 
Adventitious Products. 
Congenital Malformations. 
b. Cerebral Diseases:- 
Congestion of the Brain. 
Cerebritis. 
Softening. 
Adventitious Products. 
Cerebral Hemorrhage. 
Abscess. 
SIMPLE MENINGITIS. 
By J. Spence Ramskill, M.D. 
Definition.-By Meningitis is gene- 
rally meant inflammation of the pia ma- 
ter and arachnoid. Inflammation of the 
dura mater is described separately. At- 
tempts have been made to separate in- 
flammation of the arachnoid from that of 
the pia-mater, and some, as Lallemand, 
Parent-Duchatelet, and Martinet, have 
even gone so far as to apply the term 
Arachnitis to inflammation of the arach- 
noid, on the ground that the serous mem- 
brane was the one chiefly affected. But 
an analysis of the cases given by the very 
advocates of that opinion shows most con- 
clusively that the pia mater is in all cases 
affected, and always bears more marked 
evidences of inflammation than the arach- 
noid. There is no symptom which, during 
life, could help to distinguish between in- 
flammation affecting the pia mater and 
inflammation involving the arachnoid 
alone ; and as the treatment in either 
case would be the same, there would be 
no practical advantage gained by such a 
distinction. Cerebral fever is a name 
given by Trousseau to various acute affec- 
tions of the head in children, amongst 
which he includes Meningitis. Menin- 
gitis may be primary or secondary ; un- 
complicated or complicated; acute or 
chronic. 
Acute Meningitis. Symptoms.-In 
some rare cases, certain prodromata pre- 
cede the invasion of the disease, in the 
shape of slight but increasing pains of the 
head, irritability of temper, sleeplessness, 
and general malaise. But, as a rule, the 
invasion of the disease is decided, and 
from the outset its gravity is not to be 
mistaken. Its course may be divided into 
three stages :-1st, a period of excitement -, 
2d, a period of transition; 3d, the stage 
of collapse. These three stages are not 
always present, nor are they always dis- 
tinctly marked. When the disease is 
very violent, the first stage may rapidly 
pass into the third, or comatose period. 
In old and feeble people the first stage 
may either be absent altogether, or be so 
little marked as to escape observation. 
Again, the third stage may be absent, 
from life being abruptly cut short by vio- 
lent general convulsions in the second 
period; and lastly, the first and third 
stage may coalesce during the transition 
from one to the other, and may present 
mixed phenomena of delirium alternating 
with coma. 
Stage First. Period of excitement.-A 
well-marked rigor, with pallor of the sur- 
face and cutis anserina, opens the scene, 
and is very quickly followed by intense 
808 ACUTE MENINGITIS. 
809 
febrile reaction. In very young children 
a paroxysm of general convulsions may 
be the first symptom ; in adults, however, 
convulsions are the exception. The fever 
is very high; the skin is hot and dry; the 
pulse frequent, sharp, and hard ; the face 
flushed, particularly about the malar 
bones : sometimes it is alternately flushed 
and pale. The eyes are glistening, the 
conjunctivae injected ; the pupils in this 
stage are usually contracted; there is 
photophobia; and, in order to keep the 
light out, the patient keeps his eyes firmly 
closed, and resists all attempts at opening 
them on the part of the practitioner. 
There is sometimes strabismus on one or 
both sides, particularly in children. Acous- 
tic dysaesthesia distresses the patient: the 
least sound, the lightest footstep about the 
room gives him pain. Cephalalgia of the 
most acute character sets in from the first. 
It is referred to the forehead, vertex, 
temples, or occiput, or to the head gene- 
rally : pressure on the scalp increases, 
and movement intensifies it; hence, in 
order to prevent his head from moving, 
the patient holds it between his hands. 
Sensorial impressions of light and sound 
also exaggerate it. The pain is continu- 
ous, but presents also frequent exacerba- 
tions, during which the patient, especi- 
ally if a child, utters a peculiar, loud, 
piercing cry. The headache may precede 
the other symptoms for a day or two, or 
for a few hours only, or it may appear 
simultaneously with them. It is the most 
striking symptom of the disease; it is pre- 
sent in nearly every case, but not in all; 
and Andral has related in the "Clinique 
Medicale," cases in which it was absent 
from first to last; and, in one of these, 
sero-purulent effusion was found in the 
lateral ventricles after death. The inten- 
sity of the pain does not bear any relation 
to the stage of the inflammation and the 
nature of its products. Thus, it has been 
found as severe in cases where a post- 
mortem examination disclosed mere injec- 
tion and increased vascularity of the men- 
inges, as in cases of serous or purulent 
infiltration of the membranes, or when 
false membranes had time to develop. 
The extent over which it is felt is not pro- 
portionate to that of the inflammation, 
for it may be felt all over the head, and 
yet the Meningitis be partial only; on the 
other hand, it may be exactly limited to 
one particular spot, and yet the inflam- 
mation be general. When partial, it does 
not always correspond to the exact seat 
of the inflammation, although when an 
individual complains of a fixed pain in a 
spot never varying, the probability is, 
that the meninges are inflamed at that 
point. The cephalalgia of Meningitis dif- 
fers from that of continued fevers in its 
intensity, and in the fact that the patient 
does not wait, as in the latter, till asked 
whether he has any pain in his head, be- 
fore speaking of it himself, and craving 
for relief. The character of the pain va- 
ries ; it is described by some as a heavy 
weight pressing on their brain; by others, 
as consisting in violent shooting pains, 
either continuous or recurring at inter- 
vals. Sometimes, again, it is compared 
to the sensation of an iron band encircling 
the forehead, or of the head being squeezed 
in a vise. Vomiting is another well- 
marked symptom of acute simple Menin- 
gitis. It is purely sympathetic, and is 
unattended with epigastric pain or ten- 
derness on pressure, or with nausea. It 
recurs very frequently for the first day or 
two of the disease, and may then cease : 
but in some cases it persists unto the end, 
either continuously, or with more or less 
prolonged intermission. The matters vom- 
ited are abundant in quantity, and are 
mixed with bile. The tongue is natural, 
generally moist, and occasionally covered 
with a white creamy fur. Constipation is 
the rule, and the discharges, when there 
are any, are dark and offensive. 
The intellect is always affected from an 
early period. The temper is extremely 
irritable ; there is marked somnolence or 
constant wakefulness, or the one may al- 
ternate with the other for several days. 
Delirium sets in early ; it is generally of 
a wild, fierce character, the patient shout- 
ing and vociferating, and tossing himself 
about. In some cases, on the contrary, 
the first sign of intellectual disorder is 
obstinate mutism, the patient burying his 
head under the bed-clothes and refusing 
to answer questions. Sometimes the de- 
lirium reaches at once its maximum on 
its first occurrence, but otherwise it is 
slight at first and gradually becomes more 
and more marked. Sometimes, again, it 
is only nocturnal at the outset, and does 
not become diurnal until after a few days ; 
and again, a patient who has been wildly 
delirious for a few days may recover his 
reason before death, although all his 
other symptoms grow worse. 
From the beginning the patient stag- 
gers when walking, and his gait resembles 
that of a man under the influence of 
drink. When he has taken to his bed, he 
is extremely restless, and keeps constantly 
shifting his position. The muscles of his 
face and limbs, even in this stage, may 
begin to twitch involuntarily. When con- 
vulsions have opened the scene, as they 
frequently do in young children, they re- 
cur in frequent paroxysms one upon the 
other with scarcely any intermissions. 
The general sensibility is usually height- 
ened in this stage, although it has some- 
times been known to be normal. To sum 
up, the characteristics of the first stage 
are high fever, cephalalgia, an occasional 
sharp piercing cry, vomiting and consti- 
pation, general hypersesthesia, sensorial 810 
SIMPLE MENINGITIS. 
and cutaneous, and fierce delirium. This 
stage may last only a day or two, but gen- 
erally extends over a week, and some- 
times over two weeks. It then merges 
into the second or transition period. 
Stage Second.-The delirium becomes 
quieter; there is carphology, picking at 
imaginary flies in the air, or on the bed- 
clothes ; and the patient's eyes become 
dim and lustreless : his pupils dilate, or 
they oscillate at first before they dilate, 
and become insensible to the influence of 
light. Vision is impaired; hearing gets 
dull. The patient complains less often of 
his headache, because he is less sensible ; 
occasionally, however, he utters still a 
loud cry, he grinds his teeth, moving his 
jaws as if he were chewing, and rolls his 
head from side to side, boring his pillow 
with his occiput. Somnolence sets in, to 
be soon followed by a comatose condition. 
The pulse is less frequent, and occasion- 
ally intermits. The respiration is very 
irregular; at one time it is very rapid, 
and the next moment it is slow and suspi- 
rious, made up of a long, deep inspira- 
tion, followed by a slow and long-sus- 
tained expiration. The urine is retained, 
or there may be stillicidium after reten- 
tion. The constipation persists ; and the 
abdomen is apt to become retracted, 
sunken, and almost boat-shaped. The 
general hypersesthesia is now replaced 
by hypsesthesia, which soon makes way 
for complete anaesthesia. The muscular 
twitchings increase; there is subsultus 
tendinum, and actual convulsions often 
set in. These may be general or partial, 
usually the latter, and they then attack 
different parts successively/ The muscles 
most commonly affected are those of the 
eyeballs, producing strabismus, or rolling 
upward of the globes ; the muscles of the 
face and lips ; and lastly, of the extremi- 
ties. The tongue itself may be the seat 
of convulsions. There may be rigidity in 
one or more limbs, and the head may be 
bent backwards, or be permanently in- 
clined to one side. Spasm is apt, after a 
time, to alternate with paralysis, or the 
latter may be gradually or abruptly estab- 
lished. In some cases the paralysis may 
come and go: in others, a limb may be 
paralyzed, whilst its homologue is the seat 
of violent convulsions. The characteris- 
tics of this second stage are generally 
prostration, convulsive movements, grad- 
ually developing coma and total paralysis, 
motorial and sensory, a thready pulse, 
and an irregular, suspirious respiration. 
Stage Third.-The collapse is now com- 
plete, and the coma profound. The 
pupils are widely dilated, and are insen- 
sible to light, the eyes are half open, the 
face sunk and ghastly, the skin cold and 
clammy. The sphincters relax, the urine 
and feces are passed involuntarily, and 
the pulse becomes frequent again, indeed 
more so than before ; it is small, filiform, 
and uncountable ; the breathing is ster- 
torous, and the patient at last dies in a 
state of complete coma. 
Acute Meningitis in old persons, Dr. 
Machlachlan asserts, seldom occurs sud- 
denly, and rarely exhibits the acute symp- 
toms of Meningitis which affects persons 
of middle age, or of a younger period of 
life. It commences insidiously, and with- 
out premonitory rigors ; it may exist some 
days without the most experienced eye 
detecting it. The pulse is natural, the 
tongue clean, the bowels regular, and 
there is little or no vascular excitement, 
local or general. The temper is peevish 
and irritable, with more or less confusion 
of thought, inattention, and forgetfulness. 
The patient makes strange mistakes, 
takes possession of another's bed, uses 
the spittoon instead of the chamber-pot. 
When addressed, his replies are rational, 
but there is a peculiarity in his manner 
and expression of countenance, an appa- 
rent slowness of comprehension, and a 
vacancy of eye. The appetite mean- 
while is normal, and there is no feverish 
reaction. Yet there is great restlessness, 
unsteady gait, a trembling hand when 
the patient lifts anything to his mouth. 
After from twelve to sixty-two hours 
there comes on slight feverish reaction, 
expressed by increase of temperature only, 
and not by flushing of face or increase of 
pulse. Next, wandering, low delirium, 
and incessant talking become frequent 
and characteristic symptoms. Maniacal 
excitement is uncommon : reverie gener- 
ally passing into coma constitutes the 
rule. Headache is not a permanent symp- 
tom. The patient moans, but never com- 
plains. Unless the patient is pointedly 
asked about headache, there is never any 
allusion made to it, or to tinnitus aurium. 
Dr. Machlachlan takes especial notice of 
this absence of headache ; for even in the 
most acute pus-forming or false-mem- 
brane-forming Meningitis, headache may 
be entirely absent from the beginning. 
The eyes are suffused, the pupils slightly 
contracted, or natural. Knitting of the 
eyebrows, intolerance of light, acuteness 
of hearing, and vomiting, are compara- 
tively rare in the aged. The only objec- 
tive evidence of increased vascular action 
within the cranium may consist in a hot- 
ter scalp than natural, and suffusion and 
injection of the eyes. There is great thirst 
usually, the patient will drink freely when 
liquids are offered to him, but he will sel- 
dom ask for drink, whilst he is very apt 
to refuse all food. In the worst cases, 
nervous twitchings and convulsions are 
observed, and these symptoms may be in- 
duced when otherwise absent, by raising 
the patient in bed. When coma is pres- 
ent slight convulsions of the limbs may 
be present. The general aspect of the ACUTE MENINGITIS. 
811 
senile Meningitis resembles typhus fever 
rather than Meningitis. The dryness and 
brown color of the tongue, the muttering 
delirium, excessive prostration, injection 
of conjunctive and heat of scalp, equally 
belong to either affection ; but in Menin- 
gitis the livid hue of the surface, and the 
mulberry rash characteristic of typhus, 
are wanting, whilst the diffused heat of 
skin of the latter disease is absent, or 
limited to the forehead and scalp in Men- 
ingitis. 
Varieties as to Seat.-Meningitis may be 
partial or general. When partial, it may 
be limited to a small portion only of one 
hemisphere, generally the anterior lobe, 
or to the whole of one hemisphere alone, 
in that case stopping abruptly at the me- 
dian fissure ; or it may affect the convexity 
of both hemispheres, or be restricted to 
the base alone. In some cases it affects 
the base and the convexity of the hemi- 
spheres simultaneously. Meningitis of the 
base alone is, in the immense majority of 
cases, of tubercular origin. Parent-Du- 
chatelet and Martinet regarded very pro- 
found coma, not preceded by delirium, as 
characteristic of this variety of the dis- 
ease ; but Andral has conclusively shown 
that they were mistaken. As regards the 
relative frequency of the partial and gen- 
eral form of Meningitis, Parent-Duchatelet 
and Martinet say, that in ninety-one out 
of a hundred and seventeen cases, the 
inflammation affected the convexity of 
both hemispheres, and in twenty-six, one 
hemisphere alone.1 
A very rare form of Meningitis is that 
which is confined to the membrane lining 
the interior of the lateral ventricles, a 
membrane which is so very fine and deli- 
cate, as to be indistinguishable when in a 
healthy condition, and the existence of 
which has even been denied by Kolliker. 
Andral relates five cases of this variety, in 
one of which the granular condition of the 
membrane pointed to its tubercular origin, 
a view which was supported by the pre- 
sence of tubercle in one lung; whilst in 
another of these cases, the intra-ventricu- 
lar effusion occurring in the course of 
general anasarca and ascites, was proba- 
bly one of the results of albuminuria. The 
first case of the series, however, seems to 
be an instance of genuine inflammation of 
the membrane lining the lateral ventricles, 
which cavities were found after death to 
contain a sero-purulent fluid. The symp- 
toms of this rare form of the disease do 
not differ from those of Meningitis in 
other parts. There is the same acute 
cephalalgia, generally referred to the su- 
pra-orbital region, followed by delirium 
and coma, and in some cases attended 
with violent agitation, convulsive move- 
ments, and tetaniform rigidity of the 
limbs. 
Cerebral complications are sometimes 
apt to arise in the course of an attack of 
acute articular rheumatism. Of these, an 
affection resembling Meningitis seems by 
far the most frequent. In his work on 
"Diseases of the Brain," Abercrombie 
relates a few instances of this variety of 
the affection in a chapter headed "A dan- 
gerous modification of Meningitis, which 
shows only increased vascularity." In 
France, where the affection seems to be 
more common than here, the subject has 
been very much discussed of late years, 
and has given rise to a good many predicr 
tions. So far back as 1835, however, Sir 
Thomas Watson had called attention to 
these head complications, which he as- 
cribed to a disturbance of the cerebral 
circulation, arising from the cardiac dis- 
ease, which so often supervenes in the 
course of acute articular rheumatism, and 
which he stated to denote an inflammatory 
condition of the brain or its membranes. 
There is no doubt that cases of rheu- 
matic fever have occurred in which, from 
the character of the symptoms, the exist- 
ence of Meningitis has been diagnosed, 
whilst post-mortem examination disclosed 
no such affection. Several such cases are 
mentioned by Dr. Fuller, in his work on 
Rheumatism, pp. 303, 304. 
The invasion of the disease is, as a rule, 
very sudden; mostly appearing in the 
middle of the night. There may or may 
not have been some premonition of the 
coming complication in the shape of a 
feeling of anxiety, of terror, of strange 
forebodings of evil, a fear of impending 
death, expressed by the patient (Bourdon 
and Vigia); or, for a few hours before the 
actual attack, there may have supervened 
sudden mistiness of vision, as in a case 
related by Trousseau, in his " Clinique 
Medicale." As a rule, the disease does 
not occur at the commencement of the 
rheumatic attack, but is always preceded 
by pain and swelling of one or more joints. 
The invasion itself is characterized by 
great increase of temperature, restlessness 
and jactitation, extreme loquacity, and 
wild delirium, soon followed by coma, 
with intervals of muscular twitchings or 
slight convulsions. In some cases, the 
delirium is remarkable for the obstinate 
taciturnity of the patient. The pulse sud- 
denly becomes very frequent, small, and 
irregular. The respiration is sometimes 
hurried, and sometimes slow. In the 
majority of cases, the swelling of the 
joints goes down, the redness disappears, 
and the cerebral symptoms seem to be at- 
tributable to a real metastasis. In some 
cases, however, the articular disease per- 
sists undisturbed. As to the pain in the 
joints, it is no longer complained of; but 
this is no proof that it has ceased, it 
1 Parent-Duchatelet et Martinet, De 1'Arach- 
nitis, p. 94. 812 
SIMPLE MENINGITIS. 
merely shows that the intellect is so af- 
fected that the patient is unconscious of 
pain, or at least no longer takes cogni- 
zance of it. One of the most distinctive 
features of this form of Meningitis is the 
absence of headache and the absence of 
vomiting; two symptoms which are so 
prominent in simple acute Meningitis. In 
the latter affection, the course of the dis- 
ease is generally rapid, but its rapidity is 
much less than that of rheumatic Menin- 
gitis. The patient may die in a few hours; 
more often from two to five days. If he 
lives beyond that time, the probability is 
that he will escape ; and this prognosis 
will be all the more certain if the swelling, 
pain, and redness of the joints again 
make their appearance. Recovery, how- 
ever, is rare ; but when it does occur, con- 
valescence sets in rapidly. In some cases 
the affection terminates in insanity, but 
the rule is, that death takes place; ac- 
cording to Vigia,1 thirty out of thirty-nine 
cases terminated fatally. 
The causes of this peculiar complication 
of acute articular rheumatism are very 
obscure. It is said to occur more fre- 
quently in cold weather, in the cold 
months of the year; and there is no 
doubt that exposure to cold is often an 
exciting cause. Vigia's assertion that 
patients who perspire very profusely, and 
who show confluent sudamina, are more 
liable to the disease than others who per- 
spire less and have few sudamina, can be 
easily explained by the greater liability of 
the former category of patients to catch- 
ing cold. The disease has been attributed 
to the perturbing influence of certain 
methods of treatment. Repeated blood- 
letting has, by some, been regarded as 
the cause of the disease, on account of its 
weakening the system and causing a pre- 
ponderance of the amount of fibrine over 
the other constituents of the blood (Beau 
and Briquet). Others, on the contrary, 
have ascribed it to the large doses of qui- 
nine which, in France particularly, are 
administered in acute rheumatism. The 
well-known influence, they say, of qui- 
nine in large doses, in producing tinnitus 
aurium, giddiness, and deafness, explains 
how its administration may, in acute 
rheumatism, render the brain liable to be 
affected by the rheumatic poison circulat- 
ing in the blood. This influence of qui- 
nine in the causation of rheumatic Me- 
ningitis is far from being proved, and 
Trousseau denies it emphatically. This 
author cites a case of Dr. Beau, in which 
the symptoms of Meningitis began to 
show themselves, after the commence- 
ment of the quinine treatment, when 
small doses only of the drug had been 
given, while it completely disappeared on 
continuing the treatment, and giving 
larger doses of quinine. 
According to Trousseau, habitual ex- 
cess in drinking is the chief cause predis- 
posing to this affection, and also an he- 
reditary tendency to neurotic affections of 
any kind, and chiefly the various forms of 
insanity. The post-mortem appearances 
found in such cases are generally a con- 
siderable injection of the membranes of 
the brain, and in some cases sub-arach- 
noid effusions of serosity are met with ; 
in very rare ones, pus has been found 
over the hemispheres, as in three cases by 
Watson.1 Trousseau regards the affec- 
tion as a neurosis, and totally discards 
the opinion that it is really constituted 
by an inflammatory condition of the me- 
ninges, and it is now well known that in 
the majority of cases of acute rheumatism 
terminating by high temperature and 
head-symptoms, nothing at all resembling 
Meningitis has been discovered upon post- 
mortem examination. 
Meningitis occurs also in individuals 
suffering from tertiary syphilis; for just 
in the same way as nodes and gummy 
tumors form under the periosteum, in dif- 
ferent parts accessible to view, similar 
deposits are found in the substance of the 
dura mater. In some cases, the mem- 
brane is not inflamed in the vicinity of 
these growths, but in others the dura 
mater is thickened, and adherent to the 
brain, while itself participates in its su- 
perficial layer, in the chronic inflamma- 
tion. The symptoms indicating the pre- 
sence of such deposits are intense and 
constant cephalalgia, with nocturnal ex- 
acerbations ; in some cases with convul- 
sions, obtuseness of the intellectual fac- 
ulties, and sometimes paralysis. The 
previous history of the patient, the pecu- 
liar sallowness of his complexion, and the 
presence in many cases of periosteal 
nodes, either on the head itself or on the 
bones of the leg, sufficiently attest the 
nature of the case. In less patent cases, 
the history of the patient will often decide 
its character. According to Robin and 
Lebert, these deposits can be recognized 
to be of syphilitic origin by the characters 
which they invariably present, and the fol- 
lowing is a description of their microscop- 
ical structure as given by Robin.2 
First.-They consist of an amorphous, 
transparent, grayish, granular blastema. 
Second.-This blastema is traversed in 
spots by lamellar fibres which lie deeply 
in it, and are often difficult to see, and 
which are accompanied with fusiform, 
fibro-plastic bodies, not numerous on the 
whole. 
1 Principles and Practice of Physic, p. 302, 
vol. ii. Fourth edition. 
2 In Zambaco, Affections Nerveuses, Syphi- 
litiques, p. 80. 
1 Actes de la SocitStd M6dicales des H6pi- 
taux de Paris, 1855, Troisifeme fascicule. PROGRESS AND DURATION OF ACUTE CEREBRAL MENINGITIS. 
813 
Third.-In the portions that are whit- 
ish, the amorphous blastema is scattered 
over with a certain number of fat granules, 
and some drops of oil. 
Fourth.-The most abundant elements 
of the tissues are cytoblasts, which make 
up four-fifths of the whole. They are uni- 
formly distributed in the amorphous blas- 
tema, and between the fibres of the lamel- 
lar tissue; they are separated from one 
another by a substance which scarcely 
equals their own width. From their 
number, and their mode of distribution, 
they make the blastema look of a remark- 
able uniform composition. Free nuclei 
are found in great abundance. A few 
cells are also met with, with pale, trans- 
parent, finely granular bodies; they are 
almost spherical in shape, some are ovoid, 
a few angular : the nuclei have a distinct 
and generally dark contour. They have 
no nucleolus. 
Fifth.-A few rare embryo-plastic ele- 
ments. 
Sixth.-A few globules of pus. 
Treatment consists in the administration 
of large doses of iodide of potassium, of 
mercurial baths, or, when pain and sleep- 
lessness are constant, of calomel and opium 
at night, with salines and iodide of potas- 
sium during the day. 
Inflammation of the Dura Mater 
is exceedingly rare, as an idiopathic affec- 
tion, and generally comes under the cog- 
nizance of the surgeon as the result of a 
blow or a fall on the head. Abercrombie 
gives one case of spontaneous inflamma- 
tion of the membrane which had come 
under his own observation; but even 
there, the disease had spread to the 
arachnoid. Inflammation of the dura 
mater is apt to supervene in cases of 
chronic otorrhoea, an affection which fre- 
quently sets in after scarlatina, and some- 
times also after measles and variola. 
There is at first merely a thick muco- 
purulent discharge from the ear, with 
some tenderness about the mastoid pro- 
cess, and this goes on for a long time, 
when suddenly the patient becomes dull 
and drowsy, complains of intense pain in 
the head, he then becomes delirious, and 
lastly passes into a state of coma. After 
death, the petrous portion of the temporal 
bone is found carious and softened, and 
the dura mater overlying it is seen to be 
detached, inflamed, and generally bathed 
in pus. 
The same series of phenomena may 
also occur in cases of chronic disease of 
the ethmoid bone ; or inflammation may 
spread to the dura mater from the mem- 
brane lining the cavity of the orbit in 
cases of wounds of the eyeball or fractures 
of the orbit. 
The symptoms of the meningeal com- 
plication are well marked: there is con- 
siderable rigor recurring in paroxysms, 
followed by high fever, and so marked 
are the intermissions that the disease 
simulates an attack of ague. Headache 
is complained of, and the discharge of 
matter from the ear does not give ease. 
Vomiting is often present, together with 
hypersesthesia of the retina. There may 
be slight convulsions, but these are never 
general, and never so marked and so 
violent as in cases of pure Meningitis. 
When there is inflammation of the sinuses 
in the head, which are formed by dupli- 
catures of the dura mater, secondary ab- 
scesses show themselves in distant and 
various parts of the body, in the joints of 
the big toe, the knee, the hip, the wrist, 
&c. The aguish aspect of the symptoms 
in such cases is extremely marked : there 
are strong rigors, followed by heat and 
clammy perspiration. 
The treatment should have for its 
object to prevent, or at least to limit, the 
extension of the inflammation, by the 
application of leeches to the mastoid pro- 
cess, as soon as it is found to be tender, 
and subsequently by the use of blisters. 
The ear should be carefully syringed with 
warm water, and the pus allowed a free 
escape. When there can be no doubt that 
the meninges are attacked, the treatment 
to be recommended in Meningitis should 
at once be adopted. When secondary 
pysemic abscesses have formed, the treat- 
ment should be of a stimulating character, 
combining the administration of wine and 
strong nourishing broths, with the use of 
bark and acids, quinine and iron, &c. 
Instances of recovery have been recorded 
in cases when head symptoms have pointed 
to an extension of disease from the inter- 
nal ear to the dura mater, and Abercrom- 
bie has related a case of a young lady 
who, after the usual symptoms, lay for 
three or four days in a state of perfect 
coma. Iler medical attendants thought 
her condition utterly hopeless, and con- 
tinued to visit her as a matter of form. 
One day, however, they were agreeably 
surprised to find her sitting up and free 
from complaint; a copious discharge of 
matter had taken place from the ear with 
immediate relief, and she subsequently 
perfectly recovered. 
Progress, Duration, and Termina- 
tion of Acute Cerebral Meningitis. 
-The progress of the disease is always 
continuous ; there may be slight remis- 
sions, but never those intermissions which 
form such a remarkable feature of tuber- 
cular Meningitis, during which the appa- 
rent improvement is so great as to mislead 
the inexperienced into the belief that the 
patient is getting well. 
The duration of the complaint is ex- 
tremely variable. It has been known to 
be fatal in thirty-six hours (Rilliet and 814 
SIMPLE MENINGITIS. 
Barthez), but as a rule, death only fol- 
lows at about the end of the first week, 
although it may take place at the end of 
the second, third, and even fourth week. 
The termination of the disease is gen- 
erally in death : very few cases recover, 
and only when active treatment has been 
employed at the very outset. It is doubt- 
ful whether any acute cases ever pass 
into the chronic form. 
Pathological Anatomy. -The post- 
mortem appearances necessarily vary ac- 
cording to the stage of the disease in 
which death has occurred. Thus, there 
may be only intense redness from in- 
creased vascularity of the membranes, 
which are also remarkably dry ; or, if the 
disease has lasted a few days, there may 
be fluid effused on the free surface of the 
arachnoid, in the interior of its sac, and 
in the meshes of the pia mater. The 
effusion may be serous, sero-purulent, or 
entirely purulent. It is rarely abundant 
enough to produce a distension and prom- 
inence of the anterior fontanelle, although 
a case is related by Abercrombie' in 
which, "at an early period of the com- 
plaint, there was observed a remarkable 
prominence of the anterior fontanelle ; in 
the second week this increased consider- 
ably ; and in the third week it was ele- 
vated into a distinct circumscribed tumor, 
which was soft and fluctuating, and pres- 
sure upon it occasioned convulsion. It 
was opened by a small puncture, and 
discharged at first some purulent matter, 
afterwards bloody serum. After death 
the opening which had been made through 
the fontanelle was found to lead to a de- 
position of thick flocculent matter mixed 
with pus, between the dura mater and 
arachnoid, and covering the surface of the 
brain to a considerable extent." 
When death takes place at the end of 
the first week, the pus is no longer liquid; 
its more fluid portion has been absorbed, 
and false membranes of a bright yellow 
color are now found, which are not yet 
adherent to the arachnoid. The pus infil- 
trates the meshes of the pia-mater, and 
dips between the convolutions. The con- 
crete. pus is found in greatest abundance 
around the larger bloodvessels, and in the 
sulci between the convolutions of the up- 
per and lateral portions of the brain. 
Sometimes, as in a case detailed by Ril- 
liet,2 one hemisphere may be seen covered 
with pus or false membranes, whilst the 
pia-mater on the opposite side is merely 
infiltrated with serosity. The brain, in 
uncomplicated Meningitis, is not affected; 
it is generally of firm consistency, and 
sometimes even more firm than usual. If 
deatli has occurred at an early period of 
the complaint, between the second and 
fifth day for instance, the gray and white 
substances present scarcely any traces of 
injection. After that time, they may still 
be perfectly healthy, although in the ma- 
jority of instances the gray substance is of 
a somewhat pinkish hue, 'whilst the cut 
surface of the white matter shows numer- 
ous red points. The whole mass of the 
brain is always firm, but the peripheral 
layer of the convolutions may be softened ; 
and when stripped off, the pia-mater 
which adheres to it carries away some 
portions of it. The longer the duration 
of the disease, the greater the risk of this 
complication, although there may be ex- 
ceptions to this rule. In very young chil- 
dren, according to Rilliet, the whole mass 
of the brain is sometimes soft throughout, 
and he ascribes this softening to oedema 
of the brain. The lateral ventricles may 
be found empty, or they may contain 
transparent serosity, or even pus, and, in 
rare cases, false membranes. According 
to Andral (Clinique Medicale, vol. v. p. 
140), the presence of serosity should not 
be regarded as the result of a morbid pro- 
cess, unless the quantity amount to more 
than one ounce of fluid in each lateral ven- 
tricle. 
Etiology.-A. Predisposing causes:- 
First, Age.-According to Guersant 
(Dictionnaire de Medecine, art. Menin- 
gite) simple acute Meningitis may occur 
in the foetus in utero, and is pretty fre- 
quent in new-born infants. After the age 
of two up to fourteen, it becomes rare, 
and yields in frequency to tubercular 
Meningitis, the two being then in the 
proportion of two of the former to twelve 
of the latter. After fourteen, it again 
increases in frequency, and particularly 
attacks individuals whose ages range from 
sixteen to forty-five. 
Second, Sex.-It is considerably more 
frequent in male adults than in women ; 
according to Parent-Duchatelet and Mar- 
tinet, in the proportion of three males to 
one female. 
Third.-1Those trades or occupations 
which expose the individual to atmo- 
spheric changes seem to predispose to the 
disease. Thus masons, carpenters, sol- 
diers, &c., seem to be more liable to it 
than other men. 
Fourth.-The sanguine temperament, 
a short thick neck, hypertrophy of the 
heart, a very irritable temper, are said 
also to predispose to the disease, as well 
as the abuse of alcoholic liquors, excessive 
grief, and mental work. 
B. Exciting Causes.-The most common 
are blows on the head, falls, and concus- 
sions, &c.; and more frequently exposure 
to a hot sun in tropical countries. The 
1 Abercrombie, Diseases of the Brain, p. 57. 
2 Rilliet, De la Meningite franche chez 
les Enfants. Archives Generates de Medecine, 
1846, vol. xii. 815 
DIAGNOSIS - TREATMENT. 
sudden disappearance of a chronic erup- 
tion about the scalp, e. g., chronic eczema 
or impetigo, has been known to be fol- 
lowed by acute Meningitis ; but this cause 
is not so frequent as it has been held by 
some authors. 
Diagnosis.-It is extremely difficult to 
distinguish acute Meningitis from acute 
Cerebritis-as the two affections so fre- 
quently coexist; inflammation of the 
membranes having a tendency to spread 
to the substance of the brain, or the re- 
verse obtaining. In simple Cerebritis, 
however, uncomplicated with Meningitis, 
the excitement is not so marked, the 
delirium is not of the same wild, fierce 
character, the pulse either does not rise 
above its natural standard, or falls below 
it, even down to sixty or fifty ; it is, be- 
sides, irregular and varies considerably in 
its rate of frequency. There is also tonic 
rigidity of one or more limbs, followed by 
paralysis, which is permanent. In every 
case, however, the limitation of the in- 
flammation can at best be merely sus- 
pected. 
From Delirium Tremens, acute Menin- 
gitis may be distinguished by the absence 
of headache in the former affection, the 
peculiar trembling, the hallucinations and 
spectral illusions and fears of the patient, 
the character of the delirium, and the 
abundant, clammy perspiration. The 
previous history of the patient, besides, 
usually tells a long story of inebriation. 
Typhoid Fever may be separated from 
acute Meningitis by the headache being 
less intense, by the frequency of the pulse, 
the presence of diarrhoea, the infrequency 
of vomiting, if at all present, the gurgling 
in the iliac fossa, and abdominal tender- 
ness, the leaden tint of the countenance, 
and, after the fifth day of the disease, by 
the characteristic rose spots. 
The points of distinction between the 
simple and the tubercular forms of Men- 
ingitis will be given when treating of the 
latter affection. 
Treatment.-The treatment of acute 
Meningitis is only successful when em- 
ployed very early in the disease, and 
carried out with energy. It resolves 
itself into three great remedial measures : 
first, blood-letting; second, hard purging ; 
third, application of cold water or ice to 
the head. 
Blood-letting.-The patient is to be bled 
in the sitting posture, from a large open- 
ing in a vein in the arm, and continued 
until syncope is induced. The bleeding 
is to be repeated as often as the symp- 
toms require it, or to be followed by the 
application of leeches behind the ears and 
to the temples. Continental practitioners 
often prefer bleeding from the dorsal vein 
of the foot to opening a vein at the bend 
of the elbow. According to Guersant, in 
very irritable individuals who are very 
sensitive to pain, especially in very young 
children, the application of leeches to the 
head increases the restlessness and the 
headache, and he therefore recommends 
that the leeches should in such cases be 
applied round the anus or about the 
ankles. 
When it is not considered advisable to 
repeat the bleeding, compression of the 
common carotids in the neck, as originally 
suggested by Dr. Blaud (of Beaucaire),1 
might be had recourse to, so as to cut off 
for a time the supply of blood to the head. 
The application of leeches to the in- 
terior of the nostrils, or scarifying the 
membrane with a lancet, is a favorite 
practice with some of the German phy- 
sicians, and must directly relieve the cir- 
culation in the head on account of the in- 
osculation between the vessels which 
ramify in the pituitary membrane and 
those at the base of the brain. 
[My experience very positively confirms 
the above recommendation of venesection 
in the early treatment of simple menin- 
gitis. The now common opposition to it 
proceeds upon theoretic grounds, from 
practitioners who have never made trial 
of it. I have not, however, found diffi- 
culty in the use of leeches, instead of or 
after general bleeding. They may be ap- 
plied either to the temples or the back of 
the neck ; in children, most conveniently 
the latter. When much restlessness ex- 
ists, cut cups have the advantage of re- 
quiring less time than leeches in their 
application.-H.] 
Purgatives.-Active purging possesses 
considerable efficacy in the early stage of 
the. disease, and materially aids bleeding 
in producing its full effects. Calomel, 
jalap, and scammony are the purgatives 
usually selected, but croton oil seems by 
far the best, from the ease with which it 
may be administered, even to children, 
and the certainty and rapidity of its 
action. 
Mercury. - Apart from its purgative 
effects, it is a most valuable remedy in 
Meningitis. It should be administered in 
small and frequently repeated doses, so as 
to bring the system under its influence 
quickly ; and this is best effected by com- 
bining, with its internal administration, 
the use of mercurial inunctions in the 
groin and axilla. 
The application to the head of cold, in 
its various forms, should never be neg- 
lected. There is no remedy so effectual 
in lowering the heat of the head, calming 
the headache, and subduing the violence 
of the delirium. Simple compresses, kept 
1 Bibliothfeque Mfidicale, vol. Ixii. See also 
Valleix, Guide du Medecin practicien, vol. ii. 
p. 49. 816 
SIMPLE MENINGITIS. 
wet with cold water, are the least useful 
form of using cold, as they are soon heated 
and become dry, and the alternation of 
heat and cold thus produced might be in- 
jurious by attracting more blood to the 
head. A bladder, containing pounded 
ice, or a mixture of common salt and ice, 
is an excellent mode of applying cold, be- 
cause of the facility with which it adapts 
itself to the shape of the head. The 
most effectual method, however, is irri- 
gation, i. e. allowing a small stream of 
water to run on the head from a small 
vessel placed above it. The effect of this 
is almost magical, but it should be used 
with great caution, particularly in chil- 
dren and aged persons, so that its seda- 
tive influence might not be too powerful. 
Previous to using any applications on the 
head the hair should be cut close or 
shaved, and this simple measure is some- 
times attended with great relief to the 
patient. Simultaneously with these ap- 
plications revulsives should also be em- 
ployed at the opposite extremity of the 
body by wrapping up the calves of the 
legs in mustard poultices, or in blankets 
wrung out of hot water and sprinkled 
with turpentine. 
When the disease has passed into the 
third stage, that of coma, the above treat- 
ment is no longer admissible. Blisters 
applied to the nape of the neck and be- 
hind the ears, are exceedingly useful; and 
if the coma be very profound, a cap of 
blistering ointment applied over the whole 
skull has been known to rouse the patient. 
Flying blisters, applied in rapid succes- 
sion to the inner aspect of the thighs, the 
calves of the legs, or mustard poultices 
even, are then useful also to rouse the 
system. When collapse has set in, mer- 
cury and purgatives should, of course, be 
discontinued, and stimulants, ammonia, 
and bark had recourse to. The bladder 
should be frequently examined to prevent 
the accumulation of urine and its conse- 
quent evils. 
[The disparagement of blisters by some 
late authors induces me to add confirma- 
tion, from my own experience, of their 
value, after the early stage of high febrile 
excitement has passed, the other symp- 
toms not having given way. I have seen 
several recoveries under apparently the 
most unpromising circumstances, when 
simple meningitis was actively treated, 
with bleeding, purgation, cold to the 
head, and vesication, either of the back 
of the neck or over the whole shaven 
scalp.-II. ] 
Diet.-1The diet, in the first stages, 
should be low; no solid food is to be 
given. 
In the third stage, however, strong 
broths given in small quantities repeated- 
ly and wine become essential. 
The room in which the patient lies 
should be kept cool and dark, and well 
ventilated, and free from the slightest 
noise. 
Sometimes after the acute stage of the 
disease has passed, and convalescence has 
begun, the delirium is apt to return. 
The practitioner should carefully guard 
against the error of mistaking this con- 
dition for-one of recrudescence ; it is due 
to exhaustion, and, as such, requires a 
judicious stimulating plan of treatment. 
It may be known by the coldness and pal- 
lor of the surface, and the weak compres- 
sible state of the pulse. 
When occurring in the course of acute 
rheumatism prophylactic measures should 
always be adopted, such as the avoidance 
of cold, clothing the patient in flannel, 
and carefully watching the condition of 
the joints : if there be retrocession of the 
swelling and redness and pain in the 
joints, while the patient becomes restless 
and loquacious, we must try and bring 
back the rheumatism to the joints by 
wrapping them up in mustard poultices 
or applying blisters. Opium and musk 
have been recommended, and Trousseau 
declares that he has cured three patients 
by the combined administration of these 
drugs, although he adds that two others 
got well without any active treatment 
having been employed. In any case, the 
alkaline treatment for rheumatism should 
be continued, and careful nursing and the 
administration of unstimulating food 
adopted. 
Chbonic Meningitis.-This is a very 
rare affection, and it is generally recog- 
nized after death only from the pathologi- 
cal appearances met with in the menin- 
ges-namely, thickening and opacity of 
the arachnoid, cellular adhesions between 
it and the pia-mater, development along 
the falx cerebri of the so-called glandulse 
Pacchioni, which from their absence in 
infancy and youth are generally regarded 
as evidences of chronic meningeal irrita- 
tion. In some cases, plates of osseous 
tissue have been found in the membranes ; 
whilst during life, the symptoms pre- 
sented by the patient did not point to any 
mischief in the head. 
Troublesome headache, a disposition to 
somnolency, sometimes convulsive twitch- 
ings, and in children, vomiting, are re- 
garded as symptoms which should excite 
suspicion of the existence of chronic Me- 
ningitis. Of that form of the affection- 
which is complicated with chronic inflam- 
mation of the superficial layer of the cor- 
tical substance of the brain, and is symp- 
tomatically characterized by lofty ideas, 
hallucinations, paroxysms of maniacal ex- 
citement and embarrassment of speech, 
followed by gradual general paralysis of 
motion, sensibility being scarcely affected, 
and terminating in idiotcy - we have TUBERCULAR MENINGITIS. 
817 
nothing to say here, as the affection is 
always treated of in conjunction with in- 
sanity. 
Although chronic Meningitis in middle 
age and in early life is of rare occurrence, 
it is not so rare in old age. Concerning 
it Machlachlan observes, "The disease 
may be of a chronic nature, ab initio; 
chronic in regard to the subdued and in- 
sidious nature of its symptoms, while at 
the same time it pursues a strictly chronic 
course, seemingly, now and then existing 
one or two years, and never following an 
acute attack of the disease. It is not an 
unfrequent result of albuminuria and re- 
peated attacks of delirium tremens, or it 
follows gout and rheumatism. Chronic 
Meningitis in the aged is almost uniformly 
accompanied with great impairment of 
the mental faculties, frequently with 
thickness of speech, and paralytic weak- 
ness of the lower extremities, the gait 
being tottering and feeble. The energies 
of the system are reduced; all movements 
of the limbs are performed awkwardly, 
slowly, and with uncertainty. The appe- 
tite remains good ; but digestion is slow, 
bowels are inactive, and the various ex- 
cretions vitiated. Vertigo, singing in the 
ears, marked loss of memory, slowness of 
comprehension, periodical fits of passion, 
and occasional attacks of headache, with 
or without signs of high vascular excite- 
ment, are frequently observed. Sooner or 
later the invalid takes to his bed reluc- 
tantly. There he lies uncomplaining, 
vegetating, and gradually sinking, dying 
often in consequence of sloughs on the 
nates." 
Treatment. - The diagnosis of this 
affection being so uncertain and obscure, 
it is clear that little is known regarding 
the mode of treating it. If the symptoms 
in the least show a tendency to assume 
the acute form, the application of leeches 
behind the ears, cupping the nape of the 
neck, and administration for a short time 
of small doses of a mild mercurial, would 
be called for. Otherwise the use of re- 
peated blisters applied to the nape of the 
neck, and the internal administration of 
iodide of potassium, and occasional pur- 
gatives, seem to be the most rational 
treatment that can be employed. In the 
form occurring in old age, cold lotions to 
the head, and an occasional brisk purge 
followed up by an enema, are most ad- 
visable. The condition of the bladder 
must be frequently examined, and the 
catheter employed should retention arise; 
when, on the contrary, there is dribbling, 
a proper apparatus must be worn. Good 
nursing, cleanliness, the hydrostatic bed, 
are also essential. In the later stages of 
the disease, when the vital energies begin 
to part and fail, wine will be essential, 
but until then the treatment should be 
strictly antiphlogistic ; the patient avoid- 
ing also all mental excitement, and, if not 
secluded, he should be kept tranquil both 
in body and mind. 
Secondary Meningitis. - This affection 
sometimes shows itself in the course of 
one of the eruptive or exanthematous dis- 
orders, as typhoid fever, measles, scarla- 
tina, and variola. 
When Meningitis occurs in the course 
of an eruptive fever, some of its ordinary 
symptoms may either fail entirely, or be 
masked by those of the primary disease. 
Thus, the intense headache of acute pri- 
mary Meningitis may be absent, or it may 
be slight only, and there may be no vom- 
iting. The invasion of the superadded 
disease may, however, be recognized by a 
sudden slackening and irregularity of the 
pulse and respiration, by the pallor and 
anxious look of the face, and the extreme 
jactitation which ushers in the delirium. 
TUBERCULAR MENINGITIS. 
Samuel Jones Gee, M.D., F.R.C.P. 
By tuberculosis we mean that disease 
which is attended necessarily by the for- 
mation of miliary tubercle. Inflamma- 
tion of the brain and its membranes, 
occurring as a consequence of the pro- 
gress of tuberculosis, is called Tubercular 
Meningitis. 
Causes.-This is not the place in which 
to set forth the knowledge which has been 
gained of late years respecting the eti- 
ology of tuberculosis in general. A few 
conditions which predispose to Tubercular 
Meningitis are all that need to be dwelt 
upon. 
vol. i.-52 818 
TUBERCULAR MENINGITIS. 
Be the case as it may with regard to 
the adult, I think that most physicians 
will agree that the tubercular disposition 
in the child is strongly hereditary ; it will 
be found that a large majority of children 
attacked by Tubercular Meningitis come 
of families in which there are, or have 
been, sundry manifestations of a ten- 
dency to scrofulous or tubercular diseases. 
Yet in many cases no tendency of the 
kind can be discovered. 
The influence of sex, season, or social 
position upon the occurrence of Tubercu- 
lar Meningitis is quite insignificant. 
Tubercular Meningitis may set in at 
any age. No doubt the disease is more 
common before puberty than afterwards : 
but it is, at present, impossible to procure 
numerical proof of the fact, and this on 
account of the comparative absence of 
children from the general hospitals into 
which adults are admitted. 
Age. 
Cases. 
Age. 
Cases. 
Six weeks .... 
1 
16 to 20 years, inclusive 
10 
Two months 
1 
21 to 30 " 
12 
2 to 4 years inclusive . 
12 
31 to 40 " 
5 
5 to 7| " 
11 
41 to 50 " 
3 
8 to 10 " " 
13 
51 to 60 " 
2 
11 to 15 " " 
9 
68 years 
1 
Total 
47 
Total 
33 
However, there can be no doubt that 
Tubercular Meningitis is comparatively 
much more common under two years of 
age, and much less common after eleven 
years of age, than these figures would 
make out. At the Hospital for Sick Chil- 
dren the following cases of Tubercular 
Meningitis were examined post mortem 
between August, 1862, and March, 1871, 
inclusive- 
Under 
1 yr. 
2 years. 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
Males . . 
Females . 
3 
6 
13 
5 
10 
9 
9 
3 
6 
2 
5 
2 
1 
4 
2 
1 
... 
... 
Being 48 males and 33 females. Seven 
cases of non-tubercular cerebro-spinal 
meningitis were examined in the same 
space of time ; whereof six were males 
(at 6 months, 2, 3, G, 8, 9 years of age), 
and one was a female of 20 months. No 
case of simple cerebral meningitis, not 
traumatic, during that period. After pu- 
berty, both acute tuberculosis and Tuber- 
cular Meningitis are much more common 
in the female than in the male sex. 
Symptoms.-The symptoms of Tuber- 
cular Meningitis sometimes break in sud- 
denly upon what has seemed to be, so far, a 
state of perfect health; sometimes they are 
preceded by several weeks or months of 
indistinct poorliness : both groups of cases 
(seeing that in both the sure and certain 
symptoms of distinct disease are cerebral 
from the very first) may be classed to- 
gether under the head of Primary Tuber- 
cular Meningitis. But, on the otlier hand, 
Tubercular Meningitis sometimes attacks 
a person who has already exhibited symp- 
toms and signs of either acute general 
tuberculosis, or of local tuberculosis, acute 
or chronic : this may be called Secondary 
Tubercular Meningitis. Ordinarily its 
existence is apt to be overlooked, unless 
its special symptoms have been watched 
for; sometimes, indeed, the disease is 
wholly latent, and discovered post mortem 
only. 
I. Primary Tubercular Meningitis : 
1. With premonitory symptoms. 
2. Without them. 
II. Secondary Tubercular Meningitis, 
preceded by manifestations of 
1. General Tuberculosis. 
2. Local Tuberculosis: i. cerebral;2 
ii. thoracic ; iii. abdominal. 
The primary form of the disease with pre- 
monitory symptoms is the typical form. 
Primary Tubercular Meningitis 
in tiie Child. 
1. Premonitory Symptoms. 
Their Character.-i. Loss of flesh is the 
most constant precursor ; indeed, is almost 
1 Children under two years of age are not 
usually admitted. 
2 I. e. Tubercular tumors of the brain 
which have produced symptoms. SYMPTOMS. 
819 
constant; often the first, sometimes the 
only symptom : the child's face being very 
much spared, it is when the nurse comes 
to undress him that she finds the limbs to 
be losing their roundness, and the flesh to 
feel flabby. This loss of flesh mostly pro- 
ceeds continuously ; sometimes, however, 
the child will seem to pick up for a time 
and afterwards begin to waste again, ii. 
Loss of color concurs ; it is sometimes 
masked by a false color in the cheeks, due 
to permanently dilated capillaries ; it may 
be only now and then that this color leaves 
the cheeks, and then the real paleness of 
the child is obvious, iii. The child is 
drowsy by day and restless at night; he 
is easily tired, and in the midst of play 
will lie down on the floor and fall asleep 
for a short time ; at night he grinds his 
teeth, sleeps with his eyes half-open, starts, 
and cries out; he is sad, fretful, peevish, 
taciturn, and wants to be let alone : if for 
any reason a young child has been put to 
bed for a day or two, he will not take to 
his feet again, iv. Headache is frequently 
absent, rarely a prominent symptom, but 
mostly present to a certain degree : very 
young children will be observed to put 
their hands to their heads, and to toss 
their heads on their pillows; older chil- 
dren will say that their heads ache, and 
this especially after some exertion of mind 
or body; a child will go to school and 
come home complaining of his head : the 
headache is rarely severe, and mostly 
frontal: a strong light increases it. v. 
Feverishness is not always present; when 
it is present, it is noticed chiefly in the 
evening. I do not myself possess any 
thermometrical observations made during 
this period, nor do I know of any that 
have been published.1 vi. Loss of appe- 
tite is common; vomiting uncommon ; 
the bowels are confined, or relaxed, or 
quite regular in action. 
These symptoms are grouped in every 
manner possible ; any of them may be ab- 
sent, and how many soever be present, 
they do not justify more than a fear least 
the condition should terminate in Tuber- 
cular Meningitis.2 
They are sometimes due to progressive 
tuberculosis, but sometimes certainly to a 
catarrhal state or to simple nervous de- 
pression. The pyrexia is the most im- 
portant symptom. When a child suffers, 
day after day, from a slight elevation of 
temperature above the normal, that ele- 
vation of temperature may be due to 
tuberculosis. Inasmuch as a catarrhal 
fever does not usually last longer than 
ten or twelve days ; if the pyrexia do last 
longer than that time, and if the presence 
of continued fever or of a local inflamma- 
tion can be excluded ; the elevation of 
temperature is very probably due to tu- 
berculosis. But in actual practice we are 
not often called upon to study the precur- 
sory symptoms of primary Tubercular 
Meningitis so closely. This is certain, 
that the most careful mother will often 
fail to observe any feverishness before the 
day of invasion, even though she have 
been disquieted for weeks or months by 
her child's steady loss of flesh and 
strength. The poorliness which follows 
acute specific or other diseases often 
passes uninterruptedly into the premoni- 
tory period of Tubercular Meningitis. 
Measles, so far as I have seen, is the most 
common antecedent, hooping-cough next, 
occasionally an attack of diarrhoea and 
vomiting, bad sore-throat, or hip disease. 
The Duration of this period is different 
in different cases. Sometimes, as men- 
tioned before, there are no prodromata at 
all.1 There are all grades between this 
extreme and the other in which a child 
loses flesh for four, six, or even more 
months before the invasion. One or two 
months may be regarded as the average ; 
sometimes the prodromata last two or 
three weeks only. Again, in some cases, 
the precursory stage is interrupted by a 
temporary improvement in the health of 
the child. 
2. Invasion. 
By the invasion of Tubercular Menin- 
gitis I mean the period at which there 
occur such new symptoms as enable us to 
pass from the uncertainties of the pro- 
dromal stage, and to declare most posi- 
tively that from this date, at all events, 
the child has sickened with hydrocepha- 
lus. The invasion symptoms are the first 
which make the friends of the child think 
him dangerously ill; the poor, as a rule, 
only now begin to seek advice. 
Character of Symptoms.-(1) Vomiting 
is by far the most common special inva- 
sion symptom. In the majority of cases 
the frequent repetition of the vomiting 
makes it seem to be the most important 
symptom of the onset; but sometimes, 
although serving to mark the invasion, 
the sickness is subsidiary in urgency to 
the other symptoms. In the former group, 
1 It may afford some notion of the frequency 
with which the prodromata occur to mention 
that out of twenty-six cases of primary Tu- 
bercular Meningitis (the diagnosis having 
been confirmed by a post-mortem examination 
in all), there were only two in which pre- 
monitory symptoms had not been noticed. 
That sometimes the prodromal stage is ab- 
sent, or so slight as to be unnoticed, even in 
children carefully looked after, I have no 
doubt. 
1 The reader will bear in mind that primary 
Tubercular Meningitis only is under consid- 
eration. 
2 Refer to section on Diagnosis. 820 
TUBERCULAR MENINGITIS. 
the child may vomit incessantly with and 
without taking food ; in the latter, the 
child may be sick only once or twice. 
(2) Convulsions are the next most fre- 
quent (though much less frequent) spe- 
cial symptom of the invasion ; they, like 
the vomiting, may be repeated several 
times or not. Sometimes the attack is 
epileptiform, sudden with complete un- 
consciousness, and yet without convulsive 
movements. It will give some notion of 
the comparative frequency of the differ- 
ent modes of invasion to mention that, 
out of twenty-five cases in which the in- 
vasion symptoms were carefully ascer- 
tained, vomiting without convulsions oc- 
curred in nineteen ; vomiting followed by 
convulsions in one ; convulsions without 
vomiting in two ; several attacks of gen- 
eral rigidity, succeeded by vomiting on 
the third day, in one ; in one an attack 
of temporary unconsciousness (epilepti- 
form), followed by vomiting ; and in the 
remaining case the invasion was marked 
by a notable and comparatively sudden 
increase in the severity of the premoni- 
tory symptoms (headache, drowsiness, 
loss of flesh), without vomiting or any 
motorial symptoms. The most impor- 
tant concomitant symptoms of the inva- 
sion are: the first occurrence or the in- 
crease of headache, or of the pyrexia, or 
of drowsiness ; the co-existence of consti- 
pation as a rule with an occasional excep- 
tion ; there is often a change in the tem- 
per of the child, or some odd unreasonable 
behavior ; the character becomes morose, 
irascible, and obstinate. 
Period of Occurrence.-From seven to 
twenty-one days elapse between the inva- 
sion and death; the average is fourteen 
days. "When the meningitis sets in 
suddenly without prodromata, its dura- 
tion is from twenty to thirty days, rarely 
less, provided that no complication modify 
the course of the disease" (Rilliet, iii. 487) 
-a very necessary qualification. 
3. The Established Disease. 
It is well known that Dr. Robert Whytt 
first described the course of what he 
rightly called "the most frequent species 
of the hydrocephalus internusand so 
described it that his successors have not 
been able to add much that is useful to 
his description.1 The disease depicted by 
Whytt is a clinical entity of the most defi- 
nite kind; but when we come to use the 
phrase Tubercular Meningitis, and to 
frame a species of disease characterized 
by certain anatomical changes (namely, 
tuberculosis and inflammation of the men- 
inges), we find that we have to do with a 
more comprehensive notion than that in- 
tended by Whytt. The disease of Whytt 
corresponds to primary Tubercular Men- 
ingitis, involving the base of the brain, 
and occurring in children. But Tubercu- 
lar Meningitis may be secondary ; and, 
when primary, may not involve the base 
of the brain, or may attack adults : to 
these forms of the disease Whytt's de- 
scription ceases to apply. Nevertheless, 
the set of symptoms pointed out by Whytt 
remains the most common and best 
marked manifestation of Tubercular Men- 
ingitis during life, and may be deemed the 
typical form, and will therefore be first 
described. 
The peculiar symptoms of Whytt's dis- 
ease depend upon the fact that the men- 
ingitis affects the base of the brain ; the 
tubercular nature of the meningitis plays 
no part in the production of these symp- 
toms. For both tubercular and non- 
tubercular meningitis of the base are at- 
tended by precisely the same symptoms ; 
and Tubercular Meningitis involving the 
convexity alone is not accompanied by 
the symptoms which are peculiar to men- 
ingitis of the base. It must therefore be 
clearly understood that the form of dis- 
ease which will be first and most fully 
described is, in reality, dependent upon 
basilar meningitis ; and that, in a given 
case, finding this condition to be present, 
we assume it to be tubercular also, be- 
cause basilar meningitis (unaccompanied 
by spinal meningitis) always is tubercular. 
A. Meningitis of the Base. 
Whytt's first stage of dropsy of the 
brain includes the premonitory and inva- 
sion periods, previously described. The 
subsequent course of the disease he di- 
vides into two stages ; the one being an 
earlier period during which the pulse is 
infrequent, and the other a later period 
offrequent pulse. This division ofWhytt's 
is true to nature, but the pulse is a fallible 
criterion. In order to recognize that a 
patient is in one or other stage of the dis- 
ease, the physician must look at the symp- 
toms in a comprehensive spirit. There is 
an earlier period (the second of Whytt), 
in which the brain may be regarded as 
reacting under or against the disease: 
the symptoms are sthenic] headache, de- 
lirium, exalted sensibility, infrequency of 
the pulse, consciousness being retained. 
The disease goes on to produce destruc- 
tion of the brain ; the symptoms become 
such as are due to a steadily increasing 
paresis of the animal functions ; stupor, 
insensibility, paralysis, frequency of the 
pulse-the third period of Whytt. To 
repeat: the observer must not narrow his 
view to the variations of a single symp- 
tom, or he will often fail to perceive the 
1 Works of Robert Whytt, M.D, Edin. 
1768. 821 
MENINGITIS OF THE BASE. 
stages of Dr. Whytt, or even be inclined 
to reject them. In the second of the en- 
suing paragraphs I have noticed the va- 
riations of the pulse somewhat minutely, 
so as to show how little it is to be trusted 
as a certain sign of the stage of the dis- 
ease. 
(1) Digestive Organs.-i. Vomiting.-As 
already mentioned, the vomiting of the 
invasion is ordinarily repeated several 
times. Sometimes the symptom is very 
urgent, occurs whether food has been 
taken or not; and this may be so every 
day for a week. When once the tendency 
to vomit has ceased for twenty-four hours, 
it does not ordinarily recur, ii. Constipa- 
tion.-In the great majority of cases the 
bowels are constipated throughout the 
whole course of the disease; yet some- 
times they are spontaneously relaxed 
throughout; more frequently (especially 
when hard purging has been part of the 
treatment at the beginning of the disease) 
they are relaxed without the use of drugs, 
towards the end. The constipation is not 
often obstinate; it is easy, for the most 
part, to procure an action of the bowels 
by common means, iii. Retraction of the 
walls of the belly is a symptom which will 
be met with at some time or other in 
nearly every case : sometimes present for 
a day or two only, and at no certain pe- 
riod ; sometimes present all along. Acute 
diseases affecting the brain are the only 
acute diseases of children which, as a 
rule, cause great excavation of the belly, 
iv. The Tongue has no fixed character ; it 
may be moist and clean. Aphthae some- 
times occur as death draws nigh. 
(2) The Circulation.-i. The Pulse af- 
fords symptoms which have been much 
studied, and with good reason, for they 
are most important, a. Its frequency is 
diminished in the earlier and increased in 
the later part of the disease : this is the 
rule. The increase mostly sets in during 
the second week ; sometimes much later 
(e. g. boy, of four years, eighteenth day = 
84; 116, 128, 128, 168, on successive days, 
death on twenty-third), or earlier (e. g. 
girl, eight years, sixth day = 140). Some- 
times the increase occurs only three or 
four days, sometimes eight or ten days, 
before death. Sometimes the increase 
takes place suddenly (e. g. boy, two years 
four months, seventh day = 72 ; eighth 
day = 164), sometimes gradually. After 
the pulse has been very frequent, it may 
again become comparatively infrequent 
(e. g. girl of one year and ten months, 
eighth day = 162; ninth = 144; tenth = 
100; eleventh, day of death, =180.) This 
infrequency may persist and increase up 
to the day of death (e. g. girl, two years 
and six months, fifteenth day =120 ;• six- 
teenth = 140 ; seventeenth = 76 ; eigh- 
teenth = 70 ; i. e. day of death : cases' of 
this kind die in a state of algidity unsur- 
passed in any other disease.' As to the 
absolute frequency, I have not known the 
pulse to fall below 64. At the invasion of 
the disease " the pulse is not much accele- 
rated : 108, 112, 120 at most; sometimes 
it is even already slackened" (Rilliet, iii. 
480). The frequency is at all times easily 
increased by movement of the body. 6. 
Irregularity in the rhythm and inequality 
in the force of the pulse are two symp- 
toms upon which great stress is laid in 
the diagnosis of Tubercular Meningitis. 
They coincide with the period of infre- 
quency ; not that an infrequent pulse is 
irregular at all times, but it will be found 
so, at least, now and then. During the 
period of increased frequency the irregu- 
larity is less easy to detect, and is pro- 
bably really less common ; yet a pulse of 
e. g. .170 will sometimes be found distinctly 
irregular. ii. The modifications in the 
cutaneous circulation are well displayed in 
the face. If habitually pale (as it some- 
times is from beginning to end of the dis- 
ease), a flush is easily produced by excita- 
tion of any kind-by moving the child, 
giving him to drink, brushing the hand 
over the cheek, and so on. Sometimes 
the flushing is spontaneous : limited to 
one cheek, or general as regards the head; 
constant, or alternating with pallor. The 
highly characteristic facies of acute brain 
disease2 is chiefly effected by the conges- 
tion of the face. What is best seen in the 
face is observed to a less marked degree 
in the skin of the trunk and limbs ; that 
is, the skin is injected at times. Spon- 
taneous injection is often made evident by 
the unusually distinct white ring left by 
the pressure of the end of the stethoscope. 
As in the face, so in the skin of the trunk 
and limbs, injection, wrhen not present, 
may be easily procured : draw the finger 
across the skin, and, in a few seconds, a 
red streak will appear along the track of 
pressure. This is what Trousseau has 
called the "tache cerebrale": for my own 
part I believe it to be a sign which does 
not possess any diagnostic value. 
(3) The Respiration also yields symp- 
toms deserving careful study. The fre- 
quency is increased, diminished, or at the 
natural rate. Increased frequency of 
pulse and respiration sometimes go to- 
gether, but not always (e. g. boy of five 
years, P. = 190, R. = 24; day before 
death). Irregularity and inequality are 
often very striking in later stages of this 
as well as of all other acute cerebral dis- 
eases of childhood. Sometimes the respi- 
ration is irregular only, sometimes un- 
equal only, often both irregular and 
unequal: the child may remain for many 
seconds as if he had forgotten to breathe, 
then follow a few rapid respirations, then 
1 Refer to paragraph on Heat of Body 
2 See paragraph (8). 822 
TUBERCULAR MENINGITIS. 
another pause, and so on. A careful ex- 
amination will sometimes be necessary to 
detect irregular breathing. Sighing ex- 
piration is particularly common when 
children become half-insensible from Tu- 
bercular Meningitis. 
(4) Heat of Body. -The first three or 
four days of the established disease are 
attended by what seems to be (judging by 
the hand) a distinct increase in the heat 
of the skin. This is followed by a period 
of low pyrexia, during which the tempe- 
rature only occasionally exceeds 101°. I 
do not say that the temperature is not 
sometimes persistently higher, but I do 
not happen to possess notes of any cases 
in which it was so; whilst, on the other 
hand, for days together the temperature 
may vary between 96° and 98°. As death 
approaches (say for about the four days 
preceding death) cases have seemed to me 
to group themselves into three classes : in 
one, the state of moderate fever continues 
up to the very day of death ; in another, 
the fever greatly increases before death ; 
in a third, the body-heat falls below the 
standard of health. An example of each 
class will make this more clear:- 
Day before death. 
Third. 
Second. 
First. 
Day of death. 
Type 1. 
Boy : 4 years 
99-5 
102-0 
99-0 
101-0 
100-5 
101-5 
99-0 
101-5> 
Type 2. 
Boy : 2^ years 
97-0 
99-3 
99-2 
101-0 
100-0 
103-0 
104-4 
107-25 2 
Type 3. 
Girl: 2| years 
97'8 
96-6 
9G-2 
93-0 
82-8 
82-1 
80-5 
79-4* 
The minimum and maximum tempera- 
tures of each day are given. 
The peculiar variety of ardent fever re- 
ferred to the second type (the lipyria of 
Galen) is, perhaps, more common in Tu- 
bercular Meningitis than in any other dis- 
ease.1 "Heat of the viscera, as if from 
fire, but the external parts cold ; the ex- 
tremities-that is to say, the hands and 
feet-very cold" (Arcteeus). A thermo- 
meter in the arm-pit will prevent our 
being misled by the coolness of the ex- 
posed parts. In the third type the al- 
gidity involves the viscera themselves; 
the temperature in the example adduced 
was taken by means of a thermometer 
kept permanently in the rectum ; and, as 
the hyperpyrectic cases might deceive the 
hand applied to the limbs only, so might 
the state of algidity deceive the eye. The 
example chosen one hour before her 
death, when her temperature was 79'8°, 
her breath cold to the hand, and her pulse 
imperceptible at the wrist, still kept a 
little color in her cheeks, and (except that 
her eyes were half-open) it would have 
been impossible for one merely looking at 
her to have said that she was not a tolera- 
bly healthy child calmly asleep. The 
pulse, as a rule, agrees with the tempera- 
ture, rising in frequency as the tempera- 
ture rises, and falling as it falls : no pro- 
portion is kept in the amount of the rise 
and fall. Excessive frequency of pulse 
may concur with a moderate elevation of 
temperature; or, reversely, the tempera- 
ture may be high and the pulse infrequent 
(e. g. temperature 103°, pulse 72-a ratio 
really observed, and such as would serve 
to clench the diagnosis of acute disease of 
the brain). Heat of the head greater than 
of the rest of the body is a symptom far 
from always observed in the earlier stages 
of the disease, and still less frequently in 
the later. 
(5) Nervous System.-i. Headache con- 
curs with the invasion, or, if present pre- 
viously, is much increased then. The 
pain is mostly referred to the top of the 
frontal bone. The headache is tolerably 
constant, subject to paroxysmal exacer- 
bations, and lasts until stupor sets in. 
The temporary increase of headache is 
sometimes made known by the moaning 
of the child; sometimes he cries out, 
" Oh I my head," or shrieks,3 or holds his 
hands hard on his head ; he greatly dis- 
likes any disturbance, for that increases 
the headache. But it must not be sup- 
posed that headache of this severity is 
present even occasionally in all cases, 
ii. Eye-symptoms are very important. One 
pupil is often distinctly larger than the 
other : this state is present at some time 
or other in every instance of the disease, 
does not occur at any special period, and 
is not always constant; thus the ine- 
quality in size, present in the earlier part 
1 One hour and a half before death. 
2 At very moment of death. 
3 I copy the following particulars relating 
to the " hydrocephalic cry" from Trousseau 
(Clin. M6d. 2me edit. vol. ii. 239) :-"It is a 
single, violent cry, resembling the cry of a 
person suddenly exposed to great danger: the 
expression of the face is not that of suffering: 
any period of the disease may be attended by 
this cry, which may occur every hour, half 
hour, or even every five minutes." Rilliet 
(iii. 503) does not consider this to be either a 
common or a special symptom-an opinion 
with which my own experience would lead 
me to coincide. 
1 See article on Scarlet Fever, vol. i. p. 
83. MENINGITIS OF THE BASE. 
823 
of this stage, not rarely disappears later 
on in the disease, in order, it may be, 
that the relation of size may be reversed 
for a day or two before death : or, some- 
times, the variations are much more 
rapid. Dilatation and sluggish action of 
the pupils is the rule towards the end of 
the disease, but the absolute size of the 
pupils is of small value in diagnosis. 
Squint is present sooner or later in every 
case. Ilemiopia may occur so early in 
the disease as to be discoverable (Trous- 
seau, ii. 23G, 237). Oscillation of the 
eyeballs, or of one eyeball (the other 
being fixed), is common in the later 
period.1 iii. Paralysis of the Face, one 
eye opened less widely than the other, 
one nostril being rounder than the other, 
one corner of the mouth less acted upon 
by the muscles than the other, one side 
of the upper lip straightened-these are 
frequent concomitants of the later period, 
iv. Paralysis of the Limbs.-Quite towards 
the end of the disease we often observe 
one or more of the limbs to be unmoved, 
relaxed or feebly rigid, flexed or extended, 
v. Convulsions and Rigidity.-These have 
been already mentioned as occasional in- 
vasion symptoms. As terminal symp- 
toms they are equally frequent, occurring 
on the day of death, the child perhaps 
dying immediately after a convulsion. 
Yet they are not to be trusted as a sign 
of impending death, or even of death 
likely to occur in a day or two. When 
convulsions have been invasive they do 
not necessarily recur. The following may 
be taken as an example of the state of a 
child in convulsions towards the end of 
the disease : he lies unconscious, whole 
skin injected, eyeballs drawn upwards 
and to one side, pupils large, one side of 
face more wrinkled than the other, teeth 
clenched, limbs rigidly extended-except 
the hands, the fingers of which are flexed 
-slight twitching movements of face and 
limbs, more marked on one side than the 
other, respiration labored. As the child 
comes round the unconsciousness dimin- 
ishes, pupils become smaller, he is left 
bathed in sweat. Sometimes the clonic 
movements are more marked. Sometimes 
the limbs are relaxed throughout, and the 
twitchings limited to the face and eye- 
balls. Permanent feeble spastic rigidity 
of one or more groups of muscles is com- 
mon during the latter period ; sometimes 
the rigidity is much stronger. Opistho- 
tonos may be present during the last few 
days of life; it may be paroxysmal and 
last only a few minutes, or it may be con- 
tinuous and last until death. In such 
cases I have not found any signs of in- 
flammation about the cord or its mem- 
branes. Tremulousness of the limbs is 
very common. A shudder may he often 
observed to pass through the body from 
head to foot. Many other niceties of 
motorial symptoms might have been de- 
scribed : enough has been said to show 
the infinite variety present in Tubercular 
Meningitis, vi. Sensation.-Tenderness 
of the skin can be demonstrated to be 
present in some cases; it is often very 
obviously present in the scalp when a 
barber is employed to shave the head. 
Pains in the limbs are sometimes com- 
plained of early in the disease. Dislike 
of light is common at the same period. 
Blindness is difficult of recognition, be- 
cause occurring late. All these symptoms 
are sometimes unilateral, vii. Conscious- 
ness.-The children soon become somno- 
lent : they lie with their eyes shut or 
half-shut, reply to questions in a dry 
short way or by a nod : when raised up 
in bed they complain much, knit brows, 
throw head back, and slip down in the 
bed. They dislike disturbance extremely: 
will clench their teeth against food. As 
the somnolence increases, the children 
cease to speak, but they will put out their 
tongues when shaken and pertinaciously 
asked to do so ; they then relapse willingly 
into their former soporose state. By de- 
grees, or sometimes suddenly, the sopor 
becomes deeper: but not until near the 
very end, and not always even then, does 
the coma become so deep that the child 
will not withdraw his limbs (provided 
they are not paralyzed or rigid) when 
pinched, and also give other signs of 
being discommoded. Inability to swallow 
accompanies the coma. Retention of 
urine is sometimes rather an early symp- 
tom. The consciousness may be perfect 
the day before death. The semi-coma 
may be continuous from the invasion to 
the end of the disease. Delirium is com- 
mon, but is not a symptom of much value 
in diagnosis, prognosis, or treatment. 
(6) Physical Signs of tuberculosis of the 
lungs are not often to be detected in cases 
which, by reason of their course, are ar- 
ranged under the head of Primary Tuber- 
cular Meningitis. Yet occasionally, and 
that even when the foregoing poorliness 
has not been greater than usual, I have 
detected the signs of a cavity under one 
or other clavicle. Sonorous rales may be 
met with, sometimes a little mucous rale; 
and in exceptional cases, which are, nev- 
ertheless, cases of Tubercular Meningitis 
as opposed to acute tuberculosis, all the 
physical signs are present of that very fine 
capillary catarrh which, in children, is 
nearly always indicative of the coexist- 
ence of tubercle or pneumonia. This sign 
I have observed in Tubercular Meningitis, 
and in no other disease: namely, the chest 
heaves equally well on both sides, and yet 
over a very large part, or even the whole 
of one side, no respiratory sound is heard 
1 For the ophthalmoscopic appearances, 
refer to paragraph (6). 824 
TUBERCULAR MENINGITIS. 
by the stethoscope. In a few hours this 
sign will have passed away. It is proba- 
bly due to a slight pulmonary catarrh 
concurring with the respiratory uncon- 
sciousness of the brain disease. When 
the fontanelle is large, it is mostly dis- 
tended ; when small, the distension can- 
not be perceived. 
Of late years the ophthalmoscope has 
taken an important place among the 
means for discovering Tubercular Menin- 
gitis. Actual tubercles may be occasion- 
ally seen in the ocular choroid during life; 
but this is not a common occurrence, and 
if the ophthalmoscope were useful in this 
way only, its use would be very small. 
Choroidal tubercle was discovered, in one 
case, six weeks before the invasion of Tu- 
bercular Meningitis: Frankel, Virchow's 
Jahresbericht, 1869, p. 621. Steffen found 
choroidal tubercle in four out of five cases 
of Tubercular Meningitis, and in three 
cases of the four during life: eod. loc. 622. 
It is by detecting changes in the vascu- 
larity of the retina that the ophthalmo- 
scope renders real service. Whenever 
meningitis is basilar, we find congestion 
of the retinal vessels, and sometimes optic 
neuritis. It will be obvious that there is 
nothing peculiar to meningitis in these 
signs; and also, that to find a state of 
retina which is probably dependent upon 
intracranial causes must be a very impor- 
tant item in the diagnosis, when we are 
doubtful whether a convulsion or an at- 
tack of vomiting be due to meningitis or 
not.1 Meningitis which affects the con- 
vexity of the brain, and spares the base, 
is unattended by any unnatural condition 
of the optic disks : of this fact I have seen 
two instances. 
(7) Urine.-In the case of a boy, aged 
four years, in whom it was necessary to 
employ the catheter, I had an opportunity 
of examining the urine. The following 
was the result:- 
Day of disease. 
Water. 
Urea. 
Ch. sod. 
Phos. acid. 
19-20 
122 c. c. 
5'07 grammes 
0'195 gramme 
0'432 gramme 
20-21 
122 c. c. 
5'51 grammes 
absent 
9'367 grammes 
21-22 (day before death) 
171 c. c. 
7'34 grammes 
absent 
0'583 gramme 
Mean of 3 days in healthy) 
boy of same age j 
431 c. c. 
15'27 grammes 
3'062 grammes 
0'967 gramme 
Weight of body-case of meningitis .... 19| lb. 
" " healthy child 28 lb. 
(8) General Appearance: Summary.- 
Although the individual symptoms which 
have been now described are grouped in 
almost every possible manner in the dif- 
ferent actual examples of Tubercular 
Meningitis which we meet with, yet it 
may be well to recapitulate the chief mat- 
ters in what has gone before, and so to 
arrange them as to form a sort of idea or 
type of primary Tubercular Meningitis in 
the child. 
A boy of five years old, in whose pa- 
rental antecedents there are signs of a 
tendency to tuberculosis, begins to feel 
poorly, to lose flesh, and to complain oc- 
casionally of his head; he is restless at 
night, and languid by day; his bowels are 
rather confined ; he is subject to irregular 
feverish attacks. These symptoms last 
two months, and then, one day, the child 
vomits for the first time; during the next 
three or four days the vomiting is re- 
peated several times; afterwards it ceases; 
at the same time the fever runs higher, 
the headache increases, the nights are 
noisy, the constipation is obstinate. 
About the time that the vomiting ceases, 
other symptoms pointing to cerebral dis- 
ease appear; say, for example, on the 
sixth day after the first vomiting, he looks 
thin and pale; skin hot and dry; tem- 
perature IGO'S0 (evening); pulse 84, irreg- 
ular ; respiration 20, regular; tongue dry, 
red tip, light fur elsewhere; bowels not 
open; belly natural; converging strabis- 
mus of one eye; pupils of middle size, 
mobile, one larger than the other; he 
says he has headache, and points to his 
forehead as its seat; physical signs of 
chest are negative ; tache cerebrate uncer- 
tain ; the boy is quite rational, moves 
about in bed, sits up, answers questions, 
and the expression of his face is not pecu- 
liar : the diagnosis rests (and rests surely) 
on the previous history, the pulse, and 
the condition of the eyes. On the seventh 
day he is much the same; belly rather 
retracted ; pulse 108, very irregular ; res- 
piration regular; temperature 100*4° 
(morning) and 101° (evening). Eighth 
day: no marked change, rather lower; 
pulse 112, still irregular; temperatures, 
morning and evening, 100*2° and 100*6° : 
all the other symptoms remain unchanged. 
Ninth day: clearly much worse; con- 
sciousness failing; does not cry out; 
probably can still see; tache cerebrale 
easily produced ; cheeks, habitually pale, 
easily flush; cannot sit up; no special 
1 See especially Dr. Allbutt's papers "On 
Optic Neuritis as a symptom of disease of the 
brain and spinal cord." Med. Times and 
Gaz. 1868, vol. i. pp. 495 et seq. 825 
MENINGITIS OF THE BASE. 
expression in face ; swallows well; pulse, 
160, regular, weaker; eyes as before; 
arms very tremulous; temperatures, 
101 '2° and 103°. Tenth day: still worse, 
semi-stupor, cannot be made to speak: 
eyes only half-open ; passes excreta under 
him; lies fidgeting and picking with 
tremulous hands; pulse, 168, regular; 
temperatures, 10T8° and 102'4°. Elev- 
enth day: stupor greater; he occasionally 
moans; whole surface much injected, 
face and head greatly Hushed, dusky; and 
as the child lies on Ins back, motionless, 
with his half-opened and prominent eyes, 
their corners filled with thick secretion, 
and the corner dusty and filmed, he has 
a look quite characteristic of hydrocepha- 
lus ; pupils dilated; one eye fixed, and 
probably blind; swallows pretty well; 
belly greatly sunken ; pulse, 180, regular, 
very weak; respiration, 15, irregular; 
temperatures, 101° and 103°. Twelfth 
day: stupor deeper still; moves limbs of 
one side feebly; those of the other side 
are somewhat rigid; swallows badly; 
pulse so frequent and feeble that it cah- 
not be counted ; feet cold ; temperatures, 
101'5° and 103'6°. The next morning he 
dies. 
Duration. - The duration of primary 
Tubercular Meningitis with prodromat'a 
is from seven to three-and-twenty days. 
It has been already mentioned, on the 
authority of Rilliet, that when the pro- 
dromata are wanting the duration is from 
twenty to thirty days. 
liemission in the gravity of certain symp- 
toms is not uncommon in the acute cere- 
bral diseases of children. The direct ner- 
vous symptoms are the most variable; 
the squint, the unequal or dilated pupils, 
the rigidities, and the somnolence. The 
variations in the last symptom are the 
most striking and deceptive, semi-stupor 
passing away so as to leave the intellect 
perfectly clear. But when once the phy- 
sician has satisfied himself of the exist- 
ence of meningitis, he should not let his 
diagnosis be easily shaken. As Rilliet 
observes, " the improvement does not 
show itself in all the symptoms the 
pulse remains irregular, it may be, the 
squint or inequality of pupils persists, and 
though the remission should last a day or 
two, the child will die as surely and as 
early as if all the symptoms had been 
continuous. 
Termination. - Tubercular Meningitis, 
running the course which I have now de- 
scribed, has but one termination, and that 
is death. But it has been suspected, and 
with good reason, that recovery some- 
times takes place in the earliest stage of 
the disease.1 The probability of this 
opinion has been greatly increased by the 
result of ophthalmoscopic examinations. 
If a child become febrile, and convulsed, 
generally or partially; if it vomits, or 
complains of headache, and at the same 
time the optic disks be found congested, 
it is very likely that it has basilar menin- 
gitis. All these symptoms may pass quite 
away : but occasionally the patient is left 
more or less imbecile, oi' epileptic, or par- 
tially paralyzed, or with progressive atro- 
phy of the optic disks. In these cases, 
however, a recurrence of the disease is to 
be greatly dreaded. 
[The following is the report1 of a case 
occurring in my practice, of a sufficiently 
exceptional character to be given in full:- 
" A strong predisposition on the part of 
the patient, was proved to exist toward 
cerebral disease, by the facts that the 
child's grandmother has been for eight 
years hemiplegic after apoplexy ; that one 
of her sons has been insane, and another 
died of disease of the brain ; that the 
child's mother died a few months since at 
the Pennsylvania Hospital, having been 
there under treatment for chronic mania; 
and that the elder brother of the patient, 
aged ten years, having attended the fune- 
ral of his mother, was attacked by a con- 
vulsion on the same day, and, in spite of 
prompt treatment, died in thirty-six hours. 
"II. S., a boy,-aged five years-had 
enjoyed tolerable health during the past 
summer, with the exception of occasional 
diarrhoea. Never, however, had he ap- 
peared to be a robust child. About the 
first of October he became languid and 
peevish, with loss of appetite, and soon 
afterwards vomiting, with deranged cha- 
racter of the fecal discharges, and a ten- 
dency to costiveness, alternating with 
slight diarrhoea. 
"On the 9th of the month, he was 
brought to me, complaint being made by 
his nurse of his vomiting repeatedly 
through the day, and seeming fretful and 
miserable. His face was very pale, and 
lips bloodless. Some mild stomachic 
treatment was advised, the nature of the 
case not being then suspected. 
" The next day, pain in the head came 
on, with great restlessness ; the forehead 
being hot, and pulse full and about 100. 
The vomiting continued; two dozen 
American leeches were applied to the nu- 
cha, his bloodless aspect of the previous 
day, and other indications of an enfeebled 
condition, forbidding venesection. The 
leeches drew blood freely. Citrate of 
magnesia was directed, as the bowels 
were constipated. In the evening, the 
heat of the head was lessened, but opis- 
thotonos had come on ; the head was re- 
tracted so that he lay at times in a per- 
1 See Dr. Allbutt's papers "On the diag- 
nostic value of the ophthalmoscope in ' Tuber- 
cular Meningitis.' " Lancet, 1869, vol. i. pp. 
596 and 599. 
[' Transactions of Phila. College of Physi- 
cians, New Series, vol. ii. No. 7, p. 343.] 826 
TUBERCULAR MENINGITIS. 
fect arch, with the top of the head upon 
the pillow; even during the short periods 
of his sleep, this unnatural contraction of 
the muscles continued. 
" On the morning of the 11th, as the 
citrate of magnesia had failed to operate, 
a laxative enema was administered. 
Through this day, the opisthotonos per- 
sisted, and the child lay without signs of 
intelligence, screaming and sleeping alter- 
nately ; the cry being mostly sharp and 
not prolonged, the 'nydrencephalic cry' 
of authors. His pulse had now become 
slow-and the heat of head was very 
moderate. On this evening a blister, 
four inches square, was made to vesicate 
the back of his neck. 
" The 12th found him with some tem- 
porary amelioration. The tetanic arch 
of the neck had partially relaxed. He 
was still indifferent and restless, however, 
especially at night, at which time some 
fever was said by his attendants to come 
on. Bowels costive - moved only by 
injection. Urine retained twenty-four 
hours, and very dark colored; warm fo- 
mentations and sp. feth. nit. dulc. were 
used for the relief of the retention. The 
great nervous excitement caused by the 
effort to overcome his resistance against 
medicine, deterred me from advising any- 
thing further at this time. 
" On the 13th, I find it stated on my 
notes that he appeared to be a little 
better. No decided alteration, however, 
occurred, and the night was much dis- 
turbed by his restlessness. Vomiting had 
at this time ceased. His nourishment 
was thin tapioca, made with milk. The 
bowels still required movement by injec- 
tion. During the 14th, 15th, and 16th, 
no important difference in his symptoms 
occurred; the costiveness, retention of 
urine, indifference through the day, and 
restlessness at night, being the leading 
symptoms. Pulse, at the time of my 
visits, about 80 ; head not hot. 
"On the 17th, eight days after I had 
first seen him, and about twice that inter- 
val since his first signs of indisposition, a 
violent general convulsion occurred, lasting 
fifteen or twenty minutes. Pediluvia, 
and cold to the head, were resorted to, 
and a hyoscyamus and asafetida mixture 
was given by the mouth. After the con- 
vulsion, the pulse was slow, the pupils 
dilated, and consciousness more obscured 
than before. 
" On the 18th, his nurse reports that he 
had during the night numerous convul- 
sions, at intervals of less than half an 
hour. He screams frequently, and rolls 
from side to side. Eyes entirely vacant 
in expression. The convulsions continued 
through this day in the same manner, 
affecting chiefly the left arm and leg, and 
the muscles of the face. The pulse at 
this time, and for the four following days, 
was slow and irregular; the irregularity 
being very strongly marked. The bowels 
and bladder were opened during the 
spasms repeatedly, and, when in the in- 
terval, involuntarily and unconsciously, 
in the bed. A warm bath was at this 
time employed, his resistance while con- 
scious, having interfered with it. 
"During the 19th, the same condition 
was maintained. His father told me that 
he had a spasm every fifteen minutes- 
but feebler. The right limb occasionally 
moves during the convulsion, but is mo- 
tionless otherwise. Pulse has not lost its 
strength or irregularity. He refuses to 
swallow-or chokes when compelled to 
receive fluid into the mouth. No evidence, 
whatever, of sight or hearing exists ; the 
breathing is almost stertorous, and grit- 
ting of the teeth nearly incessant. 
Through this night also the convulsions 
continued. I noted, in my memoranda, 
that he would certainly die, and gave 
nearly the same opinion in reply to inqui- 
ries of some of the family. 
" On the 20th, at my request a renewed 
attempt was made to induce him to swal- 
low, although the attendants declared 
that he could not open his lips. He was 
raised up, and drank a few teaspoonfuls. 
Some slight appearance of improvement 
in his aspect, with the subsidence of the 
convulsions, induced me to urge, although 
without any hope, the renewal of the 
blister. This was attended to; he was 
nourished with tapioca ; the bowels were 
once more emptied by injection; and 
sponging briskly all over with warm 
spirits and water was advised and prac- 
tised. The father continued the use of 
the hyoscyamus mixture, avowing that it 
calmed his restlessness. 
" 21st. No more of the convulsions. 
Pulse still irregular. He certainly looked 
decidedly better, turning his eyes towards 
us with a conscious and attentive expres- 
sion. The right arm and leg, however, 
were paralyzed, and his apparent efforts 
to speak proved abortive. The blister 
raised well. 
"22d. All the symptoms have im- 
proved, except the paralysis. Repeated 
stimulating frictions were used to the 
affected limbs. 
" 23d. The right leg already begins to 
show some return of control. Speech is 
yet very slowly and imperfectly accom- 
plished, but his senses appear to be acute, 
and consciousness perfect. He receives 
nourishment with avidity, and sleepswell. 
He continued to improve from that date, 
and, by the 30th of October, had entirely 
regained the use of both the limbs which 
were paralyzed, being, in all respects, so 
far as I could discover, well. 
"I had, during its progress, supposed 
this to be a case of Tubercular Meningitis, 
from the slowness of its approach and ad- MENINGITIS OF THE CONVEXITY. 
827 
vance, with but moderate circulatory ex- 
citement, and most obstinate cerebral 
symptoms. Apart, also, from the diffi- 
culty of diagnosis between this form of the 
disease and simple meningitis, I had 
founded an unfavorable prognosis upon 
the same facts, with the knowledge of the 
child's inherited predisposition. The 
symptoms which especially pointed to this 
expectation were, the great frequency of 
the convulsions (according to the child's 
father, at least every twenty minutes dur- 
ing the night of the 17th, the day and 
night of the 18th, and the day-time of the 
19th-two days and two nights); the oc- 
currence of these convulsions, also, at a 
late period of the disease - between the 
eighth and the sixteenth day ; the irregu- 
lar pulse, observed steadily during four or 
five days; the total absence, through 
most of the same period, of sensation or 
any evidence of consciousness ; the invol- 
untary discharges; and, lastly, the hemi- 
plegia. 
" Rilliet and Barthez assert that when, 
with symptoms of meningitis, general 
convulsions occur frequently or with vio- 
lence, they almost always coincide with 
tubercles of the substance of the brain. 
'Perfect paralysis,' says Dr. Gerhard 
(Amer. Journ.of Med. Sci., May, 1834, p. 
107), 'did not occur, unless immediately 
before death.' And Dr. Meigs termi- 
nates his list of the signs which most 
positively indicate the near approach of 
death in meningitis with the phrase, ' par- 
ticularly general convulsions. ' 
" The same writer (Dr. J. F. Meigs) 
alludes, without details, in his work on 
the Diseases of Children, to a case which 
I suppose to have been somewhat similar; 
and, while treating of Sir Benjamin Bro- 
die's plan of mercurial inunction, he refers 
to a parallel instance, occurring under 
that treatment, recorded by the editor of 
Braithwaite''s lietrospect (vol. iv. 1846). 
"But I do not, in any of the works I 
have had opportunity to consult, find such 
definite statements, particularly with re- 
gard to the possible time of duration of 
convulsive symptoms, in cases which re- 
cover, as enable me to judge, authorita- 
tively, of the degree of rarity of such an 
occurrence as has just been narrated. 
Charpentier asserts that, in the first pe- 
riod of tubercular meningitis, a cure is 
possible. In the second stage, when no 
doubt can exist as to its nature, Guersant 
believes that he has seen one recovery in 
a hundred cases. Of those which arrive 
at the third period, he has seen none re- 
cover, even temporarily. 
" It is, then, my duty to record that the 
above-mentioned child, II. 8., continued 
in good health, with excellent appetite, 
digestion, and spirits, and increasing in 
flesh, until November 26th, about a 
month after the date of his previous re- 
covery. He was at that time, while 
returning in an omnibus from Frankford, 
attacked with a convulsion, which did not 
leave him entirely until the middle of the 
next day, the 27th, when he died. 
"Must not this, however, be considered 
a new and separate attack from the one 
above described ? 
"On referring to Guersant's elaborate 
article on 'Meningite Tuberculeuse,' in 
the Dictionnaire de Medicine (1839), I find 
a record by him of two cases somewhat 
similar in their mode of termination. 
" The one, he says, having been treated 
in the Hopital des Enfans, ' en etait sorti 
dans un etat de demi-convalescence, lors- 
qu'au bout de cinq semaines il fut repris 
de nouveau de tous les symptomes de la 
maladie aigue, a laquelle il succomba: les 
caracteres anatomiques de la meningite 
tuberculeuse furent parfaitement con- 
states par la necropsie. ' The other case 
resembled this, except that the period of 
apparent convalescence lasted two months, 
with a good appetite, and ' ayant repris 
I'embonpoint; ' after which he was re- 
attacked, and died. 
"May we not imagine, however, that, 
if such a convalescence could last two 
months, it might, in a case affected with 
nearly similar lesions, be prolonged in- 
definitely ? "-H.] 
B. Meningitis of the Convexity. 
No doubt Tubercular Meningitis usu- 
ally affects the base of the brain; but it 
is equally certain that this is not always 
the case. And inasmuch as the most 
characteristic symptoms of ordinary Tu- 
bercular Meningitis are in fact the symp- 
toms of basilar meningitis, it follows that 
when the meningitis is not basilar, it is 
not attended by those symptoms. That 
is to say, the vomiting of the invasion 
period, the constipation, the infrequent 
and irregular pulse, the unequal pupils, 
the ophthalmoscopic signs of disease, the 
strabismus and other local paralysis, are 
absent from meningitis which does not 
involve the base of the brain. A state in 
which general convulsions are either pres- 
ent or imminent, the intervals between 
the convulsions being occupied by trem- 
blings and twitches of the limbs and face, 
turning of the thumbs in upon the palms, 
clenching of the fists, stiffness of the back, 
neck, and limbs-in short, a convulsive 
state, which is constant (except perhaps 
quite at the close of the disease)-this is 
the prominent symptom of Tubercular 
Meningitis of the convexity. Add mode- 
rate pyrexia, and a pulse which is frequent 
and very variable in its frequency.1 The 
' I wish it to be understood that I do not 
speak of cases of cerebro-spinal meningitis. 828 
TUBERCULAR MENINGITIS. 
clue to diagnosis is to be found in the 
acuteness of the disease, the convulsive 
state, and the constant pyrexia : the evi- 
dences of basilar meningitis and of cere- 
bral abscess being wanting. Meningitis 
of the convexity runs a more rapid course 
than meningitis of the base : two weeks, 
one week, or even less, commonly see the 
fatal termination. 
Secondary Tubercular Meningitis 
in the Child. 
As before explained, meningitis is called 
Secondary when its symptoms have been 
preceded by manifestations not to be 
doubted of tuberculosis elsewhere. It has 
also been mentioned that, with this con- 
dition, the onset of the meningitis is, as a 
rule, obscure; a fact which will not sur- 
prise the reader when he considers the 
nicety of the premonitory symptoms, and 
the slight prominence of the commoner 
invasion symptoms appearing in the midst 
of a state of tuberculosis already existing. 
A state of acute tuberculosis, we ought 
rather to say ; for when the tubercular 
disease is of that chronicity which we 
sometimes see, lasting for years (inso- 
much that tuberculization having prob- 
ably ceased, the patient suffers from its 
permanent effects merely), the recurrence 
of actual tuberculization is only some- 
what less marked than its supervention 
upon a healthy state. The small number 
of cases then (with regard to children, 
very small) which belong to the latter 
class may be dismissed from further con- 
sideration, differing as they do from pri- 
mary Tubercular Meningitis only in this, 
that they run more rapidly to death. On 
the other hand, in a case of acute tuber- 
culosis the cerebral lesion may have 
reached the point of complete softening 
of the septum lucidum and fornix, and 
not have produced any symptoms of 
hydrocephalus which could be discovered 
even by the observer watching for them. 
Between these extremes with regard to 
curtailment of symptoms there are all 
possible grades. 
Tubercular Meningitis, when secondary 
to cerebral tubercle, is attended by symp- 
toms which are for the most part distinct 
enough. This, indeed, would almost fol- 
low from the law before laid down ; for 
cerebral tubercle (that is to say, a tuber- 
cular tumor), which has caused symptoms 
whereby it lias been recognized, must be 
so chronic that the onset of the meningitis 
is well marked. If, on the other hand, 
the symptoms of tumor have been so slight 
as to have been insufficient for its diagno- 
sis, then the case is, for clinical purposes, 
primary Tubercular Meningitis. Masses 
of yellow tubercle are often found embed- 
ded in the brains of children dead of hy- 
drocephalus acutus, whereof neither the 
prodromata nor the symptoms had led us 
to suspect the presence of anything more 
than the constant accompaniments of the 
lattei' disease. 
It is uncommon for meningitis to super- 
vene upon chronic phthisis in children; 
when this does happen, the new disease 
has been, so far as I have seen, easy of 
discovery ; the more easy, the more chro- 
nic the precedent disease. Contrariwise, 
meningitis which occurs in the course of 
acute tuberculosis of the pulmonary form 
is mostly latent; when not so, very rapid 
in inducing death. 
When tubercular peritonitis which has 
been diagnosed is complicated by menin- 
gitis, the latter is of the curtailed kind, 
apt to be overlooked, being, as it were, 
rather the harbinger than the cause of 
death-affording another proof of the 
truth of that aphorism which may be here 
repeated under another form, that the 
more tuberculosis has involved the health 
at large, the more obscure are the signs 
of a sequential meningitis; its premoni- 
tory and invasive symptoms have been 
anticipated. I have not known meningi- 
tis to supervene upon tabes mesenterica 
of such gravity as to have been a disease 
by itself. 
The recognition of the occurrence of 
meningitis in the course of acute tubercu- 
losis, which has been previously known to 
exist, depends greatly upon the degree to 
which the brain becomes implicated. Cere- 
bral symptoms may be well marked 
(though shortened in duration, reduced 
to a week or less) even when they have 
been preceded by such grave symptoms, 
independent of the brain, as have not per- 
mitted us to doubt the existence of acute 
tuberculosis. Acute tuberculosis, not 
primarily cerebral, assumes for the most 
part one of two forms, namely, the typhoid 
form, or the pulmonary form. I cannot 
do better than quote Rilliet's description 
of the typhoid form when it precedes men- 
ingitis :-"In rare cases the invasion 
symptoms are more acute and febrile than 
usual, the skin is somewhat hotter, the 
pulse somewhat more frequent. The child 
complains of his head and belly at the 
same time ; he does not vomit, but his 
bowels are obstinately constipated; he 
does not shriek, nor sigh, nor grind his 
teeth. The symptoms last from six to 
twelve days; fever continued; tongue 
covered with a thick fur ; belly somewhat 
swelled and tender. The child is drowsy, 
but easily roused ; answers sensibly ; no 
photophobia ; pupils natural; pulse regu- 
lar, equal, 120 or more ; no spots or suda- 
mina anywhere ; facies not that of hydro- 
cephalus. This state is followed by the 
second (established) stage of meningitis. " 
Let me add, that I have remarked, in 
such cases, the tongue to be pointed, with DIAGNOSIS. 
829 
a central white fur and red tip and edges, 
and the bowels to be spontaneously relax- 
ed. The pulmonary form is more common. 
The child sickens with what seems to be a 
bad cold; rapid loss of flesh and strength; 
fever rather high. The catarrh continues, 
fever increases, dyspnoea and lividity en- 
sue ; the rales heard in the lungs become 
more and more abundant, fine, sharp, and 
metallic; the percussion note is high- 
pitched and hard, without losing in reson- 
ance. After two or three months from 
the beginning, symptoms of meningitis ap- 
pear, more or less distinct, therein follow- 
ing the rule already several times laid 
down. 
Tubercular Meningitis in the 
Adult. 
It will be no small gain, if, by treating 
separately of Tubercular Meningitis as it 
occurs in the adult, a single reader be put 
upon his guurd against supposing that 
acute hydrocephalus is a disease peculiar 
to childhood. As a matter of fact Tuber- 
cular Meningitis in the adult is not often 
diagnosed ; yet were every one to study 
acute tuberculosis in the child, and then 
to transfer the knowledge acquired to the 
investigation of the diseases of the full- 
grown, there would probably be no special 
difficulty in the recognition of Tubercular 
Meningitis at any age. 
Meningitis, when intercurrent in the 
course of chronic phthisis, is characterized 
by more or fewer of the following symp- 
toms :-Headache, complained of for the 
first time; or, if previously present, greatly 
increased in severity; mostly, but not al- 
ways, very painful; frontal. Vomiting is 
an early symptom, occurring in almost 
every case: vomiting in uncomplicated 
pulmonary phthisis is uncommon, except 
when brought on by the violence of the 
cough. Convulsions, occasionally, mark 
the onset of the meningeal disease. De- 
lirium, of a quiet talkative kind, ensues. 
Sometimes the patients become speechless; 
they make ineffectual efforts to answer a 
question, or they look steadily at the 
speaker for a few moments, and then, 
without any expression of face, turn the 
head away. Numbness, paralysis, rigid- 
ity, of a limb, or of some other part, may 
be a very early indication of the affection 
of the brain. At the same time, the 
symptoms, so far as the chest is concerned, 
''abruptly improve or actually disappear." 
Then follow : comparative infrequency of 
the pulse, and irregularity both of pulse 
and respiration ; squint; inequality of the 
pupils; the patient lies in a meditative, 
semi-unconscious state, then becomes 
more and more unconscious, while moto- 
rial symptoms, of any kind, ensue. The 
phthisis is not often advanced. 
Primary Tubercular Meningitis is at 
least as common, in the adult, as second- 
ary; and, like as in the child, the symptoms 
may be nearly wholly cerebral from the 
first, or may assume a typhoid character. 
In the latter case, the disease is rather 
acute tuberculosis than Tubercular Men- 
ingitis ; the non-cerebral symptoms pre- 
dominate, at least at first. In the other 
case, the symptoms do not differ from 
those previously described, as occurring 
in the child, either in their character or 
their order of appearance ; headache, at 
the beginning, is mostly very severe, but 
is not always so. Vomiting, strabismus, 
diplopia, more or less loss of power over 
some part of the body, convulsions, numb- 
ness, dilated pupils, infrequency of the 
pulse, early delirium, the presence of any 
of these symptoms in an adult suffering 
from an acute illness, should suffice to put 
us on our guard : the physical examina- 
tion of the chest does not often help the 
diagnosis. The duration of the disease is 
from eight to fifteen days. 
Diagnosis.-The diseases which are 
confounded with Tubercular Meningitis 
may be divided for practical purposes 
into two classes : the first comprehending 
those diseases which simulate the earlier, 
and the second those which simulate the 
later, periods of meningitis. And it so 
happens that the resembling diseases of 
the first class are not attended, and of the 
second class are attended, by organic le- 
sions of the nervous centres, or their ap- 
pendages : this, speaking generally. The 
difficulty is greatest in the diagnosis of the 
earlier, the premonitory and invasive, pe- 
riods of Tubercular Meningitis from the 
diseases of the first class ; and the reason 
of the difficulty is obvious, namely, that 
the premonitory symptoms of Tubercular 
Meningitis are common to many diseases; 
so that the physician, full of a just dread 
of tuberculosis, and not wishing to be con- 
fronted by meningitis unawares, is con- 
tinually suspecting tuberculosis when it is 
not present. To have treated incipient 
hydrocephalus slightingly is a mistake 
which, once made, is not readily forgot- 
ten ; the patient's friends, at any rate, 
will remember the failure in prognostics. 
Loss of flesh going on steadily is a symp- 
tom to which it is wise to give the worst 
possible meaning. Repeated vomiting, in 
the child or the adult, occurring as a new 
symptom during a state of good health, or 
after a period of poorliness, is worthy of 
all our attention. Very carefully do we 
examine a child who has had a convul- 
sion, lest it should be the first warning of 
the existence of incurable disease. 
The First Class of diseases includes :- 
1. Simple Exhaustion ; 2. Derangement 
of the Alimentary Canal; 3. Typhoid 
Fever ; 4. Scarlet Fever and Smallpox; 830 
TUBERCULAR MENINGITIS. 
5. Hysteria ; 6. Simple Convulsions ; 7. 
Pleurisy and Pneumonia. 
1. Simple exhaustion of the vital powers 
(Morton's nervous atrophy) sometimes 
occurs so acutely and reaches such a pitch 
as to be mistaken for tuberculosis, or, in- 
deed, actually existing Tubercular Men- 
ingitis. The exhaustion may be primary: 
a child, without any obvious cause, or 
perhaps in consequence of a slight catar- 
rhal state or change of diet, loses its ap- 
petite, and therewith its flesh; becomes 
pale, languid, and restless ; there are no 
distinct dyspeptic symptoms; the nurse 
fancies that the child is feverish ; the pu- 
pils are large, and do not act very readily, 
a convulsion, or a series of fits, may occur 
-no other of the symptoms of meningitis 
being present. Wary in our prognosis, 
we submit the child to the test of treat- 
ment. We order pounded meat, milk, 
wine, or brandy, the aromatic confection, 
or a mixture of muriatic acid, cinchona, 
and chloric sether ; the next day we shall 
be able to prognosticate much less du- 
biously ; possibly, in the end, we may 
really have warded off Tubercular Menin- 
gitis. The exhaustion which is secondary 
to acute diseases, and especially to the 
longest acute disease, typhoid fever, is 
sometimes so great as to be mistaken for 
established hydrocephalus. It is chiefly 
in the houses of the poor that we see chil- 
dren, wofully mismanaged during their 
illness, wasted past belief. The alimen- 
tary canal ceases to perform a single nat- 
ural function ; the disgust for food is com- 
plete, the children are not even thirsty; 
forced to swallow broth, or food which is 
called light by a foolish metaphor, vomit- 
ing ensues ; the child is somnolent, yet 
extremely restless, lies rooting with his 
head in the pillow, tossing from side to 
side, waving his arms in the air, or con- 
stantly passing his hand over one side of 
his head; incessantly whining, occasion- 
ally screaming, and, if old enough, com- 
plaining, when asked, of severe pain in 
the head; the tongue rolls from side to 
side, the lips are dry and peeling; the 
eyesight becomes dim, the somnolence 
deepens into unconsciousness, and the 
child dies. Post mortem we find the ma- 
rasmus has invaded the brain ; it is small 
and very bloodless; the pia mater is 
watery. The sketch is from nature, and 
the possibility of mistake is more than a 
mere possibility. The diagnosis will de- 
pend upon the previous history of the 
case, upon the character of the symptoms, 
and the order in which they have been 
developed. 
2. Derangement of the alimentary ca- 
nal.-i. Acute Dyspepsia causes symptoms 
which are almost identical with those of 
the earlier periods of Tubercular Menin- 
gitis. To take an example : a child of 
four years old, of a phthisical family, sud- 
denly vomits several times, becomes fever- 
ish, complains of pain in his head, has no 
appetite ; coughs a little; is very irrita- 
ble, thick-looking, and heavy; greatly 
dislikes being touched; the bowels are 
confined. Occasional vomiting continues; 
in the course of a few days (measured by 
the thermometer, the pyrexia in such a 
case may last a week) the fever dimin- 
ishes, the pulse becomes irregular and 
much less frequent. But, happily, at the 
same time, the child begins to look bright- 
er, and to sleep better. It is important 
to bear in mind that during convales- 
cence, even from so trivial a complaint as 
dyspepsia, the pulse of many children be- 
comes actually infrequent and very irreg- 
ular. To increase the difficulty, I have 
known one pupil to become larger than 
the other at the same time, and to remain 
so several days. A diagnosis off-hand is 
often impossible; there is no help for it 
but expectation-expectation of the active 
kind. The patient is visited more often, 
examined more minutely, and treated 
more carefully than if there were no 
doubt; at least he does not suffer, proba- 
bly he derives benefit, from the uncer- 
tainty of the physician, ii. Gastro-intes- 
tinal catarrh.-A little child, who had lost 
appetite and flesh for several weeks past, 
has one day a fit, which lasts, say, a quar- 
ter of an hour ; on the same day her bow- 
els become loose ; they remain so for a 
week, then she vomits several times. All 
this time there is more or less pyrexia; 
what heaviness there is, caused by the 
diarrhoea, tends to complicate the diag- 
nosis. From one example the reader will 
learn all: diarrhoea, although no doubt an 
uncommon, is not an impossible, accom- 
paniment of Tubercular Meningitis. When 
dentition coincides, the pain caused there- 
by is not always distinguishable from the 
headache of meningitis : nor must we at- 
tribute too much to dentition; I have 
known the canines to pierce the gum and 
Tubercular Meningitis to break out at the 
same time. 
3. Typhoid fever resembles not so 
much Tubercular Meningitis as acute 
tuberculosis. But typhoid acute tuber- 
culosis is sometimes immediately fatal by 
way of meningitis. With regard to chil- 
dren, the physician, when in doubt, is far 
more ready to suspect acute tuberculosis 
than typhoid fever. The difficulty is 
caused by the aberrant forms of typhoid 
fever which we meet with; cases with 
confined bowels, with an empty belly, 
with spots which are small, dusky, and 
hard to the feel, or even vesicular at the 
apex; cases which have the facies of 
acute tubercle ; cases complicated with 
consolidation of one or other apex of the 
lung, and attended by universal mucous 
rhonchi. In the adult, however, typhoid 
fever is far more likely to be suspected DIAGNOSIS. 
831 
than acute tuberculosis. The practi- 
tioner, if fully aware that acute tubercu- 
losis does occur in the adult, will not fail 
of making the diagnosis as soon as it be- 
comes possible. Diarrhoea may accom- 
pany acute tuberculosis. Acute tubercu- 
losis, with or without meningitis, some- 
times greatly resembles typhus fever. 
4. Smallpox and scarlet fever, both of 
which invade by vomiting, may be at- 
tended at the same time by very severe 
cerebral symptoms.1 
5. Tubercular Meningitis sometimes at 
first simulates the symptoms of ulcer of 
the stomach, or may assume a quasi- 
hysterical form. 
6. Simple convulsions cannot per se be 
discriminated from those which are pre- 
cursory of Tubercular Meningitis. 
7. The vomiting of incipient pleurisy 
and pneumonia, if accompanied by con- 
vulsions, as may be the case, is apt to 
divert attention from the chest to the 
head. But acute tuberculosis tends to 
cause inflammation of all the serous mem- 
branes ; and, as a matter of actual experi- 
ence, I have heard the friction sound of 
pleurisy in cases of Tubercular Meningitis; 
so that, on the contrary, attention must 
not be diverted from the head to the 
chest. The rale of lobular pneumonia is 
less general than that which we hear in 
some cases of miliary tubercle of the lung. 
In the lobular pneumonia of children, 
chlorides are often present in the urine 
while the body temperature is still high. 
The Second Class of diseases which 
simulate Tubercular Meningitis includes: 
1. Simple Meningitis ; 2. Abscess of the 
Brain ; 3. Thrombosis of the Sinuses of 
the Dura Mater ; 4. Caries of the Atlo- 
Axoid Joint; 5. Arachnoid and Sub- 
arachnoid Hemorrhages ; 6. Intracranial 
Tumors; 7. Hypertrophy of the Brain ; 
8. Essential Brain Fever. 
1. By simple meningitis is meant men- 
ingitis which occurs totally unconnected 
with tuberculosis. Simple meningitis of 
the convexity is not a common disease. 
The symptoms are the same as are de- 
scribed under the head of Tubercular 
Meningitis affecting the convexity of the 
brain ;2 but the course of simple menin- 
gitis is more rapid. Convulsions and 
pyrexia in children ; headache, active de- 
lirium, and pyrexia in adults, are the 
symptoms present early in the disease. 
Unconsciousness ensues in a day or two ; 
the duration of the illness does not often 
exceed a week. 
Sporadic cerebro-spinal meningitis (the 
membranes of the base and ventricles of 
the brain, and the sub-arachnoid space of 
the spinal cord, being especially affected), 
totally unconnected with tubercle, has 
been, in my experience, comparatively 
common. Cerebro-spinal meningitis is 
frequently quite a chronic disease ; when 
acute, it resembles Tubercular Meningitis 
of the base very strongly.1 
2. Cerebral abscess occurs under seve- 
ral different circumstances, and differs 
accordingly in clinical details. The diag- 
nosis of Tubercular Meningitis continually 
opens up the whole field of diseases of the 
brain; the ability to distinguish them 
greatly depends upon a full and minute 
knowledge of their history. The reader 
will refer to the special articles, and make 
the necessary comparisons for himself, 
i. Cerebral abscess of pysemic origin may 
be dismissed at once as never complicating 
diagnosis, ii. Cerebral abscess due to 
suppuration of the pia mater, going on so 
far that numerous large collections of pus 
are protruded into the brain substance, 
which disappears by rapid atrophy, so far 
as I have seen, does not modify the ordi- 
nary course of simple meningitis, iii. 
Cerebral abscess (due to disease of bones 
of the skull or not) differs in its symptoms 
according as pysemia is combined with it 
or not. Abscesses merely pushed into 
the brain, inasmuch as they are not com- 
monly combined with disease of the 
sinuses, cause symptoms which are alto- 
gether those of an intracranial tumor. 
Abscesses which are separated from the 
diseased bone by a layer of brain tissue 
(often greatly altered), and which are 
therefore presumed to have originated in 
the very midst of the lobe affected, are 
for the most part attended by pyaemia, the 
symptoms being complicated accordingly. 
But pyaemia does not always accompany 
even these non-peripheral abscesses, and 
then the difficulty of diagnosis from Tu- 
bercular Meningitis is very great, espe- 
cially if we bear these facts in mind : first, 
that it is not uncommon for otorrhoea to 
concur with Tubercular Meningitis ; and 
next, that external otorrhoea, in cases of 
cerebral abscess due to disease of the pars 
petrosa, may not set in until a week be- 
fore death, and may have been preceded 
by the gravest symptoms of that intra- 
cranial otorrhoea which destroys the pa- 
tient. The pulse of cerebral abscess is 
more persistently infrequent than that of 
Tubercular Meningitis. 
3. Thrombosis of the sinuses of the 
dura mater, when secondary to neighbor- 
ing inflammation, does not admit of diag- 
nosis, unless there be present pysemial 
symptoms and some obvious possible 
cause of disease of the sinuses; caries of 
the pars petrosa is by far the most com- 
mon. Thrombosis secondary to debilitat- 
1 The symptoms are the same as those of 
epidemic cerebro-spinal meningitis, to the 
article upon which subject the reader is re- 
ferred, p. 296. 
1 See vol. i. pp. 132 and 85. 
2 Page 817. 832 
TUBERCULAR MENINGITIS. 
ing causes may be suspected if signs of 
disease of the brain follow a profuse diar- 
rhoea or hemorrhage in a young child, but 
could hardly be distinguished from the 
simple exhaustion before described; while, 
on the other hand, 1 have known a decol- 
orized softening thrombus to occupy the 
whole bore of the upper longitudinal sinus, 
to be attended by large sub-arachnoid 
hemorrhages, and to have caused no symp- 
toms during life. 
4. Caries of the atlo-axoid joint may 
cause such brain symptoms as to lead to a 
suspicion of the possible existence of Tu- 
bercular Meningitis. It is well, therefore, 
in a doubtful case, to examine the cervi- 
cal region carefully, so as to discover any 
thickening and swelling of the soft parts. 
5. Arachnoid hemorrhage, according to 
Legendre, may simulate Tubercular Me- 
ningitis.1 This can be only in exceptional 
cases of the former rare disease. 
6. An intracranial tumor at the base of 
the brain, of the soft sarcomatous kind, 
which approaches nearest to cancer in 
general appearance and in rapidity of 
growth, may cause symptoms which re- 
semble those of Tubercular Meningitis so 
closely, that, for a week or two from the 
beginning of the disease, it may be impos- 
sible to arrive at a diagnosis. In the case 
of the tumor, the pyrexia ceases for sev- 
eral weeks before death, and the disease 
becomes of a more chronic character. 
7. Local hypertrophy of the brain is 
sometimes attended by symptoms which, 
at first sight, are like those of Tubercular 
Meningitis. We discover afterwards that 
the hypertrophy is, comparatively, very 
chronic. 
8. Every practitioner, from time to 
time, will come across an acute febrile 
disease, accompanied by symptoms which 
seem to point unmistakably to some affec- 
tion of the brain: there being every reason 
to exclude the notion of suppressed exan- 
themata or analogous disorders. After 
one or several weeks of coma, delirium, 
severe headache, or whatever may have 
been the prominent symptom, the patient 
recovers, and we are left quite unable to 
say what has been the matter with him. 
To go more into detail, I could not do 
otherwise than narrate a series of cases 
which would differ from each other in 
most important points, and have nothing 
in common excepting pyrexia and brain 
symptoms. There is, generally, something 
wanting which makes us suspect that we 
have not to do with Tubercular Menin- 
gitis. Brain fever is as good a name as 
any whereby to designate these different 
anomalies; cerebral congestion, which is 
more commonly used, involves an explana- 
tion which is probably often wrong, and 
certainly never proved to be right. 
Morbid Anatomy.-I shall describe 
the morbid appearances of Tubercular 
Meningitis, in that order wherein they are 
brought under view during a post-mortem 
examination. 
Separation of the calvaria is easily 
effected as a rule. Miliary tubercle of the 
most undoubted kind was once seen by me 
upon the inner surface of the dura mater. 
Slitting up the longitudinal sinus, a pale 
narrow clot is seen in the posterior half: 
sometimes the sinus is filled with fluid 
blood and loose coagula, sometimes with a 
large black shining thrombus. Removing 
the dura mater, the great arachnoid sac is 
found to be destitute of fluid ; the mem- 
brane itself is dry, and, what is more, 
sticky to the finger passed over it. Scrape 
the surface gently with a scalpel and the 
sticky matter will be removed, minute in 
quantity, and puriform in appearance. 
Reddish serosity has been observed in the 
arachnoid sac by Senn and Becquerel; 
transparent or turbid serosity by Rilliet 
and Barthez. This serosity, was it ob- 
served before or after the brain had been 
removed ? If after, the observations are 
quite valueless, unless indeed certain pre- 
cautions were taken which probably were 
not. The ordinary unnatural state of the 
arachnoid may be looked upon as the sign 
of a feeble inflammation ; similar sticki- 
ness is common in incipient pleurisy and 
peritonitis. Empis once found the arach- 
noid sac obliterated by old adhesions in a 
patient who had probably passed through 
an attack of acute tuberculosis long before. 
Still more to the point: in Tubercular 
Meningitis there is almost constantly pre- 
sent adhesion, more or less firm, of the 
opposed surfaces of the great longitudinal 
fissure, especially just above the corpus 
callosum. 
The pia mater affords more unequivocal 
signs of disease. First, as to vascularity. 
Sometimes there is obvious hypersemia of 
the whole convexity of the brain : it looks 
rosy ; examined minutely, the fine vessels 
are seen to be injected everywhere; the 
body having lain on the back, the injection 
is nearly as well marked over the anterior 
as over the posterior lobes. More com- 
monly, the capillaries are not much in- 
jected ; what color the surface has being 
derived from large veins full of blood. 
Sometimes capillaries and veins both are 
emptied of blood, so that the brain has a 
most striking appearance, exactly resem- 
bling in color painters' putty. These dif- 
ferences depend for the most part upon 
the amount of pressure from within to 
which the surface of the brain has been 
subjected. Secondly, as to oedema. Ex- 
cess of clear serosity is commonly met 
with in the meshes of the pia mater be- 
tween the convolutions; sometimes the 
effusion is semi-opaque and lymph-like. 
Thirdly, as to tubercles. Examine the 
1 Rilliet and. Barthez, ii. 259. 833 
MORBID ANATOMY. 
membranes of the lateral region of the 
brain, corresponding in position to the 
temporal fossae, and almost certainly mili- 
ary tubercles will be seen; not that they 
are absent elsewhere, but they are most 
common at the spots indicated; they are 
common at the bottom of the great longi- 
tudinal fissure also. These tubercles are 
beneath the arachnoid, often adherent to 
its under surface ; those exposed to pres- 
sure against the skull are more or less 
flattened. Alongside the branches of the 
middle cerebral artery it is common to 
find a firm, grayish, semi-transparent 
material, which is probably confluent tu- 
bercle. Minute opacities of the pia mater 
are sometimes seen in the same region, 
most numerous by far in the neighborhood 
of the miliary tubercles, and possibly tu- 
bercular in nature, a sort of white " tuber- 
cular dust." Sometimes the tubercles are 
yellow at their centre, sometimes all of 
them are yellow throughout, remaining 
crude. The number of tubercles present 
may be very large; there may be none at 
all.1 Raising the membranes from the 
surface of the brain, small portions of the 
brain substance adhere to the membranes 
so as to be removed with them ; not that 
this is always the case; the difference 
depends upon the degree which the soft- 
ening of the cortex has reached. The 
amount of vascularity of the pia mater 
and the degree of cortical softening are 
not always in direct proportion. The 
convolutions of the brain are more or less 
flattened, the intervening sulci narrowed. 
Proceeding to slice the brain, we perceive 
that the color of the cortex is increased in 
depth if the pia mater be hyperaemic, or 
diminished vice versa, or remains natural. 
As a rule, the centra ovalia are anaemic, 
sometimes exceedingly so. Sometimes the 
texture of the whole brain is obviously 
softened. When we reach the lateral ven- 
tricles, they are found to be distended with 
fluid,-a colorless serosity, of low specific 
gravity, mostly clear, but becoming faintly 
turbid when agitated; slightly albumin- 
ous, containing chlorides and phosphates. 
The quantity of the fluid is from one to 
four ounces; sometimes more. In one 
case I found a drachm of fluid in the fifth 
ventricle, the septum lucidum being every- 
where perfect. The foramen of Monro 
is dilated. The lining membrane (epen- 
dyma) of the ventricles is toughened, 
sometimes obviously opacified in places, 
especially in the sulcus between the cor- 
pus striatum and the thalamus opticus. 
Viewing the surface of the lining mem- 
brane. sideways, we see that it looks as if 
it had been sprinkled with the finest dust. 
It seems probable that this condition is 
mostly due to small heaps of cells, a com- 
mencing suppuration of the lining mem- 
brane sometimes tlie dusty look, in part 
at least, is due to a minutely wrinkled 
state of the ependyma, resulting from the 
stretching it has previously undergone. 
Occasionally we see larger granulations 
than those described, grayish elevations, 
something midway, in every respect, be- 
tween the sandy specks and miliary tuber- 
cles. The whole ependyma down to the 
fourth ventricle may be thus granular, or 
this sanded appearance may be quite ab- 
sent. The vessels of the ventricles, the 
choroid plexuses and veins of Galen, with 
their tributaries, are sometimes obviously 
full of blood, but more often not so, and 
sometimes almost empty, the plexuses be- 
ing quite pale. Softening of the cerebral 
matter beneath the ependyma is almost 
always found ; the septum lucidum and 
under surface of the fornix are reduced to 
a pulp ; the corpus callosum, walls of the 
posterior cornua, and other parts are often 
similarly affected. The question naturally 
arises,-What are the causes of these le- 
sions of the ventricles-the dropsy and the 
softening ? We cannot suppose that the 
brain substance will soften by passive im- 
bibition of fluid ; were it possible, there 
would be no reason why softening should 
not occur in health. But is the fluid 
forced by its excess into the brain sub- 
stance ? This is not so, because the ven- 
tricles are sometimes nearly empty when 
their walls are thoroughly softened. Me- 
chanical congestion might conceivably be 
the common cause of the dropsy and the 
softening ; but, in the great mass of cases, 
it is impossible to discover any impedi- 
ment to the return of blood from the 
ventricles. The blood may be made to 
flow from the veins of Galen back into the 
straight sinus with perfect ease ; moreover, 
as stated above, the plexuses are often 
quite pale, and the veins nearly empty. 
It would be difficult to explain the effusion 
of serosity into the pia mater, and the 
cortical softening, by mechanical conges- 
tion. Inflammation will account for all 
the conditions. We have already seen 
that the ependyma presents an appear- 
ance common in inflammation of surfaces, 
-namely, proliferation of cells. The con- 
nective tissue which underlies the epithe- 
lial layer of the lining membrane is grad- 
ually lost in the neuroglia or interstitial 
non-nervous tissue of the brain. And 
hence, inflammation of the ependyma 
leads to effusion of serosity both in the 
ventricles and into the brain matter ; the 
softening being rendered complete by the 
mal-nutrition which ensue in consequence 
of the more or less arrested capillary cir- 
culation. To proceed: the velum inter- 
positum is natural, or oedematous, or 
[' See the article on Scrofula, in this vol- 
ume.-H.] 
1 Loschner and Lambl: Aus dem Franz- 
Josef Kinderspitale, 1860 ; S. 82. Prague. 
vol. i.-53 834 
TUBERCULAR MENINGITIS. 
thickened and somewhat opacified ; stud- 
ded, it may be, here and there with mili- 
ary tubercles. The condition of the third 
ventricle resembles that of the lateral ven- 
tricles : the distension is ordinarily less 
because of the resistance of the thalami 
optici: in front of these masses the dilata- 
tion sometimes goes so far as to expose 
the pia mater of the base: the commisura 
mollis is often more or less torn and speck- 
led with capillary hemorrhages. The 
fourth ventricle also is distended. I have 
several times examined the cerebro-spinal 
opening in situ, and have always found the 
membranes about it perfectly healthy. 
When the spinal canal is laid open before 
the calvaria has been removed, to punc- 
ture the sub-arachnoid space (internal 
arachnoid of Hilton) causes the escape of 
a certain quantity only of fluid, merely 
the excess in the spinal canal; when the 
calvaria has been removed before the 
spinal sub-arachnoid has been touched, 
the cerebral ventricles can be drained 
completely by opening the membranes of 
the cord. The spinal internal arachnoid 
is distended with fluid, especially around 
the cauda equina. I have never observed 
any other morbid condition within the 
spinal canal, but then it has been exam- 
ined in a minority of cases. Removing the 
brain from the base of the skull, we occa- 
sionally find adhesions of the two surfaces 
of the great arachnoid about the circle of 
Willis. The membranes at the base of the 
brain are sometimes greatly injected, 
sometimes much less so. Miliary tuber- 
cles sometimes swarm in the Silvian fis- 
sures, interpeduncular space, round the 
crura cerebri, and on the top of the cere- 
bellum : ordinarily they are not in very 
large numbers ; occasionally there is only 
a tubercle here and there ; still more rare- 
ly no unquestionable tubercles can be 
found. Sometimes the tubercle is of the 
crude yellow variety. Other parts of the 
membranes of the base than those men- 
tioned sometimes present tubercles. Be- 
sides being tuberculizcd, the membranes 
(i. e. pia mater, sub-arachnoid) undergo 
those changes which have caused the 
name of meningitis to be given to this 
disease. The meshes of the pia mater are 
filled with serosity (clear or turbid), or 
with lymph-like material, or with puri- 
form : sometimes the membrane seems to 
be merely thickened, toughened, and opa- 
cified. The inflammation of the pia mater 
is most marked in the interpeduncular 
space, but tends to spread forwards along 
the optic and olfactory nerves, sideways 
into the Silvian fissures, and backwards 
round the crura cerebri on the upper sur- 
face of the cerebellum, or right over the 
pons and as far back, it may be, as the 
medulla oblongata. There is no propor- 
tion between the amount of tuberculosis 
and of meningitis. Softening of the brain 
cortex is usual; the under surface of the 
anterior lobes, and the under surface of 
the cerebellum, are affected with especial 
frequency. Softening of the optic com- 
missure and of the smaller nerves is 
mostly found. The sinuses at the base 
present nothing abnormal. 
The foregoing description applies to the 
commoner form of Tubercular Meningitis, 
in which the membranes of the base of 
the brain are involved. In the less com- 
mon form of the disease, limited to the 
convexity of the brain, the morbid 
changes correspond. The pia mater of the 
affected part is infiltrated with puriform 
lymph ; the membranes of the base being 
spared : there is no excess of serosity in 
the ventricles. 
It is obvious to the naked eye that the 
tubercles are everywhere in the closest 
connection with the bloodvessels, es- 
pecially the small arteries. And, in fact, 
it is in the sheaths of the vessels that the 
tubercles are formed. Both by their po- 
sition (being seated upon the vessels), and 
by their structure, recent miliary tuber- 
cles of the pia mater have the closest re- 
semblance to the Malpighian follicles of 
the spleen: indeed the similarity is so 
great that when the same bodies, which 
are recognized elsewhere as being recent 
miliary tubercles, are found in the spleen, 
it is often impossible to distinguish them 
from the Malpighian follicles. There can 
be no reason for doubting that the men- 
ingeal tubercles are not of the same na- 
ture as miliary tubercles elsewhere. It is 
true that the lymphatic character of the 
vascular sheaths is very well marked in 
the brain, but the vessels of many other 
parts are similarly constructed, to say 
nothing of the lymphatic tissue which 
exists beneath the serous and mucous 
membranes, and in other places. Accord- 
ing to Dr. Bastian, the new formation in 
the sheaths of the vessels of the velum 
interpositum is sometimes so abundant 
as to cause the vessels to be obstructed. 
Accidental Lesions.-1. Masses of yellow 
tubercle are often met with in examining 
the brains of children dead of Tubercular 
Meningitis. Sometimes the tubercle is 
softened. 2. Capillary hemorrhage coin- 
cides with the softening of the cerebral 
matter, when the softening has reached a 
certain point. Most frequently seen in 
the soft commissure, hemorrhage some- 
times occurs in other parts, the brain 
proper, the pons Varolii, &c., leading to 
utter disorganization of the tissue. 3. I 
have seen miliary tuberculosis of the 
brain substance carried almost as far as 
can be conceived possible-a whole hemi- 
sphere of the cerebrum so much softened 
that it was easy to wash all the brain 
matter away ; which done, there remained 
a close network of injected and dilated 
capillaries studded everywhere with mi- PROGNOSIS AND TREATMENT. 
835 
liary tubercles. The meningitis in this ' 
case ran a very rapid course. 4. Menin- ! 
geal apoplexy, and a decolorized throm- 1 
bus of the superior longitudinal sinus, I I 
observed in one case of tuberculosis of 
the meninges, unattended with obvious 
inflammation of them. 
Other Organs. - Tuberculosis of the 
lungs, liver, spleen, lymphatic glands, 
kidneys, and ocular choroid, concurs with 
the brain disease. The tubercle is mostly 
miliary, sometimes yellow, crude, or soft- 
ened. A girl of four* died on the tenth 
day of Tubercular Meningitis without 
prodromata ; post mortem we found nu- 
merous miliary tubercles in the pia mater, 
great ventricular effusion, very little 
lymph at the base of the brain, and abso- 
lutely no tubercle in any other part of the 
body (which was carefully examined), ex- 
cepting a small mass of cheesy material 
in each lung. Tubercular ulcers of the 
intestines are often present: also intus- 
susceptions, easily reduced. The children 
will have frequently preserved a large 
amount of subcutaneous fat. 
Prognosis and Treatment. - The 
prognosis must always be unfavorable ; 
and when the disease has passed beyond 
the invasion period and has become es- 
tablished, recovery may be deemed hope- 
less. In the latter case, if we reckon 
twenty-one days from the invasion symp- 
toms we shall probably cover the fatal 
termination. When the disease does not 
pass beyond what seemed to be the inva- 
sion symptoms of Tubercular Meningitis, 
the patient's recovery is not always com- 
plete ; this has been already dwelt upon : 
moreover, a second attack sometimes 
ensues. 
What then, is to be done by way of 
prevention of the disease ? The prophy- 
lactics and ordinary hygienics are the 
same-animal food, change of air, warmth 
to the surface, moderate exercise; to 
which may be added cod-liver oil and cin- 
chona. The bad prognosis of confirmed 
Tubercular Meningitis does not belong to 
acute tuberculosis. No doubt many per- 
sons recover from acute tuberculosis: 
knowing this, any patient suffering from 
what is possibly acute tubercle should be 
treated very carefully, so as, if possible, to 
stop the disease and prevent atfection of 
the brain. If the patient be seen during 
the invasion period, he should be put 
into a dark and quiet room ; be carefully 
and regularly fed ; symptoms should be 
treated ; constipation relieved; a convul- 
sive state diminished by full doses of 
bromide of potassium. There can be no 
doubt concerning the powerful depressing 
influence exerted by continuous cold ap- 
plied to the head: this means should be 
therefore employed if the disease be seen 
in its earliest stage. Cod-liver oil may be 
tried at the same time. Later on there is 
not much that can be done. Sufficient 
liquid food should be given to the patient, 
by means of a syringe placed between the 
teeth, if need be. Leeches, active purg- 
ing, blistering, and such-like measures, 
will rather hasten the advance of death. 
It is best not to shave the head unless it 
be necessary to apply cold. If the corneas 
begin to ulcerate, it is as well to keep the 
eyelids closed by means of a little sticking 
plaster. 
[Since the discrimination in the early 
stage, between simple and Tubercular 
Meningitis, is not always easy or certain, 
the good results of active treatment in the 
former justify the moderate and careful 
use of similar measures, leeching, purga- 
tion, and blistering, at that period. After 
paralytic symptoms appear, all such treat- 
ment should be discontinued. The follow- 
ing is abstracted from an account of the 
case of a man, aged 23, reported by M. 
Du jardin-Beau metz in Le Pr ogres Medical, 
1879, p. 208 
"For five days he had persistent cepha- 
lalgia, which appeared about to usher in 
an attack of typhoid fever ; coma followed, 
and from the sixth to the tenth day the 
symptoms of Tubercular Meningitis, not- 
withstanding which the man recovered. 
The patient's antecedents were very un- 
favorable to this result, his father and 
mother having both died with phthisis. 
Examination of the eye-ground had shown 
exudation with tuberculous granulations. 
The treatment consisted in blisters, calo- 
mel, and ice to the head. M. Beaumetz's 
paper was read before the Societe M6dicale 
des Ildpitaux, and several other cases 
were brought forward by members show' 
ing a similar arrest of the disease in ques* 
tion."-IL] 
1 Under the care of Dr. West in the Chil- 
dren's Hospital. 836 
CHRONIC HYDROCEPHALUS. 
CHRONIC HYDROCEPHALUS. 
J. Spence Ramskill, M.D. 
Tins disease is a real dropsy occurring 
within the cranial cavity. The fluid may 
be collected in the sac of the arachnoid or 
in the ventricles of the brain, beneath the 
arachnoid membrane. The affection may 
be congenital or acquired. When con- 
genital, it is generally, but not invariably, 
due to an arrest of development of the 
cerebral mass, although even in such cases 
the dropsy has been regarded by Roki- 
tanksy and Vrolik, whose opinion is 
quoted and endorsed by Dr. West,1 as not 
a mere passive dropsy, but as the result of 
a slow kind of inflammation of the arach- 
noid, especially of that lining the ventri- 
cles, which may have existed during life. 
Such inflammation may also attack the 
child after its birth, and "each year," 
says Dr. West, " leads me to estimate 
more highly the share of inflammation of 
the lining of the ventricles in the produc- 
tion of Chronic Hydrocephalus. Acquired 
hydrocephalus begins to show itself about 
the period of the first dentition." Ac- 
cording to Dr. West (p. 124), out of 54 
cases, 18 of which came under his own ob- 
servation, some indications of the disease 
were obtained in 50 before the child was six 
months old ; in 14 the symptoms existed 
from birth, and in 21 more they appeared 
before the completion of the third month. 
In some rare cases, the disease attacks 
children seven, eight, or nine years old, 
who until then had seemed to be free from 
all cerebral complaint. In some ex- 
tremely rare cases, this affection has been 
known to attack persons of advanced life. 
Sir Thos. Watson2 cites several instances 
of the kind, one of which occurred under 
his own observation. A young and dis- 
tinguished lawyer of his acquaintance had 
one or two attacks of rather sudden loss 
of consciousness, while engaged in the 
Court of Chancery ; by degrees he became 
dull, stupid, forgetful, and at length insen- 
sible. In this condition he died. A large 
quantity of serous fluid was found distend- 
ing the ventricles of the brain. No other 
alteration could be detected. A case of 
Dr. Baillie's is quoted by the same author, 
the patient being a man fifty years old. 
The celebrated Dean Swift died of this 
complaint at the age of seventy-eight, 
three years after the commencement of 
the disease.1 
Golis also mentions three instances in 
which this affection began in advanced 
life: two of the patients were about 
seventy years of age ; the third, who was 
a physician at Vienna, likewise died in 
the decline of life, having suffered under 
the disorder for ten years. When hydro- 
cephalus shows itself some time after the 
birth, it is generally accounted for by the 
presence of a tumor (cancer, tubercles, or 
cysts). The dropsy in such cases is pro- 
duced, as was pointed out by Dr. Whytt 
long ago, by the same mechanism as 
ascites in cases of schirrus of the liver, of 
the spleen, or of the pancreas. Any de- 
posit compressing the veins of Galen, 
which bring back the blood from the ven- 
tricles of the brain, is sure to lead to ac- 
cumulation of serosity within those ven- 
tricles. 
Dropsical effusion within the sac of the 
arachnoid is sometimes the result of a 
former hemorrhage into that cavity, as 
pointed out by Legendre, and supported 
by Rilliet and Barthez. In some very 
rare cases, Chronic Hydrocephalus seems 
to be a result of the acute disease. Tw o 
cases of this kind are recorded by Rilliet, 
one in his work on "Diseases of Chil- 
dren," p. 162, and the other in the "Ar- 
chives generales de Medecine," for Dec. 
1847. Dr. West also relates a case in 
which the first link in the chain of morbid 
processes seems to have been an injury to 
the head; the child, when five months 
old, having fallen out of the arms of the 
person who was nursing her, and on the 
same day she had a fit, and remained 
stupid and senseless for hours. 
Anatomical Characters.-1. Ventricular 
Hydrocephalus. - The quantity of fluid 
varies from a few ounces to a few pounds. 
In a case mentioned by Trousseau,2 the 
head measured a metre (39*3 inches) in 
circumference, and about thirty pounds 
of fluid were found in the ventricles. The 
same author cites another case from 
Franck, in which the fluid amounted to 
fifty pounds. 
As a necessary consequence of the ac- 
1 Practice of Physic, 4th edit. p. 464. 
2 Trousseau, Clinique Medicale, 2e 6dit. p. 
247. 
1 Diseases of Children, p. 121. 
2 Practice of Physic, 4th edit. p. 464. CHRONIC HYDROCEPHALUS. 
837 
cumulation of fluid, the ventricular cavi- 
ties are considerably enlarged, the open- 
ings through which they communicate 
with one another are considerably dilated, 
although in some instances, from the pour- 
ing out of lymph, these apertures may 
get closed, and the fluid may therefore 
accumulate in one part more than an- 
other, producing an unsymmetrical en- 
largement of the head. Thus, Vrolik1 
has related the case of a young man who 
died from Chronic Hydrocephalus at the 
age of twenty, and in whom a false mem- 
brane had occluded the foramen of Munro 
through which the two lateral ventricles 
communicate. 
The walls of the dilated ventricles may 
be of normal consistence, or even of 
greater consistence than normal. Rilliet 
and Barthez state that they have been 
able, in some cases, to dissect the con- 
densed mass into several layers. In other 
cases the walls felt softer, and oedematous 
for some little distance. The brain mass 
above the ventricles becomes thinned and 
unfolds itself. The convolutions are flat- 
tened out, and the sulci between them 
disappear. The cerebral substance looks 
pale and ansemic. In some cases it hap- 
pens that the commissures of the brain 
yield, and that the whole, or a portion of 
the fluid which it contains, escapes into 
the cavity of the cranium. This appears 
to have taken place in the well-known 
case of Cardinal, whose skull contained 
seven or eight pints of fluid, while "the 
brain lay at its base with its hemispheres 
opened outwards like the leaves of a 
book."2 When the accumulation of fluid 
has resulted "from inflammation of the 
membrane lining the interior of the ven- 
tricles, that membrane is found thickened 
and rough, and in some cases in a granu- 
lar condition. 
2. Intra - arachnoid Hydrocephalus. - 
When the result of hemorrhage into the 
arachnoid sac, the fluid is found more or 
less yellowish in color, and may be even 
more or less mixed up with thin, serous 
blood. When it has been poured out to 
fill up the vacuum in the skull due to de- 
fective development of the brain, it is 
perfectly limpid and clear. The sinuses of 
the dura mater in this, as in the preced- 
ing form of hydrocephalus, are either 
empty, or are found to contain blood, both 
liquid and coagulated. The fluid of 
hydrocephalus, when tested by heat and 
nitric acid, is found to contain albumen ; 
chloride of sodium, soda, and traces of 
salts of lime and potash have also been 
found in it. Urea was detected by Dr. 
Bostock in his examination of the fluid 
found in Cardinal's head. 
Condition of the Bones in Chronic Hydro- 
cephalus.-They are generally found to be 
considerably thinned, and transparent; 
if the union of the sutures has been com- 
pleted, the bones are found to be less 
firmly united than usual, with less dove- 
tailing ; and there are numerous ossa tri- 
quetra found in the lines of the sutures. 
In some cases, the bones have been found 
of normal thickness, and in rarer ones 
they have been of greater thickness than 
normal (Rilliet and Barthez), hard, com- 
pact, and resisting. 
Symptoms.-When the disease is con- 
genital, signs of cerebral disturbance 
manifest themselves very soon after birth. 
There may be either strabismus and roll- 
ing of the eyes alone, soon followed by 
gradual enlargement of the head, or con- 
vulsions recurring pretty frequently may 
set in. 
According to Dr. West,1 "enlargement 
of the head is by no means invariably the 
first indication of Chronic Hydrocephalus. 
In twelve out of forty-five cases, fits, re- 
turning frequently, had existed for some 
weeks "before the head was observed to 
increase in size ; in six, the enlargement 
of the head succeeded to an attack re- 
sembling acute hydrocephalus ; and in 
four other instances it had been pre- 
ceded by some well-marked indication of 
cerebral disturbance. In the remaining 
twenty-three cases no distinct cerebral 
symptoms preceded the enlargement of 
the head." Failure of nutrition is almost 
invariably present, although Rilliet and 
Barthez assert that " the nutritive func- 
tions are as a rule well performed in hy- 
drocephalic children, unless they be in an 
advanced stage of tubercular cachexia, or 
chronic intestinal catarrh. Except such 
cases, the children are plump and well 
nourished, and even have sometimes an 
abundance of fat which is certainly mor- 
bid."2 The cases, however, in which nu- 
trition is unaffected, form the exception, 
not the rule. The child sucks well, vora- 
ciously even, and yet does not grow : he 
may even waste. His bowels are gene- 
rally constipated, and his motions are un- 
healthy. The gradually increasing head 
soon attracts notice, and the peculiar phy- 
siognomy and aspect of a hydrocephalic 
child soon develop themselves. The fon- 
tanelles enlarge, and the anterior one is 
seen often to pulsate, and grow tense and 
prominent ; and at such times there is 
heat of the head, and the child is more 
restless than usual. The sutures of the 
head widen, and the head by degrees as- 
sumes a globular shape. The forehead is 
round and prominent, the orbital plates 
of the frontal bone gradually become 
slanting, and the eyeballs become half 
1 Traite sur l'Hydroc6phalie interne. Am- 
sterdam, 1839. 
2 Bright's Reports, vol. i. part i. p. 433. 
1 Diseases of Children, p. 121, 5th edit. 
2 Mal. des Enfants, p. 161. 838 
CHRONIC HYDROCEPHALUS. 
hidden under the lower eyelid, so that the 
cornea cannot be seen until this is de- 
pressed. The parietal bones being pushed 
outwards and their edges being last to 
ossify, there is a considerable increase of 
the sagittal suture, whilst the occiput is 
driven downwards and backwards, in 
some cases to such a degree as to be al- 
most horizontal. On applying the hand 
over the opened sutures and fontanelles, a 
distinct sensation of fluctuation is percep- 
tible. The hair grows very scantily on 
the head, on which very large distended 
veins are seen to ramify. The face is 
small, and contrasts remarkably with the 
large size of the head; and looks triangu- 
lar, with the apex of the triangle at the 
chin. The child's expression is dull and 
stupid, and he has a very aged look; he 
cannot sit up, or hold up his head, but 
lies down constantly. As the fluid con- 
tinues to accumulate, and the disease pro- 
gresses, the sight becomes impaired, and 
is completely lost after a time ; the eyes 
are bright and shining, but restless and 
oscillating. Hearing is as a rule pre- 
served much longer, but is lost at the 
close of the disease. Paralysis often sets 
in ; contractions and rigidity of the limbs 
and trunk are not very rare, according to 
Rilliet and Barthez, particularly in very 
young children (p. 160). Occasional at- 
tacks of laryngismus stridulus are not in- 
frequent, and they may even come on be- 
fore there is much enlargement of the 
head (West). That form of Chronic Hy- 
drocephalus which results from the trans- 
formation of a cyst, the result of hemor- 
rhage into the arachnoid sac, may be 
recognized, according to Legendre, " by 
its being never congenital; by generally 
beginning about the tenth month, that is 
to say, about the time when the teeth 
begin to appear. The head, indeed, en- 
larges gradually, but does not acquire so 
large a size as in internal hydrocephalus ; 
while, lastly, it is always preceded by con- 
vulsions, or by some other form of active 
cerebral disturbance, which marks the 
date of the occurrence of hemorrhage."1 
At best, however, the diagnosis can be 
but hypothetical. When hydrocephalus 
becomes developed after the sutures are 
united, the bones, being subjected to pres- 
sure, become thin, and in some cases the 
sutures have been known to give way. 
Such cases are spoken of by Rilliet and 
Barthez, who also quote from the London 
Medical Journal (for 1790, p. 56) the case 
of a child who at the age of nine years, 
and eleven months before his death, be- 
came affected with chronic cerebral symp- 
toms. Nine months and a half after the 
first manifestation of the disease, the su- 
tures of the cranial bones, chiefly the 
coronal, began to open. At the time of 
his death the distance between the edges 
of the coronal suture measured half an 
inch, and at the spot where the lambdoidal 
joins the sagittal suture there was a 
marked opening, so that the occipital bone 
was completely free.1 As a rule, however, 
when hydrocephalus begins after the su- 
tures are united, the head does not enlarge 
considerably, although it may do so in 
some rare instances, as in a case men- 
tioned by Rilliet and Barthez (p. 165), of 
a child nine years old, who from the age 
of eight exhibited the symptoms of hydro- 
cephalus. and whose head became enor- 
mously enlarged in spite of the ossification 
of the fontanelles. The size of the head 
in Chronic Hydrocephalus varies consid- 
erably ; it has been known to measure 
two and even three feet in circumference. 
In the Museum of the Faculty of Medicine 
of Paris there is a hydrocephalic skull 
which measures 39 inches round. The 
shape of the head is generally globular 
and flat at the top, but in some rare cases 
it is conical, shaped like a sugar-loaf. 
The termination of the complaint is 
generally in death, which occurs either 
from some intercurrent affection, hydro- 
cephalic children being always weakly and 
unable to resist disease, or from an attack 
of laryngismus stridulus, or from convul- 
sions due to passing congestion of the 
meninges, or lastly from gradual exhaus- 
tion, from positive asthenia. The disease 
extends at least one or two years, but it 
may last from four to ten years. Cases 
have even been recorded of individuals 
living to an advanced age who had been 
hydrocephalic from infancy. Thus Dr. 
Bright's patient, Thomas Cardinal, lived 
to nearly thirty. Franck, cited by Trous- 
seau,2 speaks of two individuals, the one 
aged seventy-two, and the other seventy- 
eight, who had been hydrocephalic from 
infancy. Strictly speaking there is no 
cure of the complaint, but merely an ar- 
rest of its progress. Fluid may be no 
longer poured out, but that which has 
been already effused is not absorbed. The 
sutures and fontanelles ossify and close, 
and a good many ossa wormiana are then 
found along the lines of union ; these are 
like nuclei for the formation of bony 
matter. In some instances it has been 
said that a real cure takes place; that 4 
there is increased activity of the nutrition 
of the brain, producing hypertrophy of 
that organ, the fluid being absorbed and 
new matter deposited in its stead (Otto).3 
1 Sir Thos. Watson (p. 464, 5th edit.) also 
cites two similar cases, one from Dr. Baillie- 
the patient was a boy, seven years old ; and 
the other from Dr. Yeats' work on Hydroce- 
phalus-a boy nine years old. 
2 Clinique M6dicale, p. 247. 
3 In Rokitansky's Pathologische Anatomie, 
1st edit. vol. ii. pp. 749-769. 
1 Legendre, Recherches Anatomo-patholo- 
giques, p. 135. DIAGNOSIS - TREATMENT. 
839 
Such cases, however, must be quite excep- 
tional, and the rule is that the fluid is 
unabsorbed and remains in the cranial 
cavities. The patient's intellect and 
senses are not perfect it is true, but are 
still sufficient to enable him to perform 
the ordinary duties of life, although he is 
apt to be fretful and irritable, and some- 
what childish in his ways. 
Diagnosis.-1st. Congenital hydroce- 
phalus has to be diagnosed from encepha- 
locele and perforating fungus of the dura 
mater. In encephalocele the feel of the 
swelling is doughy and elastic, not fluctu- 
ating ; it is local and not general, and it 
is not transparent. In cases of fungus of 
dura mater, which has perforated the cra- 
nium at birth, the general size of the head 
is not affected, the perforated spot can be 
easily detected, and it is over the central 
parts, not near the sutures or fontanelles; 
the mass feels doughy, elastic, quasi- 
erectile, and when it is compressed, symp- 
toms of irritation are produced. Acquired 
hydrocephalus has also to be distinguished 
from a merely excessive development of 
the head apart from any. disease. The 
absence of all cerebral symptoms is suffi- 
cient in such cases to establish the diag- 
nosis. Sometimes hydrocephalus may be 
suspected where none exists, because of 
the disproportion between a small, emaci- 
ated, triangular face and largely developed 
skull. Rilliet and Barthez candidly con- 
fess to an error of this kind. 2d. From 
abnormal thickening of the bones of the 
skull, which sometimes obtains in rickets. 
In such cases the diagnosis may be made 
by a careful inspection and palpation of 
the bones of the head. The development 
of the skull is not uniform ; it seems as if 
flat bumps had been superadded to the 
centre of the frontal and parietal bones, 
and we can detect with the finger the ex- 
act spot where the bone begins to thicken.1 
The swelling of the articular ends of the 
bones of the limbs, which is characteristic 
of rickets, will at once awaken suspicion, 
for rickets and hydrocephalus do some- 
times coexist. 3d. From hypertrophy of 
the brain. This is an exceedingly rare 
affection, in which the head enlarges with- 
out exhibiting any symptoms at first; and 
when these show themselves after a time, 
they run an acute course which soon ter- 
minates in death. 
Treatment should be persisted in for 
a long time, without the adoption of any 
violent measures. The plan recom- 
mended by Professor Golis, of Vienna, 
seems to be one of the best. He advises 
the head to be shaved, and a scruple or 
two of mercurial ointment, mixed with 
ointment of juniper berries, to be rubbed 
on the scalp twice a clay. The child 
should wear a woollen cap, to prevent the 
risk of the perspiration being checked by 
the cold air. From a quarter to half a 
grain of calomel should be administered 
twice a day ; if it purges too much, the 
inunction of mercurial ointment must be 
alone employed. This treatment is to be 
persevered in for thirty or forty days, 
when, if there be some improvement, the 
remedies may be gradually diminished; 
but the cap is to be worn after the inunc- 
tion has been discontinued. If there be 
no marked improvement after six or eight 
weeks, some diuretic, acetate of potash or 
squills, for example, may be added ; and 
a couple of issues may be inserted in the 
occiput. Blisters to the nape of the neck 
may be advantageously substituted for 
these. Whenever there is heat of head, 
and the child grows fretful, restless, and 
irritable, a couple of leeches behind the 
ears will be found of service. Golis 
affirms that under this plan of treatment 
he has known the circumference of the 
head decrease by half an inch, or an inch, 
in a period of six weeks to three months. 
He thinks that convalescence, when once 
begun, may be accelerated by small doses 
of quinine. Dr. Gower's plan of treat- 
ment, which is said to have been success- 
ful in many cases, consisted in giving ten 
grains of crude mercury mixed by rubbing 
with about a scruple of manna and five 
grains of fresh squills. This was one 
dose, and it wras to be repeated every 
eight hours. The medicine induced great 
prostration of strength, loss of flesh, and 
profuse action of the kidneys, without 
ptyalism. 
Chronic Hydrocephalus has been treated 
by two mechanical means; by bandaging 
and tapping. Bandaging, which has 
been particularly advocated by Mr. Bar- 
nard, of Bath,1 seems to be chiefly useful 
in pale flabby children, whose bones are 
loose and yielding : strips of plaster, about 
three-quarters of an inch wide, are made 
to encase the head ; they are to be applied 
circularly, transversely, and diagonally. 
Trousseau, wrho was at one time an advo- 
cate of this plan, has given directions for 
properly carrying it out in the Journal de 
Medezine for April 1843. But this emi- 
nent practitioner had good reasons for 
changing his views, and did not latterly 
advocate this plan. In his Clinique Medi- 
cale, second edit. p. 250, he says that he 
has given it up completely, since a child 
aged five months, whom he treated in that 
way, died suddenly on the fluid making 
its way through the ethmoid bone and the 
nasal fossae. 
The second mechanical mode of treat- 
ment, namely, by tapping the skull, and 
1 Rilliet and Barthez. 
1 Cases of Chronic Hydrocephalus, &c., by 
T. II. Barnard. London, 1839. 840 
MENINGEAL HEMORRHAGE. 
letting out the fluid accumulated in its 
interior, has been opposed by such men as 
Golis, Richter, and Dupuytren. Dr. 
Conquest has been the greatest advocate 
of the operation in this country, and a 
paper on the subject may be found in the 
Medical Gazette for March, 1838. Sir 
Thos. Watson gives the sanction of high 
authority to the procedure ; and although 
Dr. West speaks rather doubtfully on the 
subject, yet he does not regard the opera- 
tion as unjustifiable in some cases ; when, 
for instance, there is good ground for be- 
lieving that the hydrocephalus is external, 
or where the enlargement of the head has 
not been attended by indications of active 
cerebral disease. The operation itself 
does not seem to be attended with any 
very great immediate risk of life, if per- 
formed carefully. The best spot for 
puncturing the skull is about an inch, or 
an inch and a half, from the anterior fon- 
tanelle, near the edge of the coronal su- 
ture, taking care to avoid the longitudinal 
sinus, and some of the large veins which 
empty themselves into it. The trocar 
should be a small one, and it should be 
introduced perpendicularly. The fluid 
should be let out very slowly, a few ounces 
at a time, and the skull supported by 
bandages, both at the time and subse- 
quently. If the child turns pale and 
faints, a few drops of ammonia, or of 
brandy, will be found useful. If any in- 
flammatory action should be set up a day 
or two after the tapping, cold lotions to 
the head and leeches behind the ears, and 
small doses of mercury, will be required. 
The administration of iodide of potassium 
internally, and of iodine lotions to the 
scalp, has been advocated by Trousseau ; 
and, when more active measures may not 
appear justifiable, some hope in the way 
of arrest of the further progress of the dis- 
ease may be entertained from the use of 
these remedies. In addition to them I 
have found great assistance from the use 
of syrup of iodide of iron, cod-liver oil 
given in small doses, and bone-earth. 
The dose of cod-liver oil should be limited 
to a teaspoonful, the object being not to 
increase, but to improve nutrition. The 
iodide of iron is usually very well borne 
by hydrocephalic children, unless there be 
a tendency to congestion, or to inflamma- 
tory action. Amongst the children of the 
poor the combination of the oil and the 
syrup of iodide almost always gives the 
most satisfactory results. Bone-earth 
mixed with fine sugar, administered with 
every meal, sprinkled on the surface of 
milk, or of other food, has appeared to me 
to possess a tonic action beyond that pos- 
sessed by any chemical compound of the 
phosphates. It has an increased value in 
cases associated with rickets or imperfect 
nutrition of the bones; and a diet, of 
which lentil flour forms part, has appeared 
to me highly advantageous. Good food, 
given in limited quantities, and at small 
intervals, is absolutely necessary, and I 
object to the use of stimulants. When 
the patient appears faint and languid, 
beef-tea will prove a better and more per- 
manent stimulant than wine or ammonia. 
The usual hygienic measures should be 
adopted,-warm clothing for the extremi- 
ties, the head being kept cool. Bathing 
with sea-water is useful, taking care that 
the limbs are rubbed to produce warmth 
and redness of the surface after the bath. 
The patient should, if possible, spend the 
summer months on the sea-coast, or in 
some elevated district, and he should al- 
most live in the open air. 
MENINGEAL HEMORRHAGE. 
By J. Spence Ramskill, M.D. 
The term Meningeal Hemorrhage is 
used to denote extravasation of blood 
either into the cavity of the arachnoid, 
■or beneath this serous membrane, and 
into the meshes of the pia mater. Hem- 
orrhage occurring between the dura mater 
and the bones of the cranium is extra- 
meningeal ; and as it is usually the result 
of a blow or a fall on the head, in which 
<ase it often takes place on the side oppo- 
site to that of the injury, by contre-coup, 
it comes within the province of the sur- 
geon and not of the physician. 
In his valuable work on diseases of the 
brain, Abercrombie, at p. 238, relates a 
most curious instance of "extravasation 
in a cyst, formed by separation of the 
laininse of the dura mater, from rupture 
of the middle meningeal artery." The 
patient, a man aged forty-eight, about 
the 12th of November, 1814, was assist- 
ing a neighbor to carry a heavy load up a SYMPTOMS. 
841 
high stair, when he felt a sudden attack 
of headache. He was from that time 
troubled with headache and giddiness, 
increased by stooping; and after these 
symptoms had continued rather more 
than a fortnight, he became sensible of 
some imperfection of vision. When seen 
by Dr. Gairdner, on the 2d of December, 
he complained of violent headache. The 
pulse was forty in the minute, and feeble. 
The pupils were at this time sensible to 
the light, but after a few days became in- 
sensible. He sank very gradually into 
coma, without any remarkable symptom, 
and died on the 13th. Inspection: On the 
left side of the head, a cyst was found in 
the course of the middle meningeal ar- 
tery, occupying the region of the lower 
part of the parietal and upper part of the 
temporal bone? It was formed by a sepa- 
ration of the laminse of the dura mater, 
and contained about four ounces of coagu- 
lated blood. The portion of the dura 
mater forming the cyst was considerably 
thickened and very vascular. There was 
a depression on the surface of the brain, 
corresponding to the cyst, and the ven- 
tricles contained a considerable quantity 
of serous fluid. There was no other 
morbid appearance. 
True Meningeal Hemorrhage is an af- 
fection which is found generally at the 
two extremes of life, in infancy and old 
age. It occurs in new-born infants, after 
severe and protracted labors, and, from 
the discoloration of the skin attending it, 
is often mistaken for cyanosis. It may 
be distinguished from this malformation, 
however, by the absence of cardiac mur- 
mur, which is almost always present in 
the latter. 
The blood may be diffused, as we have 
said, into the arachnoid sac itself, or un- 
der it, and in the pia mater. A third 
variety has also been described, in which 
the blood is said to be effused between 
the dura mater and the arachnoid; but 
recent researches have made it more than 
doubtful that the extremely delicate vis- 
ceral layer of the arachnoid can be sepa- 
rated without being torn from the dura 
mater; and Baillarger1 has shown that 
the error arose from the rapid formation 
of a false membrane resembling the arach- 
noid, which isolated the effused blood. 
An instance of this variety, of traumatic 
origin, is related by Sir Robert Carswell. 
A man fell on his head, was stunned for 
some little time, but afterwards went to 
work as usual. Three weeks afterwards 
he applied to a hospital, but was refused 
admission because he had no fever, and 
he was suspected of malingering. On 
leaving the hospital he drank some hot 
spiced wine on his way home, became de- 
lirious, and died in thirty-six hours. A 
post-mortem examination showed six 
ounces of blood effused between the dura 
mater and the arachnoid, part of which was 
in a coagulated and part in a fluid state. 
Two cases of the same form of hemor- 
rhage, but of spontaneous origin, are 
given by Andral in his "Clinique Medi- 
cale," occurring in two men, aged respec- 
tively seventy and seventy-three. Other 
instances are recorded by Rostan,* Blan- 
din, Meniere.2 Cruveilhier.3 
Hemorrhage into the arachnoid cavity.- 
This may be traumatic or idiopathic. 
When the latter, the blood accumulates 
in the cavity of the arachnoid, and is 
equally diffused over the brain, not accu- 
mulated at the base. It is generally more 
fluid anteriorly, and more coagulated pos- 
teriorly. The arachnoid and dura mater 
are colored by imbibition. After a time, 
the blood is enveloped in a pseudo-mem- 
brane, and in old cases cysts are found 
with yellowish contents and smooth walls; 
in some cases the two layers of the false 
membrane are found agglutinated, leav- 
ing no doubt as to the possibility of a per- 
fect cure occasionally being made. With 
regard to the source from which the blood 
comes, there exists a discrepancy of opin- 
ion. According to most authors, the ex- 
travasation results from the rupture of a 
bloodvessel, but Prus* maintains that 
intra-arachnoid hemorrhage is always the 
result of exhalation. Hemorrhage by ex- 
halation is, however, a pathological phe- 
nomenon not accepted nowadays, and for 
which cases of molecular rupture of blood- 
vessels used to be mistaken. 
Symptoms.-In persons of advanced 
age, there are sometimes certain premon- 
itory symptoms observed in the shape of 
drowsiness, vertigo, general malaise, dim- 
inution of motor power, loss of speech, 
&c. All these symptoms do not show 
themselves in the same case, but one or 
other of them is generally present. Ce- 
phalalgia is a symptom which is usually 
met with in old people when hemorrhage 
has occurred. 
Some authors regard the false mem- 
branes as being of inflammatory origin, 
and as the first step in the morbid pro- 
cess-the hemorrhage being only the 
second.5 There may be such cases, 
1 Rostan : Recherches sur le Ramollissement 
du Cerveau, p. 396. 
2 Anatomie Topographique. Paris, 1834. 
3 Anatomie Pathologique du Corps humain, 
livres vi. viii. xvii. 
1 Prus : Memoire sur l'Apoplexie m^ning^e 
(Mem. de l'Acad. Royale de Medecine), Paris, 
1845, t. xi. p. 18. 
5 Consult Virchow; Die Krankhaften Gesek - 
wiilste, Berlin, 1863, p. 140; and Lancereaux 
in Archives generales de Medecine, Paris, 
1862, pp. 526-679, and 1863, vol. i. p. 38. 
1 Baillarger : De Siege de quelques H^mor- 
rhagies des Meninges : These. Paris, 1837. 842 
MENINGEAL HEMORRHAGE. 
doubtless, in the adult and the old, but 
that they are very rare, in children espe- 
cially, is sufficiently proved by the sud- 
denness of the symptoms. 
There may be sudden paralysis of mo- 
tion on the side opposite to that of the 
extravasation ; and when this is consid- 
erable in amount, both sides of the body 
may be affected, or paralysis may begin 
in one side and extend to the other. Sen- 
sation is rarely affected. Motor paralysis 
is not a constant symptom, and deviation 
of the tongue and of one angle of the 
mouth, and strabismus, are of very rare 
occurrence in adults, whilst they have 
never been observed in children : accord- 
ing to Legendre,1 paralysis occurs only in 
one out of nine cases; Billiet and Barthez 
say, in one out of seventeen.2 
Contractions, rigidity of the limbs, and 
convulsions are, on the other hand, almost 
always present. There is at first somno- 
lence, which gradually merges into coma; 
and this, when once established, persists, 
as a rule, unto the end. About the third 
or fourth day of the attack, there is in- 
tense fever lighted up, accompanied by 
the other symptoms of meningitis. 
The course of the disease is exceedingly 
irregular; death may take place early or 
not until the. end of a month. The prog- 
nosis is not necessarily fatal, and according 
to Legendre serous cysts may be formed, 
which give rise to a form of chronic hy- 
drocephalus. Hemorrhage may also oc- 
cur beneath the arachnoid, between it 
and the pia mater. In some cases, it may 
take place suddenly; in others, it may be 
preceded by some headache, drowsiness, 
redness and heat of the scalp and fore- 
head. When the extravasation has taken 
place there is generally headache, but not 
very acute, and having no fixed seat. 
Paralysis of motion is rare, probably from 
the thinness of the layer of blood effused. 
It has been said that when the blood is 
derived from a ruptured artery, motor 
paralysis is more apt to occur than when 
it proceeds from a ruptured vein, the dif- 
ference being explained by the rapidity 
with which the blood escapes from the 
artery, and the incidental shock to the 
brain. Sensibility is not affected as a 
rule. The intellectual faculties are 
merely enfeebled, not perverted. After 
a time coma sets in, which persists until 
death. 
On inspection after death, which seems 
to be an invariable termination of the dis- 
ease, the blood is found in a liquid state, 
showing no tendency to coagulate, or to 
form pseudo-membranes. From the fact 
that no old cysts are ever discovered be- 
tween the arachnoid and pia mater, it is 
inferred that sub-arachnoid hemorrhage 
is invariably fatal. In his memoir on 
"Diseases of the Lateral Sinuses," Ton- 
nele1 has related instances of rupture of a 
sinus giving rise to sub-arachnoid extrav- 
asation of blood. In a case reported by 
Dr. Mullar,2 the blood came from the 
right lateral sinus, which was ruptured 
at its point of entrance into the torcular 
Herophili: death occurred in twenty-four 
hours, the symptoms preceding it having 
been those of cerebral hemorrhage. Ac- 
cording to Aitken, arachnoid hemorrhage 
occurs when the extravasation bursts 
through the pia mater and arachnoid into 
the space between the membranes ; and 
he says such an affection cannot be distin- 
guished from ventricular extravasation. 
If, however, the extravasation is imme- 
diately arachnoid at first, and of limited 
extent, it may be approximately diag- 
nosed : first, by the nature of the symp- 
toms having partaken of meningeal in- 
flammation, such as by severe pain in the 
head, with impaired intelligence and loss 
of power of movement; second, the attack 
is less sudden than in cases of congestion 
or of cerebral hemorrhage, and the symp- 
toms are progressively developed. 
The following are the combinations of 
symptoms which indicate sub-arachnoid 
hemorrhage :- 
First.- Complete and profound coma 
without paralysis, or with general paraly- 
sis slightly developed. 
Second.-Complete loss of consciousness 
without paralysis, but combined with 
rigidity or clonic contraction of limbs. 
Third.-Paralysis of hemiplegic distri- 
bution, as regards the limbs ; but without 
deviation of the features, the muscles of 
the face not being implicated. 
Fourth.-An apoplectic attack without 
anaesthesia. 
Fifth. - Imperfectly developed coma 
with general paralysis. 
Sixth.-An apoplectic attack, of which 
the symptoms are somewhat interchange- 
able or remittent.3 
The Treatment of arachnoid hemor- 
rhage must be guided by symptoms pres- 
ent. When there is perfect coma with 
full, hard pulse, which is possible, a hot 
head, flushed face, turgid veins of the 
neck, and a hot general state of surface, 
with a slow, deep respiration, we may 
open a vein and take away ten ounces of 
blood with advantage ; but in by far the 
majority of cases there will be no such 
1 Legendre: Memoire sur les H^morrhagies 
dans la Cavite de 1'Arachnoide (Reclierches 
anat. path, et clin. sur quelques Maladies de 
1'Enfance). Paris, 1846, p. 130. 
2 Maladies des Enfants, p. 257. 
1 Journal hebdomadaire de MMecine, Paris, 
1829, tome v. 
2 The Lancet, June, 1849. 
3 Reynolds: Diagn. of Dis. of Brain, &c., 
p. 101. ADVENTITIOUS PRODUCTS IN THE MENINGES. 
843 
opportunity. If the tendency be to death 
by syncope, the pulse small or feeble, the 
surface cold, the face pale and head cool, 
if there be signs of disease of the aortic 
or mitral valves, of kidney disease, or a 
general appearance of ansemia, we should 
do mischief by abstracting blood. The 
administration of a turpentine and castor- 
oil enema, and the application of an ice- 
cap or cold lotion to the shaved scalp, 
will generally limit our power of treat- 
ment, until the period of shock has passed 
away, or until consciousness has returned. 
Then the propriety of applying leeches 
must be measured by the degree of pain 
in the head, and of heat of the scalp. In 
the majority of cases even this will be 
found unnecessary. Free purgation will 
always be advisable, and the continued 
application of cold to the head. After a 
time, if the patient survives, the continued 
administration of the iodide of potassium 
promises the most hope of good. With 
respect to the abstraction of blood, it is 
right to say that the most eminent au- 
thority in Paris, Professor Trousseau, 
never saw any reason to order it. He 
denied the slightest advantage to be 
gained by it, either in arachnoid or in 
any other cerebral hemorrhage. 
ADVENTITIOUS PRODUCTS IN 
THE MENINGES. 
Under the heading of Syphilitic Menin- 
gitis the presence in the dura mater of 
so-called gummata has been adverted to. 
Calcareous deposits are also found some- 
times in the substance of the dura mater ; 
in some cases the falx cerebri has been 
found completely ossified. 
Haematoma of the dura mater is 
hardly recognizable during life. The 
symptoms, according to Aitken, extend 
over several months, and consist in gen- 
eral weakening of memory and of intel- 
ligence, the occurrence of giddiness, and 
local pain in the head. A. chronic form 
of idiopathic inflammation of the dura 
mater is set up. At a later period an 
aggravation of all the symptoms occurs, 
with transitory losses of consciousness. 
Somnolence and apathy prevail, and gen- 
erally one-sided paralysis of the extremi- 
ties, which may soon disappear ; eventu- 
ally the case terminates with symptoms 
of apoplexy. On post-mortem examina- 
tion, sanguineous and flattened masses, 
composed of fine layers of fibri ne, spread 
to a greater or less extent over the dura 
mater, are discovered, accompanied by 
small extravasations which are converted 
into pigment. By repetition of the pro- 
cess, numerous layers come to be deposited 
one on the other. Numerous and larger 
bloodvessels form in these layers ; and 
from these vessels renewal of the hemor- 
rhage occurs (Virchow, Weber). The 
lesion is sometimes described as due to 
intra-meningeal apoplexy, with false 
membranes on the dura mater ; but the 
false membranes, which are the result of 
chronic inflammation, precede the apo- 
plectic phenomena. The haematoma often 
attains considerable size. It may be four 
to five inches long, by two and a half 
broad, and one-half to three-quarters of 
an inch thick. It is generally of a flat- 
tened circular form, with a central eleva- 
tion. The long diameter is parallel to 
the falciform process. The tumor gener- 
ally occurs on one side only, or if bilateral, 
one is more developed than the other. 
The affection occurs only in the adult, 
and usually after the age of fifty. It has 
been clearly made out that the hemor- 
rhage which gives rise to the formation 
of the haematoma takes place between 
the layers of false membrane, and be- 
comes encysted there. Treatment must 
be tentative. Iodide of potassium is our 
chief remedy. Any symptoms which in- 
dicate a recurrence of the chronic inflam- 
mation must be met by the application of 
cold to the forehead, by purgatives and 
revulsives. If we can succeed in pre- 
venting the recurring attacks, there is 
fair ground for believing the newly-formed 
membranes may undergo a retrograde 
change and finally disappear. 
Tumors have not been unfrequently 
found springing from the dura mater, 
varying as to their character and the na- 
ture of their contents. They are some- 
times fatty and encysted, and have been 
known to contain hair ; and Morgagni (in 
Epist. Anat, xx.) speaks of an adipose 
tumor with hair in the substance of the 
tentorium. But sometimes also the tumor 
is of cancerous nature, constituting what 
has been termed "fungus of the dura 
mater." The celebrated French surgeon, 
Louis, has written a most important series 
of essays on the subject, published in 
" Mem. de l'Academie de Chirurgie," vol. 
v. p. 1, Paris, 1774. The cancer may be 
of the encephaloid or of the scirrhous va- 
riety : the former is the more frequent of 
the two, and indeed, when tumor has 
made its way outwards by perforating the 
bones of the skull, it has often been mis- 
taken for hernia cerebri. The tumor may 
spring from the outer or the inner lamina 
of the dura mater, and in some cases 
there may be tumors co-originating on 
both surfaces of the dura mater, as in 
cases reported by Chelius and by Dr. 
Bright. When they spring from the inner 
surface of the dura mater, they have a 
tendency to grow inwards and depress the 
surface of the brain. But in compara- 
tively rare cases they press on the skull, 
cause absorption of its substance, and 
protrude externally. In one case, de- 844 
CONGESTION OF THE BRAIN. 
scribed by Cruveilhier, protrusion had ac- 
tually occurred; in another, perforation 
was in progress. In connection with the 
dura mater are sometimes also found fi- 
brous tumors, which, on microscopical ex- 
amination, are seen to possess the same 
curvilinear stromal arrangement as the 
common uterine fibrous tumor. 
The bony plates found on the inner side 
of the dura mater have by some been re- 
garded as growth belonging to the arach- 
noid, but that they are not so is suffi- 
ciently proved both by the position in 
which they are found, and by the property 
of periosteal tissues, to which class the 
dura mater undoubtedly belongs, to gene- 
rate bone. 
In connection with the choroid plexus 
(that intra-ventricular appendix of the 
pia mater) the adventitious products found 
have been indurated yellow bodies, the 
remains of former hemorrhagic effusions, 
and more frequently round or oval bodies 
of a yellowish tinge, apparently formed of 
concentric lamime, which only become 
more apparent on the addition of acetic 
acid. They are generally microscopic, 
but sometimes accumulate into masses of 
the size of a pea or small nut. They have 
been called by Virchow corpora amylacea, 
and by Dr. II. Jones concentric corpuscles. 
Small cysts are also pretty frequently 
found on the choroid plexus, which have 
by some been erroneously spoken of as 
hydatids, but there is no evidence to show 
that they belong to those parasitic forma- 
tions. They rather seem to be due to a 
condensation of the epithelial covering of 
the plexus, and an accumulation of fluid 
beneath it, limited by an effusion of plas- 
tic matter. 
CONGENITAL MALFORMATIONS 
OF THE MENINGES. 
The dura mater is the one generally 
affected, and such cases are of extremely 
rare occurrence. Sometimes the falciform 
process is entirely or partially deficient, 
as is also the tentorium. 
The falx is, of course, absent when the 
cerebrum is undivided ; or if the cerebrum 
be single in front and divided behind, the 
falciform process begins to appear where 
the division is, namely, at the coronal su- 
ture. In monsters, in which the posterior 
lobes of the cerebrum are deficient, the 
tentorium is also deficient. In a girl, 
seventeen years old, who was idiotic and 
motionless from birth, the hinder part of 
the tentorium was deficient.1 The Re- 
ports of the Pathological Society, 1847 
and 1848, p. 178, contain the account of a 
very rare defect of the falx cerebri exhib- 
ited by Mr. Shaw. Dr. Bright also gives 
a similar case, in which no trace of the 
process was visible anterior to the tento- 
rium, and it was assumed that the defect, 
which occurred in a lady of tnirty years of 
age, had existed from birth. 
CONGESTION OF THE BRAIN.2 
By J. Russell Reynolds, M.D., F.R.S., and 
II. Charlton Bastian, M.D., F.R.S. 
Under this name there are to be in- 
cluded several forms of disease very dif- 
ferent from each other in the general 
character of their symptoms. In one of 
these the patient is feverish, and his 
attack is sometimes regarded as "brain 
feverin another the case is described 
as an "apoplectic" or "paralytic stroke;" 
in a third, as a fit, or seizure of "convul- 
sions and in a fourth, as an attack of 
"delirium," or of "wandering." Pa- 
tients taken with symptoms of disturb- 
ance, in any one of these forms, often 
die ; and upon post-mortem examination 
there may be found but one departure 
from healthy appearance of the brain, 
viz., congestion. We cannot but suspect 
that in many cases there have been altera- 
tions of nutrition which have escaped our 
notice, and that the locality and nature 
of such alterations have determined the 
form that the malady has taken. We 
may infer in others that, if the congestion 
has been the sole cause of symptoms, the 
character of the symptoms which accom- 
panied it was determined by the situation 
of the excess of blood. But we cannot 
1 Gilbert, in Edinburgh Medical and Surgi- 
cal Journal, No. 95, April, 1828. 
2 The sections on Pathology and Morbid 
Anatomy are written by Dr. Bastian. SYMPTOMS. 
845 
yet demonstrate the truth of these sur- 
mises or inferences, for we cannot see the 
brain while the symptoms last, and the 
most characteristic often pass away before 
the patients die. The premonitory, and 
even the earlier developed symptoms of 
cerebral congestion may be closely similar 
in many cases ; they then speedily pass into 
one or another of the several groups enu- 
merated above, and from the special cha- 
racters which they then present the cases 
derive their names: but if the morbid state 
continue, and advance towards a fatal 
issue, the distinctive features of these 
several forms pass away ; convulsion, deli- 
rium, and febrile action cease ; and pa- 
tients, who a few days before presented 
very wide symptomatic differences, look 
much like each other, and die in a similar 
manner. Such being the case, we should 
expect to find the traces of that which 
existed only a short time before death, 
and to fail in discovering evidences of 
those localized changes which must have 
determined the character of the previous 
symptoms. 
It will be convenient therefore to de- 
scribe first the premonitory symptoms of 
cerebral congestion, viz., those which are 
or may be common to its several forms ; 
then to detail under four distinct catego- 
ries the developed symptoms, with their 
modes of termination in recovery; and 
lastly, to describe again generally those 
which are final, and into which any one 
of the four varieties may pass by a rapid 
or a gradual progress. 
Symptoms. - A. Premonitory. - There 
is often a mixture of two classes of symp- 
toms-those which indicate both over- 
action and the reverse ; sometimes the 
two coexist, at other times they alternate ; 
in one case the former group is predomi- 
nant, in another the latter ; whereas in a 
few all the symptoms tell in the direction 
either of inaction or of undue excitement. 
It is possible sometimes to foretell, from 
the nature of these symptoms, the form 
which it is most likely that the disease 
will hereafter assume ; but such forecast 
is uncertain in all cases, and useful in 
only a very small proportion. 
The mind is changed in such manner 
that there is diminished intellectual power; 
thought becomes confused, and memory 
treacherous; the individual may be irri- 
table, "put out about little things," wor- 
ried, fanciful, peevish, or depressed; sleepy, 
and especially so after meals ; at times in- 
different and sluggish ; he complains that 
he "cannot think," and that the forced 
effort to do so makes him worse ; he talks 
at random, using wrong words - some- 
times noticing his blunder, correcting it, 
and expressing his annoyance ; sometimes 
not observing that he was wrong, and 
being greatly annoyed with any one who 
should attempt to set him right. He is 
usually worse after being in the recum- 
bent posture, and after sleep ; his sleep is 
heavy, and disturbed by dreams and 
nightmare ; sometimes there are transient 
delusions-one person is mistaken for an- 
other-the past and the present are curi- 
ously intermixed, and the conversation is 
like that of a dream, a dream which goes 
on while the patient is awake, but from 
which he may be awakened still further 
by a loud voice or any other strong ap- 
peal to the senses. 
The senses are dull: hearing is defect- 
ive, and there are rumbling " noises in 
the head ;" the sight is dim, and "black 
specks" appear before the eyes ; some- 
times diplopia is present; there is giddi- 
ness, and a feeling of oppression and ful- 
ness in the head, with " stupid headache," 
made worse by lying down. There is 
rarely "pain" in the head, but, as the 
patients say, " a confused, uncomfortable 
feeling." The limbs feel heavy, and 
there is often numbness or " pins and 
needles" in the toes and fingers. These 
sensations come and go, but between the 
periods of their recurrence there is a sense 
of general discomfort which it is often 
quite impossible for the patient to de- 
scribe. Often it is that of " oppression 
about the breathing ;" and great difficulty 
from this source is experienced in walk- 
ing upstairs, uphill, or even a little more 
quickly than usual on level ground. Some- 
times "feelings of faintness" are com- 
plained of, and with them nausea and 
increased vertigo. 
The power of movement is diminished, 
and with it yet more notably the readi- 
ness of action. The limbs are dragged 
along sleepily, or sluggishly; the step 
loses its elasticity, is shorter than in 
health; the " general bearing" is changed; 
and sometimes, but rarely, the alterations 
in power and activity are observed on one 
side of the body more distinctly than on 
the other. The patient simply leans for- 
ward, and appears weak and lethargic; 
or he may lean to one side, hold one 
shoulder half an inch or an inch higher 
than the other when standing, and when 
sitting, collapse, as it were, on the lower 
side. Friends of such patients say, " He 
seems to go down on this side," and,"We 
are afraid that he will fall off his chair, or 
off the pavement," but the physician may 
observe no paralysis ; for the stimulus 
given to voluntary effort by his presence 
is often enough to remove the trifling 
want of symmetry. The features are 
regular, the tongue is straight in its pro- 
trusion, and the grasp of the hand and 
the movements of the feet are as pro- 
nounced on the one side as on the other. 
There are other symptoms than those of 
direct change in the nervous functions, 
such as redness, and often dusky redness, 846 
CONGESTION OF THE BRAIN. 
of the lips, conjunctiva), face, and scalp. 
The head is hotter than the cheeks, the 
jugular veins are distended, and the neck 
appears thick. On stooping, sneezing, or 
coughing, the veins of the forehead are 
too full, and the beat of the carotids is too 
distinct. The pulse is slow and labored, 
or quick and feeble ; the tongue is foul, 
the urine small in quantity, and often 
loaded with lithates ; the bowels are con- 
fined, and the extremities are cold. The 
heart may be found dilated, and there 
may be tricuspid regurgitation, shown by 
the pulsation of the jugulars, and systolic 
murmur at the ensiform cartilage. 
These premonitory symptoms may exist 
for very variable periods of time ; may 
appear and disappear ; or may gradually 
increase and pass into one or another form 
of malady already hinted at, but now to 
be described. 
B. Developed Symptoms.-1. Apoplectic 
form.. - The attack usually takes place 
during some muscular exertion, such as 
lifting a heavy weight, blowing the nose, 
coughing, sneezing, straining at stool, or 
stooping to pick up something from the 
floor. Sometimes it cannot be traced to 
any one of these. But it rarely occurs 
during sleep; patients do not wake up and 
find themselves in a state of what is called 
"congestive apoplexy." They are more 
commonly doing their ordinary work, or 
trying to do a little more than they are 
able to accomplish, when the attack is 
made. Consciousness, sensation, and 
power of motion seem to be lost, and the 
patient is said to have "an apoplectic 
stroke ;" but these faculties are not alto- 
gether lost, or if they are, it is for a few 
moments only, and the physician usually 
finds the following conditions :- 
The mind is not in complete abeyance. 
There are indications that the patient 
knows, although but imperfectly, what is 
said to him; he makes some attempt to 
respond to questions, and to do what he 
is asked to do. lie starts at a loud and 
sudden noise, looks round him, and gives 
signs of annoyance when he is disturbed. 
If at the moment of seizure he should ap- 
pear to be in profound coma, this coma is 
of short, almost of momentary duration, 
and soon there are signs of returning con- 
sciousness : there is confusion of thought, 
bewilderment, and dulness of apprehen- 
sion, passing sometimes into a mild deli- 
rium, but more often into a heavy sleep. 
The senses, obtuse for a moment, are 
rapidly restored to a certain point. The 
patient shrinks from strong light, groans 
when pinched, starts when spoken to, but 
yet takes little or no notice of ordinary 
impressions. 
The power of motion is so diminished 
that the patient falls down, and the limbs 
when raised fall heavily. All of them ap- 
pear equally weak; but, in a few moments, 
occasional voluntary movements may be 
seen in them, and these are commonly 
more distinct on the one side than on the 
other. There are slight twitchings of the 
muscles, but there is no rigidity. The 
features are usually symmetrical, or if 
drawn to one side are speedily set straight 
again. There is no stertor in the breath- 
ing ; the speech is clumsy, the words are 
clipped, and wrong words are used ; but 
this is for a short time only, and the 
sphincters very rarely fail in their action. 
The pulse at the moment of attack is 
sometimes suspended at the wrist, and 
the breathing is arrested; but soon the 
pulse is felt to be heavy and labored, and 
the respiration becomes tumultuous ; and 
again, in a few seconds, both pulse and 
respiration go on as they did before. 
There is an exaggeration of the previous 
vascular fulness of the face, neck, and 
head; sometimes a bloodshot eye, or epis- 
taxis ; not unfrequently vomiting, with 
apparent faintness and a condition of col- 
lapse. 
The symptoms of a first attack usually 
abate quickly : they may last for a few 
minutes, or for several hours, but most 
commonly they disappear within an hour; 
and the patient, although languid and 
perhaps alarmed, may feel better than he 
has done for some days before. Upon the 
repetition of seizure, however, the dura- 
tion of symptoms is prolonged ; the re- 
covery of consciousness, sensation, and 
movement is less complete ; drowsiness is 
more marked ; and if there be some mo- 
mentary awakening, it is momentary 
only ; fresh attacks supervene, and each 
leaves the patient lower than he was be- 
fore. 
The apoplectic form of cerebral conges- 
tion is most common in advanced life, and 
has usually been preceded, and that to a 
marked degree, by the "premonitory" 
symptoms that have been described. 
2. The convulsive form.-The paroxysms 
that occur have the general features of 
epilepsy (see Part I.); but they differ 
from the attacks of that disease in their 
general history and mode of onset. Con- 
gestive convulsions may occur at any pe- 
riod of life, but they are most frequently 
met with at the time of full maturity, or 
when that stage is passed. There are usu- 
ally the premonitory signs of congestion, 
but these may be very slight; there may 
be no forewarnings, and the patient may 
be seized during sleep, or while making 
some unaccustomed effort. When the 
attack occurs during sleep it is difficult, 
and sometimes impossible, to say in what 
manner it commenced ; but when it has 
come on while the patient is awake and 
friends are about him, it has been usually 
observed that much discomfort has pre- 
ceded it, for a few seconds, minutes, or 
hours. A tight cravat, worn while making SYMPTOMS. 
847 
some undue exertion ; a sudden alarm ; 
or an indigestible meal, rapidly swallowed, 
may be the immediate antecedents. The 
patient, more or less suddenly, becomes 
confused, then apparently half uncon- 
scious, makes some unintelligible sounds, 
turns red and then blue in the face, stag- 
gers for support, looks round him wildly 
or imploringly, and then sits down, or 
falls down, convulsed, and a paroxysm, 
epileptiform in character, supervenes. 
From this he recovers partially, exhibit- 
ing great confusion of mind, headache, 
muscular feebleness, and sometimes par- 
tial paralysis of one side, or of one limb. 
The attack is occasionally followed by 
quasi-maniacal excitement, lasting from 
half an hour to three or four hours ; after 
which, the patient becomes exhausted 
and falls into a heavy sleep. From this 
state he may recover, or during sleep a 
second or third attack of convulsions may 
come on. 
When congestion of the brain has as- 
sumed this convulsive form, the patients, 
so far as my own experience extends, 
have usually been in middle life, and have 
recovered. But in other instances, when 
the age has been further advanced, the 
attacks have recurred more frequently, 
the intervals between them have become 
of shorter duration, and the patients-less 
sensible and less reasonable after every 
paroxysm - have presented the appear- 
ance of those whose attacks have been 
apoplectiform at their commencement. 
3. Delirium may be the most marked 
symptom of congestion of the brain in 
certain cases. This is observed almost 
exclusively in those who are of an ad- 
vanced age, but it is not absolutely limited 
to the period of senility. It may occa- 
sionally be met with in middle or even 
early life, and is then commonly accom- 
panied by some change in blood-quality. 
The attack may come on suddenly, may 
be induced by a fall or a fright, but when 
occurring spontaneously is first observed 
towards evening. Sometimes the attack 
is preceded by "depression of spirits;" 
the patient, after some hours or even 
days of undue taciturnity, becomes cheer- 
ful, or gay, and hilarious ; he talks loudly 
and incoherently, but rarely exhibits any 
violence. Ue gets out of bed, wanders 
about his room or ward, opens drawers, 
puts on his dress, and is bent upon doing 
something which he cannot explain, or 
which, if expressed in words, is unneces- 
sary, unaccustomed, and absurd. Ue is 
under a delusion, of no fixed character; 
and can usually be directed and managed 
without much difficulty. Sometimes, and 
this is especially observed in the aged, 
there may be hysterical crying ; or, still 
more rarely, great irritability of temper 
and some attempts at violence. The lat- 
ter occur almost exclusively as the result 
of bad management and rough thwarting 
of the delusive purpose. 
The patient may complain of pain in the 
head, or of uneasy sensations in the limbs ; 
and there may be twitching of the mus- 
cles, or weakness of the extremities. 
But none of these are complained of while 
the delirium lasts, although weakness and 
clonic spasm may be observed at the time 
of its occurrence. It is when the delirium 
has completely or partially subsided that 
these things are noticed, and that the 
general phenomena of cerebral congestion, 
viz., those which are described as pre- 
monitory symptoms, may be observed. 
Durand Fardel states that it is common 
to find "a mucous secretion, clear and 
viscid, produced on the eyelids, or in the 
interior of the mouth, and sometimes in 
extraordinary abundance, running over 
the whole facebut this is very com- 
mon in other diseases of old people, and 
has no special relation to mere congestion 
of the brain. 
The recurrences of delirium may be 
very frequent or very occasional: some old 
people present them nightly for many 
weeks, and know nothing about them on 
the following days; while others exhibit 
them after much longer intervals, and 
only when " upset" by the little occur- 
rences of the day. Tiie tendency, how- 
ever, is towards increase-not so much in 
degree as in persistence of mental change 
-and the patients become gentler, but 
less rational. The mind is weakened at 
each onset of delirium, and does not re- 
cover itself; there is drowsiness in the 
daytime and wandering talkativeness at 
night; but the intellectual powers are 
seen to be failing day by day ; the physi- 
cal energy diminishes, and the patient 
keeps his bed, and gradually passes into 
the state hereafter to be described. 
4. Febrile Form.-In the earlier periods 
of life, and especially in infancy and 
childhood, congestion of the brain may 
occur with marked elevation of tempera- 
ture, a dry skin, thirst, and the restless- 
ness and malaise of a pyrectic state. There 
is headache, not of great intensity, but of 
dull, oppressive character; the head is 
unduly hot, the cheeks and conjunctivae 
are flushed, while the extremities are 
cold ; the mental faculties are obscured, 
and the sleep is broken by dreams or 
transient and mild delirium. Usually 
there has been some distinct cause for 
such disturbances ; there is no marked 
prostration, no initial rigor ; there may be 
some vomiting, but it is not persistent, 
nor are the bowels obstinately confined; 
there is no photophobia, no intolerance of 
sounds, no ' eruption on the skin ; the 
secretions may be foul, but they present 
no indications of organic disease ; and the 
' Maladies des Vieillards, p. 27. 848 
CONGESTION OF THE BRAIN. 
patients usually recover speedily. Re- 
covery is, however, not always observed ; 
the distress may persist; there may be, 
alternately, convulsions and delirium, or 
there may be the changes from over- 
excitement to drowsiness, the latter grad- 
ually becoming relatively more marked, 
until the patient passes into a state of 
stupor from which he may never rally. 
C. Final Symptoms.-Under whatever 
form congestion of the brain may pri- 
marily appear, its tendency, unless speed- 
ily recovered from, is to produce a condi- 
tion of torpor and inactivity. The mind 
becomes a blank ; there is sometimes pro- 
found coma, stertorous breathing, and 
involuntary evacuation of both bladder 
and rectum ; sensibility both general and 
special is lost, and voluntary muscular 
power reduced to a minimum. Convul- 
sions may occasionally disturb the calm, 
or there may be fitful and momentary 
muttering of unintelligible sounds, but 
usually, in this latter stage, the patient 
lies quietly, with labored pulse and breath- 
ing, and with flickering contractions of 
the muscles of the limbs, until he dies. 
Causes. - Among the predisposing 
causes must be reckoned such physical 
conformations as should impede the re- 
turn of blood from the head, and the 
most important of these is a morbid con- 
dition of the heart. Dilatation of the 
right side of the heart, with loss of both 
power and valvular competency, are 
commonly found, during life and after 
death, in those who succumb to cerebral 
congestion. It is in old age that such 
changes are usually discovered, and hence 
advanced age appears a predisposing 
cause. It is more common to find severe 
cerebral congestion in men than in wo- 
men. Sedentary occupation and short- 
ness of neck have been reckoned among 
the predisponents, but I think with in- 
sufficient reason ; for attacks of cerebral 
congestion often occur in those of active 
habits and of healthy build, and indeed 
sometimes the worst forms of seizure that 
I have witnessed have been in persons of 
great mental and physicial activity, in 
those who have been overwrought, and 
who have continued in forced exertion 
beyond the bounds of reason and habitual 
practice. 
The determining causes are to be found 
in all those conditions which entail sud- 
den changes in the circulation. These 
are exposure to extreme heat or cold, and 
especially to the direct influence of the 
sun's rays ; blows upon the head or trunk ; 
violent exertions, such as make it neces- 
sary to "hold the breath ;" rarefaction of 
the air, such as is encountered in balloon 
ascents, and in some mountaineering ex- 
peditions ; violent emotion, or prolonged 
mental eflbrt; an overloaded state of the 
stomach, and this especially after undue 
abstinence ; the ingestion of large quan- 
tities of alcoholic stimulants ; a sudden 
change of posture, such as stooping or 
lying down with the head too low ; and 
tightness of the dress around the neck. 
Besides the so-called predisposing and 
exciting causes of cerebral congestion, 
there are two general conditions of the 
organism which may have some causative 
relation to the symptoms, although 
neither of the preceding words fully con- 
veys the nature of that relation. A full- 
blooded, lax-fibred, and fat man, in middle 
age, represents one of these conditions ; 
a thin, pale, wiry old person, with rigid 
vessels, is an example of the other. Both 
are prone to suffer from disturbances, ir- 
regularities, inequalities in the circula- 
tion ; and in either there may be cerebral 
congestion in a grave or fatal form. If 
these conditions be regarded as " predis- 
ponents," it must be remembered that 
they have no special relation to this lo- 
cality of congestion, and further that the 
mode in which the one operates is quite 
distinct from that in which the other 
leads to its results. In the former cere- 
bral congestion is but part of a general 
condition, and some accidental posture 
may determine that the brain shall be the 
organ upon which the weight of the bur- 
den falls ; in the latter, feebleness of cir- 
culation power, and locally increased re- 
sistance in the walls of vessels, may be 
the main factors in the production of such 
partial congestion of the brain as shall 
give rise to an apoplectiform seizure. 
Diagnosis.-Remembering the general 
character of the symptoms which were 
described as "premonitory," there can 
be but little difficulty in carrying the 
diagnosis up to a certain point, and in 
explaining them by the fact of congestion ; 
but when the malady passes into either 
one of the four forms of "developed" 
symptoms, the diagnosis is sometimes 
difficult, and it is therefore necessary to 
consider it in detail with regard to each. 
The apoplectic form of congestion re- 
sembles cerebral hemorrhage, acute soft- 
ening of the brain, urinsemia, and syn- 
cope. From hemorrhage, it may be 
distinguished by the facts of its less sud- 
den onset; its occurrence while the pa- 
tients are awake rather than when asleep 
-patients do not wake up in the morning 
and find themselves paralyzed on one 
side, as they often do in cases of hemor- 
rhage ;-the attack of "congestive apo- 
plexy" occurs during the day, and its 
onset is marked by the absence of the 
phenomena of shock ; by the equality of 
disturbance usually noticed in regard of 
mind, sensation, and motility at the com- 
mencement of the seizure-each of them 
is affected generally, and to nearly the PATHOLOGY. 
849 
same degree, but in no one direction is 
there entire and absolute loss of function 
except for a few moments ; by the subse- 
quent relative proportion of symptoms, 
such for example as partial paralysis of 
all the limbs with imperfectly developed 
coma, a combination not to be observed 
in hemorrhagic apoplexy ; by the speedy 
restoration of the mental faculties; and 
by the equable and usually simultaneous 
removal of other symptoms. 
From softening of the brain in its acute 
form, congestive apoplexy cannot be al- 
ways distinguished at the outset, for in 
some cases of the former the attack is in 
reality due to the occurrence of the latter. 
The diagnosis can only be made after 
some little time has elapsed, and then it 
will turn upon a recognition of the follow- 
ing points: In congestion the mind 
speedily recovers, in softening it does not; 
in the former there is widely distributed 
but imperfect paralysis, in the latter 
limited, but more complete, loss of power ; 
in the one the patient is generally power- 
less, in the other he is hemiplegic; in the 
one there is flaccidity of muscle, in the 
other there is rigidity; in the former the 
premonitory symptoms have been those 
of congestion of the brain, in the other 
those of chronic disease elsewhere and 
loss of power. 
From urinsemia, the attack maybe dis- 
tinguished by regard to the premonitory 
symptoms ; by the absence of oedema of 
eyelids or of lower extremities ; by the 
absence of albumen from the urine ; by 
the absence of marked rigidity of mus- 
cles ; by the nature of the coma, its mo- 
mentary profundity, rapid diminution, 
and want of that peculiar character which 
often attaches to blood-poisoning, viz. its 
apparent profundity in strong contrast 
with the ease with which the patient may 
be awakened up to a certain point; and 
further by the absence of a peculiar va- 
riety of stertor, occasioned apparently in 
the mouth or at the palate. 
From syncope, congestive apoplexy may 
be distinguished by an examination of the 
heart, and the pulse at the wrist, the car- 
otids, and the temples; by the color of 
the face and head; the premonitory 
symptoms, and the conditions which led 
to the attack. 
The convulsive form of congestion may 
be confounded with epilepsy or with 
eccentric convulsions. From epilepsy the 
diagnosis may be made by a consideration 
of the previous history : in the one there 
have been the premonitory symptoms of 
congestion, in the other no such phe- 
nomena have presented themselves; in 
the former the patient is usually of middle 
or advanced age, in the latter he is young, 
and is either under twenty years, or has 
not far exceeded that period of life ; in 
the one the period of most marked con- 
gestion is at the moment of onset of the 
seizure, in the other congestion of the face 
and head is most marked as the attack is 
passing off'; in the former there may be 
some moaning sound, in the latter the 
" epileptic cry ; " in the one there is the 
sudden onset of an acute disease, in the 
other the attack of a chronic malady. 
From eccentric convulsions it is possible 
to distinguish congestive convulsions by 
regard to age and attendant symptoms. 
Eccentric convulsions are observed in 
infancy and early life, and when some 
definite source of irritation can be dis- 
covered in certain organs of the body; 
they are found most commonly in the 
weak, irritable, and nervous subject, and 
they are attended by no premonitory 
symptoms of congestion, and by little or 
no evidence of its presence during the 
attack. There is but trifling somnolency, 
and the seizures differ from those of epi- 
lepsy and of congestive convulsion in not 
passing through the stages which were 
described as proper to the former, and 
which are closely simulated by the latter. 
Congestion of the Brain in the form of 
delirium is met with almost exclusively in 
old age ; and it is necessary only to men- 
tion delirium tremens in order to prevent 
the possibility of their being confounded. 
From senile softening of the brain, when 
this is accompanied by recurrent delirium, 
the diagnosis may be made by regard to 
the intermediate state; for when only 
congestion is present the patient returns 
to his normal condition in the intervals of 
wandering, whereas when the brain tissue 
is undergoing degeneration, and is the 
cause of delirium, no such recovery is 
possible. There is, moreover, a progres- 
sive enfeeblement of all the nervous func- 
tions, and a general condition of depraved 
nutrition such as is not necessarily found 
in cases of congestion. 
The febrile form of congestion may be 
distinguished from meningitis by the ab- 
sence of acute pain, and of intolerance of 
sensorial impressions ; by the milder cha- 
racter of the delirium, the dilatation rather 
than contraction of the pupils, the absence 
of persistent vomiting and of obstinate 
constipation, the generally milder charac- 
ter of the symptoms, and their early ces- 
sation. 
Pathology.-The circulation through 
the cerebral vessels has been supposed to 
present certain peculiarities owing to the 
inclosure of the brain within an unyield- 
ing case, and its being, therefore, beyond 
the influence of atmospheric pressure. 
This was first alluded to by the second 
Monro. It was thought that no great 
alterations could take place in the total 
quantity of blood within the cranium at 
different times, although there might be 
an altered ratio as regards the respective 
vol. I.-54 850 
CONGESTION OF THE BRAIN. 
amounts of arterial and venous blood. It 
was even held by Dr. Kellie, that in ani- 
mals which have died from hemorrhage 
there is no lack of blood in the brain; 
that where, on the contrary, we should 
expect Jo find a condition of cerebral hy- 
pereemia, we do not meet with it; and 
that the quantity of blood in the cerebral 
vessels is not affected by gravitation, and 
thus is uninfluenced by the position of 
the head with respect to the body. These 
views were also supported by Dr. Aber- 
crombie and by Dr. John Reid;1 though 
they have been ably opposed by Dr. Bur- 
rows2 and by Donders,3 many of whose 
experiments go to establish the direct re- 
verse of the results arrived at by Kellie. 
It seems by no means satisfactorily demon- 
strated that the contents of the cranium 
are so entirely removed from the influence 
of atmospheric pressure. Dr. Burrows 
says : " The numerous fissures and fora- 
mina, for the transmission of vessels or 
nerves through the bones of the cranium, 
appear to me to do away with the idea of 
the cranium being a perfect sphere like a 
glass globe, to which it has been compared 
by some writers." And the other dogma 
on which this hypothesis rests, and which 
Dr. Abercrombie supports when he says, 
"We may safely assert that the brain is 
not compressible by any such force as can 
be conveyed to it from the heart through 
the carotid and vertebral arteries," seems 
to be directly contradicted by a considera- 
tion of other facts.4 
The observations of Robin,5 and of Uis,6 
who have discovered a system of lymph- 
atic sheaths inclosing spaces around the 
cerebral bloodvessels, are of great import- 
ance, and reveal a structural adaptation 
which seems especially calculated to per- 
mit of varying amounts of fulness of the 
cerebral vessels, within certain limits, 
without injury to or compression of the 
surrounding nerve pulp. Professor Uis 
has succeeded in injecting this system of 
perivascular canals, and has found them 
most obvious in the gray matter of both 
brain and spinal cord. He has found 
that the injections at first reach the sur- 
face of the encephalon and cord, and fill a 
vast system of lacunae situated between 
the pia mater and the surface of the 
nervous centres ; while, if pushed still 
further, he has found that they fill the 
lymphatics of the pia mater itself. Thus 
there is, as it were, a second series of ves- 
sels inclosing and surrounding with a fluid 
medium all the ramifications of the cere- 
bral and spinal vascular system, whilst 
these two sets of vessels, containing and 
contained, are lodged in definite cylindri- 
cal canals permeating the nerve substance 
in all directions. The lymphatic sheaths 
are in contact with, though in general are 
easily separable from, the walls of these 
canals through the nerve substance. The 
diameter of the canal (and therefore of the 
lymphatic sheath) may be seen, in trans- 
verse sections, to be generally twice, and 
sometimes three or four times, as large as 
that of the contained bloodvessel. It will 
be easily understood that these two sys- 
tems must have such a complemental 
relationship to one another, that an extra 
fulness of the one set of vessels will corre- 
spond with diminished fulness of the other 
set. That is to say, in order to make 
room for an increased amount of blood in 
the cerebral vascular system a correspond- 
ing amount of fluid must be driven out of 
the enveloping lymphatic vessels;1 whilst, 
when the vascular supply is again dimin- 
ished, a proportionate amount of fluid re- 
enters the cerebral lymphatic canals. 
Thus, we believe that the amount of 
blood existing within the cranium may be 
subject to great variation, and that the 
peculiarities of the cerebral circulation 
have been much overrated. 
The conditions capable of bringing 
about a state of cerebral congestion are 
very various, and so also is the degree of 
hyperaemia met with, and the extent of 
its diffusion over the encephalon. In one 
class of cases, the congestions seem to be 
most obviously mechanical phenomena, 
due to some impediment to the proper re- 
turn of blood from the brain, owing either 
to diseases of the heart or lungs, to pres- 
sure upon the great veins by turners, or 
to their obliteration by thrombosis. In 
other instances, however, the condition of 
hvperaemia seems a more purely vital 
phenomenon, as when it is the result of 
prolonged study and over-mental work, 
or when it has an irritative origin, and is 
set up around some old clot, bony exos- 
tosis, or adventitious product in the brain. 
Then, too, alcoholic intoxication, great 
elevations and alternations of tempera- 
ture, exposure to the sun's rays in hot 
summer weather, and the suppression of 
accustomed fluxes, whether menstrual or 
other, are all looked upon as occasional 
causes of cerebral congestion. In connec- 
tion with inflammation of the meninges, 
congestion of the convolutional gray mat- 
ter is doubtless the initial stage of what 
afterwards becomes diffuse superficial 
1 Physiolog. Anatom, and Path Researches. 
No. xxv. 
2 Lumleian Leet. 1843, and On Disorders of 
the Cerebral Circulation, &c. 1846. 
3 Nederland. Lancet, 1850. 
4 Andral's Clinique Medicate. 
6 Brown-Sdquard's "Journal de Physiolo- 
gic," 1859. p. 527. 
6 Zeitsch. fiir wissen. Zoolog. 1865, Bd. xv. 
and The Journal of Anatomy and Physiology 
(Cambridge), No. 2, p. 347. 
1 Cambridge Journal of Anat, and Physiol., 
No. 2, p. 351, note 2. MORBID ANATOMY. 
851 
cerebritis. Well-marked Congestion of 
the Brain is also met with very fre- 
quently in persons who have died whilst 
suffering from symptoms of delirium or 
coma during the course of the acute spe- 
cific diseases, and in whom there may be 
no trace of meningeal inflammation, this 
is more especially common in typhus fever. 
From observations which I have made on 
the bodies of persons who have died from 
this disease, and also from the minute 
examination of the brain of a man who 
died delirious whilst suffering from acute 
phlegmonous erysipelas of the head and 
neck, I have been led to believe that 
these minute and wide-spread congestions 
are often due to embolism or thrombosis 
of the minute arteries and capillaries of 
the brain.1 Wide-spread obstructions in 
the small vessels, however brought about, 
would cause much of the propulsive 
energy of the heart to be wasted and a 
consequent lagging of blood in the venous 
radicles. 
Cerebral congestion is very intimately 
related to cerebral hemorrhage on the one 
hand, and to inflammation on the other. 
Hemorrhage is most likely to be associated 
with the congestions of mechanical origin, 
especially if these are brought about rap- 
idly ; and although such cerebral condi- 
tions generally give rise to well-marked 
brain-symptoms, still the groups of symp- 
toms previously described are often re- 
lated to congestions of a more active kind 
-such as are commonly spoken of as ' de- 
terminations' of blood to the head-and 
which may be said to commence rather 
on the arterial than on the venous side of 
the circulation. In these cases, perhaps 
by virtue of certain changes occurring in 
the nerve tissue itself, an increased flow 
of blood takes place to the brain, which 
may subside after a variable time and 
after the production of a certain set of 
symptoms, or which may occasion the 
death of the patient owing to the super- 
vention of symptoms of a graver type. In 
certain other cases the congested condi- 
tion of the membranes and cortical sub- 
stance may gradually lapse over into a 
state of inflammation, and it will then be 
associated with tissue changes of a more 
marked character. 
Morbid Anatomy.-Congestion of the 
brain tissue itself is almost invariably as- 
sociated with a similar condition of the 
pia mater, and the amount of cerebral 
congestion is often judged of, in a loose 
way, by the degree of fulness of the ves- 
seis of this membrane. What many per- 
sons would consider to be a state of con- 
gestion is, however, natural to the vessels 
in this situation. Hasty opinions on this 
subject should, therefore, be especially 
guarded against. This fulness of the ves- 
sels of the pia mater is most notable in 
the occipital region, whither the blood 
gravitates, for the most part, after death. 
Occasionally, however, as suggested by 
Laborde, this occipital congestion may 
take place during the last days of life, so 
as to place it in the same category with 
hypostatic congestion of the lungs. 
In some cases, where there has been 
every reason to believe that a state of 
congestion existed during life, it must be 
confessed that little or no traces of it can 
be recognized after death ; though, on the 
other hand, when it has existed for some 
time and has been carried to an extreme 
degree, or when it has been often repeat- 
ed, undoubted evidences of the present or 
previous existence of such a condition 
may be met with. In a young and mid- 
dle-aged subject, in whom no atrophy has 
taken place, but whose brain has been 
subjected to an extreme degree of conges- 
tion during life, the organ frequently 
seems, after the removal of the calvarium, 
to be in a swollen condition. The dura 
mater is tightly stretched over the organ, 
and after its reflection the convolutions 
appear broad and flattened, with sulci 
less obvious than natural, owing to the 
effects of pressure against the interior of 
the skull. Then, there is not only the 
usual fulness of the large veins of the piA 
mater, but also a more tortuous and even 
varicose condition of these trunks, to- 
gether with a more complete injection and 
turgescence of the smaller vessels than is 
usually encountered. The membranes 
may be stripped off the surface of the con- 
volutions without tearing the gray mat- 
ter, and on section this appears darker 
than natural, and dotted with bloody 
points in the situations of its loaded ves- 
sels. The white substance also shows an 
abundance of a certain number of the red 
points, which are usually gorged vessels 
pulled out for a certain distance so as to 
lie on the cut surface. These are only 
comparative signs, however, and their 
true value must be estimated accordingly, 
since all intermediate conditions may be 
met with between the ordinary healthy 
amount of fulness and the most marked 
degree of hypertemia. It is extremely 
difficult to draw the line and say what is 
morbid and what is consistent with 
health. 
If, however, the congestions have been 
often repeated or have lasted for any 
length of time, microscopic examination 
does enable us to discover evidence of 
this. The capillaries, and more particu- 
larly those of the gray matter, become 
1 "On the Clogging of Minute Vessels in 
the Gray Matter of the Brain as a cause of 
Delirium and Stupor in severe Febrile Dis- 
eases ; and on other Symptoms of the ' Ty- 
phoid State:'" Brit. Med. Journ. Jan. 23, 
1869. 852 
CONGESTION OF THE BRAIN. 
twisted and varicose, displaying partial 
dilatations, or real aneurismal swellings, 
implicating either a part only of the cali- 
bre of the vessels, or dilating them in 
numerous adjoining parts in their whole 
extent, so as to constitute " 1'etat mouili- 
forme" of Laborde.1 But a still more 
certain mark of old congestion is afforded 
by the presence of a quantity of blood pig- 
ment (hsematine) surrounding the vessels, 
though inclosed within the lymphatic 
sheath described by Robin. It is met 
with in the form of more or less rounded 
simple or molecular grains, mostly of large 
size. They may measure as much as 
in diameter. They are usually of a 
dark olive or amber yellow color, and are 
sometimes composed of a number of mi- 
nute pigment granules aggregated into 
small spherical masses. The pigment re- 
mains quite unaltered after the applica- 
tion of ether, alkalies, or the strongest 
acids. The crystalline form of blood pig- 
ment (htematoidine) is not met with, since 
this seems to be produced only in places 
where an actual extravasation of blood 
has taken place, whilst the pigment in the 
granular and amorphous condition seems 
to result from stasis of blood, and more 
or less transudation of coloring matter, or 
haematine, through the walls of the ves- 
sels into the surrounding lymphatic ca- 
nals. It seems impossible otherwise to 
account for what I have seen. I have 
found, for instance, this matter in great 
abundance around almost all the small 
vessels and capillaries that were examined 
belonging to the brain and spinal cord of 
two individuals. Both were lunatics ; the 
one an epileptic and chronic maniac, sub- 
ject to paroxysms of great excitement, 
and the other a bhronic maniac of the 
most violent and excitable disposition, 
whose fits of passion were both frequent 
and long-continued. It was during the 
examination of the brains of these indi- 
viduals that this granular blood pigment, 
surrounding the vessels, first attracted 
my attention. I have since found that a 
similar condition had been noticed and 
described by Robin, and I can endorse 
his statement that a few such masses of 
pigment are usually to be met with, here 
and there, on the cerebral vessels of even 
young and healthy subjects. It is, there- 
fore, the abundance of this matter only 
which is to be looked upon as an index of 
disease ; and the duration of past conges- 
tions may be roughly guessed at by the 
more or less excessive accumulation of 
pigment around the vessels. 
Occasionally, however, an actual rup- 
ture of one of the minute vessels may take 
place under the increased strain upon its 
walls in cerebral congestion. This is all 
the more likely to occur in elderly people 
whose vessels have been weakened by fi- 
broid or atheromatous degenerations. In 
such cases I have not unfrequently found, 
after careful preparation, evidences of 
past capillary hemorrhages on several of 
the smallest vessels of the same brain. Af- 
ter the brain substance has been washed 
away, and when the vessels are floated in 
water in a shallow dish, one or more little 
orange-colored specks may be seen, even 
smaller than a pin's head. On examina- 
tion with the microscope these are found 
to be accumulations of altered blood pig- 
ment in the form of amorphous canary- 
yellow colored flakes, interspersed with 
distinct crystals of haematoidine, situated 
around one of the minute vessels, and dis- 
tending its sheath in a more or less obtuse 
fusiform manner. In these cases the pres- 
ence of the perivascular sheath seems to 
have limited the amount of blood effused. 
As soon as the sheath became distended 
in the immediate neighborhood of the rup- 
ture, the pressure so produced would tend 
to close the aperture in the ruptured 
vessel. 
Lastly, there is to be mentioned that 
condition of certain parts of the brain 
which was spoken of by Durand-Fardcl1 
as "1'etat crible," and which he and 
others regard as an evidence of previous 
dilatation of the vessels from long-con- 
tinued congestions. This condition is oc- 
casionally well seen, more especially in 
old people, in the white substance imme- 
diately beneath the gray matter of the 
convolutions. On section a number of 
round or oval apertures appear-some 
large enough to admit a pin's head-and 
within each may be seen the cut extremity 
of a vessel. In these situations the canals 
in the nerve substance have become en- 
larged by pressure, and the lymphatic 
sheaths have been dilated to a similar 
extent, whilst in the space between the 
sheath and the much smaller bloodvessel 
a large quantity of pigment granules is 
generally met with. This dilatation of 
the vascular canals sometimes reaches an 
extreme degree in the corpora striata and 
1 "Le Ramolliss. et la Congest, du Cer- 
veau," Paris, 1866. These irregular aneuris- 
mal dilatations of thin-walled capillaries 
must not be confounded with the distinct 
though microscopic aneurisms, occurring on 
some of the smallest arteries after they have 
undergone a process of fibroid thickening in 
different parts of the brain in old people. We 
have previously hinted at the occasional con- 
nections between cerebral congestion and 
cerebral hemorrhage, and now we may state 
that the links which bind the two together 
are frequently the aneurisms just mentioned. 
Congestion may have something to do with 
their formation, as it certainly has to do with 
their final rupture, leading to effusion of 
blood. (Trans, of Path. Soc. vol. xviii. 
1867.) 
1 Loc. cit. p. 57. PROGNOSIS-TREATMENT. 
853 
In the optic thalami, and the same con- 
dition may be encountered, though to a 
less extent and less frequently, in tlie sub- 
stance of the pons Varolii. Whenever 
the granules are met with, however, the 
structural conditions and the mode of ori- 
gin seem to be the same. Durand-Fardel 
says:-"Tantot 1'etat crible du cerveau 
se trouve repandu dans une grande eten- 
due des hemispheres, tantot on ne 1'ob- 
serve que dans un espace circonscrit. " 
This condition may be met with at all 
ages, though it is found more particularly 
in old people : and in them, the same 
writer tells us, the canals are sometimes 
so large and numerous in the corpora stri- 
ata, that these bodies may seem to have 
lost nearly half their substance. It seems 
most probable that these canals have been 
produced by the dilatation and pressure 
exercised by congested vessels, though 
their method of pathogenesis cannot be 
said to have been ascertained in a thor- 
oughly satisfactory manner. 
Prognosis.-In cases of cerebral con- 
gestion regard must be paid to the age of 
the patient, the form of his attack, the 
severity of the symptoms, and the fre- 
quency with which the symptoms or the 
attack of symptoms may have occurred. 
Age cannot be fairly estimated by the 
mere duration of life, for some men are 
"older" at fifty-five than others are at 
seventy years, and are so without any 
necessary coexistence of exhausting or 
definite disease. The apparent age is a 
truer guide than the real age in the mat- 
ter of prognosis. Baldness, gray hair, 
rigid vessels, a weakened heart, arcus 
senilis, and enfeebled powers, must be 
taken into more serious account than the 
date of birth ; and judged by such tests, 
the prognosis is unfavorable in proportion 
to the oldness or agedness of the indi- 
vidual. 
The form of attack is worthy of most 
grave consideration. That which is of the 
worst omen is the apoplectic ; next to this 
is that characterized by delirium ; after it 
the convulsive form ; and least serious of 
all is the febrile, or quasi-febrile. 
The severity of symptoms is of much 
value in relation to the apoplectic form ; 
the danger being in direct proportion to 
the profundity of coma, and its duration. 
It is of but little moment when delirium 
is the most prominent symptom, and the 
value that it possesses is in inverse rather 
than direct ratio to the force of the dis- 
turbance ; the prognosis is worse when 
the delirium is mild, muttering, and con- 
tinuous, than when it is noisy, or even 
violent, and-as is usually the case-of 
short duration. When convulsions occur, 
it is not safe to base any prognosis on the 
mere fact of their severity ; for often pa- 
tients recover after the most frightful 
seizures, whereas others succumb to much 
milder paroxysms. The degree to which, 
in the intervals of seizure, the mind is re- 
stored to its normal state, is a fairer cri- 
terion of the amount of danger than is the 
violence of the convulsion. In the febrile 
form the prognosis is bad in direct pro- 
portion to the intensity of the symptoms. 
When the disturbance is slight, confident 
hopes of recovery may be entertained ; 
when it is severe, there is room for the 
apprehension of ulterior and "inflamma- 
tory" changes. 
Congestion of the Brain is rarely fatal 
at its first attack ; it becomes dangerous 
in proportion to the frequency and readi- 
ness of its induction ; and this is true with 
regard to each form in which the symp- 
toms may be developed. 
The other conditions by which the 
prognosis must be determined are those of 
organic disease or degeneration in any of 
the important vital organs. It is obvious 
that the heart, the vessels, the kidneys, 
and the liver should be examined with 
care, and that the opinion formed as to 
the future should be guided by the kind 
and amount of disease that may be found 
in them. The prognosis, however, when 
such diseases are discovered, is not that 
of cerebral congestion only, but of those 
complicated morbid conditions of which it 
is but one form of expression. It may be 
that Congestion of the Brain is likefy to 
prove the cause of death, but the nature 
of the disease which leads to such conges- 
tion furnishes the material, by a consider- 
ation of which the probabilities may be 
estimated. 
Treatment.-As there are two dis- 
tinct, practically opposite, conditions of 
the body under which cerebral congestion 
may occur, so there are two different lines 
of treatment to be adopted. If the brain 
congestion be but one of many symptoms 
of a general plethora, much may be gained 
by either general or local blood-letting; 
if it be but the outcome of weakness and 
vascular obstruction, then such measures 
may increase the evil. The previous 
habits and health of the patient, the 
present state of his integuments,-their 
warmth, vascularity, and color,-the state 
of the pulse, of the heart and vessels, will 
furnish the guides in this important mat- 
ter. A man in middle age who has over- 
strained himself, or placed his head in 
some dependent position, and who is at- 
tacked by violent convulsions, character- 
ized by great turgescence of the skin, 
bloodshot eyes, and a full but labored 
pulse, may be relieved, and greatly re- 
lieved, by venesection to the amount of 
six or ten ounces. But such cases occur 
rarely, and in the majority of instances no 
man would at the present day think of 
bleeding from the arm. When, however, 854 
CEREBRITIS. 
there is distinct general weakness, and, 
with this, heat of head, oppression, con- 
tinuous headache, and a tendency to 
drowsiness, much relief may be obtained 
by the application of leeches to the tem- 
ple, or by cupping to three or four ounces 
at the back of the neck. When there is 
no such heat of head, and no flushing of 
the face, but when the diagnosis of cere- 
bral congestion may still be made-per 
viam exclusionis-and when the vital 
powers are low, the pulse small, feeble, 
irregular, or intermittent, even a small 
abstraction of blood locally may be fol- 
lowed by the worst results. It is when 
attacks of congestion are frequently re- 
peated, and other measures have failed to 
relieve them, that local depletion may be 
found of signal service. 
It is well to raise the head, to apply 
cold water or ice to the forehead, and to 
place the feet and hands in hot baths. If 
the stomach be overloaded, an emetic of 
mustard or ipecacuanha may be given ; 
and often with the discharge of the stom- 
ach the symptoms pass away. This is 
especially useful when the attack has fol- 
lowed a full but hastily taken meal. It is 
of great importance to empty the rectum, 
and the most efficient means for doing 
this is the administration of an injection 
of warm water. Should there be any sus- 
picion of the existence of hardened masses 
of feces, the injection of a large quantity 
of warm olive oil will prove more useful 
than that of water. 
When the tendency to cerebral conges- 
tion is noted, rather than any marked 
symptoms of its presence to a high degree, 
the secretions must be carefully regulated ; 
and among these one of the most impor- 
tant is the urinary. Many cases of threat- 
ening aspect are to be relieved by saline 
diuretics ; and I have known a copious 
flow of urine to be followed by the remo- 
val of symptoms which had existed in 
spite of free purgation and other treat- 
ment. 
There are many cases occurring in ad- 
vanced life in which the congestion is of 
only momentary duration ; and the pa- 
tient, when seen by the physician, is 
simply bewildered, pale, and with a cool, 
moist skin, and feeble pulse. Under such 
circumstances the cautious administration 
of stimulants is called for ; and of these 
sal-volatile and wine are the most useful. 
It is well to combine with them carbonate 
of potash, or of soda, as there is often 
considerable "acidity of stomach," and 
the discharge of flatus by the mouth, 
which results from such administration, 
is often followed by a complete remission 
of the symptoms. 
As precautionary measures, quiet of 
mind, and gentle exercise of body, with 
the careful avoidance of either fatigue, 
sudden change of posture, or strain, should 
be enjoined ; and much relief may be ob- 
tained by insuring a position during sleep 
which shall prevent not only the head, 
but the head and shoulders, from sinking 
down to the level of the body. This may 
be easily obtained by a simple contrivance 
placed under the bed or mattress upon 
which the patient lies ; such an arrange- 
ment being much better than a mass of 
pillows, which shift their places, and often 
maintain the head in a condition of undue 
heat. 
[In patients who have been subjected to 
the influence of malaria, special care is 
sometimes needful in diagnosis, in order 
for the proper adaptation of treatment. 
A lady was placed under my care who, 
without any distinct chill, became coma- 
tose, and continued so for about twelve 
hours. Her age, over sixty years, made 
apoplexy not improbable. Her pulse, 
however, was feeble, as well as mode- 
rately slow ; and her respiration was not 
stertorous. She was known to have just 
visited a malarious region. Ordinary de- 
rivative measures were used, and, as soon 
as she was able to swallow, quinine was 
given, a grain every hour, watching its 
effects. Under this treatment she re- 
covered.-H.] 
CEREBRITIS. 
By J. Russell Reynolds, M.D., F.R.S.,1 and H. Charlton 
Bastian, M.D., F.R.S. 
It is probable that general inflamma- 
tion of the brain never exists alone, but 
that it is invariably associated with men- 
ingitis. The terms encephalitis, meningo- 
cerebritis, and phrenitis, which have been 
employed to denote the condition now 
referred to, are sufficient of themselves to 
> The section on Pathology is written by 
Dr. Bastian. CAUSES-PATHOLOGY. 
855 
point out this constant association. Never- 
theless, in some cases there is to be found, 
during life, the predominance of a class 
of symptoms which simple meningitis will 
not account for; and, after death, the 
presence of such changes in the cerebral 
tissue, as do not necessarily accompany 
the meningeal inflammation. It would 
seem, therefore, that the brain substance 
is not only susceptible of morbid change 
of an inflammatory type, but that the 
presence of such change may determine 
the clinical history of the case. We may, 
in particular instances, refer some of the 
symptoms of a complex encephalitis to in- 
flammation of the membranes, and others 
to an implication, in like change, of the 
cerebral tissue. 
Meningitis has already been described, 
and it remains for us, in this place, to de- 
scribe only those symptoms which mark 
the extension of the malady to the brain 
itself. All that relates to that which has 
been described as local Cerebritis, or lim- 
ited softening of the brain, will be found 
under the articles on Abscess of the 
Brain and Softening of the Brain. 
Causes.-The most common causes 
are injuries to the head ; such as violent 
contusions, wounds, diseases of the bone, 
and insolation. It would appear, how- 
ever, that sometimes prolonged mental 
exertion or moral excitement have led to 
the development of this disease. In rare 
cases there has been no distinctly recog- 
nizable cause, the symptoms having ap- 
peared in the absence of any one of the 
conditions above mentioned. 
Symptoms.-These are, of necessity, 
associated with those of meningitis, but 
sometimes they are the earliest to appear, 
and are predominant throughout the case. 
Thus, some mental change may be the 
first evidence of disease ; it may be very 
slight, and may be mistaken for " hyste- 
ria," "stomach disturbance," or some 
such vague malady. In one case, which 
I saw several years ago, there was a mere 
confusion of ideas, and a worried manner, 
with misuse of words, and this for two or 
three days before other phenomena ap- 
peared. Usually the patient is sullen, 
and the faculties are obscured ; there is a 
confused, "muddled" state of the intellect, 
sometimes merging into mild delirium, 
sometimes, when meningitis is present, 
alternating with, or superseded by, violent 
excitement. 
There is deep-seated, oppressive pain in 
the head, described as sometimes shoot- 
ing from the centre to the vertex, the 
temples, eyes, or ears; and this pain is 
persistent, and is out of all proportion to 
the pyrexia, which is often very slight. 
Except in dependence upon meningitis, 
there is no intolerance of light or sound, 
but there may be obscurity of vision, di- 
plopia, and failure of sight, together with 
ringing noises in the ears, and some diffi- 
culty in hearing. 
There is general muscular lassitude, but 
neither definite paralysis nor spasm ; the 
limbs are weak and aching, but they may 
all be moved. 
Such symptoms may continue for two, 
three, or four days, and then a violent 
convulsion may occur, followed by coma, 
from which the patient never thoroughly 
recovers. There is, however, partial re- 
covery sometimes, and then more or less 
general paralysis is discovered. The 
patient is stupid, sleepy, comatose, and 
lingers for a shorter or longer time, in 
proportion to the amount of nourishment 
that can be given and retained by either 
stomach or rectum. Convulsions, some- 
what epileptic in character, usually recur, 
and in their intervals there is to be ob- 
served a gradual dying out of the vari- 
ous functions of the brain. Mind, sensa- 
tion, and voluntary power are lost, and 
the patient lives a mere vegetative life, 
disturbed occasionally by slight spasmodic 
movements, or rigid contraction of the 
muscles. The convulsions are often of 
long duration, involve the limbs especially, 
and are not marked by notable asphyxia. 
The general symptoms are, as a rule, so 
slight that they attract no notice. There 
is no fever, little or no vomiting, and no 
obstinate constipation of the bowels. Very 
often the sphincters are relaxed quite 
early in the history of the case, and no- 
thing abnormal can be discovered in the 
evacuations. 
Diagnosis.-That which gives to the 
diagnosis of meningitis its gravest ele- 
ment is the recognition of coexisting 
Cerebritis, and hence the diagnosis is val- 
uable as an aid to prognosis. Cerebritis 
may be inferred when there is a rapid 
transition from the excitement of menin- 
geal inflammation to the marked loss of 
function which is characteristic of cere- 
bral change. When the signs of menin- 
gitis are unusually severe, the pain deep- 
seated, and followed after twelve or 
twenty-four hours by convulsions, coma, 
and paralysis, there is commonly Cere- 
britis of considerable extent. 
Pathology.-Of uncomplicated Cere- 
britis we have no knowledge. When 
inflammation of the brain substance ex- 
ists, it is either associated with a more 
marked change of the same kind in other 
parts, such as the meninges, in which 
case it is treated of as a concomitant con- 
dition, and not as a primary morbid affec- 
tion; or else it speedily lapses into other 
distinct pathological states, such as ab- 
scess or softening, which, on account of 
their importance, are usually described as 
independent affections of the brain. 
Two kinds of Cerebritis are usually de- 856 
SOFTENING OF THE BRAIN. 
scribed, namely, the diffuse or general 
form, and local Cerebritis, which by most 
recent writers has been held to be synon- 
ymous with "red softening" or "acute 
ramollissement" of the brain. 
The diffuse form, or general Cerebritis, 
is a more or less wide-spread affection of 
the cortical substance, or gray matter of 
the convolutions, and is always associated 
with inflammation of the meninges. It 
may be met with in surgical cases, from 
injury to the skull; when, conjoined with 
it, there is inflammation of the dura 
mater and arachnoid, together with the 
formation of purulent lymph within the 
arachnoid cavity, and also beneath the 
visceral layer, into the meshes of the pia 
mater. Cerebritis may also be met with 
in the more limited meningitis, such as 
occurs when the disease is not of trau- 
matic origin, and which, affecting the pia 
mater principally, is not accompanied by 
any purulent effusion in the sac of the 
arachnoid. In these cases there is ex- 
treme vascularity of the cortical gray 
substance, which is also more soft and 
pulpy than natural; and it is frequently 
adherent to the meninges, so as to be torn 
when these are stripped off. For further 
particulars we must refer to the articles 
" Meningitis" and " Tubercular Menin- 
gitis," under which heads these morbid 
conditions are more fully described. It 
should be stated, however, that many 
pathologists of the French school look 
upon general paralysis of the insane as a 
disease due in part to a species of chronic 
Cerebritis. The same adhesion between 
the gray matter and meninges is frequent- 
ly met with in this disease ; but for fur- 
ther information we must refer to the 
article on this subject. 
With regard to local Cerebritis, we 
think with Lebert and other pathologists 
that this may be the antecedent condition 
and proximate cause of abscess in the 
brain; and we do not deny, also, that some 
acute softening of the brain may have an 
inflammatory origin. We do, however, 
strongly object to the view that all " red 
softenings," or "acute ramollissements, " 
have to acknowledge this method of path- 
ogenesis. We believe that most of the 
softenings hitherto placed in this category 
have been brought about by embolism or 
thrombosis, owing to the interference 
with the crebral circulation thus induced; 
and that the characters usually considered 
as diagnostic of their inflammatory nature 
are capable of receiving a totally different 
interpretation, as may be seen on refer- 
ence to the article "Softening of the 
Brain." In this view we are supported 
by many recent writers on the subject. 
With regard to the occasional existence 
of softening of the brain of inflammatory 
origin, we do not altogether disbelieve in 
its occurrence, only we plead ignorance 
as to the characters by which such soften- 
ings are to be distinguished from others 
of a degenerative nature, due to arterial 
or venous obstruction. We certainly think 
it is a pathological condition which occurs 
very much more rarely than the state- 
ments of some pathologists would lead us 
to imagine. It may, perhaps, be looked 
for most confidently in cases of wounds 
or injuries to the brain, or around adven- 
titious products, as centres of irritation. 
Prognosis.-The prognosis is as bad 
as it is possible to be. There is no prob- 
ability of recovery when symptoms such 
as those above described have been de- 
veloped. 
Treatment.-Only palliative mea- 
sures can be used with any advantage. 
We have never seen any good result from 
mercury given by the mouth or by inunc- 
tion ; nor from blisters, cupping, or other 
modes of blood-letting. Pain may be re- 
lieved by the application of ice; and 
spasmodic movements may be limited by 
sedatives, such as belladonna and Indian 
hemp ; but beyond such relief of symp- 
toms therapeutic art has failed. 
SOFTENING OF THE BRAIN. 
By J. Russell Reynolds, M.D., F.R.S., and 
II. Charlton Bastian, M.D., F.R.S.1 
Definition.-A disease characterized 
during life by impairment of mind, sensi- 
bility, and motility, and after death by 
diminished consistence and degeneration 
of the cerebral substance. 
The disease now to be described is that 
which has been known as white or non- 
1 The sections on Pathology and Pathologi- 
cal Anatomy are written by Dr. H. C. Bastian. ACUTE SOFTENING OF THE BRAIN. 
857 
inflammatory softening: ramollissement 
blanc, or ramollissement non-inflamma- 
toire. 
Causes.-There is little that is satis- 
factory which can be said with regard to 
the remote etiology of Softening of the 
Brain. Among the conditions which 
predispose to its occurrence the most im- 
portant is age, or agedness. Softening of 
the Brain is essentially a manifestation of 
decay, and this may be either the natural 
result of the wear and tear of a long life's 
work, or it may be the early outcome of 
excessive strain. The real cause is that 
waste of tissue which is unbalanced by 
repair, and this may come from the long 
continuance of work,-old age,-or the 
unhealthy severity of work, and its undue 
relation to rest. The proximate causes 
may be resolved,-as will appear in the 
section on "pathology," - into mor- 
bid conditions of the vascular system. 
Neither sex, constitution, nor season of 
the year has been shown to exert any 
marked predisposing influence, nor has 
any distinct relation been made out be- 
tween any one particular condition of the 
heart and cerebral softening. Degenera- 
tion of the kidneys and impaired nutri- 
tion of the heart and vessels are among 
the conditions which frequently accom- 
pany ramollissement; but these ought to 
be regarded as certain parts of a general 
change of which the cerebral softening is 
but another or counterpart, rather than 
as predisposing causes of its existence. 
Vegetations on the valves of the heart 
may become detached and may block up 
one of the cerebral arteries ; and thus 
their presence on the valves might be re- 
garded as predisposing to Softening of the 
Brain. But it must be remembered that 
such vegetations when in situ, i. e. unde- 
tached, do not specially predispose to 
Softening of the Brain, that they may 
lodge in other vessels than those of the 
cerebrum, and that when they are carried 
from the heart to the cerebral arteries 
they become determining and not predis- 
posing causes. If we may employ the 
term " predisposing cause" under these 
circumstances, we should do so to the 
general or constitutional state that has 
led to the production of vegetations rather 
than to the vegetations themselves. 
There is nothing definite to be said with 
regard to exciting causes. Attacks have 
sometimes followed violent mental or 
moral excitement, anger, abuse of alcohol, 
over-fatigue, or local injuries ; but in the 
majority of cases no such conditions have 
been present, and in very many there has 
been a singular immunity from all appa- 
rent causes of disturbance. Exposure to 
cold has been followed by an apoplectic 
seizure, and one of the more frequent de- 
termining causes of an attack has been 
too free a purgation of the bowels. 
Symptoms. - Softening of the Brain 
may occur as either an acute or a chronic 
disease. It will be well, therefore, to de- 
scribe the affection under two general 
headings, and first:- 
Acute Softening of the Brain. 
1. Premonitory Symptoms.-These may 
be absent altogether, but such complete 
immunity is rare; for Softening of the 
Brain most frequently occurs in those 
whose health has been for some time be- 
low the average, and very frequently in 
others who are the subjects of some dis- 
tinct chronic and exhausting diseases. 
There is nothing so special in the charac- 
ter of the general condition which may 
precede Softening of the Brain as to ren- 
der it of much value in the forecast of a 
patient's chances. There is often an en- 
feebled condition, with impaired nutritive 
power, shown in the general bearing of 
the patient, and more distinctly in the 
weakness of cardiac impulse, rigidity of 
arterial vessels, and local inequalities of 
temperature. These facts may be noticed 
for months or even years, but there is no- 
thing in them that points specially to the 
brain as the organ which is likely to give 
way. In combination with symptoms of 
cerebral failure they are, however, of great 
significance. 
The symptoms which, when thus com- 
bined, are premonitory of softening, are 
often those already described as charac- 
teristic of impending or actually devel- 
oped congestion of the brain. (See p. 
845, article "Congestion of the Brain.") 
They are-headache, more or less con- 
stant in duration, and usually "dull" in 
character, dulness of sight or hearing, 
numbness, obscure pain, weight, or an 
indescribable sensation of "something 
wrong" in the extremities, slight con- 
fusion of thought, sleepiness, weakness of 
purpose, hesitation in judgment, irritabil- 
ity of temper, diminished control of emo- 
tion, deficiency of muscular power, a stoop- 
ing gait, and tendency to cramp in the 
limbs. Sometimes the face assumes a 
dull, expressionless aspect when the pa- 
tient is at rest, and he may pass hours in 
a state of apparent indifference to all 
around him ; but when called upon to ex- 
ert himself is able to resume his habitual 
manner, and do his accustomed work, al- 
though with some heaviness of manner 
and apparent effort. There may be occa- 
sional and slight symptoms of faintness, 
the face becoming pale, and the limbs 
cool; and such occurrences are of much 
significance. It sometimes happens, more- 
over, that the altered sensations above 
described are noticed more on one side of 
the body than on the other ; and the fact 
of this limited distribution is highly indi- 858 
SOFTENING OF THE BRAIN. 
cative of impending evil. There may be 
a little dragging of one leg, or only a ten- 
dency to lean to one side when either 
walking or sitting; and this, when con- 
stant in its locality, is of much graver 
meaning than is a much greater amount 
of weakness when variable in its seat. 
Such symptoms may continue for a 
shorter or longer time, and may precede 
either acute or chronic softening, and 
there is nothing in their nature, when ex- 
isting only to the degree described, and 
which can only be regarded as " premoni- 
tory," that furnishes any clue to the form 
which the developed symptoms are likely 
to assume. 
2. The developed symptoms may occur in 
one of three distinct forms. The patient 
may either have an apolectic seizure, be 
taken with convulsions, or may pass into a 
state of delirium; and it will be conven- 
ient to describe these forms separately, 
premising that sometimes they pass into 
one another, and that occasionally mixed 
cases are observed, in which stupor, de- 
lirium, end convulsions alternate. 
(a) The apoplecticform may be very grad- 
ual or very sudden in its onset. When 
the former, there is an increase of the 
premonitory symptoms for days or weeks ; 
when the latter, there may have been no 
special premonition, but the patient sud- 
denly falls down in what is termed an 
"apoplectic fit," and he is said to have 
had "a fit," or "a stroke." 
Very commonly the attack occurs after 
too long an abstinence from food, or when 
the patient is fatigued by too long a walk, 
or too protracted an effort; sometimes 
when, as in congestion of the brain (see 
page 845), he is making an excessive ex- 
ertion. It is not common, so far as my 
experience extends, for patients to wake 
up in the morning and find themselves 
paralyzed on one side of the body, a mode 
of attack by no means uncommon in the 
case of cerebral hemorrhage. 
The condition of the mind is highly sig- 
nificant. Transient excitement, talkative- 
ness, irritability, or wandering of thought, 
amounting sometimes to mild delirium, 
may occur for a few minutes. The patient 
says or does something quite out of rela- 
tion to his surrounding circumstances or 
previous conversation; speaks as if to 
some person he may not have seen for 
years, asks a question which refers to 
events long since passed, or in some other 
manner shows that he is " not quite him- 
self;" is bewildered and "queer," vexed 
or pathetic ; he makes some effort to get 
up and do some extraordinary thing which 
no one can understand, is impatient of 
attempts at dissuasion or control, looks 
faint, and becomes more or less insensi- 
ble, sometimes falling to the ground, some- 
times voluntarily sitting or lying down, as 
if merely fatigued, or disgusted with the 
stupidity of those around him, who do 
not understand what it is he wants to do. 
The patient may for a few minutes be 
completely insensible, and when he is so, 
it is probably due to sudden congestion of 
brain, or to equally sudden ansemia of 
brain, either of which may be recovered 
from in a few seconds or minutes. When, 
however, the physician sees the case, he 
rarely finds absolute loss of consciousness. 
The patient lies quietly, in apparently 
profound sleep, snoring, and taking no 
notice whatever of the questions that 
friends ask in anxious and beseeching 
tones; but if spoken to sharply, told to 
put out the tongue, open the eyes, give 
the hand, or do any other simple thing, 
he responds at once, usually makes an 
awkward failure, and then relapses into 
his former state ; if asked a question, he 
makes some inarticulate or unintelligible 
sound in reply, and again falls back into 
his heavy sleep, sometimes muttering to 
himself, but more commonly snoring con- 
tinuously, or occasionally interrupting the 
rhythm of his snore by a long-drawn sigh. 
In such a state the patient may con- 
tinue for hours, days, or even weeks. 
There is often sufficient intelligence re- 
maining for him, when roused, to swallow 
food, to recognize friends, to make efforts 
to say something ; but so much dulness of 
apprehension, and so much difficulty of 
expression, that the real life is " hidden," 
and it is impossible to know that we are 
on such common terms with it that we 
can understand its meaning. 
In some cases there is after a longer or 
shorter period marked improvement, the 
faculty of articulation returns, and a cer- 
tain amount of conversation is possible to 
and with those who will give pains to learn 
the language that is spoken. The names 
of common objects are forgotten, or are 
confounded with those of others; and 
this, sometimes with such constancy that 
friends may understand what is intended, 
sometimes with such thorough want of 
uniformity that the meaning is unintelli- 
gible. Notwithstanding this great ob- 
scurity of expression, it may be perfectly 
clear that the patient himself knows dis- 
tinctly what he means, is aware that he is 
wrong in his use of words, is vexed at his 
blunders, and ingenious in contriving 
means to counteract or avoid them. For 
example, he may know so well the words 
which he wants, and which he supplies by 
others in ordinary conversation, as to 
write down lists of words, and point to 
one or more of them in order to make up 
his sentences, or correct erroneous expres- 
sions. (See page 855.) 
Occasionally, after being even pro- 
foundly affected,e the mental condition 
may undergo great improvement, and the 
patient, although not perfectly restored, 
be carried back again to the point de- 859 
SYMPTOMS 
scribed in the notice of premonitory symp- 
toms. But far more commonly there is 
no real restoration ; some confusion may 
clear away, the stupor may be lessened; 
but when these improvements have oc- 
curred the mind is found to be dulled and 
incompetent, and in a state of gradually 
increasing deterioration ; week by week, 
and month by month, the patient is 
further and further removed beyond the 
reach of intercourse, until the attempts to 
talk with him are given up so gradually 
by the friends that they are scarcely aware 
of the change, and so imperceptibly to the 
weakening mind of the patient that he 
takes no notice. In this way a sudden 
attack of softening may pass into what is 
termed "chronic softening," the patient 
becoming imbecile of mind, and powerless 
in body. 
In a certain number of cases, the course 
is rapid, the apoplectiform attack is re- 
peated, and at the end of two or three 
days there is profound coma, passing into 
the sleep of death; in a much smaller 
number, the symptoms are very transient, 
and the recovery may be complete. For 
example, a young lady, set. twenty-two, in 
her first attack of acute rheumatism, 
marked by considerable swelling and red- 
ness of knees, wrists, and ankles, and a 
recently developed systolic murmur at the 
base of the heart, received a visit from 
some friends, was excited in conversation, 
and had palpitation of the heart. A few 
minutes after her friends had left her she 
grew faint, looked pale, became uncon- 
scious, and remained so for two or three 
hours. At the end of that time she was 
confused, unable to utter any intelligible 
sentence, clipped her words, made some 
sounds that were quite inarticulate, and 
had marked right hemiplegia, the features 
being drawn to one side, the right arm 
being completely, the right leg incom- 
pletely, paralyzed. At the end of three 
days speech was perfect; and at the end 
of a fortnight the hemiplegia had disap- 
peared. The most rational interpretation 
of such case is, that an embolus blocked 
up the left middle cerebral artery, and led 
to impaired nutrition of the brain, which 
equals the first stage of softening; but 
that, owing to either the re-establishment 
of the circulation by the breaking up or 
removal of the embolus, or to the perfect 
establishment of the circulation in the col- 
lateral vessels, the nutrition was restored 
to its ordinary condition. 
Sensibility is sometimes quite destroyed 
at the time of attack, and for some Tew 
minutes afterwards; but in the greater 
number of cases it is only dull or impaired, 
and subsequently changed. While the 
patient is lying apparently unconscious, 
or only half conscious, it is often obvious 
that some sensibility is present, for he 
moans, moves about uneasily, puts his 
hand to his head, and starts or draws 
away some one or other of his limbs if the 
skin be scratched or pinched. It is pro- 
bable, from the frequency with which the 
hand is put to the head, that there is 
headache, or an uneasy sensation in the 
head; and a general feeling of distress, 
with, very frequently, some distressing 
sensation in one or more of the limbs. 
Often before the patient is able to speak, 
he is evidently uneasy in some of the ex- 
tremities, and these are usually on one 
side of the body, and are paralyzed ; he 
looks inquiringly at them, or rubs them, 
moans at them, and cries out if they be 
either moved or touched. When suffi- 
ciently conscious to make himself intelli- 
gible, the patient often complains of cold- 
ness, or numbness, or " queer feelings" in 
the arm or leg of one side ; of headache, 
or discomfort in the head not amounting 
to pain ; of a bewildered feeling, and some 
vertigo. There is occasionally hyperses- 
thesia, and its occurrence in the limbs 
affected by a stroke of hemiplegia is 
thought to be highly characteristic of 
acute Softening of the Brain. It would 
appear, however, that, instead of true 
hypersesthesia, there is a modified sensi- 
bility, such as that described above, and 
that it renders ordinary impressions pain- 
ful. Sometimes these modifications pre- 
sent very curious features; the patient 
feels distinctly and painfully any impres- 
sion on the skin, but is unable to refer it 
to its proper locality. For example, a 
pinch on the sole of the foot is referred to 
the inguinal region, while similar irrita- 
tion above the knee may be felt in the 
shoulder, or side of the neck ; and some- 
times the sensation may be referred to the 
wrong side of the body. 
In the majority of cases the sensibility 
of the limbs is, after an apoplectic attack 
of softening, speedily restored to its nor- 
mal condition. 
The special senses are, as a rule, unaf- 
fected except in the earliest stage of the 
attack, when all of them may be in abey- 
ance. There is not rarely some complaint 
of tinnitus, and of muscle, or of dulness in 
hearing, or mistiness of sight, but there 
is no one change which is characteristic 
of softening. The optic disk is often paler 
than natural. The vessels are extremely 
small, and either white or gray atrophy 
may be apparent. The outline of the disk 
is sometimes very sharply defined, and its 
shape distorted ; but there may be integ- 
rity in the appearances presented by the 
eye when there are unequivocal indica- 
tions of Softening of the Brain. There is 
often to be observed some marked pecu- 
liarity in the eyeballs and in the pupils, 
which being, however, illustrations of al- 
tered motility rather than of sensibility 
will be described under the following 
heading:- 860 
SOFTENING OF THE BRAIN. 
The symptoms dice to changes in motility. 
- It has been often observed that the eye- 
balls are directed to one side, and that 
the head is turned in the same direction, 
so as to give the idea that the patient is 
making an effort to look at something by 
the side of him, and usually on the oppo- 
site side to that of the paralysis in limbs. 
If carefully examined it may sometimes 
be shown that the patient does not see at 
all, and that the retina is quite insensible 
to light; while in other cases the patient 
sees distinctly, and may, by an effort of 
the will, bring the eyeballs to the middle 
line or even beyond it and to the opposite 
side. In one curious care, under my care 
in University College Hospital, this sy- 
nergic condition of the eyeballs was ob- 
served for nearly a fortnight, at the end 
of which time the patient died. The pa- 
tient was, when roused, sufficiently sensi- 
ble to give a coherent account of himself, 
his sight and hearing were good, he could 
distinguish not only objects but colors, 
and seemed rather amused at being put 
through an examination on such points ; 
yet while talking to me the eyeballs were 
constantly turned towards the right side, 
and so much so as to hide a considerable 
portion of each iris beneath the lids at the 
left inner and right outer angles. The 
patient often fell asleep, and began to 
snore while the students were standing 
round his bed ; and what was very inte- 
resting to observe was this, that at the 
moment of doing so the eyeballs returned 
to the middle line. Upon touching him, 
or speaking to him so as to rouse him a 
little, the synergic movement again in- 
stantly appeared. Owing to the ease with 
which the transition from sleeping to wak- 
ing could be effected in this case, the 
above observation was repeated many 
dozens of times, and always with a simi- 
lar result. The eyeballs are usually, ex- 
cept at or soon after the occurrence of the 
attack, unaffected. It is the rare excep- 
tion, and not the rule, to meet with stra- 
bismus even to a slight degree. There is 
nothing characteristic in the condition of 
the pupils ; they may be found in almost 
every degree of either dilatation or con- 
traction, and they are usually equal on 
the two sides in case of acute softening. 
Their relation to light is determined by 
the general sensorial condition rather than 
by any special involvement of their own 
motor centres. It has been said that oc- 
casionally the pupils dilate upon expo- 
sure to light and contract upon its with- 
drawal, but there has been, I believe, a 
fallacy in such observations which it is 
very easy to correct. The facts as they 
have been witnessed by myself in many 
cases are these : that the patient is found 
asleep, or in a state of half-unconscious- 
ness, with contracted pupils; a strong 
light is brought before him, or the eyelids 
are suddenly raised, and then immediately 
there is dilatation ; left to himself, again 
the drowsiness comes on, and the pupils 
pass into the state of contraction. The 
pupils dilate because the patient is roused, 
not because they are exposed to light; the 
contraction and dilatation that have been 
observed have had no relation to light or 
darkness, but simply to the facts of sleeping 
and of waking. This I have shown again 
and again by gently raising the lids of 
such a patient, and exposing the contracted 
pupils to the light without arousing him ; 
there is then no dilatation nor change of 
any kind : but if he be addressed loudly 
by name, or if his toe be pinched so that 
he is awakened, the pupils instantly 
dilate. 
The features are sometimes quite sym- 
metrical, both when at rest and when in 
motion ; but commonly there is some de- 
viation, noticed most distinctly in the 
lower part of the face at the angle of the 
mouth when the patient speaks or laughs; 
and sometimes it is so trifling that it may 
escape observation unless the patient 
smile, or make a forced effort to exhibit 
either the upper or the lower teeth. In 
other cases there is marked paralysis of 
the face on one side, and dragging of the 
features towards the other, with deviation 
of the tongue ; but let it be remembered 
that this paralysis does not, as a rule to 
which there are very few exceptions, in- 
volve the muscles of the forehead, eye- 
balls, eyelids, or pupils. The patients 
can equally raise the eyelids, open or 
close the eyes, and there is neither ptosis 
nor strabismus. 
The speech is commonly interfered with, 
not only at the moment of attack but for 
a long time afterwards, and sometimes 
persistently. It may be so thoroughly 
abolished that no intelligible sound is ut- 
tered, although it is obvious that ideas of 
some kind are passing through the pa- 
tient's mind ; it may, on the other hand, 
be so slightly affected that alteration is 
observed only in the articulation of certain 
sounds, such as those of the letters I or r. 
Between these two extremes there is al- 
most every variety of degree in the im- 
pairment of speech as a mechanical act, 
and there is also every shade of difference 
in the precision with which it expresses 
mental processes. Some patients can 
read with ease and correctness, articu- 
lating every sound distinctly : and yet 
they cannot construct for themselves a 
sentence of half a dozen words, so as to 
answer intelligibly the simplest question. 
Such patients, although able to hold a 
pen and copy sentences, or sometimes to 
write a few words from dictation, cannot 
compose anything for themselves. In 
such instances language is interfered with 
on its intellectual side. Other patients 
can write well, when not flurried, can talk SYMPTOMS. 
861 
for a little time so as to be understood, 
can help to convey their meaning by signs 
and gestures; but when "excited," or 
sometimes even when not disturbed in 
such manner, they can make no such suc- 
cession of articulate sounds as shall be in- 
telligible. Here speech is interfered with 
on its mechanical side. In the former 
group of cases there is usually paralysis 
on the right side of the body : in the lat- 
ter there is not any constancy in such as- 
sociation. It is to the former class that 
the terms "aphasia" and "aphemia" 
have been applied; and it is not rare to 
meet with cases which illustrate either 
it or the opposite condition : it is exceed- 
ingly easy to recognize intellectually the 
difference between the two extremes of 
symptoms, or between them as conjoint 
elements in a particular case ; but by far 
the most common event is to meet with 
such combinations of the two that it is by 
no means so easy to say how much is due 
to the one failure and how much to the 
other. 
A.s the words aphasia and aphemia 
have now passed into frequent use, and 
the conditions described by them have 
become not unfrequently the topics for 
medico-legal investigation, it is desirable 
that some further attention should be di- 
rected to them, or to what they mean. 
Aphemia was the word constructed by M. 
Broca;* and aphasia, an old Greek word, 
signifying the dumbness occasioned by 
strong emotion, was that used by M. 
Trousseau2 to denote the same thing, 
viz., the loss of speech or of articulate 
language, when occurring as a symptom 
of disease. 
The condition now well known as apha- 
sia was observed by the older writers on 
medicine, some of whom appear to have 
recognized the distinction, and others to 
have failed to do so, between it and a 
more general condition of injury to the 
nervous centres. But the special patho- 
logical significance of the loss of language 
has been demonstrated within a recent 
period. Dr. Gall was the first who sought 
to discover the locality or seat of what he, 
in accordance with a certain school of 
philosophy, was led to regard as the sep- 
arate faculty of language, and he arrived 
at the conclusion that this faculty had its 
place in those portions of the anterior 
lobes of the brain which lie upon the 
supra-orbital plates. 
The idea of Dr. Gall was taken up and 
strongly advocated by AI. Bouillaud,3 who 
distinguished, with care, between the 
recollection of words and the power of 
producing distinct sounds for their ex- 
pression. M. Bouillaud's great point, 
however, was to show that lesions of the 
anterior lobes of the brain occasioned loss 
of the faculty of speech, whereas diseases 
of other portions of the nervous centres 
were not so accompanied. Exceptions to 
Bouillaud's law were somewhat frequently 
pointed out both in this country and in 
France, and until a few years ago the 
general doctrine had fallen into almost 
complete disregard, although M. Bouil- 
laud had repeatedly brought forward fresh 
facts in confirmation of his dogma. 
The next step of great importance was 
taken by M. Dax, who, in 1836, pointed 
out, as the result of his analysis of nu- 
merous observations, that disturbances in 
the faculty of speech were always related 
to lesions of the left hemisphere, and 
never to those of the right. This work, 
to which my attention has been called by 
the able author of the article on Aphasia, 
in the new " Dictionnaire encyclopedique 
des Sciences medicales," was entitled 
"Lesions de la Moitie gauche de 1'Ence- 
phale coincidant avec 1'Oubli des Signes 
de la Pensee."1 The paper of M. Dax 
appears to have attracted little notice, 
and it was not until nearly thirty years 
had elapsed that M. Broca produced his 
celebrated paper,2 in which he announced 
his conclusion that the seat of the faculty 
of articulate language was in the second, 
and especially in the third frontal convo- 
lution of the left anterior lobe of the brain. 
AI. Broca used the word aphemia to de- 
note the condition of patients thus af- 
fected ; M. Trousseau the word aphasia. 
The last step in this history, and one al- 
most equal in importance to either that 
had preceded it, was taken by Dr. Ilugh- 
lings Jackson, who arrived independently 
at a conclusion similar to that of MM. 
Dax and Broca, but who went still fur- 
ther than either, and showed the anatom- 
ical nature of the lesion which most fre- 
quently caused aphasia, viz., plugging of 
the middle cerebral artery on the left side 
by an embolus derived from valvular dis- 
ease of the heart.3 
Aphasia may be produced by numerous 
diseases of the brain, such, for example, 
as congestion, hemorrhage, or tumor-but 
the most frequent cause is that to which 
Dr. Jackson directed especial attention. 
Certain aphasic patients can write, while 
others fail to do so ; those who are capa- 
ble of the act occasionally write sense, 
frequently nonsense, but more frequently 
either unintelligible characters or distinct 
1 Gaz. Hebdomad. 28 Avril, 1865. 
2 Sur le Siege de la Faculty du Langage ar- 
ticuD, ant. cit. 
3 Loss of Speech, its Association with Val- 
vular Disease of the Heart, &c. &c.: Clinical 
Lectures and Reports, London Hospital, vol. 
i. p. 388. 
1 Sur le Si^ge de la Faculty du Langage ar- 
ticule; Bullet, de la Soc. Anat. 1861. 
2 Gaz. des Hdpitaux, 1864. 
8 Traits de l'Enc6phalite. 862 
SOFTENING OF THE BRAIN. 
but unconnected words. Those who can- 
not write at all are usually, it must be 
remembered, paralyzed on the right side. 
Certain patients are able to make intelli- 
gible signs, others fail to do so; some 
have the power to calculate, to draw fig- 
ures, and to perform on musical instru- 
ments, while others lose these faculties 
together with that of articulate language. 
The mental state of the patient varies 
greatly, from a condition of almost per- 
fect intelligence to that of almost com- 
plete fatuity. On several occasions the 
question has been raised whether an in- 
dividual in a condition of aphasia should 
be regarded as competent to make a will. 
No general principle can be laid down 
with regard to so complicated a question, 
but each case must be determined on its 
own merits ; still it must be remembered, 
■-1st, That while intelligence may remain 
intact, the power of expression may be 
so damaged that it is impossible for any 
one to be certain that he has correctly 
interpreted the patient's meaning. 2d, 
That the patient may be distinctly capa- 
ble of intellectual decision on matters up 
to a certain point of complexity, and 
quite incapable of dealing with those 
which are beyond that point ; that he 
may be able to decide some simple ques- 
tions, whereas he becomes bewildered 
when attempting to unravel those which 
require sustained thought for their com- 
prehension. 3d, That the facts which are 
most valuable as bearing on this question 
are very rare, and contradictory, viz. 
those which are supplied by patients who 
have been aphasic, have recovered, have 
remembered their previous mental con- 
dition, and have been able to give an ac- 
count of it.-On the one hand, there has 
been obvious mental obscurity; on the 
other, perfect clearness of intelligence, 
although, as in the case of Lordat, the 
memory for words was lost as well as the 
faculty for their expression.1 4th, That 
the balance of evidence is to the effect 
that the mind is usually somewhat dam- 
aged, although its degree of impairment 
may vary between wide ranges ; that the 
loss of speech in aphasia may coexist 
with loss of mental power, but that it 
does not depend upon it. A patient may 
be dumb because he has no idea to con- 
vey, but such a person is not aphasic ; he 
may have much to say, but be unable to 
find the words in which to express his 
thoughts,-such a patient is aphasic ; he 
may be quite clear in his thought, quite 
certain of his words, and able to write 
them with facility, but he cannot speak 
articulately, because he cannot make the 
sounds he wants,-such patient is not 
aphasic in the true sense of the word, but 
is paralyzed in either the tongue, lips, or 
palate, or in all of them together. 
The condition of aphasia has its ana- 
logues in locomotor ataxy, writer's cramp, 
and allied affections ; and similar physio- 
logical considerations will carry the ex- 
planation of these curious states to about 
the same level of precision. Talking, 
walking, and writing are each of them 
very complicated processes, and are, in 
man at least, the result of education. 
Artificial, as well as natural, associations 
of nerve-action are involved in each of 
them,1 and the result which ought to 
come from such co-ordination may be 
stopped at any point. We cannot yet 
assert what is the primary loss in the con- 
dition of ataxy, or in that of writer's 
cramp, neither can we do so with any ac- 
curacy in regard of aphasia. In each of 
them desire, volition, and intelligence 
may coexist with entire muscular ca- 
pacity ; and yet the patient who -wishes, 
tries, and knows how to walk, to talk, or 
to write, and -who, moreover, has full 
power in his legs, his arms, and his appa- 
ratus for articulation, is unable to accom- 
plish his purpose : he staggers and falls 
in the one instance, he makes illegible 
scrawlings in the second, and meaningless 
sounds or unintelligible jumbles of words 
in the last. 
The limbs are almost invariably para- 
lyzed when there is Softening of the 
Brain, sometimes on both sides of the 
body, but with far greater frequency on 
one side. The paralysis is usually not 
absolute : it is more marked in the upper 
than in the lower extremity ; it is seen to 
its highest degree in the fingers or toes, 
to its lowest degree in the shoulder or 
hip, and with intermediate severity in 
the forearm and leg. There is commonly 
some spasmodic contraction of the mus- 
cles which are paralyzed, and this may 
take the form of either tonic rigidity, or 
of occasional clonic, or even choreic move- 
ments. Sometimes the muscles are rigid 
at the very moment of the apoplectic 
seizure, but more commonly the reverse 
is observed-there is complete flaccidity 
-and not until after three or four hours is 
the stiffness of limb to be recognized. At 
first it is noticed only after repeated flexion 
and extension of a joint; subsequently it 
is persistent, and is not developed but 
simply exaggerated by attempts at move- 
ment. This rigidity is distributed with 
irregularity, and is noticed principally in 
the shoulder, elbow, and knee-joints ; and 
in this respect it differs notably from 
what has been termed "-late rigidity,"2 
viz. that stiffness of limb which comes on 
1 Analyse de la Parole, &c., pour servir a 
1'Histoire de l'Alalie et de la Paralalie. Par 
le Prof. Lordat. Dictionnaire, ant. cit. p. 
632. 
1 See article, "Writer's Cramp." 
2 See Dr. Todd's Clinical Lectures. SYMPTOMS. 
863 
after paralysis has lasted for many weeks 
or months, and which is distributed like 
paralysis itself with prevailing frequency 
in the distal extremities of limbs, and 
undergoes a gradual diminution as the 
joints are tested, one by one, from below 
upwards. 
The electric irritability of muscles I 
have often found to be absolutely normal, 
even when paralysis is complete, and it 
has remained so for a considerable time ; 
its persistence or the reverse has not been 
determined by either the degree, dura- 
tion, or locality of the paralysis, by the 
presence or absence of rigidity or of 
wasting. The irritability of the para- 
lyzed muscles, as tested by percussion, 
has been found often in considerable ex- 
cess, and this when the electric contrac- 
tility has been normal. Let it be dis- 
tinctly understood that I am not now 
speaking of the force of muscular contrac- 
tion, winch is invariably, or almost in- 
variably, diminished in a palsied limb, 
but of the readiness of response to elec- 
tricity, which is tested-not by the vehe- 
mence of contraction in a muscle, but- 
by the weakness of the electric power 
which will bring muscles into play. In 
this sense the palsied limb exhibits every 
condition of irritability, viz., the normal, 
excess, or diminution. It does not ap- 
pear to be of any moment in the diagnosis 
of cerebral softening from any other lesion 
in the brain, but it is well to bear in mind 
the facts that have been mentioned, inas- 
much as mistakes have sometimes arisen 
owing to a confusion of terms when the 
distinction is being made between cere- 
bral and spinal lesion or disease. 
There may be no general symptoms in 
cases of acute softening; at the time of 
seizure the patient may have been in 
apparently good health. As already stat- 
ed, however, this is not common. Usually 
the individual is "older than his years," 
as shown by aspect, manner, gait, prema- 
ture baldness or grayness of head ; he has 
been weak for some time, has been threat- 
ened with a "break-down somewhere;" 
has suffered from disease of heart or kid- 
ney ; exhibits arcus senilis, and has a 
rigid pulse.1 
Beyond these general states there is 
nothing to be noted; the patient may, 
and often does, vomit when the attack is 
beginning to clear away and some slight 
consciousness returns, but it is rare to 
meet with a repetition of the vomiting. 
The appetite often is quite good; the 
digestion, secretions, and evacuations, 
natural; the temperature, usually quite 
normal, is sometimes raised to a very high 
point, and in many cases is notably de- 
pressed in the affected limbs. When the 
temperature has been raised there has 
been considerable jactitation of the limbs, 
or convulsive movements, more or less 
general in their distribution. 
(6) The convulsive form of acute Soften- 
ing of the Brain is sometimes so distinct 
in its features that the case is more likely 
to be confounded with epilepsy than with 
hemorrhage or congestive apoplexy. After 
a few of the premonitory symptoms al- 
ready described (p. 857) the patient is 
taken in a fit, which passes through the 
ordinary phases of an epileptic attack; 
but the patient does not become profound- 
ly stupid or sleepy afterwards. He is, 
perhaps, restless, and a little loquacious, 
or he may be simply quiet, but " not quite 
himself," for a few minutes, an hour, or 
even longer, when a second seizure fol- 
lows, in its turn to be succeeded by a third, 
and so on ; each convulsion being followed 
by increasing stupor, and almost invari- 
ably by paralysis. 
Regarded closely, these facts are to be 
observed with respect to the history of 
the disease. The premonitory symptoms, 
although so slight as to have attracted 
little notice at the time of their occurrence, 
are found, when attention has been di- 
rected to them by the onset of convulsions, 
to have been highly significant of impend- 
ing evil. They consist generally in some 
marked change in the mental condition of 
the patient, such as peculiar drowsiness, 
listlessness, weariness, impatience, or 
some flaw in memory, with distinct but 
ease of the cerebral vessels. On post-mortem 
examination the diagnosis was verified ex- 
actly as to the nature and locality of the dis- 
ease ; but, strange to say, the brachial arte- 
ries, which were inspected carefully, presented, 
no unhealthy appearance, and exhibited 
their ordinary amount of elasticity when 
stretched between the fingers. The inference 
from this is important, viz.: that vessels may 
lose their elasticity during life, and that to 
such a degree as to form valuable guides in 
the diagnosis of disease, but yet there may 
be no atheromatous deposit, or other change 
in their physical appearance, which can be 
detected after death. The mode in which 
the function is performed during life is a bet- 
ter test of the physical capacity and condition 
of the organ than is the physical state of the 
dead artery when examined directly by the 
hand and by the eye. 
' In an interesting case recently under my 
care in University College Hospital, a man 
became suddenly hemiplegic and aphasic, and 
continued so until he died. There was dis- 
tinct evidence of old valvular disease of the 
heart, the radial arteries were hard and visi- 
ble, the brachial arteries when he bent his 
elbow stood out like twisted cords, the pulsa- 
tion of which was not only excessive and visi- 
ble, but distinctly locomotive; there was 
highly-marked arcus senilis; the man was 
old, bald, and gray. The inference drawn 
from these symptoms was that there was 
softening in and below the left corpus stri- 
atum, and that the softening was due to dis- SOFTENING OF THE BRAIN. 
864 
momentary incapacity to understand what 
is said. There may be, however, some 
little hesitancy in speech, the mispronun- 
ciation of a few words, a little weakness 
of one side, or some vague feeling of ma- 
laise, with numbness of extremities, ver- 
tigo, or faintness, thought to be cither 
hysteric or dyspeptic in their origin, until 
the lit occurs and demonstrates the gravity 
of their ^meaning. The convulsions, al- 
though resembling epileptic convulsions 
in the main, differ from .them in certain 
particulars, viz. :-The tonic stage is but 
feebly marked, and there is not much 
asphyxia. Clonic spasms are more violent 
on one side of the body than on the other, 
and they continue for a long time. The 
patient does not "come out of the fits," 
but passes from one into another with no 
distinct intervening period of quiescence. 
Tiie fits occur in increasingly rapid succes- 
sion, and at length the patient can scarcely 
be said to be either "in the fit" or "out 
of it. " He lies in a semi-comatose condi- 
tion, occasionally muttering, and making 
movements which appear to be voluntary, 
but which are interrupted by spasmodic 
jerkings, by suspension of the breathing, 
or by momentary tetanic rigidity. Grad- 
ually the limbs on one side cease 'to ex- 
hibit voluntary movement - they fall 
heavily when allowed to do so ; the eye- 
balls are often directed to one side, and 
the features lose their symmetry; and 
thus the case goes on until it passes from 
a convulsive into an "apoplectic" or 
paralytic form. The patient who was 
" taken in a fit," thought to be epileptic 
or dyspeptic, becomes distinctly hemi- 
plegic, and the true nature of the case is 
recognized. 
From this condition there may be par- 
tial restoration; after a few days of mark- 
ed disturbance, intelligence returns up to 
a point varying through wide ranges, and 
the state of the patient may be that de- 
scribed in the previous section (see page 
858). The convulsions, however, sooner 
or later, recur ; either to be again recov- 
ered from, or to carry the patient beyond 
the reach of hope. The intervals between 
the attacks of convulsions may be either 
weeks or months ; but in many cases the 
course is much more rapid, and the pa- 
tient dies within twenty-four or forty-eight 
hours from the onset of the fits. 
(c) The form marked by delirium has 
usually been preceded by distinct premon- 
itory symptoms, and it is most commonly 
observed at advanced age. The patient 
suddenly "wanders" in his talk, becomes 
loquacious or restless, is busy in manner, 
exerts himself, seems tired, and falls 
asleep. He wakes up, somewhat con- 
fused, but appears "to be himself again" 
for a few days, or even weeks, when the 
confusion and delirium reappear, and are 
more persistent. There is no complete 
restoration, but gradually one side is 
found to be paralyzed, or to be slightly 
weaker than the other. The delirium al- 
ternates with coma, more or less profound; 
and the patient passes into a state like 
that following either the apoplectic or the 
convulsive form. 
The delirium, usually mild, is some- 
times violent; but when it is so there is 
generally some distinct meningitis, and 
the case runs a rapid course, reaching its 
termination in a few days. 
3. The final symptoms of softening, like 
the prodromata, are similar in their cha- 
racter whatever the form in which the 
attack takes place. The patient becomes 
more and more comatose, the paralysis 
extends to the sphincters, the respiration 
becomes embarrassed, and death follows, 
usually "without a struggle." Nothing 
is more gradual or more tranquil than the 
mode in which the sleep of such patients 
often deepens, almost imperceptibly, into 
the sleep of death. 
A peculiar form of softening has been 
described by M. Buparcque, as occurring 
in children of precocious intelligence, the 
symptoms of this condition being the fol- 
lowing :-headache with drowsiness, per- 
fect integrity of the mind, exaltation of 
the special senses and of general sensibil- 
ity, without fever, delirium, or convul- 
sions. After death the only change which 
has been discovered has been Softening of 
the Brain. M. Duparcque denominates 
this disease " ramollissemcnt blanc aigu 
essenticl chez les enfants."1 
Chronic Softening of the Brain. 
The symptoms of this condition may 
follow an "apoplectic seizure," whether 
the latter has had for its anatomical basis 
congestion, hemorrhage, or acute ramol- 
lissement. They may, on the other hand, 
be developed very slowly and insidiously, 
and may, or may not, be preceded by those 
phenomena already described as "pre- 
monitory" of acute softening. 
There is diminution of intelligence. The 
patient is unable to pay attention, and 
consequently fails to receive new ideas. 
Subsequently memory is impaired, past 
ideas are not recalled with readiness, and 
there is general confusion and incoherence. 
Sometimes there is mild delirium, or mere- 
ly a restless and excited manner, towards 
the evening of the day, or in the night; 
occasionally there is the monotonous repe- 
tition of a particular word or act, which 
may continue for hours, days, or even 
weeks. 
In regard of emotion, the majority ex- 
1 Archives generates de MMecine, F6v. 
1852; quoted by M. Valleix, Guide de la 
Mel. prat., tom. 2me, p. 176. PATHOLOGY. 
865 
hibit dulness, or some degree of melan- 
choly ; and it is not uncommon to find 
that the expression of feeling is very little 
under control, and the sufferer is said to 
have become "hysterical;" and this is 
often the earliest indication of failing 
power. (See article on "Hysteria.") In 
other cases laughing and crying are very 
common ; but they occur without assign- 
able cause, and without the apparent ex- 
istence of any correspondent emotion. 
The intellectual weakness increases, and 
the patient becomes drowsy. At first he 
may be aroused, but subsequently there 
is profound coma, and the patient dies 
comatose. In rare cases, however, the 
intellect may be preserved throughout. 
The gradual failure, one by one, of the 
intellectual faculties is, per se, one of the 
most characteristic symptoms; and the 
peculiar monotony (of word or action) has 
led Durand-Fardel to a diagnosis in some 
obscure cases. 
The most common alteration of sensi- 
bility is cephalalgia. It exists in about 
half the cases, and is felt generally among 
the earlier symptoms; but sometimes it 
does not commence until an advanced 
period, and it generally disappears to- 
wards the close of life. Its intensity is 
highly variable, rarely so great as that of 
meningitis, or a fortiori of tumor ; its 
locality is frontal in the majority, and it 
is not often confined to one side of the 
head. When pain is not present there is 
generally a sense of weight and confusion 
of head ; and, as I have observed in many 
cases, such a peculiar sensation that the 
patient says he fears his " mind is going." 
Painful sensations are often present in the 
limbs; and they are sometimes referred 
to the surface, sometimes to the muscles, 
and in other cases to the articulations. 
These modifications assume the form of 
so-called hyperesthesia, cutaneous and 
muscular; or of numbness, formication, 
&c. They are commonly limited in ex- 
tent to the parts presenting motorial 
changes ; and when this is the case, they 
are highly characteristic. 
Diminution of sensibility is common, 
but anesthesia is rare ; and, in respect of 
the former, it usually exists in conjunc- 
tion with paralysis. These changes are 
gradual and imperfect in their develop- 
ment ; and it is uncommon to find com- 
plete anesthesia of the special senses. 
Unless an apoplectiform attack has 
taken place, the muscles rarely exhibit 
any sudden changes; but when such a 
seizure has occurred, there may be com- 
plete hemiplegia; the face, articulation, 
the tongue, and the limbs of one side be- 
ing involved in paralysis. 
Paralysis in the typical form of chronic 
softening is distributed generally, and 
developed gradually; weakness of the 
muscles preceding their complete removal 
from volitional control. Hemiplegia is 
the most common form that is observed 
when chronic softening has an abrupt 
commencement, but it is followed, in many 
cases, by general paralysis, incomplete in 
degree ; and this is important as a dis- 
tinction from the persistent paralysis of 
hemorrhage. At first, one leg drags in 
walking, or one hand feels less strong 
than the other, and grasps less firmly. 
The diminution progresses in an inter- 
mittent course; complete paralysis lasting 
sometimes for a few minutes or hours, and 
then the power returning to a certain de- 
gree, and for a longer or shorter time; 
but general weakness is found outside the 
range of limited paralysis. The motorial 
changes may, however, be limited to par- 
ticular groups of muscles ; for example, 
those of the face, of speech, of one arm, 
&c. Spasm, of tonic character, exists 
with great frequency, and may be found 
in the paralyzed or non-paralyzed side, 
though much more commonly in the 
former. The rigidity increases gradually, 
and persists till within a few days of death, 
when it usually disappears altogether. 
Tremors or epileptoid convulsions may 
alternate with, or take the place of, tonic 
spasm ; or there may be local clonic con- 
tractions, and the muscles may be unduly 
sensitive to percussion. General paralysis 
usually occurs for some days or hours be- 
fore death; and then stertor, involuntary 
micturition, and universal flaccidity are 
present. 
Pathology.-Since the year 1820 Soft- 
ening of the Brain has received consider- 
able attention from pathologists, and 
more especially from those of the French 
school. Previous to this time, it is true, 
such a pathological condition had been 
recognized and reported by several ob- 
servers, and among them by Morgagni ;l 
but their accounts are meagre and unim- 
portant, so that for the first real descrip- 
tion of the disease we have to refer to the 
works of Lallemand2 and Rostan.3 The 
first of these writers looked upon all soft- 
enings of the brain as of an inflammatory 
nature, and there can be little doubt that 
many of the cases he described were really 
instances of cerebritis of traumatic origin, 
associated with inflammation of the menin- 
ges ; whilst Rostan, whose observations 
were made upon people of an advanced 
age at the Salpetriere, thought these affec- 
tions were sometimes inflammatory, and 
sometimes not. The latter, also, first 
called attention to the fact of the frequent 
association of softenings of the brain with 
1 De Sedibus et Cans. Morb. t. v., Epist. v. 
ix. Ivii. 
2 Rech. Anat. Path, sur 1'Enc^ph. Ire lettre, 
1820. 
3 Rech, sur le Ramolliss. du Cerveau. 1820. 
vol. i.-55 866 
SOFTENING OF THE BRAIN. 
calcification of the arteries in old people. 
Since this time the opinions entertained 
by different writers as to the nature of 
softenings of the brain have been various, 
though for the most part they may be 
ranged under two principal categories, 
since the subject which has always been 
most in dispute (and which cannot now 
be said to be entirely settled) has been, 
whether we are to regard these affections 
as inflammatory or non-inflammatory in 
their origin. The great though pardon- 
able error of the earlier pathologists was, 
that they looked upon Softening of the 
Brain as a single substantive disease, in- 
stead of regarding it, as we now do, as 
the pathological sequence of various more 
or less different conditions. And, as we 
shall hope to show, much of the difference 
of opinion amongst later pathologists has 
been engendered and propagated because 
they have looked at various kinds of Soft- 
ening of the Brain too much from the 
mere point of view of morbid anatomy. 
Thus some have attached an undue im- 
portance to certain appearances the real 
nature and value of which could only be 
rightly estimated by a consideration of 
the pathology and mode of origin of the 
lesions in question. 
Before dwelling upon this point further, 
I will briefly indicate the nature of the 
principal fluctuations of opinion amongst 
successive writers on this subject, whose 
works have followed those of Lallemand 
and Rostan. 
Cruveilhier1 held that certain forms of 
softening were of an inflammatory nature, 
but that certain others were not, these 
latter being supposed to be more allied to 
softenings of the stomach and intestines. 
Uis "ramollissement apoplectique," or 
"apoplexie capillaire," as he afterwards 
termed it (answering to some of the forms 
of red softening), he did not regard as in- 
flammatory in nature, but he thought 
that this condition passed by almost in- 
sensible gradations into one of ordinary 
apoplexy. Bouillaud2 at first proclaimed, 
the inflammatory nature of softenings of 
the brain, though afterwards3 he acknow- 
ledged the difficulty of the question and 
the desirability of further investigation on 
the subject. Andral4 rejected the inflam- 
matory doctrine. Ue spoke of obliteration 
of arteries and poverty of the blood as 
probable causes, but he also regarded the 
state of softening as due to a special alter- 
ation of nutrition which might supervene 
under the influence of the most different 
conditions. Abercrombie1 looked upon 
softening as a species of gangrene, but 
spoke of two forms, one of which was 
essentially inflammatory in its origin, 
whilst the other-principally met with in 
old people-was due to disease and ob- 
struction of the cerebral arteries. Much 
the same views were entertained by Cars- 
well2 and Copland ;3 and others afterwards 
insisted, as Abercrombie had done, upon 
the importance of obliteration of the arte- 
ries in connection with Softening of the 
Brain. Amongst the earlier of these 
maybe mentioned Bright,4Crisp,5Piorry,6 
Gely,7 Gueneau de Mussy,8 and Bou- 
chut.9 But there appeared in France, 
almost at the same time, two of the most 
decided advocates of the inflammatory 
nature of Softening of the Brain, namely, 
Gluge,10 who founded his theory upon the 
supposed nature of certain granular cor- 
puscles or cells, to which we shall subse- 
quently have to refer, and Durand- 
Fardel.11 Those who had already called 
attention to arterial obstruction as a cause 
of cerebral softening referred to coagula- 
tions occurring in the vessels themselves, 
but Virchow, in his first memoir upon 
embolism,12 opened up a fruitful and en- 
tirely new field for inquiries into the 
pathogeny of Softening of the Brain, 
which has since attracted the attention of 
many investigators, whose labors have 
yielded the most important results. 
Amongst others who have contributed to 
elucidate this aspect of the question, I 
may mention Kirkes,13 Fritz,14 Schutzen- 
berger,15 Oppolzer,16 Cohn,17 Lancereaux,18 
1 Path, and Prac. Research on Diseases of 
the Brain and Spinal Cord. 3d ed. 1836, p. 
22. 
2 Path. Anat., Art. "Softening," and Cy- 
clop. of Pract. Med. vol. iv. 
3 Diet, of Pract. Med. 
4 Guy's Hosp. Rep. No. 1. 
8 Lancet, 1840. Cases of Cerebral Disease. 
6 Bulletin Clinique. 
f Gazette Medicale, 1838. 
8 Archiv. gen. de M^d. Ire Serie, t. xxvi. 
p. 559. 
9 Actes de la Soc. des Hopitaux, 1850, t. i. 
p. 43. 
10 Comptes Rendus, 1837, et Archiv. de 
M6d. Beiges, 1840. 
11 Traits du Ramollissement, 1843, et Malad. 
des Vieillards. Paris, 1854. 
12 Archiv fur Anat. Und Physiolog. 1847. 
13 Med. Chir. Transact, vol. xxxv. p. 281. 
14 Gazette Hebdom. 1857. 
18 Gaz. M6d. de Strasbourg, 1857, p. 50. 
18 Wien. Med. Wochensch. 1859 and 1860 
17 Klinik der Embol. Gefasskrank. Berlin, 
1860. 
18 De la Throb, et de 1'Emb. Cereb. Paris, 
1862. 
1 Introd, it PEtude de la Medecine pratique 
(1821) let cahier, p. 112.-Anat. Patholog.- 
Diet, de Med. et de Chir. prat., Art. "Apo- 
plexie." 
2 Traits de PEnc6phalite, 1825. 
3 Diet, de Med. et de Chir. prat. t. xv. p. 
793. 
4 Prdcis d'Anat. Path. 1829, and Clinique 
Medicate, transl. by Spillan, 1836, p. 160. PATHOLOGY 
867 
and Hughlings Jackson of special im- 
portance also are the experimental inves- 
tigations of MM. Prevost and Cotard.2 
Reference may, moreover, be made to the 
work of Lancereaux for further historical 
information, and to the recent volumes of 
the "Transactions of the Pathological 
Society of London" for numerous cases 
recorded by English pathologists. 
In spite, however, of the light thrown 
upon the pathology of the disease by the 
recognition of the frequency of its associa- 
tion with embolism of the cerebral arteries, 
Durand-Fardel,3 in 1854, again described 
the various softenings of the brain as in- 
flammatory affections; and a few years 
later this view received the support of 
Calmeil.4 Rokitansky5-as the repre- 
sentative of the Vienna school-also pro- 
nounced in favor of the inflammatory 
nature of red softenings ; and amongst 
British Pathologists there are some who 
still look upon various forms of Softening 
of the Brain as inflammatory, principally 
from the fact of the occurrence, in the 
softened tissue, of Gluge's granule cells, 
which are erroneously supposed to be pro- 
duced only by a process of inflammation. 
The latest French writers, however, seem 
almost entirely agreed as to the non- 
inflammatory nature of the great majority 
of cerebral softenings, as may be seen by 
reference to the works of Lancereaux,6 
Laborde,7 and Proust,8 and to the me- 
moirs of Bouchard,9 and of MM. Prevost 
and Cotard.10 
The acute course run by many soften- 
ings of the brain, and the red and swollen 
appearance of the part after death, appear 
at first sight to lend support to the doc- 
trine of their inflammatory origin, though, 
after recent inquiries into the effects of 
obstruction to the circulation in different 
parts of the encephalon, it will be found 
that we shall have no difficulty in other- 
wise accounting for these phenomena. It 
seems impossible now, moreover, to look 
upon the large granule corpuscles, or so- 
called "compound inflammation globules" 
of Gluge, as products of inflammation 
only. These bodies are constantly pre- 
sent in all but the most recent patches of 
softening, and it seems to have been the 
tolerably wide acceptance of Gluge's 
opinion as to their origin, that has kept 
up the doctrine of the inflammatory nature 
of cerebral ramollissement. In their most 
topical form these bodies present them- 
selves as large, spherical, or somewhat 
elongated aggregations of minute gran- 
ules, generally about in diameter, 
though they may vary from to 
in diameter. They may be surrounded 
Fig. 50. 
by a delicate cell-wall, or this may be no 
longer visible. Occasionally a clear space, 
indicative of a nucleus, may be detected 
in their interior. From the fact that 
bodies in every way similar have been 
found by Turek,1 Bouchard,2 myself,3 and 
others in secondary atrophic degenerations 
of the spinal cord, in which there is a 
simple process of wasting and not the 
slightest suspicion of the existence of an 
inflammatory process, there is the strong- 
est evidence in favor of the opinion of 
Virchow, Robin, and other histologists, 
that these bodies result from the degene- 
rations of pre-existing cells by the accu- 
mulations of fat and protein granules in 
their interior. They are, according to 
Virchow, produced from the cells of the 
neuroglia,4 or connective tissue of the 
brain: and on this supposition we may 
easily account for the presence of granule 
corpuscles in the midst of the white sub- 
stance of the brain, where formerly no 
cells were thought to exist. When these 
connective-tissue elements undergo the 
fatty and granular degeneration, they ap- 
pear greatly to enlarge in size, the cell- 
wall becomes progressively thinner till it 
at last disappears, and ultimately the 
spherical aggregation breaks down into a 
mass of granular debris. It is thought 
also, by some, that granule corpuscles may 
originate in part by the aggregation of 
molecules originally separate, such as are 
always plentiful in tissues undergoing de- 
generation ; and by others that they may 
arise from the granular and fatty degene- 
1 Lond. Hosp. Reports, vol. i. 
2 Recherches phys. et path, sur le Ramol- 
liss. c^r^brale. Gaz. Med. de Paris, 1866. 
3 Loc. cit. 
4 Malad. Inflammat. du Cerveau. Paris, 
1859. 
6 Path. Anat. (Syd. Soc.) vol. iii. 1850. 
6 Loc. cit. 
7 Le Ramolliss. et la Congest, du Cerveau. 
Paris, 1866. 
8 Des diff. Formes de Ramolliss. du Cer- 
veau. Paris, 1866. 
8 Archiv. gener. de Med., Mars, 1866. 
10 Loc. cit. 
i Compt. Rend. Acad, des Sc. de Vienne, 
Mars, 1857. 
2 Archiv. g6n. de M6d., 1866, p. 281. 
3 "On a Case of Concussion-lesion of the 
Spinal Cord, with extensive ascending and 
descending secondary degenerations." Med.- 
Chirurg. Trans. 1867. 
4 "Myelocytes" of Robin. 868 
SOFTENING OF THE BRAIN. 
ration of the drops *f my eline set free 
from the nerve fibres in softening nerve 
tissue. It must, however, be very diffi- 
cult to substantiate either of these modes 
of origin. 
The extreme vascularity of the brain, 
and its naturally soft consistence, must be 
taken into consideration if we wish to un- 
derstand how it is that diminution in the 
nutrition of any of its parts, and the de- 
generation which is its accompaniment, 
should lead to such marked alterations in 
consistence as are met with in cerebral 
softenings. Bearing these peculiarities in 
mind, however, the lowering of nutrition 
from vascular obstruction, with its conse- 
quent effusion of serum, together with the 
degeneration subsequently taking place, 
seems adequate to explain all the degrees 
of ramollissement which exist during life. 
Theoretically we should be compelled to 
admit that Softening of the Brain might 
be brought about by (1) an improper state 
of the nutritive fluid or blood ; (2) by a 
want of due activity in the elements of 
the tissues themselves ; and (3) by an im- 
pediment to the proper circulation of the 
blood. As matter of fact, however, we 
can say nothing positive concerning the 
first cause, as to whether it is capable 
alone of producing a condition of cerebral 
ramollissement. It can probably be 
looked upon only as a predisposing cause, 
under the influence of which softenings 
might occur, in cases where there was a 
concurrent action of even slight deter- 
mining causes. Where the vitality of the 
tissues has been lowered in anaemic and 
cachectic states of the system, such as 
we meet with in patients suffering from 
cancer, we can easily imagine that this 
poverty of blood would be a powerful pre- 
disposing cause, though we must also take 
into account the fact that these states of 
the system also tend to produce some of 
those changes in the vessels which are so 
frequently instrumental in bringing about 
Softening of the Brain. We can say little, 
also, that is definite as regards the influ- 
ence of the second cause, though a primary 
fatty degeneration of the nerve elements 
leading to one form of softening has been 
described by Dr. Hughes Bennett.1 A 
proper activity of the elements of the tis- 
sues themselves is certainly one essential 
in healthy nutrition, and io its gradual 
failure we may perhaps attribute the oc- 
currence of many of the pathological 
changes characteristic of old age. Doubt- 
less, both alterations in quality of blood, 
and diminished nutritive activity of tissue 
elements, may be looked upon as accessory 
causes of no unfrequent occurrence in the 
production of cerebral softening, especi- 
ally in old people. But undoubtedly the 
most frequent causes of Softening of the 
Brain, at all ages, are to be looked for 
under the third head, which includes all 
the varieties of impediment to the circula- 
tion of the blood. These may be classified 
in the following manner :- 
Arteries 
Embolism. 
Thrombosis. 
Morbid conditions of 
cerebral vessels 
Obstructing circulation 
Capillaries . . Embolism. 
Veins and sinuses Thrombosis. 
Diseases of coats of 
capillaries and 
small arteries. 
Preventing osmosis and nutritive exudation 
1. Obstruction of Arteries. a. Embolism. 
-The fibrinous masses of which emboli 
are composed have their origin for the 
most part in the left cavities of the heart 
and in the arch of the aorta, though more 
rarely they may proceed from the pulmo- 
nary veins. They may consist of portions 
of the fibrinous vegetations which are 
often met with on the mitral or aortic 
valves, as the result of endocarditis or 
atheroma, or of portions of those fibrinous 
depositions that are apt to form on the 
rough edges of atheromatous and calcare- 
ous patches of the arch of the aorta when 
these are not situated beyond the origin 
of the cerebral vessels; whilst at other 
times they may be constituted by de- 
tached portions of old clots which have 
been formed in the left auricle-or even 
in the left ventricle in cases where there 
has been a retardation of the force of the 
blood current, either owing to fatty de- 
generation alone or in combination with 
extreme dilatation of the heart. Vir- 
chow believes that cerebral emboli may 
proceed also from clots formed in the pul- 
monary veins ; and it seems possible that 
small cancerous masses, swept away by 
the pulmonary veins in cases of carcinoma 
of the lungs, may occasionally go to form 
cerebral emboli, since in two instances 
small cancerous fragments have been 
found in the healthy heart and aorta- 
once by Lancereaux,2 and once by Vidal.3 
b. Thrombosis.-The various causes of 
thrombosis have been so well put by MM. 
Prevost and Cotard,4 that we cannot do 
better than follow their arrangement. 
(1) Pathological changes taking place 
in the walls of the arteries, by which 
their calibre is often much narrowed, and 
1 Clinical Lectures. Fourth ed. p. 355. 
2 Bulletin de la Soc. Anatomique, 1858. 
3 Comp, rendu de la Soc. de Biologie, 1861. 
4 Gaz. Med. de Paris, Mai 19, 1866, p. 336. PATHOLOGY. 
869 
their lining membrane roughened, are 
conditions most favorable for the occur- 
rence of thrombosis. Changes of this 
kind, whether atheromatous or other, 
directly favor local coagulation. 
(2) Retardation of the rapidity of the 
circulation also predisposes to coagula- 
tion of the blood in situations where other 
conditions favorable to its occurrence are 
present. This retardation may be brought 
about by: a. Diseases which weaken the 
force of the heart, such as dilatation with- 
out proportionate hypertrophy ; and also, 
more especially, fatty degeneration of this 
organ, b. Narrowing of the calibre of 
arteries from atheromatous and other de- 
generations diminishes the rapidity of 
the circulation in these parts, and so pre- 
disposes to local coagulation, indepen- 
dently of the roughened surface with 
which the narrowing is usually associated, 
c. The loss of elasticity in the arterial 
walls, as a result of their degeneration, 
also assists in bringing about a retarda- 
tion, since M. Marey has shown* that the 
elasticity of the arteries increases the 
rapidity of the blood current. 
(3) And lastly, there are certain special 
states of the blood which seem to predis- 
pose towards the formation of arterial 
and venous thrombosis - sometimes so 
strongly as to bring this about even with- 
out an actual diseased condition of the 
vessels. This tendency is most marked 
in the cachectic states of the system be- 
fore alluded to, and it is said to exist 
more especially in those cases in which 
the cancerous diathesis is well marked. 
Here, however, it seems probable, that 
the feebly acting, and perhaps degenerated 
heart, may be almost as instrumental in 
bringing about the coagulation, as any 
special alterations in the nature of the 
blood itself. There would be a conjoint 
action of these two predisposing causes. 
All the conditions predisposing to 
thrombosis not unfrequently coexist in 
many old people, and this fact harmonizes 
well with the extreme frequency with 
which softenings of the brain, not due to 
emboli, are also met with in the same 
subjects. Any of the Cerebral arteries 
may become the seat of degeneration in 
old age, so that thrombosis, and soften- 
ings due to this cause, may be met with 
in the most various regions of the brain. 
But the middle cerebral arteries are those 
which seem more especially liable to em- 
bolic occlusion, and, according to some 
observers, that on the left side is more 
frequently occluded than its fellow on the 
right. There still seems to be some 
doubt, however, as regards this latter 
point. Thus, in forty-four cases collected 
by Lancereaux,2 although the left internal 
carotid and its branches were occluded 
fourteen times, and the right only twice, 
the left middle cerebral artery was affected 
twelve times, and the right twelve times ; 
some arteries of the pia mater near the 
left cerebral peduncle once ; and the basi- 
lar artery and its branches three times. 
In eighteen cases reported by MM. Pre- 
vost and Cotard,1 the same frequency of 
occlusion of the middle cerebral arteries 
was found, though the numbers are higher 
for the right than for the left side. Thus, 
the right middle cerebral was occluded 
seven times, and the left three times ; the 
right anterior cerebral twice, and the left 
twice; the basilar artery once ; the right 
internal carotid twice, and the left once. 
It should be mentioned also, that in the 
experiments of MM. Prevost and Cotard, 
in which they injected tobacco seeds into 
the carotid arteries of dogs, it was almost 
always found that the Silvian or middle 
cerebral arteries were more especially oc- 
cluded. In the statistics of thirty-two 
cases reported by Meissner,2 the situations 
are found to be somewhat different. Thus, 
the most frequent seats of obliteration 
were ascertained to be at the termination 
of the carotids. The obstruction was met 
with in this situation seven times in one 
of these arteries only, and twice in both 
at the same time. Next in order of fre- 
quency stood the posterior cerebral artery, 
in which the obstruction was met with 
eight times; then came the Silvian ar- 
tery, seven times ; the basilar artery four 
times ; whilst in the vertebral it occurred 
once in one artery, and once in both; and 
in the artery of the corpus callosum 
twice. 
In almost every case where Softening of 
the Brain is associated with thrombosis 
or embolism of the cerebral arteries, it is 
found that the obliteration exists in one 
of the branches beyond the circle of Wil- 
lis,3 even though obliteration of the parent 
1 Loc. cit. p. 19. 
2 Zur Lehre von der Thrombose und Em- 
bolie. Schmidt's Jahrbuch, 1861, No. 1, p. 
89. 
3 On this subject Dr. Kirkes wrote: "Al- 
though by the arrangement of the vessels 
composing the circle of Willis ample provision 
is made against obstruction ensuing in any 
of the main arterial channels on either side 
previous to their arrival at the circle, there is 
comparatively little provision for an obstruc- 
tion ensuing in any of the main branches 
into which this arterial circle breaks up. 
This remark applies chiefly to the middle 
cerebral artery, which, if plugged at its ori- 
gin, becomes at once altogether useless as a 
bloodvessel, for nearly all its divisions, espe- 
cially those for the central parts of the brain, 
proceed to their several destinations without 
receiving any anastomosing branch from the 
other divisions of the circle of Willis."- 
Med.-Chir. Trans., 1852. 
1 Physiolog. Med. de la Circ. Paris, 1863. 
2 Loc. cit. Mai 19, 1866, p. 337. 870 
SOFTENING OF THE BRAIN. 
trunk also exists at some point before it 
gives off the branches for this anastomosis. 
Obliteration of the trunk of the carotid 
alone is not sufficient, under ordinary cir- 
cumstances, to produce cerebral soften- 
ing, as may be seen from a resume by M. 
Ehrmann,1 of cases in which, the carotid 
arteries having been tied, the operation 
was followed by cerebral disturbance. 
The symptoms of cerebral mischief at 
first set up gradually disappeared when 
the circulation was re-established by 
means of the circle of Willis ; and where 
softening did actually occur, this was due 
either to the extension of a clot upwards, 
beyond the circle, into one of the cerebral 
arteries, or perhaps, as M. Ehrmann sug- 
gests, to some unusual distribution of the 
arteries themselves at the base of the 
brain, preventing the establishment of a 
collateral circulation, such as ordinarily 
takes place. 
The seat of the softening also corres- 
ponds with the anatomical distribution of 
the branch occluded, though the two are 
never coextensive. Usually the brain in 
the peripheral portions of the vascular 
department is healthy, owing to this por- 
tion of its tissue being nourished by the 
collateral capillary circulation, whilst the 
central portions of the vascular region are 
principally affected : thus, as Lancereaux 
points out, in cases of obliteration of the 
Silvian artery, softening of part of the 
corpus striatum and of the neighboring 
white substance is generally observed, 
whilst the gray matter of the convolu- 
tions as well as the walls of the ventricle 
are often intact. It has been suggested 
by Durand-Fardel that the obliteration of 
the arteries is secondary to the softening, 
and not the cause of it; but, in reply to 
this, it is only necessary to state that the 
actual seat of arterial occlusion is almost 
always outside the softened tissue, and in 
these cases, as well as in those in which 
there is obliteration of the arteries within 
the softened patch itself, an examination 
of the vessels will either show degenerated 
and roughened walls together with the 
presence of an adherent clot within, or 
else it will establish the existence of a 
small obstructing mass, differing from re- 
cent fibrine in composition and appear- 
ance, and unattached to the walls of the 
vessels. 
2. Obstruction of Capillaries.--In certain 
cases, by the rupture of old clots of the 
heart having softened centres, or by rup- 
ture of the inner coat of the aorta over 
large softened atheromatous patches, a 
mass of granular debris is carried into the 
cerebral arteries, whilst, from the minute 
size of the particles of which it is com- 
posed, these penetrate to and block up the 
minute arteries and capillaries of the part. 
If the quantity of matter thus carried to 
the brain be considerable and widely dis- 
persed, death may rapidly follow before 
there is time for definite alterations of the 
cerebral tissue to take place, and owing 
to the extent of the capillary obliteration 
the brain, it is said, may present an anae- 
mic appearance. Such was frequently 
found to be the case by MM. Prevost 
and Cotard, when they injected fine lyco- 
podium powder into the carotid arteries 
of dogs. When a smaller number of ca- 
pillaries are obliterated, either by athero- 
matous matter, by small particles of 
fibrine, or by pigment granules,1 local 
patches of softening may be produced, 
having the usual characters of Softening 
of the Brain due to arterial obstruction. 
3. Obstruction of the Veins and Sinuses. 
-The general causes favorable to the 
production of thrombosis have already 
been mentioned. The cases of oblitera- 
tion of the cerebral veins and sinuses are 
in part due to some of these, though, 
just as frequently, they are the sequences 
of blows on the head, or of inflamma- 
tory conditions of the scalp and cranial 
bones. Indeed out of the seventy-four 
instances of thrombosis in the cerebral 
sinuses which have been recorded by 
Lancereaux,2and other observers, such as 
Tonnele,3 Rilliet and Barthez,4 Lebert,6 
Gerhard,6 and Von Dusch,7 thirty-nine 
are found to belong to this latter cate- 
gory. Amongst these, in no less than 
thirty cases it was due to caries of the 
bones of the skull; in so large a propor- 
tion as twenty-four of these cases it was 
the temporal bone that was affected as a 
result of otitis. [Dr. Lidell has given the 
history8 of 130 cases of cerebral thrombo- 
sis. Of these, 86 were inflammatory in 
origin, 38 marasmic or due to debilitative 
causes, and 6 traumatic. Among the in- 
flammatory cases, facial carbuncle was the 
most frequent cause. Otitis and erysip- 
elas preceded thrombosis in a few cases. 
-H.] Both the lateral sinuses are sel- 
dom implicated at the same time in these 
secondary thromboses, and the longitudi- 
nal sinuses are even more rarely affected 
from such a cause ; whereas in those cases 
in which the thrombosis proceeds from 
more general causes, such as alterations in 
the quality of the blood or slowness of cir- 
culation, its almost habitual seat is found 
1 Lancereaux, loc. cit. p. 106; Frerichs, 
Traite des Maladies du Foie, p. 264; and 
Charcot, Gaz. Hebdom. 1857, p. 659. 
2 Loc. cit. p. 116. 
3 Journ. Hebd. de Med. 1829, p. 337. 
4 Malad. des Enfants, t. i. p. 161, 1853. 
5 Virch. Archiv, Bd. ix. p. 381. 
6 Deutsche Klinik, 1857, No. 45. 
i New Syd. Soc. vol. xi. p. 81. 
[8 American Journal of Med. Sciences, Jan. 
and July, 1874.] 
1 Theses de Strasbourg, 1859. PATHOLOGY. 
871 
to be the superior longitudinal sinus, from 
which the thrombus frequently prolongs 
itself down to the torcular Herophili and 
then on each side into the lateral sinus. 
It is in this latter class of cases, moreover, 
that cerebral softenings are associated 
with the thrombosis. These are of a pe- 
culiar kind, consisting principally of a 
number of small patches of red softening, 
occupying chiefly the gray matter on the 
upper surface of the brain ; and they are 
often distributed symmetrically over both 
hemispheres. Occasionally, softening of 
a portion of brain tissue of considerable 
extent has been noted. Besides such pe- 
culiarities in the seat and distribution of 
the softened patches, we usually meet, in 
these cases, with serous effusion into the 
ventricles and beneath the arachnoid, or 
more rarely with an actual effusion of 
blood in these situations or into the sub- 
stance of the brain itself, together with 
many minute patches of hemorrhage in 
the gray matter, such as have been de- 
scribed by Cruveilhier under the name of 
" apoplexie capillaire " The actual com- 
bination of these conditions met with in 
individual cases depends upon the seat of 
the obstruction, the rapidity with which it 
is brought about, and the condition of the 
vessels themselves. In the secondary 
thromboses, on the other hand, there is 
often evidence of more or less circum- 
scribed inflammation of the meninges, 
although the cerebral softenings and ex- 
travasations of blood very rarely occur. 
This, according to Von Dusch, is owing to 
the fact that in these cases the thrombo- 
sis starts from the veins in communication 
with the inflamed spot, and reaches the 
sinus only after the collateral circulation 
has had time to establish itself, instead of 
forming at once in the sinus, and before a 
collateral circulation has been set up. 
4. Alterations in the walls of the Capilla- 
ries.-Fatty degeneration of the walls of 
the capillaries has been described by 
Hughes Bennett,1 Paget,2 Todd,3 Moos- 
herr,4 and Charles Robin.5 This altera- 
tion is most frequent in old age, and is 
said to be especially common in indi- 
viduals suffering from Bright's disease, or 
from other maladies producing a low 
cachectic state of the system. In some of 
these cases such changes may supervene 
at a much earlier period than is usual. 
It is thought that such changes may not 
only favor the occurrence of cerebral 
hemorrhage, but that they may also lead 
to softening when the changes are univer- 
sal and well marked in the capillaries of 
a certain area. Such degenerations of the 
walls of the capillaries must not however 
be confounded with the accumulation of 
fat granules and of granule corpuscles on 
the walls of capillaries1 which are situated 
in the midst of softened brain substance. 
The first state may possibly be a cause of 
softening, but the second condition is 
always a consequence of it.2 The obser- 
vations of Moosherr and Robin, more par- 
ticularly, have shown that a certain num- 
ber of fat particles may almost invariably 
be found within the sheaths of many of 
the small arteries and capillaries of the 
brain when this is quite healthy, and that, 
too, even in children. In many cases it is 
extremely difficult to discriminate be- 
tween small fat particles and calcareous 
granules3 in the walls of the capillaries, 
without submitting them to the action of 
dilute hydrochloric acid. This calcareous 
degeneration of the capillaries is more rare 
than the ordinary fatty degeneration, 
though when it exists in an extreme de- 
gree, it is also capable of giving rise to 
Softening of the Brain, as may be seen by 
the perusal of a remarkable case reported 
M. Delacour,4 in which the small arteries 
and capillaries were completely calcified. 
In these cases, as well as in those of fatty 
degeneration, the softening is brought 
about by a gradual diminution in the nu- 
trition of a portion of the brain, the capil- 
laries of which have been altered in struc- 
ture so as no longer to permit the osmosis 
of a quantity of blood plasma sufficient to 
maintain the ordinary balance of nutrition 
in the surrounding tissue, and to prevent 
it from undergoing processes of degenera- 
tion. 
In addition to the various softenings 
of the brain, which may be produced by 
the influence of some of the conditions 
already mentioned, and others of trauma- 
tic origin,which are mostly "red," owing 
to effusion and dissemination of blood, 
there are also secondary or consecutive 
forms of softening, which may be classi- 
fied under two heads, viz. : 1. Softenings 
set up around tumors and adventitious 
products generally, in the brain. 2. Atro- 
phic softening due to the separation of 
nerve fibres from their ganglionic com- 
munications. The first variety of second- 
ary softenings will be referred to elsewhere 
(Art. "Adventitious Products"). Those 
coming under the second head are by no 
1 Edin. Med. and Surg. Journ. 1842. 
2 Medical Gaz. 1849, and Surg. Pathol, 
(revised by Turner) 1863, p. 106. 
3 Clinical Lectures on Paralysis, &c. 1854. 
4 Ueber das Patholog. Verhalt, der Klein. 
Hirngef. Wurzburg, 1854. 
6 Compt. rend de la Soc. de Biolog. Paris, 
1855, p. 142. 
1 Wedl, Patholog. Histol. (Syd. Soc.) p. 
291, fig. 64. 
2 Billroth, Archiv der Heilkunde, Drit. 
Jahrgang, p. 47. 
3 Jenner, Med. Tinies and Gaz. January 31, 
1862. 
4 Gaz. des Hopitaux, 1850, p. 107; also 
Wilks, Journ. of Ment. Sc. vol. xi. p. 191. 872 
SOFTENING OF THE BRAIN. 
means frequent; the lesion resulting from 
the separation of a tract of nerve-fibres 
from their central ganglionic connections 
being usually a simple atrophy or slow 
wasting. Although the method of de- 
generation, in this condition and in soft- 
ening, has been proved to be identical, 
nevertheless actual cerebral softening does 
not usually occur, apparently because the 
atrophic change is brought about rather 
more slowly and without the occurrence 
of obstructions in the vessels of the part 
capable of producing oedema. Still, soft- 
enings from this cause have been met 
with. This kind of atrophic change was 
pointed out by Cruveilhier1 in the cerebral 
peduncles, the pons, and the medulla ob- 
longata, and since his time our knowledge 
of the process has been greatly advanced 
by the investigations of Turek,2 Waller,3 
Van der Kolk,4 Phillipeaux and Vulpian,6 
Gubler,6 and Bouchard.' Laborde8 has, 
moreover, quite recently stated that in 
cases where there is softening of the cor- 
pus striatum or of the optic thalamus, a 
similar process is also set up on the sur- 
face of the hemispheres in some related 
portion of the superficial gray matter of 
the convolutions. These softenings of the 
convolutional gray matter are stated to be 
always on the same side of the brain as 
the lesions in the central ganglia, and La- 
borde says be lias also ascertained that a 
relationship exists between the particular 
convolutions affected and the particular 
portions of the central ganglia which have 
been destroyed, so that where softening 
of the anterior portion of the corpus stria- 
tum or optic thalamus exists, the same 
process occurs on some portion of the an- 
terior convolutions; with destructions of 
the central portions, the middle convolu- 
tions are affected ; and with destructions 
of the posterior portions of either of the 
central ganglia, a corresponding change is 
set up in some of the posterior convolu- 
tions. Should future observations confirm 
the opinions of Laborde, these changes 
would seem to be related to the secondary 
atrophic degenerations, and would be 
most interesting in a physiological as well 
as a pathological point of view : it is well 
to mention, however, that MM. Vulpian 
and Charcot maintain9 that the coexist- 
ence of these peripheral and central 
lesions is a mere coincidence, and that 
there is no necessary association between 
them. 
Seat of Cerebral Softening.-Foci of soft- 
ening may be found in all parts of the 
brain, but they exist most frequently in 
tlic convolutions and most rarely in the 
cerebellum and in the pons Varolii. Du- 
rand-Fardel1 found, as the result of an 
analysis of his own observations com- 
bined with those of Rostan, Andral, Rai- 
kem, and Lallemand-yielding altogether 
eighty-six cases of "acute" softening- 
that the convolutions were affected fifty- 
nine times ; the corpus striatum and 
optic thalamus, either singly or combined, 
twenty-eight times; and the white sub- 
stance of the hemispheres alone, only nine 
times. Although the combined statistics 
yield this result, however, it does not 
agree with the experience of Rostan2 
alone, who says expressly that the corpora 
striata and the optic thaiami are the parts 
most frequently affected with softening, 
and that after them comes the central 
white substance of the hemispheres. La- 
borde says3 that the corpus striatum is 
affected nearly twice as frequently as the 
optic thalamus, since he has found the 
former softened forty-six times and the 
latter only twenty-four times. lie states 
also, that the change most frequently 
exists only on one side, and that it is rare 
for the two corpora striata to be affected 
at the same time without a corresponding 
change in one or other of the optic thai- 
ami. The two hemispheres are about 
equally liable to undergo such a process, 
though, as before indicated, the softenings 
of embolic origin seem to occur rather 
more frequently in the left hemisphere. 
The extent of the softened patch is ex- 
tremely variable : it may be found from 
the size of a pea up to such an extent 
that the whole of one lobe, or the greater 
part of one hemisphere even, may be so 
affected. 
Periods of Life at which Softening of the 
Brain is most frequent.-Durand-Fardel 
has attempted to show by a combination 
of his own cases with those of Rostan, 
Lallemand, Bouillaud, and Andral, that 
Softening of the Brain may be met with 
at all periods of life, and that it is by no 
means a malady peculiar to old age. La- 
borde,4 however, has subjected the same 
statistics to a more rigid scrutiny, and by 
eliminating various cases of inflammatory 
softening of traumatic origin, and others 
which have been improperly included 
from various causes, he has found that 
the very statistics made use of by Durand- 
1 Anat. Patholog. 
2 Comp. rend. Acad, des Sciences de Vienne, 
Mars, 1857. 
3 Nouv. Meth. Anat, pour 1'Investig. du 
Syst. nerv. (Lett, it l'Acad. des Sc. 1852.) 
4 New Syd. Soc. vol. xi. p. 129. 
s Mem. de la Soc. de Biolog. 1859, p. 343. 
6 Archiv. g6n. de Med. 1859, p. 31. 
* Ibid. Mars, 1866. 
8 Le Ramolliss. et la Congest, du Cerveau, 
Paris, 1866. 
9 Physiolog. g6n6r. et comp, du Syst. ner- 
veux, Paris, 1866, p. 653. 
1 Malad. des Vieillards, Paris, 1854, p. 68. 
2 Ramolliss. du Cerveau, Paris, 1823, p. 
161. 
3 Loc. cit. p. 72. 
1 Loc. cit. pp. 144-185. MORBID ANATOMY. 
873 
Fardel do show, if properly sifted, that 
the most undoubted relationships exist 
between non-inflammatory Softening of 
the Brain and old age. In a total of 
eighty-one cases, seventy-five of the indi- 
viduals were from sixty to seventy-five 
years of age, four from fifty to sixty, 
whilst only two individuals were between 
thirty and fifty years of age. It must not, 
however, be supposed that Softening of 
the Brain is so exclusively a disease of 
old age as these figures would represent, 
since softenings of embolic origin are now 
known frequently to occur in young adults 
and even in children; softenings from 
thrombosis, also, may and do occur occa- 
sionally in certain adults (at any age), 
who may be suffering from cachectic dis- 
eases. Still, degeneration of the cerebral 
arteries and the various other causes of 
thrombosis increase in frequency with in- 
creasing age; and so is it with non-in- 
flammatory softenings of the brain, to 
which these conditions are bound in such 
a close pathological relationship. 
Morbid Anatomy. Softenings of 
the brain present themselves under differ- 
ent forms according to their variations in 
seat, their age or duration, and other con- 
ditions ; and the common character of 
diminished consistence, which first at- 
tracted the attention of pathologists, is 
curiously enough the one least indicative 
of a morbid change that has taken place 
during life, since marked alterations of 
this kind may be induced post mortem. 
The tests employed by earlier patholo- 
gists, therefore, which were intended to 
establish this one fact of diminished con- 
sistence, namely, the effect of a gentle 
stream of water in washing away the soft- 
ened tissue, the impressions derived from 
the sense of touch, and the speedy round- 
ing of the angles which takes place in a 
portion of brain cut out from the softened 
portion, are useless for the purpose of de- 
monstrating that we have to do with a pa- 
thological process established during life. 
To'make sure of this we must take into 
account other characters afforded by the 
softened tissue, and have recourse to more 
delicate means of investigation, such as 
are afforded by the microscope and the 
specific gravity apparatus. 
The most notable differences of appear- 
ance in softenings of the brain are due to 
variations in color. The greatest variety 
of tints may be met with. In some cases 
the softened tissue has a dead white color; 
or it may be of a reddish hue, and may 
present all shades from a uniform pinkish 
tint, through different grades of red, up 
to a claret color; whilst, in other in- 
stances, various shades of yellow and even 
brown discoloration are met with. These 
colors may exist alone, or variously inter- 
mixed. But in spite of this apparent com- 
plexity, there are three principal kinds of 
"ramollissement"-known as the white, 
the red, and the yellow-under which heads 
it will be convenient for us to describe the 
various forms of Softening of the Brain. 
But in making this division it should be 
understood that we do not necessarily 
look upon these varieties as different 
stages of the same condition, as has been 
done by Durand-Fardel' and Lancereaux2 
-both of whom describe " ramollissement 
blanc" as the last or chronic condition of 
red softening. Lallemand also looked 
upon white softening as due to a purulent 
infiltration, though the absence of pus 
has been established again and again by 
later observations. On the other hand, 
MM. Hardy and Behier,3 as well as Ros- 
tan and Abercrombie, have pointed out 
that this kind of softening is often met 
with in old people, and more particularly 
in those who are weakened and feeble, 
which agrees well also with the observa- 
tions of M. Charcot, who has often met 
with white softening in old people afflicted 
with cancer at the Salpetriere.4 MM. 
Prevost and Cotard, moreover, admit the 
existence of a Softening of the Brain, 
white from the first; and this has also 
seemed to be the case in several instances 
which have fallen under our own notice. 
It would appear probable that white soft- 
ening is mostly due to a rather more 
chronic process than that which gives rise 
to the red, and that it is such as would 
exist if this change had been brought 
about by disease of the coats of the capil- 
laries, supplemented by general mal-nu- 
trition from poverty of blood. Prevost 
and Cotard5 suggest, also, that in some of 
those cases, where the softening seems to 
be associated with obliteration of vessels, 
the absence of redness may be due to the 
extent and nature of the arterial oblitera- 
tion being such as to prevent the collate- 
ral fluxion of blood into the vessels of the 
diseased part. In other cases they admit 
that the cause seems inexplicable. Red 
softening seems to be more particularly 
limited to cases in which there is arterial 
obstruction, or impediment on the venous 
side of the circulation; whilst there can 
be little doubt that many of the shades of 
yellow in softenings of the brain are due 
to alterations that have taken place in 
what was previously red softening, al- 
though Rokitansky has described a spe- 
cial kind of yellow softening having in- 
trinsic characters of its own. 
1. White Softening.-In this species of 
ramolissement, which occurs only in the 
white substance of the hemispheres, a 
1 Malad. des Vieillards, Paris, 1854, p. 72. 
2 Loc. cit. p. 20. 
3 Traitii de Pathol, int., Paris. 
4 Vide Proust, loc. cit. p. 49. 
0 Gaz. Med. de Paris, 1866, p. 207. 874 
SOFTENING OF THE BRAIN. 
varying amount of diminution of consist- 
ence is met with, without alteration of 
color. In some cases the amount of soft- 
ening is so slight as to escape detection by 
the unaided senses, whilst in others the 
portion of brain is reduced to a thin difflu- 
ent pulp, which may be poured out so as 
to leave a distinct cavity with irregular 
though softened walls-for the degenera- 
tion is never strictly limited, it shades off 
imperceptibly into the healthy tissues. 
Thus, in what appear to be minute cir- 
cumscribed patches of white softening, 
granular corpuscles are diffused for some 
distance in the firmer tissue surrounding 
the softened patch. Sometimes nearly 
the whole of the white substance of one 
hemisphere may be found in a more or 
less softened condition. The specific grav- 
ity of softened white matter usually falls 
to 1'032, but when in its natural condition 
it is about 1'040 ; and as a general rule it 
may be said that any portion of the brain 
when softened has a specific gravity lower 
by six to eight degrees of the hydrometer 
scale than the specific gravity of the same 
part when in its normal condition.1 
2. lied Softening.-This variety may be 
met with either in the gray matter or in 
the white substance of the brain, though 
in the former the coloration is generally 
more distinct and of a darker hue, on ac- 
count of the naturally greater vascularity 
of the brain substance in this situation. 
When affecting the gray matter, the 
patches may be small and distinctly cir- 
cumscribed, so as to present the appear- 
ance of superficial ulcerations; or they 
may be more diffuse and extensive, pre- 
senting less of the appearance of ulcera- 
tions, but existing as dark, somewhat 
swollen patches, which from their color 
were formerly spoken of as "plaques ec- 
chymotiques, " and "taches scorbutiques 
des convolutions." These have also been 
described by Cruveilhier2 under the name 
of " ramollissement hortensia ou ZtVas." 
This softening of the convolutional gray 
matter may exist alone, it may be asso- 
ciated with a similar change in the subja- 
cent white matter, or, as Laborde has 
pointed out, it may coexist with softening 
of one of the central ganglia on the same 
side. In these latter cases the softening 
is often slight, and takes place without 
much alteration in the natural color of the 
part, so that it is liable to be overlooked. 
Where the convolutions are softened, the 
gray matter is frequently torn in attempt- 
ing to strip off the membranes. This may 
be due, however, to the mere fact of di- 
minished consistence, rather than to any 
increase in the natural adhesions existing 
between the parts. Red softening of the 
white matter often exhibits a general 
rosy hue, intermixed with darker-colored 
patches from effused blood and minute 
points of redness, which have been de- 
scribed as "capillary apoplexy." It may 
be diversified also with patches of simple 
white softening here and there, and after 
a certain time shades of buff, yellow, and 
even brown coloration supplant or become 
mixed up with the red. The brown color 
is most frequently met with in old patches 
of softening in the corpus striatum. The 
red color being due to the increased quan- 
tity of blood in the part, owing to extreme 
congestion of the vessels (combined with 
staining from transudation of coloring 
matter), we have, in this fact, an expla- 
nation of the circumstance that when a 
recent red softening is cut into, the sur- 
face often rises up above the level of sur- 
rounding parts, and presents a slightly 
swollen appearance. Also, when red soft- 
ening of the white matter exists combined 
with a similar condition of several of the 
contiguous convolutions, owing to the 
swelling and consequent pressure thus 
produced, these become flattened on the 
surface, whilst the sulci are rendered in- 
distinct. The process of degeneration of 
the nerve tissue is the same in this form 
as in the simple white softening, and it 
may advance to the same condition of dif- 
fluence. It is only that the color and com- 
position of the softened part in a case of 
red softening are altered by the great ad- 
mixture of blood together with the pro- 
ducts of its retrograde metamorphosis. 
Red softening, if not of traumatic origin, 
as before stated, is almost invariably con- 
nected with obliteration of the vessels or 
other impediment to the circulation, and 
the " redness" or " swelling," which were 
formerly considered so indicative of its 
inflammatory origin, are capable of re- 
ceiving an altogether different explana- 
tion, tending to show that these charac- 
teristics are dependent upon mechanical 
rather than upon vital influences. 
It has been known for some time through 
the writings of Rokitansky and Cohn,1 
that infarctus of the abdominal viscera, 
owing to arterial obstruction, commences 
as a deep red spot in the territory of the 
affected artery, this appearance being due 
to the engorged condition of its capillaries, 
and the occurrence of minute extravasa- 
tions of blood. And, quite recently, MM. 
Prevost and Cotard having injected into 
the arterial system of a dog (whose abdo- 
minal walls had been opened so as to ex- 
pose its contained viscera) some water 
holding tobacco-seeds in suspension, in a 
few moments after the injection there ap- 
peared, at the inferior extremity of the 
1 "On the Specific Gravity of diiferent parts 
of the Human Brain:" Journ. of Ment. Sc., 
Jan. 1866. 
2 Anat. Patholog. vol. i. Livraison. 
1 Klinik der Embolisch. Gefasskrankh., 
Berlin, 1860, MORBID ANATOMY. 
875 
spleen, a red prominent spot of definite 
outline, which rapidly increased in size 
till it equalled that of a two-franc piece. 
The corresponding branch of the splenic 
artery was afterwards found to be obliter- 
ated by some of the seeds. Ecchymotic- 
looking spots were produced upon the 
kidneys at the same time. What was 
here actually seen to take place accords 
perfectly with what is observed in cere- 
bral softenings brought about by the 
injection of foreign bodies into the arterial 
system. Their impaction in the cerebral 
arteries constantly results in the produc- 
tion of red softenings with great fulness 
of the vessels, as has been abundantly 
proved by the experiments of Cohn, Vul- 
pian, and by those of MM. Prevost and 
Cotard. Here, then, we have the two 
appearances, redness and swelling, pro- 
duced so rapidly as to make it quite out 
of the question for us to regard them, in 
spite of the opinion of Oppolzer, as of in- 
flammatory origin; so that we must seek 
for some mechanical cause of the phe- 
nomena. Cohn and Rokitansky attribute 
the results to a collateral fluxion of blood 
through the contiguous capillaries, whilst 
Virchow regards them as the effects of a 
venous reflux, in consequence of the sup- 
pression of the vis a tergo on the side of 
the artery. In support of the former 
view, Weber' has since pointed out that 
when an artery is obliterated, the pres- 
sure at the point of obliteration increases, 
and becomes equal to that at the origin of 
the artery, and that when a certain num- 
ber of capillaries are obliterated, the pres- 
sure augments in the artery belonging to 
them, and in those remaining pervious. 
Prevost and Cotard also support this view, 
and they call attention to the theorem of 
hydrodynamics upon which it depends, to 
the effect, that when a tube receives at 
one of its extremities a fluid at a certain 
pressure, and allows it to escape freely at 
the other extremity, the pressure dimin- 
ishes from one end to the other of the 
tube according to an arithmetical progres- 
sion. Marey2 has shown that this theo- 
rem is applicable to the circulation of 
blood, owing to the resistance in the veins 
being so slight as practically to make it 
appear as though there were a free flow 
into the capillaries.3 This increased ten- 
sion of blood in the collateral capillaries 
would, therefore, seem to account in great 
part, not only for the surrounding con- 
gestion, but for the flux of blood into the 
territory of the obliterated artery, where 
it would stagnate; and, owing to the in- 
creased tension of the blood (combined 
with the progressive weakening of the 
capillary walls, and the diminution of 
their usual support from the softening of 
the surrounding brain tissue), we can 
easily conceive the mode of origin of those 
effusions of blood and those dilatations of 
capillaries such as are actually encount- 
ered. 
3. Yellow Softening.-A special form of 
degeneration of brain substance has been 
described under this head by Rokitansky.1 
It usually occurs in sharply circumscribed 
spots-varying in size, but rarely exceed- 
ing that of a hen's egg-in which the 
cerebral substance is converted into a 
very moist, tremulous, and occasionally 
gelatinous pulp, retaining none of the 
characters of proper brain tissue. The 
altered portion rises considerably above 
the level of the section, and is of a straw 
or sulphur-yellow color. In slighter de- 
grees of the disease, the color is merely 
dull white, inclining to yellow, though 
the tissue is still much softer and moister 
than usual. The expressed fluid has a 
distinctly acid reaction. The transition 
to the healthy brain tissue is usually 
abrupt, and there are no signs of inflam- 
mation in or around the softened patch. 
Its usual seat is the white matter of the 
hemispheres, though it may affect the 
central ganglia, or,, much more rarely, the 
convolutional gray matter. With regard 
to the pathogeny of this form of softening 
we are almost entirely in ignorance. 
Rokitansky looks upon it as a peculiar 
chemico-pathological transformation of 
brain substance, in which " the liberation 
of an acid-the phosphoric, and especially 
one or more of the fatty acids-may be 
conjectured to be one of the most impor- 
tant phenomena. " Besides occurring as 
an independent condition such as above 
described, this form of yellow cerebral 
softening is said by Rokitansky to exist 
frequently around old clots, tumors, or 
other adventitious products in the brain. 
Cruveilhier2 has also frequently met with 
it around old adventitious products, 
though he has never seen it existing alone. 
Besides this special form of yellow soft- 
ening, as before stated, we meet with a 
yellow color of the brain substance in the 
secondary stage of red softening, in which 
case the tint" may be partly due to the 
presence of altered blood pigment, and 
partly, according to Lancereaux and Vir- 
chow, to the presence of what were the 
red globules of the blood, but which have 
now, in part, been deprived of their 
hsematine. 
Histological Alterations and Microscopi- 
cal Appearances in different Stages.-The 
1 Handbuch der Allgem. und Spec. Chirur. 
1865. 
2 Physiolog. Med. de la Circ., Paris, 1863. 
3 This is an important point, because Poi- 
seuille (Recher sur les Causes du Mouv. du 
Sang) maintained that the pressure was the 
same in all parts of the arterial system. 
1 Path. Anat. (Syd. Soc.) vol. iii. p. 419. 
2 Anat. Path. vol. i. Livraison viii. 876 
SOFTENING OF THE BRAIN. 
changes which take place in the nerve 
elements of a part, whether from the 
separation of these from their proper 
ganglionic connections, or from the cut- 
ting off of the supply of blood to the part, 
have been shown to be absolutely identi- 
cal in nature, and to differ only as regards 
the rapidity with which the change is 
brought about. This has been proved by 
the experiments and observations of Phil- 
lipeaux and Vulpian on the changes 
taking place in the peripheral extremities 
of divided nerves, and by the observations 
of Turek, Gubler, and Bouchard on the 
progress of secondary degenerations of the 
spinal cord, as compared with the ordi- 
nary histological changes which take place 
in softening nerve substance. In the one 
case we have a simple destruction, or 
necrobiosis, taking place amongst the ele- 
ments of the tissue, in which, from the 
comparatively slow way that they are 
brought about, all the steps of the process 
may be easily traced, whilst in the other 
we have a more rapid and tumultuous 
form of necrobiosis, which, on account of 
its rapidity, is associated with diminished 
consistence. The investigations of MM. 
Phihipeaux and Vulpian1 have yielded 
the following results. At the end of the 
first day there is found to be a diminution 
of the proper excitability in the peripheral 
extremity of the cut nerve, whilst this is 
lost altogether at the end of the fourth, 
and the filaments which had previously 
shown no change begin to alter in appear- 
ance. From the fifth day the medullary 
substance of the tubes seems to be coagu- 
lated, and at the same time fissures estab- 
lish themselves in its thickness and divide 
it into unequal blocks or divisions. This 
is called the segmentation of the nerve 
tubes. Soon after this the fragments of 
the medullary substance undergo a fur- 
ther alteration, fatty granules2 form in 
their interior, which go on increasing in 
quantity, and at last entirely replace the 
fragments of myeline. Bouchard3 has re- 
cognized precisely the same changes in 
cases of secondary atrophic degeneration, 
and, speaking of one of these cases, he 
says: "Independently of the fatty gran- 
ules contained in the altered tubes, a 
great number were free between the tissue 
elements, and, at certain points, aggre- 
gated together into masses, so as to con- 
stitute what are known as the 'corps 
granuleux' of Gluge." In the same case, 
the vessels presented on their surface 
heaps of molecular fat particles, or even a 
complete envelope of these, so as to render 
the vessels black and opaque under the 
microscope. Here, then, are produced, 
without the intervention of inflammation, 
all the appearances which have been sup- 
posed to be characteristic of inflammatory 
Softening of the Brain. Dr. Hughes 
Bennett says:1 "Exudative or inflamma- 
tory softening always contains granules 
and granule cells, which are numerous, 
according to the degree of softening. The 
granules are for the most part seen coating 
the vessels, and the cells also may occa- 
sionally be seen there in various stages of 
development. In the demonstrations that 
are made under the microscope, they are 
frequently seen diffused among the tubes, 
which, according to the severity and ex- 
tent of the lesion, are easily separated 
from one another, or broken up in a 
variety of ways." 
MM. Prevost and Cotard have found 
from their experiments on dogs, that at 
the end of the first twenty-four hours 
after the obstruction of an artery there 
was red pulpy softening, with slight dimi- 
nution of consistence, and, on examina- 
tion with the microscope, there were seen 
broken-up fragments of nerve tubes, 
drops of myeline, blood corpuscles, and 
peculiarities of the capillaries, though no 
granules or granular corpuscles wrere at 
that time visible. As early as the third 
day, however, they have found granule 
corpuscles formed, and an abundance of 
granular matter lying amongst the tissue 
elements, as well as more especially ag- 
gregated along the walls of the vessels. 
These results are quite in accordance with 
our own observations, since we lately met 
with an instance of traumatic softening 
in which a few fully developed granule 
corpuscles, and very many in a less ma- 
ture state, were seen, which must have 
been produced in rather less than two 
and a half days.2 Bouchard believes that 
these granule corpuscles may result from 
the " granulo-graisseuse" degeneration of 
drops of myeline, and Prevost and Cotard 
1 Mem. de la Soc. de Biologie, 1859, p. 343. 
2 At the end of a certain time the fatty 
granules are absorbed, and nothing is left but 
the sheath of Schwann folded on itself and 
on the axis cylinder. Little is known as to 
the actual condition of this last, though the 
researches of Schiff and MM. Phillipeaux and 
Vulpian go to prove that the return of func- 
tion in a divided nerve proceeds not from the 
production of new tubes amongst the debris 
of the old, as formerly supposed, but from 
the reformation of myeline within the wasted 
sheaths themselves, and around the old axis 
cylinder, which is capable of persisting for a 
long time without undergoing much appre- 
ciable alteration. 
3 Arch. G6n. de Med. 1866, p. 281. 
1 Clinical Lectures. Fourth ed. 1865, p. 
354. 
2 The man on whom this observation was 
made fell down an area and fractured his 
skull. He was admitted into St. Mary's 
Hospital on September 7, 1866, at 4 P. M., 
immediately after the accident, and died on 
the 10th of the same month at 3.10 A. M. 
The exact interval was, therefore, 2 days, 11 
hours, 10 min. MORBID ANATOMY. 
877 
also think they may result from the ag- 
gregation of granules originally separate. 
We have, ourselves, never been able to 
substantiate either of these modes of ori- 
gin, and we agree with Virchow1 in the 
opinion that they mostly originate from 
the fatty degeneration of the cells of the 
neuroglia, since granule corpuscles are 
commonly met with in the midst of the 
white matter of the hemispheres, having 
a more or less distinct cell wall, and 
which show a large nucleus in their in- 
terior after staining with carmine.2 The 
cells of the neuroglia are the only ele- 
ments existing in this situation capable 
of giving rise to such bodies.3 They are 
also to be seen in the gray matter lying 
between the ganglion cells, which, in old 
age, undergo more or less of the pigmen- 
tary degeneration, and always present 
quite a different appearance. Robin 
formerly held that these granular corpus- 
cles were produced by the degeneration 
of pus cells ; but pus cells in their natural 
state are never met with in simple Soften- 
ing of the Brain, and it seems scarcely 
fair or reasonable to assume that they 
should be seen only in a state of degenera- 
tion. In cases of softening of the convo- 
lutional gray matter or of the central 
ganglia, a degeneration of the proper 
nerve cells takes place, which become 
filled with dark-colored granules. These 
are generally at once distinguishable from 
ordinary granule corpuscles by their ir- 
regular, angular shape, and by the pres- 
ence of the stumps of one or more cell 
prolongations. At the same time that 
these bodies are forming in the degenerat- 
ing tissue, granules collect along the 
walls of the capillaries, partly in an alto- 
gether irregular manner, and partly in 
the form of more or less spherical aggre- 
gations. Some of the capillaries become 
completely covered in this way; but the 
collection of granules is on the walls of 
the capillaries, and is a consequence, not 
a cause of the softening. It must not be 
confounded with fatty degeneration of 
these vessels, in which the granules are 
imbedded in the walls of the capillaries. 
There are other alterations of the capil- 
laries met with, especially in red soften- 
ings, which have been particularly dwelt 
upon by Laborde.4 At first, partial dila- 
tations of the walls of the capillaries are 
seen, like minute aneurismal swellings, 
or, in other places, little ampulliform di- 
latations including the whole circumfer- 
ence of the vessel, and constituting what 
he describes as the moniliform condition 
of the capillaries. At a later stage, com- 
plete as well as partial dilatations of the 
capillaries are to be seen, together with 
actual ruptures here and there, and mi- 
nute extravasations of blood. Still later, 
the capillaries become enormously dilated, 
and their walls thin and granular from 
degeneration. The punctiform hemor- 
rhage, to which Cruveilhier gave the 
name of " apoplexie capillaire," is some- 
times due to minute extravasations from 
rupture of the capillaries, sometimes to 
the extreme dilatation of capillaries 
gorged with blood, and often to the pro- 
duction of what has been wrongly called 
"dissecting aneurism," occasioned by 
rupture of the proper wall of a minute 
artery and an effusion of blood into the 
lymphatic sheath which surrounds it. 
The blood remaining in the capillaries, 
and also that effused externally amongst 
the nerve elements, shows, for certain 
time, traces of the individual blood cor- 
puscles, more or less decolorized and yel- 
low, as well as flattened and pressed 
together ; whilst mixed up with them are 
reddish or reddish-yellow flakes of tissue, 
stained by the transuded haematine. In 
those, minute patches of extravasated 
blood, in which the coloring matter exists 
in some quantity, we afterwards find it in 
the form of amorphous, yellow or orange- 
colored granules or flakes, intermixed 
with the characteristic orange or ruby- 
colored crystals of haematoidine. These 
are very minute, and of an oblique rhom- 
boido-prismatic form. It is not known 
exactly in how short a time these crystals 
may appear in extravasations of blood in 
the human brain. Dr. Wilks' has, how- 
ever, met them as soon as three weeks 
after such an occurrence, and Cruveilhier 
found the "coloration jaune orange" de- 
veloped after twenty-five days in the seat 
of an hemorrhagic effusion into the brain. 
Once formed, the haematoidine crystals 
remain as indelible evidences of past ex- 
travasation of blood. 
In the extreme stage of softening, the 
fluid matter occupying its site no longer 
presents the slightest trace of nerve struc- 
ture-the degeneration is complete, and 
nothing can be recognized by the micro- 
scope save granules and granule cells, 
mixed up with the various kinds of blood 
pigments, amorphous fragments of tissue, 
and the debris of degenerated vessels. 
When we have to do with the last stage 
of red softening, and especially when this 
is situated in the corpus striatum or optic 
thalamus, the contents of the softened 
centre may present a brownish or even 
chocolate hue. 
1 Wiener Medicin. Wochenschr. January 
19, 1861. 
2 Case of Concussion Lesion, Med.-Chir. 
Trans. 1867. 
3 Corpuscles almost precisely similar are 
met with in other organs, whose tissues are 
in a state of degeneration, which undoubtedly 
originate from the fatty and granular degen- 
eration of pre-existing cells. 
4 Loc. cit. p. 114. 
1 Leet, on Path.. Anat. 1859, p. 133. 878 
SOFTENING OF THE BRAIN. 
. Fatty degeneration of the tissues being 
complete, the process of repair begins at 
a variable period-probably in from one 
to two months after the commencement 
of the degeneration. These alterations 
have been fully described by Durand- 
Fardel,1 and differ according as they are 
situated at the surface of the brain, or in 
its central parts. In the former situation 
the process results in the formation of the 
so-called "plaques jaunes," and in the 
latter it is accomplished by what Durand- 
Fardel calls "infiltration celluleuse." 
These so-called "plaquesjaunes," which 
have been well represented by Cruveil- 
hier,2 exist in the form of yellow or ochre- 
colored, rounded patches. They may be 
confined to a single convolution, or may 
extend over several, at the same time dip- 
ping down into the sulci. The pia mater 
over them may sometimes be easily strip- 
ped off, whilst at other times it is closely 
adherent to the tissues beneath. The 
substance of the patch, though pliable, is 
tough and resists the knife; it usually 
implicates the cortical gray matter only, 
and its circumference is pretty sharply 
defined from the surrounding healthy tis- 
sue. More rarely, however, it is separ- 
ated, as well circumferentially as beneath, 
from the healthy brain substance, by a layer 
of softened tissue. Histologically, these 
patches are composed of connective tissue 
containing an abundance of nuclei; also 
of intermingled htematine granules and 
crystals of hsematodine, together with 
fatty particles, a few granule corpuscles, 
and some degenerated vessels. Rokitan- 
sky3 denies that these yellow patches are 
the sequelae of softening of the convolu- 
tions, and looks upon them as changes 
resulting from superficial hemorrhage. 
But the result of a recent experiment by 
Prevost and Cotard goes strongly to sup- 
port the view of Durand-Fardel. They 
found a well-marked yellow patch on the 
middle lobe of one of the hemispheres of 
a dog, which is in every way similar to 
those met with in man; and the corres- 
ponding middle cerebral artery of this dog 
had been obliterated, thirty-five days be- 
fore the death of the animal, by the injec- 
tion of tobacco seeds into the carotid artery. 
From what we ourselves have seen, how- 
ever, we are inclined to think that super- 
ficial extravasations of blood into the pia 
mater may also, as Rokitansky says, give 
rise to yellow patches, though of a dif- 
ferent kind from the "plaques jaunes" 
described by Durand-Fardel. In cases 
■where a superficial hemorrhage has been 
the antecedent condition, the coloration 
is almost entirely due to an accumulation 
of blood pigment in the meshes of the pia 
mater, with atrophy of the subjacent con- 
volution, rather than to a fibro-cellular 
conversion of the substance of the gray 
matter itself. 
When a focus of softening in the midst 
of the white substance of one of the hemi- 
sheres begins to undergo the process of 
repair, the walls of the softened cavity 
become bounded by a pulpy tissue of a 
white or grayish color, which, on micro- 
scopical examination, is found to be con- 
tinuous with the neuroglia of the contig- 
uous healthy portion of the hemispheres. 
Tissue of the same kind also extends 
across the cavity in different directions, 
breaking it up into divisions or compart- 
ments, in the meshes of which may be 
found a whitish liquid containing frag- 
ments of nerve substance which have not 
yet completely undergone the fatty meta- 
morphosis. This fluid holds in suspension, 
also, fat particles, and a number of cor- 
pora amalacea. The formation of the 
vascular and nucleated connective tissue 
constitutes the " infiltration celluleuse" of 
Durand-Fardel. Though met with prin- 
cipally in the white substance of the hemi- 
spheres, it is also seen more rarely in the 
central ganglia. When situated in the 
corpora striata, the walls, instead of being 
white, are often of a yellowish or ochre 
color, which makes the identity of this 
process with that which gives rise to the 
" plaques jaunes" of the convolutions all 
the more evident. The fluid contents of 
the cavity gradually become absorbed, and 
its walls close in and contract in the same 
way as do those of an apoplectic fit. In- 
deed, in these last stages there may 
be some difficulty in discriminating be- 
tween the two. In the remains of the 
apoplectic cyst, however, more coloring 
matter is usually found ; its walls are also 
generally more dense and contractile, and 
a more complete obliteration of the old 
cavity is said to follow. 
Lastly, there is a condition of the cen- 
tral ganglia of the brain, more particularly 
of the corpora striata, which has been 
described by Durand-Fardel1 under the 
name of "etat crible." On making a 
section of these central ganglia, small 
pisiform cavities or lacunse are occasion- 
ally seen, which sometimes seem bounded 
by a distinct membrane. Similar cavities 
may also be seen, though more rarely, in 
the pons Varolii. These are regarded by 
Laborde2 and others as minute apoplectic 
cysts, resulting from slight effusions of 
blood, whilst others again look upon them 
only as dilatations of the lymphatic canals, 
1 Malad. des Vieillards, Paris, 1854, p. 72. 
2 Anat. Path.., Livraison 33, pl. 2. 
3 Patholog. Anat. (Syd. Soo.), pp. 394 and 
416. 
1 Who, however, attaches little importance 
to this condition, and looks upon the little 
cavities as the results of dilatations of the 
vessels, owing to long-continued congestion. 
2 Loc. cit. p. 94. MORBID ANATOMY. 
879 
in which, as pointed out by Uis,1 the cere- 
bral vessels are contained. Laborde, how- 
ever, thinks there is another and more 
important modification of this condition, 
in which no lining membrane is to be met 
with, but in which the little cavities are 
somewhat larger, so as to be even capable 
of containing a good-sized pea. These he 
looks upon as the result of "une desor- 
ganisation partielle et progressive," and 
as true, though minute and circumscribed, 
softenings of the parts in which they are 
found.2 [In regard to localization of ce- 
rebral lesions, see the article on Cerebral 
Hemorrhage and Apoplexy, in this vol- 
ume.-H.] 
It only remains for us now to notice the 
softenings which have a post-mortem 
origin, and to point out how these may be 
distinguished from those having a real 
pathological significance which we have 
hitherto been considering. 
Ordinary post-mortem softening of the 
brain is due to the combined influence of 
two causes; namely, putrefactive changes, 
and the maceration of the cerebral tissue 
from absorption of fluid.3 This is com- 
monly met with on the surface of the 
thalami and in the parts bounding the 
posterior portions of the lateral ventricles, 
in all those cases where an interval has 
existed between the death and the au- 
topsy, and more particularly when the 
atmospheric temperature has been high 
and the ventricles have contained an ex- 
cess of fluid. In these cases the surface 
of the parts affected is broken up, and 
presents an irregular appearance, whilst 
the tissue itself is in a more or less difflu- 
ent condition. The fornix also frequently 
shares in this change. It has been a sub- 
ject of dispute as to what is the nature of 
the process which gives rise to the soften- 
ing of the central parts of the brain in 
acute hydrocephalus-whether, in fact, 
it has been produced by inflammation, or 
is merely the result of maceration; and 
in the event of the latter method of patho- 
genesis being the real one, whether this 
maceration has occurred during life or 
after death. Doubts have been expressed 
by many pathologists as to whether such 
a process of maceration ever occurs during 
life.1 When merely macerated nerve 
tissue is examined by the microscope, 
broken up and dissociated nerve elements 
only are met with, and none of the granule 
corpuscles or other appearances charac- 
teristic of real softenings that have been 
produced during life. Examined by the 
specific gravity apparatus also, we have 
several times found the actual density of 
the altered tissue the same as that of con- 
tiguous unaltered portions. This is some- 
what remarkable and becomes very char- 
acteristic ; since if a portion of brain 
tissue having a similarly diminished con- 
sistence, brought about by a pathological 
softening rather than by a post-mortem 
maceration, had been examined, the 
specific gravity would have been found 
lower than that of similar healthy tissue 
in the same brain by from eight to ten 
degrees of the hydrometer scale. The 
specific gravity test thus becomes a most 
important auxiliary to the microscope; 
and we have several times found it most 
useful in examinations of the spinal cord. 
Thus,, a short time since, on making sec- 
tions of a cord through the cervical, dor- 
sal, and lumbar regions respectively, the 
surfaces exposed were quite pulpy and 
irregular in the two former regions, whilst 
in the lumbar portion the surfaces were 
firm and smooth. Yet the specific gravity 
of portions of the cord from the dorsal re- 
gion was the same as that of other por- 
tions from the lumbar region, whilst in 
the cervical region the specific gravity was 
even slightly higher. Microscopical ex- 
amination, moreover, yielded no evidence 
of a pathological change in any portion of 
the cord. We have found much the same 
state of things also in other cases. Di- 
minished consistence or diffluence, there- 
fore, must not be confounded with dimin- 
ished density or specific gravity ; and it 
1 The impediment to the return of hlood 
through the venae magnae Galeni, owing to 
thrombosis in these vessels, to which the col- 
lection of fluid in the ventricles is in part 
due, also gives rise to a condition of oedema 
in the walls of the ventricles themselves, and 
is followed by a true degenerative softening 
of the brain tissue. (Pathology of Tuberc. 
Mening., Edinb. Med. Journ., April, 1867.) 
Respecting this condition of oedema of the 
brain, however, which it may be presumed 
occurs occasionally in heart disease and other 
conditions impeding the return of blood from 
the head, we have no very definite knowledge. 
It seems doubtful whether any amount of 
serous infiltration would be capable of pro- 
ducing actual softening during life, or do 
more than make the brain appear flabby-a 
little moister and softer than usual-and, at 
the same time, slightly lower its specific grav- 
ity. The brain is usually said to be "wet" 
when in this condition. 
1 Zeitsch. fiir Wissen. Zoolog. 1865. Bd. 
xii. 
2 Labor de says: " Nous possedons plusieurs 
observations de ces curieuses disorganisations 
partielles siigeant au centre de la protuberance 
annulaire et paraissant ripondre au point de 
vue symptomatique, & certains cas de paralysie 
diffuse, geniralisee, dans laquelle s'iteignent 
progressivement un grand nombre de vieil- 
lards."-P. 95. 
3 Dr. Bennett calls attention, in his "Clin- 
ical Lectures," to the softenings which may 
be produced by mechanical means, owing to 
the clumsy use of instruments in removing 
the brain and spinal cord from the body. 
This mode of origin should also be borne in 
mind. 880 
SOFTENING OF THE BRAIN. 
should be remembered that it is the com- 
bination of the two, associated with cer- 
tain microscopical changes, which are the 
characteristics of real pathological soften- 
ing of the brain. 
Diagnosis.-1. Acute softening may, in 
its apoplectic form, be confounded with 
congestion of the brain, with hemorrhage, 
or with urinsemia; but by regard to the 
mode of onset of the symptoms, and to 
their proportion inter se, a diagnosis may 
be established in the majority of cases. 
At the onset of attack it may be impossi- 
ble to distinguish the nature of the malady, 
but after a few minutes, or perhaps only 
after two or three hours, it is possible to 
aim at something like certainty. 
From congestive apoplexy softening may 
be distinguished by the longer duration 
of mental obtuseness ; and by the distinct 
limitation of intellect in one or two direc- 
tions, when the general obscuration of the 
" fit," or "stroke,"has passed away. At 
the onset of attack in congestive apoplexy 
there may be complete loss of conscious- 
ness, and the same thing may occur at the 
commencement of acute ramollissement, 
and for precisely the same reason, viz. 
the presence of congestion. In the former 
case, however, the mind rapidly recovers, 
and is restored to its previous condition ; 
in the latter all that was due to mere con- 
gestion is speedily removed, but there re- 
mains the impairment due to softened 
tissue. This may be aphasia, or some 
other special alteration in the mental 
powers, such as have been described in 
the section upon symptoms. Attacks of 
softening differ still more distinctly from 
those of congestive apoplexy, when they 
are unattended by any of the phenomena 
of hyperaemia, and occur after middle life, 
and especially in advancing years. The 
patient becomes more or less suddenly 
confused, but does not lose his conscious- 
ness ; he may wander in his talk, utter 
some exclamation of alarm, or may simply 
look distressed and as if about to cry ; he 
knows what is said, and makes signs to 
those about him ; is obviously aware that 
something very wrong has happened, and 
continues in this state of mental impair- 
ment for hours, weeks, or months. The 
difference from congestion is seen in the 
primary absence of general mental change 
•-loss of consciousness-and in the per- 
sistence of limited intellectual failure. 
The two classes of change in function, 
now described with regard to mind, are 
to be observed also in respect of sensation 
and motility. There may be, at the mo- 
ment of attack, general anaesthesia and 
general paralysis ; but if so, they are due 
to congestion or to shock, and they, with 
•either of those conditions, soon pass away; 
leaving behind them, however, impaired 
sensation in one or two limbs, and with 
this, localized paralysis. On the other 
hand, there may be no general change in 
the power of feeling or of motion-there 
may be neither congestion, nor sufficient 
shock-the patient feels some numbness, 
coldness, or deadness, together with weak- 
ness of one or two limbs, and these condi- 
tions pass on into hemiplegia, i. e., loss of 
power, and loss or diminution of sensibil- 
ity in the arm and leg of the side opposite 
to the lesion. Beyond these facts there is 
not unfrequently some hypersesthesia or 
morbid sensibility of the paralyzed limb, 
and this is much more common in cases 
of softening than in those of congestion ; 
and, again, there is twitching of the limbs, 
or rigidity of those that are paralyzed. 
The general aspect of the patient differs 
from that of the person struck with con- 
gestive apoplexy. There is, unless con- 
gestion be present as a transient condition, 
pallor instead of dusky redness, coldness 
of the head instead of heat, and a faint 
look in the place of bloated suffocation; 
there is often some sweat upon the brow; 
the patient is spare in habit, and the 
attack occurs when sitting quietly at the 
desk or when making no such exertion as 
could tax the physical powers. Beyond 
these general conditions there may be ob- 
served rigidity of arteries, an irregular, 
weak, and often intermitting pulse, a fee- 
ble heart, arcus senilis, and irregular dis- 
tribution of bodily warmth. 
From hemorrhagic apoplexy acute soften- 
ing may be sometimes distinguished by the 
following considerations:-In hemorrhage 
there is often some evidence of either con- 
gestion or of shock; in softening there 
may be an entire absence of both. In 
hemorrhage the attack frequently occurs 
at night; the patient goes to bed appar- 
ently well, and wakes in the morning feel- 
ing as usual, but on attempting to move 
finds that one side is paralyzed. In 
hemorrhagic apoplexy the attack is often 
absolutely instantaneous, in softening it 
is gradual. In the former there may be 
not the least-even momentary-confu- 
sion of mind, whereas in the latter there 
is distinct mental perturbation and insuffi- 
ciency. In hemorrhage, when the intel- 
lect is profoundly affected, as it sometimes 
is at the onset of attack, there is often a 
rapid restoration, and in the course of a 
quarter of an hour the patient's mind is 
as clear as it was before ; in softening per 
se there is less distinct mental obscuration 
at the commencement, and little or no 
subsequent recovery. In hemorrhage 
there is sometimes alarm, and not unfre- 
quently anxiety and depression, whereas 
in softening there is more commonly too 
much confusion of thought for any definite 
apprehension to be entertained, and some- 
times there is transient excitement or 
mild delirium. 
Sensibility is often unaffected in liemor- DIAGNOSIS. 
881 
rhage, it rarely escapes altogether in an 
attack of softening. In the former there 
is, as a rule, unilateral anaesthesia, which 
rapidly diminishes or disappears; in the 
latter there is dulness of sensation, with 
morbid feelings of coldness, numbness, 
tingling, &c., which persist. 
The paralysis in hemorrhage is, typi- 
cally, hemiplegic ; in softening it is more 
irregular, and sometimes more closely 
limited. In the former there is neither 
rigidity nor convulsion unless the coma 
be profound, and the paralysis extensive; 
in the latter there is often either twitch- 
ing or tonic spasm even when the paraly- 
sis is slight, and the mental perturbation 
comparatively trivial. 
In hemorrhage there is very frequently 
hypertrophy of heart, with granular de- 
generation of the kidneys; in softening 
there is very commonly a weakened heart, 
with valvular disease.1 Hemorrhage may 
occur in a person of strong limb and gen- 
eral good health, whereas softening is 
more common in the aged, the enfeebled, 
and those who have suffered from exhaust- 
ing diseases, or still more exhausting 
cares. 
From urincemia as a cause, per se, of an 
apoplectic seizure, softening may be dis- 
tinguished by the fact that in the former, 
convulsions of some kind and to some de- 
gree almost invariably precede the coma ; 
and that these have followed premonitory 
symptoms of drowsiness, oppression, and 
headache. The coma exhibits in a marked 
manner the features sometimes observed 
in acute softening of the brain, viz., an 
apparent profundity, with susceptibility 
of being roused. Urimemic patients lie 
in apparently profound torpor, but they 
may be roused by a touch or a word, and 
may appear in possession of all their facul- 
ties ; left to themselves they relapse al- 
most instantly into the state of stupor. 
In softening, if the coma be highly marked 
the awakening is less distinct, and the 
answers are less rational. In urinsemia 
there is often amaurosis, and a generally 
obtuse condition of sensibility, neither 
of which is frequent in ramoilissement. 
There is much twitching of the limbs, and 
often marked rigidity in the former case, 
but the locality of these symptoms changes 
from side to side, and is not accompanied 
by fixed paralysis; there may be twitch- 
ing or rigidity in the case of softening, 
but these are found in the same limbs day 
after day, and are attended by distinct 
and persistent loss of power. The stertor 
in urinsemia is unlike that of softening, be- 
ing oral rather than guttural; * the pulse- 
respiration ratio is much changed, being 
sometimes 5:1 ;2 sensori-motility and irri- 
tability of muscles on percussion are often 
notably increased. Beyond these features 
there are the signs of characteristic debil- 
ity and cachexia, the pale waxy skin, with 
vomiting and diarrhoea; and above all 
the oedematous condition of the eyelids 
and ankles, together with albuminous 
urine. In cases of acute cerebral soften- 
ing, all these symptoms may be absent. 
The two diseases are frequently combined, 
but when they are so it is not impossible 
to determine how much is due to the one, 
and how much to the other condition. 
When Softening of the Brain occurs in 
a convulsive form, its diagnosis is to be 
established by regard to the symptoms 
already described, p. 863. It is by a con- 
sideration of the prodromata and of the 
after-phenomena that the distinction may 
be made from epilepsy ; it is by a similar 
process that tumor of the brain or of me- 
ninges may be diagnosticated.3 That 
which is characteristic of softening is not 
the fact of the convulsion, nor the form 
which the convulsion takes, but the grad- 
ual development of intellectual, sensorial, 
and motor failure, such as has been de- 
scribed in the section upon symptoms; 
and the absence of those general and spe- 
cial changes which are characteristic of 
tubercular, carcinomatous, or other mor- 
bid growths. 
The form of softening which is marked 
by delirium is not likely to be confounded 
with any other malady. It is essentially 
an affection of old age, and may be dis- 
tinguished from simple senile congestion 
by the persistence of its symptoms, and 
by the speedy development of those signs 
of failure in nerve-power, to which so 
much attention has already been di- 
rected. 
2. Chronic softening, when its course 
has been chronic throughout, has to be 
distinguished from tumor and from me- 
ningitis ; and although the distinction is 
not possible in all cases, approximation 
to certainty may be attained in the ma- 
jority by regard to the following consider- 
ations. 
In tumor there is pain, intense in de- 
gree, subject to violent exacerbations, 
limited to and fixed in one locality; the 
special senses are affected, so that there 
is blindness or deafness, or the two com- 
bined, on one side generally, but some- 
times on both; there are local paralyses 
and epileptoid convulsions; but, apart 
from the convulsions, unimpaired intelli- 
1 Dr. Kirkes found the heart hypertrophous 
in thirteen of twenty-two cases of cerebral 
hemorrhage, and in all of these the kidneys 
were diseased, being for the most part granu- 
lar and atrophous. (Medical Times and Ga- 
zette, Nov. 24, 1855.) 
vol. I.-56 
1 Addison, Guy's Hospital Reports, 1839, 
vi. 
2 Marc^, Schmidt's Jahrb., Nov. 1855. 
3 See articles Epilepsy and Adventitious 
Products ip the Brain. 882 
SOFTENING OF THE BRAIN. 
gence. There is often marked disturb- 
ance of the stomach, obstinate vomiting, 
and constipation; and there may be the 
signs of the tubercular, carcinomatous, 
aneurismal, or syphilitic dyscrasise. In 
chronic meningitis, there is pain, generally 
distributed over the whole head, not very 
severe in degree, and, although varying 
in intensity, not subject to the parox- 
ysmal exacerbations observed in tumors ; 
there may be local paralyses, and these 
are especially observed in the muscles of 
the eyeball; there is much but intermit- 
tent mental excitement and irritability of 
temper alternating with marked depres- 
sion: there are disorderly spasms and 
paralyses of the limbs together with fre- 
quent but irregular accessions of fever ; 
there is often a syphilitic taint, but there 
may be an entire absence of that dyscrasia, 
and the symptoms may have dated from a 
blow or fall. 
In chronic softening there is dull head- 
ache, and gradual impairment of intelli- 
gence, motility, and sensibility, together 
with advancing years or a prematurely 
aged appearance, a feeble heart, rigid 
vessels, and most commonly some disease 
of old standing in such important viscera 
as the kidneys, heart, or liver. 
Thus, to resume, the characteristic fea- 
ture of tumor is pain, that of softening is 
failure of power, that of chronic menin- 
gitis is the mixture of excited with de- 
pressed functional activity. It is the pro- 
gressive deterioration of cerebral faculty 
which marks out the disease we are con- 
sidering ; the patient begins to die, as it 
were, before his time, and his death begins 
in the highest element of his organism. 
Prognosis.-Occasionally there is com- 
plete recovery after an attack of acute 
softening; for example, apoplectic seiz- 
ures have occurred, which have been fol- 
lowed by hemiplegia and mental dulness 
of many months' duration; these symp- 
toms have passed away entirely, and upon 
post-mortem examination, after a number 
of years have elapsed, the signs of old 
softening have been distinctly discernible. 
It is possible, of course, that the softening 
may have originated in or around a 
"clot," but that possibility does not affect 
the general question of prognosis. Again, 
there may be improvement, but not com- 
plete recovery; a patient may suffer a sud- 
den apoplectic seizure, and may lie for 
days in a state of profound danger, the 
mind almost a blank, and the limbs hemi- 
plegic ; but after a time he may improve, 
and his improvement may continue for 
months, slowly going on from week to 
week; he becomes able to understand 
what is said, to speak or to make intelli- 
gible gestures, he may walk, or may even 
regain the use of his hands, and may re- 
main more or less aphasic for an indefinite 
period. He may have a second attack, 
and one so characterized as to show that 
the other side of the brain has been af- 
fected, and he may be partially restored 
from this. At length a third or a fourth 
seizure comes, from which there is no re- 
covery. Upon post-mortem examination 
in such cases distinct softenings may be 
found in such situations as to relate them 
to the first or second attack, and the cause 
of such softenings may be discovered in 
the obstructed arteries. The prognosis of 
softening, therefore, although unfavora- 
ble, is not necessarily fatal. 
The prognosis is relatively favorable 
when the patient is young, and has been 
previously healthy, as, for example, when 
an apoplectic attack occurs during the 
course of rheumatic endocarditis in a 
young subject. It is unfavorable when 
the patient is old, or is affected by chronic 
disease of the kidneys, liver, or heart, 
when the arteries are rigid and the circu- 
lation low. It is favorable when the soft- 
ening is, as it were, the result of acci- 
dental interference with the supply of 
blood ; it is unfavorable when that inter- 
ruption of the arterial circulation is but 
part of a general organic change. 
The severity of an attack is to be judged 
of by regard to its mode of onset. If ac- 
companied by either much congestion or 
by profound collapse, the symptoms, al- 
though very highly marked and widely 
distributed, may pass away; whereas the 
same amount of symptoms occurring with- 
out evidence of congestion or collapse 
would indicate, in direct proportion to 
their severity and extent, the gravity of 
the lesion. Coeteris paribus, the lesion is 
in proportion to the extent of the symp- 
toms ; and the prognosis is worse when 
the mind, sensation, and motion are all 
slightly impaired, than it is when either 
one of them alone is profoundly affected. 
If the patient be young, and if there be 
no signs of generarimpairment of nutri- 
tion, hopes may be entertained that there 
will be some recovery of mental and 
motor power : but if the patient be old, or 
if there be weak circulation, and rigid 
vessels ; and if the attack has had many 
forewarning symptoms, such as occasional 
forgetfulness, numbness of the extremities, 
and the like, the probability of restoration 
is very small, while the likelihood of in- 
creasing mischief or of renewed seizure is 
very great. 
The prognosis of approaching death 
after an apoplectic or convulsive seizure 
is based upon the increasing rapidity and 
feebleness of pulse, the involuntary pas- 
sage of the urine and feces, and the gene- 
ral flaccidity of the limbs. 
Treatment. - Attacks of softening 
may be postponed by attention to the ADVENTITIOUS PRODUCTS IN THE BRAIN: SYMPTOMS. 
883 
following points : 1. The maintenance of 
an even temperature in the body: the 
feet and hands when chilly and blue 
should be put in hot water, or wrapped in 
and rubbed with warm flannels, and the 
patient should be placed in the recumbent 
posture, with the head only slightly 
raised. 2. The avoidance of long inter- 
vals between meals ; food, easy of diges- 
tion should be given frequently, and the 
patient, if old, should not be allowed to 
pass the night without nourishment. 3. 
The ready administration of some gentle 
stimulant when there is any tendency to 
occasional pallor or faintness. A glass 
of wine, or some sal-volatile and water, 
should always be at hand, and should be 
given, not recklessly, but fearlessly if the 
premonitory symptoms become threat- 
ening. 4. Direction of the mental habits ; 
easy and pleasant occupation of the mind, 
with careful abstinence from lazy inaction 
on the one hand, or violent excitement on 
the other. 5. Careful attention to the 
excretions, the skin, the kidneys, and the 
bowels. Exposure to cold is very preju- 
dicial, and, although constipation and 
straining at stool are to be strenuously 
avoided, nothing is much more mischiev- 
ous than the relaxation of close and too 
warm rooms, and the production, by 
medicines, of anything approximating 
purgation of the bowels. 
When the premonitory symptoms are 
those of much headache and drowsiness, 
obvious relief may be gained by warmth 
to the extremities and by the use of such 
diuretics as the liquor ammoniee acetatis, 
with infusum scoparii, nitrate of potass, 
and spirits of nitric ether, or of juniper. 
When there is the tendency to noctur- 
nal delirium, a judicious administration 
of liquid nourishment, with very small 
quantities of wine, may suffice to give 
relief. Should this fail, the most useful 
medicine that I know of is the Indian 
hemp, in doses of a quarter to half a 
grain of the extract; and next in value is 
the chloral hydrate in doses of five or ten 
grains. 
If there are marked symptoms of spas- 
modic or convulsive character, bromide of 
potassium in doses of from five to fifteen 
grains may be given three times daily 
with a bitter infusion and some diffusible 
stimulant, such as chloric or nitric ether. 
On the occurrence of an attack, either 
apoplectic or convulsive, there is but 
little that can be done beyond the regula- 
tion of temperature and of secretionthat 
has been already described ; but when the 
attack has passed away something may 
be gained by the administration of cod- 
liver oil, hypophosphite of soda, and 
vegetable tonics. In many cases of 
chronic softening marked improvement 
follows the exhibition of cod-liver oil, and 
I am disposed to regard this as the most 
valuable agent in the treatment of the 
malady. It should be administered in 
conjunction with a fully nutritious but 
easily digestible diet, and with free expo- 
sure, without fatigue, to fresh air. It 
appears to me highly doubtful whether 
under any circumstances of softening of 
the brain the smallest good has followed 
either general or local blood-letting, the 
application of blisters, the administration 
of mercury or of iodide of potassium. 
When recovery has advanced to a con- 
siderable degree, and some limbs remain 
paralyzed, good has distinctly followed 
the exhibition of iron, and of strychnia in 
exceedingly small doses, and the cautious 
application of galvanism to the weakened 
muscles. 
ADVENTITIOUS PRODUCTS IN THE BRAIN. 
By J. Russell Reynolds, M.D., F.R.S., and H. Charlton 
Bastian, M.D.,1 F.R.S. 
Im this chapter is included a descrip- 
tion of many diseases differing widely 
from one another in their pathological 
character, but agreeing in this, that they 
lead to the development within the cra- 
nium of some abnormal physical condi- 
tions, the nervous symptoms of which 
may bear close resemblance, inter se, 
during life. 
Symptoms. - It has sometimes hap- 
pened that, on post-mortem examination, 
tumors have been found in the brain, the 
existence of which had never been sus- 
pected during life. The patient may have 
1 The section on Morbid Anatomy is written 
by Dr. Bastian. 884 
ADVENTITIOUS PRODUCTS IN THE BRAIN. 
presented no sign of cerebral disease, and 
may have died from an affection of the 
lungs or other organs ; and, with the help 
conferred by post-mortem discovery upon 
the direction of questions as to past his- 
tory, no evidence can be obtained of any 
symptom which can be referred to the 
brain. Such a case occurred to myself 
some years ago; several large hydatid 
growths being found in the brain of a 
young girl who had never suffered in any 
such way as to lead to the suspicion of 
cerebral mischief. These facts should be 
borne in mind when dealing with certain 
cases where signs of cerebral disease are 
present, but the diagnosis is obscure. 
When it is said that " a tumor cannot 
exist because of the absence of this or 
that symptom," it should be replied, that 
a tumor may exist without any symptoms 
at all. 
There may be very highly marked 
symptoms, and yet these may be of such 
a character as to mislead. Dr. Abercrom- 
bie1 has related examples of disease within 
the cranium, the locality and nature of 
which had been unsuspected during life, 
the patient's history having been such as 
to lead to a diagnosis of some affection of 
the stomach. Cases of the kind described 
by Dr. Abercrombie are rare, and it is 
probable that they will be rendered more 
so, as clinical examination becomes more 
minute. The fact, however, remains, that 
the complaint of a patient may be so 
marked with regard to dyspepsia, vomit- 
ing, constipation, and the like, and so 
trivial in respect of headache, giddiness, 
or other morbid sensations, that, although 
he has a tumor in his brain, no suspicion 
may be entertained of its existence, and 
the diagnosis that is arrived at may be 
malignant disease of the pylorus, or the 
liver. 
In other cases the symptoms of intra- 
cranial tumors are highly characteristic, 
and the diagnosis of their existence, their 
exact situation, and anatomical nature 
may be sometimes made with a precision 
and minuteness such as is scarcely attain- 
able with regard to any other diseases. 
The intellectual faculties may be quite 
unaffected; indeed, they very often are 
retained in their integrity when other 
functions of the brain are seriously im- 
paired. The changes they present are of 
two kinds : there may be on the one hand 
great irritability of temper, a condition 
totally different from the previous habit 
of the individual, and with this, but very 
rarely, some mild delirium, or confusion 
of thought; on the other hand, there may 
be loss of memory, and general impair- 
ment of intelligence, with depression of 
spirits and listlessness. When convul- 
sions occur, as they frequently do, during 
the few days that precede death, there 
may be profound coma as their sequel; 
but the convulsions which exist in the 
earlier period of the growth of tumors are 
often accompanied by only partial loss of 
consciousness, and are followed by none 
of the stupor which-is so commonly ob- 
served in epilepsy. 
Sensation is altered in various manners, 
but by far the most characteristic change 
is that of pain. Headache is often slight 
at the commencement, but afterwards it 
arrives at great severity ; it is usually 
confined to a definite point or region of 
the head, and persists in that locality ; it 
undergoes occasional exacerbation, and 
sometimes the suffering seems almost 
intolerable, and elicits from the patient 
agonizing cries; it is, however, rarely 
absent altogether during the intervals of 
paroxysm ; it is increased by intellectual 
and physical exertion, by emotional dis- 
turbance, by sensational impressions, and 
by forced respiratory movements. It is 
sometimes almost the only symptom, but 
in rare cases it is absent altogether. The 
aggravation of pain which is occasioned 
by light, or noise, or movement, is such 
as to make a patient hold his head stead- 
ily between his hands, or bury it in the 
bed-clothes •; and this intolerance has 
sometimes been regarded as hypersesthe- 
sia, from which it differs widely. The 
sight and the hearing may be dull, but 
yet sensorial impressions intensify the 
headache. The sense of sight is often 
lost in one eye or in both ; or there may 
be simply some mistiness or imperfection 
of vision, with dark or bright spots before 
the eyes. The iris does not often lose its 
irritability, but it is often found dimin- 
ished ; whereas, in some cases of complete 
blindness, it contracts readily on the ad- 
mission of even a feeble light. Various 
changes may be observed in the ophthal- 
moscopic appearances, but that which is, 
perhaps, the most characteristic of tumor 
-although by no means constantly pre- 
sent-is enlargement of the veins, an en- 
largement sometimes to be observed in 
one eye only, sometimes in both. [The 
importance of this appearance, of choked 
disk, has been differently estimated of late 
years by leading authors; but statistics 
show1 that in about ninety-five per cent, 
of cases of intra-cranial tumor, either this 
appearance or that of descending optic 
neuritis is found when sought for with the 
ophthalmoscope. Turek first called at- 
tention to retinal signs of brain disease, 
in 1853. Von Graefe, in 1860, pointed out 
the existence, in different cases, of two 
conditions ; the one, of great engorgement 
[! Annuske, Reich, Longstreth, &c. See a 
paper by Dr. W. F Norris, and a discussion 
in Pathological Society of Philadelphia, in 
Philada. Med. Times, Aug. 30, 1879.] 
1 Practical Researches, p. 337. SYMPTOMS. 
885 
of the intra-ocular end of the optic nerve 
(stasis papillae or choked disk), and the 
other, of interstitial inflammation of the 
optic nerve, descending from meningeal 
inflammation (descending optic neuritis). 
Both of these conditions are followed by 
atrophy ; and the difficulty of discrimina- 
tion between them, and of separating them 
from simple atrophy of the optic nerve, be- 
comes greatest in their later stages. Since 
1860, Bouchut, Allbutt, Hughlings Jack- 
son, and others have given much attention 
to this aid in diagnosis. Annuske found 
that, in 920 cases examined, nearly all 
brain-tumors were attended either by optic 
neuritis or choked disk. The location of 
is less commonly impaired, but it may 
be lost completely on one side without 
having attracted the attention of the pa- 
tient ; noises in the ears are common, 
either with or without any diminution of 
the faculty. Numbness, tingling, creep- 
ing feelings, sensations of heat or cold, 
may exist in the limbs, or in certain tracts 
of skin over the trunk, and sometimes 
there may be distinct ansesthesia of parts. 
Vertigo is frequent, and often most dis- 
tressing ; usually it is relieved by closing 
the eyes and maintaining perfect rest; 
but sometimes it is aggravated by dark- 
ness, and the patient has to maintain a 
fixed gaze in order to ward off the feeling. 
Commonly the vertigo is of such a kind 
that the patient feels as if rolling over, or 
swimming along in space ; and it is com- 
paratively rare to hear complaint of the 
apparent rotation or motion of surround- 
ing objects. Affections of the sight have 
been found most frequently when the 
tumor has occupied the anterior lobes of 
the brain, and least frequently when in 
the posterior lobes or cerebellum. 
In the cases which have been placed on 
record, convulsions have occurred more 
frequently than paralysis, and among 
those which have presented the latter, 
one-half have exhibited the former. Con- 
vulsions, of epileptic form, often occur 
during the few days that precede death ; 
but in certain kinds of tumor or of ad- 
ventitious product in the brain, epileptoid 
convulsions may exist for years, and the 
cases presenting them may be termed 
"epileptic." When no general parox- 
ysms occur, there are, very frequently, 
clonic spasms or tonic contractions of the 
muscles. As the result of an examina- 
tion of a large number of cases, it may be 
stated that convulsions are most common 
when the disease is situated in the pos- 
terior lobes of the brain, or in the cere- 
bellum, and least frequent when the an- 
terior lobes are affected ; the distribution 
being exactly the reverse of that which 
pertains in regard of amaurosis.1 
Paralysis is sometimes observed in one 
muscle of one eyeball, such, for example, 
as the external rectus, leading to con- 
vergent strabismus ; or in all the muscles 
supplied by the third nerve on one side, 
so that ptosis and divergent strabismus, 
with dilated pupil, are the results. The 
speech may be also affected, the patient 
being unable to articulate certain sounds ; 
the facial muscles may be so paralyzed as 
to produce every degree of deformity, or 
the paralysis may be more widely dis- 
tributed, and be hemiplegic, or, but more 
rarely, paraplegic in its form. Sometimes 
the lesion may be of such kind, and in 
such degree and locality, as to affect the 
Fig. 51. 
Choked Disk. (After Liebreich.) 
the tumor does not seem to be at all constant 
in its relation to these results. Neither 
do large tumors more constantly produce 
them than small ones. Some marked 
cases of brain-tumor, moreover, have been 
proved to be entirely without ophthal- 
moscopic indication of their presence. 
Hence Becker (1868) and Schweigger 
(1871)1 have denied the practical import- 
ance of the coincidence when it occurs. 
We must conclude, however, that at least 
an important negative value belongs to it; 
viz., that, when tumor of the brain is sus- 
pected, but not proven, the total absence 
of ophthalmoscopic changes makes such a 
diagnosis much less probable than if they 
are ascertained to exist. The ophthal- 
moscope should be used, therefore, in 
every doubtful case, even if there be no 
observed defect in the patient's vision; 
since it has been found2 that sight may be 
apparently good, and yet examination will 
show decided alterations to have com- 
menced in the optic disk.-II.] Hearing 
f1 Norris, loo. citat.] 
[2 Shakespeare, Phila. Med. Times, loc. 
citat.] 
1 Vide Auct., Diagnosis of Diseases of the 
Brain, &c., p. 186. 886 
ADVENTITIOUS PRODUCTS IN THE BRAIN. 
nutrition of muscular and other textures. 
For example, in a case under my own 
care, where a tubercular mass involved 
the seventh nerve, and also the deep ori- 
gin of the fifth, not only was there loss of 
sensibility on one side of the face, but the 
temporal muscle was much wasted, the 
conjunctiva and cornea became sloughy, 
and the mucous membrane of the mouth 
was aphthous and studded with vegetable 
parasites. The paralysis of cerebral tumor 
is developed-as a rule-slowly and in- 
sidiously ; and when it occurs in one of 
the limbs, is sometimes preceded by pain 
or some other alteration of sensibility; 
but in a few cases it is produced as an 
"apoplectic" phenomenon, and may be 
the first symptom to attract the notice of 
either patient or physician. 
The general symptoms of tumor of the 
brain vary almost indefinitely, for they 
may be simply those of reflex or direct 
disturbance of the stomach and other vis- 
cera, when hydatid or fibrous growths are 
their producing cause ; or they may be the 
special features of carcinoma, tubercle, or 
syphilis, when any one of those dyscrasise 
is the primary fact in the formation of the 
adventitious product. Thus they may, 
on the one hand, be all-important, and 
may partially conceal the cerebral disease; 
on the other they may be so trivial as to 
awaken no attention ; while in an inter- 
mediate group they may have such cha- 
racter and relation as to render it possible 
to make an accurate diagnosis of the na- 
ture of the lesion. Thus there may be 
tumors on the scalp, or, in other regions, 
glandular swellings of strumous charac- 
ter ; or there may be distinct evidence of 
syphilitic deposit, of carcinoma, or of 
aneurismal dilatation of the vessels. Tu- 
berculosis gives rise to the most common 
form of tumor in the child or young adult, 
and syphilis is the next in frequency in 
early life or middle age ; while carcinoma 
is prevalent in direct proportion to ad- 
vancing years. Sometimes there is obvi- 
ous alteration in the general contour of 
the head, but such change is almost con- 
fined to the period of growth ; whereas in 
later years there may be gradual promi- 
nence of one eyeball, or the distinct pres- 
sure of a growth through the bones. Un- 
der such circumstances the diagnosis is 
tolerably easy. 
As a rule the commencement of symp- 
toms is insidious, and their progress slow ; 
but sometimes after a few premonitory 
phenomena there is a sudden attack of 
convulsions, or an apoplectic seizure. 
Under such circumstances a diagnosis is 
possible only by consideration of the sub- 
sequent history. 
Diagnosis.-Tn some cases it is impos- 
sible to gain even a hint of the nature of 
the malady, while in others the diagnosis 
is as certain as that of any disease with 
which we are acquainted. It will be con- 
venient to speak first of the diagnosis of 
tumor generally, secondly of the diagnosis 
of the locality of growths, and thirdly of 
the recognition of particular forms of 
morbid product. 
1. If convulsions be the prominent fea- 
ture of the case the diagnosis is to be 
made from epilepsy, and here the distinc- 
tion depends upon the recognition of symp- 
toms over and above those of the latter 
disease. The convulsions are commonly 
epileptiform in type, but very often they 
present these differences-they are irregu- 
lar in development, there is not absolute 
loss of consciousness, there is little or no 
asphyxia, and no subsequent stupor, while 
the spasmodic movements are more mark- 
ed on one side than on the other, they last 
for a longer time than is observed in epi- 
lepsy, and frequently terminate without 
being followed by anything like epileptic 
coma. In many cases the age at which 
they commence is so far advanced as to 
make epilepsy improbable, and there are 
symptoms - such as pain, affections of 
the senses, and paralysis-which do not 
occur in simple epilepsy. Again, the 
mental state in a person the subject of 
tumor may remain quite intact, and may 
fail to present the peculiar sluggishness 
which is often, although by no means in- 
variably, the concomitant of repeated epi- 
leptic seizures. Epilepsy is essentially a 
chronic disease, the commencement of 
which dates in a large proportion of in- 
stances from or soon after the period of 
puberty ; it is characterized by fits of a 
peculiar type; and when uncomplicated 
it exists for years, and in the majority of 
cases without entailing any ulterior change 
in the functions of either brain or spinal 
cord. Tumor in the brain is of compara- 
tively rapid development; it begins, as a 
rule,-to which there is the one exception 
of tubercular growth, - after adult age 
has been reached, and most commonly 
when the period of middle life is passed ; 
and when convulsions are present they 
are by no means the prominent symptoms 
of the malady, for, although often severe, 
they may be cast into the shade by the 
violence of pain and the loss of special 
senses. 
It is possible that the early and even 
some of the advanced symptoms of tumor 
in the brain should be confounded with, 
or passed over as, hysteria. Such mistake 
can only arise through carelessness, or 
through a prejudiced mode of dealing with 
the obscure affections of women. Not 
long since a lady consulted me, who was 
supposed to be hysterical, and who had 
been treated upon that supposition. Yet 
her symptoms had not commenced until 
after thirty years of age ; she had violent 
paroxysmal headache, was blind of one DIAGNOSIS. 
887 
eye, and deaf of one ear, and the amaur- 
osis and the deafness had crept on slowly. 
The distinction from hysteria may be 
made by regard to age, affections of the 
special senses, the absence of the peculiar 
mental condition of the hysteric patient, 
and the nature of the paroxysms. 
Chronic meningitis may be of such char- 
acter that its physical conditions become 
identical with those of morbid growths, 
and its symptoms pass then into those of 
tumor. This is the case, for example, 
when there is syphilitic thickening of the 
membranes, which may at any time be- 
come so complicated by nodular thicken- 
ing of either of the membranes or the 
bones, as to give rise to the special con- 
ditions and symptoms of a tumor. Again, 
a tumor, of fibrous or carcinomatous char- 
acter, the growth of which is habitually 
slow, may sometimes set up, in its neigh- 
borhood, chronic meningitis, so that the 
symptoms of the two morbid processes 
may be found in association. Under 
either set of circumstances the diagnosis 
is possible by a regard to the mode of de- 
velopment of, and relative proportion 
between, the symptoms. As already 
stated (see p. 881), the distinction between 
tumor and chronic meningitis lies here- 
that in the former the characteristic feat- 
ures are violent pain, marked diminution, 
or loss, of one or more of the special senses, 
limited paralysis, integrity of mind, and 
occasional epileptoid convulsions; whereas 
in the latter the pain is slight, the special 
senses are perverted but not lost, the mind 
is damaged, and the convulsions are less 
distinctly epileptoid. In the former there 
is the predominance of pain, in the latter 
there is no such predominance, but a 
mixed condition of excited and dimin- 
ished action in mind, sensation and mo- 
tility. In the case of chronic syphilitic 
meningitis the diagnosis may be assisted 
by the history of syphilis, or by the pre- 
sence of its symptoms in a tertiary form. 
It must be remembered, however, that 
the diagnosis may often be carried to this 
point,-the obvious presence of chronic 
meningitis, and the probability of tumor ; 
but this latter cannot be affirmed to exist 
because of the absence of its special symp- 
toms (see page 884). On the other hand, 
in certain cases, there may be no doubt of 
the existence of a growth, when paroxys- 
mal pain, &c., occur in a patient exhibiting 
the features of the carcinomatous cachexia. 
From chronic softening of the brain, the 
diagnosis is to be made by recognizing the 
absence of the characteristic features of 
that malady, viz. loss of mental power, of 
sensation, of motility. Certain cases of 
tumor may be taken for examples of 
chronic softening, and they are such as 
have been marked by a small amount of 
pain, by repeated convulsions, and gradual 
failure of intelligence. It would be im- 
possible under such circumstances to 
make an accurate diagnosis. 
2. The diagnosis of the particular locality 
of a tumor may sometimes be very minute 
and accurate, but in other cases vague, 
and not unfrequently erroneous. The side 
of the brain affected is usually, but not 
invariably, the same as that upon which 
the pain is felt, and on which the special 
senses and the muscles of the eyeball are 
affected; it is the opposite to that upon 
which spasm or paralysis occurs in the 
limbs. Again, the locality of pain may 
be taken for a guide as to the situation of 
a tumor in the anterior, middle, or poste- 
rior lobes. Such guide, however, is not 
always trustworthy, for frontal pain may 
be the result of a cerebellar tumor. Upon 
analyzing a large number of cases, I find 
that convulsions are most frequent in 
tumors of the cerebellum, and that they 
diminish in frequency as the seat of lesion 
advances forwards, i. e. through the poste- 
rior and middle to the anterior lobes of 
the cerebrum ; and that amaurosis, im- 
paired articulation, and intelligence ob- 
serve a contrary relation to those lobes, 
being most common when the tumor is in 
the anterior cerebral lobes, and relatively 
less frequent as the seat of tumor retro- 
grades. Romberg has suggested that the 
position of a tumor on the upper surface 
or at the base of the brain might be deter- 
mined by an observation of the effect pro- 
duced on pain by forced inspiration or 
expiration: the pain of tumors, when 
seated at the base, being aggravated by 
inspiration, that of those on the upper sur- 
face by expiration, sneezing, or coughing. 
This Romberg explains by the rising and 
falling of the brain during the respiratory 
movements, and the consequent pressure 
of the mass against the upper or lower 
bony walls.1 I have met with several 
cases which confirm Romberg's statement, 
but several others in which no reliance 
could be placed upon the test. The par- 
ticular portion of the brain involved in a 
tumor may be sometimes determined by 
a careful consideration of the distribution 
of all the symptoms; such diagnosis, how- 
ever, requires merely the application of 
anatomical and physiological knowledge, 
and needs no further notice here. 
3. A diagnosis of the nature of a tumor 
is always of great importance both in re- 
gard of prognosis and of treatment. Some- 
times all that can be accomplished is a 
guess, but sometimes tolerable certainty 
may be attained. Under certain circum- 
stances we may distinguish between tu- 
bercle, syphilis, lead-poisoning, aneurism, 
hydatids, carcinoma, and hypertrophy. 
Tubercle is the most common form of 
tumor in the child or young adult, and 
1 Manual of the Nervous Diseases. Syd. 
Soc. Trans, vol. i. p. 159. 888 
ADVENTITIOUS PRODUCTS IN THE BRAIN. 
we might infer its presence if, in addition 
to a tubercular family history, there were 
the obvious features of the tubercular con- 
stitution, marked wasting of the body, to- 
gether with an elevated temperature, and 
the presence of tubercular disease in the 
lungs or bronchial glands. It is some- 
what curious to observe that the tempera- 
ture of cases of cerebral tuberculosis is not 
raised to the degree, nor with the persist- 
ency, that is to be noticed in regard of 
tuberculosis elsewhere, but of all cerebral 
growths that which exhibits the greatest 
amount of elevation of temperature is 
tubercle. After puberty an examination 
of the chest is of great importance in the 
diagnosis, since it rarely happens that a 
healthy state of the lungs is found co- 
existent with tubercular disease of the 
cranium. 
Syphilis may occur in such locality as 
to produce any of the varied symptoms 
which have been enumerated ; but there 
are certain features which help to distin- 
guish it from other forms of adventitious 
products in the nervous centres. Head- 
ache is rarely intense, but is prone to 
undergo nightly increase; actual loss of 
sight or hearing is not common ; but im- 
plication of the third or sixth nerve is 
very frequently observed, so that patients 
exhibit ptosis, dilated pupil, and divergent 
strabismus, or more commonly inversion 
of the eyeball; there is often much depres- 
sion of spirits, and further a wide extent 
of symptoms, the spinal cord as well as 
the encephalon being involved in the mis- 
chief. The characteristic features of this 
disease are, however, to be sought else- 
where, in the presence of periosteal thick- 
ening, eruptions on the skin, and such 
other phenomena as have been described 
in the article on Constitutional Syphilis.1 
The intoxication of lead may be followed 
by such induration of brain substance as 
shall produce the symptoms of tumor; but 
the diagnosis turns upon a consideration 
of the previous history of the case, and 
the discovery of exposure to lead by trade, 
accident, or medicine; the previous occur- 
rence of symptoms of lead colic ; the pre- 
sence of general cachaemia, of a blue line 
on the gums, and of lead in the secretions. 
The extensors of the hands and fingers 
are the most frequently paralyzed; the 
extensors of the toes, the tibialis anticus, 
and peronsei are not rarely affected ; the 
paralyzed muscles become much impaired 
in their nutrition, and exhibit marked 
diminution, even extinction, of both con- 
tractility and sensibility on the application 
of powerful faradization ; but yet they 
may respond readily to a slowly inter- 
rupted battery-current of moderate power. 
It has been further observed that this loss 
of contractility to faradization sometimes 
persists after there has been restoration 
of voluntary power. 
Induration of the brain may occur in 
scorbutus, in rickets, or in epilepsy, but 
the diagnosis of its presence in either con- 
dition would be attended with much diffi- 
culty during life. Dr. Cohn observes that 
in one case there was, in the instance of 
rickets, an entire want of intellectual dis- 
turbance ;' whereas in epilepsy-as de- 
scribed by Bouchet and Cazauvielh, and 
as observed by myself-the presence of 
induration might be inferred from the 
progress of general intellectual decay; at- 
tention, apprehension, memory, and judg- 
ment failing; the patient becoming gra- 
dually incoherent, and general paralysis 
creeping on, while the fits increased in 
frequency but diminished in violence. 
The aneurismal nature of a tumor could 
be guessed at only per viam exclusionis, or 
rendered probable by the observation of 
disease of similar kind in other portions 
of the arterial system; for it has been only 
in very rare cases that an aneurismal 
bruit has been discovered in the head 
during life ; similar remarks may be made 
with regard to hydatid growths, and it 
must be remembered that hydatids in the 
brain may exist without producing any 
symptoms whatever. 
The presence of carcinoma would be in- 
ferred only upon the recognition of the 
cancerous cachexia ; and here age would 
be an important element in the considera- 
tion. Lancinating pains in the limbs are 
not, as Rostan supposed,2 of any diag- 
nostic value ; but the diagnosis must rest 
upon the discovery, of the carcinomatous 
dyscrasia, and the coexistence of tumors 
elsewhere, and especially of such as affect 
the integument and bones of the skull. 
Hypertrophy of the brain, although not 
an adventitious product, is best described 
in this place. It may be met with in 
young children ; but the only character- 
istic feature of the disease is enlargement 
of the cranium. Dr. West observes that 
this is "first apparent at the occiput, and 
the bulging of the hind-head continues 
throughout especially striking. The fore- 
head may, in the course of time, become 
prominent and overhanging, but the eye 
remains deep sunk in the socket, for no 
changes take place in the orbitar plates, 
such as are produced by the pressure of 
fluid within the brain."3 There is no 
prominence, but actual depression, of the 
fontanelles and sutures; the general nutri- 
tion of the child is imperfect, but there is 
1 See Cohn, in Gunsb. Zeitschr. v. 35, 
3854; Schmidt's Jahrb. Bd. 86, 1855, No. 6, 
p. 322; and Bouchet and Cazauvielh, De 
1'Epilepsie dans ses Relations, &c. 
2 Recherches sur le Ramollissement, p. 404. 
3 Lectures on Diseases of Infancy and 
Childhood, p. 9. 
1 Part i. p. 423. MORBID ANATOMY. 
889 
nothing special in the cerebral symptoms 
which would lead to the diagnosis of this 
particular form of malady. Partial hyper- 
trophy of the brain may be attended by 
no disturbance of the cerebral functions ; 
the morbid condition, under such circum- 
stances, can be recognized only by post- 
mortem examination.1 
Morbid Anatomy.-In this place we 
do not profess to give an account of intra- 
cranial adventitious products as a whole, 
but shall strictly confine ourselves to such 
products or growths as have their seat in 
some part of the encephalon, and we must 
refer to another article for a description 
of the morbid growths which take origin 
from the meninges. Whilst it is indis- 
pensable, from a pathological point of 
view, to refer to these growths under dif- 
ferent heads, it must not be supposed that 
we are able clinically to exercise the same 
precision. And neither, during the life of 
the individual, is it possible to determine 
whether a new formation, imagined to 
exist, has originated in the midst of the 
brain substance, or, having sprung up 
from one or other of the meninges, has 
merely grown into or pressed upon this 
secondarily. In both cases the symptoms 
produced may be almost identical. Simi- 
lar effects are also, in rare instances, pro- 
duced by the extension of an external 
morbid growth inwards through the 
orbit.2 
In addition to the adventitious products 
more strictly so called, such as blood-clots, 
hydatids, &c., many varieties of tumors 
are met with in the encephalon. As in 
other parts of the body, these often pre- 
sent unmistakable characters, though oc- 
casionally their histological composition 
is so indefinite as to make it extremely 
difficult to classify them. They exist 
either as distinct growths, with sharply 
defined outlines, or they may be, as it 
were, infiltrations passing insensibly, at 
their circumference, into the surrounding 
brain tissue. In the former case they are 
often inclosed in a fibrous envelope, of 
more or less thickness, which now and 
then may be found in a calcified condi- 
tion ; whilst the brain tissue around may 
be quite firm and healthy, or it may be 
softened to a variable extent. The soft- 
ening may be simply white, or, if there 
have been much antecedent congestion, it 
may exhibit various shades of red ; whilst 
in other cases the yellow gelatinous soft- 
ening is met with, such as Rokitansky3 
and Cruveilhier4 have described. This 
seems to occur most frequently around 
cancerous growths. At other times the 
brain tissue surrounding adventitious pro- 
ducts is condensed and indurated. 
Such adventitious bodies as silver and 
lead are met with only^in minute quanti- 
ties, and are for the most part diffused 
through the substance of the brain. Not 
being collected into distinct aggregations, 
we require the aid of the chemist to re- 
cognize their existence. Saline matters, 
also, either abnormal in kind or in quan- 
tity, may be diffused through the tissue of 
the nervous centres, when the nutrition 
of these fails and the brain matter is 
undergoing certain modes of degenera- 
tion. This is a subject upon which, at 
present, our knowledge is very defective. 
The various new formations and foreign 
bodies which are, from time to time, met 
with in the substance of the brain, may 
be thus arranged, though they will not all 
be treated of in the present article :- 
1. Tubercle. 
2. Syphilitic growths. 
3. Cancer. 
4. Melanotic tumors. 
5. Gliomata. 
6. Fibro-plastic tumors. 
7. Fibrous do. 
8. Osseous do. 
9. Tumors of the pituitary and pineal 
bodies. 
10. Nodules of gray matter on ependyma 
of ventricles. 
11. Vascular erectile tumors. 
12. Aneurisms. 
13. Blood-clots. 
14. Abscesses. 
15. Plastic lymph on the walls of ventri- 
cles. 
16. Cysts. 
17. Calcareous and other concretions. 
a. Cysticerci. 
b. Hydatids. 
18. Entozoa 
19. Silver and lead. 
It will be convenient to place also in 
the last section the remarks that we have 
to makfc upon hypertrophy of the brain. 
1. Tubercle.-Tubercle in the brain is 
much more frequently encountered in 
children than in adults, but, as pointed 
out by Andral, it is not commonly met 
with in children under two years of age. 
The period of maximum frequency is 
thought to be from the third to the seventh 
year inclusive. It rarely occurs in the 
brain in children without at the same 
time existing in some other organ of the 
body. In 117 examinations of adults who 
had died of phthisis, Louis met with tuber- 
cle in the brain only in one case, whilst 
MM. Rilliet and Barthez discovered 
masses of tubercle in the brains of 37 out 
of 312 children in whom this morbid de- 
posit existed in one or other of the remain- 
ing organs of the body. 
1 See cases reported by Giacomo Sangalli, 
Gaz. Lom. 1858, quoted in Schmidt's Jahrb. 
Bd. 102. 1859, p. 22. 
2 Ch. Robin, Gaz. MM. 1855, 6 et 13 Oct. 
3 Path. Anat. (Syd. Soc.), vol. iii. p. 419. 
4 Anat Path., 8me Livr. p. 5. 890 
ADVENTITIOUS PRODUCTS IN THE BRAIN. 
Sometimes a single mass of tubercle ex- 
ists in the brain, sometimes two or three, 
and in others a large number of smaller 
masses. In size the separate masses vary 
between that of a millet seed and a large 
hen's egg - those most commonly met 
with, however, being about equal to a fil- 
bert or a small walnut. They are mostly 
spherical in form, but are occasionally 
more or less tabulated. All parts of the 
brain, from the surface to the centre, are 
occasionally the seat of this deposit. Per- 
haps, having regard to its size, the cere- 
bellum is the most favorite seat of tubercle. 
It is so regarded by Dr. Wilks and by Sir 
William Jenner ; and Andral was, doubt- 
less, of the same opinion, since, without 
regard to size, he placed the cerebellum 
second, after the cerebral hemisphere, in 
the prder of frequency of site. After 
these, in order of frequency, Andral 
names the pons Variolii, the medulla 
oblongata, the spinal cord, the peduncles 
of the cerebrum and cerebellum, the optic 
thalamus, and the corpus striatum. Very 
frequently, when masses of tubercle are 
situated in or upon the cerebellum, they 
impede by their pressure the return of 
blood through the venae magnae Galeni, or 
the straight sinus, and so cause effusion 
of serum into the ventricles, and all the 
symptoms of chronic hydrocephalus.1 
Very rarely, almost the whole of the cere- 
bellum, or one of its lobes, may be, as it 
were, replaced by tubercular matter.2 
The usual condition in which tubercle 
is met with in the brain is, according to 
Rokitansky, in the form of masses in the 
size and shape already mentioned, " of a 
yellow or yellowish-green color, of the 
consistence of lard or cheese, and firm, 
but easily lacerable." It is remarkable 
that the gray, translucent form of tuber- 
cle is rarely, if ever, met with in the 
brain. Lebert says he has seen it rarely, 
and Rokitansky believes "that there are 
some rare cases which prove that tubercle 
in the brain does, in part at least, com- 
mence in the gray translucent form, for 
portions of a tubercular mass are some- 
times found in that state." He believes 
that it rapidly passes over from this form 
into that of the yellow cheesy tubercle. 
So far he is very much in accord with 
Virchow,3 who holds that each mass of 
cerebral tubercle is in reality made up by 
the aggregation of a multitude of small 
miliary tubercles. Each mass is formed, 
not by the growth of one original focus, 
but " by the continual formation and ad- 
junction of new foci at its circumference." 
lie adds :-" If we examine one of these 
perfectly yellow, or white, dry, cheesy tu- 
bera, we find immediately surrounding it 
a soft, vascular layer which marks it off 
from the adjoining cerebral substance-a 
closely investing areola of connective tis- 
sues and vessels." In this layer the 
young granules' are formed. They are 
continually produced at the circumfer- 
ence, "and the large tuber grows by the 
continual apposition of new granules (tu- 
bercles), of which every one singly be- 
comes cheesy. "2 But though this is the 
condition in which growing masses of tu- 
bercle are met with in the brain, at a 
later stage the process of increase stops, 
and, owing to an irritative process, a 
fibrous envelope gradually forms round 
the mass, so as completely to isolate it 
from the surrounding brain tissue. This 
condition is so general that many patholo- 
gists have held that all tubercles occur in 
an encysted condition in the brain.3 The 
thickness of the fibrous envelope varies 
with age-it may be an almost impercep- 
tible layer of fibrous tissue, or it may at- 
tain a remarkable thickness and almost 
cartilaginous consistence. Occasionally, 
even, it becomes completely calcified.4 
Softening is met with, at times, in the 
centre of the tubercular masses; and, 
very rarely, in encysted tubercle the whole 
contents may undergo this change. Such 
a change is reported by Dr. Ogle,5 in 
which a cyst the size of a pigeon's egg, 
with thin and friable parietes, was found 
in the pons Varolii,containing a "yellow 
glairy fiuid in which a number of light- 
colored soft particles of albuminous mat- 
ter existed." More rarely still, in the 
brain, the tubercular mass has been found 
to have undergone a process of cretifica- 
tion. 
The brain tissue around masses of tuber- 
cle is often perfectly natural, at other 
times it may be congested, more or less 
softened, or even indurated. 
2. Syphilitic Growths.-These are very 
rarely met wjth in the substance of the 
brain. Instances have, however, been 
1 Gray granulations. 
2 Although differing so widely in their 
views as to the nature of tubercle, Rokitan- 
sky's description of the circumference of 
these masses in the brain is almost identical. 
He says : " An extremely moist and jelly-like 
cellular structure connects the tubercle with 
the surrounding cerebral tissue 
This stratum further contains, scattered 
mostly through its inner part, some small 
gray or grayish-yellow tubercles, which oc- 
casionally unite with the great central mass." 
-Loc. cit. vol. iii. p. 429. 
3 Vide Andral's Prdcis d'Anat. Pathol, t. 
iii. p. 841. 
4 Dr. Ogle, Brit, and For. Rev., Oct. 1864, 
p. 463. 
6 Trans, of Path. Soc., vol. v. p. 26. 
' Wilks' Path. Anat. 1859, p. 158. This 
fact is strongly insisted upon, also, by Sir W. 
Jenner in his clinical teaching. 
2 Vide Hooper's Morb. Anat, of the Human 
Brain, p. 60, pl. xi. 
3 Cell. Pathol., transl. by Chance, p. 477. MORBID ANATOMY. 
891 
recorded. Dr. Aitken saw a "gumma- 
tous tumor" occupying the left optic 
thalamus, in a patient of Dr. Goodfel- 
low's, who had suffered from syphilis, and 
some of whose children had died from in- 
herited secondary syphilitic lesions. 
Dr. Wilks has never seen independent 
tumors of this kind in the cerebral sub- 
stance, though he believes, from the 
symptoms observed in some cases, that 
such deposits were very likely to have 
existed. A firm, tough, yellowish, lymph- 
like mass, of syphilitic origin, has fre- 
quently been met with intervening be- 
tween and connecting the dura mater 
with the brain. And although it seems 
most probable that the primary seat of 
this is the dura mater, still it is desirable 
to mention it here on account of the seri- 
ous way in which the brain matter is 
often implicated. Dr. Wilks records1 a 
characteristic example of this kind of le- 
sion, met with in the post-mortem exami- 
nation of a woman of low character, who 
was believed to have suffered from sy- 
philis. He says : " At the anterior fossa 
the dura mater was united to the bone by 
a firm, yellow lymph ; here also the bone 
was slightly roughened, but not carious. 
The dura mater on the inner side was 
firmly and inextricably united to the an- 
terior lobes of the brain, especially on the 
right side, and corresponding to the ante- 
rior fossa of the skull. On attempting to 
separate them, a quantity of hard yellow 
material was seen uniting them together. 
This filled up the sulci, and involved the 
cineritious substance. On the right side 
it had penetrated to the medullary mat- 
ter, ancl here the adventitious substance 
formed a tumor, tolerably circumscribed 
on its deep side, the size of a walnut." 
In the liver were some of the characteris- 
tic tough masses, corresponding with a 
puckered and cicatriform condition of the 
surface above them. 
3. Cancer.-Cancerous growths in the 
brain are, according to Lebert, decidedly 
more frequent in the second, half of life, 
though they are met with occasionally in 
youth, or even in childhood. Dr. Walshe 
also found that out of 56 persons affected 
with cerebral cancer, 26 died between the 
ages of 40 and 60 inclusive, whilst 5 died 
before the 10th year, and 5 died between 
the 10th and 20th years. In about one- 
half of the total number of cases cancer of 
the brain is primary. 
All three forms of cancer may occur in 
the brain, though encephaloid is by far 
the most common: next to this Lebert 
speaks of a lardaceous intermediate kind. 
It may exist either in the form of a dis- 
tinct tumor, or it may infiltrate parts of 
the brain. The growths are usually soli- 
tary, though occasionally two or even 
more may be met with. The size of the 
cancerous mass varies from that of a pea 
up to an orange, or even larger. Occa- 
sionally the greater part of one hemi- 
sphere may be implicated. The cancer- 
ous mass is very rarely inclosed in a sort 
of fibrous cyst, but in the majority of 
cases it passes, at some part of its peri- 
phery, almost insensibly into the adjacent 
brain tissue. The color is occasionally 
the same as that of brain tissue, though 
various tints of rose, yellow, and even 
green may be met with either singly or 
intermixed: very many cancerous growths 
in the brain are said to have a yellow 
color. All parts of the brain are liable to 
be affected. Cancerous tumors are fre- 
quently found imbedded in the midst of 
the hemispheres, and, according to Le- 
bert, those near the convexity usually at- 
tain the largest size, whilst those in the 
pons and medulla are usually the small- 
est, owing to the more rapid death of the 
patient when the growth occurs in these 
situations. The duration of life varies 
considerably ; thus in 6 out of 11 cases 
inquired into by Lebert, the growth 
seemed to have proved fatal in about 6 
months, whilst in 4 the symptoms ex- 
tended over a period of from 2 to 5 years. 
The consistence and amount of vascu- 
larity of the cancerous growth vary much 
in different cases. Effusions of blood may 
be met with in the midst of soft cancerous 
masses, and not unfrequently cysts are 
developed in their interior, which contain 
a thick glairy fluid. The surrounding 
brain tissue may be natural (which is fre- 
quently the case), or it may be softened, 
or, still more rarely, in a state of indura- 
tion. The softening may be white, red, 
or of the yellow1 variety. 
Lebert records one instance of a cere- 
bral cancer which, by its progressive 
growth, caused a large perforation of the 
skull, in the situation of the coronal 
suture. 
4. Melanotic Tumors.-These are found 
in the shape of small nodules, generally 
varying in size from that of a pea to a 
bean. They may exist in the deeper 
parts of the brain, or at its surface, in the 
gray matter of the convolutions.2 Some- 
times these growths may be cancerous in 
their nature, but others are certainly not 
so. The black color is due to the infiltra- 
tion of the cells of the growth with black 
granular pigment, similar to that met 
with in the choroid coat of the eye. Dr. 
Ciend inning3 found a mass of melanoid 
deposit in the upper part of the right cor- 
pus striatum, as large as a horse-bean, 
1 Dr. Ogle, in Journal of Mental Science, 
1864, p. 229, cases 1 and 4. 
2 Hooper's Morb. Anat, of Human Brain, 
1828, pl. xii. figs. 2 and 3. 
3 Trans, of Path. Soc., vol. i. p. 42. 
1 Guy's Hosp. Rep. 1863, p. 49. 892 
ADVENTITIOUS PRODUCTS IN THE BRAIN. 
and, external to this, a hard pea-sized 
mass. Similar new formations existed in 
the centrum ovale, and in the right lobe 
of the cerebellum. In this individual, 
growths of the same kind existed also, in 
great numbers, in the subcutaneous tissue, 
and in most of the internal organs except 
the lungs. 
5. Gliomata.-These growths, to which 
the above name has been given by Vir- 
chow, take their origin in the neuroglia 
or interstitial connective tissue of the 
brain. They are, in fact, formed by a 
localized hyperplasia of the neuroglia, and 
contain no nerve elements in their compo- 
sition. These tumors are never sharply 
defined from the surrounding brain tissue, 
to which they bear a certain superficial 
resemblance. On section, however, they 
are often seen to have a somewhat trans- 
lucent, bluish-white appearance, whilst 
at the same time they may be firmer and 
rather more vascular than the brain tissue 
itself. Gliomata are usually solitary, and 
of slow growth, so that they may exist 
for a long time without producing any 
very appreciable symptoms. They often 
attain to a considerable size-that of an 
orange, for instance, and occasionally 
they are even much larger than this. 
They are most frequently met with in 
one or other of the posterior cerebral 
lobes, and after this, perhaps, they occur 
on some part of the upper and outer por- 
tion of the cerebral hemispheres oftener 
than in other situations. The tumors are 
composed of an intercellular substance, 
which varies in quality and consistence 
in different parts of the brain, and of an 
abundant mixture of cells and nuclei. 
The cells are variable in shape and size- 
the smaller ones occasionally possessing 
fine prolongations which are continuous 
with those of adjoining cells. There are 
two principal varieties of gliomata: the 
soft and the hard. The former, contain- 
ing a soft basis substance, and numerous 
moderately large cells, are closely allied 
to medullary sarcomata ; whilst the latter, 
having a harder and firmer basis sub- 
stance, and small cells with highly refrac- 
tive nuclei, have close affinities to fibrous 
tumors. 
Dr. Cayley1 has recorded an interesting 
case in which a tumor of this kind, about 
the size of a large walnut, involved all the 
deeper parts of the right side of the pons, 
the right processus ad testes, the corpora 
quadrigemina to some extent, the right 
half of the valve of Vieussens, and the 
fibres of origin of the right fourth and 
fifth nerves. 
6. Fibro-plastic Tumors.-These growths 
most commonly arise from the pia mater ; 
still occasionally they take their origin in 
the substance of the brain itself. They 
have been found in the midst of the 
hemispheres, in the pons, and in the 
cerebral peduncles. They vary in size 
from a pea to a hen's egg, are mostly 
spherical or ovoid in shape, and with a sur- 
face which is often mammillated or slightly 
lobulated. Their color is generally rose- 
red, mixed with yellowish and" even 
greenish tints. The amount of vascu- 
larity differs in different tumors, and in 
different parts of the same growth. They 
contract no adhesions, and, in general, do 
not infiltrate neighboring parts, although 
they erode by their growth and conse- 
quent pressure. 
Dr. Bristowe has recorded1 a charac- 
teristic instance of the occurrence of a 
tumor of this kind in a man aged 33 years. 
The growth was irregularly spherical, and 
about one square inch in bulk. It arose 
from the right half of the pons and from 
the corresponding crus cerebelli, whence 
it extended for a certain distance into the 
medulla oblongata. The surface was 
lobulated, and had somewhat the appear- 
ance of brain substance, owing to its color 
and the arrangement of vessels on its sur- 
face. There was no defined limits to the 
deeper portion of the tumor, which passed 
insensibly into the surrounding brain tis- 
sue. On section, the substance of the 
growth was grayish and slightly translu- 
cent, interspersed with patches in which 
the vascularity was more marked than it 
was elsewhere. 
Dr. Ogle2 has reported a case of fibro- 
plastic infiltration, in which the new pro- 
duct, instead of forming a distinct tumor, 
had infiltrated itself into the tissue of the 
left optic thalamus, so as to make this 
body almost twice its natural size. 
7. Fibrous Tumors.-These growths are 
very rare, and comparatively few cases are 
on record. They are mostly small and 
spherical, varying in size between that of 
a small pea and a walnut. M. Reignier3 
found a pedunculated growth of this kind 
of the size of a large filbert, growing from 
the valve of Vieussens ; and in the Trans, 
of the Path. Soc., vol. v. p. 18, an account 
is given of a fibrous tumor about the same 
size, which was found projecting into the 
left lateral ventricle, from the side of the 
corpus striatum. Lebert records two 
cases: in one a tumor of the size of a pea 
was found in the pons, composed of a firm, 
elastic, yellow, and somewhat gelatinous 
tissue, but presenting the usual micro- 
scopic characters ; in the other, 17 fibrous 
tumors were situated upon the ependyma 
of the lateral ventricles, varying in size 
between a pea and a small cherry stone, 
and of a white or slightly yellowish, or 
even rose color in some places. On sec- 
1 Trans, of Path. Soc., vol. xvi. 1865, p. 23. 
1 Ibid., vol. vii. p. 28. 
2 Trans, of Path. Soc., vol. vii. p. 12, pl. ii. 
s Bullet, de la Soc. Anat., t. ix. p. 120. MORBID ANATOMY. 
893 
tion they were homogeneous, and some- 
what translucent. Several tumors were 
situated on the septum, and superficially 
they were all covered by epithelial cells, 
similar to those of the ependyma. The 
substance of the brain, in other respects, 
was apparently quite healthy, and there 
was no excess of fluid in the ventricles.1 
8. Osseous Tumors.-True bony growths 
in the substance of t he brain are extremely 
rare, still they have been met with. Dr. 
Bristowe2 found a growth of this kind 
occupying the position of the infundibulum 
and corpora albicantia. It was a hard 
conical mass about as large as a horse- 
bean, whose apex rested on the pituitary 
body, and whose base assisted in forming 
the floor of the third ventricle. It "was 
wholly unconnected with the dura mater 
or osseous parietes of the skull." On 
microscopic examination, it presented the 
characters of the true osseous tissue, with 
perfect lacunae and canaliculi. 
9. Tumors of the Pituitary and Pineal 
Bodies.-Both these bodies are occasion- 
ally found in a morbid condition, and more 
or less enlarged. Cysts are then fre- 
quently met with in their interior. 
a. Pituitary Body.-Lebert considers 
the enlargement of this body to be a kind 
of hypertrophy. Several cases are on re- 
cord. In one of them related by Bayer,3 
this body was about 1|" in diameter, 
whilst its tissue was also more dense and 
resistant than natural. Vieussens4 found 
the "gland" as large as a hen's egg, soft, 
and containing in its interior a grayish- 
white glutinous fluid. Heslop5 records a 
remarkable case in which the tumor was 
soft, deep gray, and of the size of a large 
walnut, containing a small cavity with 
fluid in its interior. It occupied the region 
of the pituitary body, and also extended 
posteriorly as far back as the pons, and 
antero-laterally to the fissures of Silvius, 
so as to occupy the whole interpeduncu- 
lar space. The corpora quadrigemina 
were flattened antero-posteriorly, from 
pressure. Abercrombie6 also refers to a 
case described by Dr. Powell, in which 
there was found " a tumor of the size of a 
hen's egg, containing a thick purulent 
fluid under the anterior part of the brain, 
and interposed betwixt the optic nerves, 
which were much separated by it from 
each other. Below it was attached to the 
pituitary gland, which was very soft, and 
enlarged to five or six times its natural 
size." Davaine1 records three cases in 
which small cysts (supposed to be hyda- 
tids) were found in the pituitary body. 
b. Pineal Body.-Hooper2 says, speak- 
ing of this body: "It is sometimes con- 
verted into a cyst, the whole of the natu- 
ral structure being destroyed. This cyst 
is firm and membranous, and I have seen 
it of the size of a tamarind stone. The 
contents of one which I examined were, a 
turbid serous fluid, with small particles of 
solid albumen." Dr. Ogle3 also relates a 
case in which "the brain and membranes 
were natural, excepting that the pineal 
gland was exceedingly enlarged and very 
adherent, posteriorly, and contained two 
cavities, each full of transparent fluid, 
situated immediately below its investing 
membrane." 
10. Formation of Gray Matter upon the 
Ependyma of the Ventricles.-Rokitansky 
and Virchow4 have both described the 
existence of cerebral gray matter upon the 
internal surface of the lateral ventricles, 
in situations where, naturally, gray mat- 
ter does not exist. It occurs in the form 
of numerous small tubercles, from the size 
of a mustard seed to that of a cherry 
stone. 
11. Vascular erectile Tumors.-1These 
growths are very rare. Nevertheless, 
Lebert has given the particulars of five 
cases in which they were found.5 In all 
they were discovered post mortem, but had 
given rise to no notable symptoms during 
life. In one of these eases the growth 
was lodged in the right lateral ventricle, 
and was a development from the choroid 
plexus, but in the other four the tumors 
were imbedded in the cerebral substance. 
In the case related by Farre6 the 
growths were multiple ; two of the same 
size being met with in the medullary sub- 
stance of the left hemisphere, and several 
small growths in the corpora striata and 
cerebellum. Lebert7 himself has min- 
utely described an erectile tumor, of the 
size of a hen's egg, found in the posterior 
lobe of the right cerebral hemisphere, and 
Luschka,8 met with one of the same size 
1 Trait6 des Entozoaires. Paris, 1860, p. 
656. 
2 Morb. Anat, of Human Brain, 1828, p. 
43, pl. xii. fig. 8. 
3 Brit, and For. Rev., July, 1865, p. 235, 
He also adds that the Museums of King's Col- 
lege and of St. Thomas's Hospitals contain 
one specimen each of an enlarged pineal 
gland, hollowed out into a cyst. 
4 Wiirtzburger Verhandlungen t. ii. p. 
167. 
5 Gu^rard, Bullet, de la Soc. Anat., t. viii. 
p. 223. 
6 Leubuscher, Die Patholog. und Therap. 
der Gehirnkrankheiten, p. 413, Berlin. Origi- 
nal reference not ascertained. 
7 Anat. Path., t. i. p. 213. 
5 Archiv fur Path. Anat., t. vi. 1854, p. 458. 
1 Anat. Path., vol. ii. p. 71. 
3 Trans, of Path. Soc., vol. vi. p. 25. 
3 Archiv. G6n. de M6d., Ire S^r. 1823, t. 
iii. p. 350. 
1 Nov. Vasor. Corp, humani Syst.; Amstelo- 
dami, 1705, p. 248. 
5 Dublin Quarterly Journal of Medicine, 
Nov. 1848. 
6 Diseases of the Brain, &c., 3d ed. 1836, 
p. 438. 894 
ADVENTITIOUS PRODUCTS IN THE BRAIN. 
in the left anterior cerebral lobe, which 
was surrounded by softened brain sub- 
stance. Lastly, Forster1 alludes briefly to 
an erectile tumor of the size of a nut, 
found in the gray cortical substance of 
one of the hemispheres, the cavernous 
spaces of which were found to communi- 
cate with neighboring dilated veins. The 
tumors described by Lebert, Farre, and 
Guerard were made up almost entirely of 
tine vascular ramifications. 
12. Aneurisms.-The intracranial aneu- 
risms which are best known are those oc- 
curring on some one or other of the larger 
arterial trunks at the base of the brain, 
or on some of the branches of the circle 
of Willis lying m the midst of the pia 
mater and therefore whilst they are still 
on the surface of the proper brain sub- 
stance. Such aneurisms belong to the 
meninges, and will not be further referred 
to in this place. 
There are, however, aneurisms belong- 
ing to the encephalon itself, whose exist- 
ence has only recently been discovered, 
and which are remarkable principally for 
their small size, and on account of their 
frequent numerical abundance within the 
same brain. These were first detected 
and examined by MM. Charcot and Bou- 
chard,2 the latter of whom has shown, 
not only their frequent and close associa- 
tion with the phenomena of intracranial 
hemorrhage, but also their apparent de- 
pendence upon a certain general patho- 
logical condition of the small encephalic 
arteries, which may exist alone, or may 
be associated, in various degrees, with the 
more familiar atheromatous degeneration. 
The pathological condition of the arteries 
favorable to the formation of these minute 
aneurisms is one of fibroid degeneration 
•-a process of sclerosis in which there is 
brought about a great increase in the 
number of connective tissue nuclei on the 
perivascular sheaths, and also in the walls 
of the vessels, whilst the muscular fibre 
cells of the middle coat are gradually re- 
placed by fibrous tissue. This change 
diminishes, or even destroys, the elas- 
ticity of the arterial coats, so that when, 
from any increase of the ordinary blood 
pressure, they have once become unduly 
dilated, they are unable to regain their 
normal calibre. In this way, by the inci- 
dence of increased pressure upon degene- 
rated parts, are produced the various 
kinds of aneurismal dilatations, whose 
characters differ according to the degree 
and extent of the morbid changes in the 
parts involved. Thus, we may have uni- 
form dilatation of an arterial branchlet, 
for a certain portion of its length, or this 
uniform dilatation may be interrupted by 
constrictions at intervals, owing to tlie 
presence of similarly situated sounder por- 
tions of the arterial walls. The kind of 
alteration with which we are more par- 
ticularly concerned at present, however, 
and which is also the most frequent, is 
due to an altogether local and circum- 
scribed change, and results in the forma- 
tion of the minute and more or less 
spherical miliary aneurisms, as MM. Char- 
cot and Bouchard propose to name them.1 
These miliary aneurisms are very rarely 
met with before the middle of life, and 
[Fig. 52. 
Miliary Aneurisms. (Hamilton.)] 
are most common in the very aged. They 
are visible to the naked eye, and can be 
seen readily with the aid of a pocket lens. 
Their diameter varies between T£5" and 
2>5", and they are attached to vessels 
which seldom exceed j'n" in diameter. 
Sometimes only two or three can be de- 
tected in the same brain, though more 
frequently they exist in much larger num- 
bers. Bouchard has found even more 
than one hundred in the same brain. 
They may be met with in all parts of the 
encephalon, though with different de- 
grees of frequency in different situations. 
Hitherto they have been found most fre- 
quently in the optic thalami, and then, in 
decreasing order, in the pons Varolii, the 
cerebral convolutions, the corpora striata, 
the cerebellum, the medulla oblongata, 
the middle cerebral peduncles, and, lastly, 
in the white matter of the cerebral hemis- 
pheres. When abundant in the convolu- 
1 Cruveilhier (Anat. Patholog., Liv. xxxiii. 
pl. ii. fig. 3) figures and gives an accurate 
description, so far as it goes, of these very 
miliary aneurisms under the name of " apo- 
plexie capillaire & foyers miliares." He was 
therefore ignorant of their real nature, though 
perfectly familiar with the naked-eye appear- 
ance. 
1 Lehrb. der Patholog. Anat., p. 418. 
2 Bouchard, De la Pathologic des Hemor- 
rhagies cerebrates. Paris, 1867. See also 
joint papers by MM. Charcot and Bouchard, 
in the Journal de Physiologie, 1868-69. 895 
MORBID ANATOMY. 
tional gray matter, a number of minute 
and variously colored spots may be seen, 
after the membranes have been stripped 
off, lying exposed on the surface of the 
convolutions ; whilst, when sections are 
made, others may be recognized in the 
deeper strata of the gray matter. Whether 
occurring in this situation or in the more 
central parts of the brain, the color of the 
minute aneurismal grains varies from a 
bright red or violet, to a yellowish or even 
black hue according as they contain in 
their interior normal fluid blood, or more 
or less altered blood pigment. Occasion- 
ally the aneurisms secin to undergo a 
natural process of cure. Their wall, as 
well as that of the enveloping and some- 
times adherent lymphatic sheath, becomes 
thickened by an increased growth of con- 
nective tissue elements, whilst at the same 
time the white corpuscles of the blood 
have a tendency to adhere to their inner 
surface. The fibroid change creeps on, 
bringing about, sooner or later, a union 
between the wall of the aneurism and 
its sheath, the gradual thickening of these, 
and an extension of growth inwards, 
probably owing to a further organization 
taking place in the substance of the ad- 
herent and fused white corpuscles. Thus 
may the cavity of the aneurism be grad- 
ually diminished, till at last this, and even 
the minute vessels on which it is situated, 
may undergo complete obliteration. 
Such intra-cerebral "miliary" aneurisms 
may coexist with other and much larger 
aneurisms of the vessels of the pia mater. 
Bouchard speaks of a case of this kind 
where the aneurisms of the arteries of 
the pia mater were not only exceedingly 
numerous, but varied in size between a 
pea and a cherry stone. In other cases, 
minute aneurisms of these meningeal ar- 
teries may be met with precisely similar 
to those coexisting on the vessels in the 
midst of the brain substance. Frequently 
when miliary aneurisms are met with in 
the smaller cerebral arteries, the larger 
arteries at the base of the brain exhibit 
marked atheromatous changes: such a 
coincidence, however, is by no means in- 
variable. 
Although the majority of intra-encepha- 
lic aneurisms are minute, and such as we 
have described, occasionally others of 
larger dimensions are met with. The 
size of the largest, however, could rarely 
exceed that of a small walnut, seeing 
that the arteries of the brain are com- 
paratively small before they leave the pia 
mater to penetrate into its substance. 
We have collected the records of five 
cases of this kind of aneurism, and in 
each of these the patient's death was oc- 
casioned by the rupture of the sac. The 
[Fig. 53. 
Cerebellar Aneurism. (Bristowe.) 
first is related by Dr. Crisp,1 and in this 
a boy aged fourteen died from the rupture 
of one or two small aneurisms on the an- 
terior cerebral artery, in the substance of 
the anterior lobe. The aneurism which 
burst was as large as a horse bean, whilst 
the other was about the size of a pea, and 
was filled with laminated fibrin. The 
next case was recorded by Dr. Van der 
Byl,2 and was altogether remarkable from 
the fact that the aneurism, which was 
situated on the left posterior cerebral 
artery in the substance of the brain, was 
as large as a hen's egg, and was almost 
filled with laminated fibrin. In one case 
recorded by Dr. Gull,3 a small pyriform 
aneurism, ''having much the appearance 
and size of a withered grain of wheat," 
burst in the centre of the pons Varolii, 
and was found in the midst of a coagulum 
weighing two drachms. Dr. Gull gives 
the details of another case in which an 
aneurism about the size of a small filbert, 
situated on the middle cerebral artery, in 
the anterior part of the middle cerebral 
lobe, was found in a girl aged seventeen, 
surrounded by a large recent coagulum, 
and by softened brain tissue. The other 
arteries of the brain are said to have been 
healthy. Lastly, the writer has himself 
recorded a case4 in which an aneurism, 
about in length and of an elongated 
pyriform shape, with a distinct rupture 
in its larger extremity, was taken from 
the midst of an enormous effusion of blood 
1 Occasionally this blood pigment, in the 
form of amorphous yellow grains mixed with 
hsematoidine crystals, may be principally 
collected around one of these aneurisms 
(which has been ruptured), though within 
its enveloping lymphatic sheath. 
1 Diseases of Arteries, p. 165. 
2 Trans, of Path. Soc., vol. vii. p. 129. 
3 Guy's Hosp. Reports, 3d Series, vol. v. 
(1859), p. 297. 
4 Trans, of Path. Soc., vol. xviii. 1867. 896 
ADVENTITIOUS PRODUCTS IN*THE BRAIN. 
into the outer part of the right corpus 
striatum and adjacent portions of the 
hemisphere. In this case there was an 
atheromatous condition of the arteries at 
the base of the brain, and, besides the 
larger aneurism, four or five of the small 
miliary aneurisms were found in different 
parts of the organ.1 > 
13. Bloodclots. See Art. "Apoplexy." 
14. Abscesses. See Art. "Abscess in 
Brain." 
15. Plastic Lymph on the surface of the 
Ventricles.-A well-marked instance of 
this has been related by Dr. Wilks.2 It 
occurred in a man who had fractured 
the left orbital plate of his frontal bone 
by a fall. A portion of the broken bone 
had torn through the dura mater and had 
injured the anterior lobe of the brain, so 
as to lead to the subsequent production 
of an abscess in this situation. The man 
died after seventeen days: "on incising 
the roof of the ventricle (left) a membrane 
was found within it; and on cutting this 
through it was found to consist of a layer 
of lymph, which completely lined the 
cavity. Some purulent matter escaped 
from within it. It covered the roof, the 
floor, and extended from the anterior 
to the descending cornu, and was so 
tough that it was capable of being re- 
moved entire; it formed, indeed, a com- 
plete cast of the cavity, and resembled a 
croupous membrane, as seen on the trachea 
in inflammation of that organ. The sur- 
face of the ventricle was soft, and in parts 
tore when the membrane was removed; 
but in most places it could be cleanly 
taken off. The foramen of Munro was 
closed, and the right ventricle contained 
only some turbid serum." It was uncer- 
tain whether there was a communication 
between the abscess and the ventricle, 
but the lymph was undoubtedly produced 
on the surface of the latter. 
16. Cysts.-It seems extremely doubtful 
■whether simple serous cysts are ever met 
with in the substance of the unaltered 
brain tissue. Those most likely to be of 
this nature are small cysts from the size 
of a pin's head to that of a mustard seed, 
which are sometimes met with beneath or 
projecting above the surface of the lateral 
ventricles. They occur either singly or 
in groups. 
The corpora striata, on section, some- 
times present the appearance of small 
cysts, even as large as a pea. These may, 
however, be either sections of dilated 
lymphatic canals, or cavities left after 
minute softenings. 
It is true that larger cysts are not un- 
frequently met with in the brain, but 
these, when not due to one of the two 
forms of cystic entozoa, to be hereafter 
described, should rather be termed pseudo- 
cysts, since they are not primary forma- 
tions, but have, in all probability, resulted 
from the modification of pre-existing pa- 
thological states. Such cavities or pseudo- 
cysts mostly result from the later changes 
taking place in the seat of old effusions of 
blood,1 or of circumscribed softenings ; or 
else they are due to the softening of en- 
cysted tubercular2 or cancerous nodules. 
Cysts occasionally form in the substance 
of cancerous growths in the brain, and, as 
before stated, they have several times been 
met with in the interior of enlarged pitui- 
tary and pineal bodies. 
17. Calcareous and other Concretions.- 
These are not unfrequently met with in 
the brain, and are mostly due to changes 
which have taken place in masses of tu- 
bercle or in old abscesses. Such concre- 
tions consist for the most part of phos- 
phate and carbonate of lime, and only 
contain a small quantity of animal mat- 
ter. More rarely concretions may be met 
with which seem to have resulted from 
previous effusions of blood: thus Las- 
saigne3 analyzed a mass which was found 
to be composed almost wholly of fibrine, 
and contained only four per cent, of phos- 
phate and carbonate of lime, with traces 
of cholesterine. 
Concretions known as " brain sand" are 
very common on or in the pineal gland 
and its peduncles. 
18. Entozoa.-Two kinds of parasites 
only have been met with in the human 
brain, and these always in an immature 
or larval condition. They are the Cysti- 
cercus, and the Hydatid or Echinococcus 
cyst: the first representing the second, or 
scolex stage, in the development of Tcenia 
Solium, and the other an equivalent stage 
of T. Echinococcus, an animal which ex- 
ists abundantly in its mature condition in 
the alimentary canal of dogs. Goeze and 
Zeder4 have recorded two cases in which 
they suppose the Camurus cercbralis to 
have been met with, but they have not 
been supported by other observers, and 
Davaine believes these cases, in reality, 
to have been instances of hydatid disease. 
Certainly, as he says, the descriptions 
these writers have given are obscure and 
inexact, and we may well imagine mistakes 
to have been made, when we consider what 
was the state of knowledge concerning 
helminths at the time in which they wrote. 
a. Cysticerci.-In the brain these vary 
1 Many cases are recorded by Dr. Ogle 
(Med.-Chir. Rev., July, 1865, p. 212). 
2 Trans, of Path. Soc., vol. v. p. 26. 
J Clinique Med., t. v. p. 8. 
4 Nachtrag zur Naturgesch. der Eingeweide- 
wurmer, 1800, pp. 308 and 313, tab. ii. figs. 
5-7. 
[' See an article on Intra-cranial Aneurisms, 
by Dr. J. H. Hutchinson, in Penna. Hospital 
Reports, vol. ii. 1869.-H.] 
2 Trans, of Path. Soc., vol. xv. p. 5. 897 
MORBID ANATOMY. 
in size from that of a pea to a small horse- 
bean, or even larger. The serous cysts, 
in which they are usually inclosed in other 
situations, are often absent entirely, so 
that they are bounded only by a smooth 
layer of unaltered or somewhat compressed 
brain substance. They often exist in large 
numbers in the same brain, and are very 
rarely solitary. From ten to twenty are 
frequently met with. Cruveilhier1 records 
an instance in which more than 100 were 
found within the cranium of the same 
individual, and of these about 50 were 
lodged in the cerebellum. They may be 
found in almost all parts of the brain, but, 
speaking generally, they are by far the 
most abundant at the surface of the brain, 
in, or in close connection with the gray 
matter of the convolutions. They are ex- 
tremely frequent in the pia mater, also 
where they press upon and partially im- 
bed themselves in the surface gray matter. 
Sometimes they are lodged in the midst of 
the gray matter itself, whilst more fre- 
quently still they are found intervening 
between this and the white substance. 
They have, moreover, been seen in the 
midst of the white substance, in the cen- 
tral ganglia, in the pons, in the crura 
cerebri, and in the cerebellum as before 
stated; whilst Cruveilhier says he has 
seen real cysticerci in the choroid plex- 
uses of the lateral ventricles. In the lat- 
ter situation they have to be carefully dis- 
criminated from the small, non-parasitic 
cysts which so frequently occur in the 
same locality. 
Although usually giving rise to but 
slight changes in the surrounding brain 
matter, the cysticerci themselves undergo 
important modifications with age. It is 
desirable that this fact should be known, 
in order that pathologists may recognize 
them in their different stages, and that 
individual developmental modifications 
may not be mistaken for specific distinc- 
tions. According to Davaine,2 "Les alte- 
rations portent, d'une part, sur la vesicule 
qui est devenue plus ou moins globuleuse, 
plus volumineuse, sans jamais cependant 
avoir acquis un grand volume, irreguliere, 
quelquefois divisee en lobules ou meme 
double; d'une autre part elles portent sur 
la tete dont le rostre et les ventouses sont 
envahis par une matiere noiratre, pigmen- 
taire. Les crochets sont recouverts a leur 
base par cette matiere. Dans une periode 
plus avancee on les trouve en desordre, 
diminues de nombres ou meme ils ont dis- 
paru. L'ouverture de la vesicule retrecie 
ou obliteree ne laisse plus sortir le corps ; 
la tete invaginee dans celui-ci ne peut non 
plus en etre extraite par une pression me- 
nagee ; sa presence ne pent etre reconnue 
que par la dilaceration des parties." It 
should also be added that in those cases 
where the cysticercus is non-encysted-as 
when it is lodged freely in one or other of 
the ventricles - it tends to grow more 
easily into the form of a tapeworm, by 
the elongation and segmentation of the 
neck of the larval animal.1 
The cysticerci seem to occur* pretty fre- 
quently in both sexes. They may be met 
with also at all ages beyond infancy, 
though, as Cruveilhier has remarked, 
they seem to be most frequent in the lat- 
ter half of life, and have often been met 
with in very old people.2 
b. Hydatids.3-In the brain, as in other 
1 Thus constituting the third stage of de- 
velopment, when the animal is termed a 
strobilus. See Brit. Med. Journ. 1859, p. 272, 
where a specimen, apparently in this stage 
of development, is recorded to have been met 
with in connection with the fourth ventricle. 
2 Dr. Cobbold says that more than 100 
cases of cysticerci in the brain are on record. 
References to many may be found in his En- 
tozoa, p. 224, and Professor Griesinger (Ar- 
chiv der Heilkunde, 1862) has analyzed the 
details of between fifty and sixty of these 
cases. 
3 The following remarks do not refer in 
any way to hydatids having their seat in or 
between the membranes of the brain. From 
various sources I have ascertained the details 
of thirty cases of hydatids contained within 
the cerebrum and cerebellum. I have seen 
references to a few other cases also, of which 
I have not been able to ascertain the details. 
For many of the references I have been in- 
debted to Davaine's Traite des Entozoaires, Dr. 
Cobbold's Entozoa, and Dr. Ogle's paper in the 
Med.-Chir. Rev. July, 1865, p. 206. The refer- 
ences to these 30 cases are: 1. Martinet, Bond. 
Med. Repos. 1824, vol. ii. p. 408.-2. Baily, 
Bond. Med. Repos. 1826, vol. ii. p. 144.-3. 
Morrah, Med.-Chir. Trans., vol. ii. p. 262.-4. 
Hooper, Morb. Anat, of Human Brain, 1826, pl. 
xiv. p. 65.-5. Dalgleish, Lancet, 1832, p. 168. 
-6. Guerard, Lancet, 1835, p. 45.-7. Bree,. 
Lancet, 1837, p. 53.-8. Sturton, Lancet, 1840,. 
p. 494.-9. Berncastle, Lancet, 1846, p. 635.- 
10. Barker, Trans, of Path. Soc. 1859, vol. x. 
p. 6.-11. Baillarger, Brit. Med. Jour. 1861,. 
p. 286.-12. Risdon Bennett, Med. Times,. 
1862, p. 80.-13. Ogle, Brit, and For. Rev. 
July, 1865, p. 207.-14. St. Thomas's Hosp. 
Mus. No. 101.-15. St. Barthol. Hosp. Mus. 
No. 60.-16. Davaine, Gaz. MSd. de Paris, 
1862.-17. Abercrombie, Diseases of the Brain, 
&c., 3d ed. 1836, p. 447.-18. Zeder, Davaine's 
TraitS des Entoz. 1860, p. 644.-19. Barth, 
Bull. Soc. Anat. ann. xxvii. 1852, p. 108.- 
20. Calmeil, Diet, de Med., art. EncSphale, t. 
xi. p. 588, 1835.-21. Faton, Bull. Soc. Anat. 
1848, p. 344.-22. Becquerel, Gaz. Med. de 
Paris, 1837, p. 406.-23. Rendtorff, Dissert, 
do Hydat., cap. 10, p. 22, Berlin, 1822; and 
Livois, Rech, sur les Echinoc. p. 100, These, 
Paris. 1843.-24. Cazeaux, Bull. Soc. Anat.. 
1 Anat. Path. GSn., t. ii. p. 88. Paris, 
1852. 
2 TraitS des Entozoaires. Paris, 1860, p. 
657. 
vol. i.-57 898 
ADVENTITIOUS PRODUCTS IN THE BRAIN. 
organs, the hydatid or hydatids are mostly 
inclosed within an outer sac or cyst. In 
this organ, however, it is generally very 
thin, and in some cases it has been stated 
to have been altogether absent, the hy- 
datid membrane pressing immediately 
against the compressed brain tissue. 
When they occur in the lateral ventricles, 
the enveloping cyst is always absent. In 
the great majority of cases, only one hy- 
dated cyst is met with, though this may 
contain two, three, or more hydatids of 
different sizes ; usually, however, a single 
cyst exists containing a single hydatid. 
The size of the cyst varies, generally, 
from that of a marble up to a large orange, 
though occasionally this limit is much ex- 
ceeded. Thus, in a case observed by Mr. 
Headington and reported by Dr. Aber- 
crombie,1 an immense hydatid cyst was 
found within the left lateral ventricle, 
which nearly extended to the circumfer- 
ence of the brain on the same side, and 
" contained about sixteen ounces of limpid 
fluid and in another case, recorded by 
Rendtorff, an enormous mass of hydatids 
weighing two and a half pounds, was 
found in the same situation, in a girl only 
eight years of age. The cyst is frequently 
lodged in the centre of the white matter 
of one of the hemispheres, and it may in- 
crease in size till it occupies almost the 
whole of one of the lobes-anterior, mid- 
dle, or posterior, as the case may be. 
Occasionally it occupies the greater part 
of two contiguous lobes, and may project 
towards the circumference, as well as into 
the lateral ventricle. In both these situ- 
ations the cy st may be covered only by a 
thin layer of nerve substance; or it may 
be uncovered, owing to the brain tissue 
having disappeared under the influence of 
the gradually increasing pressure. I have 
only found one case on record in which 
an hydatid cyst was lodged in the sub- 
stance of the cerebellum ; in this instance, 
however, it was large, measuring three 
inches by two, projecting into the fourth 
ventricle, and extending transversely 
across from the right to the left lobe, so 
as to be covered by a coating of brain 
matter at each extremity not thicker than 
a wafer. 
Although usually only one hydatid cyst 
is met with in the brain, still sometimes 
two or three, or even many, are encount- 
ered in different parts of the organ. In 
these cases their size is generally in the 
inverse proportion to their number; so 
that in some instances, instead of meeting 
with one large cyst, such as we have be- 
fore alluded to, we encounter a number of 
little ones varying in size between a mus- 
tard seed and a hazel-nut.1 
As an instance of multiple hydatids I 
may refer to a case recorded by LeveillS, 
and quoted by Davaine, in which many 
were found in the meninges and at the 
surface of the brain, in the corpus callo- 
sum, in the left middle cerebral lobe, in 
the right optic thalamus, and in other 
parts. 
The increase in size of the hydatid be- 
ing usually slow and gradual, little or no 
change is generally observed in the sur- 
rounding brain substance, which gradu- 
ally atrophies under the pressure of the 
growing cyst. But occasionally conges- 
tion or softening does occur in the sur- 
rounding brain tissue, and, more rarely 
still, the presence of an hydatid in some 
portion of the brain seems to excite 
changes in the whole organ, and even in 
the cranium. Thus in the case'of hydatid 
in the cerebellum, before alluded to, oc- 
curring in a man 24 years of age, the 
brain was found to be denser and firmer 
than usual, the ventricles distended with 
four ounces of clear fluid, and the skull- 
cap extremely thin, having a medium 
thickness of not more than about and 
at the squamous portions of the temporal 
bone being quite wafer-like, and not more 
than 31/' in thickness. In a remarkable 
case recorded by Dr. Barker (10): "The 
calvaria was healthy but exceedingly thin, 
so as to be transparent in numerous 
places ; the outer surface was natural, 
but the inner presented a series of shallow 
depressions, separated by angular ridges, 
evidently produced by the long-continued 
pressure of the subjacent convolutions, of 
which they presented an accurate mould. 
The surface also was congested, rough, 
and softer than natural. The base of the 
skull and its dura mater were healthy. 
There was no sub-arachnoid fluid, the 
convolutions being compressed against 
each other, and against the parietes, so as 
to obliterate the sulci; the surface was 
not congested. In the posterior lobe of 
the right cerebral hemisphere was a hy- 
dated cyst, occupying nearly the whole 
ann. viii. 1833, p. 106.-25. Carrere, Diet, 
de Med. de Chir. et d'Hygiene VStSrin. 1839, 
t. vi. p. 157, art. Tournis.-26. Tonnele, Bull. 
Soc. Anat. ann. xxvi. 1851, p. 165, case xxxi. 
-27. Chomel, Gaz. des Hopit., t. x. 1836, p. 
619.-28. Montansey, Bull. Soc. Anat. ann. ii. 
1827, p. 188.-29. Aran, Arch. Gen. de Med., 
3me. Ser. t. xii. 1841, p. 98.-30. Leroux, 
Cours sur les G6ner. de M6d. prat., t. ii. p. 
12, Paris, 1825. 
1 Diseases of the Brain, &c. 3d edit. 1836, 
p. 447, case xxxiii. 
1 In cases of multiple hydatids, their small 
size may be explained by the fatal nature of 
the malady, and the early death of the pa- 
tient. The duration of the life of the patient 
naturally varies according to the situation 
and number of the hydatids. Davaine re- 
cords one case (loc. cit. p. 650) in which a 
large single cyst must have been four years 
old. MORBID ANATOMY. 
899 
lobe, which was thus converted into a 
fluctuating cyst. It had rendered the 
lobe irregular, and lobulated, and in- 
creased its dimensions ; but the hydatid 
was covered everywhere by brain sub- 
stance, although in many situations it 
was a mere film. The lobulated character 
seemed to have been produced by the 
superficial veins acting as ligatures. The 
cyst was single, about as large as a mid- 
dling-sized orange, and contained two 
hydatids, one nearly as large as the cyst 
itself, the other the size of a walnut. They 
contained no secondary cysts : the brain 
in all other respects was healthy." 
The hydatids met with in the brain are 
almost always barren, and thus correspond 
with the acephalocysts of Laennec. Some- 
times they are perfectly simple, but they 
may contain smaller secondary cysts in 
their interior, or bear them as buds on 
their exterior surface. The hydatids usu- 
ally contain a clear, limpid fluid, and their 
walls are made up of the usual thin, struc- 
tureless, and concentrically arranged la- 
mellae. In only two (12 and 23) out of the 
thirty cases of which I have read the de- 
tails, is any mention made of the hydatids 
containing echinococci or their remains. 
In these fertile cysts, in addition to the 
echinococci, the remains of the fibro- 
granular germinal membrane may be de- 
tected on the internal surface of the hy- 
datid. Many cases of so-called hydatids 
in the brain are recorded by old writers, 
which have but a very doubtful right to 
this title. The word was formerly used 
with great laxity; everything in the 
shape of a cyst receiving this appellation 
-even the vesicles so common in the cho- 
roid plexus, which are now known, in the 
great majority of cases, to be simple 
serous cysts. 
Hydatids in the brain seem to occur as 
often in the one sex as in the other. As 
regards time of life, they seem to be met 
with, in the great majority of cases, in 
individuals between the ages of 10 and 30 
years. I have found the age of the pa- 
tient stated in 24 out of 30 cases: of these, 
3 were below 10 years of age (5, 7, and 8 
years), and 3 above 30 years (one "middle 
age," 37, and 38), whilst the remaining 
18 were between the ages of 10 and 30 in- 
clusive.1 This is very notable, and in 
striking contrast with what is known con- 
cerning the cysticercus and its tendency 
to occur rather in the latter half of life, 
than in younger individuals. We know 
so little as to the mode in which the hu- 
man body becomes infected with these 
cystic entozoa, that it is extremely diffi- 
cult to explain such peculiarities. We do 
know, however, that the adult or fully de- 
veloped condition of the echinococcus hy- 
datid exists in the intestines of the dog, 
though, of course, not in that of all dogs, 
and perhaps we may also say that indi- 
viduals between the ages ot 10 and 20 
years, have generally more to do with 
these animals than those of an earlier or 
more advanced age. This is a mere sug- 
gestion which, unfortunately, we are un- 
able further to develop. 
19. Silver and Lead.-In the 11th vol. 
of the Transactions of the Pathological 
Society an account is given by Mr. Sydney 
Jones of the post-mortem appearances in 
an old epileptic, who had for several years 
been in the habit of taking nitrate of silver 
as a remedy. "The choroid plexuses 
were remarkably dark : from their surface 
could be scraped a brownish black soot- 
like material; a similar substance was 
found lying quite free in the cavity of the 
fourth ventricle, apparently detached from 
the choroid plexus." A specimen of me- 
tallic silver was obtained from the plexus. 
Lead has several times been detected 
by the aid of chemical analysis in the 
brain. 
Hypertrophy.-The accounts given by 
Dance,1 Andral,2 and Rokitansky,3 of the 
morbid appearance presented in the so- 
called hypertrophy of the brain, are so 
harmonious and striking as to point un- 
doubtedly to some definite structural 
modification, differing altogether from 
the enlargement due to congestion. A 
similar condition has also been noticed, 
and more briefly alluded to, by Bouillaud4 
and Laennec.5 
Dance and Andral give the post-mortem 
appearances met with in seven adults, 
one of whom was 39 years of age, whilst 
the others varied between 26 and 30. In 
these examinations the following patho- 
logical conditions were met with :-The 
skull was of average size and shape; a 
great turgescence of the brain was noticed 
on the removal of the skullcap, which 
became even more manifest when the 
dura mater was cut; the dura mater 
itself was rather thin, and the arachnoid 
and pia mater remarkably exsanguine, 
free from all moisture, and easily torn ; 
the convolutions were completely flat- 
tened, and separated only by small lines 
of demarcation, instead of well-marked 
sulci ; on section, the substance of the 
brain was found to be extremely anaemic, 
with much less than the usual distinction 
1 Repert. d'Anat. Patholog. par Breschet, 
1828. 
2 Clinique Medicale, Trans, by Spillan, 
1836, p. 174. 
3 Patholog. Anat. (Syd. Soc.)4 vol. iii. p. 
373. 
4 Traite de I'EncSphalite. Paris, 1825. 
6 Journal de Med. de Chirurg. et de Pharm., 
t. xi. p. 669. 
1 Several cases of hydatids in the mem- 
branes of the brain, of which I have read, 
have, however, been over this age. 900 
ADVENTITIOUS PRODUCTS IN THE BRAIN. 
between the gray and the white matter, 
owing to the extreme paleness of the 
former; the white substance presented 
an almost completely bloodless section, 
whilst its density and consistence were so 
much increased as to make it comparable 
to " the white of an egg hardened by boil- 
ing the ventricular cavities were very 
small, and quite devoid of fluid; and 
lastly, these changes, though affecting the 
whole of the cerebrum, did not extend to 
the cerebellum, pons, medulla, and cord, 
all of which had their natural consistence. 
But there is another form of "hyper- 
trophy" of the brain, which is of much 
more frequent occurrence. This is met 
with in some young children, who present 
obvious marks of being rickety, and is 
usually indicated by the existence of more 
or less enlargement and alteration in the 
shape of the cranium. The skull becomes 
especially prominent in the frontal region, 
and often approximates somewhat to the 
form met with in hydrocephalus. In this 
variety of hypertrophy, also, there is more 
or less compression of the brain, as indi- 
cated by the existence of anatomical cha- 
racters similar to, though less strongly 
marked than those already described. 
Whether any relationship exists be- 
tween the hypertrophy of the brain as it 
occurs in adults, and that which occurs in 
childhood, is not known. Nor are we 
better informed as to the precise nature 
of the histological change. We neither 
know whether it is the same in both cases, 
nor what it is in either. Most patholo- 
gists seem to agree in the supposition, 
that the increased bulk is due to an aug- 
mentation of the interstitial substance or 
neuroglia of the cerebral hemispheres, 
rather than to an increase in the number 
or size of the proper nerve elements. So 
that, if this be true, the disease cannot be 
looked upon as a hypertrophy of the brain 
in any strict sense of the term. It has 
been held by Rokitansky that there is an 
actual increase in the amount of neuroglia, 
whilst Sir William Jenner and others are 
of opinion that, in childhood at least, and 
when associated with rickets, the enlarge- 
ment of the brain is due to an infiltration, 
more particularly of the anterior lobes, 
with an albumenoid material similar to 
that met with in the liver, spleen, and 
other organs. If this be the case, then 
the brain substance ought to yield the 
ordinary reaction with iodine ; and the 
characteristic changes in the coats of the 
arteries, peculiar to this albumenoid de- 
generation, should be recognizable. Accu- 
rate and careful microscopic observations 
as to the nature of the morbid changes 
have yet to be made, and without these 
no real li^ht can be thrown upon the 
pathology of these remarkable affections. 
There are, however, two other cases of 
hypertrophy of the brain on record, which 
differ notably in all respects from the 
forms to which I have just alluded. In 
both there was great enlargement of the 
cranium as well as of the brain; and, 
owing to this coincident enlargement of 
the brain and its case, there was not only 
an absence of the signs of compression of 
this organ during life, but also an utter 
absence of the pathological appearances 
peculiar to the other forms of hypertro- 
phy. The particulars of one case, that of 
a child who died at the age of five years, 
have been narrated by Dr. Scoutetten ;* 
whilst those of the other, a patient of Dr. 
Sweetman, who died when a little more 
than two years of age, have been detailed 
by Sir Thomas Watson.2 In both these 
children, the head equalled that of an 
adult in size, the skull was somewhat 
thickened, the dura mater was unduly ad- 
herent to it, the arachnoid was moist, the 
pia mater fully injected, and the convolu- 
tions not at all flattened. The ventricles 
were small: in M. Scoutetten's case they 
contained a very slight amount of reddish 
serum, whilst in Dr. Sweetman's they 
were empty. In this latter case, also, the 
surfaces "of the medullary matter,exposed 
by repeated sections, presented very unu- 
sual vascularity." Nothing is said con- 
cerning the amount of vascularity in M. 
Scoutetten's case, and in neither of the 
reports is any mention made of an undue 
consistence or alteration in density of the 
nerve matter. The amount of brain sub- 
stance above and behind the ventricles 
seemed to be more especially increased in 
the elder child, since to reach these, from 
above, an incision nearly three inches in 
depth was required. Regarding the na- 
ture and cause of this enlargement, we 
know even less than concerning the other 
forms. Is there an actual increased growth 
of brain substance-including a due pro- 
portion of nerve element proper, and of 
interstitial substance - or does the in- 
creased bulk, in these cases, also, result 
from an augmentation in bulk of the neu- 
roglia alone ? and even if this be the case, 
we may still inquire as to the nature of 
the change which it has undergone. 
Much doubt also exists with regard to 
partial hypertrophies of the brain. Whilst 
admitting their extreme rarity, Rokitan- 
sky says:-"There can be no question 
that small portions of the brain really are j 
separately hypertrophied. Many of the 
observations brought forward as instances 
of this occurrence are undoubtedly erro- 
neous ; adventitious formations infiltrated 
through the cerebral tissue may have oc- 
casioned at once the enlargement and the 
error. There are, however, some in- 
stances which may be relied on, in which 
1 Archiv. G6n. de M6d. 1825, t. vii. p. 44. 
2 Leet, on Princip. and Pract. of Physic, 
4th ed., 1857, p. 427. PROGNOSIS-TREATMENT. 
901 
the optic thalamus and the pons were hy- 
pertrophied ; and I have myself also met 
with a most remarkable case of hypertro- 
phy of the medulla oblongata." Andral1 
also believed in the existence of a limited 
local hypertrophy of parts of the brain. 
These so-called hypertrophies were, in all 
probability, produced by a hyperplasia of 
the interstitial tissue of the parts, though 
it seems more than questionable whether 
we ought to follow Rokitansky, and apply 
this name to an increase of bulk which 
has been thus occasioned. 
Prognosis.-In all cases when the pres- 
ence of an actual growth within the cra- 
nium is diagnosticated, the prognosis is 
very grave, but the degree of gravity de- 
pends upon the nature of the growth 
rather than upon the character or inten- 
sity of the special symptoms which it has 
occasioned. Thus, if there be reason to 
believe in the existence of carcinoma, the 
future prospects are as bad as they can 
be ; if the conclusion be that syphilis is 
the cause of symptoms, there may be room 
for the hope of complete recovery. With- 
out entering upon a discussion of the gen- 
eral grounds of prognosis in the several 
cachexias which have been enumerated 
(p. 887), as the cause of tumor, it may be 
well to direct attention to a few points 
with regard to some of them. 
If tubercle is believed to exist, the 
prognosis is highly unfavorable ; but the 
course of tubercle en masse in the brain, 
is sometimes exceedingly slow, and this 
is the case especially in children. The 
advance towards a fatal issue is to be ap- 
prehended when there is marked hectic, 
much elevation of temperature, and when 
the symptoms indicate the progressive in- 
vasion of different portions of the brain. 
On the other hand, when-although there 
may be distinct paralysis, or amaurosis- 
the general health is tolerably good, and 
the symptoms have shown but little ten- 
dency to increase in either intensity or 
extent, there may be considerable prolon- 
gation of life. 
The hypertrophy of the brain which is 
met with in children is slowly progressive, 
but its prognosis, under all rates of ad- 
vance, is eminently unfavorable. 
In syphilitic diseases of the brain or its 
meninges there is much room for hope ; 
and it seems to be of little moment that 
the symptoms are varied and severe. 
Those which are the least amenable to 
treatment are the losses of sight and hear- 
ing, which not unfrequently exist; para- 
lyses and spasmodic affections are often 
removed with considerable rapidity. The 
length of time during which the symp- 
toms have lasted is a further guide in the 
prognosis, the hope of restoration being 
in inverse proportion to the duration of 
the morbid state. Still, unless the gene- 
ral condition be one of highly marked ca- 
chexia, amendment may be confidently 
expected. The presence of disease*in the 
kidneys is of unfavorable omen, but even 
it often disappears under an antisyphilitic 
treatment. There are no cases which ap- 
pear so bad and which recover so well as 
some examples of intracranial syphilis. 
Until the diagnosis of the constitutional 
state is established, the case may appear 
absolutely hopeless ; sometimes the only 
missing link in the history may be unat- 
tainable because the patient is insensible, 
or in such a state of mental incapacity that 
no reliance can be placed on his assertions, 
but yet from such condition he may com- 
pletely recover. 
In the case of lead-poisoning the prog- 
nosis is favorable, provided that after a 
few applications of either the continuous 
current, or of faradization, the muscles 
show some remnant of irritability. When 
the paralysis has existed for a number of 
years, and the wasting of muscular tissue 
is very great, it may be impossible to re- 
store the limb, but yet, by continuous 
treatment, the advance of symptoms may 
be arrested. 
In those cases where there is reason to 
suspect the existence of either aneurism, 
hydatids, or carcinoma, the prognosis is 
eminently unfavorable ; but the forecast 
of a fatal termination is to be based upon 
the state of the general health of the pa- 
tient, rather than upon the special cere- 
bral symptoms. 
Under all conditions of Adventitious 
Product uncontrollable pain and vomiting 
are the most unfavorable symptoms ; the 
former deprives the patient of rest, and 
the latter renders food useless, and often 
worse than useless, through the fatigue 
occasioned by its rejection. 
Treatment.-There is nothing special 
which can be said with regard to the treat- 
ment of adventitious products in the head, 
for under all circumstances it is simply 
that of the different dyscrasise upon which 
they depend. The only remark which it 
seems to me desirable to make, is one in 
favor of the administration of large doses 
of iodide of potassium when there is a 
belief in the existence of syphilis. I have 
repeatedly seen the most menacing symp- 
toms removed by the exhibition of KI 
in doses of forty grains, three and four 
times daily. When this has failed, re- 
course to mercury has proved curative, 
and with especial frequency when in con- 
junction with the baths and waters of 
Aix-la-Chapelle. Small doses varying 
from to TV of a grain of the red iodide 
of mercury have appeared to me to be 
more generally useful than any other form 
of mercury ; but when even those doses 
1 Precis d'Anat. Patholog., t. iii. 776. 902 
CEREBRAL HEMORRHAGE AND APOPLEXY. 
cannot be borne by the stomach-an event 
which rarely happens-happy results may 
follow the exhibition of mercury by fumi- 
gation or inunction. 
The*pain of cerebral tumor may be pal- 
liated, and sometimes removed altogether 
by Indian hemp, or the application of 
ice; and sleep may be obtained by the 
chloral hydrate. 
Sickness is sometimes treated most suc- 
cessfully by absolute rest to the stomach, 
the patient being fed by nutritive enemata. 
Convulsions may be checked by bro- 
mide of potassium, in doses of ten or 
twenty grains ; but the powers of the 
therapeutic art are, with the exceptions 
above mentioned, inclosed within pain- 
fully narrow limits, and all that can be 
done is to palliate evils which cannot be 
removed. 
CEREBRAL HEMORRHAGE AND APOPLEXY. 
By J. Hugiilings Jackson 
, M.D., F.R.C.P. 
The text1 of this article is Cerebral 
Hemorrhage, using the term in the sense 
of escape of blood within the intracranial 
nervous centres. Since very little or 
very much blood may be effused, the 
symptoms vary extremely in degree ; and 
since the parts in which rupture of vessels 
may take place are numerous, the symp- 
toms vary much in kind. When large 
and rapid effusion occurs, there is the 
apoplectic condition. Cerebral Hemor- 
rhage is one cause, and the most frequent 
cause of apoplexy. So frequently does 
hemorrhage cause apoplexy, that the 
name has got into use for hemorrhages in 
other organs. Thus we speak of Retinal 
Apoplexy and of Pulmonary Apoplexy. 
Since this use or abuse of the word leads 
to confusion, the term is often qualified by 
the word Cerebral. We shall restrict 
Cerebral Hemorrhage to effusion of blood 
into the brain, and reserve the word Apo- 
plexy for the comatose condition 'which 
large effusion of blood and other causes 
produce. Cerebral Hemorrhage will be 
chiefly considered, and other causes of 
Apoplexy will be spoken of under the 
head of diagnosis. It will be absolutely 
necessary to make occasional reference to 
meningeal hemorrhage, although this has 
been considered in another part of this 
volume, since meningeal as well as Cere- 
bral Hemorrhage may produce Apoplexy. 
Morbid Anatomy. 
Position.-The effusion of blood is cir- 
cumscribed. With rare exceptions it 
occurs in but one side of the brain, nearly 
always in a limited part of that side, most 
frequently in the ganglia at the base. 
Occasionally, however, it breaks out of the 
substance of the brain, usually into the 
lateral ventricle, but sometimes on to the 
surface. It is of little use to take as a 
basis for statistics, records of published 
cases ; from the Pathological Society's 
Transactions, for instance. No one would 
think of bringing before the Pathological 
Society an ordinary specimen of Cerebral 
Hemorrhage. Cases of special interest 
are published, such for instance as cases 
of hemorrhage into the pons Varolii sim- 
ulating opium poisoning. A goodly num- 
ber of cases of large hemorrhage into the 
cerebellum could be collected from medi- 
cal periodicals, as many such cases are 
pretty sure to get into print. But large 
hemorrhage into the cerebellum is in 
reality exceedingly rare. During the 
seven years I have been attached to the 
London Hospital, I have seen but two 
cases. Again, statistics take count mostly 
of fatal cases of hemorrhage-of effusions 
of blood into the brain big enough to kill 
quickly - and of comparatively few of 
those cases so frequently seen in hospitals 
1 In my collection of materials towards 
writing this paper, I have to acknowledge 
with my warmest thanks the help I have re- 
ceived from Dr. Anthony Roberts, Mr. F. M. 
Corner, Mr. Steggal, Dr. James Jackson, Mr. 
George Mackenzie, Mr. Frederick Mackenzie, 
Mr. Grubb, Mr. Norton, Mr. Llewellyn, Mr. 
Gordon Brown, Mr. Stephen Mackenzie, Mr. 
G. E. Herman, Mr. Louis Mackenzie, and 
others. I have to acknowledge also most 
valuable assistance in the investigation of 
cases of apoplexy from my colleagues Dr. 
Sutton, Dr. Woodman, Mr. Hutchinson, Mr. 
Waren Tay, and Mr. MacCarthy. I have to 
thank my other colleagues for their generosity 
in placing cases at my disposal for investiga- 
tion. For valuable help in the revisal of this 
article, I am indebted to my friends Dr. 
Woodman, Dr. Gowers, and Mr. Stephen 
Mackenzie. MORBID ANATOMY. 
903 
of hemiplegic patients who have recovered 
from coma, and who go out of the hospi- 
tal with more or less permanent palsy. 
Many of these patients die months or 
years after in workhouses. If we speak 
of hospital cases only, we thus exclude 
many cases of very great clinical impor- 
tance, and besides those mentioned we 
exclude cases of rapid death from menin- 
geal hemorrhage, for most of such cases 
are seen by those engaged in private 
practice. For these reasons I do not give 
nor refer to statistics, but it will, I think, 
be safe to say that large hemorrhage very 
often occurs in the corpus striatum and 
thalamus, often in the pons, rarely in the 
cerebrum, very rarely indeed in the cere- 
bellum, and scarcely ever in the spinal cord. 
We occasionally find blood in the lateral 
ventricles. In the vast majority of cases, 
it comes from a rent in the corpus striatum 
or thalamus opticus. It may extend to 
the fourth ventricle, and escape sometimes 
on the surface of the brain. I have, how- 
ever, twice known blood effused into the 
ventricle without injury of the ganglia in 
its floor. These were exceptional cases ; 
the blood came from bursting of large 
aneurisms. In one the aneurism was 
seated in the middle line of the hinder 
part of the circle of Willis at the diver- 
gence of the posterior cerebral arteries. 
In the other case an aneurism of a 
small artery of the posterior lobe had 
burst into the posterior cornu-blood had 
escaped also on to the surface of the brain. 
In the first edition of the article Convul- 
sion, a case occurring in Mr. Gayton's 
practice was mentioned, the notes of 
which were supplied by Dr. Woodman. 
In this case Dr. Woodman found no an- 
eurism, and no laceration of the brain.1 
Multiple Effusions.-Sometimes two or 
more recent clots, even large clots, are 
found in different parts of the brain. My 
friend Mr. Llewellyn showed me a speci- 
men in which there was a clot in the 
floor of the lateral ventricle, and another 
in the pons. The two clots came on at 
the same time, for the patient had gone 
to bed as well as usual and died next day 
of Apoplexy, which began in the night. 
Dr. John W. Ogle (Pathological Soe. 
Transactions, vol. xv. p. 8) has recorded 
a case in which there were three recent 
clots, one in the right corpus striatum, 
one in the left thalamus opticus, and one 
in the pons Varolii. Dr. Baiimler has 
supplied me with notes of the case of a 
man, thirty-four years of age, who died 
three hours after a fit, in whose brain four 
recent clots were found : a large one in the 
centre of the right hemisphere, a small 
one in each of the optic thalami, and a 
small one in the right crus cerebri. The 
ventricle was also full of blood. After 
discovering the main clot, we should care- 
fully search the rest of the brain, espe- 
cially the pons and medulla, for small 
effusions, often only little specks. 
So far we have spoken of recent clots. 
It is not at all rare to find effusions of 
blood of very different dates. Sometimes 
after discovering a recent clot on one side 
of the brain we may find much of the oppo- 
site motor tract damaged by old effusion 
when there has been no corresponding 
palsy for some time before death. 
Size of Clots.-The size of a clot varies 
from that of a pea or less, to a mass the 
size of one's fist or more. Its size will 
depend of course on the size of the vessel 
ruptured, and its shape depends somewhat 
upon this also. In small capillary hemor- 
rhages the blood may lie in streaks in the 
brain substance, rather pressing the tis- 
sues apart than destroying them. (We 
see by the ophthalmoscope in many cases 
of small hemorrhages into the retinae, in 
cases of Bright's disease, that the blood is 
arranged in the direction of the retinal 
nerve fibres.) It is doubtful whether ca- 
pillary hemorrhages in the brain give rise 
to symptoms. (A patient's sight may be 
quite good when there is considerable 
streaking of his retinae with blood.) When 
from a large effusion the fibres are torn, 
the clot is rounder and more distinct, and 
gives rise to symptoms. 
The larger the clot, not only the greater 
the local destruction of nerve tissue, but 
also the more squeezing there is of the 
parts not directly damaged. When a 
large quantity of blood has been effused 
in one side of the brain, we see post mortem 
that the affected cerebral hemisphere looks 
more voluminous, that the convolutions 
are flattened, and we find on section that 
the cerebral substance is more anaemic 
than on the healthy side. If after sawing 
round the skull we insert the knife in the 
line of the saw-cut, and remove the skull 
cap with the part of the brain it contains 
- a plan Mr. Hutchinson adopts to dis- 
play the position, and effects of traumatic 
hemorrhage-we may find that the falx 
bulges to the sound side, and this is evi- 
dence that the other hemisphere has been 
compressed. These facts are of import- 
ance with regard to the causation of loss 
of consciousness from Cerebral Hemor- 
rhage. 
1 A man, 24 years of age, died rather sud- 
denly twelve hours after a fit of convulsion. 
Although this man had recovered so as to 
take broth and to answer questions, his cere- 
bral ventricles were found at the autopsy full 
of blood. Mr. Prescott Hewett says that a 
very, very slight laceration of the floor of the 
lateral ventricle may, if it correspond to the 
situation of a large vein, give rise to an ex- 
tensive extravasation of blood into this cavity 
(Holmes' Surgery, p. 314). Blood in the fourth 
ventricle may come from a rent in the pons. 
Changes in .Effused Blood.-We find 904 
CEREBRAL HEMORRHAGE AND APOPLEXY. 
post mortem most varied appearances ac- 
cording to the age of the clot. Soon after 
its effusion there is seen a soft black jelly 
mixed at its edges with small specks of 
brain and lying in a bed of softened brain. 
In the later stages the appearances are 
widely different : there is a cyst-" apo- 
plectic cyst"-filled with ochre-yellow 
fluid, or there is even a cicatrix. We 
sometimes find the two extremes, a recent 
black soft clot, and one or more cysts the 
relics of old effusions. In the progress from 
the recent clot to the apoplectic cyst, we 
have to consider changes in the blood 
effused and changes in the brain about it. 
On removing as much as we can of a 
recent clot we mostly see, especially when 
the effusion is in the corpus striatum and 
thalamus, an irregularly-shaped cavity 
with a shaggy wall of soft brain intermixed 
for a short distance with specks of blood. 
The local softening results partly from im- 
bibition of serum from the clot and partly 
from inflammatory changes excited by the 
clot. The inflammation-local encephali- 
tis-may lead to extensive disintegration of 
brain ("the apoplectic clot is even trans- 
formed to an abscess of the brain," Nie- 
meyer), but usually the process is limited; 
it is conservative, and leads to the forma- 
tion of the cyst wall to be presently men- 
tioned. 
The progress to the final stage is 
gradual. The clot diminishes in bulk, be- 
comes softer and browner ; next the color 
becomes yellow ; granules of blood pig- 
ment and hsematoidin crystals form. 
Finally the clot is represented by thin 
ochre-yellow, or even clear fluid. Simul- 
taneously, as a result of a slow inflamma- 
tory change, the wall of the cavity under- 
goes great alteration. An organized mem- 
brane forms from the neuroglia, and the 
apoplectic cyst results. This is the most 
common termination, but the process may 
go even further. There may be no cyst, 
but a hard pigmented patch, an " apoplec- 
tic cicatrix." 
Traumatic hemorrhage.-In cases of in- 
jury the clot mostly affects the surface, 
and most frequently the convolutions of 
the base ; there is rather a pulp of brain 
and blood than a distinct clot. An injury 
is to be suspected whenever blood is found 
effused close to the convolutions, especially 
if these be bruised, and if there are many 
small specks of black blood near the prin- 
cipal clot; above all, if distant from the 
principal lesion, there are very many little 
specks of black blood intermixed with, and 
round about pulpy patches. 
At post-mortem examinations, espe- 
cially of those who have died of chronic 
Bright's disease, we occasionally find evi- 
dence of former hemorrhage into the gray 
matter of the convolutions. There is often 
a cup-like depression with hardened walls 
containing ochre-yellow fluid. But if 
these be in several parts which we know 
to be often bruised by injuries to the head, 
-for instance, on the under surface of the 
anterior or sphenoidal lobes,-it is prob- 
able that there has been injury to the 
head. (See Bristowe, Path. Soc. Trans. 
1869-70.) 
liupture of Aneurisms of large Cerebral 
Arteries.-We have to speak of aneurisms 
of the small arteries of the brain (miliary 
aneurisms, p. 894), but occasionally Cere- 
bral Hemorrhage results from rupture of 
aneurism of the large arteries at the base. 
As a rule, however, their rupture produces 
meningeal hemorrhage. (See arts. Ad- 
ventitious Products, Meningeal Hemor- 
rhage, and Convulsions.) 
Hemorrhage from Cerebral Tumors.- 
Cerebral Hemorrhage has occasionally, 
but very rarely, its origin from vascular 
tumors of the brain. I have recorded 
three such cases in the Lancet, Oct. 29, 
1869. The tumor is the glioma of Vir- 
chow. As he points out, ordinary Cere- 
bral Hemorrhage has its seats of election, 
and these are not precisely the places 
where glioma is most frequently found. 
Glioma occurs most frequently in the 
white mass of the hemisphere, especially 
in the posterior and anterior lobes, places 
where ordinary Cerebral Hemorrhage is 
rare. It is very important to bear in 
mind a remark he makes to the effect that 
it often requires a very attentive exami- 
nation to distinguish hemorrhagic glio- 
mata from traumatic hemorrhage, from 
red softening, and from rupture of cere- 
bral aneurism. (See art. Adventitious 
Products and art. Softening.) 
Lungs.-Of course all organs are to be 
examined post mortem for, as we shall see, 
the heart and kidneys are often diseased. 
There are, however, often striking post- 
mortem appearances in the lungs? which 
are owing to the apoplectic condition. 
These are not peculiar to apoplexy from 
Cerebral Hemorrhage, and, indeed, some 
of them at least occur in other modes of 
dying. They are very varied, and the 
variation depends on two factors-the ra- 
pidity of death and the condition of the 
patient (his age and state of health) when 
taken ill. I have not been able to make 
out any difference from position of the 
Cerebral Hemorrhage. I have known the 
lungs pale like "cholera lungs," and 
weighing only twenty-two ounces, in a 
patient who died in an hour of large Cere- 
bral Hemorrhage. But as a rule even in 
patients who die more quickly-as in some 
cases of meningeal hemorrhage-the lungs 
are congested. They are often bulky and 
oedematous in their dependent parts, 
which easily break under pressure, and 
very emphysematous (vicariously) in front. 
If the patient be a robust, full-blooded 
man, the lungs may be black, from cram- 
ming with blood up to their anterior mar- ETIOLOGY AND PATHOLOGY. 
905 
gins, and easily breaking into a pulp, as 
in cases of rapid death from traumatic 
hemorrhage. In some cases of slower 
death, we find pulmonary apoplexies. I 
have in two cases (one traumatic and one 
opium-poisoning; both patients young) 
seen lungs which on section looked like 
the " damson lungs" of heart disease. In 
other cases where patients die very slowly, 
we find on section granite-colored patches 
of various sizes slightly raised and well- 
margined. These lobular patches are 
often called lobular pneumonia, and when 
very numerous and almost confluent, the 
word pneumonia is sometimes used with- 
out any qualification. Yet these changes 
occur with rare exceptions, in both lungs 
and in the dependent parts of all lobes, 
and ought not to take the name which be- 
longs to a well-marked independent dis- 
ease. They may affect one lung more 
than the other1 - the right usually. 
Since, when we find these granite-colored 
patches, we occasionally find recent apo- 
plexies also, and indeed patches of inter- 
mediate color, I believe they are, asBrown- 
Sequard has stated, altered apoplexies. 
Sometimes one or more of them are broken 
down into a grumous pulp; over some 
nodules near the surface there may be 
slight pleurisy. 
Etiology and Pathology. 
In speaking of Etiology and Pathology 
we for the present exclude cases where 
the bleeding is the result of injury to the 
head, where it occurs from rupture of an 
aneurism of a large cerebral artery, such 
as the middle cerebral or basilar, or where 
it starts from a vascular tumor of the 
brain. We cannot speak at all of cases of 
intracranial hemorrhage occurring in pur- 
pura (see art. Purpura, Part I. p. 461), or 
scorbutus (see art. Scorbutus, Part I. p. 
456), or pysemia (see art. Pyaemia, Part 
I. p. 335), nor of "red softening" (art. 
Softening). Obviously the above are in 
their etiology and pathology very differ- 
ent things ; they only agree in that there 
is escape of blood in or upon the brain. 
Moreover they differ much clinically. We 
consider, in what follows, the common run 
of cases. 
Age.-Cerebral Hemorrhage rarely oc- 
curs in persons under forty. This age is 
that at which one of the most important 
factors in the causation of Cerebral He- 
morrhage, degeneration of arteries, begins 
to be common. Changes in the arteries 
of old men are scarcely to be considered 
morbid. " To degenerate and die is as 
normal as to be developed and live" 
(Paget). In the progress to healthy old 
age the body, as a whole, descends in vi- 
tality ; the blood wastes, numerous capil- 
laries obliterate, the lymphatic system 
undergoes involution, there is senile em- 
physema. Although the heart becomes 
somewhat bigger as years increase, there 
is not excessive cardiac hypertrophy. 
There is an increase in bulk of the whole 
organ, not an extreme hypertrophy of the 
left ventricle only, as there so often is in 
persons of middle age who die of Cerebral 
Hemorrhage. The degenerations we are 
especially concerned with in this article 
are premature, moreover they are often 
attended by disease of the kidneys. In a 
patient under forty the arteries may feel 
tougher than the arteries of another per- 
son of eighty. 
Some of the exceptional cases of large 
Cerebral Hemorrhage in young people 
whose arterial system, as a whole, has 
not undergone degenerative changes, are 
cases of rupture of aneurisms of the larger 
cerebral vessels ; for instance, of a branch 
of the middle cerebral or of the basilar. 
Indeed, if there be no evidence of the 
arterial and other degenerations in the 
body, to be presently mentioned, the pro- 
bability is that large Cerebral Hemorrhage 
in young people (excluding cases of in- 
jury, purpura, and the like) is thus caused. 
Apart from such quasi-accidental cases, 
we must observe further that the matter 
of importance in considering the influence 
of age in diagnosis is to note the general 
constitutional state the patient has arrived 
at rather than the number of years he has 
lived. For Cerebral Hemorrhage quite 
like that which occurs so often after forty 
does sometimes occur at the age of twenty 
and even under, in people who are sub- 
jects of chronic Bright's disease, who have 
degenerated arteries and hypertrophy of 
the left ventricle of the heart. I have re- 
corded such a case (London Hospital Re- 
ports, vol. iv. p. 337). 
Heredity.-It is asserted that in some 
families there is a tendency to Cerebral 
Hemorrhage. Obviously the transmission 
cannot be of a tendency to certain symp- 
toms-hemiplegia and Apoplexy-but to 
certain tissue degenerations most strik- 
ingly manifested in the arteries. Cerebral 
Hemorrhage therefore can be inherited 
only indirectly. Much used to be said of 
a certain inherited build of body and of 
the "apoplectic constitution." Little 
importance is nowadays attached to this. 
Austin Flint says, "The larger number 
of persons attacked are either spare or 
of an ordinary build." Niemeyer says, 
1 In one case, that of a woman aged 73, 
who died in forty-seven hours, of hemorrhage 
into the substance of the left cerebral lobe; 
one lung, which was universally adherent, 
was solid by this sort of change; the other, 
which was not adherent, except by one or 
two tags, was a good specimen of senile em- 
physema, and presented scarcely any other 
morbid appearance. 906 
CEREBRAL HEMORRHAGE AND APOPLEXY. 
" There is no such thing as an apoplectic 
constitution indicated by a short neck 
and broad shoulders." 
Constitutional State prior to 
Cerebral Hemorrhage. - It is con- 
venient to consider an extreme case in 
order that we may state the whole of the 
factors which may be concerned in caus- 
ing Cerebral Hemorrhage. We are, as 
was said at page 905, not now consider- 
ing cases of hemorrhage from rupture of 
aneurisms of the large cerebral arteries, 
from injuries, or from the like quasi-acci- 
dental causes. 
At autopsies on patients who have died 
of Cerebral Hemorrhage we frequently, if 
not mostly, find three things: hypertro- 
phy of the heart, chiefly the left ventricle, 
chronic renal disease, and degenerated1 
arteries (Bright, Johnson, Kirkes). A 
patient so much and so widely diseased 
has not a liability to Cerebral Hemor- 
rhage only ; he is liable to inflammation 
of serous membranes, to bronchial ca- 
tarrh, to oedema of the lungs, &c. But 
in this article we have only to do with the 
triple association as it bears on Cerebral 
Hemorrhage. We are especially con- 
cerned with the condition of the vascular 
system, and can only speak incidentally of 
the renal disease. We have two tasks. 
Going the natural round of the circula- 
tion (heart, large arteries, small arteries, 
capillaries (and nervous tissue), venous 
system and lungs), we have first to con- 
sider the abnormal conditions of different 
parts of the vascular system, and next 
how, from the sums of these several con- 
ditions, it results that rupture of the 
smaller cerebral arteries is determined. 
Heart.-The hypertrophy is of the left 
ventricle : it is of the kind called simple, 
because, although the wall of the ven- 
tricle is thickened, there is not dilatation ; 
the capacity of the ventricle is, at all 
events, but slightly increased. Yet, as in 
other kinds of cardiac hypertrophy, di- 
latation may ensue. In patients long bed- 
ridden from palsy due to Cerebral Hemor- 
rhage, we may find the heart decreased 
in size, notwithstanding that there is 
chronic renal disease. 
In this form of hypertrophy there is ob- 
viously increased power acting on the 
arterial side of the circulation, and con- 
sequently we infer obstruction somewhere 
in the arterial system. We limit our- 
selves to cases where there is no obstruc- 
tion at the aortic orifice, and no incom- 
petence of the aortic valves.2 The resist- 
ance to the heart is much further on. It 
is peripheral. Although this is agreed on, 
there are great differences of opinion as 
to the exact nature of the peripheral ob- 
struction. Dr. Bright suggested that the 
"altered quality of the blood might so 
affect the minute and capillary circulation 
as to render greater action necessary to 
force the blood through the distant sub- 
divisions of the vascular system." lie 
suggested also that the blood in Bright's 
disease might act as an unwonted stimu- 
lus to the heart. Dr. George Johnson, 
believing that the blood in renal disease 
is more or less noxious to the tissues since 
it contains "urinary excreta," considers 
that its passage into the capillaries is re- 
sisted by contraction of the small arteries- 
the vessels most rich in muscular tissue. 
The muscular coats of these vessels there- 
fore are hypertrophied in antagonism to 
the heart. Since the small arteries are 
hypertrophied throughout the body, the 
obstructions, though each is slight, are in 
their sura total so large, that in order that 
the circulation may be carried on effi- 
ciently, hypertrophy of the heart must 
ensue. 
But whilst Dr. Johnson believes that 
the thickening of the walls of the small 
arteries is genuine hypertrophy, "an in- 
creased growth of a normal tissue with- 
out change of texture," Dr. Beale doubts 
whether there is real hypertrophy of the 
muscular fibre cells, and supposes that 
the changes in the small arteries are de- 
generative. He remarks' that " there is 
an increased bulk with altered structure, 
not simply increased bulk without change 
of structure (hypertrophy)." 
Traube considers that the cardiac hyper- 
trophy in Bright's disease is a conse- 
quence of increased tension of the arterial 
circulation, partly the result of the dimin- 
ished calibre of the renal circulation, and 
partly the result of greater volume of the 
blood from diminished excretion of fluid. 
The objection which has been raised to 
this view is, that the hypertrophy of the 
heart mostly begins in the earlier stages 
of Bright's disease. 
Occasionally, although rarely, we find 
great hypertrophy of the left ventricle in 
cases of Cerebral Hemorrhage, when there 
is neither obstruction at the aortic orifice, 
mon in cases of valvular disease of the heart, 
excluding cases of aneurisms of the larger 
cerebral arteries, and ruptures of these usu- 
ally produce meningeal hemorrhage. My 
observations confirm the statement of Dr. 
Austin Flint, that important nervous symp- 
toms of any kind-excluding, of course, those 
produced by the process of embolism-are 
not common in cases of valvular diseases of 
the heart (Diseases of the Heart, 2d ed., p. 
180). 
1 Beale on the Urine, 3d ed., p. 72. 
1 Retinal changes will be alluded to here- 
after. The careful clinical observer considers 
minor degenerative changes,-baldness, gray- 
ness, state of skin, worn teeth. He inquires 
for history of gout, and of intemperance. 
8 For intracranial hemorrhage is not com- 907 
CONSTITUTIONAL STATE PRIOR TO CEREBRAL HEMORRHAGE. 
nor renal disease, but simply wide-spread 
degeneration of the arteries. From these 
cases it seems clear that degeneration of 
vessels is a sufficient cause of hypertrophy 
of the left ventricle. It must be admitted 
that there are cases of hypertrophy of the 
heart, which we are unable to explain. 
We do mostly, however, find hypertrophy 
of the left ventricle in cases of Cerebral 
Hemorrhage. 
Large Arteries.-From a degenerative1 
change the large arteries lose much of 
their chief property-elasticity; they be- 
come permanently wider, longer, and 
more tortuous. We see them move in 
curves on the temples, and we feel that 
they are tough and sometimes even 
"bony." When the large arteries which 
we can see and feel are thus changed, it 
is a reasonable inference, that the large 
arteries of the brain are similarly, although 
not perhaps equally, altered. Elasticity 
of the arteries, although it adds no new 
force, is an important aid to the circula- 
tion in equalizing the flow of the blood, 
gradually reducing it from intermittence 
in the large arteries to a nearly continuous 
stream in the small arteries. We readily 
understand, therefore, that the absence of 
elasticity of the larger arteries will be an 
important factor in leading to rupture of 
the smaller arteries. The circulation is 
carried on too much in systole. The 
smaller arteries will receive the impulse 
from the strong left ventricle intermittent- 
ly, not remittently. 
Small Arteries.-Here rupture mostly 
takes place, always in large hemorrhages. 
We have to consider several pathological 
conditions of the smaller arteries, (a) 
Fatty degeneration. Arteries of small 
size have a highly developed muscular 
coat, and this coat especially is the seat 
of fatty degeneration, a change which we 
may suppose will allow rupture when the 
vessels are unduly strained. However, 
not so much importance is attached to 
this pathological condition as was wont 
to be, for fatty degeneration is found 
sometimes in the arteries of very young 
people. Indeed, Billroth and Bouchard 
consider it to be most frequently a result 
rather than a cause of cerebral lesions. 
But even if so, degeneration of arteries, 
for instance, in a focus as softening, may 
favor the occurrence of hemorrhage into 
the part diseased. (6) Charcot, Bouchard, 
and Charlton Bastian have described what 
they term "miliary aneurisms:"' aneu- 
risms mostly visible to the naked eye, of 
the size of a pin's head more or less. 
(These have been fully described, art. Ad- 
ventitious Products.) 
Capillaries.-These vessels may be found 
the seats of fatty degeneration. But rup- 
tures allowing large hemorrhages do not 
occur here. If it be degeneration of the 
smaller arteries which produces obstruc- 
tion and thus induces hypertrophy of the 
left ventricle of the heart, the diseased 
state of the smaller arteries may protect 
the capillaries from strain.2 
1 Dr. Bristowe has drawn attention (Path. 
Soc. Trans. 1859) to ruptures of small aneu- 
risms in the substance of nervous organs as a 
cause of cerebral hemorrhage, and gives a 
drawing of an unruptured aneurism, the size 
of a grain of wheat, which lay in the sub- 
stance of the cerebellum. Dr. Henri Lion- 
ville has found miliary aneurisms in the 
retina (Gaz. des Hopitaux, 1870). See also 
Dr. Gull (Guy's Hosp. Reports, 3d Series, 
vol. v. 1859). 
2 Here reference may again be made to Dr. 
George Johnson's view, mentioned p. 906. 
In one case of large Cerebral Hemorrhage he 
failed to discover any hypertrophy of the 
small arteries of the brain, but he found them 
much hypertrophied in the subcutaneous tis- 
sue. Inferentially, they were hypertrophied 
in other organs, although, unfortunately, ex- 
aminations were made of the arteries for the 
brain and of the subcutaneous tissue only. 
In such a case, he suggests that the hemor- 
rhage results, not from rupture of the arter- 
ies, but from rupture of the capillaries of the 
brain. They rupture because they are not 
protected from the force of the hypertrophied 
left ventricle by the hypertrophy of the mus- 
cular coat of the arteries delivering blood to 
them. It is, however, unlikely that rupture 
of capillaries would cause a large effusion of 
blood. ' ' The apoplectic fit does not occur in 
capillary hemorrhages." (Niemeyer, Text- 
book of Practical Medicine ; translation of the 
eighth German edition by Drs. Humphreys 
and Hackley, vol. ii. p. 198.) 
1 I speak of results under the general term 
"degeneration." Virchow (Cellular Patholo- 
gy, Dr. Chance's translation) points out that 
the true atheromatous change in arteries be- 
gins by a slow inflammatory change of the 
tunica intima-an endarteritis strictly analo- 
gous to the inflammatory changes in endocar- 
ditis. I have in this article, however, to do 
with changes in the vessels so far only as, by 
affecting the dynamics of the circulation, 
they favor cerebral hemorrhage. I have not 
to do with the processes by which these 
changes are arrived it; therefore I use the 
general term "degenerative," which, with 
the above qualifications, need not mislead. I 
conclude the foot-note by a quotation from an 
able lecture by Moxon, Med. Times and Ga- 
zette, Nov. 12, 1870: "It is too much the 
fashion, at least in this country, to assume 
that all the processes in the arteries which 
lead to the deformation of their interior by 
yellow patches, swellings, petrifactions, or 
erosions, or to aneurisms or rupture of the 
vessels, are all of a degenerative origin, and 
that all are sufficiently described and defined 
in the common notions of atheroma. The 
truth is, that sub-inflammatory irritation 
plays a very important part in these changes." 
Since this was written, Moxon has considered 
the whole subject in a valuable article in 
Guy's Hospital Reports, 1870-71. 908 
CEREBRAL HEMORRHAGE AND APOPLEXY. 
Nervous Tissues.-The influence which 
changes in the tissues outside the vessels 
may exert in the causation of Cerebral 
Hemorrhage may be most conveniently 
considered here. 
When the brain wastes slowly, there is, 
in order that the cranium may continue 
full, compensation. There is, in some 
cases of wasting of the brain, thickening, 
genuine hypertrophy, of the skull (Paget). 
There is, sometimes, increase backward 
of the capacity of the frontal sinus (Hold- 
en); but the most important compensation 
is by increase in the quantity of the cere- 
bro-spinal fluid. To these sources of com- 
pensation Leubuscher and Niemeyer add 
dilatation of the vessels which will, they 
believe, favor rupture. And Niemeyer 
suggests that the frequency of Cerebral 
Hemorrhage, in advanced life, depends at 
least partly on the dilatation of the ves- 
sels induced by atrophy of the brain. 
Further, he thinks that since Cerebral 
Hemorrhage leads secondarily to atrophy 
of the brain, one attack favors the occur- 
rence of another attack. 
Softening of the brain, by diminishing 
the support of vessels, may favor hemor- 
rhage, but it is almost universally agreed 
on that the softening we find post mortem 
near to a clot is nearly always the result 
of the effusion, not a pathological condi- 
tion prior to the occurrence of hemor- 
rhage. 
Venous System.-We shall speak only 
of obstruction to the return of the blood 
from the brain by changes in the lungs, 
excluding cases like phthisis and senile em- 
physema, in which the volume of the blood 
is reduced, and in which, therefore, the 
pulmonary impediment is to a great extent 
compensated. From hypertrophous em- 
physema there results universal peripheral 
congestion, consequent on the difficulty the 
venous blood encounters in passing through 
the lungs-the vascular area of which is 
reduced by obliteration of a great number 
of capillaries.1 From theoretical consid- 
erations therefore we might at first glance 
attach much importance to emphysema 
as a factor in the causation of Cerebral 
Hemorrhage. ''In no other disease does 
the cyanosis attain such severity excepting 
in cases of disorder of the orifices of the 
right heart." (Niemeyer.) However, 
emphysema probably is not often an im- 
portant factor in the causation of Cere- 
bral Hemorrhage. There will, in chronic 
cases, be much compensation by increased 
power of the right ventricle. Even if 
there be not full compensation, the left 
ventricle will have less blood to send to 
the brain, and thus the arterial tension 
will be diminished. It is the venous sys- 
tem which is overblooded and strained in 
emphysema; the arterial, from which 
rupture in Cerebral Hemorrhage takes 
place, is underblooded and less strained. 
In the last stages of emphysema we have, 
Niemeyer says, the severest symptoms of 
hyperaemia of the brain. Yet Cerebral 
Hemorrhage is a rare termination of this 
or of any other form of thoracic disease. 
It is the tension on the venous side of the 
circulation which is increased in emphy- 
sema. 1 
The veins are of lower functional struc- 
ture than the arteries-very few of the 
cerebral veins contain any muscular tissue 
-and thus probably they are less liable 
to disease. The degree of hypersemia of 
the face and lips is no exact measure of 
the degree of venous congestion of the 
brain in sudden obstruction at least. The 
cerebral veins are protected from sudden 
backward strain by the large cerebral 
sinuses. Nevertheless obstruction at the 
lungs, especially when occurring quickly, 
will be a factor, if not an important one, 
in favoring rupture of cerebral arteries. 
We have now to speak of the dynamics 
of such a person's circulation, in order to 
show how abnormal strains lead to rup- 
ture. To obtain clear ideas upon this 
point, it is well to run over the peculiari- 
ties of the cerebral circulation in health. 
The brain receives a large supply of blood 
(a large quantity passes through it), but 
there are provisions by which it is pro- 
tected from suddenly increased afflux. 
There are turns of the carotid and verte- 
bral arteries, the free anastomosis of the 
circle of Willis, the numerous subdivisions 
of the arteries beyond that circle, on the 
convolutions at least, and their small size 
before they enter the brain substance it- 
self. Perhaps we may add the possibility 
of diverticular enlargement of the thyroid 
body, and of the facial arteries, by which 
in suddenly increased action of the heart 
the flow to the brain will not be in pro- 
portion to the increased quantity of blood 
sent into the carotid and vertebrals. 
Further, when there is increased afflux 
of blood, compensation can occur by dimin- 
ution of the quantity of the intracranial 
part of the cerebro-spinal fluid. Some 
parts of the brain, however, are less pro- 
1 We do not here refer to the acute emphy- 
sema which we so often find post mortem, and 
which is especially well-marked in young, 
robust men who die in the apoplectic condi- 
tion soon after traumatic intracranial hemor- 
rhage. In these cases we find great posterior 
congestion-occasionally pulmonary apoplex- 
ies aiSf)-and vicarious emphysema of the 
front parts of the lungs. 
1 Dr. Hyde Salter never saw or heard of 
Cerebral Hemorrhage during an attack of 
asthma or as a result of asthma; for, although 
here there is acute obstruction to the return 
of venous blood, the arterial tension is very 
small : in severe attacks the pulse can 
scarcely be felt. CONSTITUTIONAL STATE PRIOR TO CEREBRAL HEMORRHAGE. 
909 
tected than others. The arteries which 
supply the corpus striatum are not capil- 
lary in size. They, or many of them, 
come off from the middle cerebral, which 
artery is almost the continuation of the 
internal carotid. Thus its branches lie 
more in the way of strain from the heart. 
But on the other hand we have to observe 
that here there is special compensation. 
As Hilton points out, the corpus striatum 
and thalamus (which parts we may pre- 
sume to have greater and more frequent 
functional activity than most divisions of 
the nervous system) lie in great part in 
the large water-bed of the brain. By this 
means rapid compensation by diminution 
of the fluid in the lateral ventricle may 
occur when these highly vascular parts 
during their functional exercise swell by 
becoming for a while more vascular. 
There is even more. Dr. Bastian (on 
Tubercular Meningitis, Edin. Med. Jour- 
nal, April, 1867), speaking of perivascular 
canals, suggests (but only as one hypothe- 
sis as to their use) that they may consti- 
tute "an apparatus for the distribution 
of cerebro-spinal fluid throughout the 
structure of the brain, in order that the 
same protective influence may be exer- 
cised over each individual portion of its 
structure which is exercised over the 
whole region by that portion of the fluid 
situated in the subarachnoid spaces." 
He says too, speaking of perivascular 
canals, three times the diameter of the 
vessels they contain,-" This large size of 
the perivascular sheaths occurs more fre- 
quently in the corpus striatum and optic 
thalamus." Then on the venous side 
there is the remarkable arrangement of 
the sinuses, which is such that a back- 
ward strain, if it be sudden, will not 
reach the veins of the brain - or will 
reach them in a diminished degree. The 
blood will pass, by preference, so to speak, 
into the outer parts of the head, face, &c. 
If the backward pressure be slowly ex- 
erted as in chronic emphysema, there will 
be cerebral hypersemia, but it will be 
very slowly developed and very evenly 
distributed. 
Let us suppose that all the abnormal 
conditions enumerated, p. 906 to p. 908, 
are present. Of course the whole of these 
factors are not present in all cases. There 
may be no renal disease, but there are 
usually degenerated arteries and hyper- 
trophy of the left ventricle. But as the 
following is chiefly recapitulatory, we 
shall in its proper order mention each of 
the conditions which different observers 
have supposed as well as have proved to 
be factors in the causation of Cerebral 
Hemorrhage. The small artery is usually 
the seat of rupture. We take this as the 
fixed point, and first consider the devel- 
opment of undue strain upon it. Next 
we speak of negative circumstances which 
add to the influence of this strain-of im- 
pediments to the exit of blood from the 
arteries into the veins. 
There is a strong left ventricle. The 
larger arteries are inelastic, and thus the 
wave of the blood sent forcibly into them 
is not equalized : as a consequence the 
impulse from the heart's jerks will be 
carried on strongly to the smaller arte- 
ries of the brain. The small arteries 
of the brain-normally thinner than ar- 
teries of other parts-are degenerated. 
Though this degeneration leads to resist- 
ance, it is not the resistance of power ; it 
is a "weak obstinacy." The resisting 
arteries are fragile and may be actually 
aneurismal. Moreover if the brain be 
wasted, the arteries are dilated and less 
supported. So far for the forward strains. 
If we hold that changes of nutrition in 
the penetralia of the body-in capillary 
regions-contribute largely to the forces 
of the circulation (vis afronte), there will 
be from the imperfect nutrition which the 
disease of the arteries and capillaries 
causes (and which in some cases atrophy 
of the brain signifies), an obstruction (or 
more precisely a cessation of help) to the 
flow of blood. The capillaries will not 
readily empty into the veins. At this 
point too, as there is often renal disease, 
we have to recognize, if we follow Bright, 
Johnson, and Kirkes, a still further ele- 
ment of obstruction in the unwillingness 
of the tissues to pass impure arterial blood. 
Further, if there be emphysema or other 
obstruction at the lungs, the free return 
of blood from the brain is hindered. Per- 
haps a condition of plethora, or at least 
of transient plethora after large eating 
and drinking, may add to the tension of 
the circulation by increasing the volume 
of the blood. If all the above-named con- 
ditions be present, there is no wonder that 
the diseased small arteries, unable to 
empty readily into the capillaries and 
veins on the one hand, and jerked by a 
strong ventricle on the other, sometimes 
give way. Moreover, when we consider 
the local peculiarities of the circulation of 
the corpus striatum and thalamus, we can 
well understand that these bodies are the 
" seats of election" for large Cerebral 
Hemorrhage, notwithstanding the special 
provisions mentioned. 
The degenerations have been slowly 
going on, and the diseased vessels are 
being subjected to increasing strain. A 
time comes when a vessel more diseased 
than another, perhaps one the seat of a 
miliary aneurism, or some vessels speci- 
ally in the way of strain, mostly a branch 
to the corpus striatum, gives way. It is 
not at all rare to hear it said that hemor- 
rhage is sometimes the result of obstruc- 
tion to the return of venous blood from the 
head in paroxysms of convulsion. Dr. 
Todd (Diseases of the Nervous System, 910 
CEREBRAL HEMORRHAGE AND APOPLEXY. 
Leets, vii.'and xii.) held this view. But 
since the hemorrhage is nearly always in 
the arterial regions of the brain, and since 
in the most severe paroxysms of chronic 
epilepsy, Cerebral Hemorrhage is exces- 
sively rare, it is far more reasonable to 
suppose that the irruption of blood itself 
causes the convulsion and the subsequent 
apoplectic condition. No single instance 
of actual Cerebral Hemorrhage in an epi- 
leptic fit has presented itself in Reynolds' 
experience (On Epilepsy, p. 225). 
Hemorrhage from Aneurism of 
THE LARGER CEREBRAL VESSELS.-In 
cases of aneurism of the larger cerebral 
arteries, a very local disease of the vessel 
may be the sole flaw in the system, except- 
ing perhaps vegetations on the heart's 
valves (Dr. John W. Ogle and Dr. 
Church). If there be no misfitting of the 
valves, no hypertrophy of the heart will 
ensue, nor indeed any derangement of the 
dynamics of the circulation of the brain, 
possibly not even any change in the nu- 
trition of the part supplied by the aneu- 
rismal artery if it remains pervious. In 
a few cases the fatal attack begins, if not 
in good health, at least in what appears 
very like good health. The patients feel 
well and are about at their work. We 
can say nothing as to their constitutional 
condition. I have only to do with rupture 
of these aneurisms in diagnosis. For 
rupture of them mostly produces menin- 
geal, not cerebral hemorrhage. (See art. 
Adventitious Products.) 
Localization of Lesions. 
We have now to speak of lesions of the 
motor and sensory tract within the cra- 
nium, and of lesions of the two large 
masses therewith connected-the cere- 
brum and cerebellum. In this section we 
consider almost solely paralytic symptoms 
-those which localize ; other non-localiz- 
ing symptoms will be considered under the 
head of the Apoplectic Condition. 
The parts of the motor and sensory 
tract from above downwards are corpus 
striatum, thalamus opticus, crus cerebri, 
pons Varolii, and medulla oblongata. All 
these parts are double, right and left, al- 
though the halves of the last two, pons 
and medulla, are welded together. In 
the vast majority of cases, the lesion is of 
but one lateral half of the sensori-motor 
tract, and its results are one-sided palsy- 
hemiplegia. In the parts we have spoken 
of as being welded together, the pons and 
medulla, the lesion occasionally affects 
both halves, and thus paralyzes both 
sides of the body. We have to do especi- 
ally with lesions of one lateral half of the 
motor and sensory tract at different levels, 
and consequently with several varieties of 
hemiplegia. In all these varieties we are 
concerned with palsies of the limbs, and 
with palsies of parts supplied by cranial 
nerves. 
The limbs, since their motor fibres have 
decussated in the lower part of the me- 
dulla oblongata, are always palsied on the 
side opposite to the lesion of any level of 
the lateral half of the sensori-motor tract. 
In lesions of the medulla, near the decus- 
sation, however, there is rather a general 
weakness, and only hemiplegia in the 
qualified sense that the limbs are more 
affected on one side. As Brown-Sequard 
has pointed out in lesions of one lateral 
half of the medulla, the nerve-fibres from 
the limbs may be caught in part before 
and in part after their decussation, and 
thus from a one-sided lesion there results 
bilateral paralysis. 
Above this great decussation, cranial 
nerves emerge from the sensori-motor 
tract, and many, if not the whole, of these 
nerves have special decussations. Hence 
in hemiplegia, parts supplied by the cra- 
nial nerves are sometimes palsied on the 
same side as the limbs, and sometimes on 
the opposite side, according as the lesion 
affects the fibres of these nerves after or 
before their decussations. For instance, 
both in lesion of the lower half of the 
right1 side of the pons and in lesion of the 
right corpus striatum, the arm and leg 
are palsied on the left, but in the former 
case the face is palsied on the side of the 
lesion (tl*e right), because the fibres of the 
facial (portio dura) nerve are caught be- 
fore its decussation, whilst in the latter 
the face is palsied on the side opposite the 
lesion, because fibres of the nerve are 
caught after its decussation. We must 
observe further that the decussation2 of 
cranial nerves, the facial and hypoglossal 
nerves at all events, is incomplete, so 
that, as we shall have to insist on later, 
we find in lesion of the higher levels of 
the motor tract, that is to say, in lesions 
above the pons, and therefore above the 
decussations of these nerves, that the pal- 
sies of the face and tongue are not only on 
the side opposite the lesion, but that they 
are incomplete in degree-there is paresis 
rather than paralysis. 
Cerebral Hemisphere. - Large 
parts of one cerebral hemisphere may be 
1 It will be convenient throughout this 
part of the article to suppose the right to be 
the side of the several lesions of which we 
have to speak. 
2 Lockhart Clarke has shown very clearly 
that there is a considerable decussation of 
the fibres of the ninth nerve. He finds that 
the nuclei of the facial are united by many 
fibres-commissural; but he has traced very 
few fibres of the nerve that decussate directly. 
(See Researches on the Intimate Structure of 
the Brain: Phil. Trans. 1868, p. 300, plate 
xiii. figs. 50 and 51.) LOCALIZATION of lesions. 
911 
destroyed without producing obvious 
symptoms, either mental or physical. It 
is not said that disease in the hemisphere 
does not lead to symptoms ; it very often 
does. (See art. Convulsion, p. 737.) In 
the article on Convulsion it was pointed 
out that hemiplegia frequently attends 
gross disease, syphilitic disease for in- 
stance, of the surface of the hemisphere, 
but in these cases the hemiplegia nearly 
always follows a convulsion, and depends 
probably on the nervous discharge in the 
convulsion itself. 
It is, we repeat, certain that a large 
quantity of any part of either hemisphere 
may be destroyed while there are no 
symptoms, with one important exception. 
If the lesion involves convolutions near 
the corpus striatum-usually the left- 
there is, according to the size and exact 
position of the lesion, more or less defect 
or even complete loss of speech (aphasia).1 
The probability is that when a part of the 
brain is slowly destroyed, the undamaged 
parts take on the function of the part de- 
stroyed. Something similar is seen in the 
case of the eye. When the central vision 
is lost, the peripheral parts of the retina 
acquire greater acuteness of vision. In 
large and sudden lesions of the cerebrum 
there are symptoms, probably from the 
withdrawal of a part before this kind of 
accommodation can be effected. 
We may have no symptoms from small 
clots in the hemispheres. In very large 
hemorrhages there are symptoms. These 
are usually, however, symptoms of Apo- 
plexy ; but if the Apoplexy be not very 
severe, we may discover some degree of 
hemiplegia. The palsy results either, as 
suggested, because a large part of the cere- 
brum is suddenly destroyed, or because the 
effusion by its mere bulk compresses the 
subjacent motor tract. 
Lateral Ventricles. - In cases 
where blood breaks into the lateral ven- 
tricle from the corpus striatum or thala- 
mus opticus, there is usually, not always, 
a convulsion and rapidly deepening coma. 
The convulsion, however, I believe, oc- 
curs not because blood is effused in the 
ventricle, but because under such circum- 
stances the clot is usually a large one and 
has suddenly torn much of the brain : for 
severe convulsion (with tongue-biting) 
may usher in the Apoplexy, or may occur 
later when a large clot, starting in the 
bodies mentioned, is well walled in. If a 
patient be first hemiplegic with or without 
unconsciousness, the subsequent occur- 
rence of a severe convulsion followed by 
universal powerlessness and deep coma is 
strong evidence of rupture into the ven- 
tricle, and is a very unfavorable sign. 
We now come to the sensori-motor 
tract. In the first two divisions-corpus 
striatum and thalamus - the lesion is 
above the decussation, not only of the 
fibres for the limbs, but of all the cranial 
motor nerves, so that the paralysis pro- 
duced is altogether on the opposite side of 
the body. 
Corpus Striatum. - A lesion here 
produces what may be called " the com- 
mon form of hemiplegia." As this is the 
most valuable symptom in the diagnosis 
of Cerebral Hemorrhage, it will be con- 
sidered in some detail, but still only so 
far as bears on the diagnosis of Cerebral 
Hemorrhage. 
It is very important, however, to ob- 
serve that a very large and sudden effusion 
in this region leads to such deep coma 
that, although there must be paralysis of 
the limbs, we do not often discover any 
(just as in deep coma with fracture of the 
base of the skull we may not discover 
palsy of the face due to injury of the por- 
tio dura nerve until the patient's coma is 
passing off). We discover no local palsy, 
because there is palsy of both sides-uni- 
versal powerlessness. This may be the 
result of squeezing of the opposite side of 
the brain by the sudden intrusion of a 
bulky mass into one side, the blood per- 
haps having also escaped into the lateral 
ventricles. Possibly the universal palsy 
may be in part owing to the destruction- 
the sudden lack-of those fibres which pass 
from the side of the lesion to the same side 
of the cord, as well as of those which de- 
cussate. (I have heard Dr. Brown-Se- 
quard insist that many hemiplegic pa- 
tients, some time after their seizure, were 
a little weak on what we usually call their 
sound side.) However, even in these 
cases we may learn that the case began in 
a hemiplegic manner, or we find some 
kind of one-sided symptoms, as tremor, 
rigidity, and the like. 
As we usually see hemiplegia, always 
in chronic cases and most often in recent 
cases, the palsy is incomplete in range. 
It affects only the face, tongue, leg, and 
arm of one side. But in complete hemi- 
plegia we have the following symptoms. 
We suppose the right to be the side of the 
lesion:- 
1. The head turns to the right. 
2. Both eyes turn to the right, and fre- 
quently both upper lids are fallen. 
3. The muscles of the belly and chest 
are weakened on the left. 
4. The muscles passing from the trunk 
to the left limbs are paralyzed. 
5. The face is paralyzed on the left 
side. 
6. The tongue on protrusion turns to 
the left. 
7. The left leg is paralyzed. 
8. The left arm is paralyzed. 
Hemiplegia so complete only occurs 
1 This symptom is considered in art. Soft- 
ening. 912 
CEREBRAL HEMORRHAGE AND APOPLEXY. 
from a very grave1 lesion, and even then, 
as a rule, the first two symptoms in the 
list pass off in a few hours or days. The 
symptoms in the list are given in what I 
believe to be the order in which the several 
parts suffer. It will be found that those 
parts suffer most and suffer longest (re- 
cover latest) wdiich have the more volun- 
tary uses. This is notorious of the arm 
and leg ; the arm nearly always suffers 
more and recovers later than the leg. Of 
course the distinction into complete and 
incomplete hemiplegia is artificial. There 
are all degrees of paralysis according to 
degrees of gravity of the lesion. But 
there is an order in which paralysis in- 
creases in increasing gravity of lesions. 
We observe that the graver the lesion, 
not only are the more voluntary parts 
(arm and leg) more paralyzed, but that 
the further spread in range is the para- 
lysis, and the method of its spreading is 
from the more voluntary to the more au- 
tomatic parts-to parts higher up in the 
list. Thus, neglecting very small clots, a 
considerable lesion (I cannot use a more 
exact term, suddenness of effusion as well 
as size of clot being a factor) paralyzes 
only the most voluntary movements of 
one side of the body, those of the face, 
arm, and leg, and these parts in degree 
according to their degree of voluntary 
use. A larger lesion not only causes a 
deeper and more permanent palsy of 
these three parts, but it leads also to im- 
plication of more automatic parts; it 
causes the additional symptoms 1, 2, and 
3 in the list. In still larger lesions the 
palsy spreads to the most automatic parts 
of the body, even to parts supplied by 
ganglionic nerves. It produces stertor 
from palsy of the palate and palsy of the 
respiratory muscles and of the heart- 
the palsy of respiration and of the heart 
showing itself chiefly in slowness of move- 
ment. There is also abasement of tem- 
perature. So we see that degrees of 
hemiplegia are "compound degrees." 
Not only are there degrees of more or less 
amount of loss of power of the face, arm, 
and leg-there is also, along with increas- 
ing degrees of loss of power of these most 
voluntary parts, increasing spreading of 
palsy to the more automatic parts of the 
body. There are degrees of hemiplegia, 
compound degrees as we have seen, from 
palsy of the most voluntary parts of one 
side only to almost universal paralysis, 
when, of course, " hemiplegia" is a mis- 
nomer. 
Lateral Deviations of the Eyes and 
Head2-This is not strabismus, as both 
eyes are still parallel, although both are 
turned to the right side-to the side of 
the lesion ; to the non-paralyzed side. 
Indeed there never is, except as an acci- 
dental complication, strabismus from 
palsy of the third or of the sixth nerve in 
hemiplegia from a lesion above the crus 
cerebri. The patient,1 especially when 
there is deviation of the head also, seems 
to be looking fixedly to one side. If the 
patient be sufficiently himself, we can get 
him to follow' movements of oui- hand, 
and we may find that he can bring the 
two eyes to the middle line or even be- 
yond it, but they soon fall again into the 
condition of deviation. 
Along with this deviation there is often 
more or less turning of the head to the 
same side. There is, according to Vul- 
pian and Prevost, " rotation," as there is 
after experimental lesion of one side of 
the brain in lower animals. But in man 
the rotation is only rudimentary ; there is 
only a slight twist, not a real turning. 
The clinical importance of these symp- 
toms is that they may be, as Prevost sug- 
gests, valuable evidence of a local lesion 
-of a clot, for instance-in cases of coma 
where wre can make out no paralysis of 
the limbs on one side, and when wre are 
in doubt whether the coma is owing to a 
very large local lesion, such as extensive 
cerebral hemorrhage, or to a general con- 
dition, such as uraemia or opium poison- 
ing. Two things further are to be noted. 
In cases of convulsion of one side of the 
body, the two eyes and the head turn to 
the side convulsed, and they may be per- 
manently turned to the paralyzed side if 
it become rigid, and may strain still fur- 
ther in that direction when a convulsion 
or a higher W'ave of rigidity comes on. 
(Deviation of the head and eyes may occur 
in meningeal as well as in cerebral hem- 
orrhage. ) 
The Muscles of one side of the Chest.2- 
Whether the muscles of the chest suffer 
and. Hutchinson. It has been described by 
Vulpian and Prgvost of Geneva (Gazette Heb- 
domadaire, Oct. 13, 1865). Cases by Drs. 
Humphry of Cambridge, Lockhart Clarke, 
Broadbent, and Russell Reynolds, and some 
interesting remarks on the symptom by Dr. 
Elizabeth Garrett (now Mrs. Garrett-Ander- 
son), will be found in the Lancet for 1866. 
1 It has been likened to the conjugate de- 
viation of the heads of two horses when an 
omnibus driver drops one of his reins, the 
other rein being "in tone." As, however, 
his reins do not decussate, that deviation is 
from the side of the "lesion." 
2 Dr. Broadbent has (Medico-Chir. Review, 
April, 1866) advanced an important and very 
valuable hypothesis to explain how it is that 
whilst the muscles which can act quite inde- 
pendently of their fellows on the other side 
of the body (those of the arm, for instance), 
suffer in disease of the corpus striatum, those 
which must act together (the intercostals, for 
instance) do not suffer. 
1 This word is used to include two equally 
important factors, size and suddenness of 
lesion. 
2 In this country attention was first called 
to this symptom by Gull, Lockhart Clarke, 913 
LOCALIZATION OF LESIONS. 
or not in this form of hemiplegia, is dis- 
puted. Niemeyer says : " Patients who, 
as a result of apoplexy on the left side, 
cannot move the right arm or leg, move 
the right side of the thorax just as well 
as the left during respiration." Todd 
says that "it must be an extensive lesion 
which will paralyze the intercostal and 
abdominal muscles." In some cases of 
recent hemiplegia, when the patient 
voluntarily draws a deep breath, the side 
of the chest paralyzed certainly some- 
times moves less than the other (see 
Wilks' Pathology of Nervous Diseases, 
Guy's Hospital Reports, 1866); probably, 
however, because the muscles passing 
from the trunk to the chest on the side of 
the paralysis will not act so strongly. At 
all events palsy of the muscles of one side 
of the chest is little, and soon passes off. 
Face.-The muscles paralyzed are those 
supplied by the facial (portio dura) nerve. 
The whole of these suffer, but they suffer 
slightly. Moreover we find that the sev- 
eral parts of the face do not suffer in the 
same degree. And it is to be particularly 
noted that there is only slight weakening 
of the orbicularis palpebrarum. The pa- 
tient can close his eyes, although not so 
strongly on the paralyzed side when urged 
to close them both tightly; sometimes, 
especially in chronic cases, we discover 
no difference. Hence this cerebral facial 
palsy differs remarkably from the facial 
palsy owing to affection of the trunk of 
the nerve (Bell's paralysis). The side of 
the cheek is the part most paralyzed, so 
that when the patient is asked to "show 
his upper teeth" the mouth is decidedly 
drawn to the sound side. 
The tongue is not paralyzed ; it is only 
weakened on one side, and on protrusion 
it turns but a very little to one side ; it 
turns to the side of the paralysis. But 
sometimes, in case of loss of speech with 
hemiplegia, especially soon after the 
attack, the tongue seems to be much 
paralyzed, as the patient does not put it 
out when asked, even when he knows 
what is asked of him ; he may try to get 
it out with his fingers. The fact that he 
can utter plainly some one or more words 
-mostly "yes" or " no"-that he masti- 
cates and swallows well, and that he may 
now and then put out his tongue to catch 
a stray crumb, shows that the tongue is 
not paralyzed in the ordinary sense of the 
word. There is loss of the most volun- 
tary movements of it, and we may find 
that the patient cannot do other simple 
things that he is told ; e. g., open his 
mouth, shut his eyes, or frown. 
Arm and Leg.-The arm suffers more 
and recovers later. We must not infer 
that the leg is not affected when the pa- 
tient seems to move it as well as the other 
when he lies in bed. If we cannot get 
him up to walk, we can only say that the 
leg is not much paralyzed. Indeed it is 
an exceedingly rare thing to find paralysis 
of the arm without some weakness of the 
leg soon after the attack, although not at 
all uncommon to find that the leg recovers 
when the arm remains much paralyzed. 
Thalamus Opticus.-Disease of the 
thalamus opticus produces hemiplegia 
which, in regard of the motor symptoms, 
is very like that produced by disease of the 
corpus striatum. In grave lesions there 
is lateral deviation of the head and eyes. 
Probably, however, the palsy is not simi- 
larly distributed. I think, for instance, 
that the arm suffers less, and the leg more, 
the further back the lesion is placed in the 
two divisions of the motor tract, the cor- 
pus striatum and optic thalamus. 
But in disease of the thalamus there is 
also diminution, or, soon after the attack, 
loss of sensation, and not of the arm and 
leg only, but of the whole half of the body, 
quite up to the middle line. This loss of 
sensation has been denied ; one reason no 
doubt is, and it is important to bear this 
in mind, that sensation returns much 
more quickly than does power of move- 
ment.1 
Crus Cerebri.-Damage to the crus 
cerebri causes hemiplegia on the opposite 
side like that above described, there being 
loss of motion if the under part of the 
crus only be damaged, and loss of sensa- 
tion also if the upper strands be damaged 
as well. From the crus emerges the first 
cranial nerve, and at this level of the mo- 
tor tract we may have " cross paralysis. " 
If the under and inner part of the crus be 
involved, the third nerve is paralyzed on 
the side of the lesion-on the side opposite 
the paralysis of the limbs. The nerve is, 
so to speak, caught as it goes in,2 and of 
course before any of its fibres can have 
decussated, whilst the fibres from the arm 
and leg are caught long after their much 
lower decussation in the medulla oblon- 
gata. But we can only make the diagno- 
sis of lesion of the crus when the two 
symptoms-the palsy of the third nerve 
and the hemiplegia-come on at the same 
time. If they come on at different times, 
it is just as likely that there are two 
lesions,-one of the trunk of the nerve and 
the other in the thalamus or corpus stria- 
tum. This is important in the diagnosis 
of the nature of the lesion, for when the 
two symptoms-the palsy of the third 
nerve, and the hemiplegia-come out at 
different times, or if the palsy of the third 
nerve be on the same side as the hemi- 
1 For important observations on this sub- 
ject, see Broadbent, Med.-Chir. Review, April, 
1866. 
2 It is convenient to speak of the fibres of 
both the motor and sensory nerves as passing 
from their external distribution to the ner- 
vous centres. 
vol. i.-58 914 
CEREBRAL HEMORRHAGE AND APOPLEXY. 
plegia, we may be practically certain that 
there is not Cerebral Hemorrhage. In 
these cases the disease is mostly syphilis.1 
So far the sides of the motor tract are 
distinct. In the next two divisions the 
two sides are welded together. 
Pons Varolii.-Hemorrhage may be 
limited to one lateral half, or it may oc- 
cupy both sides of the pons. (It may ex- 
tend to the crus cerebri or crus cerebelli.) 
In the former case there is hemiplegia ; in 
the latter double hemiplegia, or rather a 
condition of universal powerlessness, in 
which, as there is usually deep coma, we 
can make out no local paralysis-a condi- 
tion, as we shall see, very like that of 
uraemia and opium poisoning. In other 
cases the palsy, although on both sides, is 
more marked on one side. 
We speak here of hemiplegia from lesion 
of one lateral half of the pons,2 and we 
speak of lesions of the right half. Here 
again we have to do with cross paralysis, 
because we have to do with cranial nerves 
which decussate in the pons itself above 
the great decussation of the fibres for the 
limbs. The cranial nerves are the fifth, 
sixth, and facial. First, for general re- 
marks on the effect of lesions at different 
levels of one lateral half of the pons, taking 
the facial nerve (portio dura) for illustra- 
tion. In the right half of the pons, there 
are fibres of the right and also of the left 
facial nerves, those of the right before its 
decussation, and those of the left after its 
decussation. (1) A lesion in the lower 
part of the pons will catch the fibres of 
the right facial nerve before its decussa- 
tion, and will also involve the fibres from 
the left limbs, which have crossed lower 
down in the medulla. There is then palsy 
of the right side of the face, on the side of 
the lesion, and of the arm and leg on the 
left, the side opposite the lesion. (2) A 
lesion in the upper part of the pons 
(Brown-Sequard, op. cit. p. 153) may de- 
stroy fibres of the left facial nerve which 
have crossed in the pons, and will also in- 
volve the fibres for the left limbs. Here 
then the facial paralysis will be on the 
side opposite the lesion, and therefore on 
the same side as the palsy of the arm and 
leg. The hemiplegia will be like the hemi- 
plegia from disease above the pons. Hemi- 
plegia of this kind is very rarely caused 
by disease of the pons. (3) Lastly, Brown- 
Sequard points out, that a lesion in the 
middle of the pons will catch the fibres of 
the right facial nerve before its decussa- 
tion, and those of the left after its decus- 
sation. Then the face is palsied on both 
sides from lesion of the right half of the 
pons and the arm and leg on the left. 
To repeat, a lesion of the right half of 
the pons affecting the facial nerve near its 
implantation causes palsy of the face on 
the right side and of the arm and leg on 
the left. A lesion in the upper part of 
the right half of the pons causes the palsy 
of the face and of the limbs on the left 
side. A lesion of the right half of the 
pons may be so extensive as not only to 
affect the right facial nerve before its de- 
cussation, but to extend to the fibres of 
the left facial nerve after its decussation. 
Then there is palsy of the face on both 
sides, more marked on the right, and 
palsy of the left arm and leg. 
What has been said applies to the fifth 
nerve. An extensive lesion may involve 
both the facial and fifth nerves, and then 
there is palsy of the region supplied by 
the fifth nerve and portio dura nerves of 
the right side and of the leg on the left. 
Here it is to be observed that in most 
cases not only does the palsy of the face 
in cross paralysis from disease of the pons 
differ from the facial palsy in the common 
form of hemiplegia, in that it occurs on 
the side opposite the limbs paralyzed, but 
it differs in that it is much more decided 
in degree. The facial palsy may be as 
extensive as that which results from dis- 
ease of the trunk of the portio dura nerve. 
There is, in short, Bell's paralysis of the 
face. And when the fifth nerve is affected, 
the face is anaesthetic, the masseter and 
temporal muscles are much palsied, and 
after a time they waste as they do in dis- 
ease of the trunk of the fifth. 
There are, in actual practice, combina- 
tions of symptoms which are more difficult 
to understand, but which can be resolved 
by a consideration of Lockhart Clarke's 
researches. (See especially Philosophical 
Transactions, Part I., 1868.) When the 
portio dura nerve is paralyzed, we often 
find paralysis of the sixth nerve on the 
same side too. The opposite sixth may 
be also paralyzed in a less degree (Brown- 
Sequard, op. cit.).1 The relation of these 
two symptoms-the facial and ocular palsy 
-is easy to understand when we remem- 
ber that the facial and sixth nerves, al- 
though they emerge at different places, 
1 An important case of hemorrhage into the 
crus cerebri has been published by Dr. Her- 
mann Weber in the Med.-Chir. Society's 
Transactions, vol. xlvi. This report gives a 
careful account of the condition of sensation 
and of temperature on the two sides of the 
body ; there is a reference to cases previously 
published. 
2 In an article on Cerebral Hemorrhage, we 
can only do so in outline. For a full account of 
the symptoms resulting from disease of the 
pons Varolii, see Brown-S^quard's Lectures 
in the Lancet, 1861, vol. ii.; and Lockhart 
Clarke's papers, Phil. Trans., 1868. 
1 We should carefully examine the condi- 
tion of the opposite sixth; and if it be not 
markedly paralyzed, we may see oscillations 
in the eyeball when the patient tries to avert 
it, showing that the external rectus on that 
side also is weakened. LOCALIZATION OF LESIONS. 
915 
arise, as Stilling and Lockhart Clarke 
have shown, from a common nucleus. 
Again, we must observe that in limited 
disease in one half of the pons, the parts 
supplied by the motor division of the fifth 
nerve may be paralyzed on the side of the 
lesion when there is no diminution of sen- 
sation on that side. We find diminution 
of sensation on the opposite side of the face 
to that on which the limbs are affected. 
(This has occurred, in the cases I have 
seen, only when there has been palsy of 
the sixth and facial also.) Since Lock- 
hart Clarke has found that the bundle of 
fibres of the sixth and the bundle of fibres 
of the portio dura nerve, after arising 
from their common nucleus, diverge so as 
to inclose the motor nucleus of the fifth- 
the fibres of the portio dura separating it 
from the sensory nucleus of the fifth-it 
is easy to understand why we have, from 
a single lesion, palsy of the portio dura 
sixth, and the motor division of the fifth 
all on one side. But the occurrence of 
the diminution of sensation on the oppo- 
site side of the face is not easy to under- 
stand unless we assume a crossing of the 
sensory and motor fibres of the fifth in the 
pons, on separate levels, analogous to the 
crossing of sensory and motor fibres of 
the limbs on separate levels, which Brown- 
Sequard has discovered. 
As to the limbs in hemiplegia from dis- 
ease of the pons, there is usually affection 
both of sensation and motion. We find, 
of course, differences in the amount of loss 
of power, and of degree of anaesthesia. 
Moreover, we find differences in distribu- 
tion of the two. I have seen the leg very 
much palsied and anaesthetic when the 
arm was scarcely weakened but nearly 
altogether anaesthetic. These points do 
not specially concern us in an article on 
Cerebral Hemorrhage, although they are 
of very great physiological interest, as 
showing relations of strands of motor and 
sensory nerve-fibres for the limbs in the 
pons. 
Whilst the diagnosis of hemiplegia from 
hemorrhage on one side of the pons is 
usually very easy, the diagnosis of hemor- 
rhage into both sides of the pons is some- 
times very difficult. A large effusion in 
this part usually produces death rapidly 
-in a few hours. In large effusions there 
is usually marked contraction of the pupil 
on both sides, and there is universal 
powerlessness-a condition so like that of 
opium poisoning, that treatment for opium 
poisoning has been adopted in cases of 
hemorrhage into the pons. (See Special 
Diagnosis.) 
Medulla Oblongata.-Of the effects 
of effusion of blood limited to the medulla 
oblongata little is known. A large effu- 
sion would no doubt be very rapidly fatal, 
but I have never seen a large effusion 
here. I have made but one autopsy on a 
patient who had had a small effusion 
limited to the medulla. I saw this patient 
with Dr. Lockhart Clarke and Dr. Morell 
Mackenzie. The patient had recovered 
from an attack of hemiplegia due, as we 
afterwards found, to a clot in his right 
thalamus opticus, when all at once he lost 
power to articulate from paralysis of his 
tongue-remaining able to write well. A 
few years later the patient died, and Dr. 
Lockhart Clarke,1 to whom I gave the 
medulla oblongata, found in it remains of 
past effusions of blood. 
The symptoms which would lead us to 
infer disease of the medulla oblongata are 
paralysis of the lips, tongue, palate, and 
vocal cords. These symptoms, however, 
mostly come on very slowly, and usually 
both sides are equally affected. This is so 
in the "Paralysie labio-giosso-laryngee" 
of Duchenne. There can be no clot nor 
any kind of sudden lesion in such cases. 
If any of these palsies are on but one side, 
they must be attributed to tumor or to 
syphilis, if they come on slowly; but 
whether on one or on both sides, if they 
or any of them come on suddenly, they 
must be attributed either to clot or to 
softening from thrombosis.2 
Cerebellum.-Nothing definite can 
be said as to the special symptoms pro- 
duced by hemorrhage into the cerebellum. 
Sometimes there is loss of consciousness, 
and sometimes there is not. Sometimes 
there is hemiplegia, and at other times 
none. And when there is hemiplegia, it 
is sometimes on the side of the lesion and 
sometimes on the opposite side. Of course 
these differences depend on differences in 
the exact part of the cerebellum injured, 
on the size of the clot, and on the rapidity 
of the effusion, but these differences have 
not yet been put in order. When there 
are no paralytic symptoms, we can make 
no diagnosis. Sometimes there is a con- 
jugate deviation of the eyes-not lateral 
deviation: one eye is turned upwards and 
outwards, and the other downwards and 
inwards. When this symptom is present, 
we may diagnose sudden lesion of the crus 
cerebelli. When there is hemiplegia, the 
palsy is not diagnostic as to the seat of the 
lesion unless perhaps we can ascertain the 
absence of facial and lingual palsy. For 
Brown-Sequard (Lancet, Nov. 2, 1861) 
says that in hemiplegia from hemorrhage 
in the cerebellum there is neither lingual 
nor facial palsy, although there is a loss 
of facial expression. In cases of deep 
1 See Phil. Trans., part i. 1868, where the 
case is published. 
2 Here I would refer the reader to very im- 
portant remarks by Lockhart Clarke (Phil. 
Trans., part i. 1868, pp. 316-17, &c.), and to 
a case illustrating his views which I have 
published (London Hospital Reports, vol. i. 
1864, p. 361). 916 
CEREBRAL HEMORRHAGE AND APOPLEXY. 
coma, however, we might be unable to 
tell whether there was facial or lingual 
palsy. But if there be hemiplegia of any 
kind in a case of apoplexy, we can at all 
events say there is a local lesion, and this 
with other symptoms would be good evi- 
dence of the existence of large Cerebral 
Hemorrhage-and this is the most im- 
portant matter-in some part of the ence- 
phalon. Vomiting occurs in Cerebral 
Hemorrhage, but very urgent vomiting 
would point to Cerebellar Hemorrhage : 
severe pain at the back of the head would 
supply still further evidence, but this 
symptom would only be presented when 
the patient was not unconscious. Fortu- 
nately, hemorrhage in the cerebellum is 
very rare, so that we have not often the 
chance of being wrong. 
[Since this article was written, an im- 
portant advance has been made in the 
direction of inquiry above pointed out. 
Localization of brain-lesions (not only 
hemorrhagic, but also traumatic, inflam- 
matory, and degenerative) has been during 
the last decade (1870-80) extensively 
studied, by combining the results of ex- 
perimental physiology with those of clini- 
cal observation and morbid anatomy. 
Since 1861, Dax, Bouillaud, and Broca 
have obtained the general recognition in 
pathology of the causative association of 
lesion of a certain portion of the left cere- 
bral hemisphere with aphasia.' Besides 
the now neglected but ingenious hypothe- 
sis of Gall (popularly known as phrenol- 
ogy), other suggestions had been often 
previously thrown out, of a similar kind. 
One of the most noticeable of these was 
that of Serres,2 based upon two actual 
cases; to the effect that "if the right arm 
be affected, the lesion will be in that por- 
tion of the brain which corresponds to the 
upper left parietal bone, and vice versa." 
The study and discussion by Bravais in 
1827 of "hemiplegic epilepsy," and some- 
what later, by Todd, of "epileptic hemi- 
plegia," followed by Hughlings Jackson's 
able analysis of unilateral convulsions, 
and of epilepsy connected with cortical 
brain lesion, prepared the way for the 
new era in localization. In 1870 were 
published the investigations of Fritsch 
and Hitzig upon the effects of electriza- 
tion of the surface of the cerebral hemi- 
spheres in animals. These -were fol- 
lowed by similar experimental inquiries 
by Ferrier, Schiff, Braun, Nothnagel, 
Eckhard, Carville, Duret, Burdon San- 
derson, Lussana, Vulpian, and Dupuy. 
In the connected clinical and pathological 
observations and studies, contributions 
have especially been made by Charcot, 
Bouchard, Pitres, Brun, Lepine, Meynert, 
Huguenin, Proust, Broca, and Hughlings 
Jackson. 
Upon the physiological portion of the 
subject, Ferrier may be considered as the 
representative authority. From the care- 
fully studied effects upon animals of the 
stimulation by electricity of different por- 
tions of the cerebral hemispheres, he con- 
cludes that, in the gray matter of the 
convolutions, there are psycho-motor zones, 
which have a functional relation to the 
voluntary movements of certain groups of 
muscles. These are not exactly the same 
in all animals ; being, for example, differ- 
ently located in monkeys, dogs, and cats. 
From experiments upon monkeys (con- 
firmed by a considerable amount of evi- 
dence from morbid anatomy), it is inferred 
that the psycho-motor zone is, upon each 
side, in the immediate neighborhood of 
the fissure of Rolando; comprising the 
ascending frontal and ascending parietal 
convolutions, the paracentral lobule, and 
probably the base of the frontal and su- 
perior and inferior parietal convolutions.1 
" Broca's convolution," the now accepted 
seat of the faculty of speech, is the third 
frontal convolution of the anterior lobe of 
the left hemisphere. 
The other "centres" in this zone are, 
by the advocates of localization, regarded 
as governing the volitional movements of 
the head, eyes, eyelids, pupils, angles of 
the mouth, arm, hand, leg, and foot. Fer- 
rier draws an important distinction be- 
tween the central determination of volun- 
tary, and that of automatic, instinctive, 
or reflex movements. The latter he refers 
to the lower centres, at the base of the 
brain ; ascribing to the gray matter of the 
limited region above named those actions 
only which involve conscious discrimina- 
tion. Ue also asserts (with less amount 
of plausible evidence, however) the exist- 
ence of sensory centres, in the parieto- 
temporal region, between the motor-zone 
and the occipital lobes. To these, the 
occipital lobes, he ascribes, hypothetically, 
a governing relation to the viscera, and 
the functions of organic life. The most 
anterior frontal and orbital regions of the 
cerebral hemispheres he believes may be 
the seats of true psychical centres. 
Somewhat confirmatory of these views, 
as to a regional subdivision of the func- 
tions of the hemispheres, are the observa- 
tions of Duret, Cohnheim, and Charcot, 
upon the distribution of the arterial cir- 
culation of the brain. Duret asserts that 
the areas or territories of vascular supply 
are to a considerable extent independent 
of each other. This has great conse- 
quence in connection with cerebral em- 
[' See Aphasia, in the article in this vol- 
ume on Softening of the Brain.] 
[* Anatomie Compare du Cerveau, 1824- 
26.] 
[' See Ferrier on the Functions of the 
Brain, 1876 ; on Localization of Cerebral Dis- 
ease, 1878.] LOCALIZATION OF LESIONS. 
917 
bolism. The " motor zone" is supplied 
by the superficial branches of the Sylvian 
artery. If thrombosis or embolism of this 
vessel occur after it has given off the 
branches going to the corpus striatum, on 
either side, softening may occur in the 
psycho-motor region alone; producing 
hemiplegia of the opposite side as one of 
its results. 
Notwithstanding the amount of evi- 
dence accumulated in favor of this theory 
of localization, it cannot bo considered 
Fig. 54. 
Lateral view of brain, showing fissures and convolutions. 
Inner surface of hemisphere, showing convolutions and fissures, and Ferrier's centres of touch, 
smell, and taste. 
Fissures (Figs. 54 and 55):-a, superior frontal; ft, Inferior frontal; c, fissure of Rolando ; d, fissure of Sil- 
vias ; c, inter parietal; f, fronto-parietal; c, parieto-occipital; h, first temporo-sphenoidal; i, second ditto; j, 
inferior ditto ; k, occipito-temporal; I, calcarine; m, hippocampal. 
Convolutions (Figs. 54 and 55):-A, superior, or first frontal; B, second ditto ; C, third ditto ; D, ascending 
frontal; E, ascending parietal ; F, superior parietal; F„ prsecureus ; G, supra-marginal; G,, gyrus angularis, 
or pli courbe ; H, first temporo-sphenoidal; I, second ditto ; J, third ditto ; K, fusiform lobule ; L, lingual 
lobule ; M, gyrus fornicatus ; My, gyrus hippocampi; M/Z) uncus gyri fornicati, or subiculum cornu Ammonis; 
N, cuneus. 
yet as a finally established doctrine in 
Physiology. Brown-Sequard has brought 
the weight of his immense experience in 
cerebro-nervous experimentation and mor- 
bid anatomy to bear against it. Vulpian, 
Lussana, and Lemoine prefer to ascribe 
to the fibres of white substance, connected 
with the cortical gray matter of the brain, 
the motor control in question. Goltz, 
Schiff,1 Munk, 'Luciani, and Tamburini® 
have obtained considerably different ex- 
perimental results from Ferrier's. 
Brown-Sequard's position on the sub- 
ject affords a remarkable exemplification 
P See also Lauterbach, Amer. Journal of 
Med. Sciences, October, 1877, p. 371.] 
[2 Brain, July, 1879, p. 189.] 918 
CEREBRAL HEMORRHAGE AND APOPLEXY. 
of the liability of vivisectory experimenta- 
tion to complicate the problems it pro- 
ceeds to solve. After having arrived at 
quite different results in his previous in- 
vestigations, they, and those of other 
physiologists, have been, by his last de- 
monstrations, swept away; with the de- 
duction of conclusions such as the follow- 
ing : a lesion of one side of the brain can 
produce symptoms either on the same or 
on the other side of the body ; a lesion on 
both sides of the brain may cause symp- 
Fig. 56. 
Lateral view of brain, showing Ferrier's psycho-motor centres. 
Upper aspect of brain, showing on left side Ferrier's centres ; on the right, the arterial areas, 
The Roman numbers in Fig 56, 57, and 55, refer to Ferrier's centres. 
I, lateral movements of head and eyes, with elevation of eyelids and dilatation of pupils; II, extension of 
arm aud hand ; III, complex movements of arm and leg, as in climbing, swinging, &e. , IV, movements of 
leg and foot, as in locomotion ; V, movements of lips and tongue, as in articulation , VI, depression of angle 
of mouth; VII, elevation of angle of mouth; VIII, supination of hand and flexure of forearm; IX. centre 
of platysma, retraction of angle of mouth ; X, movements of hand and wrist; XI, centre of vision; XII, 
centre of hearing ; XIII, centre of touch ; XIV, centre of smell and taste. (From Bristowe.) 
toms limited to one side of the body ; and 
most extensive lesions may occur in any 
or all parts of the brain without corre- 
sponding symptoms. Instead of a few 
restricted cerebral centres governing spe- 
cial functions, he believes that very nume- 
rous brain-cells related to each of such 
functions must be located throughout the 
hemispheres ; acting m solidarity by means 
of intercommunication amongst them. LOCALIZATION OF LESIONS. 
919 
Each hemisphere, especially, he asserts 
to be in itself complete for all brain func- 
tions, for both sides of the body ; although 
both are not nearly always alike devel- 
oped and actively used. Minute anatomy 
has not yet furnished a complete explana- 
tion of the intercommunication of all parts 
of the brain ; the exact nature and func- 
tions even of the neuroglia cannot be said 
to be fully understood. Analogy fur- 
nishes an important suggestion, in the 
discovery by Gerlach, confirmed by Boll,1 
of a network of extreme fineness in the 
spinal cord, composed of the union of the 
ramifying nerve-filaments of the spongy 
substance of the cord. 
Dupuy, by his experiments, has placed 
a great difficulty in the way of the adop- 
tion of the hypothesis of cortical motor 
centralization. Having exposed the "mo- 
tor zone" of the left hemisphere of a dog, 
he produced the usual movements by elec- 
trical stimulation, and then cauterized 
the cortex of that region. Electricity 
applied to the cauterized part still caused 
the same movements. Leaving the ani- 
mal for four weeks, it presented no symp- 
toms affecting the motor functions. Then, 
reopening the wound, he found a dry 
eschar, with meningeal adhesion. Elec- 
tricity applied to the eschar produced no 
movement; but application of the current 
to the parts around the eschar brought on 
muscular action. This certainly shows 
great insufficiency in the proof of the de- 
pendence of the motor function upon the 
condition of the cortical substance. This, 
indeed, is not exactly what Eerrier has 
asserted, as he refers a large class of 
movements to the corpora striata and 
other lower brain centres, and dwells on 
the fact that actions which at first are 
volitional, may become subsequently 
automatic; the superintendence of the 
higher centres being sometimes, when in- 
complete, supplemented, or even substi- 
tuted by the lower centres. This happens 
with especial facility in the lower animals. 
On the whole, all that has been pre- 
viously known and rendered probable of 
the functions of the cerebral hemispheres 
makes it reasonable to emphasize what 
Ferrier recognizes as the psychical element 
in the history of these phenomena. Other 
reasons exist, which have been very gen- 
erally overlooked, for concluding that the 
anterior portion of the cerebrum is emo- 
tional in function ; the intellectual powers 
having their seat in the posterior, or pos- 
tero-median, portion.2 For emotional 
expression there must be a relation to the 
muscles, through their immediately con- 
trolling centres ; and this relation appears 
to be wrell established in regard to certain 
parts, at least, of the anterior region of 
the brain. As a question in Physiology, 
this is all that should be claimed as set- 
tled ; the nature and extent of the relation 
being yet open for farther investigation. 
In experimentation upon the brain and 
nervous system, one of the most impor- 
tant facts is, the frequent diffusion, not 
only of electrical stimulation, but of all 
impressions. Action at a distance, 
through nervous conduction, directly 
stimulant, reflex, or inhibitory, is, rather 
than exceptional, almost the rule. This 
introduces a great difficulty into the in- 
terpretation of results, both of vivisection 
and of accidental injury or disease.1 
Coming to our immediate subject of the 
pathology and diagnosis of brain affec- 
tions, this must be considered upon the 
merits of its own evidence, while awaiting 
the explanations of Physiology, to be 
hereafter completed. It has been known 
since the time of Andral, that extensive 
lesions of the cerebral cortex may occur 
without motor symptoms. Andral, Vaut- 
tier, Marot, Herpin, Sabourin and others2 
have reported cases of this kind. Men- 
tion has been made already of the names 
of those who have especially studied of 
late the coincidence of marked muscular 
symptoms (paralysis, convulsions, &c.) 
with lesions of a limited portion of the 
surface of the hemispheres. 
It is necessarily admitted3 that, as yet, 
it is not always possible to make during 
life a certain diagnosis between paralysis 
from lesion of the cerebral cortex and 
that from lesion of the corpus striatum, 
alone, or involving a portion of the inter- 
nal capsule. In both, those movements 
are most affected which are the most voli- 
tional. Sensation is not affected in either, 
if the lesion be confined, in the one case, 
to the cortex, in the other, to the anterior 
two-thirds of the capsule. In neither is 
the nutrition or electric contractility of 
the paralyzed muscles impaired. In both, 
a tendency exists to the development, 
sooner or later, of descending sclerosis of 
the motor tracts of the crus, pons, me- 
dulla oblongata, and spinal cord, with 
late rigidity or contraction of the para- 
lyzed limbs. 
Characteristic, howrever, of paralysis of 
[i To make the most of this argument, one 
might ask what more of demonstration is there 
of purely motor centres in the cortex of the 
brain, than there is of epilepto-genetic centres 
in the skin of the guinea-pig, under Brown- 
Sequard's experiments ?] 
[2 Charcot and Pitres, Revue Mensuelle de 
Medecine et de Chirurgie, Jan. 1877.] 
[3 Ferrier, Localization of Cerebral Disease.] 
[' See Erb, in Ziemssen's Cyclop, vol. xiii.] 
[2 Since 1860, I have taught this in lec- 
tures to students of physiology ; having been 
led to it by facts in embryology and compara- 
tive anatomy, to which this would not be the 
place to allude in detail. See my Manual of 
Physiology for Students, 2d edit., Philada., 
1874.] 920 
CEREBRAL HEMORRHAGE AND APOPLEXY. 
cortical origin seems to be the occurrence 
of dissociated paralyses, or monoplegite. 
An arm and hand alone, or the face, or 
one leg, may be affected with paralysis, 
which may successively extend to other 
parts. A comprehensive summary from 
Ferrier1 may conclude our account of this 
subject:- 
''While we cannot be quite certain of 
the position or extent of a cortical lesion 
causing a sudden and complete hemiple- 
gia, we may take a monoplegia of the leg 
or of the arm and leg as an indication of 
lesion of the upper extremity of the ascend- 
ing convolutions close to the longitudinal 
fissure; brachial monoplegia as a sign 
of lesion of the upper part of the ascending 
frontal convolution, or, if the paralysis 
affect the hand more particularly, of the 
ascending parietal convolution; brachio- 
facial monoplegia as indicating lesion of 
the mid-fronto-parietal region; while fa- 
cial and lingual monoplegia, or this com- 
bined with aphasia, indicates lesion of the 
lower part of the ascending frontal con- 
volution, where the third frontal unites 
with it."-II.] 
The Apoplectic Condition". 
Apoplexy, as was remarked in the In- 
troduction, p. 902, is not peculiar to Cere- 
bral Hemorrhage. It will be seen when 
we come to Special Diagnosis that it is 
sometimes difficult and occasionally im- 
possible to tell whether Apoplexy is owing 
to a fatal lesion of the brain, or to the 
comparatively minor cause, deep drunken- 
ness. Again, from clot there are all de- 
grees, from slight and transient mental 
obscuration to profound and rapidly fatal 
coma. It is not a priori likely, when we 
consider that the clots vary in size, in the 
suddenness of their irruption, and in their 
seats of effusion, that there would be any 
uniformity in the conditions produced by 
Cerebral Hemorrhage, and, as a matter 
of fact, the conditions vary very much in- 
deed. We can here only speak of severe 
cases, admitting that they are not typical. 
Under the head of Diagnosis we shall 
notice cases of Cerebral Hemorrhage in 
which there is no loss of consciousness ; 
and under the head of Special Diagnosis, 
various degrees of impairment, or "loss 
of consciousness"-if the phrase degrees of 
loss of consciousness be permissible-will 
be spoken of. 
The striking symptoms of the apoplectic 
condition are, (ci) loss of consciousness, 
(6) states of pupil, (e) stertor, (d) altera- 
tion of pulse, respiration, and tempera- 
ture. 
Loss of Consciousness.-We are consid- 
ering a severe case-apoplexy, the result 
of a large and sudden hemorrhage-and 
as we admit that such a case is not typi- 
cal, we shall only discuss how it happens 
that from a circumscribed lesion in but one 
side of the brain there results total aboli- 
tion of consciousness. 
We know that loss of consciousness can- 
not result from mere lack of the compara- 
tively small part which the hemorrhage 
has destroyed, for, as autopsies show, 
much of the brain may remain lacking for 
years in patients who have been uncon- 
scious only a few hours or days at the 
time when the destroying lesion occurred. 
But Cerebral Hemorrhage is a bulky le- 
sion-it squeezes; it is also a brusque 
lesion-it not only destroys, but it de- 
stroys suddenly-there is shock. 
Niemeyer attributes the loss of con- 
sciousness to squeezing. He does not 
suppose it to depend on squeezing of the 
nerve-fibres and cells, but on squeezing of 
the capillaries; in other words, he attri- 
butes it to rapid anaemia of the brain, 
produced mechanically. It is true that 
there is no loss of consciousness in cases 
of very large cerebral tumor when there 
is evidently increased intracranial pres- 
sure ; but clot and tumor are manifestly 
not comparable lesions. Tumors increase 
slowly, and probably, as Niemeyer sug- 
gests, the fibres of the part of the brain 
directly compressed become atrophous, 
and thus more room is made. Again, 
there is compensation by diminution in 
the quantity of cerebro-spinal fluid. But 
blood is rapidly effused, and the clot will 
squeeze before either of these modes of 
accommodation can take place, and thus 
the accommodation is, according to Nie- 
meyer, obtained at the expense of the 
capillaries. They are emptied. In esti- 
mating the gravity of a lesion, rapidity is 
to be considered almost as important a 
factor as size, as will be best seen when 
we come to speak of sudden death from 
intracranial hemorrhage. 
Mr. Hutchinson (Lectures on Compres- 
sion of the Brain, London Hospital Re- 
ports, vol. iv., 1867) also believes that the 
apoplectic condition is the result of ex- 
tensive and rapid squeezing of a large 
quantity of the brain, and that the direct 
cause of the loss of consciousness is sud- 
den ansemia quoad arterial blood. He 
points out that an enormous effusion, if it 
occurs very slowly, need not be attended 
by any insensibility whatever. 
The above theory of the occurrence of 
loss of consciousness from ansemia, me- 
chanically caused, may serve in the ex- 
planation of many cases of large Cerebral 
Hemorrhage, but will not serve in all 
cases. It does not explain, as Jaccoud 
insists, the transitory loss of conscious- 
ness which sometimes occurs from small 
clots, the squeezing from which can be 
very trifling. Moreover, there are many 
[l Op. citat.] THE APOPLECTIC CONDITION. 
921 
cases of loss of consciousness from other 
causes in which there can be no squeezing, 
for instance in some cases of embolism1 of 
the middle cerebral artery, and in the fit 
of epilepsy. In cases of laceration of the 
brain from injury-cases without any con- 
siderable effusion of blood being now con- 
sidered-the apoplectic condition comes on 
although there is no squeezing. Thus 
Mr. Hutchinson says: "It is sometimes 
quite impossible to make any diagnosis by 
the symptoms alone [cases where there is 
no history of the mode of onset, for in- 
stance] between cases of sudden compres- 
sion of the brain and those of laceration 
of the brain." We must consider the 
shock-producing element - that of sud- 
denness of lesions. 
We may here avail ourselves of what 
Jaccoud has written in his important 
work, "Pathologie Interne," vol. i. p. 
164. The normal function of the brain, 
he says, depends on the joint and simul- 
taneous activity of its two halves. When 
one is injured, the other can in a certain 
measure compensate, provided the lesion 
occurs slowly, as in tumor. But the dis- 
turbance of a sudden, although local, lesion 
reacts on the whole brain, its two halves 
being united by "powerful" commissures. 
The torn brain receives a shock on the 
side injured directly, and this is trans- 
mitted and reflected on the other side, 
and then there is produced the "nGvro- 
lysie"2 which is apoplexy. 
In unconsciousness produced by uraemia 
there may be no arterial anaemia in the 
ordinary sense of the expression, but still 
in effect the action will be the same. The 
blood is not good arterial blood. But, if 
we accept Traube's view that Bright's 
disease leads to oedema of the brain, there 
will be veritable anaemia in uraemia from 
the squeezing which the exuded fluid will 
cause. 
Pupils.-There seems to be a wide-spread 
impression that when a patient is coma- 
tose, his pupils must be either "con- 
tracted" or "dilated."1 It is quite cer- 
tain that there may be a very large clot 
on one side of the brain when the pupils 
cannot be declared to be normal. Ex- 
treme contraction or extreme dilatation of 
the pupils are rare symptoms in Cerebral 
Hemorrhage. It is to be observed that 
in the many cases of coma, although the 
pupils are very small when the patient is 
left still, as small as in healthy sleep, they 
may become much larger when attempts 
are made to rouse him. From not con- 
sidering this, different accounts are given 
as to the condition of the pupils in the 
same case by different observers, or there 
are supposed to be remarkable variations 
in the signs of the pupils. On the whole, 
the conditions of the pupils are of little 
value.2 
We shall speak of contraction of both 
pupils under the head of Diagnosis of 
Apoplexy, owing to hemorrhage into the 
pons, from opium poisoning. The follow- 
ing further remarks on the pupils belong 
strictly to diagnosis, but they are most 
conveniently considered here. 
Importance must be attached to differ- 
ence in the size of the two pupils, but 
only when the difference is great; for the 
pupils are often of slightly different size 
in healthy people. Difference in the size 
of the pupils points to a local lesion. Thus, 
were one pupil very minutely contracted 
and the other presumably unaltered, the 
contraction would be some evidence of dis- 
ease of the pons Varolii on the side of the 
contraction. But I have not yet seen 
minute contraction of the pupil on one 
side from clot in the pons when there has 
been coma. I have seen it in cases of 
hemiplegia from disease of one side of the 
pons : in one of these cases there was a 
clot. Were one pupil very widely dilated, 
it would lead me to search most carefully 
for signs of injury to the head, as Mr. 
Hutchinson has found very wide dilata- 
tion of one pupil in cases of blood effused 
1 He says, op. cit. p. 139, of the apoplexy 
which occasionally occurs from embolism, 
that it may be attributed "soit & une n^vro- 
lysie produite par la perturbation subite de 
l'6quilibre circulatoire (Jaccoud), soit a un 
cedeme aigu generalise par suite de 1'augmen- 
tation de pression dans les arteres permeables 
(Niemeyer). Cette dernifere interpretation 
me parait difficilement admissible pour les 
cas ou l'apoplexie dure a peine quelque min- 
utes." 
2 Niemeyer, op. cih vol. ii. p. 184, admits 
that "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 difficult to explain. He thinks it is " most 
probably due to the diseased hemisphere be- 
ing decidedly swollen by collateral oedema, 
and that, as occurs in large extravasations of 
blood, the opposite hemisphere is not suffi- 
ciently protected from the pressure by the 
falx, which only offers a limited amount of 
resistance." 
1 In case-taking, I prefer the terms small 
and. large, as they have not the misleading 
implications the more technical terms have. 
2 Dr. Wilks says (Guy's Hospital Reports, 
1866, p. 177) that "we cannot connect the 
conditions of the pupils with any definite le- 
sions, for their state is very variable and lia- 
ble to be influenced by very slight causes." 
Speaking of the contraction of the pupils ob- 
served in disease of the pons, he adds, "just 
as we see this produced by effusion of blood 
at the base or into the ventricle." Callender 
(St. Bartholomew's Hospital Reports, vol. iii. 
p. 430), speaking of the pupils in cases of 
injury to the head, says, "their condition 
varies remarkably in these cases, and no sort 
of reliance can be placed upon the appearance 
they may seem to present." 922 
CEREBRAL HEMORRHAGE AND APOPLEXY. 
under the dura mater in the sphenoidal 
fossa from fractured base ; the dilatation 
is on the side of the effusion. 
During convulsive seizures the pupils 
may dilate very widely; this is not always 
the case. 
Stertor is the sign of a grave lesion, or 
more generally of serious implication of 
the brain, and, like the other symptoms 
of the apoplectic condition, is not of diag- 
nostic value. There may be ursemia, 
alcoholic poisoning, or large Cerebral 
Hemorrhage. It will occur in any one of 
these conditions. It may be absent in 
any of them, and is often absent in apo- 
plexy from Cerebral Hemorrhage. The 
noise made will depend on the condition 
of the respiration, and varies with it in 
the same case. It shows that the lesion 
is large enough or widely enough spread 
in the brain to affect muscles supplied by 
or through the ganglionic nervous system. 
It is of value in prognosis. It shows 
grave lesion. 
Pulse, respiration, and temperature.- 
This is the most important and at the 
same time the most difficult part of the 
subject. It is really impossible to give a 
proper account of the condition of pulse, 
respiration, and temperature without cit- 
ing numerous cases, and these would 
show extreme differences, differences so 
great that it is most difficult to make 
generalizations. The great point to ob- 
serve is that the condition of the pulse, 
respiration, and temperature varies very 
much according to the time elapsed from 
the seizure. So that so far as the pulse, 
respiration, and temperature are con- 
cerned, the patient may be in opposite 
conditions according as he is seen early or 
late. And since the lesions differ greatly 
in gravity-in size and suddenness-we 
can say nothing definitely as to time. 
What is early in one case is late in an- 
other. This is obvious when we consider 
that a clot may destroy life in an hour,' 
or may not kill for days, or that the pa- 
tient may recover from it. Moreover, 
alterations of pulse, respiration, and tem- 
perature, depression of them at all events, 
are not peculiar to Cerebral Hemorrhage; 
they are found in cases of meningeal hem- 
orrhage, alcoholic poisoning, and even in 
some cases of tumor of the brain. We 
are obliged then to speak most generally. 
For convenience we make two stages of 
the apoplectic condition : one we call col- 
lapse and the other reaction. There is no 
absolute demarcation betwixt the two. 
Loss of consciousness continues through 
both. Of course, if the clot be small 
there are no stages-neither collapse nor 
reaction. Again the patient may recover 
from his collapse, if it be faintly marked, 
without any obvious reaction; he may 
die rapidly, and then there is practically 
no question of stages. 
First stage :-Soon after the effusion, 
even of a large clot, the pulse, respiration, 
and temperature may be absolutely nor- 
mal, the patient seeming as if gently 
asleep. But we shall speak of cases in 
which they are abnormal; the symptoms 
are those of depression. The face is pale, 
the pulse is slow and labored, the respira- 
tion is shallow, and the temperature is 
lowered. The pulse may be 60 or under, 
the temperature may be in the axilla 06 
or lower. 
In the second stage, the stage of reaction, 
the pulse quickens, respiration quickens, 
and the temperature usually rises, for 
instance, to 101, or 103. Shortly before 
death, it may rise to 107 or more. These 
points concern us most in prognosis : the 
quicker the pulse and respiration, and the 
higher the temperature, the less likely is 
the patient to recover. We frequently 
observe also that the pulse becomes irreg- 
ular or intermittent. The respiratory ac- 
tion undergoes great variation in fre- 
quency. Thus the patient for a while lies 
breathing quickly, but pretty evenly in 
rate, and then for a short time there is a 
series of more rapid respirations, with 
loud stertor, after which comes a period 
of comparative calm. 
Again, not only is the rate of respira- 
tion to be considered, but the character 
of the respiratory movements are to be 
noted. As they quicken in rate, so do 
they become more extensive in range, 
though each respiration is still short. 
Thus, in the first stage there may be only 
quiet action of the diaphragm, but at 
length the sides of the chest evert strongly 
in inspiration, the abdominal movement 
being less obvious, and at length the up- 
per thorax takes part in the process. In 
severe cases the epigastrium sinks in dur- 
ing inspiration. This is probably partly 
owing to elevation of the attachments of 
the diaphragm from increased action of 
the sides of the thorax, and partly to 
pushing down of the diaphragm by the 
increasing bulk of the lungs from conges- 
tion or oedema. 
Diagnosis. 
An account has been given of the gen- 
eral bodily state of the patient who is 
especially liable to Cerebral Hemorrhage. 
We have described the symptoms which 
we know that hemorrhage produces-both 
the local, such as varieties of hemiplegia, 
and the general, the apoplexy which oc- 
curs from large and sudden hemorrhages; 
but other lesions produce exactly similar 
local symptoms, and many conditions 
cause Apoplexy. We now come to the 
most difficult part of our subject-Diag- 
nosis. Under this head we speak first of 
Premonitory Symptoms ; next of Modes DIAGNOSIS. 
923 
of Onset, under which will be considered 
the comparatively simple cases of patients 
who have hemiplegic symptoms ; and 
lastly, under Special Diagnosis, of the 
condition of those apoplectic patients in 
whom we can discover no hemiplegia. 
The separate consideration of those cases 
of Cerebral Hemorrhage in which there 
is, and of those in which there is not hemi- 
plegia, is justified by convenience ; for 
practically they are different things. 
When called to a patient who is hemi- 
plegic, whatever other difficulties we 
have, we are certain, since there is clearly 
a local lesion of some kind, that there is 
not only drunkenness, uraemia, poisoning, 
&c. ; but if we make out no hemiplegia, 
we may be in doubt whether the apoplexy 
be owing to a very large clot in the brain, 
to a very central one as in the pons, or to 
some one of the more general conditions 
mentioned. 
Premonitory Symptoms.-The gene- 
ral bodily condition already described (p. 
906 et seq.) furnishes the best basis for 
premonition, and in no nervous affection 
in people of, at least, middle life, however 
trivial the symptoms may be, do we neg- 
lect to examine the heart, arteries, and 
urine ; but that condition leads to, or is 
associated with, disease of many parts of 
the body. We here speak of slight ner- 
vous symptoms which point more expressly 
to the future occurrence of Cerebral Hem- 
orrhage, and which, when occurring in a 
patient who has degenerated arteries, hy- 
pertrophy of the left ventricle of the heart, 
and chronic renal disease, show it to be 
very likely that this unsound state in his 
particular case is about to lead to decided 
hemiplegia, or fatal apoplexy, from the 
rupture of vessels in the nervous centres. 
Some of these patients, however, die after 
having had slight warning symptoms- 
some evidently due to hemorrhage, for we 
may have seen clots in retinse and have 
heard of epistaxis-in other modes, as by 
pericarditis, uraemia, &c. 
Before we speak of special premonitory 
symptoms, we must remark that some pa- 
tients w'ho die of Cerebral Hemorrhage 
have had none, at least we hear of none ; 
and this is sometimes the case when ex- 
amination both during life and after death 
reveals signs of most extreme degenera- 
tion. 
The degeneration of arteries of which 
we have spoken (p. 907) leads to two pa- 
thological states of nervous centres ; to 
softening by thrombosis, and to hemor- 
rhage by rupture. The slight symptoms 
of which we are about to speak as pre- 
monitory of Cerebral Hemorrhage may 
depend on either; practically it matters 
little, since the symptoms to be mentioned 
may be taken as warnings of the possible 
supervention of large. Cerebral Hemor- 
rhage, whether they signify small hemor- 
rhages or very limited softening. It may, 
however, be denied that there is any local 
lesion when such slight symptoms as those 
I have to mention pass away altogether 
in a few hours or days. Besides the reply 
that local symptoms of necessity imply 
local lesion, it may be added that it is 
quite certain that even decided hemiple- 
gia, whether from clot or from softening, 
will pass away even when, as subsequent 
post-mortem examination shows, there 
remains a permanent, although a small, 
void in the motor tract. 
One general remark may be made : the 
premonitory symptoms of Cerebral Hem- 
orrhage are owing to affections of nervous 
centres, and not of nerve-trunks. In 
cases of Apoplexy from rupture of aneu- 
risms of the larger cerebral arteries, there 
may have been palsy of a nerve-trunk-• 
third especially-from compression of that 
nerve-trunk by the aneurism ; but rup- 
ture of such aneurisms, with very rare ex- 
ceptions, leads to meningeal, not to cere- 
bral hemorrhage. There are, however, 
some seeming exceptions to the rule laid 
down. We may have palsy of the tongue 
from hemorrhage into the medulla oblon- 
gata, and palsy of parts supplied by the 
facial nerve from thrombosis or small clot 
in the pons ;* but these are, as stated, 
only seemingly exceptional. They are 
not owing to affections of nerve-trunks ; 
and practically, when we are consulted 
for palsy of any cranial nerve, we do not 
attach much importance to it as a warn- 
ing of Cerebral Hemorrhage, we think of 
syphilis, and, if the nerve palsied be one 
of those to the muscles of the eyeball, of 
locomotor ataxy also. 
So far negatively. The symptoms which 
are premonitory of Cerebral Hemorrhage 
are innumerable. We may divide them 
into two classes, local and general. The 
local ones to be mentioned are : 
Defect of Sight2 occurs now and then 
before Cerebral Hemorrhage. In these 
cases we find mostly the degeneration of 
the retinse which occurs with Bright's 
disease, and usually linear clots are to be 
seen in the retinae too; indeed it is an 
affection of a nerve centre,3 and of one 
1 Dr. Moxon has recorded (Path. Soc. 
Transactions, 1869-70) a case of paralysis of 
the portio dura nerve from hemorrhage into 
the aqueductus Fallopii. 
2 I do not know that deafness is of value 
as a warning of Cerebral Hemorrhage ; it is a 
rare symptom in cases of serious brain disease 
of any kind. 
3 In many of these cases of retinal hemor- 
rhages there has been nasal hemorrhage also. 
Epistaxis, however unimportant in itself, is 
a serious warning if there be chronic Bright's 
disease. It is of very great importance to 
use the ophthalmoscope in all cases of brain 
disease. There are often changes significant 
of Bright's disease, so well marked that the 924 
CEREBRAL HEMORRHAGE AND APOPLEXY. 
supplied by the same arterial system of 
the brain, and is not owing to allection of 
a nerve-trunk. The existence of these 
changes makes us take a very gloomy view 
of the case of a patient who has even the 
slightest nervous symptoms.1 If we find 
either optic neuritis or any kind of optic 
atrophy, we cannot infer liability to Cere- 
bral Hemorrhage unless we know that 
the atrophy has followed the neuro-reti- 
nitis of Bright's disease. Indeed optic 
neuritis (there being no albuminuria) is 
rarely associated in any way with Cere- 
bral Hemorrhage. It rarely precedes, 
and it very rarely follows it. As, how- 
ever, optic neuritis is frequently associ- 
ated, especially in young persons, with 
tumor of the brain, there is to be consid- 
ered the liability to hemorrhage from 
tumor ; but this is of very rare occurrence. 
Limited Facial Palsy.2-This is really a 
part of an attack of hemiplegia. It is the 
kind of facial palsy which occurs in hemi- 
plegia which is so common in disease of 
the higher motor track. (See p. 913.) We 
must observe, however, that a facial palsy 
of exactly the same kind occurs after cer- 
tain epileptiform seizures; but in these 
cases there is occasional spasm of the 
paralyzed part. The patient is usually 
young, and we have often a history of 
syphilis. The facial palsy which is a 
warning of Cerebral Hemorrhage comes 
on suddenly without spasm, or is found on 
waking, and usually passes off in a few 
days. It is a very unfavorable sign, be- 
cause it shows central disease. 
Speech.-There may be loss of speech 
with the above-mentioned kind of facial 
palsy, but more often there is defect of 
speech only ; a difficulty of articulation 
for which the degree of palsy of the face 
and tongue does not account; and we find 
that the patient writes, that is expresses 
himself in writing, about as badly as he 
talks. Again, there is central disease. 
Speech defects are not of special value as 
warnings of Cerebral Hemorrhage unless 
they come on suddenly. We must also 
bear in mind that temporary loss of speech 
occurs from embolism; at all events it 
occurs in young patients who have valvu- 
lar disease of the heart. Occasional mis- 
takes in words occur in many presumably 
healthy people, and their significance as 
evidence of coming cerebral disease of any 
kind is, I think, overrated. Suddenly oc- 
curring difficulty of articulation is the 
condition of most evil import. 
Slight weakness or numbness of one arm 
and leg points to a local and central lesion, 
although to a minute one ; but many peo- 
ple are subject for years to a slight numb- 
ness and to queer feelings on one side, 
who seem to be otherwise in good health, 
or the symptom obtrudes itself when they 
are slightly out of health-dyspeptic, for 
instance. It is not uncommon in young 
and apparently healthy people. A slight 
weakness of one side is only of value as a 
warning of Cerebral Hemorrhage when it 
occurs suddenly without spasm, and even 
then we do not attach great importance 
to it unless the patient be past middle age 
and show signs of degeneration. 
Successions of slight local symptoms are of 
more value than any single symptoms. 
From syphilis also there are successions 
of nervous symptoms: they are such as 
palsies of cranial nerves, optic neuritis, 
partial convulsion. But preceding fatal 
Cerebral Hemorrhages w'e may find epis- 
taxis ; defect of sight from degeneration 
of, often with clots in, the retinse ; sudden 
numbness or weakness on one side (with- 
out spasm); occasional difficulty of articu- 
lation, and drawing of the face. These 
are due to affections of nerve-centres ; or 
the patient may have many epileptiform 
paroxysms of very different kinds, some- 
times slight without loss of consciousness, 
sometimes severe with tongue - biting, 
sometimes local, sometimes general. 
Here we suspect small meningeal hem- 
orrhages. 
General Premonitory Symptoms. - A 
page might be filled by the enumeration 
of symptoms of this class which authors 
give as warnings of Cerebral Hemorrhage. 
They are such as drowsiness, loss of mem- 
ory, especially for recent events, irrita- 
bility of temper. Such symptoms point 
only to general deterioration of brain, to 
slow wasting, for instance-and do not 
point especially to a liability to Cerebral 
Hemorrhage. More valuable symptoms 
of this class are giddiness, pain in the 
head, and vomiting. But these again 
may be found in the onset of many kinds 
of brain disease; for instance, in young 
people the subjects of cerebral tumor : in- 
deed, if the headache be intense and con- 
tinued for weeks, and if the vomiting be 
urgent, it is, provided there be no albu- 
minuria, likely that there is tumor. If, 
however, the symptoms come on suddenly 
in a person of middle age, especially if 
there be slight confusion of mind at the 
time, and above all if there be any para- 
lytic symptom, however faintly marked, 
such as thick speech or unilateral weak- 
ness, they may be taken as warnings of 
ophthalmic surgeon is the first to discover 
that the patient has Bright's disease. There 
may be no impairment of sight when the oph- 
thalmoscopical appearances are extremely 
well marked. This is to be strongly insisted 
on. 
1 I may here refer to a record of several 
cases in a lecture on Cerebral Hemorrhage 
(London Hosp. Reports, vol. iii. 1866). In 
some cases of coma the detection of these 
changes may enable us to make the diagnosis 
of Cerebral Hemorrhage. 
2 See Trousseau (Bazire's Trans.), vol. i. 
lect. 1. DIAGNOSIS. 
925 
Cerebral Hemorrhage. Doubtless they 
are owing to small clots or to limited 
thrombosis. If there be albuminuria, 
they are often ascribed to ureemia. Pa- 
tients with chronic Bright's disease are 
prone to attacks of headache and vomit- 
ing, especially on getting up in the morn- 
ing. Even if these symptoms are de- 
pendent on uraemia, they may still be 
considered as warnings - indirect, it is 
true - of the possible future advent of 
Cerebral Hemorrhage, when they occur 
in a person past middle age who has tough 
arteries, hypertrophy of the left ventricle 
of the heart, and no notable dropsy with 
his albuminuria. 
The Mode of Onset of Cerebral 
Hemorrhage.-This is often the only 
diagnostic evidence of value, and in many 
cases when it is not forthcoming we can- 
not make a diagnosis at all-as when a 
patient is found by the police in the streets 
" drunk and incapable." 
When we consider that the clot differs 
in seat, in size, and rapidity of effusion, 
we cannot d priori expect any great uni- 
formity of manner of onset; as a matter 
of fact it varies greatly indeed. A pa- 
tient may not be unconscious from a hem- 
orrhage large enough to produce perma- 
nent hemiplegia, or he may, minutes or 
hours after being hemiplegic, become apo- 
plectic, or he may become apoplectic 
almost without prior symptoms. I say 
almost, because however quickly Apo- 
plexy from Cerebral Hemorrhage comes 
on, there are nearly always some prior 
symptoms. As Trousseau says, Apo- 
plexy, in the classical sense of the word- 
a sudden falling - is rare in Cerebral 
Hemorrhage. There is nearly always 
something wrong before the patient be- 
comes unconscious, and often the interval 
is considerable-minutes, or even hours. 
Trousseau excepts cases beginning by con- 
vulsion, and also cases of hemorrhage into 
the pons Varolii; but even in cases of 
hemorrhage into the pons, there are, I 
believe, mostly some symptoms before 
the loss of consciousness. Thus, I have 
notes of a case of a man who came off a 
scaffold because he was giddy before he 
became insensible, and of another patient 
who, when taking a drink, cried out that 
he was poisoned. Dr. Hare relates the 
case of a patient who was able to knock 
at a door and say she was going to die 
before she became insensible. In each of 
these cases there was large hemorrhage 
into the pons. In considering special 
modes of onset we shall give further illus- 
trations. The first statement as to mode 
of onset is that Cerebral Hemorrhage, 
even when large enough to produce Apo- 
plexy, does not as a rule cause Apoplexy 
instantly. 
To consider mode of onset more par- 
ticularly we must make a grouping of 
cases. The following, although in actual 
practice we see all degrees of interme- 
diateness, is convenient. 
Rapid Death.-This practically includes 
onset and termination. It is a rare tiling 
for Cerebral Hemorrhage to cause rapid 
death ; within half an hour, for instance. 
'From theoretical considerations we might 
suppose that when the clot is effused near 
to the medulla oblongata-in the pons- 
death would occur very rapidly ; but as a 
matter of fact it rarely does. Yet cases 
of sudden death are frequently put down 
to "Apoplexy," Cerebral Hemorrhage 
being meant. Since this term is often 
made to include meningeal hemorrhage, 
the statement is not altogether wrong, for 
meningeal hemorrhage may cause death 
in a few minutes-five, for instance, and 
probably in less time. Yet, since menin- 
geal hemorrhage may lead to death very 
slowly, we have to infer that it is rapidity 
of effusion which is rapidly fatal, and not 
the position of the hemorrhage. If the 
patient dies rapidly, within half an hour 
let us say, cerebral hemorrhage is most 
unlikely. If he be young and healthy- 
looking, the probability is that there is 
meningeal hemorrhage from rupture of an 
aneurism of a large cerebral vessel. Usu- 
ally there is a convulsion in these cases, 
and if death occurs "in a fit," or very 
quickly after, we still incline in a young 
person to the diagnosis of ruptured aneu- 
rism ; but it is quite certain that in some 
cases of death in a first convulsion we 
discover nothing abnormal post-mortem. 
If death occurs instantly - the patient 
dying in a minute-we infer failure of the 
heart, rupture of aneurism of the aorta 
into the pericardium, or rupture of the 
heart itself. Death by intracranial hem- 
orrhage is never so exceedingly rapid as 
it often is from these causes. 
Convulsion.-This mode of onset has 
been considered in the article Convulsion, 
(p. 737). What further is to be said will 
find its place best when the cases of pa- 
tients who are apoplectic without discov- 
erable paralysis are spoken of. However, 
convulsion from clot is frequently followed 
by apoplexy with hemiplegia ; such cases 
will be considered under the head of 
" Hemiplegia with loss of consciousness. " 
Hemiplegia without loss of Consciousness. 
-If we are called to a patient of, or past, 
middle age who is hemiplegic without loss 
of consciousness, we have to consider two 
possible kinds of lesions : softening from 
thrombosis ;* clot from rupture of a ves- 
sel. In the great majority of cases hemi- 
plegia without loss of consciousness is the 
result of local softening. I believe we 
can say very little more than this, for a 
1 For further points in diagnosis, and espe- 
cially for the diagnosis of softening from em- 
bolism, see art. Softening. 926 
CEREBRAL HEMORRHAGE AND APOPLEXY. 
clot occasionally causes permanent hemi- 
plegia without producing loss of con- 
sciousness at its irruption. However, a 
very deliberate mode of onset strongly 
favors the diagnosis of softening. If, for 
instance, a patient, when he gets up in 
the morning, finds his arm weak, next his 
leg numb, and half an hour later is para- 
lyzed on one side, little or much, we diag- 
nose softening. What has been said 
before as to constitutional state-or as to 
premonitory symptoms-helps us but lit- 
tle in this difficulty, for degeneration of 
arteries leads either to softening or to 
clot, and any local premonitory symptoms 
the patient may have had may have been 
the result either of thrombosis or of rup- 
ture of small arteries. Still, the exist- 
ence of chronic Bright's disease is much 
in favor of clot; and if we see clots in 
the retinae and hear that the patient has 
epistaxis, we are warranted in inferring 
from these visible hemorrhages that the 
encephalic lesion is also hemorrhagic. 
When the hemiplegia is on the right 
side, and now and then, but very rarely, 
when on the left, there is loss or defect of 
speech. This furnishes no further diag- 
nostic evidence. I think, however, that 
frequent mistakes in words during recov- 
ery in young* people favors the diagnosis 
of plugging of vessels. 
Hemiplegia with loss of Consciousness.- 
Hemiplegia with deep loss of conscious- 
ness (Apoplexy) is nearly always owing 
to Cerebral Hemorrhage. These cases 
are therefore more important than any 
other, and we must consider the mode of 
onset in some detail. The attack may 
begin either by special nervous symp- 
toms, such as one-sided numbness, loss of 
speech, defect of speech, or by such symp- 
toms as pain in the head, vomiting, and 
confusion of mind, and, of course, it may 
begin by both sorts of symptoms at once. 
It may begin by convulsion. We here 
consider the special symptoms only; the 
general symptoms are of additional diag- 
nostic value, but we could only repeat 
what has been said (p. 924) when speak- 
ing of them as premonitory symptoms. 
When a patient has suddenly decided, 
although very slight, local palsy (for in- 
stance a little thickness of speech, a tri- 
fling drawing of the face, or loss of use of 
one arm, one-sided weakness, or even 
numbness), it is clear enough that he has 
some kind of local lesion of his nervous 
system. We should believe hemorrhage 
was that lesion if any one of these symp- 
toms were followed quickly by deep loss 
of consciousness, or if after some delibera- 
tion, or even if after partial recovery, a 
convulsion occurred. If the patient be 
above middle age, if he have tough arte- 
ries, if there be albuminuria, we are 
almost certain that hemorrhage has oc- 
curred ; and if, after such a mode of onset, 
hemiplegia is found with deep coma, we 
are practically quite certain. If the mode 
of onset has been by convulsion, we still 
think it most likely that there is hemor- 
rhage, if there be decided, and especially 
if there be complete hemiplegia-complete 
in range, that is. (See list p. 911.') 
We now consider the case of a hemi- 
plegic patient when he is fully apoplectic. 
As before said, the degree of the coma in 
cases of Cerebral Hemorrhage varies ; the 
deeper it is, the more is the diagnosis of 
hemorrhage warranted : but loss of con- 
sciousness, accompanied by stertor, slow 
pulse, lower temperature, is not diagnos- 
tic of Cerebral Hemorrhage. If we have 
no history of the mode of onset, or only 
that the patient was taken with a fit of 
convulsions, the first thing we do is to in- 
quire for hemiplegic symptoms. While 
hemiplegia is certain evidence of the ex- 
istence of local lesion, and with other cir- 
cumstances of the existence of clot, we 
must not suppose that its absence nega- 
tives clot. (See p. 911.) Hence we have 
often difficulty in saying whether there is 
cerebral hemorrhage, or poisoning, or 
ursemia. We usually discover some kind 
of one-sided symptoms if we do not find 
definite hemiplegia ; we find some differ- 
ence in the two sides when we raise the 
arms and let them fall, and when we 
pinch the legs. There may be spasm, or 
there occur occasional waves of tremor 
down one side ; or we may find both eyes 
or the head turned strongly to one side. 
These symptoms point decisively to a 
one-sided lesion at all events ; and when 
there is no history of injury, no evidence 
of embolism,2 they mostly, in persons 
past middle age, signify clot. Yet there 
may be meningeal hemorrhage, and if the 
limbs of one side be continuously rigid, 
with or without occasional higher waves 
of rigidity, the probability is that there 
is meningeal hemorrhage, although per- 
haps cerebral as well. However, and 
this really is the important matter, very 
deep coma occurring suddenly or quickly 
with one-sided symptoms of any kind, 
point at least to intracranial, if not to 
cerebral hemorrhage, in the vast majority 
of cases of patients past middle age. 
1 Plugging of cerebral arteries in older 
people is not the same thing as plugging of 
cerebral arteries in young patients, as the 
vascular condition of the brain is different at 
different ages. There is in older people less 
free anastomosis from obliteration of capil- 
laries, and also from the atheromatous condi- 
tion of small arteries. The vessels of the 
optic disk become fewer in number as age ad- 
vances. 
1 See, however, art. Convulsion, p. 753, 
"Epileptic Hemiplegia." 
2 See art. Softening. SPECIAL DIAGNOSIS. 
927 
Special Diagnosis. 
In most cases the patient becomes ill, 
at home among his friends, or at his 
work, or he is found comatose in bed, and 
in the great majority of instances the 
circumstances negative drunkenness, poi- 
soning, violence, and the like, when the 
symptoms do not. Indeed, in most cases 
the diagnosis is really easy ; or, to speak 
strictly, the prediction is usually verified. 
Suppose, however, there is no history. 
Suppose the patient, as is pretty often 
the case in hospital practice, is found in 
the streets universally powerless and 
deeply comatose, we very often cannot 
tell f rom what he is suffering. Or let us 
suppose we are called to a guest at an 
inn, who is found comatose in bed or in 
the water-closet-the discovery of an 
empty laudanum bottle may be the only 
clue to the nature of the case. In such 
cases we can only say there is apoplexy ; 
we cannot declare the cause of it, and 
simply because there is not evidence. I 
would most earnestly beg young practi- 
tioners not to trust blindly to the fact 
that the patient is found at the bottom of 
a scaffold in the diagnosis of injury, nor 
to the smell of drink, nor to an " uproari- 
ous condition," for the diagnosis of in- 
toxication ; and, above all, not to con- 
clude, from bitten tongue, that the pa- 
tient has " only had an epileptic fit." It 
is true enough that if he be led entirely 
by these circumstances, he will mostly be 
right, but he must run no risk of being 
wrong. Most painful mistakes are occa- 
sionally made because a practitioner con- 
cludes from insufficient evidence. 
Having first examined the apoplectic 
patient for hemiplegia (the existence of 
which we are now supposing that we can- 
not determine), we next inquire for con- 
vulsions. If we obtain no history of a 
convulsion, we search for evidence of 
tongue-biting. However, we cannot often 
get a look at the tongue, but we may judge 
by the presence of blood on the gums or 
by bloody foam. If the foam be very 
frothy in large bubbles, it no doubt comes 
from the bronchial tubes, and is no evi- 
dence of tongue-biting. The tongue may 
have been bitten but not lacerated. And 
when we do find evidence of convulsion, 
we must remember that to use the words 
of Gull,1 general convulsion with insen- 
sibility is in itself of little value in the diag- 
nosis of any brain disease." (The italics 
are mine.) If we feel sure that there has 
been a convulsion either before or after 
the onset of the symptoms, we can only 
exclude drunkenness and poisoning. If 
there be no convulsion, we have still these 
two causes to consider. We next ex- 
amine the urine for albumen. We speak 
first of the comatose patient who is not 
Apoplexy without Local Paralysis. - 
When there are no local symptoms in the 
apoplectic condition, no hemiplegia for 
instance, it is most difficult to make a 
diagnosis. We shall here discuss only 
the difficulties we most frequently en- 
counter. We shall suppose that we are 
called to a case of coma, and try to show 
by what means we may arrive at the 
diagnosis of Cerebral Hemorrhage. We 
often cannot; but even then we may be 
able, at all events, to decide whether 
there is a fatal lesion, or the compara- 
tively minor condition, drunkenness, and 
to exclude violence and poisoning. Speak- 
ing generally, the difficulty is to deter- 
mine whether a patient is suffering from 
local lesion so large and sudden, or placed 
so centrally (as in the pons), as to pro- 
duce coma with universal powerlessness, 
or whether he is suffering from some con- 
dition such as ursemia, poisoning by 
opium, drunkenness, &c., which, as it 
were, imitate the effects of the grave 
local lesions mentioned. 
It is important to bear in mind that we' 
may have combinations of states. I have 
known an " epileptic" fracture his skull 
by a fall in a fit, and die from hemorrhage 
the result of rupture of the middle men- 
ingeal artery. A drunken man may have 
been struck on the head. A drunken 
man falls like a log, and a seemingly 
slight blow on the curbstone, for instance, 
will lead to hemorrhage into the arachnoid 
cavity. I have seen two cases of this 
kind in drunken people. Prescott Hewett 
says that extravasation of blood in the 
arachnoid cavity is much commoner than 
is usually supposed ; that the injury 
causing such extravasation is often a 
trifling one; that it may occur without 
any apparent lesion of the brain or mem- 
branes. Mr. Stephen Mackenzie has 
known a patient who died of garroting to 
be treated for alcoholic poisoning; the 
patient was drunk when attacked. If the 
patient be often drunk, a fit of drunken- 
ness may not improbably coincide with, 
and perhaps be the direct cause of, rup- 
ture of cerebral arteries. 
But the difficulty is not nearly so great 
practically as it is logically ; for when we 
know the constitutional history of an apo- 
plectic patient (see p. 906), and if we are 
told, as we mostly are, the mode of onset 
(see p. 925), we are very rarely in doubt 
as to the cause of Apoplexy. We may 
know that the patient has had an attack 
of hemiplegia or some other paralytic 
symptom (see p. 923) before ; and this 
will favor very strongly the diagnosis of 
hemorrhage. Then cases of Apoplexy 
without hemiplegia or without some 
hemiplegic symptom are comparatively 
rare. 
1 Abscess of Brain, Guy's Hosp. Reports, 
vol. iii. 3d Series. 928 
CEREBRAL HEMORRHAGE AND APOPLEXY. 
hemiplegic and who has had no convul- 
sion, so far as we can tell, and whose 
urine is not albuminous. The first ques- 
tion is- 
Drunkenness.'-The smell of drink must 
only lead us to a very careful examination 
for evidence of drunkenness, as patients 
who suffer Cerebral Hemorrhage may 
have been drinking, or may have taken 
spirits for premonitory symptoms. Oddly 
enough, patients soundly drunk, their real 
condition not being recognized, are now 
and then treated by doses of brandy-and- 
water. This shows in another way the 
difficulties of diagnosis. A drunken man 
may be in one of two conditions. (1) He 
may be insensible without excitement; he 
may, indeed, be as deeply comatose as if 
he had extensive and fatal Cerebral He- 
morrhage. This is so when the patient 
has been "sucking the monkey," i. e. suck- 
ing raw spirits out of a cask by aid of a 
gas piping, or when he has drunk off a 
large quantity of spirits for a wager or out 
of bravado. In these cases, from the con- 
dition of the patient alone we cannot make 
a diagnosis, although, fortunately, it is 
usually made for us by the history. If we 
hear that the insensibility came on very 
slowly while the patient was drinking, 
especially if it were preceded by excite- 
ment of talk or manner, we should sup- 
pose we had to do with drunkenness. If, 
however, the insensibility began suddenly, 
or if there were a sudden increase of stu- 
pidity, or if the patient all at once stag- 
gered and fell insensible, cerebral or 
meningeal hemorrhage is almost as likely. 
Let us now suppose there is no history of 
the mode of onset, the patient being found 
in the streets by the police. We try to 
rouse him, and we may get him to give 
his name or his address. This is, per- 
haps, some evidence that the case is not 
one of Cerebral Hemorrhage, but it had 
better be disregarded, as patients coma- 
tose from fatal cerebral lesions of several 
kinds can be roused so far. That he re- 
sists our endeavors to examine him, or 
swears when roused, is of no value at all 
as excluding fatal lesion of the brain. 
The patient may vomit (as he may in 
Cerebral Hemorrhage), and the vomit 
may reveal the nature of the case. If he 
does not we are justified, in doubtful cases, 
in using the stomach-pump. Then, the 
drunken patient oftener passes his urine 
and feces than do other apoplectic patients. 
Again, we may find alcohol in the urine. 
The mere presence of alcohol in the urine 
is not to be relied on to show that the 
apoplectic patient is suffering from a 
poisonous dose of alcohol only. As before 
said, a drunken man may owe his coma, 
in part at least, to hemorrhage into the 
arachnoid cavity. However, Dr. Anstie 
tells me that it would be possible to re- 
cognize the presence of a poisonous dose of 
alcohol in the system if one drop of the 
urine itself, added to 15 minims of the 
chromic acid solution,1 turned the latter 
immediately to a bright emerald green. 
(2) The other condition is one of excite- 
ment, of which there are all degrees ; as 
we have seen, the patient, who when left 
to himself is insensible, may be roused to 
resist and to swear, but the main features 
of a case to which we are called may be 
one of " uproariousness." If the patient 
be violent, and struggle, he is probably 
drunk. A cautious man will still continue 
his examination for other causes, because 
it is certain that after severe and fatal2 
injuries to the head the patient may 
struggle and swear, and even, as I saw in 
one of Mr. Hutchinson's cases, make re- 
plies as definite as " What's that to you 
about my tongue ?" when asked to put 
his tongue out. I have recorded a case 
supplied to me by Mr. Stephen Mackenzie,3 
in which violence and swearing were the 
striking symptoms in a case of death from 
meningeal hemorrhage. As in this case, 
we have often a history of a mode of onset 
under circumstances which exclude the 
diagnosis of drunkenness. But to make a 
diagnosis from the condition of the patient 
only is quite a different thing. We can 
only make a diagnosis by exclusion, and 
the most important thing is to exclude 
injury to the head. The young practi- 
1 Here I would refer to papers on Alcohol 
Poisoning by my colleague, Dr. Bathurst 
Woodman, in the Medical Mirror, July, 1865, 
and February, 1866. Dr. Woodman has had 
an unusually large experience of cases of 
apoplexy from numerous causes, and to him 
I have to acknowledge myself greatly in- 
debted for facts serving in the diagnosis of 
causes of coma. I have recorded (Bond. 
Hosp. Rep., vol. i. p. 35, from notes by Dr. 
Woodman) a case of death by hemorrhage in 
the pons, in which, when the patient was first 
Seen, the symptoms were like those in some 
cases of deep drunkenness. He could move 
all his limbs, put out his tongue when asked, 
and, although insensible, was roused by 
shouting to answer, "What's that to you?" 
when asked his name. He had been found 
in the street by a policeman. 
1 The chromic acid solution is made by dis- 
solving one part of bichromate of potash in 
three hundred parts by weight of strong sul- 
phuric acid. Of course Dr. Anstie does not 
represent this test as a certain one for alcohol, 
but there is not likely, he tells me-and his 
experience on this point is very great indeed 
-to be any practical objection to the conclu- 
sion when the reaction is so sudden and de- 
cided on the addition of but a drop of urine 
to the test solution. 
2 See Callender, St. Bartholomew's Hosp. 
Rep., vol. iii. p. 415, and especially Case 5 of 
his series of cases. 
3 Medical Times and Gazette, April 1,1870. SPECIAL DIAGNOSIS. 
929 
tioner must not hastily conclude that a 
patient is "only drunk," even if he be 
only confused, or if he swears or is violent, 
or if he lies on his back insensible, growl- 
ing or swearing if disturbed. If he does, 
I am quite certain that he will have now 
and then bitterly to regret trusting to such 
circumstances. To have said that a pa- 
tient was "only drunk" when a post- 
mortem examination shows a fatal lesion 
of the brain is very painful to all con- 
cerned. Besides, deep intoxication is 
itself a serious matter. 
Injury.-We need not speak of cases 
where there is a clear history of very 
severe injury, because then the diagnosis 
is made for us. However, when the 
diagnosis has blindly rested on the fact 
that the patient has been in the way of 
injury, it is sometimes wrong. Prescott 
Hewett says (op. cit.), "There is no 
doubt that many a case reported as one 
of traumatic effusion of blood in the brain 
was simply a case of apoplexy."1 In all 
cases of coma we search for bruises on the 
head and face. We examine the ears for 
discharge of blood, watery fluid, or even 
brain matter; the face for evidence of 
palsy of muscles supplied by the portio 
dura nerve-two things the frequent re- 
sult of fracture of the base. We must be 
especially careful to note the condition of 
the conjunctivae and eyelids, as effusion of 
blood here coming on after the injury, or 
after the patient was comatose, is evidence 
of fracture of the orbital plates. (By it- 
self this is not, my colleague Mr. Hutchin- 
son teaches, a serious symptom.) The 
absence of external signs of injury unfor- 
tunately does not negative serious and 
fatal injury to the brain. As before said, 
a slight fall may cause hemorrhage into 
the arachnoid "cavity;" the heavy fall 
of a drunken man, or a fall in an epileptic 
fit. Even in cases of bruising and lacera- 
tion of the cerebellum, the accident is not, 
Prescott Hewett says, always severe. In 
several cases the cerebellum was thus in- 
jured by the patient falling in the street 
when drunk.2 
Even if we hear only that the patient 
has been in the way of injury some time 
before the symptoms set in, we must still 
consider the possibility of injury, as symp- 
toms due to traumatic effusion of blood on 
the surface of the brain, especially if it be 
betwixt the dura mater and the bone, may 
come on, or at least develop largely, es- 
pecially by a convulsion, sometimes hours 
or days after an apparently trifling in- 
jury. 
If there be hemiplegia immediately after 
a fall, especially if the palsy does not fol- 
low a convulsion, non-traumatic hemor- 
rhage is most likely. Yet it is not quite 
certain, for there may be laceration of the 
hemisphere. 
Opium Poisoning.-In both poisoning 
by opium and large hemorrhage, especially 
into the pons Varolii, there may be minute 
contraction of the pupils, universal power- 
lessness, and deep coma. "Contraction 
of the pupils is the most constant of all 
the effects of opium."1 Hence there are 
on record cases of hemorrhage into this 
part of the nervous system, mistaken for 
and treated as cases of opium poisoning. 
Unfortunately, there is not always minute 
contraction of the pupils in effusion into 
the pons, nor are they always contracted 
in opium poisoning. And in either con- 
dition, contracted pupils may dilate shortly 
before death2-" full active dilatation, 
which is uniformly observable when death 
(from opium) is imminent."3 
When we learn that the symptoms set 
in when the patient was with his friends, 
we must bear in mind that he may have 
taken the poison half an hour or even an 
hour before. We may detect the odor of 
opium in his breath. If there be a con- 
vulsion at the outset or soon after-cases 
of children are not here spoken of-we 
may almost certainly decide that there is 
not poisoning. My friend Dr. William 
Proctor, of York, however, has supplied 
me with notes of a case of rapid death of 
a woman in convulsion, after taking six 
grains of morphia. Caspar4 says, "There 
are fits of spasms extending even to 
general convulsions." Scoresby Jackson5 
says that occasionally convulsions precede 
death. But these accounts of the symp- 
toms refer to cases of children as well as 
of adults. I think we may say that in an 
adult, a convulsion-a severe convulsion 
at least, and certainly if it markedly 
affects but one side of the body-especially 
at the beginning, or soon after the be- 
ginning of the attack, nearly always nega- 
tives opium poisoning.6 If we hear that 
1 John Harley, The Old. Vegetable Narcot- 
ics, p. 137. 
2 See Anstie, Stimulants and Narcotics. 
8 John Harley, op. cit. p. 138. 
4 Forensic Medicine, Syd. Soc. Translation, 
by Dr. Balfour, vol. ii. p. 63. 
5 Materia Medica, p. 330. 
6 It is right, however, to state that Tardieu 
describes one rare form of opium-poisoning 
which is not, so far as I can judge, to be dis- 
tinguished from a case of large and rapid in- 
tracranial hemorrhage. "Dans la forme 
foudroyante 1'ingestion du poison est presque 
immediatement suivie d'un sommeil comateux 
que rien ne pent vaincre; la respiration est 
stertreuse et de cet etat de narcotisme pro- 
fond individus empoisonnes passent sans 
transition a la mort dans 1'espace de trois 
quarts d'heure a une ou deux heures. Rare- 
ment celle-ci est precedee de quelques mouve- 
ments convulsifs. Une remarque est pourtant 
a faire dans cette forme, c'est que les pupilles 
sont constamment dilatees." 
1 Holmes' Surgery, vol. ii. p. 265. 
2 Op. cit. p. 312. 
VOL. I.-59 930 
CEREBRAL HEMORRHAGE AND APOPLEXY. 
the onset of the symptoms was very 
gradual-there being no albuminuria-we 
think that the patient was poisoned. 
Coma from effusion of blood into the pons 
Varolii will, it is true (see p. 925), come 
on deliberately, but not so deliberately as 
opium poisoning. In hemorrhage the 
symptoms usually develop in a few min- 
utes, or there is a sudden development of 
coma after slight symptoms. Soon after 
the poison has been taken the patient may 
be roused to give his name, but later he is 
in a state of as profound insensibility as 
clot ever produces. Moreover, the test is 
of little, if any, diagnostic value in cases 
of coma of any kind. If, however, we 
have no history, suppose the patient is 
found comatose in bed (we are supposing 
there are no local symptoms-such as palsy 
of the sixth nerve, turning of the two 
eyes or of the head to one side-that there 
is no convulsion), we cannot make a diag- 
nosis. If the patient be a young adult, 
poisoning is probable ; if past forty, apo- 
plexy is more likely; and I know of nothing 
in the pulse, in the respiration, or in the 
condition of the skin, which is of certain 
diagnostic value. An extreme slowness 
of the pulse, thirty or forty in a minute 
for a long time-say an hour or more-is 
said to favor the diagnosis of poisoning. 
But the pulse is sometimes rapid in 
opium-poisoning. 
If the patient were dead wdien we were 
consulted, we should think he had not 
died of opium-poisoning if death occurred 
in less than six hours.1 Poisoning by 
opium proves fatal in from six to twelve 
hours (Taylor). Effusions of blood into 
the pons, extensive enough to cause deep 
coma, will kill at varying times, from a 
quarter of an hour, which is rare, to 
twelve hours or more. However, we 
often have exceptional cases. Dr. Wil- 
liam Proctor, of York, has recorded a 
case in which an ounce of laudanum 
killed a woman fifty years .of age in less 
than two hours. 
We have next to exclude epilepsy (see 
arts. Epilepsy and Convulsion). 
Uroemia.-We now suppose that we find 
albumen in the urine. We have many 
times insisted on the fact that patients 
who are prone to Cerebral Hemorrhage 
have frequently chronic renal disease. 
We cannot therefore logically attach 
much diagnostic importance to the mere 
presence of albumen in the urine. Prac- 
tically it is not of value when the patient 
is past middle age, for his coma may be 
due either to uraemia or to Cerebral Hem- 
orrhage ; and this is so whether the ill- 
ness begins by convulsion or not. How- 
ever it begins, we are sure there is not 
uraemia only, if there be hemiplegia, for 
then, if the patient be past middle age, 
we are practically certain that there is 
clot. But we are now supposing there is 
no discoverable paralysis. There are two 
chief ways in which uraemic coma comes 
on, without convulsion and then usually 
slowly, or rapidly and with convulsion. 
If the patient, known to be the subject 
of chronic Bright's disease, gradually be- 
comes languid, and stupid, and as it were 
sleeps into coma, we may fairly diagnose 
uraemia. If the coma comes on suddenly, 
the diagnosis of clot is more likely; and 
if the coma be very deep, and the patient 
never moves nor can be roused to move 
any of his limbs, the clot is probably in 
the pons, especially if the pupils be mi- 
nutely contracted. If, however, there is 
no history, we cannot tell when the coma 
is deep. I have known a patient found 
comatose in the street, from whose symp- 
toms it would have been impossible to 
make a diagnosis betwixt clot in the pons 
(this was found post mortem), uraemia, and 
poisoning by opium. 
Further, uraemia may begin suddenly, 
in the midst of seeming good health, by 
convulsion ; but so may Cerebral Hemor- 
rhage (hemisphere or pons); and, to make 
the matter more difficult, these are the 
cases of Cerebral Hemorrhage in which 
we often cannot make out any hemiplegia. 
If the convulsion were strictly limited to 
one side-most convulsions affect one side 
a little sooner and a little more than the 
other-I should for my part feel certain 
that there was not uraemia only, although 
of course we could not under these cir- 
cumstances say there was Cerebral Hem- 
orrhage. (See art. Convulsion, p. 759.) 
Serous Apoplexy.-This term is rarely 
used nowadays. Most cases so called 
were doubtless cases of uraemia. Yet we 
occasionally hear of cases of death by 
Apoplexy ascribed to "effusion of serum 
on the brain." If there be Bright's dis- 
ease and, inferentially, uraemia, this may 
not be an altogether inaccurate descrip- 
tion ; for Traube considers that uraemic 
symptoms are directly dependent on 
oedema of the brain. These are doubt- 
less, when there is no renal disease, cases 
of what are here called " Simple Apo- 
plexy." By this term is to be understood 
cases of Apoplexy in which no lesion is 
discovered ; that is to say, no lesion which 
we can suppose to have been the cause of 
so dramatic a mode of dying. One reason 
why these cases are called serous is prob- 
ably that there is not unfrequently found 
at the autopsy a large quantity of serum 
in the meshes of the pia mater. But this 
is rarely a chronic state of things, and so 
far from the fluid exercising pressure, it 
has simply been " effused" very gradually 
to take up the room vacated by wasting 
of the brain. This is seen strikingly in 
cases in which there is wasting of but one 
1 See, however, Tardieu, quoted in pre- 
ceding footnote. PROGNOSIS. 
931 
cerebral hemisphere; here the scrum is 
"■effused" on one side only. 
Simple Apoplexy.-Now, supposing we 
have excluded drunkenness, injury, epi- 
lepsy, and uraemia, we have still to deter- 
mine whether the case be not one which 
for want of better knowledge we can only 
name from its negative post-mortem ap- 
pearances, Simple Apoplexy. We have 
already (art. Convulsion, p. 761), when 
speaking of patients dying after attacks of 
convulsion, stated that in some we find 
marked changes post mortem, and in 
others we discover nothing abnormal in 
any part of the body. * But patients pass 
into deep coma when no convulsions have 
been observed, or after apparent recovery 
from a convulsive seizure. A patient, 
sometimes even a young man, quickly be- 
comes apoplectic and dies in a few hours, 
and in the whole body we find nothing 
abnormal which can reasonably be sup- 
posed to have been the cause of the symp- 
toms. This class of cases is well recog- 
nized. Dr. Todd1 says, speaking both of 
delirium and coma, that "both these for- 
midable states may take place in a brain 
which shall reveal on the minutest scru- 
tiny no appreciable aberration from tlie 
natural standard." Dr. Wilks says in 
his Lectures on Pathology: "Occasion- 
ally you may be called to a case where the 
patient is insensible or suffering from apo- 
plexy, and on examining the brain you 
find nothing. During the last two years 
I have seen two cases where the post- 
mortem revealed nothing." It seems 
certain that these patients die from the 
brain. At all events they die in the same 
way as patients do who die in coma from 
Cerebral Hemorrhage, and in such cases 
during life Cerebral Hemorrhage is fre- 
quently diagnosed. The post-mortem ap- 
pearances of the heart and lungs are such 
as those we find in patients who have died 
with large cerebral hemorrhage. 
I freely confess that I know of no rules 
by which to distinguish simple from san- 
guineous Apoplexy, or other forms of coma. 
We cannot rely on the kind of pulse, nor 
on the temperature, nor on the state of 
the pupils, nor on stertor. I have, in 
short, nothing to say of diagnosis here. 
I have observed that some medical men 
seem, if I may use such an expression, to 
be disappointed in not finding in the head 
of a patient who has died in an apoplectic 
manner, anything which can be supposed 
to have given rise to his symptoms. In 
these cases the suspicion of poisoning will 
occur. Indeed, this possibility ought to 
be carefully considered. Yet this part of 
the question is legal rather than medical, 
and at an inquest we can assure the coro- 
ner-who, if he be a medical coroner, 
requires no strong assurance on that mat- 
ter-that the profession recognizes such 
cases as cases of natural death. 
Some of these cases are put down to 
congestion of the brain. But this conclu- 
sion is often drawn from the distension of 
the cerebral veins, which is a very com- 
mon appearance in patients who have 
died rapidly from any cause ; and in all 
cases, even in cases of death from hemor- 
rhage, we find fulness of the veins in the 
occipital region. 
For the diagnosis of Apoplexy from 
Congestion of the Brain and from Sun- 
stroke see those articles. 
Aneurism of the larger cerebral vessels. 
(See arts. Adventitious Products and 
Convulsion, p. 759.)-Cerebral aneurism 
has been incidentally considered in seve- 
ral parts of this article. 
Hemorrhage from Tumors.-Occasion- 
ally fatal hemorrhage occurs from cerebral 
tumors. We can only make the diagno- 
sis from the evidence supplied by a his- 
tory of tumor of the brain (see art. 
Adventitious Products), and if there be 
no history we cannot make a diagnosis. 
If, however, in a young patient we dis- 
cover double optic neuritis, we should 
suspect tumor. 
Occasionally apoplectic symptoms come 
on suddenly from Abscess of the Brain 
(see art. Abscess of the Brain). We can 
only make the diagnosis from such facts 
as the history of a blow, presence of 
t; puffy" tumor, disease of the ear, &c., 
and when these facts are not forthcoming 
we cannot make a diagnosis. 
Prognosis.-Here we speak of Cere- 
bral Hemorrhage only. It is again to be 
insisted on that Cerebral Hemorrhage is 
not a constant quantity ; the clot varies 
in size, in suddenness of effusion, in posi- 
tion, and there are differences in the ages 
of the patients attacked, and in their con- 
stitutional condition. Obviously then we 
can only speak very generally on prog- 
nosis, and what would probably come 
under this head has been already in chief 
part considered. Thus, under Etiology, 
we pointed out that in many cases the 
constitutional condition of the patients 
who suffer Cerebral Hemorrhage is one of 
widespread degeneration. If therefore 
the symptoms which we attribute to 
Cerebral Hemorrhage be in themselves 
trifling and transitory (see Premonitory 
Symptoms, pp. 923-4), they are of very 
evil omen if the patient be past middle 
age, and if there be hypertrophy of the 
heart, degenerated arteries, and chronic 
renal disease. But here the evil omen is 
as to the future. We speak next of cases 
of larger hemorrhage, and of prognosis as 
to recovery from hemiplegia, or apoplexy, 
or, as is usually the case, from both. Of 
course the graver the lesion, the worse 
the prognosis. We estimate its gravity 
1 Nervous Diseases, chap. viii. 932 
CEREBRAL HEMORRHAGE AND APOPLEXY. 
by the degree of the paralysis and by the 
degree of the apoplectic condition. Under 
Localization, p. 537, it was pointed out 
that the more complete the paralysis the 
graver the lesion. Thus if the patient 
has, besides palsy of the face, arm, and 
leg, lateral deviation of both eyes and of 
the head, the worse the prognosis; if he 
escape with his life, palsy of the face, 
arm, and leg will almost certainly remain. 
If the palsy be incomplete, the prognosis 
is less grave, both as to life and recovery 
from paralysis. But we cannot judge by 
the paralytic symptoms alone. The de- 
gree of the apoplectic condition is to be 
considered also, although it is usually 
greater in degree the more complete the 
palsy. The less, and the more transient, 
the loss of consciousness, the better the 
prognosis ; the deeper the loss of con- 
sciousness, the worse the prognosis. The 
prognosis is very grave indeed if the pa- 
tient, after being simply hemiplegic, be- 
comes suddenly profoundly unconscious 
and universally powerless, and it is graver 
still if the change sets in by convulsion, 
for this mode of ingravescence points to 
rupture into the lateral ventricle. The 
other symptoms of the apoplectic condi- 
tion are to be considered. The more the 
pulse, respiration, and temperature are 
implicated-either depressed in the first 
stage or raised in the second-the graver 
the prognosis. In other words, the more 
the automatic processes are involved, the 
worse the prognosis. We have seen (p. 
911), that along with degrees of loss of 
consciousness there are in different cases 
all degrees of range of palsy, palsy of the 
most voluntary parts (face, arm, and leg), 
palsy of these and of more automatic 
parts (deviation of the eyeballs and head, 
&c.), and even palsy of the most automatic 
parts as evidenced by stertor and depres- 
sion of pulse, respiration, and tempera- 
ture. 
When the patient has come round from 
the apoplectic condition, his condition 
varies. Since there are all degrees of 
gravity of the lesion, there are all degrees 
of the conditions left when the apoplectic 
symptoms have passed off. The deeper 
and the more continued the apoplexy has 
been, the worse the after condition of the 
patient is likely to be. lie may be, espe- 
cially when speechless, in a state of com- 
plete imbecility, lying in bed, taking no 
intelligent notice of what goes on, and 
passing urine and feces in bed. Although 
frequently he eats voraciously, he gets 
gradually thinner and often dies in a few 
weeks or months. In other and less se- 
vere cases, there is great defect of memory, 
especially for recent events, and great 
emotional instability ; the patient is easily 
made to laugh or to shed tears, though he 
does not laugh with any healthy ring, and 
his crying is a blubbering, very painful to 
witness. There is also great irritability 
of temper and often a heedless selfishness ; 
the patient's disposition, his friends tell 
us, is quite changed, his mental field is 
narrowed: he seems to care much for 
his own immediate wants, and cares little 
about his family or business concerns. In 
other cases there is little more than paral- 
ysis, although the patient's mental condi- 
tion is not so good as before. 
The palsy often diminishes, and im- 
provement follows a certain order. The 
more automatic parts recover first. Thus 
the lateral deviation of the two eyes and 
the head usually passes away in a few 
hours or days. The leg is the next part 
to recover, although it rarely recovers 
completely after severe apoplexy, and the 
lingual and facial palsy diminish or pass 
away altogether. When rigidity of the 
limbs comes on, we fear no further im- 
provement will follow. We may find the 
patient speechless1 (aphasic), on recovery 
from the apoplectic condition, and he 
usually remains so if the apoplexy has 
been deep and continued. 
If there has been no loss of conscious- 
ness, or only transient loss of memory, 
the patient has a good chance of recover- 
ing altogether from the paralysis and the 
affection of speech. But as we have seen 
(p. 925), it is not easy to be sure that 
hemiplegia without loss of consciousness 
is owing to clot. Most cases of this kind 
are owing to softening from embolism or 
thrombosis. Recovery from hemiplegia 
will occur from any kind of lesion if it be 
a small one. We can only judge by the 
early beginning of the recovery. If the 
patient begins to move the arm next day, 
he is likely to get well altogether. We 
cannot infer so much from early recovery 
of the leg, as this is very often not com- 
pletely paralyzed at the outset, and we 
know that it frequently recovers when 
the arm remains much paralyzed. 
Treatment.-The recovery of the pa- 
tient, it is most probable, depends alto- 
gether on the quantity and seat of the 
hemorrhage. If the ventricles be opened, 
if there be a large clot in the pons, the 
patient will die. But, as in many cases 
we cannot be absolutely sure that there is 
any hemorrhage, we must treat the apo- 
plexy (see arts. Softening and Renal Dis- 
eases). We must particularly bear in 
mind that if the cause of the apoplexy be 
alcoholic poisoning, recovery usually fol- 
lows, even in very severe cases. When 
in doubt we should use the stomach 
pump. 
There is unfortunately little to be done, 
in cases of large Cerebral Hemorrhage, 
and the chief thing is simply to keep the 
1 See art. Softening for an account of Apha- 
sia. TREATMENT. 
933 
patient quiet, especially when we see him 
soon after the attack. Rousing him may 
lead to such increase in the size of a clot 
in the brain that it breaks into the ven- 
tricle. 
Bleeding used to be almost a routine 
practice. In this country it has fallen 
into disuse. Although I have observed 
very many cases of Cerebral Hemorrhage, 
not only in my own practice but in that 
of others, I have seen but one patient 
bled for it. I quote, however, part of 
what Niemeyer says on this point. It 
will be observed how carefully he tries to 
distinguish the cases in which bleeding is 
admissible from those in which it is hurt- 
ful: " If the impulse of the heart be 
strong, and its sound loud ; if the pulse 
be regular, and no signs of commencing 
oedema of the lungs exist, we should 
bleed without delay. Local bleeding by 
leeches, behind the ears, or to the tem- 
ples, or by cups to the back of the neck, 
cannot replace general bleeding, but may 
be used as adjuvants. If, on the con- 
trary, the heart's impulse is weak, the 
pulse irregular, and rattling in the trachea 
has already begun, we may be almost 
certain that bleeding would only do harm, 
since the action of the heart, which is al- 
ready weakened, would be still more im- 
paired, and the amount of arterial blood 
going to the brain would thus be still 
more decreased. When the latter state 
occurs, the symptomatic indications re- 
quire just the contrary treatment, in spite 
of the original disease being the same, 
and being due to the same causes. We 
must strive with all our skill, by the use 
of stimulants, to prevent paralysis of the 
heart. If we cannot give wine, ether, 
musk, &c., internally, we should apply 
large sinapisms to the chest and calves of 
the legs, rub the skin vigorously, sprinkle 
the breast with cold water, or drop melted 
sealing-wax on it." 
It must be difficult to select the right 
time as well as the right case, as the 
pulse, respiration, and temperature are 
in very different conditions at different 
stages in the same patient (see p. 922). 
In the first stage the pulse may be very 
slow, and the temperature greatly re- 
duced. We should rather give stimulants 
than bleed in this condition, but I think 
it is better not to do this, unless the pulse 
be very feeble, and the temperature much 
reduced; we may also apply mustard 
plasters to the calves. When the pulse 
and respiration become very quick, when 
there is evidence of engorgement of the 
lungs-as shown by the loud rattles we 
hear from oedema of the lungs - we 
might, from theoretical consideration, 
suppose that bleeding would be of service 
by relieving the venous system, which is 
evidently overcharged. But at this time 
the pulse is really feeble, and occasionally 
it is irregular. 
It is, I think, good practice to give 
croton oil in either stage, unless the al- 
teration of pulse, respiration, and tem- 
perature be extreme. In the second stage 
-the stage of reaction, and when the 
clot is producing a local encephalitis-it 
is well to apply cold to the head. Blisters 
relieve the severe headache in the cases 
of cerebral tumor (no doubt often one of 
the symptoms of a local encephalitis), and 
it is possible that blisters to the back of 
the neck, and behind the ears, are of 
service when the patient is recovering 
from the apoplexy, and has pains in the 
head. 
Let us now suppose that the apoplexy 
is past, or that there has been no uncon- 
sciousness, or a very temporary confusion 
when a hemiplegia, indicating effusion of 
blood, came on. The more vividly we 
realize the fact, that a mass of blood is 
lying abroad in softened and torn nervous 
tissue, the less confident do we feel in our 
power to interfere for the patient's good. 
The feeling of helplessness is greatest, 
when we are looking at a clot lying in nerv- 
ous tissue, e. g. in the retina. There is, 
to my knowledge, no treatment for effu- 
sion of blood in nervous tissue. There 
are no drugs which assist in the absorp- 
tion of the clot. However, it is quite 
certain that some patients recover satis- 
factorily from hemiplegia, the result of 
Cerebral Hemorrhage. But recovery 
from hemiplegia will follow when damage 
to the motor tract remains. From not 
recognizing this fact, erroneous conclu- 
sions may be drawn as to the effects of 
remedies. We must particularly bear in 
mind that anaesthesia disappears or di- 
minishes quickly when no drugs are 
given, and also that there is a natural 
order of recovery, as stated under Prog- 
nosis (p. 932), which probably is not in- 
terfered with by treatment. 
We have still, as in many other dis- 
eases, to improve the general health. 
This is, however, not unfrequently, rather 
general disease, and the local lesion-let 
us say epistaxis, paralysis for a few days, 
or a day's thickness of speech-is some- 
times a small matter in comparison with 
the state of the system of the patient who 
comes to us for such slight symptoms. 
The proper care of a patient who has a 
clot of blood in his brain, and who is lia- 
ble to have further effusions, consists in 
attending to his diet, excretions, sleeping 
and exercise. Care in diet is especially 
important. In this connection we may 
quote what Niemeyer says (op. cit. vol. i. 
p. 314), under the head "hypertrophy of 
the heart." We have seen that in most 
cases of Cerebral Hemorrhage, there is 
cardiac hypertrophy, and in many cases 
the nervous symptoms, when the clot is 
small, may be almost unimportant in com- 
parison with the unsound state of the sys- 934 
ABSCESS OF THE BRAIN. 
tern : " Such patients must beware of im- 
moderate eating and drinking, in order to 
avoid the plethora which, although but 
transient, always follows upon a free use 
of food or drink. How often does the 
long-threatening apoplexy set in in the 
midst of the plethora which has developed 
after a long and hearty meal! . . . In 
this connection I may mention an act of 
folly which I have often seen practised by 
tavern-keepers and itinerant wine dealers. 
The latter often suppose that, by a free 
use of water, they can counteract the per- 
nicious influences to which they expose 
themselves, although it is evident that the 
plethora arising after a full meal would 
only be increased by an immoderate addi- 
tion of fluid. Besides this, however, the 
patient must avoid all the causes which, 
independently of plethora, stimulate the 
action of the heart, and further distend 
the already overcharged arteries. Under 
this head come the use of stimulating 
drinks, mental excitement, and immode- 
rate bodily exertion. Hot water must be 
included in this class, and there is no 
wonder that the use of the Karlsbad 
Sprudel should make victims every year 
who die of apoplexy." 
ABSCESS OF THE BRAIN. 
By William W. Gull, M.D., F.R.S., and Henry G. Sutton, M.B. 
Abscess of the Brain is comparatively 
a rare disease, and it falls to the lot of no 
man to see a great many cases. We have 
collected seventy-six cases in all from 
various sources, and the details in this 
paper are based upon these records. 
Many of the cases have not before been 
published. We have arranged the diffe- 
rent parts of this subject in the following 
order: A description of the various condi- 
tions that are known to give rise to cerebral 
abscess, the morbid anatomy, the symp- 
toms, pathology, diagnosis, and treatment. 
Suppurative inflammation of the brain 
may be caused by injury to the head, espe- 
cially where the skull is fractured and the 
brain contused. Mr. Prescott Hewitt 
says : "All traumatic inflammation of the 
brain substance may end in suppuration 
and abscess." 
Cerebral abscess may follow a penetrat- 
ing wound of the brain substance, by a 
knife, by a splinter of wood, or by some 
sharp instrument being forced through 
the skull. 
Abscess of the brain may follow a frac- 
ture of the skull where there is no dis- 
placement of the bone ; acute suppurative 
inflammation of the membranes and brain 
substance being set up by the injury. In 
many cases, caused by fracture of the 
skull, the abscess in the brain is seated 
immediately under the injured bone, and 
close to the surface of the hemisphere. 
In others the abscess is not seated near 
the surface ; for instance, a person may 
receive a fracture of the skull, symptoms 
of compression may set in, and the skull 
may be, in consequence, trephined; the 
portions of depressed bone may be re- 
moved, and the patient go out of the hos- 
pital apparently well. But after a few 
weeks or months, cerebral symptoms may 
again appear, and the patient may die ; 
and the autopsy reveal an encysted ab- 
scess embedded in the substance of the 
brain, and seated at some distance from 
the surface. 
Cerebral abscess may follow an injury 
to the skull, where there is no fracture of 
the latter, and with or even without a 
scalp wound. In such cases the injury 
excites inflammation and suppuration of 
the deploe of the bone, and the suppura- 
tion extends and involves the brain. 
Cerebral abscess may follow contusion, 
or, as it is sometimes expressed, concus- 
sion of the brain, without there being any 
fracture or other discoverable injury to 
the skull. Mr. Prescott Hewett says that 
he has seen two cases of this kind, and 
the abscesses were large.* 
This is a very important class of cases, 
for it probably embraces not a few of the 
so-called idiopathic abscesses of the brain. 
In two of our cases, abscess was found 
in the brain, though in neither was there 
any evidence to show that the skull had 
been fractured or otherwise injured. 
With both patients the symptoms fol- 
lowed directly after the injury ; one had 
a fit on the same day as the accident, and 
the other suffered from almost constant 
pain in the head for a fortnight after the 
accident, and was otherwise generally in- 
disposed. The abscesses were encysted 
1 Holmes' Surgery, vol. ii. p. 185. ABSCESS OF THE BRAIN. 
935 
in both instances, and, during the time 
they were forming, there were symptoms 
indicative of cerebral disease, although, 
in the second case, the symptoms were, 
for a while, obscure. One patient died 
seven weeks, and the other three months 
after the accident. 
Cases might be given to show that ab- 
scess may follow injury to the head, with- 
out any fracture or other discoverable 
injury to the skull; and the abscess may 
remain latent for months or even longer. 
One of the commonest causes of cere- 
bral abscess is disease of the internal ear. 
The clinical history of this class of cases 
is usually as follows: the patient has a 
discharge from the ear for some time-for 
months-and, in many cases, for years ; 
the discharge being continuous or inter- 
mittent. It is common to hear it said 
that the discharge began in childhood, 
after an attack of measles, scarlatina, or 
smallpox; and since has returned, more 
or less. With the discharge there is often 
deafness and pain in the ear, but more 
often the patient makes no complaint of 
either. In some cases, the discharge is 
very offensive, and has been so for some 
time past. The extension of the disease 
to the brain is often very insidious. There 
may be no indications that the brain has 
become seriously involved until acute 
symptoms set in a few days before death. 
Very often the first sign is a great increase 
of the pain in the ear. The pain is often 
very severe, and comes on in paroxysms, 
so violent in some cases, that the sufferer 
screams with it. Occasionally the acute 
mischief in the brain is ushered in with 
rigors; at other times with nausea and 
vomiting. 
Sometimes an epileptiform convulsion 
ushers in the acute symptoms, and a few 
days after this the convulsion is repeated, 
and followed by hemiplegia. 
The accession of acute symptoms ap- 
pears, in many cases, to correspond with 
the commencement of acute inflamma- 
tory softening, either primarily in healthy 
brain, or secondarily around an old ab- 
scess. Then the skin becomes hot, the 
pulse quick, tongue dry and parched; 
great prostration, drowsiness, and stupor 
set in-such symptoms as resemble con- 
tinued fever, and have been mistaken for 
it in some cases. The discharge from the 
ear varies very much during the acute 
symptoms. It is common for it to sub- 
side, or even entirely to disappear. 
Chronic changes, dependent upon dis- 
eases of the internal ear, may be insidi- 
ously going on in the brain substance, 
without there being any symptoms of 
cerebral disease. 
Mr. Toynbee was of opinion that the 
inflammation extends to the brain, from 
the pus not escaping from the cavity of 
the tympanum externally. He says: 
"So long as there is a free exit for the 
discharge, I believe the disease rarely ex- 
tends to the brain."1 He also remarked: 
" In all fatal cases the discharge has been 
deprived of a free egress." Mr. Toynbee 
further stated, in cases where the disease 
attacks the mastoid cells in early life, the 
cerebrum is the part of the brain which 
is most likely to suffer, while in later 
periods of life the cerebellum is the part 
most generally affected. Long experience 
has clearly shown that, when disease of 
the internal ear has gone on for a long 
time, the temporal bone is very liable to 
become diseased. When the patient dies 
with cerebral symptoms, it is common to 
find caries of the petrous, or mastoid, por- 
tion of the temporal bone. It is also 
common to find suppurative inflammation 
of the dura mater covering the diseased 
bone, with or without sloughing of that 
membrane. There is, in some cases, no 
direct extension of the disease from the 
bone to the contiguous parts. In such 
cases the bone, membranes, and surface 
of the brain are healthy. A portion of 
healthy brain may lie between the abscess 
and the bone. The diseased action is 
considered to 'extend by a vein. It is 
rare to find abscess of the brain following 
acute disease of the ear; but one case is 
alluded to by Mr. Toynbee. 
In cases of chronic disease of the ear, 
the causes of the acute brain mischief are 
various. A blow on the head, violent 
exercise, or other depressing influence ; 
also cold air, or some irritating applica- 
tion, is sufficient to engraft acute changes 
upon the chronic disease. 
Cerebral abscess may be associated with, 
and apparently dependent upon, chronic 
disease in the lungs, but in two of our 
cases the morbid appearances were such 
as to indicate acute changes in the lungs, 
extending, however, over several weeks. 
In a case that occurred in St. Bartholo- 
mew's Hospital, the lung presented the 
appearance of acute pneumonia in the 
third stage ; but the symptoms indicated 
that the disease had been going on about 
two months and ten days. 
In all the other cases which have come 
under our notice, the morbid changes in 
the chest had evidently been going on 
several months and even years. In one, 
there was a large suppurating chronic 
empyema. In another, there was a large 
cavity at the apex of the right lung, 
which was firmly adherent to the chest 
walls by a thick layer of indurated tissue. 
Another patient had had flattening and 
general contraction of the left chest for 
years, signs of dilated bronchial tubes, 
and of disease in the left lung. 
Suppuration in any part of the body 
1 Vide Diseases of the Ear, by Mr. Toynbee, 
p. 303. 936 
ABSCESS OF THE BRAIN. 
may give rise to secondary abscess in the 
brain. In one of our cases there was an 
abscess in the sheath of the left rectus 
abdominus muscle, and several abscesses 
without cyst in the brain. In this case it 
is instructive to notice that the lungs, the 
common seat of pysemic abscesses, did not 
contain any abscesses, nor were there any 
in the liver or spleen. In another case 
there were pysemic abscesses in the brain, 
apparently the result of chronic suppura- 
tion of a mesenteric gland and coexisting 
recent abscesses in the spleen and kidney. 
In a case of acute necrosis of the tibia, 
which occurred in St. Thomas's Hospital, 
there were numerous abscesses in the 
brain, and pyajmic abscess in the lungs, 
liver, and spleen. In a case given by Dr. 
Bright, a whitlow was the source of gen- 
eral pysemia and abscess of the brain. In 
another case, referred to by Lebert, the 
drawing of a tooth was followed by inflam- 
mation of the upper part of the face and 
cerebral abscess. Dysentery was the 
cause in one instance ; abscess near the 
uterus; suppuration in the Fallopian 
tube ; carcinoma of the face ; abscess in 
the liver, and the phagedenic ulceration, 
following amputation of the breast, were 
the causes in other cases. Dr. Ogle re- 
lates a case of secondary purulent deposit 
in the brain, apparently the result of 
ulceration of the caecal appendage. There 
is also another recorded case following 
amputation of the forearm.1 
In chronic disease of the bones of the 
nose, and in cases of syphilitic disease of 
the bones of the skull, there is a liability 
to cerebral abscess. 
I 
Morbid Anatomy.-An abscess may 
form in any part of the brain. Usually it 
forms in the white substance, and when 
in the gray it is formed by extension from 
the white. The middle cerebral lobes are 
the most frequent seats of abscess. One 
hemisphere is as frequently attacked as 
the other. Of 80 cases, abscess was situ- 
ated in the left hemisphere in 23, and in 
the right in 29. Practically, therefore, 
one hemisphere would appear to be as 
liable to be attacked as the other. In 12 
cases abscess was situated in the middle 
lobe, but it is not stated in which hemi- 
sphere. The middle lobes were the seat 
of abscess in 23 out of 74 instances. Ab- 
scess was found in the cerebellum in 13 
cases, in the ponsVarolii twice, in the 
corpus striatum twice, in the optic thala- 
mus twice. Abercrombie mentions an 
instance of abscess in the medulla oblon- 
gata. In several of the 74 cases the ab- 
scesses were multiple, and found in more 
than one part of the brain. The appear- 
ance of the abscess varies according to its 
duration. If it have been recently formed, 
the pus is not inclosed in a cyst, but di- 
rectly surrounded by ragged suppurating 
brain tissue, and there is not a trace of 
lining membrane to the cavity. If the 
abscess have been formed some time, the 
pus is inclosed in a cyst of variable thick- 
ness. In very old abscesses the cyst wall 
has been found a quarter of an inch, or 
more, in thickness. When the abscess is 
a few weeks old, the cyst wall is usually 
a line or two in thickness. The wall of 
the cyst is formed of fibro-cellular ele- 
ments, and, in some cases, well-formed 
spindle-shaped fibres are seen ; in others 
the fibro-cellular tissue has undergone 
granular degeneration, and the fibre cells 
are very indistinct. The cyst, when of old 
date, may be divided into three parts-an 
outer layer, which is made up of loose, 
fine, fibrous tissue ; a middle layer, which 
is firmer and more coarsely fibrous than 
the outer; and the inner surface of the 
cyst is formed by a smooth, pyogenic 
membrane, in which some small irregular 
dilated veins may be seen running in dif- 
ferent directions. 
In abscesses of recent formation, the pus 
is generally of a greenish hue, and may, 
or may not, have a disagreeable smell. 
In old abscesses, the pus is green, fetid, 
mucoid, and is decidedly alkaline. The 
pus removed from old abscesses, when 
placed under the microscope, shows few 
or no well-developed pus corpuscles; there 
is a large quantity of granular fat and 
granular matter without any nuclei. 
There may be several encysted ab- 
scesses in the brain. In one of our cases 
there were no less than four ; in another 
a large encysted abscess in each hemi- 
sphere. 
The condition of the brain substance 
immediately around the abscess may vary 
very much ; it has commonly undergone 
a process of softening. Rokitansky, 
speaking of recent abscess, says, round 
the abscess the brain substance is in a 
state of inflammation, producing red soft- 
ening, yellow softening, and in more dis- 
tant parts oedema of the brain tissue. 
When a large abscess is situated in one 
of the hemispheres, the brain is often 
altered in shape; the convolutions being 
packed together and flattened : the hemi- 
spheres bulged at the side, and if the ab- 
scess be very large, the hemisphere con- 
taining it may feel more like a bag of 
pulpy thick fluid than solid brain sub- 
stance. Collections of pus, in the hemi- 
spheres, tend to make their way towards, 
and discharge themselves into, the lateral 
ventricles, or on the surface of the brain. 
1 From analogy we should expect that an 
hydatid tumor, or a so-called strumous de- 
posit in the brain, would cause abscess. We 
have, however, no record of such a case. Ab- 
scess is also said to have occurred when the 
carotid artery was tied. Probably it was 
softening of the brain, and not abscess. 937 
SYMPTOMS 
Pus, like blood, may fill one lateral ventri- 
cle only, or escape into the ventricle on the 
opposite side. In abscesses, as in very 
vascular, soft, gliomatous tumors of the 
brain, hemorrhagic effusions are occasion- 
ally met with, and a coagulum of blood 
may be seen surrounded by pus.1 
We have already stated that several 
abscesses may exist together in the brain; 
this is common when a patient has died 
of pysemic cerebral abscess. In such cases 
every part of the brain may be studded 
with minute collections of pus ; they may 
be found in the cerebrum, in the cerebel- 
lum, in the optic thalamus, in the corpus 
striatum, and pons Varolii. The size of 
these abscesses may vary from a pin's 
head to a hazel-nut, or even larger. They 
are usually situated near the surface of 
the brain. The cerebral substance around 
these pysemic abscesses may be softened, 
at other times it is firm and comparatively 
healthy. When abscess of the brain is de- 
pendent upon disease of the internal ear, 
the morbid appearances are much as fol- 
lows : the dura mater, situated over the 
diseased petrous or mastoid portion of the 
temporal bone, is often found highly con- 
gested, softened, and ulcerated ; or of a 
dirty green color, and evidently slough- 
ing, and the bone laid bare. In other 
cases the dura mater is simply thickened 
and covered with purulent lymph, and 
betwixt the dura mater and the bone there 
is often a collection of pus. The lateral 
sinuses are frequently involved and plug- 
ged, especially when there is disease of 
the mastoid cells ; the sinus is often seen 
enveloped in pus and purulent lymph. 
The suppurative inflammation may ex- 
tend along the internal jugular vein, and 
set up suppurative pleuritis and abscess 
in the lung. 
In abscess of the brain due to disease of 
the ear, there is, in the majority of cases, 
caries of the temporal bone ; the latter is 
seen of a dark color, with an irregular 
roughened surface. The abscess in the 
brain may have direct communication 
with the diseased bone, and the contents 
of the abscess make their way through 
the ulcerated openings in the dura and 
bone into the tympanum, and then escape 
through the perforated membrana tym- 
pani into the external meatus, thus con- 
stituting what has been termed "otor- 
rhoea cerebralis." A similar communi- 
cation and escape of the pus is said to 
have occurred in cases of abscess in the 
brain caused by diseased ethmoid bone. 
At other times there is no such direct 
communication, for there is a layer of 
brain substance separating the abscess 
from the membrane of the brain. This 
layer is often softened, of an ash-gray 
or yellowish appearance, and looking as if 
the pus were about to burst and discharge 
itself on the surface of the brain. 
In some cases of abscess dependent on 
disease of the internal ear, there is no 
caries of the bone, as we have already 
mentioned, the membranes may be 
healthy, and the abscess may be situated 
at a distance greater or less from the sur- 
face of the brain. 
Symptoms.-In 73 cases of abscess of 
the brain, the symptoms were as follows: 
-Pain in the head in 39 cases ; epilepti- 
form seizures in 38 ; coma in 30 ; heavi- 
ness, stupor, and drowsiness in 30 ; paral- 
ysis in 24; rigors in 17; pyrexia in 13; 
delirium in 13 ; vomiting in 12 ; inconti- 
nence of urine, or of feces, or both, in 15 ; 
vertigo in 8; disordered sensibility, not 
including pain in the head, in 6 ; defective 
articulation in 4; defective sight in 3 ; an 
apoplectic attack in 1. 
That some of the symptoms may have 
existed in greater proportion, we should 
be prepared to expect, especially such 
symptoms as vertigo, pyrexia, emacia- 
tion, and probably in a greater number of 
cases, defect of sight would have been dis- 
covered had the eye been tested. The 
symptoms, therefore, that are most fre- 
quently observed in cases of abscess in the 
brain are pain in the head, epileptiform 
attacks, paralysis, coma, heaviness, drow- 
siness, stupor, rigors, pyrexia, delirium, 
vomiting, and incontinence of urine and 
feces. In a few cases defective articula- 
tion was met with. The records show 
that the intellect was very little affected. 
Paralysis was observed in 24, that is in 
about one-third, whereas in Lebert's cases 
it was observed in about one-half. He 
included, however, not only local paraly- 
sis, but also general loss of muscular 
power, whereas we have confined the 
term to local paralysis only, such as loss 
of power on one side of the body, of one 
arm or leg, one side of the face, or some 
other part. 
The first symptom, in many cases, is 
pain in the head; it may be the only indi- 
cation of cerebral disease present for 
months. The pain is often very agoniz- 
ing.1 
1 One patient lay in bed continuously hold- 
ing his head with both his hands: another 
walked about with his hands pressed against 
one side of his head, crying out constantly, 
"Oh, my head! oh, my head!" The pain is 
often so severe that the patients shriek from 
the agony they suffer. A patient, who was 
perfectly sensible, said he could not help 
screaming; and, although he tore and bit any- 
body or anything near him, he at the same 
time expressed contrition for what he was 
doing, and said the pain in his head was un- 
bearable ; it felt as if some one was knocking 
it with a hammer. 
1 See Guy's Hospital Reports, vol. iii. 3d 
Series, Case No. 6, p. 291. 938 
ABSCESS OF THE BRAIN. 
An intense neuralgic pain situated over 
one spot is occasionally the first symptom; 
sometimes the pain is seated almost im- 
mediately over the region of the abscess. 
A boy, having an abscess in the anterior 
lobe of the right hemisphere, complained 
of almost constant burning pain over the 
front and right side of the head, but this 
localization of pain over the seat of the 
abscess is by no means constant. In 
some cases the pain is very remote. In 
one patient there was an abscess in the 
cerebellum, and the pain was felt in the 
forehead ; in another there was an abscess 
in the right middle cerebral lobe, and the 
pain was referred to the left side of the 
head. 
The pain often comes on in paroxysms ; 
in other cases it is continuous, remittent, 
or intermittent. It is not present in all 
cases of cerebral abscess, as the statistics 
of our 76 cases show. It is very commonly 
associated with pain in the ear, when the 
abscess is due to disease of the auditory 
apparatus. 
Instead of pain preceding, it may follow 
the convulsive attacks. Cases of this kind 
are by no means few. 
Occasionally the first indication of cere- 
bral mischief is a sudden and unexpected 
epileptiform seizure. The epileptiform 
seizures are occasionally the most promi- 
nent symptoms from the time of seizure 
to the patient's death. The epileptic at- 
tacks do not necessarily come on every 
day; occasionally some days elapse be- 
tween the seizures. 
After each convulsion the side affected 
is often left weak, and this increases until 
there is complete hemiplegia. The con- 
vulsive movements are sometimes unat- 
tended with insensibility, and are confined 
to one extremity, especially the arm. This 
has been long noticed. 
Abercrombie alludes to a case of Lalle- 
mand's, in which there was pain in the 
right side of the head and tremor of the 
left arm. This was followed by continued 
convulsions, flexion, and extension of the 
left arm, which after some days ended in 
palsy. 
Instead of convulsive movements, the 
first indications of brain disease may be 
numbness and tingling in one extremity. 
The symptoms in other cases of cere- 
bral abscess are like those that are said to 
indicate cerebral softening. There is 
sudden loss of power on one side of the 
body without any loss of consciousness ; 
the leg being less affected than the arm. 
In several instances rigors were very 
prominent symptoms throughout the at- 
tack. A patient, suffering from suppura- 
tion, was noticed to be getting thinner 
and weaker; then he was seized with 
rigors, diarrhoea, a dry brown parched 
tongue, and a hot skin; he became, coma- 
tose and died. Pyremic abscesses were 
discovered in the brain. 
In some cases of pysemic abscesses, 
there are no special symptoms to show 
that organic disease is going on in the 
brain ; but only the general indications of 
pyaemia. In others the accession of con- 
vulsive seizures, paralysis, or coma indi- 
cates disease in the cerebral organ. Ri- 
gors were noticed in a few instances so 
severe, and returning with such regularity 
every day, that they closely resembled 
those of ague. One patient had head- 
ache, rigors, and vomiting, returning 
every day for five days, and then became 
unconscious. Rigors do not occur, in 
some instances, until after convulsive 
seizures have indicated cerebral mischief. 
Imperfect articulation, to a marked de- 
gree, was noticed in some cases, and in 
one there was loss of language. 
With respect to the eye, Dr. Ilughlings 
Jackson has mentioned to us that lie has 
seen changes in the retina (optic neuritis?) 
in a case of cerebral abscess. Dr. Jackson 
thinks such changes are common to seve- 
ral kinds of cerebral disease. 
Mental disturbances were observed in 
some cases. Now and then, the only 
symptoms noticed were a heavy expres- 
sion, a disinclination to speak, and indif- 
ference to surrounding objects. In some 
cases with disease of the ear, it was stated 
that the patients had attempted to com- 
mit suicide. One patient appeared to 
become hypochondriacal. Emaciation 
setting in rapidly was a marked symptom 
in several cases. Similar emaciation is 
seen in some cases of tumor of the brain ; 
but is not so frequent as in abscess. 
Patients suffering from cerebral abscess 
may have symptoms so closely resembling 
continued fever, that it is exceedingly 
difficult, if not impossible with any degree 
of certainty, to say whether it be a case 
of fever or of organic disease of the brain. 
Pathology.-Cerebral abscess may be 
produced by direct injury, or by contre- 
coup, contusing or lacerating the nervous 
tissue, and setting up inflammation and 
suppuration. It may be produced by sup- 
purative inflammation in some tissue in 
the neighborhood of the brain which 
spreads to a contiguous part; namely, in 
the ear or nose, which extends, and in- 
vades the dura mater, pia mater, and 
brain substance. Or the diseased action 
may spread by continuity of structure, as 
along a vein, and thus to the brain. Dis- 
ease of the ear or nose, or of other cranial 
bones, may give rise to cerebral abscess 
in this manner. Again, abscess may be 
produced where there is disease of the 
cranial bones, or some growth involving 
them, by the veins communicating with 
the diseased bone becoming plugged. The 
process of coagulation extends and invades 
the veins communicating with the sinuses 
of the dura mater. These become plugged, PATHOLOGY. 
939 
as also the veins of the pia mater and pro- 
bably some branches entering the brain 
tissue also, and inflammation, terminating 
in suppuration, is thence set up in the 
brain. In other cases, minute coagula, or 
thromboses, are supposed to be detached 
and carried along by the circulation until 
they are arrested in the capillaries of the 
brain, and often of the lungs, kidneys, 
and other organs. 
Pysemic abscesses are occasionally found 
in tiie brain, and not in any other organ 
of the body. Besides the coagula, some 
of the elements of pus may be carried by 
the circulation to aid in, or be the means 
of, setting up suppuration in the parts 
where the thrombosis is arrested. In this 
way abscesses in the brain are probably 
caused by abscess or suppuration in the 
liver, lungs, bowels, or in other parts. 
We next inquire if every form of cere- 
bral inflammation, or encephalitis, no 
matter what its origin, be liable to end in 
suppuration and an abscess. It has been 
many times stated that such is the case ; 
but it would appear that the inflammation 
must be set up by a special cause, and un- 
less it be so, it does not end in suppuration 
and abscess. Suppuration may appa- 
rently be excited by local injury, or by 
the elements of pus or thrombosis ; but 
experience shows that other forms of in- 
flammation do not terminate in abscess. 
For instance, encephalitis and softening, 
the result of plugging of a cerebral artery, 
or encephalitis around a hemorrhagic 
effusion, or around a gliomatous tumor or 
old cyst, shows no disposition to the for- 
mation of pus or abscess. The brain may 
soften, disintegrate, and a cyst may be 
formed, but there is no pus formed. 
It is necessary, now, to ask if there be 
not good evidence to show that the brain 
may be the seat of suppurative inflamma- 
tion and abscess without there being any 
cause to account for it ? Is there not, in 
such cases, idiopathic inflammation which 
gives rise to idiopathic abscess ? By id- 
iopathic cerebral abscess, we suppose, is 
meant abscess which is not preceded or 
occasioned by injury or disease; its origin 
being unaccounted for. Lebert and others 
admit the occurrence of idiopathic cere- 
bral abscess. Such cases are, however, 
in comparison with others, rare. It is 
beyond all doubt that a certain number of 
cases of cerebral abscess do occur in which 
no disease is discovered in any other part 
of the body, and there is no history of 
any recognized cause to account for the 
cerebral abscess. 
Before, however, it be concluded that 
abscess has been formed idiopathically, it 
is necessary to remember that in the ma- 
jority of cases there is a cause to account 
for the formation of such abscess, and that 
only in a very small minority have ob- 
servers failed to find some admitted cause. 
In the face of such evidence, is there not 
good reason to think that, in this small 
minority of cases, the primary cause has 
been overlooked ? And, when it is still 
further remembered that hours have been 
passed in searching for the primary dis- 
ease or cause, and at last it has been 
found limited to a mesenteric gland, a 
gum-boil, or a whitlow-in fact the pri- 
mary disease was so small, that it might 
have been very easily overlooked-it ap- 
pears to us not difficult to understand how, 
even after very great care, the primary 
cause may have remained undiscovered. 
Bearing all this in mind, we recognize that 
in a few cases of cerebral abscess, the cause 
cannot be discovered ; but even when the 
cause is undiscovered, we should not as- 
sume that the suppurative inflammation 
has commenced idiopathically in the brain. 
Cerebral abscess proves fatal in many 
cases, not by a collection of pus in one or 
other part of the brain, but by extensive 
inflammatory softening around the ab- 
scess, involving vital parts of the brain ; 
and it is from such softening that the ab- 
scess is enabled to make its way towards 
the ventricles or the surface of the brain. 
The softening around very old encysted 
abscess w'ould appear not to be set up by 
pyogenic changes going on in its lining 
membrane, for there is not a large quan- 
tity of well-formed pus corpuscles in old 
encysted abscesses to show that such ac- 
tive changes have been going on in this 
membrane. 
The softening would rather appear to 
be due to some circumstance interfering 
with the nutrition of the parts outside of 
the abscess, but in its neighborhood. The 
nutrition of such parts, owing to the pres- 
ence of a foreign body, being very feeble, 
it is easy to understand how a blow on 
the head or a debilitated or cachectic 
state of the system may be sufficient to 
excite such feebly nourished parts to take 
on acute inflammatory softening. 
Has abscess in the brain any tendency 
to spontaneous cure? Lebert thinks not; 
and when we remember that there is no 
well-established case on record, showing 
that an abscess has been spontaneously 
cured, we readily admit that the evidence 
very strongly favors the belief that cere- 
bral abscesses do not tend to a spontane- 
ous cure. It is, however, necessary to 
remember that the brain is a very vital 
organ, severely taxed in our every-day 
labors, and, if not sound, its functions, 
which are essential to life, maybe brought 
to a stop. When there is an abscess in 
the brain, the organ being unsound, its 
functions are very liable to be perverted, 
and death follows ; wfliereas, if the ab- 
scess were seated in an organ less essen- 
tial to life, any perversion of its func- 
tional activity would not be attended with 
fatal results, and thus time would be 940 
ABSCESS OF THE BRAIN. 
gained for the abscess to pass through 
the different stages essential for its cure. 
We may therefore ask ourselves whether 
it is that an abscess of the brain has no 
disposition to spontaneous cure, or whether 
it is that the patient does not live long 
enough for such a process to be accom- 
plished ? The development of a firm cyst 
wall would show that there is a possibility 
of spontaneous cure. The cyst wall ex- 
erts a protective influence, by localizing 
the mischief and protecting the sound 
from the diseased part. And experience 
has shown that time is only required for 
such protection to be very great, and for 
the barrier guarding the pus to become 
stronger and stronger. 
We are next led to ask, is there any- 
thing in the condition of the pus discov- 
ered in old abscesses to show that these 
were in a process of cure? To our minds, 
there is. It is usual to find such pus in 
a very degenerate condition, viz. granu- 
lar and fatty, which is favorable to ab- 
sorption and concretion: such changes 
as occur in abscesses that have undergone 
spontaneous cure. This is no idle ques- 
tion. It is simply-Is cerebral abscess 
necessarily a fatal and incurable disease? 
Practically it is, but there is nothing in 
its morbid anatomy to lead us to conclude 
that it is necessarily incurable. 
Diagnosis.-Cerebral abscess is in- 
ferred when there are symptoms of brain 
disturbance indicative of organic disease, 
and there are present those morbid con- 
ditions that are known to give rise to cere- 
bral abscess, such as a discharge from the 
ear, nose, or chronic suppuration else- 
where, or when there is a history of a 
blow, or of some other acknowledged 
cause of the disease. No doubt that in 
some cases the inference proves correct, 
where there is evidence showing that the 
cerebral substance is undoubtedly dis- 
eased, and further evidence of suppura- 
tion going on in some part of the body ; 
for here there are indications of acute 
brain disease, and we are led to suspect 
that this is due to abscess, since such 
causes are present as are known to pro- 
duce it. With the brain, however, as 
with other organs, wc are more often able 
to say that it is diseased than to say what 
is the precise nature of the pathological 
changes going on in its substance. 
There may be evidence to show that a 
patient has chronic disease of the nose or 
ear, and cerebral symptoms may super- 
vene suddenly ; epileptiform seizures and 
other symptoms may be present, such as 
are seen in cases of cerebral abscess; the 
patient may die, and yet there may be no 
disease of the brain or of its membranes. 
In some cases, the membranes alone are 
diseased; in others, the brain substance 
is softened, without abscess. Disease of 
tiie bones of the skull-no matter whether 
it be fracture, syphilitic disease, or a 
growth-is liable to set up inflammation 
of the membranes of the brain, and the 
inflammation may spread, and give rise 
to suppurative inflammation of the brain 
substance. If the patient survive six or 
seven weeks, an abscess may be formed ; 
if he die in two or three weeks after acute 
symptoms have set in, the brain may be 
found softened, but -without abscess. Not 
unfrequently death takes place before 
there is time for the suppurative inflam- 
mation to form an abscess. 
There may be a history of injury to the 
head, cerebral disease may appear to have 
followed as a consequence, and the post- 
mortem examination reveal disease in the 
brain, but not abscess. 
Injury may be followed by the forma- 
tion, not of an abscess, but of a tumor, 
malignant disease, or by softening in the 
brain ; or further, the disease may not be 
in the brain at all, but on the surface. 
Experience has shown that an injury to 
the head may produce a large cyst in the 
cavity of the arachnoid, and the symptoms 
of the case may be similar to what are 
seen in cases of encysted abscess. 
Cerebral symptoms associated with of- 
fensive discharge from the ear and nose, 
would lead one to suspect abscess in the 
brain, but in one of our cases there was 
tumor, and not abscess. The coexistence 
of tumor in the brain with the conditions 
that are known to produce abscess, makes 
the differential diagnosis extremely diffi- 
cult. There are no pathognomonic symp- 
toms of abscess or of tumor. It is only 
the different manner in which the symp- 
toms are grouped, and the existence of 
those conditions that are known to pro- 
duce one and not the other disease, which 
leads the practitioner to suspect that there 
may be tumor rather than abscess, or vice 
versa. 
The symptoms of abscess may differ 
from those of tumor in the following re- 
spects. In abscess there is often marked 
cachexia and great emaciation. In tumor, 
the patients have often no marked ca- 
chexia, even look healthy, and the body 
is fairly nourished, certainly not ema- 
ciated. In abscess the duration of the 
cerebral symptoms is generally much 
shorter than in tumor. The symptoms in 
abscess are usually either latent or acute; 
in tumor they are often chronic. In the lat- 
ter there may be local paralysis extending 
over several months, which is very rare 
in abscess. The intracranial nerves are 
much more frequently affected in tumor 
than in abscess. Occasionally, however, 
a person with tumor is seen to be much 
emaciated. These differences may enable 
the practitioner, in some cases, to diagnose TREATMENT. 
941 
one condition from the other, but in neither 
case are these differences so constant that 
a certain diagnosis can be made. 
An abscess may lie latent in the brain 
for many months, and then acute symp- 
toms may suddenly set in, and the patient 
die in a few days. The same thing may 
take place with respect to cerebral tumor. 
Experience has shown that cancerous de- 
posits also may exist in the brain without 
there being any decided cerebral symptoms- 
Chronic encysted abscesses and tumors 
of the brain have many symptoms in 
common. A hydatid tumor, gliomatous 
tumor, a cyst, cancerous deposits in the 
brain, or any other substance acting as a 
foreign body, may produce pain in the 
head, epileptiform seizures, with or with- 
out paralysis, optic neuritis, vomiting, or 
gradual loss of muscular power. 
We are often able to say, when there is 
acute persistent but variable paralysis, 
with pyrexia, that there is acute inflam- 
matory softening of the brain; but whether 
that softening is going on around an ab- 
scess, a tumor, or a cyst, or whether ex- 
cited by disease situated on the surface of 
the brain, we may be unable to give any 
exact opinion. 
With respect to rigors in cases of cere- 
bral abscess, we have plready stated that 
they are very well marked in some in- 
stances, and may be not unlike those of 
ague. This symptom is not, however, 
peculiar to cerebral abscess. It occasion- 
ally occurs in other forms of brain disease, 
for instance, as gliomatous tumors or tu- 
bercle. 
Treatment of abscess of the brain 
should be, by anticipation,-obviating the 
causes which lead to it; in chronic disease 
of the ear or nose, by maintaining a free 
exit for the discharge, no matter what the 
exciting cause. Rest is the most impor- 
tant part of the treatment, avoiding 
thereby both mental and mechanical ex- 
citement. 
By a simple diet and quiet life, abscess 
may be dormant in the brain for an in- 
definite time.1 
In cases where abscess follows injury to 
the head, surgical interference must be 
thought of. The principle in such cases 
is a mechanical one, namely, to reach the 
abscess and evacuate its contents, if that 
be thought advisable,-experience shows 
but little to commend it.2 
1 This is, however, to be observed, that 
encysted abscess of the brain is fatal from 
changes outside the cyst of an acute kind, 
such as might be presumed to be preventible 
to a great extent. In support of this opinion 
we may say that, in our experience, we have 
known abscess lie quiet for months after a 
blow on the head, and the patient and the 
medical attendant become confident that all 
was well; the symptoms of lesion having 
slowly gone off, and yet a fatal issue be pro- 
duced after a few hours' suffering by neglect- 
ing the precaution of rest and regimen. 
Probably such rest and care should be con- 
tinued, not for months only but for years. 
This we say from clinical observations of the 
changes in the cyst of old cerebral abscess. 
[2 A series of statistical tables, giving the 
particulars of 76 cases of Abscess of the Brain, 
are omitted from this edition ; for the reason 
that, valuable as they are in themselves, yet 
in proportion to the space they occupy, they 
are likely to be referred to in detail by very 
few readers. Their general history, and the 
lessons to be derived therefrom, are well 
stated in the preceding article.-H.] B-PARTIAL DISEASES OF THE NERVOUS SYSTEM.- 
Continued. 
2. Diseases of the Spinal Column. 
Meningitis. 
Myelitis. 
Congestion. 
Tetanus. 
Locomotor Ataxy. 
Irritation. 
General Spinal Paral- 
ysis. 
Hysterical Paraple- 
gia. 
Reflex Paraplegia. 
Infantile Paralysis. 
Hemorrhage. 
N on-inflammatory 
Softening. 
Induration. 
Atrophy and Hyper- 
trophy. 
Tumor, etc. 
Concussion. 
Compression. 
Caries of Vertebrae. 
Spina Bifida. 
DISEASES OF THE SPINAL CORD. 
By C. B. Radcliffe, M.D., F.R.C.P. 
A. Preliminary Remarks. 
Before proceeding to cope with the 
intricate and difficult pathological topics 
which form the subject of the present 
article, it appears to be expedient to 
glance at some points in the physiology 
of the spinal cord, and also to try and 
ascertain the true significance of pain, 
spasm, and certain symptoms analogous 
to pain and spasm, which figure conspicu- 
ously in the histories of spinal maladies ; 
for if these matters be not disposed of as 
preliminaries now, they will prove to be 
the cause of frequent and distracting di- 
gression afterwards. 
I. A Glance at some Points in the 
Physiology of the Spinal Cord. 
1. Boots of spinal nerves.-The result of 
recent researches has been to establish in 
the fullest manner the truth of Sir Charles 
Bell's great discovery, that the posterior 
roots of the spinal nerves are devoted to 
sensation only, and the anterior roots to 
motion only. In one article, at least, the 
creed of to-day is the same as that of yes- 
terday : and it is some comfort to have it 
so, for in many other articles the creed of 
yesterday is not that of to-day. 
2. Posterior columns.-If these columns 
be cut across, the result is, not numbness, 
as it would be if these columns were, as 
was once supposed, simply the continua- 
tion of the posterior roots of the spinal 
nerves, but hyperesthesia and loss of co- 
ordinating power in the parts below the 
section, with a certain degree of local 
pain; and on inquiring further, it is 
found that this pain is due, not to any 
sensitiveness in the columns themselves, 
but to the irritation of the cut having 
travelled through the posterior roots of 
the spinal nerves, which posterior roots, 
as the researches of Lockhart Clarke 
show, pass through the posterior columns, 
more or less directly, to the central gray 
matter of the cord. 
3. Bestiform bodies and small posterior 
pyramids.-What has just been said of the 
posterior columns of the cord appears to 
apply equally to the restiform bodies, and 
to the small posterior pyramids of the 
medulla oblongata, which pyramids lie 
between the restiform bodies posteriorly. 
Hyperesthesia and incoordination in the 
parts below the section, with some local 
pain, are still the result of cutting these 
parts across : and as the connections of 
these parts are above with the cerebellum, 
and below with the posterior columns of 
the cord, the natural inference is, that 
942 943 
PHYSIOLOGY OF THE SPINAL CORD. 
the channel through which the cerebellum 
acts upon the body is formed of the resti- 
form bodies and small posterior pyramids 
in the upper part of its course, and of the 
posterior columns of the cord in the lower 
part. 
4. Anterior columns.-If one of these 
columns be cut across, it ceases to act on 
that side of the body in the parts below 
the section, and the paralyzed parts are 
benumbed to a certain degree, unless the 
cut be made in the part which lies imme- 
diately below the anterior pyramids of the 
medulla oblongata. In this part the an- 
terior pyramid may be cut across without 
causing any very obvious paralysis or loss 
of sensation: in this part the results of 
dividing the anterior column at a lower 
level are only obtained when the cut is 
extended transversely, so as to divide the 
lateral column. It is plain, in fact, that 
in the uppermost part of their course, the 
anterior columns have not that intimate 
connection with the anterior roots of the 
spinal nerves, and that all-important part 
to play in voluntary movement, which 
they evidently have everywhere else : and 
it is also plain that the anterior columns, 
where they have to do with voluntary 
movement, have also something to do 
with sensation, for it is a fact that a cer- 
tain degree of numbness is produced by 
the injuries which give rise to paralysis. 
5. Anterior pyramids.-A transverse 
section of one of the anterior pyramids of 
the medulla oblongata in any part of its 
course annihilates all power of voluntary 
movement in the muscles below the sec- 
tion on the opposite side of the body, with- 
out affecting the sensation in any appre- 
ciable manner; and thus it is plain, not 
only that each pyramid contains very 
many, if not all, the conductors concerned 
in carrying the orders of the will to the 
muscles of the opposite side of the body, 
but also that the conductors which are 
collected in one pyramid decussate with 
those collected in the other pyramid at the 
lower and not at the upper boundaries of 
the pyramids. In a word, all the evidence, 
old and new, goes to show that these 
bodies are composed of conductors con- 
cerned in voluntary motion without any 
admixture of sensory conductors. 
6. Lateral columns.-In the cervical 
region, for a short distance below the 
point at which the anterior pyramids of 
the medulla oblongata intercross, the 
lateral columns of the spinal cord have 
certainly very much to do in transmitting 
the orders of the will to the muscles ; for, 
as has just been seen incidentally, the 
muscles below the section on the same 
side of the body are paralyzed by cutting 
one of them across in this part. In the 
lower part of the cervical region, and in 
the dorsal and lumbar regions, it is very 
different, and the difference is not very 
clearly determined. Here some trifling 
paralysis may be produced by dividing 
these columns transversely, but never 
more than this. Here, indeed, it would 
seem that this operation is followed by a 
certain degree of anaesthesia, and by the 
same result, as regards movement, as that 
which follows transverse division of the 
posterior columns-that is, not by paraly- 
sis, but by incoordination. A certain 
degree of anaesthesia appears to be a con- 
stant consequence of cutting across the 
lateral columns in any part of their course; 
and herein would seem to be an impor- 
tant distinction between the lateral and 
the posterior columns, for, as has been 
stated already, the result of cutting across 
the posterior columns is to produce hyper- 
aesthesia, not anaesthesia. 
7. Olivary bodies. - A section of the 
olivary bodies is followed, not by any 
marked degree of paralysis, or anaesthesia, 
but by a state of persistent spasm in many 
muscles on the same side of the body, in 
the neck especially,-a state which may 
sometimes continue for days, weeks, or 
even months. It is found, also, that this 
strange result is produced by irritating 
several parts of the base of the encephalon, 
the lateral and posterior parts of the me- 
dulla oblongata and pons Varolii especi- 
ally, as well as by irritating the olivary 
bodies. These parts are not very clearly 
defined. " They seem," says Dr. Brown- 
Sequard, " to be quite different from those 
employed in the transmission of sensitive 
impressions, or of the orders of the will to 
the muscles, at least in the medulla oblon- 
gata and pons Varolii. They constitute 
a very large portion of these two organs, 
and, perhaps, as much as three-fourths of 
the one first named. They are placed 
chiefly in the lateral and posterior columns 
of these organs ; and because many of 
their fibres do not decussate, the spasm 
produced by irritating them is on the same 
side of the body." 
8. Gray substance of the cord.-Instead 
of being merely a nerve-centre-the spe- 
cial centre of Marshall Hall's excito-motor 
system of nerves-there is now reason to 
believe, with Dr. Brown-Sequard, that 
the gray substance of the spinal cord is an 
important conductor of sensory and motor 
impressions. Paralysis without loss of 
sensation on the same side of the body, 
loss of sensation without paralysis on the 
other side of the body, are the strange re- 
sults of cutting across one lateral half of 
the gray substance of the spinal cord: 
anaesthesia on both sides of the body, 
paralysis on either side, are the equally 
strange results of making a longitudinal 
section midway between the two lateral 
halves: these are the two great facts 
which, when properly interpreted, furnish 
the reasons for believing, not only that 
there are sensorial and volitional conduc- 944 
DISEASES OF THE SPINAL CORD. 
tors in the gray substance of the cord, 
but also that these two forms of conduc- 
tors follow a different and definite course. 
Nor is it difficult to see how this may be. 
Let the course of the conductors in con- 
nection with the anterior and posterior 
roots of a pair of spinal nerves be what is 
represented in the following diagram,- 
a b being the motor conductor descending 
to the right, and a' b' the corresponding 
conductor descending to the left; c d being 
the sensory conductor ascending from the 
left, and c'd' the corresponding conductor 
ascending from the right,-and very little 
reflection will serve to supply the demon- 
stration wanting. With the sensory and 
motor conductors arranged in this manner, 
it is plain that a cut across the lateral half 
of the gray substance-a lesion indicated 
in the diagram by the line A b-must de- 
side on which sensation is preserved, and 
diminished temperature on the side on 
which sensation is lost, especially if the 
section be made high up near the 
medulla oblongata. It would seem, in 
fact, that the injury has acted upon the 
vaso-motor nerves contained in the cord 
as well as upon the common motor and 
sensory nerves, causing paralysis of vaso- 
motor nerves on the side on which there 
is increased temperature and sensibility, 
and irritation of vaso-motor nerves on the 
side on which there is diminished tempe- 
rature and anaesthesia. At any rate this 
mode of explanation is neither impossible 
nor improbable. The experiments of 
Professor Claude Bernard, Dr. Brown- 
Sequard, and others upon the cervical 
sympathetic, prove that when this nerve 
is paralyzed by dividing it, a state of 
hypersemia, of which the most conspicuous 
signs are a bloodshot state of the conjunc- 
tiva and of the lining membrane of the 
nostril and ear, with a contracted pupil, 
and with increased temperature, is at once 
set up on the same side of the head : and 
also that when the end of the divided 
nerve below the section is irritated, the 
immediate result is dilatation of the pupil, 
with an almost complete blanching and 
cooling of the parts which were bloodshot 
and warm a moment before. The vessels 
in these parts evidently relax and receive 
more blood when their nerves are para- 
lyzed, and contract and receive less blood 
where their nerves are irritated ; and the 
increased temperature and sensibility 
which happen in the one case, and the 
diminished temperature and sensibility 
which happen in the other case, are 
nothing more than the natural conse- 
quences of the increased or diminished 
quantity of blood in the parts in each case 
respectively. All this is plain enough. 
Moreover, there are other facts which go 
to show that phenomena in every way 
analogous to those which result from 
paralysis or irritation of the cervical sym- 
pathetic are produced by paralyzing or 
irritating vaso-motor nerves in other 
parts. There is, therefore, no reason why 
it may not be inferred that the increased 
temperature and sensibility of one side of 
the body, and the diminished temperature 
of the other side, which happen when a 
lateral half of the spinal cord is cut across, 
are the result of vaso-motor nerves being 
paralyzed in the one case and irritated in 
the other case. Nay, such an assumption 
is well-high inevitable, for the structural 
connection between the spinal and sym- 
pathetic systems of nerves is such as to 
make it scarcely possible to believe that a 
lateral half of the cord can be cut across 
without paralyzing and irritating vaso- 
motor nerves. 
9. Motor and sensory tracks.-The con- 
ductors concerned in voluntary motion, 
Fig. 58. 
stroy the continuity of the motor conduc- 
tor a b, and of the sensory conductor c d, 
and leave untouched the motor conductor 
a' and the sensory conductor c'd'- 
must bring about, that is to say, what has 
been seen to happen in the first of the 
two experiments under consideration; 
namely, preservation of sensation with 
loss of motion on the side of the lesion, 
and preservation of motion with loss of 
sensation on the opposite side. Again, 
with the sensory and motor conductors 
arranged in this manner, it is plain that 
a section of the gray substance of the cord 
midway between the two lateral halves- 
a lesion indicated in the diagram by the 
line C A D-must leave the motor conduc- 
tors a b and a' b' untouched, and cut across 
the sensory conductors c d and c'd' at their 
point of decussation-must bring about 
what happens in the second of these two 
experiments, viz., numbness on both sides 
of the body, and paralysis on neither side. 
In saying that paralysis without loss of 
sensation, on the same side of the body, 
and loss of sensation without paralysis, on 
the other side of the body, is produced by 
cutting across a lateral half of the spinal 
cord, all is not said that has to be said. 
In such a case there is, in addition, in- 
creased temperature and sensibility on the PHYSIOLOGY OF THE SPINAL CORD. 
945 
and those belonging to common sensation, 
both intercross in the cord, but not at the 
same place. From the right side of the 
brain, voluntary impressions pass to the 
motor nerves of the left side of the body, 
their course thither being, first, down the 
right anterior pyramid, then across to the 
left lateral column, then for a short dis- 
tance down the left lateral column, then 
down the left anterior column, and to 
some extent also down the left side of the 
gray substance and the left lateral column, 
and so out at the left anterior roots : from 
the left side of the brain, these impres- 
sions pursue a similar course, only pass- 
ing to the right side of the body instead 
of the left. Entering at the right pos- 
terior roots of the spinal nerves, the im- 
pressions which give rise to common sen- 
sations pass to the left side of the brain, 
up the left side of the gray substance, and 
to some extent also up the left lateral 
column and the left anterior column, the 
crossing to the other side of the cord 
being at the level of the entrance of the 
conductors into the cord, or thereabouts : 
entering at the left posterior roots of the 
spinal nerves, the impressions in question 
take a similar course to the right side. 
Both sets of conductors intercross in the 
cord, but not at the same place. The 
conductors concerned in voluntary motion 
intercross at the decussation of the an- 
terior pyramids. The intercrossing in 
this case is at this place, and at this place 
only : there is none above it, none below 
it. The conductors belonging to common 
sensation, on the other hand, intercross 
below the decussation of the anterior 
pyramids, and throughout the whole 
length of the cord. These are the main 
points to be remembered with reference 
to the tracks of these two forms of con- 
ductors in the cord. 
The conductors which have to do with 
coordination of movement appear to be 
confined to the posterior columns of the 
cord, and to the parts which connect these 
columns with the cerebellum, the resti- 
form bodies, and the small posterior pyra- 
mids. They are quite distinct from the 
conductors concerned in voluntary move- 
ment, and they also differ from these con- 
ductors in this, that those belonging to 
the two sides of the body do not inter- 
cross anywhere. 
The vaso-motor conductors which enter 
into the composition of the cord appear 
to lie chiefly in the gray substance, -for 
the dilatation of vessels resulting from 
paralysis of these nerves is brought about 
by dividing the gray substance rather 
than the white. Moreover, the fact that 
this dilatation of vessels is on the same 
side as that on which the gray substance 
is divided, must be taken as a reason for 
believing that the vaso-motor conductors 
belonging to the two sides of the body, 
like the conductors which have to do with 
the coordination of movement, do not 
intercross in the cord. 
And so likewise with certain other con- 
ductors of a vaguer sort. These lie in 
and about the olivary bodies, and in the 
upper third of the lateral column; and 
there is, as it would seem, no intercross- 
ing between those belonging to the two 
sides of the body, for the simple fact is 
this, that the persistent spasm which is 
brought about by irritation, which spasm 
is the only fact pointing to the existence 
of these conductors, is always on the 
same side as that to which the irritation 
is applied. 
On the other hand, there appears to be 
nothing peculiar in the sensory conduc- 
tors which are not concerned in common 
sensations-those which have to do with 
pain, tickling, temperature, and the rest. 
What has been said of the common sen- 
sory conductors would seem to apply to 
them in every respect, and indeed it may 
be doubted whether different conductors 
are required for the transmission of the 
different kinds of impressions. 
10. Increased reflex action.-When the 
continuity of the cord is entirely inter- 
rupted by being cut, torn, compressed, or 
injured in any other way, voluntary move- 
ment and sensation are abolished in the 
parts below the injury ; and at the same 
time the paralyzed muscles, especially in 
the lower extremities, become much more 
prone to reflex action. This increased 
proneness to reflex action is developed 
immediately, or all but immediately, and 
it may continue with little or no change 
for days, weeks, or even months. It 
makes its appearance before there is time 
for the development of inflammation or 
congestion ; it continues after the time 
when any inflammation or congestion re- 
sulting from the injury which led to it 
may be supposed to have come to an end ; 
and therefore it is difficult to look upon it 
as an indication of inflammation or con- 
gestion. Indeed the history of inflamma- 
tion or congestion of the cord is opposed 
to this idea, for most certainly increased 
reflex action does not figure among the 
symptoms of unequivocal instances of 
these disorders. And this is all that need 
be said now, except this, that the history 
of increased reflex action would seem to 
be more intelligible on the view of muscu- 
lar action which recommends itself to the 
writer, than on that which is commonly 
accepted. 
11. Increased temperature.-In a paper 
on injuries of the spinal cord, published 
more than thirty years ago,1 Sir Benja- 
min Brodie says : "M. Chopat has given 
an account of some experiments on ani- 
mals, in which he found that the division 
vol. i.-60 
1 Med.-Chir. Trans., vol. xx. 1837. 946 
DISEASES OF THE SPINAL CORD. 
of the superior portion of the spinal cord 
produced a remarkable evolution of ani- 
mal heat, so that it was raised much 
above the natural standard. I have made 
experiments similar to those of M. Cho- 
pat, and have met with similar results. 
I have also seen several cases in which an 
accidental injury of the spinal cord has 
produced the same effect. The most re- 
markable of them was that of a man who 
was admitted into St. George's Hospital, 
in whom there was a forcible separation 
of the fifth and sixth cervical vertebrse, 
attended with an effusion of blood within 
the theca vertebralis, and laceration of 
the lower part of the spinal cord. Respi- 
ration was performed by the diaphragm 
only, and of course in a very imperfect 
manner. The patient died at the end of 
twenty-two hours ; and, for some time 
previously to his death, he breathed at 
very long intervals, the pulse being weak 
and the countenance livid. At last there 
were not more than five or six inspira- 
tions in a minute. Nevertheless, when 
the ball of a thermometer was placed be- 
tween the scrotum and the thigh, the 
quicksilver rose to 111° of Fahrenheit's 
scale. Immediately after death the tem- 
perature was examined in the same man- 
ner, and found to be still the same." A 
Russian observer, Dr. Tscheschechin,1 
has also ascertained that considerable ele- 
vation of temperature, with quickened 
pulse and breathing, follows a section of 
the pons at its junction with the medulla 
oblongata, and that these symptoms go 
on increasing for two or three hours, until 
the state is that of high fever. Moreover, 
increase of temperature on one side of the 
body and decrease on the other has been 
seen to be one effect of dividing one-half of 
the gray substance of the cord. There is, 
indeed, reason to believe, not only that 
increased temperature is one effect of divi- 
sion of the cord, but that this change is in 
some way connected with paralysis of vaso- 
motor nerves ; for in speaking previously 
of the experiment last mentioned, it was 
shown that this paralysis may well be sup- 
posed to lead to this result. 
12. Hints for determining the level of the 
injury in certain forms of spinal paralysis, 
&c.-If the injury be at the upper limit of 
the sacral region of the cord, the muscles 
of the bladder and anus will be paralyzed, 
and so will the muscles of the lower ex- 
tremities, with the exception of those 
which are supplied by the anterior crural 
and obturator nerves (the psoas, iliacus, 
sartorius, pectineus, adductor longus, a. 
magnus, a. brevis, obturator externus, vas- 
tus externus, v. interims, rectus femoris, 
&c.), which nerves come off from the 
second, third, and fourth lumbar pairs of 
spinal nerves. If the injury be very low 
down in the sacral canal, the compressor 
urethra? and the accelerator urinse, as well 
as the sphincter ani, will be paralyzed, but 
not the muscles of the legs ; for the nerves 
of the three muscles, specified by name, 
come off almost from the extreme end of 
the cord, and below those which go to form 
the great sciatic. When the injury to 
the cord is higher up in the cord, in addi- 
tion to the loss of voluntary power in the 
lower extremities and in the bladder and 
anus, the respiratory muscles will be more 
or less paralyzed. If the injury be at the 
upper limit of the lumbar region, the 
lateral muscular walls of the abdomen will 
be paralyzed, and so will all the muscles 
of the lower extremities, and one effect of 
the paralysis of the abdominal walls will 
be to compromise greatly the expiratory 
movements of respiration. If the injury 
be high enough to paralyze intercostal 
muscles, inspiration will be interfered 
with as well as expiration, and the degree 
of interference will be in proportion to the 
number of intercostal muscles implicated. 
If the injury be low down in the cervical 
region, all the intercostals will be para- 
lyzed, and so will the muscles of the upper 
extremities, except those of the shoulders, 
which receive their nerves from higher 
portions of the cervical region. If the 
injury be at or above the middle of the 
cervical region-at or above the level of 
the fourth cervical pair of spinal nerves- 
death will at once result from the suspen- 
sion of all inspiratory movements. In 
this latter case it is customary to ascribe 
the stoppage of breathing to paralysis of 
the nerve which supplies the diaphragm- 
that is, the phrenic ; but this explanation 
does not go far enough. The injury which 
paralyzes the diaphragm paralyzes the 
scaleni, the inter-costales, and the serrati 
magni, which muscles elevate the ribs in 
ordinary respiration, and in so doing play 
a part which is scarcely less important 
than that played by the diaphragm ; and 
not only so, but it paralyzes also the 
greater number of those accessory respi- 
ratory muscles which, acting upon and 
from the shoulders, come to the rescue 
when a great effort at inspiration is neces- 
sary, and produce additional expansion in 
the upper part of the chest. Not only is 
there a great difference between calm res- 
piration and forced respiration, but there 
is a great difference also between the res- 
piration of males and that of females. 
"In males," says Dr. Hutchinson, "the 
abdomen first bulges outwards, and the 
ribs and sternum nearest to the abdomen 
quickly follow this movement, until the 
motion, like a wave, is lost over the tho- 
racic region. In females, the breathing 
commences with a gentle heaving of the 
upper part of the thorax, more or less ap- 
parent according to the fulness of the 
1 Reichert's and Du Bois-Reymond's Ar- 
chiv f. Anat. u. Phys. 1866. 947 
PAIN AND SPASM. 
mammae, and with some slight elevation 
of the shoulders ; and this movement of 
expansion spreads from rib to rib in a 
downward direction, and any bulging of 
the abdomen from the descent of the dia- 
phragm is distinctly after this heaving of 
the lateral wall of the chest, not before it. " 
In females also this bulging of the abdo- 
men is so inconsiderable that the number 
of respirations cannot be counted by the 
hand resting on that region as it can be in 
the male. In calm breathing, in fact, the 
diaphragm does more and the ribs do less 
in males than in females : and this differ- 
ence is so real that, for the sake of distinc- 
tion, calm breathing may be spoken of as 
diaphragmatic in males, and as costal in 
females. This difference is such, indeed, 
that respiratory movements which are 
healthy in women are morbid in men ; and 
vice versa, that movements which are 
healthy in men are morbid in women. 
"In forced breathing," Dr. Hutchinson 
again says, " the greatest enlargement of 
the thoracic cavity in both sexes is made 
by the ribs and not by the diaphragm, as 
is generally believedand that this 
statement expresses what really happens, 
appears to be evident in the fact that in 
such breathing the hollow at the pit of the 
stomach, instead of being filled out and 
protruded, as it must be if the diaphragm 
descended in any marked degree, is actu- 
ally drawn in and depressed. In forced 
breathing, indeed, the costal inspiration 
of women becomes more costal, and the 
diaphragmatic inspiration of men changes 
from this form to the costal. It is cer- 
tain, however, that there may be forced 
diaphragmatic breathing as well as forced 
costal breathing, and that the one may be 
made to take the place of the other by an 
easy effort of the will, or by changes of 
position which interfere with the action 
of the diaphragm on the one hand, or of 
the ribs on the other. There is, indeed, 
no difficulty in understanding why dis- 
eases which interfere with the action of 
the diaphragm or ribs should make the 
breathing costal or diaphragmatic, as the 
case may be. As regards the expiratory 
movements of respiration there is little to 
say. In tranquil breathing, in males and 
in females alike, expiration is performed 
by the relaxation of the diaphragm allow- 
ing the abdominal viscera to press up 
into the position from which they had 
been depressed in inspiration by the con- 
traction of this muscle, by the relaxation 
of the costal muscles allowing the ribs to 
spring back into the position from which 
they had been pulled up in inspiration by 
the contraction of these muscles, and by 
the resiliency of the air-passages them- 
selves. In forced expiration the lateral 
and inferior muscular walls of the abdo- 
men will help to empty the chest by pull- 
ing down the ribs and by contracting upon 
the abdominal viscera, so as to cause them 
to push up the diaphragm more effectually. 
It is easy, indeed, to see how a lesion of 
the spinal cord which paralyzes the late- 
ral and inferior abdominal walls must in- 
terfere with the movements of expiration, 
and especially with such violent move- 
ments as coughing or sneezing. In a 
word, the whole case of the respiratory 
movements is one which makes it impos- 
sible to continue in the belief, that the 
one reason why the division of the cord at 
or above the origin of the phrenic nerve 
proves fatal, is because the diaphragm is 
paralyzed ; for the plain fact is, that the 
injury which paralyzes the diaphragm 
paralyzes the muscles which elevate the 
ribs, both ordinary and extraordinary, 
and so puts an end to movements which 
are quite as important as those of the dia- 
phragm, if not more so, in carrying on 
respiration. Of the other phenomena 
which may be present when the injury 
which interrupts the continuity of the 
cord as a conductor is in the neck, but not 
so high as to destroy life immediately, 
and which are not likely to be present 
when the injury is much below the cervi- 
cal region, difficulty of swallowing, diffi- 
culty in vocalization, contraction of 
pupils, palpitation, and priapism appear 
to be the most important. 
II. On the Practical Significance 
of Pain and Spasm, and of certain 
other Symptoms more or less akin 
to Pain and Spasm. 
Have these symptoms to do with in- 
flammation, or with a state which, though 
not unfrequently passing into inflamma- 
tion, is in reality diametrically opposed to 
inflammation ? This is the question to 
which I propose now to seek the answer, 
first, in relation to pain and the symp- 
toms akin to pain, and, secondly, in rela- 
tion to spasm and the symptoms akin to 
spasm. 
1. On the practical significance of pain 
and the symptoms akin to pain.-There are 
some points in the history of common 
neuralgia-the beginning and ending of 
the paroxysm periodically at a given 
time, the association of the pain with 
rigors, the frequent ending of the pain in 
an obscure fit of feverishness, and others 
-which are calculated to suggest some 
relationship between this disorder and 
ague. It would seem, indeed, especially 
in that form of neuralgia which is met 
with in aguish districts, as if the neu- 
ralgia and the rigors were companion 
symptoms-as if there was some connec- 
tion between the pain and a depressed 
state of the circulation such as is met 
with in the cold stage of ague. There is 
also some reason to believe that neuralgia 948 
DISEASES OF THE SPINAL CORD. 
is antagonized rather than favored by in- 
flammation and fever. It is no uncom- 
mon thing for the history of facial neu- 
ralgia or tic-douloureux to be this : first, 
neuralgia, without local tenderness and 
swelling, and redness, and with frequent 
chills and shivers, and a decidedly de- 
pressed state of the circulation ; after- 
wards, cessation of neuralgia, cessation 
of chills and shivers, with local tender- 
ness, redness, and swelling, and with 
some slight feverish reaction. What I 
have experienced in my own person, as 
well as what I have witnessed in others, 
enables me to speak with all confidence 
upon this point. It is also the rule, 
rather than the exception, for the neu- 
ralgic pain of toothache to come to an end 
when the face becomes swollen and in- 
flamed ; and it does not seem to be other- 
wise with the stabbing neuralgic pains 
which so generally precede the inflamma- 
tory eruption of herpes, for it is usual for 
these pains to subside concurrently with 
the development of the eruption. Nay, 
I know of several cases of sciatica, in 
which the relief to the neuralgic pain was 
coincident with the development of a 
tenderness which seemed to betoken neu- 
ritis at one or more points in the course 
of the painful nerve, and in which, after 
this change the patient was comparatively 
free from pain so long as the lame limb 
was kept still and let alone. With re- 
spect to neuralgia, in all its manifold 
forms, indeed one thing is certain, and 
this is, not only that neuritis is not neces- 
sary to its production, but also that this 
form of inflammation is at most a very 
exceptional complication. 
Nor is a different conclusion to be 
drawn from the history of rheumatic and 
gouty pain. 
In acute rheumatism it is generally 
found that the pains which had been tor- 
turing the patient for days, or weeks, or 
months previously, preventing him from 
being at ease in the daytime, and causing 
him to toss about in sleepless misery at 
night, come to an end when the feverish 
reaction and local inflammation of the 
fully-formed disorder make their appear- 
ance. After this, the joints are tender 
enough ; but if the patient keep as still 
as he is very likely to do under the cir- 
cumstances, he is comparatively or ac- 
tually at ease so far as his old rheumatic 
pains are concerned. Or, if it be other- 
wise, the pains will generally be found to 
be in a part in which the signs of rheu- 
matic inflammation are imperfectly es- 
tablished or absent, or else at a time 
when there is a decided remission in the 
feverish reaction-an event which hap- 
pens more frequently in this disorder than 
is commonly supposed. 
And certainly it is impossible to look 
upon the local inflammation of gout as 
essential to the racking pain of this dis- 
order. " About two o'clock in the morn- 
ing," says Sydenham, who knew full well 
from personal experience what he ought 
to say, " the patient is awakened by a 
severe pain in the great toe, or, more 
rarely, in the heel, ankle, or instep. The 
pain is like that of dislocation, and yet 
the parts feel as if cold water were being 
poured over them. Then follow chills 
and shiverings, and a little fever. The 
pain, which was at first moderate, be- 
comes more intense ; and with its inten- 
sity the chills and shivers increase." 
After tossing about in agony for four or 
five hours, often till near daybreak, the 
patient suddenly finds relief and falls 
asleep. Before falling asleep, the only 
visible change in the tortured part is 
some swelling in the veins ; on waking in 
the morning the part has become swollen, 
shining, red, tender beyond measure, and 
more or less painful, but painful only to a 
degree which is as nothing in comparison 
with the torture of the night past. It 
seems, indeed, as if the pain which now 
exists may in great measure be referred 
to the mere tension and stretching of the 
inflamed ligaments, for it may be re- 
lieved, or even removed, by judiciously 
applying support to the toe and sole of 
the foot. On the night following, and 
not unfrequently for the next three or 
four nights, the sharp pain may return, 
reappearing and disappearing suddenly, 
or almost suddenly, and resulting in the 
development of additional inflammatory 
swelling in the interval between falling 
asleep and waking in the morning. The 
pain in these relapses, like the pain in 
the first attack, is accompanied by chills 
and shivers, and by the most distressing 
irritability and excitability ; but, until 
unequivocal signs of inflammation are de- 
veloped in it, the painful part is not 
tender in the true sense of the word. The 
inflammation, moreover, is attended by 
no fever, or by very little ; or if it be 
otherwise, as it is occasionally, the in- 
flammation runs higher than usual, and 
the characteristic pain is less urgent than 
usual. Dr. Garrod points out this latter 
fact in his excellent work on Gout. From 
its history, then, it would seem as if the 
pain went hand in hand with the rigors 
which belong to the cold stage of gouty 
inflammation. It would seem as if the 
inflammation, as inflammation, had little 
to do with the pain ; for if it were other- 
wise, it is scarcely to be supposed that 
the pain should be less urgent in the cases 
of gout in which the inflammation is 
most marked, and that the unequivocal 
signs of inflammation should make their 
appearance during sleep without waking 
the patient. Nay, it would even seem as 
if the pain were put an end to by the es- 
tablishment of inflammation-as if, in PAIN AND SPASM. 
949 
fact, the pains were antagonized rather 
than favored by the inflammatory condi- 
tion. Moreover, the suddenness with 
which it begins and ends in the majority 
of cases must be looked upon as a reason 
for referring the pain to the category of 
neuralgia-a disorder with which, as I 
have already shown, inflammation has no 
necessary connection. 
There is also reason to believe that pain 
holds the same relation to fever and in- 
flammation in other kinds of fever besides 
the rheumatic, and in other kinds of in- 
flammation besides the gouty. 
The pain in the back, often very severe, 
which ushers in smallpox, disappears be- 
fore the hot stage is fully established. It 
comes and goes hand in hand with the 
rigors, and it belongs to the cold stage as 
evidently as do the rigors. And this 
would seem to be the case also in other 
fevers ; for it is the rule, and not the ex- 
ception, for the pains which attend upon 
the onset of these disorders to pass away 
or to become greatly mitigated as soon as 
the cold stage gives place to the hot. 
Nay, it would seem as if pain gave place 
for the time to what may be called arti- 
ficial feverishness. At any rate, I have 
more than once felt tic-douloureux in my 
face pass away as soon as I could set my 
blood in brisk motion by violent bodily 
exercise ; and on two occasions I have 
put a stop to a sudden attack of lumbago 
while in the saddle, by a practice which 
is not unfrequently adopted in such a case 
in the hunting-field-that is, by leaning 
forwards, and beating the loins with the 
hands until the whole body was aglow, 
and the perspiration dropped from the 
forehead. 
The acute pain of a dislocation or 
sprain-the pain to which Sydenham 
likens that of gout-does not, as a rule, 
remain after the parts have begun to be 
hot and tender and swollen; and as a 
rule, also, the pain of idiopathic inflam- 
mation goes before, and not along with, 
the redness and heat and swelling. In 
the idiopathic, as well as in the traumatic 
forms of inflammation, it would seem, 
indeed, as if the pain were related to the 
cold stage of the disorder, and not to the 
hot. Nor is a contrary conclusion to be 
drawn from the history of those cases in 
which the pain continues after the hot 
stage of the inflammation is fully estab- 
lished, for in these cases this persistent 
pain is evidently (in great measure at 
least) due to the stretching of parts made 
tender by the inflammation. Thus, for 
example, the pain which remains after 
the hot stage is fully established in or- 
chitis and pleuritis, is at once removed or 
relieved by means which obviate this 
stretching,-in the former case by the 
free use of the knife, in the latter case by 
the application of a roller around the 
chest so as to prevent the movement of 
the ribs over the seat of inflammation. 
Even in inflammation of the membranes 
of the brain, severe pain in the head can- 
not be looked upon as a symptom of this 
inflammation. About six years ago I had 
a youth in the Westminster Hospital with 
well-marked symptoms of acute cerebral 
meningitis. When I first saw him, he 
complained of frequent rigors and of a 
constant agonizing pain in the head, and 
at this time his face was pale and perspir- 
ing, his ears and his head generally were 
below the natural temperature, his pupils 
somewhat dilated, and his pulse con- 
tracted and feeble. Eight hours after- 
wards, when I saw him the second time, 
his face was flushed, his head burning hot, 
his pupils contracted, his eyes ferrety, his 
skin hot and dry, his pulse strong and 
full, and fierce delirium had taken the 
place of the pain. And this, so far as my 
experience goes, is the regular history of 
pain in this disorder. It is pain ceasing, 
not pain beginning, as the symptoms of 
active determination of blood to the brain 
make their appearance. It is pain in 
association with an aneemic rather than 
with a hypersemic condition. 
Eor these among many reasons it is that 
pain (with the exception of that form of 
pain which is dependent on tenderness, 
and which is accidental only) does not ap- 
pear to be a symptom of inflammation or 
fever. Tn inflammation or fever the pain 
would seem to be connected with the cold 
stage preceding the hot stage, and not 
with the hot stage itself-with a state of 
capillary contraction and deficiency of 
blood, and not with a state of capillary 
relaxation and excess of blood-with a 
state of vaso-motor irritation, and not 
with a state of vaso-motor paralysis : in 
other cases, the pain would seem to have 
to do with a state of circulation which is 
in reality closely akin to that which ex- 
ists in the cold stage of inflammation and 
fever. Pain, however, must not be re- 
garded as a symptom of inflammation or 
fever because it happens to be associated 
with the so-called cold stage of these dis- 
orders. In point of fact, this so-called 
cold stage of inflammation or fever is a 
state which is diametrically opposed to 
the so-called hot stage. In this cold stage, 
the vaso-motor nerves (and not these 
nerves only) are in a state of irritation, 
and, as the result of this irritation, the 
capillaries are contracted and compara- 
tively bloodless ; in the hot stage, on the 
contrary, the vaso-motor nerves are para- 
lyzed, and, as the result of this paralysis, 
the capillaries are relaxed and bloodshot. 
Instead of being stages in the same pro- 
cess, the so-called cold stage and the so- 
called hot stage are conditions diametri- 
cally opposed to each other. Instead of 
being stages in the same process, it would 950 
DISEASES OF THE SPINAL CORD. 
rather seem that the hot stage has a re- 
medial relation to the cold stage-that, 
within certain limits, the hot stage is the 
salutary refluence of a tide of life which 
has ebbed too low in the hot stage. It is 
not difficult to see that there is an inti- 
mate connection between the so-called 
cold stage and the so-called hot stage, and 
that the first may easily change into the 
second. It is not difficult to see that there 
must be this relation between these stages ; 
for if, as there is good reason to believe, 
irritation of vaso-motor nerves may bring 
about the cold stage by causing contrac- 
tion of vessels, it is easy to understand 
that the paralysis of vaso-motor nerves, 
which follows when this irritation is car- 
ried beyond a certain point, may lead to 
the hot stage by causing relaxation of ves- 
sels. At any rate, be this as it may, the 
plain fact would seem to be that pain, 
with the exception of that form of pain 
which is dependent on tenderness, is a 
symptom belonging to the so-called cold 
stage of inflammation and fever, or to a 
state of circulation closely akin to it, and 
not to the hot stage of inflammation and 
fever, or to a state of circulation akin to 
it. Nay, it may even be supposed, and 
not without some show of reason, that 
pain must be associated with contracted 
and empty capillaries; for, the sympathies 
of the nervous system being what they 
are, it is not easy to believe that the vaso- 
motor nerves do not participate in the 
irritation of the sensory nerves, for which 
pain is the expression in words. 
And if this be so-and this is the prac- 
tical conclusion to which these remarks 
tend-it follows that pain is likely to be 
relieved by measures which are calculated 
to rouse the circulation and increase the 
quantity of blood in the capillaries of the 
painful part, and not by those which have 
a contrary action. 
With regard to tingling and other symp- 
toms which are more or less akin to pain, 
there is little to say. Indeed all I can say 
is that the history of these symptoms, so 
far as is known to me, would seem to 
agree rather than to disagree with that of 
pain, in connecting them with a state of 
irritation, and not with a state of actual 
inflammation. 
2. Of the significance of spasm and the 
symptoms akin to spasm.-The violent and 
general epileptic form of convulsion which 
attends upon death by hemorrhage or 
suffocation is associated with a defective 
and not with an excessive supply of arte- 
rial blood to one or other of the great 
nerve-centres. Nor is it otherwise with 
ordinary epileptic or epileptiform convul- 
sion. The deathly paleness of the counte- 
nance which precedes the convulsion is, 
indeed, a plain proof that the fit com- 
mences in a state of circulation which is 
the very opposite to that of active deter- 
mination of blood to the head, and the 
strong pulse which is usually perceptible 
in the arteries as the fit progresses is no 
contradiction to this conclusion. This 
strong pulse is usually regarded as a sign 
of arterial excitement-as a proof that 
more arterial blood is being injected into 
the arteries at this time, and that, on this 
account, certain nervous centres are ex- 
cited to an unwonted degree of activity : 
but the simple fact is, that the strong 
pulse which is present under these circum- 
stances derives its strength, not from arte- 
rial blood, but from venous. Black blood 
is being pumped into the arteries at the 
time ; and because black blood moves less 
readily through the capillaries than red 
blood, the arteries become distended and 
the pulse endowed with a counterfeit 
power. The strong pulse in question is 
caused by the suffocation which is a part 
of the fit: it is a pulse of black blood and 
not of red, as may easily be proved by 
making an opening into the artery : it is 
nothing more, in fact, than the natural 
pulse of suffocation. Hence, the strong 
pulse of the epileptic or epileptiform 
paroxysm is no proof that this form of 
convulsion is connected with an excited 
condition of the circulation ; on the con- 
trary, when rightly read, it points only to 
the opposite conclusion. 
It would seem also that convulsion is 
not associated with an over-active con- 
dition of the circulation, even in those 
cases in which at first sight it might ap- 
pear to be so. In the fevers of infancy 
and early childhood, especially in the ex- 
anthematous forms of these disorders, 
convulsion not unfrequently takes the 
place occupied by rigor in the fevers of 
youth and riper years. It occurs in the 
initial cold stage, or else in the last mo- 
ments of life, not in the intermediate hot 
stage. Again in inflammation of the 
membranes of the brain, convulsion, when 
it occurs, is connected with the cold stage 
before the hot stage, or with the cold stage 
after the hot stage, and never with the 
hot stage itself. Nay, I am disposed to 
think that there is something altogether 
uncongenial between convulsion and a 
state of febrile reaction in the circulation, 
for it is a fact not unfrequently verified 
that fits of common epilepsy are often sus- 
pended during the continuance of such 
reaction. 
As indeed I have endeavored to show 
at length elsewhere,1 the physiology and 
pathology of muscular action, so far as I 
can read them, serve only to connect all 
1 Epilepsy, &c.: Lectures delivered at the 
Royal Coll, of Phys, in London. Post 8vo. 
Churchill, 1862.-"Dynamics of Nerve and 
Muscle," and "Electrophysiologica," in "Na- 
ture," Jan. 4, 11, and 16, 1872. Post 8vo. 
Macmillan & Co., 1872. 951 
SPINAL MENINGITIS. 
the varied forms of tremoY, convulsion, 
and spasm, with diminished and not with 
increased activity of the circulation ; and 
thus the practical significance of spasm 
and the symptoms akin to spasm would 
appear to be the same as that of pain and 
the symptoms akin to pain-namely this, 
that the measures calculated to afford re- 
lief are likely to be those which will rouse 
the circulation to greater activity and in- 
crease the quantity of blood in the capil- 
laries, and not those which have a con- 
trary action. 
B. On Diseases of the Spinal Cord. 
Under the head of diseases of the spinal 
cord there is no lack of subjects. As of 
primary importance may be mentioned 
spinal meningitis, myelitis, spinal conges- 
tion, tetanus, locomotor ataxy, and spinal 
irritation; as of secondary importance, 
reflex paraplegia, infantile paralysis, hys- 
terical paralysis, hemorrhage, white soft- 
ening, induration, atrophy, hypertrophy, 
tumor, concussion, compression, vertebral 
caries, spina bifida, &c. I shall take each 
of these subjects in the order in which it 
has been enumerated, and, as far as I can, 
apportion the limited space at my com- 
mand (very limited for such a purpose) so 
that there may be room for saying most 
where most is wanted. 
I. Spinal Meningitis. 
Inflammation of the membranes of the 
spinal cord is usually associated with in- 
flammation of the substance of the cord 
(myelitis) or with inflammation of the 
membranes of the brain, but uncompli- 
cated cases do occur now and then, and 
with care it is not difficult to discriminate 
between the symptoms which are essential 
to spinal meningitis and those which are 
only accidental. 
1. Symptoms.-In order to arrive at a 
knowledge of the symptoms of spinal me- 
ningitis, I will relate as a text one of five 
cases verified by post-mortem examina- 
tion which have come under my own no- 
tice, and then proceed to see wherein it 
agrees with or differs from other cases of 
the kind. I choose an acute case rather 
than a chronic one, for it is only in the 
acute form of the disease that the symp- 
toms are to be defined with certainty. 
Case.-A lightly-made, delicate-looking 
youth, nineteen years of age, a cigar- 
maker by trade, was admitted into one of 
my wards in the Westminster Hospital on 
the 27th December, 1864. 
(a) When I saw him first-this was on 
the day after his admission-he complain- 
ed chiefly of pain in the back and great 
general weakness and weariness, and ex- 
pressed his belief that he had got rheu- 
matic fever. He was then sitting by the 
fireside, and looking very ill. On telling 
him that he had better lie down, he got 
up and walked towards his bed, or rather 
he attempted to do so, for the first step 
brought on a severe pain in the back and 
legs, with a feeling of faintness and want 
of breath, and he would have fallen if 
assistance had not been at hand. Very 
soon after lying down he passed about a 
quart of water without any difficulty. 
(6) The account he gives of himself is 
this. A week ago, after being very tired 
by a long walk, he was seized by shiver- 
ings and sharp pain between the shoul- 
ders. During the next three days he was 
feverish and without appetite, but still 
able to go about and do his work. All 
this while he had very little pain, and his 
nights were not disturbed. On the night 
of the fourth day from the commencement 
of the illness, he was awakened by violent 
pain along the whole course of the spine, 
in the groins, and in the right leg. Next 
day the pain occurred several times in 
paroxysms, and was accompanied by a 
good deal of starting and jerking in the 
legs ; and so also on the two days follow- 
ing. On the day before admission to the 
hospital, some difficulty in opening the 
jaw was experienced, and the paroxysms 
of pain, and jerking, and starting had 
become more frequent and urgent. All 
this while the bowels and bladder acted 
properly. 
Dec. 28.-There is no material change 
since yesterday-not for the worse, cer- 
tainly. 
Dec. 29.-Last night, after three or 
four hours' sleep, the patient awoke with 
very severe pain along the spine and 
down both legs, and since that time the 
pain has recurred several times. These 
attacks are separated by intervals of com- 
parative or complete ease, and instead of 
the jerks and starts, which went hand in 
hand with it previously, the pain is now 
accompanied by stiffness in the muscles 
of the back and legs. At the present 
moment (about 2 p. M.) the head is drawn 
back on the pillow, and considerable pain 
and stiffness in the neck is caused by 
moving it. Before making such move- 
ment the patient was free from pain and 
stiffness in this region. Asking him to 
try and sit up, he attempted to do so, but 
was stopped at once by a severe paroxysm 
of pain along the whole length of the 
spine and down the legs, and by the mus- 
cles in the painful parts becoming stiff. 
The action of the muscles produced in 
this way arched the body backwards al- 
most as much as in ordinary cases of 
tetanus, and at the same time pursed up 
the mouth and eyes, and gave a set ex- 
pression to the features generally, so that 952 
DISEASES OF THE SPINAL CORD. 
the patient for the time had the appear- i 
ance of a person considerably older than 
himself. The pain went off in a few 
minutes, and soon afterwards the stiffened 
muscles relaxed. The eflbrt to move one 
of the legs spontaneously gave rise to a 
sharp pain in the thigh and loins, and the 
limb became somewhat stiffened in a 
semi-flexed position, and this state of 
things did not pass off for several minutes : 
and passive movement produced the same 
result. There was no numbness : on the 
contrary, the condition of the skin as to 
sensation everywhere, as judged by prick- 
ing and pinching and by differences of 
temperature, was plainly that of slight 
over-sensitiveness. Pressure along the 
spinal column failed to detect tenderness 
anywhere, and the result of applying a 
sponge wrung out of hot water was equally । 
negative. 
In the course of the examination it was 
evident that any movement of the body, 
or neck, or legs, active or passive, gave 
rise to pain and stiffness in the muscles 
moved ; and also that there was little or 
no pain or stiffness so long as the patient 
kept quite still. It was evident, in fact, 
that the muscles were relaxed, except 
perhaps in the neck, in the intervals be- 
tween the paroxysms. The poor sufferer 
was evidently in a great strait, dreading 
all movement, because he knew full well 
what the effect of movement would be, 
and at the same time continually prompted 
by an intolerable feeling of unrest and 
fidgetiness to wish to have his position 
changed in a way which he could not or 
dared not compass by his own efforts: 
and it is difficult to avoid the conclusion 
that the stiffness is, in the main, an in- 
stinctive act to prevent the movement 
which gives rise to the pain, rather than 
spasm like that which is met with in teta- 
nus. The arms are affected as well as the 
legs, but not to the same degree. They 
are weak-so weak that it is not easy to 
find strength to carry the food to the 
mouth, the left arm being somewhat the 
weaker of the two. The left arm also 
cannot be moved, either actively or pas- 
sively, without giving rise to pain and 
rigidity, to pain shooting up between the 
shoulders, to rigidity flexing the limb 
somewhat at the elbow, and bending the 
thumb slightly into the palm : not so the 
right arm. There is no numbness in 
either arm, and no very decided over- 
sensitiveness. Mastication is difficult, 
and deglutition still more so, apparently 
from the muscles set in movement becom- 
ing stiff in moving. The breathing is 
shallow and slow ; the pulse quick (130) 
and very wanting in strength; the skin 
profusely perspiring after a paroxysm, and 
hot and moist at other times. Thirst is 
much complained of. The bladder is full, 
and it cannot now be emptied voluntarily. 
The urine is acid. The penis is flaccid, 
and has been so ever since the commence- 
ment of the illness. The bowels have not 
acted. The pupils are equal and natural, 
and there is no headache or other " head 
symptom." 
Dec. 30.-A tolerably good night has 
been passed, and this afternoon the pa- 
tient thinks himself a little better. 
Dec. 31.-There has been a bad night, 
and much ground has evidently been lost 
since the last visit. In a paroxysm which 
is just over, want of breath was experi- 
enced rather than pain. Sensation is still 
somewhat exaggerated everywhere. Urine 
cannot be passed without the catheter, 
but the bowels have responded to-day to 
a dose of castor-oil and spirits of turpen- 
tine which was administered yesterday. 
During my visit I had an opportunity of 
seeing the patient after a paroxysm as 
well as in it, and I quite satisfied myself 
that the muscular stiffness of the parox- 
ysm soon passed off, and that in the in- 
terval between the paroxysms the muscles 
were relaxed, except perhaps at the back 
of the neck-with this possible exception, 
because all along the head remained 
drawn back to some degree upon the 
pillow. 
Jan. 1, 1865.-The night has been per- 
fectly sleepless, with now and then some 
trifling light-headedness. The paroxysms 
of pain, stiffness, and difficulty of breath- 
ing are not so frequent (three hours have 
passed since the last), but the respiration 
is certainly shallower and less sufficient, 
and the pulse more rapid and unsteady. 
There is the same want of power over the 
bladder. When I left the ward, it was 
plain enough that the patient was sinking: 
when I returned two hours later all was 
over, death having happened in a fit of 
choking and suffocation caused by at- 
tempting to swallow a spoonful of beef-tea 
with a morsel of bread sopped in it. In 
the agony, the patient not only sat up in bed, 
but got out of bed and stood for a moment 
with his hands bearing upon the shoulders 
of the nurse who had been feeding him. The 
body was carefully examined after death 
by Dr. Bazire, and the following notes 
were taken at the time from his dicta- 
tion :- 
"Time, twenty-four hours after death. 
Weather frosty. Cadaveric rigidity well 
marked. The muscles of the back dark 
and highly congested. On cutting through 
the posterior arches of the vertebrae the 
vertebral vessels are seen to be gorged 
with dark fluid blood. There is no effu- 
sion of blood outside the meninges in the 
interior of the canal. The meninges are 
highly congested throughout the whole 
length of the canal, but to a considerably 
greater degree in the region between the 
scapulae. In this latter region, in addition 
to the thickening, opacity, and intense SPINAL MENINGITIS. 
953 
red color of the dura mater elsewhere, 
there are streaks in its substance of black 
coagulated blood. The arachnoid is in- 
tensely red, and the pia mater extremely 
congested in the same region. Beyond 
it, the dark red color of the dura mater 
gradually passes into a lighter shade, and 
becomes a bright pink near the cauda 
equina in one direction, and near the me- 
dulla oblongata in the other. The arach- 
noid is whitish again near the cauda equina. 
There is no effusion of serosity, blood, or 
pus, either between the meninges or on 
the surface of the cord; indeed, there 
seems to be a smaller quantity than usual 
of cerebro-spinal fluid. The substance of 
the cord itself looks normal in consistence, 
color, and size. The central vessel of the 
cord is highly congested, and on section 
of the cord there exudes from the centre 
fluid black blood in minute drops. The 
cerebral meninges are normal. The cere- 
bral sinuses are highly congested, and the 
same appearances of congestion (due prob- 
ably to the mode of death) are met with 
in the substance of the brain. The organ 
itself is normal." 
The symptoms of acute spinal meningi- 
tis are plainly exhibited in this case, and 
there need be no difficulty in distinguish- 
ing those which are of primary importance 
from those which are secondary. 
As symptoms of primary importance 
may be enumerated thesefits of pain 
produced by movement along the spine 
and in the extremities: fits of muscular 
stiffness in the painful parts along with 
the pain ; intervals of comparative or 
complete freedom from pain and muscular 
stiffness so long as movement can be 
avoided ; absence of paralysis ; some ex- 
altation of sensibility ; loss of power over 
the bladder ; partial loss of power over 
the bowel; absence of spinal tenderness. 
Fits of pain along the spine and in the 
extremities, produced by movement.-This 
pain, as I think, must be regarded as the 
most prominent symptom in acute spinal 
meningitis. It may be confined to the 
region of the spine, but more generally it 
shoots into the extremities, into the legs 
especially. As a rule, it does not shoot 
beltwise round the trunk. It is brought 
on by any movement of the trunk, and, in 
great measure at least, it may be pre- 
vented by avoiding such movement. It 
is often brought on also by moving one of 
the extremities, the pain in this case be- 
ginning in the limb, and extending thence 
to the spine. It seems to depend, in part 
at least, upon the same cause as the pain 
of pleurisy, viz. the dragging of an in- 
flamed and therefore exquisitely tender 
serous membrane, and its character is cer- 
tainly more like the pain of pleurisy than 
like that of rheumatism (to which latter it 
has been likened), for it occurs in the same 
sharp, sudden, breath-stopping catches. 
Fits of muscular stiffness in the painful 
parts along with the pain.-It is usual to 
regard this stiffness as analogous to the 
spasm of tetanus : it is necessary, as I 
believe, to look upon it as expressing an 
instinctive act of muscular contraction, of 
which the object is to prevent pain by 
arresting certain movements which pro- 
duce pain. The spine and extremities 
cannot be moved without causing pain : 
the stiffness prevents the pain by pre- 
venting the movement; this would ap- 
pear to be the true view. This explana- 
tion, originally given by M. Dance as 
applying to the muscular stiffness in a case 
of'acute spinal meningitis observed by 
him and recorded by M. Ollivier, applies 
perfectly to the muscular stiffness of the 
case which has been related as the text, 
and it applies, as I believe, with the same 
exactness to all cases of the kind. In- 
deed, I believe there can be no greater 
mistake than to confound the stiffness in 
question with the spasm of tetanus. This 
will be seen more particularly when speak- 
ing of tetanus : and here I will only say 
that tetanus in its most violent form is 
constantly present where there are no 
signs of spinal meningitis, and that, in the 
few cases in which such signs chance to 
be met with, it may be supposed that the 
inflammation is a consequence rather than 
a cause of the irritation which gives rise 
to the tetanic spasm-a consequence of 
the irritation in the vaso-motor nerves 
having proceeded until it has issued in 
paralysis of the vaso-motor nerves. Nay, 
after what has been said in the prelimi- 
nary remarks, it is not impossible that the 
spinal meningitis which is occasionally 
associated with tetanus may have served 
to counteract the spasm rather than to 
cause it. At any rate, it is certain that 
spasm of the spinal muscles is not so 
marked a phenomenon in acute spinal men- 
ingitis as in tetanus, and that it is not to 
be'regarded "comme indiquant positive- 
ment la phlegmasie des membranes de la 
moelle and it is, to say the least, highly 
probable that the muscular stiffness which 
simulates true tetanic spasm is in great 
measure an instinctive act of muscular 
contraction to prevent a movement which 
produces pain. 
Intervals of complete or comparative free- 
dom from pain and muscular stiffness so 
long as movement can be avoided.-These 
intervals are sometimes of considerable 
length, even for days. According to my 
own experience, indeed, the rule would 
seem to be that as long as the patient can 
keep still, so long is he, comparatively at 
least, free from pain and stiffness-a rule 
which is very different from that which 
obtains in tetanus. 
Absence of paralysis.-The patient is 
weak, very weak, and he seems to be pa- 
ralyzed, but in reality he fears to move 954 
DISEASES OF THE SPINAL CORD. 
because movement brings back the pain. 
" Les mouvements, qui sont en quelque 
sorte enchaines par la douleur, ont moins 
de force, mais ilsne sont point paralyses." 
(Ollivier, p. 595.) Let this fear be forgot- 
ten, and it is possible not only to sit up, 
but to get out of bed and stand, as hap- 
pened in the final agony of the patient 
whose case I have given. This power of 
movement has been noticed in several 
cases, of which one is related by Ollivier, 
and another referred to ; and I believe it 
would be witnessed in all cases of uncom- 
plicated acute spinal meningitis in which 
the fear of suffering pain from movements 
was not the one absorbing feeling. 
Some exaltation of sensibility. - In the 
case which I have given there was some 
exaltation of sensibility as to touch, pain, 
and differences of temperature, but to no 
very marked degree ; and this would ap- 
pear to be the rule in cases of the kind. 
It would seem, indeed, that numbness is a 
purely accidental symptom, which is never 
present unless the substance of the cord is 
implicated iu the meningeal inflamma- 
tion. 
Loss of power over the bladder. - In 
acute spinal meningitis, when the symp- 
toms are fully developed, this particular 
symptom is scarcely ever absent, if ever. 
Before this time it may be absent, as it 
was in the case on which I am comment- 
ing ; but this absence must certainly be 
looked upon as the exception rather than 
the rule. Not unfrequently the inability 
to empty the bladder is preceded by a 
state of irritability which makes it neces- 
sary to pass water almost incessantly. 
Partial loss of power over the bowel. - 
On this point M. Ollivier makes a remark 
which is certainly true: "Je ferai re- 
marquer que l'abolition des functions de 
la vessie persiste toujours au meme degre 
depuis le commencement jusquA la fin, 
tandis qui! n'en est pas de meme pour 
1'intestin, puisqu'il y a assez souvent des 
garderobes naturelies dans les derniers 
temps de la maladie." (Vol. ii. p. 601.) 
Absence of spinal tenderness.-This ab- 
sence is certainly a common, if not a con- 
stant, feature of acute spinal meningitis. 
In some chronic cases, no doubt, there 
may be some local spinal tenderness, but 
on inquiry these prove to be cases in 
which the phenomena of spinal irritation 
are mixed up with those of spinal inflam- 
mation-in which the inflammatory affec- 
tion is complicated with that condition of 
which, as will appear in due time, local 
spinal tenderness is the distinctive fea- 
ture. 
These are the points which may be re- 
garded as of primary importance in com- 
parison with those which have still to be 
considered, namely - absence of marked 
spasmodic symptoms, difficulty of masti- 
cation and deglutition, difficulty of breath- 
ing, no increased reflex excitability, no 
priapism, fits of perspiration, no active 
inflammatory fever, no marked "head- 
symptoms." 
Absence of marked spasmodic symptoms. 
-The rigidity which attends upon the 
paroxysms of pain has been seen to be in 
the main an instinctive act of muscular 
contraction to prevent a movement which 
produces pain, and there appear to be no 
other symptoms of a spasmodic character 
which occupy a conspicuous place in the 
history of spinal meningitis. Or if there 
be any such symptoms, these are in all 
probability confined, as were the jerks and 
starts in the case under consideration, to 
that early period of the disorder in which 
it may be supposed that actual meningeal 
inflammation was not developed-to the 
so-called cold stage of the disorder prob- 
ably. 
Difficulty of mastication and deglutition. 
-This difficulty is often absent, and when 
present it is at most a trifling trouble com- 
paratively. There is no true trismus as 
in tetanus ; there is at most only stiffness 
which prevents the jaws from opening 
easily and moving freely. This stiffness, 
moreover, is late in making its appear- 
ance, whereas in tetanus trismus is one 
of the very first symptoms. In a word, 
difficulty of mastication and swallowing 
would seem to occur only in those cases 
of spinal meningitis in which the higher 
portions of the cord are implicated. 
Difficulty of breathing.-This difficulty 
is always present in some degree, and 
especially during a paroxysm of pain and 
stiffness. In some cases, indeed, the 
movement of the chest may be actually 
suspended at this latter time, and deatn 
may happen from this cause, as indeed 
was the case in a patient whom I saw not 
long ago with Dr. Julius of Richmond. 
No increased reflex excitability. - This 
is not, perhaps, what might be expected 
theoretically: but, be the explanation 
what it may, the fact would seem to be 
that reflex irritability is not increased in 
acute spinal meningitis in the way in 
which it is ordinarily increased in tetanus. 
So far as I have been able to ascertain, 
there would seem to be no material change 
of reflex excitability in the meningeal in- 
flammation. 
No priapism. - The cases in which 
erection of the penis would seem to be a 
symptom appear* to be those in which the 
substance of the cord is affected rather 
than the membrane-cases, too, in which 
the seat of the disease is in the cervical 
and upper dorsal region rather than in 
the lumbar region. At any rate, it would 
seem to be the rule for tire penis to be 
flaccid in uncomplicated cases of acute 
spinal meningitis. 
Fits of perspiration.-As in tetanus 
these follow a paroxysm almost invari- SPINAL MENINGITIS. 
955 
ably, especially in the latter stages of its 
disease. Of this there appears to be suf- 
ficient evidence. 
No active inflammatory fever. - Thirst 
is a frequent symptom throughout, and 
there may be at first some heat of skin, 
but in the most acute cases there is little 
or no active sympathetic fever. On the 
contrary, there is usually, even in the 
cases which have most claim to be con- 
sidered as acute, a decided want of febrile 
reaction from the beginning to the end. 
No marked head - symptoms. - In very 
many cases inflammation of the spinal 
meninges is only a part of a more general 
disorder in which the cerebral meninges ' 
are also implicated, and, therefore, " head- 
symptoms" of one kind or other will often 
enough be mixed up with the spinal 
symptoms ; but in cases like the one un- 
der consideration, where the spinal men- 
inges were alone inflamed, " head-symp- 
toms" do not figure at all, or figure only 
as phenomena of very secondary import- 
ance. Upon this point there is no lack of 
evidence. Where spinal meningitis is 
chronic in its course, its symptoms are 
often so mixed up with the Protean symp- 
toms of spinal irritation (of which more 
in due time) as only to be detected with 
great difficulty. It may be suspected that 
the meninges are affected by inflamma- 
tion rather than by simple irritation if 
fits of pain and stiffness are produced by 
movement in the spine and extremities, 
and if there be at the same time no spinal 
tenderness, no paralysis, and no tingling 
or numbness ; and this is all that can be 
said except this, that this suspicion will 
gather strength if there be chronic dis- 
ease in the bones and ligaments of the 
spine. But it may be questioned whether 
long-continued contraction of the muscles 
of one or more of the extremities or of the 
cervical muscles can be reckoned among 
these symptoms, for such contraction is 
certainly common enough in cases where 
the only condition of disorder in the spinal 
cord or its membranes is one which, from 
the sudden way in which it begins and 
ends, and for other reasons as well, would 
seem to be one of simple irritation. 
2. Post-mortem Appearances.-As 
Ollivier pointed out, the traces of spinal 
meningitis after death are met with usu- 
ally, not in the arachnoid membrane, | 
which is non-vascular, but in the subja- 
cent vascular tissue. The arachnoid is so 
thin and transparent as to allow the vas- 
cular injection produced by the inflamma- 
tion in the deeper structures to appear 
through it, and that is all. This injection 
is generally less evident on the surface of 
the cord than on that of the dura mater, 
because in the former place it is hidden 
by the effusion of turbid, sero-purulent, 
or purulent fluid in the space between the j 
arachnoid and pia mater-in the space 
naturally occupied by the rachidian fluid 
-is hidden by an effusion which, before 
the arachnoid is opened, often causes the 
cord to have a swollen, opaque, yellowish- 
white, or yellowish appearance. Any 
fluid effusion is usually in this space, but 
sometimes there may be fluid, in this case 
often sanguinolent, in the space outside 
the dura mater, especially if there be dis- 
ease in the bones or ligaments of the spine. 
Sometimes the rachidian space is obliter- 
ated here and there by inflammatory ad- 
hesions ; sometimes the surface of the 
arachnoid is roughened or otherwise 
altered by calcareous or other deposits in 
patches ; sometimes the opposed surfaces 
of the arachnoid are more or less ad- 
herent : but generally these surfaces are 
smooth and free, and the inflammatory 
products are met with below this mem- 
brane, and not above it. Very often, 
also, the proper signs of spinal meningitis 
are mixed up with those of cerebral men- 
ingitis or myelitis, or with those of disease 
in the bones or ligaments of the spine. 
3. Causes.-The causes of spinal men- 
ingitis are often very obscure. In some 
cases it is rheumatism, or syphilis, or the 
suppression of some menstrual, hemor- 
rhoidal, or other habitual discharge, or 
the spreading of cerebral meningitis 
downwards, or of disease in the bones and 
ligaments of the spine inwards, which 
would seem to figure as a cause ; in other 
cases it is a casual injury to the back, or 
a chill caught by lying on the back on the 
cold and damp ground, or some particular 
disease, as tetanus, chorea, or hydro- 
phobia, to which blame appears to belong. 
In fact, the causes are legion, and it is 
impossible to connect spinal meningitis 
with any particular cause or set of causes. 
4. Diagnosis.-One or two points of 
diagnosis have been mentioned incident- 
ally when dealing with the symptoms of 
spinal meningitis, and with these it is best 
to be content at present, for before this 
matter can be gone into advantageously 
materials must be had which can only be 
forthcoming when the phenomena of mye- 
litis, spinal congestion, tetanus, and other 
spinal maladies have been passed in re- 
view. 
5. Prognosis.-Acute spinal menin- 
gitis is, without a doubt, a very formida- 
ble and fatal disease. There are, indeed, 
few well-authenticated instances of re- 
covery on record, and by some it is 
doubted whether there be any. Life may 
be cut short in four or five days, or it may 
be prolonged to twenty or thirty days, 
but not often-not often indeed-beyond 
six or seven days. In the subacute and 
chronic forms of the disease, the prognosis 956 
DISEASES OF THE SPINAL CORD. 
is of course less gloomy, but even Here it 
is far from cheering. 
6. Treatment.-In all cases of spinal 
meningitis, rest in the recumbent position, 
more or less strictly enforced according to 
the urgency or leniency of the symptoms, 
is indispensable, the best position, per- 
haps, being not strictly on the back, but 
rather upon the side, and with the limbs 
a little lower than the back, so as to favor 
the draining away of blood from the con- 
gested parts, and, at the same time, to 
facilitate the use of the local applications 
to the spine which may be necessary. 
Upon this point there can be little or no 
difference of opinion; upon all other 
points, in all probability, few will think 
alike. For my own part, I should be dis- 
posed to place most confidence in iodide 
of potassium and opium, with the local 
application of ice to the back in acute 
cases, and to bichloride of mercury, with 
counter-irritation in one form or other to 
the spine, in chronic cases. At the same 
time, I am inclined to think that the pres- 
ent fashion has set very unwarrantably 
against the old practice of giving calomel 
and opium, so as to affect the gums 
slightly and speedily, and of using local, 
if not general, bleeding in acute inflamma- 
tory disease. There can, I think, be little 
doubt as to the marked influence for good 
of calomel and opium in acute inflamma- 
tion of serous membranes; and it would 
require very little persuasion to induce 
me to prefer this mode of treatment to 
that of iodide of potassium in acute spinal 
meningitis ; and, further, I can readily 
believe that in such a case recovery wouki 
be promoted by judicious abstraction of 
blood. I have twice seen symptoms, so 
closely resembling those of acute spinal 
meningitis as not to be distinguishable 
from them, disappear coincidently with 
the occurrence of local hemorrhage, once 
from piles, once in the form of menstrua- 
tion ; and I can well believe that a similar 
result might be furthered by the applica- 
tion of leeches around the anus or to the 
cervix uteri-to these parts rather than 
to the back, because their vessels would 
seem to communicate more directly with 
the deep spinal vessels. It is very proba- 
ble, however, that the time will soon pass 
in which depletion in any form, or depress- 
ing remedies of any kind are required, 
and that the indications will rather be 
towards brandy, or ammonia, or turpen- 
tine, or ether, than towards the remedies 
which have been mentioned, for all acute 
diseases of the spinal cord would seem to 
have a rapidly devitalizing influence upon 
the system. In acute cases the catheter 
will be necessary to empty the bladder; 
in chronic cases, aching and stiffness of the 
limbs may point to friction and shampoo- 
ing as likely means of relief. In every 
case there is sure to be some peculiarity 
to which attention must be directed if the 
plan of treatment be all that it ought to 
be ; and, in short, every case must be 
treated on its own merits. 
II. Myelitis. 
Myelitis, or inflammation affecting the 
substance without involving the mem- 
branes of the cord, is a well-defined and 
not very uncommon disease. It may oc- 
cur in an acute or in a chronic form : it 
may be general or partial: and, to say 
the least, its features are quite as well 
marked and distinctive as those of spinal 
meningitis. 
1. Symptoms.-As an instance of acute 
myelitis, and as a text for what has to be 
said under this head, I take the notes of 
the case of a hospital patient under my 
care some time ago. 
Case.-Charles K., a draper's assistant, 
twenty-six years of age, unmarried, a pa- 
tient admitted into the National Hospital 
for the Paralyzed and Epileptic on the 9th 
of January, 1804. 
(a) The chief symptoms complained of 
are paralysis and anaesthesia below the 
waist, a disagreeable feeling of tightness 
around the waist, inability to pass water, 
involuntary stools, and pain in the left 
side of the chest. Above the waist, the 
power of movement and the power of sen- 
sation are natural; below the waist, all 
the voluntary muscles are entirely para- 
lyzed, and the sensibility to pain, to tick' 
ling, to differences of temperature, as well 
as to touch, are completely lost. Pressure 
along the spine is felt above the point to 
which the anaesthesia reaches, but not be- 
low it, and where felt the patient bears it 
without wincing. In other words, there 
is no tenderness on pressure in that part 
of the spine which preserves its sensibility. 
The feeling of warmth produced by pass- 
ing a sponge soaked in moderately hot 
water along the spine is felt above the 
point to which the anaesthesia reaches, 
but not below it; and, where felt, the 
feeling of heat is natural, except at the 
line of junction between the sensitive and 
insensitive parts, and there the feeling 
produced is that of burning. Moreover, 
the warm sponge produces the same feel- 
ing of burning all around the body in the 
course of this line of junction, and thus it 
is plain that this local over-sensitiveness 
to heat is not confined to the spine. No 
reflex movements are produced by tickling 
the soles of the feet. The aloe nasi work 
very much, the lips are somewhat dusky, 
the lower intercostal muscles are motion- 
less, and the accessory inspiratory muscles 
are in full work; the air-passages (espe- 
cially on the left side) are loaded with MYELITIS. 
957 
phlegm, the pulse is hurried and weak, I 
the skin is moist and somewhat cooler 
than natural, and the voice is so low as to 
be scarcely audible. A cough of the 
feeblest sort is almost incessant, but the 
expiratory power at command is alto- 
gether insufficient to bring about the ex- 
pectoration which is so much needed. All 
appetite is gone, but food can be taken, 
and there is no thirst, or none to speak of. 
The urine, which is acid, and of the spe- 
cific gravity of 1015, has to be drawn off 
by the catheter. There is no priapism. ; 
A stool has just passed without the pa- • 
tient being aware of it until his nose took 
account of the accident. 
(5) A week ago, on awakening from a 
short nap, the patient found that his toes 
had gone to sleep, and that he had to 
"take long breaths." Instead of passing 
off, the feeling of tingling spread rapidly 
from the toes to the feet, from the feet to 
the legs, from the legs to the thighs, until 
it reached the seat, becoming less and less 
endurable as it spread, and being at last 
accompanied by a feeling of tightness 
around the waist and around the left in- 
step, and by a state of restlessness which 
made it scarcely possible to sit still for a 
moment. After suffering in this way for 
a couple of hours, an attempt to pass 
water, which failed altogether, was fol- 
lowed by an almost intolerable uneasiness 
at the end of the penis, and by a sudden 
weakness in the legs which made it neces- 
sary to remain on the bed upon which he 
had fallen. Up to this time there had 
been no difficulty in standing, or walking, 
or even in going up and down stairs. A 
friend of the patient's now present says : 
-I saw him on the evening of the day 
on which he was attacked, a couple of 
hours or so after he had been obliged to 
take to his bed. I thought he was suffer- 
ing from severe rheumatic pains. For 
some hours those pains were excruciating. 
I had never before seen any one suffer so 
much. He tossed about in dreadful 
agony; he roared out with pain often, 
and, when not roaring, he groaned." 
Having thus passed seven or eight miser- 
able hours, he fell asleep, and slept until 
breakfast-time ne/t day. Upon waking 
in the morning he could neither move his 
legs nor empty bis bladder; he had lost 
all feeling below the waist, and all the 
miserable feelings which had kept him in 
a state of continual unrest before he fell 
asleep were gone. On inquiring whether 
these feelings were of the character of 
pain, he says, "No, not exactly; worse 
than pain, one continued numb stinging 
feeling, as if the parts were asleepso 
that the friend's words which have just 
been given must be taken as meaning not 
exactly what they seem to mean in this 
particular. For the six days preceding 
his admission to the hospital a state of . 
imperfect priapism was apt to come on of 
itself, or to be brought on by introducing 
a catheter to draw off the water, and this 
is the only point remaining to be noticed 
here, for in other respects the condition 
seems to have remained stationary, ex- 
cept, perhaps, that a little ground was 
lost every day. 
The patient seems to have come of a 
healthy family, and, though never very 
strong, to have himself always enjoyed 
tolerably good health. He was confined 
to the house for a few days about two 
months ago by ''influenza," and this is 
the only illness of any kind he remem- 
bers to have had. He says, "I was 
fatigued by a long walk on the day I was 
taken ill, and for a month and more I had 
felt more tired in my back and legs than 
usual in an evening, and more rheumatic 
-less up to the markand also, "My 
back always ached at the end of the day's 
work, and so did my legs, and I was al- 
ways glad to go to bed soon, for in bed I 
was comfortable:" and besides these 
statements there appears to be nothing at 
all calculated to throw light upon the 
history of his present malady. 
Jan. 10.-Early this morning, after a 
sleepless night, a severe rigor commenced 
in the right arm, and then extended first 
to the back, and afterwards to the whole 
body. This rigor continued a full quarter 
of an hour, and was followed by profuse 
perspiration. During its continuance the 
paralyzed parts were very cold : after it 
had ceased the warmth returned, and 
brought with it a considerable mitigation 
of the cough and trouble of breathing. 
Indeed, after the establishment of reac- 
tion, difficulty of breathing ceased to be 
an urgent symptom, except for a moment 
or two after waking from an occasional 
and very brief doze. The anaesthesia in 
the trunk has mounted full an inch higher 
since yesterday, but it has not extended 
to either of the upper extremities. Pria- 
prism occurs frequently. The pulse is 
150; the respirations are 36 in the 
minute. 
Jan. 11.-There has been no sleep in 
the night. The engorged condition of 
the lungs has gained headway, and the 
harassing suffocative cough has returned. 
Hiccough is frequent and distressing. 
Once during the day the passage of the 
catheter was obscurely felt, this being the 
first sign of feeling in this part since the 
commencement of the illness. The urine 
is decidedly acid. The electro-contrac- 
tility and electro-sensibility of the para- 
lyzed muscles are annihilated. 
Jan. 12. - For the last twenty-four 
hours the increased difficulty of breathing 
attending sleep has caused the patient to 
wake immediately if he for a moment 
forgot himself. "I can't breathe except 
I keep awake," he said in a voice scarcely 958 
DISEASES OF THE SPINAL CORD. 
audible ; and also, " I hope I have not 
long to live." The passage of the cathe- 
ter is still obscurely felt, and the escape 
of flatus and feces is perhaps not so en- 
tirely unfelt as it has been since the com- 
mencement of the illness. In other parts 
the anaesthesia, like the paralysis, re- 
mains as complete as ever. The urine is 
still acid, distinctly so. For the last 
twenty-four hours there has been no pria- 
pism, and scarcely any cough. At present 
hiccough is almost constant, the pulse is 
fluttering, the hands are cold and clammy, 
and, in short, the signs of the near ap- 
proach of death are not to be mistaken. 
Jan. 13.-The patient lingered through 
the night, and died about daybreak ; his 
mind unhappily remaining too clear to 
the very last. 
The notes of the post-mortem exami- 
nation are as follow :- 
Jan. 14, 4.30 P. M.-Rigor mortis is 
fully established everywhere. The de- 
pendent parts present considerable signs 
of suggilation, especially along the course 
of the spine, and there is incipient break- 
ing of the skin on both the nates. The 
arachnoid covering of the cord every- 
where is clear, smooth, and without any 
traces of inflammation. The outside of 
the lumbar enlargement is curiously no- 
dulated. On making a longitudinal sec- 
tion, the whole substance of the cord, 
from the brachial enlargement to its in- 
ferior extremity, is found to be of a yel- 
lowish-red color, softened in a remarkable 
manner, and in the lumbar region almost 
like cream in consistence. Several small 
patches of extravasatcd blood are scat- 
tered in the softened structure, these 
patches being undefined in outline, more 
numerous in the lumbar than in the dor- 
sal region of the cord, and situated chiefly 
in the posterior columns. The red dis- 
coloration which has been mentioned is 
most marked in the neighborhood of these 
patches. The examination did not ex- 
tend further, the friends of the patient 
consenting to it only on condition that it 
should be thus partial. 
Jan. 15.-On examining some portions 
of the diseased cord under the microscope, 
the natural structure is found to be alto- 
gether broken down, and mixed up with 
blood-corpuscles, exudation granules, and 
(in fewer numbers) pus-corpuscles. 
With a view to arrive at a knowledge 
of the general features of myelitis, I 
select as the principal points for comment 
in this particular case the following: 
Paraplegic anaesthesia, ushered in by 
tingling or some similar sensation in the 
parts which eventually became anaesthe- 
tic ; paraplegia ushered in by uncontrol- 
lable restlessness ; a disagreeable feeling 
of tightness around the waist and else- 
where ; absence of pain in the spine or 
extremities-of pain produced by move- 
ment especially ; absence of trismus and 
other spasmodic or convulsive symptoms ; 
retention of urine ; involuntary stools; 
absence of pain on pressure (spinal ten- 
derness) in any part of the spine ; increased 
sensibility to differences of temperature, 
by which moderately warm or iced water 
gave rise to a feeling of burning instead 
of the natural feeling over the vertebra 
which marks the upper limit of the mye- 
litis ; annihilation of reflex excitability in 
the paraplegic parts ; priapism ; acidity 
of urine ; comparative voicelessness ; im- 
peded respiration ; engorgement of lungs 
and other viscera ; tendency to bed-sores ; 
loss of electro-contractility and electro- 
sensibility in the paralyzed muscles ; ab- 
sence of head-symptoms; absence of 
fever. 
Paraplegic anaesthesia, ushered in by tin- 
gling or some similar sensation in the parts 
which eventually became anaesthetic.-In this 
case the anaesthesia was developed sud- 
denly during the first night's sleep; it was 
deep-seated as well as superficial; it im- 
plicated the sensibility to pain, tickling, 
and differences of temperature, as well as 
that of touch; it had a paraplegic dis- 
tribution : and this would seem to be the 
rule in cases of acute myelitis. In chronic 
cases it is developed more gradually, and 
it may not extend to all the various forms 
of sensibility; moreover, it may in some 
instances be quasi-hemiplegic instead of 
paraplegic; but the rule in acute cases 
appears to be what it is found to be in 
this. The anaesthesia seems to be usually 
ushered in by tingling or by some analo- 
gous sensation, disagreeable enough, but 
not amounting to actual pain. In this 
particular case the preliminary sensation 
was not pain, but an unbearable "numb 
stinging," as if the parts were asleep, 
with a feeling of tightness around the 
waist, and around one of the insteps. In 
acute cases it is right to speak of anaesthe- 
sia as ushered in by tingling or some simi- 
lar sensation, but scarcely so in chronic 
cases. In chronic cases, indeed, these 
anomalous sensations may never exactly 
come to an end, because in these cases 
the destruction of sensibility may never 
get beyond numbness-may never reach 
nearer to anaesthesia ; that is to say, than 
dysaesthesia. 
Paraplegia ushered in by uncontrollable 
restlessness.-The paralysis was thus ush- 
ered in in the case under consideration, 
and in six similar cases which have come 
specially under my notice, by restlessness, 
and not by any more marked tremulous, 
convulsive, or spasmodic symptom. Nei- 
ther does it appear that a different rule 
obtains in other cases, acute, subacute, 
or chronic. In the great majority of 
cases, no doubt, the paralysis has a para- 
plegic form, but in a few cases it is not MYELITIS. 
959 
so. In the great majority of cases, the 
paralysis is accompanied by numbness, 
but not absolutely in all. Sometimes, for 
example, as in. the case in which the 
paralyzing lesion is limited to a portion 
of one lateral half of the spinal cord,-the 
case about which enough was said in the 
preliminary remarks,-there is paralysis 
without numbness on one side, and numb- 
ness without paralysis on the other side. 
Several cases of this kind are on record, 
and the number of them which I have 
myself met with is sufficient to convince 
me that they are scarcely to be looked 
upon as out of order and exceptional. 
Sometimes, also, as in the case where the 
paralyzing lesion is confined to a portion 
of one of the anterior columns, the paraly- 
sis may be divorced from numbness, and 
not only so, but it may be hemiplegic in 
its distribution; and in such a case it 
may, in fact, be no easy matter to say 
whether it is dependent upon a cerebral 
or upon a spinal cause. In some cases, 
also, the paralyzing lesion may be so lo- 
calized as to affect only, or chiefly, an arm 
on one side and a leg on the other side. 
Usually, however, the paralysis is distin- 
guished by being associated with numb- 
ness, and by being paraplegic in its dis- 
tribution. 
A disagreeable feeling of tightness around 
the waist and elsewhere.-A feeling of cir- 
cular constriction around the trunk, or 
around some part of an extremity, around 
the trunk especially, is so common as to 
deserve to be considered as an almost 
constant symptom in myelitis. I do not 
recall a case, acute or chronic, in which it 
was entirely absent at all times. 
Absence of pain in the spine and extremi- 
ties-of pain produced by movement more 
especially.-In chronic cases of myelitis, 
Dr. Brown-Sequard speaks of "a constant 
pain in the part of the spine correspond- 
ing to the upper limit of the inflammation 
of the cord" as a characteristic symptom; 
but I question very much whether this 
statement is in accordance with well-sifted 
clinical facts. Pain, either in the spine 
or elsewhere, is not mentioned, for exam- 
ple, in the nineteen cases, acute or chronic, 
given by Oliivier, except in three ; and of 
these three the myelitis was complicated 
with meningitis in two, and in the one 
remaining the symptoms justify the pre- 
sumption (and there was no post-mortem 
examination to set it aside) that the same 
complication existed. At any rate, it is 
certain that there is not in uncomplicated 
myelitis that severe pain in the back and 
limbs which is brought on or aggravated 
by movement in spinal meningitis. 
Absence of spasmodic symptoms. -Oliivier 
speaks of continuous contraction df the 
limbs as being met with "assez ordinaire- 
ment," in chronic myelitis ; but the cases 
cited by this excellent observer do not 
substantiate this statement. Thus, out 
of nineteen cases of myelitis, complicated 
and uncomplicated, acute and chronic, 
there are three only in which these con- 
tractions were present, and not one of the 
three can be cited correctly as a case of 
myelitis. In one of the three (No. 87) 
the sensibility was intact, and the disease 
of the cord confined almost exclusively to 
the anterior column ; in another (No. 93) 
there was obtuse sensibility, and the dis- 
ease wras chiefly in the gray matter ; and 
in the third (No. 94) sensibility remained, 
and there was no post-mortem examina- 
tion to show what the disease in the cord 
really was. In each one of these cases, 
also, there were "head-symptoms" which 
do not figure in uncomplicated myelitis. 
Again, prolonged contraction of the ex- 
tremities is a not unfrequent symptom in 
cases in which there is neither myelitis 
nor spinal meningitis-cases which come 
properly under the head of "spinal irrita- 
tion," and about which more will have to 
be said in another section of this article. 
In these cases the contraction, instead ot 
pointing to inflammation of the cord or 
its membranes, is really no more than one 
of a series of so-called hysterical phenom- 
ena. It is a sign of functional disorder 
only, and that it is so is evident (these 
among other proofs) in the sudden and 
complete way in which it passes off, as 
well as in the fact that it does not leave 
behind it any permanent organic traces. 
It depends, as it would seem, upon a state 
of irritation in some part of that track in 
which irritation gives rise to prolonged 
spasm-a state issuing, it may be, now 
and then in inflammation, but in itself, 
so far as the condition of the bloodvessels 
is concerned, diametrically opposed to in- 
flammation. Nay, even in those excep- 
tional cases of myelitis in wfliich there is 
increased reflex excitability in the para- 
lyzed limbs, it is difficult to connect these 
spasmodic symptoms with the inflamma- 
tion. Dr. Brown-Sequard says: "When 
the dorso-lumbar enlargement is inflamed, 
reflex movements can hardly be excited 
in the lower limbs, and frequently it is im- 
possible to excite any. On the contrary, 
energetic reflex movement can always be 
excited when the disease is in the middle 
of the dorsal region, or higher up. " And 
again, when speaking of the reflex con- 
vulsions which may happen in the cases 
where the inflammation is in the middle 
of the dorsal region or higher up, he says, 
"Convulsions do not take place at the 
beginning of the inflammation, but some 
time after, and they recur by fits for 
months and years after." And this is 
precisely what happens. In a word, the 
truth would seem to be that these reflex 
spasmodic movements must be referred, 
not to inflammation in the lumbar enlarge- 
ment of the cord, nor yet to inflammation 960 
DISEASES OF THE SPINAL CORD. 
higher up in the cord ; for in this case, to 
repeat what has just been said, "the con- 
vulsions do not take place at the begin- 
ning of the inflammation, but some time 
after, and they recur by fits for months 
and years after.'11 They happen, as it 
would seem, after the inflammatory disor- 
ganization has interrupted the continuity 
of the cord, and produced a state of things 
analogous to that of a guinea-pig, or other 
animal, whose spinal cord has been cut 
across experimentally-a state of things of 
which increased reflex excitability in the 
paralyzed parts is one of the consequences. 
Nor is a different conclusion to be drawn 
from the occasional presence in the para- 
lyzed muscles of a state which is analogous 
to or identical with the " late rigidity" of 
Todd. This "late rigidity" is very dif- 
ferent from "early rigidity." In "early 
rigidity" the electro-motility of the mus- 
cles is increased, and the muscles relax 
during sleep, and to a less degree under 
the influence of warmth. The muscular 
contraction is evidently of the nature of 
spasm. In "late rigidity," on the con- 
trary, the muscles are wasted, their elec- 
bro-motility annihilated, and sleep or 
warmth do not tell in causing relaxation. 
This form of muscular contraction, indeed, 
if not identical with rigor mortis, is, as it 
would seem, more akin to this state than 
to spasm. In the case of myelitis which 
serves as my text, there was none of the 
painful muscular rigidity produced by 
movement which is so prominent a symp- 
tom in spinal meningitis. There was, 
indeed, no spasmodic symptom of any 
kind, with the exception of the rigor 
which ushered in the extension of the dis- 
ease on the day after the admission of the 
patient to the hospital. And this absence 
of spasmodic symptoms would seem to be 
the rule in all cases of myelitis, acute or 
chronic. In children, it is true, myelitis 
may be ushered in by convulsion - in 
which case the convulsion manifestly 
represents the rigor which may usher in 
myelitis in adults, and as manifestly be- 
longs to the precursory stage of irritation, 
and not to the state of actual inflamma- 
tion-but even in children, unless there 
be some meningeal complication along 
with the myelitis, this preliminary con- 
vulsion would seem to be a rare phenome- 
non. 
Want of control over the bladder.-This 
appears to be the earliest as well as the 
most constant of the symptoms of myeli- 
tis. It usually depends upon paralysis of 
the accelerator urinse and compressor ure- 
thrse, but now and then it would seem to 
be connected, for a while at least, with a 
state of spasm in the latter of these mus- 
cles, in which case the dribbling away of 
the water or the introduction of a cathe- 
ter will sometimes produce marked reflex 
spasms in the legs. I remember one case 
-a case in which the myelitis seemed to 
have interrupted the continuity of the cord 
high up in the back-where an attempt to 
use the catheter often gave rise to strong 
reflex spasms in both legs, and to a state 
of spasm in the urethra strong enough to 
prevent the passage of the instrument. 
Want of control over the rectum.-In mye- 
litis, paralysis of the sphincter ani is usu- 
ally associated with paralysis of the accele- 
rator urinse and compressor urethrae. Now 
and then also, the sphincter ani, instead 
of being paralyzed, may be in a state of 
reflex spasm : thus, in the case to which I 
have just referred, the administration of 
an enema was sometimes rendered impos- 
sible by the spasm set up in the sphincter 
ani and in the femoral muscles by the 
pipe. 
Absence of local spinal tenderness.-As in 
spinal meningitis, so in myelitis, absence 
of tenderness on pressure in any part of 
the spine would seem to be the rule, and 
not the exception. Ollivier, speaking of 
pain in the back in myelitis, says, "Elle 
n'est jamais rendue plus aiguepar la pres- 
sion," and my own experience in the mat- 
ter is, without question, to the same 
effect. 
Altered sensibility to heat and cold, by 
which a feeling of burning is felt when a 
sponge soaked in moderately warm water or 
a piece of ice is applied to the spine immedi- 
ately above the seat of inflammation.-Seve- 
ral years ago it was pointed out by Mr. 
Copeland that, when a sponge soaked in 
water a little above the temperature of 
the blood was passed along the spine from 
above downwards, it gave rise to the 
natural feelingof heat until it reached the 
inflamed part, and that then this feeling 
changed to that of burning: and more 
recently Dr. Brown-S^quard has shown 
that a similar result is arrived at by pass- 
ing a piece of ice down the spine, the 
natural feeling of cold being felt until the 
inflamed part is reached, and then an 
unnatural feeling of burning. In many 
cases, no doubt all this would seem to be 
quite true, but not in all, perhaps not in 
the majority ; and therefore it is impossi- 
ble to look upon the feeling of burning 
thus produced as more than an occasional 
occurrence in myelitis. 
Annihilation of reflex excitability.-"What 
has to be said under this head has been 
anticipated when speaking of the absence 
of spasmodic symptoms in myelitis. It 
has indeed been seen to be the rule for all 
reflex movements to be annihilated or 
greatly weakened in the paralyzed parts, 
and that the apparent exceptions to this 
rule are to be explained, not by referring 
the increased reflex movement to myeli- 
tis, but by supposing the inflammatory 
disorganization to have interrupted the 
continuity of the cord and produced a 
state of things analogous to that of a MYELITIS. 
961 
guinea-pig whose spinal cord has been 
cut across for experimental purposes. 
Diminution of electro-motility and electro- 
sensibility in the paralyzed muscles.-Ex- 
cept in those few, very few, cases in 
which the reflex excitability is increased, 
the electro-motility and electro-sensibility 
of the paralyzed muscles are invariably 
diminished in myelitis. Where the re- 
flex excitability is increased the electro- 
motility may also be increased, and so 
also may the electro-sensibility, but more 
generally the increase in the former pro- 
perty is without a corresponding increase 
in the latter. The paralyzed muscles are 
wasted in almost all cases, and relaxed 
also, except in those few cases in which 
the paralysis has lasted for a very long 
time and become associated with that 
state of "late rigidity" which, sooner or 
later, is often found to seize upon paral- 
yzed muscles. Marshall Hall noticed the 
impairment of irritability in spinal paral- 
ysis, and was of opinion that an opposite 
state of things existed in cerebral paraly- 
sis. As was pointed out by Todd, how- 
ever, this supposed distinction between 
spinal and cerebral paralysis does not 
hold good, the simple fact being that in 
the great majority of cases of cerebral 
paralysis the irritability of the paralyzed 
muscles, instead of being increased, is 
either not materially altered or else more 
or less diminished-most generally dimin- 
ished in a very marked degree. In a 
word, the investigations of this very ac- 
complished physician show most clearly 
that in cerebral paralysis the irritability 
of the paralyzed muscles is only increased 
in those comparatively few cases in which 
the paralysis is associated with "early 
rigidity." 
Priapism.-It is difficult to attach any 
diagnostic value to this symptom. As in 
acute spinal meningitis, so in acute mye- 
litis, it is sometimes present and some- 
times absent, less frequently present in 
the latter affection perhaps than in the 
former. 
Acidity of the urine. - Dr. Brown- 
Sequard says : "One of the most decisive 
symptoms in myelitis is alkalinity of the 
urine. There is no patient attacked with 
myelitis in the dorsal region of the cord 
whose urine is not unfrequently alkaline. 
At times, especially after certain kinds of 
food, the urine is acid, but the alkalinity 
soon returns." And no doubt the urine 
is very generally alkaline in myelitis, es- 
pecially in those cases in which the 
paralysis of the bladder has led to secon- 
dary disease of this organ ; at the same 
time, as in the case under consideration, 
the urine is too often acid to make it pos- 
sible to insist upon alkalinity of the urine 
as a necessary feature in myelitis. 
Dyspnoea.-Difficulty of breathing was 
a very urgent symptom in the case which 
serves as my text, and so it must be in 
every case where respiratory muscles are 
so gravely implicated in the paralysis, and 
where the lungs are so much engorged. 
Indeed, the usual way in which myelitis 
proves fatal is by compromising the suffi- 
ciency of the respiration. Now and then, 
especially when chronic inflammation af- 
fects the higher regions of the cord, the 
difficulty of breathing may occur in parox- 
ysms not unlike those of asthma, but 
usually the difficulty shows itself rather 
as simple shortness of breath,-shows it- 
self in a way which supplies another proof 
of the absence of the spasmodic element 
in the history of myelitis. 
Want of power in the circulation.-There 
is little or no sympathetic fever in the 
most acute form of myelitis; and in the 
ordinary chronic forms, the feeble pulse, 
the oedematous condition of the paralyzed 
extremities, the disposition to passive en- 
gorgement in the lungs and elsewhere, 
and other symptoms of like meaning, 
show very plainly that the state of the 
circulation is eminently asthenic. It 
would even seem as if there were some- 
thing in the very fact of myelitis which 
has a positive influence in subtracting 
power from the circulation-which exer- 
cises a devitalizing influence upon the 
system generally. 
A tendency to bed-sores, wasting, and 
other signs of defective nutrition in the 
paralyzed parts.-Sooner or later, gene- 
rally at a very early date, a marked dis- 
position to bed-sores in places where 
paralyzed parts are subjected to pressure 
is apt to show itself in myelitis, and so 
also are other signs of defective nutrition 
in the same parts, such as oedema, dry- 
ness and scurfiness of the skin, and a 
wasted and flabby state of the muscles. 
So marked, indeed, is this impairment of 
nutritive power in these paralyzed parts, 
that it is only by very great care that 
bed-sores and the other lesions which have 
been mentioned can be prevented. 
Absence of head-symptoms. - In cases 
where acute myelitis attacks the higher 
portions of the cord, there may be, and 
there in all probability will be, various 
"head-symptoms"-vertigo, singing in 
the ears, grinding of the teeth, delirium, 
convulsion, coma, or others-but these 
cases, to say the least, are not common. 
Whether acute or chronic, indeed, mye- 
litis is much more apt to attack the lower 
portions of the cord than the upper, in 
this respect differing from spinal menin- 
gitis ; and when it attacks the upper por- 
tions of the cord, and its symptoms present 
cerebral complications, the chances are 
that the case is not simple myelitis, but 
myelitis with more or less spinal menin- 
gitis in addition. 
When the cord is affected generally, 
the symptoms of myelitis will not differ 
VOL. I.-61 962 
DISEASES OF THE SPINAL CORD. 
greatly from those which are present in 
the case which has been given ; when the 
inflammation is more localized, the symp- 
toms will vary accordingly. If, for exam- 
ple, the inflammation be limited, as it 
usually is, to the lumbar enlargement of 
the cord, the level of the paralysis and an- 
ajsthesia will be proportionally low down ; 
and if the extreme end of the cord only 
be affected, it is possible that the legs 
may escape altogether, and the bladder 
and anus be alone at fault. As indeed 
the level of the inflammation in the cord 
falls or rises, so must the level of the 
paralysis and anaesthesia fall or rise also. 
Exaggerated reflex movements in the in- 
ferior extremities will also (in all proba- 
bility) be associated with the paralysis 
and anaesthesia, if the lower part of the 
cord be sound and the inflammation con- 
fined to a portion of the cord higher up. 
Again, the symptcc s which are present 
when the inflammation is limited to a 
part only of the thickness of the cord will 
be different in many respects from those 
which are met with when the whole 
thickness is affected. If, for example, a 
portion (the upper half inch of their course 
excepted) of the anterior columns be af- 
fected solely, there would be paralysis 
without anaesthesia; or if the posterior 
columns were alone affected, there might 
be incoordination of movement and some 
hyperesthesia instead of paralysis and 
anaesthesia. In short, the variations of 
symptoms, which occur where myelitis is 
restricted to particular parts of the cord, 
can only be properly intelligible to him 
who has clear notions respecting those 
physiological matters which were glanced 
at in the preliminary remarks,-which 
were then glanced ai chiefly in order to 
avoid perplexing physiological digression 
and discussion in the present place among 
others. I will, therefore, assume that 
what wras said in the preliminary glance 
at some points in the physiology of the 
spinal cord, will serve to explain suffi- 
ciently the variations of symptoms which 
may be expected to exist when the integ- 
rity of particular parts of the spinal cord 
is destroyed by myelitis or in any other 
way: and, for the rest, I will only say 
that myelitis may be chronic and sub- 
acute as well as acute in its course, and 
that these several varieties interblend in- 
sensibly the one with the other. 
2. Post - mortem Appearances. - 
Myelitis may result either in softening or 
in hardening of the spinal cord. Most 
frequently the cord :s broken down, re- 
duced to a yellowish cr reddish cream-like 
consistence; the color, derived from the 
admixture of pus or blood-corpuscles, 
being more yellow or more red according 
as the one or the other of these corpus- 
cles predominates. This softening may 
affect the whole thickness of the cord, or 
certain parts more than others, the gray 
matter especially; it may extend from 
one end of the cord to the other, or it 
may be confined to certain regions, in 
which latter case the part most likely to 
be affected is the lumbar enlargement; 
and it would often seem to have its start- 
ing-point in the central gray matter, 
which is the most vascular part of the 
cord. In the first stage of myelitis this 
central gray matter has a rosy or vinous 
tinge, which is not natural to it; it is 
plainly more vascular than it ought to be; 
and, in short, it has undergone the very 
same change which is met with in the 
gray matter of the brain in encephalitis. 
Sometimes the spinal cord is considerably 
swollen, and sometimes the surface may 
have a nodulated appearance in certain 
parts, from the membranes having yielded 
at these points to the blood which may 
have escaped, or to the pus or other fluid 
which may have collected, underneath. 
Not unfrequently small collections of 
blood are met with in the softened nerve 
tissue, especially in the position of the 
central vessel, so that the first impression 
upon opening the cord may be that of 
hemorrhage rather than that of myelitis. 
One remarkable feature of inflammatory 
softening, says Dr. Todd, is that "it ex- 
hales a marked odor of sulphuretted hy- 
drogen, and so indicates a rapid advance 
of putrefaction and again, "It is a fact 
deserving of attention that the substance 
of the spinal cord softens very rapidly 
after death, the lapse of half an hour, 
during which the nervous substance has 
been exposed to the air, often producing 
a manifest alteration." Indeed, there are 
reasons for believing that the amount of 
disorganization met with in the cord after 
death does not necessarily represent the 
exact amount which existed during life, 
and that a cord which is found to be 
broken up after death almost utterly, 
may have retained during life sufficient 
integrity to allow of the transmission of 
certain sensitive and motor impressions. 
On this view the return of slight sensa- 
tion in the urethra and rectum shortly 
before death, and the preservation of the 
power of moving and feeling in the arms, 
which were noticed in the case which 
serves as my text, are not altogether un- 
intelligible. 
Induration, the other result of myelitis, 
is looked upon by some as a stage always 
preceding softening, but it would rather 
seem, to mark, as Ollivier supposed, a 
less acute form of inflammation. In it 
the fibrinous products of the inflamma- 
tion seem to have been more organizable. 
The cord thus indurated varies greatly in 
appearance ; it may be almost as pale, 
bloodless, crisp, and hard as cartilage ; it 
may be more or less red and vascular ; MYELITIS. 
963 
and in either case, when examined under 
the microscope, its proper tissues are 
found to be broken up and destroyed al- 
most as effectually as they are when the 
cord is softened. A cord which is indu- 
rated has usually a shrunken appearance, 
but it may be swollen considerably. 
There is no doubt an induration of the 
cord, as well as a softening, which cannot 
be referred to myelitis, and which must 
not be confounded with that which is the 
result of inflammation; but I must not 
stay to point out the differences, nor yet 
to do more than say that in myelitis there 
will in all probability be found, in addi- 
tion to the signs which have been indi- 
cated, engorgement of the lungs, kidneys, 
and other viscera, possibly more marked 
vascular changes, with bed-sores, oedema, 
dry and scurfy skin, wasted muscles, and 
other signs of defective nutrition in the 
paralyzed parts. 
3. Causes.-Nothing very much to the 
point can be said under this head, and 
the only remark I feel called upon to 
make is this, that as in spinal meningitis 
a rheumatic habit has been found to 
figure more or less conspicuously among 
the causes of the malady, so here a like 
position would seem to be due to a stru- 
mous habit. I would also confess to a 
growing impression that myelitis may not 
unfrequently be connected more with ex- 
cess of sexual indulgence than with any 
other single cause, but I cannot say that 
this impression has yet taken the form of 
a definite conviction. 
4. Diagnosis. - In dealing with the 
symptoms of myelitis it has been shown 
that these are very different from those of 
spinal meningitis-so different as to make 
it difficult to confound them, if only mod- 
erate care be taken in realizing them. 
In spinal meningitis the most prominent 
symptom is pain in the back and extremi- 
ties, produced or aggravated by move- 
ment ; in myelitis pain of any kind has 
scarcely a title to be reckoned among the 
symptoms, pain produced by movement 
certainly not. In spinal meningitis the 
sensibility is somewhalt exalted, in mye- 
litis it is abolished. In spinal meningitis 
there is muscular weakness, and the mus- 
cular movements are fettered by pain, 
but there is no true paralysis : in myeli- 
tis, paralysis is the symptom of symptoms. 
In spinal meningitis there is a state sim- 
ulating trismus and tetanus, a state of 
muscular rigidity half voluntary as to its 
character, of which the object is to pre- 
vent certain movements which give rise 
to pain ; in myelitis the muscles are lim- 
ber, and there is usually an utter absence 
of any symptom akin to tremor, convul- 
sion or spasm. 
Nor need the symptoms of common 
paraplegia (resulting from chronic mye- 
litis) be confounded with those of loco- 
motor ataxy. In common paraplegia 
there is paraplegia more or less marked of 
the lower extremities, and the nutrition 
and irritability of the paralyzed muscles 
are, as a rule, unmistakably impaired ; 
not so in locomotor ataxy. In common 
paraplegia the paralysis extends to the 
bladder and sphincter ani, and the sexual 
power is greatly weakened, if not alto- 
gether abolished; not so, or not to any- 
thing like the same degree, in locomotor 
ataxy. In common paraplegia the cha- 
racteristic neuralgic pains of locomotor 
ataxy are wanting, and numbness is no- 
thing like so prominent a symptom as in 
the ataxic disorder. In common para- 
plegia, where walking is possible, the gait 
-instead of being precipitate and stag- 
gering, the legs starting hither and thither 
in a very disorderly manner, and the 
heels coming down with a stamp at each 
step, as in locomotor ataxy-is hampered 
and slow, each leg being brought forward 
with evident difficulty, even with the help 
of an upward hitch of the body on the 
same side, and the part of the foot first 
coming in contact with the ground being, 
as a rule, not the heel, as in ataxy, but 
the toes. In common paraplegia, impair- 
ment of sight or hearing, or strabismus, 
or ptosis, or injection of the conjunctivae, 
or contraction of the pupils, frequent if 
not constant symptoms in locomotor 
ataxy, form no part of the history. In 
fact, in these respects, and in others of 
minor importance which might be men- 
tioned, the histories of common paraple- 
gia and locomotor ataxia are so different 
that it is not easy to see how, with only a 
moderate amount of care, the two can be 
confounded. 
Now and then, it is true, instances oc- 
cur in which it is not so easy to distin- 
guish this gait of common paraplegia from 
that of locomotor ataxy-cases in which 
the weakened muscles contract somewhat 
spasmodically when put in action, but, as 
a rule, the gait in common paraplegia and 
in locomotor ataxy is sufficiently charac- 
teristic to make it difficult to confound 
these two affections. 
In cases where the myelitis is confined 
to the posterior columns of the cord, the 
symptoms will be those of locomotor 
ataxy rather than those which have been 
ascribed to myelitis ; for. so far as the 
production of symptoms is concerned, it 
is of no moment whether the disease dis- 
organizing the posterior columns be in- 
flammatory or non-inflammatory, acute 
or chronic; and in other cases of local 
myelitis symptoms are sure to be present 
winch cannot fail to lead to a correct 
diagnosis, if what wras said in the pre- 
liminary remarks upon the physiology of 
different parts of the spinal cord be borne 964 
DISEASES OF THE SPINAL CORD. 
in mind in interpreting them. Indeed, 
with what is known of the physiology of 
the spinal cord, there need not be much 
difficulty in determining the whereabouts 
of local mischief in the cord. 
That myelitis cannot well be confounded 
with other spinal disorders-spinal con- 
gestion, tetanus, spinal irritation, and the 
rest-will be seen readily enough when a 
clear idea of these disorders has been 
realized, and only then ; and this being 
the case, it is best to waive these ques- 
tions in diagnosis until the fitting oppor- 
tunities for dealing with them present 
themselves. 
5. Prognosis.-Acute myelitis affect- 
ing any considerable extent of the spinal 
cord is, without doubt, a very grave dis- 
order. It may be fatal in fifteen or twenty 
hours, and it is seldom that life is pro- 
longed beyond the end of the second week. 
Instances of recovery are on record, it is 
true, but these are very few in number, 
and of them there is, perhaps, no single 
one in which the correctness of the diag- 
nosis may not be impugned. Even chronic 
myelitis is a very grave disease; for though 
lire may be prolonged, especially where 
the disease is confined to the lower part 
of the cord, the mischief once done seems 
to be in a great measure irreparable. At 
the same time it is only right to say that 
of late years the results of treatment have 
been much more satisfactory, and that it 
is possible now to hope where there was 
little room for hoping formerly. 
6. Treatment.-There appears to be 
little room for what is called active treat- 
ment even in acute myelitis. The in- 
flammation is evidently of a very low 
type, and, reasoning from what is known 
of its beneficial action in erysipelas and in 
some other low forms of inflammation, it 
seems to me that sesquichloride of iron 
would be likely to be of more real service 
than iodide of potassium. Indeed, I should 
be disposed, until I know of a better plan, 
to trust chiefly to full doses of this prepa- 
ration of iron, to food and wine, and to 
the position recommended by Dr. Brown- 
Sequard for draining away blood from 
the spine-a position in which the patient 
is made to lie upon his abdomen or side, 
with his hands and feet in a somewhat 
dependent position. 
With regard to the good or bad effects 
of belladonna, or ergot, or strychnia, it is 
not very easy to arrive at a satisfactory 
conclusion. I agree with Dr. Brown- 
Sequard in thinking that belladonna and 
ergot may have the effect of counteracting 
a hyperremic condition by causing con- 
traction in the vessels, and that the ves- 
sels of the spinal cord may, perhaps, re- 
spond most readily to their action, but 
not as to the indications for employing 
these remedies. Pain and spasm are, to 
Dr. Brown-Sequard, signs of hypersemia : 
to me, except tiie pain produced by move- 
ment, they are signs of irritation only-of 
a state which is connected, not with hy- 
persemia, but with anaemia, a state of con- 
traction of the vessels which may pass 
into relaxation, but which need not neces- 
sarily do so; and, therefore, to me pain 
and spasm, instead of being indications 
for the employment of belladona or ergot, 
are in very deed contra-indications. Nor 
can I agree in thinking that strychnia 
acts by increasing the amount of blood in 
the spinal cord and in its membranes, and 
that on this account it is contra-indicated 
in hypersemic conditions of these parts. 
Strychnia, without doubt, produces tetanic 
sp isms and other unequivocal signs of 
spinal irritation, but it is begging the 
question altogether to suppose that the 
strychnia increases the amount of blood 
in the cord and its membranes, that this 
increase of blood augments the vital ac- 
tivity of the cord, and that the spasms 
and other signs of irritation attest this 
augmentation of vital activity. Indeed, 
so far from this being a necessary conclu- 
sion, all the evidence presented in the 
preliminary remarks, as it seems to me, 
points in the opposite direction, and con- 
nects the state of irritation of w hich the 
spasms are the signs, not with a hyper- 
semic condition, but with an ansemic; 
and most assuredly I know of nothing 
in the history of myelitis or spinal men- 
ingitis which is calculated to invalidate 
this conclusion. Moreover, the investi- 
gations of Dr. Harley upon the action 
of strychnia upon the blood go to show 
that this action is really equivalent to loss 
of blood in that it directly interferes with 
the proper arterialization of the blood. 
In a word, I cannot find any fundamental 
difference between the action of bella- 
donna, ergot, and strychnia upon the 
bloodvessels, neither can I understand 
why strychnia, properly used, might not 
be of as much service as belladonna or 
ergot in lessening a hypersemic condition 
of the cord. For my own part, however, 
I confess to a feeling w hich makes me 
hesitate to employ either belladonna, or 
ergot, or strychnia in myelitis, or in any 
analogous condition, until I know' more 
of their action, or until I have more un- 
equivocal empirical evidence of the good 
resulting from their use. 
In chronic cases the one grand indica- 
tion of treatment, as it seems to me, is to 
improve the nutrition of the cord, and 
the medicines best calculated to carry out 
this indication are cod-liver oil, sesqui- 
chloride of iron, phosphorus in one form 
or other, arsenic, and possibly bichloride 
of mercury, which latter preparation, 
when properly used, I believe to be tonic 
and antiseptic in a high degree, and in 965 
SPINAL CONGESTION. 
many respects much more analogous in 
its action to arsenic than to any of the 
proto-compounds of mercury in common 
use. 
The local means for promoting the re- 
covery of the paralyzed muscles are cer- 
tainly of not less importance than the 
general means, possibly of much greater 
importance, and these local means are 
very various. The efficacy of frictions 
and shampooings appears to be indisputa- 
ble. The efficacy of proper movements 
can only be doubted by those who are un- 
acquainted with the results arrived at by 
the " movement cure," and by systematic 
movements of one kind or another, with 
or without the help of mechanical appa- 
ratus. The efficacy of faradization has 
been abundantly proved, and there is 
good reason to believe that this is not the 
only mode of using electricity which will 
be of great service ; that in fact statical 
positive electricity, or the interrupted gal- 
vanic current, or the application of the 
galvanic current in such a way that the 
paralyzed nerve is acted upon chiefly by 
the positive pole-a mode of using elec- 
tricity about which I have spoken else- 
where, and which I have used extensively 
during the last five or six years-will often 
be of great service in proper cases. In- 
deed I should think that the treatment 
was wanting in very essential particulars 
if these local means, one and all, were 
not associated with the general means of 
treatment, and employed systematically 
and perseveringly; and especially I should 
regard it as a great blunder if these local 
means were deferred so as to allow the 
paralyzed muscles to lose what when lost 
is not easily recovered-that is, their irri- 
tability and healthy organization. 
There are also other local measures 
which are of great service in the treat- 
ment of paralysis, and one of these to 
which I am disposed to attach especial 
importance is to protect the paralyzed 
parts from cold. In many cases, as is well 
known, these paralyzed parts are cool, 
and in not a few instances, where the 
paralysis is incomplete or associated with 
early rigidity, this paralysis and rigidity 
is greatest when these parts are coldest. 
For example, it is no uncommon thing 
for a partially hemiplegic patient whose 
paralyzed fingers are contracted, stiff, and 
altogether useless when acted upon by 
cold, to be able to open his hand and use 
his fingers with comparative freedom 
when the hand is warm in bed, or placed 
in a warm bath, or held a while before 
the fire. At any rate, I have long been 
satisfied that the well wrapping up of the 
paralyzed parts in woollen, or silken, or 
india-rubber coverings is an important 
help in treatment. 
It would also seem that good of the 
same kind, much good, may be got from 
an exhausting apparatus made on the 
principle of Junot's boot. The effect of 
such an apparatus, properly used, is to 
make the paralyzed parts warmer at the 
time, and to enable them to preserve this 
warmth for a considerable time-to pro- 
duce a change in the circulation, which 
must have a good effect upon the nutri- 
tion and irritability of the paralyzed 
muscles. 
It is also more than probable that elec- 
tricity may be of service in improving the 
condition of the circulation in the para- 
lyzed parts, for an increased feeling of 
warmth in the paralyzed parts is the re- 
sult of faradizing these parts, or of electri- 
fying them with statical electricity; indeed 
I have been more than once disposed to 
think that the beneficial effects of elec- 
tricity in the resuscitation of paralyzed 
parts are as much brought about indirect- 
ly by changes produced in the circulation 
as by changes wrought directly in the 
nerves and muscles. 
As regards the necessity for tenotomy 
and the use of orthopaedic apparatus in 
certain cases, it is difficult to speak to any 
good purpose. I shall have to refer to 
these subjects when speaking of infantile 
paralysis, and here I will only say, that 
in many cases, in children especially, the 
cure will be greatly facilitated by tenoto- 
my and orthopaedic apparatus, and that 
it is not always easy to decide between 
the cases in which these measures are 
desirable and those in which they are not 
desirable. [For Polio-myelitis (inflamma- 
tion of the gray substance of the cord) see 
Infantile Paralysis.-II.] 
III. Spinal Congestion. 
Spinal congestion, or plethora spinalis, 
is not less definite in its history than 
myelitis or spinal meningitis, neither is it 
of less practical interest. In the sequel, 
indeed, it may appear, not only that 
spinal congestion is fully entitled to the 
place which has been assigned to it in the 
catalogue of diseases, but also that it 
really comprehends more than one spinal 
disorder which is now known under a 
different name. 
1. Symptoms.-As an instance of well- 
marked spinal congestion, I take the notes 
of a case under my care not long ago. 
Case- Mary L., aged 28, but looking 
very much older, married but never preg- 
nant, was admitted into the Westminster 
Hospital on the 12th of June, 1866. 
(a) With the exception of being able to 
turn her head on the pillow and to move 
the fingers and toes a little, all power of 
voluntary movement appears to be want- 
ing. The symptoms chiefly complained 
of are tingling in the tips of the fingers 966 
DISEASES OF THE SPINAL CORD. 
and toes, a dull burning aching along the 
back and in the limbs, and a feeling of 
being 1,4 tired to death. " If altered in any- 
wise, the sensibility to touch, pain, tick- 
ling, and differences of temperature, is 
somewhat more acute than natural. The 
spine is nowhere tender on pressure, but 
the dull burning aching in this region is 
increased by the application of a sponge 
soaked in hot water. The soles of the feet 
may be tickled without giving rise to un- 
due reflex movements. The bladder and 
bowels act properly. The mind is not 
at all affected. The state generally is 
evidently one of great exhaustion and 
prostration without fever, the pulse being 
quick, unsteady, and very compressible, 
the respiration shallow, and curiously 
interrupted by sighs. 
16) Three weeks ago, menstruation, 
which had only just begun, was suddenly 
checked by an alarm of fire. This was 
shortly before bedtime. The next morn- 
ing, after a very sleepless and miserable 
night, the state had become very much 
what it now is. Up to this time the pa- 
tient had never been obliged to remain in 
bed a single day on account of illness. 
She had often been weak and ailing, and 
she had suffered a great deal at the men- 
strual periods from pain and weakness in 
the back and legs, and that is all. She 
also appears to have sprung from a toler- 
ably healthy stock. 
(c) Within the first fortnight after ad- 
mission to the hospital, the tingling in the 
tips of the fingers and toes came to an 
end, and so did the aching in the back 
and limbs. A week later the arms as 
well as the hands could be moved a little. 
At the end of six weeks the legs remained 
almost as helpless as at first, but the arms 
and trunk had so far recovered power as 
to allow of a change from the lying to the 
sitting posture without any great diffi- 
culty. At the end of twelve weeks it was 
possible to get out of bed, and, with the 
help of a stick, to move to the table in 
the centre of the ward. On the 3d De- 
cember, five months after admission, the 
patient left the hospital convalescent. All 
this while the appetite was tolerably good, 
and the bladder and bowels acted properly. 
Now and then, in the progress towards 
recovery, especially about the menstrual 
periods, there were short relapses in which 
the tingling in the tips of the fingers and 
toes, and the aching in the back and limbs, 
came back, and the paralytic weakness of 
the muscles was almost as great as at first, 
-in which the ground already gained 
seemed all but lost. Now and then, also, 
the nights were disturbed by a distressing 
state of shortness of breath, not amount- 
ing to asthma. Before the legs recovered 
power their muscles were somewhat 
wast ed, but not considerably so ; indeed, 
neither here nor elsewhere was the paraly- 
sis accompanied by any marked wasting 
of the muscles, or by any appreciable im- 
pairment of electro-sensibility or electro- 
contractility. Moreover, any movement, 
whether active or passive, had always the 
effect of relieving rather than of increasing 
the aching in the back and limbs, when 
this symptom was present. The treat- 
ment pursued was chiefly rest, good liv- 
ing, hypophosphite of soda, nux vomica 
now and then in small doses, cod-liver oil, 
and faradization. 
Assuming, as I well may, this to be a 
case of well-marked spinal congestion, I 
take as points of comparison between it 
and other cases of the kind, general and 
partial, these :-suddenness of access ; in- 
complete paralysis in a paraplegic form ; 
no numbness ; tingling in the tips of the 
fingers and toes ; no exaggeration of reflex 
excitability in the paralyzed limbs ; no 
want of control over the bladder and 
bowel; no spinal tenderness; aching in 
the back increased by warmth ; pains in 
the back and limbs not increased by move- 
ment ; no marked impairment of the elec- 
tro-contractility and electro-sensibility, 
and no material wasting, of the paralyzed 
muscles ; no feverishness ; breathlessness ; 
no bed-sores ; proneness to relapses. 
Suddenness of onset.-To be well, or 
comparatively well, on going to bed, and 
to be paralyzed in the morning, as in the 
case which I have given, is no uncommon 
thing in spinal congestion. It is indeed 
the rule rather than the exception for the 
illness to be spoken of as a " stroke" by 
the sufferer. 
Incomplete paralysis in a paraplegic form. 
-Paralysis, often all but complete, but 
never quite so, and taking the paraplegic 
form, must be looked upon as the rule in 
spinal congestion. The paralysis is de- 
cidedly paraplegic in the end, and it may 
be so from the beginning, but not unfre- 
quently one leg or one arm is affected be- 
fore the other, and occasionally the leg 
and arm of the same side may for a short 
time be affected, as in hemiplegia, before 
the disease extends to the leg and arm of 
the other side. Not unfrequently there 
remains a difference in the degree of 
paralysis on the two sides, one leg or arm 
being more affected than its fellow. In 
cases where the congestion of the cord is 
general the arms as well as the legs are 
paralyzed, the former perhaps as much as 
the latter; but in the common run of 
cases, where the congestion is confined 
chiefly to the lumbar region of the spine, 
the legs are exclusively or chiefly affected. 
No anaesthesia.-Numbness is a symp- 
tom of myelitis, but not of spinal conges- 
tion. In the latter disorder, indeed, 
instead of numbness there is occasionally 
a state of things which may be spoken of 
as hypersesthesia: thus, in a case very 967 
SPINAL CONGESTION 
like the one I have given, which came 
under my notice in private practice about 
three years ago, the weight of a single 
bed-sheet was distressingly heavy to the 
patient, and long-continued aching of the 
paralyzed arms and legs was produced by 
handling them ever so lightly. 
Tingling in the tips of the fingers or toes of 
the paralyzed limbs. - This symptom is 
almost always present at one time or 
other, coming and going and staying a 
longer or shorter time, often, as it would 
seem, very capriciously. One is glad to 
get rid of it, for while it remains it is 
difficult altogether to put aside the fear 
lest the state of the cord should pass out 
of simple spinal congestion into the graver 
disease of myelitis. 
No exaggeration of reflex excitability in the 
paralyzed limbs.-Increased disposition to 
reflex movement is usually regarded as 
one of the symptoms in spinal congestion. 
It is supposed that the greater affiux of 
blood to the spinal cord must bring with 
it greater reflex excitability. I believe, 
however, that this supposition is not at 
all borne out by the facts. I believe, in- 
deed, that the moderate reflex excitability 
in the case under consideration is not at 
all exceptional, and that it is the rule in 
all cases of spinal congestion for this man- 
ifestation of muscular contractility to be, 
if altered at all, diminished rather than 
increased. 
No paralysis of the bladder or sphincter 
ani.-In myelitis, paralysis of the bladder 
or sphincter ani, more or less complete, is 
a prominent symptom : in spinal conges- 
tion, on the contrary, these symptoms are 
absent, except in those mixed cases where 
there is reason to believe that some degree 
of myelitis is also present. In the case 
which I have given there was not the 
least want of control over the bladder or 
bowel from the beginning to the end. 
No tenderness on pressure along the spine. 
-Absence of spinal tenderness I believe 
to be the invariable rule, not only in 
spinal congestion, but also in myelitis and 
spinal meningitis. I believe, indeed, that 
spinal tenderness is a sign of the presence 
of that functional disorder of the cord 
which is usually called spinal irritation, 
and that it does not accompany the graver 
diseases of the cord which have been 
named when they are uncomplicated with 
spinal irritation. Upon this subject I 
shall have more to say presently. 
Dull aching along the spine increased by 
warmth.-I have noticed this symptom in 
three cases of well-marked general spinal 
congestion which have come under my 
own observation, and in many cases of 
partial congestion ; and I am disposed to 
think that this will prove to be one of the 
points of difference between spinal conges- 
tion and spinal irritation. I have also 
noticed the same symptom in myelitis and 
spinal meningitis, and therefore I cannot 
regard it as having any special connec- 
tion with spinal congestion. In fact, so 
far as my experience goes, I can say that 
this symptom is likely to be met with in 
congestive or inflammatory diseases of the 
cord, but not in spinal irritation simply ; 
and that in this latter case, the local ap- 
plication of warmth to the spine is more 
likely to relieve pain than to cause it. 
Pains in the back and limbs not increased 
by movement.-This symptom has some 
claim to be regarded as constant. The 
aching would seem to go and come with 
the congestion; and the fact, for fact it 
seems to be, that 't is not increased by 
movement, may help to distinguish spinal 
congestion from spinal meningitis, for in 
the latter affection movement of the 
limbs, whether passive or active, is at- 
tended with pain in the parts moved and 
in the back. 
No marked impairment of electro-contrac- 
tility and electro-sensibility in, and no wast- 
ing of , the paralyzed muscles.-In myelitis 
the paralyzed muscles are prone to waste 
and to lose their electro-contractility and 
electro-sensibility, and herein, therefore, 
would seem to be a marked difference be- 
tween this disorder and spinal congestion ; 
for, so far as I know, the contrary state of 
things invariably holds good in spinal con- 
gestion. 
No feverishness.-This is no special fea- 
ture ; indeed, fever would seem to have 
little to do with any affection of the cord, 
not even excepting meningitis in its most 
active form. 
No bed-sores.-A marked disposition to 
bed-sores would seem to be the rule in 
myelitis, but not so in spinal congestion 
or spinal meningitis. Upon this point, 
more than upon many others, there is 
tolerable unanimity of opinion. 
Shortness of breath.-AV here the spinal 
congestion is at all general, this state of 
things may be readily accounted for by 
the paralytic weakness of muscles con- 
cerned in respiration. In the case which 
serves as my text, the occasional short- 
ness of breath is noticed as not amounting 
to asthma ; and this is a point of some 
interest, for it may be supposed that the 
difficulty of breathing would have taken 
this form-would have had something of 
a decidedly spasmodic character-if the 
congested condition of the cord involved, 
as it is supposed to do, an exaggeration 
of reflex excitability. 
Proneness to relapse.-Whether this may 
prove to be a constant feature in spinal 
congestion remains to be seen. That it 
is not an uncommon one is, to say the 
least, highly probable. 
Spinal congestion varies greatly in its 
degree and in the extent of cord im- 
plicated. Limited to the lumbar region, 
and carried to a degree which produces. 968 
DISEASES OF THE SPINAL CORD. 
not paralysis, but weakness more or less 
approaching to paralysis in the legs, it is 
common enough; indeed, many women 
seem to suffer from it before every men- 
strual period; and between this partial 
and incomplete form and the general and 
complete form, of which the case which 
has been given is an instance, there arc 
all possible grades of transition. It would 
seem to be most common in women, but 
it is not peculiar to the female sex or to 
any age. The onset of the disorder is 
generally sudden, in relapses as well as 
in original attacks ; and the cases do not 
at all divide themselves into acute and 
chronic as do the cases of many other 
disorders. 
2. Post-mortem Appearances. - 
These appearances are very vague and 
unsatisfactory, at most being simply some 
engorgement of the veins of the spinal 
cord and membranes, with some excess 
of the spinal fluid, both of which phe- 
nomena, as will be easily understood, are 
not very unlikely to escape detection un- 
less the post-mortem examination be con- 
ducted with unusual care. With the 
exception of this engorgement and serous 
effusion, the only morbid sign which has 
been noticed (and this by no means con- 
stantly) is slight infiltration with blood of 
the cellular tissue exterior to the dura 
mater. In all uncomplicated cases, the 
structure of the cord and of its mem- 
branes is in nowise altered. 
3. Causes.-As in the case which I 
have given, the suppression of the cata- 
menia would seem to figure most con- 
spicuously among the causes of spinal 
congestion, and next to this the cessation 
of hemorrhage from piles. Beyond this 
it is difficult to single out any one cause 
which has a just claim to be considered 
as at all special: and, for the rest, no- 
thing further need be said except this,- 
that spinal congestion is not unfrequently 
a consequence of pulmonary or abdominal 
congestion or inflammation - a conse- 
quence, perhaps, which has often more to 
do in compromising the safety of the pa- 
tient than the primary disorder itself. 
4. Diagnosis.-Paraplegic paralysis is 
a symptom common to spinal congestion 
and myelitis, with this difference, that it 
is less complete in the former affection 
than in the latter. The paralysis is as- 
sociated with anaesthesia in myelitis ; not 
so in spinal congestion. The control over 
the bladder and bowels is lost in mye- 
litis ; not so in spinal congestion. The 
paralyzed muscles are prone to waste and 
lose their electro-contractility and electro- 
sensibility in myelitis; not so in spinal 
congestion. The absence of anaesthesia 
would seem, indeed, to connect spinal 
congestion more closely with spinal men- 
ingitis than with myelitis, and so also 
would the pain in the back and aching in 
the limbs; but the pain and aching in 
spinal congestion cannot well be con- 
founded with the pain which is met with 
in spinal meningitis, for the pain in this 
latter affection is produced by movement 
and accompanied by rigidity, whereas the 
pain in the former afiection is not pro- 
duced and accompanied in this manner. 
Hysterical paralysis, so called, agrees 
with the paralysis depending upon spinal 
congestion in some respects, but not in 
others. It agrees in that the paralyzed 
muscles are neither prone to waste nor to 
lose their electro-contractility; it dis- 
agrees in that numbness is a prominent 
symptom, more prominent even than the 
paralysis, and that the electro-sensibility 
of the paralyzed muscles is either anni- 
hilated or very much diminished. 
5. Prognosis.-Recovery is the rule, 
no doubt, in cases of spinal congestion, 
but there is no difficulty in finding cases 
in which the disease has been fatal, and 
quickly fatal too. In the partial form, 
affecting the lumbar portion of the cord 
only, spinal congestion may come and go 
quickly without any great damage being 
done ; but in the cases in which the cord 
is more extensively and more profoundly 
affected, as in the case which has been 
cit ed, recovery may occupy a considerable 
time. Thus, of the cases recorded by 
Ollivier, No. 55 remained in hospital 
nearly five months, No. 56 two months, 
No. 57 three months, and No. 58 " assez 
longtemps. " Recovery is slow, it may 
be, because time is required for the ab- 
sorption of the excess of the spinal fluid 
to which the state of spinal engorgement 
had given rise. 
6. Treatment.-What has been said 
respecting myelitis must be supposed to 
apply here equally. Indeed, the only 
special remark which appears to be called 
for in this place is this,-that in cases 
where, as very generally happens, the 
spinal congestion can be referred to sup- 
pression of a menstrual or hemorrhoidal 
discharge, the primary indication would 
appear to be the setting up of an equiva- 
lent discharge by applying leeches to the 
os uteri or to the anus. 
IV. Tetanus. 
Tetanus is unhappily no rare or unfamil- 
iar malady. The name,from TtcVw, I stretch, 
refers to that rigid and cramped condition 
of the muscles which is the most charac- 
teristic symptom, and which, in sober 
earnest, is suggestive of rigor mortis, not 
only in posse but actually in esse; for there 969 
TETANUS. 
are some cases in which, without any in- 
terval of relaxation, tetanic rigidity at 
once passes into cadaveric rigidity. Hy- 
drophobia alone excepted, tetanus is at 
once the most appalling and the most 
perilous of all spasmodic diseases. 
1. Symptoms.-As an instance of well- 
marked tetanus, I take the notes of a case 
which I happened to see from the begin- 
ning to the end ten years ago. 
Case 1.-Patrick M , a fair, slightly- 
built, delicate-looking man, unmarried, 
aged 27, the coachman of a gentleman 
then under my care. On the 21st of April, 
1861, meeting him as I was leaving the 
house of his master, he took the oppor- 
tunity of saying that he was not well 
enough to bring round the carriage, and 
of asking me what he had better do. 
What he complained of chiefly were a 
stiff neck and sore throat, with a feeling 
of weakness and illness. The stiff neck 
and sore throat made their appearance 
for the first time this day ; the feeling of 
illness and weakness has been present for 
the last three days. The mouth cannot 
be opened so as to allow a fair look at the 
tongue, and a meal, it appears, has just 
been left unfinished, not for want of appe- 
tite, but simply on account of the difficulty 
experienced in masticating and swallow- 
ing the morsels. There is no feverishness. 
P. M. ascribes his second indisposition 
to having been out with the carriage seve- 
ral hours in the wet and wind three nights 
ago, and he says further that he is liable 
to colds. Before speaking to me, he had 
taken some opening medicine which a 
chemist had prescribed and prepared for 
him, and he thinks that this dose may ac- 
eount for the fact of feeling so ill and weak 
at the present moment. Some simple 
treatment was recommended, and I took 
my leave, not at all divining what was so 
soon to follow. 
April 22.-Receiving information that 
this poor fellow was very ill, I went round 
to see him at his lodgings. I found him 
strangely altered. Ills teeth were firmly 
and inseparably clenched, and he looked 
literally like an old man-so like, that his 
mother, who lived with him, said that she 
could have thought his father had come 
back to life if only his hair had been gray. 
His voice had also become so low and in- 
distinct as to make it difficult to catch 
what he said. The medicine given by the 
chemist yesterday, it appears, has purged 
him violently several times in the night, 
and more than once while at stool he has 
been seized with acute pain in the pit of 
the stomach, which took away his breath, 
and made him think he was going to die. 
It was in the night, while at stool, that 
the jaws became closed. I wished him to 
go to the hospital, and he was willing to 
do so, but his mother would not consent. 
Eggs beaten up with brandy were ordered 
to" be given repeatedly, and every three 
hours a draught containing five grains of 
quinine and half a drachm of Hoffmann's 
anodyne. I now noticed on one of the 
fingers, which was tied up in a piece of 
rag, a small wound, healing and appa- 
rently healthy, the result of a tear by a 
rusty nail about a fortnight ago. 
On a second visit, later in the day, I 
found that repeated attempts had been 
made in the interval to give the food and 
medicine, but with very trifling success. 
There was no great difficulty in getting 
the food or medicine into the mouth, for 
almost all the teeth on the right side were 
gone, but the attempt to swallow brought 
on spasm in the throat, and on more than 
one occasion the spasm forced the greater 
part of what was taken back through the 
nostrils. And this difficulty was all the 
more distressing, because a feeling of 
hunger prompted the patient of his own 
accord to make frequent attempts to swal- 
low. The chief complaint now was of a 
dragging pain at the pit of the stomach, 
piercing through to the back. In answer 
to a question whether he could sit up in 
bed, he said, " I think I am too stiff to do 
so," and then he tried to sit up, and suc- 
ceeded after making two or three abortive 
attempts. While sitting up, I found that 
he could scarcely move his head, and that 
the muscles of the neck and back were 
very stiff and hard. I had only just no- 
ticed these phenomena when the noise 
caused by the upsetting of a chair brought 
on a fit of spasm, in which the patient 
was suddenly thrown backwards upon the 
bed with considerable force, and left rest- 
ing upon his head and heels, in a state of 
complete opisthotonos-a state so com- 
plete as to make it possible for me to pass 
my hand under the loins without touching 
either the body or the bed. This severe 
spasm lasted not less than a couple of 
minutes, and the only muscles which did 
not seem to be implicated in it were the 
abdominal, those of the arms and hands, 
and those of the eyeball. In this spasm 
the complexion became dusky and livid, 
and the features altered in a frightful 
manner, the angles of the mouth being 
drawn upwards and outwards so as to give 
the expression known as the risus sar- 
donicus, the set teeth being slightly un- 
covered, the nostrils spread, the eyes 
staring and prominent, the brow knit, the 
hair bristling-the complexion and fea- 
tures became changed, that is to say, as 
they are changed in sudden suffocation. 
All this while, too, the skin generally was 
dusky and hot and drenched in perspira- 
tion. For some time after this spasm had 
passed off the patient remained moaning, 
and unable to speak audibly, and then be 
said, "that pain will kill me if it comes 
back." I noticed, also, that there rc- DISEASES OF THE SPINAL CORD. 
970 
mained after this spasm a state of tetani- 
form rigidity and contraction, by which 
no inconsiderable degree of opisthotonos 
was still kept up. The eggs and brandy 
and the medicine were ordered to be 
given by enema. 
April 23. -Two attempts were made to 
administer the enemata ordered over 
night without success, the irritation of the 
pipe in each instance bringing on a tit of 
spasm ; indeed, all that it has been possi- 
ble to give since my last visit have been a 
few sips of wine and water. There has 
been no sleep whatever during the night. 
During the last eighteen hours several fits 
of spasm like the one described have oc- 
curred, and the permanent rigidity and 
contraction remaining between the fits 
have increased. The abdominal muscles, 
which were not at all implicated yester- 
day, are now as hard and stiff as those of 
the neck, back, and legs. The pulse is 
quick (about 140), weak, and somewhat 
irregular: the breathing is shallow, hur- 
ried, and frequently checked by gasps and 
catches, even when it is not interrupted 
by the fits of spasm. 
No material change has taken place 
since the morning. On one occasion in 
the course of the day an egg beaten up 
with some brandy has been swallowed, 
but all other attempts to administer food 
or medicine, whether by the mouth or 
by the rectum, have been rendered abor- 
tive by the fits of spasm to which they 
gave rise. 
April 24.-Again the night has passed 
without sleep, and to-day the constant 
tetaniform contraction has become almost 
universal. In fact; the only muscles 
which are not obviously affected are those 
of the hands, and tongue, and eyeball. 
The fits of spasm, also, are now more fre- 
quent and severe, being not more than 
fifteen or twenty minutes apart, and last- 
ing until death from suffocation seems 
even more than imminent; they are 
brought on by the most trivial causes-an 
attempt to swallow, a draught of air, the 
simple straightening of the bedclothes- 
or they come on without any apparent 
cause. There is no improvement in the 
breathing and pulse, but if anything a 
change for the worse. During the fits the 
skin is hot, dusky, and drenched in per- 
spiration : in the intervals it has an 
ominous coolness and clamminess. The 
mouth is full of viscid frothy saliva, and 
there is much thirst. While I was present 
a small quantity of dark urine was passed 
slowly and with some difficulty, and this 
appears to be the only time the bladder 
has acted for at least twenty-four hours. 
The pupils are large, especially in the 
paroxysms. 
snatch of sleep, which had been abruptly 
brought to an end by an attack of opis- 
thotonos, in which the tongue or cheek 
had been bitten, and now the frothy vis- 
cid saliva which tilled the mouth to over- 
flowing was deeply crimsoned with blood 
-a ghastly addition to a countenance 
already overcharged with horrors. Dur- 
ing the last six hours the paroxysms have 
been less frequent and severe, but the 
vital powers are evidently fast ebbing 
away. ''I cannot get my breath," was 
the answer slowly and almost inarticu- 
lately given to the question, " Have you 
much pain ?" 
Death happened about midnight, an 
hour after 1 had taken my leave, after a 
paroxysm of opisthotonos of no special 
violence, brought on, as it would seem, 
by an attempt to wipe away the bloody 
saliva from the lips. When I left the 
mind was perfectly clear and collected, 
and at no time, either before or after, was 
it otherwise. 
For the rest it only remains to add (for 
the objections made to a post-mortem ex- 
amination were insuperable) that the 
countenance appears to have retained 
after death the aged expression it had 
before death, and that the corpse when 
" laid out" was found to have stiffened 
without losing altogether the opisthotonic 
attitude. The mother of the patient is 
my only authority upon these points, for 
unfortunately it did not occur to me to 
make inquiries respecting them before the 
funeral had taken place. 
In order to realize the points of resem- 
blance and difference between this case 
and other cases of the kind, the course I 
propose to pursue is to take one after the 
other, as the points demanding attention, 
these-permanent muscular contraction, 
beginning by causing trismus, ending by 
causing opisthotonos, and implicating 
when at its height almost all the voluntary 
muscles except those of the hands, the 
eyeball, and the tongue : pain at the pit 
of the stomach, piercing through to the 
back ; difficulty of swallowing, from the 
occurrence of spasm : fits of painful spasm 
in the permanently contracted muscles ; 
risus sardonicus, and an aged expression 
of countenance; apnoea in the fits of 
spasm, and more or less dyspnoea at other 
times; increased temperature, without 
true fever ; increased reflex excitability ; 
absence of sleep ; absence of numbness or 
tingling ; absence of " head symptoms 
no marked want of control over the bladder 
and bowels ; comparative voicelessness ; 
the mouth clogged with viscid frothy sa- 
liva ; a bitten tongue or cheek ; dilatation 
of pupils ; absence of priapism ; presence 
of a wound ; death by apnoea ; early if not 
immediate rigor mortis. 
Shortly before I went again, at the end 
of the day, there had been a momentary TETANUS. 
971 
Permanent muscular rigidity, causing, 
first, trismus, then opisthotonos, and impli- 
cating, when at its height, almost all the 
voluntary muscles except those of the hands, 
the eyeball, and the tongue.-Muscular 
rigidity, continuing without any marked 
relaxation from the time of its first appear- 
ance, is the most characteristic symptom 
of tetanus. It would seem to be the rule 
for this state of stiffness to begin in the 
muscles of the jaws, causing trismus, and 
to extend from thence as a centre, first 
to the muscles of the face and neck, then 
to those of the back, causing opisthoto- 
nos, then to those of the lower extremi- 
ties, and lastly, to those of the upper ex- 
tremities, the progress in both extremi- 
ties being from above downwards; but 
there are exceptions to this rule, for a 
few cases are on record in which the mus- 
cles of the nedk have been affected before 
those of the jaws, and others, also only 
few in number, where the muscles near a 
wound, as of a stump after amputation, 
have been the first to become rigid. 
Even in the most extreme cases, the hands 
and the tongue are found to remain lim- 
ber, and it is but very rarely, except per- 
haps in children with " head symptoms" 
in addition to the ordinary phenomena of 
tetanus, that a squint or a fixed stare 
shows that the deep muscles of the orbit are 
affected. Fits of spasm, of which more 
will have to be said presently, may seize 
upon the tongue, as they do very fre- 
quently upon the muscles of the throat in 
attempts to swallow, but there is no proof 
that either the tongue or the muscles of 
the throat are ever in a state of perma- 
nent contraction. Neither is there any 
certain proof that the heart or other in- 
voluntary muscles are in any degree per- 
manently contracted. The affected mus- 
cles are very hard, curiously so, feeling 
very much as they do in rigor mortis, and 
they are not unfrequently somewhat ten- 
der when pressed or squeezed. In the 
great majority of cases, w ithout question, 
the first effect of tetanic rigidity is to close 
the jaws and cause trismus, and the next 
to bend the body backwards and produce 
opisthotonos. Opisthotonos, indeed, is 
almost as characteristic and constant a 
phenomenon as trismus. Now and then, 
it is true, instead of the body being bent 
backwards it may be bent forwards (em- 
prosthotonos), or sideways (pleurosthoto- 
nos), but these cases are quite exceptional, 
and opisthotonos may in reality be looked 
upon as the position which the body 
always takes or tends to take in tetanus. 
Pain at the pit of the stomach piercing 
through to the back.-This is reckoned by 
the late Dr. Chambers as the pathognomo- 
nic symptom of tetanus, and in fact it is 
scarcely ever absent, not even at the very 
beginning. This pain is especially severe 
in the fits of spasm, and then it is often 
agonizing, but it is present also, if not in 
a severe, at least in a mitigated form, in 
the intervals between these fits, scarcely 
ever ceasing altogether, even for a mo- 
ment, when once it has made its appear- 
ance. It depends, there is little reason 
to doubt, upon the diaphragm being im- 
plicated in the tetanic condition. Once 
it was looked upon as a certain death- 
warrant, but this opinion, as Air. Curling 
has shown, is untenable. 
Difficulty of swallowing from the occur- 
rence of spasm.-This spasm, which is pro- 
voked by the attempt to swallow, may be 
in the pharynx or gullet, or in the cardiac 
aperture of the diaphragm, one or all, 
making swallowing impossible, and often 
leading to the violent ejection of fluids 
through the nose or from the mouth. The 
distress consequent upon it may some- 
times cause a horror of liquids not unlike 
that which exists in hydrophobia, and it 
always constitutes a grave difficulty, for it 
not only incapacitates the patient from 
feeding in the usual way, but it prevents 
him from being fed by means of the stom- 
ach-pump. 
Fits of painful spasm in the permanently 
contracted muscles. - These fits become 
more frequent as well as more violent 
and painful as the disease progresses, re- 
curring when at the worst every ten or 
fifteen minutes, and lasting from one to 
two and a half minutes. So violent has 
been the muscular contraction in some of 
these fits, that the teeth and thigh-bones 
have been broken, and great muscles like 
psoas and recti femorales torn across. 
These fits of spasm are almost invariably 
very painful, the being that of cramp, but 
now and then the pain has been absent: 
thus, Sir Gilbert Blane mentions, on the 
authority of a surgeon in the navy, a case 
of severe tetanus, fatal in four days, in 
which the fits of spasm only gave rise to 
a sort of pleasurable tingling; and Mr. 
Curling instances an analogous case. 
Most generally the pain in the fit of 
spasm is felt chiefly at the pit of the 
stomach, and very often the pain in this 
region may be so agonizing and stifling 
as to make the patient insensible to pain 
elsewhere. Sometimes the pain in the 
neighborhood of a wound, as in the stump 
after amputation, is that which is most 
complained of. 
Pisus sardonicus and an aged expression 
of countenance.-The sneering expression, 
caused by the angles of the mouth being 
drawn backwards and upwards, and 
known as the risus sardonicus, in asso- 
ciation with spread nostrils, staring and 
prominent eyes, knitting of the brows, 
and bristling of the hair, is so often pre- 
sent as to be properly reckoned as pathog- 
nomonic of tetanus. In the fits of spasm 
the lips are often drawn apart so as to 
expose the set teeth, but sometimes they 972 
DISEASES OF THE SPINAL CORD. 
are kept tightly pressed together by the 
spasmodic action of the orbicularis oris. 
The aged expression which was present 
in the case I have given, is exceptional, 
but it has been met with in other cases. 
Thus, Mr. Curling refers to a case of idio- 
pathic tetanus, related by Dr. W. Farr, 
in which the patient, who was only twen- 
ty-six years of age, looked at least sixty; 
and he says further that he himself has 
"observed the same circumstance in an 
equally remarkable degree." 
Dyspnoea with fits of comparative apnoea. 
-When tetanus is fully developed, an ap- 
prehension of suffocation is often present 
even in the intervals between the fits of 
spasm, and in these fits the suffused eyes, 
the livid countenance, and the agonizing 
struggle for breath show plainly enough 
that this is no sense a groundless fear. 
How this difficulty is brought about is 
not easy to say, and probably the way is 
not always the same. Sometimes spas- 
modic closure of the glottis would seem 
to be a prominent cause; sometimes the 
thorax is, as it were, held in a vice by the 
spasm of all its muscles generally; most 
commonly, perhaps, these two causes act 
together. From my own small expe- 
rience I should be disposed to attach 
more importance to the last cause than 
to the first, and I question whether much 
relief would be obtained in any case by 
carrying out Marshall Hall's suggestion 
of opening the windpipe in cases of 
tetanus. 
Increased reflex excitability.-In P. M., 
as the disease advanced, the fits of spasm 
were brought on by the most trivial causes 
-a draught of air, a sudden noise, an 
attempt to swallow, an attempt to admin- 
ister an injection, the arrangement of the 
bed-clothes, the lightest touch even-and 
hence it may be inferred that increased 
reflex excitability was an element in this 
case. Nor is this case at all exceptional 
in this respect. As the disease advances, 
in fact, the controlling influence of the 
nervous system is removed, and this is 
all, for what are counted as signs of in- 
creased reflex excitability are in reality 
no more than signs of nervous exhaustion, 
such as manifest themselves whenever the 
vital powers are sufficiently lowered by 
loss of blood, or in any other way. 
Greatly increased temperature, without 
true fever.-In the fits of spasm, and in a 
lesser degree in the intervals between the 
fits, the skin is very hot and damp, this 
heat rising in some cases as high as 
110'75° Fahr., the sweat having now and 
then a peculiar pungent smell. Usually 
the skin is literally drenched in perspira- 
tion and covered with sudamina. Usually 
the pulse is quick and weak ; and if in the 
fits of spasm it acquires more force, the 
state of semi - suffocation then present 
shows very plainly that this change in its 
character is, as I have shown elsewhere, 
due, not to the injection of more red blood 
into the artery, but to the greater resist- 
ance which imperfectly aerated blood has 
to encounter in getting out of the artery. 
The increased heat of skin in tetanus 
at first sight appears to show that fever 
is a part of tetanus, but further inquiry 
points to a very different conclusion. As 
death approaches, the temperature, in- 
stead of falling, as it might be expected 
to do, may actually rise higher, and, what 
is stranger still, the rise may not be at its 
maximum until the patient has been dead 
for some time. Dr. Wunderlich' gives 
three cases which establish this fact- 
which he was the first to observe-beyond 
all contradiction. 
The first of these cases is one of idio- 
pathic or rheumatic tetanus, the patient 
being a butcher, aged 29. The disorder, 
which presented nothing remarkable in 
its symptoms, run its course in five days. 
Shortly preceding death there was some 
delirium, with marked abatement in the 
spasms, death happening in the exhaus- 
tion following a bout of spasm of no spe- 
cial severity. Putrefaction was unusually 
rapid. The brain was healthy, the cord 
was injected, and its texture (neuroglia) 
considerably broken down. The temper- 
ature of the ward at the time of death was 
77° Fahr. What is of interest in the state 
of the breathing, the pulse, and the tem- 
perature, is as follows :- 
1 Archiv der Heilknnde, Bd. ii., iii., and 
v. (1861, 1862, and 1863). TETANUS. 
973 
Sate. 
Respirations. 
Pulse. 
Temperature, 
Degrees Kahr. 
24th July, 1861 . .... 
24 
96 
102 
25th " 
22 
82 
102 
26th " " 9 A.M 
20 
96 
104-45 
" " " 6 P.M 
32 
112 
103-55 
" " " 9.20 P.M 
36 
180 
110-1 
" " " 9.35 P.M., death 
112-55 
After death 2' . . . 
112-77 
" 5' . 
113 
" 20' . 
113-22 
" 35' . 
113-55 
" 55' . 
113-67 
" 60' . 
113-55 
" 70' . 
113-22 
" 90' . 
113 
" 100' . 
111-8 
" 6 hours • 
106-25 
" 9 " . 
104 
" 12 " . 
102 
" 13i " . . 
101 
The second case is one of traumatic tet- 
anus in a man aged 20, fatal tenth day. 
Up to twenty-four hours before death the 
tetanic symptoms were fully marked, and 
the mind quite clear; at this time, and 
especially in the six hours immediately 
preceding death, unrest, talkativeness, jac- 
titations, and slight delirium were more 
prominent symptoms than the spasms. 
The appearances after death were like 
those found in the first case. In the last 
three days the mercury went up slowly 
and steadily from 100° to 105°'8, at which 
point it stood three hours before death ; 
at death and afterwards the notes made 
of the temperature are these :- 
At death. . . . 107'6 Fahr. 
J 0'after death . 107'8 
15' " . . 108- 
20' " . . 107'8 
38' " . . 106-4* 
58' " . . 105-8 
1 hour 5' " . . 105-31 
"20' " . . 104-45 
. " 35' " . . 103-55 
2 hours " . . 101-75 
4 " " . . 99-3 
The third case is that of a man, aged 
57, a bookbinder by trade, with idiopathic 
or rheumatic tetanus. Tetanic symptoms 
set in in the usual way on the 20th June, 
1863, and were fully developed two days 
afterwards, when also symptoms of pneu- 
monia were detected. Death happened to- 
ward the end of the day following, as much 
or more from the pneumonia as from the 
tetanus; and after death the only very 
marked appearances were those of pneu- 
monia. In this case the temperature, which 
was never higher than 104°-55, was- 
3| hours before death 102'85 Fahr. 
At death .... not stated 
10' after death . . 103*32 
21' " . . 103-55 
Other cases are also on record which 
show that this strange rise in temperature 
up to death and after it, is not peculiar 
to tetanus. Dr. Wunderlich gives three 
such cases:-(1) A case apparently of 
lead-poisoning in a plumber, ending fa- 
tally in 40 hours: the symptoms being 
sudden insensibility, and, later on, tetanic 
and epileptiform convulsions. In this case 
the temperature at death was 107°'7, and 
there was some slight increase afterwards; 
(2) a case of cerebro-spinal meningitis, 
with unrest, delirium, and retraction of 
head for four days, and then sopor, in 
which the temperature was 107°-26 at 
death and 107°'37 after death ; and (3) a 
case of rheumatic fever, with cerebral 
meningitis, shortly ending in coma on the 
sixth day, in which the temperature 
ranged from 109°-62 to 110°-75 in the five 
hours before death, and stood at 111°'87 
thirty minutes after death. Dr. Erb1 also 
gives three cases with fuller detail, name- 
ly, these :- 
A young man, aged 22, with tubercular 
inflammation of the base of the brain, who 
died without convulsions, after having 
been in a state of profuse perspiration and 
unconsciousness for twenty-four hours, 
with rapid respiration (60 to 44), and a 
pulse quite uncountable, towards the end. 
In this case the temperature in the twen- 
ty-four hours before death, at death, and 
afterwards, was as follows :- 
24 hours before 0 
death . . . from 1020'65 to 104'9 Fahr. 
At death 104'9 
13' after death 105.12 
25' " 104'67 
55' " 104 
A w'oman, aged 22, six months gone in 
pregnancy, who died with symptoms of 
* Deutsches Archiv fiir Klin. Medicin. vol. 
i. 1866. 974 
DISEASES OF THE SPINAL CORD. 
coma, without convulsions, the coma hav- 
ing set in suddenly an hour and a half be- 
fore death, and in whom signs of purulent 
meningitis were detected after death. 
During the comatose state the breathing 
was very labored, and the pulse full and 
frequent. The temperature, of which the 
notes are as follows, was only taken after 
death:- 
At death Temp, not stated. 
6' alter death .... 103'45 Fahr. 
10' " .... 104 
15' " .... 104-67 
20' " .... 104-9 
25' " .... 104-9 
35' " .... 105-12 
45' " .... 105-12 
1 hour 40' after death . 104 
2 hours 40' " . . 101-22 
A woman, aged 22, who after having 
suffered from diabetes mellitus in its ordi- 
nary form for three and a half years, 
passed into a state of sopor, after having 
had headache and some delirium for 
twenty-four hours. Death happened in 
about forty-eight hours from the com- 
mencement of the head symptoms. Dur- 
ing the twenty-four hours of sopor preced- 
ing death, the degree of heat ranged from 
102°'65 to 106°; at death and afterwards 
the notes made of the temperature are 
these:- 
At death 106 Fahr. 
5' after death . . . 106-25 
15' " .... 106 
25' " .... 105 
The body has been found to become 
very hot before death, and to remain very 
hot after death, in cholera, in yellow fever, 
and in several other cases, of which in- 
stances are given by Dr. Erb and by sev- 
eral other writers in Germany, and by 
Drs. Ringer,1 Weber,2 Murchison,3 San- 
derson,4 and others in this country ; the 
cause of death in the majority of these 
cases being some sudden affection of the 
brain, coma in others; but there are but 
few cases in which the heat of the body has 
been found to rise after death. Indeed, I 
know of no such cases besides these I have 
quoted, except one, which came under my 
notice a short time ago-a case of a man, 
aged 60, who died from sunstroke in 
twenty-six hours, the symptoms being 
sudden coma, with great oppression of 
the pulse and breathing, without convul- 
sion. In this case the temperature was- 
12 hours before death . . . 103-25 Fahr. 
3 " " ... 104 
At death . . . not ascertained. 
7 hours after death . . . 105-5 
If, then, the temperature rises in this 
manner under these circumstances, it is 
more than difficult to connect the increased 
heat of tetanus with increased activity of 
the circulation or with anything like fever 
in the ordinary form of the word. The 
temperature rises as the time of death ap- 
proaches, when the state of the circulation 
must every moment be becoming more 
and more the reverse of increased activity: 
the temperature continues to rise even 
after actual death, when the blood has 
come to a standstill. These are the facts ; 
and, these being the facts, it may be that 
the increased heat in tetanus may be con- 
nected, not with increased activity of the 
circulation, not with true fever, but rather 
with the contrary state of things. Nor is 
it more easy to connect the increased heat 
of tetanus with the spasms. A part of the 
increase may be accounted for in this man- 
ner, but only a small part. Indeed, the 
simple fact that in one of the cases which 
has been instanced a marked abatement 
in the severity of the spasms was accom- 
panied by an actual rise in the column of 
mercury, and that the column continued 
to rise after death, when all spasm is at an 
end, is in itself a sufficient proof that it is 
not in muscular action that the explana- 
tion of the increased temperature of teta- 
nus is to be found. Moreover, the fact 
that the temperature rises in the same 
way before and after death, in cases where 
neither convulsion nor spasm was among 
the symptoms during life, must lead to 
the same conclusion. How to explain the 
increased heat of tetanus is another mat- 
ter. Increased heat, as was shown in the 
primary remarks, is an effect of injuries 
by which the cord or medulla oblongata 
is torn or cut across. Increased heat, as 
is seen in some of the cases which have 
just been alluded to, is an accompaniment 
of certain diseases which annihilate, more 
or less completely, cerebral action. It 
seems as if one condition of this change in 
temperature was the paralyzing of a regu- 
lating cerebral influence ; and beyond this 
it is difficult to see further, except it be 
that this paralysis, reaching to the vaso- 
motor nerves, allows the minute vessels 
to dilate and receive more blood, and that 
the increased quantity of blood, even 
though this blood may be stagnant, may 
lead to increased molecular changes, of 
which increased heat is an effect. What 
is necessary, however, is not to find the 
cause of the increased heat in tetanus, but 
simply to point out the fact that increased 
heat in this case does not imply increased 
activity of circulation-that true fever, in 
the ordinary sense of the word, is not a 
part of tetanus. And this, as it seems to 
me, is a legitimate inference from the evi- 
dence which has been cited, and the com- 
ments which have been made. 
Absence of sleep.-In the acute cases, 
1 Med. Times and Gazette, vol. ii. 1867. 
2 Clinical Soc. Trans, vol. i. 1868. 
3 Ibid. * Ibid. TETANUS. 
975 
sleep, as a rule, is banished altogether, 
and even in the subacute cases this bless- 
ing is only realized in unrefreshing broken 
snatches. Want of sleep, indeed, is one 
of the not least distressing features of this 
disease. "Ttie muscles," says Mr. Curl- 
ing, " are observed to be relaxed during 
sleep, a striking example of which oc- 
curred to Mr. Mayo in a boy who recov- 
ered from the disease. On visiting his 
patient before the symptoms were sub- 
dued, Mr. Mayo found him asleep, and 
remarked that he lay perfectly relaxed. 
The abdominal muscles were soft and 
yielding, and had not the least tension. 
The boy was awakened, and at the instant 
the full tension of the muscles returned. 
Not being further disturbed, he fell asleep 
in a few minutes, when the muscles again 
became relaxed, and again, on his being 
awakened, resumed the state of spasm. 
I have, on several occasions, witnessed 
the same phenomena. " Except the biting 
of the tongue, on waking from a brief nap, 
be a reason for believing that the muscles 
of the jaws had been relaxed during sleep, 
so as to allow the tongue to get between 
the teeth, there was no proof that the 
muscles were relaxed during sleep in the 
case I have given; but in other cases I 
have had proof sufficient of this relaxation. 
Absence of numbness and tingling.-Of 
this there can be no doubt-that numb- 
ness and tingling form no part of the his- 
tory of tetanus. 
Absence of ' ' head symptoms. ' '-The mind 
is clear from the beginning to the end of 
the disease almost invariably, and not un- 
frequently it is a matter for wonder how 
well the patient bears up under his atro- 
cious sufferings-a marked difference this 
between tetanus and hydrophobia. And 
in the few instances in which delirium or 
coma has made its appearance a short 
time before death, it is not improbable, 
as more than one writer has observed, 
that this derangement is often more the 
result of the remedies employed than of 
the disease. 
No marked want of control aver the blad- 
der or bowel.-In tetanus there is, as a 
rule, none of the difficulty with the blad- 
der which is almost invariably met with 
in acute spinal meningitis. The bladder 
may act seldom, but it is not incapable of 
acting. Constipation is a common but 
not a constant symptom, and when it is 
present it may be a question whether, like 
the " head symptoms," it is not as much 
due to the medicines used as to the dis- 
ease. Now and then, however, there may 
be great difficulty in voiding the contents 
of the bladder and bowels, and in some of 
these cases the resistance to the intro- 
duction of a catheter or enema-pipe has 
shown that a part of this difficulty is 
owing to spasm of the compressor urethrae 
or sphincter ani. 
Comparative voicelessness. - This phe- 
nomenon is readily accounted for as a re- 
sult of the spasmodic interference with 
the action of the chest and of the tight 
shutting of the jaws. Indeed, it could 
not well be otherwise in the fully devel- 
oped disease. 
The mouth clogged with viscid frothy sa- 
liva.-This is a common if not a constant 
symptom, though not so marked in degree 
as in hydrophobia, and there is no diffi- 
culty in accounting for it in either case, 
for the inability to drink and swallow will 
explain at one and the same time why the 
saliva is viscid and why it accumulates in 
the mouth. 
A bitten tongue or cheek.-This accident 
is of rare occurrence, and its rarity may 
be taken as an incidental proof of sleep- 
lessness as a symptom of tetanus, for it is 
to be supposed that the opening of the 
jaws, from the relaxation of their muscles 
during sleep, would allow the tongue or 
cheek to get between the teeth-to get 
into that position in which the spasm 
which attends the moment of waking 
would be sure to crush it. 
Dilatation of pupil.-This condition was 
always present in the case which serves 
as my text, especially in the fits of spasm, 
and this has been the rule in several cases 
of tetanus in which I have examined the 
pupil. Mr. Curling, on the contrary, 
found the pupil contracted in the majority 
of his cases. 
Absence of priapism.-Mr. Morgan states 
that priapism occurs occasionally, but this 
observation is not confirmed by other wri- 
ters on the subject. I have never seen it, 
and I am very much disposed to think 
that the case or cases in which Mr. Mor- 
gan saw it were cases, not of tetanus, but 
of acute spinal meningitis, in which dis- 
order priapism is an occasional symptom. 
Presence of a wound.-The great majo- 
rity of cases of acute tetanus appear to be 
in some way depending upon a wound or 
injury of one kind or another in one place 
or another. I shall have occasion to re- 
fer to this relationship elsewhere : and at 
present I would only notice, in passing, 
the presence of a wound which, to all 
appearance, presented no indications of 
an inflammatory or otherwise unhealthy 
character. 
Death by apnoea.-Apnoea is one way, 
and perhaps the common way, in which 
death is brought about in tetanus. Not 
unfrequently, however, the patient sinks 
from asthenia, having been to a great de- 
gree free from fits of suffocative spasm for 
some time before death. Spasm of the 
heart has also been mentioned as a method 
of dying in tetanus, and the heart has not 
unfrequently been found to be curiously 
hard and contracted after death ; but an 
examination of the facts tends very much 
to discountenance this idea, and to show 976 
DISEASES OF THE SPINAL CORD. 
that death is either by apnoea or asthenia, 
singly or together. 
The immediate occurrence of rigor mortis. 
-Sommer and others have noticed that 
rigor mortis may occur without any ap- 
preciable interval of muscular relaxation 
after death from convulsions, and Dr. 
Brown-Sequard has confirmed this obser- 
vation and given a definiteness to it which 
it had not before. lie has indeed done 
more than this, for he has not only con- 
firmed the fact that rigor mortis may oc- 
cur without any appreciable interval of 
muscular relaxation, but he has estab- 
lished the law that rigor mortis is long in 
coming on and long in passing off where 
death was not preceded by any long-con- 
tinued violent action of the muscles, and 
that it is quick in coming on and quick in 
passing off in direct proportion to the 
amount of long-continued violent action 
which preceded death. In many animals 
killed by strychnine, for example, in which 
death was brought about, not by one vio- 
lent spasm, but" by many, he has found 
rigor mortis set up before the heart had 
ceased to beat. Nay, he even refers to 
the case of a man under his own observa- 
tion in which rigor mortis occurred before 
the heart had ceased to beat. I have 
never witnessed this phenomenon either 
in animals or in man; but I have more 
than once failed to find any line of sepa- 
ration between tetanic stiffness and ca- 
daveric rigidity in animals killed by strych- 
nine, or by the shocks of a Ruhmkorff 
coil: and I am therefore quite prepared 
to understand that in P. M 's case, 
where there were many convulsions before 
death, rigor mortis may have occurred 
without any appreciable interval of mus- 
cular relaxation, and in this way fixed in 
the corpse the age expression of the coun- 
tenance, and the opisthotonic attitude. 
Two distinct varieties of tetanus are 
usually recognized, and properly so-the 
traumatic, in which a hurt of some kind or 
other is believed to be the primary cause ; 
and the idiopathic, in which the only ob- 
vious cause would seem to be exposure to 
coldand damp. In each variety the symp- 
toms are much the same, any difference 
of moment being only one of degree. In 
the acute form, the spasms come on sud- 
denly, occur frequently, and grow in vio- 
lence with each recurrence: in the less 
acute forms the spasms are more slowly 
developed in the first instance, the parox- 
ysms are comparatively far between, and 
they do not recur with increasing rapidity 
and violence. The traumatic, as a rule, 
is more acute than the idiopathic variety. 
Trismus nascentium is considered by 
many as a distinct variety of tetanus, but 
this appears to be a distinction without a 
real difference. It is tetanus in newly- 
born infants, - traumatic, because the 
wound of the navel seems to have a good 
deal to do with its production, and at the 
same time idiopathic, for it is certain that 
cold and damp, and foul air and other 
general causes also figure conspicuously as 
sources. It is, indeed, to this form of 
tetanus that a remark of Sir Thomas Wat- 
son applies especially, which is applicable 
to all forms, namely this, that " although 
tetanus may be excited by a wound inde- 
pendently from exposure to cold, or by' 
cold, without any bodily injury, there is 
good reason for thinking that, in many 
instances, one of these causes alone would 
fail to produce it, while both together call 
it forth." 
2. Post-mortem Appearances. - 
There are no morbid changes in the ner- 
vous system peculiar to tetanus. " Serous 
effusion with increased vascularity," says 
Mr. Curling, "is generally observed in 
the membranes investing the medulla spi- 
nalis, and also a turgid state of the blood- 
vessels about the origin of the nerves," 
and the same changes may also be met 
with in the cranium, but in a less degree, 
and less frequently. It is also a fact of 
considerable moment in relation to this 
point, that Majendie, Ollivier, and Orfila 
failed to detect any perceptible lesion in 
the spinal cords of animals dying from the 
tetanus produced by strychnia. Out of 
seventy fatal cases collected by Mr. 
Curling, there were only two in which 
changes in the nervous system unequivo- 
cally the result of inflammatory action 
were discovered after death, and these two 
were cases where there had been a blow 
or wound to the back, where the symp- 
toms had plainly to do with the inflam- 
mation of the cord or its membranes 
rather than with tetanus, and where the 
signs of inflammation found after death 
may, to say the least, be referred to the 
injury quite as easily as to the tetanus. 
Mr. Curling also points out, as a fact not 
to be overlooked, that the turgid state of 
the vessels of the pia mater, together with 
the effusion of serum which is met with 
in the spinal cord and brain after death 
from tetanus, is also met with in those 
persons who may have been poisoned by 
opium, hydrocyanic acid, and other power- 
ful agents often employed in the treat- 
ment of tetanus, as well as after death 
from delirium tremens, hydrophobia, epi- 
lepsy, and other diseases ; and as bearing 
upon these exceptional cases, in which 
unequivocal signs of inflammation in the 
cord or brain have been met with after 
death from tetanus, he says, "Whether 
inflammation be the result of injury or 
arises spontaneously, it is worthy of notice 
that the spasms, though continued and 
severe, do not occur in such violent parox- 
ysms as in traumatic tetanus. " Neither 
can the preternaturally injected state of TETANUS. 
977 
the minute vessels supplying the sympa- 
thetic ganglia, especially the cervical and 
semilunar, met with by Mr. Swan and 
others in some cases of tetanus, be looked 
upon as at all constant phenomena after 
death from tetanus. 
Nor do recent microscopic investiga- 
tions into the condition of the spinal cord 
in tetanus bring to light any clearer signs 
of inflammatory change. Mr. Lockhart 
Clarke1 finds the vessels injected, and the 
substance of the cord in a state varying 
from simple softening to complete solu- 
tion, the softened or dissolved portions 
forming irregular "areas of disintegra- 
tion," filled with the debris of bloodvessels 
and nerves, or with a fluid finely granular 
or perfectly pellucid. These areas of dis- 
integration were chiefly in the gray sub- 
stance around the canal, but they were 
also in the white substance. They were, 
in fact, in no one part exclusively or par- 
ticularly. Here and there were extrava- 
sations of blood, and "other exudations," 
but pus corpuscles are not mentioned. 
"In the walls of the bloodvessels," Mr. 
Clarke says, " there was no morbid de- 
posit, nor any appreciable alteration of 
structure, except where they shared in the 
disintegration of the part to which they 
belonged; but the arteries were fre- 
quently dilated at short intervals, and in 
many places were seen to be surrounded, 
sometimes to a depth equal to double 
their diameter, by granular and other 
exudations, beyond and amongst which 
the nerve-tissue, to a greater or less ex- 
tent, had suffered disintegration. " " The 
appearances met with," says Mr. Clarke, 
are "exactly similar in kind to the lesions 
or disintegrations which I find in various 
cases of ordinary paralysis, in which there 
is little or no spasmodic movement." 
The cord is broken up, in fact, as at a 
certain time it is broken up by ordinary 
putrefaction, and, the dilated vessels and 
certain exudations of blood and serum 
excepted, this is all that is noticed. The 
case points to disintegration, not to in- 
flammation ; and what Mr. Clarke finds 
in six cases is substantially the same as 
that which Dr. Dickenson2 finds in the 
one case examined by him. Indeed the 
only peculiarity in this latter case is, in 
the presence, in addition, of an excessive 
quantity of a translucent, structureless, 
and finely granular, carmine-absorbing 
material, evidently the sero-fibrinous 
plasma of the blood, which has escaped 
from the minute arteries into various 
parts of the substance of the cord where 
the nerve tissue nas broken down, or 
which lies in pools here and there between 
the cord and its membranes. It is a state 
of oedema rather than anything else, cer- 
tainly not a state of inflammation. 
Traces of inflammation in the wound, 
especially in the injured nerves, may be 
met with after death from tetanus, and 
more frequently than in the spinal cord or 
other great nervous centres; but these 
again, instead of being constant, are not 
even common appearances. In the great 
majority of cases, indeed, the wound, if 
there be one, is perfectly healthy and 
healing. Neither are there any other 
post-mortem facts which can be looked 
upon as essential to tetanus, for those 
which remain to be mentioned, as rup- 
tured muscles, broken or dislocated bones, 
engorged lungs, injection or contraction 
of the pharynx and palate, worms in the 
alimentary canal, and others, are plainly 
accidental and exceptional. 
3. Causes.-The two great causes of 
tetanus are, as has been mentioned al- 
ready, cold and damp, and bodily injury 
of some sort. Exposure to cold and damp 
tells most in this manner when acting 
upon a body previously relaxed by heat 
and perspiring, and this is all that can be 
said, except that this exposure is more 
likely to issue in tetanus in a foul atmo- 
sphere than in a fresh one. As regards 
the hurt which may give rise to tetanus, 
it is difficult to know what to say. In the 
Peninsular war, as Sir James McGregor 
states, tetanus supervened on every de- 
scription and in every stage of the 
wounds, from the slightest to the most 
formidable, in the healthy and sloughing, 
the incised and lacerated, the most sim- 
ple and the most complicated; and this 
statement expresses the opinion of all 
surgeons, military and others. Indeed, 
all that can be said is, that punctured 
wounds seem to be more likely to issue in 
tetanus than incised, and wounds in the 
extremities more than wounds in the 
head, breast, and neck. And certainly 
an inflammatory condition of the wound 
cannot be regarded as essential. In a 
great number of cases, in the majority 
perhaps, the primary wound was com- 
pletely healed and almost forgotten when 
the symptoms of tetanus made their ap- 
pearance ; and Dr. Rush, who had exten- 
sive opportunities for observation in the 
military hospitals of the United States, 
and who was unquestionably a most com- 
petent observer, remarks that there was 
invariably an absence of inflammation in 
the wounds causing the disease. John 
Hunter also says: " The wounds produc- 
ing tetanus are either considerable or 
slight When I have seen it from 
the first, it was after the inflammatory 
stage, and when good suppuration was 
come on; in some cases when it had 
nearly healed, and the patient was con- 
1 Med.-Chir. Transactions, vol. xlviii. 1865. 
2 Ibid. vol. li. 1868. 
vol. i.-62 978 
DISEASES OF THE SPINAL CORD. 
sidered healthy. Some have had locked 
jaw after healing was completed. In such 
I have supposed the inflammation to be 
the predisponent cause, rendering the 
nervous system irritable as soon as it was 
removed. When tetanus comes on in 
horses, as after docking, it is after the 
wound has suppurated and begun to 
heal." There is, indeed, abundant evi- 
dence to show that an inflammatory con- 
dition of the wound is not necessary to 
the production of tetanus, and some evi- 
dence even which is calculated to lead to 
a contrary conclusion, by showing that 
where an inflammatory condition of the 
wound has been present, this condition 
has passed off before the tetanic symp- 
toms made their appearance-the inflam- 
mation, to repeat the words of John Hunter 
just used, "rendering the nervous system 
irritable as soon as it was removed," not 
rendering it irritable as long as it was 
present. The interval between the hurt 
and the development of the tetanic symp- 
toms varies considerably. In eighty-one 
of the cases collected by Mr. Curling, the 
symptoms made their appearance between 
the fourth and fourteenth days, both in- 
clusive, and in nineteen on the tenth day. 
Four cases are also given in which the 
symptoms came on more speedily, one 
(somewhat doubtful) almost instanta- 
neously, another in one hour, a third in 
two hours, and the fourth in eleven hours, 
and, at the other extreme, one in which 
they were deferred as late as the tenth 
week. In traumatic tetanus the sooner 
the symptoms show themselves the more 
acute and dangerous is the malady. In 
idiopathic tetanus the symptoms, as a 
rule, commence sooner than in traumatic 
tetanus, often in a few hours; but the 
idiopathic, notwithstanding, is generally 
of a more chronic kind than the traumatic, 
and far less dangerous. 
Tetanus is not a malady peculiar to any 
country, or climate, or people, but it is 
more common in hot countries than in 
cold. It would appear, also, that negroes 
are more likely to be attacked than whites. 
Great atmospheric changes, especially 
from heat to cold and damp, as to a cold 
and dewy night after a sultry day, are 
evidently most favorable to the develop- 
ment of tetanus, and so in a less degree 
are foul air, despondency, terror, physical 
exhaustion. It must be confessed, how- 
ever, that cases of idiopathic tetanus, as 
compared with those which are trau- 
matic, or partly idiopathic and partly 
traumatic, are, to say the least, extremely 
rare in this country. 
4. Diagnosis. - The differences be- 
tween tetanus and acute spinal menin- 
gitis are sufficiently marked to prevent 
any confusion as to diagnosis if only a 
moderate degree of attention be paid to 
the subject. In tetanus the jaw is firmly 
set from the first, and, in addition to the 
fits of spasm, there is permanent muscular 
rigidity between the fits: in spinal menin- 
gitis, if the jaw be set at all, it is rather 
at the close of the disease, and then only 
in an inconsiderable degree, and spasms 
or muscular rigidity are neither constant 
nor conspicuous phenomena. In spinal 
meningitis, indeed, it is plain that the 
muscular rigidity and seeming spasms 
are in great measure voluntary or semi- 
voluntary acts to prevent the pain in the 
back and limbs which is produced by 
movement, and that the muscles are re- 
laxed almost as long as the patient can 
keep perfectly still. Ina word, the true 
involuntary fits of spasm and the perma- 
nent muscular rigidity which are constant 
and characteristic phenomena in tetanus, 
are not present in acute spinal menin- 
gitis. 
Nor can hydrophobia be very well con- 
founded with tetanus. In tetanus the 
features are drawn into the risus sardon- 
icus, the eyes are natural, and the whole 
countenance is expressive of pain and 
suffering,-nothing more : in hydrophobia 
there is an impress of excitement and 
distress and horror and unrest upon the 
features which has no counterpart in the 
tetanic countenance. In tetanus the 
body is for the most part rigidly fixed in 
one position by tonic spasm; in hydro- 
phobia the spasmodic movements are 
clonic, and the body is in a state of per- 
petual unrest until the stage of final ex- 
haustion. In hydrophobia, noisy attempts 
are continually made to spit and hawk 
away the viscid phlegm which clogs the 
mouth and throat-the noises being some- 
times not altogether unlike the bark of a 
dog-and any effort to relieve the tor- 
menting thirst, or even the bare thought 
of such an effort, brings on the fit of fear 
and convulsive agitation which has given 
rise to the name hydrophobia : in tetanus 
there are no symptoms which can be con- 
sidered as strictly comparable to these. 
In tetanus, finally, the mind is clear to 
the last, whereas in hydrophobia there is 
almost from the first a peculiar and often 
very wild delirium. 
The tetanic symptoms produced by 
strychnia and some other poisons may be 
more easily confounded with traumatic 
tetanus, but even here it is possible, with 
care, to make a correct diagnosis. It is 
possible, as Dr. Christison pointed out, 
for strychnia to be given in repeated 
doses so regulated as to produce a train 
of symptoms scarcely, if at all, distinguish- 
able from traumatic tetanus ; but not so 
if, as is usually the case, an amount suffi- 
cient to produce death be given in one 
dose. In this latter case, indeed, the dif- 
ferences of the symptoms are sufficiently 
marked. In the toxic tetanus the symp- TETANUS. 
979 
toms run a rapidly fatal course, death 
happening in a quarter of an hour, half 
an hour, and usually within the hour : in 
traumatic tetanus, with very few excep- 
tions, life is prolonged for two or three 
days at least. In the toxic tetanus the 
arms are stretched stiffly out, the hands 
clenched, and the legs separated widely 
from each other and rigidly extended : in 
traumatic tetanus the hands are usually 
free from spasm, and the arms nearly so, 
and even the legs are scarcely ever af- 
fected to the degree which is seen in toxic 
tetanus. In the tetanus caused by strych- 
nia, Mr. Poland says, "The patient can 
open his mouth to swallow ; there is no 
locked jaw in traumatic tetanus, locked 
jaw is the first and most constant mani- 
festation of the spasm. 
The jaw may be locked for a long time, 
and various muscles in other parts may 
be affected with continuous spasm, in 
cases in which hysteria is supposed to 
figure largely as a cause-cases in which 
there is the condition called spinal irrita- 
tion : but these cases, as will appear in 
due time, even when most like, are in 
reality so unlike tetanus as scarcely to 
deserve even this passing mention. 
5. Prognosis.-In the cases "in which 
the access is slow, the spasms by no means 
violent, the paroxysms slight and recur- 
ring at long intervals, and where the pa- 
tient can obtain sleep, whether traumatic 
or not, we may generally anticipate a 
favorable result;" and, again, "the 
longer the interval before the appearance 
of the symptoms, the more chronic the 
disease, and the greater the probability of 
recovery." So speaks Mr. Curling of the 
chronic cases of tetanus in contradistinc- 
tion to the acute ; and in illustration of 
the probability of recovery, he adds : " In 
thirteen cases, symptoms of tetanus oc- 
curred about three weeks after the wound, 
and four only were fatal; and in seven 
cases in which they did not make their 
appearance till after a month, only two 
ended fatally. " In the cases, on the other 
hand, in which the spasms supervene 
rapidly upon the injury, and recur with 
increasing violence at decreasing inter- 
vals, and in which sleep is banished, a 
vast majority die-die, as Hippocrates 
noticed ages ago, within four days. 
Death may happen in a fit of suffocation 
in which sometimes there is obviously 
spasm of the glottis, but more frequently 
it would seem to be brought about by 
asthenia after a fit of spasm. The time 
occupied in recovery varies greatly,-one, 
two, three, four, five, six, seven, eight 
weeks, or even longer. A certain degree 
of weakness and stiffness may also remain 
in the muscles long after recovery. In 
one case rigidity of the muscles of the jaw 
remained for six months; in another it 
returned whenever the patient caught 
cold up to nine months ; and in a third, 
at the end of three years, it is stated that 
the " features retained the indelible im- 
pression of the disease. " These cases are 
given by Mr. Curling. 
6. Treatment.-After passing in re- 
view the principal remedies that have 
been tried in tetanus-opium, blood-let- 
ting, the cold bath and cold affusion, ice 
to the spine, the warm bath, bark, wine 
and spirits, mercury, purgatives, fox- 
glove, tobacco, musk, prussic acid, carbo- 
nate of iron, oil of turpentine, strychnia, 
woorali, ether and chloroform inhalations, 
amputation, division of nerves, tourni- 
quets-Sir Thomas Watson says : " In all 
cases, there being no special indication to 
the contrary, I should be more disposed 
to administer wine in large quantities, 
and nutriment, than any particular 
drugand this statement, I take it, ex- 
presses a very general feeling in this 
country. For my own part, I should 
certainly be more disposed to trust to 
alcohol than to any drug ; but, in saying 
this, I do not say that I should place no 
confidence in drugs. I should certainly 
place no confidence in any sedative or 
narcotic given by the stomach in sedative 
or narcotic doses; but, on empirical as 
well as on theoretical grounds, I should 
say that opium can scarcely be dispensed 
with, and that chloroform or ether inhala- 
tions will be of infinite service in relieving 
pain and spasm, and that too without 
compromising the chances of recovery, if 
care be taken to pour in wine and to sup- 
ply nourishment at the same time so as to 
prevent the patient from waking up almost 
immediately after the inhalation. 
If the rationale of spasm be that which 
is hinted at in the preliminary remarks, 
the great indication of treatment must 
be, not to depress the circulation, but to 
rouse it into greater activity; and one 
reason why the treatment of tetanus has 
been so eminently unsatisfactory may be 
that this indication has not been fully re- 
alized and carried out. In tetanus much 
wine may be given without producing 
anything like intoxication, or without re- 
laxing the spasms in any degree. The 
system in this disease is altogether insen- 
sible to the action of wine in ordinary 
doses. As to this there can be no doubt. 
Whether a different result would have 
been arrived at if alcohol had been given 
more boldly, ardent spirits in place of 
wine, ardent spirits undiluted rather than 
diluted, is yet an open question, but I am 
disposed to think that the spasms might 
have been conquered without compro- 
mising the safety of the patient if this 
had been done. There are now not a few 
cases on record which show that the bite 
of a rattlesnake or cobra or other deadly 980 
DISEASES OF THE SPINAL CORD. 
serpent may be prevented from killing by 
at once giving ardent spirits in sufficient 
quantity, and I am disposed to think that 
these facts have an important bearing 
upon the treatment of tetanus. There 
are, undoubtedly, great differences be- 
tween the condition in tetanus and the 
condition in these poisoned bites, but 
there are also certain resemblances which 
must not be lost sight of. There is the 
same insensibility to the action of alcohol 
in ordinary doses ; there is an exhaustion 
to be counteracted, which is more rapidly 
fatal in the poisoned bite than in tetanus, 
but which in acute tetanus is sufficiently 
rapid to create the gravest fears, and to 
justify the most heroic measures ; there 
may even be a poison at work in both 
cases as well as a wound, a poison intro- 
duced into the wound in one case, a poi- 
son generated in the wound in the other 
case. There are resemblances between 
the two cases, indeed, which, though not 
very close, may be close enough to justify 
the hope that a practice which has been 
found to answer in the bite of a poisonous 
serpent may also be found to answer in 
acute tetanus. 
In speaking thus, it is not intended to 
imply that ardent spirits are the only way 
of fulfilling what has been said to be the 
primary indication of treatment in teta- 
nus. Fan de luce has been found to be 
of great service in the bites of serpents, 
and it might be of service in tetanus. 
Ether, also, might be of use, or turpen- 
tine, or camphor, or ammonia. But to 
my mind these and other medicines of a 
like nature are more likely to disorder the 
stomach and system generally, and in 
other respects are less manageable and less 
certain in their action,than ardent spirit. 
As regards local measures it is less dif- 
ficult to arrive at a conclusion. In many 
cases, no doubt, there is an eccentric irri- 
tation, starting from the wound or some 
other point, and much good would be 
done if this could be removed. It is 
probable, also, that this end might be 
gained in more ways than one, and that 
one very direct way is by the subcutane- 
ous injection of various substances-mor- 
phia, atropine, woorali, conia (which seems 
to be strictly analogous in its action to 
woorali), Calabar bean, &c. The results 
of these injections in causing the relaxa- 
tion of spasm in collection with the minor 
forms of spinal irritation are very en- 
couraging. One thing, however, ought 
to be borne in mind, and that is, that 
these injections should be used so as not 
to produce a general depressing or para- 
lyzing effect upon the nervous system. 
All that ought to be aimed at is to obvi- 
ate local irritation merely ; and, to my 
mind, to go beyond this point is both 
wrong in principle and dangerous in 
practice. 
[Dr. Joseph Hartshorne called atten- 
tion many years ago to the value of vigor- 
ous counter-irritation along the spine, fn 
tetanus. He employed a solution of can- 
tharides in oil of turpentine for this pur- 
pose.-H.] 
For the rest, it is, of course, desirable 
that the patient should be carefully 
guarded from* cold, and from anything 
which would excite or disturb him, as too 
much light or noise, or too meddlesome 
nursing. In a word, quiet and warmth 
are not only desirable ; they are indis- 
pensable. 
V. Locomotor Ataxy. 
Until very recently the disease which 
forms the subject of the present article 
was confounded with paraplegic diseases. 
The difficulty in locomotion, which is the 
most characteristic symptom, was sup- 
posed to be owing to simple paralytic 
weakness of the legs. It was not per- 
ceived that the legs, in the earlier stages 
of the disease at least, had lost little, if 
any, of their power to act separately-so 
little, indeed, that it might require all the 
force of a strong man to bend or straighten 
them against the will of the patient-and 
that what they had lost was that power 
of co-ordination by which the two limbs 
are enabled to act together, as they have 
to do in standing and moving about. The 
credit of having first drawn this distinc- 
tion, and at the same time shown that 
this want of co-ordinating power is so 
associated with a definite group of other 
symptoms as to deserve to be regarded as 
a distinct disease, is due to Dr. Duchenne 
(of Boulogne). Before this time, no 
doubt, the characteristics of such a dis- 
ease had been more or less clearly realized. 
They had been described, in fact, under 
the old name of tabes dorsalis, especially 
in the sketch of this disease given by Dr. 
Bomberg. They had been detected by 
the late Dr. Todd, and not only so, but 
associated with that particular lesion with 
which they are now known to be con- 
nected, namely, with chronic disease of 
the posterior columns of the spinal cord. 
"Two kinds of paralysis of motion," 
wrote Dr. Todd, "may be noticed in the 
lower extremities, - the one consisting 
simply in the impairment or loss of volun- 
tary motion ; the other distinguished by a 
diminution or total loss of the power of 
co-ordinating movements. In the latter 
form, while considerable voluntary power 
remains, the patient finds great difficulty 
in walking, and his gait is so tottering and 
uncertain, that his centre of gravity is 
easily displaced. The cases are generally 
of the most chronic kind, and many of 
them go on from day to day without any 
increase of the disease, or improvement LOCOMOTOR ATAXY. 
981 
of their condition. In two examples of 
this variety of paralysis I ventured to 
predict disease of the posterior columns, 
the diagnosis being founded upon the 
views of the functions of the columns 
which I advocate ; and this was found to 
exist on a post-mortem inspection ; and 
in looking through the accounts of re- 
corded cases, in which the posterior 
columns were the seat of lesion, all seem 
to have commenced by evincing more or 
less disturbance of the locomotive pow- 
ers. ' ' (Cyclopaedia of Anatomy and Phys., 
vol. iii. p. 721, S.) 
Dr. Todd published these remarks in 
1845 ; Dr. Duchenne's first memoir ap- 
peared in 1857. Dr. Todd must, there- 
fore, have the credit of having anticipated 
Dr. Duchenne ; but still the lion's share 
of honor must be assigned to the latter, 
for the plain fact is that Dr. Duchenne 
has developed in a series of formal memoirs 
what Dr. Todd has only indicated in these 
few sentences. In a word, it must be 
allowed that Dr. Duchenne deserves al- 
most the entire credit of being the first to 
detect the exact features of the disease 
now known as progressive locomotor 
ataxy, and to call the attention of others 
to the subject. 
The name of progressive locomotor 
ataxy [ataxie locomotrb e progressive), from 
a, privative, and (order), is that 
which was chosen by Dr. Duthcnne. It 
is not a very fortunate one, but it has been 
adopted, and must be retained, until a 
better one is found. It is certainly to be 
preferred to tabes dorsalis, for this name is 
commonly supposed to imply past inconti- 
nence on the part of the patient. How 
far it is right to perpetuate the cheerless 
affix progressive is, however, very question- 
able. At present, no doubt, the prognosis 
is full of gloom. From bad to worse is the 
common course of things, but, at the same 
time, there are cases-and their number 
is increasing every day-in which the 
symptoms have been long stationary, and 
others in which there has been unequivo- 
cal amendment. But even if the element 
of hope were wanting, it is surely desira- 
ble not to bring this unhappy tact into 
undue prominence. It is surely not neces- 
sary to continue to use an epithet of which 
the effect must be to frighten the patient 
and discourage the practitioner, and this 
too without compensating advantages of 
any kind. As it seems to me, indeed, 
everything is gained by the name loco- 
motor ataxy which is gained by the name 
progressive locomotor ataxy, and nothing 
is lost but what can well be spared ; and 
therefore in what I have to say I shall 
drop the term "progressive," and speak 
simply of " locomotor ataxy." 
motor ataxy, I take from my note-book a 
case which was some time ago (April, 
1865) under my care in the National Hos- 
pital for the Paralyzed and Epileptic. 
Case.-A sailor, thirty-four years of 
age, by name J. C , well proportioned, 
unusually well developed as to muscle 
everywhere, very lean, and much bronzed 
by long exposure to sun and sea. 
(a) This man is capable of walking with- 
out a stick, but his gait is peculiar-stag- 
gering, precipitate, the legs starting about 
vaguely and spasmodically, and the heels 
coming down heavily at each step. With 
his eyes shut, or in the dark, he reels over 
at once and falls to the ground, if left to 
himself. Sitting or lying down, he can 
lift either leg steadily into any position, 
and fix it there so firmly that it is out of 
my power to bend or straighten it against 
his will. In order to do this, however, he 
must see what he has to do, for if his 
eyes are shut, his limb at once becomes 
uncertain and unsteady in its movements, 
and comparatively powerless. His right 
leg is a little weaker than the left, but not 
in any well-marked degree. He finds it 
very difficult to come downstairs, or to 
turn round, or to quicken his pace much, 
and he is speedily fatigued by the acts of 
standing or walking. On being told to 
shut his eyes, and touch his nose with the 
forefinger of each hand in turn, he does 
so with tolerable accuracy, especially with 
the forefinger of the left hand. On being 
told to stretch out his arms, and keep 
them out, he does so, but only so long as 
he is allowed to see what he is doing; for, 
on holding a book up before his eyes, the 
arms, shoulders, neck, and head-the up- 
per part of his body generally-at once 
became afflicted with convulsive agitation. 
When the book was taken away, these 
movements speedily came to an end, but 
not before they had issued in a fit of cry- 
ing and sobbing which was not a little 
distressing to witness. This lit took the 
patient quite by surprise, and it could not 
be accounted for by the examination hav- 
ing been conducted roughly, or carried on 
for an undue length of time ; indeed, the 
holding of the book before the eyes, which 
was the immediate cause of the fit, did not 
occupy more than a minute at the most. 
The muscles of the lower limbs stand 
out firm and hard when made to contract 
by the will, and the contraction seems to 
be not at all wanting in force. Indeed, 
as has been already stated, it is out of my 
power to bend or extend the limb against 
the will of the patient. There is no tremu- 
lousness in the legs or elsewhere, and there 
are no marked reflex movements when the 
soles of the feet are tickled. 
What are complained of chiefly are severe 
pangs of pain, stabbing, boring, in flashes 
like lightning, flitting from one spot to 
another in a very erratic manner, recur- 
1. Symptoms.-As a text for what I 
have to say upon the symptoms of loco- 982 
DISEASES OF THE SPINAL CORD. 
ring in paroxysms varying in length from 
a few minutes to twelve, twenty-four, or 
forty-eight hours, and generally remain- 
ing at the same spot during the same 
paroxysm. These pangs are most fre- 
quently felt in the two feet, especially 
along the outer side of the metatarsal 
bone of the little toe ; and they also are 
not unfrequently met with at the back of 
the thigh, in the nates, and in the upper 
arm about the lower part of the belly of 
the biceps. They are scarcely ever absent, 
especially at night; at night, too, there is 
often a sensation of great coldness, with 
some degree of constriction at the seat of 
pain. 
Tactile sensibility, measured by the 
compasses, is found to be much impaired 
in both feet, especially in the soles, in the 
calves of both legs, and to some degree 
also at the back of the thighs, in the nates, 
and in the palms of the hands. The 
ground is felt very obscurely, but, so far 
as it is felt, the sensations are accurate- 
that is to say, it does not seem as if there 
were elastic cushions, pebbles, or other 
imaginary bodies upon the floor, or as if 
the feet had nothing under them but free 
air, as is sometimes the case. Very rough 
pinching is scarcely at all felt in the be- 
numbed parts, but elsewhere the sensibil- 
ity to painful impressions is keen enough. 
There is also evident impairment of the 
proper sensibility of the muscles, joints, 
and bones in the limbs, and especially in 
the legs. Thus, the patient never knows 
clearly where his feet are without looking 
at them, and now and then he has been 
so uncertain in this respect, that a foot 
has slipped out of bed without his being 
the wiser ; and thus, again, his finger has 
not the power of discriminating between 
a sovereign and a shilling by the weight 
merely. 
The sight of each eye is defective, and 
glasses afford no relief. The pupils are 
equal in size, and respond fairly to the 
light. The conjunctivae are very much 
injected. There is no arcus senilis. There 
is no squinting or ptosis. 
The hearing is so dull as to make it 
necessary to speak in a very loud tone in 
order to be heard, and one ear seems to 
be as deaf as the other. There are also 
constant singing and humming noises in 
the head--"I still hear the wind in the 
shrouds," he says. 
The memory is bad, the spirits are de- 
spondent, and of late (this statement is 
volunteered by the patient) there has been 
a frequent disposition to commit suicide. 
The pulse is feeble, and about 70 in the 
minute. The appetite is good. The 
bowels are somewhat constipated, and a 
long time is spent over a stool. The 
urine is voided slowly, and with difficulty, 
although there is no stricture, and now 
and then it escapes during sleep. Sexu- 
ally, the state may be spoken of as ap- 
proaching to spermatorrhoea. 
(6) Five years ago J. C began to 
suffer from pains in the legs and back, 
and to be unsteady in his gait; about the 
same time, also, his sight and hearing be- 
gan to fail; and from that time to this he 
has continued to get gradually worse and 
worse. Four years ago he had sunstroke 
in the West Indies, of which the imme- 
diate symptoms were violent agitation 
and shaking, without loss of consciousness, 
and for which he was taken into a hos- 
pital and bled. But this accident was 
twelve months after his present malady 
had commenced, and therefore it is not 
possible to look upon it in the light of a 
cause. There never was either squinting 
or ptosis. Ue was at sea seventeen years 
in all, chiefly in hot climates, as the West 
Indies and the West Coast of Africa, and 
he remained on board three years after ne 
had begun to suffer from unsteadiness of 
gait, and from the other symptoms which 
have been mentioned. Once during the 
time he was at sea he had chancres, with- 
out constitutional symptoms; and repeat- 
edly he had diarrhoea; but, with these 
exceptions, his health on all occasions ap- 
pears to have been pretty good. He says 
that he was always very careless, often 
sleeping, almost without clothes, on the 
bare deck, or on the ground, and that he 
was always "too much given to drink and 
women." For the last two years the sex- 
ual inclinations have been much damped, 
but before this time, from what he says, 
he appears to have been little better than 
a very satyr. Two years ago, when 
obliged to abandon his calling as a sailor, 
he was for a while treated in the hospital 
at Quebec for rheumatism. Afterwards 
he found his way to this country, and be- 
came an out-patient first at one hospital 
and then at another. During this time 
he appears to have been frequently blis- 
tered along the spine, and on one occasion 
to have been salivated. For the rest. I 
have only to add that his father died early 
in life of consumption ; that his mother 
died young of some unknown chronic dis- 
ease ; and that a brother, the only child 
besides himself, is now dying of the dis- 
ease which proved fatal to his father. 
This case has not yet ended in a post- 
mortem examination ; and of many other 
cases which have come under my notice, 
not one as yet is ccnuplete in this sense. 
All, therefore, that I can do is to say that 
in other cases of the kind the posterior 
columns of the spinal cord, and the pos- 
terior roots of the spinal nerves, are found 
to be diseased in the lumbo-dorsal region, 
and that the morbid appearances consist 
sometimes in a kind of gray degeneration, 
and sometimes in a gelatiniform and 
translucent condition, in a diminution of 
consistency, or in a state of induration LOCOMOTOR ATAXY. 
983 
called sclerosis. These changes are con- 
fined to the posterior columns of the cord; 
or if they extend further, it is not to the 
antero-lateral column, but only to the 
neighboring portion of the posterior cornu 
of the central gray matter. In the ma- 
jority of cases the disease is confined to 
the lumbo-dorsal portion of the cord, and 
it is only in quite exceptional instances 
that it extends upwards, so as to implicate 
the cervical portion. In the majority of 
cases, the diseased structure is more vas- 
cular than the healthy structure of which 
it has taken the place, the vessels being 
more or less deeply imbedded in oil- 
globules of various sizes, and when ex- 
amined further, it is found to be made up 
of atrophied and degenerated nerve-tissue, 
of the connective tissue in excess, and of 
amorphous granular matter. Now and 
then, also, traces of degeneration have 
been found at the roots or in the course of 
the optic nerves, or of one or other of the 
nerves of the muscles of the eye. 
[The term sclerosis is now, by common 
consent, applied to the morbid change ob- 
served in Locomotor Ataxy, as well as in 
several other spinal affections. (See In- 
duration, in a later part of this volume.) 
Charcot and Pierret have endeavored to 
rior horns, including Clarke's pillars, at 
their bases, are also affected. Lockhart 
Clarke has raised the question whether 
the diseased action does not begin in the 
posterior cornua. 
The conclusions of Erb1 very well repre- 
sent the present state of knowledge upon 
this subject. 
"It is in the highest degree probable 
that in tabes we have to deal with a 
chronic inflammatory process; that it 
merely represents, therefore, one form of 
chronic myelitis. 
" It is possible, and perhaps probable, 
that this chronic myelitis may take its 
origin in two different ways : at one time 
from a primary irritation and degenera- 
tion of the nerve-elements themselves 
(parenchymatous sclerosis), at another 
from a primary irritation and proliferation 
of the interstitial tissue (interstitial scle- 
rosis)-thus giving a double method of 
origination of tabes, as was believed by 
Remak, Sr. 
"It is possible, and perhaps probable, 
that the sclerosis begins in the external 
bands of the posterior columns, and 
spreads from thence further, and that the 
sclerosis of the fasciculi graciles, or Goll's 
columns, must, to a great degree, be re- 
garded as a secondary degeneration. 
"It is certain that the disease 
does not begin in the posterior roots. 
" It is, finally, probable that scle- 
rosis of the posterior columns is not 
the exclusive and essential change 
in tabes, but that a simultaneous 
involvement of the posterior gray 
horns and of certain portions of the 
lateral columns is constant, and, 
perhaps, equally essential-a state- 
ment which, it is true, finds its sup- 
port more in clinical observation 
than in the anatomical facts now be- 
fore us."-II.] 
In order to see how far the case of 
which the notes have just been given 
agrees or disagrees with other cases 
of the kind, I single out, as points 
to be noticed in turn, the following : 
-Difficulty in standing or in moving 
about from inco-ordination of move- 
ment in the lower extremities ; no 
true paralysis in the lower extremi- 
ties ; neuralgic pains, in the feet and 
legs more especially ; more or less 
numbness in all forms of sensibility 
except that by which difference of 
temperature is recognized ; impaired sight 
and hearing; no strabismus or ptosis; 
some incontinence of urine, and some want 
of control over the lower bowel, without 
marked paralysis of the bladder or sphinc- 
ter ani; no obvious impairment of sexual 
power ; no tingling or kindred phenome- 
non : no marked tremulous, convulsive, 
Fig. 59. 
Pierret's ca*e of Locomotor Ataxy: transverse section of 
lumbar portion of spinal cord. A. Posterior roots. B. In- 
ternal radicular fasciculi. On the right, the sclerosis has 
extended to the anterior cornu, C, which has suffered diminu- 
tion in every diameter. Also, the external group of motor 
cells has disappeared ; there being left a dense, opaque, 
fibroid tissue, containing numerous myelocytes. (Charcot.) 
show that, in Ataxy, the sclerotic altera- 
tion begins in the external bands (funiculi 
cuneati) of the posterior columns, near to 
the posterior roots of the spinal nerves. 
The lumbar portion of the cord is the first 
seat of the disease, which afterwards ex- 
tends to the dorsal, and sometimes to the 
cervical region. In the upper part of the 
cord, the columns of Goll (funiculi gra- 
ciles), which lie next to the posterior fis- 
sure, become involved. The gray poste- 
[> Article, Tabes Dorsalis, in Ziemssen's 
Cyclopaedia, vol. xiii.] 984 
DISEASES OF THE SPINAL CORD. 
or spasmodic phenomena; no marked im- 
pairment of muscular nutrition and irri- 
tability; some impairment of mental and 
moral power ; some injection of the con- 
junctivad with contraction of the pupils ; 
the sex and age; and, lastly, the frequent 
limitation of the disti nctive phenomenon of 
locomotor ataxy (the want of co-ordinating 
motor power, to the lower extremities). 
Difficulty in standing or moving about 
from want of co-ordinating motor power to 
the lower extremities. - This difficulty is 
very evident, especially in the act of rising 
from a chair or in turning round suddenly 
when walking. If the patient cannot 
avail himself of some sufficient support at 
the time, the disorder in the movements 
of the leg produced by the act of rising 
from the sitting position, or of turning 
round suddenly when walking, is apt to 
throw him down. Walking is possible 
without a stick, but the gait is precipi- 
tate, staggering, the legs starting hither 
and thither vaguely, and the heels coming 
down at each step in a way which has 
gained for such patients at Grafenberg 
the epithet of stampers. Moreover, it is 
less difficult to move on than to remain 
long in one position standing. In order 
either to stand or walk, however, the help 
of the sight is necessary. In less ad- 
vanced forms of the disease, it may be dif- 
ficult at first to detect inco-ordination in 
the movement of the legs, but this diffi- 
culty is not likely to last long. Often a first 
sign is reeling about upon getting out of 
bed in the dark. The patient may fall 
more than once under these circumstances, 
and think that he is only half awake or 
half sober. In that early stage of loco- 
motor ataxy in which there is no evident 
inco-ordination of movement while the 
eyes are open, there is likely to be such 
disorder when the eyes are shut: and in 
an earlier stage still, even when it may be 
possible to stand steadily with the eyes 
shut, provided the patient be allowed to 
plant his feet where he pleases, it is more 
than likely that he will lose his balance 
if he be made to stand with the inner 
edges of the feet in close apposition. In 
more advanced stages of the disease, 
walking, or even standing, becomes alto- 
gether impossible, and it is curious to no- 
tice the extreme disorder in the move- 
ments of the legs when the patient is 
propped up under the arms, and made to 
try to walk or stand; for under these 
circumstances the legs are seen to go 
every way but the right way-backwards, 
forwards, sideways, unless it happens, as 
it often does, that they get foul of each 
other, and become interlocked. In all 
cases, indeed, the inco-ordination of 
movement in the lower extremities, by 
which standing and moving about are in- 
terfered with in a greater or less degree, 
is a constant symptom in locomotor 
ataxy ; and in a case of average severity, 
like the one under consideration, the gait, 
arising from this want of co-ordination, 
is quite characteristic-namely, precipi- 
tate, staggering, the legs starting hither 
and thither, and the heels coming down 
with a stamp at each step. 
No true paralysis in the lower extremities. 
-When the patient is sitting or lying, he 
can, provided he sees what he is doing, 
move either leg singly, into any position 
with tolerable precision, and keep it there 
steadily ; and the muscular force at his 
command is such, that it is out of my 
power to straighten the limb if bent, or to 
bend it if straightened. There is plainly 
no paralysis. Nor is it otherwise in 
other cases of locomotor ataxia, not even 
in those extreme cases in which the inco- 
ordination of movement in the legs has 
proceeded to the extent of making stand- 
ing an impossibility. And, certainly, it is 
no objection to the conclusion that my pa- 
tient was speedily fatigued by the acts of 
standing or walking, for in reality this 
fatigue may easily be accounted for by re- 
ferring it to the effort necessary to keep 
the ataxic movements of the leg in check. 
Paroxysms of neuralgic pain, in the feet 
and legs principally.-My patient's chief 
complaint was of neuralgic pains-pains 
boring, stabbing, or shooting in their cha- 
racter, pains like those caused by a sharp 
electric shock-in various parts of the 
lower extremities, in the feet especially, 
and sometimes in the arms and abdomen, 
occurring in paroxysms varying in dura- 
tion from a few minutes to many hours, 
flitting from one spot to another, but gen- 
erally remaining at the same spot in the 
same paroxysm. And this was the chief 
complaint from the very beginning of the 
malady. Nor is this case at all excep- 
tional in this respect: on the contrarv, 
pain of the same character is met with in 
the great majority of cases of locomotor 
ataxy. Moreover, Dr. Trousseau speaks 
of this symptom as the most constant pre- 
cursory phenomenon of the disease. In 
some cases, no doubt, pain is either ab- 
sent altogether, or present only as an oc- 
casional symptom of very secondary im- 
portance. ' I have myself met with four 
cases of well-marked locomotor ataxy in 
which there was no pain, or none to speak 
of. The pain may begin in a way in which 
it may be mistaken for rheumatism, and 
be slow in acquiring its special character, 
but it has, as a rule, these special neural- 
gic characters from the first throughout. 
Numbness in all the forms of sensibility 
excepting that by which differences of temper- 
ature are recognized.-In the case under 
consideration the sense of touch is almost 
annihilated in the soles of the feet and in 
the lower parts of the calves of both legs, 
and it is impaired greatly in the back of 
the thighs, in the nates to a less degree, LOCOMOTOR ATAXY. 
985 
and in the palms of both hands. In the 
parts also which are thus benumbed tick- 
ling is felt very obscurely, or not at all, 
and very trifling pain or none at all is 
caused by pinching or pricking. In the 
legs also the "muscular sense," as well 
as the special sensibility of the joints and 
bones, are considerably impaired, as is 
evident in the fact that the patient does 
not know where his feet are unless he can 
see them. Indeed, the only form of sen- 
sibility which seems to be unimpaired, is 
that by which differences of temperature 
are recognized. In other cases of loco- 
motor ataxy, also, a similar state of things 
as to sensation would seem to be the 
almost constant rule, the numbness be- 
ginning, first in tactility, then in the sen- 
sibility to pain and tickling, afterwards 
passing to the "muscular sense," and 
always, curiously, skipping over, or leav- 
ing oil before reaching, the sense by which 
differences of temperature are perceived. 
In some instances the sensibility of the 
mucous membrane of the anus and urethra 
is greatly deadened. The numbness is 
most marked in the lower extremities, 
especially in the feet, and very often it is 
confined to these parts, but now and then 
it may extend further. I know of one 
case in which the tip of the nose and the 
middle of the upper and lower lip are thus 
affected. 
It would-seem to be the rule for numb- 
ness to make its appearance at the same 
time as inco-ordination of movement, 
and for the two symptoms to make pro- 
gress pari passu; but there are cases of 
locomotor ataxy in which, to say the 
least, numbness in any form is a very in- 
conspicuous phenomenon. Moreover, it 
is certain that cases of well-marked loco- 
motor ataxy are met with in which the 
"muscular sense" is not affected. Out 
of nineteen cases, I have met with two 
such. I believe, also, that in cases of lo- 
comotor ataxy in which the "muscular 
sense" is affected considerably, it will be 
often found that this form of numbness 
makes its appearance after the inco-ordi- 
nation of movement, and not before it. 
In a word, I believe that the history of 
locomotor ataxy furnishes little counte- 
nance to a theory which has been ad- 
vanced-that the inco-ordination of move- 
ment in this disorder is nothing more 
than the consequence of loss of muscular 
sense. 
In some exceptional cases of locomotor 
ataxy there may be numbness in some 
parts, and an opposite state of things in 
others. Thus, I have myself met with a 
case in which there is anesthesia almost 
complete in the lower extremities gene- 
rally, and the most distressing hyperes- 
thesia as to tickling in the thumb. But, 
as I have said, cases of this kind are quite 
exceptional. 
Impairment of sight and hearing.-Im- 
pairment of sight appears to be a com- 
mon symptom in locomotor ataxy; im- 
pairment of hearing an occasional symp- 
tom. In the former case, Dr. Hughlings 
Jackson has shown that in the cases 
where sight is impaired or lost there is a 
gradual whitening of the optic disk with- 
out any marked change in the size of the 
retinal arteries and veins-a chronic form 
of atrophy which is more common in men 
than women, and which is not at all 
peculiar to locomotor ataxy. 
[T. Grainger Stewart reports the oc- 
currence of color-blindness, in three out of 
twenty cases of the disease.1-II.] 
Strabismus and p>tosis.-Dr. Duchenne 
and Dr. Trousseau both speak of strabis- 
mus or ptosis as frequently met with in 
the early stage of locomotor ataxy, as 
frequently passing off after a time, and 
not unfrequently as returning, to remain 
permanently, at a later period. Dr. Du- 
chenne has also twice met with paralysis 
of the fifth cranial nerve concurrently 
with paralysis of the third. Speaking of 
these symptoms, Dr. Trousseau says, 
"Some may be absent, but it rarely oc- 
curs that they are all absent in the same 
case. I have nearly always found them, 
and Dr. Duchenne is right in attaching 
great importance to them for diagnosing 
the disease at the onset. Remember, be- 
sides, that they may have been transi- 
tory, and been forgotten by the patient, 
so that the physician must needs make 
careful inquiries in order to discover their 
existence in the patient's previous his- 
tory." Ptosis or strabismus was not 
present in the case which I have given, 
and never had been ; and the same may 
be said of seven out of eighteen other 
cases of locomotor ataxy which have 
come under my notice. In the remain- 
ing eleven cases, strabismus or ptosis, 
one or both, were either present at the 
time of observation, or had been present 
for a time at an earlier period, generally 
at the onset of the disease. I find, also, 
as Dr. Trousseau did, that these paralytic 
affections of the muscles of the eye, or 
the impairment of sight or hearing, may 
be present at an early stage of the dis- 
ease, may disappear for a while, and then 
reappear at a later stage. 
Hb very obvious paralytic condition of the 
bladder or lower bowel.-Incontinence of 
urine at night, and now and then at other 
times, as after unusual fatigue, is a com- 
mon and often a very early symptom in 
locomotor ataxy, and a less common, and 
usually a comparatively late symptom, is 
some trifling want of control over the 
lower bowel. Dr. Trousseau, speaking of 
the phenomena of the fully developed 
disease, says, " Just as in confirmed cases 
[> Brain, July, 1879, p. 189.] 986 
DISEASES OF THE SPINAL CORD. 
of paraplegia, there is paresis of the blad- 
der and rectum, or even paralysis of the 
sphincters." As it seems to me, how- 
ever, there is a marked difference be- 
tween cases of confirmed locomotor ataxy 
and common paraplegia in these respects, 
the difference being that in locomotor 
ataxy there is not that obvious state of 
paralysis of the bladder, or sphincter ani, 
which is so generally present in para- 
plegia. Indeed, I have never met with a 
case of locomotor ataxy in which the way 
in which the bladder could be emptied in 
a steady stream, did not prove that this 
viscus retained a fair amount of power ; 
and in one or two cases of this disease, 
in which the feces have passed involun- 
tarily at times, I have found a state of 
things which enabled me to account for 
this accident without assuming the exis- 
tence of paralysis of the sphincter ani, 
namely, a want of sufficient sensitiveness 
about the anus. Moreover, I do not find 
in the cases which have come under my 
notice one in which the urine was re- 
tained, as it so often is in paraplegia, and 
where the consequences of such retention 
-cystitis, alkaline urine, and the rest- 
were present. Indeed, in all my cases 
the urine has been acid, and otherwise 
healthy - a state of things which is 
scarcely compatible with the presence of 
paralysis of the bladder. 
No obvious impairment of sexual power. 
•-From a sexual point of view, it is easy 
to see that, as a rule, there is a marked 
difference between locomotor ataxy and 
common paraplegia, the difference being 
that in the former disorder there is not 
that impairment of desire and powrcr 
which is so constantly met with in the 
latter. Not unfrequently, indeed, it is 
plain that there is no impairment of sexual 
power in ataxy ; and now and then there 
is a curious exaggeration of virility, evi- 
denced, it may be, in the aptitude to re- 
peated acts of connection within a short 
period. Thus, Dr. Trousseau instances 
twro cases in which these acts could be 
repeated as often as eight, nine, or ten 
times in a single night, and I have met 
with one case which is a fit fellow to these. 
In all these cases spermatorrhoea was a 
symptom. I also know of two cases of 
advanced locomotor ataxy in which fer- 
tilization has been successfully effected, 
and other cases of the kind are on record. 
No tingling or kindred phenomena.- 
Tingling, or sensations analogous to ting- 
ling, are not among the symptoms noted 
in the cases of locomotor ataxy which 
have come under my owrn notice, and, so 
far as I know, they have not occurred in 
other cases of the kind. At any rate, I 
think it cannot be doubted that such 
symptoms are infinitely more common in 
common chronic paraplegia than in loco- 
motor ataxy. 
No obvious tremulous, convulsive, or spas- 
modic phenomena.-Dr. Trousseau says : 
" At an advanced period of locomotor 
ataxy, spasmodic contractions are fre- 
quently observed, not only when the pa- 
tient wills a regular movement, but even 
in the state of rest. In the latter ease, 
they consist in very powerful jerks of the 
limbs, and are an important symptom of 
this singular neurosis." But my expe- 
rience of the disease does not bear out 
this statement. Moreover, the cases given 
by Dr. Bazire, in the valuable appendix 
to his translation of Dr. Trousseau's lec- 
ture on locomotor ataxy, is not confirma- 
tory of the passage in the lecture which I 
have just quoted. Indeed, if I except 
certain attacks of convulsive agitation, in 
which one or two patients have now and 
then awakened out of sleep, and the feel- 
ing of constriction in the abdomen and 
lower extremities, which is occasionally 
met with, and which may possibly have 
some remote connection with spasm, I 
know of nothing in the history of locomo- 
tor ataxy which requires a place in the 
category of tremulous, convulsive, or 
spasmodic phenomena. 
No marked impairment of muscular nutri- 
tion and irritability.-This is another fea- 
ture of locomotor ataxy, and, therefore, 
another point of difference between this 
affection and common paraplegia. The 
electro-sensibility is impaired -in the mus- 
cles in which the "muscular sense" is 
impaired, not the electro-contractility. 
Some impairment of mental and moral 
power.-Bad memory, despondency, sui- 
cidal tendency, are mentioned among the 
symptoms in the case which serves as my 
text, but troubles of this kind do not 
figure in the history of other cases ofloco- 
motor ataxy. In fact, it would seem to 
be the almost constant rule for the mental 
faculties to be unscathed in this disease. 
Some injection of conjunctivce with con- 
traction of pupils.-In the case under con- 
sideration, the pupils were contracted and 
comparatively disobedient to light, and 
the whites of the eyes were considerably 
bloodshot; and this appears to be a not 
unusual state of things in eases of the 
kind. Dr. Trousseau says that he has 
often noticed in ataxic patients, in the in- 
tervals between the paroxysms of pain, 
injection of the conjunctivae, sometimes as 
marked as in the most violent conjunctivi- 
tis,sometimes amounting to a sort of che- 
mosis, and, in association with this, a state 
of extreme contraction of the pupils ; and 
he also tells us that he has seen this in- 
jection of the conjunctivae and contraction 
of the pupils disappear during a paroxysm 
of pain. In J. C , I failed to perceive 
this change during pain. Dr. Bazire also 
failed to perceive it in others who have 
come under his notice. I have observed 
it in two cases, of which that of my friend LOCOMOTOR ATAXY. 
987 
M. Ernst, the prince of violinists, was 
one. In these two cases, what I noticed 
was this - that the eyes ceased to be 
bloodshot, and the pupils opened when 
the pain reached a certain degree of 
severity and continued for a certain time, 
and not otherwise. This I observed on 
several occasions in M. Ernst while he 
was staying with me on a visit; and I 
expect that the discrepancy which at 
present exists between the statements of 
Dr. Trousseau and his translator upon 
this point, will disappear as soon as the 
influence of the degree and duration of the 
pain is taken into account. 
[Occasional arthritic affections.-Charcot 
has described what he designates as the 
arthropathy of ataxic patients.' Without 
known external cause, one of the limbs 
swells considerably, without pain or febrile 
reaction. In a few days the tumefaction 
subsides, except at a joint; commonly the 
knee, shoulder, or elbow, occasionally the 
hip-joint. Hydrarthrus exists, but within 
a week or two the fluid disappears, and 
crackling sounds on motion show the oc- 
currence of change in the articular sur- 
faces. The joint is at the same time very 
movable ; luxations are not infrequent. 
increase or disappear, from time to time, 
as the painful attacks experience exacer- 
bation or remission. 
Disappearance of tendon-reflex.-With- 
in a few years Westphal,1 Erb and others 
have called attention to the significance 
of the absence or modification of pheno- 
mena called those of tendon-reflex, in 
connection with spinal diseases. If a 
person in health sits with one leg crossed 
over the other, or upon a table with the 
legs dangling over its edge, and a smart 
blow is struck upon the tendon of the 
quadriceps femoris muscle, at its junction 
with the patella, the leg and foot will be 
jerked involuntarily forwards. 
Experiments upon animals, by Schulze, 
Siirbringer, Tschirjew, Gowers and others, 
have shown the physiological relation of 
this movement to the nervous system. 
Section of the crural nerve will abolish it. 
Gowers found that the time between the 
tap upon the patella and the muscular 
movement was sufficient for a reflex pro- 
cess, through the spinal cord. Burk- 
hardt's experiments led him to question 
the sufficiency of this interval. It is 
shown, however, that, as there may be 
loss of cutaneous sensibility with persist- 
ence of the movement described (e. g. 
under the influence of ether spray), 
and disappearance of it when the 
sensibility of the skin is exaggerated, 
the phenomenon must be concluded 
to be of a reflex nature. While some 
have thought it explicable by direct 
stimulation of the muscles, through 
their being suddenly made tense, the 
generally prevailing opinion is that 
the contraction is a true excito- 
inotor nervous action, the centre 
concerned being low down in the 
spinal cord. 
Similar to this is the ankle-clonus 
of recent authors. If the foot is 
firmly flexed by pressure on the sole, 
and then the tendo Achillis is tapped 
briskly, the foot at once undergoes 
flexion and extension, in rapid suc- 
cession, for a considerable number 
of times. Gowers found the average 
number of contractions to be a little more 
than six in a second. Joffroy has re- 
garded this as a cutaneous reflex. It has 
been shown, however, to be quite inde- 
pendent of the sensibility of the skin, or 
the liability of the muscles of the limb to 
reflex action from cutaneous excitation. 
By aid of the myograph, Gowers has as- 
certained that the commencement of the 
ankle-clonus occurs too soon after the 
blow upon the tendo Achillis for the im- 
pression to travel up to the spinal cord 
and back to the muscles of the leg. It is 
therefore concluded that, unlike the knee 
Fig. 60. 
Upper extremity of a healthy humerus, and of a humerus 
affected by ataxic arthropathy. (Charcot.) 
In a few months the ends of the bones 
at the joint may be almost entirely de- 
stroyed. Charcot has found these affec- 
tions to coincide with the extension of 
sclerosis to the gray matter of the anterior 
cornua of the cord ; a secondary trophic 
degeneration. 
Cutaneous eruptions.-Papular and even 
pustular eruptions, as well as bed-sores, 
are, according to Charcot and others, not 
rarely associated with the lancinating or 
"fulgurant" pains of locomotor ataxy. 
These eruptions often follow, tolerably 
closely, the track of the nerves which are 
the subjective seats of those pains ; and 
[' Lectures on Diseases of the Nervous 
System, Lecture III.] 
[' Archiv fur Psychiatric und Nerven- 
krankheiten, Ed. v. 1875, p. 819.] 988 
DISEASES OF THE SPINAL CORD. 
phenomenon, the foot-clonus is produced 
by the direct stimulation of the muscles 
both on the front and back of the leg, 
through suddenly increased tension. The 
foot phenomenon is less nearly always 
capable of being brought about in healthy 
persons than that called the knee tendon- 
reflex. 
Clinically, it has been established, that 
the tendon-reflex of the knee is quite con- 
stantly abolished, early, in cases of Loco- 
motor Ataxy; while it is increased in cases 
of lateral sclerosis of the spinal cord 
(spasmodic spinal paralysis). Ankle- 
clonus has, as yet, been less fully studied 
in Locomotor Ataxy. It has been found 
to be produced with unusual facility and 
violence in lateral sclerosis of the cord. 
-HJ 
The sex and age.-Locomotor Ataxy is, 
without doubt, more common in males 
than in females. As regards sex, indeed, 
it is with this as it is with other disorders 
of the spinal cord ; for out of 177 cases of 
all forms of disease of the spinal cord 
tabulated by Dr. Brown-Sequard, as Dr. 
Bazire pointed out, 128 occurred in men, 
and only 49 in women. Locomotor ataxy 
is also a disorder of adult life. In the 
cases which have come under my own 
notice the age ranges from 23 to 60, and 
but few cases are on record in which the 
patient was under 20. Indeed, the only 
cases under 20 would seem to be three 
reported by Dr. Friedrich of Heidelberg ; 
of which the ages are respectively 18, 16, 
and 15 years. 
The probable limitation of the distinctive 
phenomenon of locomotor ataxy (the want of 
co-ordinating motor power) to the lower ex- 
tremities.-In many cases of locomotor 
ataxy the upper extremities are not af- 
fected at all; in others, their sensibility is 
blunted in one form or other, and their 
movements are wanting in precision, 
especially if the sight be defective, or the 
eyelids closed. In the cases in which the 
movements of the upper extremities are 
wanting in precision, there is always, so 
far as I know, more or less impairment of 
sensibility, of the "muscular sense" per- 
haps most frequently ; and my belief is, 
that the want of precision in movement 
is rather to be ascribed to the want of the 
proper guidance of sensation than to the 
loss of any co-ordinating motor power. 
One ground for this belief is the fact that 
the disease of the posterior columns of the 
cord which is met with in locomotor ataxy, 
and upon which, there is every reason to 
believe, the want of proper co-ordination 
in movement is dependent, is confined to 
the lumbo-dorsal region of the cord in the 
great mass of cases. Moreover, it is to 
be remembered that the movements of the 
arms in a biped like man are not so inter- 
dependent as the movements of the legs, 
and that, on this account, movements of 
inco-ordination are less likely to occur in 
the arms than in the legs. It is also very 
possible that some of the cases in which 
the irregular movements of locomotor 
ataxy would seem to have extended from 
the legs to the arms may not have been 
true cases of locomotor ataxy. I remem- 
ber one case of what at first seemed ex- 
treme locomotor ataxy, in which the arms 
were affected as much as the legs, but the 
patient in this case was totally blind and 
bedridden, and all but totally deprived of 
all kinds of sensibility in the arms, and of 
the "muscular sense" in the legs; and 
there was no difficulty in believing that 
the irregular movements of the arms (and 
possibly those of the legs also) were due, 
not to impairment in co-ordinating power, 
but simply to the muscular anaesthesia1 
and the blindness ; and I do not remem- 
ber any case in which the arms were 
affected in which the patient was not 
more or less in the same plight, as to mus- 
cular anaesthesia, if not as to blindness 
also. 
Looking back, then, at the case which 
has been cited, and at the comments to 
which it has given rise, it is not difficult 
to see that locomotor ataxy is character- 
ized by these symptoms :- 
A peculiar gait arising from want of co- 
ordinating motor power in the lower ex- 
tremities-a gait precipitate and stagger- 
ing, the legs starting hither and thither in 
a very disorderly manner, and the heels 
coming down with a stamp at each step. 
No true paralysis in the lower extremi- 
ties or elsewhere. 
Characteristic neuralgic pains, erratic, 
paroxysmal, in the feet and legs chiefly- 
pains of a boring, throbbing, shooting 
character, like those caused by a sharp 
electric shock. 
More or less numbness, in the feet and 
legs chiefly, in all forms of sensibility, ex- 
cepting that by which differences of tem- 
perature are recognized. 
Frequent impairment of sight or hear- 
ing, one or both. 
Frequent transitory or permanent stra- 
bismus or ptosis, one or both. 
No very obvious paralysis of the blad- 
der or lower bowrel. 
No necessary impairment of sexual 
power. 
No tingling or kindred phenomenon. 
No marked tremulous, convulsive, or 
spasmodic phenomena. 
No marked impairment of muscular nu- 
trition and irritability. 
No impairment of the mental faculties. 
Occasional injection of the conjunctivae 
with contraction of the pupils. 
[Occasional secondary inflammations of 
the joints. 
1 Vide article on Muscular Anaesthesia. LOCOMOTOR ATAXY. 
989 
Absence or diminution of tendon-reflex 
movements.-II. ]. 
The probable limitation of the distinc- 
tive phenomenon of locomotor ataxy (the 
want of co-ordinating motor power) to the 
lower extremities. 
For the rest, I will only say that a 
chronic disease with these characteristics, 
and without fever or other signs of disor- 
dered health, may safely be pronounced 
to be locomotor ataxy. 
Dr. Duchenne, whose description of the 
disease is the best as well as the first, 
marks out three stages in locomotor 
ataxy. In the first stage the patient suf- 
fers from paralysis, often only temporary, 
of one or other of the motor nerves of the 
eye, from some degree of amaurosis, usu- 
ally accompanied with unequal pupils, 
and from the peculiar neuralgic pains. 
In the second stage the characteristic un- 
steadiness in standing and moving about 
begins to show itself together with anaes- 
thesia, the interval between the first stage 
and the second varying from a few months 
to several years. In the third stage the 
malady becomes more profound and gen- 
eral, but the precise point at which the 
second stage ends and the third stage be- 
gins is not very clearly defined. Dr. Du- 
chenne does not regard the affection of 
the bladder, the rectum, and the genital 
apparatus as essential symptoms of the 
disease in any of these three stages; he 
regards them as epipldnomenes only. Dr. 
Trousseau does not divide the disease 
into distinct stages, but he speaks of a 
premonitory stage in which paroxysms of 
pain, spermatorrhuea or impotence, pa- 
ralysis of one or other of the motor nerves 
of the eye, and disorder of vision are the 
symptoms to be met with. As Dr. Bazire 
says, however, "it is hardly possible to 
regard these merely in the light of pre- 
monitory symptoms, because they form 
part and parcel of the fully developed dis- 
ease and, in fact, the various symptoms 
are so mixed up together, and make their 
debut at such varying periods, that it is 
not easy to separate symptoms and ar- 
range them in this stage or that. 
[For Morbid Anatomy, see ante, at close 
of account of the case whose symptoms 
are described.-II.] 
2. Causes.-In some cases sexual ex- 
cess would seem to figure as a cause, but 
not in others-not perhaps by any means 
in the majority. And this is one reason 
why it is not well to continue to use the 
name of tabes dorsalis as the equivalent of 
locomotor ataxy, for rightly or wrongly it 
has come to this, that the name tabes dor- 
salis is supposed to imply past abuse of 
the sexual organs. Nor is it possible to 
speak of syphilis, or rheumatism, or gout, 
or struma as a cause, for in a great many 
cases, to say the least, there is no evi- 
dence of one or other of these morbid con- 
ditions. In fact, it is not possible to refer 
locomotor ataxy to any special cause. 
What predisposes to other diseases of the 
nervous system predisposes to this, family 
predisposition especially, and this is all 
that can be said. With regard to family 
predisposition some curious instances 
might be given. I know of one case in 
which one brother is epileptic, another 
brother hypochondriac, and two sisters 
are suffering from different forms of paral- 
ysis ; and Dr. Marius Carre instances a 
family in which eighteen members have 
become ataxic in turn - namely, the 
grandmother, the mother, eight relations 
of the latter, seven children, and one 
cousin. 
3. Prognosis.-The prognosis of the 
disease is unhappily full of gloom. Usu- 
ally, without doubt, the course is slowly 
but steadily in a downward direction-so 
slowly, often, that it is only after the 
lapse of many months, or even years, that 
the patient distinctly realizes the fact of 
having become decidedly worse: but on 
the other hand, several cases are on 
record in which the disease has advanced 
to the extent of destroying the power of 
standing and walking in four or five 
months. Long pauses in the progress of 
the disease are not uncommon ; thus, for 
example, I know of one case in which the 
condition has remained stationary for 
fourteen years. Moreover, it is not im- 
possible to find a few cases in which the 
symptoms have changed for the better 
considerably, and are still changing. 
Cases of this kind, it is true, are not very 
common, but they are to be met with. I 
myself can testify to the existence of sev- 
eral of them. 
4. Diagnosis.-Locomotor ataxy, it is 
said, may be confounded with several dis- 
eases, especially with common chronic 
paraplegia, with simple loss of " muscular 
sense," with cerebellar disease, and with 
chorea, but this can scarcely be if only 
moderate care be taken. 
In common chronic paraplegia there is 
unequivocal paralysis in the lower ex- 
tremities, and the nutrition and irritability 
of the paralyzed muscles are, as a rule, 
unmistakably impaired. In these funda- 
mental particulars, indeed, the difference 
between this affection and locomotor 
ataxy is as complete as it can be. In 
common chronic paraplegia the bladder 
and sphincter ani are implicated in the 
paralysis which affects the legs, and the 
sexual power is almost sure to be greatly 
weakened or entirely extinguished. In 
common chronic paraplegia the charac- 
teristic neuralgic pains of locomotor 
ataxy are wanting, and numbness is 
nothing like so prominent a symptom as DISEASES OF THE SPINAL CORD. 
990 
in the ataxic disorder. In common 
chronic paraplegia, where walking is pos- 
sible, the gait, instead of exhibiting the 
want of co-ordination which is met with in 
locomotor ataxy, is hampered and slow, 
each leg being brought forward with evi- 
dent difficulty even with the help of an 
upward hitch of the body on the same 
side, and the part of the foot first coming 
in contact with the ground being, as a 
rule, not the heel as in ataxy, but the 
toes. In common chronic paraplegia im- 
pairment of sight or hearing, strabismus 
or ptosis, injection of the conjunctiva!, or 
contraction of the pupils, frequent, if not 
constant, symptoms in ataxy, form no 
part of the history. In fact, in these re- 
spects, and in others of minor importance 
which might be mentioned, tlie histories 
of common chronic paraplegia and of loco- 
motor ataxy are so different that it is not 
easy to see how, with only an ordinary 
amount of care, the two disorders can be 
confounded. 
The ataxic movements which depend 
upon anaesthesia muscularis are only pre- 
sent when the patient does not see what 
he is doing: the ataxic movements which 
characterize simple locomotor ataxy con- 
tinue whether the patient see what he is 
doing or not. Nor is this simple rule in 
diagnosis invalidated by the fact that in 
the majority of cases of locomotor ataxy 
the sight has a marked influence in keep- 
ing the unruly muscles in check, for the 
cases are almost exceptional in which loss 
of muscular sense docs not form an im- 
portant element in the disorder. 
In some diseases of the cerebellum 
there appears to be, often at least, the 
same disorder of muscular movement 
which is met with in locomotor ataxy, but 
this resemblance is more apparent than 
real. In the next bed to that then occu- 
pied by the patient whose case has served 
as an instance of locomotor ataxy, was a 
boy, also under my care, whose cerebel- 
lum never seemed to have been properly 
developed, and whose gait was precisely 
that which I have seen in two cases of 
tumor of the cerebellum, and which seems 
to be associated with serious cerebellar 
disease in all cases. This boy reeled and 
rolled about in walking, but there was 
nothing peculiar in the way in which he 
moved his legs and planted his feet; on 
the contrary, these movements were those 
which would be instinctively made to pre- 
vent falling. He was not giddy, but 
merely unsteady, and the volitional and 
automatic movements of his legs were 
what they ought to be under the circum- 
stances, no more. His mode of progres- 
sion was widely different from that of the 
ataxic patient, as was at once apparent 
when the two were set to walk side by 
side ; how different I need not again stay 
to say. In certain diseases of the cerebel- 
lum also, some symptoms are likely to be 
present which will assist in the formation 
of a correct diagnosis, especially violent 
pain, often augmented by movement, in 
one or other part of the head, and frequent 
and obstinate vomiting, and at the same 
time other symptoms are likely to be ab- 
sent which are present in locomotor 
ataxy; namely, neuralgic pains and 
anaesthesia in the feet and legs, and else- 
where. 
In chorea there is great want of co-ordi- 
nating motor power, but the history is 
quite different from that of locomotor 
ataxy. Chorea is an affection of child- 
hood and earlv youth ; locomotor ataxy of 
adult life. The choreic muscular disturb- 
ances affect especially the head and arms ; 
the ataxic are chiefly confined to the legs. 
Moreover, there are not in locomotor 
ataxy those involuntary movements which 
in chorea keep the affected muscles in a 
state of almost perpetual unrest. And as 
to the other symptoms, it is, in fact, a 
question of differences, not of resem- 
blances. 
It must not be forgotten, however, that 
the different diseases of the nervous sys- 
tem, like all other diseases, are not fenced 
in by any boundaries except those which 
have been fixed almost arbitrarily for the 
convenience of description, and that cases 
of a mixed character are continually being 
met with, which in reality lie across these 
boundaries in every direction. 
5. Treatment.-The treatment of 
locomotor ataxy is not a subject upon 
w hich much can be said at present. No 
specific treatment can be recommended on 
good grounds, not even that by nitrate of 
silver, about which so much has been said 
of late in Germany and France ; and the 
only treatment which finds favor in my 
eyes is one of a general character in w Inch 
figure some preparation of phosphorus 
with or without cod-liver oil, or arsenic, 
or bichloride of mercury. [Althaus1 says 
that he has "completely cured" two 
cases with drachm doses of liquid extract 
of ergot, three times a day, continued for 
six or eight months.-H.] I should 
endeavor to act upon general principles, 
meeting as well as I could any special 
indication, as syphilis, or gout, or rheu- 
matism, or struma. I should trust to a 
liberal allowance of stimulants rather 
than to sedatives for the relief of pain : 
and for the relief of pain also I should 
have much confidence in regular sham- 
pooing, in faradization, and the use of 
positive statical electricity. I am also 
disposed to think that good may be done 
by the use of irons and crutches, one or 
both. What is chiefly at fault is the 
[' Amer. Journal of the Med. Sciences, Oct. 
1878, p. 348.] SPINAL IRRITATION. 
991 
motor power by which the two legs act in 
concert in standing and moving about; 
and what is wanted primarily is to do 
away, as far as possible, with the neces- 
sity for calling into exercise this power 
until it can have had time to recover by 
rest. This is an intelligible indication, 
and the use of irons or crutches is an 
intelligible means of carrying it out. 
Perhaps it is too much to expect that 
great good can be done in any way in ad- 
vanced stages of the disease ; but in early 
stages I cannot but think that the disease, 
to say the least, might be arrested if the 
patient would consent for a longer or 
shorter time to the use of these means. 
For surely it must go far to neutralize the 
good to be derived from treatment if the 
patient is continually trying to do, by 
walking about without help, or with only 
the imperfect support of a stick, what the 
diseased condition of his spinal cord inca- 
pacitates him from doing. Nor are these 
remarks alone applicable to the treat- 
ment of locomotor ataxy ; on the con- 
trary, they apply equally to the treatment 
of all forms of spinal disease in which the 
acts of standing and moving about are at 
all compromised. 
VI. Spinal Irritation. 
The first important work on the dis- 
order now generally known as spinal irri- 
tation was published by Mr. Teale, of 
Leeds, more than forty years ago ;* the 
next by the brothers Dr. and Mr. Griffin, 
of Limerick, about fifteen years later.2 
To Mr. Teale, indeed, belongs the credit 
of being the first to direct attention to 
this disorder, for, in reality, his claim 
either to priority or originality is scarcely, 
if at all, invalidated by the short commu- 
nications which were made previously 
to medical periodical literature by Mr. 
Player, of Mahnsbury,3 by Dr. Brown, of 
Glasgow,4 by Dr. Darwell, of Birming- 
ham,5 and still less so by anything written 
about the commencement of the century 
by Franks, Nicod, Ludwig, and others. 
It would also seem to be difficult to find 
any work of more recent date which de- 
serves to be mentioned as at all equal in 
merit and importance to that of the 
brothers Griffin. The name " spinal irri- 
tation" was first proposed by Dr. Brown, 
of Glasgow. 
1. Symptoms. -The symptoms of spinal 
irritation at lirst sight appear to be as 
vague and various as those of hysteria. 
They are in reality so far hysterical as to 
be not readily distinguishable. When 
further examined, however, one symptom 
stands out prominently, with which the 
others are obviously connected in a pecu- 
liar manner, namely, spinal tenderness; 
and the upshot of the whole matter ap- 
pears to be that spinal irritation is a 
definite malady which must not be con- 
founded with hysteria or with any other 
disorder. Tor example :- 
Case.-In the early part of 1863, an 
unmarried lady, aged twenty-three, con- 
sulted me for pains in the head and face, 
loss of appetite, nausea, flatulence, palpi- 
tation, breathlessness, "sinkingfeelings," 
weakness, and low spirits. The pain, 
which was the chief suffering complained 
of, was sharp and neuralgic in its charac- 
ter, and varying in its seat, being some- 
times in one part of the head or face, 
sometimes in another, and generally on 
the left side only. In the head it was 
often limited to a spot which might be 
covered with the tip of the finger, as in 
true clavus hystericus. Headache in one 
form or another was brought on or exag- 
gerated by any effort, physical or mental: 
it was usually relieved by lying down and 
keeping perfectly still; it was scarcely 
ever absent except when face-ache had its 
turn; and sometimes it was so continuous 
and oppressive as to necessitate remain- 
ing in bed for days together. Nausea 
and sickness were its frequent accompani- 
ment, and vomiting and great prostration 
were its common termination. In the 
cervical region of the spine there were 
considerable tenderness and a disagree- 
able feeling of weight, and pressure there 
brought on or increased the headache- 
the pain shooting from the occiput for- 
wards- and caused a feeling of great 
nausea and oppression at the prsecordia. 
The feet were always cold ; ' ' chills and 
flushes" were of frequent occurrence, and 
so were yawning, sighing, and stretching 
of the arms. Sleep was often made 
hideous by nightmare ; fits of lowness of 
spirits and crying, attended by a sense of 
choking, as from a ball or knot in the 
throat, and followed by plentiful gushes 
of pale, limpid urine, were brought on by 
the most trival causes; and the manner 
and appearance were altogether those of 
an eminently nervous or hysterical per- 
son. Menstruation was regular, neither 
excessive nor deficient, and it could not 
1 A Treatise on Neuralgic Diseases depend- 
ent upon Irritation of the Spinal Marrow and 
Ganglia of the Sympathetic Nerve. By T. P. 
Teale, 8vo. London: Highley, 1829. 
2 Observations on the Functional Affections 
of the Spinal Cord and Ganglionic System of 
Nerves, in which their Identity with sympa- 
thetic, nervous, and irritative Diseases is il- 
lustrated. By William Griffin, M.D., and 
David Griffin. 8vo. London: Burgess and 
Hill. 1844. 
3 Quarterly Journal of Science, January, 
1822. 
4 Glasgow Medical Journal, May, 1828. 
5 Midland Medical and Surgical Reporter, 
May, 1829. 992 
DISEASES OF THE SPINAL CORD. 
be said that the sufferings were either 
more or less at this time. The bowels 
also acted properly, and (but for the dis- 
position to pass large quantities of pale 
urine, which has been already mentioned) 
so did the kidneys and bladder. 
These symptoms, it appears, had their 
starting-point about twelve years ago in 
the shock and grief caused by witnessing 
the death of a brother, her last remain- 
ing near relative, in an epileptic fit, and 
ever since this time they have continued 
very much as they now are, with but lit- 
tle intermission. Before this time the 
personal history of the patient was toler- 
ably good, but not so her family history ; 
for, in addition to the brother whose 
death in epilepsy has just been men- 
tioned, it appears that her father died 
years before of phthisis, and that her 
mother is now in a lunatic asylum. 
Under the use of a more liberal diet, 
with ammonia and calumba, and with 
occasional blisters to the nape of the neck, 
health was re-established in little more 
than a month, notwithstanding the fact 
that several days at the commencement 
were wasted in overcoming a dislike to 
take the wine and medicine necessary- 
in converting, in fact, the patient from a 
firm belief in teetotalism and homoeopa- 
thy. 
Towards the close of the same year, 
18G3, this young lady again returned to 
me, looking very worn and thin, with all 
her old symptoms in force, and with cough 
and difficulty of breathing in addition. 
The cough was very violent, barking, un- 
attended with expectoration, and often 
carried on until it ended in retching and 
vomiting. The difficulty of breathing 
was chiefly at night: usually it did not 
amount to more than what might be met 
by a voluntary effort at inspiration; now 
and then it seemed to deserve the name 
of asthma; almost invariably it wras ac- 
companied, not by a feeling of a ball or 
knot in the throat, but by a sharp pain in 
the left hypochondrium, or else by severe 
aching in the left shoulder and down the 
left arm. Percussion and auscultation 
failed to bring to light any signs of disease 
in the heart or lungs, but pressure along 
the spine revealed tenderness in the cer- 
vical and upper dorsal regions, in the lat- 
ter especially, and at the same time 
brought on cough, deep inspirations, pain 
and throbbing at the epigastrium, and a 
feeling of great faintness and breathless- 
ness. 
On this occasion a very fair state of 
health was soon re-established by the 
plan of treatment which proved success- 
ful in the first instance. 
At the beginning of 18G5, this lady 
again required my services. For the 
three weeks before my seeing her she had 
been in bed, with her thighs drawn up 
tightly against her abdomen, and with 
her heels buried in her nates. This con- 
traction was unremitting during the wak- 
ing state, and only partially remitting 
during sleep: it was unattended by pain ; 
and it could be partially overcome, for a 
time, without causing much pain in the 
contracted muscles, by slow and steady 
extension. The headache and face-ache 
had gone months before, and so had the 
pain in the epigastrium and in the left 
shoulder and arm ; the cough and diffi- 
culty of breathing and palpitation were of 
very unfrequent occurrence ; the appetite 
and digestion and the action of the bowels 
were tolerably natural; and what was 
complained of now were colicky pains in 
the lower part of the abdomen, pains 
often very severe and sickening about the 
loins and hips, and in the region of the 
left ovary, with constant calls to pass 
water, and much pain in the urethra in 
attending to these calls. The spine was 
now tender, not as before in the cervical 
and dorsal region but low down in the 
lumbar region, and pressure on the ten- 
der part brought on colicky pains in the 
lower part of the abdomen, and a cutting 
pain in the urethra, with an almost irre- 
sistible impulse to pass water then and 
there. Pressure in the cervical and dor- 
sal regions of the spine gave rise, not to 
the marked symptoms produced in this 
way in the two previous illnesses, but 
simply to a disagreeable thrill all over the 
body. There was no numbness or ting- 
ling in the legs or elsewhere, and no hy- 
pereesthesia, except perhaps to a very 
trifling degree over the left ovary. Tick- 
ling the soles of the feet gave rise to pain- 
ful spasmodic shocks in the legs, to a dis- 
agreeable thrill passing up the body as 
high as the throat, and to the involuntary 
escape of a small quantity of urine. The 
condition as to general health was tolera- 
bly good-much better than during the 
two previous illnesses : and, in fact, the 
only sign of disorder, in addition to those 
which have been indicated (and this can 
scarcely be reckoned as such), was the 
absence of menstruation since the birth of 
a child about three months ago. 
Somewhat more than twelve months 
ago, after having been quite well for the 
year previously, this patient married and 
became pregnant. In the early months 
of pregnancy she had much headache, 
depression, weakness, and sickness; but. 
after a while these symptoms passed off, 
and everything went on smoothly and 
satisfactorily until two months after con- 
finement, when her baby died suddenly. 
And then began her present troubles. 
The fretting about her baby brought back 
the old headaches, the headaches produced 
great sleeplessness and irritability of the 
stomach, and then came on a state of un- 
controllable fidgetiness, which kept her SPINAL IRRITATION. 
993 
incessantly moving about until her legs, 
one leg especially, failed altogether, and 
obliged her to take to her bed. The very 
next morning her legs had become con- 
tracted, and she herself is convinced that 
this change for the worse, as she regards 
it, was brought about by the pain and 
loss of blood produced by introducing a 
large speculum and by applying leeches 
to the os uteri on the previous evening. 
The treatment on this occasion consisted 
chiefly in a liberal allowance of food and 
wine, in repeated blisterings to the lum- 
bar region of the spine, and in the admin- 
istration of bromide of potassium and am- 
monia ; the result was the cessation of 
the contractions in about three weeks, 
and the complete re-establishment of 
health in about two months and a half. 
In commenting upon this case with the 
view of separating the general phenomena 
of spinal irritation from the particular, I 
take the following as the points which 
most deserve to be attended to, namely, 
these : Spinal tenderness, neuralgia, spas- 
modic cough and difficulty of breathing, 
palpitation and vascular throbbings, nau- 
sea, vomiting and eructations, and irrita- 
bility of the bladder, all in connection 
with spinal tenderness ; the connection of 
particular symptoms or groups of symp- 
toms with tenderness in particular parts 
of the spine ; prolonged muscular contrac- 
tion ; no paralysis of the limbs; no pa- 
ralysis of the bladder or rectum; no numb- 
ness ; variability and inconstancy of the 
symptoms ; a nervous constitution. 
Spinal tenderness.-In the great majority 
of cases this symptom would seem to be 
present in spinal irritation and absent in 
spinal meningitis, myelitis, or spinal con- 
gestion, acute or chronic. It would seem, 
indeed, to deserveto be regarded as the pa- 
thognomonic symptom of spinal irritation; 
for in the few cases of spinal meningitis, 
myelitis, or spinal congestion in which it 
is met with, there is reason to believe 
that its presence may be accounted for by 
the association of the phenomena of irri- 
tation with those of inflammation or con- 
gestion. At any rate, it is certainly the 
rule that spinal irritation without spinal 
inflammation or congestion is accompa- 
nied by spinal tenderness, and that spinal 
inflammation and congestion without spi- 
nal irritation is not accompanied by spinal 
tenderness. Spinal tenderness, however, 
can scarcely be spoken of as a prominent 
symptom in spinal irritation. It is often 
not complained of until it is specially in- 
quired after ; and now and then its exist- 
ence is not even suspected by the patient 
until he or she is made to wince under 
pressure applied to the spine. In a few 
cases which from their symptoms would 
seem to come under no other head than 
that of spinal irritation, there is no spinal 
tenderness-only five such cases are met 
with among the 148 cases brought together 
by the brothers Griffin, and these may 
without difficulty be in great measure ex- 
plained away; but such cases are much 
too exceptional and doubtful to throw 
discredit on the rule in question, that 
spinal irritation and spinal tenderness go 
together. Spinal tenderness, however, 
does not appear to be equally marked in 
all forms of spinal irritation. It appears 
to be much less marked where the irrita- 
tion shows itself in spasm and prolonged 
muscular contraction than in the cases 
where it shows itself in pain; and it is 
certainly absent in tetanus, which in one 
sense may be looked upon as the manifes- 
tation of spinal irritation in its most ag- 
gravated form. 
Nervous pains, often in connection with 
tenderness in a particular part of the spine. 
-Nervous pains, neuralgias, in one place 
or another, often intermittent and more 
or less regularly periodical, and often 
shifting suddenly from one place to an- 
other, are a very common, perhaps the 
most common, symptom in spinal irrita- 
tion. They are often brought on or exag- 
gerated by lifting any weight, by twisting 
or straining the back in any way, or by 
any effort, mental or physical: and as 
often they are relieved, to some extent at 
least, by lying down. Very often, also, 
there is tenderness in the portion of the 
spine corresponding to the insertion of the 
affected nerves - in the upper cervical 
region, where the pains are in the scalp 
(clavus hystericus, megrim, and others), 
face, or neck ; in the lower cervical region, 
where they are in the upper extremities, 
shoulders, and upper part of the thorax ; 
in the dorsal region, where they are in 
the lower part of the thorax and upper 
part of the abdomen (pleurodynia, gastro- 
dynia, infra-mammary stitch, and others); 
in the lumbar and cervical regions, where 
they are on the lower part of the abdo- 
men, hips, loins, and lower extremities. 
In the majority of cases the pain would 
not seem to be in the part of the spine 
which is tender, or in any other part. In 
some cases there may be aching in some 
part of the spine, or else a sense of weight 
and heat; but I am very much inclined 
to believe that these last mentioned symp- 
toms, and "back-ache" generally, have 
often to be referred to spinal congestion 
rather than to spinal irritation in its un- 
complicated form. When the spina1 ten- 
derness is very great, slight pressure will 
often cause pain to strike from the tender 
spot of the spine to the distant seat of 
pain, or will bring about or exaggerate 
this pain. This fact is illustrated in the 
case I have given, and better still in some 
of the cases related by the Griffin brothers. 
In one of these cases, for example, where 
the whole spinal column was found to be 
vol. I.-G3 994 
DISEASES OF THE SPINAL CORD. 
acutely tender, "pressure of the first or 
second vertebra occasioned pain, which 
shot forwards from the occiput to the 
brow ; a little lower, pain was excited at 
the larynx ; on pressing one of the lower 
cervical, it occurred at the point where it 
dips behind the sternum ; on pressing the 
upper dorsal, at the middle of the ster- 
num ; from the third or fourth dorsal to 
the eighth or ninth, it was excited at the 
ensiform cartilage; yet lower, at the 
sides; and in the lumbar vertebra?, pain 
was excited in the iliac and pubic regions" 
(p. 19). And in another case, where 
there was some tenderness of the middle 
cervical vertebra?, and acute tenderness 
from the fourth dorsal to the eighth or 
ninth, "pressure on any of those last, 
especially the seventh or eighth, brought 
on violent pain, which darted forwards to 
the ensiform cartilage. When the last- 
mentioned vertebra was pressed upon, the 
patient said that she thought her ' heart 
would break' " (p. 119). The pain is 
often curiously localized : sometimes it 
gives the idea of a nail being driven into 
the part, as in clavus hystericus; some- 
times the feeling produced by it is as if 
a walnut or other hard substance were 
pressed under a tight belt; sometimes it 
is very severe, and neuralgic in its cha- 
racter rather than rheumatic : and not 
unfrequcntly, when it has existed some 
time, the painful part becomes tender on 
pressure. Most generally this morbid 
sensation is in the form of pain, but now 
and then it may take that of cold, ting- 
ling, itching, or some other feeling which 
is disagreeable rather than painful. The 
amount of constitutional disturbance at- 
tending the pain varies very much, but it 
is usually comparatively trifling, and, as 
it would seem, quite out of proportion to 
the degree of suffering. 
Nausea, retching, vomiting, eructation, &c. 
often in connection with tenderness in a par- 
ticular part of the spine.-These are com- 
mon symptoms in spinal irritation : next 
to pain, indeed, they are perhaps the most 
common. They are also intimately con- 
nected with certain forms of pain, espe- 
cially cephalalgia and gastrodynia, some- 
times preceding, sometimes accompany- 
ing, but more generally following, the 
pain. As regards the particular part of 
the spine which is likely to be tender 
when the stomach is the seat of irritation, 
the Griffin brothers say that " nausea and 
vomiting appear to bear more relation to 
tenderness of the cervical spine, pain of 
stomach to tenderness of the dorsal; but 
that where there was soreness of both, 
nausea and vomiting was still more fre- 
quent, and pain of stomach scarcely ever 
absent. " The epigastric disorder in these 
'cases is generally accompanied with ten- 
derness on pressure, not merely in the 
spine but also in the epigastrium and in 
the left hypochondrium-with those three 
patches of tenderness which M. Briquet 
speaks of as the "trepied hysterique"- 
as the tripod upon which the" diagnosis of 
hysteria rests. 
Spasmodic cough, difficulty of breathing, 
&c., often in connection with tenderness in a 
particular part of the spine.-These again 
are symptoms which are common enough 
in spinal irritation, and mostly so, as it 
would seem, when the tenderness in the 
spine is in the cervical and upper dorsal 
region. 
Palintation, &c., often in connection with 
tenderness in a particular part of the spine. 
-Palpitation is another symptom of 
spinal irritation which seems to be often- 
est met with when there is tenderness in 
the upper half of the spine. It seems to 
be not unfrequcntly associated with a 
feeling of epigastric pulsation, and with 
nausea, vomiting, and other signs of gas- 
tric disorder. Vascular throbbings in 
other places, as in the temples, and 
"chills and flushes," and a disposition to 
syncope, and other signs of disturbed bal- 
ance in the circulation, may, and often 
do, go hand in hand with the palpita- 
tion, and seem to have to do with the 
same condition of the spine. 
Irritability of the bladder, often in connec- 
tion with tenderness in a particular part of 
the spine.-This was a marked symptom in 
the case which I have related when the seat 
of spinal tenderness shifted to the lumbar 
region, and it seems to be a very common, 
if not a constant symptom, in cases in 
which the tenderness is in this region. 
The connection of particular symptoms or 
groups of symptoms with tenderness in par- 
ticular regions of the spine.-The data best 
calculated to illustrate this connection are 
those supplied by the brothers Griffin. 
These consist of no less than 148 cases, of 
which 26 are in males, 49 in married 
women, and 73 in girls. In these 148 
cases, the spinal tenderness was in the 
cervical region in 28, in the cervical and 
upper dorsal region in 46, in the dorsal 
region in 23, in the dorsal and lumbar 
region in 15, in the lumbar region in 13, 
and in the spine generally in 23. In the 
following table the prominent symptoms 
connected with each one of these forms of 
spinal tenderness are set forth in a way 
which requires no comment except this- 
that this grouping of symptoms with ten- 
derness in particular parts of the spine 
must only be looked upon as approximat- 
ing to the truth, and that now and then 
any symptom may appear out of the order 
in which it is set down. SPINAL IRRITATION. 
995 
Pegion of Spinal Tenderness. 
A. Cervical region. 
Cases 28 in number. 
B. Cervical and Dorsal region. 
Cases 40 in number. 
C. Dorsal region. 
Cases 23 in number. 
D. Dorsal and Lumbar region. 
Cases 15 in number. 
E. Lumbar region. 
Cases 13 in number. 
F. All regions together. 
Cases 23 in number. 
Prominent Symptoms. 
Headache, nausea, vomiting, face-ache, fits of in- 
sensibility, cough, pains in the upper extremities, 
&c. 
Nausea and vomiting in 5 cases, pains of stom- 
ach in 2 only. 
In addition to the symptoms in group A, pain of 
stomach and sides, pyrosis, palpitation, oppression. 
*** Pain of stomach in 34 cases, nausea and vomit- 
ing in 10. 
Pain in the stomach and sides, cough, oppression, 
fits of syncope, hiccup, eructations. 
*** Pain in the stomach in almost all these cases, 
nausea or vomiting in only one. 
In addition to the symptoms in group C, pains in 
the abdomen, loins, hips, lower extremities, dysury, 
and ischury. 
*** Nausea in only one case. 
Pains in the lower part of the abdomen, testes, or 
lower extremities, dysury, ischury, disposition to 
paralysis in lower extremities. 
*** Retching and spasm of the stomach in one case 
only. 
A combination of the foregoing groups of symp- 
toms, one group changing into another as the spinal 
tenderness becomes more marked in one region than 
in another. 
Prolonged muscular contraction.-This 
is a very conspicuous symptom in the 
case which serves as my text, and it is no 
uncommon symptom in other cases of 
spinal irritation. The lower extremities 
appear to be the parts most commonly 
affected, one or both of them ; but the up- 
per extremities can claim no exception, 
nor even the muscles of the jaws and neck, 
trismus or torticollis being among the re- 
sults in this latter case. '' Occasionally, ' ' 
says Mr. Teale, " there is an inability to 
perform complete extension of the elbow, 
the arm appearing restrained by the ten- 
don of the biceps, pain and tightness be- 
ing produced in this part when extension 
is attempted beyond a certain point 
and to this fact I can testify. Moreover, 
I can testify as to the not unfrequent oc- 
currence of long-continued closing of the 
fingers and thumb upon the palm. The 
rule appears to be, for the extremities to 
be affected before the trunk or head. 
This contraction, which is generally pain- 
less, may be prolonged for weeks or even 
months continuously, even during sleep, 
or with occasional intermissions of uncer- 
tain duration ; and the attacks, primary 
or secondary, are usually found to begin 
and end suddenly and unexpectedly. The 
relations between this form of contraction 
and that which occurs in other cases, 
especially in tetanus and in that some- 
what vague disorder to which Dr. Trous- 
seau lias given the name of tetany (teta- 
nic), are not very easily determined. In 
tetanus, with very rare exceptions, the 
contraction is painful, especially in the 
paroxysmal bouts, and the order in which 
it attacks the body is different-first, the 
jaws ; then the trunk ; and the extremi- 
ties only at a late period, if at all. In 
tetany, as in tetanus, the contraction is 
painful, but the order in which the body 
is attacked is different to that which is 
observed in tetanus, centripetal not cen- 
trifugal,-first the extremities, then the 
trunk or head; the contraction, in fact, 
being confined to the extremities, except 
in cases of unusual severity. In the way 
in which it affects the extremities first, 
and often exclusively, the contraction of 
tetany agrees with the contraction under 
consideration, but in other respects it dif- 
fers. It differs, especially, in being ush- 
ered in and accompanied by symptoms 
which do not seem to form part and par- 
cel of simple spinal irritation ; namely, 
tingling and some degree of anaesthesia, 
and also (so it is said) in the form of the 
contracted hand being peculiar-like that 
which the hand of the accoucheur takes 
in order to be introduced into the vagina 
-and in the possibility of bringing on the 
contraction by firm pressure upon the 
principal nerves or arteries of the affected 
muscles. It may be questioned, however, 
whether there are absolutely fixed lines oi 996 
DISEASES OF THE SPINAL CORD. 
division between these different forms of 
prolonged contraction, and whether the 
difference which exists may not be ac- 
counted for as the result of different de- 
grees of irritation, affecting, it may be, 
different parts of the spinal cord. It may 
be questioned, also, whether a sufficient 
case is made out for describing tetany as 
a definite disorder, and whether it is not 
rather a form of spinal irritation compli- 
cated with some graver spinal disease- 
spinal meningitis, myelitis, spinal conges- 
tion-in varying proportions. The asso- 
ciation of tingling and numbness with the 
prolonged contraction is, as it seems to 
me, a reason for an affirmative conclusion. 
At any rate, prolonged muscular contrac- 
tion, be its significancy in tetanus or teta- 
ny what it may, must be looked upon as 
a not unfrequent symptom in single spinal 
irritation-as a symptom, too, which is 
usually of no very grave import. Of this 
there need be no doubt. 
No paralysis of the limbs.-In the case 
I have given in illustration there was 
great weakness of the legs, and one leg 
seemed to "drag" immediately before 
the contractions came on. There was a 
disposition to paralysis in the legs, but 
not more than this ; nor do I find paraly- 
sis of the limbs among the symptoms of 
spinal irritation strictly so called. There 
is, no doubt, a connection between pa- 
ralysis and spinal irritation which cannot 
be overlooked; and under that form of 
paralysis which is known as "hysterical 
paralysis," and about which more will 
have to be said in due time, and under 
spinal irritation, there is a common basis. 
As it seems to me, however, it is patho- 
logically as well as physiologically incor- 
rect to speak of hysterical paralysis as a 
symptom of spinal irritation. Also, it 
seems to me, the right place of this pa- 
ralysis is after spinal irritation, not along 
with it, when the capability of morbid 
action which is implied in the term irri- 
tation is worn out; and so in the other 
exceptional cases in which paralysis is 
connected with spinal irritation, it will, 
I believe, be found on careful examina- 
tion that the paralysis is not a symptom 
of actual spinal irritation, but of a state 
of vascular change into which this irrita- 
tion may issue and has issued-spinal 
congestion, it may be, or even myelitis. 
No paralysis of the bladder or bowel.- 
The remarks which have just been made 
apply equally to paralysis of the bladder 
or sphincter ani. Paralysis in either of 
these parts, or even a disposition to it, is 
rarely met with in any case which can be 
strictly brought under the head of spinal 
irritation ; and in the few exceptional in- 
stances which do occur, it is plain enough, 
when the matter is fairly inquired into, 
that the boundary has been passed which 
separates the state of irritation from the 
state of exhaustion, and that, in fact, the 
case is no longer one of simple spinal irri- 
tation. 
No numbness.-Numbness, again, is a 
symptom which is scarcely ever met with 
in cases to which the name of spinal irri- 
tation is strictly applicable, and, when it 
is met with, it is easily accounted for. In 
short, the relationship of numbness and 
paralysis to spinal irritation appears to be 
one and the same, the numbness and the 
paralysis being alike connected, not with 
the state of morbid action called irrita- 
tion, but with the after-state of morbid 
inaction for which exhaustion seems to be 
one of the appropriate names. 
Variability and inconstancy of symptoms. 
-One most characteristic feature of 
spinal irritation is the way in which one 
symptom or group of symptoms may 
change, and change suddenly, into an- 
other symptom or group of symptoms. It 
is now this disease which is simulated, 
now that, there being scarcely any dis- 
ease which may not be copied : at one 
time the head is affected, at another the 
chest, at another the abdomen or the ex- 
tremities : and the only thing constant 
among these ever-shifting phenomena ap- 
pears to be this-that the spinal tender- 
ness changes from one part to another in 
a manner which is intelligible enough 
when the connection of the spinal nerves 
with the affected part is taken into con- 
sideration. 
A nervous constitution.-The subjects of 
spinal irritation, with few if any excep- 
tions, may be spoken of as hysterical, 
hypochondriacal, or nervous. They have, 
in fact, that nervous constitution which 
Whytt, following in the steps of Syden- 
ham, showed to be the common basis of 
hysteria and hypochondriasis. First in 
order among the signs of this constitution 
comes that sign which Sydenham regarded 
as pathognomonic of hysteria and hypo- 
chondriasis-namely, a proneness to pass, 
under or after strong emotion or excite- 
ment, large quantities of pale limpid 
urine. Then come other signs scarcely 
less characteristic : proneness to tender- 
ness, not only in some part of the spinal 
column, but also in the epigastrium and 
left hypochondrium-le trepied hysterique 
of Dr. Briquet already referred to; pronc- 
ness to sudden and distressing flatulent 
distension of the stomach and bowels, 
with loud rumbling and explosions, and 
with a feeling of a ball rolling about, first 
in the left flank, and then mounting, or 
tending to mount, into the throat, where 
it gives rise to a sense of choking and to 
repeated acts of swallowing ; proneness 
to bursts of crying and sobbing or of 
laughing ; proneness to sighing, yawning, 
and stretching the arms ; and proneness 
to fits of convulsive agitation and strug- 
gling. Then comes a promiscuous series spinal irritation. 
997 
of signs : proneness to erratic pains of a 
neuralgic character, breathlessness, nerv- 
ous cough, palpitation, throbbing in the 
temples, epigastrium, and elsewhere ; 
"flushes and chills," syncope, hiccup, 
nausea, vomiting, aversion to food or un- 
natural craving for it, heartburn, oppres- 
sion at the prsecordia, languor, debility, 
fidgetiness, tremulousness, vertigo (espe- 
cially on rising hastily), ringing in the 
ears, fickleness, fancifulness and inability 
to discriminate between fact and fiction, 
undue lowness of spirits or the contrary, 
and other symptoms whose name is legion. 
Not only, indeed, is the name of these 
different symptoms legion, but there is 
ever going on a process of mutual meta- 
morphosis in the symptoms themselves; 
and, in conclusion, it is this very hysteri- 
cal or hypochondriacal variability and 
mutability of the symptoms which must 
be looked upon as the great characteristic 
of the nervous constitution. 
2. Post-mortem Appearances.-The 
morbid structural changes strictly be- 
longing to spinal irritation are nil. The 
disease is nervous or functional in its cha- 
racter, and on this account it leaves no 
obvious traces after death. Still, as Dr. 
Copland wisely says, "an affection which 
may with justice be viewed as functional 
to-day-as spinal irritation merely-may 
be inflammation on the morrow, and rap- 
idly followed by the consequences of 
inflammation. " Such a termination, how- 
ever, is altogether exceptional; and when 
it does occur, the history during life will 
show very clearly that any traces of in- 
flammation which are met with after 
death are to be ascribed, not to irritation, 
but to inflammation. IIow far irritation, 
which involves in its very essence, as I 
believe, capillary contraction and blood- 
lessness, not capillary paralysis and con- 
gestion, may involve changes which are 
opposed to inflammation-deficiency of 
blood and organic changes brought on by 
the part being starved for wrant of blood 
-remains to be seen. I take it that such 
changes would have been found if they 
had been looked for with the same amount 
of care which has been expended in the 
search for inflammatory changes; but the 
investigations have yet to be made which 
will verify or disprove this conjecture. 
3. Causes. - Neglect of gymnastic 
training, insufficiency of wine or other 
alcoholic drinks, over-indulgence in sex- 
ual matters, onanism, would seem to de- 
serve a conspicuous place among the 
causes of spinal irritation. It is idle, 
however, to weigh the importance of par- 
ticular causes, or even to attempt to in- 
dividualize them, and it is enough to be 
content with the broad fact that every- 
thing which tends to induce a nervous 
habit-that is, everything which exhausts 
vital power-must be reckoned as a cause. 
I believe that the starting-point of the 
disorder will very often be found in some 
strain or blow to the back, and I also be- 
lieve that a congenital predisposition may 
also be detected in very many cases. 
4. Diagnosis.-The fundamental ques- 
tion for consideration in this place is how 
to distinguish between functional and or- 
ganic affections of the spinal cord, and 
this question fortunately is one which is 
less difficult to answer than it might seem 
to be at first sight. In fact, the charac- 
teristics of spinal irritation indicated by 
the Griffin brothers are sufficient of them- 
selves to supply the answer to any one 
who has tolerably clear ideas respecting 
the principal diseases with which spinal 
irritation may be confounded. These 
characteristics are:-"1st. The pain or 
disorder of any particular organ being 
altogether out of proportion to the consti- 
tutional disturbance. 2d. The complaints, 
whatever they may be, being usually re- 
lieved by the recumbent posture, and 
always increased by lifting weights, bend- 
ing, stooping, or twisting the spine. 3d. 
The existence of tenderness at that part 
of the spine which corresponds with the 
disordered organ, and the increase of pain 
in that organ by pressure on the corre- 
sponding region of the spine. 4th. The 
disposition to the sudden transference of 
the disordered action from one organ or 
part to another, or the occurrence of hys- 
terical symptoms in affections apparently 
acute ; and 5th. The occurrence of fits of 
yawning or sneezing, which, though not 
very common symptoms, yet, as rarely 
ever occurring in acute organic disease, 
may generally be considered as character- 
istics of nervous irritation." 
In the diseases of the spinal cord which 
have already been under consideration- 
spinal meningitis, myelitis, spinal conges- 
tion, and tetanus-it has been seen that 
it is the rule for the spine not to be tender 
on pressure, and in spinal irritation it has 
been seen that such tenderness is so con- 
stant as to deserve being reckoned as the 
distinctive feature. Here, then, is a point 
of difference which will serve as a guide 
to a cor