A TEXT-BOOK

OF

PRACTICAL MEDICINE,

WITH PARTICULAR REFERENCE TO

PHYSIOLOGtliND PATHOLOGICAL ANATOMY.

BY

DR. FELIX VON NIEMEYER,

LATE PROFESSOR OP PATHOLOGY AND THERAPEUTICS, DIRECTOR OP THE MEDICAL CLINIC OP
THE UNIVERSITY OP TUBINGEN.

TRANSLATED FROM THE EIGHTH GERMAN EDITION, BY SPECIAL
PERMISSION OF THE AUTHOR.

BY

GEORGE H. HUMPHREYS, M. D.,

ONE OF THE PHYSICIANS TO TRINITY INFIKMARY, MEMBER OF THE NEW YORK COUNTY MEDICAL
SOCIETY, FELLOW OF THE NEW YOBK ACADEMY OF MEDICINE, ETC.,

AND

CHARLES E. HACKLEY, M. D.,

ONE OF THE PHYSICIANS TO THE NEW YORK HOSPITAL AND TRINITY INFIRMARY, MEMBER OP THE
NEW YORK COUNTY MEDICAL SOCIETY, ETC., ETC.

REVISED EDITION.

VOLUME II.

NEW YORK:
D. APPLETON AND COMPANY,

1, 3, AND 5 BOND STREET.

1884.

ENTERED, according to Act of Congress, in the year 1869, by

D. APPLETON & CO.,

In the Clerk's Office of the District Court of the United States for the
Southern District of New York.

ENTERED, according to Act of Congress, in the year 1880, by

D. APPLETON & CO.,
In the Office of the Librarian of Congress at Washington.

TABLE OP CONTENTS OP VOL. II.

DISEASES OF THE URINARY ORGANS.
SECTION I.

DISEASES OF THE KIDNEYS.

PAGE

CHAP. I. — Hyperaemia of the Kidney 1

II. — Haemorrhage from the Kidney 7

III. — Acute Bright's Disease 10

IV. — Chronic Diffuse Nephritis — Chronic Bright's Disease ... 14
V. — Nephritis Vera— Interstitial Nephritis — Renal Abscess — Metastatic

Deposits in the Kidney . . . . . . • . .36

VI.— Perincphritis . . 40

VII. — Amyloid Degeneration of the Kidney 41

VIII. — Granular Degeneration of the Renal Epithelium .... 43

IX. — Carcinoma of the Kidney 45

X. — Tuberculosis of the Kidney . 46

XI.— Parasites in the Kidney . . .47

XII. — Deformities of the Kidney — Irregularities of its Shape and Position 48

XIII.— Addison's Disease— Bronzed Skin . 49

N

SECTION II.
'DISEASES OF THE PELVIS OF THE KIDNEYS AND URETERS.

CHAP. I. — Dilatation of the Pelvis of the Kidney, with Atrophy of the Renal

Substance — Hydronephrosis 54

II. — Inflammation of the Pelvis of the Kidney — Pyelitis ... 56

III. — Stony Concretions in the Pelvis of the Kidney 59

IV. — Carcinoma and Tuberculosis of the Pelvis of the Kidneys and of the

Ureters 64

SECTION III.
DISEASES OF THE BLADDER.

CHAP. I.— Catarrh of the Bladder— Cystitis Catarrhalis 66

II. — Croupous and Diphtheritic Cystitis 72

III. — Pericystitis 72

jv TABLE OF CONTENTS OF VOL. II.

FACE

CHAP. IV. — Tuberculosis and Carcinoma of the Bladder .... 73

V. — Haemorrhage from the Bladder— llicmaturia Vesicalis ... 74

VI. — Stony Concretions in the Bladder 75

NEUROSES OF THE BLADDER 79

VII.— Hypencsthesia of the Bladder 80

VIII.— Anesthesia of the Bladder 80

IX. — Hypcrcinesis of the Bladder — Spasm of the Bladder — Cystospas-

mus 82

X.— Acinesis of the Bladder— Vesical Palsy— Cystoplegia ... 84

Additions to the Revised Edition of 1880 87

SECTION IV.

DISEASES OF THE URETHRA.

CHAP. I. — Virulent Catarrh of the Male Urethra — Clap — Gonorrhoea ... 88

II. — Non-virulent Catarrh of the Urethra . 98

DISEASES OF THE SEXUAL ORGANS.
^.—DISEASES OF THE MALE SEXUAL ORGANS.

CHAP. I. — Nocturnal and Diurnal Pollutions — Spermatorrhoea . . . .100
II. — Impotence and Irritability, with Weakness of the Male Sexual Organs 104

B.— DISEASES OF THE FEMALE SEXUAL ORGANS.

SECTION I.
DISEASES OF THE OVARIES.

CHAP. I. — Inflammation of the Ovary— Oophoritis (Ovaritis) . . . .109

II.— Ovarian Cysts .111

III. — Complicated Ncoplasia and Solid Tumors in the Ovary . . ,120

SECTION II.
DISEASES OF THE UTERUS.

THAI-. I. — Catarrh of the Uterus and Catarrhal Ulcers of the Cervix Uteri . .122
II. — Parenchymatous Metritis — Acute and Chronic Infarction of the Uterus 131

III. — Perimetritis and Parametritis 135

IV. — Contractions and Closures of the Uterus — Haemomctra, Hydrometra . 137
V. — Curvatures of the Uterus — Flexions and Infarctions . . . 140

VI. — Changes of Position of the Uterus 144

VII. — Fibroid Tumors of the Uterus — Fibromyomata, Fibroids, Dermoids 147

VIII.— Cancer of the Womb . . .154

IX.— Anomalies of Menstruation 158

X. — Retrouterine Haematocele — Haematoma Retrouterinum — Pelvic Haema-

tocele ... 165

TABLE OF CONTENTS OF VOL. II. v

SECTION III.

DISEASES OF THE VAGINA.

PAGE

CHAP. I.— Virulent Catarrh of the Vagina ........ 170

II. — Non-virulent Catarrh of the Vagina 171

III. — Croupous and Diphtheritic Inflammation of the Vagina ; . .173

DISEASES OF THE NERVOUS SYSTEM.
SECTION I.

DISEASES OF THE BRAIN.

CHAP. I. — Hyperaemia of the Brain and its Membranes 175

II. — Partial Hyperasmia and Partial (Edema of the Brain ... 193

III. — Anasmia of the Brain and its Membranes 195

IV. — Partial Anaemia and Partial Necrosis of the Brain — Thrombosis and

Embolism of the Cerebral Arteries — Softening . . . .201

V. — Cerebral Haemorrhage — Apoplectic Stroke — Apoplexia Sanguinea . 215
VI. — Haemorrhages of the Cerebral Membranes — Apoplexia Meningea —

Haematoma of the Dura Mater 230

INFLAMMATIONS OF THE BRAIN AND ITS MEMBRANES .... 233
VII. — Inflammation of the Dura Mater — Inflammation and Thrombosis of

the Cerebral Sinus 233

VlII. — Inflammation of the Pi a Mater, with Puro-fibrinous Exudation — Menin-
gitis of the Convexity — Meningitis Simplex .... 236
IX. — Basilar Meningitis, Tuberculous Inflammation, and simple Miliary Tu-
berculosis of the Pia Mater — Acute Hydrocephalus . . . 240

X. — Epidemic Cerebro-spinal Meningitis 247

XI. — Inflammation of the Brain — Enc^halitis 254

XII. — Partial Sclerosis of the Brain 260

XIII. — Tumors of the Brain and its Membranes 262

XIV.* — Serous Effusions in the Mature Skull— Hydrocephalus Acquisitus . ' 275

XV. — SWous Effusions in the Incomplete Skull — Hydrocephalus Congenitus 278

XVI. — Hypertrophy of the Brain 280

XVII.— Atrophy of the Brain .'...•.... 282

XVIII. — Aphasia — Asymbolia. . . 285

Additions to the Revised Edition of 1880 ... . . . 287

SECTION II.
DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES.

CHAP. I. — Hyperaemia of the Spinal Marrow and its Membranes . . . 289
II. — Haemorrhage of the Spinal Marrow and its Membranes — Spinal Apo-
plexy 290

III. — Inflammation of the Membranes of the Spinal Marrow — Meningitis

Spinalis . . 292

IV. — Inflammation of the Spinal Marrow — Myelitis .... 295

i TABLE OF CONTENTS OF VOL. II.

PAOB

CHAP. V. — Growths and Parasites of the Spinal Medulla and its Membranes . 299

VI.— Hydrorhachis Congenita— Spina Bifida ..... 300
VII.— Consumption of the Spinal Cord — Tabes Dorsualis — Ataxie Loco-
motrice Progressive (Duchenne) — Gray Degeneration of the Pos-

terior Columns of the Spinal Cord (Leydcn) — Locornotor Ataxy . 302

Additions to the Revised Edition of 1880 ..... 310

SECTION III.
DISEASES OF THE PERIPHERAL NER YES.

CHAP. I. — Inflammation of the Nerves — Neuritis ...... 313

II. — Neuroma . . . . ' • . - ; ..... 315

III.— Neuralgia . . . . ....... 317

IV. — Neuralgia of the Trigeminus — Prosopalgia — Tic Douloureux— Foth-

ergill's Faceache ......... £27

V. — Hemicrania — Migraine ......... 331

VI. — Cervico-occipital Neuralgia ....... 333

VII— Cervico-brachial Neuralgia ...... i . 334

VIII. — Intercostal Neuralgia ...... ' . . 336

IX.— Mastodynia— Irritable Breast (Cooper) . . . * . . 337

X. — Lum bo-abdominal Neuralgia . . . . . . 338

XI. — Neuralgia Ischiadica — Ischias — Ischias Nervosa Postica Cotunnii —

Sciatica — Hip-Gout ...... ' •". • I . 338

XII. — Crural Neuralgia — Ischias Antica Cotunnii . '.".» . . 342

Xin.— Anaesthesia of the Cutaneous Nerves . , ' . . . . 342

XIV. — Anaesthesia of the Trigeminus . . . ; . . . 348

SPASM INVOLVING PARTICULAR PERIPHERAL NERVES . . .349

XV. — Spasm of the Facial Nerve — Mimic Spasm of the Face— Tic Con-

vulsif . ......... 351

XVI. — Spasm in the region of the Spinal Accessory Nerve of Willis . . 353

XVII. — Scriveners' Spasm — Mogigraphia ...... 355

XVIII. — Idiopathic Cramp of the Muscles of the Extremities — Arthrogryposis 357

XIX.— Peripheral Palsy ......... 359

XX.— Palsy of the Facial Nerve— Mimic Facial Palsy— Bell's Palsy . 366

XXI.— Palsy of the Serratus Muscle ....... 370

XXII. — Progressive Palsy of the Cerebral Nerves, Tongue, Velum Palati,

and Lipa . . ......... 372

XXIII.— Essential Palsy of Children— Spinal Infantile Palsy (Heine) . 373

Additions to the Revised Edition of 1880 ..... 377

SECTION IV.
GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

CHAP. I.— Chorea— Chorea St. Viti— St. Vitus's Dance ..... 378

II. — Lockjaw — Trismus — Tetanus ....... 384

III. — Epilepsy — Falling Sickness ........ 390

IV.— Eclampsia Infantum ......... 405

V.— Hysteria ........... 409

VI.— Catalepsy . .......... 424

TABLE OF CONTENTS OF VOL. II. VH

PAGE

— Hypochondriasis ... 426

VIII.— Paralysis Agitans— Shaking Palsy 431

IX. — Delirium Treraens — Mania a Potu . 432

X.— Morphine Habit— Opium-Eating 435

Additions to the Revised Edition of 1880 . . . . . 437

DISEASES OF THE SKIN.

I.— HYPERTROPHY OF THE SKIN 440

CHAP. I. — Diffuse Hypertrophy of the Papillary Layer and of the Epidermis —

Ichthyosis 444

II. — Diffuse Hypertrophy of the Skin and Subcutaneous Connective Tis-
sue— Pachydermia — Elephantiasis Arabum . . . . 446

II. — ATROPHY OP THE SKIN 447

III. — HYPER^EMIA AND ANEMIA OF THE SKIN .... 450

IV. — INFLAMMATION OF THE SKIN 452

III. — The Slighter Form of Acute Inflammation of the Skin without Vesi-

cation^-Erythematous Dermatitis — Erythema . . . 453

IV. — Erysipelatous Dermatitis — Erysipelas 456

V. — Herpes — Acute Superficial Dermatitis, attended by Formation of

Groups of Vesicles upon the Skin 462

VI.— Urticaria— Nettie-Rash— Acute Superficial Dermatitis, with Forma-
tion of Weals 464

VII. — Eczema — Diffuse Superficial Dermatitis, with Serous Exudation upon

the Free Surface, and without Typical Course .... 466
VIII. — Impetigo — Diffuse Superficial Dermatitis, with Formation of Small

Pus-tules . . .479

IX.— Ecthyma — Dermatitis, with Formation of Large, Isolated, Permanent

Pustules ....- 481

X. — Pemphigus — Pompholyx — Superficial Dermatitis, with Formation of

Large Isolated Blebs 482

XI. — Rupia — Dermatitis, with Formation of Isolated Flat Vesicles, from

which Scabs of a peculiar Shape are formed .... 484
XII. — Psoriasis — Chronic Dermatitis, with Infiltration of the Corium, and

Abnormal Growth of Epidermis 485

XIII. — Lichen — Dermatitis forming Groups of Persistent Conical Nodules 489
XIV. — Prurigo — Dermatitis with Small, Scattered, Itching Nodules . 490
XV. — Acne, Acne Vufgaris, Acne Disseminata — Inflammation and Suppura-
tion of Obstructed Sebaceous Follicles 493

XVI. — Mentagra — Sycosis — Inflammation and Suppuration of the Sebaceous

Glands and Hair-Follicles of the Beard 495

XVII. — Acne Rosacea — Gutta Rosacea — Chronic Inflammation of the Seba-
ceous Glands of the Face, with Dilatation of the Blood-vessels and
Growth of the Connective Tissue about them . . . .497

V. — HAEMORRHAGES OF THE SKIN — PuRPURA . . . 498

VI. — GROWTHS IN THE SKIN 500

XVIII. — Lupus — Lupus Exedens 500

Vlii TABLE OF CONTENTS OF VOL. II.

PAGE

VII. — PARASITES IN THE SKIN 505

CHAP. XIX. — Favus — Porrigo Favosa, Lupinosa 605

XX.— Herpes Tondcns 608

XXI. — Pityriasis Versicolor 610

XXII.— Scabies— Itch 610

VIII. — DERANGEMENTS OF SECRETION IN THE SKIN . . . 515

APPENDIX TO DISEASES OF THE SKIN.

Scleroderma 521

Leprosy — Elephantiasis Greece-rum 622

Additions to the Revised Edition of 1880 . 623

DISEASES OF TEE ORGANS OF LOCOMOTION.

RHEUMATISM 626

CHAP. I. — Acute Articular Rheumatism — Rheumatismus Articulorum Acuta —

Rheumarthritis Acuta — Flying Gout 527

n. — Chronic Articular Rheumatism— Rheumatismus Articulorum Chronicus

— Rheumarthritis Chronica 535

III.— Deforming Articular Inflammation — Arthritis Deformans, Arthritis

Nodosa, Arthritis Pauperum — Arthrite Chronique Sfcche . . 640

IV. — Muscular Rheumatism — Rheumatismus Muscularis . . . 642

V.— Gout— Podagra— Arthritis 545

VI.— Rachitis— Rickets 657

VII. — Osteomalacia 565

VIII. — Progressive Muscular Atrophy — Atrophie Musculaire Graisseuse Pro-
gressive— Paralysie Musculaire Progressive Atrophique . . 567
IX. — Progressive Muscular Paralysis as a Result of Hypertrophy of the In-
terstitial Fatty Tissue • . 670

Additions to the Revised Edition of 1880 . .671

CONSTITUTIONAL DISEASES.

SECTION I.
ACUTE INFECTIOUS DISEASES.

CHAP. I. — Measles — Morbilli — Rubeola — Rougeole 673

II.— Scarlet Fever— Scarlatina 685

III.— Rose-Rash—Roseola Febrilis 595

IV.— Small-Pox— Variola— Petite V6rolc 596

V. — Cow-Pock — Vaccina 608

VI.— Wind-Pox, Water-Pox, Sheep-Pox, Varicella, Chicken Pox . . 612
VII.— Typhus Fever— Exanthematic Typhus— Petechial Typhus— Spotted

Fever .614

VIII. — Abdominal Typhus— Ileotyphus (Typhoid Fever) .... 623

IX. — Febris Recurrens — Relapsing Fever 654

TABLE OF CONTENTS OF VOL. IT. ix

PAGE

CHAP. X. — Epidemic Diphtheritis — Malignant Pharyngitis — Angina Maligna —

Diphtheria * 664

MALARIAL FEVERS 669

XI.— Intermittent Fever . 669

XII. — Remittent and Continued Malarial Fever ..... 687

XIII.— Yellow Fever 690

XIV. — Sudor Anglicus — Suette Miliaire — Sweating-Sickness — Fricsel

Fieber 694

XV.— Cholera Asiatica 699

XVI.— Bloody Flux— Dysentery 722

XVII.— Trichina Disease— Trichinosis . 731

Additions to the Revised Edition of 1880 738

SECTION II.

CHRONIC INFECTIOUS DISEASES.

CHAP. I.— Syphilis 742

APPENDIX. — THE GLANDULAR CHANCRE — THE VIRULENT ACUTE BUBO 750

II. — Congenital and Hereditary Syphilis 784

•APPENDIX. — INFECTIOUS DISEASES TRANSMISSIBLE FROM BRUTES TO II u-

. MAN BEINGS 788

CHAP. I. — Human Glanders 788

II. — Hydrophobia — Lyssa — Rabies 793

SECTION III.

GENERAL DISORDERS OF NUTRITION WHICH DO NOT DEPEND UPON
INFECTION.

CHAP. I.— Chlorosis 802

II. — Scorbutus — Scurvy 810

III. — Purpura Haemorrhagica — The "Morbus Maculosus" of Werlhof . 815

IV. — Progressive Pernicious Anaemia 817

V. — Haemophilia (Haemorrhagic Diathesis) 819

VI.— Scrofula 820

VII.— Diabetes Mellitus— Mellituria ., 832

VIIL— Diabetes Insipidus . . 843

Additions to the Revised Edition of 1880 . , 847

DISEASES OF THE URINARY ORGANS.

SECTION J.
DISEASES OF THE KIDNEY.

OHAPTEK I.

. HYPER^EMIA OF THE KIDNEY.

HTPEE^EMIA of the kidney and its consequences are not to be con-
founded with inflammation of the kidney, although during life it is some-
times quite impossible to distinguish between the two, and notwith-
standing that similar symptoms appear in both disorders, such as the
presence of blood and albumen in the urine, as well as the appearance
in it of peculiar objects, generally called fibrinous casts (although it is
probable that they are not composed of fibrin, and certainly are not
pure fibrin, but consist in great part of mucin).

ETIOLOGY. — A thorough knowledge of the normal circulation of
the kidney is indispensable to a proper understanding, not only of the
physiology, pathogeny, and etiology, but also of the symptoms of hy-
peraemia of this organ. To Virchow the credit is due of having cor-
rected some of our former ideas upon this subject, and of having ren-
dered others more complete.

According to the result of his researches, the branches oi one par-
ticular portion of the renal artery (that, namely, which belongs to the
middle and outer part of the cortical substance) go exclusively to
form the afferent vessels, and, entering the Malpighian capsules as
such, these divide to form the vessels of the glomeruli. Then, leaving
the Malpighian capsule as efferent vessels, they again break up into
branches, once more to reunite as renal veins. On the boundary be-
tween the cortical and pyramidal substances there is a sort of " neutral
ground." Here there are arteries from which branches arise, some
forming afferent vessels, glomeruli, and efferent vessels, with long off-

2 DISEASES OF THE KIDNEY.

shoots running into the cortical and medullary substance, and others
wliich act directly as nutrient vessels for the medullary substance.
Finally, the renal artery has branches upon which there are no glome-
ruli at all, and whose function is simply nutrition of the medullary
substance.

The resistance encountered by the blood wliich passes through the
gloineruli is far greater than that met by the blood which merely flows
directly from the arteries into the capillaries. Even under normal
conditions the blood-pressure in the renal arteries is a very consider-
able one, that vessel being both short and of disproportionately large
calibre. When the pressure within these arteries is increased, hyper-
a-inia of course will first arise in that portion of the kidney where the
blood encounters the greatest resistance, namely, in the cortical sub-
stance, and, above all, in the glomeruli. Where the resistance is less,
as in the medullary substance, although the circulation is accelerated
there, the actual amount of blood which the part contains is not ma-
terially increased. It is very different, however, when the escape of
the blood from the renal veins is impeded. In such a case the quan-
tity of blood in the veins and capillaries is augmented, but the en-
gorgement cannot extend through the narrow efferent vessels into the
glomeruli ; and, as the contents of the arteries are abnormally reduced
in most of the disorders in which there is an obstruction of the renal
veins (as in cardiac and pulmonary diseases), the reason at once be-
comes apparent why, even in cases of extreme obstructive hyperaemia
of the kidney, the glomeruli are scantily supplied with blood, and the
secretion of urine is proportionately small. Perhaps, too, nervous in-
fluence may not be without effect in bringing about this condition,
since it is possible that in the kidneys, just as in other organs, the ar-
teries of the various vascular systems are not subject to the same kind
of innervation.

The causes which induce fluxion to the kidney are :

1. The transient plethora induced by every copious draught of
liquid This hyperaemia is most pronounced in the secretory portion
of the kidney, and the profuse transudation which takes place out of
the overloaded glomeruli is the principal step in the process by which
the general plethora of the system is relieved.

2. There is a second cause of renal hyperaemia, which is closely
analogous to the first, and which occurs when the left side of the heart
is hypertrophied, and which also is confined to the arterial system, in-
cluding the glomeruli.

3. Collateral fluxion to the kidney may result from compression of
the abdominal aorta, or iliac arteries, by a tumor or gravid uterus, as
well as from derangement of the circulation in the capillaries of the

HYPEILEMIA OF THE KIDNEY. 3

skin in the cold stage of intermittent fever. In the second stage of
Bright's disease, compression of the vessels of the cortical substance,
by the distended urinary tubules, also gives rise to collateral fluxion in
the medullary substance of the kidney ( Virchow).

4. Dilatation of the afferent vessels, from palsy of their muscular
elements, seems to be the principal cause of that arterial hyperaemia
of the kidney, the existence of which is revealed by the discharge of
a large quantity of limpid urine in certain spasmodic diseases (urina
spastica).

. ' ^5. Fluxionary hyperaemia is found in the vicinity of inflamed regions
and deposits of morbid product. This form of hyperaemia we have
already endeavored to account for, in treating of an analogous condi-
tion in other organs, ascribing it to a loss of tone in the tissues, and
to a dilatation of their capillaries, whose walls are ill supported by the
surrounding relaxed parts.

6. Renal hyperaemia complicates inflammatory disease of the urinary
passages, especially 'disease of the pelvis of the kidney.

7. The renal hyperaemia which sometimes attends the use of can-
tharides, balsam of copaiba, and similar drugs, as well as that which
accompanies certain infectious diseases, especially scarlatina, measles,
typhus, and cholera, seems to be of similar origin. However, the affec-
tions of the kidney which arise from the diseases above named cannot
all be attributed to hyperaemia. Many of them belong to the class of
maladies which we shall describe as parenchymatous degeneration of
the kidney, in Chapter VII., and which, undoubtedly, are capable of de-
veloping without the occurrence of hyperaemia. This io equally true
of the renal affections which so often accompany pregnancy.

Obstructive engorgement of the kidney arises from causes similar
to those which induce engorgement of the liver (see Volume I.), so
that the two diseases often accompany one another ; but it will readily
be understood, from what has already been said as to the peculiar
character of the hepatic circulation, that engorgement of the liver
usually is of earlier occurrence and greater intensity than engorgement
in the kidneys. Engorgement of the kidney arises: 1. In uncompen-
sated valvular disease of the heart; 2. In structural disease of the
heart, which depresses the functional energy of the organ ; 3. When
the vigor of the heart is impaired by a condition of marasmus; 4. In
disease of the lungs, which causes compression or wasting of the pul"
mohary capillaries; 5. In conditions in which the aspiration of the
blood to the thorax is arrested ; 6. In rare instances, contraction and
closure of the vena cava or emulgent veins, by compression or throm-
bosis, give rise to engorgement of the kidney, but the hyperaemia
arising in such cases is of very great intensity.

4 DISEASES OF THE KIDNEY.

ANATOMICAL APPEARANCES. — A kidney in a state of recent by-
peraemia is of a more or less dark-red color. Sometimes it is enlarged,
owing either to dilatation of its vessels or to serous infiltration. The
oedema of its parenchyma and subcapsular connective tissue renders the
hyperaemic organ unnaturally moist and soft, and loosens its capsule.
When cut into, and when the vessels of the glomeruli are much dis-
tended by blood, the Malpighian coils dot the surface of the section,
as dark-red points.

When the hyperaemia is of long standing, particularly when there
is habitual engorgement, as occurs in chronic disease of the heart and
lung, the changes which arise are of a different kind. The kidney is then
but little enlarged, or remains of its normal magnitude, or may even
be somewhat smaller than natural. It is more resistent in texture,
and is of a uniform red color. Upon microscopic examination, the
epithelium of the urinary tubules of the cortical substance is found to
be swollen, the contour of the cells is ill-defined, and they are filled
with finely-granular contents, which clear up upon the addition of
acetic acid. Sometimes there is a desquamation of the degenerated
epithelium here and there ; and the tubules collapse after the epithe-
lium is expelled, causing the surface of the kidney to become uneven
by depressions of varying depth. Traube and Beckman have called
particular attention to the difference between this condition and the
degenerative chronic inflammation of the kidney, which we shall de-
scribe in Chapter IV. as chronic Bright's disease.

While the alterations above described are going on in the epithe-
lium of the cortical substance, the straight tubules of the medullary
substance are usually found filled with a material which is sometimes
transparent and pale, and sometimes of a more yellow color. By mod-
erate pressure upon the pyramids, a large quantity of an opaque creamy
liquid is discharged from the papillae, which contains a great deal of
epithelium and a few of those casts of the tubuli, in the form of homo-
geneous transparent tolerably firm cylinders.

SYMPTOMS AND COURSE. — The kidney has so few nerves of sensa-
tion, and its capsule is so distensible, that hypersemic swelling of the
organ is never accompanied by pain. As the amount of urine secreted
depends chiefly upon the degree of pressure within the vessels of the
glomeruli, its secretion necessarily becomes more profuse in that form
of renal hyperaemia which involves the arterial system of the kidney,
including the vessels of the Malpighian tufts. This is almost the only
symptom caused by fluxion to the kidney, which arises from copious
drinking, hypertrophy of the left heart, compression of the aorta 01
iliac arteries, and dilatation of the renal arteries. The urine is copi-
ous in quantity, dilute in quality, of low specific suavity, and of a Dale

HYPERJSMIA OF THE KIDNEY. 5

3olor. In such cases, the pressure in the glomeruli hardly ever is suf-
ficient to occasion transudation of albumen, or to rupture the vessels,
and cause extravasation of blood into the Malpighian capsules. This
fact is in accordance with the results of physiological experimenta-
tion.. Ligation of the abdominal aorta below the origin of the renal
arteries, in spite of the increase of pressure which ensues in those arte-
ries, never results in albuminuria.

A very different train of symptoms follows upon a moderate de
gree of obstructive engorgement of the kidney. Since, as we have
just shown, in almost every case of obstruction of the renal veins the
degree of tension within its arteries is very small, there is a diminution
instead of an increase of the secretion of urine. On the other hand,
the strain upon the capillaries becomes exceedingly severe, since they
cannot discharge their contents into the already overloaded veins until
the pressure within them exceeds that within the veins. Hence, not
only does the plasma of the blood readily escape from the capillaries
into the urinary tubuies, so that the scanty, concentrated, dark-colored
urine contains albumen, and the so-called fibrinous casts (or, more
•properly speaking, exudation casts), but the delicate walls of the capil-
laries give -way before the strain, so that the urine is also full of blood-
corpuscles. According to the recent observations of Liebermeister, the
simultaneous appearance of blood and albumen is so usual in obstruc-
tive hypersemia of the kidney, that the appearance of albumen alone,
without a trace of blood, almost excludes the idea of simple engorge-
ment from the diagnosis, and indicates the existence of inflammation.
This fact in pathology, which may be verified in almost every case of
chronic disease of the heart, and traced through all its phases, agrees
with the results of physiological experiment. Albuminuria and haema-
turia are .the never-failing consequence of ligation of the renal veins,
or of the vena cava above their point of entrance. The escape of
plasma from the capillaries of the kidneys, in obstructive congestion,
into the uriniferous tubules is analogous to the extravasation from the
pulmonary capillaries into the air-vesicles, which occurs in engorgement
of the lungs, and which is there called hypostasis. The so-called
hypostatic pneumonia is quite as independent of genuine inflammatory
action as is the disorder of the kidney at present under consider-
ation.

The form of renal hyperaemia which apparently proceeds from re-
laxation of the tissues of the kidney and consequent dilatation of its
capillaries, has no effect either in augmenting or diminishing the quan-
tity of urine secreted. It is attended, however, by a more or less pro-
fuse transudation of blood-plasma, as well as by a greater degree of
shedding, and probably too by a more active reproduction of the eel-

(j DISEASES OF THE KIDNEY.

lular contents of the uriniferous tubules. Hence, when, after the abuse
of irritating diuretics, or in disease which we know to be frequently
complicated with this form of renal hyperaemia, we find the urine to
be albuminous and full of casts thickly studded with epithelial cells,
our diagnosis may be renal catarrh. This name, which has been applied
to the form of hyperaemia in question by most modern pathologists, is-
not quite appropriate, it is true, as the tubules have no mucous mem-
brane, and as the term catarrh itself means an affection peculiar to such
a membrane. However, it is quite as appropriate as is the term catar-
rhal pneumonia. (See Vol. L)

The course of both fluxionary and obstructive hyperaemia of the
kidney, when the exciting cause is of a transient character, usually is
favorable, and the disease in itself probably never causes death. Al-
though, during the last few weeks of a case of heart-disease, this affee-
tion appears in its most intense form, yet it is not renal hyperaemia of
which the patient finally dies, but the respiratory derangement, the
dropsy, and other symptoms which proceed immediately from the
cardiac disorder. However, it cannot be denied that the albuminuria
aggravates the dropsy and hydraemia, and aids in undermining the
strength of the patient. The renal catarrh also runs a favorable course
as a rule, and, when the primary disease tends toward recovery, usually
terminates hi complete restoration to health. Far more rarely, diffuse
parenchymatous inflammation of the kidney may develop from renal
catarrh.

TREATMENT. — The measures called for in treatment of the cause
of hyperaemia of the kidney may be inferred from the account above
given of the causes themselves. When the hyperaemia of the kidney
is but a symptom of a more wide-spread and grave disease, it is to the
latter rather than to the hyperaemia to which the treatment should be
directed Where it has arisen from the abuse of irritating diuretics,
their employment must be discontinued, and all application of vesi-
cants, and use of irritating salves upon suppurating surfaces (a very
common cause of fluxion to the kidney), must be abstained from. Be-
sides this, large quantities of drink must be administered, in order as
much as possible to dilute the acrid matter which has been secreted in
the kidneys. Pure water or the dilute acids are the most suitable for
the purpose. The old practice of using barley-water, linseed-tea, milk
^>f almonds, and the like mucilaginous or oleaginous liquids, must be
regarded as obsolete, as it is well known that such articles have no
effect upon the character of the urine.

General and local blood-letting, and derivatives to the skin or intes-
tines, are only to be resorted to in fulfilling the indications from the
disease itself, when such remedies are indicated for other reasons, 01

HAEMORRHAGE FROM THE KIDNEY. 7

when the hyperaemia is extreme, and there are no counter-indications
against blood-letting.

CHAPTER II.

HAEMORRHAGE FROM THE KIDNEY.

ETIOLOGY. — The causes of haemorrhage from the kidney are : 1.
Wounds, contusions, and other injuries of the organ. The presence of
calculi in the pelvis of the kidney is one of the most common sources
of such injury. Rayer tells about a patient with renal calculus who
had haematuria whenever he was compelled to ride. 2. Haemorrhage
from the kidney may proceed from intense hypersemia, and rupture of
the overloaded renal capillaries, and especially from that form of
hyperaemia which accompanies the first stage of inflammation of the
kidney, and which ensues after the employment of irritating diuretics,
as well as in that form of the affection which follows scarlatina, small-
pox, typniis, malarial fevers, and other infectious diseases. The hyper-
aemia which exists about the seat of a parasite, or a neoplastic growth,
especially cancer, often gives rise to haematuria. Finally, the exces-
sive obstructive engorgement of the kidney, produced by disease of
the heart and lungs, often results in an escape of blood from the renal
capillaries. 3. In rare instances renal haemorrhage depends upon u
hcemorrhagic diathesis, that unknown disorder of the olood-vessels
from which scorbutus and purpura haemorrhagica proceed. 4. In the
Isle of France, Brazil, and some other tropical regions, haemorrhage
from the kidney is endemic, there being no known cause for the disease.

A peculiar form of renal haemorrhage, haemorrhagic infarction, arises
under conditions similar to those in which haemorrhagic infarction takes
place in the spleen. This can be traced in most cases to embolism.

Genuine renal apoplexy is usually the result of severe injury, but
in children may also proceed from severe hyperaemia (Hokitansky).

ANATOMICAL APPEARANCES. — In haemorrhage from the kidney, the
blood may be effused into the normal interstices of the tissues without
detriment to the latter. In this way ecchymoses arise, in which there
are spots of varying size stained of a deep red, and from which blood
flows freely when they are cut into. They are situated sometime* •
under the albuginea, or within the tissues of the kidneys themselves.

In variola and diseases of that class, besides ecchymoses in the
renal tissue, the mucous membrane lining the pelvis of the kidney is
usually of an even, dark-red color, decidedly thickened (haemorrhagic
infiltration), and rough on the surface.

When recent, haemorrh agio infarction has the appearance of a dark-
red deposit of a cuneiform shape, the point of the wedge being directed
toward the hilus of the kidney. When of longer standing, the deposit
51

8 DISEASES OF THE KIDNEY.

loses its color, beginning at the middle, and becomes converted iiito a
yellow, caseous mass, or else breaks down, forming a renal abscess,
with yellow puruloid contents, which at first consist of detritus alone,
but afterward are mixed with pus. Finally, these caseous or purulent
masses also are reabsorbed, and at the site of the former infarction
there is left a cicatricial contraction.

The seat of renal apoplexy is generally the medullary portion of
the kidney. Collections, of varying size, form in the lacerated paren-
chyma, their contents consisting partly of clotted blood, and in part
of crushed and broken-down debris of the tubules. It would seem
that the contents, both of apoplectic extravasations and of haemor-
rhagic infarctions, may undergo fatty degeneration and absorption, and
that recovery may take place, leaving a depressed cicatrix. Part of
the blood effused into the tubules coagulates, forming cylinders, which
are densely studded with blood-corpuscles. Sometimes we find pig-
ment in the tubules and Malpighian capsules, as the residue of some
former extravasation of blood.

SYMPTOMS AND COURSE. — The occurrence of renal haemorrhage
does not become recognizable unless the blood be effused into the
tubules, and discharged with the urine. Hence it not unfrequently
happens, in post-mortem examinations, that haemorrhagic infarctions
and apoplectic extravasations are discovered, which were quite undis-
coverable during life, because the blood did not enter the uriniferous
tubules. If the amount of blood mingled with the urine be very small,
the color of the latter is a peculiar dirty red when viewed by reflected
light, while by transmitted light it is a pure red of greater or less
depth. After standing for some time, a somewhat characteristic,
slightly flocculent, brownish sediment is precipitated. When urine
containing blood is exposed to the action of heat and nitric acid, the
albumen of the serum of the blood coagulates. If the sediment be
examined microscopically, blood-corpuscles are found, some of which
are well preserved, while others are somewhat altered. There are also
the casts above described, studded with blood-corpuscles, which are
peculiarly characteristic of renal haemorrhage. I strongly recommend
Heller's test for blood as very simple and convenient, and by means
of which the faintest trace of blood may be discovered. Heat the
urine, then add caustic potash and heat anew. The phosphates arc
thus precipitated, taking with them the coloring matter of the blood,
which imparts a dirty yellowish-red color to the sediment viewed by
reflected light, and, when seen by transmitted light, gives a splen-
did blood-red color. Neither the coloring matter of the blood nor
tlmt of the bile is precipitated with the phosphates, so that color-
ation of urine which shows this reaction cannot be ascribed to the
of the latter pigments. When the quantity of blood in the

HEMORRHAGE FROM THE KIDNEY. 9

urine is very large, it is of a dark or brownish red, and, after standing,
forms a cake of blood at the bottom of the vessel. Not unfrequently,
a partial coagulation of the blood takes place in the bladder, and the
coagula thus formed can only be got rid of after great suffering on the
part of the patient. Sometimes the blood coagulates while in the
ureters. ' In such instances, the symptoms of renal colic, hereafter to be
described, may arise, and long, worm-like coagula (casts of the ureters)
may be voided.

The course of renal haemorrhage necessarily depends upon the na-
ture of the disease which causes the haemorrhage. When induced by
renal calculus, bleeding occurs regularly after every violent exertion.
Haemorrhage arising from the presence of a tumor, especially cancer,
is usually very profuse and persistent. The bleeding which accompa-
nies inflammation of the kidney and the infectious diseases, or which
results from venous obstruction or scorbutus, is not often very severe,
[n the endemic haematuria of the tropics there are periodical profuse
flows of Wood from the kidneys.

In haemorrhagic infarction, if there be haematuria at all, it is always
slight. It is usually ushered in by a chill, and is attended by pain in
the region of the kidney, and by violent sympathetic vomiting. The
occurrence of such a train of symptoms — a chill, lumbar pain, vomiting,
and haematuria — in a case of heart-disease, would warrant the diagnosis
of a renal infarction, which otherwise generally escapes detection.
Renal apoplexy is marked by similar symptoms, which, however, are
of much greater intensity.

The results of renal haemorrhage cannot be described in detail until
after a more thorough discussion of the diseases whereon they depend.
The haematuria arising from cancer, from renal calculus, and from the
tropical disease, acts chiefly by producing exhaustion from loss of blood.

TREATMENT. — The main point in the management of a case of renal
haemorrhage is the treatment of any hyperaemia, inflammation, or other
constitutional disease from which it proceeds. In most instances, when
the main disease is susceptible of efficient treatment, the haemorrhage
does not require any especial attention. Sometimes, however, the
danger of exhaustion arising from repeated attacks of profuse and per-
sistent haemorrhage, such as occur in cancer and renal calculus, may
require relief. Cold, in the form of a bladder of ice laid over the re-
gion of the kidney, cold sitz-baths, or cold injections, should then be
resorted to. Internal administration of styptics has been recommended,
and the whole list has been given seriatim in many cases, each failing
in its turn. Articles containing tannin, especially tannic acid itself,
which is eliminated through the kidneys in the form of gallic acid, and
thus is enabled to act directly upon the bleeding point, deserve the

10 DISEASES OF THE KIDNEY.

greatest amount of confidence. Next to it, secale cornutum, or ergotine,
may be given, but the doses must be large. The only effect to be ex-
pected from the preparations of iron is the beneficial action which
they exert upon the deterioration of the blood.

CHAPTER III.
ACUTE HEIGHT'S DISEASE.

ETIOLOGY. — The name Bright's disease is generally applied to two
forms of inflammation of the kidney. The first, which is the subject
of the present chapter, is closely allied to croup of the larynx and air-
vesicles, not only in its anatomical lesions — consisting of a coagulating
exudation, containing epithelial cells, and often extravasated blood-
cells, and which fills up and occludes the urinary tubules — but in its
course, which is always acute, like that of the other croupous diseases
above mentioned, and nearly always terminates either in recovery or
death within a few days. It is rare for the disease to pass into the
second form of Bright's disease, which we shall describe in the next
chapter, under the name of " parenchymatous nephritis." This latter
circumstance, indeed, seems to me to indicate that it is both right and
practical to regard acute and chronic Bright's disease as independent
and distinct affections. I attach little value to the term " croupous
nephritis," applied to acute Bright's disease, in the previous editions
of this work, as I must acknowledge that it is a matter of doubt
whether the exudation which fills up and obstructs the uriniferous
tubules consists of fibrin like the exudation of croupous laryngitis and
croupous pneumonia, and as it cannot be denied that the epithelium of
the uriniferous tubules takes a more active part in the nutritive disor-
ders attending acute Bright's disease than is taken by the epithelial
cells of the larynx and air-vesicles in croupous laryngitis and croupous
pneumonia.

1. Acute Bright's disease is a frequent complication of scarlatina.
There is a prevalent notion among the laity that a child who dies of
dropsy, after scarlet fever, "has not been well taken care of;" and
many an unhappy mother, who has lost her child from this cause, re-
proaches herself for years for having changed its linen too soon, or im-
prudently opened a door, and thus brought about her child's death. It
is possible that chilling of the skin during scarlet fever may sometimes
favor the occurrence of croupous inflammation, and may even actually
produce it, but it is certainly not the case in the majority of instances.
Besides the disturbance of the skin which it occasions, scarlatinous
inrus constantly induces disorders of the fauces and kidnevs. In mosl

ACUTE BRIGHT'S DISEASE. H

epidemics they are of a hyperaemic nature, and give rise to the welt-
known symptoms of catarrhal angina in the throat, and in the kidneys
cause renal catarrh, as described in the foregoing chapter. There are
malignant epidemics of scarlatina, however, which give rise to much
graver disorder of these organs. Instead of simple catarrh, there is
nearly always a diphtheritic inflammation of the fauces, and, instead
of a simple renal hypersemia, the urinary tubules are attacked by
croupous inflammation. In such epidemics, many children die of
dropsy who have received the best possible care, while many, who
have been actually neglected, escape unscathed. The virus of measles,
typhus fever, and the poison of malaria, may also induce croupous
aephritis, but they are far less frequent causes of the disease than is
scarlatina.

2. Acute Bright's disease arises during the typhoid stage of chol-
era, and by many is regarded as a constant complication, if not
the actual cause, of this very common and obscure sequel of cholera.
Although we cannot subscribe to this latter opinion, having witnessed
the- death' "of many patients from cholera typhoid, whose urine was
abundant and free from albumen, yet the frequence of croupous ne-
phritis, as a sequel to cholera, cannot be denied. It remains an open
question whether the vascular engorgement and inspissation of the
blood, which take place in the algid stages of cholera, induce obstruc-
tion of the renal capillaries from crowding together of the blood-cor-
puscles, and extravasation of plasma and blood into the tubules, or
whether the inflammation of the kidneys, like the other inflammatory
affections of the typhoid stage of cholera, be ascribable to infection
of the blood. It, undoubtedly, is very rare for croupous nephritis, in
healthy subjects, to proceed from contusions, the misuse of irritating
diuretics, exposure to cold, or other unknown exciting causes.

ANATOMICAL APPEARANCES. — The anatomical alterations found
post mortem after croupous nephritis are identical with those so ad-
mirably described by Frerichs as the first stage of Bright's disease,
the "stage of hypersemia and incipient exudation." The kidney is
often enlarged to twice its proper size, and its surface is smooth. The
tunica albuginea is opaque, injected, and is easily detached. The
cortical substance, to whose swelling the increase in volume of the
kidney is mainly due, is of a more or less dark-brown color, soft, and
easily torn. When cut into, a bloody adhesive liquid bathes the face
of the section. Both the superficial and deeper parts of the cortical
substance are dotted with dark-red points. The pyramids also are hy-
persemic and striped with red, and an opaque and often bloody liquid
is usually found in the calices and pelvis of the kidney, which like-
wise are injected with blood. Microscopic examination does nol

12 DISEASES OF THE KIDXEF.

exhibit any important change in the texture of the kidney. The
glomeruli, being overloaded with blood, are very distinct. Extravasa
tions of blood are almost always found in the Malpighian capsules and
tubules, which account for the blood-red points above alluded to.
There are likewise extravasations between the albuginea and the tu-
bules. The uriniferous tubules, especially those of the cortical sub-
stance, are filled with coagulated exudation. Upon microscopic ex-
amination of the liquid expressed from the cut surface of the diseased
kidney, we find the cylindrical masses of exudation covered with epi-
thelium and blood-corpuscles, forming casts of the tubules. The epi
t helium is not materially altered, only moderately swollen and clouded,
SYMPTOMS AND COURSE. — Sometimes croupous nephritis is ushered
in by a rigor, followed by fever and a sharp pain in the region of the
kidney. In addition to this, there is almost always more or less
violent (sympathetic) vomiting ; indeed, vomiting is a more constant
token of incipient disease of the kidney than either fever or pain, and
it is well to warn parents of children with scarlatina of the serious
nature of this symptom, and to require them to seek medical aid
should it arise. The patient feels a constant inclination to pass water,
but is unable to expel more than a few drops with each effort. The
suppression of urine may be so complete that the whole amount se-
creted in course of a day may not exceed an ounce or two. Its spe-
cific gravity is high. Sometimes, and for a short time, it may be of the
color of pure blood ; more usually it is opaque, and of a peculiar dirty
reddish-brown hue, and looks as though it really contained dirt.
Both urine ancL-sediment have this dirty appearance, which alone, to
the eye of an expert, is a tolerably sure sign of acute Bright's disease.
There is a very large quantity of albumen in the urine, and, upon the
application of heat and nitric acid, the half or even three-quarters of
the liquid will coagulate. Upon microscopic examination of the sedi-
ment, we find large quantities of epithelium from the tubules and
urinary passages, as well as many blood-corpuscles, and casts stud-
ded with blood-corpuscles. [Exact observation has taught us that
the vascular walls, when inflamed, become permeable to substances
which normally would not pass through them. Hence we may pre-
sume that it is not the effect of mere pressure upon the Malpighian
tufts, but rather of some change in their filtering power which gives
rise to the albuminuria in acute Bright's disease.] Dropsical symp-
toms set in, and in most cases the dropsy soon becomes very se-
vere. The face, hands, legs, and scrotum swell up, and the skin
is so tensely swollen that an impression made upon it by the finger
is soon effaced. The dropsy of croupous nephritis, like that of pa-
renchymatous nephritis, as we shall presently see, shows a great

ACUTE BRIGHT'S DISEASE. 13

tendency to shift its position, the swelling increasing in one part of
the body, while it diminishes in another.

When the progress of the disease is favorable, the coagula which
block up the uriniferous tubules are washed away, the urine be-
comes freer and more abundant, and the albumen diminishes. At
the same 'time there is an abatement of the dropsy, which, in this
disease, seems rather to depend upon suppression of the secretion of
urine than upon that lack of the albumen in the blood which takes
place in acute hydrsemia. In the most fortunate cases, the dis-
ease may terminate in from eight to fourteen days, recovery being
complete and without sequelae. In very many instances the nephri-
tis is accompanied by acute inflammation of the lung, pleura, peri-
cardium, or peritonaeum, and it is to one of these complications that
the patient usually succumbs in fatal cases.

It happens much more rarely that croupous nephritis, instead of
terminating in the above manner, gives rise to the so-called uraemic
intoxication. It is easy to comprehend that, in consequence of the
suppression of the urinary secretion, substances may accumulate in
the blood which act perniciously upon the nutrition and functions
of the various organs. It used formerly to be supposed that the
urea, which is the most abundant of the solid constituents of the
urine, and which is the best known of all its organic ingredients, by
accumulating in the blood, induced convulsions, coma, and ultimate
palsy of the entire nervous system ; and when such symptoms ac-
companied suppression of urine, they were called uraemic symptoms,
or uraemic poisoning. Frerichs afterward supposed that this toxic
effect was due to the presence of carbonate of ammonia, resulting from
decomposition of the urea, rather than to the urea itself. This the-
ory, however, cannot by any means be regarded as proved, and we
must acknowledge that we are unacquainted with the excrementitious
material retained in the blood, which exerts so pernicious an in-
fluence upon the organism in cases of suppression of urine. How-
ever, notwithstanding the rarity of uraemic poisoning in croupous
nephritis, yet it is of great importance, as regards both the prog-
nosis and treatment of the disease, not rashly to ascribe any con-
vulsions or stupor which may arise to inflammation and exudation in
the brain. Cases occur in which the convulsions and coma subside
as the free secretion of urine is reestablished, and the attack termi-
nates favorably. (For further details of the so-called uraemia, and of
the frequent dependence of cerebral symptoms upon oedema of the
brain, see Chapter IV.) I should finally state that cases of croup-
ous nephritis occur in which the disease improves somewhat, but
does not subside completely ; the albuminuria continues, and the

14- DISEASES OF THE KIDNEY.

character of the acute croupous nephritis (acute Bright's disease)
runs into that of chronic diffuse nephritis (chronic Bright's dis-
ease). I have never seen such a case, and they must be very rare.

TREATMENT. — In recent cases, and in tolerably robust subjects,
it is advisable to resort to local depletion over the region of the kid-
neys, by means of leeches or cups. The effect of the first applica-
tion will decide as to the propriety of its repetition in case of recur-
rence of the symptoms. General blood-letting should be rejected,
as liable to aggravate the already existing tendency to deterioration
of the blood. The use of calomel and other so-called antiphlogistics
is equally improper. Warm baths, followed by envelopment of the
body in woollen blankets, are much preferable to the internal ex-
hibition of diaphoretics. In treating of chronic Bright's disease,
we shall go more into detail upon this subject, and upon the brilliant
results which are sometimes obtained from diaphoresis. If the bow-
els be confined, a few powerful doses of drastic medicine should be
given — jalap, senna, or even colocynth. The profuse serous tran-
sudation into the intestine caused by these medicines may have a
beneficial effect upon the dropsy ; but it sometimes happens that the
patient has a violent diarrhea, and yet the dropsy continues to in-
crease rapidly. Mineral waters containing carbonic acid are the most
suitable beverage. We should not be too sparing in their adminis-
tration, as the increase of pressure in the glomeruli, and the aug-
mented transudation, may assist in washing away the obstructing
coagula. On the other hand, drastic diuretics are contraindicated,
owing to the inflamed condition of the kidney. During convales-
cence, and in tedious cases even prior to convalescence, the ten-
dency to deterioration of the blood must be combated by the
administration of quinine and iron, and a plentiful supply of albu-
minous food.

CHAPTER IV.

CHRONIC DIFFUSE NEPHRITIS CHRONIC BRIGHT'S DISEASE.

[PATHOLOGY AND ETIOLOGY. — The following synopsis may serve
to give the reader an insight into the present state of knowledge
regarding Bright's disease. We have long made use of Frerichs's
classification of the anatomical stages of the disease : 1st, the stage
of hyperaemia ; 2d, that of exudation and of commencing conversion
of the exudation , 3d, the stage of retrogression and atrophy. But
it has been found that the first of these conditions properly belongs
only to acute diffuse nephritis ; so that for chronic nephritis there

CHRONIC BRIGHT'S DISEASE. 15

%

remain only the stage of inflammatory swelling and that of atrophy
and shrinkage. But even the connection between these two stages
has been denied by certain authors — Johnson and other English
writers — who maintain that these conditions, instead of being phases
of one and the same disease, are the products of totally different
pathological processes.

The very great diversity of opinion regarding the histology of
Bright's disease may be summed up as follows : For some authors
the essential primary lesions in all forms of the malady originate in
the renal epithelium (Johnson) ; for others, the disease begins only
in the interstitial connective tissue (Traube). Others again believe
that it may commence in both or either of these tissues. Hence
they recognize an intertubular or interstitial, and an intratubular
or parenchymatous form of the malady ; but they admit the coex-
istence of the two forms. Johnson first pointed out a hypertrophy
of the muscular coat of the small arteries, not only of the kidney,
but of other organs, and -showed that under such circumstances the
epithelium cannot remain intact ; and he traces back the hyper-
trophy of the left ventricle of the heart, so often met with in Bright's
disease, to the greater resistance opposed in that affection by the
hypertrophied vessels. Latterly there has been great controversy
upon the views of Gull and Button, according to whom, in the con-
tracting form of the disease, the primary lesion is not in the kidney
at all, but the atrophied kidney is merely one of the lesions which
accompany a general disorder of the minute arteries and capillaries,
and which consists in a deposit of hyaline lymph in the adventitia
of the arteries (seldom in the intima), and in the outer coats of the
capillary walls. It must be admitted that shrinking of the kidney
and degeneration of the arterial walls often coexist ; but further
research has shown that such coexistence of the two lesions is by
no means constant.]

In Bright's disease the epithelium of the uriniferous tubules
exhibits the alterations which we have repeatedly described as char-
acteristic of all parenchymatous inflammations. Its cells first in-
crease considerably in bulk, through imbibition of an albuminous
liquid ; their contents then undergo fatty metamorphosis, by which
the epithelial cells gradually become converted into cells of fatty
granules. Finally, the cell-membrane perishes, and the fat-globules
emerge free into the urinary tubules.

While these are the essential changes which the kidney under-
goes, in the majority of cases coagulating exudations are also formed
in the tubules, and in many instances proliferation of the interstitial
connective tissue occurs. Atrophy of the kidney, which sets in

16 DISEASES OF THE KIDNEY.

afterward, is the natural and necessary consequence of the inflam-
matory process above described.

Bright's disease is a very common affection. Predisposition to
it is far less in childhood than in more advanced life. Men are
attacked by it somewhat more frequently than women ; persons
of debilitated and depressed constitution more readily than those
who are robust. Hence the poorer part of the community are more
afflicted by the disease than the well-to-do class, being more ex-
posed to the evils which produce it.

1. Chief among the predisposing causes of Bright's disease is
the temporary, and in a still greater degree the continual exposure
of the skin to the effect of cold and moisture. This accounts for
the great frequence of the disease in England, Holland, Sweden,
and on the German coasts ; and not only upon that of the North
Sea, as Frerichs has assumed, but also upon the eastern shore. In
the very moderate number of beds in the Greifswald clinic, there
used always to be many cases of Bright's disease.

2. It would seem that the misuse of irritating diuretics and the
incautious exhibition of cubebs and copaiba may sometimes lead to
Bright's disease, although, perhaps, this does not pccur very fre-
quently.

3. On the other hand, the abuse of ardent spirits unmistakably
plays a most important role in the etiology of the disorder, so that
Bright's disease appears almost as frequently among hard drinkers
as does cirrhosis of the liver. We have no physiological explanation
of this circumstance ; but as recent researches have proved that
alcohol taken into the system is not all consumed in the blood, as
used formerly to be supposed, but that at least a portion of it, pass-
ing through the urinary organs, is eliminated from the system unal-
tered, it is conceivable that the alcohol may act locally upon the
kidney, just as we have shown it to act in cirrhosis of the liver.

4. Bright's disease very frequently is associated with tedious
suppuration, with caries and necrosis of the bones, the surgical
wards of the hospitals always furnishing a rich contingent of this
malady ; although the latter causative agents lead to amyloid
degeneration of the kidney with equal if not greater frequence.
The connection between these exhausting affections and Bright's
disease is obscure. However, just as in other cachectic conditions,
so the appearance of inflammation in the most diverse organs is so
common an occurrence in these depressing maladies, that it becomes
a question whether nephritis holds a closer relationship to such con-
ditions than is held by pleuritis, pericarditis, peritonitis, and the
like.

CHRONIC BRIGHT'S DISEASE. 17

5. Finally, Bright's disease often accompanies conditions of dys-
crasia, resulting from gout, rachitis, syphilis, scrofula, and malarial
cachexia, in which, however, besides the inflammatory degeneration,
the lardaceous metamorphosis hereafter to be described is often
observable.

I agree with Traube, that it is improbable that simple obstructive
hypersemia from disease of the heart and the like gives rise to in-
flammation of the kidney ; and I believe that, hitherto, there has
been a great deal of confusion of this malady with that described
in the preceding chapter. Nor can I regard pregnancy as one of
the remote causes of Bright's disease. The albuminuria so com-
mon among pregnant women is not generally a result of inflamma-
tion, but is rather due to a parenchymatous degeneration of the
kidney, to be described in Chapter VIII.

[Malarious poison predisposes to Bright's disease, and, according
to Jfartels, is one of the most prominent of its causes. But an
albuminupia arising during an acute febrile disorder has never been
observed to terminate in chronic renal disease. On the other hand,
chronic suppuration with continued fever may be followed not only
by amyloid degeneration, but also by chronic inflammatory swell-
ing of the kidney.

Those observers who regard parenchymatous and interstitial ne-
phritis as distinct diseases naturally ascribe each of them to differ-
ent causes. The causes of that form which develops so insidiously
and so very gradually in the interstitial substance are extremely
obscure ; and Cartels remarks regarding these so-called " contracted
kidneys" which he looks upon as a separate disease, that in scarcely
one of his cases could his patients even guess at any cause for their
malady over and above the influences which always more or less be-
set them. English writers ascribe shrunken kidney largely to gout
and to lead-poisoning. Dickinson states that twenty-six out of
forty-two persons with lead-poison had died of shrunken kidney.
While this form of renal disease is more common in advanced age,
the other oc'curs more often between the ages of twenty and forty.
In childhood it is rare, if we except cases of acute diffuse nephritis
following scarlatina.

PATHOLOGICAL ANATOMY. — According to the present views of
many, the term chronic Bright's disease must be regarded as em-
bracing two distinct forms of nephritis, the interstitial and the pa-
renchymatous. The former, according to Klebs, begins with intense
hyperaemia, with exudation of a lymph-like liquid throughout the
whole cortical substance of both kidneys, which dilates the lymph-
spaces of the interstitial tissue, and is accompanied by a constantly

IS DISEASES OF THE KIDNEY.

increasing emigration of the white blood-corpuscles. Under favor-
able conditions these cells may undergo fatty degeneration, and a
complete resolution of the process may ensue ; otherwise they may
convert themselves into fibrous tissue, causing permanent thicken-
ing with or without shrinkage of the intertubular substance.

In such a case as this, the process drags on for years ; and we
find after death both kidneys shrunken, sometimes even to a third
of their normal size, and the capsule thickened and opaque, and
firmly adherent to the parenchyma. The surface of the organ is of
a dull brownish-red, here and there of a dirty-yellow hue. The
atrophy being complete in some parts of the kidney and less ad-
vanced in others closely adjacent to the first, the surface becomes
studded with small nodules, some of the size of a pin's head, and
some as large as a pea. Hence the term granular kidney. Such a
kidney is very hard and tough. Upon section, the cortical substance
is often found to be so much wasted that the secreting parenchyma
only forms a narrow rim around the pyramids, while the latter are
often but little reduced in size, being but sligthly affected by the
disease. Certain whitish stripes sometimes observed correspond to
the straight tubules which have become obliterated for want of sup-
ply of secretion. The general diminution of the kidney, with atro-
phy of many of its glomeruli and tubules, is always in the main as-
cribable to the compression exerted by the contracting newly-formed
connective tissue ; but other factors also contribute to this, such as
wasting of the epithelium and urinary tubules. It is sometimes
found that the process of thickening of the tissues is much more
pronounced in the Malpighian capsules and their vicinity ; or, on
the other hand, the greatest change may be in the tunica propria of
the tubules and in the connective tissue between them. Accord-
ingly, Traube distinguishes two forms of interstitial nephritis, the
circumcapsular and the intratubular, each of which presents certain
peculiarities from a clinical point of view. Not unfrequently, in
the cortical substance we find numerous small cysts having clear
contents, and varying in size from that of a millet-seed to that
of a pea. These probably are the product of constriction and dila-
tation of parts of a uriniferous tubule, particularly of one of the
convoluted tubes.

The chronic parenchymatous form is regarded by some observ-
ers as an inflammation which occurs exclusively and entirely in the
secretory cells of the tubules. We do not hold it proved that there
is such a form, and think that there may be confusion with the so-
called "opaque swelling" of the kidney epithelium (Chapter VIII. ).
But we find that in some cases the elements of the tubules take

CHRONIC BRIGHT'S DISEASE. 19

little part in the inflammatory process which is going on in the in-
tervening tissues, while in others it is the prevailing seat of the dis-
order. We believe that it depends upon the degree of the inflam-
mation whether the secretory or merely the interstitial part of the
organ shall be invaded. We shall see by and by that chemical ob-
servation also teaches that cases of a very tedious insidious course
betoken an interstitial disease, while, on the other hand, chronic
cases of a more active and less protracted form indicate the exist-
ence of the parenchymatous disease. In the acute diffuse nephritis
above described, the implication of the renal parenchyma proper is
most apparent both from a clinical and anatomical point of view.
If we trace back the difference between the parenchymatous and
interstitial forms to a gradual variation in grade of the inflamma-
tion, the existence of many intervening forms will be easy of com-
prehension.

In the chronic parenchymatous form, the kidney, in consequence
of .swelling of the epithelium and of deposits of exudation in the
tubules, becomes very soft and swollen, sometimes to double its nor-
mal size. The vessels of the cortical substance are bloodless (in
the cadaver at least), the capsule is opaque and easily detachable,
and beneath it the renal surface looks pale or yellowish, except
where one or two venous trunks remain filled with blood. Upon
section it is seen that the enlargement is all due to swelling of the
cortical substance, which is sometimes an inch thick ; and that the
pyramids take no part in the pallid coloring of the cortical sub-
stance, but often form a marked contrast with it by their deep-red
hue. Here and there a Malpighian body still remains like a red
point on the pale field. The chief seat of the morbid process is in
the convoluted tubules of the cortical substance, while the straight
tubules of the pyramid rarely, and in but small degree, exhibit the
exudation which causes the swelling and softening of the cortical
substance. The cylindriform deposits, which occlude and render
varicose many tubules, consist partly of swollen fatty epithelium,
partly of lymphatic elements (pus) and blood-corpuscles, but espe-
cially of hyaline or granular cylindrical masses.

Many observers assume that, after a certain duration, the en-
larged kidney gradually shrinks and atrophies, and suppose the
atrophy to arise from the perishing of the glomeruli, by pressure of
the intracapsular exudation, and the collapse of their tubules which
have lost their epithelial lining. Even admitting the occurrence of
such obliteration of some of the tubules, it may be questioned
whether atrophy of the kidney can really be brought about through
such a process alone, and without the concomitant thickening of

20 DISEASES OF THE KIDNEY.

the intertubular tissue by interstitial nephritis. In fact, even the
eminent authorities who believe in the distinct nature of the two
forms of nephritis, nevertheless admit the possibility of the exist-
ence of many intermediate or combination forms between the two.
(Cartels.)

To conclude our description of the pathological anatomy of
this affection, it may be well to remark that in many instances the
morbid changes which take place in the kidney are by no means
easy of recognition by the naked eye. When the inflammation is
of moderate extent, we often find merely a few pale-gray streaks
lying in the renal tissue, which in all other respects looks perfectly
healthy. Sometimes, when the disease is diffuse and scattered,
it would be impossible without the aid of the microscope to de-
termine with certainty its presence in the tubules and interstitial
tissue. The numerous consecutive changes which chronic diffuse
nephritis is apt to bring about in other organs and tissues will be
duly mentioned when we come to discuss the symptoms of Bright's
disease.]

SYMPTOMS AND COURSE. — Pain in the region of the kidney, which
has been reckoned by most authors as among the most constant symp-
toms of morbus Brightii, according to my observation, is wanting in
the majority of cases throughout the entire course of the disease. It
is true, that if we press with great force upon the kidney, the patients
complain that the procedure is uncomfortable and distressing, but we
shall hear a like complaint from well folk, whom we may subject to
similar infliction. It is as unusual for the attention of the patient to
be called to the grave nature of his disease by any marked diminution
in the amount of urine which he passes, as it is for him to suffer pain
hi the renal region. After the dropsy and the albuminuria have placed
the diagnosis beyond a doubt, most patients, if asked whether they
have passed too little urine in the course of their disease, will not only
deny it, but will even declare that throughout the entire duration of
their dropsy they have made a great deal of water. Such an account
as this, from a patient with chronic dropsy, is in itself suggestive of
the probable dependence of the dropsy upon chronic renal disease. On
the other hand, if a patient assert that his dropsy has developed grad-
ually, and that since its commencement he has always passed remark-
ably little urine, there is a certain amount of presumption that the
dropsy is of cardiac or pulmonary origin, and that it does not proceed
from disease of the kidney. However, we must not ignore the fact
iJiat such statements from patients, as to their passing an unusual
juantity of water, are often the result of a delusion upon their part. An
inclination to pass water frequently, a symptom due to sympathy of

CHRONIC BRIGHT'S DISEASE. 21

the Urinary bladder, and common both to chronic and to acute Bright's
disease, but which is never very severe, impresses the patient with the
idea that, in his frequent acts of micturition, he has discharged a large
quantity of water. Accurate measurement of the amount passed in
twenty-four hours shows that, in many cases, it does not quite reach
the normal flow. In others it is normal ; while in others, again, the
proper quantum is really exceeded. A considerable diminution of the
normal secretion or actual suppression of urine seldom occurs, and then
merely forms, as it were, a short episode in the disease. This peculiar
behavior of the urinary secretion, in chronic Bright's disease, is alto-
gether enigmatical. The slighter degree of suppression, which is the
most frequently observed, admits of the easiest explanation ; as the
obstruction of numerous tubules by swollen and degenerated epithe-
lium would obviously impede the outflow of the urine, and the com-
pression of many of the glomeruli must effect a diminution in the
amount of urine secreted. But how shall we explain the fact that, in
.many instances, in spite of this hinderance to the discharge, and in spite
of the limitation of the secreting surface, the flow of urine still remains
normal, or even is abnormally profuse ? How account for the fact
that the increase in this secretion is peculiarly common in the third
stage of the disease, at a period when the kidney is atrophied, and
when many of its tubules and Malpighian capsules have collapsed and
wasted away ? We admit that the hypertrophy of the left ventricle of
the heart may perhaps assist in augmenting the secretion of urine bv
increasing the pressure within the glomeruli, which still remain intact,
thus hastening the filtration of liquid through them ; but its influence
is by no means to be so highly rated as to suppose that the absence
of many defunct glomeruli can be more than compensated for by in-
crease of internal pressure upon those which remain. Nor does the
collateral fluxion to the remaining glomeruli, induced by obliteration of
the blood-vessels in the affected portion of the kidney, do more than
to explain why there is not a material decrease in the secretion of
urine, and by no means accounts for its augmentation. There is some
probability that privation of the blood of its albumen may have some
effect in increasing the secretion from the kidney. As is well known,
a liquid will pass more freely through an animal membrane from a
dilute solution of albumen, than from a solution which is more concen-
trated, the pressure being the same. But even this does not seem to
account for the increased production of urine which we so often observe
in the third stage of Bright's disease.

Although, as before said, neither pain in the region of the kidney,
nor any unusual flow of urine, calls attention to the grave disease
which is going on, yet its recognition is no longer difficult, since it has

22 DISEASES OF THE KIDNEY.

become the practice of the better class of physicians to make careful
examination of the urine. Hospital patients do not generally apply
for aid until the dropsy has appeared. Exclusion of other causes of
dropsy will establish a strong presumption that we have a case of
Bright's disease to deal with. Examination of the urine places the
diagnosis beyond a doubt. In private practice, the observant and ex-
perienced practitioner will have recognized the disease before the
dropsy sets in. The history of the case is almost invariably as follows :
The patients have long remarked a failure of their strength, and a
pallor and anaemic aspect of their skin, and visible mucous membranes.
As all their functions are apparently normal, they are unable to ac-
count for this paleness and debility. The physician, after careful ex-
amination of all other organs, can find no appearance of disease to
which the loss of strength and impoverishment of the blood can be
ascribed. He examines the urine, and finds it to be loaded with albu-
men, and the symptoms are accounted for. No elaborate demonstra-
tion is required to show that, in addition to the other expenditures of
the blood, a daily loss from the blood of large quantities of albumen,
which may amount to from twelve to twenty grammes in the twenty-
four hours, cannot be made good by the daily supply of nourishment ;
or, in other words, a person subject to a daily drain from his blood of
from twelve to twenty grammes of albumen necessarily becomes pale,
bloodless, and enfeebled. As an examination of the urine reveals the
existence of the disease before the occurrence of the dropsy as well as
after it, it will be well to give a more detailed account of the charac-
teristics of the urine secreted in parenchymatous nephritis. It is gen-
erally of a pale-yellow color, and often exhibits a somewhat opalescent
reflection. As it is more viscid than common urine, on account of the
albumen which it contains, it is more easily made frothy than urine
free from albumen, and the froth lasts longer. When there is no in-
tercurrent febrile disease, its specific gravity is remarkably low, and
may sink to 1005. This is principally on account of a decrease in its
urea, and in a lesser degree owing to a diminution of the salts, especial-
ly the alkaline chlorides. The reduction in the amount of urea cannot
at first be ascribed to its retention in the blood. It would seem
rather that, just as in other hydrsemic conditions in which the urine is
abnormally light, the metamorphosis of material in the body is going
on more slowly than is natural, thus retarding the production of urea.
The explanation of Schmidt as to the decrease in the saline constitu-
ents of the urine, especially its alkaline chlorides, is less satisfactory,
namely, that the saline ingredients of the blood augment as its albu-
men diminishes, and vice versa. When the patients are already drop-
sical, the transfer of the chlorides into their dropsical effusion is a

CHRONIC BRIGHT'S DISEASE. 23

phenomenon of far greater importance. The significance of this cir-
cumstance consists in the fact that, as long as the dropsy keeps in-
creasing, the saline contents of the urine are very small, but whenever
any rapid diminution of the effusion takes place, the salts are elimi-
nated into the urine more freely, much more freely, indeed, than under
normal conditions.

If a portion of the urine be heated, after addition of a few drops
of acetic acid, in case its reaction should be alkaline, or if nitric acid
be added, the albumen coagulates. According to Frerichs, its quan-
tity ranges from about 2.5 to 15.0 p. M. This presence of albuminuria,
which usually persists throughout the whole course of the disease, and
only disappears now and then, for short periods, unfortunately cannot
be satisfactorily accounted for. One might be led into mistaking the
albumen and the exudation cylinders for the products of inflammation,
excreted from the free surface of the tubules, were it not that, in other
and non-inflammatory diseases of the kidney, the urine contains both
tube-casts 'and large amounts of albumen. I believe the presence of
albumen in the urine to depend upon the destruction or degeneration
of the epithelium. That normal urine should not contain albumen is
confessedly extremely perplexing to the physiologists. They are al-
most forced to suppose that the albumen does transude into the kidney,
together with the water and salts ; and they are reduced to the hy-
pothesis that its absence from normal urine is in some way connected
with the epithelial lining of the uriniferous tubules, the transuded
albumen either becoming assimilated for the nutrition of the epithe-
lium, or else its diffusion into the tubules, receiving some other modifi-
cation, as yet unknown to us, from the epithelium. The observation
that albuminuria exists in all diseases of the kidney, in which its epi-
thelium is either degenerated cr destroyed, fully confirms this physio-
logical hypothesis.

After the urine has been allowed to stand for a while, a light,
whitish, flocculent precipitate falls to the bottom of the vessel. If this
sediment be placed under the microscope (for this purpose it is best to
let it deposit in the bottom of a pointed champagne-glass), the well-
known casts are found. At the commencement of the disease they
are covered by epithelium, in a state of fatty metamorphosis ; at a later
period, they seem quite bare, or are merely covered with granules and
globules of fat. Besides this, the sediment contains common epithe-
lial cells from the urinary passages, and smaller round, slightly-gran-
ular cells.

[By many the so-called urinary cylinders are supposed to be a
product of the blood ; others ascribe their origin to alteration of
the epithelium. They probably originate in various ways. The
52

24 DISEASES OF THE KIDNEY.

cylinders should be distinguished from those so-called epithelial
tubes formed by separation of long pieces of the lining of the
straight tubes, and recognizable under the microscope as oblong
rolls of epithelial cells. Such casts appear in the less serious dis-
eases of the kidney ; hence their temporary presence warrants a
favorable prognosis unless gainsaid by other signs. The cylinders
proper belonging to the graver malady are solid plugs of exudation
which have filled portions of tubes. There are two typical forms of
them, with intermediate varieties : 1. Hyaline casts, which, though
well defined, are transparent as glass, and hence are apt to be over-
looked unless foreign matter adheres to them ; 2. Granular casts,
more or less closely studded by minute fat-globules. Hyaline casts
are probably formed by the exudation of a fibrogenous substance,
which becomes fibrin within the tubules. Some ascribe their ori-
gin to colloid metamorphosis of the epithelium. Another special
modification of the hyaline cast is the waxy cast, which proceeds
from the former, and is to be distinguished from it by its greater
consistence, its yellowish color, and its more distinct outline. By
many, granular casts are supposed to be the product of fatty meta-
morphosis of hyaline cylinders ; others regard them as the result of
croupous degeneration of the tubular epithelium. Other objects
are often found adhering to the casts, such as pus, white blood-cor-
puscles, blood-disks, degenerated epithelium, and clusters of fat-
globules, vestiges of broken-down cells ; likewise the various crys-
tals which are found in the urine. All the above-named objects
are also found free in the urine of Bright's disease. During an in-
flammatory relapse an exceptionally large number of casts will
appear in the urine ; otherwise they are not numerous, and some-
times can only be found after filtering the urine and examining
the dregs. Urinary casts are not a pathognomic sign of Bright's
disease, for they are found, as we shall see, in other renal affec-
tions ; nor can we positively determine the form or stage of the
disorder frem the character of the casts. Nevertheless, the discov-
ery of many casts, both hyaline and granular, with here and there
an adhering lymph-cell or granular epithelial cell, favors a diagno-
sis of an active progressive inflammation (a parenchymatous ne-
phritis) ; while, if the casts are few, small, and hyaline, or if they
are absent altogether, the urine being profuse, clear, and scant of
sediment, we may suppose the disease far advanced, and that the
kidney is shrunken (interstitial nephritis).]

Dropsy is one of the most characteristic signs of Bright's disease,
excepting in a few rare instances, in which it has been absent through-
out the entire course of the malady. It generally begins as anasarca.

CHRONIC BRIGHT'S DISEASE. 25

At first the face and feet swell, the upper extremities, abdomen, and
scrotum not becoming affected until a later period. The oedema often
shifts its position in a peculiar manner, so that at one time the face or
upper extremities may be the more swollen, at another the feet, ab-
dominal walls, or scrotum, while the tumefaction subsides in the region
at first affected. Moreover, if the patient be out of bed, the feet gen-
erally show the greatest amount of swelling in the evening, while in
the morning the feet are smaller again, and the swelling involves the
hips, back, and hands. The more slowly the anasarca develops, so
much the more does the skin lose its elasticity, and so much more
slowly is the imprint of the finger effaced from the oedematous surface.
The addition of ascites and hydrothorax to the anasarca does not take
place until a more advanced period. In one exceptional instance, I
have witnessed the appearance of hydrothorax and cedema of the lungs
early in the disease, where previously there had only been a slight
cedema of the integujnent, a condition of apparent security thus sud-
denly becoming one of great danger. In cases which advance rapidly,
the dropsy may attain great magnitude in a few weeks. I have seen
a patient who weighed a hundred kilogrammes (i. e., two hundred
and twenty pounds), who affirmed that, eight weeks before, he did
not weigh fifty. Such extreme dropsical swelling, from the strain
which it exerts, may be the cause of inflammation and gangrene of
the skin, especially of the scrotum and labia majora. In the worst
cases, the skin often bursts at several points, and the liquid trickles
copiously from the rents.

The pathogeny of the dropsy of parenchymatous nephritis is ex-
ceedingly difficult of explanation. As is already stated, the dropsy
often develops in the midst of a copious excretion of liquid from the
kidneys, and hence cannot be ascribed to any increase of pressure
upon the veins of this organ, although this must be regarded as the
main cause of the dropsy of acute croupous nephritis, in which disease
there is always a suppression of urine. It is true that, during any
check to the secretion of urine which may occur in this disease, the
dropsy makes rapid headway ; and when the urine is scanty through-
out the entire course of the malady, the dropsy soon becomes exces-
sive, and the malady runs a subacute course. There is no doubt but
that a " hydrsemic crasis," a lack of albumen in the blood, favors the
occurrence of dropsy. Owing to the continual loss of albumen, which
the blood is suffering, in Blight's disease, a liquid which contains but
little albumen flows through the capillaries of the system. Hence, an
abnormal transudation takes place from the capillaries into the inter-
stices of the tissues, and hence, too, the amount of serum returned to
the veins is abnormally small. It is not to be doubted that the ab

26 DISEASES OF THE KIDNEY.

sorption of liquid from the interstices of the tissues into the vessels is
more active, in proportion as the difference in concentration in the
liquid contained in the vessels and that without them is greater.
Now, as, in parenchymatous nephritis, this difference is abnormally
small, it follows, of course, that not only more liquid should leave the
vessels, but that less should return to them. I have observed cases
at my clinic which confirmed the correctness of this in the most strik-
ing manner. A girl, who had been suffering for a year from paren-
chymatous nephritis, stated that, some time before the appearance of
the oedema, she had felt exceedingly dull and miserable. Being con-
sidered plethoric, she was advised to get bled. A week after the
blood-letting, the first symptoms of anasarca- showed themselves, and
since then have never entirely disappeared. It may be inferred in this
case that the hydraemia, which, though extant in moderation, still had
not as yet produced dropsy, was so much aggravated by the blotfd-
letting as to cause the dropsical symptoms to appear. In another
case, the patient became anasarcous after a haemorrhage, but the ana-
sarca afterward disappeared for a while, and set in anew after the es-
tablishment of profuse suppuration. Nevertheless, hydraemia is not
the sole cause of Bright's disease, and probably not even its chief
cause. Dropsy, as severe as that seen in Bright's disease, is hardly
ever observed in any other form of hydraemia. It £>ften occurs early,
but does not keep pace with the privation of the blood of its albumen.
The peculiar manner in which the oedema shifts from one region to
another is another argument against its dependence upon simple
hydraemia. If we abstract blood from an animal, and inject a corre-
sponding amount of water into its veins in its stead, the animal does
not become dropsical. Finally, the dropsy is so very often accompa-
nied by attacks of inflammation as to indicate that, besides, the thin-
ning of the blood, there is another source both of the transudation and
exudation, consisting in some disorder of the tissues as yet unknown
to us.

It sometimes happens that the continual aggravation of the symp-
toms above described, and the excessive dropsy, which finally may in-
volve the serous sacs and alveoli of the lungs, cause death without
further complication. In most cases, however, remissions occur, in
which the condition of the patient improves, the albumen in the urine
diminishes, and the dropsy subsides. After a while he grows worse
again, perhaps once more to improve at a later period, and thus the
disease will fluctuate. In such protracted cases the above symptoms
are seldom the only ones, but are accompanied by others which arise
in part as complications of the main disease, and in part are immediate
consequences of it.

CHRONIC BRIGHT'S DISEASE. 27

Of these, inflammation of the lungs, of the pleura, pericardium, perito-
naeum, and meninges, deserve the first mention, as they are extremely
frequent complications of Bright's disease, and because it is of these
intercurrent affections that the patient most frequently dies, far more
frequently, indeed, than of the so-called uremic symptoms — to be de-
scribed presently — or even of excessive dropsy. Such inflammations
of the lungs, pleura, etc., do not differ from similar inflammations in
other conditions of anaemia. The patient seldom succumbs at once to
.the first attack; and we not uncommonly find vestiges of previous
' inflammation, such as adhesions of the pleura, pericardium, and peri-
tonaeum, besides the marks of the final seizure. Parenchymatous
nephritis is often complicated by catarrh, particularly by catarrh of
the bronchi and intestine. There is nothing peculiar about the for-
mer, although in some cases the secretion is tolerably copious. The
latter, however, is almost always characterized by a very abundant
serous transudation, and by its extreme obstinacy. It would seem
that the eame. cause which induces the escape of such large quantities
of liquid into the subcutaneous connective tissue also gives rise to this
immense transudation upon the free surface of the bronchial and in-
te'stinal mucous membrane. Nevertheless, since the dropsy is not in-
variably accompanied by catarrh, it must be admitted that its origin
is somewhat obscure.

According to my experience, chronic oedema of the lung is of very
common occurrence in Bright's disease. It gives rise to great dyspnoea,
to a tormenting cough, and, at the climax of the coughing-fit, not unfre-
quently induces vomiting. I have had repeated opportunity of observing,
whenever the vomiting caused the patient to eject much secretion,
that his breath became freer for a while, his cough ceased, and that
the fine subcrepitant rales subsided. Paroxysms of so-called urinous
asthma, which are said to occur in Bright's disease, are probably de-
pendent in a great degree upon oedema of the lung.

Many patients with parenchymatous nephritis suffer from disease
of the heart. Besides the adhesions of the heart and pericardium
from former pericarditis, and the valvular derangement resulting from
endocarditis, none of which are uncommon in Bright's disease, we
very often find a hypertrophy of the heart, and more especially a
hypertrophy of its left ventricle. Traube has advanced the theory
that this hypertrophy is a result of derangement of the circulation
of the kidney, which he claims should augment the labor of the
heart. This theory is disputed by Bamberger and others, who reply
that the hypertrophy develops in a stage of the disease when no
obstruction of any importance to the circulation of the kidney ex-
ists. A more extensive collation of facts will be necessary to decide

28 DISEASES OF THE KIDNEY.

this disputed point ; but, at all events, enormous hypertrophy of the
neart sometimes occurs even in the second stage of Slight's dis-
ease, and assuredly the circulatory disturbance of the kidney is not
the sole cause of it. As is well known, the signs of the enlargement
are not very striking, but, by paying attention, we can often detect an
augmented heart-shock, or, in its absence, hear remarkably loud car-
diac sounds.

In a great number of cases, the symptoms of the so-called uraemio
poisoning do not appear at all throughout the entire course of the com-
plaint. Sometimes they develop slowly and gradually; sometimes
they come on very suddenly. At times (but not always), the attack is
preceded by a decrease in the secretion of urine, and in rare instances
it has happened that, during or immediately prior to the appear-
ance of the uraemic phenomena, the normal flow of urine has been
largely exceeded (Liebermeister). It is a suspicious sign when pa-
tients complain of severe headache, and become languid and apathetic,
and still more so, if these symptoms be accompanied by vomiting,
which occasionally is so very obstinate as to awaken apprehension of
serious disorder of the gastric mucous membrane. All these symp-
toms may subside again, without evil consequence ; in other cases,
however, the drowsiness increases to a deep stupor, or convulsions of
an epileptic or more rarely of a tetanic character may arise. Even
when the convulsions have not been preceded by drowsiness, they are
usually followed by a condition of deep coma with stertorous breathing.
The fits recur at longer or shorter intervals, the stupor meanwhile con-
tinuing to grow deeper ; and the patient may finally succumb to gen-
eral paralysis. It is not at all rare, however, for the fits gradually to
become less frequent, the intervening stupor less profound, and for the
signs of " uraemia " to disappear, perhaps not to recur for weeks or
months. In a previous section, we have already acknowledged that
we are unacquainted with the nature of the poison causing uraemic
intoxication. There is a second difficulty in explaining the uraemia of
parenchymatous nephritis, since certain well-attested cases of uraemia
poisoning have been observed, in which there was no suppression of
urine. If the urea and other material to be eliminated from the blood
pass into the tubules by a process of pure endosmosis, it remains in-
explicable how these materials can accumulate in the blood when the
urine is secreted freely ; hence we must assume that the epithelium
of the urinary tubules has some important influence over the secretion
of urine, and therefore that its disease or death may occasion an ab-
normal state of the blood, even though the kidneys continue to dis-
charge a sufficient quantity of liquid. Moreover, I think that it would
be going too far to attribute all the grave nervous symptoms which

CHRONIC BRIGHT'S DISEASE. 29

arise in parenchymatous nephritis — the headache, the convulsions, the
coma, etc. — simply to a poisoning of the blood ; and for many cases at
least I agree to the equally one-sided views of Traube, according to
whom the so-called uraemic symptoms depend upon oedema of the
brain and cerebral anaemia. Since the first appearance of my text-
book, I have been much gratified at the steady advance made by the
doctrine which I propounded long ago, that the symptoms of the so-
called cerebral pressure, due to encroachment upon the cavity of the
cranium, whether by a depression of the skull, haemorrhage, tumor,
abscess, inflammatory exudation, or serous transudation, all depend
upon an arrest or obstruction to the flow of blood to the ganglion-cells
and nerve-fibres of the brain. But, in spite of the experiments of Munk,
I hold it to be unproved, and even improbable, that the acute cedema of
the brain in Bright's disease should have an origin different from that
of cedema of other regions, or that it should be ascribable to an increase
of pressure within the cerebral arteries. Moreover, it seems to me to
be extravagant to encleavor to ascribe all cases of so-called uraemia to
compression of the cerebral capillaries, and to anaemia of the brain.
My position in this question is as follows : In chronic parenchymatous
nephritis, various organs are subject to O3dema, the precise cause of
which is unknown. It is characteristic of this cedema, that it shifts its
position. It may attack the lungs at any period, either early or late
in the disease, sometimes causing death, and sometimes subsiding
again after a short duration. In a manner precisely similar, and for
the same unknown reason, the brain may become the seat of an acute
or subacute cedema, to which many succumb, while in others the cedema
changes its position, and the patients are restored to a state of tolera-
ble comfort for a period of variable duration. Many cases of so-called
uraemic intoxication, but by no means all, are the result of cedema of
the brain, and consequent anaemia of the cerebral capillaries. We
may infer that an attack of this kind depends upon such an cedema,
and not upon blood-poisoning : 1. When the seizure takes the form
of deep coma, with intercurrent eclamptic spasms. 2. When, at the
time of its occurrence, the secretion of urine is normal or increased. 3.
When the attack is accompanied by marked cedema of the face. 4.
When the carotids pulsate strongly during the attack. As we shall
see directly, this is a valuable but often ill-appreciated sign of repletion
of the cranial space with blood, and of impediment to the exit of the
blood from the same.

[The temperature in uraemia may be either increased or dimin-
ished. According to Bourneville, the average temperature is re-
duced, but rises during the fits, and remains high during the inter-
vals. In fatal cases it is very high, but it sinks gradually to the

30 DISEASES OF THE KIDNEY.

normal when the outlook is favorable. According to prevalent
modern views, the cause of the uraemic symptoms is due to insuf-
ficient elimination by the kidneys of certain products of the body
which, when sufficiently concentrated in the tissues, have a poison-
ous action upon them, especially upon certain parts of the brain.
This poisonous effect is exercised chiefly by the urea and its prod-
uct of decomposition, carbonate of ammonia.

According to Jtosenstein, however, poisoning by carbonate of
ammonia alone induces but one of the trains of symptoms, that of
epilepsy, while the agent which produces the uraemia occasions not
only epilepsy, but coma, convulsions, and delirium. Moreover, we
must remember that in cases of uraemia, even when the presence of
carbonate of ammonia in the blood has been demonstrated, the de-
pendence of the ursemic symptoms upon its presence has not been
proved. The quantity of urea excreted in the course of a day is
generally diminished in Bright's disease. This diminution of the
daily quantum of excretion is often considerable at the very time
when the secretion of urine is also reduced ; while in patients with
extreme polyuria, whose health is as yet unshaken, the quantity of
urea excreted, in spite of the small percentage contained in the
urine, may even exceed the normal. If the daily excretion of urea
is very small, we are justified in fearing that the disproportion be-
tween production and excretion may lead to uraemia.]

In many cases of Bright's disease, the patients observe a grad-
ual failure of their power of vision ; in others, blindness, more or
less complete, sets in suddenly. I have heard a patient, upon com-
ing to himself, after a uraemic convulsion followed by coma, ask to
have the gas lit, although it was burning brightly at the time. This
partial or total extinction of vision, too, used formerly to be re-
ferred to uraemic intoxication, and was called uraemic amblyopia or
amaurosis. Latterly, however, the real source of this disorder has
been found to be an extravasation into the retina, accompanied by
inflammation. A diagnosis of Bright's disease has repeatedly been
made by means of the ophthalmoscope alone. In one case which I
have watched, the impairment and subsequent improvement of vis-
ion which occurred manifestly coincided with the formation and
absorption of such extravasations.

[This disturbance of vision is not to be confounded with another
— urwmic amaurosis — which appears sometimes superadded to an
already existing retinitis, and sometimes comes on suddenly with
the other uraemic signs, without previous derangement of the sight.
In a few days, or even in a few hours, the sight fails so that a light
cannot be distinguished ; but should the uraemia subside, vision may

CHRONIC BRIGHT'S DISEASE. 31

soon be completely restored again. The speedy abatement of this
form of blindness argues against its dependence upon permanent
lesions. Somewhat more rarely, deafness and roaring in the ears
have been noticed in uraemia.

COURSE. — The course of chronic diffuse nephritis varies greatly.
In one class of cases the disease may last for ten or even for twenty
years, and may be so latent that the patient is scarcely aware that
he is ill, and so that a careless physician who neglects to examine
the urine can make but little out of his patient's persistent but
vague complaints of loss of strength and energy, of impaired appe-
tite and digestion. When the inflammatory process runs this slug-
gish course, the urinary tubules take but little part in the changes
which are going on in the interstitial connective tissue. There are
but slight and merely transient inflammatory exudations into the
tubules, whose epithelium suffers but little direct damage ; hence, in
such a case, but few^if any casts or other characteristic forms are
found in the urine. This languid process results merely in thicken-
ing of the renal connective tissue, followed by shrinking. It is this
grade of inflammation, according to our view, which marks the dis-
tinction, both anatomically and clinically, between the forms of
Bright's disease. Sometimes the disease maintains this insidious
character throughout its course. The patient then preserves a tol-
erable appearance of health for years. His urine, which is copious
and pale, shows but little albumen ; but late in the disease he gen-
erally presents signs of a hypertrophy of the heart. In such a case
death may take place suddenly in a uraemic convulsion, before there
has been any dropsy whatever. In other cases attacks of eclampsia
recur at irregular intervals. Still other patients die of apoplexy in
consequence of the hypertrophy of the left heart and of the accom-
panying disease of the arterial walls.

In another and larger class the course of the disease is less slug-
gish and insidious. The inflammation is more active, and involves
the tubules directly, so that dropsy soon develops. In some instances,
which nevertheless are rare, the disease progresses steadily and
with unabated activity to the end, causing the death of the patient
in a few months by dropsy, secondary inflammations, or uraemia.
Much more commonly there are marked fluctuations in its intensity.
There will be periods, sometimes long ones, in which the urine re-
tains its normal volume, is but moderately albuminous, and shows
few casts or none at all. The dropsy abates and disappears ; in a
word, the symptoms of parenchymatous nephritis fade away or dis-
appear. But between these intervals come exacerbations, during
which, in spite of the most urgent and incessant efforts of the

32 DISEASES OF THE KIDNEY.

patient to micturate, the daily secretion of urine is decreased, the
percentage of albumen augments, numerous casts and cellular forms
appear in the urine, and the dropsy makes further progress. Dur-
ing these long remissions of the malady the diagnosis may be difficult ;
or beyond a moderate albuminuria, which alone affords no proof of
Bright's disease, the patient presents but vague symptoms, such as
gastro-intestinal disturbance, anaemia, and loss of flesh. A patient
is thus not unfrequently supposed to be convalescent, or even cured,
until, sooner or later, relapses occur ; so that, after an average dura-
tion of about two years, he succumbs to dropsy, to secondary inflam-
mation of vital organs, or perhaps to uraemia. Should he escape
all these dangers for a considerable time (as may happen exception-
ally), then the active symptoms of the parenchymatous form of
Bright's disease may give place to that of shrinking and atrophy.
There will be a very profuse pale urine, of low specific gravity,
containing a moderate quantity of albumen (sometimes, though very
rarely, absent), and but few or no casts.

PROGNOSIS. — While recovery from acute diffuse nephritis is by
no means uncommon, the prognosis in the chronic form of the mal-
ady is far less favorable ; and indeed it becomes almost absolutely
bad as regards old or neglected cases, or when, from the condition
of the heart and of the urine, an irreparable atrophy of the kidney
can be made out. Nevertheless, even in some of these cases, though
incurable, a hope may be held out of a tolerably comfortable exist-
ence for some years, or at least so long as the dropsy is moderate
and transitory, as the serous cavities are free, and as the secondary
lesions and the uraemia do not appear, and while the patient main-
tains his digestive powers. When the disease is recent and has
been well and promptly treated, the prospects of complete cure are
a little better. Sometimes the malady seems to run a medium
course between that of the acute and chronic forms. The immedi-
ate danger is then much increased, but the hope that, after many
weeks or even months, a complete recovery may take place, is much
more warrantable than in the chronic form. In a diffuse nephritis
which is secondary to some other grave disorder, such as an old
malaria or a tedious suppuration, the nature of the primary affection
must be considered in the prognosis.]

In respect to the duration and results of Bright's disease, it
may be said that there are cases which run their entire course in a
period of from six weeks to three months, and others in which the
malady drags on for years. I used to know a physician of large
practice in Altmark, who only died within a few years, although he
had all the symptoms of Bright's disease as long as twenty years

CHRONIC BRIGHT'S DISEASE. 33

ago. We have already alluded to the fluctuations in the intensity
of the symptoms which take place in protracted cases. The most
frequent termination of Bright's disease is death ; although patients
more commonly die of the intercurrent inflammations than directly
of the disease itself. Complete recovery may possibly take place,
but it is extraordinarily rare. The longer the duration of the mal-
ady, so much the less is a favorable result to be looked for. In re-
cent cases, the question always arises whether we have not to do
with a croupous nephritis, which, as we have explained, admits of a
better prognosis.

TREATMENT. — The causal indications require that a patient with
parenchymatous nephritis should wear flannel next his skin, and ex-
change his dwelling, if damp and cold, for a dry and warm one ; and
that he should be forbidden to go out at night or in bad weather,
even during any temporary improvement. Well-to-do people, who
dwell in bleak, damp, windy, seaside neighborhoods, should be in-
duced to change theif abode. Excesses in spirituous liquors, and
the Use of "diuretics, cubebs, copaiba, and spices, are to be strictly
prohibited. The discovery that Bright's disease is an inflamma-
tory affection has done but little toward an efficient treatment of
it. The so-called antiphlogistic method is inapplicable to any of
its stages.

[The practice of blood-letting, the application of cold com-
presses, and the use of calomel no longer find advocates. We
possess no means of extinguishing this obstinate and refractory
disorder. Our task is therefore by no means simple, nor can any
uniform plan of management be adopted for. all cases. Its treat-
ment must be chiefly a treatment of symptoms. The main disor-
der can only be attacked indirectly, by seeking to combat the indi-
vidual pernicious or dangerous manifestations as they arise, and by
striving to remove all influences tending to irritate the kidneys.
From this point of view the scope and value of therapeutics in
the varying phases of Bright's disease, as tending to prolong the
life and to ameliorate the condition of the sufferer, should not be
underrated.]

In fulfilment of the indications from the disease itself, derivation
from the intestines by drastics, and from the skin by diaphoretics,
has been proposed. We shall recur to the employment of this
measure while treating of the management of the symptoms, as it
often acts favorably upon the dropsy ; but we do not believe that the
inflammation of the kidney can be arrested or allayed by such deri-
vation. Frerichs speaks favorably of tannic acid, which he gives
three times daily, in doses of from two to six grains, in combination

34: DISEASES OF THE KIDNEY.

with aloes and in the form of a pill. The elimination of tannic acid
through the urine in the form of gallic acid and pyrogallic acid,
to which we have alluded elsewhere, warrants this treatment from
a theoretical point of view. Frerichs himself admits that, although
he has observed a diminution in the quantity of albumen excreted,
yet, in chronic cases, he has but seldom seen a complete disappear-
ance of it. My own experience does not speak at all in favor of
tannic acid.

Bad as we have represented the prognosis of parenchymatous ne-
phritis to be, we have often succeeded quite brilliantly in palliative
treatment, and, in fulfilling the symptomatic indications, the therapeu-
tics of Bright's disease are by no means to be regarded as powerless.
We have recognized the loss of albumen from the blood as the imme-
diate cause of most of the symptoms of the disease, and hence our
most important task by far is to cover the loss of albumen by a diet
rich in protein substances, and by appropriate medication. Soft-boiled
eggs, milk, strong meat-broths, and roast-beef, in as large quantity as
the patient is able to digest, are probably the best preventives of the
dropsy ; and, while patients in comfortable circumstances often with-
stand the loss of albumen with impunity for years, the poor, on the
other hand, succumb to it far more speedily, because the former have
better means than the latter to supply the daily losses which they
suffer. Besides this, a moderate amount of beer or good wine should
be prescribed, as by the use of these articles the waste of tissue is
retarded and the nutrition promoted. Quinine and iron are the most
suitable medicines. The former was thrown overboard by many phy-
sicians during the time of a generally prevailing nihilism in therapeu-
tics, and its supposed tonic action upon the fibres has been much de-
rided. But, in these days of reaction against such nihilism, tonics, and
especially the preparations of quinia, have once more come into repute,
and, indeed, it would seem that they do exert a beneficial action upon
the state of nutrition by diminishing the consumption of material.
Preparations of iron are equally appropriate, since their effect upon the
formation of blood is most decided, and it is not the albumen of the
blood alone but also the red blood-corpuscles which are reduced in
quantity in this disease. Neglect of such directions as the above, a
blind groping in search of a specific remedy, and a vague, planless ex-
hibition of diuretics after the dropsy has set in, are merely so many
tokens of incapacity on the part of the physician. In a series of cases,
which have been described by Dr. Schmidt, in his inaugural thesis, I
have obtained most brilliant results where all other treatment had
failed, by putting the patients upon an exclusive diet of milk. The
patients did not take a grain of any medicine whatever, but drank

CHRONIC BRIGHT'S DISEASE. 35

from five to six pints of cows' milk daily. After the " cure " had beeo
continued in this manner for about four weeks, some of the patients
who, prior to the treatment, had been in the most wretched condition,
had got rid of then* dropsy, recovered an appearance of health, and re-
gained so much of their strength as to be able to resume their business
and even to perform hard labor. The albuminous character of the
urine, however, has disappeared in but one case ; in all the others it
persisted. I am unable to account for the eminently beneficial action
of milk upon Bright's disease. I propose to try whether it be possible
to obtain a physiological explanation of these results by a careful
analysis of the phenomena attending an exclusively milk diet, during
health as well as disease, especially by careful weighing of the body
and by taking accurate account of every thing taken into and ejected
from the system.

If the above measures prove unsuccessful in averting the dropsy, or
in allaying that which already exists, the establishment of active dia-
phoresis is* strongly to be' recommended. No benefit, however, is to
be expected from the use of spiritus mindereri, the antimonials, and
other so-called diaphoretics. I have known patients in an advanced
stage of dropsy to rid themselves of it completely, in a few weeks, by
the daily use of a hot bath, of a temperature of 80° to 100° F., fol-
lowed by sweating for two hours in woollen blankets. The diaphoresis
was so great in one case, that as much as 800 cubic centimetres of the
sweat which had soaked through was collected in a wash-basin placed
undei the bed. All these patients were weighed before and after the
sweating, and the clinical journals show that, during the sweating,
they had lost two, three, and even four pounds in weight. However,
it cannot be denied that, in some cases, this procedure also failed, nor
that debilitated patients sometimes suffered so much from the process
that I was obliged to desist from it. Finally, I may state that, in one
instance, the abatement of the patient's dropsy was coincident with
the first appearance of uraemic convulsions. The profuse drain of
liquid from the skin naturally makes the blood more concentrated, and
this accounts for the absorption of the interstitial effusion. Since,
however, in parenchymatous nephritis, the effusion contains urea and
perhaps other salts, it is readily conceivable that an active abstraction of
liquid from the system would have the effect of overcharging the blood
with these materials, and might thus give rise to uraemia. However,
a closer investigation of the cases above mentioned has led to the con-
clusion that the supposed connection between diaphoretic treatment
and the uraemic symptoms is improbable.

Whatever the theoretical objections against the employment of
diuretics may be, yet, in desperate cases, recourse should alwa}^s be

p,(5 DISEASES OF THE KIDNEY.

had to them. Sq iills and other stimulating diuretics must not be em-
ployed without the utmost caution, on account of the irritating action
which they exert upon the kidneys ; but there are certain salts, espe-
cially cream of tartar, and the tartarus boraxatus (soluble cream of
tartar), which are decidedly beneficial in their effect. The physician
above alluded to has repeatedly freed himself of his dropsy through
the free use of buttermilk, and the employment of cream of tartar and
small doses of Dover's powder.

We have yet to mention the drastics as remedies against the dropsy.
Observations upon cholera have taught us that a heavy drain of water
from the intestinal capillaries will render the blood more concentrated,
and thereby promote absorption of dropsical collections. There was a
very instructive case at the clinic of Tubingen, which has been de-
scribed by Ztiebermeister, where a patient with Bright's disease was
attacked by dysentery and died. In consequence of the thin, copious
diarrhoea, the extensive general dropsy, from which this patient had
long suffered, was reduced to a minimum a few days before his death.
It may also be said in favor of the drastics that, during their employ-
ment, the kidneys are saved from irritation. Nevertheless, we should
never have recourse to them save in time of extreme need, since the
patient is liable to be intensely affected by them, and since, by then-
persistent use, the digestion becomes impaired. The drastics most
frequently employed in treatment of Bright's disease are, elaterium,
gr. -J — J, colocynth, in form of decoction, 3 j — 3 ij, to water, § vj, or
else in the form of tincture.

As remedies against uraemic intoxication, Frerichs, who ascribes
this condition to surcharge of the blood with carbonate of ammonia,
has proposed the acids, especially benzoic acid, in order to form harm-
less ainmoniacal combinations. In the cases observed by me, I have
not been able to perceive any effect from this treatment which is based
purely upon theory ; whereas strong drastics, and iced applications to
the head, always seem to produce a favorable impression.

CHAPTER V.

NEPHRITIS VERA INTERSTITIAL NEPHRITIS — RENAL ABSCESS — METAS-

TATIC DEPOSITS IN THE KIDNEY.

ETIOLOGY. — While in acute and chronic Bright's disease the chief
pathological changes take place in the uriniferous tubules, the altera-
tions which occur in the intervening substance being altogether of a
subordinate and secondary charactei, in the variety of renal inflamma-
tion which forms the subject of the present chapter, the disease lies

INTERSTITIAL NEPHRITIS— REN AL ABSCESS. 37

mainly in the scanty connective tissue which binds the tubules together.
The most common causes of true nephritis are as follows :

1. Wounds and contusions. The kidney is seldom subjected to
external violence, owing to its sheltered position. It is far more liable
to injury from the presence of stones within the pelvis of the kidney.

2. Collections of decomposed ammoniacal urine in the pelvis of the
kidney, the result of urethral stricture, enlargement of the prostate,
palsy of the bladder from injury of the spine, and so forth. Here the
irritation to which the kidney is subject is of a chemical instead of a
mechanical nature.

3. Propagation of inflammation from the urinary passages to the
kidney. It is easy to comprehend that an inflammation of the pelvis
of the kidney, a pyelitis, might readily extend into the parenchyma of
the organ, and cause nephritis ; but the fact that nephritis is sometimes
associated with gonorrhoea, but is not a result of extension of the latter
disease by contiguity, and where there is no accumulation of urine in
the pelvis'.pf the kidney, is altogether enigmatical.

4. Propagation of the inflammation from the connective tissue of
surrounding parts, the peritonaeum and other organs. This is the
rarest of all the modes of origin.

5. Embolism of small arteries of the kidney, and the introduction
of septic or miasmatic material into the blood. This is the source of
the so-called metastatic nephritis, observed in endocarditis, valvular
disease of the heart, and in the various disorders classed under the
general title of pyaemia, as well as in the infectious diseases.

There is usually no doubt as to the embolic origin of the cuneiform
deposits, which, in the disease of the heart above alluded to, occur
almost as frequently in the kidney as in the spleen ; but it is sometimes
extremely difficult to trace the origin of the small metastatic deposits
which form in the kidney during the later stages of septicaemia, puer-
peral fever, typhus, etc., to the action of embolism. It is questionable
whether interstitial nephritis ever arises from the effect of cold, or from
that of acrid diuretics.

ANATOMICAL APPEARANCES. — In traumatic nephritis, or in ne-
phritis arising from an extension of inflammation from the pelvis of
the kidney, or from other organs, the kidney at first is enlarged, and
is of a deep-red hue, which is either diffused over its whole substance,
or else is confined to single spots in the cortical or medullary portion.
Its consistence is much less firm. The albuginea is injected, thickened
by infiltration, and easily detached. Upon section, the structure is
indistinct, and the boundary between the cortical and pyramidal sub-
stance is effaced. A bloody, thick liquid can be expressed from the
surface of the cut. At a more advanced stage the redness subsides.

38 DISEASES OF THE KIDNEY.

The color of the renal substance becomes of a dirty brown or gray,
owing to compression of its vessels by the interstitial exudation, which
already, here and there, contains pus.

The discoloration usually begins at detached points, of the size of a
hemp-seed. As it increases, these spots soften, until they finally break
down into a purulent liquid. In this way small abscesses form, by the
melting down of the renal substance, under the pressure of the con-
stantly-accumulating pus-cells. In the cortical substance, the form of
the abscess is more rounded ; in the pyramidal, more elongated. The
abscesses enlarge and coalesce, finally forming a great sac of matter,
which may occupy one-half or even two-thirds of the kidney. Such
an abscess may become incapsulated, and long remain embedded in
condensed cellular tissue. In other cases, the deposits discharge in
various directions, as into the pelvis of the kidney, the cavity of the
abdomen, externally through long fistulous tracks, into neighboring
parts of the intestine, which have become adherent to the wall of the
abscess, or even, through the diaphragm, into an adherent portion of
the lung. When the disease runs a more chronic course, it sometimes
terminates differently. In such cases the interstitial substance of the
kidney undergoes proliferation, while the peculiar tissues of the organ
perish. At the close of such an attack of chronic interstitial nephritis,
the kidney is irregular, and nodulated in shape. The elevations are
more marked than those of the third stage of Blight's disease, and
the albuginea is firmly adherent in the sulci between them. Upon
cutting into one of these depressed spots, instead of renal-tissue proper,
we find nothing except the indurated substance of a cicatrice.

The metastatic nephritis, which accompanies disease of the heart,
shows no tendency to suppuration. In recent cases, distinctly circum-
scribed, dark-red cuneiform spots are found in the kidney. The base
of the wedge lies toward the periphery of the organ, the apex toward
its hilus. Microscopic examination shows an intense engorgement of
the vessels with dark masses of blood, blood being also effused into
aud between the tubules. Haemorrhagic infarction of the kidney, when
of longer standing, undergoes metamorphosis similar to that already
described as occurring in haemorrhagic infarction of the spleen. A dis-
coloration commences in the middle of the point of infarction, which,
having undergone a complete fatty metamorphosis, and all the fat
having been absorbed, cicatrizes, leaving a depressed scar. The me-
tastatic deposits which form in the kidney in infectious disease, and in
consequence of the absorption of putrid matter into the blood, are
generally much smaller, and far more numerous, than the infarctions
which occur in disease of the heart. Moreover, their tendency to break
down is very great, so that, upon examination, it is not usual to find

INTERSTITIAL NEPHRITIS -RENAL ABSCESS. 39

solid spots, but merely abscesses in the kidney, surrounded by an area
of redness.

SYMPTOMS AND COURSE. — When not of metastatic origin, acute in-
terstitial nephritis, like acute inflammation of other important organs,
sometimes commences with a rigor. At the same time there are vio-
lent pains in the region of the kidney, and, in this form of renal in
flammation, there is a pain, which is hardly ever absent, which becomes
almost intolerable upon the most moderate pressure, and shoots along
the ureters to the bladder, and toward the testicle and thigh of the
affected side. The sympathetic vomiting, which we have described as
an almost constant accompaniment of acute parenchymatous nephritis,
is nearly always present also in this form of nephritis. Owing to com*
pression of the urinary tubules and Malpighian capsules by the inter-
stitial exudation, the secretion of urine is repressed. That which is
passed is concentrated, dark, and is often mingled with blood. The
fever which accompanies this disease from the outset is very apt to
assume a typhoid character; The patients become disturbed in mind,
delirious, somnolent, and fall into a state of stupor, with convulsions ;
symptoms which are to be ascribed to a suppression of the urine, and
to a surcharge of the blood with excrementitial matter. The disease
may terminate fatally, in the course of a few days, through general pa-
ralysis of the nervous system.

The occurrence of suppuration in the kidney may be suspected
when the disease continues without remission, and when its course
is marked by numerous chills, and, above all, when pus is discharged
with the urine. When an abscess forms in one part of the kidney,
the rest of which has not been affected, or has regained its healthy
condition, the disease takes a more chronic course; but the fever
continues, and consumes the patient gradually, who almost always
dies sooner or later of a phthisis renalis. To detail the various modi-
fications of symptoms which arise from the complications of pyelitis,
cystitis, and the bursting of renal abscesses in various directions,
would lead us too far. The different courses which the matter may
take have already been mentioned above. There is a form of inter-
stitial nephritis, which is very difficult of recognition, in which the
substance of the kidney gradually perishes, and is replaced by a new
growth of connective tissue. A permanent derangement of the urinary
secretion, a constant desire to pass water, dull pains in the region of
the kidney, dropsy, great listlessness, which gradually increases to
coma, with other indications of the so-called uraemic poisoning, are the
symptoms of this form of disease, but they are very rarely properly
interpreted.

Metastatic interstitial nephritis, not having any characteristic symp
53

40 DISEASES OF THE KIDNEY.

toms, is usually overlooked during life. However, I have sometimes
noticed that the formation of a large haemorrhagic infarction in the kid-
ney is accompanied by a chill, that the patient complains of severe
pain in the kidney affected, and that the urine is scanty and contains
blood. When we encounter symptoms like these, in a case of disease
of the heart, we may confidently diagnosticate the existence of an in-
farction of the kidney, particularly when there is or has been evidence
of embolism elsewhere. Renal metastases, which form during septi-
caemia, puerperal fever, etc., are usually mere ^accidental" discov-
eries upon the dissecting-table. We cannot even suspect their exist-
ence during life.

TREATMENT. — As, in most cases of interstitial nephritis, it is im-
possible to meet the causal indication when the affection proceeds
from the presence of a stone, or from a collection of putrid urine in the
pelvis of the kidney, or from embolism or infectious disease, we must
confine our efforts to an antiphlogistic treatment, which is much more
appropriate in this case than in those heretofore described. The repeat-
ed application of leeches, cut cups, and of cold over the kidney, with
the subsequent use of long-continued warm baths and warm poul-
tices, and the exhibition of drinks containing carbonic acid, are the
most approved measures. The sequelae, especially the abscesses and
fistulae which may form, must be treated according to the symptoms.

CHAPTER VI.

PERINEPHR1TIS.

ETIOLOGY. — In rare instances the adipose tissue, in which the kid-
ney is enclosed, becomes the seat of a primary, independent inflamma-
tion, which is usually the result of an injury, or, as has been claimed
now and then, of exposure to cold. Much more frequently the inflam-
mation is secondary to a suppurative action within the pelvis or sub-
stance of the kidney. I have seen one case in which a pericystitia
extended along the ureter to the fat around the kidney.

ANATOMICAL APPEARANCES. — As a rule, inflammation of the
areolar envelope of the kidney soon results in suppuration. The tis-
sues then become discolored, and then- meshes are filled with pus.
The small collections of pus coalesce and an abscess forms, often of very
considerable magnitude, and which may point in almost any direction.
In other cases there is no suppuration, but the loose cellular tissue be-
3omes condensed and indurated, and is converted into a thick fibrous
rind.

SYMPTOMS AND COURSE. — When perinephritis is acute, its symp-

PERINEPHRITIS. 41

toms bear a strong similarity to those of acute interstitial nephritis.
A violent fever, which sometimes is ushered in by one or more rigors,
and by severe pain in the region of the kidney, which becomes intoler-
able whenever the adjacent muscles of the body contract, or are sub-
jected to any strain by movement of the body, is a symptom common
to both diseases. There is one important distinctive point between
the two; in pure uncomplicated perinephritis, there is no suppres-
sion of urine, nor does the urine contain either blood, albumen, or
pus. If the disease goes on so as to give rise to a large abscess, a tu-
mor appears in the renal region, which fluctuates with greater or less
distinctness. If the abscess break into the cavity of the abdomen, it
occasions an acute peritonitis, which speedily terminates in death.
Recovery may take place where the abscess discharges into the intes-
tine, or where it points externally, or is opened artificially. External
opening of the abscess generally occurs in the back, below the false
ribs, and is usually prepeded by an excessive aggravation of the pain
upon movement of the body, and by a more or less extensive oedema
of the skin over the region affected. In other cases the pus descends
along the psoas muscle, giving rise to a symptomatic abscess, which
usually makes its appearance below Poupart's ligament.

TREATMENT. — The most appropriate treatment of a recent case of
perinephritis is local blood-letting, and, in a later stage of the disease,
the systematic application of cataplasms and, the use of lukewarm
baths. Abscesses must be opened as soon as possible, according to
surgical rules, and should be kept open for a while.

CHAPTEK VII.

AMYLOID DEGENERATION' OP THE KIDNEY PARENCHYMATOTJS NE-
PHRITIS, WITH AMYLOID DEGENERATION.

THE kidney, like the liver and the spleen, not unfrequently under-
goes a degeneration, by the deposit in the elements of its tissues of a
material whose reaction against iodine and sulphuric acid resembles
that of the cellulose of plants, but whose chemical constitution is more
like that of the protein substances. Amyloid degeneration of the kid-
ney takes place under conditions similar to those under which it oc-
curs in the liver and spleen, its causes being severe chronic disease,
such as syphilis, mercurial poisoning, rachitis, consumption of the
.ungs, and long-standing suppuration, such as occurs in caries and
necrosis.

The degeneration probably always commences in the walls of the
blood-vessels, particularly in those of the glomeruli, to which it usually

42 DISEASES OF TllE KIDNEF.

remains limited ; while, at the same time, the epithelium of the tubules
undergoes the changes already described in Chapter IV. The name
u parenchymatous nephritis, with amyloid degeneration," is, therefore,
more appropriate for this form of disease than the term " amyloid or
lardaceous degeneration of the kidney." Even microscopic examina-
tion is not by itself sufficient to enable us to distinguish between the
affection in question and simple parenchymatous nephritis. But, if a
thin slice of the specimen be treated for a few moments with a solution
of iodine, the red color of the glomeruli becomes so distinct even to the
naked eye, that, even before resorting to the microscope, the appear-
ance of a multitude of small red dots, standing out in contrast to the
surrounding yellow ground, makes the diagnosis almost certain. Under
the microscope the loops of the glomeruli seem remarkably large, and
present a peculiar dead lustre. The Malpighian capsules, too, often ex-
hibit a broad, homogeneous, dull outline. If, prior to the examination,
the preparation have been laid for a time in a dilute solution of iodine,
the bodies above described will assume the characteristic yellowish-
red color. Upon the subsequent addition of a few drops of sulphuric
acid, they become of an indistinct violet or dark blue. It is very un-
usual for the tunica propria, and still more so for the epithelium of the
urinary tubules, to participate in the amyloid degeneration.

When an individual, who hitherto has enjoyed good health, is
affected by albuminuria, dropsy, and deterioration of the blood, it is
so very improbable that he is suffering from amyloid degeneration of
the kidney, that that disease may confidently be excluded from the
diagnosis. On the other hand, the appearance of similar symptoms in
a person who has long been afflicted by syphilis, consumption, tedious
suppuration, or any other exhausting malady, makes it extremely prob-
able that we have to deal with an amyloid degeneration of the kidney,
or, more properly speaking, with a parenchymatous nephritis with
amyloid degeneration of the walls of the renal vessels. If the patient
also have an enlargement of the liver and spleen, and if the portions
of these organs accessible to palpation present the characteristic
resistance of amyloid degeneration, the diagnosis is still more sure.
In distinguishing between amyloid degeneration and simple parenchy-
matous nephritis, Traube lays great stress upon the high specific grav-
ity and dark color of the urine in the former disease. My own obsei
vations fully confirm the truth of Traube's views, and I may add thai
I have been struck, not only by the darkness of the urine, in amyloid
renal degeneration, but also by its unnatural, yellowish-brown color ;
moreover, my colleague, JZbppe-Seiler, has shown that such urine con-
tains extraordinary quantities of indican. There is nothing in the
quality of the exudation-casts, or in the degree of frequence of ursemic

GRANULAR DEGENERATION OF THE RENAL EPITHELIUM. 43

symptoms, whereon to base a differential diagnosis between a sim-
ple parenchymatous nephritis and one which is complicated by
amyloid degeneration. Moreover, the difference between the two
conditions is a matter of but little practical interest.

The treatment recommended for amyloid degeneration of the
liver and spleen is equally appropriate in amyloid disease of the
kidney. It is questionable whether a retrogression of the disease
be possible. The preparations of iron and iodide of iron may act
beneficially upon the primary disease, but can hardly cure a degen-
eration of the kidney.

CHAPTER VIII.

GRANULAR DEGENERATION OF THE RENAL EPITHELIUM.

[FREQUENTLY on ^ autopsy we find the kidneys flabby, bloodless,
of a pale; dirty, grayish-red color, somewhat enlarged, or of normal
size. From their cut surface we may scrape off a cloudy grayish
pulp. This pulp consists of epithelial cells swollen by albuminous
infiltration and dotted with numerous fine granules, which render
the nuclei indistinct, but which vanish in the presence of potash and
acetic acid (thus showing that they consist of albuminous particles).
At a later period fat-granules may appear. When the disorder is
intense, the kidney becomes tender and flabby, and the epithelium
falls off ; but, if of only a moderate degree, the cells may undoubt-
edly be restored to their normal condition. Proliferation of the
epithelium occurs, but very rarely, and then only late in the disease.
Granular degeneration is not peculiar to the kidney, but is often
found simultaneously in the cells and tissues of the most diverse
organs, particularly in the liver, the heart, and the muscles. This
widespread appearance of the disease shows that its cause must be
a general one. In the bodies of persons who have died of infectious
diseases — pyaemia, typhus, or acute miliary tuberculosis — more or
less marked granular degeneration is found, as a result either of
some abnormity of the blood, or perhaps as a consequence of the
persistent elevation of the temperature which attends these diseases,
and which, according to Schultze, exercises a most pernicious in-
fluence upon cellular formations. But the disorder also is found
when there has been no fever, in chronic anaemia, chronic disease
of the heart or lungs, and in poisoning by phosphorus, sulphuric
acid, and carbonic oxide. Sometimes the cause of the granular de-
generation is purely local, and is limited to the kidney where it is
found, supplementing other morbid conditions. Very important

44 DISEASES OF THE KIDNEY.

results are ascribed to the more intense grades of this lesion. Thus
it is supposed in acute forms often fatally to cripple the action of
the heart. -

The condition is also found in the bodies of pregnant and puer-
peral women. At present we have no definite knowledge as to how
pregnancy affects the minute structure of the kidney and other or-
gans in these cases.]

The most common and frequently the sole symptom of parenchym-
atous degeneration of the kidney is the presence of albumen in the
urine. We may say, too, that whenever there has been albuminuria
during pregnancy or during grave disease, the renal epithelium will
be found to be in a more or less advanced state of degeneration after
death. How often the question is asked by the anatomist during the
autopsy, whether the patient had albuminous urine ! On the other
hand, I will not venture to state positively that the albuminuria, which
e»o often accompanies the conditions above referred to, is always the
result of degeneration of the epithelium of the kidney, or that degen-
eration of the renal epithelium is always attended by albuminuria.
The quantity of albumen which the urine contains is probably never
so great in parenchymatous degeneration as in amyloid degeneration,
and parenchymatous inflammation of the kidney. . When it arises after
acute febrile disease, it never produces dropsy. This symptom is often
absent, too, during pregnancy accompanied by parenchymatous renal
degeneration and albuminuria. Sometimes, however, there is a mod-
erate degree of dropsy, and in rare instances a very large one. When
it accompanies pregnancy, it is sometimes a source of danger, owing
to the eclamptic attacks which it provokes during and immediately
after parturition, and of which we shall have more to say when we
come to treat of diseases of the nerves.

If the original disease terminate in recovery, the nutritive disorders
of the renal epithelium to which it has given rise are also completely
repaired. Soon after delivery the albuminuria and dropsy disappear
in almost all cases, another proof that the malady in question is not
to be confounded with interstitial nephritis. We are quite ready to
admit that in most cases of eclampsia puerperarum there is renal dis-
ease ; but we deem it quite inadmissible to attribute the albuminuria.
dropsy, and eclampsia to " Bright's disease."

After what has been said already regarding parenchymatous degen-
eration, further discussion of its treatment becomes superfluous. We
shall treat hereafter of the proper management of the eclampsia.

CARCINOMA OF THE KIDNEY. 45

CHAPTEE IX.

CARCINOMA OF THE KIDNEY.

OF the malignant neoplastic growths, carcinoma is the- one. most
frequently seen in the kidney. Renal cancer is sometimes primary ;
sometimes it accompanies carcinoma of other organs, as a secondary
formation. Young persons, and even children, are quite frequently at-
tacked, although it is somewhat more common in advanced age.

Cancer of the kidney generally assumes the medullary form.
Scirrhus and colloid are far more rare. The former sometimes de-
velops in the form of circumscribed nodules of varying size, which
gradually replace the parenchyma of the kidney. Sometimes the can-
cerous degeneration spreads farther and farther into the surrounding
tissues from its original point of development, so that the kidney
gradually becomes transformed into cancer (Rokitansky, infiltrated
cancer). A carcinomatous kidney may attain an enormous bulk some-
times, forming a' nodular tumor of the size of a child's head. The de-
generation often involves the lymphatic glands in the hilus of the kid-
ney, whence it spreads to the retroperitoneal and mesenteric lym-
phatics, and to the ligaments and periosteum of the spinal column ; or
else it may grow inward into the cavity of the organ, and thence into
that of the adjoining veins. The frequency with which cancer of the
kidney is complicated with cancer of the testis is a matter of impor-
tance, which calls to mind the still more common coincidence of tuber-
culosis of these organs. Haemorrhages both within the tumor and on
its periphery are very apt to occur. In the latter case, the blood is
effused either into the peritonaeum or else into the urinary passages.

The disease often remains latent for a long time. It is usually by
the gradual advance of a marasmus, for which no other cause can be
assigned, that suspicion is awakened of the existence of a malignant
tumor in a region inaccessible to palpation. There may be no pain at
all in the lumbar region, and, when it does exist, it is not character-
istic. The renal secretion may go on undisturbed, and the urine may
be quite free of blood and albumen. As the disease advances, the tumor
formed by the cancerous kidney, which is often of enormous size, can
generally be felt through the abdominal walls, especially when the
latter have become wasted and relaxed. The form of the tumor, and
especially its immobility, will prevent our mistaking the enlarged kidney
for an enlargement of the liver or spleen. It cannot be moved from
side to side, nor does it follow the motions of the diaphragm. Very
large cancers of the right kidney sometimes produce a remarkable and
peculiar displacement of the liver inward, causing it to turn upon its

|6 DISEASES OF THE KIDNEY.

long axis, so as to bring a large part of its convex surface in contact
with the abdominal wall. Hsematuria and albuminuria are absent
about as frequently as they occur. As already stated, part of the
bleeding proceeds from the vessels of the growths which push into the
urinary passages, while another part is the result of excessive hyper-
jemia of the surrounding tissues. Owing to the large quantity of
blood thus discharged, the haematuria often forms one of the most
prominent symptoms of this disease. The complexion of the patient
assumes the dirty hue so common in cancer, and he dies of exhaustion
which progresses all the more rapidly when the haemorrhages are
frequent and profuse ; unless, indeed, death ensue in consequence of
some intercurrent disorder, or from the invasion of other vital organs
by secondary cancer. Treatment is ineffectual, and must be limited to
husbanding the patient's strength, repression of the haemorrhages, and
removal of coagula from the bladder, according to surgical rules.

CHAPTER X.

TUBERCULOSIS OP THE KIDNEY.

ROKITANSKY recognizes two forms of renal tubercle. The first
form is symptomatic of a tuberculosis involving several or even the
majority of the organs. In acute miliary tuberculosis, gray nodules, sim-
ilar to those found studding the lungs, pleura, peritonaeum, etc., are also
found in the albuginea and parenchyma of the kidney. In extensive
chronic tuberculosis, tolerably large, yellow, cheesy deposits of tubercle
are sometimes met with in the kidneys, but they rarely contain collec-
tions of softened tubercular matter or tubercular cavities. The first
of these forms has but little effect upon the action of the organ. It is
unrecognizable during life, and is of more moment in a pathological
than in a clinical point of view.

The second form of renal tubercle is generally complicated with
tuberculosis of the testicle, prostate, seminal vesicles, and urinary pas-
sages. It is not constantly preceded by pulmonary tubercle ; but this
disease almost always sets in at a more advanced period of renal dis
order. In this second form the deposit is very copious, and the indi-
vidual nodules soon coalesce into large tubercular masses. The organ
becomes enlarged, assumes an irregular, knobby shape, and within it
we find large cheesy collections, some of which are filled with tubercu-
lous pus. This form of renal tuberculosis, too, would likewise frequently
escape observation, were not the diagnosis almost always aided by the
complications above mentioned. The longer a chronic disease of the
urinarv passages has coexisted with the admixture of pus, and now and

PARASITES IN THE KIDNEY. 47

then of blood in the urine, the tuberculous character of which is in-
dicated by the coexistence of an enlargement of the testicle, so much
the more likely will it be that the kidney itself has become involved
in the disease. The diagnosis receives further confirmation if we are
able to feel an uneven tumor in the region of the kidney, through the
flaccid walls of the abdomen.

CHAPTER XI.

PAEASITES IN THE KIDNEY.

THE echinococcus is the parasite most frequently found in the kid-
ney, although even there it is met with less frequently than in the liver.
Its presence in this organ is originally due to the existence of the
embryo of the tenia echinococcus in the intestinal canal (see Vol. L).
We have no knowledge as to why the young brood, in their emigra-
tion from the bowel irito the other organs of the body, should some-
times enter the kidney. The echinococcus sacs, which occasionally
attain the size of a fist or of a child's head, are quite like those found
in the liver and spleen. They are embedded in a fibrous capsule be-
longing to the kidney. They may atrophy and burst, discharging their
contents in different directions. They may also occasion inflammation
and suppuration in the parts about them, and the renal abscess thus re-
sulting may burst into the peritonaeum, intestine, or pelvis of the kidney.

The development of echinococci in the kidney may be entirely un-
attended by symptoms. In some instances, however, the patients com-
plain of a dull pain in the lumbar region, which we cannot well account
for. A tolerably sure diagnosis may be made out if we can feel an
irregular nodular tumor in the region of the kidney, and at the same
time can exclude carcinoma, tuberculosis, and hydronephrosis, to be
treated of hereafter. Certainty is only possible when cysts of the
echinococci or traces of them are discharged with the urine. The
hyaline walls of the daughter cysts, consisting of concentric layers,
distinctly recognizable under the microscope, are not easily mistaken.
Symptoms of renal colic may arise during their passage through the
ureters, and their discharge from the bladder is often attended by the
utmost distress, especially in men.

[The strongylus gigas is the largest of known round worms. The
female may attain the length of half a yard or more. Its mouth is
bordered by six wart-like projections. The male is smaller, and at
his tail-end has a cup-shaped appendix, at the bottom of which is
the genital opening with the penis protruding from it like a hair.
The method of development of this parasite has not been ascertained.

48 DISEASES OF THE KIDNEY.

Schneider found worms in certain fish which seemed to represent
the early forms of a strongylus ; and the fact that the strongylus
species most generally infest fish-eating animals argues in favor of
this view. Its occurrence in man is very rare indeed. According
to Davaine, but seven well-authenticated cases have been collected.
We know, however, that in brutes the creature usually occupies the
pelvis of the kidney, more rarely descending the ureter into the
bladder, and that its presence causes symptoms similar to those of
calculus, and may cause retention of urine and hydronephrosis.]

CHAPTER XII.

DEFORMITIES OF THE KIDNEY — IRREGULARITIES OF ITS SHAPE AND

POSITION.

ABSENCE of one kidney usually is accompanied by abnormal
magnitude of the other, and the secretion of urine remains normal.
Union of the two kidneys, which then are generally connected by a
narrow bridge of renal substance at their lower ends — the so-called
horseshoe kidney — is a matter of mere anatomical interest, and of no
clinical importance. The same is true also of lobulation of the kid-
ney, which depends upon a persistence after birth of 'the foetal con-
dition of the organ, and is distinguishable from an acquired lobular
state of the kidney by the healthy condition of the renal parenchy-
ma and capsule at the depressed points. Irregularity of position is
most common in cases of horseshoe kidney ; the united organs then
usually lie much deeper than natural, sometimes as low down as the
last lumbar vertebrae. But, even without the coexistence of this
malformation, an unnaturally deep position of the kidneys is not an
uncommon congenital deformity, and is usually accompanied by
irregularity in the origin and number of the renal vessels, as well as
by anomaly in the lengths of the ureters.

Misplacement of the kidney, with abnormal mobility, is a mat-
ter of greater importance. Quite a considerable number of cases of
this anomaly have been observed since attention was first called to
it. In Greifswald alone I know of three cases of movable kidney.
The kidney (and almost always the right one) lies embedded in a
loose areolar tissue. Its vessels are elongated, and have a sort of
mesentery formed out of the reduplication of their peritoneal coat.
Such anomalies are most common among women whose abdominal
integuments have become greatly relaxed by repeated child-bearing.
According to Rayer, it may also result from violent concussion of

ADDISON'S DISEASE. 49

the body — as from a fall from a great height. In other cases there is
no other anomaly, nor is there any apparent cause for the mobility
of the viscus. When the patient stands erect, the movable kidney
may be felt usually below the liver, or even still deeper. Its char-
acteristic bean shape is distinctly recognizable, and it often can be
pushed a considerable distance to the right or left, but more easily
upward and downward. A patient in my ward, by moving and
shaking his body, was able to get his kidney into a great variety of
positions. There are either no evil results whatever attending the
affection, or they depend upon complications, although colics and
slight inflammations of the peritonaeum may result from pressure of
the movable organ upon the other viscera. The knowledge that
she has a tumor in her abdomen often acts very injuriously upon
the spirits of the patient, who sometimes becomes hypochondriac.
Little can be done by way of treatment for a movable kidney ; but
the patient (particularly if she have very flabby abdominal walls)
generally feels better when she wears an elastic bandage of gum
elastic or knit cotton.

CHAPTER XIII.
ADDISON'S DISEASE — BKONZED SKIN.

[THIS disease, first described by Addison, still presents an obscure
problem, notwithstanding the laborious researches of many of our
most acute observers ( Virchow, Meissner, Averbeck, Klebs, Eulen-
burg, Guttmann, Risel, and others). All former doubts as to the
real existence of such an independent affection are now dissipated ;
but it has been shown that the lesions which used to be thought
fundamental and characteristic of it, namely, the morbid state of
the suprarenal capsules and the dark stain upon the skin, though
commonly present, are not its essential features. The original as-
sumption that Addison's disease depends upon a degeneration and
destruction of the suprarenal capsules is contradicted by the nega-
tive results of experiments made in seeking out the hitherto un-
discovered functions of these organs, as well as by the fact that the
capsules have been found destroyed or in a state of disease in bodies
of persons who during life presented none of the symptoms of the
malady. Attention was thus directed to the sympathetic plexus of
nerves adjacent to the capsules, the implication of which in this
affection Addison himself had already pointed out ; and the opinion
was gradually reached by a number of English, French, and German
observers that a morbid state of the abdominal sympathetic, par-

5Q DISEASES OF THE KIDNEY.

ticularly of the cceliac plexus and semilunar ganglia, and of the
nerves connecting them with the suprarenal capsules, is of essential
importance in the disease. The circumstance which speaks most in
favor of this view is, that in most of the cases in which the sympa-
thetic has been examined, besides the suprarenal lesion usuallypresent,
there has been also found either redness, swelling, thickening, fatty
degeneration, atrophy, pigmentation, or wasting of the ganglia.
But out of twenty-nine cases collected by Guttmann and Eulenburg
the sympathetic was found more or less altered in nineteen and nor-
mal in ten. This negative result, though of only a minority of
cases, reduces the above attempt at explanation to a mere theory ;
the more so when we read that experiments by Adrian Schmidt,
Lamansky, Schiff, and others upon the abdominal ganglia give rise
to no symptoms suggestive of Addison's disease. A further hy-
pothesis was then advanced, that the disorder depended upon
derangement of the central nervous system and not upon that of
the sympathetic ; and Itossbach describes it as a hitherto undefina-
ble functional disturbance of the nervous system lying in close re-
lation to, but not inseparable from, the suprarenal capsules, and
characterized by psychic disorder, intense anaemia, debility, and
very often by a dark staining of the skin.

In order to account for a connection between a nervous disturb-
ance and a morbid stain upon the skin, the cases of albinism have
been invoked in which the anomaly is very distinctly limited to a
district of skin corresponding to a certain nerve-district, as have
also the cases of sudden turning gray of the hair under the influence
of mental emotion. The deposits of pigment which form in the skin
of pregnant women, and in many who suffer from menstrual and
uterine disease, have also been pointed out in support of the view
that staining of the skin may proceed from disorder of the supra-
renal capsules.

The anatomical changes of the suprarenal capsules found in
Addison's disease are not always the same. In most cases there is
a caseous fibrous degeneration resulting from chronic inflammation
of the organ. The capsules are often of two or three times their
normal size, sometimes even as big as a hen's egg, and are converted
into masses of dense connective tissue containing cheesy or calcare-
ous nodules. Their surface is irregular and knotty, and often adhe-
rent to adjacent structures. Their consistence is tough and hard.
The inflammation, instead of being general, may however be only
partial and limited to single spots. The disease is generally bilateral.

The many cases in which both capsules have been found totally
destroyed argue against the theory that the suprarenal capsules are

ADDISON'S DISEASE. 51

secreting organs, and Addison's disease a result of over-production
of deleterious chemical matters in the blood (particularly tauro-
cholic acid), which partially dissolves the blood, thus causing the
anaemia, while a precipitation of the pigment of the blood occasions
the bronze color. In rarer cases, instead of this degeneration, we
have found carcinoma, extravasation of blood in the tissues of the
capsules, and sometimes simple atrophy ; hence it must be concluded
that the bronze color is not due to any special process. The imme-
diate cause of the brown skin is a deposit of pigment in the rete
Malpighii ; but pigment-cells are also to be found in the true skin,
and are to be distinguished from those in the rete Malpighii by their
containing iron.

There are sometimes no lesions whatever of other important or-
gans ; but more frequently there will be found enlargement of the
spleen and of the intestinal follicles, cheesy degeneration of the mes-
enteric glands, and sometimes caries of the vertebrae.]

SYMPTOMS AND COURSE. — The darkening of the skin, whence the
malady derives one of its names, although it is by no means its most
important or most dangerous symptom, occurs gradually. If the
patient die before it has become very pronounced, it is apt to be
overlooked entirely. Such cases, however, do not disprove the con-
nection between disease of the suprarenal capsules and the deposit
of pigment in the rete Malpighii. It is only by degrees that the
discoloration of the linea alba and nipples in pregnancy acquires a
sufficient degree of intensity to become conspicuous, and indeed
there are many persons in whom it is never very marked even at
term ; and yet no one denies the existence of a connection between
pregnancy and such pigmentary deposit.

In some instances the skin becomes so dark as to resemble that
of a mulatto or negro. One of my patients, a baker, from Heil-

bronn, used to be generally known as " Black R ." The color

sometimes is a pure gray, inclining to black, like plumbago. At
other times it has a brown or yellowish tinge. It generally com-
mences upon the exposed parts of the body, but, although more in-
tense upon those regions, is by no means confined to them, a cir-
cumstance which might save us from errors of diagnosis in dealing
with sailors, field laborers, and others whose hands and faces are
often of an exceedingly dark grayish-brown tinge. The roots of the
nails also remain white. The palms of the hands and soles of the
feet are spotted here and there, but are not uniformly discolored.
The sclerotica never participates in the discoloration, and its pearly
hue often forms a marked contrast with the dark color of the face.
Black spots upon the lips and mouth seem to me to be pathogno-

52 DISEASES OF THE KIDNEY.

monic of the affection. At all events, no mention is made of them
in any of the negative reports of bronzed skin without disease of
the capsules.

Its more serious symptoms consist in an extreme debility, often
combined with deep depression of spirits. In some instances this
debility increases from time to time into profound and long-con-
tinued swoons. Sometimes the adynamic symptoms are so promi-
nent as to remind one of a severe attack of typhus, or of some other
acute affection, with so-called typhoid symptoms. Mistakes for
typhus, however, may always be avoided if all the elements of the
case be attentively considered, especially if the temperature be ob-
served. If, however, the case has not been long under observation,
and if the discoloration of the surface be not very distinct, it may
be impossible to make a positive diagnosis. The great lassitude and
insurmountable sense of weakness, unattended by any apparent
cause of exhaustion, would seem to proceed from a disorder of in-
nervation. The richness of the suprarenal capsules in nervous ele-
ments, and the numerous communications existing between them
and the various nervous plexus, especially the solar plexus, rather
confirm such a supposition.

Pain in the back, and still more frequently pain in the epigas-
trium, is a very frequent but not a constant symptom. In one of'
my cases the pain was so violent that the patient for weeks was
treated with poultices. In a second, severe pain in the epigastric
region was one of the most conspicuous symptoms, while in the
third the patient never complained of pain at all.

Dyspepsia and vomiting are reported as occurring in nearly
every case ; yet even these symptoms are sometimes absent. The
vomiting of Addison's disease may be regarded as a so-called sym-
pathetic vomiting ; since, in disease of other organs adjacent to
the stomach, and even in such as contain fewer nerves than the
suprarenal capsules, and whose nervous connection with the stomach
is much less obvious, such sympathetic vomiting occurs.

Diarrhoea has been observed in many cases. In two of my three
cases the dirrahoea was very obstinate. It would be easy to account
for this diarrhoea, could it be proved post mortem that the cceliac
ganglion always was diseased ; since, according to the experiments
of JBudge, all the rabbits whose cceliac ganglia he removed suffered
from diarrhoea. But independently of this, there is nothing sur-
prising in the occurrence of diarrhoea in disease of the suprarenal
capsules, these organs being richly endowed with nerves, and stand-
ing in intimate relation with the nervous plexus of the abdominal

ADDISON'S DISEASE. 53

organs, and since, too, there is no doubt as to the dependence of
liquid discharges upon disturbance of innervation.

The convulsions and other grave nervous disorders which some-
times occur are difficult to account for. One of my patients had
repeated epileptic attacks. Post-mortem examination usually affords
no clew as to the origin of these symptoms.

The temperature of the body is not increased, unless there be
some complication of a febrile character.

The beat of the heart and the pulse is accelerated, and toward
the close of the malady is often extremely feeble. The great fre-
quence of the pulse stands in striking contrast with the lowness of
the temperature, and, if no note be taken of the latter, it is liable
to cause an erroneous impression that there is fever.

The progress of the disease is almost always chronic. There are
but two or three known cases where the process has run an acute
course, speedily terminating in death.

Although there are a few cases in which a temporary improve-
ment has been observed, yet we have no well-authenticated instance
of complete recovery ; and death must be regarded as the most fre-
quent, and probably, indeed, as the sole termination of this malady.

TKEATMENT. — Of course, the treatment of Addison's disease
must be a mere treatment of symptoms. In one of my cases it was
very evident that good nourishment and careful nursing were not
without a beneficial effect upon the course of the disorder. The
patient, a poor servant, was repeatedly received at the clinic, in a
state of extreme emaciation, and unfit for any labor. He always
gained considerably in weight in the course of a few weeks, and so
far recovered his strength that he could be employed in a variety
of occupations ; until, three years and a half after his first recep-
tion at my clinic, he suddenly and unexpectedly died in one of the
above-mentioned epileptif orm attacks.

SECTION IL

DISEASES OF THE PELVIS OF THE KIDNEYS
AND URETERS.

CHAPTER I.

DILATATION OP THE PELVIS OF THE KIDNEY, WITH ATROPHY OF THE
RENAL SUBSTANCE HYDRONEPHROSIS.

ETIOLOGY. — Whenever the flow of the urine, through the ureters,
into the bladder, becomes permanently obstructed, the urine accumu-
lates in the pelvis and calyces of the kidney. If the pressure of the
urine within the pelvis of the kidney be very great, the openings in
the tubuli recti and papillae are closed, and the papillae themselves be-
come compressed. The urine then ceases to flow from the kidney into
it* pelvis, and distention of the latter would progress no farther were
it not that the pelvis and calyces possess a mucous membrane, and still
continue to produce mucus, which is mingled with the accumulated
urine. Hence more and more liquid collects in the renal pelvis, dis-
tending the latter, till finally the pressure flattens out the papillae, and
induces a gradual atrophy, which may terminate in the total loss of the
STibstance of the organ.

Closure of the ureter may proceed from the impaction into it of a
stone. Far more frequently, hydronephrosis depends upon compres-
sion of the ureter by a tumor, or by a callous contracting cicatrix in
the peritonaeum which covers it, or by a growth, especially by a cancer,
of the subperitoneal connective tissue. In other cases, closure of the
ureter is the result of inflammation, which has induced swelling of its
mucous membrane, or adhesion of its walls. The lower and the closer
to the bladder the obstruction is, so much the larger is the portion of
ureter which takes part in the dilatation.

Moderate degrees of dilatation of the uriniferous apparatus some-
times arise from an impediment to the discharge of urine, which exists

DILATATION OF THE PELVIS OF THE KIDNEY. 55

m the urethra or bladder, but, in such cases, the affection being bilat-
eral, the dilatation of the renal pelvis can never become so great as to
close the mouths of papillae of the kidneys without involving danger
to life. It seems strange that, on autopsy, hydronephrosis of both
sides, which seems to have existed a long time, is frequently found.

ANATOMICAL APPEAKANCES. — According to Rokitansky^ in the
milder degrees of hydronephrosis, the papillae are shrunken, hardened,
and leathery. Gradually the papillae disappear in the concavity of the
dilated calyx, while above it the renal substance diminishes, its tissues
becoming compressed, leather-like, and tough. In extreme cases, the
substance of the kidney is only a line or two in thickness, finally dis-
appearing, leaving a membranous sac, of a lobulated appearance exter-
nally, and cellular within. The cells communicate with each other,
their walls having burst or atrophied ; they contain a urinous liquid,
clear and serous, or turbid and containing a sediment, varying greatly
in character. These sacs may attain the size of a child's head, or even
that of a man's. A dilated ureter may attain almost any conceivable
size, its calibre equalling or even exceeding that of the small intestine.
The walls of the ureter are thickened, and the tube itself, instead of
running straight to the bladder, is tortuous and convoluted, like a gut.

SYMPTOMS AND COTJESE. — Hydronephrosis cannot be detected, ex-
cept in its most intense form, and, of course, this cannot exist when
both ureters are obstructed. The secretion of urine is not diminished,
as the active kidney acts vicariously for the disabled one. There may
not be any pain in the lumbar region. Diagnosis is solely based upon
the discovery of a somewhat soft and ^distinctly-fluctuating tumor in
the region of the kidney. If there be any temporary abatement of
the obstruction to the escape of urine from the organ, the tumor may
diminish from time to time, and such an occurrence sometimes aids the
diagnosis. When the sac becomes inflamed (as has sometimes been
observed), there is much pain, accompanied by severe rigors. The pus
which forms may point in various directions, thus giving great diversity
to the character of the symptoms. Should the impediment which has
obstructed one ureter extend so as to prevent the flow of urine into
the bladder from both kidneys, all secretion of urine will cease, and
the patient will speedily perish, under symptoms of uraemia.

TREATMENT. — If the obstruction lie in the urethra only, diligent
catheterization may prevent dilatation of the urinary passages, or arrest
such dilatation when it has commenced. It is out of our power, how-
ever, to arrest or to allay the graver forms of dilatation with atrophy
of the renal substance, which proceed from obstruction of a ureter
unless the obstruction of the ureter be caused by a tumor, susceptible
of relief by medical or surgical interference.
54

56 DISEASES OF THE PELVIS OF THE KIDNEYS AND URETERS.
CHAPTER II.

INFLAMMATION OF THE PELVIS OF THE KIDNEY PYELTTIS.

ETIOLOGY. — In rare cases, the pelvis of the kidney is the seat of a
oroupous or of a diphtheritic inflammation. This is usually accompa-
nied by similar inflammation of other mucous membranes, and is usually
a concomitant of infectious disease. It is most commonly observed in
the typhoid stage of cholera, but may also proceed from catarrhal in-
flammation, especially that arising from calculous pyelitis.

Catarrhal pyelitis, in the great majority of cases, is the result of
an irritation of the mucous membrane, induced by the presence of
calculi in the pelvis of the kidney. In similar manner, the ammonia
of stagnant and putrid urine may provoke a most intense catarrh of
this region. Much more rarely, catarrh of the urinary passages is
caused by acrid substances, such as cantharides, the balsams and resins,
which have been taken into the system, and excreted with the urine.
Again, we frequently find pyelitis as the result of severe gonorrhoea,
the inflammation having extended to the bladder and ureters.

A mild form of catarrhal pyelitis is a common complication of
Bright's disease. It sometimes appears during pregnancy, and during
the later stages of typhus, as well as during the desquamative period
of the acute exanthemata. A hsemorrhagic form of this affection
sometimes accompanies scurvy, and the morbus maculosus of Werlhof.

ANATOMICAL APPEARANCES. — In croupous or diphtheritic inflam-
mation of the pelvis of the kidney, its mucous membrane is found
either to be covered by membranous exudation, or else is converted
into diphtheritic eschars, which, upon separation, produce irregular
losses of substance.

In recent cases of catarrhal pyelitis, the mucous membrane is red-
dened by injection, and (especially in the scorbutic form) by ecchy-
mosis. At the same time, it is relaxed, and covered by purulent mucus.
When of longer standing the redness disappears, or becomes discol-
ored, the tissue of the mucous membrane is swollen, and, in some cases,
is incmsted with urates, or with salts of lime. The pelvis of the kidney
usually is dilated, and its walls are thickened. Not unfrequently, the
renal parenchyma has suffered atrophy, as in hydronephrosis. In cases
of long-continued mechanical irritation, there often is ulceration of the
mucous membrane, which may terminate in its perforation, followed by
infiltration of urine into the surrounding areolar tissue, with suppurative
destruction of the latter. The resulting abscesses may point in various
directions, as into the cavity of the peritonaeum, or externally, forming
long fistulous openings ; or, previously forming adhesion, it may bursl

PYELITIS. 57

into some neighboring organ (such as an intestine). Now and then
the liquid contained in the pelvis of the kidney is gradually absorbed.
The pelvis shrivels into an indurated tissue, which incapsulates its in-
spissated contents, the ureter becoming obliterated and converted into
a tendinous cord.

SYMPTOMS AND COUESE. — Croupous and diphtheritic pyelitis are
scarcely ever recognized during life, as in the majority of cases they
are only partial manifestations of those grave and wide-spread disor-
ders which attend the malignant infectious diseases, septicaemia, scar-
latina, small-pox, or the typhoid stage of cholera. Sometimes when ca-
tarrhal calculous pyelitis becomes aggravated into the croupous or diph-
theritic form, shreds and lumps of fibrin are discharged with the urine

Acute catarrhal pyelitis may commence with a rigor or with re-
peated chills, and be attended by febrile symptoms. The patients
complain of pain in the region of the kidney, which radiates along the
ureters, toward the testicles, and which is increased upon pressure.
When the inflammation has been severe, I have also repeatedly observed
vomiting, even in the cases where the disease had spread from the
urethra to the pelvis of the kidney. A frequent and sometimes pain-
ful inclination to pass water is a constant symptom. According to
Oppolzer, the secretion of urine increases ; this may to some extent
be due to hyperaemia of the kidney, in the parts supplied by the vasa
afferentia; but if the pyelitis be complicated with interstitial nephritis,
the secretion of urine may be diminished in amount. Very often at
the outset the urine contains blood, in greater or smaller quantity ; and
it always contains pus, and in some cases, but not in all, tesselated epi-
thelium, lying row upon row, detached from the pelvis of the kidney. If
the disease be of long duration, still more pus appears in the urine. When
recently passed, the latter is opaque ; after standing a while, a well-
defined sediment is deposited, of a yellowish-white color. Owing to
the pus serum which it contains, the supernatant liquid shows the
characteristic coagulation of albuminous urine upon the application
of nitric acid and heat. The microscope shows the sediment to con-
sist of innumerable pus-cells. In pyelitis calculosa, affecting one side
only, the impaction of a calculus sometimes causes a temporary but
complete arrest of the flow of urine from the pelvis of the kidney.
Any urine which is then discharged from the bladder must, therefore,
proceed from the healthy kidney. Hence, as long as the obstruction
continues, the urine is usually quite limpid, although the symptoms are
all aggravated. When the obstruction is removed, the urine again be-
comes turbid. One patient, whom I have seen, had learned, by ex-
perience, that her suffering would be more severe as long as her urine
remained clear ; and she used to long for the time when pus would bo-
pin to pass again.

58 DISEASES OF THE PELVIS OF THE KIDNEYS AND URETERS.

Owing to persistent suppuration, and to the slow fever which gen-
erally accompanies it, chronic pyelitis may lead to marasmus and
dropsy, terminating in death. When due to stones in the renal pelvis,
the chronic disease is liable to acute exacerbations, particularly after
any jolting of the body ; or else periodical haemorrhages occur, which
accelerate the exhaustion of the patient. Violent pain in the back,
difficulty of motion of the spinal column, pain on drawing up the
thighs, aggravation of the fever, and repeated chills, are indicative of
threatening perforation of the wall of the renal pelvis. After per-
foration has actually occurred, and when an abscess has formed in the
surrounding tissues, the disease assumes the characteristics of perine-
phritis. A tumor which fluctuates more or less distinctly is found in
the region of the kidney, etc. (see Sec. I., Chap. VII.). When the ab-
scess bursts into the peritoneal sac, the patient speedily perishes, with
the symptoms of acute peritonitis. If the pus burrow downward, a
cold abscess forms, which makes its appearance in the lower part of
the back, beneath Poupart's ligament, or in the perinaeum. If the
perforation take place into the intestine, masses of pus are discharged
with the stools ; the tumor which had formed diminishes or disappears
entirely, and a more or less permanent recovery takes place.

It is not always easy to decide if a pyuria originate in the bladder
or in the pelvis of the kidneys. In a pyelitis without implication of
the bladder, the desire to micturate may be very troublesome, and the
act of urinating may be accompanied by pain in the urethra. In
chronic pyelitis as well as in chronic cystitis, the urine contains
quantities of pus-cells, which render it cloudy, and when it stands
for some time they sink to the bottom as a whitish-yellow sediment.
The idea that the acid reaction of such urine indicates a pyelitis, while
alkaline reaction speaks for a cystitis, is not absolutely correct ; for in
chronic vesical catarrh even when of long standing it is generally acid,
and only becomes alkaline in the bladder under certain circumstances,
of which we shall speak when treating of catarrh of the bladder.
Another criterion also, which I formerly considered valuable in the
diagnosis of pyelitis from cystitis — namely, that in inveterate vesical
catarrh the purulent sediment was usually mixed with quantities of
mucus, while in chronic pyelitis the urine did not contain a trace of
mucus — is not always true. The mucous masses evacuated in the urine
in some cases of chronic vesical catarrh are the result of mucous trans-
formation induced in the purulent secretion from the vesical mucous
membrane by alkaline fermentation of the urine. If the urine does
not undergo this decomposition in the bladder, when freshly passed, it
will contain no mucous masses ; but, if we leave urine with a simple
purulent deposit (wnether it come from the bladder or the pelvis of

STONY CONCRETIONS IN THE PELVIS OF THE KIDNEY. 59

the kidney) in an open vessel till it undergoes alkaline fermentation,
the sediment will become tough and mucous. We can only be sure
of disease of the pelvis of the kidney, when we find connected
groups of spindle-shaped flat epithelium in the urine, especially
after violent exercise. But, even in cases where the patient com-
plains of pain in the region of the kidneys, extending thence to the
pelvis and testicles, we must not be misled, by any existing dysuria,
into the diagnosis of pyelitis.

TREATMENT. — For acute catarrhal pyelitis we may refer to what
has been said already concerning acute interstitial nephritis. At the
outset, the application of leeches, cut cups, as well as of cold, over the
region of the kidney, is advisable ; and, when the pain and strangury
are very severe, the exhibition of opium and the subcutaneous injection
of a solution of morphine. In order to dilute the urine as much as
possible, the patient should drink freely of liquids, avoiding the use of
salted or spiced food or beverage. The employment of alkalines, and
the alkaline-saline mineral waters of Vichy and Karlsbad is deserv-
edly in repute in the treatment of pyelitis. If the malady assume a
tedious form, let the patient use long-continued warm baths, and apply
hot poultices to the lumbar region. The acratothermae are coming
more and more into use in the treatment of pyelitis and its kindred
complaints. At the baths and springs of Wildbad, I have seen the
utmost benefit result from making the patient spend as long a time in
the bath as possible, and causing him to drink as much of the pure
lukewarm water of the springs as he could take without inconvenience.
We do not attempt to decide whether camphor, which enjoys so high
a reputation as a remedy for all irritations of the urinary passages,
really exerts the beneficial action ascribed to it. Where there is
tedious suppuration, astringents should be employed, especially tannin,
for reasons already given. In order to diminish the production of pus,
we may also try whether the patient will bear the exhibition of the
balsams, especially copaiba. For this purpose, Oppolzer recommends
the patient to drink lime-water and milk (aquae calcis, milk, aa Ib. £ to
Ib. ij. daily).

CHAPTER III.

STONY CONCRETIONS IN THE PELVIS OF THE KIDNEY.

[ETIOLOGY AND PATHOLOGY. — Stony concretions may form in
any part of the urinary passages, from the uriniferous tubules to the
bladder. They may assume the shape of a fine powder (sand or

60 DISEASES OF THE PELVIS OF THE KIDNEYS AND URETERS.

gravel), or form masses varying in size from that of a mustard-seed
to that of the fist. They are classified, according to their composition,
into — 1. Those composed of pure uric acid, or of uric-acid salts ;
2. Those composed of oxalate of lime ; 3. Stones of phosphate of
magnesia and ammonia and phosphate of lime ; 4. Stones of car-
bonate of lime ; 5. Cystine calculi ; 6. Xanthine stones. Besides
these, there are stones of several components, which are often so
formed that around a nucleus alternating strata are superimposed,
which vary as the conditions for the excretion of the different ma-
terials have varied from time to time. The most common of these
stratified stones are composed of a nucleus of uric salts or of oxa-
late of lime covered by shells of phosphatic matter.

The causes of urinary calculus are many, and in part still un-
known. The formation of uric-acid stones is ascribed to the long-
continued over-acidity of the urine, due either to the actual increase
in the quantity of the acid in the body as a result of imperfect oxy-
genation, to a sluggish mode of life, to a diet too rich in flesh, or to
lack of the supply of oxygen, or else to such an increase of the free
acids of the urine that the soluble uric salts which it contains are
decomposed, and the uric acid separated. This may proceed from
an acid fermentation within the organ, in which the coloring and
extractive matter of the urine turn into lactic acid, or else an acid-
ification in the primary passages favors such an excretion. Con-
ditions which produce a concentrated urine, as abstinence from
water, persistent diarrhoea, or badly-compensated heart-disease, may
also give rise to such excretion.

Oxalate-of-lime stones, generally called mulberry calculi, have
likewise various modes of origin. Sometimes, when the urine is
alkaline, the acid f orms in the urine itself, probably through decom-
position of the uric acid. Sometimes the stone forms when the
diet has been exclusively vegetable, from excessive use of sorrel,
tomatoes, and the like. Again, these calculi may appear under con-
ditions of body not fully understood ; but, as we know, the charac-
teristic crystals of oxalate of lime are found in the urine of many
patients of sluggish habit, disordered digestion, or derangement of
the respiratory or nervous apparatus.

Stones of phosphate of lime or ammonia, or of a mixture of the
two, are apt to form wherever a long-continued alkaline condition
of the urine produces alkaline precipitates in it. Such decomposi-
tion of the urine may proceed from chronic inflammation or other
diseases of the urinary tract, due to retention of urine. It may be
caused by the use of foul catheters, or by the presence of a foreign
body, such as a uric-acid or oxalate-of-lime calculus, which thus may

STONY CONCRETIONS IN THE PELVIS OP THE KIDNEY. 61

furnish a nucleus for a phosphatic shell. From the experiments of
Studensky, who inserted foreign bodies into the bladders of dogs
and put lime into their food, it would seem that an excess of lime
in the food predisposes toward phosphatic calculi. Even the phos-
phates which properly exist in the body may by morbid and exces-
sive transformation produce stones in the urine, as sometimes hap-
pens in osteomalacia.

Gravel and stones form at all ages of life. In childhood, how-
ever, the disposition toward stones — perhaps through uric-acid in-
farction of the new-born — seems the greater ; and in old age it is
also common. That men should suffer more often than women
would seem to be because of their different modes of life. How
much geological and climatic influences have to do with endemic
tendency to stone in certain countries, as England, Holland, and
parts of Germany, has not been made clear.

Concretions rarely form in the kidney-substance proper ; but
cases like those of uric-acid infarction of the new-born have been
seen in the adult, in which uric acid was found after gout, hgema-
toidin crystals after haemorrhage, and bile-pigment after jaundice.
Carbonate of lime, too, has been met with. Real stones are also
found as very great rarities in the kidney proper, or rather in por-
tions of the dilated urinif erous tubules. The ordinary seat of gravel
and of stone is in the calyces or pelvis of the kidney. The smaller
stones are roundish ; larger ones mould themselves to the shape of
the region which they occupy, so that stones of the calyx acquire
a pyramidal form.]

Stony concretions form in the pelvis of the kidney, probably
under the same conditions which cause them to form in the bladder.
When treating of vesical calculus, we shall discuss the pathogeny
and etiology of these calculous formations more fully. Many, and
perhaps the majority of stones in the bladder, originate in the pel-
vis of the kidney, and pass thence through the ureters into the blad-
der, where they increase in size by precipitation from the urine.

ANATOMICAL APPEARANCES. — In cases of uric-acid infarction,
upon section through the pyramid, we see delicate yellowish-red
stripes running in the direction of the tubules. Upon microscopic
examination, these tubules are found to be filled with a blackish,
coarsely-granular material. Upon the addition of an acid, these
masses disappear, and are replaced by crystals of uric acid. Ac-
cording to Virchow, dilatation of the tubules and the formation of
cysts in the kidney of the f 03tus may arise from permanent obstruc-
tion of the efferent tubules. In the haemorrhagic-pigmentous in-
farction we also see red streaks, with a tinge of yellow in them, in

62 DISEASES OF THE PELVIS OF THE KIDNEYS AND URETERS.

the pyramidal substance ; and, under the microscope, the tubules
are seen to be filled with granular, or globular, or lumpy masses,
and with the well-known haematoidin crystals. In calcareous in-
farction, whitish-yellow stripes are found in the pyramids ; and,
under the microscope, black masses are visible in the tubules, which
dissolve with effervescence upon the addition of acid. The deposits
of triple phosphate, which also produce yellowish-white stripes in
the pyramids, sometimes coalesce into stones of the size of a hemp-
seed, and may cause suppuration and destruction of the renal pa-
renchyma.

Calculous concretions which form in the pelvis and calyces of
the kidney have the same chemical composition as vesical calculi.
There is great variety in their size, shape, and number. The smaller
ones are no larger than a grain of sand, and are of a rounded form,
or else have the shape of a calyx of the organ. The larger ones,
which may be of the size of a pigeon's or hen's egg, fill up the
whole renal pelvis, often forming a complete cast of its shape, and
of that of the calyces.

SYMPTOMS AND COURSE. — Red gritty deposits upon the napkins
of newly-born infants, which cease to appear in the course of a few
weeks, constitute the sole and not very trustworthy sign of the ex-
istence of uric-acid infarction. That of calcareous infarction and
the presence of phosphatic deposit in the tubules cannot even be
suspected during life.

In many instances stony concretions in the pelvis of the kidney
give rise to no symptoms whatever. We often enough see small
urinary calculi, which certainly must have formed in the kidney,
voided with the urine, the patient never having suffered the slight-
est inconvenience prior to their discharge. In other instances there
is renal haemorrhage, and in others the signs of pyelitis calculosa.
(See Chapter II.) Some persons experience a sense of weight and
of pain in the lumbar region whenever the body is jolted. As
these symptoms are very ambiguous, we are not warranted in in-
ferring even the probable existence of a renal calculus from them,
unless from time to time the pain grow worse, with slight attacks
of fever, and unless, after such exacerbations, the urine contain fine
granular sediment, or small fibrinous clots incrusted with crystals,
and a few blood-corpuscles, or perhaps perfect calculi.

In two of my cases, the diagnosis of renal calculus was strength-
ened by the fact that, on examining some flocculi which swam in
otherwise limpid urine, groups of connected epithelial cells, of the
characteristic form of epithelium of the pelvis of the kidney, were
recognized ; and they showed no signs of fatty metamorphosis, and

STONY CONCRETIONS IN THE PELVIS OF THE KIDNEY. 63

had sharp outlines and distinct nuclei, which rendered it probable
that they had been detached by some mechanical force.

The passage of a calculus through the ureter is sometimes at-
tended by symptoms to which the term renal colic has been applied.
Clots of blood and parasites passing through the ureter may like-
wise give rise to renal colic ; and it is not impossible, though very
improbable, that a mere spasm of the ureter may sometimes have
like effect, but such cases are comparatively rare. It is incompre-
hensible why large stones often pass unnoticed through the ureter,
while much smaller ones (which are not always rough or angular)
may cause intense anguish. In this aif ection, the patient (often
after a severe jolting) suddenly feels a frightful pain darting from
the kidney toward the bladder, and thence to the thigh and testicle.
He screams and writhes with agony, and grows cold, prostrate, and
demoralized. Though constantly striving to micturate, but little
water flows. Vomiting is frequent, so that the seizure is apt to be
mistaken for biliary colic or eriteralgia. In irritable subjects there
may be convulsions. Sometimes temporary remission interrupts the
torment of the patient — soon, however, to be followed by renewed
and violent exacerbations. In other cases the pain increases -stead-
ily, and then ceases as suddenly as it commenced ; and, unless the
calculus give rise to fresh trouble by its presence in the bladder, a
complete recovery ensues immediately. Such attacks may pass off
in a few hours, and rarely last over twenty-four hours ; and, in spite
of the formidable aspect of its symptoms, life is hardly ever en-
dangered by renal colic. Sometimes, though not often, the im-
provement is incomplete ; the pain diminishes, but does not cease1
entirely, the symptoms of colic becoming complicated with those
of pyelitis.

TREATMENT. — The treatment of uric-acid and calcareous infarc-
tions is, of course, out of the question. In discussing the treat-
ment of vesical calculus, we shall speak of the procedures theoreti-
cally proposed for the purpose of dissolving stones, and shall then
point out their inefficiency.

In treating renal colic, it is merely necessary that the physician
be sure of his diagnosis, in order to obtain the happiest results.
He must not content himself by applying leeches, giving restora-
tives for the small pulse and cool skin, or with other useless half-
measures, but should boldly order opium every hour or two. The
anaesthetic action of the opium alone is insufficient to account for
the relief which usually follows this treatment. It is much more
likely that the muscular fibres of the ureter, which have been
thrown into a state of contraction by the irritation of the stone,

64 DISEASES OF THE PELVIS OF THE KIDNEYS AND URETERS.

which they have spasmodically grasped, are relaxed by the narcot-
ism induced by the opium. If the opium given internally be vom-
ited, a subcutaneous injection of morphine may be used. Inhala-
tion of chloroform vapor seems to have an action similar to that of
the opium, and is the next best remedy. In like manner, a copious
blood-letting may be of service, from the relaxation to which it
gives rise ; but in most cases this may be dispensed with. The
patient, however, who is demoralized by pain and terror, will not
be satisfied by the mere hourly administration of a powder and the
inhalation of chloroform. He will loudly demand that something
more be done for him, and, as a matter of humanity, we should
yield to his entreaty. If circumstances permit, let him. make use of
a warm sitz-bath or complete bath. It has also often been recom-
mended to seat the patient naked upon a stool, and to lay his bare
feet upon a cold floor. As a beverage, copious draughts of some
mineral water, containing carbonic acid, should be prescribed, in
order, if possible, that the urine pressing after the stone niay drive
it before it into the bladder.

CHAPTEK IV.

CABCINOMA AND TUBERCULOSIS OF THE' PELVIS OP THE KIDNEYS
AND OF THE UBETEES.

CARCINOMA of the urinary passages is rare. It scarcely ever
occurs except where cancer of other organs, especially of the kid-
ney, extends into the walls of the renal pelvis. In rare instances,
independent nodules of cancer appear in the pelvis of the kidney
and ureters, accompanying carcinoma of the bladder or kidney.
Tubercle of the uriniferous apparatus has already been alluded to
in treating of tuberculosis of the kidney, and was there stated to
be a partial manifestation of a general disposition to tubercle, in-
volving the testicle, prostate, seminal vesicles, and kidney. The
diffuse caseous decomposition, which the mucous membrane of the
urinary passages presents, cannot always be referred to the forma-
tion and softening of discrete tubercular granulations ; although
sometimes nodules as large as a millet-seed, either in groups or dis-
crete, and (where these have broken down) round or irregular ulcer-
ations, are found upon the mucous membrane. Sometimes the uni-
form proliferation of cells and their caseous metamorphosis convert
the inner wall of the ureter and of the pelvis of the kidney into a
yellow pultaceous mass. In other places the degenerated mucous

CARCINOMA AND TUBERCULOSIS OF THE KIDNEY. 65

membrane is fissured and broken down, containing extensive losses
of substance. Under such circumstances the urinary passages are
always much dilated, and their wall thickened. Tuberculosis of
the urinif erous apparatus is easy of diagnosis, when it can be ascer-
tained by palpation that the prostate and testicle also are diseased,
and when the urine is alkaline and mingled with pus and debris.
Extension of tuberculosis from the bladder to the ureters is so com-
mon an occurrence that it may always be anticipated in such cases.

SECTION HI.
DISEASES OF THE BLADDER.

CHAPTER I.

CATARRH OF THE BLADDER CYSTITIS CATARRHAL1S.

ETIOLOGY. — Catarrh of the urinary bladder may arise : 1. From
lirect irritation of the vesical mucous membrane. Unskilful injections
in gonorrhoea, frequent or rude catheterization, foreign bodies, espe-
cially calculi, may also produce the affection. The admixture of acrid
substances in the urine, or the formation of irritating matter in the
bladder, owing to decomposition of the urine, may give rise to a most
intense form of catarrhal cystitis. To this class the vesical catarrhs
belong, which are induced by the misuse of cantharides and of balsam
copaiba, as well as those which arise in cases of spinal disease, typhus,
stricture, and enlargement of the prostate, and other conditions caus-
ing retention of urine. In the same way, drinking of new beer will
occasion a very transient catarrh of the bladder.* 2. In other cases
catarrhal cystitis arises from the extension of an inflammatory irrita-
tion from other organs to the bladder. First under this heading stands
the cystitis which accompanies inflammation of the prostate, and in
many cases of gonorrhoea, and which often long outlasts the original
disease. 3. Chilling of the skin, especially of the feet and abdomen,
not unfrequently results in catarrh of the bladder. 4. Finally, a symp-
tomatic vesical catarrh is one of the concomitants of growths and
other grave disorders of the bladder.

ANATOMICAL APPEARANCES. — In acute cases the mucous mem-
brane of the bladder is reddened, swollen, and relaxed. Its surface is
covered with mucus, mixed with detached epithelium and young cells
in variable quantity.

In chronic catarrh of the bladder this redness of the mucous mem-
brane fades, and the color sometimes becomes a dirty gray. The mu-
cous membrane is swollen and thickened. The submucous and inter-

* Or is this annoying but harmless and transient malady due to acute irritation of
the urinary passages by large sharp crystals of oxalate of lime, which may appear after
drinking bad beer containing much carbonic acid ? I have often urged my students
(but hitherto in vain) not to miss an opportunity of examining microscopically the
urine passed during such an attack.

CATARRH OF THE BLADDER— CYSTITIS CATARRHALIS. 67

muscular connective tispue, and the muscular fibres themselves, are
also thickened and hypertrophied. Upon the inner surface of the blad-
der there lies a gray puriform mucus, or a yellowish purulent secre-
tion. The urine contained in the bladder is often decomposed, is of
an acrid ammoniacal odor, and alkaline reaction.

Chronic catarrhal cystitis rarely terminates in recovery. Far more
frequently, as the malady advances, the proliferation of cells upon the
free surface of the bladder is complicated with a vast cell-growth in
the tissues of its mucous, submucous, and muscular coats. In this
way catarrhal mucous ulcers and submucous abscesses are formed.
Perforation of the vesical wall sometimes takes place. Should this
occur after the bladder and its neighboring organs have become con-
solidated by pericystitis, abscesses may form around the former, which,
under favorable circumstances, may open either externally, or into the
rectum, or vagina, and, in unfavorable ones, may break into the ab-
dominal cavity. Another, but not a very common, result of vesical
catarrh is diffuse suppuration. This generally occurs in cases of reten-
tion of urine, and arises from the corrosive action of the putrid contents
of the bladder upon its mucous membrane. The mucous membrane is
then found to be extremely soft, discolored, and of a brownish-red or
blackish hue. It is covered with dirty exudation, or broken down into
a ragged, pultaceous substance, infiltrated with fetid pus. The mus-
cular fasciculi are pale and tear easily. The submucous and intermus-
cul&r tissue is infiltrated with ichorous matter; within the bladder
there is a blackish-brown, chocolate-like liquid, of an intensely ammo-
niacal odor, consisting of decomposed urine, blood, pus, and shreds of
detached mucous membrane. In the worst cases the destruction at-
tacks all the coats of the viscus, whose contents escape into the ab-
dominal cavity.

An enormous thickening of the walls of the bladder, a common
result of the hypertrophy of the muscular fasciculi already referred to,
may be mentioned as a third termination of chronic vesical catarrh.
This condition, however, sometimes arises in cases of long-standing
impediment to the passage of the urine, without vesical catarrh. In
such cases the wall of the bladder attains a thickness of from several
lines to half an inch or more. The muscular fasciculi have .grown into
rounded bars, and form rib-like projections upon the interior, the ap-
pearance of which has been compared with that of the right ventricle
of the heart (vessie d colonne). According as the capacity of the
bladder is increased or diminished by this hypertrophy, it is called ex-
centric or concentric. In the former case the bladder may rise into
the abdomen as far up as the navel ; in the latter it may be shrunken
to the size of a walnut. In some cases of chronic vesical catarrh, es-

68 DISEASES OF THE BLADDER.

pecially when associated with impediment to the exit of urine, the
mucous membrane, pressing asunder the muscular fasciculi, is forced in
between them, forming diverticuli. At first small and round, these
latter ultimately expand into large bottle-shaped pouches, of the size
of a fist. Their communication with the bladder is at first a narrow
chink, which afterward becomes round and sphincter-like. Owing to
the incompleteness with which these diverticuli are evacuated, they
often become the seat of urinary deposit, and of incapsulated calculi.

SYMPTOMS AND COUBSE. — Acute catarrh of the bladder is some-
times accompanied by febrile symptoms. As a rule, however, there is
neither elevation of temperature nor acceleration of pulse. In quite
recent cases, the patients complain of an undefined pain in the hypo-
gastric region and perinaeum, which extends upward toward the kid-
ney, and along the urethra toward the glans penis. In the more
severe forms of vesical catarrh, pressure exerted upon the region of
the bladder gives rise to pain. The hyperaemic and irritable vesical
mucous membrane evinces the utmost intolerance against its contents.
The collection of a few drops of urine in the bladder occasions the
most urgent desire for its expulsion. The sphincter vesicae also is in
a constant state of spasm, thus causing a vesical tenesmus quite analo-
gous to that of the rectum already described in catarrhal rectitis.
The patient scarcely has the urinal out of his hand, micturition is ex-
tremely painful, and the few drops of urine which are expelled in short
spirts from the urethra produce a feeling as though molten lead were
running through the penis. As in all recent catarrhs, at first the
quantity of mucus formed is small, so that but a few flocculi are
scattered through the urine. Afterward the urine passed becomes
turbid, and lets fall a mucous sediment in greater or less profusion.
The disease may run its course, and get well in a few days ; and that
form caused by drinking fresh beer usually passes off within a few
hours. In other cases it is more protracted, or passes into the chronic
form. Sometimes the spasmodic contraction of the sphincter vesicae,
which occurs in acute vesical catarrh, gives rise to complete retention
of urine, and in old persons especially, owing to secondary diseases
(oedema and fatty degeneration of the muscles of the bladder), a my-
opathic palsy of the detrusors arises, which also causes retention. It is
this circumstance which renders simple vesical catarrh a dangerous
disease to old persons. In chronic catarrh of the bladder, the pain
usually abates after a while, but the intolerance of the viscus against
its contents and the constant inclination to urinate continue. The
quantity of mucus increases considerably. At first a somewhat trans-
parent stratum of mucus sinks to the bottom of the vessel, after-
ward the urine becomes thick and turbid, and its sediment is moro

CATARRH OF THE BLADDER— CYSTITIS CATARRHALIS. 69

opaque, and of white or yellow color. If the urine undergoes the
so-called alkaline fermentation in the bladder — the secretion of the
diseased mucous membrane, full of pus-cells and disintegrating epi-
thelium, suffers a peculiar transformation (already mentioned when
treating of pyelitis) forming a gelatinous coherent mass, which, when
poured from one vessel to another, holds together, and can be drawn
into long threads.

In previous editions of my text-book I have stated that this pro
fuse secretion of mucus often acted as a ferment upon the urine, giv-
ing rise to an " alkaline fermentation ; " that in this alkaline fermen-
tation the urea was decomposed into carbonate of ammonia, and that
new ammoniacal combinations formed, namely, urate of ammonia and
phosphate of ammonia and magnesia (triple phosphate). I was
compelled to add that the mucus contained in the urine did not al-
ways act as a ferment ; and that, in many cases of protracted vesical
catarrh, I had constantly found the reaction of the urine to be acid.
In the course^of the last year,* from observations made by Traube,
as well as from investigations and experiments of my own, which have
oeen published by Teuffel^ in the ^Berliner Jflinischen Wbchenschrift,
I have become convinced that this alkaline fermentation is not pro^
duced by the mucus, but is owing to the presence in the urine of or-
ganisms of a low grade, which probably usually find their way thither
through the introduction into the bladder of dirty catheters. A high-
ly interesting observation, made in my clinic, upon a young girl with
palsy of the bladder, affords striking evidence of the correctness of
this opinion. In the bladder of this patient, who for weeks had been
catheterized with an ill-cleansed instrument, there had developed a
most typical alkaline fermentation. Her urine, which was of a pun-
gent ammoniacal odor and alkaline reaction, contained the thorn-
apple-like crystals of urate of ammonia, large coffin-lid-shaped crystals
of ammonio-magnesia-phosphate, with many vibriones and fungi of a
low order ; but it contained neither cellular elements nor large quan-
tities of mucus. A careful research into the history of the case showed
that the pdiient never had had any symptoms of vesical catarrh.
Chronic vesical catarrh drags on for weeks, months, and even for
years. It is a remarkable fact, and one difficult to explain, that it usu-
ally i£ accompanied by loss of appetite and by derangement of diges-
tion. The longer the disease has lasted, sc much the less are the
chances of a perfect recovery.

Ulceration of the vesical mucous membrane is to be suspected
when the sediment of the urine grows more and more purulent, when,
from time to time, blood is discharged with the urine, and when a slow
fever arises, which consumes the strength of the patient. He then

70 DISEASES OF THE BLADDER.

ultimately dies of vesical-phthisis, especially if it be associated tnth
abscess about the bladder, or tedious suppuration from fistulous pas-
sages.

When catarrhal inflammation of the bladder passes over into dif-
fuse suppuration, the patient becomes collapsed, his countenance ap-
pears sunken, the pulse is small and thready, and the skin cold. The
urine is discolored, of a brownish or blackish hue, contains shreds
of mucous membrane, and exhales a fetid odor. Even though the wall
of the bladder be not completely destroyed, and though there be no
escape of its contents into the abdominal cavity, yet malignant peri
tonitis soon develops, and the patient dies within a few days, of gen-
eral prostration.

Thickening of the wall of the bladder, from hypertrophy of its mus-
cular fasciculi, may be detected when the viscus also is dilated, by the
appearance above the symphysis pubis of a firm tumor, which some-
times extends as high as the navel, or even higher, and which in fe-
males is apt to be mistaken for a distended womb. Generally speak-
ing, patients are unable to empty a bladder thus thickened and dis-
tended, even though there be no obstacle to its evacuation in the vesi-
cal neck or urethra. It is only the excess of urine (for which, so to
speak, there is no room left in the already enormously overfilled blad-
der) that is passed by the patient, or which runs from him involuntari-
ly if the sphincter be palsied. Thus it may happen that, in the course
of twenty-four hours, he may pass a normal amount of water, and still
retain from two to six pounds or more in his bladder, which can only
be removed by means of the catheter. In concentric hypertrophy, the
bladder can be felt through the wall of the vagina or rectum, as a hard
tumor, which may give rise to all sorts of blunders. In these cases,
the bladder being incapable of distention, there is a constant desire to
pass water, which does not give the patient a moment's rest ; and,
when the sphincter is relaxed, there is an incessant dribbling of urine.

TREATMENT. — The causal indication, first of all, demands the pro-
tection of the vesical mucous membrane from the injuries which have
occasioned the disease. This is most difficult of accomplishment
where rude catheterization or careless injections into the urethra have
provoked catarrh of the bladder ; as well as where the exhibition of
cantharides and the like, or the long-continued use of fly-blisters, or of
irritating ointments, or where persistent retention and decomposition
of the urine are the irritants which are acting upon the mucous mem-
brane. When it proceeds from the extension of an inflammation of the
urethra or womb, the application of a few leeches upon the perinaeum,
or portio vaginalis, is advisable. If the apparent cause be cold, we
should resort to a diaphoretic course of treatment. It is only when

CATARRH OP THE BLADDER— CYSTITIS CATARRHALIS. 71

quite recent and of great intensity that the indications from the dis-
ease itself call for local blood-letting, which then is better performed
upon the perinaeum than above the symphysis. In most cases of acute
catarrhal cystitis, hot poultices upon the abdomen, and general warm
baths, suffice to relieve the symptoms and to bring about a favorable
termination. Besides this, we must take care that the urine enter the
bladder in as dilute a condition as possible ; but, if we strictly forbid
the use of all salt and spices, it will be useless to mix oleaginous or
mucilaginous materials in the patient's drink. It is best to let the
patient drink the artificial or natural mineral waters — the Seltzer,
Wildunger, Fachinger, or Gailnauer waters, or soda-water, or lime-
water, mixed with equal parts of milk. The semina lycopodii have a
peculiar reputation as a remedy for vesical catarrh (sem. lycopod.
| ss — to mel. despumat. § jss. f. elect, s. 3 j every two hours), as has
also camphor, where the complaint arises from the abuse of cantharides
(camphor pulv. gr. vj, emulsion of almonds, § vj). The employment
of small doses*, of opium in the form of Dover's powder, given at night
before bed-time, or in the form of tinctura thebaica, in divided doses,
is not only harmless, but a most efficient remedy against pain and
vesical tenesmus. The more the pain abates, and the more copious
the admixture of mucus and pus in the urine, so much the more ur-
gently are the astringents indicated. The astringent most commonly
employed is a decoction of the folia uva ursae ( | ss. to § vj, a table-
spoonful every two hours). The continued use of tannin is still more
efficacious : I have obtained some most happy results from it in cases
which seemed almost desperate. In the later stages of acute vesical
catarrh, and still more in the chronic form of the disease, the balsams
and resins, which are of such striking benefit in catarrh of the urethra,
also do excellent service. To this class belong the oil of turpentine,
tar-water, Peruvian balsam, and, above all, balsam copaiba, which may
be given in capsules of gelatine. If these remedies fail, we should
have recourse to local treatment. I have repeatedly made injections
with lukewarm water, the temperature of which I gradually bring
down to 65° F. after the manner recommended by Civiale, and cannot
sufficiently praise their efficacy, especially in treatment of women.
Astringent injections, among which solutions of nitrate of silver, sul-
phate of zinc, and tannic acid, are recommended; should be used witr
greater caution ; so too with injections of emulsion of balsam copaiba
( 3 j to § j), the efficacy of which is greatly extolled by some phy-
sicians. No modification of this treatment is demanded where ulcera-
tion of the bladder is detected. Suppurative destruction of the vesical
mucous membrane is quite insusceptible of treatment. In excentrio
hypertrophy, the bladder mubt be emptied by the catheter regularly
55

72 DISEASES OF THE BLADDER.

every eight or twelve hours, and an elastic bandage should be fitted
to the abdomen. In concentric hypertrophy, on the other hand, the
patient must be charged to retain his water as long as possible, in
order gradually to dilate the bladder. It has also been proposed to
introduce an elastic catheter, closed by a cork, into the bladder, by which
the 'irine may be evacuated every two or three hours.

CHAPTER II.

CROFPOUS AND DIPHTHERITIC CYSTITIS.

CROFPOUS and diphtheritic cystitis scarcely ever occur, excepting
in cases of severe infectious disease — in septicaemia, typhus, small-pox,
and scarlatina — and are accompanied by similar inflammation of other
mucous membranes. Far more rarely it arises after the abuse of can-
tharides, after difficult labor, or in consequence of very intense irrita-
tion of the bladder from decomposed urine. In this form of inflam-
mation a coagulating exudation of variable thickness and consistence
is formed, a portion of it infiltrating the tissues of the mucous mem-
brane, while another portion lies upon its free surface. The process
rarely extends over the entire surface of the bladder. More usually it
is confined to detached streaks and spots of a rounded form. After
separation of the diptheritic slough, there remain losses of substance
in the mucous membrane. The disease can only be recognized when
whitish membranous coagula are discharged with the urine, with
symptoms of severe tenesmus. In the croupous cystitis which some-
times follows the abuse of cantharides, or difficult forceps deliveries, we
occasionally see large tenacious false membranes discharged with the
urine. The treatment of croupous and diphtheritic cystitis should be
similar to what we have already advised in cases of violent and acute
catarrhal cystitis.

CHAPTER III.

PERICTSTITIS.

BESIDES the inflammation induced by perforation of the bladder,
and by abscesses and suppuration of its walls, another and independent
inflammation, which we call pericystitis, sometimes involves the connec-
tive tissue which surrounds this organ, and connects it with the adja-
cent parts. It is of far less frequent occurrence than the inflammation
which takes place about the rectum, and is hardly ever observed
excepting as an accompaniment of infectious disease, typhus, the acute
exanthemata and septicaemia. As a still greater rarity, it arises idio-

TUBERCULOSIS AND CARCINOMA OF THE BLADDER. 73

pathically without known cause, in persons previously in good health.
This inflammation shows great tendency to pass into suppuration, and
to destroy the parts involved ; it is very apt to spread into the tissues
which attach the bladder to the other pelvic viscera, and to the sides
of the pelvis. The pus may ultimately penetrate into the bladder,
rectum, vagina, or externally into the perinoeum. There is also a form
of chronic pericystitis, which not unfrequently accompanies chronio
vesical catarrh, and vesical ulceration, and which creates induration
of the surrounding connective tissue, and causes firm adhesion of the
bladder and surrounding parts. Sometimes this also results in the
formation of an abscess.

The affection is generally difficult of recognition, as the resulting
painful tenesmus of the bladder, the dull, continuous pain in the pelvis,
the repeated chills, and the complete retention of urine, which occur
when the urethra or the ureters are obstructed by an abscess, furnish
insufficient data for a diagnosis. A diagnosis can only be in some de-
gree certain w;hen an abscess projects above the pubis from the ante-
rior surface of the bladder, presenting a spherical prominence, which
does not disappear when the bladder is emptied ; or else when we can
feel a tumor in the perinaeum, or through the rectum or vagina. The
treatment of pericystitis belongs to the province of surgery.

CHAPTER IV.

TUBERCULOSIS AND CARCINOMA OF THE BLADDER.

TUBERCULOSIS of the bladder usually appears as a complication of
tuberculosis of the ureters, renal pelvis, and kidneys. Discrete and
conglomerate tubercles also form in the bladder sometimes, which, upon
breaking down, produce rounded or irregular excavated ulcers. Some-
times (but more rarely than in the ureters and pelvis of the kidney)
there is a diffuse caseous degeneration of the mucous membrane, which
occasions wide-spread destruction.

The symptoms of tuberculosis of the bladder are very similar to
those of chronic vesical catarrh and vesical ulceration. The copious
admixture of mucus and pus in the urine, which is often in a state of
ammoniacal decomposition, the tormenting desire to urinate, the fre-
quent hsemorrhages from the bladder, which are the signs of excentric
and concentric vesical hypertrophy, also attend vesical tuberculosis.
Our only positive data for a differential diagnosis are the coexistence
of degeneration of the prostate or testicle, and the appearance of elastic
fibres, or of larger bits of tissue in the urine, from which we may infer
the destructive nature of the process which is going on. In a female

74 DISEASES OF THE BLADDER.

patient of mine, suffering from tuberculosis of the bladder, urinary
passages, and kidneys, I found an irregular eroded ulcer, with peculiar
edges, in the vulva, surrounding the orifice of the urethra.

The treatment of tuberculosis of the bladder is identical with that
of chronic vesical catarrh, but is generally quite unavailing.

Carcinoma of the bladder is not common. Sometimes it is primary,
sometimes it occurs secondarily to similar disease of the uterus or rec-
tum. It assumes the form of scirrhus, more often the medullary form,
but the villous cancer is more frequent than either. The former twt
sometimes produce diffuse degeneration of the wall of the bladder,
which, upon breaking down, forms communicating openings with the
vagina, uterus, or rectum. Sometimes they take the shape of circum-
scribed and even pedunculated growths. The villous cancer forms
soft tumors, consisting of thin, delicate villous excrescences, which float
in water, and which often become detached during life, giving rise to
haemorrhage.

The most prominent symptoms of cancer of the bladder are, like-
wise, those of chronic vesical catarrh. Haemorrhage is still more com-
mon than in tuberculosis. Diagnosis must depend upon the continuance
and constant aggravation of the symptoms, the early appearance of a
bad cachectic condition, in the discovery of cancer of other and espe-
cially of neighboring regions, and, above all, upon microscopic exami-
nation of the detached particles of the growth discharged with the
urine. Treatment is in vain, and should be limited to a repression of
the haemorrhage, the relief of any retention of urine which may arise,
and the combating of intercurrent symptoms.

CHAPTER Y.

HAEMORRHAGE FROM THE BLADDER — H^EMATTTRIA VESICALIS.

HAEMORRHAGE from the vessels of the bladder is often of traumatic
origin. Sharp-edged stones, or foreign bodies, which have entered the
viscus, are the usual causes of the bleeding. In hysterical women, we
must be prepared for the most extraordinary devices. Not at all un-
frequently, they introduce foreign bodies into their genitals, or into
their urethra, which may be the cause of the haemorrhage. In other
cases, ulcers of the bladder cause erosion of its vessels, and consequent
bleeding. Neoplastic formations also, tubercle, carcinoma, but espe-
cially the villous cancer, give rise to losses of blood. Very rarely,
such haemorrhages depend upon the misuse of cantharides (haematuria
toxica), or upon a haemorrhagic diathesis. Finally, an excessive dila-
tation .)f varicose veins of the part may result in their rupture, with

STONY CONCRETIONS IN THE BLADDER. 75

an effusion of blood. Haematuria from this cause, however, is very
rare, although the laity are much inclined to ascribe all haematuria
to " haemorrhoids of the bladder." The conditions producing impedi-
ment to the circulation and dilatation of the vessels are far less favor-
able in the bladder than in the rectum ; and, as a rule, this last and
rarest of the causes of vesical haemorrhoids is not to be thought of,
•unless, after a scrupulous review of all the symptoms, all other forms
of the disease can be excluded from the diagnosis.

In haemorrhage into the bladder, the blood and urine are less inti-
mately mixed than when the bleeding comes from the ureters, renal
pelvis, or kidneys. The clots which form are also of larger size. Nev-
ertheless, both these signs may jprove fallacious, and hence diagnosis
of the region whence the bleeding proceeds is often a matter of great
difficulty. The attendant symptoms furnish the most trustworthy aids
to diagnosis of the source of the haemorrhage. Vesical haemorrhage
is almost always accompanied by evidence of change of structure in
the bladder. '. During the intervals between the bleedings the urine
contains mucus and pus, and there is dysuria, etc.

Our main task in the treatment of vesical haematuria should be to
combat the original disease. In severe cases, cold should be applied
to the region of the bladder, and large doses of tannin should be given.
Where the bleeding threatens to exhaust the patient, we must have
recourse to injections of cold water, with a solution of alum, sulphate
of zinc, or nitrate of silver. In vesical haemorrhoids as well as othei
forms of vesical haemorrhage, cold injections have the best effect.

CHAPTER VI.

STONY CONCRETIONS IN THE BLADDER.

ETIOLOGY. — The manner in which stones form in the kidney and
bladder is obscure. None of the current explanations of the process
have shown themselves proof against the various objections made to
them. Especially is this the case with the theory that these concre-
tions are the result of a peculiar derangement of assimilation, of a
diathesis, wherein uric acid, oxalic acid, the phosphates, etc., form so
profusely in the system, and are eliminated from the blood through
the kidneys in such quantities, that they are precipitated in the urinary
passages.

The explanation of Scherer is very plausible. He believes that
the substances deposited in the urinary passages, and which sometimes
form stones, are not eliminated from the kidneys in then* present shape.,
and only form through the decomposition which the urine undergoep

76 DISEASES OF THE BLADDER

during its abode in the uiinarj passages. This decomposition is similar
to that which takes place in urine when allowed to stand exposed to
the air. There is at first an acid fermentation. The coloring and ex-
tractive matter of the urine become converted into lactic acid, so that
the urea is liberated from its soluble combinations, and is precipitated.
The acid fermentation is followed by an alkaline one. The urea is
converted into carbonate of ammonia, and, by a combination of the
ammonia with the phosphate of magnesia, an ammonio-magnesian
phosphate is formed — the so-called triple phosphate. The ferment
which excites this decomposition in the urine, while yet in the bladder,
is the mucus resulting from vesical catarrh ; but, according to ScJierer,
besides this, the mucus plays another and most important role in the
formation of calculi, by forming a cement to hold the sediment together,
since coagula of mucus form the nuclei of most stones, to which the
deposits afterward adhere by accretion. According to the theory of
Scherer, the formation of stones, which consist of a nucleus of uric acid
enclosed in layers of phosphates, is as follows : As long as the acid
fermentation of the urine continues, uric acid is precipitated ; when,
however, the catarrh has continued for some time, and, perhaps, has
become aggravated by the presence of a calculus in the bladder, alka-
line fermentation sets in, and the phosphates are thrown down.

According to a very brilliant hypothesis of Meckel, the formation
of precipitates is not requisite for the production of a urinary calculus.
He claims that almost all stones consist originally of oxalate of lime,
and are formed as follows : The mucous membrane of the urinary pas-
sages becomes the seat of a specific catarrh, called by Meckd the
"stone-forming catarrh" (stein-bildenden catarrh). In this catarrh a
tough adhesive mucus is secreted, which has a tendency to acid fer-
mentation, and in which oxalate of lime appears when such fermenta-
tion occurs. At first this oxalate-of-lime mucus is of a gelatinous con-
sistence. Gradually, however, it takes up more and more oxalate of
lime from the decomposed urine, and thus, growing more and more
firm, finally becomes stony. As long as the urine remains decidedly
acid, the stone enlarges, from the accretion and petrifaction upon it of
fresh layers of oxalate-of-lime mucus. If the urine afterward become
alkaline, the stone no longer grows from " apposition," but from " in-
tussusception," combined with a " metamorphimus," that is to say.
the oxalate of lime is at first displaced by uric acid, and urate of am
monia, and afterward by the phosphates. In this manner an oxalic
calculus becomes converted into a phosphatic calculus.

To attempt to point out all the flaws in each of these theories, and
the various objections which might be advanced against them, would
take too long. Among other matters, the fact still remains unex-

STONY CONCRETIONS IN THE BLADDER. 77

plained, (hat hereditary tendency should play so decided a part in the
formation of stone in the bladder. All the different generations of
one family have been observed to suffer from the same sort of stone.
Males are attacked by stone more frequently than females. The age
of childhood is by no means exempt ; indeed, children are rather liable
to the formation of calculi and gravel in their urinary passages. In
some countries, as in England, the malady is much more common than
in others. Drinking-water which contains lime seems to have some
influence in the production of stone, and the use of fermenting bever-
ages containing carbonic acid is quite decided, at least as to its effect
in producing oxalate-of-lime calculi. Any irritation which occasions
catarrh of the urinary passages may give rise to stone in the bladder ;
but it is quite enigmatical why many catarrhs last so long without
forming concrements, while others give rise to their formation very
soon.

ANATOMICAL APPEARANCES. — Urinary calculi vary in size, shape,
and .chemical composition. The smaller, which are usually extremely
numerous, we call "gravel." Their form and color depend mainly
upon their composition. They may be classified as follows :

1. Stones consisting chiefly of uric acid and its salts. They are
round or oval ; usually of a reddish-brown color, very hard and heavy,
and with a smooth or nodular surface.

2. Stones of oxalate of lime. They usually present a nodulated,
gland-like surface, whence their name, " mulberry calculus." They are
very hard, and of a dark-brown or blackish color (through the admix-
ture of transformed haematine). Yet some oxalate-of-lime stones are
small and pale, and in form bear a strong resemblance to hemp-seeds.

6. Stones consisting of ammonio-magnesia phosphates. They are
of a whiter or grayer color ; have a round or oval shape ; are light in
weight, and are of friable, chalky consistence.

4. Calculi of cystine. These are rare. They are usually of a yel-
lowish-white color. Their surface is smooth, more rarely nodular.

5. Stones formed of xanthin, which are more rare even than the
cystine calculi. They are very hard, of a yellowish-red color, and usu-
ally have a smooth surface.

6.. Stones, consisting of various layers and strata of diverse com-
position, are very common. Sometimes, the nucleus is of uric acid and
the outer layers of oxalate of lime ; more rarely, the contrary arrange-
ment obtains. The most common form of stratified calculus is that in
which a nucleus of uric acid or of oxalate of lime is enclosed in a hull
of phosphates, or in which there are several alternate layers of these
substances.

Stones often lie free in the bladder, changing their position as the

73 DISEASES OF THE BLADDER.

attitude of the body is varied. Quite frequently, too, they are lodged
and embedded in pouches and diverticuli in its wall. The mucous
membrane is either in a state of catarrh or of catarrhal ulceration. The
muscular tunic is usually hypertrophied ; yet, if the calculus be smooth
and light, all of these appearances may be absent.

SYMPTOMS A.ND COURSE. — Sometimes, but not very often, patients
with " stone " have a distinct perception that there is a foreign body
in their bladder which changes its place as the posture of the patient
is altered. A more important and constant symptom is pain about the
bladder, which is aggravated by walking, driving, or riding, and which
is relieved by lying upon the back. The pain darts along the penis to
the glans, and causes the patient, especially if he be a child, to pull
upon the prepuce, so that in children an cedematous thickening or ab-
normal length of the prepuce is to be regarded as a characteristic, or,
at least, as a suspicious sign of vesical calculus. During micturition,
the stream of urine is often suddenly interrupted, owing to obstruction
of the neck of the bladder by the stone. If the patient change his
attitude, his ability to pass water is frequently restored. Even though
the beginning of the act of micturition be easy and painless, yet, tow-
ard its close, there is usually the most acute suffering. This is com-
bined with aching in the testicles, thighs, and lumbar region, with
spasmodic contraction of the anus, and even with general reflex phe-
nomena. The whole of these symptoms, however, together with occa-
sional haematuria, are insufficient to establish a diagnosis; and we
should make it a rule never to pronounce a positive opinion until the
presence of a stone has been reduced to a certainty by means of the
sound.

TREATMENT. — The possibility of dissolving large vesical calculi, by
means of internal medication, must be pronounced as hitherto un-
proved, although theoretically such possibility cannot well be denied.
Means have been proposed of rendering the urine alkaline, or else of
increasing its acid reaction, according to the chemical constitution of the
stone. The former task, as is well known, is far easier of accomplish-
ment than the latter, as the carbonates and vegetable salts supplied
to the system are discharged with the urine as alkaline carbonates,
while it is quite difficult to augment the quantity of acid in the urine.
Theoretically, the benzoic acid, which is excreted in the form of hippu-
ric acid, is adapted for the solution of a phosphatic calculus. But the
continued exhibition of this remedy in large doses is forbidden, owing
to its pernicious action upon the digestive organs. The administration
of tartaric and citric acid might also have a good effect in the solution
of phosphatic calculi; but these harmless articles have never come
into use. Indeed, as soon as a stone in the urinary passages has been

STONY CONCRETIONS IN THE BLADDER. 79

diagnosticated, it is usual to administer alkaline carbonates, quite re-
gardless of the chemical nature of the stone, and to send well-to-do
patients to Vichy or Karlsbad, those springs having a world-wide
reputation as remedies against lithiasis. Perhaps the benefit derived
from this mode of treatment depends upon the effect of the remedies
upon the vesical catarrh, which is one of the main causes of the affec-
tion. According to MecJceVs theory, the exhibition of the alkaline
carbonates and salts of the vegetable acids is indicated, because the
urine is thereby rendered alkaline, and the metamorphosis of a stone,
consisting of oxalate of lime, or of uric acid, into a softer and more
friable phosphatic calculus, is promoted. At all events, we strongly
advise that the old method of treatment be adhered to, and that no
new " cures " be adopted, based merely upon a priori reasoning. Be-
sides the alkaline carbonates, and the basic phosphate of soda, of
which about two drachms may be taken daily, the carbonate of lithia
has of late obtained a great reputation as an antilithic, and is warmly
recommended»by many. I should attach little weight to such recom-
mendations, were they based solely upon the theoretical ground that
the carbonate of lithia has a solvent power of uric acid six times as
great as that of bicarbonate of soda. But, as we have some reports,
upon good authority, of good clinical results obtained by its use, I
admit the propriety of making further experiment with this drug
(lithiae carb. gr. j — v t. d.). The Wildunger, Vichy, or Karlsbad
waters may also be used as a beverage.

We have already discussed the mode of treating the catarrh and
haemorrhage of the bladder to which calculus gives rise. The opera-
tion for stone in the bladder is a matter for the surgeon.

NEUROSIS OF THE BLADDER.

WE are still hi need of considerable physiological light as to the
normal innervation of the bladder, and to the process of micturition.
It is difficult satisfactorily to account for the well-known facts that a
healthy man is often unable to pass water when required to do so in
the presence of a stranger who watches him, and that the first attempts
of a novice to make water while on horseback or in a wagon are often
attended with difficulty, while these things are easy enough to one
who is accustomed to them. Nevertheless, our comprehension of the
nervous disorders of the bladder will be facih'tated if we classify them
into motor and sensory neuroses, and subdivide the latter class into
hyperassthesia and anaesthesia, the former into hypercinesis and acinesis.

80 DISEASES OF THE BLADDER

CHAPTER VII.

HYPERJESTHESIA OP THE BLADDER.

HYPERAESTHESIA of the bladder is most commonly seen in indi«
tiduals addicted to sexual excess, especially to onanism — a very mod-
erate degree of fulness of the bladder causing in them a most intense
desire to urinate — " castus raro mingit" If they have not opportunity
to indulge their inclination to pass water, they suffer pain over the
bladder and along the penis. The power of retaining the urine is not
generally impaired in such cases, the hyperaesthesia being pure and
uncombined with motor disturbance. Sometimes, however, this irri-
tability of the bladder is accompanied by a diminution of power in the
detrusors ; and it is not without reason that a strong stream of urine
passes for a sign of chastity among the laity, and a languid dribbling
one for a token of the reverse. Extreme hyperaesthesia of the bladder
sometimes follows gonorrhoea. Patients are sometimes met with who
are quite unfitted for their previous occupation, being unable to hold
their water for over a quarter of an hour at a time, and are thereby
reduced almost to desperation. This form of hyperaesthesia, perhaps,
is always accompanied by a slight catarrh. The intolerance of the
bladder against its contents is the most prominent symptom of this
form of catarrh ; and I have never noticed any excessive production of
mucus.

For the milder form of hyperaesthesia of the bladder, such as affects
dissipated persons and onanists, I recommend cold river and sea baths,
cold sitz-baths, and cold douches. The more severe forms, which re-
main after cure of a gonorrhoea— rthe cold- water-cure, injections into
the bladder, and other active procedures, proving ineffective — I have
in some instances seen disappear rapidly and without trace under
large doses of balsam copaiba.

There are no well-authenticated observations of neuralgia of the
bladder, that is, of painful excitement of the sensory nerves, which
cannot be traced to irritation of their peripheral extremities.

CHAPTER VIIJ.

ANAESTHESIA OF THE BLADDER.

SOME persons can suffer the accumulation of a very large amount
of urine in their bladder without feeling an urgent inclination to evacu-
ate it. This condition, however, is hardly to be regarded as a morbid
one. On the other hand, it seems to me admissible to ascribe the

ANAESTHESIA OF THE BLADDER. 81

enuresis nocturna (nocturnal wetting the bed) to an imperfect anaes-
thesia and diminished irritability of the vesical sensory nerves. This
extremely distressing affection, for which the patient not unfrequently
is subjected to the most abominable treatment, and which often de-
stroys the happiness of families whose older children are afflicted by
it, is usually classed with palsy of the bladder. Many cases of enu-
resis nocturna as I have seen, however, I have never been able to per-
ceive that the sphincter vesica failed in its duty during the day, or that
the children had any dribbling of urine, nor when the inclination to
urinate came upon them were they ever in great haste to reach the
urinal. Indeed, there are only two possible ways of accounting for
enuresis nocturna. Either the sensation to which a full bladder gives
rise is too feeble to awaken the child from his normal sleep, or else
the sensation is of its normal intensity, but the sleep is unusually pro-
found. In the latter case it would seem as though nocturnal incon-
tinence of urine occurred somewhat as do those well-known cases in
which children sometimes fall out of bed in their sleep without awak-
ening. In the cases which I have seen, especially in adult patients, I
have not been able to discover such unnaturally profound sleep. For-
tunately, it is rare for enuresis nocturna (which usually affects chil-
dren, and often lasts up to the time of puberty) to continue after the
twentieth year. Knowledge of this fact is of importance, the best
means of comforting the patient and his relatives in their distress be-
ing the communication of this intelligence.

It is customary to deprive children, suffering from this affection, of
all drink or liquid food during the evening hours, and to waken them
during the night once or twice to make them pass water. There is no
objection to be made to these measures, excepting that they scarcely
ever do the least good. I must protest most earnestly, however,
against the cruelty of whipping or otherwise punishing a patient with
nocturnal incontinence, unless the wettings of the bed manifestly be
the result of laziness. In families, but still more in boarding-schools,
orphan asylums, poor-houses, and prisons, punishment for this offence
is inflicted all the year long, generally without effect ; and if we only
take the trouble to listen to the shocking stories of " piss-a-beds " of
the lower classes, it will be clear to any one that the ineffidacy of the
punishment was not due to its want of severity. Without attempting
any explanation of the fact, I will merely call to mind that the dread
of going to sleep often has a soporific effect, the desire to do so the op-
posite, and that, if one wishes to awake at a certain hour, the fear of
oversleeping is injurious, while the confidence that one will awaken in
time is beneficial. In the same way, we find that children with noc-
turnal incontinence, who have been severely chastised the day before,

82 DISEASES OF THE BLADDER.

and who go to sleep in dread of further punishment, still awake in the
morning with their bed wet through. On the other hand, if we can
excite confidence in the use of some entirely inert medicine, for which,
however we promise great things, so that the patient can go to bed
hopefully, and without fear, he is often awakened in the night by the
inclination to micturate, and remains for some time, or even perma-
nently, cured of his affection. From time to tune secret remedies for
nocturnal incontinence, with testimonials as to then: efficacy, are adver-
tised in the newspapers. That such testimonials are not all inten
tionally false, is certain; but it is equally certain that the success
of the remedies is due more to the psychical impression made by the
confident commendation of the article, than upon the medicinal effect
of the article itself. We must never tire of again and again exciting
the hopes of the patient, and of writing harmless prescriptions for him,
of the value of which he must be assured. Even in little children,
and still more frequently in grown persons, I have seen at first a tem-
porary and afterward a permanent effect produced in this way, which
amazed both the patient and his friends. I have usually ordered small
doses of carbonate of potash, and recently, according to a suggestion
of Trousseau's, one-fifth to one-third of a grain of pulv. herb, bella-
donna, with equal parts of the extract. Other remedies, such as
strychnine, cantharides, large doses of syrup, ferri iodidi, and injec-
tions of irritating matter into the bladder, are objectionable. It is of
importance, however, to pay attention to any indications which may
arise from the special condition of the patient.1

CHAPTER IX.

IirPERCINESIS OF THE BLADDER — SPASM OF THE BLADDER — CYSTO-

SPASMUS.

VIOLENT contraction of the muscles of the bladder frequently arises
in consequence of the irritation which foreign bodies, especially stones,
create within it. Such spasm is usually accompanied by organic dis-
ease of the viscus. However, since abnormal irritability of the motor
nerves of an organ arising as a reflex symptom, in consequence of ex-
citement of the sensory nerves of that organ from structural disease,
is not usually counted among the neuroses, the term spasm of the
bladder is not to be applied to such symptomatic contractions of the
vesical muscles, but should be reserved to designate the abnormal con-
dition of the motor nerves, which exists independently of any struc-
tural alteration hi the wall of the bladder.

SPASM OF THE BLADDER. 83

Momberg divides the causes of spasm of the bladder into cerebral}
spinal, and reflex. With regard to the first, I would call to mind the
fact that the irritability of the sympathetic nerve, though independent
of the influence of the will, is by no means entirely independent of
the irritability of the fibres and ganglia of the brain. Mental emotions
have a distinct action upon the sympathetic system; and just as the
muscles of the skin contract under the influence of terror, producing a
" goose-skin," so we often, under like circumstances, see violent con-
traction of the detrusor urinse muscles, with intense inclination to pass
water. So, too, in inflammation of the spinal marrow and in struc-
tural disease of the brain, spasm of the detrusors occurs, according to
Romberg — a fact which is not easy to explain, as the innervation of
the detrusor is derived from the sympathetic ; although, indeed, we see
an analogous condition in the occurrence of vesical spasm from mental
emotion. Yesical spasm is generally of reflex origin. In an irritable
subject the impression upon the sensory nerves of the urethra, pro-
duced by the*, introduction of a catheter, will provoke spasm of the
sphincter vesica. In other cases, irritation of the rectum and, very fre-
quently, irritation from the womb give rise to spasmodic contraction
of the bladder. Finally, there are cases of vesical spasm which are
merely local manifestations of a general neurosis, and must be ascribed
to a morbidly exalted irritability of the entire nervous system, which
we usually call hysteria.

The symptoms of spasm of the bladder vary according as the af-
fection involves the detrusor urinse or sphincter vesicse muscles. In the
former case, a very slight degree of fulness excites intense desire to
urinate. The patient can scarcely prevent a constant escape of water
by closure of the sphincter ; or else he is quite unable to do so, so that
the urine is constantly flowing away — a condition generally termed
enuresis spastica. On the other hand, when the sphincter muscle is in
a state of spastic contraction, the patient can only pass water drop by
drop, or in a very fine stream, and with great effort (dysuria spastica).
Sometimes the closure of the sphincter is absolute, and there is com-
plete retention of urine (ischuria spastica). Finally, the antagonistic
muscles, both detrusor and sphincter, may be attacked simultaneously.
A condition of great distress then ensues, in which, in spite of violent
desire to void the urine, there is inability, more or less complete, to
satisfy such desire. In these cases the spasmodic affection sometimes
extends to neighboring organs, giving rise to spasm of the rectum, to
tremors of the entire body, and occasionally to general convulsions.
One characteristic of spasm of the bladder is the alternation of violent
paroxysms and intervals of exemption. The former often last but a
minute or two, although sometimes they last half an hour or more.

34 DISEASES OF THE BLADDER.

They recur at longer or shorter intervals, and usually cease as suddenly
as they have begun.

Diagnosis of spasm of the bladder in its stricter sense demands
caution, as its occurrence is somewhat rare, and as it is often extremely
difficult to distinguish it from other maladies of that viscus. It is only
when the latter can be excluded from diagnosis, after careful examina-
tion of the urine, and scrupulous attention to the attendant symptoms
of the case, and after we have assured ourselves by repeated sound-
ing that there is no foreign body lodged in the bladder, that we are
warranted in supposing tne existence of a pure vesical hypercinesis.

Treatment of spasm of the bladder, first of all, demands removal
of the exciting cause. In some instances, the cure of a fissure of the
anus, or of a chronic hyperaemia or inflammation of the womb, consti-
tutes the chief, or, indeed, only remedy, for vesical spasm. In other
cases, it will subside if we can succeed in altering the nutritive con-
dition of the patient, by a thorough modification of external relations,
and thus quiet the morbid irritability of the nervous system. For the
paroxysms themselves we should have recourse to warm baths, clys-
ters of camomile or valerian tea, with the addition of a narcotic ; and,
above all, to the internal exhibition of opium. In addition to this,
Pitha warmly recommends the cautious and gentle introduction of 9
wax bougie into the bladder.

OHAPTEK X.

ACINESIS OF THE BLADDER — VESICAL PALSY — CYSTOPLEGIA.

PALSY of the bladder may involve the sphincter muscle, the detru-
sor urinae, or both of these muscles simultaneously. Contraction of the
detrusor is not dependent upon volition, but arises reflexly from the
stimulus of the urine collected in the bladder. Contraction of the
sphincter, on the other hand, is subject to the will. Up to a certain
point of distention, the tone of the sphincter suffices to counteract the
action of the detrusor, which presses upon the contents of the bladder
and strives to open its outlet. If this point be exceeded, the tone is
overcome, and the sphincter requires the action of volition to keep it
closed. From these physiological facts, the causes of vesical palsy be-
come somewhat more comprehensible. In the first place, it is quite
plain, both in structural disease of the brain and in grave febrile consti-
tutional disease, in which the function of the brain is overthrown, why
palsy of the sphincter should be a very common symptom, and why
palsy of the detrusor should be somewhat more rare. In apoplexy
and in typhus, the number of patients who wet their bed is greater

PALSY OF THE BLADDER. 85

than that in which the use of the catheter is required. If, however,
the paralysis finally extend from the cerebro-spinal system to the sym-
pathetic; if the power of involuntary movement be also impaired;
if the patient can no longer swallow ; if the abdomen become tympa-
nitic from palsy of the intestinal muscles ; the detrusor urinae also takes
part in the paralysis, and the distended bladder rises above the sym-
physis. There is another very common circumstance, however, which
also contributes to the occurrence of incontinence of urine in cases of
disease of this kind, namely (as happens in a variety of conditions of
other peripheral organs), the overfilling and overflowing of the bladder
(KoJilrauscK) make no impression on the consciousness, and hence no
impulse is derived from the will to contract the sphincter and to close
the bladder. At the same time, however, it must be admitted that, in
some cases of apoplexy and of severe typhus, palsy of the detrusor sets
in early, and before there is any general palsy, and without our being
able to account for this phenomenon. In disease of the spinal marrow,
likewise, palsy of the sphincter *is of far more common occurrence than
palsy of the detrusor. Most paraplegic patients have to wear a urinal,
in order not to wet themselves, because the conducting power of then*
spinal marrow is iftterrupted. The use of the catheter, on the other
hand, is but seldom necessary, on account of palsy of the detrusor.
However, the fact that such necessity does sometimes occur, perhaps is
owing to the locality of the lesion. It seems to be the ganglia which
transmit the impression from the sensory nerves of the bladder to the
motor nerves. It is possible that, if that portion of the spinal cord be
destroyed at which this transmission takes place, the detrusor will be
palsied ; on the other hand, that, if the lesion of the spinal marrow be
above this point, transmission of impressions from the brain to the
sphincter will be interrupted, while that from the sensory nerves of
the bladder to the motor fibres of the detrusor continues unimpaired.
The result of comparison of a large number of cases of this kind, which
I have examined within the last few years, fully supports this hy-
pothesis.

Besides this form of vesical palsy, the cause of which is central,
there are others in which the peripheral expansions of the nerves
have suffered lesions, through which they are deprived of then: function ;
although, indeed, it is generally out of our power to furnish anatomical
proof of such structural disorder.

Finally, there is a myopathic palsy of the bladder arising from dis-
ease in the minute texture of the muscular fibres of the organ, and in
the nerve-tips which terminate in them. The most common cause for
this form of vesical palsy is the severe stretching of the vesical mus-
cles, and their participation in the affections of the mucous membrane.

8(5 DISEASES OF THE BLADDER.

A distention of the bladder, which perhaps has occurred but unce, and
to which a mechanical obstacle to the discharge of the urine, or<a false
shame in some over-modest person, has given rise, may result in penna
nent vesical paralysis. It may also proceed from a vesical catarrh,
especially in aged persons, from implication of the vesical muscles in
the disease.

The symptom* of vesical palsy vary according to the muscles
affected. When the palsy is complete and is confined to the sphinc-
ter, the urine flows away involuntarily as soon as the bladder has be-
come full enough to overcome the tone of the sphincter. When the
paralysis is incomplete, the patient is able to resist the pressure of a
somewhat fuller bladder, but he must hasten to find some befitting
place to pass water, as his sphincter will fail of its office if he wait too
long and the pressure increase. This incomplete palsy of the sphincter
is of very common occurrence in conjunction with partial paralysis of
the lower extremities, and is attributable to an incomplete interruption
of conducting power of the spinal marrow.

In palsy of the detrusor, the tone of the sphincter is not overcome
by such a degree of tension of the bladder as, under normal conditions,
would excite contraction of the detrusors sufficient to overcome it.
Unless artificially emptied, the bladder is distended excessively, and it
is only after the distention has reached an extreme point, or by the
action of the abdominal muscles (where they are not paralyzed also),
that a portion of the contents of the bladder is expelled. If the
palsy be pure and uncomplicated, the patient can arrest or postpone the
outflow of urine. When incomplete, the bladder does not become so
full before evacuating a portion of its contents as it does in complete
palsy. The patient, however, endeavors to assist the action of the
detrusor, by bringing his abdominal muscles into play, so that he
often 'jreaks wind while passing water. In spite of all his efforts,
he cannot eject a strong arched stream, but the urine dribbles verti-
cally down between his feet. This form of incomplete palsy of the
detrusor is chiefly seen in marasmic subjects, and individuals weakened
by sexual excess.

Finally, in patients in whom both sphincter and detrusor are pal-
sied, the bladder is in a state of permanent over-distention, the tone
of the sphincter yielding later than it normally should do. Every ad-
dition made to the contents of the bladder induces a corresponding out-
flow from it, and the patient is unable to hinder or to arrest this flow.
The patient usually, indeed, is quite unaware that his bladder is full,
and only seeks medical aid on account of the continual enuresis, and
generally is greatly surprised when we evacuate the urine from the
bladder, which often contains an enormous quantity of it.

PALSY OF THE BLADDER. . 87

In treatment of palsy of the bladder, the causal indication can rarely
be met. Especially is this the case in the forms of it arising from dis-
ease of the brain or spinal marrow. When it is due to immoderate
distention of the organ, it is of importance to use the catheter assidu-
ously, partly in order to prevent further distention, which might aggra-
vate the palsy, partly to excite more vigorous contraction of the de-
trusor, by the irritation which the catheter induces. In cases of in-
complete palsy, instead of passing a catheter, Pitha recommends the
introduction of a solid wax bougie as far as the neck of the bladder,
claiming that " the catheter " relieves the muscles of all exercise, and
thus encourages " their indolence." The indications from the disease
call for the use of cold baths, douches, and clysters. If these fail, and
if the source of the palsy be peripheral, we should proceed with due
precaution to the injection of water into the bladder, which at first
should be lukewarm, and afterward should gradually be reduced in
temperature. If this be of no avail, the application of electricity, as
recommended 'by Duchenne, will also prove ineffectual. We shall
hardly find a well-authenticated case of cure of vesical palsy by the
.use of strychnine, which has also been recommended.

ADDITION TO THE REVISED EDITION OF 1880.

SECTION III. — DISEASES OF THE BLADDER.

1.— P. 82.

I have now and then earned the thanks of an adult by recom-
mending to him a contrivance which has been advertised in the
newspapers. A bit of leather or caoutchouc, of the size of a bean,
is to be pierced through its middle by a fine opening, through
which the loop of an elastic band is to be drawn, so as to slide
stiffly. Upon going to bed, the prepuce, having been stretched
over the glans, is to be inserted into this loop, which must then be
tightened just enough to close its orifice, but not closely enough to
cause discomfort, and so that upon urinating the prepuce will be
put on the stretch by the water which is held back. The patient
will be awakened by the distention of the prepuce if he passes water
during sleep, and may then take off his apparatus, confident that
for that night his bed will not be soiled. One young man tells me
that only since obtaining this contrivance has he ever dared to sleep
away from home.
56

SECTION IV.

DISEASES OF THE URETHRA.

ACCORDING to the plan of our book, we omit without notice all
affections of the urethra pertaining to the department of surgery, and
which are treated of in detail in surgical works, and shall merely de-
scribe the inflammation of the urethra.

CHAPTER 1.

VIRULENT CATARRH OF THE MALE URETHRA — CLAP — GONORRHO3A.

ETIOLOGY. — The urethral mucous membrane does not undergo any
specific change in gonorrhoea. The process which takes place in it is
identical with that which arises in any other mucous membrane, under
the action of other irritants, and bears the name of catarrh or blen-
norrhcea. Nevertheless, gonorrhoea is a specific disease. Its course
distinguishes it plainly from all other catarrhs which affect the urethral
mucous membrane, or that of other regions. The difference is all the
more especial in an etiological point of view, for a gonorrhoea never
arises otherwise than by contagion, in spite of the persistent denial of
some authorities, and the lying assertions of shame-faced patients.

Of the nature of the virus of gonorrhoea we know as little as we
do of that of small-pox or other infectious matter ; but we do know
that the matter exerts a specific influence upon the system — that it
always produces a clap, never a chancre or syphilitic ulcer. True,
opinions are still divided as to whether this disease is followed by
becondary disorders, and by a general implication of the system ; but
even authors who still believe in metastatic gonorrhoea and gonorrhoeal
constitutional infection now agree that the consecutive diseases are
altogether different from the sequelae of syphilis, with which they have
nothing in common. The gonorrhoeal virus is a contagium Jixum, its
vehicle is the secretion of the diseased mucous membrane, and it is

GONORRHCEA. 89

only by contact of this secretion with a mucous membrane susceptible
of infection that the complaint can be transmitted from one person to
another, or from the mucous membranes of one organ to that of another
in the same individual. As in other infectious disorders, between the
time of infection and. that of the outbreak of the disease there is a
certain interval, known as the period of incubation. The length of
this period is from three to eight days. The appearance of a gonor-
rhoea as early as twenty-four hours after an impure coitus, or as late
as three or four weeks afterward (Simon), if it occur at all, is to be
regarded as a rare exception. Credulous persons will hit upon cases
where the period of incubation has lasted longer still. Every physician
who has had much to do with venereal patients, especially with patients
from the better classes of society, will have found out that it is much
easier for a .patient to 'confess to excesses perpetrated six or eight
weeks ago than to those of which he has been guilty but recently.
The more reason he has to be ashamed of himself, so much the more
is he 'disposed- to antedate his delinquency. Least of all are married
people to be trusted in this respect, and their assurance that " they
would just as lief confess to sins of a week's standing as those of six
weeks " is not to be relied upon.

Contact of a mucous membrane with gonorrhceal virus does not
always result" in infection. Indeed, the susceptibility to contagion
varies greatly in different individuals. Daily experience teaches us
that two men may have intercourse with a woman having virulent
fluor albus, one of whom may contract gonorrhoea, while the other may
escape. We do not know by what causes this predisposition to gon-
orrhceal infection is increased or diminished. It cannot be attributed
either to the greater or less degree of venereal excitement during
coitus, nor to incomplete introduction of the penis, nor to the degree of
" acclimatization " of the exposed individual to the person of the other.
It is idle to indulge in unsupported theories upon this question. "We
do not even know why it is that, of all the various mucous membranes
of the human body, only that of the urethra, those of the female gen-
itals, the eye, and in some degree those of the rectum, are susceptible
of gonorrhceal inflammation, while all others are quite proof against
the infection. Even different portions of one mucous membrane ex-
hibit different degrees of susceptibility to gonorrhceal poison. Al-
though the infecting secretion acts first upon the orifice of the urethra,
the gonorrhoea is most apt to develop in the fossa navicularis.

AKATOMICAL APPEAKANCES. — Opportunities of making post-mor-
'em examination of patients with gonorrhoea are rare, and it was long
ere we could obtain positive knowledge that the seat of gonorrhoea
was ttie urethra. In recent cases of the disease the mucous membrane

90 DISEASES OF THE URETHRA.

is reddened, injected, swollen, and coated with punform secretion. It
is a matter of importance for the prognosis and treatment of gonorrhoea
to know that, hi the first and second week of the complaint, the ana-
tomical changes only involve the anterior portion of the urethra —
the fossa navicularis — which is very richly endowed with glands;
and it is not until afterward that the lesions extend to the mem-
branous and prostatic portions of the urethra. In very severe cases,
the inflammation of the mucous membrane is accompanied by inflam-
mation and infiltration of the corpora cavernosa, which not only dimin-
ish the calibre of the urethra, but render a uniform enlargement
of the penis during erection impossible. Far more rarely submucous
abscesses form in severe gonorrhoea, or, what is a much more serious
accident, inflammation and suppuration of the prostate occur. The
lymphatics of the penis may also become implicated in the inflamma-
tion, and sympathetic swellings of the inguinal glands are not unfre-
quent complications of the disease, although suppuration in such cases
is quite exceptional.

The most common complications of gonorrhoea are inflammation
of the epididymis and catarrh of the bladder. These affections both
make their appearance about the end of the first or second week, that
is, at the time when the pars prostatica becomes involved in the in-
flammation, and when opportunity is afforded for the extension of the
inflammation to the vasa deferentia and neck of the bladder.

In chronic gonorrhoea the mucous membrane is swollen and stud-
ded here and there with fungous granulations. Its follicles are en-
larged and its secretion is more mucous. In many cases, circumscribed
spots, and sometimes extensive tracts of the submucous tissue, are
hypertrophied, indurated, and firmly attached to the mucous mem-
brane. It is to this that most urethral strictures are due.

SYMPTOMS AND COURSE. — The commencement of a clap is an-
nounced by an itching sensation at the mouth of the urethra, which
does not amount to pain, accompanied by a scanty secretion of a trans-
parent, clear mucus. At the same time the meatus seems slightly
reddened, and its lips are usually agglutinated by the dried secretion,
a thin scale of which is also spread over the tip of the glans. An in-
creased desire to pass water then sets hi ; the patients often have noc-
turnal pollutions, and during the day suffer from frequent erections,
which often induce thoughtless persons to indulge in further excesses.
Gradually, generally in the course of a day or two, the sense of itch-
ing in the urethra gives place to a burning pain, extending from the
meatus to the fossa navicularis. This pain increases, and, during the
act of micturition, is extremely severe. The inclination to pass water
becomes more frequent than before, so that with each effort a few

GONORRHOEA. 91

drops only are voided, and those with the utmost suffering. The se-
cretion, formerly scanty, tenacious, and transparent, gradually becomes
more copious, thicker, and purulent, making yellow, stiff stains upon
the patient's linen. The lips of the meatus are red and swollen ; the
entire penis also, especially the glans, is more or less swollen, and the
urethra throughout its entire length is sensitive to pressure. At this
period, the prepuce, irritated by the discharge, or else owing to propa-
gation of the irritation, often becomes excoriated and cedematous ; so
that the product of a balanitis is added to the secretion which flows
from the urethra. If the outlet of the prepuce be small, a phymosis is
very apt to occur, or paraphymosis, if the patients imprudently re-
tract the prepuce behind the glans. At this stage erections occur
with still greater frequence than at the outset of the disease ; but the
stretching and expansion which the organ undergoes during the pro-
cess cause the most intense pain to the patient, deprive him of his
rest at night, and induce him to resort to the wildest expedients to
arrest- his suffering. All these symptoms, the painful micturition, the
flow of thick, yellowish-green pus, the redness and swelling of the
urethra, and the painful priapism, usually continue to increase for a
period of about eight or fourteen days. After attaining their acme,
the pain upon micturition usually begins to abate, the redness and
swelling of the meatus gradually subside, the erections are less fre-
quent and less painful ; but at this time the discharge is often more
profuse than ever, so that the laity regard this as a favorable sign,
and think that the " clap must be made to run " in order to relieve
their suffering.

After a lapse of a week or two the discharge gradually diminishes,
becomes mucous, and may finally cease altogether in the course of five
or six weeks without any treatment whatever, as has been proved by
the results of homoeopathic practice. Much more frequently, however,
there remains a stationary scanty mucous discharge which may last for
months and years. During the day, if the intervals between the acts
of micturition be long, this secretion glues the lips of the urethra
together. When the patient awakens in the morning, a tolerably
large drop of it has collected, and runs out between the adherent lips
of the meatus as soon as they are separated. The stiff stains upon
the linen are now of a more grayish color, although generally there is
a small but distinct yellow spot in their middle. A discharge of this
kind is called " gleet " or " goutte militaire." If, while it lasts, the
patient exposes himself to further exciting cause, the gonorrhoea not
unfrequently breaks out again ; that is, the pain does not return
but the discharge once more becomes abundant and more purulent.
Excess in wine or sexual intercourse is the most apt to cause such

92 DISEASES OF THE URETHRA.

relapses, but exposure to cold and over-exertion seem to have- a similar
effect.

The symptoms and course of gonorrhoea present a good deal of
variation. First of all, they vary in the degree and duration of the in-
flammatory symptoms, and the pain, redness, and swelling of the ure-
thral mucous membrane. A classification of the affection into various
species, such as the erysipelatous, eynochal, erethetic, and torpid, has
been based upon this variation, without, however, any practical advan-
tages being derived from such arrangement. Generally the inflam-
matory symptoms of a first clap are far more severe than those of the
second and third, but there are exceptions to this rule. In severe
gonorrhoea, with intense hyperasmia, rupture of small blood-vessels
with haemorrhage often occurs, imparting a reddish or brownish hue to
the discharge. Although this haemorrhage is not at all dangerous, yet
the " bloody," or " black," or " Russian clap," has a terrible reputation
among the laity. The flexion which the penis undergoes during erec-
tion (known as chordee) is of greater moment. These flexions result
from a loss of elasticity on the part of the inflamed portion of the cor-
pus cavernosum, which prevents it from participating in the enlargement
of the penis. It sometimes happens that the inflamed portion of the
corpus cavernosum undergoes permanent atrophy, and that thenceforth
the penis when erect is distorted. Sometimes, too, when the atrophy
extends entirely through the corpus cavernosum at one point, ever
afterward erection is only practicable from the root of the organ up to
that point. Among the less serious accidents which may occur during
gonorrhoea, is the formation of small abscesses about the urethra.
Severe pain, increased by pressure, and a hard circumscribed swelling
about the urethra, are the characteristic signs of the formation of such
abscesses. They nearly always run a favorable course, whether they
perforate externally or into the urethra. A much more dangerous but
also a more rare complication of gonorrhoea is inflammation of the
prostate. We may infer that the prostate is the seat of hyperaemic
swelling, from the unpleasant sense of pressure in the perinaeum
of which the majority of patients with gonorrhoea complain, as well as
from the enlargement and induration of the prostate so often seen in
old persons, chiefly in those who have had gonorrhoea in their youth.
If the prostate be much inflamed, there is an extremely unpleasant
sense of pressure, or a dragging, throbbing pain in the perinaeum, extend-
ing into the bladder and rectum, which is greatly aggravated upon the
passage of the urine or the faeces. Both in the perinaeum and through
the rectum we can feel a tumor of varying size. Micturition becomes
more and more difficult, and the dysuria may increase to absolute
retention of urine. If the inflammation go on into suppural ion, an ab

GONORRHCEA. 93

§cess forms, which may point either externally or else inwardly, giving
rise to symptoms of the most serious and varied character, for further
description of which we refer to the text-books of surgery. Gonor-
rhceal lymphangitis and lymphadenitis present no extraordinary features.
Resolution is the more frequent termination of a gonorrhceal bubo.
Suppuration of such a bubo indeed is so rare an occurrence, that it
always should excite suspicion of the existence of a glandular chancre.
Finally, gonorrhoeal orchitis, the most common of all the complications
of this disease, is undoubtedly the result of propagation of the inflam-
mation from the urethra to the seminal vesicles and vas deferens.
At first the pain in the cord, testicle, and epididymis is not very
severe, the patient complaining rather of a sense of weight in the
testicle. Soon, however, the pain augments, and the epididymis, which
is the chief seat of the inflammation, becomes very sensitive to the
slightest touch. To the hard irregular tumor formed by the inflamed
epididymis there is soon added an effusion into the tunica propria tes-
tis, so that in. a few days the testis may become as large as a goose-
egg or fist, or even larger. The enlarged testicle is less movable
than before, as the thickened and indurated spermatic cord has become
less flexible than when healthy. The greater the effusion into the
tunica vaginalis becomes, so much the more does the tenderness,
upon pressure of the swollen organ, concentrate itself at the point
where the epididymis is situated. Generally the disease terminates in
resolution, but a slight induration of the epididymis almost always
remains for some time, or even during life, occasionally proving an
object of groundless hypochondriacal anxiety to the patient. Some-
times, especially in persons suffering from varicocele, the gonorrhceal
orchitis recurs several times. The discharge from the urethra almost
invariably subsides during the continuance of the inflammation, but as
invariably reappears when the orchitis abates. Far more rarely, the
affection terminates in suppuration, tuberculous degeneration, or in-
duration.

For some time the term gonorrhceal metastasis has been applied to
a variety of morbid processes affecting individuals who had had gon-
orrhoea. In the majority of cases, it cannot be proved that there is
any relation of cause and effect between these affections and the dis-
ease in question. Gonorrhoeal ophthalmia and the well-known inflam-
mation of the joints known as gonorrhceal rheumatism, or gonorrhoeal
gout, are the only ones of these maladies in any sense of the word
entitled to such name. The former proceeds from a direct transfer of
the virus to the conjunctiva, and is one of the most dreadful con-
sequences of the disease. I have seen an instance in which a married
man, having contracted a clap, abstained from all sexual intercourse

94: DISEASES OF THE URETHRA.

with his wife, but communicated a gonorrhoeal ophthalmia to her and
to his child, whereby both mother and child lost their sight, the man
escaping. That the inflammation of the joints above referred to ac-
tually stands in genetic relation to gonorrhoea may be inferred from
the fact that it occurs in individuals who have not been exposed to
any other cause of disease ; that it attacks patients who have never
suffered from such symptoms before, and who never have them after-
ward, and that it sometimes recurs with every gonorrhoea which the
patient contracts, and disappears as the gonorrhoea subsides. This
arthritis has no particular effect upon the progress of the main disease,
nor do the anatomical lesions of the affected joint, or the symptoms
and termination of the affection, present any peculiarity. The seat
of gonorrhceal arthritis is almost always in the knee, more rarely the
foot or hip-joint, never in the joints of the upper extremity.

TREATMENT. — The only reliable prophylactic measure which I can
recommend is the avoidance of all danger of infection. I do not feel
called upon to make further suggestions for the benefit of dissolute
men, who merely desire to continue their irregularities unpunished.

We shall spare ourselves any detailed enumeration of the various
methods and means employed in the treatment of gonorrhoea, and con-
fine ourselves to a description of the most important and desirable
ones.

The best therapeutic results are to be obtained in a perfectly recent
gonorrhoea before the symptoms have become severe, as it then gen-
erally can be cured in a few days. In order that the number of trac-
table cases of this kind may be increased — for it is only now and then
that we see one — we should make all our patients aware that the dis-
ease is continually increasing in extent and violence, so that each day
of delay only makes it worse. Such opinions, delivered by physicians
who have the confidence of that portion of the public among whom
gonorrhoea is most commqn, have marked effect. It is scarcely
credible how coolly and with what cynicism these people talk of their
debaucheries and their consequences, what an extensive knowledge of
the subject is shown by some of the laity, and how much one can learn
from them. For instance, in Magdeburg, where the innumerable com-
mercial travellers of the various mercantile houses meet annually at the
hotels, report is always made as to whose pox has relapsed, and who
remained cured, and what injections have answered the best for gon •
orrhcea, etc. Only a short time after I had begun to prescribe injec
tions of tannin hi recent claps, where the symptoms were still trifling
(and I had been very successful with this treatment), the number of
recent gonorrhoeas which sought my aid multiplied considerably. 1
usually ordered three powders, each of which contained half a drachm

GONORRHCEA. 95

of tannin. One of these was to be dissolved in a half pint of red wine,
and the solution was to be used as an injection. If the result was un-
satisfactory, the two other powders were to be put into the same quan-
tity of wine, and the injection to be continued with this doubly-strong
solution. It has repeatedly happened to me that a patient has pulled
one of these very powders out of his pocket which I was about to pre-
scribe for him, and which he had obtained from a friend, and has asked
whether he might try that first. In order that these injections may be
of service, we must give them once or twice ourselves, or let a skilled
assistant give them. If we neglect this precaution, it often happens
that the liquid does not enter the urethra at all, or perhaps is merely
thrown under the prepuce, and flows back past the syringe. Gon-
orrhoea syringes must be so small that they will not hold more liquid
than the urethra is capable of containing. It is then unnecessary to
compress the posterior end of the canal. The best plan is to have a sup-
ply of suitable syringes at some particular instrument-maker's, and to
give them some* unobjectionable name, since many patients, feeling too
much embarrassed to ask for a " penis-syringe," get an " ear-syringe,"
or other unsuitable article instead. I have cut short a large number
of recent virulent gonorrhoeas in two or three days by injection of
tanrin. Even where the disease is not quite recent, but where the in-
flammation is not very violent, I have often used the tannin, and ob-
tained excellent results, although the cure was less rapid. I have no
idea of claiming especial qualities and merits for tannin ; but I have
employed this article much more often than nitrate of silver, sulphate
of zinc, sugar of lead, and other astringents. I have never had occa-
sion to prescribe the strong solution of nitrate of silver (gr. x — xv. to
§ j), for its effects can hardly be better than those obtained from tan-
nin, and since even its introducers admit that it sometimes causes
severe and even. violent symptoms, such as I have never seen in my
treatment. When the inflammation is very severe, it is well to wait
for its abatement before resorting to injections. A restricted but not
over-restricted diet and a strong cathartic of calomel and jalap aro
"~ also advisable in such cases. The customary prescription of milk oi
almonds makes the patient unnecessarily conspicuous, without being
of the slightest benefit to him. When there is extreme tenderness to
pressure along the urethra, but only then, we should apply from ten to
fifteen leeches to the perinaeum. Cold applications are also service-
able ; but, to do good, they must be kept up continuously. Cold com-
presses must be changed industriously, or the patient must be allowed
to sit for a long time in a sitz-bath. Compresses which are allowed to
remain until they grow warm, and sitz-baths continued for a short
period only, merely increase the tendency to erection, and aggravate

96 DISEASES OF THE URETHRA.

the pain. After the inflammation has subsided somewhat, we should
proceed to the use of injections of tannin in these cases also. The
fact that their action is less certain in this stage of the disease is
probably because, when of long standing, the inflammation is no longer
confined to the more accessible anterior portions of the urethra, but
has spread into the posterior regions, where an injection can reach it
less easily. In tedious cases, in which injections of tannin are more
apt to fail, I have often made use of the other astringents above men-
tioned, without, however, obtaining any better success. When astrin-
gent injections remain without effect, it is time to have recourse to cu-
bebs and balsam of copaiba. There is no doubt but that these articles
are also efficacious in the earlier stages of the disease, and that many
a clap has been " aborted " by their use in free doses. If, however, we
can succeed without them, it is better to do so, rather than to subject
the stomach and intestine to the action of these noxious substances.
It not unfrequently happens that protracted gastric and intestinal
catarrhs result from the abuse of cubebs and balsam of copaiba. More-
over, the abortive action of these remedies, according to my experience,
is often merely temporary — much oftener than is that of injections —
so that patients, who have supposed themselves well of then* disease,
in a few days have as free a discharge again as they had before using
the medicine. The idea, that strictures are more liable to occur under
the use of injections than where gonorrhoea is treated by internal
medication, is based upon an error. It is true that formerly a great
many patients who were treated by injections had strictures after-
ward ; but the reason of this was, that injections were only resorted
to in very chronic cases of the disease, while cubebs and copaiba were
given in the more recent ones.

The long duration of a gonorrhoea is the most frequent cause of
strictures. The early use of injections, and consequent speedy stoppage
of the blennorrhcea, is the best preventive of their occurrence ; just as
permanent thickening of the conjunctiva is best averted by the early
and active applications of astringents. Where cubebs and copaiba are
used, it should be in full doses, which, however, must not be kept up
too long ; that is, not longer than three or four days after the discharge
has ceased. Large doses are relatively better borne than is the long-
continued administration of smaller ones, while the latter do not ac-
complish the object better, even when kept up for weeks. Cubebs
alone can be taken very well, if finely powdered and stirred up in
soda-water. Four or five heaped teaspoonfuls of the powder may be
given in the day. Balsam of copaiba is best prescribed in gelatine
capsules, four, six, or eight of which may be taken daily. Should we
wish to combine the two articles, we recommend the pills of cubebs.

GONORRHOEA. 97

§ ss., bals. copaibae 3 ij, cera alba q. s. u. f. pil. 120. About three
boxes of such pills will be required; ten of the pills to 'be taken at
first three times a day, and afterward four times a day. The gelatine
capsules, containing extract of cubebs and balsam of copaiba in com-
bination, are also to be recommended. If there should be a diarrhoea,
with severe scalding pain about the anus, or if an eruption — spots of
roseola — appear upon the face and body (which is not uncommon), the
use of the medicine must be suspended.

The results of treatment in a recent gonorrhoea are most satisfac-
tory ; that of an old inveterate gleet, however, is quite the reverse,
and the longer it has lasted so much the worse will the prognosis be.
Before all else, we must satisfy ourselves, by the introduction of a
catheter, as to the existence or non-existence of an urethral stricture.
When there is such a stricture, the inflammation often lurks just be-
hind it, and no benefit is to be expected from the use of injections
which cannot well reach the affected point, until the stricture has been
relieved by the use of bougies. Where there is no stricture, or where
the existing stricture has been dilated, we should inject a strong solu-
tion of tannin or of nitrate of silver, and, when this fails, should intro-
duce a sound, smeared with an ointment of lunar caustic, into the ure-
thra. Guthrie's unguent, opthalmicum magicum may also be employed
(arg. nit. gr. ij — g. x, ung. cetacei 3 j, liq. plumb, gtt. xv.)

The haemorrhage which sometimes occurs during gonorrhoea scarcely
ever requires particular attention. If it be exceptionally profuse, we
may apply cold, or endeavor to stanch the bleeding by compression
of the point whence it proceeds. In order to prevent the painful erec-
tions which occur chiefly during the night, the patient should eat but
very little food toward evening, and, above all, should avoid drinking.
If, nevertheless, his rest be disturbed, and if the customary popular
remedies fail of effect (such as walking barefoot about the room or
jumping from a chair), we may give a Dover's powder in the evening.
I have no personal experience of the effect of lupuline, which has also
been recommended. If chordee develop, apply leeches (but rather to
the perinaeum than to the penis), and give an opiate at night. Ab
scesses forming in the urethra require poultices, and the prompt punc-
ture of any fluctuating point. Upon the first signs of inflammation of
the prostate, apply a large number of leeches to the perinaeum, and,
after the leeches have fallen off, encourage the bites to bleed, by the
application of hot stupes. Sometimes the leeching has to be repeated.
Internally give calomel with opium, in divided doses. Whether this
last prescription really be of service I do not venture to say. The
catheter is never to be applied without the utmost caution, and in
some cases it must be laid aside altogether for a while. If the

98 DISEASES OF THE URETHRA.

retention of urine be absolute, puncture of the bladder may be neces-
sary. Fluctuating abscesses of the perinaeum are to be opened
promptly. For further information regarding inflammation of the
prostate, we refer to the books of surgery.

The lymphangitis and lymphadenitis usually subside quickly under
simple rest in bed. If, after the gonorrhoea has entirely abated, there
still remain a swelling in the inguinal region, we should resort to com-
pression, a practice which has often and very improperly been applied
to syphilitic buboes. If the patient be walking about, let him wear a
hernia truss with a large pad. If he be confined to his bed, a heavy
bag of shot, which, not being quite full, yields and makes a uniform
pressure over the tumor, is the best means of compression. In order
to avert gonorrhceal orchitis, it is desirable to cause all patients with
gonorrhoea to wear a suspensory bandage, to which suitable appliances
may be attached to save their linen from becoming soiled. This latter
precaution is necessary, as the envelopment of the penis in rags, made
fast with bandages, does harm. We should select and apply the sus-
pensory ourselves, so as to make sure that it does not " bind " any-
where. Badly-fitting ones, of course, do more harm than good. Upon
the first sign of orchitis the patient must betake himself to bed, and
there remain, with a wedge-shaped cushion between his thighs, upon
which the scrotum is to be so arranged that there shall not be the
slightest strain upon the spermatic cord. Besides this, a large number
of leeches should be applied to the cord, the after-bleeding from
which should be encouraged. The pain almost always subsides after
the depletion. When this has been accomplished, hot poultices must
be applied night and day to the scrotum, and, should there be any
fresh attack of pain, the leeching must be repeated. Much benefit
has also been ascribed to the internal exhibition of calomel combined
• with opium in this affection. Compression of the testicle, by means of
which abatement of the pain and rapid subsidence of the tumor are
sometimes effected, is a procedure which often fails, and which, accord-
ing to my experience, generally can be dispensed with.

CHAPTER II.

NON-VIRTJLENT CATAERH OP THE URETHRA.

SIMPLE non-virulent catarrh of the urethra is a somewhat rare af-
fection. Local irritation of the urethra by foreign bodies, irritating
injections, sexual excess, especially coitus practised during the men-
strual period, are its most usual causes. A symptomatic catarrh also
accompanies urethral ulcers, particularly urethral chancres. In other

NON-VIRULENT CATARRH OF THE URETHRA. 99

instances, the inflammation of other organs, as the prostate or bladder,
spreads to the urethra.

The symptoms of non-virulent urethral catarrh are swelling and
redness at the meatus, painful burning along the urethra, especially
during micturition, and the discharge of a scanty mucous secretion.
All this usually subsides in a day or two without medical aid. The
more intense and protracted catarrh which accompanies a urethral
chancre however, is attended by purulent discharge, and may easily
be mistaken for a gonorrhoea. We shall have more to say as to the
distinction between the two conditions, in treating of urethral chancre.

Avoidance of the causes from which the affection proceeds, and
removal of the conditions by which it is kept up, are the sole treatment
requisite for this unimportant and mild disease.

Occasionally a simple catarrh of the urethra only shows itself by
adhesion of the lips of the urethra in the morning. Then the patient,
annoyed at the idea of having a gleet, presses and squeezes the penis
till he .brings out a little mucous discharge. This may be relieved by
warning him against thus irritating his urethra.

DISEASES OF THE SEXUAL ORGANS.

A— DISEASES OF THE MALE SEXUAL OKGAKS.

IN this section we shall speak only of spermatorrhoea and impo-
tence, leaving the other diseases of the male sexual organs to surgery.

CHAPTER I.

NOCTURNAL AND DIURNAL POLLUTIONS — SPERMATORRHCEA.

FROM the occurrence of puberty till the virile power has been lost,
most men have occasional nocturnal emissions, without our being able
to say that they are a sign of disease. If the emissions are repeated
at unusually short intervals, if they come without lascivious dreams, if
tney are accompanied by incomplete erections, or if they occur during
the waking state (diurnal pollutions), the condition is a pathological
one.

The persons who consult physicians on account of pollutions are
chiefly young men from seventeen to twenty-five years of age. They
complain of having emissions of semen one or more nights each week,
which weaken them greatly, and that they feel particularly dull and list-
less the day after an emission. We should not have too much confidence
in these patients, or rather we should mistrust that they are concealing
some important fact. The first glance at these confused and embar-
rassed young men usually shows that they have a bad conscience ; in
many cases we may tell what the trouble is from the mysterious letters
in which they request a consultation. It is not generally difficult to
obtain from these patients a confession that they have previously mas-
turbated, and some even appear to be relieved by making the acknowl-
edgment. We must not be satisfied with this confession, however,
but should carefully seek to find out if they do not still continue the
practice. This confession is generally far more difficult for them ; but
I shall not exaggerate in saying that full two-thirds of the patients

SPERMATORRHCEA. 101

who have consulted me for their pollutions have at last acknowledged
that they still masturbated. These persons seek aid because they
have been frightened by reading the miserable books which give such
overdrawn pictures of the results of onanism. They hope that it will
only be necessary to tell of the frequent occurrence of the emissions,
and that they may be silent concerning the cause.

The case is somewhat different with a second class of persons who
seek medical aid for their pollutions. These also have masturbated
during youth, but have subsequently ceased to do so ; they also, how-
ever, have come across some bad book describing the terrible results
of the habit, and they have been greatly terrified, and have become
very hypochondriacal. They do not have nocturnal emissions oftener
than healthy persons, but each recurrence gives new stimulus to the
hypochondriasis ; they are considered very dangerous, and the patients
imagine they are experiencing the evil effects of which they have read.
The letters that such patients write often form a wonderful contrast
to theiF personal appearance. From the account of their case as given
in the letter, we may be prepared to meet a deplorable-looking being,
instead of whom comes in a hearty, robust man, that it is difficult to
recognize as the writer of the letter.

A third class of persons who consult the physician for their pollutions
do suffer from general debility, are badly nourished and anaemic. They
have never been given to onanism ; nor do the emissions occur fre-
quently, but the day after their occurrence the patients feel peculiarly
dull and relaxed, and are inclined to refer the cachexia from which
they are suffering to their pollutions. It is well known that, in dis-
eased, exhausted persons, the excitability of the nervous system is
more apt to be abnormally increased than it is in strong and healthy
ones, and that inclination to pollutions, as one symptom of erethism, is
more frequently seen in the former than in the latter. We often find
that persons, who have never suffered from pollutions while in health,
are afflicted with them when attacked by severe disease or during con-
valescence.

Besides the last class of persons, in whom the pollutions are not the
cause but the result of the diseased and exhausted constitution, and in
whom this exhaustion with its causes must be the objects of treat-
ment, there are patients in whom the repeated pollutions are the only
reasons we can find for a feeling of great debility and an unconquer-
able lassitude. Such patients are very peculiar : they cannot think
acutely, are sad, cannot work ; they are cowardly, easily frightened,
complain of trembling, noises in the ears, dizziness, neuralgic pain in
the back of the head, etc. Their complaints remind us most strikingly
of those of hysterical women, and it is perfectly justifiable to designate

102 DISEASES OF THE MALE SEXUAL ORGANS.

this collection of symptoms as hysteria. It is difficult to understand
why pollutions should have so injurious an effect on the organism in a
few persons, while by most they are borne without observable harm.
We cannot consider the loss of semen as the cause of the exhaustion and
nervous disturbance. The sexual excesses to which young husbands!
generally give way very rarely have any injurious effect on their
health ; even if they have daily intercourse, most of them remain just
as strong as they were previously while perfectly continent. In such
persons the loss of seminal fluid is so very much greater than in those
who suffer from occasional pollutions, that injurious results would
occur much more frequently in them if the loss of the fluid were the
cause of the injury. From the favorable results that I have had of
late years in treating this affection, and patients with spermatorrhoea
by repeated cauterizations of the caput galinaginis, I believe that the
hysterical symptoms occurring in it are exactly analogous to those
occurring in women who have erosions of the os uteri ; or in other
words, that they do not depend on loss of semen, but that morbid irri-
tability of the sexual organs may excite extensive disturbances of
innervation in men just as it does in women. When speaking of hys-
teria I shall explain more in detail that erosions of the os uteri do not
necessarily induce hysteria, but that this is only apt to occur where
there is a decided predisposition for it. The case is just the same in
men who masturbate or who have pollutions or spermatorrhoea from
irritation of the genital organs. I must, however, warn my readers
against taking it for granted that all men who have hysterical symp-
toms masturbate or suffer from pollutions or spermatorrhoea. Hys-
teria does not depend exclusively on affections of the sexual organs,
either in men or women.

By spermatorrhoea, in the strict sense, is understood a condition
where the semen is not regularly ejected during a complete or incom-
plete erection, but where it is washed out by the urine, or flows out
slowly while the bowels are being evacuated. The statements of
Lallemand and several other authors, concerning the frequency of
spermatorrhoea, are exaggerated. Increased excretion of prostatic
fluid is often mistaken for spermatorrhoea. In the white, frothy, or
transparent viscous fluid which sometimes collects in considerable
quantity at the mouth of the urethra after sexual excitement without
coitus, there are usually no spermatozoa or they are very few in
number. Frequently also the frothy fluid secreted from the urethral
mucous membrane during a gleet, or the mucous filaments in the
urine when there is catarrh of the bladder, are mistaken for semen
The microscope alone can render the diagnosis positive.

The causes of true spermatorrhoea are obscure. Relaxation 01

SPERMATORRHCEA.

103

dilatation of the excretory ducts of the vesiculae seminales arid other
morbid but not well-known changes (probably catarrh and erosions),
in the caput galinaginis, appear to be at the root of the disease.

Lallemand and others have exaggerated the injurious results as
well as the frequency of spermatorrhcea. I knew a railroad agent in
Magdeburg who, for at least ten years, lost a considerable quantity of
semen with every stool, without any observable bad effect on his gen-
eral health. He was married, and his wife had several children by
him while he was affected with the spermatorrhoea ; he also acknowl-
edged that, during his daily trips to Leipzig, he not unfrequently
committed sexual excesses. In some persons, it is true, the same
symptoms occur that we described when speaking of pollutions.

Treatment is comparatively powerless against a morbidly-increased
inclination to pollution. The best results are attained by paying par-
ticular attention to the constitution of the patient, and seeking to rec-
tify any thing that is out of order. This may be the reason why fer-
ruginous preparations and the natural chalybeate baths are so popular
for pollutions, and why some patients are improved or cured by sea-
bathing, others by the cold-water treatment. Cold sitz-baths and
washing the genitals with cold water have the reputation of strength-
ening the sexual organs and arresting pollutions ; but these should
not be used in the evening, especially just at bedtime, for, if used at
that time, they absolutely favor the occurrence of pollutions. Heavy
suppers and drinking freely of tea, etc., just before bedtime, should
be forbidden. It is improper to prescribe camphor, lupulin, and sim-
Jar medicines.

Greatly as cauterization of the caput galinaginis, by means of
Tjdllemand's porte-caustic, was esteemed for a time, it has since gone
out of fashion. When Lallemand' }s work first became known, every
practitioner considered it necessary to have one of his instruments,
but most of them have been laid on the shelf for years. However,
where the emissions of semen are abundant, and the constitution of
the patient undermined, and where, by excluding other anomalies, we
may regard relaxation or dilatation of the ducts of the vesiculae semi-
nales, or chronic inflammation in the back part of the urethra, as the
probable causes of spermatorrhoea, we may cauterize the caput galina-
ginis, lege artis. In other cases we may confine ourselves to prevent-
ing constipation, ordering the genitals to be washed in cold water, and
treating any existing complications.
57

104 DISEASES OF THE MALE SEXUAL ORGANS.

CHAPTER II.

IMPOTENCE AND IRRITABILITY, WITH WEAKNESS OF THE MALE
SEXUAL ORGANS.

DURING the period of manhood, complete and permanent inability
of performing coitus successfully is rarely seen. Even some deformi-
ties of the penis, loss of one testicle, or disease of both, often will not
cause absolute impotence. On the other hand, cases of diminished
power and of temporary impotence are very frequent, and it is of the
utmost importance for the practitioner to be thoroughly acquainted
with the various and peculiar forms under which these states may
occur. Unhappy marriages, barrenness, divorces, or perhaps an occa-
sional suicide, may be prevented by an experienced physician, who has
the entire confidence of his patient, if he can give him comfort and
consolation when consulted concerning impotence. The persons that
come to the physician for counsel are chiefly young husbands, filled
with despair at the discovery that they cannot cohabit with their wives.
Not only sensual women, but all, without exception, feel deeply hurt,
and are repelled by the husband whom they may previously have loved
dearly, when, after entering the married state, they find that he is im-
potent. The more inexperienced and innocent they were at the time
of marriage, the longer it often is before they find that something is
lacking in their husband ; but, once knowing this, they infallibly have
a feeling of contempt and aversion for him. And it is not the lost
pleasure or the fear of remaining childless that brings the young hus-
bands to the physician, but a sense of shame, and the knowledge that
they are becoming contemptible and disgusting to their wives. This
sad secret is often concealed from the nearest relatives, and confided
only to the physician, in whose art and discretion the patient has full
confidence.

The next most frequent class of persons that consult the physician
for impotence are young men engaged to be married, who, previous to
their wedding-day, have experimented whh lewd women to see whether
they were impotent, and who have not succeeded on that occasion.
Impossible and disgusting as this may sound to the student, when he
acquires a moderate practice he will often encounter persons who will
relate such things to him with perfect unconcern.

Under proper treatment the great majority of these cases terminate
well, so that, when the desperate spouses fall into the right hands, in
the course of tune they almost always become happy husbands and
fathers. The most frequent cause of temporary impotence is lack of
self-confidence, and a consequent straining of the mind for the success

IMPOTENCE. 105

of the coitus. Erections not only come without the influence of the
will, but the ardent desire for -them interferes with their occurrence.
The more unconcerned the individual, the less attention he pays to the
erections, the more certain and permanent they will be when there is
sexual excitement. The patients usually volunteer the information,
that they have powerful and continued erections at times when they
are of no use, but have none when there is an opportunity for coitus,
or that, if erections occur, they pass off even during the coitus, before
the ejaculation has taken place. Even when such patients have re-
gained their self-confidence by one successful coitus, and have then re-
tained their virile power for some time, they often have long relapses
of their impotence from a single failure of the act. There arc also
cases where the virile power of the patients returns perfectly when
they have intercourse with their wives, and they can even visit them
at very short intervals ; but it always fails if they make the attempt
with some other women with whom they have not previously had con-
nection:

The most frequent cause of this diminished power is onanism ;
sexual excess or repeated pollutions far more rarely cause it. But the
diminished power of the onanist is usually first increased to temporary
impotence by reading popular and medical treatises on the results of
masturbation. In those writings the loss of manhood is described as
the inevitable result of onanism, and the readers are thus robbed of
all self-confidence. If both the depressing effect of onanism and the
despondency from reading these papers act on the same person, the
first attempt at coitus almost always fails. But, as we have already
said, the effect of this first failure is to induce subsequent ones for a
long time. Other persons, not debilitated by onanism, and under-
taking coitus with perfect confidence, fail in the act from being intox-
icated at the time ; but even such persons may become temporarily
impotent from the disturbance of self-confidence by the failure, and
from paying too much attention to the success of the next attempt,
for fear it also will fail.

In still other cases the only causes for the failure of the first coitus
are excessive excitement and a certain embarrassment and anxiety.
Such persons have often led an unusually chaste life, and, with a rare
innocence after marriage, they have attempted coition, being perfectly
ignorant of the process. In the first weeks of their married life they
are greatly depressed and troubled by their sad experiences. If we
meet them a few years subsequently, when they have healthy, bloom-
ing children, they laugh freely over the mishaps of their honey-moon.

Besides the numerous cases of deficient power and temporary im-
potence under the above classes, we must mention the rarer cases,

106 DISEASES OF THE MALE SEXUAL ORGANS.

where the impotence depends on actual functional debility of the
sexual organs during the age of manhood. They are distinguished
from the above by the fact that, during sexual excitement, even when
there is no psychical impediment, there are no erections ; nor do these oc-
cur, as they usually do even in children, without a feeling of desire, when
the patient wakes up with a full bladder. Occasionally examination
of the genitals in such cases shows something abnormal : the testicles
are atrophied, small, and soft ; the scrotum hangs relaxed, or else the
penis is flabby and cool, or very small and hard. In other cases the
most careful examination of the genitals shows nothing abnormal.
Some years since, a farmer consulted me for his impotence. As he
was somewhat over thirty years old, and a strong, muscular man,
without excess of fat, and as I found nothing wrong about his gen-
itals, the penis being well-developed, the testicles large and hard, I
considered it certain that his impotence was of the first variety, and
consequently gave a good prognosis. But the case turned out differ-
ently from what I had expected ; and, after being married a year, the
man was divorced, the impotence having continued all this time. This
second form of impotence must also remain unexplained until OUT
knowledge of physiology and pathological anatomy advance beyond
their present state.

We shall pass over the cases where congenital malformations, cas-
tration, or other imperfections, are the cause of the impotence, as well
as those where it is only one symptom of general debility in exhaust-
ing diseases, especially in diabetes, and shall only add a few words
concerning irritability with weakness of the male sexual organs.
Some authors include the form of impotence first described under the
head of irritable weakness, and, in fact, the persons there described
are on the one hand irritable, as they are very readily excited by con-
tact with women or other causes ; and, on the other hand, they are
weak, for the erections are not strong and do not last long. But by
irritability with weakness, in the strict sense, we understand a condi-
tion where, during sexual excitement, the ejaculation occurs before
actual copulation has taken place, or even before the erection is
perfect. This weakness also occurs chiefly among persons who have
previously masturbated. As long as strong erections still take place
occasionally, the prognosis in these cases is almost always good. Even
when, from masturbation, this affection has lasted for a long time be-
fore marriage, and continues during the first weeks of wedded life, it
generally disappears if the mode of life be regulated, and the sexual
desire be moderately gratified, but not artificially excited.

In the first form of impotence the causal indications require chiefly
a psychical treatment. It is often enough to tell the patient of the

IMPOTENCE. 107

nappy results in similar cases that we have treated, and to assure him
that, according to all experience, his disease is unimportant and only
temporary. Others are cured by having coitus forbidden. The non-
chalance that they thus acquire during sexual excitement and the in-
attention to the strength and duration of the erections render co-
habitation possible, and they have the first successful coitus during
the time it was forbidden, while previously it had always failed. For
ignorant persons we may order some harmless substance, and promise
the best results from it, but, at the same time, forbid coitus for a sea-
son. In such cases the patients will often come back in a few days
and confess deploringly that they could not abide by the restriction.
We should particularly warn all persons, suffering from impotence,
against artificial excitement, especially against fingering and rub-
bing the genitals, and thus attempting to excite erections ; we
should represent to them most earnestly and continuously both the
injurious effects and the indecency of such a procedure. All the so-
called aphrodisiacs are useless and injurious. Washing the genitals
with cold water, cold hip-baths, and cold douches, occasionally appear
beneficial, and we should employ these remedies in the second form
of the affection also. In some cases of impotence, and particularly in
cases of irritability with weakness, cauterization of the prostatic por-
tion of the urethra, by means of Lallemand^s porte-caustic, has been
remarkably beneficial. Probably in these cases the disease depended
on spermatorrhoea due to relaxation and dilatation of the ducts of the
vesiculse seminales ; occasionally, also, the operation may have had a
favorable psychical influence. In the latter cases, reading LattemancFs
book would greatly aid the cure, for there the result of the cauteriza-
tion is pictured in such glowing colors that the description must re-
store courage to the most faint-hearted. Recently some electro-thera-
peutists have strongly recommended electricity for impotence; and
this treatment (besides which these men, according to their own ac-
counts, advise the impotent husbands to refrain from seeing their
wives, and to try coitus with lewd women [!]) is said to be very
beneficial. In men of full virile power I have often induced erections
by faradisation of the inner surface of the thigh, but, where there was
impotence even after using electricity for weeks, I have seen no re-
sults worth mentioning. But, as my own observations have not been
very numerous, I will not pronounce decidedly on the subject, and
shall simply give a short account of the plan of treatment advised by
Benedict and Schultz. According to Benedict we should place the
copper pole of a constant battery over the lumbar vertebrae, and pass
the zinc pole forty or fifty times in the direction of the spermatic cord,
then transversely over the different zones of the upper and lower sur-

108 DISEASES OF THE MALE SEXUAL ORGANS.

faoe of the thighs, and then lengthwise in the perineum. Such a sit-
ting should last two or three minutes. Moreover, about three times a
fortnight the copper pole should be applied, by means of a catheter-
shaped rheophore, to the vicinity of the ejaculatory duct, and passes
should be made with the zinc pole in the direction of the spermatic
cords. If there are any particularly insensible places, Benedikt uses
Faraday 's galvanic brush, and, if the testicles are peculiarly insensible,
he passes a strong current through them. The sittings should take
place every day, and be continued for some time, as improvement did
not take place for months in some cases.

Schultz, in Vienna, has for a long time used the induced current
for pollutions and impotence. Under this treatment the success was
very poor; but he claims that it is much greater since he has com-
menced using a constant current. He places the positive pole over
the fifth dorsal vertebra, the negative over the sacrum or to the peri-
naeum. Each sitting lasts from one to three minutes, and they are re-
peated three or four times a week. Schultz employs a battery with
twenty or thirty DanieTs elements of medium size.

B. -DISEASES OF THE FEMALE SEXUAL OKGANS

SECTION L
DISEASES OF THE 0 VARIES.

CHAPTER I.

INFLAMMATION OF THE OVAEY, OOPHOEITIS [OVAEITIS],

ETIOLOGY. — The Graafian follicle, the stroma of the ovary, and its
serous coating, may become the seat of inflammation. The first two
forms occasionally lead to suppuration of the parenchyma, the last
almost always leaves thickening of the serous coat and adhesions to
neighboring organs.

Parturition, with its sequelae, most frequently causes oophoritis ;
but, as we exclude the diseases caused by pregnancy, delivery, or child-
bed from discussion in this section, we shall here pass by puerperal
oophoritis. Next to childbed, the disease appears to begin most fre-
quently at times when the ovary is hypersemic, and is the seat of a
physiological injury from the rupture of a Graafian vesicle. The best-
known causes of non-puerperal oophoritis are injurious influences act-
ing on the body at the time of menstruatipn, such as catching cold,
getting the feet wet, coitus during menstruation, etc. One attack of
the disease predisposes to another.

ANATOMICAL APPEAEANCES. — Ovaritis attacks only one ovary. If
the inflammation start from the follicles, we find one, or more rarely
several, of the Graafian vesicles swollen to the size of a pea or a
cherry, filled with a variegated exudation, and their external envelopes
reddened by capillary injection. At the same tune the ovary is usu-
ally but little enlarged ; except a slight oedema, the stroma appears
normal ; the serous covering usually participates in the inflammation.
In most cases the disease runs a favorable course ; the exudation is

HO DISEASES OF THE OVAKIES.

reabsorbed and the follicle atrophies ; in other cases it degenerates to
a serous cyst, and exceptionally ends in suppuration and formation of
an abscess. If the inflammation start from the stroma of the ovary,
the process is usually limited to a decided hyperaemia, an inflammatory
oedema, and a proliferation of the connective tissue, which subsequent-
ly leads to thickening and shrinking of the ovary. Suppuration and
formation of abscesses, or diffuse destruction of the ovary, rarely occurs
in these cases. In non-puerperal ovaritis, J&wisck has only twice
seen this rare termination. Inflammation of the peritoneal covering
is sometimes primary, sometimes secondary to that of the parenchyma.
In recent cases the ovary is usually covered by a scanty fibrinous ex-
udation, which unites it loosely to the neighboring parts, particularly
to the broad bands of the uterus and the Fallopian tubes, whose peri-
toneal covering usually participates in the inflammation. Subsequent-
ly firm adhesions, by means of fibrous bands and filaments, readily
form between these parts ; not unfrequently these closely envelop the
ovary and openings of the tubes. Exceptionally, peritoneal ovaritis
causes abundant exudation, and encapsulated foci are formed in the
pelvis.

SYMPTOMS AND COURSE. — The symptoms of a partial peritonitis
in the neighborhood of one of the ovaries are the only signs usually
furnished by ovaritis. If the peritoneal covering be not inflamed,
the disease almost always remains latent. The ovary lies so deep in
the pelvis, and is so completely covered by intestines, that pressure
downward from above the symphysis pubis does not affect the ovary,
unless the abdominal walls are very much relaxed and distensible.
Hence it is important to decide, by vaginal examination, whether
the ovary be really the origin of the pain. Occasionally the diseased
ovary may be reached through the rectum. The etiology, also, may
confirm the diagnosis. If we meet the above symptoms in a patient
who has caught cold, or received injury in some other way at the
menstrual period, and the menses have suddenly ceased, the presump-
tion that the partial peritonitis starts from the ovary is more tenable
than that it depends on disease of some other organ, covered by peri-
tonaeum. TRe symptoms may be modified by an extension of the in-
flammation to neighboring organs. Uterine blennorrhcea and bloody
or bloody serous discharge from the uterus, pain in passing water 01
faeces, neuralgic pains or numbness in the corresponding extremities
may accompany ovaritis, while in other cases they do not occur.
Oophoritis is only exceptionally accompanied by fever. The course ot
the disease varies greatly. In favorable cases the symptoms pass off
in a few days, without leaving a trace. Probably the combination of
symptoms called colica scortorum (colic of prostitutes) depends on

OVARIAN CYSTS. Ill

slight ovaritis, which runs a rapid course, and terminates favorably.
At least, in women of suspicious character, I have often seen severe
pain in the lower part of the abdomen, which appeared to originate
in the ovaries, and was increased by slight pressure, rapidly dis-
appear after the application of leeches. If the disease lasts long;
if it causes adhesion of the ovary with neighboring parts, and thick-
ening of the peritoneal covering, the symptoms of ovaritis will fre-
quently recur periodically for a long time, particularly at the men-
strual periods. As the opening of a Graafian vesicle, even under nor-
mal circumstances, is accompanied by symptoms like those of inflam-
mation, it may be readily understood that, under the above-described
normal circumstances, it is often accompanied by those of actual inflam-
mation. I know a lady who was treated over ten years ago by a cele-
brated gynecologist for severe ovaritis, and who has had returns of her
disease several times a year ever since. The copious exudations in
peritoneal ovaritis, and the perforation of abscesses in the parenchym-
atous forms, may cause the above-described encapsulated effusions
in the pelvis, or even diffuse peritonitis, with rapid course and fatal
results.

TREATMENT. — In acute ovaritis we should apply ten to fifteen
leeches in the inguinal region, or, where it can be done readily, we
may apply a smaller number to the neck of the womb. Cataplasms
and warm baths aid their action. "We should also secure copious
evacuations from the bowels ; but should avoid drastics, and limit our-
selves to giving castor-oil and enemata. Calomel and mercurial oint-
ment are not needed in the treatment of ovaritis. If the disease be
protracted, the blood-letting should be repeated occasionally. The
systematic use of brine-baths and the internal administration of prepa-
rations of iodine and iodine mineral waters also appear beneficial.

CHAPTER II.

OVARIAN CYSTS.

[THEEE are various forms of ovarian cyst.

1. Hy drops follicularis. Here one or more Graafian vesicles
are transformed into cysts, which is proved by the fact that in
young cysts of this kind the ovulum is still to be found. It is sup-
posed that such cysts owe their origin to an abnormal thickness of
the walls of the ripe follicles, which, under the influence of the
menstrual afflux, swell up to the size of a pea, but do not burst, as
physiologically they should do. But the appearance of these cysts
before puberty, and even in newly-born children, proves that a mere

112 DISEASES OF THE OVAKIES.

indisposition to burst is not the sole cause of their formation, and
that a morbid state of the secretion within the follicle may be the
real cause. Sometimes these cysts are solitary ; sometimes they
exist in great numbers. They are generally small, and hence often
remain undetected until after death. Exceptionally, a cyst or a
cluster of cysts makes a tumor of the size of a fist, very rarely of
the size of the head. Such a cyst has thick walls, is smooth within^
and contains a yellow, serous liquid. In young cysts traces of fresh
or altered blood can be perceived. Communication between several
cysts due to atrophy of the intervening tissues is rarely seen.

2. The so-called cystomata, or cystoids — that is to say, prolif er- >
ating cysts — are by far the most common and important form of
ovarian tumor. By most new authors the histogenesis of a cystoma
is sought in the epithelial components of the ovary. According to
Waldeyer's graphic account, a cystoma does not originate from the
ordinary egg containing a Graafian follicle, but rather from the
more rudimentary forms of the epithelial portion of the ovary,
from the rounded balls of epithelium, and from the tubular struc-
tures, the so-called "Pflttger's tubes" which have probably origi-
nated at the embryonal period of the organ. Instead, however, of
normally developing into Graafian follicles, from the very commence-
ment they have developed into cystomata ; or else the follicle is
converted into a cystoma by repeated proliferation of the epithelium
of its inner surface. As in all mixed tumors in their later periods,
there is in a cystoma an intergrowth of epithelial, dermoid, and
vesicular structures, out of which the various types of tumor are
built. This growth by proliferation of the interior of the cyst the
author classifies in two groups, glandular and papillary. In the
glandular form sections through the cyst-wall everywhere exhibit
small, simple, tubular epithelial pits (almost always cylinder-epithe-
lium) in the substance of the wall, which present the character of a
glandular formation. The mouths of these tubes soon become
stopped up by tough secretion, and then, almost exactly as other
" retention-cysts " form, they become first distended pouches and
then small sacs. Upon the interior of the walls of these sacs new
depressions form, which in their turn deepen and form pouches and
cysts, and so on ; thus a honeycomb appearance is produced. In
the papillary cystoma the proliferation of the connective tissue of
the cyst-wall is the main feature. From their inner surface numer-
ous ramifying, shaggy, highly-vascular vegetations sprout. Some-
times these are circumscribed, growing only within a certain limit ;
sometimes they increase incredibly, filling the whole sac. There
are many intermediate forms.

OVARIAN CYSTS. 113

Many of the smaller, more recent \jystomata are of a more solid
structure, and upon section show numerous vesicles filled with gelat-
inous matter. Older tumors, which are often as large as the head,
and which sometimes widely distend the whole abdomen, and con-
tain fifty litres or more of liquid, consist mainly of a principal cyst,
in which the accessory cysts grow, and, as their walls become thin-
ner, finally burst. Thus the multilocular cysts tend to become uni-
locular.

The contents of a cystoma are not always the same, but consist
generally of a stringy, thick, dirty-brown or yellowish-green liquid,
of specific gravity 1018 to 1024. More rarely, it is a thin liquid or
a stiff jelly. According to E. ~Eichwaldy the chemical contents con-
sist of two series of organic substances : 1. Mucous matter, derived
from direct conversion of the cell-protoplasm of the epithelium.
M^cin is gradually converted into what is known as colloid matter,
and further is changed into mucopeptone (JEichwald), a substance
analogous to the albuminpeptone of albumen. 2. Albumen appears
either free or combined with soda. The latter is converted into
paralbumin (which then no longer coagulates upon heating), and
further into metalbumin, which will not precipitate with nitric acid.
Finally it becomes albuminpeptone, the last of the series. Wai-
deyer considers paralbumin and metalbumin as of value in a diag-
nostic point of view. The former is never wanting in ovarian cysts,
and never present in ascites. A more convenient test of the liquid
obtained from the abdomen by puncture is by the microscope, under
which the discovery of cylinder-cells is of the greatest importance.
Colloid globes (degenerate, swollen cells), blood, pigment, and cho-
lesterin-crystals are often found. Wandering cells are not found
unless the cyst-wall suppurates, which, however, is not very uncom-
mon. The liquid of ascites is usually of a clear, light-yellow color, of
specific gravity 1010 to 1015, and contains amoeboid corpuscles and
pavement-epithelium ; and upon standing exposed to the air, if any
blood. has become mingled with it during the puncture, it often,
after a lapse of twelve or twenty-four hours, throws down a clot .of
fibrin, which never occurs in ovarian liquid. If a viscid substance
of a somewhat dark color and a specific gravity of about 1018 or
1024 be drawn from an abdominal puncture, it is hardly necessary
to seek any further proof that ovarian cyst is its source.

Ovarian cysts are attached by a pedicle, which is sometimes long
and narrow, sometimes short and thick, and which includes the
ovarian ligament, the tube, and the broad ligament of the womb.
Sometimes the seat of the tumor is upon the side of the womb it-
self. The main cyst-wall embraces the entire tumor, and in the

DISEASES OF THE OVARIES.

larger cystomata adhesions more or less extensive to the neighbor-
ing serous surfaces are often found — a matter of great importance
in a question of ovariotomy.

Regarding the causes of ovarian cysts little that is trustworthy
is known. In exceptional instances such growths are met with even
in childhood, and it is probable that many which are not detected
until adult age have existed during youth. Of three hundred and*
forty-eight cases observed by Lee, West, Scanzoni, and Schroeder,
ninety-seven were prior to the thirtieth year, one hundred and
forty -five between the thirtieth and fortieth years, seventy between
the fortieth and fiftieth years, thirty-one between fifty and sixty,
and two between seventy and eighty. Both ovaries are very often
found diseased (fifty out of ninety-nine times, Scanzoni) ; but the
changes in the less affected ovary are usually stationary, and both
ovaries are seldom found simultaneously in such a state of cystic
degeneration as to form large tumors, and it is equally rare for the
extirpation of one ovary to be followed by the growth of a tumor
upon the other.

3. Dermoid cystomata are always congenital. From the sketch
given by His and Waldeyer of the embryonal development of the
so-called axischord, from which the rudiments of the genitals de-
velop, it will be seen that in this part, in which the different ele-
ments of the embryonal rudiments grow into one another, and in
which especial germinal Iamina3 are no longer distinguishable, ele-
ments of skin, fat, nerves, muscle, and bone might stray into the
sexual sphere. Dermoid cysts do not usually become developed
until after puberty ; they are rare during childhood. As a rule,
they are relatively small (about the size of an apple or fist), but
sometimes grow as large as the head. The structure of the interior
wall of the cyst closely resembles that of the skin. There is an
epidermic covering, beneath which is a layer of connective tissue
resembling the cutis, and in which irregularly-arranged papillae can
sometimes be found. A layer of fat (panniculus adiposus) is very
constantly found beneath the cutis. Sometimes deposits of true
bone are found in the connective tissue, which may even contain
rudimentary teeth embedded in alveolar processes. More rarely a
growth of gray nsrve-substance or of transverse striped muscular
fibres is made out. The wall of the cyst, like the skin, contains
sebaceous hair-follicles, sometimes even sweat-glands ; and the cav-
ity of the cyst is filled with the products of these organs, a mixture
of epidermic cells, sebaceous secretion, masses of fat and choles-
terin, and of hair either still growing or cast off and rolled into a
ball.]

OVARIAN CYSTS. 115

SYMPTOMS AND COURSE. — In some few cases the symptoms as-
cribed to ovaritis in the last chapter precede hydrops' ovarii. More
frequently there are no premonitory symptoms, and even the cysts
themselves excite no symptoms as long as they are small and do not
press against any neighboring organ. It depends on the position
of the cyst whether it will cause trouble on attaining some size, and
as to what the nature and amount of this trouble will be. Cysts of
even moderate size, situated behind the uterus in Douglas's cul-de-
sac, and pressing the uterus against the bladder, may cause severe
urinary difficulty ; this may be either strangury or dysuria, accord-
ing to the part of the bladder pressed upon. Defecation may also
be hindered by small tumors ; and pressure on the nerves running
along the posterior wall of the pelvis may cause pain in the small
of the back, or signs of pressure on the nerves of the extremities ;
these are sometimes pains, sometimes a feeling of numbness. Last-
ly, oedema and varices of the lower extremities sometimes result
from pressure of an ovarian cyst on the venous trunks in the pelvis.
Besides the above symptoms, there are sometimes changes in the
breasts, particularly swelling, discoloration of the areola, and even
secretion of colostrum. Occasionally, too, there is sympathetic
vomiting, and a general disturbance like that which takes place at
the commencement of pregnancy.

As the tumor grows and rises out of the pelvis, the symptoms
of pressure on the pelvic organs usually subside. Many patients
then feel quite well, and the disease can only be recognized by ex-
amination, of which we shall speak hereafter. In some cases, how-
ever, the inconveniences continue. For instance, in spite of the
enlargement of the other parts, the wedge-shaped, thin portion of
the cyst may extend far down into the pelvis, and continue to cause
the symptoms of pressure on the pelvic organs. On the other hand,
as it rises, the cyst may stretch the bladder, and thus induce more
trouble with the urine.

As the tumor continues to enlarge, the space in the abdomen is
gradually lessened ; the movements of the diaphragm are hindered,
and it is pressed upward. Then we have the symptoms of com-
pression of the abdominal viscera and of the lower lobes of the
lungs. Even a moderate fulness of the stomach, or a slight disten-
tion of the intestines by gas, becomes very annoying ; vomiting is
easily excited ; the patient becomes short of breath, and bronchial
catarrh results from the collateral fluxion to the upper lobes of the
lungs. Even the secretion of urine maybe interfered with by com-
pression of the kidneys and their vessels. Finally, the general nu-
trition, which has usually been unimpaired up to this time, suffers

116 DISEASES OF THE OVARIES.

from the various disturbances of the organs engaged in the forma-
tion of blood. Anaemia and hydraamia are developed ; the patient
loses strength and emaciates ; the menses, which have previously
been regular, cease ; even where there is no compression of the
veins, the lower extremities become cedematous as a result of the
hydrsemia ; finally, the patient dies, with the symptoms of general
marasmus.

The duration of the disease before its fatal termination varies
greatly. It often continues for years ; sqme patients, however, die
much sooner from mtercurrent diseases, and not a few as the result
of their treatment. The tumor does not usually grow steadily, but
increases at intervals. Scanzoni has observed cases where the liquid
in the cyst increased and decreased periodically. Just before men-
struation, the tumor increased in size, as a result of increased secre-
tion from the wall ; when the menses ceased, it diminished again.
Some cysts only attain a moderate size, and then remain stationary.
In one case that I saw, an ovarian cyst, which developed when the
patient was eighteen years old, and rapidly attained a considerable
size, remained for twenty years without growing any more. It has
not been clearly proved that ovarian cysts can entirely disappear
from reabsorption of their contents, but a diminution in size seems
to occur occasionally from metamorphosis of the walls, such as
ossification.

Among the complications that may arise during the disease,* we
shall first mention the peritonitis which is so frequent ; this some-
times occurs spontaneously when the cyst grows very rapidly, some-
times it is the result of operation. It is characterized by more or
less pain, which is increased by pressure, and by fever. Since it
causes adhesion of the ovary to the neighboring parts, it is very im-
portant for the prognosis of ovariotomy. Inflammations of the inner
surface of the cyst-wall are rarer and more difficult to recognize
than inflammation of the external surface. They are usually caused
by tapping, and induce a change in the quality of the contents of
the cyst. This inflammation is generally painless, and a slight fever
is usually its only symptom. Occasionally ovarian cysts burst from
excessive distention, or from the action of external forces, and their
contents enter the abdominal cavity. This accident may be favor-
able, or the reverse, according to the quality of the contents. There
have been cases where purely serous fluid was evacuated into the
abdomen, and was quickly absorbed, and the cyst did not fill again
for a long while, and in some cases it never filled. But even in such
cases the escape of the fluid into the abdomen is accompanied by
severe pain and constitutional disturbance. Where the ruptured cyst

OVARIAN CYSTS.

contained a more irritating liquid, or fat, hairs, etc., death resulted
from severe peritonitis. In the case above mentioned, rupture of
the cyst was caused by concussion of the body twenty years after
the formation of the cyst. At first only a moderate peritonitis was
induced by the escape into the abdomen of the thick, almost pulpy,
contents of the sac, which contained quantities of cholesterin. It
seeme^ as if the fall the woman had was really a piece of good
luck. The abdomen was entirely collapsed just after the rupture,
and only filled slowly ; but the fulness increased steadily, and, after
a few weeks, the abdomen was more distended than ever before.
It was evident that the inner wall of the ruptured cyst continued
to secrete liquid, which was emptied into the abdomen ; and, besides
this, there was peritoneal exudation. Tapping was repeatedly nec-
essary. At the first tapping there were drawn off twenty thousand
cubic centimetres of a mixture of the secretion of the cyst and of
peritoneal exudation, which weighed fifty-one pounds, being one-
third the* entire weight of the patient before tapping. Death from
exhaustion took place a few weeks after the fourth tapping. Au-
topsy entirely confirmed the diagnosis made during life. Lastly,
instead of rupturing suddenly, ovarian cysts may be gradually
opened by inflammation of their walls, and their contents may be
evacuated into the abdomen, unless the cyst has previously become
adherent to some neighboring organ, in which case they are emptied
into it. Such perforations most frequently occur iffto the rectum,
and atrophy of the cyst has been observed in a few cases as a con-
sequence of this.

Not unfrequently ovarian cysts may be recognized by physical ex-
amination, even before they have risen out of the pelvis. If situated
in Douglas's cul-de-sac, or between the uterus and bladder, or even
to the side of the uterus, a distinct, sharply-bounded, and more or less
movable tumor may usually be felt through the vagina ; it displaces
the uterus in various directions, according to its position. Occa-
sionally, also, we may feel the tumor through the rectum. The
more distinctly we can perceive that the tumor does not perfectly
follow the movements of the uterus, the more certain is the diag-
nosis. If the ovarian cyst rises out of the pelvis, it usually forms a
round, movable, painless tumor, with a distinct upper border, and
there is more or less evident fluctuation. If we move the tumor
with one hand, while the other is in the vagina, we find that the
uterus .only moves with the tumor when the movements are very
extensive, and vice versa.

[When the tumor is adherent to the uterus, this test, of course,
fails ; and then, unless its want of hardness gives the right clue, it

DISEASES OF THE OVARIES.

is liable to be mistaken for a fibroma of the womb. It is also diffi-
cult sometimes to distinguish between such a growth and a cyst of
the ligament, or dropsy of the tube. Parametritic and perimetritic
exudations, especially when situated in Douglas's space, can be felt
through the vagina as rounded masses ; but under conjoined manip-
ulation, it can be ascertained that they are not well-defined ball-
like tumors. Moreover, they are accompanied by the symptoms of
an inflammation of which they are the product, and after abatement
of the inflammation increase no further, but rather tend to diminish.
Faecal masses which are often to be felt through the vagina can be
indented like putty by the finger, and disappear after unloading the
bowel. As it grows, the tumor rises out of the pelvic cavity, unless
held down by adhesions in Douglas's cul-de-sac, in which case vio-
lent symptoms arise like those which are presented by the retro-
flexed gravid womb in a case of incarceratio uteri.

The tumor first appears as a round body in one or other iliac
fossa, recognizable by percussion and palpation, sharply marked
above, and painless. It may be confounded with sundry other
pelvic tumors. From a distended bladder it may be distinguished
by the introduction of a catheter. From haemometra, from inter-
stitial fibroid, and from pregnancy, it may be distinguished by care-
ful palpation per vaginam, showing that the latter tumors are all
directly in connection with the vaginal portion of the womb, besides
possessing other peculiarities.

As the tumor grows larger it rises in the belly, assuming a mid-
dle position, so that when the pedicle is long it is difficult to decide
whether the growth springs from the right or left side of the pelvis.
Since the bowels are attached to the back of the abdomen, they
necessarily yield backward as the tumor mounts in the cavity, so as
to lie behind and beside it, although sometimes a coil of bowel lies
in front of it. Upon making the patient lie upon her back, the
tumor may be grasped more or less distinctly, and fluctuation sooner
or later becomes perceptible, notwithstanding the fact that these
growths are generally multilocular, because many of the small cysts
gradually coalesce so as to form large ones. The tumor may present
a uniform surface, or its multilocular character may be disclosed by
the distinct ball-like prominences on the abdomen. Its consistence
is sometimes uniform, and sometimes elastic and fluctuating in one
portion, while at others solid masses may be felt, consisting of
papillary growth or extensive proliferation of the cellular tissue.

It is easy to distinguish an ovarian cystoma from corpulence of
the abdomen and from meteorism. In such cases the percussion -
sound is tympanitic. An ovarian sac with its walls not very tightly

OVARIAN CYSTS. 119

distended, and lying closely in contact with a large part of the ab-
dominal wall, may be so difficult to feel, and its fluctuation is some-
times so marked, that it may be mistaken for an ascites ; of course,
only with that extreme grade of ascites in which the tympanitic
sound of percussion is extinguished even in the very highest part of
the belly, and in which therefore the patient cannot by sudden
changes of attitude cause dull and tympanitic sounds to be heard
alternately upon percussion, a very characteristic mark of ascites of
moderate degree. The distinctive signs usually given — that when
the patient lies upon the back the abdomen is rounded when there
is a cyst and flattened in ascites ; and that when there is a cyst,
the percussion in the lumbar region will be tympanitic because the
bowels are displaced downward and backward, -but that in ascites
the percussion-sound is dull — deserve attention, but may cause error.
The vaginal portion of the cervix often gives no positive informa-
tion, since the tumor cannot always be touched from below through
the vagina. The womb, although at times grown fast to the tumor
and dragged up with it into the belly, and at others pushed down,
displaced, or bent, now and then presents no change of position.

The state of the lower extremities deserves great attention in
the diagnosis. If but little swollen, then the fluctuating abdominal
tumor is probably a cyst. In obscure cases exploratory puncture
and aspiration, although not quite free from risk, give valuable aid,
both by rendering an exact palpation of the tumor practicable, and
by furnishing the material for chemical and microscopic tests.

. The diagnosis of a dermoid cyst is based chiefly upon its small
size and slow growth. Not unfrequently it remains undiscovered
during the life of the patient. If, however, it continues to grow, it
may lead to perforation into the bladder, intestine, or vagina, or
else through the abdominal wall. The discharge of its peculiar
contents will then reveal its character. In one or two instances a
complete recovery has followed such an evacuation of a dermoid
cyst. Malignant degeneration sometimes occurs.]

If the tumor grows, it usually approaches the median line. Very
large ovarian cysts, which rise to the costal cartilages on both sides,
and fill both sides of the abdomen, can no longer be distinctly
bounded and distinguished as separate tumors. The abdomen, which
is enormously distended and very tense, is usually more prominent
than broad, and changes its shape very little with change of the
position of the body. At the same time both inspection and palpa-
tion show the irregular shape of the distended abdomen, which is
due to the fact that these large tumors do not consist of one tumor,
but of a union of several cysts. Wherever the tumor comes in con-
53

120 DISEASES OF THE OVARIES.

tact with the abdominal wall, percussion is absolutely dull. Since
the intestines are pushed upward and to the side by ovarian tumors,
the dulness becomes most decided at the prominent parts of ther
abdomen, where it is full in ordinary ascites ; at the most dependent
lateral portions, on the contrary, the tone is less dull and is tympa-
nitic. The uterus may be dislocated in various directions by large
ovarian cysts. Hence the result of vaginal examinations varies
greatly in different cases. The uterus may be pushed downward so
much as to constitute a prolapse ; it may be displaced forward, or
the vagina may be elongated, and the uterus elevated, so that the
os uteri cannot be reached by the finger.

TREATMENT. — The treatment of ovarian cysts belongs almost
exclusively to surgery. All absorbent remedies are useless, and, as
most of them are active, they are injurious. This is particularly
true of the preparations of iodine and mercury. Occasionally we
may retard the growth of the cyst by laxatives and derivatives ;
but, as we can only carry out this treatment for a short time, the
effect is only temporary, and it is no advantage to the patient to
have the tumor remain stationary for a few weeks, and then con-
tinue its growth. But we cannot hope by internal remedies to
cause a change in the inner wall of the cyst that shall deprive it of
its expansibility. In spite of the slight prospect of benefit from
medicinal treatment of ovarian cysts, humanity requires us to give
the patients a chance at the renowned baths and springs in Kreuz-
nach, Tolz, etc. [When the tumor threatens life, ovariotomy should
be performed. The success of certain specialists of late years is
remarkably good. Out of five hundred ovariotomies, Spencer Wells
has saved three hundred and seventy-two patients, and lost one hun-
dred and twenty-eight.]

CHAPTER III.

COMPLICATED NEOPLASIA AND SOLID TUMORS IN THE OVARY.

FROM the excessive formation of new connective-tissue cells that
accompanies the development of cysts, we have cystosarcoma. This
forms tumors which rarely attain the size of those described in the
last chapter.

Fibroid tumors, unaccompanied by the formation of cysts, rarely
develop alone in the ovary, but they have occasionally been observed
of very large size. For several years past I have been treating a
patient, aged fifty-five years, who has a very hard, nodular fibroid

SOLID TUMORS IN THE OVARY. 121

tumor, as large as a child's head, in the right ovary ; it can be
moved to the right or left, and is easily rotated on its axis.

Carcinoma of the ovary is of somewhat more frequent occur-
rence, but it also is rare. Medullary carcinoma is almost the only
form that occurs here ; scirrhous and colloid cancer of the ovary
are very rare. From complication with formation of cysts, carci-
noma of the ovary may form immense tumors. This neoplasm
almost always extends over large portions of the peritonaeum.

Occasionally we may decide with more or less certainty that
there is not a simple cyst of the ovary, from the hardness of the
tumor, and from the course of the affection differing from that usual
to ovarian cysts. In most cases the diagnosis is obscure. If ascites
accompany a nodular tumor of the ovary, and we can discover no
other cause for it, the chances are that there is cancerous degenera-
tion. In one case of excessive ascites I made the diagnosis of car-
cinoma of the peritonaeum starting from the ovary, even before
feeling the nodular tuinor of the ovary (which was rendered very
perceptible by tapping), by excluding other causes of ascites, and
from the account the patient gave of having had pain in the lower
part of the right side of the abdomen and right thigh, as well as of
varicose veins of the right leg that had preceded the abdominal dis-
tention . The treatment of these ovarian tumors is the same as that
of ovarian cysts ; but the hope of success is even less than it is in
the latter disease.

SECTION II.

DISEASES OF THE UTERUS.

CHAPTER I.

CATARRH OF THE UTERUS AND CATARRHAL ULCERS OP THE CERVIX

UTERI.

ETIOLOGY. — During menstruation the hyperaemia of the uterine
mucous membrane is so excessive that the overfilled vessels are rup-
tured. Before the hyperaemia attains this grade, and when it is di-
minishing, the mucous secretion from the uterus is increased and
changed. This catarrh, which is physiological as it were, becomes
pathological if the hyperaemia of the uterine mucous membrane and
the change of the secretion last beyond the normal duration of men-
struation, or come at a time when no ripened ovum has been detached.
Remembering this, we may readily understand why catarrh of the
uterus is among the most frequent of diseases, being at most excelled
in frequency by catarrh of the stomach, an organ subjected to the
same conditions.

The tendency to uterine catarrh varies greatly with the age. It is
rare in childhood, when periodical recurrence of physiological conges-
tion of the uterus does not yet exist ; during the age for child-bearing
it is very frequent ; in old age the predisposition is decidedly less.

Among the exciting causes are :

1. Congestion in the vessels of the uterus ; in diseases of the heart
and lungs, where the return of blood to the right heart is impeded, the
hinderance to the flow of blood from the veins of the uterus usually ap-
pears as catarrh of the mucous membrane, and is analogous to cyanosis
and dropsy of other parts of the body. Still more frequently the ob-
struction to the escape of blood is nearer the uterus. In many cases,
compression of the hypogastric veins by tumors, or, more often, by col-
lections of hardened faeces in the rectum or colon, are the causes of

UTERINE CATARRH. 123

catarrh of the uterus ; we have before said, that some patients suffer-
ing from uterine catarrh, dissatisfied with the treatment of their phy-
sicians or even of celebrated gynecologists, fall into the hands of
charlatans, or use Morrison's pills, and for a certain time are benefited
by the continued use of these laxatives that are vaunted as panaceas.

2. Many cases of uterine catarrh are caused by direct irritation of
the uterus, and, from what was said above, it is evident that any nox-
ious influence acting on the uterus, when in a state of congestion,
will prove more injurious than at other times ; hence that imprudence
during menstruation most readily induces uterine catarrh. The uterus
is directly irritated by too frequent or too energetic coitus, by mastur-
bation, or by wearing pessaries, etc. The uterine catarrh accompany"
ing other diseases of the uterus, such as parenchymatous inflammation,
neoplasia, etc., and which is usually called symptomatic catarrh, also
depends on the direct irritation.

3. Like other catarrhal affections, this also may depend on consti-
tutional disease. Acute .catarrh of the uterus occurs in typhus, cholera,
variola, and other infectious diseases ; chronic catarrh usually accompa-
nies chlorosis, scrofula, and tuberculosis. As we have often said, the
connection between the local disturbance and these general diseases is
not understood.

4. When we read of the epidemic appearance of uterine catarrh,
it simply means that, without any known cause, the disease occurs
more frequently at one time than at another.

ANATOMICAL APPEABANCES. — Acute catarrh of the uterus is rarely
seen post mortem. The changes of the mucous membrane of the uterus
in acute catarrh do not differ from those of other mucous membranes
in the same disease. There are hyperaemia, swelling, succulence, and
relaxation of the tissue ; the secretion of mucus is diminished at first,
but subsequently increased ; in the first stages this mucus is clear and
deficient in solid constituents ; subsequently it becomes yellowish, and
contains quantities of young cells.

In chronic catarrh the mucous membrane is more swollen and hy-
pertrophied ; it is brownish red or slate gray ; the secretion from the
cavity of the uterus appears more or less purulent, and is often mixed
with blood. The secretion from the cervix uteri, on the other hand, is
usually tough, coherent, and forms gelatinous plugs. Where the pro-
cess has lasted a long while, the structure of the mucous membrane is
changed. The ciliated epithelium is replaced by cells without cilia.
Part of the glands is destroyed; while others swell up like cysts. In
many cases the surface of the uterine cavity, particularly of the poste-
rior wall, is covered with granulations that bleed readily, or with poly-
poid growths. The swollen and granulated mucous membrane often

124:

DISEASES OF THE UTERUS.

projects from the gaping os uteri, particularly when a large speculum
is introduced (Hoser's ectropion of the os uteri).

The ovula Ndbothi are very frequently found. These are round
translucent nodules, from the size of a millet-seed to that of a pea, and
filled with liquid, which are seated in the cervical canal and about the
os uteri. They are the distended follicles of the portio vaginalis,
whose excretory duct is closed, but whose secretion continues.

Both forms of catarrhal ulcers that come on other mucous membranes
also occur very frequently in catarrh of the uterus, and are very readily
observed, as they occur chiefly at the os uteri. Diffuse catarrhal ulcer
or catarrhal erosion is most frequently found at the posterior lip of the
uterus ; it may thence spread to the anterior one. The loss of sub-
stance is very superficial, irregular in shape, has a dark-red base, and is
usually covered with puriform secretion. Follicular ulcers, which re-
sult from the suppuration or rupture of obstructed follicles, form small
round losses of substance, which show no inclination to spread laterally.
Granulating ulcers of the os uteri are almost as frequent accompani-
ments of uterine catarrh as are the ovules of Ndboih^ simple erosions,
or follicular ulcers, and are more important than these. They are dis-
tinguished from simple erosions, from which they appear to proceed,
by their irregular, granular, readily-bleeding surface. The softness
of the granulations prevents our mistaking them for simple erosions oc-
curring over a thi3k group of ovules of Naboth, which have a nodulated
granular appearance.

SYMPTOMS AND COURSE. — If we except the virulent form, of which
we shall hereafter speak, severe catarrh of the uterus running an acute
course is rare. The disease usually begins with symptoms of severe
congestion of the pelvic organs, with pains in the sacral and inguinal
regions, with a feeling of fulness and weight in the pelvis, often also
with dysuria and tenesmus. Pressure on the lower part of the abdo-
men gives the patient pain, although we cannot feel the uterus. When
the disease is mild, these symptoms usually appear without fever;
when it is more severe, especially in irritable subjects, they are not
unfrequently accompanied by fever. After three or four days, the
patients notice a discharge from the genitals ; this is at first transparent
and somewhat glutinous ; it leaves gray spots on the underclothes ;
subsequently it becomes cloudy, more or less purulent, and leaves yel-
low spots on the clothes. If we introduce the speculum (a measure
which causes great pain if the vagina participate in the disease), we
find the portio vaginalis swollen, dark red, and the secretion above
described is escaping from the os uteri. While the reaction of the
paginal secretion is acid, this is alkaline. In most cases the pain
and any accompanying fever disappear in from eight to fourteen da vs.

CHRONIC UTERINE CATARRH 125

The discharge also generally becomes less copious about this tune, 01
a little later ; it loses its purulent appearance, and finally disappears
entirely. • In otlier cases these symptoms of acute catarrh are followed
by those of chronic catarrh of the uterus.

The latter cases, where chronic uterine catarrh is developed from the
acute form, are far rarer than those where only the symptoms peculiar
to the former were developed at first. In these cases the commence-
ment of the disease can rarely be recognized with certainty. As long
as it is not abundant, the patients do not usually attach much importance
to the discharge, which is the most prominent, and for a long time the
only, symptom of their disease. If asked how long they have had it,
they are almost always unable to tell exactly. The daily amount of
the discharge varies : sometimes it is slight ; in other cases the patient
must change the underclothes daily, and must even lay folded napkins
under her at night. The dependence of the discharge on catarrh of
the uterus may be inferred whop glairy plugs are evacuated from time
to time, br if we find in the underclothes the gray, stiff spots that this
form of secretion leaves. It is uncertain whether a discharge that
leaves yellow spots comes from the uterus or vagina. The more readily
it chafes the inner surface of the. thighs, the more probable that part of
it at least is vaginal secretion. Later in the disease it not unfrequently
happens that the secretion from the uterine cavity is retained there by
swelling of the mucous membrane, and by tough plugs of mucus that
obstruct the canal. The retained secretion collects in large quantities,
and distends the uterus. Under these circumstances, there are occa-
sionally pains like labor-pains, very painful contractions of the uterus,
that are usually called uterine colic. The longer the catarrh lasts, and
the more change it has caused in the mucous membranej the more fre-
quently we see abnormal symptoms accompanying the physiological
congestions of the uterine mucous membrane that occur during men-
struation. Among these, the most frequent are severe molimina before
the occurrence of menstruation, and pain while it lasts, dysmenorrhoea.
In other cases there is too much blood lost, or, on the contrary, too
little or none at all. Conception is not always prevented ; the fact,
that occasionally women with very obstinate and excessive catarrh of
the uterus conceive, appears to indicate that it is not the uterine
catarrh, but the extension of the disease to the oviducts and their
closure by the secretion of the mucous membrane that lie at the root
of the sterility wnich is so common in the disease. When women with
chronic catarrh of the uterus do conceive they abort easily, and are in-
clined to placenta. praevia. Veit believes that both the deep seat of
the placenta in the uterus and the sterility common in this disease are
due to the circumstance that it is difficult for the ovum to become en>

126 DISEASES OF THE UTERUS.

bedded in the uterine mucous membrane. In the former case the ovule
does not become attached near the opening of the ovary, but at a deeper
point ; in the other case it is not even arrested at the os uteri, but falls
through and is lost. The symptoms of uterine catarrh are not much
altered by the development of the ovules of Naboih^ and catarrhal and
follicular ulcers at the os uteri. Granulating ulcers, on the contrary,
cause pain, and bleed readily during coitus, and are most apt to induce
the nervous symptoms of which we shall hereafter speak.

The influence of chronic uterine catarrh on the general health varies
greatly. Some women bear even high grades of the complaint well ;
their nutritive condition, strength, and blooming appearance is all that
could be wished for. But some soon emaciate, become dull, relaxed,
and pale or dirty-colored, with blue rings around the eyes.

From the anaemia and hydraemia, but particularly from irritation of
the nerves of the uterus having a reflex action on other nerve-trunks,
we find anomalies of innervation in many patients with chronic uterine
catarrh. Most frequently there is general hyperaesthesia ; but neuralgic
and spasmodic affections, and decided hysteria, not unfrequently accom-
pany chronic uterine catarrh. Proving the frequent association between
these so-called " hysterical " symptoms and catarrh and other diseases
of the uterus, and carefully studying them up, were certainly steps
in advance ; but recently there is great tendency to fall into the error
of referring all hysteria to uterine disease without due examination,
thus neglecting the other causes of hysteria. Since in this disease the
whole attention has been paid to the portio vaginalis, and both laity
and physicians have almost exclusively given over the treatment to
gynecologists, it cannot be denied that many cases are cured which
would formerly have remained uncured ; but many also remain uncured
now, which would formerly have received aid. Hence it is important
that every physician should have a certain acquaintance with " the
diseases of women," and particularly that he should understand the
use of the speculum. If he do not wish to enter on the local treat-
ment, he may turn the case over to a gynecologist ; but he should be
able to determine whether local treatment is advisable or not. The
fact, that the objection women have to the use of the speculum is
almost overcome, is due to the specialists. In the upper classes the
women and their husbands consider it as a matter of course that, when
there is fluor albus, the speculum must be introduced ; but among the
middle classes also, a physician who has the confidence of his patients
will find but little difficulty if he says that it is necessary to make a
careful examination with the speculum. It is only by introducing this
instrument that we can attain any certainty as to the source of the
discharge, and concerning most of the changes of the os uteri above

CATARRH OF THE UTERUS. 127

mentioned. Exploration with the finger alone can, at most, decide
that there is swelling of the portio vaginalis, which, as we shall here-
after see, accompanies most cases of uterine catarrh, and that the ovules
of Naboth are present. Catarrh of the uterus generally runs - a very
tedious course. The disease may drag on for years, and it often defies
all treatment. In the proper place we shall speak of chronic p'aren-
chymatous metritis, flexion and closure of the cervical canal, as the
frequent results of this disease, which, in other cases, is due to this
closure, and is kept up by it.

TREATMENT. — In the treatment of catarrh of the uterus it is most
important to fulfil the causal indications. Grateful as we should be
for the labors of recent gynecologists, and brilliant as the results of
their treatment of uterine catarrh appear when compared with the
results of former treatment, still some of them are not free from the
reproach of neglecting the causal indications while attending to the
indications from the disease. Where catarrh of the uterus is one of the
symptoms due to general venous congestion, dependent on disease of
the heart or lungs, very often the causal indications cannot be fulfilled,
and the remedies that have a beneficial effect on catarrh of the uterus
are not employed for the uterine disease, but for some other disturb-
ance. If the congestion of the uterine mucous membrane be due to
habitual constipation, proper treatment of this disease, as previously
advised, has the best results. We do not treat catarrh of the rectum,
which depends on congestion of the hemorrhoidal veins due to habitual
constipation, with local remedies till we have tried whether " sublata
causa cessat effectus ; " nor should we employ local treatment for
catarrh of the uterus till we are satisfied that removal of the existing
constipation is not sufficient for the cure. Then the peculiar conditions,
of which we shall hereafter speak, will preponderate. After active local
treatment, laxative mineral waters are often prescribed as after-treat-
ment ; and these do more good than the actual treatment, because they
fulfil the causal indications. A woman named G-raff^ living in Thurin-
gen, has an enormous practice among patients with leucorrhcea. They
all drink complicated infusions of manna, rhubarb, senna, and other
laxative remedies, and many bless the result of this treatment, to which
they were driven by the lack of success of all previous treatment.
Physicians, who do not pay sufficient attention to the causal indications
in treating catarrh of the uterus, deserve the blame for this. Of course,
any thing, that could have induced or can keep up irritation of the
uterus, must be carefully removed and kept away. Hence the causal
indications may require the removal of tumors of the uterus, or the cure
of other changes of structure which induce the catarrh of the uterus
Where the uterine catarrh depends on constitutional disease, it is not

128 DISEASES OF THE UTERUS.

always possible to remove the cause ; but frequently the original dis-
ease is so important, or other dangerous results of it are so prominent,
that we cannot attend to the uterine catarrh. This is particularly true
of tuberculosis.

Finally, it is not always possible to say whether anaemia and chlo-
rosis are the results or cause of this disease. If we think that the
sequence in which the symptoms occur and other causes justify us in
the latter supposition, we may often obtain the best results from the
use of iron, quinine, a moderate amount of wine, and nutritious diet.
Moreover, the good result of cold-water treatment, sea-bathing, and
different mineral waters in uterine catarrh, is due to the fact that they
have fulfilled the causal indication. Any practitioner will bear witness
that the constitution suffers in many cases without our being able to
discover the cause ; and that anomalies of the constitution, which show
themselves by a change in the secretion and function of different or-
gans, cannot always be cured by preparations of iron and nourishing
diet, even if there are evident coexistent signs of anaemia and hydrae-
inia. Under such circumstances, all we can do is, to change and im-
prove the constitution by placing the patient under the most different
circumstances, changing the entire mode of life, and particularly by
modifying as much as possible the exchange of tissue by baths and
douches, by giving quantities of water with or without the addition
of salts, and by other means. Among the anomalies of secretion that
occur in the different organs of such patients, catarrh of the uterus is
very frequent ; and it often disappears very quickly when we succeed
in improving the constitution, while it does not yield to exclusively
local treatment. I have seen the most surprising results from such
treatment in the Greifswalder clinic, where the arrangements to some
extent replaced the treatment by mineral waters and baths, and where
Professor Liebermeister, at that tune assistant physician of the medi-
cal clinic, kept account of the effect of the changed diet, increased ex-
ercise, and copious supply of salty liquids, of the baths and douches, by
weighing the body and examining the urine.

The indications from the disease may be far more readily fulfilled
in catarrh of the uterus than in catarrh of other organs that are less
accessible. The uncertainty of internal remedies for catarrh has been
repeatedly mentioned They may be dispensed with in the treatment
of uterine catarrh, and muriate of ammonia (which many physicians
consider just as efficacious foi bronchial catarrh as for gastric and hi
testinal catarrh) is not used in uterine catarrh because we have bettei
and more certain remedies for it. I should be entirely misunderstood,
if it were supposed that I considered the local treatment of uterine
catarrh as superfluous, or underrated its results ; in what was said

CATARRH OF THE UTERUS. 129

above, I only intended to show that one indication should not be
followed to the neglect of the others. In all cases where the cause
of the catarrh cannot be discovered, as is most frequently the case,
local treatment must be used ; and where it has existed for a l6ng
time, and is complicated with ulcers, particularly granulating ulcers,
local treatment should be used with that for fulfilling the causal
indications. Among the local remedies we shall first mention in-
jections into the vagina. It is not long since these constituted the
only local treatment for " leucorrhoea," no matter whether it came
from the uterus or vagina. They aid the treatment and are re-
quired for cleanliness, although they are of far less use than the
procedures to be hereafter mentioned. In acute catarrh we inject
lukewarm water ; in chronic catarrh, at first lukewarm, and after-
ward cold water, or solutions of sulphate of zinc, tannin, or alum.
[Thomas, Emmet, and other eminent gynecologists of America
prefer to employ vaginal injections of water, of as high a temper-
ature as .the patient can comfortably bear, the action of heat upon
the tissues being more enduring than that of cold.] Instead of
using an enema syringe with a uterine nozzle, it is well to employ
a clysopompe (Davison's syringe), so that we may throw in a large
amount of liquid without irritating the vagina by frequent intro-
duction of the nozzle. The application of leeches to the os uteri
in acute catarrh is indicated when it begins with great severity, and
in chronic catarrh when the substance of the uterus participates in
the inflammation, or when there is acute exacerbation of the disease
with symptoms of severe congestion in the pelvis. Scanzoni also
recommends them when there are granulating ulcers on the os
uteri. We should apply leeches to the os uteri ourselves, or have
it done by a nurse skilled in the operation. Gynecologists of the
present day are refraining more and more from the use of leeches
in the treatment of catarrh of the uterus and ulcers of the os, while
formerly they were used far too often. The local application of
nitrate of silver, in substance or in strong solution, is by far the
most effective treatment of chronic uterine catarrh, and particu-
larly for catarrhal erosions and follicular ulcers of the vaginal por-
tion of the uterus. To prevent the caustic from breaking off in the
cervical canal, we should employ sticks of double-annealed nitrate
of silver, or have, it hardened by the addition of a few grains of
nitrate of potash. When thus prepared, we may push it boldly
into the cervical canal. If cauterizations with solid nitrate of sil-
ver cause hemorrhage, which is often the case even in simple ulcer,
we should use in its place concentrated solutions (one part to two
or four of water), which should be poured in through the speculum

130 DISEASES OF THE UTERUS.

rather than used on a brush. I should employ these solutions much
oftener, if it were not so difficult to protect the fingers and clothes
from being soiled. The application should be repeated once a week
or oftener, till the discharge diminishes and the portio vaginalis
has regained its normal appearance. The result of this treatment
is so striking, that touching the os uteri and its cervical canal, in
chronic catarrh of the organ, must be classed among the most grati-
fying operations in medicine. The pain induced by the cauteriza-
tion is usually very insignificant, but in some cases it is quite se-
vere. If the nitrate of silver be passed far into the cervical canal,
some women will have painful contractions of the uterus, that may
continue for hours. Besides nitrate of silver, the remedies most
frequently used for catarrhal erosions and follicular ulcers of the
os uteri are pyroligneous acid, liquor hydrargyri nitrici, and cuprum
aluminatum (lapis divinus). Pyroligneous acid is particularly bene-
ficial where the ulcers have a great tendency to bleed ; the liquor
hydrargyri nitrici, and still more the lapis divinus, are to be tried
when the nitrate of silver has failed. In such cases the actual cau-
tery is a very effective remedy, and the opposition to its use is
ascribable to its psychical effect rather than to the pain or danger
accompanying it. Pyroligneous acid poured through the speculum
is an invaluable remedy for the granulating ulcers of the os uteri
that bleed readily. In most cases it arrests the haemorrhage more
certainly than sesquichloride of iron or alum ; the latter is applied
to the os uteri in substance more readily than in solution. We
should only use injections into the cavity of the uterus in cases of
absolute necessity, i. e., only when the above treatment fails, and
we are forced to believe that the cavity of the uterus chiefly is dis-
eased. In such cases we should use the ordinary solutions of nitrate
of silver (3 ss. to water § j). The effect of these injections is
much more severe than that of touching the os uteri with nitrate
of silver ; they not unfrequently induce severe inflammatory symp-
toms ; where the cervical canal is contracted, they should never be
employed.

[Injections into the cavity of the uterus are never to be prac-
tised except in cases of the utmost urgency, when other treatment
fails, and when the chief seat of disease is known to be within it.
For this purpose nitrate of silver (0'5 to 30'0) may be employed,
or, when there is a tendency to bleed in consequence of prolifera-
tion of the mucous membrane, the liq. ferri chloridi, tincture of
iodine, alum, tannin, or carbolic acid. It is well known that the
liquid injected may possibly pass through the tubes into the peri-
tonaeum ; but aside from this danger, the operation not only excites

PARENCHYMATOUS METRITIS. 131

severe uterine colic, but in many instances has induced a fatal
metritis or peritonitis. Hence the operation demands the utmost
precaution. A ready escape for the liquid injected must be secured
by dilating the cervix by means of sponge-tent, and the quantity of
liquid used must be very small. When the womb is tender to the
touch, and when we suspect that there is a parenchymatous metri-
tis or other complication, intrauterine injection must not be at-
tempted.]

CHAPTER II.

PARENCHYMATOUS METRITIS — ACUTE AND CHRONIC INFARCTION OF

THE UTERUS.

ETIOLOGY. — The changes of the substance of the uterus in acute
and chronic parenchymatous inflammation rarely go beyond exces-
sive hyperaemia, inflammatory oedema, and proliferation of its con-
nective-tissue elements, in which the muscular elements usually par-
ticipate but little or not at all. There is rarely suppuration or for-
mation of abscesses. We do not include the puerperal form here.

For the etiology of parenchymatous metritis we may refer to
that of the catarrhal form. The injurious influences there men-
tioned sometimes cause inflammation of the substance of the uterus ;
at others, of its mucous membrane ; but most frequently of both.
These influences also cause parenchymatous metritis more readily if
they act while the uterus is in a state of physiological congestion.
Lastly, the parenchymatous metritis of an unimpregnated uterus
must often be regarded as the continuation of a puerperal metritis ;
or at least a large number of cases date from the period of a con-
finement or of an abortion.

ANATOMICAL APPEARANCES. — In acute parenchymatous metritis,
we find the uterus increased in size, particularly in thickness. It
may attain the volume of a hen's egg or larger. The over-filling
of the blood-vessels causes its substance to appear more or less
dark, and usually irregularly reddened. These changes are most
marked in the layers lying next the mucous membrane. Occasion-
ally there are effusions of blood into the parenchyma. The mu-
cous membrane almost always shows the signs of acute catarrh.
The serous coat also often participates in the inflammation, and is
covered with deposits of fibrin.

In chronic infarction, the uterus is often enlarged to three or
four times its normal size ; its cavity increases, particularly in the
long diameter ; its walls may become an inch thick. The hyperaB-

132 DISEASES OF THE UTERUS.

mia which is at first present subsequently disappears, as the vessels
are compressed by the neoplastic shrinking connective tissue. Then
the substance appears very pale and dry, and becomes denser and
harder, often to such an extent that it creaks under the knife. In
rare cases we find hypersemic spots and veins that have become
dilated as a result of the obstructed flow of blood. If the vaginal
portion be chiefly affected, the os uteri is greatly swollen, and occa-
sionally elongated like a snout. The mucous membrane almost in-
variably shows the changes described in the previous chapter. On
the peritoneal surface we often find firm adhesions to neighboring
organs.

SYMPTOMS AND COUESE. — Acute parenchymatous metritis begins
with a chill more frequently than the catarrhal form does, and is
more apt to be accompanied by symptoms of fever in its subsequent
course. The pain in the sacral and inguinal regions, the feeling of
pressure in the pelvis, the sensitiveness of the lower part of the ab-
domen, the dysuria and tenesmus, are present in the former as well
as in the latter, and almost always attain a higher grade than they
do in the simple catarrh. The uterus can rarely be felt above the
symphysis pubis, but through the vagina we may usually detect en-
largement and tenderness of the inferior segment, and a moderate
shortening and thickening of the portio vaginalis. There are also
anomalies of menstruation. If, as is commonly the case, the dis-
ease begins during menstruation, the bleeding usually ceases sud-
denly ; if the time for menstruation occurs during the progress of
the disease, we either have metrorrhagia (metritis haemorrhagica),
or, as more frequently occurs, there is no bleeding. Except during
the period of menstruation, the discharge characteristic of uterine
catarrh (the constant companion of parenchymatous metritis) is
present. In favorable cases the disease runs its course in from
eight to fourteen days, the symptoms subside gradually, and the
disease ends in perfect recovery ; in unfavorable cases, chronic in-
farction remains. There have been some very rare instances where
an abscess formed and perforated into the abdomen, and the dis-
ease thus terminated fatally.

Except at the menstrual periods, the symptons of chronic in-
farction of the uterus are often not very prominent. Frequently
the patient complains only of a feeling of weight in the pelvis and
a sensation of "bearing down." The pressure of the enlarged
uterus on the rectum and bladder usually causes constipation, as
well as a frequent and annoying inclination to go to stool and to
urinate. At the commencement of the disease, menstruation is
often free and prolonged ; but the more the vessels of the uterus

PARENCHYMATOUS METRITIS. 133

are compressed by the neoplastic connective tissue, the more diffi-
cult menstruation becomes and the scantier the flow. Finally, the
menses are often absent for months or years, while the regularly
recurring molimina seem to indicate that the ripening and throwing
off of the egg takes place at normal periods. In this form of me-
tritis also — which, moreover, is always accompanied by the catarrhal
form — the nutritive state of the patient usually suffers after a time,
and the hyperaesthesia and other disturbances of innervation, men-
tioned in a previous chapter, usually develop. On physical exami-
nation we may often feel the enlarged uterus through the abdominal
walls above the symphysis pubis, particularly if we push it up a lit-
tle with the finger introduced into the vagina. On vaginal exam-
ination, we also discover that the vaginal portion is enlarged, indu-
rated, and more or less painful. On introducing the uterine sound
(which should not be employed unless the practitioner is skilled and
experienced in its use), the increase in the long diameter may be
ascertained. Although not dangerous, the disease is very obstinate
and tedious. Even in its advanced stages it cannot be regarded as
absolutely incurable ; the decrease after confinement of the uterus,
which had been greatly enlarged during pregnancy, renders it not
improbable that there may also be a retrocession of the pathologi-
cally increased tissues of the uterus. Occasionally improvement
and cure of infarction of the uterus have been seen directly after
pregnancy, and in such cases it seemed as if, with the involution of
the uterus after confinement, there had been at the same time a
diminution of the physiologically and pathologically increased tissue.

TEE ATMENT.— According to the variety of the exciting cause,
the causal indications are fulfilled by the different rules prescribed
in the preceding chapters. In many cases the continued use of
slight laxatives is very beneficial, particularly the laxative waters
of Marienbad, Franzenbad, Kissingen, etc.

The indications from the disease are best answered by the repeated
application of leeches (four to six) to the portio vaginalis. Although
I have seen a most favorable effect from this treatment, in my own
practice and in that of others, where the disease was recent, it has
seemed of little use in protracted cases. Theoretically, also, we may
expect better results from abstraction of blood while the connective-
tissue formation is still new, and the catamenia are plentiful and con-
tinued, than when the capillaries have been compressed, the uterus
deprived of blood, and the menses have ceased. Before convincing
ourselves by personal observation of the brilliant results of abstraction
of blood in the first stages of parenchymatous metritis, and finding
how well the patients bear the loss, it is usually difficult to make up

134: DISEASES OF THE UTERUS.

our minds to increase the copious loss of blood by applying leeches
to the vaginal portion of the uterus every week or two. A more
irritating treatment, particularly the continued use of warm douches
to the uterus, seems preferable in the later stages of the disease.
These douches should be used about ten minutes every day ; the
water employed should not be over 99° or 103° F. It is also worth
while trying the use of Kreuznach and other saline baths, as well as
the baths and waters of Krankenheil. The internal administration
of iodide of potassium and of bromide of potassium, as recommended
by Simpson, is also beneficial.

[Acute metritis demands absolute rest in bed, the pelvis being
kept somewhat elevated. When, from the tenderness of the belly,
we suspect a complication with peritonitis, leeches should be applied
to the abdomen and followed by cold compresses. When the inflam-
mation seems limited to the womb, local depletion of that organ
should be practised by leeching the vaginal portion of the cervix,
unless the virgin condition of the patient forbids it. Scarification
by means of Mayer's lance-knife has, however, in a great measure
supplanted the leech applied to the womb. It has the advantages
over leeching that the procedure is quite painless, and that the
amount of blood to be drawn can be nicely regulated by making the
incisions deeper or shallower. Moreover, many . observers believe
that the suction of a leech may set up an irritation which tends
rather to augment the fluxion toward the affected part than to check
it. According to Schroeder, scarification should be repeated about
every third or fourth day, not more than half an ounce of blood
being drawn at one operation as a rule ; but if the patient is ple-
thoric and the womb enlarged, an ounce may be taken. Syringing
the parts with cold water is a practice which should never follow
scarification ; for, although the cold produces a momentary con-
traction of the vessels, a relaxation quickly follows, which brings
with it a renewed congestion and thwarts the purpose of the op-
eration.

The demonstration by Emmet, of New York, that the majority
of so-called ulcerations of the womb are really the effect of laceration
of the cervix, is an important advance in the pathology and thera-
peutics of this subject. He holds that lacerations occur during labor
more often than has been hitherto supposed. They occur most fre-
quently in the median line, and then heal readily, and generally
escape notice. But if the rent is extensive, and runs in a lateral
direction, the weight of the womb tends to force the lips of the
wound asunder, so that union by first intention cannot take place.
When the woman assumes an erect posture, the flaps diverge still

PERIMETRITIS AND PARAMETRITIS. 135

further, and the mucous membrane of the cervical canal becomes
everted and chafes against the vaginal walls. Through the irritation
thus set up, the angle of the laceration becomes the seat of an ero-
sion, which may spread over the everted surfaces. Such an ulcer
heals with great difficulty, and only by granulation and by the for-
mation of a dense cicatrix. The womb usually suffers subinvolution
with all its consequences, and the cicatrices are a fruitful source of
neuralgia and other forms of uterine irritability. As long as the
fissure remains open, the ulceration is most refractory to all treat-
ment. It is necessary to close the laceration by a surgical opera-
tion. This in judicious hands is neither difficult of accomplish-
ment nor dangerous, and yields most satisfactory results.]

CHAPTER III.

PEEIMETEITIS AND PAEAMETEITIS.

INFLAMMATIONS of the parts about the uterus occur very fre-
quently just after confinement, and not unfrequently at other times.
In the latter case they usually depend on disturbance of the menses.
If the inflammation starts from the serous coat of the uterus and its
appendages, and the case is one of partial peritonitis, the disease is
called perimetritis / if, on the contrary, the inflammation is in the
subperitoneal connective tissue, it is called phlegmon periuterina,
or, according to Virchow, parametritis.

Perimetritis leads to more or less copious exudation on the free
surface of the peritonaeum. Scanty fibrinous exudations cause adhe-
sions with the neighboring organs. Even large fluid exudations are
usually encapsulated by adhesions at their edges. After absorption
of the exudation, adhesions to the pelvic organs often remain. In
parametritis there is infiltration of the subperitoneal tissue, which
is firm from the first. The infiltration may be reabsorbed ; but a
firm induration often remains as the result of connective-tissue pro-
liferation. In other cases the inflammation goes on to suppuration,
and abscesses form, whose contents may perforate into the rectum,
vagina, bladder, or abdomen.

It is often difficult to distinguish between perimetritis and para-
metritis during life ; they begin and run their course with more
or less severe subjective and objective symptons of fever. The
patients complain of pain deep in the pelvis, which is increased by
pressure on the lower part of the abdomen. Generally, also, there are
symptoms of compression of the pelvic organs, the bladder, rectum,
59

136 DISEASES OF THE UTERUS.

and, according to my experience, of the nerves along the walls of
the pelvis. The presence or absence, and the degree of severity and
obstinacy of dysuria and difficult defecation, as well as of the pain
extending along the sacral, sciatic, and crural nerves, depend in
each case on the seat and amount of the exudation. Where there
has been extensive exudation, on examination we may find a tumor
of variable size above the pubis. Examination through the vagina
or rectum usually shows that the uterus is displaced and firmly
wedged in. Intraperitoneal exudations usually fill Douglas's cul-
de-sac, and may be readily felt. Subperitoneal infiltrations and
abscesses are generally somewhat higher, but they also can mostly
be reached by the finger.

[Unless the two conditions should happen to coexist, the results
of physical exploration show differences in many respects which can
be made out by bimanual palpation. A peritoneal exudation sinks
into Douglas's space, as being the lowest level in the abdominal
cavity. The cul-de-sac becomes distended and pushed downward.
If the exudation has coagulated, or when a liquid exudation is incap-
sulated so that it cannot yield to the finger, we can feel a more or
less voluminous tumor, such as a retrouterine hcematocele presents,
lying behind the uterus and vagina, displacing the one upward and
forward, and bulging the other forward and downward. On the
other hand, the extraperitoneal exudation of parametritis is found
as a rule toward the side of the womb, sometimes on both sides ;
and through the vagina it feels at first like a resisting infiltration, and
afterward like a hard, sharply-defined tumor, which seems to spring
from the lateral edges of the womb, the boundary-line between the
two being sometimes difficult to determine. In exceptional cases —
as when Douglas's cul-de-sac is closed by adhesions — a perimetritic
exudation may likewise form in a more lateral region of the pelvic
peritoneum, and bulge downward ; and conversely, there have
been rare cases of parametritic exudation into the areolar tissue,
behind and even in front of the uterus and the upper vaginal region.
In such instances, when the intra- and extra-peritoneal exudations
exist together, a diagnosis becomes extremely difficult.] The disease
may continue for weeks, and greatly exhaust the patient by the
accompanying fever.

[Extraperitoneal abscesses tend by preference to find an outlet
at the surface of the body, especially in the groin, or from the iliac
fossa, or after passing under Poupart's ligament to appear upon
the front surface of the thigh, or else to perforate backward through
the ischiatic foramen and muscles of the buttock. On the other
hand, intraperitoneal abscesses open more often into the cavities of

CONTRACTIONS AND CLOSURES OF THE UTERUS. 137

the body, particularly into the intestine and vagina. As a diagnos-
tic hint, we will here mention that pain in a limb, really caused by
pressure of an exudation upon a nerve, has now and then been mis-
taken for a pure sciatica.

Schultze also describes a latent parametritis posteriori, of insidi-
ous, tedious course, usually due to mechanical causes, and said to
produce a shortening of Douglas's folds, and to be a most important
factor in the production of anteflexion and anteversion.]

The perforation of subperitoneal abscesses or of intraperitoneal
exudations into the intestines or bladder is marked by the sudden
decrease in size of the tumor, and by the evacuation of purulent
masses with the stools or urine ; perforation into the abdomen causes
severe general peritonitis, which quickly proves fatal. Even in
favorable cases the patients generally recover slowly. In many of
the patients under my observation the neuralgic pains lasted for
months.

TREATMENT. — [Treatment of an acute recent perimetritis de-
mands absolute confinement to the bed, leeching to the groins, the
application of ice-bags to the abdomen, mercurial inunction, confine-
ment of the bowels by opium — in short, the treatment of a peritoni-
tis. A recent parametritis calls equally for complete repose, but
in other respects the treatment may be less active. The bowels
should be gently moved, while cleansing and disinfecting injections
should be frequently repeated, to clear away all putrid secretions,
which are the common exciting cause of this form of inflammation.]

Local abstraction of blood and the application of cataplasms to
the lower part of the abdomen act well in the treatment of recent
cases of perimetritis and parametritis. We should continue the use
of the latter as long as there is any swelling left, even if there be
no pain. In protracted cases I have found great benefit from the
use of warm salt baths, with an addition of mother-liquid, and the
internal administration of iodide of iron. At the same time, we
must keep up the nutrition and strength by proper diet, and treat
any existing fever by antipyretics.

CHAPTER IV.

CONTRACTIONS AND CLOSURES OF THE UTERUS — H^EMOMETRA,
HYDROMETRA.

IN young persons who develop late, moderate degrees of contrac-
tion of the os uteri are quite frequent. They hinder conception,

138 DISEASES OF THE UTERUS.

without rendering it impossible. Moreover, they impede the escape
of the menstrual blood, and cause it to collect temporarily in the
uterus, and to be expelled by painful contractions (uterine colic).
I have frequently known women to menstruate without difficulty
after their first confinement, who, during their maidenhood and the
first years of married life, had severe uterine colic during menstrua-
tion. Great flexions and angular curvatures cause contraction of
the cavity of the uterus at the point of flexion, which also impedes
conception, and occasions uterine colic during menstruation. Final-
ly, neoplasia, which encroach on the calibre of the uterine cavity
and the cervical canal, have the same effect. Perfect closure, atre-
sia of the uterus, is very rare. It is sometimes congenital, some-
times the result of erosions and ulcers, which, in cicatrizing, have
caused adhesions. The seat of congenital closure of the uterus is
usually at the external orifice, that of the developed form at the
internal orifice.

As long as the women continue to menstruate, the menstrual
blood collects behind the point of closure, causing hcemometra. If
the closure does not take place till the menses have ceased, the
catarrhal secretion from the mucous membrane occasionally collects
in the closed cavity, and distends the uterus. Sometimes this secre-
tion resembles serum or synovia, doubtless because the excessive ten-
sion destroys the secreting glands in the mucous membrane, and
the latter becomes like a serous membrane. The above state is
called hydrometra.

In hcemometra, which, moreover, depends upon atresia of the
vagina oftener than upon atresia of the uterus, the uterus may
be gradually distended till it becomes as large as it does in the later
months of pregnancy, and the blood contained in it, which is usually
black and tarry, may amount to eight or ten pounds. According to
the observations of Scanzoni and Veit, when the distention takes
place rapidly, the walls of the uterus are thinned ; if it comes on
slowly, they are thickened by hypertrophy. In the early stages it
is difficult to diagnose haemometra. During childhood closure of
the uterus or vagina is hardly ever discovered. The first morbid
symptoms occur about the commencement of puberty. At intervals
of four weeks there is severe uterine colic, with a feeling of pressure
and weight in the pelvis, and signs of severe congestion of the other
pelvic organs, or of perimetritis. At first the patients feel well
again after these symptoms have continued a few days ; but after
four weeks there is a relapse. After a time the intervals are no
longer free from pain. The abdomen increases in size ; the uterus
rises above the symphysis pubis, and may rise as high as the navel.

CONTRACTIONS AND CLOSURES OF THE UTERUS. 139

In the monthly attacks the pains become very severe. The patients
emaciate, and may become marasmic ; or, if no mode of escape be
furnished for the blood, the uterus may rupture, or they may die of
peritonitis. The latter disease is particularly apt to occur if the
tubes be also filled with blood, and their contents escape into the
abdomen. Hsemometra cannot be recognized with certainty, or
distinguished from other forms of amenorrhoea or dysmenorrhcea,
particularly at its commencement, without a careful local examina-
tion. If, at the commencement of puberty, there be uterine colic
at regular intervals of four weeks, while there is no escape of blood,
and if there be, at the same time, a distention of the abdomen,
which periodically increases slightly, we should suspect the develop-
ment of a haemometra, and urge an examination. If the haemome-
tra depend on atresia of the vagina, we find the latter distended to
a tense tumor, whose lower end extends into the vestibule. If the
external os uteri be closed, the vaginal portion is often entirely
obliterated, and the position of the os uteri may not be recogniza-
ble. If, on the other hand, the internal os uteri be closed, the vagi-
nal portion may retain its normal length. Besides this, we find the
uterus distended to a considerable size ; sometimes, but not always,
there is fluctuation. The treatment of haemometra is purely sur-
gical.

It is rarely that a haemometra terminates favorably without the
intervention of skilled assistance. In such exceptional cases the
blood finds a way either through the normal passages or else into
one of the abdominal cavities. Sometimes menstruation ceases pre-
maturely, or the climacteric arrives, when the symptoms abate, and
the bloody contents of the uterus assume the character of hydro-
metra. The treatment of haemometra is purely surgical, and con-
sists in opening the sac between two menstrual periods. The mode
of operation must necessarily vary greatly according to the circum-
stances of the case. The procedure is a somewhat dangerous one,
and demands attentive study in the books of surgery and gyne-
cology.

Of course, hydrometra can only result from acquired closure of
the os uteri or vagina, and after the menses have ceased. Mild
cases of the disease #re seen quite often ; severer cases, where the
uterus is distended to the size of a head or larger, are rare. The
most important symptom of bydrometra is an enlargement of the
uterus, which usually occurs gradually, and without exciting atten-
tion, while in some few cases it is quite rapid and decided. This
may be detected on physical examination, and is often even per-
ceived by the patient. If the walls of the distended uterus be

14-Q DISEASES OF THE UTERUS.

thinned, there is occasionally distinct fluctuation ; if they be hyper-
trophied, we do not find this most important sign for distinguishing
hydrometra from almost all other uterine tumors. Occasionally
there is uterine colic, particularly during severe congestions of the
uterus. If the closure be incomplete, these contractions sometimes
force out the collected fluid, and, according to tScanzoni, occasion-
ally also gases that have formed from them. The treatment of hy-
drometra consists in surgically making a passage for the liquid, and
in attempting, by astringent injections, to limit the secretion of the
mucous membrane.

CHAPTER V.

CURVATURES OF THE UTERUS — FLEXIONS AND INFARCTIONS.

ETIOLOGY. — [Any abnormal change between the directions in the
axis of the neck of the womb and that of its body is called a flexion ;
but it must be borne in mind that when the bladder is empty the
womb is normally bent slightly forward. The bend or angle is
nearly always at the internal os. When the deformity is such that
the fundus inclines forward, and the curve or angle included be-
tween it and the cervix is anterior, we have an anteflexion ; the con-
trary constitutes a retroflexion. There may also be lateral flexions,
but they are rare.]

There are various views regarding the pathogeny of these dis-
tortions. Most authors think that the causes of the flexure lie in
the uterus itself, and support their view on the fact that, at the
point of distortion, the wall of the uterus is always flattened, and
its parenchyma loose and reflexed. Virchoio considers the changes
at the point of flexion as secondary symptoms, due to the pressure
on the walls of the uterus at this point, and to the anaemia of the
parenchyma caused by this pressure. It is his opinion that most
distortions of the uterus, particularly anteflexions, are caused by
congenital or developed shortening of the ligament of the uterus, and
by its consequent fixation on distention of the bladder and rectum.
It is most probable that the causes of the flexions are not always the
same — that they are sometimes within, sometimes outside of the
uterus. [Schultze believes that a posterior parametritis of insidious
course and somewhat frequent occurrence causes a shortening and
rigidity of the fold of Douglas, thereby producing a displacement
backward and upward and fixing of the cervix, which is the com-
monest cause of anteflexion as well as of anteversion.]

Retroflexions, the most frequent form in women who have had

CURVATURES OF THE UTERUS. 141

children, are, on the other hand, rare in those who have had none ;
they almost always date from the time of a confinement or an abor-
tion. If the involution of the uterus go on slowly after its contents
have been evacuated, if it remain enlarged and relaxed, the fundus
readily sinks down on account of its weight, or is pressed down by
the other contents of the abdomen. As the greater part of the ute-
rus remains in the posterior wall after delivery, it is natural that it
should most frequently sink backward ; but we cannot wonder if
there are deviations from this, as they may readily be induced by
different positions of the distended intestines in the vicinity, and by
other accidental causes. At this period a complete return to the
normal state is certainly possible. The bending of the uterus is
straightened out when it contracts early. But, if this do not take
place soon, the parenchyma, at the point of curvature, becomes
anaemic and atrophied from the continued pressure, or the fundus
uteri forms some abnormal attachment. In either case we have a
permanent .anomaly — a distortion in the strict sense. Scanzoni men-
tions, as the most frequent cause, the slow and incomplete involu-
tion of the uterus, and, as the most important etiological factors of
the retroversion, early marriages, frequent and quickly repeated
pregnancies, abortion, artificial delivery, etc.

Anteflexions chiefly occur in those who have had no children.
In young persons the most frequent cause seems to be a relaxation
of the substance of the uterus by chronic catarrh ; in aged persons
it is a senile atrophy of the uterus, at the point where these distor-
tions always occur, that is, near the internal os uteri. It is easy to
understand that anteflexion should be the more frequent form of
distortion in women who have had no children, if we remember that
a virgin uterus has normally a slight inclination forward. In this
case also, it seems to me, there is no doubt that the flattening of the
wall of the uterus, and the atrophy of the tissue at the point of
flexion which takes place after a time, are due to the pressure and
anosmia.

Besides these flexions, caused by anomalies of the substance of
the uterus, there are others which are undoubtedly caused by short-
ening of the uterine ligaments, as is proved by the cases observed
by Virchow, where there were flexions without any structural change
in the parenchyma. ' In the same way, distortion may result from
fibroid tumors in the anterior or posterior wall of the uterus, from
tense adhesions, or from the pressure of tumors. The more securely
the lower portion of the uterus is held in place by a rigid vagina,
the more readily flexions occur ; the less firmly it is held, the more
often displacements will occur instead.

142 DISEASES OF THE UTERUS.

ANATOMICAL APPEARANCES. — On autopsy, flexions of the uterus
may be readily recognized, as part of the anterior or posterior wall
of the body, instead of the fundus, forms the highest part of the
uterus. Generally we may readily restore the sunken fundus to its
position, but it sinks back again to its former place when we let go
of it. In some cases it cannot be restored to its normal position on
account of peritoneal adhesions with the surrounding parts. Be-
sides the flexion, there is almost always a slight anteversion or re-
tro version. If we cut the uterus out of the body, and hold it erect
by the vaginal portion, the fundus sinks down, either anteriorly or
posteriorly ; if it be held horizontally, it not unfrequently holds its
weight if the flexed portion be upward, but it bends together if we
reverse it. The point of flexion is always near the internal os uteri.
Here the flexion is sometimes slight, sometimes at right angles, or
even at an acute angle. The os uteri is almost always moderately
open, even in women who have had no children ; this is a natural
result of the tension on the anterior lip in retroflexion, on the pos-
terior lip in anteflexion. The internal orifice, on the contrary, is
contracted partly by the flexion itself, partly by the swelling of the
mucous membrane. In older women, we occasionally find complete
atresia of the internal os uteri. The contraction or closure of the
internal os uteri causes more or less hydrometra. The disturbance
of circulation at the point of flexion sufficiently explains the almost
constant complication with catarrh of the uterus, ulcers of the os,
and parenchymatous metritis.

SYMPTOMS AND COURSE. — The most constant symptoms of flexion
depend on the impeded escape of the contents of the uterus. Hence
the patients usually suffer severely from dysmenorrhoea as long as
they continue to menstruate. Small clots of blood that has coagu-
lated in the uterus are often mixed with the menstrual blood, which
is evacuated with severe uterine colic. Uterine colic may also be
caused, in the interval between the menses, by the impeded escape
of the mucous and serous secretions, retained above the point of
flexion. In many cases there are also the symptoms of uterine
catarrh, as described in the first chapter, the fluor albus uterinus,
decided loss of blood during menstruation, etc. Difficult and pain-
ful evacuation of the rectum, desire to urinate and pain while doing
so, the signs of anaemia and bad nutritive condition, and finally the
disturbances of innervation that have been so often mentioned, com-
plete the description given by many women suffering from flexion
of the uterus. But we must add that sometimes women with very
decided flexions of the uterus never have any, or have but few, of
these symptoms ; or, if they do occur, they soon pass off without

CURVATURES OF THE UTERUS. 143

the disappearance of the flexion. Sterility itself, although very fre-
quent, does not constantly accompany flexions of the uterus. Hence
it appears that it is not the flexions, but the other anomalies of the
uterus, which complicate them, that cause the symptoms above de-
scribed. These complications are so frequent that their absence is
an exception. This is partly because the same injurious influences
that induce the flexions also excite the different forms of metritis ;
partly because the disturbances of circulation at the point of flexion
cause hypersemia and exudation in the parenchyma, mucous mem-
brane, and serous covering of the uterus. The course of flexions is
very tedious. The disappearance of the condition is exceedingly
rare, if it ever takes place. Flexion can only disappear completely
if new parenchyma is formed in place of the flattened and atrophied
uterine tissue. When, with advancing years, the periodical recur-
rence of physiological congestion of the uterus ceases, all the symp-
toms usually moderate ; and when, in aged persons, the uterus and
part of its blood-vessels become atrophied, the patient may feel
pretty well.

On physical examination, the finger introduced through the va-
gina first feels a dislocation, anteriorly or posteriorly, of the portio
vaginalis, caused by the coexistent anteversion or retroversion. We
also generally find the os so patulous that the point of the finger
may be readily passed into it, even in women who have had no chil-
dren. From the vagina, either before or behind the vaginal portion,
we may find the body and fundus of the uterus, forming a round,
firm, movable tumor. Usually, also, we may reach the point of
flexion. The fact that the opposite part of the vagina is empty
prevents our mistaking a flexed uterus for one that is enlarged, or
diseased in some other way. The introduction of the uterine sound
aids the diagnosis ; but when the uterus is flexed this operation is
peculiarly difficult, and we again repeat that, in the hands of an
unskilful physician, or even in those of a skilful one, the uterine
sound is a dangerous instrument, which should be used as little as
possible.

TREATMENT. — We have already said that total disappearance of
a flexion must to a certain extent be considered as a physiological
impossibility, as it is almost always accompanied by atrophy of the
parenchyma of the uterus at the point of flexion. " Flexion instru-
ments," sounds, redressers, and intra-uterine pessaries, which were
for a time much used for flexions, do actually no good, but much
harm. Scanzoni has stated plainly that in his large gynecological
practice he has never cured a flexion, and that he considers the use
of flexion instruments as of no use, and dangerous. Tonics also,

14:4: DISEASES OF THE UTERUS.

whether used locally or internally, promise no benefit. The advice
that patients with anteflexion should hold their urine as long as
possible, so that the distended bladder may raise up the fundus, and
that patients with retroversion should retain the faeces for the same
reason, is given from theoretical grounds, and has not proved correct.
( Virchow says that anteflexion results from great distention of the
bladder while the uterus is fixed.) Most gynecologists advise wear-
ing a firm girdle around the pelvis and lower part of the abdomen,
and many patients praise the results of this treatment. It is diffi-
cult to understand that, even in retroflexion, pressure on the lower
part of the abdomen should relieve the patient. Perhaps their
greater ease may be due to the compression of the uterus and its
consequent bloodless state.

Little as we can do to remove the flexions, we may do much to
relieve the sufferings of the patient if we treat the catarrh and pa-
renchymatous inflammation of the uterus, which first call attention
to the flexion, according to the rules laid down in previous chap-
ters. Occasional abstractions , of blood from the portio vaginalis
are peculiarly beneficial, and are almost always effective in cases
of flexion.

[To allay the distressing menstrual colic caused by retention of
clots at the constricted point of flexure, most gynecologists resort to
mechanical dilatation of the cervical canal. According to the expe-
rience of Sims and others, bloodless dilatation by means of bougies
is less beneficial than, and fully as dangerous as, incision of the neck
by the metrotome.]

CHAPTER VI.

CHANGES OF POSITION OF THE UTERUS.

THE uterus, which is very movable, may be dislocated in any
direction. The most important deviations in position are antever-
sion, retroversion, descent, and prolapse.

Anteversion most frequently occurs in women with strongly
curved pelvis. The natural inclination forward of the uterus may
be increased by the pressure from above of fluids in the peritoneal
sac or of tumors, and anteversion may thus be caused. More fre-
quently the uterus sinks forward from its own weight ; hence al-
most always moderate degrees of anteversion accompany infarc-
tions and new formations in the fundus uteri. Anteversion rarely
becomes excessive, since each distention of the bladder restores the
uterus to place, if some peculiar circumstance does not interfere with

CHANGES OF POSITION OF THE UTERUS. 145

the reposition. Corresponding to this, the annoyance caused by the
disease is usually slight, and it is only when the uterus is otherwise
diseased and enlarged, or when it swells up at the menstrual period,
that compression of the pelvic organs and tension of Douglas's liga-
ments cause pain in the small of the back, pressure in the pelvis,
difficult micturition, desire to go to stool, and pain during defeca-
tion. On vaginal examination, we find the portio vaginalis directed
backward toward the hollow of the sacrum, and passing the finger
forward we come without interruption upon the body and fundus,
which lie against the anterior part of the vagina.

Retroversion depends on the same causes as anteversion. A con-
tinued pressure from before backward, tense adhesions on the pos-
terior surface of the uterus or tumors in its posterior wall, cause a
sinking of the fundus uteri into Douglas's space, and a prominence
of the vaginal portion toward the symphysis pubis. The retrover-
sion that occurs independently during the first months of preg-
nancy, an$ soon after confinement, is a very important disease ;
that occurring at other times is generally only a subordinate result
of other diseases of the uterus or other pelvic organs. The symp-
toms of retroversion are analogous to those of anteversion, and they
also depend on the pressure of the horizontally-displaced uterus on
the pelvic organs, particularly on the rectum and bladder.

Descent and prolapse of the uterus depend chiefly on relaxation
of the parts that maintain the uterus in position, particularly its
ligaments, the pelvic fascia, and the vagina. If, during this relaxa-
tion, a stronger pressure from above downward act on the uterus,
the latter is pressed down, inverts the vagina, and passes deeper
into it, and the result is a descent. If part of the uterus protrude
from the vulva, we speak of a prolapse ; when the entire uterus lies
outside of the vulva, it is called a prolapsus completus. Relaxation
of all the parts that should maintain the uterus in position occurs
most frequently in the puerperal state ; and it is the abdominal
pressure that most often presses the uterus downward. Poor wo-
men, who cannot take care of themselves after confinement, but are
obliged to do hard work that causes abdominal pressure a few days
subsequently, are peculiarly liable to descents and prolapses. As
every descent of the uterus inverts the vagina, and each prolapse of
the uterus induces' prolapse of the vagina, so, on the other hand,
prolapse of the vagina may give rise to descent or prolapse of the
uterus. If the lower end of the vagina be prolapsed, as a result
of rupture of the perinseum during delivery, or from some other
cause, the upper end exercises traction on the uterus, which either
results in elongation of the vagina or descent of the uterus. De-

DISEASES OF THE UTERUS.

scent or prolapse of the uterus only exceptionally occurs in women
who have had no children. When they do occur, it is because the
same conditions exist as after confinement, and particularly because
the vagina is relaxed by blennorrhoea and venereal excesses, or the
uterus is pressed downward by heavy tumors in the pelvis. If
prolapse of the uterus take place suddenly, as occasionally happens
from lifting heavy weights, from severe coughing, or strong bear-
ing-down efforts, the stretching of the ligaments causes severe pain
in the abdomen, and great general disturbance, fainting, nausea,
etc. If the descent or prolapse develop slowly, there is usually but
little annoyance at first ; this consists chiefly in an undecided feel-
ing of pressure downward, and in stretching pain in the lower part
of the abdomen and small of the back. The deeper the uterus de-
scends, the more annoying these symptoms become ; they increase
when the patient stands up, walks, coughs, etc ; they diminish dur-
ing rest, and in the horizontal position. There are also inconven-
ience and pain during urination and defecation, and there are con-
stipation, colic, and other symptoms due to dislocation, pressure,
and tension of the abdominal organs. If the uterus project from
the vulva, it at first forms a round or oval tumor, as large as a wal-
nut, which may be easily replaced ; but soon the uterus covered by
the vagina advances, the tumor rapidly increases in size, and is re-
placed with difficulty ; it feels doughy, but on firm pressure we
may distinguish a hard body more deeply seated. If, with the
anterior wall of the vagina, the fundus and posterior wall of the
bladder be drawn through the vulva (cystocele), on the anterior
wall of the prolapse we may see a tense and sometimes fluctuating
tumor, which swells and subsides again several times during the
day, and into which, by exercising some skill, we may introduce a
male catheter through the urethra. On introducing the finger into
the rectum, we find it bulged forward. The os uteri gapes open,
because the vaginal portion is averted ; it is reddened and covered
with glairy mucus. The prolapsed vagina is dry, parchment-like,
thickened ; the epithelium resembles epidermis ; frequently it is ex-
coriated by the friction of the clothes and the irritation of the urine
that trickles over it, and not unfrequently deep ulcers form in it.

The treatment of dislocations of the uterus is purely surgical ;
and it would lead us too far to speak even of the choice of certain
pessaries, and of the rules for their introduction and employment.

FIBROID TUMORS OF THE UTERUS.

CHAPTER VII.

FIBROID TUMOES OF THE UTERUS FIBROMYOMATA, FIBROIDS,

DERMOIDS.

[PATHOLOGY AND ANATOMICAL APPEARANCES. — These growths
are to be regarded as partial hyperplasias of the uterine parenchy-
ma, and consist of masses of smooth muscular fibres intermingled
in varying proportion with connective tissue. In their original form
they always present rounded, sharply-defined tumors. They are
non-malignant in their character, and are far more common than
any other form of uterine growth. They rarely appear before pu-
berty, and their liability to develop increases up to a certain point
with the age, so that they are most commonly found in persons from
thirty to fifty years old, while beyond this age they are compara-
tively rare. They are met with both in the married and unmarried,
and are often associated with menstrual disorder and sterility,
which, however, must be looked upon as consequences rather than
as causes of the disease. Nothing certain is known regarding
their cause. Fibromyomata vary greatly in size. They may be no
larger than a pea, or may form a tumor as large as the head, and
may weigh several pounds ; but this is somewhat rare. They are
sometimes solitary and sometimes multiple, and in the latter case
they are usually small.

The constitution of a fibromyoma varies. Sometimes the fibrous
element preponderates, giving it more the character of a pure fibro-
ma ; sometimes (but rarely) the growth consists almost purely of
unstriped muscular fibres, thus approaching the true myoma in na-
ture. Upon section, their structure is found to consist of more or
less regular concentric layers of wavy connective tissue, between
which the finer bundles of muscular fibres are arranged. The more
the firm, tendinous, fibrous tissue preponderates, so much the harder
is the tumor and the paler its cut surface. When the muscular ele-
ment prevails, the section presents more of the grayish-red coloring
of the normal uterine tissue. As a rule, fibromyomata are but spar-
ingly vascular, and very seldom contain large blood-vessels. There
is, however, one form in which these tumors consist, either partially
or totally, of enormously dilated blood-vessels. Sinuses filled with
blood may even form, giving to the tumor a likeness to the erectile
tissue of the corpus cavernosum, and also its capacity to swell and
shrink ; so that sudden changes of volume in such a tumor can be
observed ( Virchoitfs telangiectatic or cavernous myoma).

148 DISEASES OF THE UTERUS.

Fibromyomata often exist in a conglomerated form. The tumor
is then irregular and knobby in contour, instead of rounded. This
shape is sometimes attributable to the blending of several indepen-
dent tumors ; but more commonly the self -same morbid process
which causes the original growths in their simpler form again re-
peats itself in the substance of the new growth. Each vessel, with
its appertaining connective tissue and muscular fibres, proliferates,
and begets, as it were, a second generation of nodules within the
older ones. Although the fibromyoma springs from the uterine paren-
chyma, yet at a later stage it no longer remains closely connected
with it, but lies within the uterine substance, though quite isolated
from it by a layer of loose areolar tissue, so that it can very easily
be enucleated. Sometimes, however, old fibroids of large size main-
tain their connection with the womb by a pedicle, or even by a
broad fibromuscular band. Such an attachment usually contains
large blood-vessels. The womb is usually hypertrophied, but in
advanced age it is atrophied. Now and then it is elongated and
thinned, and it is often out of place.

Fibromyomata rarely spring from the cervix, but rather from
the f undus or body. Their classification according to their more su-
perficial or deeper seat in the uterine wall is of great practical im-
portance. Thus we distinguish (1) the su bserous, (2) the submucous,
and (3) the interstitial fibroids, although many tumors present in-
termediate forms. In the subserous fibroma, the tumor, which
usually has originated in the outer layers of the womb, tends to-
ward the abdominal cavity, into which it projects in strong relief.
Its base, at first wide, may by degrees grow narrower, and ultimately
even present a mere stalk of the peritonaeum. Total detachment,
indeed, has been observed ; but in such cases the growth has soon
formed new adhesions, either in the vicinity of its point of origin
or in Douglas's cul-de-sac. Subserous fibroids are often multiple,
and usually are small ; but if their vascular connection with the
uterine parenchyma, by which they are nourished, should happen
to be kept up, they may attain a great size, and rise into the abdo-
men. By these large subserous tumors the womb is misplaced,
distorted, and stretched ; but it is almost never hypertrophied.
When springing from the side of the womb, they may penetrate
between the two folds of the broad ligament, forcing them asunder
so as eventually to lie quite outside of the peritonaeum. The sub-
mucous fibroid, on the contrary, tends to grow inward, toward the
cavity of the womb, into which it juts like a globe, distending it,
and displacing it to the side opposite to that whence it springs. Its
surface is covered either by mucous membrane alone, or by a thin

FIBROID TUMORS OF THE UTERUS.

layer of parenchyma. The womb itself is usually hypertrophied as
if pregnant, and the portio vaginalis is soon obliterated. Practically
it is of great importance to distinguish between submucous growths
having a broad attachment to the womb, and those which project
into it so completely as to be held by a mere pedicle. The latter, the
so-called fibrous polypi, are a subject for surgical treatment. The
interstitial, intraparietal, or intramural tumors tend less to project
from the uterine wall ; but, where they become large, they cause a
bulging of both inner and outer wall, thus taking an intermediate
position between the two extraparietal forms of fibromyoma.

The same variation as to seat holds good with regard to the far
rarer fibromyomata of the neck and vaginal portions of the womb.
Submucous fibromata of the cervix usually appear as fibrous polypi.
These must not be confounded with the more common mucous poly-
pus, which is merely a product of catarrhal relaxation of the mu-
cous membrane with cystic enlargement of the follicles (ovula Na-
bothi). The latter are easily distinguishable from the fibromyomata
by their softness and smallness, rarely exceeding a hazel-nut in size.

Uterine fibromyomata may undergo many further transforma-
tions. The commonest one is an accumulation of liquid in the lymph-
spaces, which dilates them, causing an oedematous softening of the
tumor, and sometimes a cystic metamorphosis. In the latter case we
find either numerous small cysts, or else a large cavity whose ragged
sides and trabeculge announce it to be the product of the blending
of several smaller cysts. Heteroplastic action may also arise, such
as myxomatous or colloid degeneration, sarcoma, or cystosarcoma.
True cancer probably does not occur, except as a secondary disease,
by metastasis or by propagation in continuity from a cancer of the
uterus proper.

SYMPTOMS AND COURSE. — The symptoms of a fibromyoma vary
greatly, according to the size and seat of the tumor. Small subse-
rous growths, or those which are completely extraparietal, and
which, being merely attached by a thin stem, have ceased to grow,
often give no symptoms at all. Sometimes a small growth flexes or
upsets the womb by its weight, either backward or forward, accord-
ing as its seat is in the front or back wall of the organ. A large
extraparietal tumor,, on the other hand, displaces the womb in the
direction away from its geat, or sometimes draws the womb up with
it into the abdomen. The pressure exerted by a dislocated womb
or by a voluminous tumor upon adjacent parts may cause various
evils — backache, incontinence or retention of urine, obstruction of
the rectum, swelling of the feet, neuralgia, or even paresis of a leg.
The irritation often causes local peritonitis, with consecutive incap-

150 DISEASES OF THE UTERUS.

sulated exudation, or with adhesions ; and these latter may by and
by hinder the tumor from lifting itself as it grows out of the pelvis,
so that the pressure upon the other pelvic organs may give rise to
the symptoms of incarceration. All these pressure-symptoms usu-
ally grow worse during the menstrual period.

The submucous fibromyomata also soon create serious distress.
In this form the distended and hypertrophied womb itself forms the
tumor, and when large it naturally produces the same pressure-symp-
toms as those caused by subserous tumors. But the growth, being
enclosed in muscular masses, excites the latter to strong contraction.
The tumor, projecting into the womb, stretches and irritates its mu-
cous lining, thus inducing leucorrhoea and haemorrhages of great
frequence and severity. These metrorrhagias occur even when the
tumor itself is very poor in blood-vessels, and proceed entirely from
*the mechanically overladen vessels of the mucous membrane. At
first the bleedings seem to attend the menstrual periods, which are
then excessive and followed by a watery mucous discharge. By
and by the haemorrhages recur irregularly, and with ever-increasing
frequence and severity, so that the patient's life may be jeoparded
by sheer loss of blood. Great suffering during menstruation also
arises in this form of fibroma. There is pain, which is sometimes
continuous, and sometimes an intermittent uterine colic, like labor-
pain, due to the obstruction by the tumor to the menstrual flow.
If the catamenial function ceases permanently — and this is apt to
take place quite late in life in these cases — this distress is materially
abated or ceases entirely. Interstitial tumors occupy a middle posi-
tion both as regards seat and symptoms. Being well surrounded by
uterine tissue, and being under more favorable conditions for growth
than the subserous and submucous tumors generally are, their de-
velopment is often quite rapid, and they sometimes attain colossal
dimensions.

The existence of a fibromyoma cannot be made out without man-
ual examination, and even then it is sometimes very difficult. The
subserous tumor is felt as a hard ball-like or nodular lump, which,
if it spring from the f undus, can be felt more easily through the ab-
dominal wall, and if from the lower part of the womb, is best found
through the fornix vaginae. The examination should aim to prove
that the tumor really proceeds from the womb, and does not merely
lie next to it. Sometimes an ovarian cyst or an old parametritic or
perimetritic exudation adheres so closely to the uterus that nothing
will shed light upon the case but a due weighing of other facts,
such as the consistence of the mass, which, if a fibroma, should be
hard, and never is soft unless it be in a state of cystic degeneration,

FIBROID TUMORS OF THE UTERUS. 151

when it is more like an ovarian cyst in consistence ; or else the his-
tory of the case would show a preexisting pelvic inflammation, had
any occurred. Subserous fibroids attached only by a thin fibrous
stem are often thought not to belong to the womb, and, although too
hard to be mistaken for ovarian cysts, may be diificult to distin-
guish from a solid ovarian growth. The examination should further
determine that the object felt is not the womb itself, displaced and
enlarged. An anteflexed or retroflexed womb may simulate a tumor
lying in the uterine wall ; but conjoined manipulation will demon-
strate that beside the tumor in question a second one exists, which,
in situation, form, and consistence, corresponds to the womb ; and,
if necessary, the introduction of a sound will show by its direction
that it does not enter the tumor, but takes an entirely normal course.
Sometimes by means of the sound we can tell that the uterus, al-
though distorted and displaced, by no means corresponds in length
with the volume of the tumor.

Submuoous fibroids lie hidden within the womb, and distend it ;
hence they may be confounded with other conditions which cause
uterine enlargement — above all, with pregnancy, uterine infarction,
and hsemometra. Unless the history of the case and other circum-
stances distinctly preclude the supposition, the tumor may be mis-
taken for a gravid womb, because the same general disorders which
characterize pregnancy, as well as the changes in the breasts which
then arise, may likewise be met with now. The condition of the
vaginal portion is of great value in the diagnosis. In pregnancy it
is remarkably soft and flabby. In a case of fibroma the cervix
rapidly disappears, and the os uteri will gape so that the tumor
within it can easily be found. The uterine souffle so regularly
heard in pregnancy is, nevertheless, not a sure sign of that condi-
tion ; for it also is heard in cases of fibroma, and in rare instances
where there is an ovarian growth. In chronic metritis the tender-
ness of the womb to pressure stands in contrast to the insensibility
of a fibroma. Moreover, in infarction the vaginal portion is thick-
ened and not obliterated, and the sound enters easily ; whereas a
fibroma opposes an obstacle to its passage, not always readily over-
come.

After excluding pregnancy, the diagnosis may be sometimes
facilitated by the introduction of a sponge-tent into the cervix.
The canal being thus dilated, it becomes practicable to examine
precisely the tumor with the finger and sound, and particularly to
determine whether the tumor is attached by a broad base or by a
slender pedicle — a matter of the utmost importance as regards
therapeutics and prognosis. Interstitial tumors bulge less distinctly
60

152 DISEASES OF THE UTERUS.

into the uterine cavity, and the enlargement of the organ is not so
general and uniform. Very large interstitial fibromata, which rise
into the abdomen, may be mistaken for other abdominal growths ;
not for ovarian cysts, however — which, though hard in places, also
as a rule present elastic, fluctuating portions to the touch — but rath-
er for solid ovarian tumors and for subserous fibromata. But in
these two cases the womb itself does not form part of the tumor,
but is merely displaced by it ; and we must strive to ascertain if the
two bodies can be made to move independently of one another. If
so movable, the growth is probably ovarian ; if attached, it is most
likely a subserous fibroid ; but no absolute certainty of this can be
attained, because an ovarian growth may be bound fast to the womb,
and a subserous fibroid with a long pedicle may float freely. When
the uterine sound passes deeply into a tumor, or when its tip can
be felt through the walls of the growth, we may infer that the mass
is not merely attached to the uterus, but is the uterus itself. An
expert with the sound can also determine that the enlargement of
the organ is not uniform, but chiefly affects one or other wall. This
decidedly points toward the presence of an interstitial fibroid.

Fibromyomata of the cervix, which are more rare, are easy of
diagnosis. They present either rounded, hard, circumscribed lumps,
which distend one of the lips of the os, or else appear as fibrous
polypi protruding from the cervix.

PROGNOSIS. — The prognosis of uterine fibromyomata has its good
and its bad points of view. The fact is well attested that such
tumors have now and then shrunk away and disappeared, but such
good fortune must never be counted on ; the more so, because these
rare cures seem never to be due to treatment, but rather to favor-
able accidental conditions — parturition, the climacteric, or the like.

The affection is generally to be regarded as incurable ; yet the
prognosis is so far favorable that life is seldom immediately imper-
illed by it. Sometimes, indeed, the envelope of the tumor suppu-
rates, causing peritonitis or pyaemia ; and the general nutrition has
been known to suffer seriously through the pressure of an enormous
fibrous tumor upon adjacent abdominal organs. The tumor some-
times ceases to grow so early as never to cause any symptoms ;
while others by their development render life a burden, until the
attainment of the climacteric brings about an arrest of development,
or until a sort of imperfect retrogression takes place by calcification
of the tumor. Spontaneous expulsion of the growth through the
uterine canal has been observed in a series of cases. A few times it
has been known to be expelled into the abdomen or into the blad-
der, and even to be discharged through the abdominal walls. Such

FIBROID TUMORS OF THE UTERUS. 153

an event is either the result of sloughing and suppuration of the
capsule, with subsequent bursting of the resulting abscess, in which
case the danger to life is very great, or else the extrusion comes to
pass by the less dangerous method of spontaneous enucleation. A
tumor juts from the os ; at its apex an opening forms by sloughing
of the mucous membrane, and through this opening, which enlarges
more and more, the tumor is gradually pushed by the uterine con-
tractions. It sometimes happens that pregnancy occurs notwith-
standing the presence of a fibromyoma. Childbed in such a case is
beset with peculiar dangers.

TREATMENT. — Very little reliance is to be placed upon medical
treatment of a fibromyoma with a view to its dispersion, arrest, or
atrophy. Iodide of potassium, bromide of potassium (first proposed
by Simpson), chloride of calcium (Rigby), arsenic and phosphorus
( Gu&niot), seem to effect very little ; while the brine-baths, particu-
larly those containing bromine and iodine (Kreuznach, Minister am
Stein, and Adelheidsquelle in Bavaria), seem sometimes to bring
about a certain reduction in bulk of the tumor. Hildebrand claims
that by means of subcutaneous injections of ergotine, employed
originally to control the bleeding, not only the haemorrhage, but
also the tumor, was made to disappear; but, in spite of other
corroborative testimony, the value of this treatment is not yet es-
tablished. Some fibromyomata are curable by surgical treatment ;
and by following nature's suggestion of spontaneous enucleation,
not only submucous tumors, but even interstitial ones, have been
removed through the vagina by a surgical operation, though at
considerable risk to life. As a last resort, indeed, to save life, when
the rapid growth of the tumor was obviously about to kill the pa-
tient, extirpation of the tumor, either with or without the womb,
has been successfully accomplished.

The surgical treatment of pedunculated submucous tumors is
more satisfactory ; and we not seldom meet women, who have been
brought almost to death's door by persistent haemorrhage from
fibrous polypi, restored in a few months after their removal to a
state of blooming health.

As a rule, however, we must renounce the expectation of actually
curing a fibromyoma, and content ourselves with enjoining a quiet
mode of life, with little physical exertion or excitement, forbidding
frequent sexual intercourse, and with practicing small local blood-let-
ting upon the vaginal portion, with regulation of diet ; also with the
recommendation of a treatment during the summer-time by baths
calculated to retard the growth of the tumor. Regarding the treat-
ment of the bleeding, we refer to the article upon menorrhagia.]

154 DISEASES OF THE UTERUS.

[CHAPTER VIII.

CANCER OF THE WOMB.

ETIOLOGY AND ANATOMICAL APPEARANCES. — Primary cancer
appears more frequently in the womb than in any other organ of
woman, not excepting the breast. Secondary cancer of the womb,
on the other hand, is rare. Nothing certain is known as to the
cause of this miserable disease, and its assumed hereditary trans-
missibility is not proved. It is met with chiefly among married
persons, especially among multipara, and with increasing frequency
from the thirtieth year up to the climacteric period, which age fur-
nishes the most victims. Beyond it cancer is common enough still,
and does not become a rarity until the seventieth year.

The point of origin of primary cancer is almost always in the
neck of the womb, very rarely in its body. According to 'Waldeyer,
all forms of cancer spring from the true primordial epithelium of
the organism, and hence are to be regarded generally as epithelial
growths ; and even the smooth and papillated cancroids formerly
distinguished as carcinomata are to be included in this category.
The development of cancer of the cervix is as follows : The super-
ficial epithelium of the mucous membrane proliferates, throwing
offshoots into the connective and muscular tissue beneath it. These
sprouts, ramifying in all directions, everywhere form new nests of
cancer-cells, and encroach more and more upon the normal tissues,
which finally break down and ulcerate through pressure and arrest
of circulation. The cancerous infiltration meanwhile continues to
invade new tissues around it, which in their turn ulcerate. This is
often accompanied by considerable development of the papilla3 of the
mucous membrane, and this is in the beginning liable to be confound-
ed with the non-malignant papillary outgrowth due to catarrh. In-
deed, it has been assumed that papillomata, originally simple, might
change into cancer by consecutive ingrowth of their epithelium into
their basement-tissue. At a later period the malignant papilloma
is distinguishable from the simple form by the rapidity and luxuri-
ance of its growth, and by its early ulceration. At other times, in-
stead of papillae, there develops a smooth, knotty group of swellings
in one or other lip, or perhaps throughout the whole circumference,
of the os. These nodules, unless they prematurely break down by
ulceration, may form a tumor which fills the upper part of the va-
gina. But there are cancers which do not begin at the surface, but
originate deep in the interior of the neck, and develop as circum-

CANCER OF THE WOMB. 155

scribed knots pushing toward the surface. Even this form of can-
cer, however, must derive its origin from preexisting epithelium,
probably from isolated cervical glands, and from abnormally dis-
tributed vestiges of the primordial epithelial germ. Sometimes the
disease takes the form of a firm scirrhus, but more commonly it
assumes that of a soft medullary cancer, with a predominance of
epithelium and with scanty connective tissue. The infiltration and
ulceration travel upward to the internal os, and sometimes even in-
vade the body of the womb. Thus not the neck alone, but a large
part of the body of the organ, may disappear. An extension of the
disease to the vagina imparts to the latter a hard, puffed-up, brawny
quality, so that the finger can no longer recognize the os uteri. Still
later, the cancerous infiltration of the ureters often causes obstruc-
tion of the urine and hydronephrosis (even to the extent of fatal
uraemia), and, by invasion of the bladder and rectum, with conse-
quent destruction of the septa separating these cavities, large fistulas
are formed ; and it has even happened that all three cavities have
been blended into one horrible cloaca. The tubes, ovaries, and
other pelvic organs, and the muscles, areolar tissue, and even the
bones, are finally attacked, either by contiguity or by metastasis ;
so that at last the womb is, as it were, walled up by cancerous in-
filtration and peritoneal adhesions. More distant regions finally arc
invaded — the inguinal and retroperitoneal glands, the peritonaeum,
omentum, mesentery, intestine, liver, and perhaps even the breast.

SYMPTOMS AND COURSE. — In the earliest stages of uterine can-
cer there is slight pain in the back and abdomen, the menstrual
flow is augmented, and there is leucorrhrea, which is not at first
profuse, except in a case of malignant papilloma. So little is pre-
sented to distinguish it from the more unimportant disorders of the
sexual organs, that in the beginning the malady is rarely recognized.
It would seem, indeed, that that form of it which commences by
deep-seated nodules presents no symptoms whatever so long as the
mucous membrane remains intact. In many cases no serious symp-
toms arise until the cancerous mass begins to ulcerate and break
down ; so that the period for operative interference has already
passed ere the nature of the malady has been recognized. Indeed,
even in the earlier stages, while the mucous membrane remains
sound, a local examination will not always reveal the existence of
cancer, and the most experienced gynecologists admit that the dis-
tinction between a cervix enlarged by cancerous infiltration and a
simple hypertrophy of the neck may at first be impossible. Schroe-
der describes a condition of the mucous membrane as characteristic
of cancer even before the period of ulceration. The membrane is

j[56 DISEASES OF THE UTEKUS.

tightly adherent to the tissues underlying it. As Waldeyer has it,
the mucous membrane seems to be tacked down by the ingrowing
epithelial sprouts, which penetrate the tissues beneath them like so
many brads. After it has attacked the vagina and surrounding
connective tissue, the recognition of cancer is easy.

When the period of ulceration sets in, a series of grave and often
very distressing symptoms arise. The leucorrhoea becomes more
profuse, and somewhat sanguinolent (like meat-washings), and final-
ly, by admixture of gangrenous particles, acquires an ichorous char-
acter, and assumes a darker dirty-brown or greenish-black color,
and emits so foul and putrid an odor as to disgust not only the
neighbors but the patient herself. Haemorrhage is rarely absent.
In the beginning there is merely an augmentation of the menstrual
flow, but the bleeding afterward becomes irregular, and is often
the first symptom which alarms the patient. Elderly women, how-
ever, are prone to ascribe such bleedings to the irregularities com-
mon at the menopause, and hence give themselves little concern
over it. Only in cases of hard cancer is haemorrhage ever absent.
It is most profuse in the papillary form. Notwithstanding its fre-
quence and abundance, which often reduces the patient to the low-
est stage of anaemia, a fatal haemorrhage is rare.

The abdominal and lumbar pains are sometimes insignificant
throughout the disease ; while at other times the patient suffers in-
describable agony, especially during the night. This violent pain
does not depend upon the ulceration, but upon extension of the can-
cerous growth into the connective tissue and other parts of the body,
and appears to be due to pressure of the indurated mass upon the
nerve-twigs which it encloses. Besides this, there may be sharp
pain from pressure set up by a secondary peritonitis, arising from
the irritation of the cancerous nodules. Finally, the pain may as-
sume a paroxysmal form — a uterine colic — in consequence of an ob-
structed outflow of blood and secretion from the womb. Incessant
and painful urinary irritability indicates invasion of the bladder,
while a suppression of the urine makes it probable that the ureters
are occluded by the growth. Obstinate constipation, followed by
tenesirius, haemorrhoids, and diarrhrea, indicates an implication of
the rectum.

Prior to the stage of ulceration the general health of the patient
is fairly comfortable ; afterward she grows pale, anaemic, cedema-
tous, and emaciated, and the countenance often presents that dirty-
yellow coloring so commonly seen in cancer, although not a trust-
worthy sign of it. The more frequent tne bleedings, the more
profuse the discharge, and the more constant and severe the pain,

CANCER OF THE WOMB. 157

so much the sooner does the general health of the patient give way.
There is also almost always a derangement of the stomach, with
loss of appetite and loathing of food, and a tendency to nausea
which contributes to break down the strength ; and it is often hard
to determine whether the vomiting is due to a sense of disgust, or
arises from gastric catarrh or gastric irritation reflected from the
genital organs, or from the effect of ursemic poisoning.

Ulceration usually first attacks the inner surface of the lips of
the os. After this has once begun and loss of substance has taken
place, the diagnosis by digital and ocular examination is no longer
difficult. One source of error might be the destruction of the va-
ginal portion of the cervix by that very rare form of ulcer (ulcus
phagedwnicum corrodens) first described by Clarke, and identified
with certainty in a few instances only by Klebs and .Focrster, and
the cause of which is still unknown. In a doubtful case, nothing
but the microscopic examination of an extirpated portion of the
cervix can determine whether the base of the ulcer contains traces
of carcinoma or not. But, after all, the prognosis of a corroding
ulcer is scarcely better than that of cancer ; for our experience has
shown that neither by the strongest caustics, nor even by the hot
iron itself, can the ravages of the latter be checked and the ulcer
healed.

As we do not generally know how long the latent stage of cancer
has existed, its duration can rarely be stated with certainty. Dating
from the time of first discovery, Gusseroio estimates that most pa-
tients succumb in about a year or a year and a half. Yet there are
examples of a rapid course of only a few months, and others again
of several years' duration. Death usually takes place from exhaus-
tion, or else the patient dies of complications. These are acute or
chronic uraemia, gradual or perforative peritonitis, miliary carci-
nosis of the peritonaeum, septicaemia, dysentery, diphtheritic inflam-
mation of the vagina or bladder, pneumonia, or (what is more rare)
embolism of the pulmonary artery, embolic gangrene of the lungs,
fatty degeneration of the heart, pyelonephritis, or pylephlebitis as
a consequence of putrid thrombosis of the portal vein.

TREATMENT. — The treatment of cancer of the womb is essen-
tially surgical, and an operation, although it very rarely cures the
patient, yet affords the only chance of effecting even a temporary
improvement. Unfortunately, the malady is seldom brought under
treatment until the vagina has become implicated, or until so much
of the cervix is involved that an amputation can no longer be made
through healthy tissue. Yet even then the operation is justified as
affording a last chance for prolonging life. This is best done by

158 DISEASES OF THE UTERUS.

removing all parts which seem affected by knife or scissors, and by
scooping away the less accessible portions by means of Simon's
sharp spoon, and then by cauterizing the wound with the hot iron,
or by means of the alcoholic solution of bromine first recommended
by Routh, and approved by Schroeder and Henneberg. Otherwise
the escape of cancerous offshoots which often exist in parts seem-
ingly healthy, or of remnants of the ulcer which often extend up to
the inner os, may render the operation abortive. The relief of pain
is the most important duty in treatment of the symptoms. Hypo-
dermic injections of morphine and opiate enemata are often quite
indispensable. When the flow is profuse, copious astringent vagi-
nal injections are demanded ; and for the foul odor we must employ
disinfectants, such as carbolic acid, permanganate of potash, and
chloride of lime. The haemorrhage is to be combated by the use
of ice, or of cold or very hot injections, or of dilute liquor ferri ses-
quichloridi ; or else we must tampon with sponges, or plugs of cot-
ton charged with strong liquor ferri chloridi. For the insomnia
which is so common, chloral furnishes an invaluable remedy.]

CHAPTER IX.

ANOMALIES OP MENSTRUATION.

[!T has generally been assumed that the menstrual flux is inti-
mately connected with the ripening and bursting of a Graafian ves-
icle, and with the escape therefrom of one or more eggs ; but this
view of the subject has latterly been contested, and the complete
independence of ovulatiou and menstruation has been asserted (Bei-
get). According to our present information upon the subject of
ovulation, the uterine mucous membrane at puberty undergoes cer-
tain periodical metamorphoses, the nature of which has been ascer-
tained by the researches of Kundrat and Engelmann. They find
that at the menstrual period the uterine mucous lining swells up and
develops ; its glands elongate and dilate, and a proliferation of the
round cells of its basement-tissues takes place. This process is fol-
lowed by a retrogressive one, based upon a fatty degeneration of
the upper layers of the mucous membrane, so that the bleeding is
caused, not, as is generally supposed, by a menstrual fluxion and hy-
persemia, but by destruction of the mucous membrane through fatty
degeneration. The purpose of the increased development of the
mucous membrane is that the egg may be received into it, and only
at this time of so-called nidation is the growth of a fructifying egg

ANOMALIES OF MENSTRUATION. 159

possible ; while in the remaining period, that of so-called denida-
tion, during the menstrual flow and during the exfoliation of the
mucous membrane, any egg which may reach the uterus will perish.

Hence it would at first seem as though conception could only
take place after a coitus immediately preceding menstruation, and
never from coitus following it ; but we should bear in mind that
the ripened egg which leaves the ovary at the menstrual epoch re-
quires a certain period of time, not precisely known, for its passage
through the tube, at the end of which period the state of denidation
may have passed over. According to the newest views, those of
John Williams, based upon examination of twelve wombs, the re-
generation of the fatty mucous lining begins immediately after ces-
sation of the bleeding, and progresses steadily until the next retro-
gressive period commences. Thus the womb would seem never to
be at rest, but to be either in a state of evolution lasting about three
weeks, or of involution lasting about one week. Only at the period
of involution would implantation and fixing of the ovum (as far as
the womb is concerned) seem to be impossible, while impregnation
might take place at any part of the period of evolution. Bischoff,
however, doubts if an egg be capable of fructification during the
latter part of the period of evolution. More probably the egg must
receive an impulse toward further development from the seminal
fluid while still in the tubes, and only in the improbable event of an
egg's requiring three weeks to traverse the tube would there be no
period of intermenstrual unfruitfulness.]

Anomalies of menstruation are not independent diseases, but are
symptoms of affections of the sexual organs, or of other diseases
impairing the general health. Hence the discussion of amenor-
rhoea, dysmenorrhoea, menorrhagia, etc., does not properly belong
to a text-book of special pathology and therapeutics, but to a work
on semeiology and diagnosis. Following the example of most au-
thors, for practical reasons, we will give a short account of the most
important menstrual disturbances.

Too early menstruation — menstruatio prcecox — is not frequent,
if by this term we mean only those cases of haemorrhage from the
female genitals before puberty that are accompanied by the expul-
sion of a ripe ovum. As we have no certain means of finding out
whether this complication exists or not, we must note whether the
haemorrhage recurs at regular intervals ; whether it is accompanied
by disturbance of the general health, by pains in the back, and
other symptoms which almost always accompany menstruation
proper. Haemorrhage occurring once, or at irregular intervals in
the course of acute diseases, particularly of acute infectious dis-

160 DISEASES OF THE UTERUS.

eases, as well as in chronic dyscrasia and venous congestions, has
nothing to do with menstruation. If, in our climate, menstruation
begins between the twelfth and fourteenth years, instead of the
fourteenth and sixteenth, it is only a morbid symptom if the girl be
undeveloped. Many girls at this age, who still go to school and
wear short clothes, have full breasts and hair on the pubes. We
may say that they have developed too early, but not that they have
any anomaly of menstruation ; in them the absence of the menses
would be pathological. But, besides these cases, we not unfre-
quently find apparently undeveloped girls, aged eleven or twelve
years, with regularly-recurring haemorrhages from the genitals, and
such characteristic symptoms of congestion in the pelvis that we
cannot doubt there is a case of early ovulation — a true menstruatio
praecox. Experience shows that almost all such girls subsequently
suffer from obstinate chlorosis. Cases where menstruation has been
observed in small children are only partially reliable.

It is very rare indeed for menstruation to cease several years
too late. Among us, women usually menstruate till forty-five or
forty-eight years old. If menstruation has begun early, it usually
ceases somewhat sooner ; if the reverse, it continues a few years
longer. Scanzoni has seen only one case, in his practice, where an
unmistakable menstrual haemorrhage continued to the age of fifty-
two years. Even very old women are inclined to regard all haemor-
rhage from their genitals as menstrual.

Of course, we can only speak of amenorrhoea when the menses
are absent in a woman who has attained the age of puberty, and
has not passed the climacteric, and who is not pregnant or nursing.
[Above all, be it observed that the absence of menstrual flow does
not warrant the inference that ovulation has ceased. We know, in-
deed, that conception may take place during amenorrhcea. On the
other hand, the cessation of ovulation after destruction of the ova-
ries is not always followed by absence of the menses. In excep-
tional cases menstrual bleeding has been observed to continue for
some time after the sexual function has been destroyed.]

Tardy menstruation is one form of amenorrhoea ; too early ces-
sation is another form. If a girl sixteen or eighteen years old be
no more developed than one of ten or twelve years, she can no
more be said to have retarded menses than a fully-developed girl of
twelve or thirteen who menstruates can be said to have menstru-
atio praecox. Except in cases of tardy menstruation or too early
cessation of the menses, amenorrhoea more frequently depends on
constitutional disease than on local affections of the genitals. It
is chiefly chlorosis, scrofula, and tuberculosis that retard the occur-

ANOMALIES OF MENSTRUATION. 161

rence of menstruation, or cause its arrest. It is not always easy
to determine, in these cases, whether the ovum does not ripen, or
whether only the haemorrhage that usually accompanies the expul-
sion of the ovum is absent. If, at intervals of four weeks, we no-
tice more or less decided molimina, accompanied by swelling of the
breasts and increased discharge of mucus from the genitals, it
would seem as if only the haemorrhage were wanting ; in the reverse
cases, we may suppose that ovula do not ripen. Among the dis-
eases of the sexual organs, degeneration of the ovaries rarely causes
amenorrhoaa, and only does so when both ovaries are at the same
time the seat of organic disease. Among the various diseases of
the uterus, chronic catarrh, and especially chronic infarction, in
which the blood-vessels are compressed by the shrinking connective
tissue, most frequently induce this disease. Amenorrhoea occasion-
ally occurs in strong, .healthy girls, in whom the genitals have not
developed £O rapidly as the rest of the body. Lastly, Scanzoni
concludes, from the cases where the menses (which had previously
been normal) ceased on the occurrence of paraplegia, that amenor-
rho3a may result from abnormal innervation.

The sudden arrest of the menstrual flow — suppressio mensium —
is most frequently the symptom of acute metritis. It depends on
the same injurious influences that we mentioned in the etiology of
that disease, and is accompanied by the same symptoms. More
rarely the menses cease suddenly, if the amount of blood in the
uterine vessels be lessened by a diminution of the entire amount of
blood in the body by venesection, or by excessive fluxion to some
other organ.

[Sometimes, at the period when the menstrual flow should appear,
instead of it a bleeding occurs from some other region, from a
haemorrhoid, from a wound or ulcer, from the nose, the bronchi, or
the stomach. Such bleeding, it would seem, might properly be
called " vicarious " so long as it was supposed that the menstrual
flux had the effect of evacuating effete matter from the system.
It might then have been inferred that refuse which was not voided
by legitimate methods might be advantageously got rid of by un-
usual processes. Nowadays, however, with our present conceptions
of the nature of menstruation, it is difficult to find a reason for a
vicarious menstrual haemorrhage. When we remember that the
amount of the flow in all is only from about eight ounces to (at the
utmost) about thirty ounces, the theory that the omission of an
habitual menstruation can give rise to a general plethora must seem
very rash. Most probably vicarious haemorrhages stand in close
relation to a very active general nervous and circulatory excite-

DISEASES OF THE TJTERUS.

ment, accompanying ovulation, under the influence of which bleed-
ings may take place at points predisposed to it, both when the
menses are absent and when they are present.

The direct treatment of amenorrhcea by emmenagogues has un-
dergone great limitation of late years. Many of the ancient physi-
cians (mistaking cause and effect) were disposed to ascribe divers
disorders to amenorrhcea as a cause, and to consider the reestablish-
ment of the menstrual flow a matter of great importance ; where-
as, in many a broken-down subject, it is rather to be wished that
she may not be still further prostrated by loss of blood. Some-
times, however, in exhausted, bloodless patients, the growth of the
Graafian vesicle is arrested, and the periodical ovulation with its
uterine hyperaemia does not take place. Such amenorrhceas, arising
from defective nutrition and anaemia, can only be successfully
treated by allaying the main disease by tonics, iron, strengthening
diet, fresh air, and the like. All the different emmenagogues pos-
sess in common the property of inducing hyperaemia of the pelvio
organs, and especially of augmenting a congestion which already
exists, and thus of producing a haemorrhage. This object is most
certainly obtained at the time when the menses should naturally
return. This period is not, however, invariably one of twenty-
eight days ; for it may vary by several days in the same woman.
Accepting the results of recent researches, that menstrual flow does
not proceed from engorgement alone, but is also the effect of a fatty
degeneration and exfoliation of the uterine mucous membrane, it
becomes impossible to admit that the flux can be induced by em-
menagogues at any other time' than that of nidation.

Artificial induction of the menstrual flow may be called for
when certain disturbances (pain in the back, local congestion, and
the like) which normally accompany menstruation indicate a con-
gestion of the pelvic organs, and that the haemorrhage which should
promptly relieve them has failed to arise. Measures calculated still
further to augment the hyperaemia of the womb may then be re-
sorted to to bring on the bleeding. These are irritating foot-baths,
warm sitz- or full-baths, dry cups or mustard-plasters to the thighs,
a hot or even a cold douche to the sacrum, clysters of aloes, or direct
irritation of the womb by irritating vaginal douches. More rarely,
painting the os with iodine, passage of a sound, or electricity may
be tried ; but we should be slow to resort to the internal exhibition
of aloes or of savin, on account of their undesirable secondary ef-
fects. We must bear in mind, too, that, if we fail to induce the
flow by these means, we may nevertheless so augment the uterine
congestion as to aggravate the existing distress. Hence the use of

ANOMALIES OF MENSTRUATION. 163

emmenagogues is only proper when the amenorrho2a is due solely
to feebleness of the uterine congestion. In other cases the conges-
tion is to be relieved by local depletion, leeches, or scarification of
the vaginal portion, or in virgins by cups applied to the inner side
of the thighs.]

Menorrhagia, or too copious menstrual haemorrhage, has been
already mentioned as a symptom of various structural changes and
of tumors in the uterus. But it also occurs without perceptible dis-
turbance of nutrition, where the escape of blood from the uterus is
hindered in heart and lung diseases, etc., as well as in fluxions in-
duced by irritation of the uterus from sexual excess, perhaps also
by sensual excitement. In very rare cases menorrhagia depends on
a haemorrhagic diathesis, being a symptom of scurvy, purpura
hsemorrhagica, acute infectious diseases, such as hsemorrhagic small-
pox or measles, or of typhus, etc. Where it is due to obstructed
efflux or increased afflux of blood to the uterus, it is usually pre-
ceded by symptoms similar to, but more marked than, those with
which normal menstruation usually begins. Part of the blood
passes off in a fluid state, part coagulates in the vagina, forming
irregular clots ; rarely it coagulates in the uterus, and there forms so-
called fibrinous polypi, such as frequently appear after abortions.
Plethoric patients often bear very decided loss of blood without
injury ; anaemic patients have the symptoms of increased anemia.
The treatment of menorrhagia requires great attention to the origi-
nal disease. The occasional application of leeches to the cervix is
often of surprising benefit in those cases dependent on chronic in-
flammation of the uterus. As soon as the loss of blood is decided
and threatens to impair the strength, it is important to prevent all
bodily exertion and mental excitement, and to keep the patient in a
horizontal position during menstruation. At the same time we for-
bid all stimulating food and drink, and order mineral or vegetable
acids. It will only rarely be necessary to employ cold water or ice-
compresses, or to have recourse to styptics. In some cases, how-
ever, the bleeding threatens life, and then it is necessary to act
energetically, and even to inject hot-water solutions of chloride of
iron, etc., into the uterus.

[The term dysmenorrhcea is applied to the conditions under
which, instead of the trifling disorders which are almost normal,
grave and distressing symptoms arise, especially violent pain in the
back, belly, groins, and thighs, and sometimes sympathetic derange-
ment of remote organs, such as cramp in the stomach, vomiting,
diarrho3a, numbness, headache, dizziness, and convulsions. The
causes of dysmenorrhoea are numerous. It has been assumed that

164: DISEASES OP THE UTERUS.

a menstrual congestion of extraordinary activity might give rise to
pain in the womb and ovaries, by irritating the nerves of those or-
gans (congestive dysmenorrhcea). In other cases we are reduced to
assuming that an unnatural irritability of the nerves — either gen-
eral and combined with hysteria, or else local and limited to the gen-
ital region — is the cause of the suffering (nervous dysmenorrho3a).
But there is no doubt that we more often have to do with organic
disease of the womb or ovaries or other pelvic organs, or with a
fibromyoma, an infarction, a dislocation, or a degeneration of the
ovaries. One form of dysmenorrhceal pain proceeds from spasmodic
contractions which the womb sets up in order to expel some foreign
body from its cavity — a polypus, a blood-clot, or a collection of
liquid blood. The obstacles to the menstrual outflow are stricture
of the cervical canal, either congenital or acquired, acute flexion of
the womb, and growths blocking up the channel ; perhaps also spasm
of the internal os (obstructive dysmenorrho3a). In this form the
pains present a characteristic intermitting type, like those of colic
or like labor-pains, the spasms corresponding with the periods of
uterine contraction (uterine colic); and these attacks, which are
more severe before the flow begins, subside after the contractions
have expelled the stagnant blood from the uterine cavity.

Membranous dysmenorrhoea is a special form of obstructive
dysmenorrhcea. Under normal conditions at the period of deni-
dation, the outer layers of the proliferating mucous lining of the
womb undergo fatty degeneration, and are cast off impercepti-
bly and in minute particles. Sometimes, however, by a morbid
exaggeration of this process, there arises an exfoliation more or less
profound of the mucous membrane, which then comes away in
sheets. Indeed, the entire menstrual decidua may be cast off, in the
form of a complete three-cornered sac corresponding to the form of
the uterine cavity, with its smooth inner surface riddled by holes
(mouths of the uterine glands), and its outer surface rough and rag-
ged. Microscopic examination of the connective tissue of the mu-
cous membrane, and the finding of the glands embedded in it, will
prevent confusion of such an object with a mere fibrinous clot ;
while the more difficult distinction between this process and that of
an early abortion will be aided by the circumstance that the expulsion
of menstrual decidua is seldom confined to a single menstruation,
but is often repeated for months and years, even up to the climac-
teric period.

The chronic metritis and endometritis which often accompany
this form of exfoliative menstruation are regarded by many as the
cause of the process. The affection is attended by colic of greater

KETROUTERINE H^EMATOCELE.

or less violence, according as the expulsion of the membrane and
blood is retarded or accelerated. The diagnosis depends upon dis-
covery of the membrane.

The prognosis and treatment of dysmenorrhcea must of course
depend mainly upon a true understanding of its cause. Obstructive
dysmenorrhcea is best treated by artificial widening of the cervical
canal, either by bloodless dilatation, or else by incision or divulsion,
which give far better results. For details we refer to the text-books
on surgery. In membranous dysmenorrhcea, the objects of treatment
should be the metritis and endometritis, regarded by some as the
causes of the symptoms. When no complication forbids it, after
subsidence of the period we may resort to applications of nitrate of
silver, liquor ferri sesquichloridi, carbolic acid, or tincture of iodine
in the cavity of the uterus, always observing the precautions given
elsewhere. Although the result will probably not be perfect, yet a
thinning oj temporary arrest of the membranous formation may be
obtained. Here, too, in obstinate cases, dilatation of the uterine
neck may facilitate the escape of the decidua, and thus diminish the
uterine colic. Violent pain is to be allayed by opiates, either by
the mouth, rectum, or hypodermic injection, and by hot compresses
to the belly. If there be fever, and the pain assume an inflamma-
tory type, an acute metritis or perimetritis is to be feared, and
proper steps should be taken to meet it.]

CHAPTER X.

RETROUTERINE H^EMATOCELE H^EMATOMA RETRO UTERINTJM — PEL-
VIC H^MATOCELE.

[THE French were the first, and Nelaton was the foremost,
who investigated the subject of retrouterine hsematocele, and fixed
its position as a form of disease. The seat of a hsematoma may be
either within or without the peritoneal sac. The latter is very rare,
occurring from haemorrhages into the areolar tissue surrounding the
cervix and vagina, ..and into that between the folds of the broad
ligaments of the womb. These extravasations do not present any
very definite symptoms, but merely form a tumor of variable char-
acteristics. As regards the intraperitoneal haematoma, of which
alone we now treat, let us premise that it is not every free accu-
mulation of blood in the peritoneal sac that is included under this
term ; for a free collection of blood, like a free effusion of serum,
cannot at first present to the touch a well-defined tumor. "We limit

166 DISEASES OF THE UTERUS.

the term to those bloody effusions which are cut off from the peri-
toneal sac above them, and which are completely enclosed by inflam-
matory exudation and adhesion, so that they may exhibit all the
qualities of a tumor. It is true that a free extravasation, after the
blood has coagulated, may present to the examiner's touch an object
of a certain solidity and firmness ; but it does not offer the resist-
ance opposed by the tensely-stretched walls of the encapsulated
blood-tumor, into the cavity of which more and more blood is es-
caping, nor does it displace the neighboring organs. The effused
blood usually collects in the most dependent part of the peritoneal
cavity, the deep pouch between womb and rectum known as Doug-
las's cul-de-sac. It pushes the womb forward and upward, and the
rectum backward. Douglas's fold is forced downward upon the
posterior vaginal fornix, thus forming a large tumor, which may
even extend upward above the brim of the pelvis.

An anteuterine hsematocele, which is a very great rarity, con-
sists in an encapsulated blood-tumor situated in the shallow anterior
pouch between the bladder and the womb. An intraperitoneal
haematoma may form in one of two ways : Either the haemorrhage
takes place within a closed pouch already formed by previous peri-
tonitic adhesions, or else the bleeding may come first, and the encap-
sulation follow as a result of adhesive peritonitis which the contact
of the effused blood excites in the peritonaeum of the superimposed
coils of intestine. The capsule once closed, a further extravasation
may distend the sac and gradually displace the neighboring organs.

The sources of pelvic haemorrhage are many and diverse, and
during life they can, as a rule, only be conjectured. The bleeding
proceeds most often from the ovarian vessels, and the insignificant
physiological loss of blood which accompanies rupture of a Graafian
vesicle may be aggravated into a profuse and alarming haemorrhage.
This may take place as a consequence of an excessive hyperaemia of
the sexual organs, caused by violent exertion, or by blows, falls,
mental excitement, masturbation, or coitus. Various diseases of
the ovary, such as inflammation with abscess, bursting of a haemor-
rhagic cyst, or rupture of a superficial varicose vessel, may have a
like effect. In certain disorders of the tubes, so large an accumula-
tion of blood or of inflammatory exudation may form in them as
to result in rupture or perforation of their walls. It is less probable
that the blood can accumulate in the tubes (as it does in the womb
in haemometra), and thence can pass through the abdominal opening
into the peritonaeum in sufficient quantity to form a tumor. It has
long been known that by the bursting of a tubal or extrauterine preg-
nancy, if the resulting haemorrhage is not speedily fatal, a haematoma

RETROUTERINE H^EMATOCELE. 1(37

may form. Rupture of varicose veins of the broad ligaments may
lead to intra- or extra-peritoneal hsematoma, according as the blood
passes into the pelvic cavity or into the areolar tissue between the
serous folds. Finally, the pelvic peritonaeum itself is a not unfre-
quent source of the bleeding. Dolbeau first announced that the
blood might flow from vessels in a pseudomembrane, the product
of a slow peritonitis. Virchow shares his views, which are in some
measure supported by the fact that in a slighter degree a similar
process may take place in men. The predisposing factors in pelvic
haemorrhage are the catamenial periods, the disorders giving rise to
the so-called haemorrhagic diathesis, scurvy, purpura, icterus gravis,
and the haemorrhagic exanthemata. Gynecologists differ greatly as
to the frequence of the affection. Schroeder found it in five per
cent, and Seyfert in seven per cent, of his cases. JBeigcl thinks
that mild cases are very common, but that they run their course un-
detected except by accident. The disease is liable to arise at any
time throughout the whole period of sexual activity ; it is most
common between the ages of twenty -five and forty, and in women
who have borne children.

The formation of a pelvic haematocele is usually preceded by
symptoms arising from the remoter fundamental disturbance which
causes the haemorrhage. The establishment of the haematoma itself
is in most cases attended by unmistakable signs of internal bleeding,
sudden pain in the belly, faintness, pallor, feeble pulse, coldness of
the extremities, nausea, vomiting, and the like. Sometimes these
symptoms recur again and again, whenever, as may happen from
time to time, the bleeding is renewed. The history of an obscure
case of this kind may furnish important data toward forming a
diagnosis. The haemorrhage having taken place, there ensues a
more or less severe peritonitis, excited by the presence of the effused
blood. This has the effect of encapsulating the effusion, unless in-
deed it be already included within an envelope, the result of ancient
adhesions. Then follow the symptoms of pressure and crowding of
neighboring organs by the tumor, tenesmus or impediment at stool,
vesical pressure, and neuralgia from pressure upon the nerves of the
lower extremities or engorgement of the dislocated womb, some-
times of such intensity as to cause metrorrhagia. The most impor-
tant diagnostic test is by vaginal and rectal touch, whereby we may
detect a retrouterine tumor of rapid growth, which often rises above
the pelvic brim, but which also bulges downward into Douglas's cul-
de-sac, and more or less against the posterior vaginal wall. The tu-
mor is soft, elastic, even fluctuating to the touch, but grows more
firm after a few days, when the blood has coagulated. Should re-
61

DISEASES OF THE UTERUS.

absorption take place as the weeks or months go by, it becomes very
hard and uneven, and at the same time shrinks, becoming smaller
and smaller, until it finally vanishes altogether, save a small lump
close to the back of the womb. In unfavorable cases, as when the
hcematoma is very large, the size and tension of the tumor continue
to increase ; the fever, the tenderness upon pressure, and other signs
of local peritonitis are aggravated ; so that a distinction between an
inflammatory exudation and a hsematocele may at this period be
very difficult, unless the sudden onset of the attack and the precur-
sory signs of internal hemorrhage can be taken into account. In
such cases the blood is generally discharged spontaneously through
the rectum or vagina, and the sac may finally close up after grad-
ually evacuating its black, grumous, tarry contents. In exceptional
cases a haematoma proves fatal through sloughing of the sac-wall
and blood-poisoning, or through general peritonitis after bursting
of the sac into the abdominal cavity ; for it would seem that the
altered blood is far more irritating to the peritoneum than that
which is recently effused. Long-continued suppuration of a fistu-
lous sac may finally wear out the patient.

The treatment of a haematoma requires, above all, perfect and
continued rest, and avoidance of anything which can accelerate tho
circulation. If the bleeding persists or recurs, we must apply ice
to the abdomen or insert it into the vagina, at the same time giving
the liquor ferri sesquichloridi internally, and injecting ergotin be-
neath the skin. Should the symptoms of haemorrhage threaten life
itself, transfusion of blood or milk is indicated, as in all other
haemorrhages. Pain is best allayed by hypodermics of morphine.
The inflammatory symptoms and local peritonitis are to be met by
striving, by full doses of opium, to arrest movement of the bowels,
and thus to favor the adhesions by which the haematoma is becom-
ing enclosed. Only after the inflammation has abated should the
bowels be cautiously moved by enemata or by irrigation (Hegar's
method). Gynecologists differ as to the merit of evacuation of a
haematoma by puncture. Since opening the sac entails the danger
not only of renewal of the bleeding, but also of putrefaction within
the sac and its consequences, it should not be lightly attempted, nor
until all hope seems lost of resorption, or else until violent symp-
toms make it seem hazardous to await spontaneous evacuation.
The sac is to be punctured with a small trocar— or, better still, by
the aspirating needle — the entrance of any air being carefully pre-
vented. Puncture is most commonly made through the vagina or
rectum. Should the contents prove to be suppurating or putrid,
the opening must be freely enlarged, and the putrescent matter as

RETROUTERINE ILEMATOCELE.

169

completely as possible removed by disinfectant irrigation, in order
to prevent the consequences of septic absorption.

When the symptoms of a haematoma are mild, and it seems in-
clined toward absorption, the patient is merely to be kept at rest,
with a light, nutritious diet, and impediments to the stools or urine
are to be properly relieved.]

SECTION III.
DISEASES OF THE VAGINA.

IN this section we shall only treat of the inflammations of tho
vagina, leaving the congenital anomalies, tumors, and other diseases
of that organ, to the text-books on obstetrics and surgery.

CHAPTER I.

VIRULENT CATARRH OF THE VAGINA.

ETIOLOGY. — For the pathogeny and etiology of gonorrhceal catarrh
of the vagina, we may refer to what we have said of virulent catarrh
of the male urethra. Anatomically, it is not distinguishable from non-
virulent catarrh, but its course and origin are different. The disease
is not induced by sexual excess, or any other cause than infection with
gonorrhceal matter.

ANATOMICAL APPEARANCES. — In women the chief seat of virulent
catarrh is the mucous membrane of the vulva and vagina ; more rarely
it extends to that of the uterus. But in almost all cases the catarrh
extends to the urethra, and this is important in the diagnosis. The
affected mucous membrane at first shows the changes peculiar to the
most severe form of acute catarrh ; subsequently those of chronic ca-
tarrh. The secretion, which, in the beginning, is usually scanty, sub-
sequently becomes very copious, purulent, irritates the vulva and inner
surface of the thighs, but is only peculiar in that it is the bearer of the
contagion.

SYMPTOMS AND COURSE. — The first symptoms of gonorrhoea in the
female, a feeling of itching and warmth in the sexual organs, and a
scanty mucous discharge, are not very characteristic, and are often un-
noticed. A few days after the commencement of the disease, there are
severe burning pain in the genitals, swelling of the vulva, ardor urince ;
but these troubles rarely become so severe as to interfere greatly with

NON-VIRULENT CATARRH OF THE VAGINA.

walking, sitting, and moving the body. The secretion, wliich in this
stage is yellowish-green, thick, and purulent, often oozes up in large
quantities between the labia ; in the vulva and its vicinity, even to the
anus, we find shallow ulcers, which are not to be confounded with
chancres. We may almost always press pus out of the urethra. Af-
ter the disease has lasted a fortnight or three weeks, the pain abates
and ceases ; the discharge loses its purulent appearance, but continues
a long while till the secretion, which constantly becomes more mucous,
dries up, and loses its power of inoculation.

TREATMENT. — The local treatment, which we preferred to internal
remedies for gonorrhoea in men, is almost exclusively used for the dis-
ease in women. Considering the different seats of gonorrhoea in the
two sexes, it may be readily understood that copaiba or cubebs, whose
active constituents are excreted with the urine, may have an effect on
gonorrhoea in the male urethra that it cannot have on the disease in
the female, where the vagina is chiefly affected. While there is se-
vere pain; we prescribe scanty diet, laxatives, long-continued sitz-
baths, during which a speculum should be left in the vagina, if its in-
troduction be not too painful. If there be no symptoms of inflamma-
tion, or if they have been allayed, we may employ injections of solu
tions of tannin, nitrate of silver, alum, sulphate of zinc, acetate of
lead, etc. Injections of plumbi acet. crystall. 3 iij. — Aquas conj. j, as
recommended by Ricord, are very efficacious ; instead of being inject-
ed, this solution may be poured in through a speculum, and the latter
slowly withdrawn, so that the fluid shall come in contact with all parts
of the vagina. In very obstinate cases we may introduce wads of
charpie, sprinkled with alum, into the vagina, or touch the parts with
solid nitrate of silver.

CHAPTER II.

NON-VIRULENT CATARRH OP THE VAGINA.

ETIOLOGY. — Kolliker and Scanzoni, who have carefully examined
the secretion from the vaginal mucous membrane, both in health and
disease, found perfectly healthy secretion in very few women, and onty
in those who had had no children, and had not frequently indulged in
coitus. It was so scanty that the surface of the mucous membrane was
dnly lubricated by it ; it was nearly as clear as water, fluid, only viscid,
white or yellowish in spots ; it was almost always acid, and, besides a
small amount of pavement epithelium, it contained no noticeable solid
constituents. Shortly before and after menstruation the secretion was
more copious, always fluid, and almost always acid ; at this time ii

DISEASES OF THE VAGINA.

contained more epithelial cells, and, after the cessation of the menses,
as long as it retained its red color, there were more or less blood-cor-
puscles in it. In catarrhal affections they found the secretion either
milky and thin, or more yellowish and thicker. The more opaque,
white, or yellow, the secretion appeared, the more numerous were its
pavement epithelium and young cells (mucous and pus-corpuscles),
often also the infusoria discovered by Donne (trichomonas vaginalis),
and some few fungous filaments and vibriones. Hence we see that
these observers rarely found a perfectly normal secretion, and that
catarrh of the vagina is ( one of the most common of female diseases.
Irritation of the vagina, by sexual excess, is the chief cause of catarrh
of that part, it is true ; but it is often induced by other causes, which
were mentioned when speaking of uterine catarrh. It is particularly
to be borne in mind that catarrh of the vagina, like that of the uterus,
depends as often on constitutional as on local causes. A consideration
of the exciting causes shows that ,this disease must be rare during
childhood ; and this is true, except in the cases where oxyuris have
passed over the perinaeum from the anus to the vagina, and have there
caused great irritation.

ANATOMICAL APPEARANCES. — In acute catarrh we find the mucous
membrane bright red, swollen and relaxed ; in many cases we see
small prominences on it, which give the membrane a granular appear-
ance, and which are not, as was formerly supposed, due to distention
of the follicles, but to swelling of the mucous papillae. Sometimes
these changes affect the entire vagina, at others only parts of it. At
first the secretion is scanty, but, after the disease has lasted a very
short time, it becomes more copious and more or less opaque.

[The inflammation usually spreads all over the vagina, and over
the vulva as well. Sometimes, however, a portion only of the va-
gina is involved. For instance, at the beginning of a vaginal gon-
orrhoea the lower part only will be attacked, while a catarrh caused
by disease of the cervix or uterus will be confined chiefly to the up-
per part of the canal.

Hildebrand describes a peculiar ulcerous form of inflammation
of the upper vagina, caused by loss of the epithelium and slight
hypertrophy of the papillae, and finally adhesion of the vaginal por-
tion to the vaginal walls, so that the fornix vaginae is obliterated,
and the os uteri is to be felt at the top of a funnel-shaped tube.
Schroeder has also seen this disease, which in one case resulted in
complete atresia, in another in partial closure of the vagina below
the vaginal portion, and in a third case in complete contraction
(stenosis) of the entire upper vaginal region.]

In chronic catarrh the walls of the vagina appear distensible and

NON-VIRULENT CATARRH OF THE^AGINA. 173

flaccid. The membrane is m*>re bluish red and its surface more fre-
quently granular than in the acute variety ; the secretion is some-
times more milky, sometimes more yellow and thick. Not unfre-
quently the relaxation of the vagina induces prolapse, particularly
of the anterior wall.

SYMPTOMS AND COURSE. — In non-virulent catarrh also, if it begin
acutely, the patient complains of prickling and burning in the pri-
vate parts ; but, as the mucous membrane of the urethra is unaffect-
ed, she has no pain on urination. In chronic catarrh the discharge
of the abnormal secretion, the leucorrhoea (fluor albus vaginalis), is
often the only symptom of the disease. The chief means of decid-
ing whether the discharge be from the vagina or uterus is by exam-
ination with the speculum. Many women bear the drain without
any injury ; in others it induces anaemia, pallidity, weakness, and
emaciation.

TREATMENT. — In treating non-virulent vaginal catarrh, just as
in uterine catarrh, we must first attend to the causal indications.
But we cannot often cure the disease without accompanying local
treatment. We would chiefly recommend the hip-baths and injec-
tibns mentioned in the last chapter ; in obstinate cases, the introduc-
tion of a tampon sprinkled with alum, and even the application of
solid nitrate of silver.

CHAPTER III.

CROUPOUS AND DIPHTHERITIC INFLAMMATION OF THE VAGINA.

CROUPOUS and diphtheritic inflammations of the vaginal mucous
membrane are common during puerperal fever, but are rare except
in the puerperal state. They either depend on local irritation or on
constitutional disease. Thus, the discharge from a sloughing can-
cer of the uterus, the urine constantly flowing through a vesico-vag-
inal fistula, a bad pessary, or a large uterine polypus projecting into
the -vagina, may induce croupous or diphtheritic inflammation of the
vaginal mucous membrane ; while the disease is also often observed
in the later stages, of typhus, cholera, measles, and small-pox, and
accompanying similar affections of other mucous membranes.
Usually only certain spots of the vagina are covered with croup-
membrane, or changed to diphtheritic sloughs. In the vicinity of
these spots the mucous membrane is dark red ; after the slough has
been thrown off, irregular losses of substance remain ; these are
sometimes superficial, at others deep. Our attention is called to
the disease by severe pain in the parts, and by a fetid, often bloody

DISEASES OF THE VAGINA.

discharge, which begins in a few days. Local examination is the
only means of certain diagnosis. Where a large or putrefied pes-
sary has caused the inflammation, its removal, and the use of luke-
warm, and later of cold and astringent, injections, ordinarily suffice
to cure the disease. The affection usually disappears readily also if
a large polypus, that has forcibly distended the vagina, be removed.
On the other hand, where sloughing cancer or vesico-vaginal fistula
has caused the disease, we must limit ourselves to a palliative treat-
ment. In those cases occurring in the course of infectious diseases,
it is usually sufficient to attend to cleanliness, as the secondary dis-
ease generally passes off with the primary.

DISEASES OF THE NEEVOUS SYSTEM.

SECTION I.
DISEASES OF THE BRAIN.

CHAPTER I.

HYPERJ3MIA OF THE BRAIN AND ITS MEMBRANES.

ETIOLOGY. — For a time the fact was ignored that on autopsy the
olood-vessels within the skull were sometimes found distended and at
others empty, and it was supposed that the amount of blood contained
in the closed cranium of an adult could neither increase nor dimmish, but
was constant; and that anaemia or hyperaemia was only supposable
when the brain-substance was increased or diminished, that is, when
there was hypertrophy or atrophy of the brain. This view was based
on the following reasoning : The brain is not compressible, at least not
by the pressure to which it is subjected from the contents of the
blood-vessels ; and it is surrounded by walls which do not expand ;
consequently only the same amount of blood can enter the skull as
passes out from it, and conversely only as much blood can pass out of
the skull as enters it. This reasoning is false, as it starts with the
supposition that the contents of the cranium consist only of the mem-
branes of the brain, the brain-substance and the blood-vessels with
their contents ; it leaves the cerebrospinal fluid out of consideration.
This, which is a simple transudation, can rapidly increase or diminish,
and can at least partly pass into the spinal canal, which is not entirely
enclosed by rigid walls. In almost all autopsies it may be seen that
the amount of blood contained in the vessels and the amount of cere-
brospinal fluid are in inverse proportion ; that a distention of the ves-
sels of the menmges is accompanied by a decrease of arachnoid fluid,
and conversely that, when the vessels are less full, the meshes of the

176 DISEASES OF THE-BRAIX.

textus cellulosus subaraclmoidealis contain a greater amount of serum.
Only when the brain is atrophied do we find oedema of the membranes
with overfilling of the vessels ; and only when an effusion of blood, a
tumor, or a collection of fluid in the ventricles, has contracted the space
in the skull do we find, along with anaemia, dryness of the membranes,
and disappearance of the sulci between the cerebral convolutions.

The division of cerebral hyperaemia into active and passive, or, to
retain the expressions previously used, into fluxionary and congestive,
is practically valuable not only on account of the consideration being
easier, but because the symptoms of one form differ from those of
another.

Fluxionary hyperaemia results — 1. From" increased heart-action.
It is true that, in this case, while the arteries are fuller than usual, the
veins are less so ; hence the entire amount of blood in the vessels of
the brain and its membranes is not increased by the stronger action
of the heart. But the increased lateral pressure induces increased ful-
ness of the capillaries, and it depends chiefly on these (not on the
amount of blood in the large vessels) whether or not the brain acts
normally and is normally nourished. This form of cerebral hyper-
aemia occurs temporarily from augmented energy of contraction of a
healthy heart, as in fever and great bodily or mental excitement ; it is
habitual in the permanently increased activity of a hypertrophied
heart, but only when the hypertrophy is an independent disease, or in
case it accompanies an obstruction to circulation, when it has become
greater than is necessary for the compensation. Simple, non-com-
plicated hypertrophy of the heart is not frequent, and occurs almost
exclusively in topers and persons who continually do hard work. On
the other hand, hypertrophy that has become greater than was neces-
sary to compensate the obstruction to the circulation is quite frequent.
Examples of this are the occasional enormous hypertrophies of the left
ventricle when there is insufficience of the aortic valves, and perhaps
also the hypertrophy of the heart in morbus Brightii.

2. Fluxionary hyperaemia of the brain results from too slight resist-
ant power of the afferent blood-vessels, whether this be congenital or
acquired. When the cerebral arteries have delicate, thin walls, so
that they yield to an increased pressure of the blood sooner than the
other arteries of the body do, and hence, when the action of the heart
is only moderately increased, fluxionary hyperaemia of the brain is in-
duced, it is customary to say that the person so affected has a tendenc}
to " rush of blood to the head."

3. Fluxionary hyperaemia to the brain results from an increase of
the lateral pressure in the carotids as a consequence of obstructed
escape of blood from the aorta into other branches. As a type of this

HYPEILEMIA OP THE BRAIN AND ITS MEMBRANES. 177

collateral fluxion " to the brain, we may mention the habitual cere-
bral hyperaemia where there is contraction or closure of the aorta at
•the point where the arterial duct terminates in the aorta (Volume I.,
page 363). It frequently results from compression of the abdominal
aorta and its branches, by the distended intestines and by exudations.
In the same way obstruction of the cutaneous circulation during the
cold stage of intermittent fever, and from the action of severe cold,
induces collateral fluxion to the brain. According to Watson, in cold
nights many unfortunates are arrested in the streets for being drunk,
when they are only suffering from cerebral hyperaemia as a result of
disturbance of the cutaneous circulation. It is not improbable that
severe muscular exertion may also induce increased fulness of the
carotids and £uxionary cerebral hyperaemia, by the pressure of the con-
tracted muscles on the capillaries.

4. A fourth cause is paralysis of the vasomotor nerves of the cere-
bral vessels. Physiological experiments show that, if the cervical por-
tion of the 'sympathetic nerve be divided, the vessels on the correspond-
ing side of the head become dilated. The cerebral vessels appear to
be similarly affected by the use of spirituous liquors, by some poisons,
as well as by great emotions and excessive mental activity. I would
particularly call attention to the last cause, as I have frequently seen
dangerous .hyperaemia of the brain after too prolonged mental labor,
which resulted fatally from the occurrence of oedema. We can hardly
give any other explanation for these cases, than that the walls of the
vessels are paralyzed by the above influences, their calibre dilated, and
the supply of blood consequently increased.

5. Lastly, fluxion to the brain results from atrophy of that organ.
The space left in the skull by the disappearance of the brain-substance
is partly filled by the dilatation of the vessels. We shall find this
dilatation of the vessels to be a frequent cause of their rupture ; and,
as atrophy of the brain often follows apoplexy, it is also a cause of
returns of apoplexy. We shall not attempt to say whether or not the
fluxionary hyperaemia of the brain, occasionally observed during con-
valescence from severe disease, is the result of atrophy of the sub-
stance of the brain or of the neuroglia and consequent dilatation of
the vessels.

Passive hyperaemia, congestion of blood in the brain, depends —

1. On compression of the jugular veins and vena cava descendens.
As a type of this form, we may mention the excessive cerebral con •
gestion caused 'by strangulation. The jugular veins are most fre
quently compressed by enlarged thyroid or lymphatic glands, the vena
cava descendens by aneurisms of the aorta.

2. Congestion of the brain results from energetic expiratory move-

178 DISEASES OF THE BRAIX.

ments while the glottis is contracted. In coughing, straining, playing
wind-instruments, etc., as we have often shown, the flow of blood into
the thorax is hindered ; the pulmonary circulation contains too little,
the general circulation too much blood. Under such circumstances,
the brain must sufler far more from hyperaemia than other organs sup-
plied by the general circulation, particularly the liver, spleen, and
kidneys ; because the passage of blood through the upper aperture of
the thorax is more impeded than it is through the lower, since these
abdominal glands undergo the same compression from the abdominal
muscles that the veins of the thorax and the heart do.

3. We have cerebral congestion in all those diseases of the heart
where the function of that organ is impaired, if they are not compli-
cated by other anomalies of. opposite effect, and so compensated. In
non-compensated valvular disease of the left ventricle, the whole
amount of blood in the vessels of the brain and its membranes is not
increased, it is true, since, while the veins are overfilled, the arteries
are less full ; but the overfilling of the veins obstructs the flow of blood
from the capillaries, thus inducing capillary hyperaemia, which, as we
have shown, is the most important cause of the cerebral hyperaemia.
The affection caused by valvular disease of the right heart is far greater
than that from valvular disease of the left heart ; for, in the former
case, not only is the escape of venous blood from the brain impeded,
but the entire amount of blood in the skull is increased.

4. The same state of affairs occurs in extensive compression or
atrophy of the vessels of the lungs as in pleuritic effusions, emphy-
sema, or cirrhosis of the lungs. In these diseases also, when the right
ventricle is not hypertrophied in proportion to the impediment to the
circulation, the systemic circulation is overloaded at the expense of the
pulmonary, and the amount of blood in the skull is increased. Since
the contents of the cerebral veins and -sinuses cannot pass into the
overfilled jugular veins, the same excessive cyanosis occurs in the brain
that is so evident in the skin, and which is almost pathognomonic of
the diseases in question. The last stage of emphysema gives us an
excellent opportunity of studying the gradual development, steady in-
crease, and, finally, the severest symptoms of congestion of the brain.

Lastly, we must mention a form of cerebral hyperaemia which is
neither fluxionary nor congestive, and which is peculiarly important, as
it should be very carefully avoided by persons suffering from disease of
the blood-vessels, and having a tendency to apoplexy ; I mean those
cases of hyperaemia that appear as one symptom of temporary general
plethora induced by a very free supply of food and drink.

ANATOMICAL APPEARANCES. — On post-mortem examination, it is
often difficult to decide whether the vessels of the cerebral membranes.

HYPER J3MIA OF THE BRAIN AND ITS MEMBRANES. 179

and still more so whether those of the cerebral substance, have been
more than normally filled with blood during life. Mistakes in the
account of the autopsy are frequent.

The mistakes regarding the amount of blood in the cerebral mem-
branes depend partly on the fact that, when unaccustomed observers
find the vessels much distended at the dependent parts of the surface
of the brain, they diagnose a hyperaemia of the cerebral membranes,
even if the blood has only sunk downward, and the vessels in the upper
part be empty. Still more frequently another error is committed even
by practised observers : that is, from a similar distention of the vessels
on the convex surface of the cerebrum, hyperaemia of the cerebral
membranes is decided on without looking further. It should be borne
in mind that the arteries supplying the cerebral membranes with blood
lie at the base of the brain, and that only very fine arterial twigs reach
the convexity of the greater hemispheres. All the large blood-vessels
usually seen on the surface of the brain, when the skull is opened, are
veins. Distention of these veins is a normal appearance, if the indi-
vidual has died of an acute disease by which his blood was not con-
sumed, or, if he has. died suddenly from suffocation, acute poisoning,
or from some other accident involving no loss of blood. Hence it is
entirely wrong, in such cases, to decide, from the overfilling of the
veins, that there has been hyperaSmia of the brain or its membranes
during life, and to connect this pretended hyperaemia with the symp-
toms that have been observed. In the history of the post mortem^
accounts of excessive hyperaemia of the brain and its membranes are
often combined with others of a similar excessive hyperaemia of the
lungs, liver, kidneys, etc. If there were no mistake here, did we not
have to suppose that, in the body of a previously healthy person, who
had died neither from exhausting disease nor loss of blood, the normal
amount of blood was often considered pathological, these accounts
of post mortem would only convey the absurd idea that the entire
amount of blood in the body was increased by poisoning, suffocation,
etc. We must make it, a rule to consider hyperaemia of the cerebral
membranes as proved only in those cases where the finest vessels also
are injected, and where the overloading of the cerebral vessels is not
at all in proportion to the amount of blood in other organs.

The great difficulty of detecting, in the cadaver, a hyperaemia of the
substance of the brain, that has existed during life, depends chiefly on
the fact that the first fine ramifications of the vessels supplying the
brain take place in the pia mater, and that the vessels passing thence
to the substance of the brain are mostly capillary (iMSchka). As
these can scarcely be recognized with the naked eye, it is customary
to use the size and number of the drops of blood oozing up on a cut

180 DISEASES OF THE BRAIN.

surface of the brain as a means of determining the amount of blood
contained in the cerebral vessels. I do not deny that this sign has
some value, particularly in judging of passive cerebral hyperaemia;
but I must add that the size and number of these drops of blood de-
pend far more on the fluidity of the blood than on the fulness of the
vessels. At all events, in cases where there can be no doubt of death
having resulted from increased flow of blood to the head, or from its
obstructed escape thence, on a section through the brain, its substance
is often found very pale, and on its cut surface only a few small blood-
drops ooze up. This circumstance, and the symptoms of paralysis
occurring in the severer cases of cerebral hyperaemia (of which we shall
speak more fully in the next paragraph), cause it to appear to me very
probable that, when there is increased lateral pressure in the small
arteries and veins of the brain, a transudation of serum from them
into the perivascular spaces and interstices of the brain may very
readily take place, and cause compression of the capillaries. It is only
in yielding and distensible organs and tissues, which are not enclosed
by firm envelopes, that any considerable cedema can coexist with a
normal fulness of the capillaries. In all tissues enclosed by fascia or
other firm capsule, cedema causes anaemia of the capillaries. If the
size of the brain be not diminished by atrophy, and if the skull be
closed, or, it remaining opened, if the dura mater be tense, there is no
doubt that a sh'ght transudation of serum will suffice to completely
compress the capillaries of the brain. It is true, we cannot be sure,
from post-mortem examination, that there is such a secondary cedema ;
but the supposition that such is the case appears to us perfectly justi-
fiable when a patient has died with the symptoms of cerebral paralysis,
and if, on autopsy, we find that the very white hue of the brain-sub-
stance and the slight number of small blood-points appearing on its
cut surface contrast strongly with the distention of the large vessels
in the meninges.

Where the hyperaemia is often repeated, atrophy of the brain and
decided dilatation of the vessels result. The vessels of the meninges,
which are unmistakably dilated, run a tortuous course; on section
through the brain, we may distinctly see the gaping mouths of the
vessels; the dilatation may even be observed in the capillaries on
microscopical examination. There is plenty of serum in the sub-
arachnoid spaces, the brain-substance is moist and shining. This ap-
pearance, which is frequent in topers, is readily understood, if we
remember that, in atrophy of the brain, the fluid contents of the skull
must increase so as to fill the cavity. It is doubtful whether the de-
velopment of the Pacchionian bodies can also be considered as a result
of repeated hyperaemia; they are sometimes solitary, sometimes

HYPEILEMIA OF THE BRAIN AND ITS MEMBRANES. 181

grouped as whitish, opaque excrescences of the arachnoid, coming par-
ticularly along the sides of the longitudinal sinus. The pressure that
they exercise on the dura mater separates its filaments, so that they
perforate it ; by further pressure they also cause atrophy of the bone,
and they are then found embedded in little fossse in the skull. Micro-
scopically, they consist of connective tissue ; occasionally they contain
fat and chalky salts.

SYMPTOMS AND COURSE. — Before taking up the symptomatology
of hyperaemia of the brain, I shall warn against the wide-spread error,
so injurious to the patient, of considering all cases of disturbance of
function of the brain, where severe structural changes can be excluded,
as due to hyperaemia (or anaemia).

Thus, the disturbance of the cerebral functions in fever is not due
to increased afflux of blood to the brain from excited action of the
heart ; but, as we have repeatedly pointed out, it depends partly on
the high temperature of the blood in the cerebral vessels, partly on its
abnormal quality, the " feverish state," a necessary result of the in-
creased transformation of tissue during the fever. Delirium and other
severe cerebral troubles are most common in the so-called asthenic
fevers, just where the increase of bodily temperature and the produc-
tion of warmth attain the highest grade, while the heart's action is
hastened, but weakened, and there is no fluxion to the brain.

According to the observations made during the last war, as well
as from the valuable investigations and experiments of Obernier, the
symptoms of sun-stroke, or insolatio, do not, as was formerly sup-
posed, depend on hyperaemia of the brain, induced by the action of
the sun's rays on the head. The symptoms of this disease consist in
a paralysis of all the functions of the brain, occurring either suddenly
or gradually. In the latter case the paralysis is preceded by excite-
ment, delirium, and other symptoms of cerebral irritation. It has been
determined that, in our zone at least, the action of the sun's hot rays
is not alone sufficient to induce these severe attacks, but that they
only occur when individuals are subjected to great fatigue, on a very
hot day, particularly if, at the same time, they sweat very little, be-
cause they do not drink enough. We may assume that, under such
circumstances, while the radiation of heat is limited on account of the
high temperature of the surrounding atmosphere, while the production
of heat is increased by the active muscular exercise, and the coolness
induced by free perspiration is limited, there is an overheating of the
body, an increase of the bodily temperature to a height incompatible
with life. "We have already sufficiently explained the significance of
the fulness of the veins of the meninges, which is found on autopsy ic
cases of sun-stroke.

182 DISEASES OF THE BRAIN.

[The condition known under the term " sunstroke," or better,
" heatstroke " (for the direct action of the sun's rays is by no means
essential to it), used formerly to be ascribed to a hyperaemia of the
brain ; a belief which has now been completely exploded by experi-
ments upon animals and by post-mortem examinations. It is now
known, from the researches of Obernier, that in this disease there is
a serious derangement of the heat-producing function and a great
rise in the bodily temperature, which in extreme cases may reach
109° or 110° Fahr. Absolutely nothing as yet is known, however,
of the anatomical lesions upon which sunstroke depends. It was
formerly ascribed to grave alterations in the blood, to its over-acidity
by overloading with carbonic and lactic acid, to destruction of its
red corpuscles, to accumulations in it of urea, and the like. Koester
in one case has found a haemorrhage in the right superior sympa-
thetic ganglion, and in the right sympathetic itself, as well as
smaller extravasations about and in the two vagi, and thinks we
should look for the derangements in the vasomotor and respiratory
nervous systems. Arndt seeks for an anatomical basis for the disease
in the so-called "turbid swelling" (trilben Schwettung) developed
in the brain, liver, kidneys, and other tissues, under the influence
of the enormously high temperature, just as it occurs in high fever
from other causes. The different symptoms presented during life
may depend upon the degree in which the turbid swelling has at-
tacked individual organs. In milder cases the temperature is below
104° ; the mind is muddled, the chest oppressed and uneasy, the pulse
very frequent, the heat great, the skin moist, and there is a general
but moderate feeling of languor. . If relief cannot be gained through
water-drinking and quiet, graver symptoms appear. The temper-
ature then rises above 104°, the pulse to 130 or 140 ; the sweating
becomes profuse and the thirst distressing. The patient loses con-
trol over himself,- and is oppressed by fulness of the head, dizziness,
sensory delusions, and precordial distress. He is forced to sit down,
or else sinks suddenly unconscious, and lies with flickering imper-
ceptible pulse and sunken features. Sometimes there are epilepti-
f orm fits. Although under proper treatment many very severe cases
recover, yet the number which end fatally, particularly during the
marches of armies in hot weather, is sometimes large. Many pa-
tients improve at first, and then relapse unexpectedly. This fact, as
well as the experience that recovery after sunstroke is slow, that it
has many sequelae, such as vague pains, disposition to faint, indi-
gestion, unnatural drowsiness, and the like, which are often obsti-
nate, and the circumstance that sometimes there remains a psychical
irritability or a permanent impairment of intellectual function, all

HYPEILEMIA OF THE BRAIN AND ITS MEMBRANES. 183

indicate that the disorder has a definite material basis, which in bad
cases is not always repaired.]

Lastly, the symptoms of acute alcoholic poisoning, as well as that
from opium and other narcotics, do not depend at all, or at any rate
depend to a very small extent, on over-fulness of the cerebral vessels,
although in them the brain is hyperaemic. The case appears to be
different in the symptoms induced by the immoderate use of liquor
for a length of time, or the continuous misuse of narcotics, a practice
which has greatly increased since the introduction of subcutaneous
injections of morphine. In such cases cerebral hyperaemia plays a
more important part, at least, than it does in the symptoms of intoxi-
cation and of acute opium-poisoning.

[Abnormal fulness of the brain and its membranes is a common
enough affection. Its symptoms may vary greatly. Not unfre-
quently they are so insignificant as to attract little or no attention ;
so that many persons with habitual plethora about the head are fa-
miliar with the sensation which it causes, and do not consult a phy-
sician. But there are other cases in which hyperaemia causes symp-
toms of the utmost gravity ; and between the mere sense of giddi-
ness after stooping which one man may feel, and the formidable —
nay, fatal — apoplectiform seizure which may befall another, there is
a long series of interchanging types, whose differences, however, by
no means always correspond to differences in grade of the hyperae-
mia. Most of the symptoms bear the character of a morbid nervous
excitement with exaltation, although others take on the form of
depression and paresis. The psychical, the sensory, or the motor
functions may be especially disturbed, according to the seat of the
hyperaemia and to the receptivity of the individual. One might at
first suppose that the symptoms of an active hyperaemia of the brain
should be widely different from those of a passive congestion ; since
in the first there is an increased afilux to the brain of arterial blood,
the constant supply of which is so essential to the continuance of
the brain-function, whereas in the latter this arterial supply must be
more or less diminished, and the symptoms of carbonic-acid poison-
ing should also be present. But in reality the two forms of hyperse-
mia bear a close resemblance ; and this is due to the fact that a lack
of blood in the brain is capable of causing like symptoms with those
from overloading of the brain with arterial blood ; and it is well
known to the practitioner that the distinction between cerebral hy-
peraemia and cerebral anaemia may present obstacles at the bedside
only to be surmounted by prolonged observation of the patient.

The symptoms of the mildest grade of hyperaemia of the brain
consist in a feeling of pressure and weight in the head, or of an
62

DISEASES OF THE BRAIN.

actual headache, often accompanied by dizziness and an extraordi-
nary susceptibility of the special senses. There is a buzzing in the
ears, and a dazzling light before the eyes. This latter usually be-
gins at a spot in the eccentric field of vision, with a quivering as
though smoke were rising. It advances to the middle of the field,
obscuring the whole, and renders accurate seeing impossible. The
part first affected begins to clear, and in half an hour all is over.
The arteries of the eyeball are branches of the internal carotid, and
would naturally participate in an intracranial hypersemia. Hence,
in an obscure case the ophthalmoscope should aid us.]

Hyperaemia of the brain is marked partly by symptoms of increased
excitability of the nerve-filaments and ganglion-cells and by their mor-
bid excitement (symptoms of irritation), partly by symptoms of dimin-
ished or lost excitability of these nerve-elements (symptoms of depres-
sion). Usually the symptoms of irritation precede those of depression,
in other cases the former do not occur, and the latter begin from the
outset. It is commonly supposed that this difference of symptoms
depends on difference of pressure on the brain from the more or less
distended blood-vessels, and reference is made to the analogous action
of the peripheral nerves, which are also irritated by a moderate pressure
and paralyzed by a stronger one. This explanation appears very suit-
able as regards the symptoms of irritation. Experience shows that
nerves, passing through bony canals in company with blood-vessels,
are thrown into a state of increased excitability and morbid excite-
ment by overfilling of these vessels ; the nerve-elements of the brain,
enclosed by the dura mater and skull, are in a like condition when the
cerebral vessels are overfilled. On the other hand, the reference of
the symptoms of paralysis to an increase of the " intra vascular pres-
sure " appears to me erroneous, for even in the severest forms of hy-
peraemia this pressure does not nearly approach the grade necessary
to induce paralysis of a peripheral nerve. In support of the above
view, it has been said that paralysis is also caused by the scarcely
greater " extravascular pressure " of small extravasations on the brain ;
but I shall hereafter show that the apoplectic symptoms from cerebral
haemorrhage do not depend on contusion of the brain from the extrav
asation. It is much more probable that the symptoms of depression
and paralysis arise because the requisite supply of arterial, oxygenated
blood to the nerve-filaments and ganglion-cells of the brain is limited
or entirely stopped in excessive cerebral hyperaemia. In congestive
hyperaemia the escape of venous blood from the brain is checked ; and
it is evident that, when the veins finally become filled to a certain
point, no new arterial blood can enter the capillaries. It is often as-
serted that the symptoms of cerebral hyperaemia are very similar to 01

HYPERAEMIA OF THE BRAIN AND ITS MEMBRANES. 1Q5

exactly identical with those of cerebral anaemia ; this is true in regard
to congestive hyperaemia and anaemia, and the explanation of the cor
respondence is easy. In both cases the brain lacks its new supply of
arterial blood. To explain the symptoms of paralysis occurring in
fluxionary hyperaemia also, we must take the hypothesis that, during
its course, there is a secondary oedema of the brain, as a result of
which we have capillary anaemia, a condition directly opposite to the
original hyperaemia. The symptoms of cerebral hyperaemia are ren-
dered more varied by the fact that, in different cases, the irritation or
paralysis is more prominent at one time in the sensory, at another in
the motory, and again in psychical functions. We cannot give any
satisfactory explanation of this difference.

Among the symptoms of irritation in the sensory functions are
headache, great sensitiveness to external impressions, and simple sub-
jective impressions from the nerves of special sense. The headache,
a very frequent symptom1 in #11 cerebral diseases, is very difficult to
explain ; we do not even know if it is of central origin (that is, if it
originates in the parts of the brain where irritation causes symptoms
of pain after the insensible greater hemispheres have been removed),
or whether, as I think is more probable, it depends on irritation of the
filaments of the trigeminus going to the dura mater. The great sen-
sitiveness to impressions on the senses depends on the increase of ex-
citability caused by the cerebral hyperaemia on the hyperaesthesia of
those portions of the brain through which peripheral irritations are
perceived. The patients do not exactly feel, see, and hear more sharply
than ordinarily, but they are annoyed by irritations far weaker than
such as usually annoy them. Light troubles them ; a slight sound, or
an insignificant irritation of the nerves of touch, excites disagreeable
feelings. Morbid excitation (which must not be identified with in-
creased excitability) of the same central parts causes the dazzling be-
fore the eyes, seeing sparks, roaring and buzzing in the ears, the sen-
sation of formication, or of undefined pain, which are not induced by
peripheral irritation. Among the motory symptoms of irritation we
have restlessness, sudden starting, gnashing the teeth, crying out,
without the expression of pain, the automatic movement of the ex-
tremities, twitching of single muscles, and lastly the general convul-
sions which are observed in the course of cerebral hypersemia. In re-
gard to the first of these symptoms, particularly the restlessness, the
constant tossing around in bed, we may often be doubtful whether it
depends on increased excitability of those portions of the brain through
which the motor nerves and muscles are excited and motions induced,
or on morbid states of excitement in the organs affected. On the
other hand, there is no doubt that the twitching of individual muscles,

186 DISEASES, OF THE BRAIN.

occurring independently of mental influences, and convulsions affecting
the whole body, are the results of a morbid excitement of the cerebral
motor centres. It is very remarkable that general convulsions occur-
ring in cerebral hyperaemia and other affections of the brain, as well
as in epilepsy and eclampsia, are not accompanied by other symptoms
of cerebral irritation, but, on the contrary, are constantly combined
with symptoms of cerebral paralysis, especially with complete loss of
consciousness. By a series of valuable experiments, JZussmaul and
Tenner have shown that the same combination of general convulsions,
with loss of consciousness, may be induced by artificially obstructing
all the arteries supplying the brain with blood ; but it is entirely un-
explained, and it is enigmatical, how it happens that the same patho-
logical process induces a state of the greatest excitement in some parts
of the brain and paralysis in others. Until this contradiction is ex-
plained, the investigations as to whether the above symptoms depend
directly on the lack of oxygenated blood, or indirectly on changes oc-
curring in the blood, which remains unrenovated on account of the ob-
struction, are of little value. Since these attacks of convulsions are
constantly accompanied by symptoms of paralysis, and since we do not
believe that the latter can proceed from the pressure of the distended
vessels on the nerve-elements of the brain, and, lastly, since we may
artificially induce loss of consciousness and general convulsions by
preventing the flow of arterial blood to the brain, we consider the fol-
lowing decisions justifiable: The general convulsions and loss of
consciousness occurring during hyperaemia of the brain, which are usu-
ally termed epileptiform attacks, either occur because in passive hy-
peraemia the veins become so full that more arterial blood cannot en-
ter, or because the hyperaemia has induced a transudation of serum
into the perivascular spaces and interstitial tissue of the brain, with
consequent anaemia. Among the symptoms of psychical irritation,
there is first such a rapid change and loose connection between the
thoughts, that clear thinking is impossible. Along with this confusion
of ideas, the patient often has false notions about himself and the out-
side world, or delirium.

Delirium is sometimes so real and intense that the patient cannot
distinguish it from true perceptions. This is the origin of hallucina-
tions and illusions. By the former we understand erroneous impres-
sions, which are considered as the product of direct perceptions, with-
out there being any actually existing external object corresponding to
the impression. The patients think they see animals and other ob-
jects which are not present, and that they hear voices when all is
quiet. By illusions, on the other hand, we understand the misappre-
hension or false interpretation of external objects which reallv exist.

HYPERAEMIA OF THE BRAIN AND ITS MEMBRANES. 187

As a result of illusion, the most harmless things may become objects
of great terror to patients suffering from hyperaemia of the brain, par-
ticularly to children. Dizziness^ which is one of the most frequent
symptoms of hyperaemia of the brain, and of many other cerebral dis-
eases, is, as a rule, a simple hallucination, since it consists in a vivid
representation of a movement of the body of the patient himself, or of
the bodies of surrounding objects which the patients imagine they see
or feel, although they are actually at rest. "We shall hereafter speak
of other forms of dizziness. Closely related to the symptoms of in-
creased mental excitement are sleeplessness and the disturbance of
sleep by vivid dreams, symptoms which are very common in hyperae-
mia of the brain.

Among the symptoms of depression observed in the sensibility in
cerebral hyperaemia, we must first mention a certain insensitiveness, a
tolerance to external irritation, bright light, loud noise, etc. There is
no reaction to slight irritation. On an increase of this in complete anaes-
thesia to complete cerebral anaesthesia, the patients do not perceive
even the severest irritation. The excitability of the portions of the
brain through which external impressions are perceived is lost. The
motor symptoms of depression are decided slowness and sluggishness
in the motions of the patients ; " their limbs are as heavy as lead."
If this state increases, there is complete inability to make any volun-
tary movement (cerebral paralysis). The excitability of the motor
centres is extinguished. The psychical symptoms of depression are :
loss of interest, and indifference ; great slowness of thought, and limi-
tation of the ideas; inclination to sleep, from which the patient is
aroused with difficulty, and subsequently cannot be aroused at all.
When this state is increased to the highest point, consciousness is com-
pletely lost.

In hyperaemia of the brain there is not unfrequently, also, a devia-
tion from the normal in those movements that are excited by the cere-
bral nerves, independently of the will. Thus, in states of irritation the
pupil is contracted, because the oculo-motor nerve is more excited ; in
depression it is dilated, because then the sympathetic filaments of the
iris act more strongly. In the same way, just as, in physiological
experiments, increased excitement of the vagus causes the heart to
beat slower, while in central paralysis of the vagus, as well as after its
division, the heart's action is more frequent. In paralytic states of the
brain, respiration is often very slow, deep, and stertorous. Although
we cannot give an exact explanation of this symptom, we may still
call attention to the fact that, after division of the vagus in animals,
besides other symptoms, there is always retardation of the respiration.
Lastly, we must mention vomiting as a very frequent and importanl

188 DISEASES OF THE BRAIN.

symptom of irritation of the brain. Without understanding the pro-
cess in the central organs, by which the motions of vomiting are brought
about, we nevertheless know that it is artificially induced in animals
by dividing the vagus, and then irritating the central end.

The above symptoms of morbid excitement, and of increased,
diminished, or lost excitability of the brain, which we shall also meet
in many other cerebral diseases, occur in the most varied groups ill
cerebral hyperaemia. When speaking of general convulsions, we called
attention to the constant coincidence of this symptom, which is due to
morbid increase of excitement in the medulla oblongata, with loss of
consciousness, which indicates loss of excitability of the other central
ganglion-cells and nerve-filaments ; and we must add that, not unfre-
quently we meet other complications of symptoms of irritation with
those of paralysis, in hyperaemia of the brain. For instance, the power
of motion is occasionally lessened while the patient is under great
mental excitement, complaining of headache, sparks before the eyes,
etc. Hence, from the state of the pupil, the slowness or rapidity of the
pulse, etc., we may recognize the state of excitement in which the
central organs of the nerves governing these states are at the time,
but we cannot come to any conclusion regarding the condition of other
parts, or of the entire brain. The variety of appearances, resulting from
the different combination of symptoms, is so great, that Andral has
represented, as different forms, eight different combinations of symp-
toms which appear in cerebral hyperaemia. We shall only give a
short account of the most frequent and important forms.

In many cases of hyperaemia of the brain, disturbances of sensibility,
of an irritating character, are the most prominent symptoms. Such
patients complain of the head feeling contracted, of more or less severe
headache ; they are sensitive to bright light and loud noises ; have
flashes of light before the eyes, and noises in the ears. They go to
sleep with difficulty, and the sleep is disturbed by unquiet dreams. In
severer cases, there are often dizziness and a feeling of formication in
the extremities. The face and conjunctiva are usually reddened, the
pulse full and rapid. But we must not consider these symptoms as
constant ; for, in the most dangerous cases of hyperaemia of the brain,
in those induced by excessive mental labor, continued night-watching,
etc., the amount of blood in the external organs does not at all cor-
respond to the supply in the brain ; and frequently the conjunctiva is
not at all injected in such patients, nor is the face flushed ; on the con-
trary, it is pale. Occasionally the above symptoms only last a few
minutes. In some patients a few glasses of wine, or some hot coffee,
suffice to induce these symptoms of " congestion in the head ; " while
they remain exempt from them if they keep quiet, and avoid excitement

HYPER^EMIA OF THE BRAIN AND ITS MEMBRANES. 189

The symptoms of hypersemia of the bruin in children, where the
motor disturbances are usually greatest, may very much resemble those
of meningitis. The two diseases are often confounded, and occasionally
they can only be distinguished by their course. Such children have
usually suffered from constipation for a few days, have had restless
sleep, gnashed their teeth during sleep, or have been frightened out of
it by dreams, which disquieted them after waking, and prevented their
sleeping again. Then there were vomiting, contraction of the pupil,
and twitching of some of the limbs. But these symptoms are often
only preliminary to far severer ones, which cause great anxiety. They
are followed by general convulsions. In rare cases, these convulsions
also occur without premonition, as the first symptoms of great hyper-
aemia of the brain. The twitching usually begins in one extremity, or
one half the face, and rapidly spreads over the body. Occasionally the
convulsive movements alternate with tetanic contractions, or certain
muscles, particularly those of the back of the neck, are tetanically con-
tracted, while the face twitches, and the extremities are tossed about
by clonic spasms. The children do not respond when called, or when
the strongest irritants are applied to their skin. They are bathed in
perspiration, the abdomen is puffed up, the respiration impaired ; the
saliva, made frothy by the movements of the masticatory muscles, flows
from the mouth. Occasionally there is a pause in the severity of the
convulsions, and we hope the attack will pass off; but, after a short
remission, the spasms begin again with their former severity, and, in
severe cases, the attack may continue, with varying intensity, for many
hours. In one child I saw the spasms last over twenty-four hours,
with only slight occasional interruptions. Still, in the great majority
of cases, the attack ends in half an hour or an hour. In spite of the
terror that patients in this state cause the laity and inexperienced
physicians, we may give a favorable prognosis, if we can exclude a
meningitis. This can usually be done with certainty. Purulent menin-
gitis is, on the whole, a rare disease, which, as we shall hereafter show,
only exceptionally occurs in previously healthy children without pre-
cedent injury of the head, or disease of the cranial bones. Tubercu-
lous basilar meningitis, a far more frequent disease, often escapes ob-
servation till the children have convulsions ; but, if we inquire carefully,
we shall find that the attack has been preceded by a long illness,
and by other symptoms that have been overlooked, or at least under-
valued, which we shall hereafter describe. If the child has been well
the day before the attack, except some 'signs of cerebral hyperaemia ;
if it has had no injury of the head, no otorrhcea, etc., we may be
pretty certain that it will be better, if not quite well, the next day.
The attack is usually followed by a deep sleep, from which the child

190 DISEASES OF THE BRAIN.

awakens fatigued, but otherwise free from threatening symptoms. In
a moderately extensive practice, there is occasion every year to see
cases of cerebral hyperaemia in children, which take the above-described
very regular course. Not unfrequently several children of the same
family will have these attacks at different times, or the same child may
have repeated attacks. It is rare for epilepsy to develop from them ;
but, as we shall hereafter show, repeated hyperaemias may induce
hydrocephalus.

In a third form of cerebral hyperaemia the mental symptoms pre-
dominate to such a degree that the disease is often mistaken, and, to
the great injury of the patient, is sometimes considered as an attack
of melancholy ; at others, as mania. In the former case, after a few
days of headache, disturbance of sensibility, and sleeplessness, the
patients are seized with an undefined feeling of anxiety and disquiet.
They cannot stay long in one place, go about restlessly, are worried,
and are conscience-stricken about slight oversights. There is also
delirium, which has the same character as the above-described frame
of mind, and results from the attempts to explain it. At first the
patients struggle against this delirium, which they occasionally recog-
nize as such, and which they fear, as they think they are " out of their
minds ; " but they soon weary in this struggle, and give it up. In
such cases the sleeplessness is almost absolute; opiates, given by
ignorant physicians, have no effect, or, after the exhibition of this rem-
edy, which is injurious and dangerous to the patient, there is a short,
restless sleep, from which the patient awakes with all the symptoms
increased. In this form of cerebral hyperaemia, which develops chiefly
as a result of excessive mental labor, there is usually frequent pulse
and other symptoms of fever ; but in these very cases a greater amount
of blood in the face, etc., does not correspond to the greater amount
in the brain ; the patients are not high-colored, but are often even pale.
From the fever and sleeplessness they rapidly lose strength, emaciate,
and, if they do not fall into the right hands, they are in great danger
of dying from their disease. Finally, the excitement gives way to
apathy, the insomnia to deep sleep, from which the patient cannot be
aroused, and in which they die. Far more rarely, there is permanent
mental disease.

In other persons, where the psychical disturbance is in excess, it ap-
pears in maniacal attacks, with corresponding delirium. This form is
especially seen after a long-continued excessive use of spirituous
liquors, in that class of topers who for a year will use very little liquor,
but when they have begun to drink do not know when to stop. This
cannot be easily mistaken for an attack of delirium tremens. The
patients are sleepless, run about, fight and bite if they are held, de-

HYPER.EMIA OF THE BRAIN AND ITS MEMBRANES. 191

stroy any thing that comes in their way, cry, laugh, or sing. There is
also delirium of varying character ; usually the patients consider them-
selves as injured and betrayed, and rage against their enemies and
persecutors. The continued muscular exertion throws them into a
perspiration, the heart-beat and pulse are accelerated and stronger,
the face is usually reddened. This form is also very dangerous if it be
mistaken and improperly treated, for then an apoplectic attack, a true
apoplexy, or an excessive hyperaemia of the lung with acute cedema,
causes death. According to my observation, cases exactly like the
following, detailed by Andral, are by no means rare ; in the Mag-
deburg hospital, and in the Greifswalder clinic, I have seen several of
them within a few years : " For several days a middle-aged man kept
up a series of cries sufficient to disturb the whole hospital-ward.
These cries ceased suddenly, and on approaching his bed he was found
dead. He would not have died more suddenly if struck by lightning.
On opening the body, the only lesion found was a lively injection of
the cerebral substance."

Lastly, we must mention those forms of cerebral hypera3mia where
symptoms of general depression and paralysis appear, and by their
sudden occurrence so resemble an apoplexy than an exact diagnosis is
often impossible. In some cases the attack is for a time preceded by
headache, disturbance of sensibility, dizziness, sleeplessness or psychi-
cal disturbances ; in others, it occurs without premonitory symptoms.
The patient suddenly becomes dizzy ; " every thing whirls around with
him ; " he staggers, all looks dark before him ; he loses consciousness
and sinks to the ground, either with or without slight spasm. Such
an attack, where all activity of the brain is lost, may cause death by
the paralysis extending from the brain to the centres of the organic
nervous system. More frequently the patients recover consciousness
after a time, with an indistinct remembrance of what has passed or
without any recollection of it. These apoplectiform attacks, occurring
in the course of hypergemia of the brain, correspond with the above-
mentioned epileptiform attacks, as regards the cerebral anaesthesia and
the paralysis of the psychical functions, and like them appear to
depend partly on obstructed escape of the venous blood, partly on
secondary cedema of the brain. As we have previously shown, both
states prevent the supply of oxygenated arterial blood, which is indis-
pensable for the excitability of the brain and the entire nervous sys-
tem. Traube, who refers the epileptiform attacks in Bright* s disease
also to oedema of the brain, has advanced the theory that an oedema,
limited to the greater hemispheres, induces simple loss of conscious-
ness ; when it affects both the hemispheres and medulla oblongata
there are loss of consciousness and convulsions. We shall not discuss

192 DISEASES Of THE BRAIN.

the correctness of this hypothesis ; it has something seducing about it,
but opposed to it is the fact that, if it be true, the same pathological
change (compression of the capillaries by serous exudation) has a par-
alyzing effect on the greater hemispheres and an irritant effect on the
medulla oblongata.

TREATMENT. — Although, in the treatment of hypersemia of the
brain, general and local blood-letting, cold to the head, and derivation
to the skin and bowels justly enjoy a good reputation, we must not
use one or the other indifferently, or employ all at the same time, in
any case that arises. In fact, there is no disease where it is more im-
portant to fulfil the causal indications, and to attend to the causes of
the disease when prescribing the remedies required by the indications.

In those forms where increased action of the heart and a coincident
diminution of resistance in the vessels of the brain have induced fluxion
to that organ, the same regimen must be observed as was recom-
mended in the first volume, in the treatment of habitual fluxions to the
lungs. If danger threatens, we should bleed ; in such cases venesec-
tion cannot be replaced by ice-compresses to the head, or by leeching
oehind the ears.

If there be collateral fluxion to the brain, we must first of all
attempt to remove the obstructions to the circulation by which the
pressure of blood in the carotids is increased. Evacuating the intes-
tines, by laxatives or by enemata of water and vinegar, often has a
marvellous effect, which is induced by nothing else, both in adults who
are constipated and suffering from headache, tinnitus, dizziness, etc.,
and especially in children where constipation is accompanied by con-
vulsions, etc. If these remedies are insufficient and symptoms of de-
pression occur, from which we fear danger, it is proper to draw blood
here also, in adults by venesection, in children by leeches to the head.

The treatment must be quite different when the cerebral hyper-
aemia has resulted from the continued misuse of alcohol or of narcotics,
or from excessive mental excitement. In such cases nothing is to be
expected from general bleeding, and large venesections are often in-
jurious ; on the other hand, the indications are, to apply a bladder of
ice to the head, or else moist compresses, that have laid under a tin
vessel filled with ice and salt, till they were frozen. In some cases of
this variety derivatives are good ; by these we attempt to remove the
fluxion from the brain by inducing fluxion to the skin, intestines, geni-
tals, or rectum. The most common remedies used with this object are
irritant foot-baths, among which those of ice-water, in which the patient
only passes a short time, are better than those of hot water, with mus-
tard or salt, and wood-ashes. In acute cases, blisters to the nape of
Ihe neck, and in chronic ones the establishment of an issue in the arm —

PARTIAL HYrEILEMIA AND (EDEMA OF THE BRAIN. 193

«ui old remedy, from which I have seen great benefit — and, lastly, the
administration of active purges, are also among the more common
remedies. In acute threatening hyperaemia of the brain, croton-oil is
peculiarly in repute, while, in chronic cases, pills of aloes, colocynth,
jalap, etc., are usually prescribed. If, as occasionally happens, there
be fluxion to the brain, instead of to the pelvis, at the menstrual period,
we may apply leeches to the cervix of the uterus, or cups to the inside
of the thighs. Occasionally, also, the application of leeches about the
anus has a wonderful effect, as is shown by the well-known histories
of the patients that Goethe so much ridicules under the name of
" proktophantasmisten."

In congestive hyperaemia resulting from compression of the jugular
veins or vena cava, as well as in that occurring from heart and lung
diseases, venesection or leeches behind the ears may be employed, if
the obstruction to the flow of blood cannot be removed. We have
shown that congestion, by arresting the supply of arterial blood to the
brain, diminishes or removes the excitability of the brain filaments and
ganglia. The greater freedom of escape we give the venous blood,
the sooner we shall succeed in removing the symptoms of depression
and the paralysis. This may be done by the application of leeches
behind the ears, since this moderates the tension in the veins outside
of the skull, with which the emissaria Santorini communicate ; or by
venesection, by which the tension in the anonymous veins is dimin-
ished, because less blood enters them from the arm. In such cases we
cannot expect any thing from the employment of cold, or from laxatives
and blisters.

In hyperaemia of the brain resulting from too much nourishment,
instant diminution of the quantity of blood may be urgently indicated,
and a well-timed venesection not unfrequently prevents a threatening
apoplexy. It is very important to regulate the mode of life of such
patients, to show them the danger of prolonged, luxurious meals, and to
let them eat little, drink water instead of wine, and walk a great deal.

Of course, in each case, peculiar circumstances will require some
deviation from the plans of treatment advised, and different directions
as to regimen.

CHAPTER II.

PABTIAL HYPEE^MIA AND PARTIAL CEDEMA OF THE BKAIN.

A SHOUT consideration of partial hyperaemia of the brain will de-
cidedly facilitate the comprehension of the symptoms of diseases ol
the brain limited to circumscribed spots.

194: DISEASES OF THE BRAIN.

The causes of the partial hyperaemia are to be sought for within
the skull. Fluxions and congestions result from extravasations of
blood, points of softening and inflammation, tumors, and all other dis-
eases of the brain that affect the circulation at circumscribed spots.
If an artery or a gieat number of capillaries be compressed, or other-
wise closed, there is fluxion in the collateral branches ; if, on the other
hand, a vein be contracted or closed, there is congestion in the capil-
laries supplying it. Of course, there will usually be fluxion at one
place, congestion at another, and anaemia at still others, at the same
time. But the circumscribed diseases of the brain not only induce
hyperaemia by compression of the vessels, but most of them also excite
it by irritation of the surrounding parenchyma. Just as we see hyper-
aemia and oedema result in the vicinity of tumors, inflammations, ex-
travasations of blood, etc., in all other parts of the body, so they also
develop in the brain when it is the seat of these diseases.

On autopsy, it is just as difficult to discover a partial hyperaemia
of the brain as it is to make out a general hyperaemia, particularly if
the hyperaemia has led to oedema, without the oedema having softened
the brain-substance. In some cases, however, in the vicinity of tumors,
points of inflammation, etc., we see clearly that the parenchyma is
more infiltrated and relaxed, or that there have been small extravasa-
tions from the vessels.

The symptoms of partial hyperaemia of the brain are those of irri-
tation and depression, but they are much more limited than the symp-
toms of general hyperaemia of the brain, and come under the head of
so-called local symptoms (" Herdsymptome," Griesinger). Among
these are circumscribed headache, glimmering or sparks before one
eye, or blindness of one eye, contraction or dilatation of one pupil,
noise or deafness in one ear, neuralgia or anaesthesia limited to one
nerve, but especially spasms, contractions, or paralysis, affecting only
one-half of the body, one extremity, or a single group of muscles, and,
lastly, partial disturbance of the mind.

The grade and extent of the partial hyperaemia of the brain vary
with the greater or less amount of blood contained in the organ, and
with the phases and stages of development of the point of disease
that they surround. This explains why the local symptoms depending
on partial hyperaemia of the brain are sometimes more prominent than
at others, or may even disappear and return again. Since, in all severe
structural disease of the brain there is complete loss of function of the
affected part, whether the trouble there be the development of a tumor,
or that the nerve-filaments and ganglion-cells have been broken down
or destroyed by an extravasation of blood, the only symptoms that we
can consider as immediately due to severe local disease of the brain

ANAEMIA OF THE BRAIN AND ITS MEMBRANES. 195

arc partial anaesthesia, partial paralysis, and the loss of certain mental
functions.

If, in the course of an apoplexy, of an abscess of the brain, or of a
cerebral tumor, etc., we have symptoms of partial irritation, as well as
those of partial paralysis, the former cannot possibly depend on the
disease itself, but must be due to the anomalies of circulation in its
vicinity. Moreover, all temporary symptoms of paralysis occurring in
the course of local destructive diseases do not depend on the disease
itself, but mostly on the disturbances of circulation around it. (When
speaking of diseases encroaching on the space in the skull, we shall
show that temporary paralysis may also result in other ways.) The
fact that in apoplexies, tumors, abscesses, etc., where complete or
even partial restitutio ad integrum is not conceivable, paralysis not
unfrequently decreases or entirely disappears, seems at first difficult to
explain, but the explanation is simple when we bear in mind that the
symptoms of paralysis may depend on a collateral oedema in the vi-
cinity of the disease, and that the extent of this oedema varies greatly.

Lastly, the most varied diseases of the brain would induce the
same symptoms, if they had similar locations and extent, if the dis-
turbances of circulation in the vicinity of the different diseases did not
vary. But the disturbances of circulation in the vicinity of a tumoi
are different from those in the vicinity of an abscess, and these again
differ from those about a portion of brain broken down by an extrava-
sation of blood. This, to some degree, explains the difference of
symptoms in different diseases of the brain that have the same seat
and extent.

The treatment of partial hyperaemia is to be conducted on the same
plan as that for general hyperaemia of the brain. If we lessen the
supply of blood, or facilitate its escape, we moderate the local fluxion
or congestion.

CHAPTER III.

ANEMIA OF THE BRAIN AND ITS MEMBRANES.

ETIOLOGY. — For a time the possibility of anaemia ot the brain was
denied, just as that of hyperaemia was, and on the same grounds which
were given in the first chapter. We have already called attention to
the errors in these conclusions, and shall only mention here that, inde-
pendently of the numerous autopsies where the brain has been found
anaemic, Donders^ Kussmaul and Tenner have observed excessive
anaemia through an opening (covered by a glass plate) in the skull of
living animals.

The causes of anaemia of the brain are —

196 DISEASES OF THE BRAIN.

1. Those that diminish the entire amount of blood in the organ.
Among these belong not only abstractions of blood and spontaneous
haemorrhages, but extensive losses of fluid, considerable exudations,
pnd tedious, particularly feverish, diseases. Unfortunately, it occasion-
ally happens that, in internal haemorrhage, anaemia of the brain is mis-
taken for hyperaemia, and treated accordingly. The form of the dis-
ease which, since the time of Marshall Hall^ has been known as hy-
drocephaloid, is particularly common in children who have suffered
from continued diarrhoea. Typical examples of this are not unfre-
quently seen as a result of extensive hepatization in weak persons
with pneumonia. But protracted fevers also consume the flesh and
blood of the patient, induce general poverty of the blood, and, as one
symptom of it, anaemia of the brain. In all of these diseases, blood
and the fluids of the body are lost or used up too rapidly ; on the
other hand, the amount of blood may be diminished by its formation
being limited from insufficient supply of nourishment. Thus, in per-
sons who have died of starvation, the most marked symptoms of anae-
mia of the brain have been observed before death (as Gerstenberg has
described in his " Ugolino," in very vivid terms, it is true, but still
quite accurately).

2. This affection not unfrequently results from the overloading of
other organs with blood. The best example of this form are the cases
where it is induced by the application of JunocTs cupping-boot, by the
injudicious use of which the anaemia may readily become dangerous.
This also explains why, when the heart's action is weak, a person
faints more readily when standing up than when lying down. It is
evident that, in the upright position, the lower extremities will become
overloaded with blood, if the propelling power is insufficient to over-
come the obstruction caused by the weight of the venous blood in this
long course. On the other hand, in diminished action of the heart,
the obstruction from the weight of blood in the short carotid artery
must have a very inferior influence on the occurrence of anaemia of the
brain in the upright position.

3. Another cause is compression or obstruction of the arteries sup-
plying the brain. In almost all of the cases of this class that have
been reported, the obstruction was artificially caused by ligation of the
carotid. In a few cases only the carotid or vertebral arteries were
compressed by tumors or closed by emboli.

4. Cases where, from mental excitement, without lessening of tht*
heart's action, there are paleness of the cheeks and even loss of con
sciousness and other symptoms of insufficient supply of blood to the
brain, seem to indicate that anaemia of the brain may also be caused
by abnormal innervation or spasmodic contraction of the arteries.

ANJ3MIA OF THE BRAIN AND ITS MEMBRANES.

5. Anaemia of the brain is the necessary result of diminution of the
space in the skull by exudations, extravasations, or tumors of the brain
and its membranes. Under this form would come a variety which
does not belong in our domain, that is, the cases of anaemia which
necessarily result from depressed fractures of the skull. We lay pe-
culiar stress on the anaemia of the brain resulting from encroachment
on the cranial cavity, which is the most frequent form of the disease,
because we believe that the so-called symptoms of pressure in apo-
plexy, tumors, the various forms of hydrocephalus, and other diseases
encroaching on the intercranial space, are not immediately referable
to the pressure on the brain-substance, but to the consequent anaemia.
Other observers also, amorg them Traube and Leyden^ have recently
come to my conclusion.

Since it is not merely the presence of blood in the vessels of the
brain, but the supply of oxygenated arterial blood that is indispensa-
ble for the normal functions of the organ, it is evident that, even
where the absolute amount of blood in the brain is not diminished,
but where its circulation and distribution are changed so that only a
small amount of blood enters through the arteries, and but little es-
capes through the veins, the same symptoms must arise as in true
anaemia. And the experiments of JZussmaul and Tenner entirely con-
firm the experience of pathologists, that, in degeneration of the heart
from non-compensated valvular obstruction, and in other diseases im-
pairing its action, there is an overloading of the veins at the expense
of the arteries, and a retardation of the circulation, that is, the same
symptoms that occur in anaemia of the brain.

Lastly, we must mention that, without a diminution of the amount
of blood in the brain, and where that fluid is normally distributed in
the arteries and veins, symptoms very similar to those of anaemia may
result from the blood being too poor in red corpuscles. This symptom
also is readily explained, for we are fully justified in considering the
red corpuscles as the " bearers of oxygen." Now, if this be so, a dim-
inution of red corpuscles will affect the supply of oxygen to the brain,
just as a diminution of the blood would.

ANATOMICAL APPEARANCES. — The substance of the brain is dis-
colored ; the gray substance appears paler and more resembles the
white. The latter is very milky and shining. On section, few if any
blood-points are seen on the cut surface. The vessels of the cerebral
membranes are empty and collapsed. We do not always find a con-
siderable amount of fluid in the subarachnoid space. Kussmaul and
Tenner could not prove, on examination, any increase in the cerebro-
*pinal fluid which, on theoretical grounds, they had expected to find,

SYMPTOMS AND COURSE. — The symptoms of anaemia of the brain

198 DISEASES OF THE BRAIN.

that comes on suddenly, and quickly attains a high grade, differ from
those due to one which comes on slowly and is less severe. In the
former case the patients become dizzy ; every thing appears dark be-
fore them; they become insensible to impressions and incapable of
movement; then* pupils dilate, their respiration becomes slow, and
they lose consciousness ; they sink to the ground, usually with slight
spasms. In most cases the patients come out of this fainting-fit in a
short time; in other cases, usually termed apoplexia nervosa, con-
sciousness does not return, the swoon ends in death. Anaemia of the
brain artificially induced in animals by free bleeding, or by ligation of
all the arteries supplying the brain, has just the same symptoms ; only
the convulsions are usually more severe and more prominent than in
persons whose brain has suddenly become anaemic. The symptoms of
paralysis in sudden, extensive ansemia of the brain are more easily ex-
plained than are the convulsions. The former unmistakably depend
on the arrested supply of oxygen to the brain. It is known that liga-
tion of the abdominal aorta immediately induces paralysis of the lower
half of the body, whose nerves are thus deprived of arterial blood.
But how shall we explain the convulsions? Henle thinks that in
anaemia of the brain the blood from the venous plexuses of the spinal
marrow and the cerebro-spinal fluid from the spinal canal press toward
tne brain, and that the medulla oblongata and parts at the base of the
brain are thus thrown into a state of excitement. But J&issmaul and
Tenner, after ligating the afferent vessels, found not only the greater
hemispheres, but also the medulla oblongata, bloodless ; hence the
convulsions cannot be referred to congestion of the medulla. But it
is just as remarkable, and as contrary to all experience, to suppose
that there should be increased excitement of the nerve-filaments and
ganglion-cells, with consequent convulsions, from absolute anaemia.
Eiissmaul and Tenner distinctly state that, on autopsy of animals
whose cerebral arteries had been ligated, the arteries at the base of
the brain contained a " slight amount of blood," while all others were
found " entirely empty ; " this observation gives a small point on
which to hang an explanation. For we might suppose that the liga-
tion of those vessels caused absolute anaemia in the greater hemi-
spheres and their consequent paralysis, but (from the anastomosis of
the cerebral and spinal arteries) in the parts at the base of the brain
it only induced oligaemia and consequent morbid excitement.

In anaemia of the brain that comes on slowly, just as in hyperaemia,
at first there are usually symptoms of irritation, subsequently those of
paralysis. To explain this correspondence, the hypothesis has been
advanced that a certain tension of the molecules of the brain is neces-
sary for its normal activity and that an increase or diminution of this

ANAEMIA OF THE BRAIN AND ITS MEMBRANES. 199

tension, by too great or too slight a fulness of the vessels, modifies
the excitability of the brain in the same way. I have already said
that this, is a hypothesis, and, I may add, that it is difficult for me to
believe that, in anaemia of the brain, the symptoms of irritation depend
on an inconsiderable, and those of paralysis on a decided, diminution
of the normal pressure of the blood-vessels on the brain. On the other
hand, it is a physiological fact that the excitability of a nerve is in-
creased a short time before it is entirely lost, and that the greatly-
increased excitability of a nerve is not a sign of increased normal nu-
trition, but, on the contrary, of its diminution. It is true we do not
know why this is, but the knowledge that it is so renders it less
strange thac, in gradually-developing anaemia of the brain, symptoms
of irritation should, as a rule, precede those of paralysis, and that,
where the anaemia does not attain a high grade, only the symptoms of
irritation should be seen.

Occasionally the symptoms of anaemia consist chiefly or exclusively
of disturbances of sensibility. The patients complain of severe head-
ache, either in the forehead or occiput ; they are sensitive to light and
sound, have flashes before the eyes, noises in the ears, dizziness, etc.
These symptoms occur most typically after severe metrorrhagia and
other extensive losses of blood, and frequently only the consideration
of the cause, the pulse, color of the skin and lips, and the symptoms of
want of blood in other organs, enable us to decide that there is anae-
mia, and not hyperaemia, of the brain.

In other cases of anaemia of the brain, particularly in children, the
motor disturbances are more prominent. The symptoms of anaemia
of the brain in children from exhausting diarrhoea and other debilitat-
ing causes, so-called hydrocephaloid, often so closely resemble those
of acute hydrocephalus, that the distinction of the two states may be
very difficult. Marshall Hall divides hydrocephaloid into two stages,
one of irritation, one of torpor. In the first stage the children are very
restless and capricious, constantly toss about in bed ; readily fright-
ened, they cry out in their sleep, gnash their teeth ; the face is usually
flushed, the pulse frequent, and temperature elevated. There is al
most always slight twitching of some limbs, frequently also there are
general convulsions. In the second stage the children collapse, be-
come entirely apathetic, no longer attend to objects held before them ;
the eyelids are half closed, the pupils insensible to light ; respiration
becomes irregular and rattling ; finally death occurs with symptoms of
coma. Since we regard the so-called symptoms of pressure in diseases
of the brain and its membranes (among which are effusions into the
ventricles), which encroach on the cranial cavity, as due to compres-
sion of the capillaries and obstruction of the supply of arterial blood
63

200 DISEASES OF THE BRAIN.

to the nerve-elements of the brain, we do not consider the great simi-
larity of the symptoms of hydrocephalus to those of hydrocephaloid as
very strange. Different as are the modes of origin of the two dis-
eases, we believe that in both of them there is ultimately the same
pathological disturbance, that is, capillary anaemia.

Lastly, in anaemia of the brain, morbid symptoms in the mental
functions preponderate ; there are sleeplessness, great excitement, deliri-
um, etc. In some cases this state increases to paroxysms of frenzy and
decided maniacal attacks. The latter are seen in persons who have
had no food or drink for a long time, but they are also not unfrequently
seen in weakly, bloodless patients, if their anaemia has been greatly
increased by exhausting diseases and abstractions of blood.

TREATMENT. — If the anaemia of the brain be one symptom of gen-
eral impoverishment of the blood, this is to be treated by limiting the
consumption and increasing the supply of suitable nourishment. A
consideration of the etiology and other circumstances of each case gives
the indications for treatment. If profound and continued faintness,
convulsions, and other signs of excessive hyperaemia of the brain come
on after extensive loss of blood, even transfusion may be necessary.
In treating the exhausting diarrhoea of infants, we should think early,
of the danger of hydrocephaloid, and attempt to prevent it by giving
raw flesh, wine, etc. If, nevertheless, the symptoms above described
come on, a false interpretation of them is very dangerous. If the
practitioner be misled into applying leeches or employing debilitating
treatment, the children usually die. But if he sees through the con-
dition and, in spite of the restlessness, twitching, and consequent
sopor, gives concentrated broths and large doses of stimulants, cam-
phor, ether, but especially of strong wine, he often attains the hap-
piest and most surprising results. In the form of anaemia of the brain
which occurs as one symptom of general impoverishment of the blood,
it is also very important that, until the normal quantity and quality of
the blood is reestablished, we see that the heart does not receive too
little blood ; and it is just as important for us to combat any tempo-
rary weakness of the heart, that prevents it driving its blood energet-
ically into the arteries. Very many patients, with impoverished blood,
and convalescents die, solely because the physician has neglected to
give them the strictest orders to maintain a horizontal position. If
we permit exhausted patients to rise to stool, or to leave the bed too
soon, the feet are readily overloaded with blood, the heart receives tcxj
little ; consequently a sufficient supply does not go to the brain ; the
patient swoons, and not unfrequently does not awake from the fainting-
tit. On this very point I have had an experience in my private prac-
tice which will always prove a warning to me, not to permit convales-

PARTIAL AN^EMU OF THE BRAIN. 201

cents to leave their beds too early. To prevent the second danger from
temporary lessening of the heart's action in anaemic patients, besides
the horizontal position, we may order irritating remedies both by in-
halation and internally. The patients should not use these remedies
constantly, but only occasionally when they feel an attack threatening.
Indeed, it may be important to have Cologne-water or Hoffman's ano-
dyne instantly at hand on such an occasion. Trephining is occasion-
ally the only remedy for anaemia caused by encroachment on the cra-
nial cavity ; however, in recent times this is very properly limited to
those contractions of the space caused by depression of the cranial
bones. Paradoxical as it may seem on superficial observation, we must,
nevertheless, say that a venesection often has the best effect on the
course of anaemia of the brain due to a contraction of the intracranial
cavity. We shall give the reasons for this assertion more fully when
speaking of apoplexy, and shall only say here, that a venesection
hastens the escape of venous blood from the brain, and thus facilitates
the entrance of arterial blood.

CHAPTER IV.

AND EMBOLISM OF THE CEREBRAL ARTERIES — SOFTENING.

ETIOLOGY. — Partial anaemia of the brain occurs — 1. When the
access of blood to certain sections of that organ is prevented by closure
of the afferent vessels. 2. When collateral oedema develops in the
vicinity of apoplexies, of points of inflammation, and softening, and of
tumors, etc. 3. When the capillaries of certain sections of the brain
are compressed by extravasation of blood, by tumors, or other diseases
contracting the cranial cavity.

In regard to the pathogeny of the first form of partial anaemia of
the brain, which develops in the parts supplied by obstructed arteries,
we must call attention to the following points :

In rabbits, the symptoms of anaemia of the brain do not occur till
both carotids and both vertebral arteries have been ligated. If all
these vessels be not ligated, those that have been left free supply
plenty of blood, and the free anastomosis of the cerebral arteries
among themselves prevents anaemia even of those parts which draw
their blood chiefly from the vessels ligated. In the human being it is
somewhat different ; here, after ligation of one carotid, there is occasion-
ally a symptom which certainly depends on anaemia of one side of the
brain, that is, paralysis of the half of the body on the opposite side.
In other cases of ligation of the carotid in man, this symptom does no!

202 DISEASES OF THE BRAIN.

arise, which proves that in these cases the endangered hemisphere
receives a sufficient amount of blood from collateral branches, particu-
larly through the circle of Willis. The reason for this difference is
not fully known. Hasse thinks that in the former case the continua-
tion of the thrombus from the point of ligation beyond the circle of
Willis prevents the formation of a collateral circulation. On closure
of the internal carotid or of the vertebral artery on one or both sides,
partial anaemia does not generally occur, since a collateral circulation
is usually quickly established through the circle of Willis. On the
other hand, closure of an artery originating above the circle of Willis,
e. g., the arteria fossae Sylvii, almost always induces anaemia of the
part supplied by the obstructed vessel, since here circumstances are
much more unfavorable for the formation of a collateral circulation.

The pathological processes that chiefly induce closure of the arte-
ries of the brain are in some cases compression by tumors, but in most
cases obstruction by thrombosis formed at the spot or by emboli from
some other part.

It is only exceptionally that the blood coagulates in cerebral ar-
teries whose walls are healthy (marasmic thrombosis). As a rule, the
thromboses form at points where, as a result of chronic endarteritis, or,
as is usually said, of atheromatous degeneration, the calibre of one of
the vessels of the brain is diminished and its inner wall roughened.

The emboli by which cerebral vessels are closed are almost always
detached clots of fibrin, that have been deposited, in endocarditis or
valvular disease, on rough parts of the valves, or else portions of the
valves themselves, that have been washed off by the current of the
blood. These rarely come from necrotic points in the lungs, or from
thromboses of the pulmonary vein. In one very instructive case, pub-
lished by JSsmarch, an embolus obstructing the internal carotid came
from an aneurism of the carotid, having been set free by the manipu-
lations during an examination.

We have but little to add in regard to the etiology of this form of
anaemia of the brain. Since the atheromatous affection, which most
frequently causes thrombosis of the cerebral vessels, generally occurs in
advanced age, the stoppage of the arteries of the brain by thromboses
is almost exclusively seen in aged persons, and plays an important
part in the diseases of old age. The case is different with embolism
of the cerebral arteries ; this is seen in young persons also, since en-
docarditis and valvular disease of the heart occur at all ages.

The pathogeny of the partial necrosis, which results in many cases
of thrombosis and embolism of the cerebral arteries, is perfectly evi-
dent. This form of softening of the brain is analogous to the gangrene
of the extremities induced by closure of the vessels. In both cases

PARTIAL ANEMIA OF THE BRAIN. 203

the death of the tissue is due to abstraction of the supply of nutritive
material ; but the necrosed parts within the skull, not being exposed
to the action of the atmosphere, are rarely decomposed. This only
happens when the embolus, that has stopped the vessel, comes from a
suppurating spot, and transfers with it a tendency to suppuration.
Closure of a vessel induces necrosis more readily the later and more
incompletely a collateral circulation is established. If the degenera-
tion of the walls of the vessels that has induced a thrombosis of the
cerebral arteries be extensive, the collateral branches, the elasticity
of whose walls is diminished, cannot dilate sufficiently to supply the
place of any large arteries that may be closed, hence the partial anae-
mia is only partly removed, and the anaemic part softens. Whether
or not closure of a cerebral artery by an embolus shall induce necrotic
softening depends chiefly on the seat of the obstruction, since in such
cases the walls of the vessels are usually healthy and distensible. If,
as rarely happens, there be anaemia in the parts chiefly supplied by a
vessel which has been obstructed by an embolus before reaching the
circle of Willis, it will generally pass off soon, and no necrosis results ;
if, on the other hand, a vessel be closed by an embolus beyond the
circle of Willis, necrosis is the usual termination of the partial ana>
mia.

The second form of partial anaemia of the brain, due to develop-
ment of collateral oedema around an apoplexy, or a point of inflam-
mation or softening, or a tumor, etc., has already been mentioned as
the not unfrequent termination of excessive fluxionary hyperaemia.
When speaking of the different diseases of the brain, we shall fre-
quently recur to this form.

The third division that we have made of partial hyperaemia of the
brain, resulting from compression of the capillaries in certain sections
of the brain by extravasations of blood, tumors, and other diseases
contracting the space in the skull, has hitherto been too little appre-
ciated. Along with the best authorities, I myself denied the occur-
rence of " partial cerebral pressure." From the fact that the brain is
incompressible and is enclosed by an inelastic capsule, I reasoned
that an increased pressure, acting on any part of the brain, would
spread evenly over the entire organ. In support of this view, I ad-
vanced the popular illustration that, if a cork be driven forcibly into a
bottle, the latter is not by any means always broken at the neck, but
just as often at some distance from the point where the force was ap-
plied, perhaps at some particularly weak part. However, a series of
observations where there was no doubt that those portions of the
brain where the disease was located were far more bloodless than the
rest of the brain, and a careful consideration of all circumstances af-

DISEASES OF THE BRAIN.

fecting the space in the skull, have shown me that, in the above rea
soning, I overlooked an important fact and hence came to a false conclu
sion. Indeed, in spite of the brain being incompressible, and being
surrounded by an unyielding capsule, partial pressure on it may occur }
this is so, because the cranial cavity is divided into three chambers by
two tensely-stretched membranes, because the falx and tentorium pro-
tect, to some extent at least, parts of the brain lying on one side of
them from pressure acting on the other side.

The three chambers of the skull communicate with one another, it
is true, and, if the cerebral substance were liquid, pressure on any part
of it would affect the whole organ equally, in spite of the tense septa
traversing it. But the consistence and tenacity of the cerebral sub-
stance, which only permit a slight protrusion of a section of brain
pressed from an opposite chamber of the skull toward the excavation
of the tentorium or the lower border of the falx, cause portions of
the brain lying in one chamber to be protected to some extent from
pressure on those lying in one of the other chambers, in spite of the
openings in the septa, particularly the large opening in the falx. The
protection afforded by the tentorium is greater than that given by the
falx, and the posterior lobes of the cerebral hemispheres are far better
protected against a pressure acting on the opposite hemisphere than
the frontal lobes are, because the falx is much broader posteriorly, and
hangs much farther down than it does anteriorly. In subsequent chap-
ters we shall frequently refer to these circumstances also, whose great
significance in the explanation of the symptoms of disease encroaching
on the cranial cavity I was, to the best of my knowledge, the first to
point out.

ANATOMICAL APPEARANCES. — Partial anaemia of the brain cannot
by any means always be definitely made out in the dead body. The
distribution of blood after death and during life is not the same;
places which, during life, were distinguished by their vascularity from
other less vascular parts, often become just as bloodless as the latter
after death. In the cutis, where we have an opportunity for compari-
son, we may see this daily ; in the brain the state of affairs is just the
same. It is remarkable that emboli are almost always found in the left
arteria fossae Sylvii. Perhaps this is partly because the left carotid ar-
tery leaves the arch of the aorta almost in the direction of the current of
blood, while the innominate forms a considerable angle with it (Rtthle).
The necrosis resulting from obstruction of the vessels and insuffi
cient development of collateral circulation induces relaxation and soft-
ening of the brain-substance; hence necrosis caused by anasmia is
designated as a peculiar form of softening of the brain, as " simple " or
" yellow " softening. Corresponding to the most frequent and obsti-

PARTIAL ANJEMIA OF THE BRAIN. 205

nate obstructions of the vessels, the softening is usually in the greatei
hemispheres and chiefly in their medullary substance. It varies in
size from that of a bean to a hen's egg. The grade of the softening
differs. In the highest grades the cerebral substance, at the point of
necrosis, is found changed to a moist, gelatinous trembling pulp. The
color of the softened point is sometimes white or grayish-white, some-
times more yellowish. In the former case there is usually a reddish
tint about the periphery, due partly to dilatation, partly to rupture of
the capillaries and escape of blood from them. In the first of the
three forms of partial ansemia which we have described, that due to
thrombosis or embolism of a cerebral artery, on autopsy we do not find
the parts supplied by the plugged artery remarkably pale, but they
are not unfrequently studded with small capillary haemorrhages, par-
ticularly at the periphery. This exactly corresponds with what is
found in other organs when there is stoppage of the vessels by throm-
ses or emboli ; but, as we said when speaking of haemorrhagic infarc-
tions of the lung, it is difficult to explain. On account of the difficulty
of deciding whether a portion of brain has been anaemic during life,
we should make it a rule to seek most carefully for any obstruction of
the cerebral arteries, particularly of the arteria fossae Sylvii, in any
cases where the patient has died from a chronic brain disease or from
an acute one beginning with a sudden occurrence of hemiplegia, unless
the autopsy gives some other satisfactory explanation of the symp-
toms. Before attention was called to the occurrence of this anomaly,
autopsy, in cases of severe brain-disease with hemiplegia, often fur-
nished nothing satisfactory. There was nothing left but to suspect an
" intravascular apoplexy," which did not at all explain the occurrence
of the hemiplegia. The yellow color of the affected part often de-
pends on this capillary haemorrhage, and is due to the infiltration of
the disintegrated brain-substance with escaped and altered coloring
matter of the blood. After the disease has existed some time, we
find the affected part changed to a cellular network filled with a
chalky, milky fluid (Durand-FardeV s infiltration celluleuse). On
microscopical examination of necrosed portions of brain, we usually
find only remains of nerve-filaments, granular cells, which correspond
to the ganglion-cells or neuroglia-nuclei that have undergone fatty
degeneration, coloring matter, and masses of detritus.

Partial anaemia of the brain caused by collateral oedema, occurring
in the vicinity of circumscribed disease, can occasionally be recognized
on autopsy by the affected part having a peculiar moist lustre and di-
minished resistance, as well as by its becoming very slightly promi-
nent on a section through the brain. When the disease is more se-
vere, the brain-substance is still more relaxed, and finally a state maj

206 DISEASES OF THE BRAIN.

occur which is usually designated as white (hydrocephalic) softening.
Small capillary extravasations are often found in the vicinity of tu
mors, abscesses, or along with collateral oedema.

The form of partial anaemia of the brain, induced by diseases en-
croaching on the cranial cavity, is the variety most readily recognized on
autopsy. The pressure exercised by large extravasations of blood and
extensive tumors is so great that, not only the capillaries and finer
arteries and veins of the brain-substance, but also the larger vessels of
the meninges, that are subjected to this pressure, are compressed and
bloodless. If the disease be in one of the large hemispheres, this be-
comes more prominent after the skull is opened, so that on the affect-
ed side the dura mater appears more tense than on the other side. If
the dura mater be opened and turned back, we see that the surface of
the diseased hemisphere is remarkably even, that there is very little,
if any, liquid in the subarachnoid space, that the convolutions are
lower, the furrows shallower, and that the vessels of the pia mater are
not so full or are quite empty. Lastly, also, on section through the
brain, we cannot fail to see a decided difference in the two hemi-
spheres in regard to their color and as to the number of blood-points
appearing on the cut surface. In those cases where the falx and
tentorium have to a certain extent given way to the pressure propa-
gated to them, the falx showing a convexity toward the healthy side,
the tentorium being flattened, or, when the disease is in the posterior
cranial fossa, being more strongly curved, it is certain that the capil-
laries are compressed in those portions of the brain where the disease
encroaching on the space is located. But at the same time it is found
that the anaemia does not remain limited to the part first affected, but
extends to other parts subsequently, although to a less extent.

SYMPTOMS AND COURSE. — Anaemia limited to one portion of the
brain induces the so-called " herdsymptome " (page 194) ; if the anae-
mia be absolute,, these consist of symptoms due to complete loss of
excitability in the anaemic portions of the brain ; if it be not absolute,
there may even be signs of increased excitability, or morbid excite-
ment of the affected portion of the brain. In the vicinity of the
anaemia, often even through the entire brain, the circulation is dis-
turbed, so that, besides the direct symptoms of partial anaemia, we
may have those of more or less extensive secondary disturbances of
circulation. However, neither the " herdsymptome," nor the symptoms
of secondary disturbance of the circulation in the brain, nor a combina-
tion of the two, are pathognomonic of partial anaemia of the brain ;
on the contrary, we must distinctly state that each of these also occurs
in many other diseases of the brain. Not unfrequently, we can recog-
nize one or other form of partial anaemia of the brain, and exclude

PARTIAL ANJEMIA OF THE BRAIN. 207

other local diseases there, by basing our diagnosis on the etiological
conditions, the sequence of the symptoms, the existence of symptoms
corresponding to the peculiar frequence of certain forms of disease in
certain sections of the brain, as well as on the course of the disease.

We shall first describe the symptoms of the occurrence and course
of partial anaemia of the brain due to obstruction of the vessels, and
show how it is often possible to diagnose this form of partial anaemia
with probability or with certainty by attending to the inducing causes.
However, the etiology of thrombosis of the cerebral vessels differs
from that of embolism, and the other factors also, which might be of
aid in diagnosis, are not exactly the same in thrombosis and embolism
of the cerebral arteries ; hence we shall speak of them separately.

Since thrombosis of the cerebral vessels most frequently depends
ultimately on atheromatous degeneration of the vascular walls, and as
this occurs chiefly in old age, we are more apt to suspect thrombosis,
and consequent softening of the brain, in an old, decrepit person, who
has the symptoms of severe brain-trouble, than in a young, vigorous
one, having the same symptoms. If the peripheral arteries be rigid
and tortuous, there is still greater presumption that the arteries of the
brain are also degenerated, and that the brain-symptoms are due to
this degeneration. However, the condition of the peripheral arteries
does not furnish any certain proof of that of the cerebral arteries. In
many cases the degeneration is confined to the latter ; in other, rarer
cases, while the peripheral arteries are extensively degenerated, the
cerebral arteries remain free. Moreover, partial anaemia of the brain,
and softening of the brain due to necrosis of the anaemic portion, is
not the only brain-disease caused by atheromatous degeneration of the
cerebral arteries. Experience shows that atheromatous degeneration
of the walls of the vessels usually induces dilatation of the larger
arterial trunks, and, on the contrary, contraction of the smaller arteries.
The atheromatous arteries of the brain are also usually contracted for
a long while before they are closed by thromboses. Hence the symp-
toms of thrombosis, or, rather, of the partial anaemia and partial ne-
crosis of the brain depending on it, are almost always preceded by
premonitory symptoms, either of disturbance of circulation, induced
by the contraction of certain cerebral vessels, or by symptoms of
senile cerebral atrophy, which has been caused and hastened by de-
generation of the cerebral vessels. The patients complain of pain in
the head, dizziness, ringing of the ears, flashes before the eyes, loss of
memory and power of thought; they are apathetic and indifferent,
and much inclined to sleep, but their sleep is disturbed by uneasy
dreams. As a rule, very small arteries are at first obstructed, either
by the atheromatous process causing their entire obliteration, or be-

208 DISEASES OF THE BRAIN.

cause their calibre is contracted, and then obstructed by a thrombosis.
The ansemia resulting from closure of these small vessels is limited in
extent, and hence may readily be removed by an increased supply of
blood through neighboring vessels. "We must bear this in mind when,
in a marasmic patient, who for some time has had the brain-symp-
toms that we designated as premonitory, limited regional symptoms
(herdsymptome) occur, and, after lasting for a time, disappear again.
Among these symptoms are inability to say different words, loss of
memory for certain names and numbers, pain, or a feeling of formica-
tion, or of certain limbs going to sleep, occasionally only of certain
fingers or toes, contractions and paralysis, which are also occasionally
limited to certain fingers or toes, etc.

Many authorities have explained this variation of symptoms, par-
ticularly the occurrence and disappearance of paralysis, as a peculiar
symptom of softening of the brain. This is a false view of the matter.
In cases where the symptoms have presented this variation, if soften-
ing of the brain be found on autopsy, the softening did not occur at
the time the symptoms changed, but at a later period, when they were
constant. On the other hand, the occurrence and disappearance of
circumscribed paratyses are certainly, to some extent, characteristic of
partial anaemia of the brain resulting from atheromatous degeneration
and thrombosis of small cerebral arteries, and are rapidly removed again
by the establishment of collateral circulation. (The occurrence and
disappearance of circumscribed paralyses do not render it certain that
there is thrombosis of small arteries of the brain ; the same symptom
is also seen from small extravasations. See Chapter V.) If a large
artery, or several small ones going to the same part of the brain, be
closed by thrombosis, as we have already shown, a collateral circula-
tion cannot be established, particularly if the degeneration of the
walls of the vessels be extensive, and then the affected portion of
brain loses its functional power forever. There are some parts of the
brain — for instance, the large medullary masses of the hemispheres —
that may be destroyed without any apparent loss of function. This
fact, which is proved by numerous examples, explains the occurrence
of those cases of softening during whose course there have never been
any symptoms of paralysis. We must know this in order to under-
stand that it is occasionally quite impossible to diagnose softening
of the brain, and to distinguish it from simple senile atrophy, because
the most important point for the differential diagnosis is wanting.
But, far more frequently, the results of thrombosis of a large artery,
or of numerous small ones, extend to parts of the brain, whose loss of
function induces paralysis, and even hemiplegia, particularly to the
oorpus striatum and thalamus. The arteries supplying the great hemi-

PARTIAL ANAEMIA OF THE BRAIN. 209

spheres, and the above-mentioned large ganglia lying in them, with
blood, are the ones that are most frequently closed by thromboses ;
and, even if the anaemia directly resulting from the obstruction, and
the consequent softening, do not extend to the corpus striatum and
optic thalamus, these parts will readily lose their functional power
from the collateral oedema about the point of softening, or from the
capillaries of the entire hemisphere being compressed by it. If a large
vessel be closed by a thrombosis originating from the walls, and grow-
ing slowly, or if numerous smaller arteries be closed one after the
other, the paralysis comes on slowly, and increases gradually. Cases
running this course are the most readily recognized; for, although
gradually-forming and slowly-progressing paralysis also occurs in many
other cerebral diseases, if this symptom arise in an old marasmic pa-
tient, who has had the previously-described symptoms, we must first
think of thrombosis of the cerebral vessels, and of the form of soften-
ing of the brain at present under consideration. While the symptoms
of paralysis, which are very often and unaccountably accompanied by
contractions of the paralyzed part, gradually increase and extend, the
patients become more apathetic, grow imbecile, pass their excrements
involuntarily, have bed-sores, and finally die of marasmus and coma.
The course is different when a large vessel or numerous small ones are
rapidly closed by thrombosis. In such cases hemiplegia occurs sud-
denly, and the symptoms may be very similar to or identical with those
of cerebral haemorrhage. This correspondence is easily explained.
In cerebral haemorrhages, also, most frequently, the corpus striatum
and thalamus are either broken up, or their functional activity is ar-
rested by the compression that capillaries of the whole hemisphere
suffer from large effusions. In cerebral haemorrhages also, hemiplegia
usually occurs suddenly. Moreover, ruptures of the cerebral arteries
usually occur in old persons, and are most frequently due to the same
disease of the vascular walls that generally induces thrombosis. We
shall not enumerate the symptoms given for a differential diagnosis,
and shall only refer to an assertion of JBamberger's, for which science
is indebted to such an undisputed authority on diagnosis. Bamberger
says that, in his notes, he finds seven cases where there was an error
of diagnosis, and the real state of affairs was only discovered at the
autopsy ; he considers it impossible to avoid this error, and says he
seldom ventures to make an absolute diagnosis of cerebral haemorrhage
from an apoplectic attack.

Partial anaemia and necrosis of the brain due to embolism are
also almost always preceded by characteristic premonitory symp-
toms. But these are not brain-symptoms, as they were in the pre-
vious form of anaemia of the brain ; they are those of the diseases which

210 DISEASES OF THE BRAIN

almost exclusively cause embolism of the cerebral arteries, that is, ol
valvular disease of the heart, of endocarditis, or of severe destructive
disease of the lungs. The occurrence of these premonitory symptoms,
and the presence or absence of valvular disease, endocarditis, or severe
disease of the lung, have such an effect on the diagnosis betweem em-
bolism of a cerebral artery and other brain-diseases, that with the
same set of symptoms we may diagnose embolism if we find them, and
exclude it with certainty if they are absent. The sudden shutting off
of arterial blood from the part of the brain supplied by the obstructed
artery, instantly arrests its functional power. Experience shows that
emboli almost always lodge in the arteria fossae Sylvii, particularly
the left one ; as the closure of this large artery causes great anaemia
of the parts supplied by it, we may readily see that sudden hemiple-
gia, especially of the right side, is the most important symptom from
which we can diagnose embolus in the cerebral arteries, if it occur in
a patient with valvular disease, etc. The entire loss of consciousness,
the apoplectic attack, which usually accompanies the commencement
of Jiemiplegia, when the arteria fossae Sylvii is stopped by an embolus,
is more difficult to explain. I think that this symptom is most prob-
ably due to the diseased hemisphere being decidedly swollen by col-
lateral oedema, and that, as occurs in large extravasations of blood, the
opposite hemisphere is not sufficiently protected from the pressure by
the falx, which only offers a limited amount of resistance. In embo-
lism of peripheral arteries at least, I have always found a very decided
and wide-spread cedema in the vicinity of the obstructed vessel, and
have witnessed considerable enlargement of the spleen from embolism
of the splenic artery. It is evident that a hemiplegia occurring sud-
ienly with an apoplectic attack may readily be mistaken for a cerebral
haemorrhage. In some cases, it is true, the age of the patient gives
grounds for distinguishing a hasmorrhage from an embolism. Haemor-
rhages occur chiefly, although not exclusively, in advanced age, embo-
lism comes in persons of any age ; hence, in young persons, the pre-
sumption is in favor of embolism. However, the only way of avoiding
error is the careful examination of the heart and lungs. The certainty
that the diagnosis receives from the discovery of valvular disease is
still more increased if we can also find a coincident embolism of a pe-
ripheral artery or of one of the internal organs, such as the spleen or
kidney. In most cases death occurs sooner or later after the attack,
with the symptoms of general paralysis ; in other cases consciousness
returns after a time. The symptoms of paralysis rarely disappear ; this
is sufficiently explained, as we have previously shown, by the difficult
establishment of a collateral circulation.

Partial anaemia of tne brain, due to collateral oedema in the vicinity

PARTIAL ANAEMIA OF THE BRAIN. 21 1

of abscesses, tumors, and other local diseases, induces symptoms of
Irritation or paralysis, according to the degree of the anaemia ; these
symptoms complicate those directly depending on the original disease,
and are due to functional disturbance of portions of the brain lying
beyond the actual disease. On autopsy, it is usually difficult or even
entirely impossible to decide, whether oedema and capillary anaemia
exist in the vicinity of an abscess, tumor, etc., and how far they ex-
tend. But we have a right to suppose that the vicinity of these points
of disease is in a similar state to that of parts affected in the same
way, which are exposed to observation ; and we are the more justified
in this supposition, because for a long time it has not escaped the more
accurate observers that, in many cases of partial disease of the brain,
symptoms occur that cannot depend on the coarser structural changes
of the brain found on autopsy, but must be referred to an impercep-
tible participation of other portions of the brain lying in the vicinity
of the affected part. It is most probable that this participation
depends on disturbance of the capillary circulation and the occurrence
of oedema, because in other parts of the body also these anomalies
often leave no traces. Occasionally the symptoms observed during
life give a better means of judging of the extent of the secondary dis-
turbances of circulation, or of the collateral oedema, than the autopsy
does. For instance, if paralysis and spasm accompany a disease of the
cortical and medullary substance of the cerebrum, which does not
encroach on the cranial cavity, and whose destruction does not induce
paralysis and spasm, there is probably an anaemia extending to por-
tions of the brain lying far deeper. As numerous examples have
proved that an entire half of the cerebellum may be destroyed without
inducing hemiplegia, we cannot refer a hemiplegia, observed along
with structural changes confined to the cerebellum, directly to that
organ, but must consider it due to the extension of collateral oedema
to portions of the brain whose loss of function causes paralysis of half
the body. The strange experience, that, in disease of one side of the
cerebellum, there is sometimes no hemiplegia, at others there is hemi-
plegia of the same side, and in still other oases that it occurs on the
opposite side, is doubtless due to the fact that, in the latter cases, a
collateral oedema extends along the crura cerebelli ad frontem to the
lateral regions of the pons ; while, in those cases where the same side
is affected, the oedema extends along the crura cerebelli ad medullam
oblongatam to the lateral branches of the medulla oblongata; and
where there is no hemiplegia the collateral oedema has not advanced
.n either direction to regions whose loss of function involves that symp-
tom. These examples may suffice to show how important a r61e par-
tial anaemia of the brain, due to collateral oedema, plays in the symp-

212 DISEASES OF THE BRAIN.

tomatology of brain-diseases .confined to certain points. I have already
remarked that the variation of symptoms, the temporary improvement
or exacerbation, observed in the course of some brain-diseases, depend
greatly on the increase or decrease of the collateral oedema about the
point of disease.

The third form of partial anaemia of the brain, the result of com-
pression of the capillaries of portions of the brain from diseases caus-
ing pressure, induces constant and characteristic symptoms, which of
course vary according as the anaemia is in one of the greater hemi-
spheres or is below the tentorium. If the capillaries of one of the
greater hemispheres be compressed by an effusion of blood, by a
tumor, or any other local disease contracting the space in the skull,
there will be hemiplegia, no matter where the said disease be located.
This hemiplegia is limited to the lower half of the face, and to the
two extremities of the opposite side. It has often been considered as
enigmatical, that in many cases diseases above or below one of the
greater hemispheres, as well as within it, led to hemiplegia, while in
other cases the same diseases at the base, convexity, or in the medulla
of a great hemisphere did not induce hemiplegia; and tables have
been made out which show at a glance this want of correspondence.
I consider these tables as utterly worthless, unless the variety of the
disease be stated in them ; and I think it very important to distinguish
between two classes of disease, whose effect is very different ; namely,
those which occupy more space than the brain-filaments and ganglion-
cells which they supplant, and those which do not. Diseases at the
base, convexity, or in the medullary portion of the cerebrum only in
duce hemiplegia when they lessen the space, in other cases they do
not cause it (unless collateral oedema in their vicinity extend to the
thalamus and corpus striatum). There are exceptional cases where
hemiplegia does not occur in disease of one of the greater hemisphere?
whose products certainly contract the space. When tumors grow
very slowly the brain usually atrophies, and as much space may be
gained in the skull by the disappearance of brain-substance as is lost
by the slow growth of the tumor. In such cases there is no anaemia
of the affected hemisphere from compression of the capillaries, and
consequently, if the tumor be not in the immediate vicinity of the
corpus striatum and thalamus, hemiplegia does not occur. We must
also remember the extensive communication between the two uppei
chambers of the skull at then- anterior part. It is evident that at tmY
place pressure on one hemisphere may more readily be propagated tc
the other than at any other part. But, the more pressure is divided
up, the weaker its action becomes. In accordance with these consid-
erations, diseases of the anterior lobes, which do not encroach too much

PARTIAL ANJ3MIA OF THE BRAIN. 213

on the space, do not entirely compress the capillaries of the affected
hemisphere, so that they do not cause hemiplegia, or at least it is only
slight, while the propagation of pressure to the other hemisphere is
shown by psychical disturbances, which are usually absent where the
affection is limited to one side of the brain. Perhaps this may partly
explain the aphasia, which is found with disease of the frontal lobe of
one side, particularly (but not constantly) of the left side ; since, in
the region of the frontal lobes, pressure acting on one side is very
readily propagated to the other. As the two sides of the brain are so
symmetrical, it is difficult to believe that there is any organ in one
which does not exist in the other.

Even more characteristic and more constant is the combination of
symptoms accompanying compression of the capillaries of the parts of
brain in the posterior cranial fossa. This is apparently because the
tentorium can offer greater resistance to pressure acting on it than the
falx can ; also because the communication from the posterior and lower
chamber of the skull, bounded by the tentorium and occipital bone,
with the upper chambers, is far less free than that which exists be-
tween the two upper chambers. As is well known, we may readily
err in diagnosis of diseases of the brain, but I do not remember to
have made a mistake when I have given a diagnosis of disease con-
tracting the space in the posterior cranial fossa. Many of my former
pupils also have assured me that, from experience in their own practice,
they must regard the diagnosis of diseases limiting the space in the
posterior cranial fossa as easy, and that they have repeatedly diag-
nosed them according to my instructions, and have verified the diag-
nosis by autopsy. The combination of symptoms from which we may
diagnose compression of the capillaries of the parts lying in the pos-
terior cranial fossa is as follows : Pains in the back of the head, sym-
pathetic vomiting, a peculiar dizziness, diminution of sensibility and
motor power, but no complete paralysis and anaesthesia regularly
spread over the body, and impaired articulation and deglutition. The
pains at the back of the head doubtless proceed from the filaments of
the trigeminus going to the tentorium. As the sympathetic vomiting
occurs in various brain-diseases, it alone has no diagnostic value, but,
in combination with other symptoms, it greatly aids to render the pic-
ture of the disease characteristic. The dizziness accompanying dis
eases contracting the space in the posterior cranial fossa is not a hallu-
cination, a subjective sensation of movement of the patient's own body,
Dr of surrounding objects, that does not really take place. Unlike
this far more frequent hallucinatory form of dizziness, it does not occur
while the patient is quietly lying or sitting down, but results from
certain bodily movements. When a patient complains of dizziness,

214: DISEASES OF THE BRAIX.

we should make it a rule to ask at once whether the attacks come on
during rest, or only during walking, rising, etc. ; if the latter points
be answered affirmatively, we have obtained an important diagnostic
point. The dizziness observed in diseases encroaching on the posterior
cranial fossa depend, as Immermann has fully proved, on actual move-
ments of the body, which the patient does not perfectly perceive, but
which only have a general influence on his feeling of equilibrium. In
healthy persons, vibratory movements of the body would also occur in
walking, rising, etc., if they were not prevented by contraction of the
muscles which straighten and curve the spinal column. "When a
person is walking stiffly and uprightly, we may readily see, by the in-
creased prominence of the bellies of these muscles, that he is uncon-
sciously using them. This facility of limiting, by muscular action, the
movements and vibrations conveyed to the trunk is very much im-
paired in persons with disease encroaching on the posterior cranial
cavity, a circumstance which is apparently supported by the supposi
tion that the cerebellum chiefly causes innervation of the body, and is
the prop of the spinal column ( Griesinger). The diminution of sensi-
bility and that of motor power, which render the patient awkward and
uncertain, without increasing to complete paralysis and anaesthesia, are
simply explained by the fact that the nerve-filaments, passing from the
cerebrum through the foramen occipitale superius, enter the posterior
cranial fossa, again leave it by the interior occipital foramen, and are
thus subjected to a compression which impairs the propagation of ex
citement from the brain to the motor nerves, and of peripheral excite-
ment of the sensory nerves to the brain. In the disturbance of speech
it may be readily seen that it does not depend on lack of thoughts, or
on the impossibility of finding words for the thoughts, but on the un-
certainty and clumsiness in executing the movements necessary for
distinct, rapid, and connected articulation. The disturbance of deglu-
tition is occasionally designated as difficulty of swallowing ; it usually
manifests itself by slight choking while drinking. I shall not attempt
to decide whether this disturbance of articulation and deglutition de-
pends on disturbance of the function of the hypoglossal and glosso-
pharyngeal nerves at their origin, or in the nerves themselves, by dis-
eases affecting the space in the posterior cranial fossa. Besides the
above-mentioned symptoms, there are usually others depending on the
injury of certain nerves, and, if the orifice of the venae Galeni into the
straight sinus be compressed, and the escape of blood from the ventri-
cle prevented, we have the symptoms of chronic hydrocephalus. We
shall hereafter speak of this when treating of tumors and abscesses of
the cerebellum, pons, medulla oblongata, and of chronic hydrocepha-
lus. Here will be the place to mention those symptoms which are

APOPLEXF. 215

observed, with remarkable regularity, in diseases affecting the space
in the posterior cranial cavity, no matter what their nature or location.
Among my pupils I have noticed that the interest in brain-diseases
rapidly increases when it becomes evident that, in many cases, a sure
diagnosis can only be made within certain limits. Not unfrequently
we are obliged to stop at the diagnosis of a disease encroaching on
one side of the cerebrum, or on the posterior cranial fossa. In the
following chapters we shall show under what circumstances we can go
further, and how, in other cases, a certain diagnosis may be made of
the nature and exact seat of the disease.

TREATMENT. — As may be readily understood, the treatment of
partial anaemia and necrosis promises little benefit. In thrombosis and
embolism of the cerebral arteries, the obstruction to^the supply of
blood cannot be removed by therapeutic remedies. Hence the indica-
tion would be to favor the development of a collateral circulation,
without exposing the patient to new danger from too great collateral
fluxion. It is very difficult to fulfil these indications, and we may
readily do harm instead of good. The purer the symptoms of partial
paralysis, the more obstinate they remain ; if no symptoms of irrita-
tion accompany them, the more a strengthening and stimulant treat-
ment is indicated. Hence we always find the administration of stimu-
lants recommended in the treatment of softening of the brain. If, on
the other hand, the symptoms of irritation caused by fluxionary hyper-
gemia, such as severe headache, contractions, etc., are prominent, it is
advisable to use cold, and apply leeches behind the ears repeatedly.
We should be careful about venesection, as it is readily followed by
collapse. From what has been said, it is evident that we can give no
general rules, but the treatment must be suited to each case. We
shall speak of the treatment of partial anaemia of the brain, induced
by collateral oedema and compression of the capillaries, when we treat
of the diseases that this form of partial anaemia accompanies.

CHAPTER V.

CEREBRAL HAEMORRHAGE — APOPLECTIC STROKE — APOPLEXIA SAN-
GUINEA.

BY the term stroke, or apoplexy, was originally meant, as the word
indicates, the sudden occurrence of complete functional inactivity of the
brain. Apoplexy is divided into various forms, according as the paral-
ysis is induced by an extravasation of blood or by a serous effusion,
or as organic diseases can or cannot be found as the cause : thus we
have Apoplexia sanguinea. A. serosa, A. nervosa, etc. In the present
64

216 DISEASES OF THE BRAIN.

chapter we treat of the lesion of the brain characterized by rupture of
the blood-vessels and escape of their contents, whether it induces the
symptoms of sudden paralysis of the brain or not.

ETIOLOGY. — Cerebral haemorrhages almost always occur from the
smaller arteries or the capillaries of the brain, and are caused partly
by structural disease of the arterial walls, partly by an anomalous con-
dition of the part of brain surrounding the vessels, partly by increased
pressure of the blood against the wall of the vessel. The bleeding
most frequently occurs when several of the factors act together.1

The structural changes in the walls of the vessels, to which their
abnormal fragility is due in most cases, are the results of endarteritis
deformans, which was treated of in the first volume. This explains
the frequency of apoplexy in persons over forty years of age, which
was noticed even by Hippocrates. Next to this, simple fatty degen-
eration of the arterial walls, not dependent on inflammation, but occur-
ring in badly-nourished cachectic and chlorotic persons, also induces
greater fragility and ruptures of the cerebral vessels. Still we must
say that fatty degeneration of the finer cerebral arteries is found far
more frequently than would be expected from the proportionately rare
occurrence of apoplexy. Occasionally rupture of the entire arterial wall
is preceded by rupture of the inner and middle coats, while the adven-
titia still resist. In such cases the blood escapes between the external
and middle coats, and small dissecting aneurisms are formed. Lastly,
there are cases where abnormal weakness of the cerebral vessels must
be supposed, although it cannot be proved. These are the rare cases
where cerebral haemorrhages are found in convalescents from typhus
and other acute infectious diseases and during scorbutus.

We have already mentioned that, in necrotic softening of the
brain, capillary haemorrhages not unfrequently occur along the borders
of the softened part. Frequently, gradual atrophy of the brain causes
dilatation and final rupture of the vessels. While the brain-substance
disappears, a vacuum cannot form in the skull ; hence increase of the
cerebro-spinal fluid and dilatation of the vessels are necessary results
of senile or any other form of atrophy of the brain, which is a frequent
sequel of the most varied forms of disturbance of nutrition. Perhaps
the frequency of apoplexy in advanced age depends at least partly OP
this circumstance, and there is no doubt that the atrophy of the brain,
which is in many cases caused by the first apoplectic attack, has some-
thing to do with the frequent recurrence of apoplexy.

The increased pressure of the blood on the walls of the vessels, by
which the latter are ruptured, may depend on any of the causes which
wo indicated in the first and second chapters as causes of hyperaemia.
The frequent occurrence of apoplexy during long and luxurious meals

CEREBRAL APOPLEXY. 217

tends to show that the hyperaemia of the brain induced by temporary
plethora is one of the most dangerous forms. Hypertrophy of the
left ventricle, particularly that form resulting from any extensive en-
darteritis deformans, plays an important part in the ruptures of cere-
bral vessels. In the latter case two dangerous factors unite — the mor-
bid fragility of the vessels and the increased pressure of the blood on
them. Moreover, small arteries, in which there is otherwise a regular
pressure of the blood, and whose walls also maintain a nearly equal
tension during the systole and diastole of the heart, pulsate when
there is extensive atheromatous degeneration, and at every systole of
the heart the normal medium tension of their walls is decidedly in-
creased. It will be readily understood that this circumstance also in-
creases the liability of the vessels to rupture. Cerebral haemorrhages
so often depend on the complication in question, that, in doubtful
cases, the discovery of hypertrophy of the left ventricle and of a.n
atheromatous degeneration of the arteries may decide the diagnosis.

Apoplexies occur at all times of the year ; occasionally, without
any known cause, cases accumulate remarkably. They have also
been observed at all times of the day, and statistical tables have been
made of their comparative frequency at morning, mid-day, and even-
ing. Although advanced age furnishes the largest number of cases,
apoplexy does occur even among children. Men are somewhat oftener
attacked than women. There is no such thing as an apoplectic con-
stitution, indicated by a short neck and broad shoulders.

ANATOMICAL APPEARANCES. — The distinction is made into capil-
lary haemorrhage and haemorrhagic clots, according as the bleeding
consists of numerous small, closely-packed effusions, or of a larger
quantity of blood.

In capillary haemorrhages the cerebral substance appears dotted
with dark-red punctate extravasations at some point of variable size.
The cerebral substance between the small extravasations either re-
tains its normal color and consistence, or is colored yellow or reddish
to a variable extent by imbibition ; it is relaxed and moist, or, lastly,
it is broken down to a red pulp by the extravasation (red softening).

Small haemorrhagic spots sometimes press the brain-filaments
apart ; but larger ones break up and become mixed with the brain-
substance. In the former case the effusion is sometimes elongated in
the direction of the filaments ; in the latter it is more roundish or irreg-
ular. In the former case the walls of the effusion are to some extent
smooth ; in the latter they oftener appear ragged, and are frequently
surrounded, for a space some lines thick, by a broken-down pulpy
brain-substance discolored with blood. The size of the clot varies
from that of a hemp-seed to that of the fist. If it be in the vicinity

218 DISEASES OF THE BRAIN.

of a ventricle, it often breaks through the wall of the latter, and its
blood escapes into the ventricle. Haemorrhagic effusions, lying near
the surface of the brain, not unfrequently break through the cortical
substance and pia mater, so that the blood enters the subarachnoid
space. Usually there is only one haemorrhagic effusion in the brain,
rarely several. Their most frequent locality is the corpus striatum,
the thalamus opticus, and the large medullary masses of the hemi-
spheres ; less frequently they occur in the cortical substance of the
cerebrum, in the cerebellum and pons. Apoplexies in the corpora
quadrigemina and medulla oblongata are rare, and they hardly ever
occur in the corpus callosum and fornix. The contents of a recent
apoplectic clot consist of blood and broken-down brain-substance. The
blood either remains fluid or is partly coagulated, and then the fibrin
is occasionally deposited at the periphery, while the middle of the clot
consists of fluid blood. Changes of the contents and walls of the clot
soon begin. The fibrin of the blood and the portions of brain mingled
with the effusion break down into a detritus, the contents become
more fluid, the dark-red color becomes brown, then saffron yellow.
Granular pigment and often also haematoidin crystals are formed from
the hasmatin. At the same time, in the immediate vicinity of the clot,
there is a new formation of connective tissue starting from the neu-
roglia, which develops into a thick, hard layer that encloses the clot.
In the same way there is a new formation of delicate connective tissue,
colored yellow by the pigment contents and serous infiltration, which
covers the wails and traverses the clot as a fine network. After the
elements of the effusion have broken down, all its remains disappear,
while their place is gradually supplied by serum ; and then we find in
the brain a cavity filled with clear liquid, surrounded by a callous sub-
stance, and covered and traversed by delicate yellow-colored connec-
tive tissue — an apoplectic cyst. The cysts usually remain permanently.
But occasionally the serum is reabsorbed, the walls approximate, and
finally are only separated by a stratum of pigment. These callous
spots, enclosing pigment striae, are called apoplectic cicatrices. The
cicatrization of a haemorrhagic effusion in the cortical substance is
somewhat different. The effusion of blood under the pia mater, which
is usually flat and extended, undergoes the same changes as do the
contents of central clots. The red pulp gradually becomes a reddish-
brown or saffron-yellow crumbly mass, which is bounded below by
callous brain-substance, above by the pia mater. Lastly, we find an
excavated pigmented plate, above which a serous effusion fills the cav-
ity resulting from the depression. While the above terminations of
cerebral haemorrhages must be regarded as the most favorable, in
some cases the reactive inflammation in the vicinity of the broken

CEREBRAL APOPLEXY. 219

down portion of brain is not limited to a new formation of connective
tissue, but there is extensive destruction from inflammatory softening,
or the apoplectic clot is even transformed to an abscess of the brain.
The parts untouched by the haemorrhage are bloodless if the extrava-
sation has been considerable, and the more so the larger the extrava-
sation ; small capillary haemorrhages have no influence on the amount
of blood in the rest of the brain. In large effusions the hemisphere
containing the clot is particularly anaemic. The subarachnoid spaces
also are empty, the convolutions flattened, and the furrows have dis-
appeared. Since the uneven appearance of the surface of the brain is
to a great extent due to the presence of cerebro-spinal fluid and of
vessels containing blood between the convolutions, the surface of the
brain appears very smooth and even when there is a large extravasa-
tion. The brain rarely endures the injury from an apoplexy without
impairment of the general nutrition. The gradual diminution of men-
tal power seen in almost all apoplectic cases corresponds to a general
atrophy of the brain ; which, according to the examinations of Turk,
is associated with a degeneration, extending into the spinal medulla,
of those filaments communicating with haemorrhagic effusion.

SYMPTOMS AND COURSE. — Sometimes apoplexy -occurs unexpect-
edly in persons who have previously felt quite well ; in other cases it
is preceded by premonitory symptoms that excite in the physician, and
even in the laity, the apprehension that the patient is threatened with
apoplexy. The patients complain of headache, or of heaviness and
fulness of the head, of noise in the ears, flashes before the eyes, and
attacks of dizziness ; they sleep badly, are excited and irritable. There
are also, as peculiarly ominous symptoms, occasional temporary feel-
ings of formication and numbness in certain limbs, momentary loss of
memory for some words and figures, or temporary paralysis confined
to certain groups of muscles. Thus we see the premonitory symptoms
of apoplexy are those that we gave in preceding chapters, as due to
general and partial hyperaemia of the brain, and to partial anaemia of
the brain resulting from degeneration of the walls of the vessels ; a
condition that entirely corresponds with the frequent dependence of
cerebral haemorrhages on increased lateral pressure in the cerebral
vessels, and on degeneration of their walls. In general it cannot be
determined whether the temporary partial paralysis and anaesthesias,
the " warnings " preceding the apoplectic attack, depend on throm-
bosis of small vessels, or on small capillary haemorrhages. In the
latter case, of course they could not be classed among premonitory
symptoms.

The destruction of brain-filaments, whether they be broken up by
large extravasations or be softened by small capillary haemorrhages,

220 DISEASES OF THE BRAIN.

San, as we have often shown, have no other direct result than partial
paralysis. Since the destruction of certain portions of the brain, par-
ticularly in the medulla of the cerebrum, does not cause any perceptible
disturbance of function, we may readily understand that small haemor
rhages, as well as other diseases of those parts, may occasionally es-
cape recognition during life.

We have designated the corpus striatum and thalamus opticus as
the most frequent seat of haemorrhage ; a destruction of these parts, or
of the pedunculi cerebri, induces paralysis of the opposite half of the
body. We may readily determine that the paralysis, resulting from
destruction of the above parts, only depends on interruption of the
conduction between the organs acting in thought and will and the
motor nerves and muscles ; the power to think and will is unimpaired.
After the apoplectic seizure, during which there is complete loss of
consciousness, has passed off, if we ask the patients to give us the
affected hand, they show their desire to fulfil the request, by taking the
paralyzed hand in the other one, whose nerves and muscles are under
the control of their will, in order to accomplish the act. On the other
hand, in recent cases, every motor nerve on the paralyzed side, to which
we apply the induced current, causes contraction in the muscles sup-
plied by it. Hence the only failure is in the communication between
the central excitory apparatus and the motor nerves. This interrup-
tion has no effect on those movements of the paralyzed side that occur
in a reflex manner without the influence of the will ; for patients, who,
as a result of apoplexy on the left side, cannot move the right arm or
leg, move the right side of the thorax just as well as the left during
respiration. And the connection between the motor nerves and those
nerve-filaments and ganglion-cells which are excited during certain
states and feelings of the mind is not always removed with the inter-
ruption of conduction at present under consideration. This is shown
by the fact that some patients who cannot make the motions of laugh-
ing or crying on the one side of the face, at our request, can do so
when they do not will to do it, but when their feelings lead them to
do so. In the same way, the interruption of conduction of the impulses
of the will, from the central organs to the motor filaments, does not
necessarily imply that the communication of the latter with sensory
and with other motor filaments is interrupted. On the contrary, we
find that occasional reflex movements sometimes remain undisturbed
in the paralyzed parts, or even occur more readily, so that it appears
as if, when the excitement of the motor filaments is no longer subject
to the will, it occurs more readily than it otherwise would. Paralysis
of half the body, due to destruction of the corpus striatum and thalamus
of one hemisphere, is characterized by its limitation to the muscles of

CEREBRAL APOPLEXY. 221

the extremities, to those muscles of the face going to the angle of the
mouth and the nose, and to the muscles that protrude the tongue.
The patients can almost always chew normally on the affected side,
they can wrinkle the forehead, open and close the eyelids, move the
eyes in any direction, etc. On the other hand, the patient frequently
cannot lift the paralyzed arm and foot an inch from the bed ; the mouth
hangs down on the affected side, and the nostril is contracted, occasion-
ally the cheek flaps about like a loose sail at every expiration, wliile,
on the sound side, the angle of the mouth is drawn up and the nostril
dilated. If the patient protrude the tongue, its point goes toward the
paralyzed side, because only the muscles of the opposite side push for-
ward the root of the tongue and elongate that organ. In most cases,
along with the hemiplegia, there is also anaesthesia of half the body, but
after a time this usually passes off partially or entirely. This course
of the anaesthesia, as well as the experience that animals have no sensa-
tion after destruction of then* corpus striatum and thalamus, and that,
after taking them away, the power of feeling peripheral pain continues,
appears to indicate that the temporary anaesthesia of the paralyzed
half of the body does not depend immediately on destruction of the
corpus striatum and thalamus, but on the compression of the capil-
laries in the sections of brain lying below them, caused by the effusion
of blood.

The same symptoms as are caused by effusions of blood into the
thalamus and corpus striatum, are induced by effusions at other parts
of the cerebrum, provided they are extensive enough to compress the
capillaries of the thalamus and corpus striatum. After the discussion
in the previous chapter concerning partial anaemia of the brain and its
influence on the cerebral functions, this similarity cannot appear strange
to us, but must rather be regarded as evident and necessary. The
only difference is the following : A large apoplectic clot, destroying
the corpus striatum or thalamus, leaves a hemiplegia that never dis-
appears ; only small clots in these parts, by which the filaments and
ganglion-cells are not broken down, but only pressed apart, leave
paralysis which is occasionally temporary. Hence we may conclude
that the apparatus for exciting the motor nerves, which doubtless exists
in the brain, although it may itself be excited by the will, is located in
the vicinity of the corpus striatum and thalamus. On the other hand,
extensive apoplectic clots at other parts of the cerebrum not unfre-
quently leave paralysis, which sooner or later disappears again. From
this course we may suppose that the capillaries of the motor centres,
being relieved of the pressure by the partial resorption of the extrav-
asation, have again become permeable to the blood ; or that the col-
lateral oedema in the vicinity of the broken-down part of brain, which

222 DISEASES OF THE BRAIN.

extended to the motor centres, has disappeared with the cicatrization
of the apoplectic clot.

Hemiplegia occurs in some, but not in all, of the cases where the
effusion is into the cortical substance of the cerebrum ; these are gen-
erally accompanied by haemorrhage into the tissue of the pia mater.
The difference, doubtless, depends on how far the frequently-mentioned
results of the haemorrhage, compression of the capillaries, or collateral
oedema, extend inward ; whether they reach the corpus striatum and
thalamus or not. When the clot is in this position, general convulsions
are often observed, and in most cases there is severe disturbance of the
psychical functions. Since experience shows that persons with very
advanced and extensive degeneration or atrophy of the cortical sub-
stance (if it be only on one side) often have no psychical disturbance,
the frequent occurrence of the latter in apoplexy on one side is prob-
ably because haemorrhages readily affect the other hemisphere; and
particularly because this is likely to occur in the complicating inflam-
mation of the pia mater, which has a great tendency to spread.

Haemorrhages in the pons, if of any considerable size, and in the
medulla oblongata, even if very slight, usually cause death. In small
effusions in the lateral portions of the pons, there are anaesthesia and
paralysis on the opposite side of the body ; in small extravasations in
the middle of the pons, there is paralysis of both sides.

In haemorrhages of the cerebellum we often find paralysis of the
opposite side. But this cannot depend on the affection of the cerebel-
lum, for there is often no paralysis observed when this is extensively
destroyed.

We must not think that, because haemorrhages are found at very
different parts of the brain, the different cases of paralysis dependent
on cerebral haemorrhages will differ widely from each other. On the
contrary, the large majority of cases show a great similarity, as they
induce the hemiplegia above described. It is, of course, of great prac-
tical importance to know this, which is simply explained by the fact
that, according to statistics, seven-eighths of all cerebral haemorrhages
are located in the cerebrum and particularly in the vicinity of the cor-
pus striatum and thalamus. There are some very wonderful excep-
tions to the one-sidedness of the paralysis and to its occurrence on the
opposite side, in haemorrhage of the cerebrum, which we are at present
unable to explain satisfactorily. However, we must add that, of late,
since all anomalies existing with the haemorrhage, particularly plugging
of the cerebral arteries, are more carefully attended to, and used in
explaining the symptoms, the number of such cases published has
greatly decreased.

Another series of symptoms in cerebral haemorrhage, which is

CEREBRAL APOPLEXY. 223

Cfilled a stroke of apoplexy, and is only absent when the haemorrhage
is slight, do not depend directly on the local injury of the brain, but
Dn its effect on the rest of the brain. We shall hereafter show that
the apoplectic fit usually occurs at the outset, but sometimes does not
come on till after the appearance of the paralysis. The stroke of
apoplexy rarely develops gradually and probably only does so when
the haemorrhage occurs slowly ; in most cases it comes on suddenly,
and the patient falls to the earth (often with a cry) as if " knocked
down." During the attack, consciousness is entirely lost, as well as
the power of feeling and moving. The sphincters also are generally
paralyzed, so that faeces and urine are passed involuntarily. Respira-
tory movements alone, which depend on the medulla oblongata, are
continued ; but the inspirations follow at long intervals, and are usually
loud and stertorous, since the paralyzed and pendulous soft palate is
thrown into vibration by the air. The patient has a peculiar appear-
ance, from the relaxed cheeks being puffed out with every expiration.
There is often vomiting at the commencement of the attack; the
pulse is very slow, the pupils contracted.

It is usually supposed that the apoplectic fit is a result of the pres-
sure or bruising of the nerve-filaments and ganglion-cells of the entire
brain by the extravasation. However, it is evident that this pressure
can never exceed that of the blood in the cerebral arteries ; for, as
soon as the pressure in the parts around the arteries is as great as that
of the blood in the vessels, no more blood can escape from the latter.
But, from experiments that we can make on peripheral nerves, there
is no doubt that such a pressure is entirely insufficient to annul the
excitability of the nerve-filaments. The following fact also tends to
disprove the current explanation : If the symptoms of paralysis de-
pended on the pressure to which the filaments of the brain are sub-
jected in apoplexy, bleeding should remove these symptoms not only
in some but in all cases, provided enough blood be drawn to lessen
the pressure in the whole vascular system, particularly in the arteries.
Byrtl) who also speaks most decidedly against referring these symp-
toms to pressure on the brain, thinks that the accidents generally re-
ferred to " pressure on the brain " are due to a slight amount of con-
cussion ; but, apart from the fact that there is no such concussion in
cases of extravasation which are not of traumatic origin, no anatomi-
cal changes referable to such a cause can be found. We refer the
apoplectic fit to sudden compression of the capillaries, that is, anaemia
of the brain-substance. In all large haemorrhages this anaemia may
not only be recognized with certainty after death, but even during life
it shows itself by a very important symptom which is usually falsely
interpreted, that is, by a remarkable pulsation of the carotids. This

DISEASES OF THE BRAIX.

symptom is very generally regarded as a sign of " increased pressure
of blood to the head," although it really indicates that the flow of blood
into the skull is obstructed ; we may at any moment induce the same
phenomenon in the artery of the finger by tying a string tightly
around the end of the finger. All diseases of the brain and its mem-
branes affecting the space in the skull enough to obstruct the afflux
of blood from the afferent vessels, hence not only large effusions of
blood, but also abundant exudations and transudations, large tumors,
etc., are accompanied by increased pulsation of the carotids. If we
find this symptom, when there is no hypertrophy of the left ventricle,
nor corresponding pulsation in other arteries, it will, in doubtful
cases, be a great aid to the diagnosis of some brain-disease encroach-
ing on the cranial cavity. In my clinic my pupils have frequently had
an opportunity of satisfying themselves of the correctness of the indi-
cation and of the great diagnostic value of this symptom. If we re-
gard the physical conditions, we see that anaemia, at all events arte-
rial anaemia', of the brain can never result from rupture of the capil-
laries ; for the escape of blood from the ruptured capillaries can only
last till the tension of the contents of the skull equals that of the
blood in the capillaries. In accordance with this we see that the apo-
plectic fit does not occur in capillary haemorrhage. If, on the other
hand, an artery be ruptured, and the bleeding does not soon cease
from some other cause, the tension in the surrounding parts finally
becomes as great as it is in the artery ; and, as it is greater there than
in the capillaries, the latter must be compressed and become impassa-
ble for the arterial blood. In accordance with this, apoplectic fits al-
most always accompany arterial haemorrhages of any extent. If we
analyze the above symptoms of the apoplectic fit, we find that, while
it lasts, the functions of both sides of the cerebrum are lost. The pa-
tients have no feeling, even on the strongest peripheral irritation;
they cannot make the slightest motion, and consciousness is entirely
lost. On the other hand, those portions of the brain through which
acts indispensable to life, especially respiration, are performed, retain
their functional power. This is, apparently, because the falx protects
the opposite hemisphere less, from the compression of the capillaries
by the extravasation, than the tentorium does the medulla oblongata.
Effusions of blood below the tentorium, even when slight, are very
dangerous, because in them the medulla oblongata is not thus pro-
tected, and its functions are readily disturbed by compression of its
capillaries. I shall not attempt to decide whether or not the slowness
of the pulse, the diminished frequency of respiration, and the contrac-
tion of the pupil, observed during apoplectic fits from effusions above
the tentorium, are due to increased excitement of the vagus and oculo-

APOPLEXY. 225

motor nerves as a result of pressure acting on them, but somewhat
modified by the tentorium.

If the patient does not die during the apoplectic fit, but recov-
ers consciousness, he shows signs of a more or less severe encepha-
litis in a few days. This depends on the injury to the brain from
the haemorrhage, hence must be regarded as traumatic. When it
does not reach a great height, and only leads to new formations of
connective tissue about the clot, the symptoms are increased fre-
quence of pulse and other signs of fever, headache, sparks before
the eyes, delirium, occasionally also twitchings and contractions of
the paralyzed parts. After a time these " symptoms of reaction "
moderate and finally disappear, and the patient is well except for
the remaining paralysis. But, if the inflammation in the vicinity of
the clot is of considerable intensity and induces inflammatory soft-
ening, the above symptoms are accompanied by those of general
paralysis, and the patient dies as a result of too great severity of
the so-called symptoms of reaction.

[Hemiplegia caused by cerebral apoplexy shows the peculiarities
of all cerebral palsies (as contrasted with spinal and peripheral pal-
sies). The loss of sensation is less marked and more transitory than
that of motion, and the reflex action is almost always preserved or
even increased through irritation from the apoplectic centre. Hence
a slight increase of electrical irritability argues in favor of a cere-
bral palsy. The arm is usually more affected than the leg, and, for
a time at least, the tongue and facial muscles are often likewise in-
volved. Cerebral palsy of the face especially affects the nervous
twigs which supply the muscles of the alae nasi, those of the angle
of the mouth, and the buccinator muscles ; while the nerves of the
orbicularis palpebrarum almost always escape, so that the eye can
always be closed (in contrast to what occurs in peripheral facial
palsy). A facial palsy of cerebral origin is upon the same side as
that of the hemiplegic limbs ; whereas peripheral palsy of intracra-
nial origin (like that by compression of the facial nerve along its
course in the base of the skull) is upon the side where the lesion
exists. There are often vasomotor disturbances, and the paralyzed
side (Eulenburg) shows by the sphygmograph that the arterial
tone is sunken and the current retarded, and that the temperature
is lower than upon the healthy side ; moreover, the hand and foot
are often swollen. The psychical functions also are apt to be more
or less altered.

The derangements which remain after an apoplectic attack has
abated may continue to improve for weeks and months ; but where
a perfect recovery does* not promptly take place, it seldom does so

226 DISEASES OF THE BRAIN.

afterward, so that a paresis of the arm and leg is apt to remain.
The palsied limbs often move sympathetically, particularly during
the acts of coughing and sneezing. Several weeks after the fit
there generally occurs a gradually increasing contraction of the
crippled limbs (of the hand and arm especially). Thus all the
joints of these members become permanently flexed, and this may
go so far as to require that the palm of the hand be protected
from the impression of the finger-nails. This change from flaccid-
ity to stiffness is an evil prognostic sign, meaning that the case is
incurable.

Arthropathy of the hemiplegic, described by Scott Alison,
Brown-Sequard, and Charcot, is confined to the palsied limbs, and
prefers the arm, and especially the shoulder. This complication,
like the contractions, appears several weeks after the fit, and the
pain, redness, and swelling are sometimes so marked that the at-
tack might be mistaken for acute articular rheumatism, did not
the seat of the disease upon a paralyzed limb indicate its true sig-
nificance.

A very rare sequel of apoplexy is a permanent hemi-ansesthe-
sia, which persists even after the motor derangement has been
restored. This anaesthesia may be complete or incomplete ; it in-
volves not merely the skin, but the deeper parts of the lip, tongue,
and palate.

The consequences of an apoplectic stroke, however, are by no
means always alike. The situation of the clot may affect the char-
acter of the symptoms. While a small extravasation upon the cor-
tical substance may cause no recognizable symptoms, a large one,
or numerous extravasations in the cerebrum, would be apt to cause
mental derangement. There may be stupor, convulsions, delirium,
mania, and permanent insanity. Large clots in the posterior brain
may cause paralysis or prove speedily fatal.

Haemorrhagic, embolic, and other lesions affecting the third
frontal convolution, particularly those of the left anterior lobe, cause
the well-known disturbance of speech known as aphasia, of which
more hereafter. Numerous dissections would seem to show that
the whole region involving the fossa Sylvii, the island, and the cor-
pora striata may be similarly affected by injuries. Apoplexy of
the crura cerebri is said to be characterized by marked anaesthesia,
slight facial palsy, and squinting, while the psychical functions
remain unchanged.

Apoplexy may result in paraplegia when the lesion is bilateral.
In such cases the two sides are usually affected in unequal degree.
This very rare consequence of cerebral apoplexy is to be distin-

APOPLEXY. 227

guished from paraplegia of spinal origin by the presence of mental
derangement or of palsy of one of the facial cranial nerves ; it
being borne in mind, however, that cerebral and spinal palsies may
coexist.

When an apoplectic effusion bursts its way to the meninges or
into one of the ventricles, death usually ensues. As a rule, such
penetrations are attended by convulsions, and by the very early
appearance of contractions upon the palsied side, sometimes even
upon the other. There are also epileptiform fits. Apoplexies of
small extent often are purely local in their effect, causing paresis of
a single extremity, thickness of speech, facial palsy without hemi-
plegia, sudden amaurosis or amblyopia of one eye, ptosis, etc.
Such small extravasations may form without the symptoms of a
fit, so that doubts as to the real nature of the disease may exist
until a subsequent grave apoplectic stroke clears up the mystery.]

From the varied size and number of the haemorrhages, their dif-
ferent seats, the greater or less rapidity of their occurrence, as well
as from the more or less severe inflammation of the surrounding
brain, we have many varieties in the course of cerebral haemor-
rhages, of which we shall mention only the more important.

A rather frequent appearance of the disease, which corresponds
to a rapidly-occurring extensive haemorrhage, or to the coincident
occurrence of several haemorrhages, is the following : After some
premonitory symptoms, or even without them, an apoplectic fit
suddenly occurs ; the patient does not again recover consciousness,
the paralysis extends to the medulla oblongata, the breathing be-
comes irregular, the pulse intermittent and slow, the pupils dilated,
and death occurs in a few minutes (apoplexie foudroyante), or after
some hours.

In a second class, which is most frequently seen, and which is
also due to a rapidly-occurring but probably less extensive haemor-
rhage at the usual places, there is also first an apoplectic fit ; even
during unconsciousness we may see by the distortion of the face, by
the peculiar relaxation of the muscles on one side, sometimes also
by the dilatation of one pupil, which is the paralyzed side. After
a few minutes or some hours, or occasionally not till next day, the
patient gradually arouses from the stupor ; but he speaks indistinct-
ly, and hemiplegia, with the peculiarities above described, becomes
evident. On the second or third day there are fever and the other
symptoms of traumatic encephalitis. After these have disappeared,
the patient remains for the rest of his life paralyzed on one side of
his body, although the part of the paralysis due to oedema in the
vicinity of the apoplexy disappears after a time.

228 DISEASES OF THE BRAIN.

In other cases, most probably when the haemorrhage ceases for a
time and returns again, and continues moderately, the disease begins
with an apoplectic fit, from which the patient arouses after a time.
We note the hemiplegia, but hope that this time the patient will es-
cape with his life. But, after a few hours, consciousness again begins
to disappear, and finally is lost entirely, does not return, and the pa-
tient dies comatose.

A slowly-occurring haemorrhage, which finally becomes very abun-
dant, appears to induce the cases where an apoplectic fit does not open
the scene, but where there is first hemiplegia, and, later, loss of con-
sciousness and general paralysis of the brain.

It would require too much time to fully describe other appearances,
particularly the modifications resulting from the different severity of
the reactive inflammation in the vicinity of the clot, and from the
varied grades of the consecutive atrophy of the brain.

TREATMENT. — For the prophylaxis of apoplexy, we may refer to
Chapters I. and IV. of this section, since the prophylaxis of cerebral
haemorrhage demands the same general rules that we gave for the
treatment of cerebral hyperaemia, and for the disturbances of circulation
resulting from disease of the arteries. If a patient has had one attack
of apoplexy, he must be particularly careful to avoid all causes by
which the cerebral vessels may be overfilled and distended ; he must
especially avoid long, luxurious meals, and must keep his bowels
regular.

If cerebral haemorrhage has occurred, it becomes our object to pre-
vent a continuance of the bleeding, to induce reabsorption of the ex-
travasation, and the formation of an apoplectic cicatrix. But we must
not deceive ourselves as to our power, and must understand that we
have no remedy for arresting the haemorrhage, or for hastening the
reabsorption and cicatrization. In the treatment of this disease we
are restricted to combating the more dangerous symptoms as well as
possible. Not a few patients, in apoplectic fits, recover consciousness
during venesection, and it seems as if we could, not unfrequently, pre-
vent the extension of the paralysis from the cerebrum to the medulla
oblongata, which is indispensable to life, and so save the patient by
bleeding. On the other hand, there is no doubt that, in many cases,
bleeding during an apoplectic fit hastens a fatal result ; collapse occurs
immediately after the venesection, and the patient never arouses. We
have previously said that bleeding must always prove beneficial, if the
symptoms given as signs of pressure on the brain were actually in-
duced by the pressure to which the brain is subjected by the extrava-
sation ; and we have also said that the want of success in venesection,
in many cases, spoke against this explanation. From the explanation

AFOPLEXT. 229

that we have given of the apoplectic fit, it is evident that, under some
circumstances, venesection is a very useful remedy ; under others it is
very injurious, and the indications for it may be very exactly given.
In order that as much arterial blood as possible may enter the brain,
we must try to facilitate the escape of the venous blood, without, how-
ever, diminishing the propelling power too much. If the impulse of
the heart be strong and its sounds loud, if the pulse be regular, and
no signs of commencing oedema of the lungs exist, we should bleed
without delay. Local bleeding by leeches, behind the ears, or to the
temples, or by cups to the back of the neck, cannot replace general
bleeding, but may be used as adjuvants. If, on the contrary, the
heart's impulse is weak, the pulse irregular, and rattling in the trachea
has already begun, we may be almost certain that bleeding would only
do harm, since the action of the heart, which is already weakened,
would be still more impaired, and the amount of arterial blood going
to the brain would thus be still more decreased. When the latter
state occurs, the symptomatic indications require just the contrary
treatment, in spite of the original disease being the same, and being
due to the same causes. We must strive with all our skill, by the use
of stimulants, to prevent paralysis of the heart. If we cannot give
wine, ether, musk, etc., internally, we should apply large sinapisms to
the chest and calves of the legs, rub the skin vigorously, sprinkle the
breast with cold water, or drop melted sealing-wax on it.

If the patient has recovered consciousness after the apoplectic fit,
we simply prescribe a mild, unirritating diet, keep the bowels open,
and cover the shaved head with cold compresses, so as to prevent, if
possible, too severe inflammatory reaction. According to the severity
of the inflammatory symptoms which, nevertheless, occur, we may
continue this simple treatment, and at most give a purge, or apply
leeches behind the ears, and repeat the application if necessary. In
this stage venesection is superfluous and dangerous. On the other
hand, especially when the fever-symptoms have moderated, good is
done by derivatives to the nape of the neck, such as blisters and pus-
tulating ointments, wliich subsequently are no more to be used.

If the stage of inflammatory reaction has happily passed, and the
patient is pretty well, except the paralysis, we should avoid prescribing
strychnia and other remedies, which are neither theoretically nor prac-
tically useful, but should regulate the diet and bowels, and place the
patient under the best possible hygienic influences. Well-to-do pa-
tients may be sent to Wildbad, Gastein, PfSfers, or Ragatz. We must
not hope that the destroyed filaments of the brain will be restored by
the use of these waters, but experience shows that, at these places,
both cerebral and spinal paralysis often improve ; probably this im-

230 DISEASES OF THE BRAIN.

provement is due to the favorable influence of the baths on the inflam-
mation about the clot, and on that portion of the paralysis due to it.

Lastly, it cannot be denied that paralyses are generally improved
by the employment of the induced current of electricity. This is doubt-
less solely because " faradisation localised " is one of the most powerful
means of therapeutic gymnastics. After paralysis has lasted some
time, its degree almost always depends partly on diminished excita-
bility of the nerves, and on commencing atrophy of the muscles from
long disuse. For both of these states the methodical excitement of
the nerves by the induced current is certainly the best remedy, and,
at all events, it deserves the preference to irritating liniments, salves,
and tinctures.

CHAPTER VI.

HAEMORRHAGES OF THE CEREBRAL MEMBRANES APOPLEXIA MENIN-

GEA H^EMATOMA OF THE DURA MATER.

ETIOLOGY. — Excepting traumatic haemorrhages of the meninges,
among which are to be classed those occurring during birth, this is a
rare affection. Effusions of blood in the subarachnoid space, or be-
tween the dura mater and arachnoid, result mostly from the breaking
through of a cerebral haemorrhage. Occasionally, ruptures of aneu-
risms, or of degenerated arteries, cause the meningeal bleeding; in
other cases, the cause cannot be found.

The extensive capsulated collections of blood occasionally found,
on autopsy, on the under surface of the dura mater, are not, according
to Virchow's instructive examinations, as was formerly supposed,
simple extravasations of blood, at whose periphery the fibrin has been
precipitated and the fluid part capsulated, but they are the remains
of chronic inflammations of the dura mater (pachy meningitis), with
haemorrhagic exudations. Virchow calls this blood-sac haematoma of
the dura mater. The blood filling it comes from the numerous large
and thick-walled capillaries that have formed in the pseudo-membrane
of the dura mater during this variety of chronic inflammation, and it
has been effused between the layers of the pseudo-membrane. The
causes of chronic pachymeningitis, with haemorrhagic exudation, are
not perfectly known. The disease occurs chiefly in old age, and re-
markably often in persons with mental disease, and in drunkards. It
appears to develop sometimes as an independent, sometimes as a sec-
ondary disease, due to injuries of the brow. In the latter case it is
said that years may intervene between the injury and the first symp •
terns of haematoma ( G-riesinger).

ANATOMICAL APPEARANCES. — If the blood be effused hi the sub

HAEMATOMA OF THE DURA MATER. 231

arachnoid space, we usually find it as a more or less thick layer spread
over the surface of the cerebrum and cerebellum. If the arachnoid be
not torn, of course we cannot wash off the extravasation by turning a
stream of water on it. Usually part of the extravasation reaches the
ventricles, and there also we find more or less blood. In haemorrhages
between the dura mater and arachnoid the extravasation is generally
collected, more particularly on the tentorium and at the base of the
skull, and thence extends into the vertebral canal. But on the con-
vexity of the hemispheres we also find bloody masses, which may be
washed off by squeezing out the sponge over them. In both forms of
haemorrhage there is either simply flattening of the convolutions and
anaemia of the brain-substance, or else the layers of brain-substance
next to the haemorrhage are suffused with blood and softened.

Haematoma of the dura mater is usually located near the sagittal
suture and has the form of an oval flat sac, which may attain consid-
erable size, and may be four or five inches long, two or three broad,
and half an inch thick. The walls of the sac are colored rusty-brown
by altered haematin ; its contents are partly fresh fluid or coagulated
blood, partly dirty reddish-brown clots, that are unmistakably older.
The corresponding half of the cerebrum is flattened, or even shows a
depression. Not unfrequently the haematoma is on both sides. We
have the opportunity, rather frequently, of observing the commence-
ment of a pachymeningitis haemorrhagica ; for, in many autopsies, we
find a delicate yellow or brown connective tissue, larger on the inner
surface of the dura mater and firmly adherent to its surface.

SYMPTOMS AND COUESE. — Haemorrhages in the subarachnoid space
or on the free surface of the arachnoid, do not belong to the " local "
but to the " diffuse " diseases of the brain. Hence, when there is no
complication with cerebral haemorrhage, they are not accompanied by
the regional symptoms characteristic of this, especially hemiplegia;
on the other hand, the apoplectic fit is usually uncommonly severe, as
the bleeding is generally very abundant, and is spread over both sides.
Frequently the apoplectic fit occurs suddenly without any premonitory
symptoms, and the patients die with the above-described symptoms of
apoplexie foudroyante. When this occurs, we can, at most, make only
a probable diagnosis, which depends solely on the absence of hemi-
plegia, the symptoms of which may, as a rule, be distinguished, even
in the severest fits, from cerebral haemorrhage. In other cases the
apoplectic stroke is preceded by severe headache, and in some cases
by general convulsions. Since these symptoms, particularly the latter,
only occur exceptionally in cerebral haemorrhage, and are often seen
in extensive disease at the convexity of the hemisphere, they, in con-
nection with the absence of all signs of hemiplegia, enable us to decide
65

DISEASES OF THE BRAIN.

with greater certainty that the case is not one of cerebral but of me-
ningeal haemorrhage.

Haematoma of the dura mater often runs its course with symptoms
from which the disease cannot be certainly diagnosed, and when it
occurs in the course of mental affections, as so often happens, we can-
not usually make even a probable diagnosis. In other cases, the fol-
lowing factors, to which Griesinger has called attention, enable us,
with more or less assurance, to make a diagnosis of haematoma of the
dura mater ; if circumscribed headaches, gradually increasing to great
severity, in the vicinity of the vertex and forehead be the first, and, for
a long time, the only trouble of which the patients complain ; and if,
between the appearance of these pains and that of other severe brain-
symptoms, there be an interval not so short as in acute diseases of 'the
brain and its membranes, but shorter than in most chronic diseases of
these parts, particularly in the different cerebral tumors, the first sus-
picion falls on inflammation of the meninges, particularly of the dura
mater, since inflammation of the other membranes has so great a ten-
dency to spread, that it is accompanied by diffuse, not by circumscribed,
headache. We are the more justified in this, as the form of pachy-
meningitis in question occurs just at the point where the patients com-
plain of pain. If the patient had been mentally diseased before the
commencement of the headache, or given to drinking excessively, or it
he had had an injury of the head, particularly of the forehead, some
time previously, there is still more reason for supposing the case one of
pachymeningitis, as is evident from the etiology. But we also know
that this form of meningitis usually leads to a large effusion of blood,
encroaching on the cerebral cavity, and that then the effusion is cap-
sulated on one or both sides of the sagittal suture. Hence, if the
headaches be subsequently accompanied by the signs of compression
of the capillaries of the cerebrum, by mental disturbances, loss of mem-
ory, diminished power of thought, increased inclination to sleep, which
finally increases to coma, a slowly-developing and usually not pure
hemiplegia, after excluding various brain-diseases, we must think of
haematoma of the dura mater as being in the first rank of those that
may possibly be present. Since, in haematoma of the dura mater, there
may be reabsorption of the blood and consequent freedom of the brain
Irom the pressure on it, a favorable course of the disease and recovery
of the patient speak for haematoma in doubtful cases. If the effusion
of blood does not take place gradually, as in the course of the disease
above described, but occurs suddenly ; if it is large and limited to one
side, the symptoms are those of an abundant haemorrhage in one side
of the cerebrum. On superficial examination it may appear remarkable
that, even in large haematomata of one side, there is occasionally no

INFLAMMATION OF THE DURA MATER. 233

hemiplegia, or else it is very incomplete ; but we must bear in mind
that haematoma occurs just at the place where the increased pressure
on one hemisphere is most readily transferred to the other, through
the free communication between the two sides in the anterior portion
of the skull, particularly when the haemorrhage comes on slowly.
Among the symptoms of haematoma, Griesinger also lays stress on
the almost constant contraction of the pupil, and is inclined to regard
this as a " symptom of irritation of the surface." In the previous
chapter I attempted to give another explanation of the contraction of
the pupil (which was also hypothetical) in diseases encroaching on the
space above the tentorium.

TREATMENT. — In the treatment of meningeal haemorrhages, the
same rules hold good as were given for that of cerebral haemorrhages,
and we may the rather refer to the former chapter, as it is impossible
to make an exact diagnosis between the two.

If we consider the diagnosis of a haematoma as certain, we may, in
recent cases, apply leeches behind the ears, ice-compresses to the head,
and give a purge occasionally. In the latter stages, blisters or pustu-
lating ointments to the nape of the neck suffice. With this treatment
I have had very good results in two cases that I have observed ; still,
in spite of the very characteristic symptoms in these cases, there may,
possibly, have been an error of diagnosis.

INFLAMMATIONS OF THE BRAIN AND ITS MEMBRANES.

IN the following chapters we shall speak — 1. Of inflammation of
the dura mater and its sinus. 2. Of inflammation of the pia mater,
with puro-fibrinous exudation. 3. Of tuberculous inflammation of the
pia mater, including acute hydrocephalus. 4. Of epidemic cerebro-spi-
nal meningitis ; and 5. Of inflammation of the brain-substance. Since
inflammation of the arachnoid cannot be distinguished from that of the
pia mater, we shall not treat separately of arachnitis.

CHAPTER VII.

INFLAMMATION OF THE DURA MATER, INFLAMMATION AND THROM
BOSIS OF THE CEREBRAL SINUS.

IN the previous chapter we spoke of one form of pachymeningitis,
because, on account of the haemorrhage it causes, and its clinical
oourse, it is most suitably classed among meningeal haemorrhages.
Now we have only to speak of that form which, since Virchow's studies
<m haematoma of the dura mater, is called pachymeningitis externa.

234: DISEASES OF THE BRAIN.

ETIOLOGY. — It is very doubtful whether pachymeningitis occurs, aa
a primary and independent disease, from cold and other causes. At
all events, it is generally secondary, and as such accompanies fissures,
fractures, and especially caries of the cranial bones, particularly of the
petrous and ethmoid bones, as well as caries of the upper cervical
vertebra. In periostitis of the outer surface of the skull also, pachy-
meningitis occasionally occurs, without our being able to distinguish
any continuity between the two diseases by changes in the cranium.

Inflammation of the cerebral sinus, with consequent thrombosis, or
even thrombosis of the sinus, with subsequent inflammation of its walls,
occurs proportionately often, being most frequent in the sinus lying on
the petrous bone, the lateral and petrosalt This is evidently because
inflammation and thrombosis of the cerebral sinuses are induced, in the
great majority of cases, by caries of the petrous bone advancing to the
base of the skull. The numerous patients suffering from tedious
otorrhcea, as a result of otitis interna, are constantly threatened, as
with a Damocles' sword, by inflammation or thrombosis of these si-
nuses. Not unfrequently there are suppuration and breaking down of
the thrombus, and then particles of it may enter the efferent veins
and lead to embolism and metastatic inflammation.

ANATOMICAL APPEARANCES. — The anatomical changes in mild and
chronic cases of pachymeningitis externa are limited to a gradual
thickening of the dura mater as a result of proliferation of connective
tissue on its outer surface; the dura mater thus becomes firmly
attached to the cranium, and subsequently the neoplastic tissue partly
ossifies. In acute and severe cases the dura mater is usually reddened
by vascular injection and small ecchymoses, is thickened and infiltrated
in circumscribed spots corresponding to the point of injury or caries
of the cranial bones. Later, this membrane becomes discolored, its
tissue is relaxed and softened ; finally, there is suppuration, and, if pus
collects between the dura mater and cranium, the inflamed part be-
comes detached from the bone. In the latter case the pia mater also
is almost always inflamed, and generally to a great extent. Even on
autopsy it is often difficult to decide whether the inflammation of the
wall of the sinus preceded the thrombosis, or the reverse. If the
thromboses be not disintegrated, they adhere firmly to the relaxed
rough inner surface of the thickened wall of the sinus, and occasionally
extend backward to the torcular Herophili, and in rare cases down to
the internal jugulars ; as has been shown by the observations of Lebert^
who has very greatly advanced our more accurate knowledge of this
disease. More frequently on autopsy we find the thrombus already
broken down, and the inflamed sinus filled with a purulent or sanious,
occasionally gray-green and stinking fluid, mixed with flocculi. Along

INFLAMMATION OF THE CEREBRAL SINUSES. 235

with these changes we generally find those of otitis interna, and ex-
tensive caries of the petrous bone ; viz., destruction of the drum,
absence of the ossicula, polypoid proliferations of the mucous mem-
brane, the tympanum full of pus, which also infiltrates the labyrinth,
cochlea, and mastoid cells.

SYMPTOMS AND COURSE. — Chronic pachymeningitis, which causes
thickening of the dura mater, and its firm adhesion to the cranium
and ossification of the thickened layer, may be accompanied by
headache and other symptoms ; but these are not at all characteristic
and do not show us what the disease is. The symptoms and course
of acute pachymeningitis externa also are almost always so modified
by the symptoms of the original disease, by complications with ex-
tensive inflammation of the pia mater, and by extension of the in-
flammation to the cerebral sinus with its results, that it is impossible
to give a pure description of the disease. If an injury of the skull,
or, still more, if a caries of the temporal bone, due to otorrhoea, be
accompanied by unusually severe and extensive pain in the vicinity
of the diseased bone, by fever, vomiting, dizziness, noises in the ear,
twitching, delirium, and other symptoms of irritation of the brain,
which are subsequently followed by those of depression, and finally
by general paralysis, we may conclude that the disease of the bone
has at first caused inflammation of the dura mater, and later, diffuse
inflammation of the pia mater. The first stage is often short and
indistinct, and, on the first visit or at their reception into the hospi-
tal, we find the patients in deep sopor. But even in such cases the
above diagnosis may be made with tolerable certainty, if we find an
injury of the skull, or particularly a chronic otorrhcea, and can dis-
cover no other causes for the brain-disease.

The symptoms induced by inflammation and thrombosis of the
cerebral sinuses are always accompanied by those of meningitis as
given above; hence it will be enough to limit ourselves to pointing out
under what circumstances we are to suspect inflammation or thrombo-
sis of a cerebral sinus, when we have a meningitis or encephalitis ac-
companying caries of the petrous bone. From the great frequency
of this complication, I think it is well to keep in view its possibility
and even its great probability, although the very doubtful signs of the
disease should be absent. The suspicion will acquire more probabil-
ity, should we observe a symptom of thrombosis of the transverse
sinus that was given by Gerhardt with great acuteness, namely, less
fulness of the jugular vein drawing its blood from the obstructed sinus.
The same would be true if we found a symptom given by Griesinger,
which was only observed in one case, a circumscribed painful oedema
behind the ear ; although, in caries of the mastoid process, this redema

236 DISEASES OF THE BRAIN.

(which G-riesinger calls a phlegmasia alba dolens en miniature) may
arise from other causes than from the extension of the thrombus
through the emissaria santorini which pass out in the sigmoid fossa.
In most cases it is only from the occurrence of rigors and the signs of
metastatic deposits in the lungs that we can conclude that caries of
the petrous bone has not only induced meningitis and encephalitis,
but has also led to thrombosis in the cerebral sinuses.

TREATMENT. — On the signs, or even suspicion, of inflammation of
the dura mater, we should use energetic antiphlogistic treatment by
repeated application of leeches behind the ears. At the same time, if
there be any otorrhcea, we should make warm injections into the af-
fected ear and cover it with cataplasms. Active purges and large
blisters to the back of the neck are also useful. In other respects, the
treatment of pachymeningitis corresponds with that £>f inflammation
of the pia mater.

CHAPTER VIII.

INFLAMMATION OP THE PIA MATER, WITH PTJRO-FIBRINOTJS EXUDA-
TION— MENINGITIS OF THE CONVEXITY MENINGITIS SIMPLEX.

ETIOLOGY. — In acute meningitis, an exudation containing many
pus-cells is effused into the subarachnoid space ; in chronic meningitis
there are diffuse cloudiness and thickening of the pia mater and arach-
noid, from proliferation of the connective tissue.

Acute meningitis, with puro-fibrinous exudation, is in many cases a
secondary disease, and as such accompanies injuries and diseases of
the skull and of the dura mater or other inflammations and other dis-
eases of the brain. Except in the epidemic form, of which we shall
speak in Chapter IX., it rarely occurs as an independent disease in pre-
viously healthy persons, but is somewhat more frequent in cachectic
individuals or in those exhausted by long illness. Thus it is observed
in convalescence from pneumonia and pleurisy, or from acute exanthe-
mata and other infectious diseases, and from protracted diarrhoeas, but
especially during Bright s disease, etc. Although in these cases we
frequently cannot discover any new source of injury acting on the
body, we have no right to consider this inflammation of the pia mater
as metastatic or even as secondary. The action of the sun's rays or
of a very high or even of a very low temperature on the head, chilling
the body, or getting wet, misuse of liquor, etc., are mentioned among
the exciting causes of meningitis. But only the last of these causes
has been proved to have any influence in exciting this disease. Re-
cently Grriesinger has called attention to a form of meningitis which

MENINGITIS SIMPLEX. 237

appears as one symptom of constitutional syphilis ; and in the Greifs-
walder clinic I have seen a case of this kind, which has been fully de
scribed by Professor Ziemssen, at that time my assistant.

ANATOMICAL APPEARANCES. — Meningitis, with puro-fibrinous exu-
dation, occurs chiefly on the convexity of the cerebrum. In the acute
form we there find the small vessels of the pia mater more or less dis-
tinctly injected, and in the subarachnoid space, especially between
the convolutions and around the large vessels, we find a yellowish,
generally firm exudation, consisting of pus-corpuscles and fine granular
fibrin. In milder grades of the disease the exudation is chiefly in the
perivascular spaces. Occasionally the arachnoid is at the same time
covered with a more fibrinous or more purulent coating. The cortical
substance of the brain is sometimes of normal consistence, sometimes
it is softened by inflammation. The ventricles which, in tubercular
basilar meningitis, are almost always filled with fluid, are generally
found empty in purulent meningitis of the convexity. In chronic me-
ningitis we usually find the arachnoid adherent to the dura mater
either by a few points or throughout a considerable extent; the pia
mater is thickened and cloudy, the subarachnoid spaces filled with
turbid fluid ; or else we find the pia mater also transformed to a firm,
decidedly thickened membrane, which cannot be removed from the
brain without tearing.

SYMPTOMS AND COURSE. — Acute inflammation of the pia mater is
accompanied by symptoms of severe fever, particularly by a very fre-
quent pulse, and, like acute and extensive inflammation of other or-
gans, occasionally begins with a chill. Fever of similar character and
equal severity occurs in scarcely any other disease of the brain, and
consequently is very important in the diagnosis of meningitis. If the
frequency of the pulse disappear after the disease has lasted some
time, if it fall from 120-140 beats per minute to 60-80 beats, while
the other symptoms of fever and the functional disturbance of the
brain increase, the evidence is still more in favor of meningitis. The
other symptoms of the disease are headache and the repeatedly-men-
tioned functional disturbance of the brain, partly with the character
of irritation, partly of depression or complete paralysis. In acute me-
ningitis, the headache becomes very severe ; patients not only com-
plain of it while they retain consciousness, but even when this is im-
paired they frequently grasp the head and moan slightly, so that we
may suppose they still feel pain. In almost all cases there are psychi-
cal disturbances even at the outset of the disease, probably from the
vicinity of the cortical substance ; the patients are very excited and
restless, usually quite sleepless, and soon become delirious. In the
sensory functions also there is more irritability, so that the patient

238 DISEASES OF THE BRAIN.

is very sensitive to light, sound, and even to slight friction on the
skin. [A mere touch, especially upon the skin of the legs, will make
the patient cry out ; and even after the stage of stupor has set in
he will wince if touched, showing that reflex irritability still con-
tinues. This hypersesthesia of the extremities is a sign that the
meningitis has extended to the spinal cord. Autopsies conducted
by Gerhardt, both in children and in adults, uniformly support this
interpretation of the symptom. On the other hand, the contraction
of the neck-muscles so common in meningitis, which has also been
ascribed to the coexistence of cerebral and spinal meningitis, is
found more frequently in pure cerebral meningitis than when com-
plicated with meningitis of the cord. In some cases a marked draw-
ing-in of the belly affords a noticeable diagnostic mark.] Finally,
there are noises in the ears, sparks before the eyes, restlessness,
gnashing of the teeth, twitchings, and often also contraction of the
pupil, and vomiting. We have had to mention all these symptoms
in treating of simple hyperaamia of the brain and of hydrocepha-
loid ; indeed, there is no pathognomonic sign of meningitis which
is present in this and absent in other brain-diseases. It is true, the
etiology, the grade of the fever, especially the height of the pulse
and the unusual severity of the headache, occasionally speak, even
in this stage, with great probability against simple hyperaemia
or anaemia of the brain ; but frequently it is only the subsequent
course, the severe accidents that characterize it, the want of success
in treatment, and the usually fatal result, that render the diagnosis
certain.

If any of the characteristic symptoms be absent in the first stage,
we must give a guarded diagnosis. Frequently only the effect of a
laxative or of local blood-letting verifies the diagnosis between hy-
peraemia of the brain and meningitis. An attack of convulsions,
usually preceded by stiffness of the neck, from tonic contraction of
the muscles of the nape of the neck, often indicates the passage into
the second stage. In this the patient falls into a deep sopor, becomes
entirely insensitive to the irritation, and cannot move his limbs,
although certain muscles, particularly those on the back of the neck,
are in a state of tonic contraction, and there are general convulsions
from time to time. [For some time after the commencement of the
stage of stupor, periods of excitement recur, with delirium and loud
screaming and convulsive paroxysms. It is remarkable that even at
this stage of the malady fluctuations occur, with temporary improve-
ment in the patient's condition ; sometimes even the consciousness
returns, and other deceptive signs inspire a hope of final recovery.
The most important diagnostic marks of depression are the palsies,

MENINGITIS SIMPLEX. 239

which by their appearance often set at rest any remaining diag-
nostic doubts. These palsies are rarely complete hemiplegias, and
seldom are they so marked as when arising from local disease of the
brain ; but they ought not to escape the attention of any but a su-
perficial observer. Sometimes an arm or a leg loses its strength.
More commonly, however, there is a partial palsy of the face, such
as dilatation of the pupil with insensibility to light, squinting, or the
like.] The pulse also is usually, but not always, retarded. While
the stupor and general paralysis increase, the patient generally dies
of coma in a few days, more rarely not till the second or third week.
These stages in the clinical course, between which there is occasion-
ally a slight improvement, cannot be referred to any perceptible
change in the pathologico-anatomical course ; as if, for instance, the
first stage corresponded to the hypersemia of the meninges, and the
second to the exudation in the subarachnoid space. Nor must we
omit to mention that not unfrequently, especially where the menin-
gitis is due to caries of the petrous bone or to disease of the brain,
the first stage is very little marked or not at all noticed. In these
cases the symptoms begin with an attack of convulsions, which is
repeated several times, and is followed by deep coma and general
paralysis, usually accompanied by contraction of certain muscles.

[Stories of recovery from acute meningitis must be accepted
with hesitation, error of diagnosis being a more probable event.
Nevertheless, limited and mild inflammations of the pia mater un-
doubtedly have got well, but convalescence is very slow, and various
derangements of the nervous apparatus persist for a long time. In
chronic cases, and less often in acute ones, there may be imperfect
recoveries, with permanent damage to the meninges and cortical
matter of the brain — with trembling paresis, numbness of a limb,
squinting, or deafness ; sometimes there are epileptic fits. The pro-
gressive palsy of the insane appears to depend upon a creeping
inflammation of the meninges and upon periencephalitis, with occa-
sional exacerbations and rises of temperature. The periods of men-
tal excitement, headache, and convulsions correspond to those of
elevation of temperature. Many other cases of insanity, character-
ized by psychical depression and ending in idiocy, must also be
attributed to permanent injury to the cortical substance and menin-
ges from inflammation.

The diagnosis of meningitis may present great difficulties. It
has no pathognomonic symptom, and it is only by a careful grouping
of the signs and a history of the case that a positive determination
can be made.]

The symptoms of chronic meningitis are not accurately known, fre-

24:0 DISEASES OF THE BRAIN.

quently as its remains are found on autopsy of drunkards and insane
patients. This is especially true of the commencement of the disease.
It is probable that it is accompanied by headache and functional dis-
turbance of the brain of an irritative character ; but in drunkards, for
instance, it will always be doubtful whether these are symptoms of
inflammation of the brain or of alcoholic poisoning. The advanced
stages of the disease may be more readily made out. If, in a patient
who has been exposed to the above causes, and in whom we can ex-
clude other brain-diseases, we find decided impairment of memory, dul-
ness of intellect, disjointed frame of mind, if there be also trembling
of the limbs, tottering gait, and other symptoms of gradually-progress-
ing paralysis, we may diagnose chronic meningitis.

TREATMENT. — There is no doubt that favorable results are some-
times attained by active treatment in acute meningitis with puro-fibri-
nous exudation. It is not generally proper to bleed from the arm, but
we may apply leeches to the brow and behind the ears, and, if the
strength of the patient permit, may repeat the application. We may
also cover the shaved head with cold compresses, and give an active
purge of calomel and jalap. In the later stages of the disease, if, in
spite of the previous treatment, there be coma and other signs of cere-
bral palsy, we may apply a large blister to the nape of the neck, and
rub pustulating ointment on the head. Still more efficacious than
these derivatives are douche baths, pouring cold water over the head
from a pitcher held some distance above it. The patients almost al-
ways recover consciousness as this is being done ; but, it must be re-
peated at intervals of a few hours, to secure a permanent result ; with
each successive employment of the douche we must increase the num-
ber of pitcherfuls. I shall lastly mention that frictions with mercurial
ointment, and the continued administration of calomel, are much em-
ployed. In chronic meningitis, Kruckenberg also recommended cold
douche baths as the most efficacious treatment. He particularly quoted
the case of an old official, over whose head he daily poured as much as
fifty pitcherfuls of cold water.

CHAPTER IX.

BASILAR MENINGITIS, TUBERCULOUS INFLAMMATION, AND SIMPLE MIL-
IARY TUBERCULOSIS OP THE PIA MATER — ACUTE HTDROCEPHALUS.

ETIOLOGY. — In basilar meningitis there is a deposit, in the sub-
arachnoid space at the base of the brain, of a readily-coagulating exu-
dation, containing few pus-corpuscles. At the same time, there are
almost always tubercular granulations in the meninges, causing a form

ACUTE HYDROCEPHALUS.

of disease designated as tuberculous basilar meningitis. This must be
distinguished from simple miliary tuberculosis of the meninges, where
the development of tubercle is not accompanied by inflammation and
exudation, because the symptoms and course of the two diseases differ
m some respects. Both basilar meningitis and simple tuberculosis of
the meninges almost always cause effusions of fluid in the ventricles,
and softening of their walls and the surrounding parts. The latter is
the result of maceration, or destruction of the brain-substance by a
simple transudation or inflammatory exudation.

Tuberculous basilar meningitis, as well as miliary tuberculosis of
the meninges, rarely occurs, as a primary and independent disease, in
persons previously healthy. We must bear this in mind, as it is very
important for the differential diagnosis of the various forms of menin-
gitis. These diseases are most frequently parts of a general acute or
chronic miliary tuberculosis, or, at least, of one affecting most of the
organs of the body. This form of the disease has many victims among
those children of whom, when speaking of pulmonary tuberculosis, we
said they had a strong predisposition to pulmonary consumption, if
they did not die early of croup or hydrocephalus. These are not only
children with marked scrofulous diseases, but also the offspring of con-
sumptive or otherwise debilitated parents. They are badly nourished,
and not well developed physically, but are often very bright men-
tally ; have a fine skin, very perceptible veins, long eye-lashes, and a
blue sclera. Caseous degeneration of the bronchial and mesenteric
glands, caseous deposits in the lungs, and other old disturbances of
nutrition, which, along with fresh deposits of tubercle in different
organs, are found on autopsy of these children, if they finally die of
hydrocephalus, cannot usually be recognized with certainty during life ;
hence the brain-affection is regarded as a primary disease. The case
is different when the tuberculous inflammation or miliary tuberculosis
of the meninges attacks adults. For then the symptoms of meningeal
tuberculosis have either been preceded, for a short time, by those of
acute miliary tuberculosis, or, more frequently, for a long time, by those
of chronic consumption of the lungs. In other cases, tuberculous me-
ningitis and miliary tuberculosis of the nieninges accompany old
tuberculous affections, such as chronic pulmonary or cerebral tubercu-
losis, and cheesy degeneration of the bronchial and mesenteric glands,
but are not accompanied by fresh deposits of miliary tubercle in other
organs ; they form the only acute complication of these chronic tuber-
culous affections. Lastly, although rarely, tuberculous meningitis or
miliary tuberculosis of the meninges occurs, without any precedent
tuberculosis of other organs, in previously healthy persons, or during
convalescence from severe diseases, such as typhus, measles, etc.

242 DISEASES OF THE BRAIN.

During the first year of life, tuberculosis of the meninges is rare ;
jiter, during childhood, it is proportionately frequent ; in adults, only
solitary cases occur, except where it complicates chronic pulmonary
consumption. Among the exciting causes, premature or excessive
mental exertion is blamed most frequently for exciting hydrocephalus
in children ; this is probably unjust. Children not predisposed to it
may be mentally stimulated to any extent without inducing hydro-
cephalus ; and the early development of children falling a prey to this
disease is due to their predisposition, not to their bringing up ; this is
not the cause of their hydrocephalus. The same is true of the asser-
tion that a blow or fall on the head induces tuberculosis of the menin-
ges and acute hydrocephalus. It is almost always easy to make out
that the sick child has, some time or other, fallen on its head ; but it
does not thence follow that this fall is to be regarded as the cause of
his disease.

ANATOMICAL APPEARANCES. — In basilar meningitis we find a yel-
lowish, opaque exudation, which is sometimes very plentiful, in the
meshes between the pia mater and arachnoid, especially about the
optic chiasm, as well as in the portions of the meninges extending
toward the pons and medulla oblongata, and thence along the larger
cerebral fissures, particularly the fossa of Silvius, toward the convex
surface of the brain. At the same time, we almost always find the
pia mater covered with whitish granulations, the size of a grain of
sand or a hemp-seed, most distinctly so in the vicinity of the blood-
vessels.

In simple miliary tuberculosis of the meninges the changes are less
marked, and it is only on careful examination at the above places that
we find numerous, usually very small, whitish, granular opacities of
the pia mater, whose significance is often only rendered evident by the
coincident occurrence of hydrocephalus and the presence of tubercle
granulations in other organs.

In both forms, the ventricles, especially the lateral and the third
ventricles, are sometimes moderately, sometimes considerably dilated
by serous fluid. The latter is occasionally quite clear, but is usually
clouded by flocculi. The walls of the ventricle, but especially of the
fornix and commissures, are at the same time so softened that they
usually break down on the slightest touch. This (hydrocephalic) soft-
ening spreads indefinitely, often far beyond the immediate neighbor-
hood of the ventricle. The larger the effusion in the ventricles, the
more bloodless and pale the brain becomes, and the whiter the soft-
ened parts.

SYMPTOMS AND COURSE. — There is no symptom pathognomonic cf
oasilar meningitis, and which alone will render a diagnosis possible*

ACUTE HYDROCEPHALUS. 243

Nevertheless, the disease is almost always easy to recognize and to
distinguish from other diseases. Characteristic peculiarities in the
sequence of the symptoms, distinct signs from which the original seat
of the affection and its subsequent extension may be determined, as
well as the very regular subacute course of the disease, almost always
give sufficient grounds for a certain diagnosis. At the commencement
it is a local disease, situated at some point on the base of the brain,
where numerous nerves start from that organ and run to the foramina
through which they leave the skull. Later, when the disease extends
to the ventricles, the local disease at the base becomes complicated, by
the excessive effusion in the ventricles and by extensive hydrocephalic
softening of the brain-substance, with diffuse disease of the cerebrum.
In accordance with this, among the most constant symptoms of basilar
meningitis are such as indicate irritation and afterward paralysis in
the parts supplied by the nerves of the eye, the vagus and medulla
oblongata. Among these are contraction and, later, dilatation of the
pupil, ptosis of the upper eyelids, vomiting, slowness and subsequent
frequence of the pulse, the peculiar changes of the respiration, and de-
pression of the abdomen, according to the results of Budge's observa-
tions. In the same way, corresponding to the course of the patho-
logico-anatomical changes, the functions of the cerebrum at first show
no marked disturbance, except the symptoms of so-called general cere-
bral irritation, while, as the disease advances, there is severe disturb-
ance, of the character that we have frequently mentioned as due to
compression of the capillaries by diseases encroaching on the space ;
such as loss of consciousness, epileptiform convulsions, paralysis of the
extremities, etc. In cases where this second set of symptoms is not
very marked, we may even conclude that the effusion in the ventricles
is not very large. Lastly, when the symptoms of paralysis are limited
to one side in certain cases, or are more decided on one side than on
the other, it is usually because the hydrocephalic softening is more ad-
vanced on one side than on the other.

Although basilar meningitis, particularly its tuberculous form, and
miliary tuberculosis of the meninges, very rarely occur in persons pre-
viously healthy, we must not count among its premonitory symptoms
those of the diseases which it usually accompanies, On the other
hand, in most cases, especially in children, the violent symptoms char-
acteristic of a later stage of the disease are usually preceded for a time
by insidious and indefinite symptoms, which may correctly be consid-
ered as premonitory. Such children show a change of manner, have
no desire to play, like to sit in a corner, rest the head on the hands, are
sleepy, and dream a great deal. They do not always complain of
severe headache, and when they do it is especiallv in cases where therf

244 DISEASES OF THE BRAIN.

J3 not simple miliary tuberculosis, but a tuberculous inflammation of
the meninges. During these symptoms, which usually last for several
weeks, the children become emaciated because their digestion is im-
paired, and probably also because they have fever. Nevertheless, it
often happens that the mother overlooks or pays little attention to
this period, and subsequently, when severe symptoms appear, assures
the physician that the child was suddenly taken sick. We must know
how important it is to decide whether there is the beginning of a new
disease, or the commencement of the final stage of an old one, so as to
make a more accurate examination. I have often found that the rela-
tives and neighbors had noticed the altered manners of the child, while
the mother had entirely overlooked them.

If the above symptoms be accompanied by vomiting, which cannot
be traced to errors of diet, and does not occur after eating, but when
the child is raised up, if the patient at the same time suffer from con-
stipation and the abdomen is sunken, the physician must regard the
case as very serious, although the parents usually think it free from
danger. The little patients soon begin to complain more of their
heads ; they become sensitive to light and sound, gnash their teeth
during sleep, and occasionally give a piercing cry (crie hydrocepha-
tique). From time to time we see twitchings of certain limbs, or sud-
den spasm of the entire body. The patients start from their sleep
with terror at some dream, and do not find relief from it even in wak-
ing. They are very much excited, and often repeat the same word or
phrase innumerable times. At this time the pupils are usually con-
tracted and the pulse is more frequent. When these symptoms succeed
the premonitory stage, and when we at last see the child bending its
head backward, boring into the pillows, with the muscles of its neck
contracted, and the cervical lymphatic glands swollen, we become cer-
tain of the sorrowful fact.

After a few days, or even sooner, the scene usually changes very
suddenly. The passage into the second stage is generally marked by
an attack of general convulsions, such as we have already described.
The vomiting then becomes rarer or ceases entirely, the children no
longer complain of pain, but put their hands to their heads in a pecu-
liar way ; loud noise does not disturb them, and they do not turn the
face away if a bright light be held before it ; the peculiar cry and the
gnashing of the teeth continue. We often find the muscles of some
of the limbs or of one half the body slightly contracted, while those of
the other side are relaxed. Now the previously-contracted pupils be-
some dilated, occasionally first one, then the other ; the children no
longer regard objects held before them, and they begin to squint. The
previously-frequent pulse becomes slower, falling to sixtv beats a

ACUTE HYDROCEPHALUS. 245

minute or even less. The respiration generally shows very peculiar
changes ; for a time the inspirations are very superficial, and it almost
looks as if the child forgot to breathe ; then there is a deep sighing in-
spiration with which it repairs the neglect, as it were. The coma
gradually becomes deeper ; the lucid intervals that at first interrupted
it grow more incomplete and shorter; the eyelids are either not
closed, and the eye stares into space, or else the upper lid droops, and
the eyeball is rolled .up, so that the pupil is half covered by the upper
lid. At the same time the color of the face often changes in a short
time, and such a child, with its blooming cheeks, widely-open eyes,
which have a peculiar dark and brilliant appearance from the dilata-
tion of the pupil, has, to an uninitiated person, the appearance of not
being very sick. During this stage there usually are attacks of con-
vulsions at intervals ; these are sometimes on one side of the body,
sometimes on both. We must not conclude, from the convulsions on
one side the body, that the opposite side of the brain is chiefly affected.
The tetanic contractions of the muscles on the back of the neck, and
I he backward curvature of the neck, usually continue in this stage.

The stage of the disease last described occasionally continues a
week or more. In spite of the hopelessness of the patient's state, the
physician must continue his visits, and at each one he is asked anew
if there is no chance of averting the danger ; at last the parents are
utterly overcome, but even then the disease occasionally continues for
days, or a temporary appearance of improvement again excites deceit-
ful hopes. These are hard times for the physician, especially as he is
almost powerless against the slowly-advancing but inevitable result ;
and as, for days, he has but little to do except prepare the parents for
the child's death. We must note that death is not imminent till some
decided changes occur in the symptoms, to which it is well to call the
attention of the attendants. Almost always twelve to twenty-four
hours before death the pulse becomes very frequent, the skin is covered
with copious perspiration, the previously-sunken belly becomes puffed
up ; defecation and urination are involuntary, and we may hear exten-
sive moist and uneven rdles in the chest.

Most cases of tuberculous basilar meningitis, and of miliary tuber-
culosis of the meninges in children, run their course in the above man-
ner and resemble each other very much. Slight differences result from
the predominance of certain symptoms, and from the different dura-
tions of certain stages or of the whole disease. But we must add that
in some cases the disease runs a much more rapid course, and is accom-
panied by symptoms so similar to those of acute meningitis, that it is
impossible to distinguish them. On the other hand, we must mention
that occasionally, on autopsy of patients who have died of consump

24:6 DISEASES OF THE BRAIN.

lion, we find miliaiy tuberculosis of the meninges, and slight amounts
of hydrocephalus, which were not indicated by any prominent symp-
toms during life. These cases seem to show that, in the description
of the disease first given, the premonitory stage belonged to the com-
mencement of the cerebral affection, and not to its complications or to
the general tuberculosis. Lastly, we must point out that tuberculous
basilar meningitis, and miliary tuberculosis of the meninges, develop-
ing during advanced pulmonary consumption in adults, have no dis-
tinct premonitory symptoms, but are first recognized from the occur-
rence of contractions of the muscles of the nape of the neck, coma,
slow pulse, dilatation of the pupil, and the other symptoms of the fully-
formed disease. Death is the most frequent termination. Well-
proved cases of recovery are very rare ; but, even excepting the cases
where the diagnosis was somewhat uncertain, there is no doubt that it
has occurred. Neither the ordinarily variable course of the disease, nor
the surprising remissions that usually occur, should induce us to give a
more favorable prognosis ; only a continued improvement of all the symp-
toms dare excite the hope that the disease will take a favorable course.
TREATMENT. — Until within a short time, the treatment of tuber-
culous meningitis and acute hydrocephalus presented no difficulty to
the physician. The inflammation of so important an organ naturally
required the employment of all kinds of antiphlogistics. At the out-
set of the disease, venesections were ordered, calomel and flor. zinci
were administered, and mercurial ointment was rubbed in the nape of
the neck, then the occurrence of calomel stools, or the first signs of
salivation, were anxiously awaited, for they were a guaranty for the
efficacy of the treatment. In the later stages, absorption of the exuda-
tion was to be induced ; hence the mercurial frictions were continued,
and diuretics and active derivatives, even moxa on the shaved scalp,
or pustulating ointments to it, were prescribed. If, in spite of all this,
the paralysis continued to advance, an infusion of arnica and camphor
was given. The more this disease was recognized as one symptom of
extensive tuberculosis, the more antiphlogistic treatment was aban-
doned; then the opposite error was fallen into, either nothing was
done (expectant treatment), or else all the efforts were directed to the
cure of the tuberculous dyscrasia. The best mode of treatment of
tuberculous meningitis and miliary tuberculosis of the meninge?
«s as follows: At the commencement of the disease, especially
when severe headache indicates tuberculous inflammation rathei
than simple miliary tuberculosis, we should apply leeches behind
the ears. This is the more urgently to be advised, as in this stage
an exact diagnosis of the different forms of meningitis is scarcely
possible, and we do not certainly know whether the disease

EPIDEMIC CEREBRO-SPINAL MENINGITIS. 247

is not at first a simple inflammation of the meninges, which is sub-
sequently accompanied by the development of the tubercle, after
repeated relapse of the inflammation. When the local abstraction of
blood proves beneficial, it may be repeated during subsequent relapses.
In these cases, at the onset of the disease, laxatives and ice compresses
may also be used. Otherwise the treatment is the same as that for
meningitis, with puro-fibrinous exudation. But the treatment must be
entirely different when the inflammatory symptoms are less decided,
when the headacne is slight, and the disease drags on slowly. Then
a single venesection is admissible, it is true, but it rarely has even a
temporary effect, and its repetition is almost always injurious. On
the strength of two successful cases, opposed, it is true, by a large num-
ber of unsuccessful ones, I recommend large doses of iodide of potas-
sium, continued for a long time. In the cases above mentioned, where
recovery took place under this treatment, there was a very extensive
iodine eruption, and an iodine catarrh of the nose. These signs of
iodism were absent in the unsuccessful cases. It cannot be denied
that cold douches have a palliative effect, but I would advise against
their use in marked cases of tuberculous basilar meningitis, and con-
sequent acute hydrocephalus. During the affusion, the children almost
always recover consciousness, but it is only for a short time. More-
over, when not successful, the operation is very painful, not for the
children, but for the persons around. The latter feel very much
pained that the child was worried at the last, when it could not be
assisted. The same is true of the application of moxse, and of frictions
to the scalp with tartar-emetic ointment. Hasse recommends very
small doses of morphia (^ of a grain) even in the early stages, as he
has seen undoubtedly beneficial effects from it in some cases.

CHAPTEK X.

EPIDEMIC CEREBRO-SPINAL MENINGITIS.

FROM the fatal epidemics of this disease which have occurred of
late years in Germany, cerebro-spinal meningitis has acquired a greal
interest for German physicians, to whom it was previously almost ex-
clusively known from the accounts of French observers. In 1865, 1
wrote a treatise on epidemic cerebro-spinal meningitis ; this article was
well received on many sides, but also caused some opposition, because,
in spite of the small number of my observations, I had ventured to
make various hypotheses concerning the nature of the disease and the
indications of the symptoms. But, on careful examination of the ex
tensive literature on the subject, of late years, I have found nothing
66

248 DISEASES OF THE BRAIN.

decidedly new, and have satisfied myself that my views had been gen-
erally received ; so, in the present chapter, I shall chiefly follow my
previous work.

ETIOLOGY. — We are unacquainted with the injurious power whose
action induces this form of meningitis, and whose spread over greater
or less extents of country excites more or less extensive epidemics of
the disease. But we may regard it as very probable that epidemic
cerebro-spiiial meningitis does not depend on atmospheric or telluric
influences, but is rather due to an infection of the body with a specific
poison. It is true, the occasional frequent occurrence of a disease in
regions generally free from it, and even the affection of several mem-
bers of the same family, do not alone justify the conclusion that the
disease depends on infection. But the passage of an epidemic from
place to place, as is often seen in epidemic cerebro-spinal meningitis,
is an important evidence of miasmatic extension. Apparently there
is no transfer of the disease by contagion, although solitary instances
are brought up to prove the infection of one person from another.

But cerebro-spinal meningitis does not, by any means, belong to
that class of infectious diseases, of which we may take typhus as an
example, and of which we shall hereafter speak in a separate section.
The consideration of this disease as a peculiar form of typhus, which
was formerly so common in France, has been entirely disproved
during the late epidemic in Germany. I separate this affection from
classes of infectious diseases to which the different forms of typhus
belong, on the following grounds: In the latter, the severe con-
stitutional symptoms, especially the fever, for the most part, depend
immediately on the reception of the infecting material into the blood,
and the anatomical changes in the organs, caused by the infection, are
very peculiar; they are induced only by infection with the specific
poison. In epidemic cerebro-spinal meningitis, on the contrary, the
fever and all other symptoms depend solely on the local disease in-
duced by the infection, and on its injurious effect on the body, just as
they do in croupous pneumonia or in erysipelas ; and the changes in
the meninges of the brain and spine are just the same as those some-
times induced in other ways. This circumstance also induces me to
treat of cerebro-spinal meningitis amcng the local diseases, in spite of
its miasmatic origin.

Epidemics of this disease are more frequent in winter than in sum-
mer, and usually disappear as warm weather begins. But there are
exceptions to this, which contrast very remarkably with most epidemic
diseases. Among the different ages, childhood has the greatest quota
of cases and deaths. Persons of middle age are often attacked also,
the aged ai« rarely affected. Unfavorable hygienic influences

EPIDEMIC CEREBRO-SPINAL MENINGITIS. 219

of all kinds, among which are crowding of -barracks, dwellings, etc.,
favor the outbreak of the disease. Persons exposed to these influences
are in greater danger, at times of epidemics, than those who live under
more favorable circumstances.

ANATOMICAL APPEARANCES. — In recent cases, the result of au-
topsy is almost always as follows : The subjects show no emaciation,
protracted rigor mortis, or extensive hypostasis ; there are often groups
of dried herpes vesicles on the face an£ other parts of the body ; the
muscles are dark ; in rare cases they are pale (Ziemssen).

The cranium contains much blood ; in the longitudinal sinus there
is abundant fluid, or softly-coagulated blood ; the dura mater is more
or less tense, and occasionally covered with small hsemorrhagic or pa-
chymeningitic deposits. There is usually no effusion between the dura
mater and arachnoid ; in the subarachnoid space there is an exudation,
which, both in extent and character, occupies about a medium position
between the pure purulent exudation in meningitis of the convexity
and the priro-serous exudation in basilar meningitis. In almost all
cases, the convexity of the cerebrum and the base of the brain are
affected at the same time, the latter usually the more severely. The
exudation appears to be peculiarly plentiful about the chiasm, in the
fossa Sylvii, at the base of the cerebellum, and in the fissures of the
cerebrum. The nerves, from the base of the brain, are 'often entirely
embedded in it. The brain itself is more or less vascular, almost al-
ways less resistant, even becoming pulpy in the vicinity of the ventri-
cles; the latter generally contain small amounts of purulent fluid,
rarely large quantities of clear serum.

The dura mater of the spine is more or less vascular, occasionally
very tense, especially at the lower part. Between the dura mater and
spinal arachnoid there is rarely a clear or purulent opaque fluid. The
arachnoid usually presents no peculiarity except a decided opacity.
There is more or less purulent fluid between it and the pia mater.
The tissue of the pia mater is infiltrated with sero-purulent exudation.
This infiltration extends very irregularly ; in most cases the cervical
portion is free; the process first begins in the dorsal region, thence
extends toward the cauda equina, and is almost exclusively on the pos-
terior surface. The puruleritly-infiltrated spots form, irregular humps,
broader in the middle, smaller at the ends, which are usually connected
together by small striae accompanying the larger vessels. Even where
the pia mater does not contain this puro-serous infiltration, its tissue
appears thickened and cloudy. The spinal medulla itself is more or
less vascular, occasionally infiltrated and relaxed. In a case related
by Ziemssen^ the central canal was dilated and filled with purulent
Huid.

250 DISEASES OF THE BRAIN.

Except some accidental complications, there are no particular anom-
alies of the other organs; we should especially note here that the
spleen is almost always normal.

The post-mortem appearances, in protracted cases, are known only
from a very few observations. In one such case I found the exudation
thickened, and partly affected with caseous metamorphosis, as well as
considerable fluid in the ventricles. The same appearances have been
noted by other authors.

SYMPTOMS .LNT> COURSE. — I must again repeat that the symptoms
and course of epidemic cerebro-spinal meningitis may be fully explained
by the changes in the meninges of the brain and spine, and that, on
this account, the malady differs from most other infectious diseases.
Every thing that has been advanced in opposition to this view may be
refuted by the simple fact that, in genuine croupous pneumonia, which
no one classes among the infectious diseases, certain symptoms, such
as the frequent herpetic eruptions, albuminuria, etc., are just as diffi-
cult to explain, from the inflammatory changes in the lung and the
copious exudation hi the alveoli, as are some of the occasional symp-
toms of epidemic cerebro-spinal meningitis.

Only in rare cases is the outbreak of the disease preceded by a
premonitory stage, characterized by slight headache and pain in the
back. Usually the scene opens with an unexpected chill of variable
duration, which is soon accompanied by severe headache, and in most
cases by vomiting. The headache rapidly becomes very severe, the
patient grows very restless, tosses about constantly, the pupils are con-
tracted, the intellect remains clear. The pulse is 80-100, the bodily
temperature moderate, the inspirations increase to 30-40 per minute.
Even at the end of the first or second day, rarely later, we notice
that the head is drawn backward. At this time there is often a
herpetic eruption near the mouth, on the cheeks, eyelids, ears, and oc-
casionally on the extremities. The complaints about severe headache
continue ; the pain extends from the head to the nape of the neck and
the back. The restlessness becomes excessive, the ideas confused, the
pupils remain contracted, the belly is sunken, and the bowels are con-
stipated. The pulse and respiration become more frequent, occasion-
ally the pulse is over 120 and the respiration over 40 per minute ;
the bodily temperature still remains proportionately low, or rises to
103° or over. The third or fourth day of the disease the tetanic con-
tractions of the muscles of the neck and back become more evident,
and are occasionally accompanied by trismus ; there is excessive opis-
thotonus ; consciousness is lost, but the patient still tosses about in bed,
the pupils remain contracted, constipation continues, the belly is sunk-
en, urine is passed involuntarily, or else the bladder becomes distend-

EPIDEMIC CEREBRO-SPINAL MENINGITIS. 251

ed, and must be evacuated with the catheter. The now unconscious
patient falls into deep stupor, the moaning respiration is accompanied
by moist rales, and death occurs with the symptoms of acute oedema
of the lungs.

In some particularly severe cases the above symptoms develop far
more rapidly; consciousness is lost even during the first day, while
severe tetanic spasms of muscles of the neck and back draw the head
far backward. Death may occur even on the first or second day, when
the disease is very malignant.

Lastly, in some few cases (of which there can be no doubt) the dis
ease runs a still more rapid course, and causes death in a few hours,
from general paralysis, occasionally even without the appearance of
the most characteristic tetanic symptoms (mkningitefoudroyante).

But the disease does not by any means always terminate fatally
when it has commenced and run its course for the first few days in the
manner above described. As favorable signs, we usually first notice
that there is less jactitation, and the mind becomes clearer, while the
complaints of pain in the head and back and the tetanus of the cervi-
cal and dorsal muscles continue, or only slightly decrease. If the im-
provement progresses, all symptoms of the disease may disappear in
a few days, and the patient begin his tedious convalescence.

Occasionally improvement begins, but does not continue, and the
disease drags on. In such cases convalescence may not occur for
weeks. Headache, contraction of the neck or opisthotonus continue.
Paralysis of the motor and psychical functions causes a complicated
series of symptoms, and the majority of such patients finally die of
gradually-increasing marasmus.

Lastly, I must mention the occasionally intermittent course of the
disease. I have only seen one such case. Hirsch distinguishes three
forms of the intermittent course : in the first it only occurs in the first
stage ; one or more attacks of evident premonitory symptoms pass
away, but another follows which is immediately succeeded by the out-
break of the disease. In the second form there is a sudden remission
of the symptoms ; these again grow worse the next day, and occasion-
ally this alternation occurs several times, usually with a more or less
regular quotidian type. In the third form, which is far the most fre-
quent (to which my case belonged), perfect intermissions are seen
during convalescence. The symptoms remaining after the disease,
particularly headache and stiff neck, regularly increase very consider-
ably for some time, usually with a quotidian type, while in the inter-
val the patient feels quite comfortable.

To the above view of the symptoms and course of cerebro-spinal me-
ningitis I will now add a short description of the individual symptoms,

252 DISEASES OF THE BRAIN.

ooth of those that I have already mentioned, and of others of which 1 ha\ e
not yet spoken, as they are less constant. Severe headache occurs even
in those cases which, as me*ningite foudroyante, terminate in death in a
few hours. In the cases that run the usual course, as long as the pa-
tients retain consciousness they complain of headache, either sponta-
neously or on being questioned, and it also seems as if the restless-
ness, groaning, and complaints of the patients, after the intellect is
clouded, were partly due to the headache. Lastly, during an epidemic
of this disease, there are almost always a few cases where, without
the disease actually occurring, persons complain of very severe head-
ache continuing for several days without any other apparent cause.
We may consider such cases as abortive forms.

Cervical and dorsal pains usually begin very early either with the
headache or very soon after ; they are generally increased by pressure
on the spinal processes of the vertebras ; with rare exceptions, this
pain is far greater when the patients make voluntary movements of
the spine or on passive motion being made. If the disease be pro-
tracted, the dorsal pains and their increase by movements of the spine
may continue for weeks.

Painful sensations in the extremities, unmistakably neuralgic in
their nature, and caused by irritation of the posterior roots of the spi-
nal column, are not constant symptoms ; occasionally they only occur
on motion of the spine.

Hyperc&sthesia and Anaesthesia of the Skin. — Usually for the first
days of the disease, and in some cases during its whole course, the pa-
tients are very sensitive to any rough handling; their restlessness,
groaning, and complaints are increased when they are turned over in
bed, occasionally even if they be percussed. Later, we often see no
reaction even when the skin is greatly irritated ; but in such cases,
when the patients are in a state of stupor, there is cerebral anaesthesia.
Far more rarely, there is peripheral anaesthesia, during which, while
the patient is quite conscious, he feels irritation of the skin very little
or not at all. This symptom apparently depends on loss of excitabil-
ity of the posterior roots from inflammation.

Tetanic spasms of the cervical and dorsal muscles are only absent
in some few cases of me"ningite foudroyante. At first the head is only
slightly retracted, later it may form almost a right angle with the
body. This position of the head and the addition of opisthotonos in
the dorsal and lumbar regions usually render it impossible for the pa-
tient to lie on the back. If the tetanus attain a high grade, it almost
always affects the respiration. Occasionally it disappears shortly be-
fore death ; more frequently it continues more or less severe till death
or convalescence.

EPIDEMIC CEREBRO-SPINAL MENINGITIS. 353

Epileptiform convulsions are rare, which is very remarkable, con
sidering the exudation is often widely spread over the convexity of the
hemispheres.

Paralysis. — Usually there is no actual paralysis till death; but
there are a few cases where hemiplegia or paraplegia, and quite a
number where paralysis of the facial, oculomotor, or of the abducens,
were observed. It is not at all difficult to explain these paralyses ; on
the contrary, it is almost wonderful they are not more frequent.

Psychical Disturbances. — At the commencement of the disease,
the intellect is almost always unclouded ; the patients answer ques-
tions correctly. But they soon become ill at ease and very restless.
Then questions prove annoying, and they will only give short and in-
complete answers. The incessant jactitation, which is scarcely inter-
rupted by pauses of a few minutes, is very characteristic in the first
stage of tne disease. Subsequently most patients have delirium of
variable intensity, which finally gives place to a soporose condition.

Disturbances in the Organs of Special Sense. — Patients not un-
frequently become blind from keratitis, which is probably induced by
incomplete closure of the eyelids, due to paresis of the orbicularis
palpebrarum, or from exudative choroiditis and neuro-retinitis, prob-
ably a result of direct propagation of the purulent infiltration along
the optic nerve from the cranium to the eye. Deafness is remarkably
frequent, so that we are almost obliged to suppose that it has several
causes, among which, however, the most important, doubtless, is the
propagation of purulent infiltration along the auditory nerve to the in-
ternal ear.

Among the eruptions, groups of herpes vesicles in large numbers
are very often seen, and more rarely erythema, roseola, urticaria, pete-
chia, and siidamina. The frequency of the exanthemata, and particularly
the occasional symmetry of their occurrence, have led to the supposition
that they might depend on irritation of the cutaneous nerves, as Bar
rensprung has shown to be the case in herpes zoster from neuralgia.

According to Ziemssen's numerous and accurate observations, the
fever has no regular course. Very few temperature curves resemble
each other ; sudden leaps and exacerbations of short duration often
occur. But generally a remitting type, with exacerbations of half a
degree to a degree, is most frequent. Very high temperatures are al-
most exclusively seen in severe cases that terminate fatally. In most
3ases the temperature does not rise above 103°. The intermittent
fever that occasionally accompanies the other symptoms during conva-
lescence is regarded by Ziemssen as a reabsorbing fever, while he re-
fers that occurring during the first and second weeks to an interrupted
progress of the meningitis. The frequency of the pulse does not at

254 DISEASES OF THE BRAIN.

all accord with the height of the fever ; with moderate fever it is oc-
casionally very high ; slowness of the pulse is only rarely observed at
the commencement of the fever.

TREATMENT. — Just as in other malignant and fatal epidemics, in
deciding the best means of treatment, we must only consider cases
where there is at least a slight hope of recovery. Whoever tries any
proposed plan only on the severest cases will attain negative results
by any -procedure. The customary treatment of sporadic meningitis,
consisting of the energetic use of cold as ice-compresses to the head,
the application of leeches behind the ears, and the internal adminis-
tration of calomel, is also advisable in epidemic cerebr»spinal menin-
gitis, as is very evident from its excellent effect in patients attacked
by the premonitory symptoms of the disease, severe headache, and
pain in the neck, during an epidemic.

But, according to most observers, this mode of treatment has pre-
served its reputation even in marked cases of the disease ; there is but
little opposition to it, and even this is based on its want of success in
the severest forms. I have no personal knowledge of the success of
morphium when given internally or hypodermically. But a number
of trustworthy observers, Ziemssen and Mannkopff among others,
speak most favorably of it, especially in the form ef subcutaneous in-
jection. Ziemssen says : " Although we have used morphia frequent-
ly, we have never seen any injurious effects from it, but, on the con-
trary, such a decidedly palliative action that, along with cold, it seems
the most indispensable remedy in the treatment of meningitis." Al-
most all observers agree that quinine is entirely useless even in deci-
dedly intermittent cases.

CHAPTER XI.

INFLAMMATION OP THE BRAIN — ENCEPHALITIS.

ETIOLOGY. — In encephalitis, just as in the inflammation of other
organs containing little connective tissue, there is not much interstitial
exudation, but there are most important changes in the nerve-filaments
and ganglion-cells and their scanty interstitial tissue. These tissue-
elements swell from absorption of nutrient fluid and subsequently
break down, partly to simple detritus, partly after precedent fatty de-
generation ; in the latter case, in the inflamed parts we find quantities
of fatty granular cells (the formerly so-called Gluge's inflammation
globules), which we have a right to suppose come directly from fatty
degeneration of ganglion-cells and neuroglia nuclei. In the subse-
quent course of encephalitis there is often an extensive formation of

INFLAMMATION OF THE BRAIN— ENCEPHALITIS. 255

pus-cells ; abscesses are formed, which, besides the usual constituents
of pus, often contain some remains of disintegrated brain-substance.
Cerebral abscesses are either surrounded by brain-substance softened by
extension of inflammation to tne surrounding parts, or by newly-formed
connective tissue ; in the latter case they are said to be capsulated.

Encephalitis is a rare disease, and is not induced by the causes
which usually excite inflammation in other organs. 1. The most fre-
quent form is traumatic encephalitis ; it results not only from direct in-
juries affecting the brain after the skull is opened, but there are nu-
merous cases where the cranium has remained uninjured, and where
there was apparently only slight contusion. It is most probable that
in such cases the brain has been bruised by the vibrating cranium, and
some small vessels have been ruptured and ecchymoses formed. It
also appears as" if the small extravasations of blood occasionally in-
duce no symptoms at first, but excite inflammation in the surround-
ing parts, and thus subsequently cause encephalitis. At least, the
first signs of the inflammation are occasionally not observed till long
after the injury. Among the cases of traumatic origin we must in-
clude those where breaking down of the brain by an extensive extrav-
asation of blood has caused inflammation in the vicinity. 2. In other
cases the encephalitis depends on the irritation of the brain from neo-
plasia and necrosed spots. 3. Among the most frequent causes of en-
cephalitis are diseases of the cranial bones, especially of the petrous
bone. As we shall hereafter show, the presence of an otorrhcea may
decide .the question between an abscess of the brain and a tumor.
Cases are also known where caries of a superior maxillary extended to
the brain and caused encephalitis. I remember a clergyman in Mag-
deburg who died of abscess of the brain a few years after a large por-
tion of the upper jaw had been exsected on account of extensive ca-
ries. 4. Occasionally the disease occurs in the course of acute and
chronic infectious diseases, such as pyaemia, glanders, typhus, etc.,
without our being able to give any plausible explanation for it. 5.
Lastly, but rarely, encephalitis occurs without any known cause in
persons previously healthy.

ANATOMICAL APPEARANCES. — This disease never attacks the entire
brain ; it is always confined to certain points. The size of these spots
varies from that of a bean to that of a fist, or larger. They are usually
of an irregular spherical shape. Ordinarily there is only one, but
sometimes there are several. They may be located either in the cere-
brum or cerebellum ; they are most frequently in the gray substance
and very near the surface, if they do not quite reach it. In the com-
mencement of the disease at the affected parts, we find the brain-sub-
stance swollen, infiltrated, softened, and pointed with red spots from

256 DISEASES OF THE BRAIN.

small extravasations of blood. The swelling of the inflamed parts may
be recognized by the surface of the brain on the affected side appear-
ing smooth, just as in apoplectic effusions, and the brain itself being
anaemic from encroachment on the cranial cavity. On incision also
the diseased portion not unfrequently rises above the level of the in-
cised surface. After long existence, the relaxation of tissue gets the
upper hand, and a red pulp results, which gradually acquires a rusty-
brown or yellow color, from change of the hasmatin, or when there is a
slight admixture of blood it "becomes grayish. This pulp, which may
be washed off by a slight stream of water, consists of remains of nerve-
filaments, blood-corpuscles, granular cells, and fine granular exudations
or masses of detritus. The subsequent changes in the inflamed parts,
which are usually called the results of inflammation, vary. Occasion-
ally, in the vicinity of the inflammation, there is a new formation of
connective tissue, which is also continued through the inflamed spot
as a delicate network ; the contents of the abscess are absorbed, and
there remains a cavity, filled with a chalky milky fluid, the " cellular
infiltration" of Durand-Fardel^ previously mentioned in apoplexy.
In some cases, especially when these cysts lie near the surface of the
brain, their walls gradually approach each other, while the contents
disappear, and in place of the abscess there is formed a cicatrix, at first
pale red and vascular, subsequently white and callous. When ence-
phalitis terminates in suppuration, the appearances are different. Re-
cent abscesses of the brain form irregular round cavities filled with
yellow or gray, occasionally also reddish, thick fluid ; their walls con-
sist of ragged masses infiltrated with pus. In the immediate vicinity
of the abscess we usually find inflammatory softening ; farther off there
is oedema of the brain-substance. Such abscesses increase till they
break into a ventricle, or reach the meninges ; or, if extensive menin-
gitis do not occur in the latter case, the ulceration extends to the cere-
bral membranes and the skull, and finally the pus may perforate out-
wardly or into neighboring cavities, especially into the cavity of the
tympanum. If the cerebral abscess be capsulated by new formations
of connective tissue in its wall, it has a more regular form and smooth
walls. If it has lasted a long time, we occasionally find the capsule
much denser, and the contents thickened by reabsorption of the fluid
part, and changed to a cheesy chalky mass.

SYMPTOMS AND COURSE. — Like the symptoms of cerebral haemor-
rhage and of partial necrosis, those of encephalitis are partly the im-
mediate result of destruction of the portion of brain affected, and
partly the result of disturbances of circulation in the brain, especially
in the vicinity of the seat of inflammation.

Since large portions of the brain may be destroyed without caus-

INFLAMMATION OF THE BRAIN— ENCEPHALITIS. 257

mg perceptible functional disturbances, and since encapsulated ab-
scesses frequently do not decidedly affect the circulation in the skull,
we may readily understand that we should occasionally find abscesses
of the brain on autopsy, which had not been suspected during life.
With this knowledge we may also understand those cases of cerebral
abscess which run their course without any symptoms except the inju-
rious influence they exercise on the general nutrition of the brain. It
s not at all rare for a patient to have dull headache, increasing
apathy, loss of thinking-power, even advancing to idiocy, a blunting
of the senses, increasing weakness, and uncertainty of movement-
symptoms which indicate the existence of severe brain-disease, it is
true, but which do not by any means justify a diagnosis of abscess of
the brain. Even the most experienced and accustomed observers
occasionally mistake abscesses of the brain. But these and similar
mistakes, which unfortunately are made public far less frequently
than brilliant diagnoses, can only seem strange to the ignorant, and
to those wTho are not thoroughly acquainted with the physiology and
pathology of the brain, and with the diagnosis of brain-diseases.

These latent cases of encephalitis are far less frequent than those
where the disease may be very strongly suspected or recognized with
certainty. If the abscess be located at a point where it destroys the
centres of special sense, or interrupts the conduction of the impulse of
the will to the motor nerves, or the impressions of special sense to the
organs, we have partial anaesthesia and partial paralysis, sometimes of
the cerebral nerves, again of the cerebro-spinal, at others of both. These
anaesthesias and paralyses riot unfrequently extend to both extremities
of one side of the body ; in other cases they are confined to the parts
supplied by certain cerebral or cerebro-spinal nerves, but in the latter
case also they are always on one side. Bilateral anaesthesias and paral-
yses only occur exceptionally, and in cases where the abscess is in the
middle portion of the brain, which is not double, or where different
abscesses are in the same parts of the brain on opposite sides. From
the occurrence of these symptoms we can only determine that there
is some local disease ; but we cannot decide on its nature, for they
occur in the most varied forms of local disease where nerve-filaments
and ganglion-cells are destroyed. To come to a conclusion on this
point, we must pay particular attention to the etiology, to the course
of the disease, and to those symptoms which show the effect of the
local disease on the rest of the brain.

If we can make out that the symptoms of a local disease of the
brain have begun after an injury of the head, or if the patient has
caries of the petrous bone, the case is most probably one of ence-
phalitis. If, on the other hand, there has been no injury of the hoadf

258 DISEASES OF THE BRAIN.

and no caries of the temporal bone can be found, it is almost equally
improbable that there is encephalitis. While these points are gen-
erally true, they have in some cases led to erroneous diagnosis.
Autopsy has revealed abscesses of the brain where there had been no
injury of the head or caries of the cranial bones. There have also
been cases where patients wiih cerebral tumors have had a blow on
the head, and occasionally Ine previously latent brain-disease had
not become manifest till after this injury. (These cases are analo-
gous to those where women first have their attention directed to a
carcinomatous mamma by a blow on it, and then consider it beyond
a doubt that it is due to the injury they have received.) But, prac-
tically, it is best only to think of these exceptional cases where thero
is sufficient reason.

Encephalitis never affects the entire brain, but is always limited
to certain points ; nevertheless, at the commencement of the disease,
there are almost always signs of temporary irritation of the entire
brain or meninges, such as increased frequency or great slowness of
the pulse, increased bodily temperature, headache, dizziness, sleepless-
ness or restlessness, exciting dreams, psychical irritation, even mild
delirium, great sensitiveness to slight irritation of the organs of special
sense, bodily disquiet, and great weakness, etc. According to Gries-
inger, this violent commencing stage, which may be followed by quiet,
is almost pathognomonic of encephalitis and abscess of the brain. In
the criminal records there are numerous cases where the above symp-
toms were considered by the attending surgeon as traumatic fever, be-
cause they apparently disappeared without any traces, and the complete
recovery of the patient from the injury received was officially certified
to, while, after a time, there were unmistakable signs of a severe brain-
disease, and autopsy showed abscess of the brain as the fatal termina-
tion of the injury. Even in those cases where an injury of the skull
is followed at first by the symptoms of general irritation of the brain
and meninges, and subsequently by the above-described decrease of
all the cerebral functions, we should first think of abscess of the brain,
and attribute the absence of local symptoms to the location of the ab-
scess at a point where it does not interrupt the conduction of excite-
ment, in the centripetal and centrifugal cerebral filaments.

The influence that local inflammations in the brain have on the rest
of the organ consists partly in their encroachment on the cranial cavity,
and chiefly on those chambers of the skull where they are located,
partly on the collateral hyperaemia and oedema in their vicinity, and,
lastly, partly on their injurious effect on the nutrition of the entire
brain. On the first of these factors depend the headache, the attacks
Df dizziness and vomiting, as well as the evanescent occurrence of pain,

INFLAMMATION OF THE BRAIN— ENCEPHALITIS. 259

indefinite feelings, anaesthesia, twitchings, contractions, paralyses in
some parts of the bo$y, which, in many cases, accompany the symp-
toms previously mentioned, and which we fully described in the second
and fourth chapters, as the results of partial hyperaemia and partial
anaemia of the brain. These do not continue unchanged, like the local
symptoms, which are the immediate results of partial destruction of
the brain from the inflammatory process, but are rather apt to have a
variable course ; this is partly due to occasional enlargement of the
abscess, by which the space is more contracted, partly on the occasional
increase and decrease of collateral hyperaemia and collateral oedema.
It is evident that such a variation in the symptoms would occur oftener
in encephalitic inflammations than in slow and steadily-growing tumors
of the brain.

The attacks of epileptiform convulsions, which not unfrequently
occur during encephalitis, are more difficult to explain, and we shall
not even offer a hypothesis as to the mode of their occurrence. Sta-
tistics have been made as to how often headache, contractions, epilep-
tiform convulsions, etc., were present or absent in a large number of
cases of cerebral abscesses. In individual cases, the results of these
statistics are, of course, of but little value in the diagnosis of abscess
of the brain, or in its differential diagnosis from tumor of the brain.
The injurious influence of the local inflammation on the general nutri-
tion of the brain, which may occur earlier or later, but never fails wheii
the disease is protracted, evinces itself by the previously-described
symptoms of a general paralysis of all the cerebral functions. I think
I have fully shown, by this description, that, in many cases, it is possi-
ble to recognize an abscess of the brain, although it has no constant or
pathognomonic symptom.

The duration of encephalitis varies ; some cases terminate in death
after a few days or weeks, while in others this does not occur for years.
Occasionally, while the symptoms of cerebral paralysis increase, so
that the patient becomes idiotic, we find a remarkable development of
fat. Death occurs either suddenly and unexpectedly, from the devel-
opment of meningitis, from sudden increase of the abscess, and, occa-
sionally, without our being able to find, on autopsy, any cause for the
sudden catastrophe ; or else it occurs with the symptoms of gradually-
increasing sleepiness, finally becoming deep coma, or else it is induced
by intercurrent diseases. Recovery is very rare. Even in the most
favorable cases, where the cellular infiltration forms a cicatrix or en-
capsulates the abscess, while its contents calcify, we can only speak of
a- relative cure, since both the remains of the inflammation and the
atrophy of the brain, which usually develops under such circumstances,
affect the f-mctions of the brain for the rest of life.

260 DISEASES OF THE BRAIN.

TBEATMENT. — The treatment of encephalitis cannot be very suo
3essful, from the simple fact that the disease is not generally recog-
nized until it has induced irreparable destruction of the brain. In very
recent cases, particularly in those of traumatic origin, we should em-
ploy local antiphlogistics, leeches, and cold compresses. Later, but
little can be expected from this treatment. Moxae and setons, which
were formerly much used in protracted cases, have been abandoned,
and very justly so, as has the administration of mercurials. The prepa-
rations of iodine also, which have been recently recommended, promise
but little benefit ; hence, in most cases, there is little to do but have
•/he patient observe proper regimen, particularly to guard him from
*.very thing that can increase the pressure of blood to the head, and to
confine ourselves to combating the most urgent symptoms. Among
the latter, the apoplectiform attacks are to be treated according to
the rules given for the treatment of cerebral haemorrhage, while any
intercurrent meningitis demands the employment of energetic anti-
phlogistic remedies.

CHAPTER XII.

PARTIAL SCLEROSIS OF THE BRAIN.

IN previous chapters we have repeatedly mentioned the formation
of indurations in the brain as the results of cicatrization of apoplectic
and inflammatory deposits. Besides these, partial scleroses, which
occur as a result of other processes, indurations from new formations
of connective tissue, and displacement of the normal elements, occur
at circumscribed spots in the brain, whose pathogeny is entirely ob-
scure, and of whichx it is even doubtful whether they are of inflamma-
tory origin or not. These idiopathic forms of partial sclerosis of the
brain have been almost solely observed early in life, and more fre-
quently in males than in females, but their causes have never been
discovered.

On anatomical examination the points of disease are found oftener
in the white than in the gray substance; their number varies; some-
times they are solitary, occasionally several are present. They form
irregular nodules, or rough spots as large as a lentil or an almond,
which may be distinguished from the parts around by their hardness
and toughness. On the cut surface they appear bloodless, dull, and
milk-white ; after remaining exposed for a while, they are covered
with a scanty serum, and become somewhat depressed. In the midst
of the nodules there are usually small blue or grayish -red spots,
which contract strongly and exude a quantity of serum, after being

PARTIAL SCLEROSIS OF THE BRAIN. 261

divided. On microscopical examination we find amorphous fine gran-
ular masses along with well-preserved nerve-elements in the milk-white
indurated spots. In the grayish-red prominences, on the other hand,
there are no nerve-elements ; they consist of a filamentary mass and
the remains of capillary walls, in which fat granules are embedded
( Valentiner).

The symptoms and course of partial sclerosis of the brain are not
so characteristic as to render the disease easy of recognition ; on the
contrary, it must be regarded as a triumph in diagnosis, that this has
been done in a few cases (Frerichs). Since the sclerosis is limited to
scattered and circumscribed points and develops slowly, the paralyses
accompanying the disease have the peculiarity that, in the commence-
mejnt at least, they do not extend over one-half the body, but always
begin in single groups of muscles, or in a single extremit}'- (always
one of the lower extremities), and thence extend gradually to other
groups of muscles and other extremities, till finally the central parts
governing respiration, deglutition, and the actions of the heart, are
affected. This extension is not regular : for example, paralysis of the
right hand does not necessarily follow that of the right foot, but it is
entirely lawless. This fact in itself speaks in any case for the depend-
ence of the paralysis on numerous separate points of disease, and
not on one gradually-increasing spot. Besides the paralyses, which
are the most 'constant, and, from their peculiar mode of extension, the
most characteristic symptoms of partial sclerosis of the brain, there are
also disturbances in the other functions, but these are far less distinc-
tive and less characteristic of the disease. Headache is absent in most
cases ; but there are often peripheral pains, and a feeling of formica-
tion in the extremities which is followed by a diminution of sensation,
increasing to perfect anaesthesia. The special senses are rarely affected,
and among these that of sight almost exclusively. In most cases there
are moderate symptoms of irritation in the psychical functions ; but
these are soon followed by a gradually-increasing deep depression,
which in some Ceases exists from the first. Convulsions only occur
exceptionally ; but trembling is a very constant symptom. The nutri-
tion of the body is not generally affected till late in the disease, and
in some patients, just as in encephalitis, there is even a remarkable
development of fat. The course of the disease is very tedious ; most
of the cases observed lasted from five to ten years. During this time
the disease occasionally appeared to remain at a stand-still, but no
existing paralysis was ever observed to disappear. No instances of
recovery are known. In the cases that have been described, death
resulted partly from the extension of the disease to the medulla ob-
longata and consequent disturbance of the respiration, partlv from

262 DISEASES OF THE BRAIN.

marasmus and hydreemia which developed toward the end, partly from
ntercurrent diseases.

Treatment is fruitless against this affection ; it can only be of use
in combating the more severe symptoms.

CHAPTER XIII. ^

TUMORS OF THE BRAIN AND ITS MEMBRANES.

UNDER the head of tumors of the brain are included growths and
parasites occurring in the skull, and aneurisms of the cerebral arteries.
We shall follow this custom, since it is very convenient on account of
the great correspondence of the symptoms due to these otherwise dif-
ferent diseases.

ETIOLOGY. — The pathogeny and etiology of cerebral tumors is very
obscure. This is true not only of carcinoma, sarcoma, glioma, and myx-
oma, but also of the rarer tumors, cholesteatoma or pearl tumors, lipoma,
and cystoid growths. Cancer of the brain occurs chiefly in advanced
age ; it is sometimes primary, and then usually remains the only carci-
nomatous disease in the body ; sometimes it is secondary to carcinoma
of other organs. The other neoplasia that we mentioned above, also
occur chiefly, but not exclusively, in advanced age, and according to
statistics are more frequent in males than in females. We know
nothing of the morbid predisposition or the exciting causes to which
these neoplasia are due. They have been frequently observed after
precedent injuries of the head ; but in such cases there is no certainty
of a genetic connection between the injury and the growth. We must
bear in mind how frequently slight injuries of the head occur, and how
carefully they are inquired after, in any patient suffering from symp-
toms of brain-disease, and, when found, how strong the inclination is at
once to refer the disease to them.

Tubercles in the brain with rare exceptions occur in children, and
chiefly in those over two years old. They are rarely primary ; but
almost always form complications of the so-called tuberculosis of the
lymphatic glands, and of pulmonary tuberculosis.

Cysticerci and echinococci of the brain, as of other organs, depend
on the emigration of the embryos of these parasites.

Aneurisms of the cerebral arteries are usually due to degeneration
of the arterial walls from endarteritis deformans.

ANATOMICAL APPEARANCES. — Carcinoma of the brain is usually in
the form of round or lobulated, generally circumscribed tumors, with
tne softness and other peculiarities of medullary cancer ; more rarely
they have the firm tissue of scirrhus, and then they usually pass into
the neighboring cerebral substance without having any distinct bound

TUMORS OF THE BRAIN AND ITS MEMBRANES. 263

aries. They sometimes start from the brain itself, sometimes from the
dura mater and cranial bones, or they develop originally from the
external soft parts of the skull and neighboring cavities, especially in
the orbit, and thence press into the skull. On the other hand, it rarely
happens that carcinoma occurring in the brain perforates the meninges
and cranial bones. There is usually only one carcinomatous tumor of
the brain, and this is generally located in the cerebrum ; where there
have been several, they have occasionally been found symmetrically
located on the two sides of the brain. Cerebral carcinomata, which
may attain the size of the fist, never suppurate unless they perforate
outwardly ; on the other hand, they readily undergo partial retrogres-
sive metamorphosis, become yellow and cheesy in the middle, shrink,
and thus cause umbilicated depressions on the surface of the brain, if
the cancer had advanced so far.

Sarcomata occur as often as carcinomata in the brain. They are
often attached to the meninges, and the tumors of this variety, at the
base of the brain, usually attain greater size than those of the dura
mater that covers the convexity. (Just as often sarcomata are em-
bedded in the midst of the brain-substance, in the majority of cases in
the cerebrum.) They form round or lobulated tumors, from the size of
a hazel-nut to that of a good-sized apple ; their cut surface is smooth,
dirty white, or grayish red ; they are usually soft, even medullary, more
rarely hard and fibrous. Occasionally they contain cavities filled with
fluid. Sarcomata consist chiefly of spindle-shaped cells, arranged in
filamentary striae. They differ from cancer, and especially from glioma,
not only in being sharply bounded, but in being often surrounded by a
vascular envelope, from which they can be turned out. Small lumps
of carbonate of lime not unfrequently occur in sarcoma of the dura
mater ; on rubbing the tumor between the fingers, these lumps cause
a sandy feel. Virchow has designated tumors, containing numbers
of the chalky lumps, as psammonea, or sand-tumors. Then* mode of
origin is not yet exactly known.

Myxomata consist of mucous tissue — that is, of variously-formed
cells, embedded in a homogeneous, mucous, hyaline, intercellular sub-
stance. They are not very rare in the brain. Like sarcomata, they
are located most frequently, but not exclusively, in the medullary sub-
stance of the cerebrum, where they generally appear as circumscribed
tumors, more rarely as infiltrations of soft gelatinous substance. The
tissue of myxoma is somewhat translucent, and of a weak yellowish
or red color, but may acquire a varied hue from extravasated blood.
Myxomata also correspond with sarcomata in regard to the size they
may attain ; and, between these two forms of tumors, there are all
possible grades of transformations (gelatinous sarcoma).
67

264: DISEASES OF THE BRAIN.

Oliomata result from a local proliferation of the neuroglia, or con-
nective tissue of the brain, at the expense of its nervous elements.
Microscopically they consist of roundish nuclei, distributed through a
finely-reticulated basement substance. By the naked eye they are
distinguishable from not forming circumscribed tumors, but passing
gradually into the healthy brain-tissue ; also from the fact that they
never pass from the brain to its membranes. (Jliomata may attain the
size of a fist ; they most frequently originate from the medullary sub-
stance of the cerebrum. Haemorrhages into or partial retrogression
of glioma may take place after precedent fatty degeneration of its ele-
ments. The consistence of these tumors varies between that of a me-
dullary cancer and of healthy brain. The cut surface varies in color
from whitish yellow to bright grayish red, and usually shows a number
of cut vessels. Formerly glioma was regarded as infiltrated cancer,
and, as it occurs chiefly in young persons, or, at least, in those under
forty years of age, we see why it was said that cancer of the brain
has been observed at all ages.

Cholesteatomata, or pearl tumors, are rare. They sometimes start
from the cranial bones, at others from the meninges, again they de-
velop in the brain itself. They form irregular tumors, of variable size,
of a pearly lustre ; they are enclosed by a delicate membrane, and con-
sist of concentric layers of epidermic cells.

Lipomata, as small lobulated tumors, starting from the dura mater,
cysts filled with fluid, or fat and hairs, and cystoid neoplasia, with
cauliflower excrescences from the walls, belong to the rarities, and
have more pathologiccnanatomical than clinical interest.

Tubercles of the brain are the most frequent form of cerebral tu-
mors. Usually we find only one collection of tubercles, occasionally
two, more rarely a greater number. The size varies from that of a
hemp-seed to that of a cherry, or, in rare cases, to that of a hen's egg.
They are located most frequently in the cerebellum or cerebrum, more
rarely in the mesencephalon. Tubercles of the brain form irregular,
roundish, non-vascular tumors, of a yellow, dry, and cheesy character.
They are sometimes surrounded by a layer of loose connective tissue,
which separates them from neighboring parts of the brain ; sometimes
the main portion of the yellow nodule gradually passes into the brain-
substance as a gray-white, slightly-translucent, narrow margin, consist-
ing of young tubercle elements. In the latter case the tubercle has
been growing till death ; in the former, where it can be readily turned
out of its capsule, growth has ceased long before death. From soft-
ening of its centre, the tubercle nodule is occasionally transformed into
a vomica, filled with tubercle pus.

Syphilomata only rarely occur in the brain in the form of nodules

TUMORS OF THE BRAIN AND ITS MEMBRANES. 265

(gummata) ; they are more frequent as diffuse infiltrations. Nodular
syphiloma always passes from its edges very gradually into the healthy
brain-substance. Since such nodules become changed by atrophy, and
fatty metamorphosis of the cells commencing in the centre, to a sub-
stance resembling yellow tubercle, syphiloma has probably been occa-
sionally mistaken for tubercle. This may be avoided by bearing in
mind that, in syphiloma, the passage from the cheesy centre to the
broad, grayish-white, peripheral zone, is very gradual, while, in infil-
trated, growing tubercle, these zones follow each other more closely
and, in tubercles that can be turned out, they do not exist. In regard
to consistence, and the character of the cut surface, syphilitic infiltra-
tions greatly resemble old, simply sclerosed parts ; indeed, even the
microscope cannot always decide between them.

Cysticerci are not very rare in the brain, and, when found, they
are usually in large numbers ; they generally occur in the gray sub-
stance. Occasionally some of these parasites are found dead, and
changed to a mortar-like concrement, in which some of the hooks from
the circle can usually be recognized.

Echinococci of the brain are much rarer. They form large vesicles,
enclosed by a very delicate adventitia, with the well-known peculiari-
ties of which we have often spoken.

Aneurisms of the cerebral arteries are not frequent. They chiefly
occur in the vessels at the base of the brain, in the arteria basilaris,
a. corporis callosi, a. fossae Sylvii, and in the a. communicantes of
the circle of Willis. In rare cases, they attain the size of a small
hen's egg, while usually they only reach that of a pea or a small
hazel-nut.

SYMPTOMS Am> COUESE. — The symptoms of cerebral tumors have
the greatest resemblance with those of the local diseases of the brain
previously described. There is no symptom, occurring during the
course of a cerebral tumor, that does not sometimes occur from soft-
ening of the brain, from abscess, or from some other local disease.
This resemblance cannot astonish us ; on the contrary, we could not
understand how it should be otherwise, since, like other local diseases,
a tumor of the brain destroys a circumscribed portion of the organ,
encroaches on the intracranial space, and interferes with the circulation
in the vicinity of the diseased part. Nevertheless, it is only in rare
cases that it is difficult or impossible to recognize a cerebral tumor,
and to distinguish it from an abscess, or other local disease of the brain.
(According to my experience during the last ten years, I must hesitate
about agreeing with the first part, at least, of Bamberger's assertion,
which I have previously quoted, where he says, " With few exceptions,
the diagnosis of tumors of the brain is rather a guess than a diagnosis.

266 DISEASES OF THE BRAIN.

and the determination of its locality, likewise with certain exceptions,
is impossible.") This apparent paradox is due to the fact that, in spite
of the absence of constant symptoms pathognomonic of tumors of the
brain, in most cases the diagnosis may be made partly from the eti-
ology, partly from the location of the disease at a point where other
local diseases are rare and tumors common, and, lastly, partly from the
peculiarities of the entire course of the disease.

The important evidence furnished by the etiology is chiefly nega-
tive. In every case of brain-disease we should make it a rule to seek
for the exciting cause by obtaining an exact history of the case. If
we thus find that the patient has had no injury of the head, that he
has no caries of the petrous bone, no hypertrophy or valvular disease
of the heart, and probably also no degeneration of the arteries ; in
short, if we can find no cause for the disease, our suspicions must first
turn to a tumor of the brain. Before speaking of the cases where
cerebral tumors can be recognized with facility and certainty, I shall
say a few words concerning the rare cases wheie they induce no symp-
toms, or else have those of severe brain-disease, but do not give any
means of determining that they are caused by a tumor. The tumors
with latent course can only be located at parts of the brain where they
do not disturb the intercerebral centres of the cranial nerves, or inter-
rupt the conduction of excitement in the centripetal and centrifugal
brain-filaments, that is, chiefly in the extensive medullary masses of the
cerebrum. At this part tumors often attain a large size without in-
ducing local symptoms (herdsymptome), while at most parts of the
base of the brain, and in the vicinity of the large ganglia, even the
smallest tumors are accompanied by these symptoms. But even in
the cerebrum only those tumors run a latent course which grow slowly,
and are not so vascular as to swell at times from the vessels being
overfilled, and at others to decrease in size from containing less blood.
To explain the remarkable but very certain fact that the symptoms ac-
companying rapidly-growing tumors are not unfrequently absent in
those that grow slowly, a certain " power of accommodation " has been
ascribed to the brain, which enabled it to accustom itself to gradually-
increased pressure. I consider the following explanation more satis-
factory : In tumors that grow rapidly there is a compression of the
capillaries and a loss of function of those parts of the brain where
they are located. On the contrary, in the vicinity of slowly-growing
tumors there is atrophy of the brain-substance, and its shrinkage sup-
plies as much room as is lost by the growth of the tumor. Under these
circumstances the capillaries of the affected part of the brain are not
compressed, and its function not disturbed. Perhaps the presence or
absence of local symptoms (herdsymptome), in tumors of the cere-

TUMORS OF THE BRAIN AND ITS MEMBRANES. 267

brum having the same location and equal size, depends partly on
whether the tumor has displaced the brain-filaments or has developed
at their expense and has substituted them. My colleague, Prof.
Schuppel, who has given me some other valuable points on the histol-
ogy of cerebral tumors, asserts that the different forms of tumors vary
in the above respect. Naturally, tumors, rich in vessels which increase
and diminish in size according to then* fulness, are not apt to run their
course without symptoms ; but, as a rule, are at least occasionally ac-
companied by symptoms of irritation and paralysis. Lastly, I shall
mention that tumors running a perfectly latent course are proportion-
ately more frequent than those having the symptoms of a severe in-
explicable cerebral disease. In abscesses of the brain, just the opposite
is true. This difference is probably due to the entire nutrition of the
brain being generally more severely impaired by the presence of an
abscess than by a tumor.

Even those tumors of the brain of which we succeed in making a
certain diagnosis during the course of the disease, do not always begin
with the symptoms which play the most important part in the diagno-
sis, that is, with the partial paralysis and anaesthesia, which we have
designated as local symptoms (Herdsymptome), and which we have
repeatedly and fully described. In many cases the first, and often for
a long time the only, symptom indicative of brain-disease, is a severe
headache. Although this occurs during the most different brain-dis-
eases, and although we may even say there is no disease of the brain
which is not, under some circumstances, accompanied by it ; still there
is no cerebral disease where continuous, unusually intense, and severe
headache is so prominent a symptom, and there is no other disease
where it is so often observed as in tumor of the brain. The cases
where patients with cerebral tumors do not complain of headache are
such rare exceptions, that its absence in a doubtful case rather speaks
against a tumor. The fact that headache occurs even in those tumors
of the brain which are% located at a distance from the sensitive parts,
supports the view we advanced, that in cerebral diseases the pain in
the head started from the filaments of the trigeminus supplying the
dura mater. We must be very careful about localizing the tumor
from the seat of the pain. Only pains constantly confined to the back
of the head permit us to conclude that very probably the tentorium is
stretched, and that the tumor is probably situated in the posterior
cranial fossa.

In many patients, attacks of dizziness and vomiting accompany the
headache, particularly the severe exacerbations which occur, from time
to time, with or without perceptible cause. This may facilitate tho
correct interpretation of the headache, and show its dependence on

268 DISEASES OF THE BRAIN.

disease of the brain, if it should have been doubtful, in spite of the
duration, severity, and obstinacy of fhe pain.

Among the local symptoms of tumors of the brain, those of partial
irritation (hyperaesthesia, neuralgia, indefinite sensations of formica-
tion, twitching, etc.) very frequently precede the partial anaesthesias
and partial paralyses, and there are cases of cerebral tumors where
these symptoms, and not the headache, open the scene. We have
seen that partial symptoms of irritation, occurring in severe structural
diseases of the brain, are only to be regarded as secondary effects, and
are referable to disturbances of circulation in the vicinity of the affected
part. Also that they occur in the most varied diseases, and alone are
not pathognomonic of any of them. However, in cerebral tumors,
there is one circumstance which is characteristic of the hyperaesthesia,
neuralgia, and twitchings, and the anaesthesia and paralysis which
usually follow them, namely, that these local symptoms are observed
more frequently, even among the cerebral nerves, than in any of the
previously-described forms of brain-disease. But we cannot say that
symptoms of irritation and paralysis of the cerebro-spinal nerves, such
as hemiplegia, etc., are rare, or do not occur; but only that, apart from
other symptoms, the occurrence of neuralgia, hyperaesthesia, or anaes-
thesia, or of spasms and paralysis in the parts supplied by the cerebral
nerves, goes to prove, in doubtful cases, that there is a tumor in the
brain. The simple explanation of this peculiarity is as follows : In
all the local diseases hitherto treated of, in necrotic softening of the
brain, in cerebral haemorrhage, in encephalitis, and its results, the mor-
bid process is, with rare exceptions, limited to the brain, and does not
attack the nerves passing from it. The case is quite different with
tumors, which not only often pass from the brain to the nerves origi-
nating from it, but which, in many cases, start from the meninges or
skull, and then not unfrequently destroy the cerebral nerves before
attacking the brain. Let me call attention to another point, which
was first published by my friend Ziemssen, at that time assistant in my
clinic. Most paralyses of cerebral nerves are peripheral, when due to
tumors, whether these have originated in the brain, or have advanced
to the brain from the meninges or cranial bones. On the other hand,
most of the few cases of paralyses of cerebral nerves occurring in the
other forms of brain-disease are of central origin. Now, it is well
known that the state of the nerves and muscles, on electrical irritation,
is a certain means of distinguishing central and peripheral paralyses.
In central paralysis, the muscle contracts normally when an induced
current is passed through the nerve ; in peripheral paralysis, on the
contrary, the contraction does not take place. Hence we may thus
amplify the above proposition : In cases of local disease of the brain,

TUMORS OF THE BRAIN AND ITS MEMBRANES. 269

paralysis in the parts supplied by the cerebral nerves (especially if
the paralyzed muscles do not contract on passing an electric current
through their nerve) renders it very probable that there is tumor of
the brain. The assertion that, other things being equal, paralysis of a
cerebral nerve favors the idea of a tumor, and that most paralyses of
cerebral nerves are of peripheral origin, is not actually true of the facial
nerve. Paralysis of the facial, as one symptom of hemiplegia, occurs
just as often in other local diseases of the brain as in cases of tumor,
and is unmistakably of central origin. What was said above is not
true of these cases, but of the other peripheral facial paralyses. Next
to the facial, among the motor-cerebral nerves, the oculo-motor and
abducens are most frequently attacked. Paralysis of the pars minor
trigemini is rare ; this is also true of complete paralysis of the hypo-
glossal and motor filaments of the glosso-pharyngeal ; while incom-
plete paralysis of these nerves, as shown by disturbances of articulation
and deglutition, is rather common. Peripheral facial paralysis, due
to tumors of the brain, is occasionally preceded by twitching of the
facial muscles; while twitching of the muscles of the eye precedes
paralysis of the oculo-motor, which is characterized by dilatation of
the pupil, ptosis, disturbance of mobility of the eye ; often, also, by
diplopia and strabismus. If the oculo-motor be unaffected, paralysis
of the abducens induces diplopia and strabismus convergens. Before
the destruction of the filaments of the trigeminus has caused anaes-
thesia of the half of the face, of the conjunctiva, mouth, and nose,
most patients complain of severe pain in all the parts supplied by the
nerve, and not unfrequently these pains continue during the anaesthesia
(anaesthesia dolorosa). Hardness of hearing, or complete deafness,
from destruction of the acousticus, is usually preceded, for a time, by
troublesome noises in the ears. Disturbances of vision, even to com-
plete blindness, are very frequent in tumors of the brain, but they are
not, by any means, always due to direct lesions of the optic nerves,
chiasm, tractus opticus, or corpora quadrigemina. Not unfrequently,
the tumor is at a distance from these parts, as in the cerebrum or cere-
bellum. I consider it a mistake to suppose that, in such cases, the
pressure has extended, through the intervening substance, to the optio
nerve, and, by pressing this against the base of the skull, caused its
atrophy. The correctness of this view appears to be opposed, among
other things, by the fact that, in blindness from tumors in the cere-
brum or cerebellum, the motor nerves of the eye, which are under
abou+ the same conditions as the optic nerve, are rarely paralyzed.
Many of the cases of amblyopia and amaurosis, caused by cerebral
tumors, depend on venous congestions in the eye, and the consequent
structural changes in the retina and optic nerve, and are due to com

270 DISEASES OF THE BRAIN.

pression of the cavernous sinus and obstructed escape of blood from
the veins of the eye. Tumors in the posterior cranial fossa only have
this effect after they have caused abundant effusions in the ventricles,
by compression of the openings of the venae Galeni into the straight
sinus. Since tumors, which destroy the optic nerve, very rarely spare
the oculo-motor, I consider the presence or absence of disturbances
of mobility of the eye as an almost certain means of distinguishing
whether the amaurosis, caused by cerebral tumor, is due to destruction
of the tractus opticus, chiasm, optic nerves, or to interference with the
intraocular circulation. Ophthalmoscopy also gives important informa-
tion on this point. The changes of the optic nerve, in blindness from
cerebral tumors, as revealed by the ophthalmoscope, and the conclu-
sions that may be deduced from them, are about as follows, according
to Graefe:

1. Simple swelling of the optic papilla, with great tortuosity of the
vena centralis. It is indicative of obstructed venous circulation, and,
in its purer forms, is most frequently seen with tumors that encroach
on the cavity.

2. Slight inflammatory swelling of the optic papilla, with less dis-
tinct venous hyperaemia and inflammatory participation of the retina.
It occurs as a result of an inflammation of the perineurium, and of the
optic nerve itself, which extends to the retina (neuritis descendens),
and accompanies those intracranial processes, which, from their ana-
tomical character or location, are suited to induce irritation in the parts
above named.

3. Atrophy of the optic nerve. This may occur primarily, from
direct lesion of the optic nerve by a tumor, meningitis, etc., or second-
arily, as a final result of either process.

The partial disturbances of sensibility and motility in the parts
supplied by the cerebro-spinal nerves, that occur in cerebral tumors, do
not differ from those accompanying other local affections of the brain.
Neuralgic pains, or indefinite sensations of prickling, formication, furri-
ness, etc., as well as complete anaesthesia, occur, both over large sur-
faces and limited to very narrow bounds. The same is true of mus-
cular twitchings, of contractions, and paralyses, although, among the
latter, hemiplegia far exceeds the other paralyses.

If there be morbid symptoms in the parts supplied by the cerebro-
spinal and cerebral nerves at the same time, they almost unexception-
ally show the peculiarity of being on opposite sides of the body.
This " alternation " is simply because the paralysis, anaesthesia, etc.,
of the cerebro-spinal nerves are caused by a lesion of the nerve-fila-
ments before they cross, while those of the cerebral nerves depend on
destruction of nerve-filaments that have already crossed.

TUMORS OF THE BRAIN AND ITS MEMBRANES. 271

In accordance with the slow growth of most cerebral tumors, the
development and extension of the local symptoms of irritation and
paralysis are usually slow and gradual. Many patients cannot state
exactly when their disease began. In doubtful cases this may de-
cidedly aid in the diagnosis, since, from such a course, we may exclude
most other local diseases of the brain. But not very rarely these local
symptoms come on suddenly ; this is chiefly the case where vascular
tumors are suddenly increased in size by overfilling of their vessels,
or by haemorrhage from them, or where the parts around them are at-
tacked by inflammation or softening, or by capillary haemorrhages.
If the tumor have previously run a latent course, and these symptoms
of paralysis come on suddenly, the case will most probably be mis-
taken for one of cerebral haemorrhage, and there are numerous in-
stances where the best diagnosticians have made mistakes in such cases.
If, on the other hand, there has been a suspicion of tumor of the brain,
the frequency of such incidents in the course of this disease should
prevent our being deceived.

Attacks of epileptiform convulsions occur more frequently from
tumors of the brain than from any other local disease of that organ ;
but it is very remarkable and inexplicable that they occur almost
solely when the tumors are in the cerebrum, and especially when they
are near the cortical substance.

In many cases psychical disturbances do not present themselves
throughout the disease. Indeed, it seems that the psychical functions
of the brain only suffer when the cortical substance of both hemi-
spheres is affected by organic disease, or by disturbance of circulation.
The correctness of this view is proved by the peculiarities of those
cases where the state of the psychical functions forms an exception to
the above. For the general mental ruin that we described when
speaking of abscess of the brain also occurs in cerebral tumors, when
they are accompanied by extensive chronic meningitis of the convex-
ity, or when the cortical substance of both hemispheres is the seat of
numerous tumors (cysticerci), or when then* capillaries are compressed
by encroaching tumors in both hemispheres, or by extensive secondary
effusions in the ventricles.

In the rare cases where the tumors perforate the skull, the symp-
toms above described are accompanied by other symptoms, which are
very characteristic. The perforation usually takes place through the
parietal or temporal bones, near the root of the nose, more rarely
through the occipital bone. At the point of perforation the hair is
lost, the skin becomes red, and is traversed by varicose vessels ; ulcera-
tion of the integument is rare. We may often feel a bony margin at
the border of the tumor, which is generally soft and nodular. It is a

272 DISEASES OF THE BRAIN.

characteristic but not a constant symptom for the tumor to move with
respiration; occasionally it may be replaced. Attempts to do this,
which suddenly contract the space in the skull and prevent the en-
trance of arterial blood to the brain, usually induce loss of conscious-
ness and convulsions.

The nutrition, general condition, and the functions of the body in-
dependent of the brain, often show no anomaly for a long time. In
other cases it seems as if the organic processes went on with a certain
sluggishness : the heart and pulse beat slowly, respirations are rare,
the bowels constipated, secretion of urine scanty, and, perhaps as a
consequence of this, the body often increases remarkably in size. In
other cases, on the contrary, marasmus occurs early, the patients ema-
ciate, the skin becomes dry and scaly, the mucous membranes, espe-
cially the conjunctiva, are affected with blennorrhcea. Lastly, there
are bed-sores and dropsy of the feet.

The course of cerebral tumors shows many variations which we
shall not discuss in detail. At first, there are generally exacerbations
and remissions of the symptoms, which subsequently become constant
and steadily grow worse.

In carcinomatous tumors the disease usually lasts only a few
months, but occasionally a year or more. Non-carcinomatous tumors
often run on for several years.

The most usual, and perhaps the only, termination is death. If it
be not induced early by complications or intercurrent disease, the
symptoms of general limitations of the space in the skull become more
and more marked. The patients fall into deep coma, followed by
death.

It is rarely possible to recognize the seat and size of a tumor ex-
actly ; but it may often be approximately decided in what part it is
located, whether in the cerebrum, medulla oblongata, or in the cerebel-
lum, at the base or at the convexity. The "brilliant diagnoses,"
where the precise localization of a tumor is fully confirmed by autopsy,
are not usually due to acumen of the observer, but are cases of lucky
diagnosis. If a basilar tumor destroys the function of several cerebral
nerves, one after the other and in regular sequence, while it spares
neighboring nerves, any one, having a knowledge of only the coarse
anatomy of the brain, can decide the seat and extent of the tumor
with almost absolute certainty. However, such cases, which are pub-
ashed with much self-satisfaction, are exceptions, as said before.

It would occupy too much time to speak fully of all the factors, be-
sides the participation of the different cerebral nerves, which are to be
considered when deciding the location of the tumors. We must limit
ourselves to the following short hints. The presence of hemiplegia

TUMORS OF THE BRAIN AND ITS MEMBRANES. 273

indicates that the tumor is either in one side of the cerebrum (the most
frequent seat) or in one crus cerebri, in one side of the pons or in one
side of the cerebellum. In tumors of the cerebrum the hemiplegia is
usually pure, that is, the other half of the body is entirely free from
paralysis. In tumor of one crus cerebri, the paralysis of the opposite
side of the body is almost always accompanied by paralysis of the
oculo-motor of the same side. In tumors of the lateral portions of the
pons, besides the hemiplegia and very common anaesthesia of the oppo-
site half of the body, there is usually facial paralysis or anaesthesia of
the side of the face corresponding to the tumor. In tumors of the
cerebellum, as we have previously shown, hemiplegia is not constant,
and when present is not pure, but extends to the other side of the body
to a less extent, especially affecting the muscles of the spinal column.
Paresis of the muscles inducing bending, erection, and lateral move-
ments of the spinal column, first shows itself by a peculiar form of diz-
ziness, which we have already fully described, and referred to vibra-
tions of the spine in walking and similar acts ; subsequently, it often
evinces itself by an utter inability of the body to maintain itself, so
in the sitting position the patients collapse and cannot move the body,
unless held by both shoulders. Paralysis of both sides results from
tumors in both sides of the cerebrum, in the middle parts of the
pons and in the medulla oblongata. In the above description of
the different symptoms it has already been shown that epi]eptiform
convulsions indicate that the tumor is near the cortical substance
of the cerebrum ; pain in the back of the head shows that it is in
the posterior cranial fossa ; and severe psychical disturbance either
indicates numerous tumors in the cortical substance of both hemi-
spheres, or that there is secondary meningitis or hydrocephalus. It
appears to me that too little attention has been paid to the fact that
the intelligence which is at first intact is very much impaired in the
later stages of tumors encroaching on the posterior cranial fossa,
which impede the escape of blood from the ventricles and induce ex-
tensive transudations into them.

Even on most carefully weighing all the symptoms, many errors
occur, and it is very desirable that observers, who have access to a
large number of cases, should publish their errors of diagnosis, as well
as their successes, more than has hitherto been done. The trust-
worthiness of the different aids to the diagnosis and localization of
cerebral tumors cannot become perfectly clear till this is done.

The wide-spread error of designating the various forms of neopla-
sia, aneurisms of the brain, and even parasites, by the common name
of cerebral tumors, is undoubtedly due to the fact that there are very
few cases where the nature of the tumor can be certainly determined

274 DISEASES OF THE BRAIN.

during life. If the symptoms of cerebral tumor occur in a person who
shows signs of carcinoma, tubercle, aneurism, or parasites in some
other organ, we are justified in presuming that the cerebral growth is
of the same nature as the other tumor, neoplasia, or parasite ; but this
aid to diagnosis fails in most cases, except where there are tubercles
of the brain in persons with tuberculosis of the lungs, and syphilomata
of the brain in persons with the same affections of other organs. Car-
cinoma of the brain is, as a rule, primary and solitary ; aneurism of a
cerebral artery is usually the only one in the body, and, when cysti-
cerci and echinococci enter the brain, as a rule they also are limited
to that organ.

The age of the patient gives some indication as to the nature of
the tumor. Most frequently children are affected with tubercle, young
adults with benignant tumors, especially sarcoma and glioma, and per-
sons of advanced years with carcinoma. In his classical observations
on brain-diseases, Griesinger has shown that, under some circum-
stances, it is possible to make a diagnosis of cysticerci in the brain,
even when there are none in other parts of the body. The large num-
ber of these small parasites, and their customary seat in the superficial
layers of the cerebrum, explain the severe psychical disturbances and
the epileptiform attacks, while the absence of a large compressing
body explains the non-occurrence of symptoms of paralysis, on which
factors Griesinger founded the diagnosis in his case. On the other
hand, I regard Griesinger's experiment, of compressing both carotids
firmly against the transverse processes of the cervical vertebrae, as entire-
ly useless for the diagnosis of basilar aneurism, and he, too, says it is
" purely theoretical." The occurrence of convulsions during this act
is not at all significant of an aneurism, even of an obliterated one. In
many other diseases, also, where there is any thing encroaching on the
mtracranial space, compression of both carotids causes dizziness and
loss of consciousness with or without convulsions.

TREATMENT. — We can do but little to remove carcinoma, sarcoma,
and the neoplasia generally, in other organs, by the hunger-treatment,
by the administration of iodine, arsenic, etc., and these remedies are
of no more benefit in tumors of the brain. They hasten the fatal re-
sult instead of retarding it. The treatment can only be palliative and
symptomatic. It is useless, and annoys the patient, to apply a seton
or issue to the nape of the neck. On the contrary, it is advisable to
guard him in every way from hyperaemia of the brain, by which
acute swelling of the tumor and threatening attacks are most fre-
quently caused ; to regulate the nutrition and mode of life ; to attend
to the bowels, etc. Apoplectic or inflammatory attacks must be com-
bated by venesection, local bleeding, ice-compresses, etc., as before

HYDROCEPHALUS ACQUISITUS. 275

advised. When the pain in the head is unusually severe, we may or-
der local abstraction of blood and cold-compresses or derivatives to
the nape of the neck. If these fail, we should not be too timid about
giving narcotics, and particularly small doses of morphia. When there
is the slightest suspicion of syphiloma of the brain, instead of this
symptomatic treatment, we should institute an energetic antisyphilitic
course. It is unpractical to delay this treatment, or to neglect it al-
together, if the syphilitic nature of the disease be not accurately deter-
mined. Experience teaches that even very severe structural changes
are capable of recovery, and often disappear under proper treatment,
and, on the other hand, that treatment is powerless against carcinoma,
sarcoma, etc. Hence, we risk little and may gain much, if, on the mere
suspicion of syphiloma of the brain, we treat the patient as if there
was no doubt about the diagnosis.

CHAPTER XIV.

SEEOUS EFFUSIONS IN THE MATTJKE SKULL HYDKOCEPHALUS ACQUI-
SITUS.

WE have already spoken of one form of hydrocephalus, that which
almost constantly complicates basilar meningitis, and, in the next
chapter, when treating of congenital hydrocephalus, we shall also
treat of the effusions occurring shortly after birth, before the sutures
are closed. In the present chapter we shall only consider those serous
effusions into the cranial cavity which occur without basilar menin-
gitis and after the skull has closed.

ETIOLOGY. — Serous effusions into the arachnoid sac (hydrocephalus
externus) are rare, and hardly ever become extensive. Effusions into
the subarachnoid space and ventricles and oedema of the brain are
more frequent.

Hydrocephalic effusions are due partly to increased lateral pressure
m the vessels, partly to an abnormally slight amount of albumen in
the blood, partly to disturbances of nutrition, which render the walls
of the vessel more permeable. As one symptom of general dropsy,
whether dependent on disturbance of circulation or on abnormal quality
of the blood (morbus Brightii), the hydrocephalus rarely attains a high
grade, although, perhaps, some sudden deaths occurring in the dis-
eases inducing the dropsy are to be referred to slight effusions in the
ventricle and to a slight oedema of the brain. Tumors and other dis-
eases in the posterior cranial fossa, by compressing the venae Galeni or
straight sinus, and obstructing the escape of blood from the ventricle,
sometimes induce high grades of hydroceiDhalus. Hydrocephalus, de-

276 DISEASES OF THE BRAIN.

pendent on certain disturbances of nutrition in the capillaries, is more
of an independent disease than the other forms ; it closely resembles
the inflammatory processes, and may be ranked with the inflammations
of the skin that cause serous blebs. This view is supported by an in-
teresting observation of Hoppe^ who, on examining the fluid from a
chronic hydrocephalus, found it differently constituted from the normal
cerebro-spinal fluid, particularly that it contained more albumen. This
form of hydrocephalus occurs chiefly among children, and, when seen
later in life, it almost always dates from childhood.

We must mention, as a peculiar variety of the disease, hydrocepha-
lus ex vacua, which develops as a necessary result of diminution of the
size of the brain, whether from general, especially senile, involution
(hydrocephalus senilis), or from partial atrophy of the brain.

ANATOMICAL APPEARANCES. — The amount of fluid effused into the
arachnoid sac is difficult to decide, since, on removing the brain from
the skull, the fluid from the subarachnoid space is always mixed with
it ; but, as we have before said, it never becomes considerable.

The fluid effused in the subarachnoid space is sometimes regularly,
sometimes irregularly spread over the surface of the brain ; in the latter
case the arachnoid often forms a vibrating sac filled with serum. When
slight, cedema of the brain shows itself by the moist lustre of the cut
surface ; when more decided, the coherence of the brain is decreased,
and, if we press on some part, the resulting pit is filled with liquid
after a time. When of very high grade, the brain-substance is broken
down by the cedema, and changed to a thin white pulp (hydrocephalic
softening).

In acute hydrocephalus internus the fluid effused into the ventricle
rarely exceeds half an ounce or an ounce ; it is either clear, or, as is
usually the case, slightly clouded by a scanty admixture of cast-off
epithelium, flocculent clots, and fragments of the surrounding brain-
substance. The walls of the ventricle, especially the septum, fornix, and
commissures, are in a state of hydrocephalic softening.

In chronic hydrocephalus internus we generally find the ventricles
considerably dilated : they may contain ten or twelve ounces of fluid,
which is usually clear. The ependyma of the cerebral cavities is thick-
ened and often strewn with fine granulations. The surrounding brain-
substance is also more dense and tough.

SYMPTOMS AND COURSE. — Of course, the cavity of the skull is as
much encroached on by serous effusions as by extravasations of blood
or products of inflammation. As a necessary result of this, we have
mentioned obstruction to the entrance of arterial blood, and have given
attacks of convulsions and loss of consciousness as the symptoms of
complete and sudden arterial anaemia ; general symptoms of irritation

HYDROCEPHALUS ACQUISITUS. 277

and depression as those of incomplete and gradually-developing anaemia,
[f, at the same time, we remember that those portions of the brain
bounding the ventricles are destroyed, in acute hydrocephalus, by soft-
ening, in the chronic form by atrophy, and that this may induce partial
paralysis, we may construct a picture of the disease, either in the acute
or chronic form, exactly corresponding with direct observation.

Sudden and large effusions of serum into the cerebral substance
and ventricles lead to a combination of symptoms which, from its re-
semblance to the apoplectic attack induced by extravasation of blood,
is usually termed apoplexia serosa.

After what was said above, it is hardly worth mentioning that a
distinction between serous and sanguineous apoplexy is not by any
means possible in all cases, and that, if a diagnosis be made, it is
chiefly from the etiology, which indicates one form rather than another.

In children, acute hydrocephalus almost always runs its course with
the symptoms that we ascribed to high grades of cerebral hyperaemia,
and to the first stages of acute meningitis. Severe attacks of convul-
sions, with loss of consciousness, are the most frequent and character-
istic symptoms. If these attacks occur very often, and last unusually
long, they should excite the fear that the hyperaemia has induced con-
siderable transudations in the ventricles, and it is to be feared that the
transudation will not be absorbed, or, at least, only partly so, and that
chronic hydrocephalus will remain.

The symptoms of chronic hydrocephalus either succeed those of the
acute form, or they develop insidiously and gradually. They consist
of headache, dizziness, weakness of the special senses, particularly of
the eyes, very often of a general paresis, preceded by a tottering gait
and trembling of the limbs. Among the constant symptoms are dis-
turbances of the intellect, especially its gradual loss, even to idiocy.
This is sometimes accompanied by convulsions, and occasional vomit-
ing. The patients usually have a slow pulse, are readily chilled, are
occasionally ravenous ; they have a puffy look, and varicose vessels on
the cheeks. Of course, these symptoms only render the diagnosis of
chronic hydrocephalus certain when other cerebral diseases, accompa-
nied by similar symptoms, can be excluded, and, consequently, that
the diagnosis can rarely be made with absolute certainty. The course
of the disease is usually very tedious. If death do not sooner occur
from some intercurrent disease, it finally results, sometimes rapidly and
unexpectedly, from acute increase of the effusion, sometimes slowly,
from its gradual increase, being usually preceded, for some days, by
continued deep sopor.

TREATMENT. — The treatment of acute hydrocephalus is the same
as that of acute hyperaemia of the brain and acute meningitis. In

278 DISEASES OF THE BRAIN.

chronic hydrocephalus, the continued employment of cold douche baths
deserves most confidence.

CHAPTER XV.

SEROUS EFFUSIONS IN THE INCOMPLETE SKULL — HYDROCEPHALUS

CONGENITUS.

ETIOLOGY. — It is most probable that congenital dropsy of the brain
is due to inflammation of the ventricular walls that has occurred during
foetal life. The etiology of the disease is entirely obscure. Some
women have had several hydrocephalic children, without any apparent
cause.

ANATOMICAL APPEARANCES. — In congenital hydrocephalus the
amount of serum, usually clear and limpid, effused into the cerebral
cavities, is occasionally very small, while it sometimes amounts to six
or ten pounds. In such cases the ventricles are distended to large,
thick-walled sacs, the brain-substance around them is thinned, and
often atrophied to a layer only a few lines thick ; the corpora striata
and optic thalami are flattened and pressed apart, the corpora quad-
rigemina flattened, the commissures stretched and thinned. The sep-
tum is occasionally broken through, and the floor of the third ventricle
is often thinned and projecting. The pons and cerebellum appear
compressed from above downward.

Where the effusion is not large, the skull preserves its normal size ;
where it is large, on the other hand, it is almost always decidedly dis-
tended. Even at birth the head is usually enlarged, but becomes still
larger after birth, and may be distended to two feet in circumference.
In such cases the cranial bones, especially the frontal and parietal
bones, are very large, and are, at the same time, very thin. The mem-
branous interstices also, especially the fontanels, are very wide. The
forehead is prominent, the roofs of the orbits are depressed, and they
are transformed into narrow, transverse slits ; the squamous portions
of the temporal bones and the occipital bone are more horizontal. The
ossification, which is delayed, takes place from formation of points of
ossification in the membranous interspaces, or even from the formation
of innumerable small bones. The cranium, which, previous to the
ossification, was very thin, often becomes thick subsequently, and, in
many cases, such a skull retains an asymmetrical or remarkable spheri-
cal form.

SYMPTOMS AND COURSE. — Many children, born with hydrocephalus,
die at birth or shortly after. In others, during the first weeks of life,
if the skull be not enlarged, no symptoms of the disease can be
observed. This is due partly to the difficulty of judging of the cere-

HYDROCEPHALUS CONGENITUS. 279

bral functions at this age, partly to the yielding nature and gradual
distention of the skull. If an equal amount of transudation occurred
in the mature skull, the severest symptoms would arise.

Even during the first years of life, the increasing size of the skull
and the growing difficulty that the child finds in holding its head up-
right are the most prominent and only characteristic symptoms. If
the head be not enlarged, or so slightly so as not to be noticed, the
disease is generally overlooked in the first year also. It is true the
mother wonders that, when the child is nine months old or over, it still
remains uncleanly, makes no attempts to walk, and does not even try
to speak ; she hardly asks the physician's advice, and, when she does
finally consult him, he also reassures her. But gradually the child
appears more strange. First of all, there is an idiotic manner with
outbursts of pleasure or fear, in which the child often shrieks out, dis-
torts the face into horrible grimaces, and drums with the extremities.
The first year passes, and the child continues to stick all toys, for
which other children of the same age seem to understand the use, into
its mouth, because it does not know what else to do with them. The
eye does not regard any object held in front of it, but rolls about un-
steadily. The face has no expression, but is empty and silly ; often
saliva flows constantly from the half-open mouth. And gradually
comes the sorrowful conclusion that the child does not develop intel-
lectually, or even loses ground. Many such children do not learn to
walk. If we attempt to teach them to walk, they often cross the legs
instead of setting them forward. Others, who do learn to walk, have
such an uncertain and helpless gait that they readily fall, and fre-
quently cannot step over any elevation. There are usually no anom-
alies in the organs of special sense. On more careful observation,
apparent deafness generally turns out to be deficient attention. It is
difficult to come to any decision regarding the senses of smell and
taste ; the sense of sight usually remains intact, though there is often
strabismus or dilatation of the pupil.

In those cases where the head quickly becomes very large, the dis-
ease is recognized sooner and more easily, although in them the above
symptoms are usually less developed than where the head is mod-
erately or not at all enlarged. The little old face, which does not
agree with the large skull, and forms with it a triangle pointing toward
the chin, the distended veins traversing the skin, especially in the
frontal and parietal regions, the thin hair covering the broad skull, the
often rachitic bones or a general dwarfy appearance, the vain attempts
of the child to hold up the heavy head, which sinks again every time
it is raised, give the disease an appearance as melancholy as it is
characteristic.

68

280 DISEASES OF THE BRAIN.

Apart from the intercurrent attacks of convulsions, which are quite
frequent, the course of the disease is sometimes regular and steady, so
that the symptoms increase gradually till death results from general
paralysis, or it is irregular, so that the symptoms are worse at times,
while at other times there is a temporary stand-still or even improve-
ment. Lastly, it is not rare for the disease, after attaining a certain
point, to remain permanent, or even for part of the existing disturbances
to disappear. This disappearance probably never goes on to recovery ;
some intellectual weakness always remains, though it may be only a
slight amount.

The most frequent termination of the disease is death ; this often
occurs during the first years of life, partly from the disease itself with
convulsions and consequent coma, partly from complications.

The increasing encroachment on the cranial cavity shows its effects
earlier in the mature skull than in the opposite case, and the life of
the child is in greater danger when the skull remains of the normal
size than when it is considerably dilated. In rare cases death results
from rupture of the distended ventricle and soft parts covering it,
either spontaneously or from a fall or blow. Few patients live beyond
puberty, and it is very rare for them to attain mature age.

TREATMENT. — In congenital hydrocephalus nothing can be accom-
plished by absorbent remedies, diuretics, drastics, preparations of
iodine, calomel, or mercurial salve. Compression of the distended
skull by strips of adhesive plaster is not free from danger, and in cases
hitherto observed has proved of little use. Nor are the results of
evacuating the serum by operation very encouraging. Most patients
died soon after the first puncture or after its repetition, so that the
operation should be limited to those cases where the head has attained
a colossal size, and where a steady progress of the enlargement is
observed. In the treatment of congenital hydrocephalus as in the
acquired form, the treatment is mostly symptomatic, and the patients
are to be protected as much as possible from all injurious influences.

CHAPTER XVI.

HYPERTROPHY OF THE BRAIN.

ETIOLOGY. — Since, in so-called hypertrophy of the brain, there is
jot an increase of the true tissue-elements of the brain, the nerve-fil-
aments, and ganglion-cells, but only a proliferation of the delicate
insterstitial substance which unites the nerve-elements, the name
hypertrophy of the brain is not exactly correct. It is sufficient, how-
ever, to have noticed this point, and we may preserve the old name

HYPERTROPHY OF THE BRAIN. 281

without fear of being misunderstood. We do not know whether the
proliferation of the neuroglia is the result of frequently-recurring hyper-
semia, or of some other cause.

Hypertrophy of the brain is occasionally congenital, and then often
accompanies dwarfishness ; more frequently it develops after birth, is
chiefly limited to childhood, and becomes rarer with advancing years.
Hypertrophy of the brain acquired after birth is usually accompanied
by rachitis, deficient involution of the thymus gland, and hypertrophy
of the lymphatics (Rokitansky). Mental excitement, abuse of liquor,
and lead-poisoning, are mentioned as exciting causes of the disease, but
it is very doubtful whether they act in this way.

ANATOMICAL APPEARANCES. — The brain, almost exclusively the
cerebrum, is larger and heavier than normal. On autopsy, if the top
of the skull be removed it is difficult to replace it, because the brain
bulges out so, and protrudes between the sawed edges of the bone. The
cerebral membranes are very thin and bloodless. We often find no trace
of liquid in the subarachnoid space. The convolutions on the surface
of the cerebrum are flattened and pressed together ; the sulci between
them are scarcely perceptible. The centrum semiovale is unusually
large, the ventricles are small on section ; the brain-substance, like the
membranes, appears bloodless and dry. Its consistence and elasticity
are increased.

If hypertrophy of the brain develop before closure of the skull, the
latter is distended, just as in congenital hydrocephalus. If, on the
other hand, it does not begin till the sutures are closed, the cranial
wall is often thinned by absorption, and the inner lamella loses its
smoothness. More rarely, when the disease increases rapidly, the
closed sutures are opened and pressed apart.

SYMPTOMS AND COURSE. — Of course, hypertrophy of the brain has
the same influence on the intracranial circulation as any other increase
of the contents of the skull has ; hence it is accompanied by extensive
symptoms of irritation and of paralysis. And it may readily be un-
derstood that these symptoms often do not occur, or only attain a low
grade, as long as the sutures of the skull are not closed, and the skull
can distend in proportion to the enlargement of the brain. The cir-
cumstance that children with hypertrophy of the brain are not always
deficient in intellectual development, but are sometimes remarkably
sharp and competent in proportion to their physical development,
, forms a strong point in diagnosis between hydrocephalus and hyper-
trophy of the brain in children with very large heads. Among the
symptoms most frequently seen, when there is no enlargement of the
head, or when it does not correspond to the increase of the brain, the
most important are attacks of epileptiform convulsions. These at«

DISEASES OF THE BRAIN.

tacks seem to occur principally when the one constantly present cause,
arterial anaemia, is accompanied by any other, often a very slight one,
which suddenly and temporarily greatly increases the anaemia. Head-
ache, dizziness, photophobia, general hyperaesthesia, mental irritability,
occasional vomiting, and subsequently anaesthesia, general muscular
debility, mental hebetude and drowsiness, are much less frequent and
far less characteristic of the disease. The malady can only be diag-
nosed with an approach to certainty where the skull is enlarged and
hydrocephalus can be excluded, while in most cases only a probable
diagnosis can be made. The course of hypertrophy of the brain is al-
ways chronic. It is doubtful whether it ever ends in recovery. Death
results either from the disease itself, generally not from a gradually
increasing paralysis, but during a severe attack of convulsions, or else
from complication with haemorrhages and inflammatory exudations;
as may readily be understood, even when very slight, these are ex-
tremely dangerous for such patients.

We cannot speak of treatment of hypertrophy of the brain, for,
even where the disease is recognized, we cannot expect any remedy to
remove the existing disturbance.

CHAPTER XVII.

ATROPHY OF THE BRAIN.

ETIOLOGY. — We must not term every diminution of the brain-sub-
stance, particularly those due to destruction of its tissue and to develop-
ment of shrinking cicatricial tissue in the place of the destroyed por-
tion, atrophy of the brain. True atrophy of the brain consists rather
in a diminution of the size or number of the elements, without any per-
ceptible previous destruction of them.

It is convenient to distinguish two forms of atrophy of the brain.
In the first, the so-called agenesis, there is incomplete development ;
in the second there is a retrogression, a disappearance of the previous
ly well-developed constituents of the brain.

We pass over those forms of agenesis where the brain is so incom-
pletely developed that there is either complete idiocy or that life can-
not continue, and turn our attention to the interesting and not very
rare form of one-sided atrophy of the brain, occurring during fcetal life
and the first years of childhood, in which not only may life continue,
but there may be a certain amount of intellectual development. The
etiology of monolateral agenesis is obscure. It is probably due to in-
flammation of the brain, meninges, or skull, during fcetal life or early
childhood.

ATROPHY OF THE BRAIN. 283

The atrophy occurring after complete development of the brain is
sometimes primary, sometimes it accompanies other affections of the
brain as a secondary disease. Among the primary atrophies we must
first mention that form which occurs as a symptom of senile marasmus.
Other senile changes attain unequal grades in different persons, and
we also meet very aged individuals who do not show the least sign of
cerebral atrophy, while it advances to the highest grade in much
younger persons. Next to this comes the atrophy of the brain, which
develops in the course of exhausting and consuming diseases. In
many cases which are quoted as examples of great resignation and
wonderful firmness at the approach of death in tedious diseases, the
facts were really badly interpreted ; very often the resignation is cer-
tainly due to the dulness and apathy induced by cerebral atrophy.
Local diseases of the brain are the chief causes of secondary atrophy.
We have already mentioned it as the result of precedent apoplexy,
partial necrosis, and partial encephalitis. The paralytic form of idiocy
appears to depend on an atrophy of the brain caused by chronic me-
ningitis or inflammatory processes in the cortical substance. In other
cases the atrophy is the result of continued pressure on the brain.
Under this head come the cases where the size of the brain gradually
decreases under the pressure of cerebral tumors and hydrocephalic
effusions. In meningitis, also, perhaps part of the atrophy is due to
the pressure of the inflammatory exudation in the subarachnoid space.
Lastly, we must mention that injury and destruction of peripheral
nerves occasionally induce secondary atrophy of their centres.

ANATOMICAL APPEARANCES. — When cerebral agenesis is limited
to one side, the left is the one generally affected; sometimes the
vvhole hemisphere is affected, sometimes only parts of it. In high
grades of the disease, the cerebral substance between the ventricles
and convex surface has become a thin layer only a few lines thick. The
convolutions are scarcely perceptible, or else are very small. The large
cerebral ganglia are usually atrophied, and the atrophy extends from
them through the crura cerebri to the spinal marrow. The consistence
of the atrophic brain is usually increased, its color is somewhat dirty.
The space created by the atrophy is filled with fluid that has collected
partly in the ventricles, partly between the meninges. The skull is
often unsymmetrical, and is thickened at the atrophied part.

Atrophy of the brain occurring late in life is usually total, but,
when it results from partial destruction of the brain, it is generally
further advanced on the side corresponding to the disease than on the
other. The medulla of the cerebrum is diminished, the convolutions
appear thinner, the furrows broader and deeper. The medullary sub-
stance is dirty white, more dense and tough, the cortical substance is

284: DISEASES OF THE BRAIN.

thinner, harder, and of a pale or light-brown color. The ventricles
are dilated and filled with serum. There is also a quantity of fluid in
the subarachnoid meshes (hydrocephalus ex vacuo).

.SYMPTOMS AND COURSE. — Although, as we have previously men-
tioned, agenesis of one side is not always accompanied by psychical
disturbances, still it is rare to find cases where we dare assert that one
side of the brain fully replaces the other. Far the greater number of
patients suffer from weakness of intellect, and many from decided
idiocy. The organs of special sense, particularly the eye, are usually
very insensitive, and the excitability of the sensory nerves of the par-
alyzed half of the body is diminished. The most important and ap-
parent symptoms are paralysis and a peculiar and excessive atrophy
of the side of the body opposite to the atrophied brain. The paralysis
is not usually complete, so that the patients can generally perform
some imperfect movements. The paralysis is ordinarily combined
with contractions. The atrophy of the paralyzed side affects all the
tissues, the bones not excepted, so that the thin and short extremities
of a grown person appear like those of a child. Most patients suffer
from epileptic attacks. As the other functions of the body are usually
well performed, the disease itself is rarely fatal. But the patients
seldom attain old age. Their power of resistance to intercurrent dis-
eases is lessened, and they succumb to them more readily than other
persons would.

The primary atrophy of the brain, which develops chiefly in old
persons, and secondary atrophy, which accompanies apoplexies, partial
necrosis, and other local brain-diseases, are characterized by gradual
weakening of the psychical functions, loss of memory, slowness of
thought, absent and childish manners, as well as dulness of the senses,
and gradual weakening of the motor power, unsteadiness of motion,
trembling, incomplete control of the sphincters, etc.

The atrophy of the brain found on autopsy of insane patients, who
have suffered from paralytic idiocy, belongs to the terminal symp-
toms observed in that form of insanity during life, to the symptoms of
mental weakness and idiocy, but not to the monomania which pre-
ceded the mental paralysis, or to the intercurrent maniacal and apo-
plectiform attacks. These are rather to be referred to the precedent
meningitis, which is rekindled from time to time during the subse-
quent course. At the stage of the disease when the psychical exalta-
tion of the patient decreases, when the insane ideas and hallucinations
lose their richness and reality, when the thoughts are confused, mem-
ory defective, symptoms of paralysis also begin to appear in the motor
sphere ; and the more the signs of psychical weakness increase, the
more extensive and marked become the signs of motor paralysis. The

APHASIA— ASYMBOLIA. 285

first symptom of the latter is always impaired articulation, which
gradually becomes sheer mumbling. The attitude is negligent, the
gait uncertain and tottering, the patient easily falls, and his hands
tremble when held out. Later, he cannot leave the bed, lies mo-
tionless, does not react to the strongest irritation, and finally dies
of marasmus.

TREATMENT. — We cannot expect to treat atrophy of the brain
successfully. Treatment must be directed against the original dis-
ease, to prevent the progress of the atrophy, if possible. On this
occasion we shall again call attention to the cold douches which
we recommended as peculiarly efficacious in chronic meningitis.
For the rest, we have to limit ourselves to combating the more
threatening symptoms. In monolateral agenesis, we may attempt
to arrest the atrophy and fatty degeneration of the muscles by
using the induced current of electricity, which, in this case, is of
course to be regarded only as a gymnastic remedy.

[CHAPTER XVIII.

APHASIA ASYMBOLIA.

THEEE is a disease of the brain which, while it impairs or even
totally destroys the power of speech, does not in the least disable
the apparatus for speaking, nor derange the faculty of thinking.
This incapacity to express thoughts in words, although the mind be
clear and the muscles of speech in good order, is called aphasia.
Trousseau and Broca observed that such disorders of speech stood
in close connection with a lesion of the third frontal convolution, and
that nearly always an affection of the left third, and quite excep-
tionally a similar one of the corresponding convolution of the right
side, was at the root of failure of speech. This relation the French
authors first explained by assuming that in most persons the organ
of speech is developed only upon one side, and that usually the left
one ; while among left-handed persons the right third convolution
should represent the function of speech. Besides the third convo-
lution, however, there seem to be other spots in the brain which
have to do with the speaking faculty ; and in a good many cases
the diseased point has been found elsewhere, in the fissure of Syl-
vius, the island, or nearer to the corpora striata, or even in the pos-
terior lobes of the brain.

The lesions which may cause aphasia are various — apoplexies,

286 DISEASES OF THE BRAIN.

inflammatory and embolic points of softening, injuries of the head
followed by inflammatory growths, and the like. When the lesion
is extensive, of course other functional derangements of the brain
will accompany the aphasia. These coarse structural changes, how-
ever, are not the only causes of aphasia. It has appeared during
the course of acute infectious disease, such as typhus, and as a con-
sequence of poisoning by lead, belladonna, and chloroform. It has
also arisen in hysteria and epilepsy, as well as after violent mental
emotion.

Generally only one or two words remain at the command of an
aphasic person. With these he in vain strives to express his
thoughts, repeating them malapropos on all occasions. In some
cases the speech is quite lost, or the patient can only utter unintel-
ligible sounds. Although this lack of power to clothe the thoughts
in words is the commonest and most marked phenomenon, yet it is
not the only one. Very often the patient cannot write (agraphid)
nor read (alexia) ; sometimes even the power to communicate ideas
by gesture is also lost. Hence the term asymbolia (Finkelburg)
would seem more suitable to the disease than aphasia. Finkelburg
defines asymbolia as an affection in which the faculty of conveying
.ideas by means of signs, or else the ability to understand such signs,
is impaired or lost. Indeed, aphasic persons are very often incapa-
ble of reading or understanding either written or printed words.
In very exceptional cases the speaking faculty has been preserved,
while the ability to make or to comprehend signs has failed. To this
condition the term aphasia certainly does not apply. An aphasic
patient now at the Giessen clinic for some weeks presented the odd
peculiarity of being unable to open his mouth when told to do so.
He would make awkward and vain attempts to open it with his fin-
gers ; but the moment a spoonful of food was presented to his lips,
the mouth would gape to the verge of its ability.

We have not as yet any satisfactory explanation of the physiol-
ogy of aphasia. Trousseau ascribed the loss of speech to two con-
ditions : 1. To partial lack of memory. In such cases the patients
do not speak because they cannot remember the words ; but they
can still repeat words spoken to them (amnestic form). 2. To for-
getting the art of articulation, so that repetition of words spoken to
the patient is difficult or impossible to him (atractic form).

It is very easy to recognize an uncomplicated, well-pronounced
case of aphasia ; but the diagnosis of an ill-marked case, or of one
combined with other mental disorders, may be very difficult. Hemi-
plegia often exists on the side opposite to that of the brain-lesion
(hence generally upon the right side) ; and since the aphasia in such

ADDITION TO THE REVISED EDITION OF 1880. 287

cases probably depends upon destructive local disease of the brain,
the prognosis should be unfavorable, although improvement may
perhaps take place. When there is no paralysis, and when we have
reason to ascribe the attack to a transitory derangement of the cir-
culation, to a watery exudation, or the like, we may hope that the
affection may pass away.

Treatment of aphasia should be mainly a treatment of its cause.
Later in the disease the attempt may be made to develop the speak-
ing faculty from the opposite half of the brain, by judicious prac-
tice of reading, writing, and elocution. Such vicarious compensa-
tion is, however, not to be relied on.]

ADDITION TO THE REVISED EDITION OF 1880.

SECTION I. DISEASES OF THE BKAIN.

1.— P. 216.

The discovery that the bursting of a vessel is preceded by an
aneurismal dilatation of its walls is most important in the etiology
of apoplexy. It used to be assumed that the fatty degeneration at-
tacked only the inner and middle coats, causing an escape of blood
into the adventitia, which then bulged out under the blood-pressure
(Kolliker's and PestalozzVs spurious aneurism ; Virchow's dissecting
ectasy). Char cot and JBouchard take quite a different view of the
vascular dilatation which plainly lies at the root of most apoplexies.
According to them, a periarteritis, or inflammation of the lymphatic
sheath, forms the starting-point of the process, and the morbid
changes progress from without the vessel inward (the reverse of
what occurs in atheroma), the adventitia thickens more or less, or
at least shows a multiplication of its nuclei, while the muscular
coat tends to atrophy. At points where the thickening of the ad-
ventitia has failed while the muscular coat has atrophied, the vascu-
lar wall yields before the blood-pressure ; thus there form small
round knots (miliary aneurisms), situated on the vessels, and hav-
ing the diameter of -J — 1 millimetre. If these little aneurisms con-
tain liquid blood, their color will be red ; if the blood be coagulated,
they present a brown or blackish appearance. If the thickening of
the wall be considerable, the sac may attain the consistence of a
grain of sand.

ZenJcer, while supporting the Frenchmen regarding the fre-

288 DISEASES OF THE BRAIN.

quence and importance of miliary aneurism, believes that they
originate in a sclerosis of the tunica intima, like that which attacks
the larger vessels.

Apoplexies which arise during scurvy, morbus maculosus, and
malignant infectious disorders, appear to depend upon a morbid
tenderness of the vascular walls caused by fatty degeneration.

SECTION II.

DISEASES OF THE SPINAL MARROW AND ITS
MEMBRANES.

OHAPTEE I.

HYP^EKEMIA OF THE SPINAL MARROW A1ST> ITS MEMBKANES.

THEKE is hardly any doubt that the amount of blood contained in
the spinal marrow is subject to variation, and that hyperaemia and
anaemia modify its functions just as they do those of the brain. Never-
Iheless, the symptoms which we are in the habit of referring to an
abnormal amount of blood in the spine are not directly deduced from
comparison of the symptoms observed during life with the results of
autopsy, but from a priori reasoning. Moreover, in most autopsies no
attention is paid to the amount of blood in the spinal marrow, and its
estimation offers even more difficulty than is the case in the brain.

Remarkable vascularity of the spinal medulla and its membranes
is most frequently found on autopsy of new-born children and of per-
sons who have died of spasmodic affections or of acute febrile diseases.
We also find varicose dilatations of the venous plexus in the lower
part of the spinal canal, as one of the symptoms of abdominal plethora
accompanying cirrhosis of the liver and other diseases that impair the
circulation in the abdomen.

Hyperaemia of the spinal medulla itself leads to swelling and relax-
ation of its substance, and to the formation of small ecchymoses ; iu
higher grades there is softening of the medullary substance. Accord-
ing to Hasse, hyperaemia of the membranes induces increased transu-
dation, as a result of which there may be overfilling of the subarach-
noid space, extending from below upward as far as the skull.

As symptoms of hyperaemia of the spinal medulla and its mem-
branes, the above author mentions a dull pain, mostly limited to the
sacral and lumbar regions, a feeling of numbness and formication in thp

290 DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES.

lower extremities and their incomplete paralysis. These disturbances
of sensation and motility, proceeding from below upward, rarely extend
to the upper extremities ; when this does occur, the respiration is also
said to be occasionally affected, while the bladder and rectum hardly
ever participate in the paralysis. From this combination of symptoms
we cannot decide on hypersemia of the spinal marrow with any cer-
tainty, unless there are other symptoms of it, and the symptoms dis-
appear after bleeding from the haemorrhoidal or uterine veins, which
anastomose with those of the spinal medulla, or after local abstraction
of blood. It is at least doubtful whether convulsions result from ex-
cessive hyperaemia of the spinal marrow, since the hyperaemia found
on autopsy after severe convulsions may just as well be the result as
the cause of the spasm. The same is true of the association between
the spinal hyperaemia, found after febrile diseases, and the symptoms
of the fever. " Spinal irritation," which for a time caused a good deal
of talk, is a term used to indicate a condition chiefly characterized by
sensitiveness of certain spinal processes to pressure, great inclination
to reflex movement, and a general hyperaesthesia. We find these
symptoms just as frequently as we do headache in many acute and
chronic diseases, without its being possible to interpret them. At all
events, we are not justified in deciding from their presence, without
further proof, that there is hyperaemia of the spinal marrow, any more
than we are in diagnosing cerebral hyperaemia in patients who have
only headache.

If the causes of the spinal hyperaemia be made out, we should, in
the first place, attempt to fulfil the causal indications. When the hy-
peraemia has attained a certain grade and we cannot hope for its sub-
sidence without therapeutic aid, we may employ local blood-letting by
wet cups and leeches. We should apply the former along the spinal
column, the latter about the anus, especially when there is coincident
abdominal plethora. The effect of the abstraction of blood is sup-
ported by cathartic medicines, particularly the neutral salts.

CHAPTER II.

HAEMORRHAGE OF THE SPINAL MARROW AND ITS MEMBRANES

SPINAL APOPLEXY.

EXCEPT small ecchymoses, which accompany excessive spinal hyper-
eemia, extravasations between the meninges and into the substance of
the spinal marrow are very rare. Degeneration of the walls of the
vessels, and increased pressure of blood in the arteries, which are the
chief causes of cerebral haemorrhages, appear to have no effect on

HYPEILEMIA OF THE SPINAL MARROW AND ITS MEMBRANES. 291

spinal haemorrhage. Intenneningeal haemorrhages may almost always
be traced to injuries of the spinal meninges from wounds, contusions,
or stretching. Their occurrence chiefly among the newly-born is due
to the severe tension to which the spinal column of the child is so
often subjected during severe labor. Extravasations of blood in the
medulla spinalis are usually terminal symptoms of chronic destructive
processes of the cord, and are only rarely due to injuries of the spinal
column.

The extravasations of blood from meningeal haemorrhage are usu-
ally considerable ; they collect chiefly in the lower part of the spinal
canal, but often fill large portions of the subarachnoid space. Where
the haemorrhage is into the medulla, we find it containing a bloody
pulp. The changes undergone by the apoplectic clot, when it has ex-
is^ed a long time, are little known, but seem to resemble those under-
gone by the brain under similar circumstances.

Apparently intermeningeal haemorrhages only gradually compress
the vessels of the spinal cord sufficiently to entirely cut off the supply
of arterial blood, and so remove the excitability of the nerve-filaments.
In effusions of blood between the meninges, symptoms of severe irrita-
tion, pains in the back, and spasms, especially tonic spasms in the
parts supplied by the nerves going off below, opisthotonos, rigid con-
traction of the extremities, etc., usually precede the paralysis. But
where there are large extravasations, there is perfect anaesthesia, and
paralysis of the parts receiving nerves from the compressed portion of
the spinal cord. If the respiratory muscles be among these parts,
death soon occurs ; if they remain unaffected, death may be delayed.
It is doubtful whether the conduction can be restored and recovery
take place after disintegration and reabsorption of the extravasation.
From the above symptoms we can only make a diagnosis of meningeal
spinal apoplexy when they have been preceded by an injury of the
spinal canal. If the history be imperfect, and we find no causes ren-
dering haemorrhage probable, the disease cannot be recognized with
certainty.

Since the substance of the spinal marrow is usually entirely broken
down by haemorrhages into it, the conduction from the brain to the
peripheral nerves, and from them to the brain, is generally interrupted
at the moment of the haemorrhage. The more sudden the symptoms
of this interruption— anaesthesia, and loss of voluntary motion in the
lower half of the body, combined with paralysis of the bladder and
rectum — appear, the more probable it is that the communication has
been interrupted by a rapid breaking down of the spinal medulla from
an extravasation of blood, and not by its gradual destruction from in-
flammation, softening, or paralysis. When the apoplexy is high up, so

292 DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES.

that respiration is affected, death occurs quickly. If, on the other hand,
a part far down be destroyed, death does not result for years, and is
generally caused by large bed-sores, or cystitis, induced by paralysis
of the bladder.

Since we cannot, by therapeutic means, hasten the reabsorption of
the effused blood, or aid the regeneration of the broken-down nerve-
filaments, the treatment of spinal apoplexy can only be symptomatic.
At first, as long as there are severe pains in the -back and symptoms of
inflammation, the proper treatment is local bleeding, and the applica-
tion of an ice-bladder to the part where the haemorrhage is suspected.
Subsequently there is usually little to do but to guard the patient
against bed-sores, to carefully empty the bladder at regular intervals,
and to maintain the strength of the patient. Well-to-do persons, who
remain paralyzed from spinal apoplexy, may be sent to Wildbad,
Pfaffers, or Gastein. But, the more certain the diagnosis, the more
improbable it is that these baths will prove beneficial.

CHAPTER III.

INFLAMMATION OF THE MEMBRANES OF THE SPINAL MARROW

MENINGITIS SPINAUS.

ETIOLOGY. — Inflammation of the dura mater probably never occurs
as an independent disease, but it very frequently follows injuries, and
especially inflammations of the spinal column. Acute inflammation of
the arachnoid is also almost solely observed as an accompaniment of
inflammation of the dura and pia mater ; but chronic inflammation of
the arachnoid, resulting in partial thickening and ossification, occurs as
a primary and independent disease, without perceptible cause. Acute
inflammation of the pia mater from epidemic influence has already
been described, among the diseases of the brain, as meningitis cerebro-
spinalis. Besides this form, there are sporadic cases of inflammation
of the pia mater of traumatic origin, or due to inflammation of the
dura mater ; and, lastly, although rarely, cases that must be referred
to catching cold, or some other injurious influence acting on the body

ANATOMICAL APPEARANCES. — Inflammation of the dura mater is
never spread over large surfaces, but is always more or less circum-
scribed. At first the inflamed spot appears injected, infiltrated, and
relaxed ; later it becomes discolored, friable, and is occasionally cov
ered with purulent exudation. The results of pachymeningitis spinalis
are permanent thickening of the dura mater, and its adhesion to the
bone ; more rarely there is perforation of the dura mater by the pus col-
lected between it and the bone, and, as a consequence, diffuse meningitis.

MENINGITIS SPINALIS. 293

We must regard as remains of chronic inflammation :>f the arach-
uoid, milky opacities of that membrane, and cartilaginous or bony
plates, about the size of a millet-seed, which have a rough inner and
smooth outer surface, and which are generally very numerous, espe-
cially in the lower portion of the spinal cord.

Inflammation of the pia mater is usually very extensive. In the
acute form we find the pia mater injected, swollen, and relaxed. In
the subarachnoid space there is a copious, purulent, flocculent exuda-
tion, or else the pia mater and arachnoid are covered with membranous
deposits. The spinal medulla is usually pale and bloodless ; rarely it
is injected, relaxed, or softened. Most cases of so-called hydrorhachis
acquisita appear to be due to chronic inflammation of the pia mater.
We spoke of opacities and oedema of the cerebral membranes as very
frequent post-mortem appearances in topers, and referred them to a
chronic meningitis ; it is also probable that inflammatory disturbance
of nutrition of the meninges induces the collections of large amounts
of fluid in the subarachnoid space of the spine, when they do not de-
pend on general dropsy or atrophy of the spinal marrow (in which
case they are unimportant, and do not cause any symptoms). More-
over, it is difficult to decide, from the tension of the dura mater before
it is incised, or by estimating the amount of liquid that escapes after
it is incised, whether the amount of subarachnoid fluid is abnormally
increased. The more cloudy or bloody the escaping fluid, the more
probable it is that the hydrorhachis is due to chronic inflammation of
the meninges.

SYMPTOMS AND COURSE. — Inflammation of the dura mater is not
accompanied by very prominent or characteristic symptoms when it
does not lead to perforation, and, by escape of pus into the subarach-
noid space of the spine, induce diffuse meningitis. When patients,
who have had an injury of the back, or have caries of the spine, com-
plain of pain in the back, it is, difficult to decide whether it is due to
inflammation of the dura mater or of the bones and ligaments.

The symptoms of chronic inflammation of the arachnoid, and during
the formation of the little plates above described, are perfectly ob-
scure.

Acute inflammation of the pia mater is accompanied by symptoms
of severe irritation in the parts supplied by spinal nerves, which are
subsequently generally followed by symptoms of paralysis ; it is usu-
ally distinctly characterized and readily recognized by these symptoms
and their sequence. Occasionally after a chill there is fever, and the
patients complain of severe pain in the back, which becomes insup-
portable on motion, and usually on pressure over the spine. It is
oHinarilv accompanied by pains in the extremities. Both the pain in

294 DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES.

the back and the peripheral pain are to be referred to the irritation of
the sensory nerves within the spinal canal, from the inflammation of
their envelopes. Tcaic spasms in the muscles of the back and extremi-
ties, causing opisthotonos and contraction of the limbs, are just as
constant symptoms as tne morbid excitement of the sensory spinal
nerves. These tonic spasms, which, as is well known, we may induce
artificially in animals, by irritating the spinal medulla with the in-
duced current, usually remit and exacerbate. The exacerbations are
not, as in tetanus, induced by irritating any part of the skin, but by
movements of the spinal column, a fact which indicates that the tonic
spasms in meningitis spinalis are not due to increased reflex excitabil-
ity, but are direct results of irritation of the motor nerves from the
inflammation of then: envelopes. The rigidity and tension of the body,
which prevent the patient, who is not at first paralyzed, from moving,
are from time to time interrupted by convulsive starts. If the respira-
tory muscles participate in the tetanic rigidity, breathing becomes im-
possible, and the patient soon dies as a consequence. If the res-
piratory muscles remain unaffected, there is occasionally a gradual im-
provement ; but more frequently paraplegia is developed, or the fever
increases, and the patient succumbs to the paralysis, which advances
to the medulla oblongata, or to the exhaustion induced by the fever.

In the chronic form of inflammation of the pia mater, whose symp-
toms we described with those of hydrorhachis acquisita, since we con-
sider a distinction between them as impracticable, the pain in the back
is usually inconsiderable and is easily overlooked. On the other hand,
at the onset of the disease, the pain in the extremities is often such a
prominent symptom, that the affection is mistaken for peripheral rheu-
matism. The most important symptoms are those of paralysis, which,
commencing in the lower extremities, extend to the bladder, rectum,
and subsequently to the upper extremities. The paralysis is usually
incomplete at first, and only gradually increases to complete para-
plegia ; along with it there is usually a feeling of formication and fur-
riness in the lower extremities, the precursor of anaesthesia, which,
however, rarely attains a high grade. In some of these cases the
paraplegia develops quickly, occasionally in a few days after being
preceded only for a short time by pain, which is considered as rheu-
matic (hydrorhachis rheumatics). The paralysis then often remains
stationary at the height it has attained, or may entirely disappear. In
other cases the paraplegia develops more slowly and insidiously. In
such cases the hope of a permanent decrease of the paralysis is
slighter, although the disease almost always shows remarkable varia-
tions in its course. Most patients die sooner or later from extension
of the paralysis to the medulla oblongata, from bed-sores, or from

MYELITIS. 295

catarrh of the bladder. Paraplegia occurs in some other spinal dis«
eases as well as in chronic meningitis. The gait of the patient is not
characteristic, and does not differ from the gait in other forms of para-
plegia. The old belief that the symptoms of paralysis, due to a col-
lection of fluid in the spinal canal, grew worse when the body was
upright and less when it was horizontal, from the fluid being dis-
tributed more evenly, was purely theoretical and not derived from
direct observation. The most important points, in distinguishing
chronic meningitis and hydrorhachis acquisita from other diseases of
the spinal cord, are the symptoms of irritation, particularly the painful
sensations which precede the paralysis ; also the gradual advance of
the paralysis from below upward, which does not occur in the disease
limited to certain points, and particularly the varying course of the
disease, the exacerbations and remissions, which do not occur in dis-
eases destroying the spinal medulla.

TREATMENT. — Acute spinal meningitis requires energetic antiphlo-
gistic treatment, particularly the application of leeches and wet cups to
both sides of the spine. If the disease be of traumatic origin, we should
at the same time use cold to the back by means of an ice-bladder, or the
frozen compresses before mentioned. In very recent cases, as there is
danger in delay, and not much can be lost, we may employ the much-
lauded frictions with meiourial ointment, and give calomel internally.
If the acute stage passes off and the disease is protracted, we may
apply flying-blisters to both sides of the spine ; commencing with them
at the neck, we gradually descend to the sacrum, and then begin again
at the neck. In meningitis, flying-blisters appear to be more efficient
than moxae and the hot iron, which deserve the preference in diseases
of the vertebrae, and in inflammations of the spinal medulla limited to
certain points. In protracted cases, or at the commencement of those
running a chronic course, cold plunge-baths and douches, and particu-
larly continued warm baths, ane very serviceable. The reputation of
these remedies, in paraplegia generally, depends chiefly on their results
in chronic meningitis spinalis, which is the most amenable to treat-
ment of the diseases of the spinal medulla and membranes. Such
patients are also benefited by the bath-treatment at Wildbad and
other similar thermal springs.

CHAPTER 1 V.

INFLAMMATION OF THE SPINAL MAEEOW — MYELITIS.

IN the present chapter we discuss also softening and hardening of
the spinal medulla, myelomalacia, and myelosclerosis, since we shall
consider these degenerations (except where the softening is due tc
69

296 DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES.

haemorrhage and oedema, as already described) as results or fbrnjs of
myelitis until we shall have learned some other mode of origin for
them, as we have for the analogous changes in the brain.

ETIOLOGY. — Myelitis induces the same structural changes as en-
cephalitis does. In it there is no abundant interstitial exudation, but
the nerve-elements undergo inflammatory disturbances of nutrition, and
finally break down, just as the ganglion-cells and nerve-filaments of
the brain do in encephalitis.

Apart from the cases due to propagation of inflammation from the
vertebrae to the medulla, myelitis must be regarded as a rare disease.
But this extension occurs quite frequently. Most paraplegias which
come on during vertebral disease are not results of the curvature of
the spine, but of inflammation extending from the vertebrae to the
membranes, and thence to the medulla. This view is supported by
the fact that in vertebral disease there is frequently paralysis before
the spine is curved, and, on the other hand, great curvature often exists
for years without symptoms of paralysis, till these at last accompany
the deformity without any increase of the curvature, but usually after
j.ain in the back. More rarely, wounds and contusions of the spinal
column, or the development of syphilitic exostoses, induce myelitis.
Occasionally the disease develops about neoplasia and extravasations
of blood. Lastly, sexual excesses, excessive straining, catching cold,
suppression of the perspiration of the feet, etc., are given as causes of
myelitis. We do not know whether in such cases the disease is
really due to these causes or to other unknown influences. Patients
with paraplegia, besides their other misfortunes, are usually subjected
to the unfounded suspicion that they have brought on their disease by
dissolute habits.

ANATOMICAL APPEARANCES. — Myelitis is sometimes confined to
circumscribed spots, and then, usually starting from the gray sub-
stance, it attacks the whole thickness of the medulla ; sometimes, as
" central softening," it extends widely through the gray substance, and
then affects the white substance but little.

In the circumscribed spots we find the spinal medulla swollen in
recent cases. If we cut into it, a more or less consistent red pulp (red
softening) rises above the cut surface. In older cases, the color of
the pulpy soft spot becomes more brown or yellow (yellow softening),
from change of the haematin and fatty degeneration of the broken-down
nerve-elements. Far more rarely than in the brain, the inflamed spot
in the spinal medulla is converted into an abscess by the extensive
formation of pus-cells. The inflammation in the meninges usually ex-
tends beyond that of the medulla. From disintegration and reab-
sorpt:on of the disintegrated elements in circumscribed myelitis a

MYELITIS. 297

cavity, filled with serum and traversed by delicate connective tissue,
may be formed in the spinal medulla. In other cases there is in-
duration from connective-tissue proliferation. These sclerosed spots,
which are usually somewhat retracted and colored yellow by pigment,
form analogues to the yellow plates, which we found as remains of
peripheral encephalitis.

In the second (central) form of myelitis we find the medulla but
little swollen at first. On section, the contours of the gray substance
appear lost ; it is somewhat darker in color, reddened, and less con-
sistent. In oldes and typical cases the spinal medulla is decidedly
swollen, and in its centre we find a thin reddish, rusty, or yellow pulp.
In this form, also, the tissue-elements, which have broken down to a
fine detritus, are sometimes reabsorbed, and fluid exuded in their place,
so that, at last, in the axis of the spinal medulla, there is a cavity filled
with serum, and surrounded by delicate connective tissue, or traversed
by a framework of the same.

SYMPTOMS AND COURSE. — Since acute myelitis is always accom-
panied by meningitis, it is also accompanied by the symptoms of spinal
meningitis described in the last chapter, and we can only decide, from
certain modifications of the symptoms there described, that the me-
dulla itself, as well as the meninges, is inflamed. In the commence-
ment of the disease there is usually severe fever and more or less ex-
tensive pain in the back and extremities, tetanic rigidity of the mus-
cles of the back and nape of the neck, contractions of the extremities,
alternating with convulsive attacks, and where the respiratory muscles
participate in the tetanic tension there is great dyspnoea. The more
circumscribed the pain in the back, the more distinctly the peripheral
pains and spasms are limited to the parts supplied by nerves from a
certain portion of the medulla ; but especially the earlier and more
completely paraplegia follows these symptoms of irritation, the more
probable it becomes that the spinal medulla itself is inflamed. In very
malignant cases these symptoms may get the upper hand very quick-
ly, and, even in the first days of the disease, the patient may die from
disturbance of the respiration. In other cases the storm passes over,
but a paraplegia remains, which hardly ever recovers. Cases running
the above course are rare, and are almost always of traumatic origin,
or result from perforation of an abscess into the vertebral canal.

Chronic myelitis, also, is generally preceded by symptoms of irrita-
tion ; but, as the participation of the meninges in the tedious inflam-
mation of the spinal medulla is slighter and less extensive, they are
jsually limited to vague pains, formication, momentary twitching, or
painful contractions of the extremities. At the same time many pa-
tients complain of a dull pain in the part of the spine corresponding

298 DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES.

to the point of inflammation, which is increased by pressure on the
spinous processes, but not by movements of the spinal column, which
is an important point in the diagnosis between myelitis and meningitis
spinalis. This pain is sometimes accompanied by the feeling of a cord
tied firmly around the waist. In other cases there is no spontaneous
pain, but the corresponding vertebras are sensitive to pressure. If
we pass a sponge, previously dipped in hot water, along the spine, the
part at the seat of inflammation is generally more sensitive than else-
where. These symptoms, which are usually little thought of, are ac-
companied by a heaviness and helplessness in the tower part of the
body, which sooner or later become perfect paraplegia. The higher
up the seat of the inflammation, the more extensive the paralysis. If
the lumbar region be diseased, the lower extremities are paralyzed ;
if the thoracic region be affected, the sphincters participate in the pa-
ralysis ; if the cervical region suffer, the paralysis extends to the upper
extremities and corresponding respiratory muscles; with the para-
plegia there is generally also anaesthesia of the lower part of the
body, but this rarely extends to entire loss of sensitiveness to irrita-
tion. While the paraplegia and anaesthesia, slowly increasing, attain
a high grade, the affected muscles are still occasionally attacked by
spasmodic twitchings, and, if the anaesthesia be incomplete, by painful
contractions. This symptom is readily explained by the irritation in-
duced in the motor nerves of the extremities from the progress of the
inflammation, even after their connection with the central filaments is
lost. In cases where the connection between the motor nerves and
central filaments is completely broken, so that no muscular contrac-
tions are induced by the will, it is not at all impossible for an excite-
ment to pass from the sensory to the motor filaments, and for reflex
movements to occur. On the contrary, we often see the reflex excita-
bility increased in the parts of the spine below the interruption. This
pathological experience exactly corresponds with experiment. It is
well known that, in decapitated animals, reflex movements occur more
readily than in those whose motor nerves are under the influence of
the brain. In Greifswald I saw a young woman, who was paraplegic
as a result of vertebral disease, in whom the reflex symptoms in the
paralyzed part were so severe that the slightest touch on the skin of
the lower extremities caused their muscles on both sides to contract
spasmodically. It was very interesting to observe that, in this case,
when, contrary to all expectation, the paralysis improved, and the pa-
tient was able to make voluntary movements of her extremities, the
inclination to reflex symptoms entirely disappeared. The course and
results of chronic myelitis vary. The disease may run on for years ;
frequently it advances to a certain point, and remains stationary. If

GROWTHS IN THE SPINAL CANAL. 299

such patients belong to the educated classes, t or to the mechanics
proper, they often continue their occupation in spite of their para-
plegia. Those cases of paraplegia, where improvement and recovery
take place, as I before said, appear to belong to meningitis spinalis,
not to myelitis, as it is very improbable that nerve-elements, which have
been extensively destroyed, can be regenerated ; the favorable course
of incised wounds of the nerves does not disprove this assertion. In
chronic myelitis, death most frequently results after the patient has
been confined to bed a long while by the increasing paralysis. The
consequent bed-sores, or the cystitis caused by stagnation of the urine,
generally form the terminal symptoms, if the patient do not sooner die
of tuberculosis or intercurrent diseases.

TREATMENT. — The treatment of myelitis promises little. It is to
be conducted on the principles laid down for meningitis spinalis. Only,
instead of flying blisters, it is well to apply moxae or the hot iron near
the supposed seat of inflammation.

CHAPTER Y.

GROWTHS AND PARASITES OF THE SPINAL MEDULLA AND ITS
MEMBRANES.

EXCEPT the cartilaginous and bony plates of the arachnoid, which
we have already described, growths rarely occur in the spinal canal.
Carcinomata, which are usually of the medullary variety, either form
primarily in the spinal medulla or dura mater, or extend from the ver-
tebrae to the meninges and medulla. When they grow considerably,
they may at last fill the spinal canal, as the medulla atrophies from
pressure, or is transformed into cancer substance. Occasionally, after
destruction of the vertebrae, they have been seen to spread outwardly,
so as to lie just under the skin. Only a few cases of sarcoma and
glioma have been observed in the spinal canal. They almost always
started from the inner wall of the dura mater, and rarely attained any
considerable size. Tubercles in the medulla itself only occur when
lhere is advanced tuberculosis of other organs. Just as in the brain,
they usually form yellow nodules, the size of a pea or hazel-nut. They
are usually in the cervical or lumbar regions. Somewhat more fre-
quently we meet tuberculous degeneration of the dura mater, under
the form of so-called infiltrated tuberculosis, along with tuberculour
caries of the vertebrae. Cysticerci and echinococci have also beer
very rarely found in the spinal canal. The latter had either devel-
oped between the membranes, or an echinococcus sac, near the spinal

300 DISEASES OF THE SPINAL MARROW AN D ITS MEMBRANES.

canal, had penetrated ii.to the canal, after destroying the vertebrae or
their processes.

Tumors in the spinal canal interrupt the communication between
the brain and peripheral nerves; hence they cause paraplegia and
anaesthesia of the lower part of the body. According as they simply
induce atrophy of the spinal medulla by pressure, or cause inflamma-
tion of it by the irritation of the parts about them, the paraplegia and
anaesthesia are preceded by moderate or by very severe symptoms of
irritation. Of course, the seat of the growth modifies the extent of
the symptoms. The fact that, in tumors, there is usually less pain in
the back, but more peripheral neuralgia preceding the paralysis, arid
that the paralysis often did not begin at the same time on both sides,
but gradually extended from one side to the other, is not absolutely
decisive in the differential diagnosis between tumors of the spinal me-
dulla and chronic myelitis. We can only make an absolute diagnosis
in those cases where the cancer extends from the spinal marrow out*
ward. The development of carcinoma, tubercles, or parasites in other
organs, at least justifies the suspicion of a similar disease in the spinal
canal being the cause of a slowly-progressing paraplegia. Treatment
is entirely powerless against all tumors of the spinal medulla.

CHAPTEK VI.

HYDROEHACHIS CONGENITA SPINA BIFIDA.

HYDRORHACHIS congenita is divided into internal and external.
The former depends on a collection of serum in the dilated foetal cen-
tral canal. It causes atrophy or entire destruction of the spinal me-
dulla (amyelia) by pressure, or else splits it more or less completely.
Hydrorhachis externa consists in an abnormal collection of water in
the subarachnoid space. In both forms the vertebral canal may eithei
remain closed (hydrorhachis incolumis), or there is, at the same time,
a more or less extensive opening of the canal (hydrorhachis congenita
dehiscens).

In spina bifida we find a sac filled with serum, and covered by the
spinal membranes on the spinal column, which communicates with the
spinal canal, as a result of rudimentary formation of one or several
vertebral processes. Such tumors are usually located in the sacral 01
lumbar regions, more rarely in the cervical or dorsal. Their size varies
from that of a walnut to a child's head. The skin covering them i?
sometimes normal, sometimes thinned ; occasionally, at the summit, it
has entirely disappeared; then the sac is exposed, the place appears
excoriated, and is occasionally covered with pus and granulations.

HYDRORHACHIS CONGENITA- SPINA BIFIDA. 301

When the spina bifida results from hydrorhachis externa, the wa J of
the sac consists of the arachnoid and dura mater ; the latter is occa-
sionally thinned or perforated, and then the wall consists of the arach
noid alone. If, on the other hand, the spina bifida result from hydro-
rhachis interna, the pia mater also assists in the formation of the wall.
The contents of the sac are pure serum, of the same constitution as
the cerebro-spinal fluid. When the spina bifida has resulted from hy-
drorhachis interna, the spinal medulla is either altogether absent, 01
is undeveloped. On the other hand, if it be due to hydrorhachis ex-
terna, the medulla may be perfectly normal ; but occasionally, even in
such cases, it is defective (Forster).

The pathogeny and etiology of hydrorhachis congenita are obscure.
The collection of water is probably the primary disease, the incom-
plete formation of the spinal canal the secondary.

The symptoms of hydrorhachis, complicated with partial spina
bifida — of which alone we shall speak, as, in all cases combined with
great defect of the spinal medulla and extensive opening of the canal,
the children die before birth, or very soon after — consist chiefly of the
objective signs due to the above-described tumor. There is usually
distinct fluctuation in it. At its base the edges of the bone may be
felt. It increases on expiration, still more on crying and straining,
and diminishes on inspiration. Occasionally it may be replaced, but
attacks of loss of consciousness and general convulsions are readily in-
duced by these attempts. In some cases the innervation of the lower
extremities, bladder, and rectum, is normal ; in others, especially where
the lower part of the medulla is defective, or has disappeared, the
lower extremities, bladder, and rectum, are paralyzed. The tumor usu-
ally increases rapidly in size and tension soon after birth. If the skin
reddens, becomes thin, and finally perforated, death, preceded by con-
vulsions and subsequent sopor, generally quickly follows the perfora-
tion. But, even where perforation does not take place, most of the
children die early of general marasmus, and it is very exceptional for
patients with spina bifida to attain or pass the age of puberty.

Operative procedures are to be abstained from when complete pa-
ralysis and decided emaciation of the lower extremities indicate that
the spinal medulla is incompletely developed. In other cases we may
attempt careful compression, and, where this fails, proceed to the opera-
tions described for spina bifida in the text-books on surgery.

302 DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES.

CHAPTER VII.

CONSUMPTION OF THE SPINAL CORD — TABES DORSUALIS — ATAXIE LO-

COMOTRICE PROGRESSIVE (Duchenne) — GRAY "DEGENERATION 'OF

THE POSTERIOR COLUMNS OF THE SPINAL CORD (Leyderi) LOCO-
MOTOR ATAXY.

TABES dorsualis, which was discovered and described by Duchenne
as ataxie locomotrice progressive, long after it was generally known in
Germany from the classical description of Romberg, has recently ex-
cited much discussion. The views regarding the significance of the
symptoms especially vary. According to the plan of my book, I can
only criticise the views of others, so far as is necessary to support
my own. The following description is, in the main, the same as was
given in the dissertation of my former assistant, Dr. Ernst Spaeth,
which was written under my supervision, and which has not, by any
means, received the attention it deserved. (The dissertation of Dr.
Spaeth was published under the title of " Beitra'ge Zur Lehre von der
Tabes dorsualis," at Tubingen, 1864, by Aug. Ludwig.)1

ETIOLOGY. — In some few cases of decided tabes dorsualis, on
autopsy we find no palpable changes in the spinal medulla. This
" negative appearance " does not by any means prove that the spinal
medulla is normal, but only that its functions may be impaired by
molecular changes that escape observation, just as they are by the
coarser changes found in other cases. The latter consist in a peculiar
degeneration and atrophy affecting particularly the posterior columns
and the posterior roots, but occasionally the gray substance also and
other columns. In some cases there is no doubt that the degeneration
in question is the result of inflammation of the spinal medulla, but
in other cases no inflammatory origin can be made out.

The predisposition to tabes dorsualis is occasionally hereditary, as
is shown by a number of cases, where several brothers and sisters were
attacked by the disease. On the other hand, I only know of two
cases where it was inherited, that is, where the parents of the patient
had tabes dorsualis. Children are not inclined to tabes, persons of
mature age are most so, while in the aged the tendency almost disap-
pears. Men are far more disposed to it than women.

The exciting causes are almost always said to be — 1. Venereal
excess. The great physiologist Johannes Mttller, usually very careful
and discreet in his assertions, says directly that tabes dorsualis comes
only from venereal excess. Besides then* other sufferings and mis-
fortunes, these poor patients are made to bear the accusation which in
many cases at least is unjust, that they have themselves to blame for

LOCOMOTOR ATAXY. 303

their disease. There is no doubt that many of the patients attacked
have been addicted to excess in venery, but there is just as little doubt
that many patients with tabes dorsualis have led an exemplary life, while
others who have been unbounded in their excesses escape the disease.

From the great frequency of lewd habits, and from the difficulty of
deciding the amount in any given case, I consider the dependence of
tabes on venereal excess as not yet proved. 2. On the other hand,
there appears to me no doubt of the influence of catching cold and
bodily fatigue, especially when they act together, in inducing tabes
dorsualis. The disease occurs with remarkable frequency among those
who, wearied and heated by severe marches or other bodily exertions,
have stretched themselves on the damp earth to rest. 3. Many patients
ascribe their disease to suppressed perspiration of the feet. We can-
not generally lay much weight on these accounts, for the laity give
suppression of habitual perspiration as a very common cause of dis-
ease. Doubtless in most cases where the occurrence of a disease is
accompanied by the absence of habitual perspiration of the feet, it is
because the latter has ceased with the appearance of the disease. But
I think it is going. too far to deny the possibility of a genetic connec-
tion between the arrest of perspiration of the feet and tabes dorsualis.
At all events, many patients with tabes have previously suffered much
from, perspiring feet. 4. Lastly, the disease appears occasionally to
be of syphilitic origin, a supposition chiefly supported by the fact that
some tabes patients who had previously suffered from syphilis were
benefited by an antisyphilitic treatment.

ANATOMICAL APPEARANCES. — The usual appearance of the spinal
medulla and its membranes, in decided cases of tabes dorsualis, is as
follows: The dura mater is either unchanged or its posterior half is
slightly thickened, the arachnoid is moderately opaque, if the medulla
be atrophied the fluid in the subarachnoid space is increased; on the
posterior surface the pia mater is constantly thickened, clouded, and
more or less adherent to the posterior columns.

In the early stages, where no decrease of volume of the spinal medulla
is as yet observable, there is a peculiar degeneration of the posterior
columns ; this always begins in the immediate vicinity of the posterior
fissure, close under the pia mater, and thence spreads toward the sides
and the gray commissure ; the diseased part always retains the shape
of a wedge, with the base directed toward the pia mater. The degen-
eration consists in a transformation of the white substance of the pos-
terior columns into a gray or grayish-red, half-translucent, soft mass.
On microscopical examination of the latter we only find a few nerve-
filaments, partly in various stages of atrophy ; most of them have com-
pletely disappeared, and between the atrophied cells there is a richly

304 DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES.

nucleated connective-tissue substance, corresponding to the ordinary
neuroglia and resulting from its proliferation, in which we find only a
few granular cells, molecular fatty masses, and numerous corpora
amylacea. The vessels passing out from the pia mater have a greatly-
thickened adventitia, and thus cause the firm adherence of the pia
mater to the surface of the medulla. Corresponding to the extent of
the degeneration in the posterior columns, the posterior roots of the
spinal nerves are atrophied. They resemble thin, vascular, translucent
connective-tissue cords, far more than they do nerves with medulla.
This is especially true of the posterior roots of the cauda equina. The
anterior roots of all the nerves, cauda equina included, are normal, cor-
responding to the general nutritive condition of the spinal medulla.

In the later stages the degenerated gray parts of the medulla
shrink greatly. They become a hard tissue, and are less transparent.
If the degeneration be limited to the posterior columns, the medulla
acquires a cylindrical form. The points of exit of the posterior roots
are approximated. If, on the other hand, the degeneration extend to
the posterior parts of the lateral columns, the medulla shrinks more in
an antero-posterior direction, and we may readily receive the impres-
sion that it has become broader. The neuroglia, which in the early
stages of the degeneration corresponds exactly with the normal neu-
roglia, during the shrinking acquires the appearance of a fine filament-
ary substance. A secondary atrophy and induration succeed the
growth of the neuroglia.2

SYMPTOMS AND COURSE. — Although Duchenne is to be reproached
for ignorance of Momberg's works, or else for ignoring them, when he
published his first writings on ataxie locomotrice progressive, we cannot
deny that he has done much for the correct interpretation of the symp-
toms of tabes dorsualis. He originated the doctrine, at present almost
generally adopted, that in tabes there is not paralysis, but disturbed
coordination of muscular movements. To use our muscles properly, it
is not enough that we can contract each muscle, we must also be able
to cause a harmonious action of all the muscles participating in any
motion. Acts apparently the most simple fail or are clumsily performed,
if any of the muscles participating in them be contracted too much or
too little, too quickly or too slowly ; or if the antagonists be not re-
laxed just enough or exactly at the right moment. This power of
causing the muscles to act properly together, or, as it is usually called,
the power of coordination, is much impaired in patients with tabes ;
and the symptoms resulting from this anomaly are peculiarly charac-
teristic of the disease. But, along with this, there is almost always a
decided diminution of the cutaneous and muscular sensibility, which
Romberg has excellently described : "The floor is no longer distinct! v

LOCOMOTOR ATAXY. 305

felt ; the foot seems to rest on wool, soft sand, or on a bladder filled
with water. The horseman no longer feels the resistance of the stir-
rup, and has the strap shortened .... If the patient do not see his
movements, they will be still more uncertain ; if, while erect, he closes
his eyes, he immediately begins to sway about and totter. If his eyes
be closed while in the horizontal position, he cannot tell the location
of his limbs ; he cannot say whether the right foot be crossed over the
left, or the reverse."

If, as some celebrated authorities assert, the posterior spinal col-
umns have the function of coordinating the movements, the anatomical
changes found on autopsy of tabes patients fully explain the symptoms
observed during life. We have said that the degeneration and atrophy
of the spinal cord constantly start from the posterior columns, and
that the posterior sensory roots almost always participate in the de-
generation. Leyden, who does not believe in a peculiar power gov-
erning the coordination of movement and its location in the posterior
spinal columns, has advanced a theory for the explanation of the disturb-
ances of coordination in tabes dorsualis, which, at first sight, is very enti-
cing. ' He explains the loss of power of coordination as due solely to
the diminished cutaneous and muscular sensibility. We must, indeed,
admit that Longet is correct in saying that a person, who has lost the
perception of his actions, who cannot judge of the position of his
limbs, who does not even know whether they are present, and, lastly,
who does not feel the floor under his feet, cannot walk erect, preserve
his equilibrium, and move his limbs with certainty and accordance.
Moreover, the peculiarities of the anomalies of movement observed in
tabes patients, the energetic lifting of the foot and its passive fall
when walking, the spasmodic, uncertain movements, their shooting
beyond the mark, all give the impression that the patient is so awk-
ward because he does not know what he has done till he has done too
much. Lastly, the fact that the helplessness of the patients is greatly
increased when they close the eyes, and cannot control their move-
ments by the sight, is favorable to the view that the anomalies of
movement in tabes dorsualis result from diminution of the cutaneous
and muscular sensibility. Nevertheless, Leyderfs theory is false. Its
correctness is opposed by the following facts : first, that in many pa-
tients the disturbances of sensibility are in marked disproportion to
the impairment of coordination of movement ; second, that in persona
whose cutaneous and muscular sensibility is far more diminished than
is the case in any tabes patients, there is often no indication of dis-
turbance of coordination. In Spaeth's work there is a full histcry of a
peasant, from Wurmlingen, who is known to all my students, as I
show him in my clinic almost every half year. This interesting pa-

306 DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES.

tient has a very marked and extensive anaesthesia of the skin and
muscles. He is insensible to the severest injuries. He does not know
if he bathes in warm or cold water. On loading his extremities with
a weight of twenty-five pounds, he perceives no difference of pressure.
On being requested to estimate weights, by lifting them, he cannot
distinguish between weights of one pound and a hundred pounds.
When his eyes are closed, he cannot tell whether his limbs are flexed
or straightened to the greatest possible extent by strong electric cur-
rents. When standing erect or sitting up, if he closes the eyes he
immediately falls. He perceives the resistance of his bed so little
that, when the light is extinguished at night, he feels as if he were
swimming in the air. But this patient has no marked disturbance of
coOrdinative power ; he does not in the least remind us of a tabes pa-
tient ; as long as it is light he walks very well, although carefully ; he
travels on foot, without a stick, the mile between Wurmlingen and Tu-
bingen. A single such case is enough to prove that the disturbance of
coordination of the tabes patient does not depend, certainly not solely,
on the diminished sensibility, but that it exists along with the latter.

In many cases the above symptoms are accompanied by disturb-
ances of the excretion of urine. Most patients are obliged to attend
to the call to urinate as quickly as possible, as they can only stand it
a few moments, and hence, when their means allow it, they buy uri-
nals, which they wear in their trousers during the day. I think this
symptom arises because the patient does not perceive the fulness of
the bladder, and the desire to urinate does not occur till a few drops
are pressed out of the bladder into the urethra. Far more rarely than
this incomplete enuresis we find retention of urine, and it becomes
necessary to draw it off with the catheter. In such cases there is
probably paralysis of the bladder, from its having been distended too
much or too long.

It is asserted that, at the commencement of the disease, sexual de-
sire is usually increased but the energy and duration of the erections
lessened, as well as that, in the later stages, the virile power is en-
tirely lost. The latter assertion alone is certain.

We must also mention the paresis of the oculo-motor and ab-
ducens, which occasionally occurs in tabes, which is shown by diplopia,
more rarely by strabismus and ptosis of the upper lid ; and, lastly, the
amaurosis and psychical disturbances which are sometimes met with.
There is no doubt that these symptoms are due to the disease advan-
cing to the cerebral filaments, but hitherto autopsy has failed to show
what course this advance takes. Atrophy of the optic nerve was only
"ound in some of the few cases where there was disturbance of vision ;
but even here the atrophy only extended to the corpora quadrigemina,
and could not be followed further.

LOCOMOTOR ATAXY. 307

After having described and analyzed the most important symptoms,
L shall attempt to give a general description of tabes dorsualis, and pic-
ture the most frequent course of the disease as briefly as possible.

In many patients, the characteristic disturbances of coordination,
and the decrease of cutaneous and muscular sensibility are preceded
for a long time, even for years, by attacks of severe tearing pain in
the lower half of the trunk, and in the lower extremities ; these are
generally considered as rheumatic. In other patients, on the contrary,
the first complaints are that the lower extremities become fatigued
very easily and very soon. Persons accustomed to walking notice that
they tire sooner and more easily than formerly. These symptoms,
which are not usually very suspicious, either to the patient or physi-
cian, may precede the decided symptoms of tabes for a long time.
But this difference in the initial symptoms is not so marked or decided
as it seems to be on superficial examination. The attacks of pain are
unmistakably neuralgic, and depend on morbid excitement of the pos-
terior roots, while the tendency to fatigue depends on their hyperses-
thesia — that is, on their morbidly-increased excitability. Under physi-
ological circumstances, the feeling of fatigue depends on the amount
of work done by the muscles. The state of the muscles resulting from
overwork is perceived through the sensory muscular nerves. If the
excitability of the posterior roots be increased, slight exertion of the
muscles will produce the same effect, which would otherwise only be
induced by far greater exertion. Hence the tendency to fatigue in
tabes is perfectly analogous to the increased sensitiveness, at the com-
mencement of certain brain-diseases, to light, sound, and other irrita-
tions, which are not generally unpleasant. The tearing-pain and ten-
dency to fatigue in the lower extremities are not recognized to be
serious and threatening until they are accompanied by other disturb-
ances of sensibility, such as formication, a feeling of furriness, numb-
ness, and the sensation of a ligature around the abdomen. Gradually
the gait becomes uncertain and awkward ; at first this is so only in the
dark, so that the patients prefer remaining at home in the evening ;
afterward it is the same in day-time. The feet are lifted too high, and
thrown forward and outward, and then brought heavily down on the
floor. If the patient closes his eyes while standing erect, he begins tc
totter, and, unless supported, falls to the ground. And, even at this
time, he must usually be on his guard when the desire to urinate seizes
him, so that he may reach a convenient place in season. After a time,
walking becomes impossible, even with the aid of a stick or, crutches,
although, when the body is fixed, the patient can generally make un-
complicated movements of the extremities with nearly normal force.
The same uncertainty and awkwardness come on in the upper ex-

308 DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES.

tremities much later than in the lower. Then, when eating or drink-
ing, the patients shake out the contents of the spoon or glass, they
can no longer dress without aid, especially the buttons trouble them ;
finally, they cannot write, knit, or do any other work. The enuresis
now often attswns such a grade that the patient voids his urine in bed.
If, in consequence of this, a constant moisture of the parts be added to
the patient's indistinct perception of the irregularities of the bed and
his helplessness in changing his position, we may readily have bed-sores.

The course of the disease is always tedious. We see most patients
drag on for years in a miserable state, the objects of pity, which is not
unfrequently pharisaical. Occasionally the disease remains stationary ;
in other cases it appears to improve temporarily. Perfect cures are
certainly very rare.

Nutrition is frequently not impaired till late ; the lower extremities,
the nates, and muscles of the back emaciate first, so that the spinous
processes project. It is not till toward the end of the disease that the
emaciation extends to the rest of the body. Death generally results
at last from the increase of the bed-sores, from severe cystitis, from
pulmonary consumption, or from intercurrent diseases.8

TREATMENT. — Romberg's assertion, that there is no hope of cure
for a tabes patient, that they are all doomed, contrasts strongly with
the views of Memak, as published by Cyon, according to which the
former is said to claim that his treatment was successful in the ma-
jority of cases, and that, therefore, he cannot be reproached for not
having autopsies on his cases. The truth probably lies between the
two. Of late, few authorities regard the treatment of tabes so hope-
less as Romberg. But very few would agree with Remdk, Benedikt,
and others, in saying that tabes is a disease where very favorable re-
sults can be attained by treatment.

We may hope for the best results when there is a suspicion that
the disease is of syphilitic origin. In such cases an antisyphilitic treat-
ment should be instituted, on the plan to be described hereafter.

The more probable it is that the disease has resulted from taking
cold, the more acute its occurrence, the more severe the pains in the
lower extremities which preceded the symptoms of disturbance of coor-
dination and diminished sensibility, the more probable is it that the
disease is of inflammatory or congestive origin, and the stronger the
indications to begin the treatment with the local abstraction of blood
by leeches, and derivation to the skin by blisters along the spine.
Subsequently we may order for such patients the waters of Wildbad,
Gastein, Ragaz, Pf&ffers, TOpntz, etc. There is no doubt that tabes
patients have been decidedly benefited by the treatment at these
olaces. On the other hand, I must warn against the careless emplov

LOCOMOTOR ATAXY. 309

merit of the cold-water treatment, which, especially in the form of cold
douches to the back, has not come up to the expectations entertained
of it at the time it was fashionable, and the water-cure establishments
are now rarely patronized by tabes patients, who, for a time, all rushed
to them for treatment. In very recent cases only, sweating in moist
sloths and a subsequent short bath appear to be beneficial.

If it be not a favorable time of year to send the patient to Wild-
bad, etc., or if these mineral waters do not seem indicated, or if they
nave done no good, we should try the administration of nitrate of
silver as recommended by Wunderlich. Nitrate of silver has long
held the reputation of being one of the most effective nervines ; and it
is not at all impossible or improbable that it exercises a modifying
influence on the nutrition of the nervous system; it is not these
reasons, however, but the fact that reliable observers have found some
benefit from the employment of the remedy in tabes dorsualis, that
induce me to use it in most cases of the disease. My experience of the
efficacy of the remedy, which I have given in a large number of cases,
in doses gradually increasing to half a grain daily as advised by
Wurtderlich, has not been particularly favorable. It is true that most
of my patients at the clinic have praised their state a time after using
the remedy, but I suspect that many did so to induce me to keep them
longer at the hospital. In other cases, the patients actually seemed
to move forward more nimbly; but here also it was possible that
either greater confidence or increased attention of the patient, with
the view of showing me improvement, had a favorable effect on the
attempts to walk. I shall continue for a time to prescribe nitrate of
silver to my tabes patients.

My experience of the constant current of electricity is about the
same as it is in regard to nitrate of silver. I have no reason to doubt
that Remak, Benedikt, and others, have had some success with the
constant current which I consider to be a very active remedy, but thus
far I cannot claim any success from its use in tabes, although I have
had an excellent apparatus in my clinic these four years, and have
treated all my tabes cases with it in the manner advised by Remdk
This want of success will not prevent my continuing the use of galvan
ism in tabes for a time ; and, instead of letting the current act on the
spinal column as hitherto, I shall try the current through the spinal
nerves, as advised by Benedikt, not because I attach much importance
to the theories and the indications he gives for the treatment of, dif-
ferent diseases, with the current through the roots of the spinal nerves
(Ruckenmarks-Wurzelstr5men), through the spinal nerves (Rucken-
marks-NervenstrOmen), etc., but simply because I have no reason to
ioubt what he says on the subject.

310 DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES.
ADDITIONS TO THE REVISED EDITION OF 1880.

SECTION II. DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES.

1.— P. 302.

Some diseases may affect the entire cross-section of the spine
unequally, while others are limited to certain parts. In the latter
only certain physiological functions are affected, so that their symp-
toms must differ. Infantile spinal paralysis and progressive mus-
cular atrophy are affections of certain parts of the anterior portion
of the medulla spinalis, while in locomotor ataxy the posterior .part
is affected.

2.— P. 304.

It is doubtful whether the disease starts from the nerve-fila-
ments or from the intervening substance ; the fact of the process
being generally limited to the posterior columns favors the former
view. The vessels are sometimes unchanged, at others their adven-
titia is thickened and fatty, their calibre diminished or closed.

Some observers think the affection is due to disease of certain
limited portions of the posterior roots — two lateral, thin, gray striae,
corresponding to the intermedullary extensions which Kolliker terms
inner root-filaments. According to Char cot, sclerosis of these lat-
eral striae is the only constant anatomical change. The sclerosis
may spread from the posterior columns to other parts, as the poste-
rior nerve-roots, or even to different nerves, as the sciatic, crural,
and brachial, but especially to some cerebral nerves, as the optic,
oculo-motor, trochlear, and hypoglossal. It may also extend to the
posterior horns of the gray substance, and to the lateral columns,
or to the gray anterior horns ; in which cases, of course, the symp-
toms will be varied. The disease may begin at any point of the
spine, but generally spreads in the long axis ; usually it begins in
the lumbo-dorsal region, and spreads along the lateral striae of the
posterior columns to the cervical region, or even to the cerebral
nerves and brain, as is shown by psychical changes and depression.
On the other hand, primary cerebral disease may be followed by
tabes, and it has been asserted that the progressive paralysis of the
insane sometimes chiefly affects the posterior roots.

3.— P. 308.

In many tabes patients, sometimes as the first symptom, there is
impairment of vision, beginning as concentric limitation of the vis-
ual field in one eye, or sometimes as achromatopsia, gradually grow-

ADDITIONS TO THE REVISED EDITION OF 1880. 3H

ing worse and ending in double amaurosis, with gray degeneration
of the optic nerve. Other cerebral nerves are more rarely affected,
but there may be anaesthesia of the trigeminus, impairment of hear-
ing, deglutition, or speech, and periodical rapidity, irregularity, or
dicrotism of pulse due to the vagus. Implication of the sympa-
thetic is often shown by inequality of the pupils. On the side of
the contracted pupil there may be signs of vaso-motor paralysis,
such as red cheeks, chemosis, and increased temperature. Among the
early symptoms there may be a painless swelling of the joints, most
frequently of the knee, then in the shoulder, elbow, etc. Charcot
regards this as allied to arthritis deformans, and refers it to impli-
cation of the gray anterior horns. In a case recently observed, the
anterior horns were intact, but the spinal ganglia were very large
and perceptibly changed.

The neuralgias are due to inflammatory irritation of the poste-
rior roots of the nerves ; there may be formication, tearing, con-
tracting, and especially shooting pains, which may recur weekly or
monthly, and are worse at night ; they are rarely entirely absent.
The period of pain varies in duration ; in incomplete cases the latter
characteristic symptoms may never occur. As the disease pro-
gresses, the pains, which might readily be regarded as rheumatic or
neuralgic, spread from the legs to the body, and the sensation of a
girdle about the body is noticed ; there may be painful contraction
of the rectum or bladder, or incomplete erections and pollutions.
Later there is neuralgia of other nerves in upper parts of the body,
arms, etc.; but there is rarely spinal pain or tenderness. An occa-
sional early symptom is an attack of gastralgia and obstinate vomit-
ing, lasting several days ; these attacks often accompany the shoot-
ing pains, and seem due to irritation of the sensitive gastric fila-
ments of the vagus.

Perfect cure of tabes is only possible when the sclerosis is but
slightly advanced, and even then is probably very rare ; though
Benedict asserts the contrary, claiming that mild cases are often
mistaken for other diseases. Incomplete cures are more common,
the progress of the symptoms being arrested and life made endur-
able. But most cases progress, though some symptoms improve
temporarily. As the disease advances, the upper limbs may be af-
fected ; formication and neuralgic pains in the arms and fingers
precede Uncertainty of the grasp in writing, etc., till the patient
becomes entirely helpless. Exceptionally, the arms may be first
affected ; and when the prominent symptoms indicate the part
affected to be high in the spine or in the cerebral nerves, a cer-
vical or basilar tabes has been spoken of ; but the symptoms are
70

312 DISEASES OF THE SPINAL MARROW AND ITS MEMBRANES.

usually so combined that these regional forms cannot be distin-
guished.

Although one of the most tedious of diseases, tabes usually
shortens life. It may continue five or ten years, or longer ; but the
symptoms, especially the motor disturbances, may progress rapidly
and death occur early. As the disease advances, the patient may
attain a pitiable condition ; the nutrition of the body, which has
been good, may suffer, the legs emaciate, the feet become oedema-
tous ; the previous irritable weakness of the sexual function gives
way to entire impotence ; urination and defecation are impaired,
sensibility blunted, and vision lost ; more especially the power of
motion is lost from ataxia and paraplegia. Death is rarely directly
due to paralysis of respiratory muscles, and not so often to bed-sores
and purulent cystitis as it is in spinal paralysis ; but more frequent-
ly it is due to consumption, pneumonia, bronchitis, etc.

In well-developed typical cases diagnosis is easy. The periodi-
cal lancinating pains in the legs or arms, quick fatigue, gastralgia,
paralysis of ocular muscles, disturbance of vision, and ophthalmo-
scopic appearances, and especially the ataxia of motion, give the
disease a decided character. Diseases of the cerebellum also induce
an uncertain tottering gait when the eyes are closed, and dizziness ;
but there are usually other symptoms, occipital pain, occasional
vomiting, epileptic or tonic spasms, hemiplegia, etc. ; while the lan-
cinating pains, ready fatigue, girdle feeling, and anaesthesia are ab-
sent. Amblyopia and amaurosis occur from tumors of the brain
as well as from tabes ; but the ophthalmoscope may show whether
the papilla indicates tabes or the optic neuritis and choked disk due
to tumors. Electro-muscular contractility gives no certainty to
diagnosis, as the excitability of the muscles may be increased, nor-
mal, or lessened ; although in the first stages it is generally in-
creased, while in other spinal diseases it is apt to be lessened very
early. When incompletely developed, tabes may be mistaken for
neuralgic, rheumatic, hypochondriac, hysterical, or syphilitic affec-
tions. Errors may also occur where the posterior columns are im-
plicated in diseases of other parts of the spinal cord.

SECTION III.

DISEASES OF THE PERIPHERAL NERVES.

CHAPTEK I.

INFLAMMATION OP THE NERVES — NEUBITTS.

ETIOLOGY. — Inflammatory disturbances of nutrition rarely occur in
(lie peripheral nerves. They sometimes affect the nerve-filaments,
sometimes the neurilemma. The first form ranks among parenchyma-
tous inflammations, and ends in the destruction of the nerve-medulla
to a fine granular, fatty detritus. In the second form there is an inter-
stitial exudation, and a proliferation of connective tissue, by which the
neurilemma is decidedly thickened. There is rarely any formation of
pus. "We shall hereafter speak of the diffuse hyperaemia of the neu-
rilemma of a wounded nerve, without any perceptible exudation,
observed in some cases of tetanus.

Among the exciting causes of neuritis, the most important are
injuries of the nerves, particularly punctured wounds, contusions, or
lacerations. In other cases neuritis is due to the propagation of in-
flammation from neighboring organs. Lastly, some few cases of spon-
taneous or so-called rheumatic inflammation are said to have been
observed.

ANATOMICAL APPEARANCES. — Inflammation of the neurilemma is
characterized by a more or less intense redness, which sometimes de-
pends on overfulness of the blood-vessels, sometimes on the presence
of small extravasations. The neurilemma also appears relaxed, swol-
len, and infiltrated. If the neuritis has taken on an acute course, and
led to suppuration, there is usually more or less pus in the loose con-
nective tissue around the nerve. When the disease is chronic, the
neurilemma usually appears much thickened, hard, and firmly adherent
to the surrounding parts.

Inflammation of the nerve-substance is shown by its redness, swell-
ng, and relaxation ; in severe cases it is transformed to a red pulp

314: DISEASES OF THE PERIPHERAL NERVES.

The neurilemma is always affected at the same time, and consequently
we find the different bundles of nerve-filaments separated by the swell-
ing of their envelopes and by interstitial exudation. Occasionally,
after reabsorption of the disintegrated medulla of an inflamed nerve,
only a simple cord of connective tissue is left.

SYMPTOMS AND COURSE. — The symptoms of neuritis cannot be
clearly distinguished from those of neuralgia, or rather neuritis is one
of the various causes of neuralgia. The most important symptom of
neuritis is pain in the course of the inflamed nerve, extending to its
peripheral terminations. The pain is increased by pressure on the
nerve, and its exacerbations and remissions are usually less distinct,
and the paroxysms and intervals particularly are usually less marked
than in other forms of neuralgia. While this pain lasts, the sense of
touch is usually lost in the parts supplied by the inflamed nerve ; and
this symptom may be easily explained, although it seems paradoxical
on superficial examination. The morbid excitement of the trunk of
the nerve, caused by the inflammation in the medulla or neurilemma,
is conducted to the brain, and excites the sensation of severe pain ;
but the inflamed part of the nerve has become a bad conductor ; hence
irritation of its peripheral termination and the papillae of touch are
conducted to the brain either incompletely or not at all, and cause
either no sensation or an indistinct one. At first, at the correspond-
ing portion of the periphery, the patient has a feeling of numbness ;
subsequently, if resolution of the inflammation do not take place, there
is complete anaesthesia to external injuries, while the pain continues.
If the inflamed nerve contain motor fibres, the pain is accompanied by
twitching and contraction, while the patient's power of voluntarily
contracting the muscles is much affected or entirely lost. This also
depends on the morbid excitability of the motor nerves being increased
by the inflammation while their conducting power is lost. If the in-
flamed nerve lie near the surface, it may occasionally be felt as a hard
cord ; and we often find the skin covering it slightly reddened and
O3dematous. In most cases there is no fever, unless there be some
other inflammation besides the neuritis.

The course of neuritis may be either acute or chronic. The more
acute it is, the sooner anaesthesia and paralysis follow the neuralgia
and contractions, and the more probable it is that these symptoms
were caused by an acute neuritis that has destroyed the nerve. Even
after resolution of the inflammation, the nerve usually remains to some
extent incapable of function for a long time. When the neuritis runs
a chronic course, if the nerve be destroyed, anaesthesia and paralysis
occur in the same way ; but, if the nerve be preserved and is only sub-
jected to pressure from the swollen and thickened neurilemma, the

NEUROMA.

315

patients suffer for years from neuralgic pain or spasmodic attacks in
the parts supplied by the inflamed nerve.

TREATMENT. — In the first place the causal indications must be ful-
filled ; with this view foreign bodies driven into the nerve must be re-
moved, and inflammations in its vicinity must be carefully treated.
Leeches, or wet cups may also be applied along the course of the
nerve ; cold applications may be made, or, if the disease continue long,
mercurial ointment may be rubbed in if the nerve lie near the surface.
Chronic neuritis may be treated by derivatives, such as blisters, and,
hi obstinate cases, moxae, and superficial linear cauterizations of the
skin with hot iron. If the disease has run its course, and the nerve has
not been destroyed, but its functional activity is affected, we may use
electricity to restore its normal excitability, if possible, by methodical
excitement of the nerve.

CHAPTER II.

NEUROMA.

ETIOLOGY. — Strictly speaking, we can only designate as neuromata
those tumors originating from nerves which are chiefly, or at least to a
great extent, made up of nervous elements. The tumors, not unfre-
quently occurring on nerves, which have developed without hyperpla-
sia of the nerve-elements, and in which consequently the number of
nerve-elements has remained the same or even actually diminished,
are not neuromata, but, according to their structure, come under the
head of carcinoma, fibroma, or glioma, etc. ( Virchow). Neuromata
which consist chiefly of nerve-filaments, or where these exceed the
intercellular substance in amount, are termed pure neuromata, in con-
tradistinction to those where the intercellular substance is in excess ;
this division, however, has more pathological-anatomical than clinical
interest.

The etiology of neuromata is obscure. Occasionally they may be
referred to a congenital or hereditary predisposition. Such cases, as
well as the frequent occurrence of numerous neuromata on different
aerves, and their repeated recurrence after removal, speak for the con-
stitutional orgin of some neuromata. Others unmistakably result
from injury of the affected nerve, by a puncture, contusion, etc. In
most cases no cause can be discovered.

ANATOMICAL APPEARANCES. — Neuromata generally form hard, elas-
tic tumors, from the size of a hemp-seed to that of a fist, or larger ;
they are usually round or oval ; in the latter case their long axis lies

316 DISEASES OF THE PERIPHERAL NERVES.

in the course of the nerve. Virchow divides them into fibro-, glio,
and myxo-neuromata, according as the interstitial tissue between the
nerve-filaments resembles fibrous tissue, neuroglia, or mucous tissue.
They sometimes contain small cavities filled with fluid. Neuromata
are occasionally seated on the nerve ; again they originate from its
interior, and contain more or less nerve-filaments in proportion to the
distance of their origin from the centre of the nerve. The most fre-
quent seat of neuromata is the spinal nerves ; but there are examples
of their occurrence on the sympathetic and cerebral nerves, particularly
on the auditory. Usually there is only one neuroma, and its size is
not at all in proportion to that of the nerve from which it originates.
In other cases there are several neuromata on the same nerve, in still
others there are great numbers, originating from the most varied
nerves. Under the head of neuromata appear also to belong the pain-
ful tumors, about the size of a pea or bean, readily moved about under
the skin, which are also called tubercula dolorosa, painful tubercle, or
neuromantia ; although their connection with a cutaneous nerve or the
presence of nerve-elements in them cannot always be proved.

SYMPTOMS AND COURSE. — Peripheral neuromata, which alone can
be recognized, show themselves as a more or less elastic tumor, seated
in the course of one of the cutaneous nerves, which is only movable
laterally, and is covered by the unaltered skin. Large multiple neu-
romata occasionally cause neither pain nor other inconvenience, so that
their diagnosis can only be made by the apparent connection between
the tumors and a cutaneous nerve. The case is different with the
customary single small neuroma. It is often accompanied by ex-
cruciating pain extending along the course of the nerve and to its
peripheral termination. This is not usually continuous, but has par-
oxysms with intervals of ease. Slight pressure on the tumor, often
even the contact and rubbing of the clothes, increases the pain in the
tumor to an unbearable extent. Severe paroxysms of pain are also
induced by movement, catching cold, etc. In neuroma, as well as in
neuritis, the conducting power of the nerve may be impaired, so that,
besides the pain, there may be a feeling of numbness or even of more
or less complete anaesthesia of the skin supplied by the nerve affected.
Rarely, when the motor filaments are affected, there are twitchings
and contractions and subsequently paralysis. The extension of the
pain from the diseased nerve to other trunks, as well as the increased
disturbance of innervation that occasionally complicates the local
symptoms, is common to neuroma, neuritis, and to neuralgias of the
most varied origin ; we shall therefore defer their discussion to the
next chapter. Neuromata generally grow slowly, and, after attaining
a certain size, often remain stationary. They are among the most

NEURALGIA. 317

painful of diseases, and may wear the patient out by the loss of sleep
and restlessness induced by the pain.

TREATMENT. — We can never cause resolution of neuroma. The
only true and trustworthy remedy is removal by the knife.

CHAPTER III.

NEURALGIA.

As we have thus far made use of the anatomical changes lying at
the root of the disease as grounds of distinction, it is inconsistent to
treat of neuralgia as a disease, and to class it with neuritis and neu-
roma. Neuralgia is a combination of symptoms, which does not de-
pend on constant anatomical changes. Since no anatomical changes
can be discovered in many cases of neuralgia, and since, in many cases,
where changes have occurred, they alone are not enough to explain
the neuralgia, we seem driven to the above-mentioned inconsistency,
and we shall be unable to escape it in other morbid processes of the
nervous system, which are not due to certain anatomical causes.

ETIOLOGY. — The sensation of pain depends on the conduction to
the brain of the excitement of a sensory nerve by an abnormal irrita-
tion. Those sensations of pain, also, that are called neuralgic, depend
on a propagation of this excitement to the brain. If neuralgic pains
be distinguished from others, it is because they are due to the excite-
ment of the sensory nerves by different irritations, or by the action of
irritants at different places, from those causing ordinary pain. If a
blow, heat, cold, or other cause acting on the termination of the nerves,
induce pain, or if this be due to inflammation or other structural change
of the skin, mucous membrane, or of the parenchyma of different or-
gans, we do not call it neuralgia. But if we can discover no irritation
of the peripheral termination of a nerve as the cause of the pain, or
if it be probable that the irritation has affected the trunk of the nerve,
the pain felt in the distribution of the nerve is called neuralgia. We
may mention neuralgia of the supra-orbital branch of the trigeminus
which is not unfrequently induced by malarial infection, as the type of
the form where the pain occurs in the distribution of a nerve, without
the perceptible action of an irritant on the nerve itself, or on its termi-
nations. As a type of the second form, where the pain in the parts
supplied by a nerve is unmistakably due to an irritation of the nerve-
trunk, we may mention the very temporary neuralgia induced by
bruising the ulnar nerve near the elbow, at the part known as " the
crazy-bone." It is most probable that, in those cases, also, where the
injurious influence acting on the nerve escapes observation (as in neu-

318 DISEASES OF THE PERIPHERAL NERVES.

ralgia caused by malarial poisoning), the action affects the trunk rathei
than the peripheral termination. This view is favored first by the
exact limitation of the neuralgic pain to the peripheral expansions of
a single nerve, and the freedom of the parts immediately adjacent, if
these are supplied by other sensory nerves. This limitation would be
quite inexplicable if the irritation acted on the periphery. How should
we explain the constant freedom of the radial side of a finger, or the
supra-orbital region of one side, from the injury that so severely af-
fected the ulnar side of the same finger or the supra-orbital region of
the other side ? The view that neuralgia starts from the nerve-trunk
is also supported by the fact that no idea of the variety of the irrita-
tion accompanies the pain. It is well known that the cutaneous pa-
pillae connected with the terminations of the nerves are the chief
source of the sensation of pressure and temperature. If the neuralgic
pain were induced by the action of an imperceptible cause on the skin,
the patients would have some impression of the quality of this irrita-
tion ; they would complain of burning, piercing, or some other kind of
pain. But, on the contrary, if a very cold or very hot body be applied
to an exposed nerve-trunk, if we puncture or squeeze it, there is al-
ways the same sort of pain, just as in neuralgia ; and, from the pain,
the patient cannot tell what cause induced it. Finally, the want of
benefit, in most cases, from division of nerves, indicates that the seat
of the disease is to be sought for in the trunk or branches, not in the
peripheral expansions of nerves. We do not know what physical or
chemical changes of the nerves cause their morbid excitement in neu-
ralgia. We may even suspect that they do not consist in any very
evident deviations from the normal, for these remove the excitability,
but that injuries only act as causes of neuralgia, when they exercise a
comparatively slight irritation on the nerves. If we find a nerve,
which was affected with neuralgia, much changed at some point, we
may be sure that this was not the starting-point of the pain, but that
it originated from some point higher up, where no changes of structure
can be made out with the naked eye or with the microscope.

The predisposition to neuralgia varies with the person. A morbid
increase of excitability of the entire nervous system, so-called nervous
debility, of which we shall speak hereafter, and which is seen more
frequently in women than in men, in bloodless and debilitated persons
than in the full-blooded and strong, appears to lead to the occurrence
of neuralgia in some persons more readily than in others.

The exciting causes — that is, the irritations which, by their action
on the nerve-trunk, induce the neuralgia — are partly known, partly un-
known. We are not justified in distinguishing cases from unknown
causes as " genuine " or " pure " neuralgia. The pain caused in the

NEURALGIA. 319

finger by striking the ulnar nerve near the inner condyle of the hu
menis, or in the toes by a blow on the sciatic nerve where it escapes
from the sciatic notch, is also a genuine, pure neuralgia. Practically
it would be better to designate as pure neuralgia those cases that con-
tinue after the cause that induced them has ceased to act. Among the
injuries that may be regarded as direct causes of neuralgia, the most
frequent are : 1. Wounds of the nerves from sharp instruments, such
as lancets, needles, etc. ; a complete solution of continuity is far less
dangerous than these punctured wounds. 2. Irritation from foreign
bodies that have entered and become incapsulated near the nerve ; ob-
stinate neuralgia has very often been observed as a result of the irrita-
tion caused by pieces of musket-balls. 3. Compression of the nerves
by contracted cicatrices. 4. Pressure on the nerves by aneurisms, ex-
ostoses from bones and teeth, and tumors, particularly carcinoma. 5.
Neuroma, described in the last chapter. 6. Overfilling of the veins in
the vicinity of the nerves where they pass through bony canals. From
the predisposition of the left side of the body to intercostal neuralgia,
Herile concludes that the latter cause has a material influence on the
occurrence of neuralgia. The left side differs from the right in the
arrangement of the venous circulation, so that the blood must make a
circuit (from the hemiazyos vein into the azyos) to pass from the veins
of the spinal cord into the vena cava ; if there be any obstacle to the
escape of blood from the heart, it must necessarily have a worse effect
on the left side than on the right. The theory that neuralgia often
depends on dilatation of the venous plexuses surrounding a nerve where
it passes through an opening in the bone, is also supported by the fact
that the first branch of the trigeminus (whose relation to the venous
plexuses in its vicinity resembles that of the intercostal nerves) is far
more frequently the seat of neuralgia than the second or third branch,
where this is not the case. In the so-called rheumatic neuralgias,
caused by catching cold, we can find no material changes in the neu-
rilemma to explain the irritation of the nerve ; nevertheless, although
hypothetical, it is very probable that this rheumatic neuralgia is due
to a hyperaemia and cedematous swelling of the neurilemma, which
disappears after death. Lastly, we may mention, as causes of neu-
ralgia, poisoning by metallic substances, such as mercury, lead, copper,
etc., as well as by malarial infection. It is perfectly inexplicable, in
these cases, why the irritation from a constitutional disease should
only affect a very circumscribed nerve-tract.

SYMPTOMS AND COURSE. — In neuralgia we may distinguish two
forms of pain : one continuous, increased by pressure, confined to cir-
cumscribed points in the course of the nerve (points douloureux, Val-
kix>8)3 not very severe but annoying pain ; the second occurs in parov-

320 DISEASES OF THE PERIPHERAL NERVES.

ysms, spreading from a point along the course of the nerve ; the pain
is terrible and almost unbearable. The points douloureux occur par-
ticularly where the nerve escapes from a bony canal, or from fascia
that it has perforated, and approaches the surface. These spots seem
larger to the patient than they prove to be when we mark them out
by pressing the finger around. Budge made some very interesting
observations on the excitability of the motor nerves of frogs at differ-
ent places ; he found some spots very excitable while the parts im-
mediately next to them were very slightly so ; perhaps Valleix's points
douloureux on the sensory nerves correspond to those that Budge
found peculiarly excitable in the motor nerves. While Valleix almost
always found the points douloureux in neuralgia, other observers have
just as constantly failed to find them. The paroxysmal pains some-
times pass downward, sometimes pass upward along the course of the
nerve, so that there has been a division made into neuralgia descendens
and ascendens, the latter being far the more rare. Patients usually
say that the pain is not superficial but deep. It is rare for the parox-
ysms of pain to be limited to one small twig of a nerve ; usually
several twigs of one branch, but only rarely all the twigs of one nerve
participate in the affection. It is very remarkable that not unfre-
quently the neuralgia extends from one nerve to another that has a
different origin. From the laws of conduction we should suppose that
such a transfer could only occur in the central organs, through the
ganglia ; but the observation that neuralgia not unfrequently extends
from a cerebral nerve, as the trigeminus, to a spinal nerve, as the
occipital, renders the transfer in that way very improbable ; and we
must content ourselves with having mentioned the curious fact.

Anomalies in the distribution of blood, in the secretion and in the
nutrition of the parts supplied by the affected nerve, are not unfre-
quently observed without our understanding how the morbid excite-
ment of the sensory can cause abnormal excitement of the vasomotor
nerves. At the commencement of neuralgic attacks we occasionally
see the skin become pale, more frequently at the height of the attack
that it reddens, that the secretion from the nasal mucous membrane ,
conjunctiva, and from the lachrymal and salivary glands, is increased
In the same category come the exanthemata that develop in thecourst
of the affected nerve in some neuralgias, particularly in intercostal
neuralgia (herpes zoster), and lastly, the atrophy or excessive develop
ment of fat in parts supplied by the affected nerve, when the disease
has lasted a long while. The morbid excitement of the sensory nerve
is rarely transferred through a gland to a motor nerve. We musi
beware of carelessly considering the twitchings of patients, during theii
attacks of pain, as reflex symptoms.

NEURALGIA.

321

Except in the cases resulting from malaria, the course of the dis-
ease is chronic. It is rarely regular, the individual attacks are marked
by paroxysms of pain interrupted by free intervals, and in the general
course of the disease we are apt to see remissions and exacerbations.
At times the attacks of pain are more frequently repeated and are
more severe, at others, they return less frequently and are less severe.
It is only in the neuralgia caused by malaria, in the so-called febris
intermittens larvata, that the paroxysms of pain show a regular type.
In other cases the type is irregular, and the attacks not only recur
spontaneously, that is without assignable reason, but they are excited
by various recognizable causes. Among these are irritation of the
skin which the affected nerve supplies, by pressure, friction, cold, heat,
etc. Slightly touching the skin often appears to induce attacks of
pain more readily than heavy pressure does. Movements of the parts
where the pain is located, i. e., chewing in neuralgia of the trigeminus,
walking in neuralgia of the sciatic, coughing and sneezing in that of
the intercostals, excite attacks of pain. Mental excitement occasion'
ally has the same effect. I treated one old gentleman, with neuralgia
of the trigeminus, who had such a severe attack of pain every time I
entered his room, that he could not salute me for some time. Each
attack of pain usually lasts only a few seconds. But these short at-
tacks are often repeated several times in the course of one or a few
minutes, and then cease for a while, so that in fact we may say that
in neuralgia long attacks occur which are composed of a number of
short paroxysms. As we are almost compelled to believe that the
irritation acting, on a nerve, which causes the neuralgia, acts continu-
ously, the intervals between the pains appear enigmatical : for their
explanation we must refer to the physiological fact that the severe
irritation of a nerve exhausts its excitability for a time ; then in neu-
ralgia, states of great excitement would alternate with states of dimin-
ished excitability. This hypothesis is to some extent supported by
the observation that, after severe attacks of pain, the peripheral ter-
minations of the nerve are for a time less sensitive to irritation, as ii
their excitability were diminished, as well as by the observation that,
after inducing a severe neuralgic attack by continued pressure on a
painful point, a repetition of the pressure does not induce a second
attack. The gentleman above mentioned also had attacks of pain as
soon as he began to eat. In order that he might be able to eat at
meals, he began them by biting vigorously on some hard bread ; this
induced a severe attack, but after it passed over he remained free from
pain during the remainder of the meal.

Neuralgia may continue for many years. Except in the oases
caused by malaria or the so-called rheumatic neuralgia, complete cure

DISEASES OF THE PERIPHERAL NERVES.

is by no means frequent. Even the termination in permanent anaes-
thesia is comparatively rare, although we should a priori regard it ad
the most frequent, since it would seem very probable that continued
irritation must finally destroy the nerve. In many cases neuralgia,
particularly certain forms of it, remains stationary and lasts till death.
This is not apt to result from the neuralgia itself, but from accidental
complications, or from the disease causing the neuralgia.

TREATMENT. — Where the neuralgia is induced by pressure on, 01
compression of, the nerves by foreign bodies, tumors, or contracted
cicatrices, the causal indications require surgical interference. The
circumstance that neuralgia occasionally continues after the removal
of foreign bodies and tumors from the vicinity of nerves, should not
deter us from operation ; since we cannot know beforehand whether the
neuralgia has become "habitual," that is, whether the injurious influ-
ences that have acted on the nerve have affected it permanently, and
have induced a state that will not subside after removal of the cause.
The so-called antirheumatica are of little use in rheumatic neuralgias.
These would be more successfully treated by the methodical use of
artificial or natural warm-baths. Numbers of patients with rheumatic
neuralgia seek relief, and some find it, at Wildbad, Baden-Baden,
Wiesbaden, and other warm springs. Where the disease is due to
malaria and has a regular type quinine, the antidote to malarial poison-
ing has a very brilliant effect. Sulphur-baths and the internal admin-
istration of sulphur have a peculiar reputation in the neuralgias caused
by poisoning with copper, mercury, and lead. Finally, the causal
indications require the treatment of the disposition for neuralgia ; and,
as we know, to some extent at least, what it depends on, we cannot
unfrequently fulfil this indication successfully. We cannot regard car-
bonate of iron as a specific for neuralgia, but, when poverty of the
blood is one of its chief causes (or, as Mademacher has it, " when the
neuralgia is an iron affection of the constitution"), the carbonate and
other preparations of iron often have a surprising effect. In the same
way neuralgia may often be benefited by modes of treatment that
greatly modify the change of tissue and the nutrition. Where we
cannot remove the causes of neuralgia, the indications from the disease
require that we should attempt to equalize the disturbances of nutri-
tion on which it depends, or to destroy the excitability of the nerves,
or finally to prevent the propagation of the morbid excitement to the
brain.

Among the most effective modes of treatment for this purpose is
the use of electricity. Excellent results are not unfrequently attained
both by the induced and constant current. Dr. Leube, in his inaugu-
ral dissertation in 1862, reported a number of cases of obstinate neu-

NEURALGIA. 323

ralgia that were cured at my clinic by the induced current. Since
then, my experience in the result of this treatment has greatly in-
creased, and I may combine the results in the following propositions :

1. In treating neuralgia with the induced current, it is best to em-
ploy the metallic electrodes known as the electric brush : while one
electrode containing a moistened sponge is held in one of the patient's
hands or against any part of his body, we stroke the brush along the
course of the affected nerve ; if there are any points douloureux we
allow the brush to remain over them rather longer (electric moxae).

2. Many cases of neuralgia, which had been previously treated with-
out benefit by the most varied remedies, were completely and perma-
nently cured in from twelve to twenty applications, or even sooner.
In other cases no benefit or cure was effected. 3. The first sitting
shows whether the neuralgia can be cured by the induced current.
We can only expect a cure where the pain is decidedly relieved or
entirely disappears immediately after the first electrization, even if
it should only be for a short time ; if this temporary result do not take
place, the continuation of the treatment will also prove ineffectual.
The application of the induced current as above directed is very pain-
ful ; and it is only after the patient has actually experienced benefit
that he suffers it with patience, and even then he moans and whimpers
during the application. An erythema, that lasts for some time, forms
where the current is applied. I shall not attempt to decide whether
the induced current acts by derivation to the skin like the linear cau-
terizations advised by Valleix, or as blisters and irritating frictions, or
whether it acts in some other way.

The constant current is far more effective than the induced in neu-
ralgia. Some cases that have been treated without result by the
induced current have been cured by the constant, while I have never
seen the reverse. I place both poles along the affected nerve, and,
without attending to the course of the current, hold the zinc pole on
the most painful part, and on those parts where the nerve approaches
nearest to the surface, as at the supra or infra-orbital foramen, or at
the zygomatico facial foramen, or at the sciatic notch. If it be possible
to get the nerve between the poles, as in the cheek or nose, I introduce
one pole into the mouth or nose to the point whence the pains radiate,
while I place the other at the corresponding point on the skin. At
first, the application of the constant current is not particularly painful,
but an unpleasant, burning, piercing pain soon commences and grad-
ually increases ; where the number of elements is large, it may become
unbearable. The changes induced in the skin at the point of applica-
tion of the constant current, if the electrodes be applied for a length
of time, are far greater than those caused by the induced current

324 DISEASES OF THE PERIPHERAL NERVES.

They not only consist in a lively erythema, a decided swelling of the
skin, and an increase of the subjacent tissue, but papules and blebs
arise on the skin, particularly at the positive pole ; if the action con-
tinues long, the surface of the elevations sloughs off. These changes
take place not only at the point of application, but occur equally or at
least similarly in the deeper parts, as is shown not only by the increase
in volume of the subcutaneous tissue and muscles, but also by the fol-
lowing experiments (JErU)^ which show a great deal about the mode
of action of the constant current in neuralgia and other neuroses, as
well as in some diseases of the muscles, joints, etc. If we cross the
forearms, placing the volar surfaces in contact, and apply the electrodes
to their dorsal surfaces, there will be reddening not only of the parts
to which the electrodes are applied, but of the corresponding points
on the anterior surfaces. Generally, relief immediately follows the ap-
plication of the constant current just as it does that of the induced
current ; but occasionally the pain is at first increased, and that should
not always induce us to stop the treatment. There seems to me no
doubt that the curative action of the constant current, in most cases
of neuralgia, is to be explained by the modification of the circulation,
endosmosis or change of tissue in the diseased nerve, its neurilemma,
or the parts around; this "catalytic action" may result from the
chemical disintegration induced through the nerves, or the attraction
of the constituents of the nutrient fluids toward the pole, or it may
occur in some other way. The swelling of the skin, and the eruption
of nodules and blebs on it after the application of the constant current,
do not prove its action on the vasomotor nerves any more than the
redness of the skin after a mustard plaster shows a similar action in oil
of mustard. I consider it perfectly unjustifiable, in most of the recent
writers on electrotherapeutics, to make a distinction between the effect
of the constant current in neuralgia, paralysis, etc., and its effect in dis-
turbances of nutrition. In most cases of neuralgia or other nervous
diseases, just as in the affections of the muscles, joints, etc., where
galvanism has proved useful, there is no molecular change or any alter-
ation in the electrical state of the nerves, but, as Remak distinctly
asserts, there are disturbances of nutrition, anomalies of circulation
and structure, exudations, etc. For the sake of the good cause, I can-
not help regretting the numerous attempts that have been made to
explain the benefits from the constant current in disease of the nerves
and muscles, by referring to the laws concerning the contractions at
the opening and closing of the current, concerning anelectrotonus and
catalectrotonus, or concerning the results of irritation and division of
the sympathetic, instead of resting solely on the evident results of clin-
ical observation. These very imperfect doctrines, which are founded

NEURALGIA. 325

on the results of experiments made on healthy frogs and rabbits, fur
nish no useful data for the explanation of cures induced in diseased hu-
man beings by the employment of electricity. Supposing, in a paral-
ysis, neuralgia, or anaesthesia, we can succeed in changing the electro-
tonus of the affected nerve, which I do not at all deny, there is not the
slightest probability that we shall thus remove the textural changes
which lie at the root of the existing paralysis, anaesthesia, or neuralgia.
On the contrary, if cure results, we may make up our minds that, besides
the changes of the electrotonus, some other action has been induced.
And supposing we succeed, by a few minutes' irritation of the sympa-
thetic, in contracting the vessels supplied with nerves from that part,
for the length of the sitting, which I also shall not deny, it is just as
improbable that we should thus remove a disturbance of innervation
existing in the parts supplied by the contracted vessels. If application
of the constant current to the sympathetic causes a cure, we may sup-
pose that the disease depended on some disturbance of nutrition of the
sympathetic, that has been removed by the catalytic action of the cur-
rent. The marked difference between the constant and induced current
in regard to their chemical action on water, solutions of salt, albumen,
etc., has long been known, and I am fully convinced that the introduc-
tion of the former into practice is one of the most valuable advances
of modern times, and that in the constant current we have a means,
more powerful than any other, of modifying the nutritive conditions
of parts that are deeply situated. But I fear that the rationalistic and
doctrinal teachings about galvanotherapeutics, which are recently so
popular, and the attempts to make this so "exact," may interfere
with moderate and experimental observation, and injure the popularity
of an important remedy.

In the same class as electrical treatment come the blisters, moxae,
actual cautery, and cutaneous irritants, which are used as derivatives
to the skin, and which are being more and more supplanted by elec-
tricity. Superficial linear cauterization is considered, particularly in
France, as one of the most effective of remedies.

Among the means by which the excitability of the nerves is de-
stroyed, we shall first mention cold. Besides compresses of cold water
and ice, lotions with ether and liquor Hollandicus are used ; these in-
duce cold by their rapid evaporation. If they are more effective than
ice-compresses, it is because they are breathed in at the same time,
and to some extent stupefy the patient. Cold is a valuable pallia-
tive ; we cannot generally continue its use long enough for a radical
cure. The narcotics, particularly in the form of hypodermic injections
of solutions of morphia, are at present the most common remedies for
neuralgia. Formerly, if the local action of morphia was desired, a

326 DISEASES OF THE PERIPHERAL NERVES.

blister was applied, the resulting vesicle was opened, and the desired
dose of morphine was sprinkled on the denuded spot, or else the mor-
phine was mixed with saliva and inoculated into the skin. The intro-
duction of hypodermic injections, instead of these troublesome proce-
dures, was a great event, and was regarded as an immense advance in
treatment. It was thought that the affected nerves might now be
narcotized with facility. The results were perfectly surprising. In
numerous cases, instead of writing a prescription of doubtful efficacy,
the physician could free the patient from his pain in a few minutes.
Moreover, it soon became evident that, not only in neuralgia, but in
many other painful diseases also, this effect followed the hypodermic
injections of morphine ; and, secondly, that it did not make much dif-
ference whether the injection was made at the seat of the pain or at
some other point. I know many physicians who never go out to their
practice without a Pravads syringe and a solution of morphine in their
pocket, and who usually bring the morphine-bottle home empty. It
cannot be denied that the hypodermic injection of solution of morphia
is sometimes abused. From this abuse we have become acquainted
with a form of chronic morphine-poisoning that was previously little
attended to. If injections of morphia have been made for some time,
and the dose has been increased more and more, independent of the
return of the pain, the patients begin to feel an absolute need of the
injections. They feel dull, and complain of an undefinable weakness,
discomfort, trembling, etc. Some describe their state as resembling
that after a debauch. Indeed, the condition before and after the injec-
tion often reminds us most strikingly of that of a toper, before and after
his first glass of spirits in the morning. But these bad results may be
avoided by the careful use of hypodermic injections of morphia. It is
doubtful whether they have any local action ; but it is certain that the
general effect of the morphine is much more complete and precise, if it
be injected under the skin, than if it be administered internally, and
we must regard the hypodermic injection of % to % of a grain of mor-
phine as an invaluable palliative for neuralgia. Next to the employ-
ment of cold and narcotics, come frictions of the skin with veratrine
ointment (gr. iv — x to fat § j), or aconite ointment (gr. j to fat 3 j).
After using veratrine ointment, the patients feel a peculiar prickling
in the skin, which occasionally benumbs the pain. [A mixture of
equal parts of chloral hydrate and camphor forms a clear liquid,
which painted on the part relieves pain.]

We have stated that a third requirement of the indications from
the disease is to prevent the conduction of excitement from the irri-
tated nerves to the brain. The most effective mode of doing this is
by dividing the nerve between the brain and the affected part, or by

NEURALGIA OF THE TRIGEMINUS. : 327

cutting out part of the nerve, since it readily heals up if simply di-
vided. The want of success in this operation is chiefly due to a di-
vision of the wrong nerve, or to its being divided at the wrong place,
that is, to the distal side of the point whence the pain orginates
(Bruns). Unfortunately, the division at " the right spot " is in most
cases entirely impossible, because the pain originates from a point
above which the nerve cannot be reached. Cauterization of the nerve,
for the purpose of disconnecting it from the brain, should be given up;
compression is only to be used as a palliative. The least benefit is
obtained from the specifics recommended in neuralgia, such as arsenic
in the shape of Fowler's solution, the preparations of zinc, particularly
the valerianate and hydrocyanide, nitrate of silver, and other metallic
and vegetable nervines. There are cases recorded where each of these
remedies is said to have produced brilliant results, but these examples
are few, and are far outweighed in number by those where they have
had no effect. Up to the present time it is absolutely impossible to
determine exactly in what cases these remedies are useful.

OHAPTEK IV.

NEURALGIA OF THE TRIGEMINUS — PROSOPALGIA — TIG DOULOUREUX —
FOTHERGILL'S FACEACHE.

ETIOLOGY. — Next to the sciatic, no nerve is so often the seat of
pain as the trigeminus. This is partly because many branches of the
trigeminus pass through narrow canals and openings, where they may
readily be compressed, partly from the distribution of the nerves to
portions of the skin where they are more exposed to cold than other
nerves are. Hyrtl is doubtless correct in supposing that the passage
of the branches of the trigeminus through narrow openings of the
bones has much to do with the occurrence of facial neuralgia ; for see
the great immunity to the disease of those branches which pass
through the wide sphenopalatine foramen to the nose, compared with
its frequent occurrence in the infraorbital, zygomaticus malse, and su-
perior and inferior dental branches.

Only in a few cases have foreign bodies under the skin (in one
celebrated case of Jeffreys there was a piece of porcelain) and tumors
pressing on the branches of the trigeminus been found as causes of
prosopalgia. Somewhat more frequently changes in the bony canals
can be found to explain the morbid excitement of the nerves traversing
them ; among these are exfoliations of a bony wall in neuralgia of the
infraorbital, exostosis of the root of a tooth in neuralgia of the in-
framaxillary. general thickening of the bones of the skull witli con-
71

328 DISEASES OF THE PERIPHERAL NERVES.

traction of the foramina through which the nerves pass, or even inflam-
mation and projections on the bones. Finally, in some cases, aneurisms,
tumors, thickening of the dura mater, exostoses within the skull, which
pressed on the trigeminus, have been found as evident cause for ob-
stinate and extensive neuralgia of the branches of that nerve. I do
not know a single case that shows an unequivocally central origin of
facial neuralgia. Among the cases described by Romberg, in one
case of neuralgia of the trigeminus that had lasted for twenty-six
years, it is true there was a small diseased spot in the pons, but there
was at the same time an aneurism of the carotid compressing the tri-
geminus, which would fully have accounted for the neuralgia.

Far more frequently no material causes can be found for facial neu-
ralgia. In such cases it is very probable, but cannot be proved, that
the disease is occasionally caused by catching cold, which induces hy-
peraemia and slight oedema of the neurilemma that disappear after
death. Cases of haemorrhoidal facial neuralgia and those from sup-
pression of perspiration and exanthemata are very problematical;
arthritic cases are somewhat less so. Neuralgia of the trifacial is the
most frequent form when the disease is due to malaria.

The rather worthless results of statistics show that facial neural-
gia is rare in childhood, most frequent between the thirtieth and
fiftieth years, and somewhat more common in women than in men.

SYMPTOMS AND COURSE. — Of course, the pain from which patients
with neuralgia of the trigeminus suffer is more extensive in proportion
as the branch of the nerve affected is larger ; and conversely, from the
limitation of the pain to a circumscribed spot, we may decide that a very
email branch is the seat of the disease. Moreover, as the filaments of
a nerve are the more numerous the nearer we go to its origin in the brain,
and become fewer as it approaches the surface, it follows that, when
the pain is very limited, we may consider its origin as peripheral ; where
it is very extensive, we may decide that the injurious influence is in the
skull itself. In fact, in neuralgias caused by pressure on the trunk of
the fifth pair, pain has been observed hi all parts supplied by its sen-
sory filaments, in the anterior surface of the ear, in the skin of the
forehead, temple, face, in the orbit, nose, palate, body of the tongue,
floor of the mouth, teeth, and probably in the dura mater. Vattefa
mentions numerous points douloureux in facial neuralgia; we shall
only call attention to three of them, which lie nearly in a vertical
straight line, and correspond to the supraorbital foramen, the anterioi
opening of the suborbital canal, and the mental foramen. If the neu-
ralgia be seated in the first branch of the trigeminus, the pain spreads
particularly in the branches of the supraorbital, and affects the forehead,
eyebrows, and upper eyelid. In some rare cases the pain is chiefl\T ir

NEURALGIA OF THE TRIGEMINUS. 329

the eye, and, from participation of the infratrochlearis, at the inner
canthus and caruncula lachrymalis. The twigs of the first branch,
which go to the lachrymal gland and conjunctiva, explain the increased
secretion of tears and redness of the conjunctiva, almost always ob-
served in neuralgia of that branch, particularly on remission of the
paroxysms. If the second branch of the trigeminus be the seat of the
neuralgia, the pain is usually most severe in the parts supplied by the
infraorbital, that is, in the lower eyelid, alas nasi, upper lip, and teeth
of the upper jaw. The attacks of pain in these cases are sometimes
accompanied by watery or mucous secretion from the nasal mucous
membrane. Neuralgia is rare in the course of the third branch of the
nerve : this is particularly true in the course of the auriculo-temporal
and lingual branches; it is somewhat more frequent in the inferior
alveolar, especially in the mental, after it escapes from the foramen ;
then the patient has pain in the chin and lower lip. Salivation often
accompanies neuralgia of the third branch ; this symptom agrees per-
fectly with the experiments of Ludwig (see vol. i.). Occasionally the
neuralgia chiefly affects those twigs of the second and third branches
that accompany the ramifications of the facial nerve. This explains
why the facial nerve itself was formerly often considered as the seat
of the neuralgia.

In facial, as in other neuralgias, the patients suffer partly from a
permanent dull pain located at different points of the trigemmus;
partly from attacks of agonizing pain, wBich occur suddenly, then
cease as suddenly, in half a minute or so, and again return till the
attack, composed of these short twinges, " Tics," is over. The face
often twitches during these attacks, but does not usually do so invol-
untarily. Parson JBartk, who has given a very careful account of his
own facial neuralgia, was even able to continue preaching during the
attack. The attacks sometimes occur spontaneously, and, except in
the cases due to malaria, they are irregular ; sometimes they are in-
duced by the causes previously mentioned, such as speaking, sneezing,
gaping, blowing the nose, by using too cold or too warm food, occa-
sionally even by any attempt to chew. During the attack the face is
usually reddened, its temperature increased, and there is active pulsa-
tion of the arteries. To the cases observed by Brodin and Eomberg.
where, after long duration of severe facial neuralgia, the countenance
of the patient was greatly disfigured by swelling and development of
fat, I may add the case of one of my Magdeburg colleagues, in whom
there was decided disfigurement, particularly by swelling of the lower
lip, from facial neuralgia of one year's duration. In old cases of the
disease other disfigurements of the face have also been observed, sucfc
as increased thickness and prickliness of the beard, acne pustules, etc.

330 DISEASES OF THE PERIPHERAL NERVES.

The duration of the disease is rarely short, except in the regular
intermittent malarial affection; in almost all other forms it usually
lasts a long while, even half a lifetime, or more. Among the termi-
nations, besides recovery, severe melancholy occurs, which may drive
the patient to suicide. Death also occasionally results from the cause
of the disease, but not from the disease itself.

TREATMENT. — For the treatment of facial neuralgia we have little
to add to the rules given for the treatment of neuralgia in general.
Only in a few cases can we cure prosopalgia quickly, by the removal
of foreign bodies, tumors, and contracting cicatrices. Extraction of
teeth does not often prove of benefit. Usually the unfortunate patient
has one tooth after the other drawn, without the slightest relief to the
pain.

In recent cases, caused by catching cold, Valleix urgently recom-
mends flying blisters and superficial cauterizations with the hot iron. If
the disease be due to malaria, large doses of quinine are almost always
of service. The administration of Fowler's solution (four to six drops
every three hours) is only indicated when quinine has failed. In de-
cided anaemia, we may give preparations of iron, and, when we con-
clude that there is some other constitutional disease, whose nature we
cannot determine, we may order alterant mineral waters and baths.

Concerning the employment of electricity, cold, veratrine, and
aconite, as well as of morphine, particularly in the form of subcutane-
ous injection-, the same is true in facial as in other forms of neuralgia.
I have seen two cases of tic douloureux cured by the constant current ;
one of them was of thirty years' standing, and in the other eleven
operations, some of them severe ones, such as the ligation of the
carotid, resection of the superior maxilla, etc., had been performed
without benefit. In no form of neuralgia is division of the nerve, or
excision of part of it, more frequently done. After this operation had
for a time almost gone out of use, Bruns has shown, by a careful ex-
amination of the cases where it had been done, that, after excluding
the cases where its want of benefit depended on error of diagnosis or
operation, and after excluding the cases where the recurrence of the
pain was to be regarded as a new attack, not as a relapse, there was
a considerable number of cases where the neurotomy caused either a
complete and permanent benefit, or at least a temporary one, for a
few months or years. According to Bruns, the operation (whose per-
formance we will not describe) is indicated when the pain is very
limited, and it is probable that its exciting cause is situated at a point
beyond which the nerve is accessible to the knife, when other treat-
ment has proved fruitless, and when the pain renders the patient unfit
for business. There is also an indication to operate when we cannot

HEMICRANIA— MIGRAINE.

331

hope to divide the nerve between the point of disease and the brain,
but when the pain never occurs spontaneously, being always the result
of some external irritation acting on the peripheral terminations of the
nerve. In such cases the operation may, to some extent, protect the
patients from the exciting causes of their attacks of pain. The tem-
porary compression of the affected nerve and the artery supplying it
has also sometimes proved an excellent palliative, and deserves a
trial in suitable cases. Among the so-called specifics, Romberg speaks
most highly of arsenic ; under its use he saw the most evident and
speedy benefit in those cases that occurred in hysterical women, or
from disease of the sexual organs. Its effect was the more certain, the
more anaemic the patient. Romberg also saw temporary benefit from
nitrate of silver in large doses (gr. j). Hell, who, as Watson says,
" shot an arrow at random," claims to have had excellent results from
the internal administration of croton-oil with compound extract of
colocynth. Among the narcotics, besides the preparations of opium
and morphine, belladonna, stramonium, conium, and their alkaloids,
particularly Meglirfs pills (consisting of equal parts of extract of hy-
oscyamus and flowers of zinc), have a good reputation; we begin with
a two-grain pill, morning and evening, and increase to twenty or thirtv
of them daily.1

CHAPTER V.

HEMICRANIA — MIGRAINE.

THE combination of symptoms designated as migraine is difficult
to explain. It is even doubtful if we are justified in classing it among
the neuralgias, as is almost universally done. The almost constant
occurrence on one side, of the headache (to which hemicrania owes its
name), the paroxysms and free intervals observed in the disease, the
negative results of anatomical examination, are the chief reasons for
this view. On more carefully examining into the general course of the
disease, and the course of individual cases, however, this view is not
supported. There is no variety of neuralgia which, beginning, like
migraine, in childhood, and lasting into advanced age, only attacks the
patient a few times a year during this period, and, in these attacks,
shows a steady increase and diminution of the pain, but never an in-
stantaneous occurrence or disappearance. Still other objections to the
consideration of migraine as neuralgia will appear from the description
of the symptoms and course. Whether migraine be a neuralgia or not,
the pain must result from excitement of sensory filaments, but it ia
doubtful whether this excitement occurs in the filaments from the

332 DISEASES OF THE PERIPHERAL NERVES.

trigeminus to the dura mater, in the sympathetic filaments accompa-
nying the vessels, or in the brain itself! According to a fanciful hy-
pothesis of Du Bois-Meymond, which Dr. Mollendorf has carried still
further, the attack of migraine depends on a dilatation of the branches
of the internal carotid, the result of abnormal innervation of the vessels
from the ganglion supremum of the sympathetic. According to this
view, the brain would, during an attack, be in the same condition as
the ear of a rabbit that has had the cervical portion of the sympathetic
divided.

Migraine is a very common disease, so that, in a moderately-exten-
sive practice, we may usually observe a series of cases for years, and
be again and again reminded by them of the impotence of our art.
The disease occurs in both sexes, but is far more frequent among
women than men. Like gout, migraine is considered a fashionable
disease, but it also occurs among the lower classes, and is for them a
peculiarly-distressing disease, as they cannot lie by for it. In most
cases its commencement dates from the time of going to school, if not
from early childhood. Probably in half of the women affected with
migraine, the attacks occur at the menstrual period, or immediately
before it. In other cases the attacks are unmistakably due to mental
excitement. I treated one lady, who never had a party without suf-
fering from migraine next day ; another was affected in the same way
after each visit to the theatre. In some cases a severe attack, particu-
larly if it end with sick stomach, results in a certain immunity to re-
lapses. The first lady above mentioned had her guests invited the
day she had migraine, so that she might be certain of being able to
receive them the following day. In the cases that I have seen, the
attack could rarely be referred to an error of diet ; but, on the other
hand, the pain and general disturbance were almost always increased
if the patient took any food, no matter how digestible, during the
attack.

After feeling perfectly well the day before an attack of migraine,
the patients perceive the first symptoms as soon as they awake, or im-
mediately afterward. They feel heavy and depressed, are uneasy and
irritated, complain of slight chilliness, are inclined to gape, usually
have no appetite, and have a slimy taste in the mouth. Besides the
above, there is headache, which is almost always limited to one side,
increases rapidly, and becomes almost unbearable. The relaxatior
and pain drive the patients to bed ; they are very sensitive to light
and noise ; hence they seek the darkest and most retired chambers.
They dislike all visits, even that of the physician, during the attack
The pulse is usually slower. In many cases, at the height of the at-
tack (in some patients at every attack), there is nausea, and, after great

CERVICO-OCCIPITAL NEURALGIA. 333

retching, vomiting, by which quantities of a very bitter greenish fluid
are evacuated. Patients who have frequent attacks of migraine, usu-
ally long for the commencement of vomiting, and even try to excite
it by irritation of the pharynx. Generally, toward evening, rarely
earlier, the patient falls asleep, and awakes next morning free from
pain, although much depressed. The disease never threatens life;
but, although the attacks sometimes occur at shorter or longer inter-
vals, patients rarely entirely recover from the disease. In women
alone, particularly those who have the migraine at their menstrual pe-
riods, the disease occasionally ceases at the change of life.

Watson asserts that " four to six drops of liquor arsenicalis, given
three or four times daily, with attention to the digestion, effected a
cure in ten cases of hemicrania ; " but this assertion is a solitary one ;
most other observers say that the disease generally resists all treat-
ment. Nor have I seen any decided benefit from arsenic, pulsatilla,
marsh-trefoil, or from the very expensive citrate of caffein (which is
also called a specific), of which we prescribe pills (I£ caffein citr. gr. x,
ext. grani [Triticum repens] &] ; ft. pil. 10), and, to cut short the at-
tack, give one or two of these pills every hour on the first symptoms,
or from the paulinia sorbilis, which is prescribed in the form of pasta
guarana Qss — ^j. One patient prepared for herself an infusion of
unroasted coffee, and, as long as she drank this daily, appeared to have
the attacks more rarely and less severely. Another patient escaped
the attacks as long as she took sea-baths at Ha'ringsdorf ; but, when
she returned home, they began again. In most cases we can do noth-
ing but attend to existing disturbances of the general health and of
the digestion, and the chances of benefit from treatment are much
greater where we can discover any such disturbances. During the
attack we should spare the patients from the use of any remedies, and
let them take nothing but water. It is best for the patient not to trv
to defy the attacks, but to go to bed early.

CHAPTER VI.

CERVICO-OCCIPITAL NEURALGIA.

CERVico-occrPiTAL neuralgia, or neuralgia of the sensory nerves of
the occiput, neck, and nape of the neck, which originates from the first
four cervical nerves, is far more rare than facial neuralgia. The cases
known, up to the present time, are not sufficiently numerous to give
us any thing definite concerning the etiology. From the observations
of Vatteix, according to which the disease often began after prolonged
exposure to cold, and from one case where relapses often occurred, and

334 DISEASES OF THE PERIPHERAL NERVES.

came only in winter, as well as from the generally favorable course
and good result of treatment, it seems probable that this disease most
frequently results from catching cold. Diseases of the vertebrae also
appear to induce this form of neuralgia, in some few cases, by pressing
on the veins as they pass out of the vertebral canal ; and swollen lym-
phatic glands, deep in the neck, may cause it by pressing on the cervi-
cal plexus and the occipitalis major.

In cervico-occipital neuralgia, patients also complain of a continued
dull pain, limited to small spots, which is, from time to time, accompa-
nied by attacks of very severe lancinating pain shooting out in various
directions. According to Valleix, these isolated painful spots are : 1.
An occipital point located below the occipital bone, between the mas-
toid process and the first cervical vertebra, corresponding to the point
where the nervus occipitalis major [posterior occipital] perforates the
complexus muscle and becomes subcutaneous. 2. A superficial cervical
point, somewhat above the middle of the neck, between the trapezius
and sterno-cleido-mastoid muscles, corresponding to the point of exit
of the chief cervical nerves. 3. A mastoid point, lying behind the
mastoid process, corresponding to the occipitalis minor and auricularis
major nerves. 4. A parietal point near the parietal protuberance. 5.
An auricular point in the auricle. In the attacks the pain darts from
these points toward the occiput, the posterior, and upper part of the
neck, anteriorly to the face, and, occasionally, downward, toward the
shoulder. Cervico-occipital neuralgia is not unfrequently complicated
with prosopalgia and neuralgia of the brachial plexus. The attacks
Bometimes occur at irregular intervals, sometimes from movements of
the head, or other slight causes. They are rarely so severe as the at-
tacks of tic douloureux. Disturbances of nutrition in the territory of
the cervical nerves are exceedingly rare, if they ever occur. Cervico-
occipital neuralgia is far less obstinate, and is rarely so permanent as
facial neuralgia.

In this affection division of the nerves has not been tried. In
recent cases blisters are recommended, particularly by Valleix} as well
as MegUrfs pills and all other remedies that are used in prosopalgia.

CHAPTER VII.

CERVICO-BRACHIAL NEURALGIA.

BY cervico-brachial neuralgia we mean a neuralgia located in the
sensory twigs of the brachial plexus, which is composed of the lower
four cervical and the first dorsal nerves.

This form of neuralgia has perceptible causes far more frequently

CERVICO-BRACHIAL NEURALGIA.

335

than other forms. Among these are injuries of the peripheral branches
of the brachial plexus in the arm or hand from lancets and other
pointed instruments, pressure on the nerves from fragments of bullets,
contusions, neuromata, etc. The brachial plexus itself is occasionally
compressed in the axilla by swollen lymphatic glands, under the clavi-
cle by the callus of a fractured rib, by aneurisms of the subclavian or
arch of the aorta. Finally, the nerves forming the brachial plexus may
be pressed upon and irritated just at their escape from the spinal
canal, by diseases of the vertebrae. In other cases the irritation act-
ing on the brachial plexus or its branches cannot be perceived, and we
have to refer the neuralgia to a rheumatic affection of the neurilemma,
or to an imperceptible alteration in the nerves, from over-use of the
muscles in knitting, playing the piano, etc. Lastly, we must mention
that attacks of angina pectoris are usually complicated with pain in the
course of the brachial plexus. The transfer of the morbid excitement
from the nerves of the heart to those of the arm is best explained,
according to my idea, by the intervention of the nervus cardiacus mag-
nus and parvus, as they originate from the middle and inferior cervical
gangh'a which are connected by many twigs with the inferior cervical
nerves.

In some cases the pains spread over a large part of the sensory
filaments of the brachial plexus, in other cases they are limited to the
axillary region and the upper part of the arm ; occasionally they fol-
low exactly the distribution of the ulnar, radial, or musculo-cutaneous
nerves. Vatteix most frequently found a point douloureux in the
axilla, and one for the ulnar nerve, the point between the inner con-
dyle and the olecranon, and another near the ulna above the hand
where the ulnaris becomes superficial ; and for the radial nerve the
point in the arm where this nerve winds around the humerus, and a
second one at the lower end of the radius just above the hand. The
lancinating pains, particularly those extending to the fingers supplied
by the affected nerve, are severe and recur very frequently, so that
the intervals of perfect freedom from pain are usually shorter than in
other neuralgias. The pain is generally accompanied by a sense of
formication and numbness in the fingers, which lasts longer than the
attack. Disturbances of nutrition in the parts supplied by the mor-
bidly-excited nerve occur in some cases of brachial neuralgia in the
shape of exanthemata (pemphigus, urticaria), or inflammations of the
fingers. There are very often complications with neuralgias of other
nerves, particularly with cervical, intercostal, and sciatic neuralgia.
The course, duration, and termination of cervico-brachial neuralgia are
about the same as in other neuralgias.

If injuries of the finger, venesection, or similar injuries have in-

336 DISEASES OF THE PERIPHERAL NERVES.

duced brachial neuralgia, neurotomy proves triumphant, particularly
in recent cases, and when the neuralgia has not become " habitual."
Besides other remedies that we have already mentioned, the internal
administration of oil of turpentine has some reputation ; we shall refer
to it again when speaking of sciatica.

CHAPTER VIII.

INTERCOSTAL NEURALGIA.

WE designate as intercostal neuralgia the morbid excitement of
one or several spinal nerves, particularly of those which as intercostal
nerves pass along the upper intercostal spaces to the sternum, and
along the lower spaces to the epigastrium.

Intercostal neuralgia is among the most frequent forms of neural-
gia. It is met more frequently in women than in men, shows a sur-
prising predisposition for the sixth, seventh, and eighth intercostal
nerves. We have already spoken of the shrewd explanation that Henle
gives for this peculiarity. The fact that the inferior intercostal nerves
are chiefly affected, that is, the ones that empty then* blood into the
hemiazygos vein, supports the view that one of the chief causes of niter-
costal neuralgia is dilatation of the venous plexus, which most readily
occurs at these places, and exercises pressure on the roots of the spinal
nerves. In some cases the dorsal nerves are pressed upon, where they
pass through the intervertebral foramina, by inflamed vertebrae, or, after
they have passed through, by carious ribs and swollen glands. Inter-
costal neuralgia not unfrequently occurs after recovery from pleurisy.
Within a year I have seen two cases which undoubtedly had this
origin. It is doubtful what anatomical changes in the neurilemma or
in the parts surrounding the nerves, during a pleuritis or the reabsorp-
tion of the pleuritic exudation, have occurred in these cases. The
same is true of those cases of intercostal neuralgia that occasionally
accompany tuberculosis of the lungs. Lastly, as the disease is par-
ticularly liable to occur in hysterical women with chronic uterine dif-
ficulty, it has also been referred to a propagation of the morbid excite-
ment from the nerves of the uterus through the spinal medulla to the
brachial plexus (Bassereaii).

In intercostal neuralgia, the three painful points mentioned by
Valleix are more frequently observed than in most other forms of
neuralgia. The first or vertebral point is in the posterior part of the
intercostal space, somewhat outward from the spinous process, and
about on a level with the point of exit of the nerve from the interver-
tebral foramen. The second or lateral point lies in the middle of the

MASTODYNIA— IRRITABLE BREAST. 337

intercostal space ; it corresponds to the point of division of the inter-
costal nerve ; from it the nerves pass toward the surface. The third
point is near the sternum between the costal cartilages in the upper
intercostal nerves, in the lower ones it is in the epigastric region some-
what outward from the median line ; it is called either the sternal or
epigastric point, and corresponds to the place where the terminal
branches of the intercostal nerves approach the skin. These usually
very circumscribed points are generally so sensitive to pressure, that
the patient cries out as soon as they are touched. The patients
often discover the points themselves, and voluntarily point out their
position to the physician, and, as the pain very much resembles that
from a contusion, they are sure they must have struck themselves
somehow. This constant pain is increased by deep inspiration, cough-
ing, sneezing, occasionally also by moving the arms, as well as by
touching the points ; and attacks of lancinating pain are excited, which
generally start from the vertebral point and pass anteriorly along the
intercostal space ; occasionally they pass forward and backward from
the lateral point. Hard pressure often relieves the pain. Romberg
tells of a man whose coat had become threadbare at the point where
he was in the habit of pressing his hand. The frequent complication
of intercostal neuralgia with herpes zoster is very interesting, although
just as obscure as the disturbances of nutrition in the parts supplied
by other nerves affected with neuralgia. The disease runs a very
irregular course ; it usually develops slowly and passes off gradually
after variable duration. Occasionally it is very obstinate and hangs
on for years.

For the treatment of intercostal neuralgia we would advise the re-
peated application of blisters to the points douloureux, and particular-
ly the employment of the induced, or, still better, of the constant, cur-
rent of electricity. During the treatment any anomalies of constitution
are to be looked after, and, where the pain is very severe, morphia
should be used internally or subcutaneously as a palliative.

CHAPTER IX.

MASTODYNIA IRRITABLE BREAST (Cooper).

IT is doubtful whether mastodynia be a neuralgic affection of the
branches of the intercostal nerves going to the mammary gland, or
of the nervi supraclaviculares anteriores. According to Romberg's
excellent description, women, about the period of puberty, or from
then to the thirtieth year, without any perceptible cause, become sen-
sitive to the slightest touch at one or more points over the mammarv

338 DISEASES OF THE PERIPHERAL NERVES.

gland. Severe pain, like tic douloureux, occasionally shoots out tow-
ard the shoulder, axilla, or hip. Occasionally, at the height of these
attacks of pain, vomiting comes on. The patients cannot lie on the
affected side ; they are unable to bear the weight of the breast. Tho
pain usually increases shortly before the appearance of the menses.
The disease often lasts for months or years without any perceptible
change in the mammary gland. In other cases, sharply-bounded, very
movable tumors, as large as a pea or a hazel-nut, develop in the mam-
ma and form the starting-point for the pain, occasionally they cease to
be painful ; they consist of connective tissue, not of the substance of
the gland ; they have been previously mentioned as tubercula dolo-
rosa or neuromata. Fur worn on the breast, a plaster of equal parts
of emplas. saponat. and extr. belladonna, recommended by Cooper ', and
pills of ext. conii, ext. papaver (ana gr. ij), ext. stramonii (gr. J — J),
are mentioned by Momberg as the most trustworthy remedies.

CHAPTER X.

LUMBO-ABDOMINAL NEURALGIA.

NEURALGIA lumbo-abdominalis is the form that affects the cuta-
neous nerves of the lumbar plexus, going to the lower part of the
back, to the nates, anterior abdominal wall, and genitals. In this
neuralgia, also, there are constantly pains at circumscribed points,
which are occasionally accompanied by lancinating pains. These
points are : 1. The lumbar points, somewhat outward from the first
lumbar vertebrae. 2. The hip point, somewhat above the middle of
the crest of the ilium, where the ilio-hypogastric nerve perforates the
transversalis muscle. 3. The hypogastric point, somewhat inward
from the anterior-superior spine, where the ilio-inguinal nerve per-
forates the transversalis muscle ; and, lastly, some points on the monp
veneris, vulva, or scrotum at the terminations of the cutaneous nerves.
Where the posterior branches are affected, the lancinating pains chiefly
pass toward the nates ; where the anterior are affected, they chiefly
pass toward the external genitals. The etiology, course, and treat-
ment of lumbo-abdominal neuralgia are exactly the same as in inter-
costal neuralgia.

CHAPTER XI.

NEURALGIA ISCHIADICA — ISCHIAS — ISCHIAS NERVOSA POSTICA COTUN-
NH — SCIATICA — HIP-GOUT.

BY sciatica we mean a neuralgic affection of the sensory nerves of
the sciatic plexus, which is formed from the fourth and fifth lumbar
and first and second sacral nerves.

SCIATICA. 339

ETIOLOGY. — The nerves forming the sciatic plexus may be pressed
upon by carious or carcinomatous vertebrae, just where they pass through
the intervertebral foramen, and may thus be morbidly excited. And
sciatica not unfrequently depends on pressure, which acts on the sci-
atic plexus in the pelvis. In a patient with lymphatic leuchaemia,
whom I had the opportunity of observing at Greifswald, a severe in-
termitterit neuralgia, which was undoubtedly caused by the pressure
of the immensely-swollen retroperitoneal glands on the sciatic plexus,
was for years the most prominent symptom. Tumors in the pelvis
occasionally act in the same way, by pressure on the sciatic plexus,
particularly ovarian cysts, collections of hard faeces, or, as in a very
instructive case of Bamberger's, collections of cherry-pits in the sig-
moid flexure, also the gravid uterus, particularly if the child's head
remain long impacted. Cases of sciatica that are very obstinate, but
usually terminate in cure, result from the pressure of exudations of
parametritis and perimetritis in the subperitoneal tissue or in capsu-
lated intraperitoneal spaces on the sciatic nerve.

Lastly, irritation of the peripheral branches of the sciatic may
sometimes be found as a cause of the sciatica. In this class belong
the cases due to pressure from tight boots, from phlebotomy, an-
eurisms of the arteries of the lower extremity, tumors near the nerve,
etc.

Among the causes of sciatica that leave no perceptible anatomical
changes are excessive straining, suppression of habitual perspiration
and exanthemata, and catching cold. It is quite natural that the lat-
ter should occur. Indeed, the majority of cases of sciatica are of rheu-
matic origin, as they result from exposure to cold of the skin covering
the sciatic nerve, as occurs particularly in windy privies. It is not at
all astonishing that, among the cutaneous nerves, the trigeminus and
sciatic should be affected most frequently ; the former being all day
exposed to the danger of catching cold, and the latter being exposed
for a short time once or twice daily.

Statistics show that sciatica is one of the most frequent forms of
neuralgia, that it rarely occurs among children, is most frequent be-
tween the ages of twenty and sixty years, and that it occurs more fre-
quently in males and the lower classes than in females and the higher
3lasses.

SYMPTOMS AND COURSE. — Most cases of sciatica support Horn-
berg's assertion that there is no cutaneous nerve of the lumbar and
sacral plexus, from the hip-joint to the ends of the toes, which may
not be affected with neuralgia, and that it is only tradition that locates
the pain in the trunk of the nerve. The most frequent seats of the
neuralgic pain are the nervus cutaneus femoris posterior, in which

340 DISEASES OF THE PERIPHERAL NERVES.

case the posterior and outer part of the thigh becomes painful ; the su-
perficial branch of the peroneal nerve, where the pain is in the outer
and anterior surface of the leg and dorsum of the foot; the sural
nerve (communicans tibialis), where the pain is in the outer side of
the ankle and foot. The sensory filaments going to the sole of the
foot are rarely the chief seat of pain. In the heel and back part of
the sole of the foot severe neuralgia, proceeding from the terminal
branches of the tibial nerve, is sometimes seen. Valleix gives, as the
most frequent points douloureux, some points behind the trochanter,
about three points in the thigh corresponding to the course of the
chief trunks, some points on the knee, one below the head of the
fibula, one above the outer ankle, and a few points on the ankle and
dorsum of the foot.

Sciatica rarely begins with great severity ; it usually develops grad-
ually and slowly attains its height. The patients are never free from
pain, but complain of its constant presence deep in, particularly near
the tuberosity of the ischium, at the point where the sciatic nerve
passes out, and of pains in the small of the back. As the latter do
not come from the branches of the sciatic, but from the posterior
sacral nerves, Romberg calls them sympathetic. Besides these con-
stant pains, there are convulsive pains, particularly in the course of the
above-named nerves. A division into ascending and descending sciatica
is made, from the direction of these pains being from below upward or
the reverse. The pains sometimes begin spontaneously, especially after
going to bed, so that they not unfrequently drive the patient out of
bed ; sometimes they are caused by outward pressure and movements
of the legs. Even moderate tension of the fascia may have this effect ;
consequently the patient usually lies with his legs slightly flexed.
Greater tension of the fascia in coughing, sneezing, or straining, is often
accompanied by severe pain. In walking, the patient places the foot
of the affected side very carefully, because any quick motion or mis-
step usually causes severe pain. Participation of the motor filaments
in the disease, or a transfer of the irritation from the sensory to the
motor filaments through the spinal marrow, not unfrequently causes
cramps in the calf or other muscular contractions. Disturbances of
nutrition in the parts supplied by the affected nerve are not found in
sciatica as they are in other neuralgias. If the disease prove chronic, the
limb which the patient favors not unfrequently emaciates decidedly.
Occasionally the excitability of the sciatic is gradually impaired, and
we have anaesthesia and partial paralysis.

Sciatica is a very obstinate affection. Even in favorable cases
several weeks usually elapse before the disease disappears, and it
generally subsides as gradually as it developed. In less favorable

SCIATICA.

341

cases it often lasts for months or years. Even after the disease has
disappeared, relapses very readily occur.

TREATMENT. — The causal indications can rarely be fulfilled. If
disease of the vertebrae be the cause of the sciatica, we may use moxa,
the hot iron, etc., to the back. Of the injurious influences that act on
the sciatic plexus in the pelvis, overfilling of the sigmoid flexure is
almost the only one that is accessible. Although rarely the sole cause
of sciatica, this is a frequent complication, hence the old habit of be-
ginning the treatment with a laxative is quite proper. If sciatica
remain after difficult delivery, and if we have reason to refer it to a
para or perimetritis, we may employ frequent abstractions of blood,
and use cataplasms for a long while. In rheumatic sciatica warm-
baths are useful, particularly the systematic treatment with baths at
Teplitz, Warmbrunn, Wiesbaden, or Wildbad. Among the antirheu-
matics administered, iodide of potassium in large doses appears to do
most good. I saw relief of the pain occur particularly in those cases
where the running from the nose, and the eruption caused by the
iodine, came on early.

In recent cases, the indications from the disease are best answered
by the local abstraction of blood, and wet cups are preferable to
leeches. The almost universal mention in text-books of one or more
venesections, in the treatment of sciatica, appears to be merely out of
respect to old medical authorities, particularly Cotugno, for at present
no one ever bleeds for sciatica. In cases not very recent we should
use derivatives to the skin, particularly blisters. We apply the first
blister to the small of the back near the vertebra?, on a level with the
points of exit of the nerves forming the sciatic plexus ; the second
behind the trochanter, and so gradually pass down to the foot, applying
blisters to the places where the nerve lies close under the skin. Be-
sides blisters, superficial linear cauterizations of the skin in the course
of the nerve, the energetic application of the hot iron and of moxae to
certain points in the course of the nerve, as well as the actual cautery
to the dorsum of the foot and between the outer toes, and finally,
even the cauterization of the ear, particularly of the helix, have often
been tried. After the use of the last-mentioned remedy there is
almost always temporary benefit, which it is difficult to explain. Even
in the most obstinate cases of sciatica, the induced, or still more the
constant, current of electricity rarely fails. Among specific remedies,
oil of turpentine as an electuary (ol. terebinth. 3 i, mell. f i, a table-
spoonful twice daily), plays a very important part in the treatment of
sciatica. Among others, Romberg speaks very highly of it. Neurot-
omy should only be performed on small branches, in whose peripheral
terminations we can clearly Icrate the starting-point of the morbid

342 DISEASES OF THE PERIPHERAL NERVES.

excitement. Regarding the use of veratrine, aconite, and morphine as
palliatives, we may refer to what we said in the treatment of neural-
gias in general.

CHAPTER XII.

CRURAL NEURALGIA — ISCHIAS ANTICA COTUNNII.

BESIDES the branches of the lumbar plexus whose neuralgic affec-
tions we have described as lumbo-abdominal neuralgia, the sensory
filaments going to the thigh and leg are occasionally affected by neu-
ralgia. This affection has received the peculiar name of ischias antica,
because in it the pain is along the anterior and inner surface of the
thigh, leg, ankle, and dorsum of the foot, and in the great and second
toes, instead of being along the outer and posterior surface as in sci-
atica. Ischias antica, or crural neuralgia, is far more rare than ischias
postica. Like the latter, it may be caused by pressure on the nerves
at then: point of escape from the spinal canal, or by injuries to the
sacral plexus in the pelvis, or to its peripheral branches. Irreducible
inguinal hernia, sprains of the thigh, hip-joint disease, not unfrequently
induce morbid excitement of the cutaneous branches by pressure on
or tension of the crural nerve. The course and results of crural neu-
ralgia are analogous to those of sciatica, and the treatment must be
according to the same general laws.

In very rare cases the obturator nerve is also affected with neural-
gia. This is characterized by the extension of the pain to the inner
surface of the thigh, and, as the motor filaments of the obturator sup-
plying the adductor muscles usually participate in the morbid excite-
ment, the function of these muscles is frequently disturbed. The sudden
occurrence of these symptoms, together with those of acute obstruction
of the intestines, with ileus and peritonitis, are the only means of
diagnosticating strangulated hernia through the obturator foramen.

CHAPTER XIII.

ANAESTHESIA OF THE CUTANEOUS NERVES.

ANAESTHESIA — that is to say, lack of sensitiveness to external im-
pressions— arises :

1. When the portion of the brain by which the excitement of sen-
Bory nerves is recognized has been destroyed or incapacitated. In
such a case, notwithstanding that the patient is entirely insensible to
external impressions, the excitability of the sensory nerves may still
oe normal. For the present, we shall, without notice, pass over this

ANESTHESIA OF THE CUTANEOUS NERVES. 343

form of anaesthesia, which we have mentioned as one of the symptoms
of many of the diseases of the brain, as this section of the work is to
be devoted to a study of diseases of the peripheral nerves.

2. Anaesthesia may occur when, owing to destruction of the con-
ducting fibres of the spinal cord, transmission of the impressions from
the peripheral nerves to the brain is interrupted. In this form, like-
wise, the excitability of the peripheral nerves may be normal. In
treating of myelitis, we have already mentioned that, while the stronger
stimulants, acting upon the periphery, fail to call forth any excitement
at the centre, even a very feeble stimulus is frequently transmitted
from the sensory to the motor fibres, and gives rise to reflex symptoms.
Such phenomena as these prove that the excitability, both of the motor
and sensory nerves, still remains unimpaired below the point at which
the conducting power is interrupted. This form of anaesthesia, also,
is not the subject of the present section.

3. Anaesthesia occurs when there is nutritive disorder capable of
destroying the irritability of the peripheral nerves, as well as when
their connection with the brain and spinal cord has been interrupted
mechanically. It is with this form alone that we are at present con-
cerned. We shall here observe that we consider all sensory and motor
nerves as peripheral as soon as they leave the brain, no matter whether
they continue to lie within the skull or spinal canal, or whether their
track be outside of the same. This is by no means an arbitrary dis-
tinction. It depends chiefly upon the fact that the portion of nerve
lying within the skull or spinal canal is in just the same state as
the peripheral portions, as regards extinction of its irritability upon
interruption of its connection with the central organs. In the
motor nerves this can be proved with ease. In a patient who is
unable to move the right side of his face at will, owing to an apo-
plexy of the left corpus striatum, the nerves of the palsied side retain
their irritability for weeks, and all the muscles of that side may be
made to contract under the influence of the induced electric current.
On the other hand, if the facial be destroyed within the skull after its
departure from the brain, its irritability soon becomes extinct, just as
though its peripheral branches had been divided, and it is impossible
to make the muscles of the palsied side contract by the influence of
the induced current. With regard to the sensitive nerves, the proof
cannot be made so plain, yet we are warranted in inferring that the
conditions are very similar. At all events, in central anaesthesia, the
trigeminus long remains sensitive, as is proved by the continuance of
the power of reflex action, for instance, as is shown in winking when
the conjunctiva is touched.

ETIOLOGY. — The nutritive disorder, whereby a nerve is deprived of
72

344 DISEASES OF THE PERIPHERAL NERVES.

its irritability, is often so subtle in character as to escape our direct
observation. The moment a nerve loses its supply of arterial oxy-
genated blood, it loses its functional power. There is no doubt but
that this loss of irritability is due to physical or to chemical changes
within the nerve. Not unfrequently, in the region of an artery oc-
cluded by an embolus or thrombosis, we find anaesthesia to exist until
the collateral circulation has been established. The action of continued
cold induces anaesthesia of the skin. Part of this is undoubtedly due
to the contractile power of cold upon the skin, and to the anaemia of
the cutaneous nerves thus produced. Of the anaesthesiae of peripheral
origin — that is, depending upon extinguished irritability of periph*
eral nerves, without appreciable alteration of their structure — there is
the so-called rheumatic anaesthesia, which not unfrequently takes place
after exposure to cold, as well as a form which Homberg has noticed
in the hands and forearms of washerwomen. It is doubtful whether
the anaesthesia arising from lead-poisoning be due to impalpable nutri-
tive lesion of the peripheral nerves, or to a morbid state of the central
organs. This is also true of the locally anaesthetic action imputed to
ether and chloroform. It does not seem to me to be proved that the
action of these substances is purely local, when locally applied ; and I
think it more likely that their influence is more or less centric at such
times, if not entirely so. Can we expect to find a perfect anaesthetic
action from such agents, the cerebral function remaining intact mean-
time ? It bears a peculiar relation to hysterical anaesthesia, of which
we shall treat in our chapter upon hysteria.

Anaesthesia due to permanent and uniform pressure of an over-
tight bandage or piece of clothing, constitutes a connecting link with
those forms of anaesthesia where structural lesion of the peripheral
nerves is not merely a matter of supposition, but can be absolutely
demonstrated. In such cases we find all the tissues, subjected to pres-
sure, to be in a state of atrophy and fatty degeneration, and, of course,
the peripheral nerves are by no means exempt. The irritability of a
nerve is not unfrequently suspended, and its continuity is finally inter-
rupted by the pressure of a tumor, an exudation, or extravasation. In
other cases of anaesthesia, portions of the nerve are destroyed by in-
flammation. It would be superfluous further to continue the enumera-
tion of the structural alterations capable of producing anaesthesia, as
it would be but a repetition of what we have already stated in treat-
ing of the etiology of neuralgia. The very causes which, excited mildly,
or for a short time, serve to exalt the excitability of a nerve, have a
more pernicious effect should their action be prolonged or intensified,
as the nervous excitability is then arrested, or even the nerve itself
may be destroyed.

ANESTHESIA OF THE CUTANEOUS NERVES. 345

SYMPTOMS AISTD COURSE. — Anaesthesia is either complete or in-
complete. In the first case, irritants acting from without, especially
pressure and change of temperature, produce no sensation whatever.
In the second case, though an impression is produced, it is indistinct
and inaccurate. Where the anaesthesia is incomplete, there is often a
numb or muffled sensation. The patient feels as though a foreign body
lay between his skin and the object which he actually touches. HenU
believes that this state of affairs is due to an extinction of sensibility of
the peripheral terminations of the nerves, and a retrocession of the
sensibility in the direction of the centre, so that there actually is a
layer of passive substance between the nerve and the object touched.
Upon this hypothesis, it is very easy to explain why cold, whose im-
mediate action is upon the tips of the sensory nerves, should make the
skin feel numb and muffled. There is a peculiar form of anaesthesia
called analgesia. In these cases there is no pain, even under the most
intense irritation of the nerve, although the sense of touch is not im-
paired. We have no satisfactory means of accounting for analgesia.
With Henle, we might suppose it to be a low grade of anaesthesia,
and might assume that excessive irritation, instead of producing the
usual amount of perception, namely pain, merely gives rise to that
normally induced by moderate stimulation of the nerve, were it not
that, under such a condition, moderate irritation should be impercepti-
ble, which is not the case in analgesia. The modifications of anaes-
thesia, known as partial losses of sensation, are still more obscure.
Here the effect of certain irritants is extinguished, while that of other
irritants of no greater power continues. For instance, there may be a
loss of the sense of touch, with unimpaired sense of temperature, or
conversely.

The so-called " law of excentric impression," according to which
the excitement of a sensory nerve, even though produced by irritation
of its trunk, always produces the impression of an excitement of its
peripheral extremity, fully explains why patients often suffer pain in
regions which are entirely insensible to external irritation, a phenome-
non to which the name of ancesthesia dolorosa has been applied.
Anaesthesia dolorosa arises, first, in all cases in which a nerve has lost
its sensitiveness throughout a certain portion of its length, while, at
the same time, a severe irritation is made to act, above this point, upon
that portion of the nerve which still remains in connection with the
brain. It is easy to see that both of these factors often coexist, as
when a tumor presses upon a nerve. Here the tract of nerve, lying
between the compressing growth and the brain, remains excitable and
receptive of lasting impressions, while from the tumor to the periphery
ihe nerve has lost its irritability.

346 DISEASES OF THE PERIPHERAL NERVES.

In anaesthesia of the muscular nerves, perception of the degree of
contraction or relaxation of the muscles is diminished or destroyed.
Sometimes such patients are capable of making every motion required
of them, but are unable to tell, without the help of vision, to what ex-
tent they have moved. They can hold fast to an object as long as
their eyes serve them as " check-lines of motion " (Romberg], but let
it fall as soon as their eyes are closed. If anaesthesia of the muscular
nerves affect the lower extremities, the patient is often able to move
about tolerably well during the day, but in the dark he will stagger
about, and is quite unable to walk even a step or two (see chapter on
tabes, page 305).

Very often anaesthesia is complicated with derangement of circu-
lation and nutrition in the insensible region. The temperature of the
part is often depressed several degrees, its function is impaired, and
its secretions are diminished. Besides this, there is an increased vul-
nerability of the region. A comparatively trifling degree of heat or
cold suffices to burn or freeze the part. Wounds and ulcers heal more
slowly, or not at all ; bed-sores are very apt to form. The epidermis
and nails become fissured and liable to scale off; the skin becomes
livid, and oedema develops in the subcutaneous areolar tissue. This
peculiar state of the insensible region is in some degree attributable to
the retardation of the circulation, but the cause of this retardation is
obscure. From experiments made by Axmann, it seems probable that
it is due to an implication of the sympathetic fibres which accompany
the spinal nerves. In frogs, whose spinal nerves had been divided be-
tween the spinal marrow and the spinal ganglion, Axmann only found
anaesthesia and palsy, but no nutritive disorder of the palsied part.
If, however, the nerves were divided at a point beyond that at which
they are joined by the communicating branches of the sympathetic, in
addition to the anaesthesia and palsy, there was desquamation of the
epidermis, obstruction of the capillary circulation, and oedema.

If the nerve, which has been cut off from its central organ, or which
has lost its irritability from any other cause, contain both motor and
sensory fibres, partial anaesthesia and partial palsy are combined. It
would almost seem as if a nerve which had lost its irritability could
transmit this passive condition through its ganglion to other nerves,
just as an excited nerve can communicate its excitement by means of
its ganglion-cells to other nerves. It is in this way that we account
for the impairment of the sense of taste and smell in anaesthesia of the
.rigeminus, and for the anaesthesia of the auditory organs in cases of
nervous deafness, as well as for the partial paralysis which sometimes
supervenes upon long-continued anaesthesia.

It is not always easy to distinguish peripheral from central anses-

ANAESTHESIA OF THE CUTANEOUS NERVES.

347

thesia. We may rely for a diagnosis, in some degree, upon the fol-
lowing points : 1. Upon the extension of the anaesthesia and its com-
plication 01 non-complication with motor palsy. If the anaesthesia be
confined to one side, and be combined with hemiplegia, it is probably
of the cerebral form. If, however, it extend over the lower half of the
body, and be combined with paraplegia, the case is almost always one
of disease of the spinal marrow. The coexistence of palsy of the face
with facial anaesthesia indicates a central cause of disease, while anaes-
thesia, with normal motion, indicates its peripheral origin. 2. The
character of the reflex symptoms are of great importance as a means
of distinguishing between the two forms. When the anaesthesia is
peripheral, the nerve being either separated from the brain, or having
lost its power of excitability, no stimulus can be transmitted from it to
the motor nerves, and there can be no reflex symptoms ; but if the
anaesthesia be central, that is, if the region of the brain in which we
become conscious of impressions be disabled, the route by which the
excitement is transmitted from sensory to motor fibres may still re-
main quite perfect, and reflex symptoms may readily appear. It is
just the same, in cases of circumscribed disease of the spinal mar-
row, as in spondylarthrocasis, and partial myelitis. On the other
hand, in diffuse inflammation, as in tabes dorsualis, reflex symptoms
are not apt to be seen. The following is a striking example of the
difference of these two conditions. When anaesthesia of the conjunc-
tiva occurs from apoplexy, the eye may be touched without the pa-
tient's perceiving it, and yet he involuntarily closes the eye because a
stimulus is transmitted from the sensory fibres of the trigeminus to the
motor ones of the facial. But if the anaesthesia be dependent upon
loss of the ganglion of Gasser, or of the ramus-ophthalmicus, the pa-
tient neither feels the touch, nor does he involuntarily close his eye,
since transmission of the excitement to the facial has then become im-
possible.

The course of an anaesthesia depends upon the main disease. If a
nerve be divided by an incision, sensation is sometimes restored after
a while. If, however, a large portion of a nerve have been destroyed,
the anaesthesia will remain during life. Rheumatic anaesthesia, as well
as that occasioned by a moderate and uniform pressure over the course
of the entire nerve, warrants a better prognosis than the other forms.

TREATMENT. — The treatment of anaesthesia is never satisfactory,
excepting when it is possible to remove the cause. Sometimes a sur-
gical operation is indicated, sometimes a course of antirheumatic
treatment. It does not always immediately happen that cessation
of the cause is followed by removal of the effect. In such cases
spirituous and ethereal embrocations may be used, as well as eleo

DISEASES OF THE PERIPHERAL NERVES.

tricity, cold douches, the baths of Gastein, Wildbad, or Pfaffers, and
even the disgusting so-called Thierbader. The ree'stablishment of ex-
tinguished sensibility of sensory nerves by such means, however, is a
very uncertain matter.

CHAPTER XIV.

ANESTHESIA OP THE TRIGEMINUS.

ETIOLOGY. — According to an explanation given in a previous chap-
ter, the same pernicious agents which we have found to be the causes
of prosopalgia, when of greater severity or of longer duration, may
give rise to anaesthesia over the region of the trigeminus. In anaes-
thesia of one-half of the face, the Gasserian ganglion of that side has
been found compressed, degenerate, or destroyed by a tumor or in-
flammatory process. In other cases but one of the three branches has
suffered permanent pressure or other injury within the skull, or else in
the passage through the sphenoid bone. In still others, which indeed
are the most common of all, a few twigs only of the trigeminus have
been cut through, or have been destroyed by the pressure or suppura-
tion of glands or tumors, or torn during the extraction of teeth (espe-
cially the inferior alveolar branch). The favorable course taken by
some cases shows that anaesthesia of the trigeminus may also proceed
from transitory affections of the neurilemma, or of the nerve itself,
which probably are due to cold.

SYMPTOMS AND COURSE. — When all the fibres of the trigeminus
have lost their irritability, it may be assumed that its main trunk or
the ganglion of Gasser is degenerated or destroyed. In such cases
the face is divided into halves, standing in abrupt contrast with one
another, the one being sensitive, the other insensible. The various
cavities of the face, whose supply of nerves comes from the trigeminal,
are in similar condition. Upon the affected side the eye may be
touched, the bulb pinched or pricked, the nose irritated with a sharp
instrument, with snuff, or with acrid vapors, without the patient's feel-
ing it. If the patient put a glass to his lips, he feels but one side of
it, and receives the impression that it is broken. Half of the tongue
also is insensible. The saliva flows from the mouth at the affected
side, and the remains of food hang to the lips without the patient's
being aware of it. Upon irritating the conjunctiva, there are none of
the reflex movements referred to in the previous chapter. If, how-
ever, the eye be exposed to a strong light, reflex action occurs, as irri«
tation of the optic nerve transmits its impression to the facial nerve
Not only do the patients fail to wink when the conjunctiva is touched

SPASM OF PERIPHERAL NERVES.

349

but they do not sneeze when the nasal mucous membrane of the at-
fected side is irritated, since no reflex action upon the respiratory ap-
paratus can be set up in this region. Nutritive disorders of the affect-
ed side are associated with these symptoms, similar to those which
may be provoked artificially in the lower animals by extirpation of the
ganglion of Gasser, such as varicosities of the eye, with ulceration and
atrophy, fungous flabbiness of the gums, bleeding from the mouth and
nasal cavities, blueness and oedema of the cheeks. In contrast to the
observed cases of " ageustia," there are a good many others in which
the sense of taste remained normal. The sense of smell and of vision
often suffers ; but in such cases it is difficult to say what part the
disorders of the nasal mucous membrane and bulb above referred to
play hi producing such impairment of function. If both portio major
and portio minor of the trigeminus be destroyed, in addition to the
palsy of sensation of one side of the face, there will be palsy of the
muscles of mastication upon that side. If the destruction of the gan-
glion be caused by the presence of a large tumor or other extensive
disease affecting the base of the skull, the function of other cerebral
nerves is likewise usually disturbed, especially that of the oculomoto-
rius, the facial, the acoustic, and there are ptosis, dilatation of the pupil,
palsy of the corresponding side of the face, and deafness of the ear of
that side.

If but one branch of the trigeminus, instead of the whole nerve, be
diseased, the anaesthesia is limited to the region of the face which is
supplied by that branch ; if it be the first branch, to the socket of the
eye, the second to the nose, the third to the cavity of the mouth. If
the affection be confined to a few twigs alone, the insensible parts of
the face are still smaller, and the cavities may be normal.

An isolated central anaesthesia of the trigeminus without, simultane-
ous anaesthesia of the corresponding half of the body, is one of the
greatest of rarities. In a previous chapter we have stated the chief
means of distinguishing such a case from a peripheral anaesthesia.

With regard to treatment, we must also refer to what has already
been said of the treatment of anaesthesia in general.

SPASM INVOLVING- PARTICULAR PERIPHERAL NERVES.

IN the following chapter we shall treat of the morbid conditions of
excitement to which the various motor nerves are subject. Just as ex-
citement of a nerve of sensation is evinced by a feeling of pain and by
reflex symptoms, so that of a motor nerve is indicated by contraction
of the muscle which it supplies. If the motor nerve be acted upon bv

350 DISEASES OF THE PERIPHERAL NERVES.

a series of morbid impressions in quick succession, the muscular con-
traction resulting from the first impression will continue until the second
3ne succeed it. In this way permanent muscular contractions occur
which are called tonic spasms. If the nerve be irritated at somewhat
longer intervals, so that the muscle relaxes ere another impression
make it contract again, thus causing alternate spasm and relaxation, we
speak of clonic spasms.

In the healthy subject the motor nerves receive a portion of their
stimulus from the grand centre of the will, thus producing the voluntary
movements ; another portion of it is obtained from parts of the brain,
which, when thrown into excitement, are independent of the action of
the will. To this class belong the movements which occur during the
painful emotions, and in anger, and which we call outbursts of pain
and anger. It is not through our will that we contort the face in
weeping, when we are in grief; we do not voluntarily clinch the fists
when angry ; these events occur in spite of our will. Finally, in the
healthy subject, there is another series of motions which are likewise
brought about without the action of the will, and even against the
will, by the transmission of a centripetal impression to a centrifugal
channel. These are called normal reflex movements ; and a distinction
is made between those induced by a regularly recurring stimulus of
moderate intensity, such as the respiratory movement which is called
forth by the collection of carbonic acid in the blood, and the act of
deglutition which follows upon the introduction of a bolus into the
oesophagus (these being called automatic movements), and those in-
duced by stronger but less frequent impressions, such as sneezing,
winking, and the like.

The terms cramp, spasm, and hypercinesis, are applied to certain
morbid conditions in which excitement of the motor nerves is produced
by an irritant of unusual and generally speaking of unknown origin,
and entirely independently of the volition, or else to a condition in which
the action of an ordinary stimulus calls forth an excitement of extraor-
dinary extent and violence in the motor tract.

It is impossible in the present state of science to classify spasms
according to the kind of irritant which gives rise to the nervous ex
citement, or according to the region in which the irritant operates
Spasms of which we are about to treat are the result of a variety of
causes, and often of unknown causes ; and although in some instances
the affection is confined to the province of a single motor nerve, yel
we are not at all certain that it proceeds from direct irritation of the
fibres of that nerve.

SPASM OF THE FACIAL NERVE. 351

CHAPTER XV.

SPASM OP THE FACIAL NERVE — MIMIC SPASM OF THE FACE — TIC

CONVULSIF.

ETIOLOGY. — A morbid irritability involving the twigs of the facial
nerve which go to the muscles of the face, but which does not involve
the fibres running to the stylohyoid and digastric muscles, is called
tic convulsif whenever it is not combined with general convulsions.
The cause of this affection of the facial is obscure. Probably the cases
of isolated irritation to which alone we refer at present are never de-
pendent upon lesions of the brain. Nor does the cause of tic convul-
sif seem ever to be an irritation of the facial within the skull, or during
its passage through the canal of Fallopius. Whenever the morbid
excitement of this nerve is due to the action of some noxious influence
upon the face itself, such as cold, a contusion, or the pressure of a
tumor, it becomes a matter of doubt whether these influences act
directly upon the fibres of the facial nerve, or whether their immediate
effect is not upon the filaments of the trigeminus, the facial merely
becoming irritated by reflex action. Sometimes, too, tic convulsif has
been viewed as a reflex neurosis, arising from the irritation of remote
organs, such as the rectum in helminthiasis, or the uterus in hysteria.
Finally, mental emotion and the imitative instinct are set down among
the causes of tic convulsif. The affection seems to be somewhat more
common among men than among women.

SYMPTOMS AND COURSE.— In almost all cases of tic convulsif, but
one side of the face is affected ; sometimes the spasm is clonic, some-
times tonic. Romberg, in a few brief but graphic lines, gives the fol-
lowing description of the mimic spasm : " Grimaces occur, either inter-
mittent or constant, involving one side of the face, and, more rarely,
both sides. In the former case they consist chiefly of elevation or de-
pression of the occipito-frontal muscle, corrugation of the eyebrows,
blinking and closure of the eyelids, twitching and snuffling of the alae
nasi, and drawing up and down of the corners of the mouth. These
attacks set in suddenly, and as suddenly subside, to recur, with equal
suddenness, at short intervals. In permanent tonic contraction of the
facial muscles, the furrows and hollows in the affected side of the face
are deeper ; the tip of the nose, the commissure of the lips, and the
chin are drawn toward the convulsed side. The muscles feel hard and
tense, and so impede motion that the one eye cannot be as completely
closed as the other." The patient is unable to prevent or to control
these motions at will. As a rule, any individual motion, made volun-
tarily, is accompanied by involuntary contractions of other muscles.

352 DISEASES OF THE PERIPHERAL NERVES.

Iii the beginning of the disease the affected side of the face is often
somewhat painful. Afterward the pain abates, and, as a great rarity
it is followed by incomplete anaesthesia. In some cases, instead of all
the nerve-fibres of the facial, a few only are involved in the morbid
irritability, as the palpebral branch, the malar, or the labial, or, as in a
case reported by Momberg, the auricular branch. The affection of the
rami palpebrales causes a series of rapid openings and shuttings of the
eye — nictitatio, or a rigid, violent closure of the lids — blepharospas-
mus. The derangement of the buccal and labial branches gives rise
to a movement of the lips, upon one or both sides, as if from laughter,
the so-called risus caninw, or sardonicus. In the case of tic convulsif
of the auricular branches, described by Romberg, repeated fits of
twitching of the ear set in daily, during which the ears were drawn
up and down for fifteen minutes at a time. Sometimes the tic con-
vulsif spreads to other nervous trunks, as does the tic douloureux ; so
that movement is excited in the muscles of mastication, or those in the
region of the hypoglossal nerve, and of the accessory of Willis, or of
some of the spinal nerves.

The course of the disease is usually chronic, and of uncertain dura-
tion. Commencing suddenly (or gradually, which is rather more com-
mon), it generally continues during the remainder of life. In order
not to mistake the tonic form of mimic facial spasm for the distortion
of the face arising from hemiplegia, we must observe the unimpaired
muscular power of the undistorted side, and the normal behavior of
its muscles under the induced current. Moreover, according to Bruns,
in hemiplegic palsy, upon handling the healthy side of the face, we do
not find the smallest trace of permanent contraction of the muscles,
and, by stroking and drawing upon the skin of the face, the mouth
may be brought into proper position.

TREATMENT. — In recent cases of tic convulsif, a diaphoretic and de*
rivative procedure always seems to do good, while, according to my
experience, an old case resists all treatment, even the application of
electricity. Where the morbid irritation of the facial manifestly is of
reflex origin, and if we can tell from which filaments of the trigeminu?
the disturbance proceeds, division of those twigs from the brain by
neurotomy is indicated. In two cases reported by Romberg, where
the supra-orbital nerve was divided, great benefit was obtained. On
the other hand, division of branches of the facial nerve is not advisable,
as that procedure gives rise to another deformity scarcely less un-
pleasant than the former one, namely, mimic facial palsy. In one ob-
stinate case of tic convulsif, subcutaneous incision of the facial muscles
nas been practised by Dieffenbach, with good result.

SPASM OF THE SPINAL ACCESSORY NERVE. 353

CHAPTEE XVI.

SP^SM IN THE REGION OP THE SPINAL ACCESSORY NERVE OP WILLIS.

ETIOLOGY. — Like the facial, the accessory nerve of Willis is some*
times the seat of morbid irritability. The pathogeny and etiology of
this condition are as obscure as are those of tic convulsif. Violent
twisting of the neck, cold, disease of the cervical vertebras, have been
the assigned causes. The nodding spasm, or salaam convulsions, seen
in children, particularly at the period of dentition, does not seem to be a
genuine affection of the spinal accessory nerve and the cervical nerves.
Indeed, from its complications and course, it seems probable that it is
symptomatic of cerebral disease, or of an eclampsia.

SYMPTOMS AND COURSE. — Morbid excitement of the spinal acces-
sory nerve is manifested by spasm, either of a tonic or clonic character,
in the muscles supplied by that nerve, the trapezius, and the sterno-
cleido-mastoideus.

In the former 'case, in each paroxysm, the head is drawn obliquely
downward several times in succession, the occiput approaching the
shoulder, and the ear the clavicle. The direction assumed by the head
is more forward or backward, according as the contractions are greater
in the trapezius or sterno-cleido-mastoideus. In the same way the
shoulder-blades and shoulders are drawn up during- the contractions of
the trapezius. If the irritation spread to the facial, the face twitches
also; if it involve the portio minor of the trigeminus, the jaws are
convulsively set. If the cervical nerves be also implicated, the head
is twisted, and the arms are thrown into convulsive agitation. Such
paroxysms, which are usually accompanied by pain in the muscles or
their attachments, usually last but for a second or two. At the outset
of the disease the attacks are less frequent ; as it advances, they recur
oftener ; so that as many paroxysms as thirty may occur in a minute,
driving the patient almost to desperation (JETasse). They do not come
on during sleep. These clonic spasms of the region of the accessory
nerve generally develop in a very slow and gradual manner. They
rarely cease, but, as a rule, endure through life, without endangering it.

The term " salaam convulsion " of children is applied to solitary
or periodically-recurring paroxysms of clonic spasm of both sterno-
mastoid muscles, whereby the child is made to nod its head incessantly,
like a Chinese image. The nodding is very rapid, and sometimes in-
creases in rapidity as the attack goes on, making occasionally eighty
to a hundred nods a minute. Generally speaking, the muscles
of the face, especially the orbicularis palpebrarum, sympathize in the
movement. Epilepsy and idiocy develop in some children affected

354: DISEASES OF THE PERIPHERAL NERVES.

in this way, while in others it is said to disappear when dentition is
complete.

Tonic spasm of the accessory nerve of Willis is the cause of the
spastic form of torticollis or caput obstipum. The spasm is usually
confined to the sterno-cleido-mastoideus, so that the head is inclined
forward and downward. The affection occurs more frequently in chil-
dren than in adults, and perhaps, too, it sometimes affects the foetus
if congenital torticollis be attributable to an intra-uterine foetal tonio
spasm of this muscle. Sometimes the tonic spasm is preceded by a
brief attack of clonic convulsions ; more generally, however, the muscu-
lar contraction is of a tonic character from the first. At the com-
mencement the disease is apt to be considered of little moment, and,
as it is usually attended by pain, is looked upon as of rheumatic char-
acter. An embrocation of opodeldoc is ordered for the " stiff neck,"
or else some other equally harmless prescription. Finally, however,
the obstinacy of the attack and its gradual aggravation furnish evi-
dence of its more serious nature. The head is drawn more and
more to one side, the sterno-mastoid muscle of that side, particularly
its sternal portion, stands out like a hard cord, while upon the up-
turned side of the neck the skin is stretched and the muscles are not
prominent at all. If the disease last long, the face becomes distorted,
the hypertrophied muscles drawing their corresponding half of the face
downward. In the same way the permanent obliquity of the attitude
often leads to curvature of the spine, and to sinking of the thorax of
the affected side.

TREATMENT. — Treatment of clonic spasm of the spinal accessory
nerve is seldom very successful. It is true that Moritz Meyer, in five
sittings, completely cured a soldier affected with tic convulsif and
clonic spasm of the neck, by faradizing each one of the contracted mus-
cles. The negative results, however, which I myself as well as others
have witnessed in the treatment of tic convulsif, by faradization and
galvanism, would imply that such brilliant cures were exceptional.
So, too, the internal use of sulphate of zinc, and of carbonate of iron,
and the application of moxas to the back of the neck, would seem to
have sometimes been of service. Section of nerves has not succeeded,
although, in two cases, division of the muscles was successful. In a
third case, in which the division of the muscles was practised more
than once, no benefit was derived.

We can give no rules for the treatment of the salaam convulsion,
since the nature of this affection, and especially its etiology, is entirely
unknown. The treatment of tonic spasm, which belongs to the prov-
ince of orthopedic surgery, can boast of some success in cases which
were not of too long standing.

SCRIVENERS' SPASM— MOGIGRAPHIA.

355

CHAPTER XVII.

SCEIVENEES' SPASM — MOGIGRAPHIA.

ETIOLOGY. — The term scriveners' spasm is employed to denote a mor-
bid excitement of the motor fibres of the nerves which supply the muscles
of the figers, and which renders further writing impossible, by inducing
spasmodic contraction of the muscles to which they belong. If such
spasms are provoked by other kinds of manipulation, and not by writing,
for instance, by shoemaking or by milking, they receive other names, such
as " cobblers' " or " milkers' spasm." Numerous as are the hypotheses
as to its origin, we know nothing positive as to the pathogeny of this
disease, which is not at all uncommon, and which often deprives the
individual afflicted of his means of subsistence. The theory of Fritz
is in some respects satisfactory. He regards it as a reflex neurosis, in
which, however, excitement of the motor nerves is not derived from
the cutaneous nerves, as in most reflex neuroses, but proceeds from the
muscular nerves. The observation that the touch of a feather or paper
is not of itself sufficient to excite the cramp, although holding the
hand in the attitude of writing, even though it touch neither pen nor
paper, will do so, argues in favor of this view. The theory is equally
probable, however, that the morbid irritation is not reflected from the
sensory to the motor nerves, but proceeds from transmission of the im-
pression of the nerves excited by the will to other motor nerves.
Scriveners' cramp would then resemble the convulsive movements of
chorea, and stammering, and the movements which disturb the writer
would have to be regarded as sympathetic movements.

With regard to its etiology, it is to be observed that the affection
is much more common among men than among women, in whom it
has only been observed occasionally. Will it not turn out upon ex-
amination that, just as in many other diseases (although perhaps less
strikingly so), the apparent difference of tendency to the disease in the
two sexes is really due to a difference of habit and occupation ? Wri-
ters' cramp is most liable to occur between the ages of thirty and fifty
years, that is, during the time of life when occupation is most intense.
Professional penmen, clerks, teachers, and merchants are most subject
to the affection. Narrow coat-sleeves, which compress the muscles of
the arm during writing, an inconvenient attitude, but, above all (since
scriveners' spasm has only come into notice since the introduction of
steel pens), the use of a hard steel pen seems to favor the devel-
opment of the affection. Why the disease should develop under these
causes alone is unknown.

SYMPTOMS ANT> COURSE. — The usual precursory signs of writers'

356 DISEASES OF THE PERIPHERAL NERVES.

cramp are a feeling of slight fatigue of the hand, and a sense of inse-
curity as if the writer must grasp his pen more firmly. Sometimes the
affection does not advance beyond this stage. When the disease is
fully developed, the muscles of the first three fingers become convulsed
during writing, and, in bad cases, upon every attempt to write, some-
times the flexor muscles, sometimes the extensors, are the most con-
tracted. Various forms of this spasm have been recognized according
to the predominance of one or other convulsive movement, such as
convulsive flexion of the thumb, jerking of the index-finger, loss of
control of the hand, and a form made up from the last two of these
varieties. During these spasms the pen is rapidly twitched up and
down, but, hi stead of regular, distinct letters, it forms grotesque inter-
rupted scribbling. The occurrence of the paroxysm is favored by ap-
prehensive attention to the subject and fear of its arising. The harder
the patient tries to continue his writing, so much the stronger is the
spasm, as so much the more is it apt to extend up the forearm and
arm. It is usually painless, although sometimes it is attended by a
feeling of tension in the arm. The moment the patient suspends his
attempt to write, the cramp ceases, and he can execute all other move-
ments undisturbed. In a case of this kind, described by Romberg, a
nailsmith, as soon as he grasped his hammer and prepared to strike,
was seized by painful spasm of the forearm. He was obliged to give
up his trade, and afterward become a useful and skilled painter. Wri-
ters' spasm is a very obstinate and tedious disorder. Recovery is
very rare, and its uniform persistence is hardly ever broken even by a
temporary improvement of the symptoms. Some patients, who are
ready for any sacrifice in order to be rid of their burdensome disease,
and from their anxiety for this means of subsistence, learn to write
with the left hand. Unfortunately, however, sometimes in such cases
the left hand is also attacked by the disease.

TREATMENT. — The treatment of scriveners' spasm is as a rule unsuc-
cessful. Experience has shown that very little benefit is to be derived
from the long-continued prohibition of writing, and by only allowing
the patient to resume the practice cautiously, and only permitting him
to use goose-quills, or by the use of cold douches, sea-baths, and stim-
ulating friction. Division of the nerves is of no benefit to the patient,
as it causes paralysis of the finger. In one case only has section of
the muscles been followed by benefit. In all other instances there
was either no improvement at all, or it was a merely transient one.
In one case of scriveners' spasm, when, without hoping for success, I
applied the constant galvanic current in a manner almost rude, I
nave succeeded in curing the disease, so that the patient, who for years
had written with the left hand, now uses his right once more. The

IDIOPATHIC CRAMP. 357

treatment proposed by Benedict, by which he has obtained some suo
cess, and which consists in the application of " spinal-root, and spinal
nerve-streams," has utterly failed in my hands ; and in one or two
cases it has aggravated the disease. If the pathogeny of scriveners'
spasm be really as I have suggested above, my treatment of it was an
entirely rational one, although I myself was not aware of it at the
time. I applied the current to the muscle of the thumb and index-
finger, and hence to the sensory muscular nerves running into them :
thus if the explanation be correct, the cure would be accounted for by
an abatement of the morbid nutritive state, and of the morbid exci-
tability of the sensory nerves of the muscles, from whose reflex action
the cramp proceeds, by the catalytic action of the constant current.
Sometimes apparatus, by means of which the patient writes without the
aid of his fingers, also are of service for a while.

CHAPTER XVIII.

IDIOPATHIC CRAMP OP THE MUSCLES OF THE EXTREMITIES —
ARTHROGRYPOSIS.

ETIOLOGY. — According to the example of the Frenoh authors, the
term idiopathic spasm (spasmes musculaires idiopathiques) is applied
to tonic contractions which sometimes attack the muscles of the ex-
tremities, without being attributable to disease of the brain or spinal
marrow. They are analogous to the neuralgias, but we are still less
able to point out the anatomical cause of this morbid condition of the
motor nerve, causing idiopathic muscular spasm, than to discover that
which acts upon the sensory nerves in neuralgia. The harmless course
usually taken by the disease makes it probable that idiopathic cramps
of the extremities are due to trifling and transient lesions of the
nerves and their sheaths. By many observers, these affections are
regarded as a form of rheumatism, and are attributed to hyperaemia
and oedema of the neurilemma. In some cases, this may be the truth,
especially in such as occur in children previously healthy. However,
the occurrence of idiopathic muscular spasm during the course of and
convalescence from acute and chronic disorders, which have an exceed-
ingly pernicious effect upon the assimilation and nutrition of the body,
and which often lead to great functional disturbance, such as typhus,
intermittent, Bright's disease, and epidemic diphtheritis, makes it
quite probable that in other instances idiopathic muscular cramps are
the result of derangement of the tissues, the character of which is
almost unknown, and which develops during the diseases above men-
tioned, giving rise to a great variety of functional disturbance.

The muscular spasms which arise during pregnancy, during laboi

358 DISEASES OF THE PERIPHERAL NERVES.

and after it, must be regarded as of this character. The affection
is most common during childhood, especially the primitive form in-
duced by cold. The statement of Vatteix, that the disease is so rare,
that few physicians ever see it, strikes me as strange, as not only have
I myself observed a great number of such cases, but I well remember
that Krukeriberg used to describe it as a by no means uncommon
form of rheumatism among children.

SYMPTOMS AND COURSE. — Sometimes the disease is preceded by
a feeling of illness, languor, and depression of several days' duration.
The actual commencement of the disease is marked by pain, which
apparently shoots along the courses of the nerves, sometimes involving
the upper and lower extremities simultaneously, sometimes only the
hands and forearms, sometimes the feet and legs. In addition to this,
there is a sense of formication, and of stiffness and sluggishness in the
suffering members. These symptoms having lasted for a variable
period of time, fugitive cramps, in the calves of the legs and other
muscles, set in, which soon are converted into continued tonic contrac-
tions. The upper extremities are usually brought into a state of per-
manent flexion, the lower into permanent extension. If we are unac-
quainted with the malady, and see a child thus affected for the first
time, we shall be deeply impressed by the aspect of the rigid immov-
able limbs, the extended knees, the heels drawn up, the thumbs forced
into the palms of the hands, and shall be inclined to ascribe it to some
serious lesion of a central organ. The attempt to extend the upper
extremity or to flex the lower is extremely painful to the patient.
The contracted muscles are hard and prominent. Generally the joints
seem somewhat swollen by a slight oedema of the skin. Sometimes -
the tonic contractions extend to the muscles of the back and belly,
and even to those of mastication and to those of the face. The affec-
tion is either entirely free from fever or else the fever is of but little
intensity. In some patients the commencement of the contraction is
accompanied by a sensation of oppression and of rush of blood to the
head. In many instances the course of the disease is brief; the con-
tractions ceasing after a lapse of a few days, and free mobility becom-
ing reestablished. In other instances it is more protracted. Some-
times, too, relapses occur after some days or even some weeks have
passed. Certain observers, as Delpeche and Hasse, state that the dis-
ease consists of a series of spasmodic attacks, that these paroxysms last
for some minutes, some hours, or a day or more, and that in the inter-
vening period there is merely a certain degree of stiffness and swelling
of the limbs, accompanied, perhaps, by anaesthesia of the skin and mus-
cles. In the cases which I have had opportunity to observe, no such
paroxysms and intervals were discoverable.

PERIPHERAL PALSY. 359

TREATMENT. — The course of the disease, which usually is favorable,
renders active therapeutic interference superfluous. Krukeriberg used
to recommend fumigation with juniper-berries. The pain in the limbs
and the contractions of the muscles certainly subside quite as soon
ander this simple treatment as under the use of other stimulating and
antispasmodic embrocations, and by the internal use of remedies for
convulsions, such as flores zinci, henbane, opium, and the like. If the
idiopathic muscular spasm be the effect of some grave general disease,
the case is different. The spasms do not then cease until the normal
assimilation and nutrition have once more become reestablished ; and
treatment must be regulated accordingly.

CHAPTER XIX.

PERIPHERAL PALSY.

THE term palsy — acinesis — of the province of the cerebro-spinal
nerves is applied to a morbid condition, in which the motor fibres are
no longer acted upon by volition, so that the muscles cannot be made
to contract at will. Derangements of the voluntary motion having
another origin, especially those caused by disease of the bones and
joints, are not counted as palsy. Myopathic palsy shall be treated of
hereafter.

In treating of disease of the brain, we have already described that
class of paralysis proceeding from destruction or derangement of the
grand centre of volition, whereby the motor impulse to the peripheral
nerves is arrested. Under the same heading, also, we have treated of
those palsies due to general derangement of the cerebral circulation
and nutrition, in which, the entire mental function having become arrest-
ed, no impression is made, and no voluntary motion can take place.
Besides this, in a previous chapter, we have already considered the
subject of paralysis arising from destruction of the fibres of the spinal
marrow, through which the impulse from the seat of volition is con-
veyed to the motor nerves. The present section is exclusively devoted
to the variety of palsy arising either from separation of the peripheral
nerves from the brain or spinal marrow, or from a loss of irritability on
the part of these nerves owing to alteration in their structure.

ETIOLOGY. — Separation of motor nerves from the central organs is
not unfrequently the result of injury, and in this class belong the cases
of section of nerves by a surgical operation, and by wounds of other
kinds. In other instances the disturbance of continuity depends upon
the extension of an ulceration or other destructive process to a neigh-
boring nerve. The destruction of the facial nerve, during its cours'
73

360 DISEASES OF THE PERIPHERAL NERVES.

througn the canal of Fallopius in caries of the petrous bone, may be
regarded as a prototype of this variety. A peripheral end of a nerve
may also be separated from its central organ by the continued pressure
of a tumor, an aneurism, or an exostosis which gradually consumes it.
Sometimes even a temporary pressure upon a nerve has the same ef-
fect, which is probably owing to the continuity of the nerve's having
become broken at the compressed point. Thus JSasse has seen a mo-
tor palsy of the arm which proved refractory to all treatment, in a per-
son who had slept some time with his arm resting over the back of a
chair. In very rare cases the disturbance of continuity of the nerve is
due to a primary partial neuritis.

The structural changes whereby the motor nerves lose their excita-
bility, without undergoing solution of continuity, are as unknown as are
those which destroy the function of the sensory nerves. Thus cutting
off the supply of arterial blood will arrest the irritability of the motor
nerves without producing in them any structural alteration. It is
probable, although not proved, that rheumatic palsy is due to hyper-
aemia and oedema of the neurilemma, causing compression of the nerve-
fibres. Physiological experiment warrants the supposition that the
paralysis, which sometimes arises after violent attacks of cramp, is
the result of over-exertion ; but a nerve which has lost its excitability
through undue exertion does not differ appreciably from an excitable
nerve. It is the same in case of a paralysis arising in consequence of
a moderate pressure or strain. Here, from its favorable course, we
must attribute the palsy to a diminution of the irritability of the nerve,
and not to its destruction. Finally, the structural changes of the
nerves are unknown, 'which give rise to the paralysis of lead-poison-
.ing and of miasmatic poisoning, as well as in the so-called essentia
palsies. (See Chapter XXI.)

Although hysterical palsy has not been counted either among the
cerebral diseases or among those of the spinal marrow, it probably
does not belong to the class of peripheral paralyses, but rather de-
pends upon some impalpable anatomical abnormity of the centre of
volition, as we shall explain more in detail when treating of hysteria.

SYMPTOMS AND COURSE. — Complete separation of a nerve from
its central organ renders the muscles which it supplies incapable of
motion, producing complete palsy or paralysis. Textural changes,
which absolutely destroy the irritability of the nerve, have the same
effect. When the nervous irritability is merely diminished, but not
annihilated, feeble contractions still remain possible. This condition
is called incomplete palsy or paresis.

A paralysis or paresis of peripheral origin is usually distinguishable
from a central palsy : 1. By its extent. As we have seen, the charac-

PERIPHERAL PALSY. 361

teristic forms of cerebral and spinal palsy are hemiplegia and paraple-
gia, while a palsy limited to the range of influence of some particular
nerve is an almost pathognomonic symptom of peripheral paralysis.
It is only as a symptom of incipient sclerosis, and in rare instances,
that the power of volition is suspended in single nerves owing to dis-
ease of the brain, or that the connection between the spinal marrow
and any particular nerve is broken. The converse of this proposition
is not true, however, as there are many peripheral palsies which in-
volve large numbers of nerves. Even in such cases, however, the
mode of extension of the malady often reveals its source. When a
tumor of the brain causes palsy of the region supplied by the various
cerebral nerves, the palsy does not arise in all of the nerves simulta-
neously, but extends gradually from one to another as the tumor
grows. I shall mention one case observed in the Greifswalder clinic,
as a striking example of how extension of the palsy may be of great
importance as a means of distinction between spinal and peripheral
paralysis due to .caries of the vertebrae. The patient suffered from
caries of the vertebrae, and his upper extremities were in a state of al-
most complete paralysis with anaesthesia, while the mobility and sen-
sation of the lower limbs was quite normal. From the manner in
which this palsy had developed, it could be decidedly inferred that it
was the nervous trunks of the brachial plexus which were affected by
the vertebral disease, and not the spinal marrow. Rheumatic palsy,
which likewise not unfrequently affects a large number of nerves, does
not present any peculiarity with regard to its manner of extension,
and for a differential diagnosis we can only avail ourselves of the fact
that it is not apt to assume the form of hemiplegia or paraplegia. On
the other hand, the mode of development of lead-palsy is very charac-
teristic, so that from it alone the real nature of the disease may be de-
termined, and other forms of peripheral palsy, as well as the central
palsies, may be excluded from the diagnosis. Lead-poisoning always
affects the upper extremities first, attacking the extensors of the fin-
gers, hands, and arms in succession, while the flexors remain quite free
from disease.

2. If, from the outset of an attack of palsy, there have never been
any derangements of the cerebral function, the origin of the disease
is, in all probability, peripheral. The converse of this proposition
also does not hold good ; for a paralysis may be combined with serious
cerebral disorder, and the paralysis may still be a peripheral one.
Ample proof of this condition is given in cases of tumors at the base
of the brain.

3. When the affected nerve is a nerve of mixed function, the com-
oHcation of palsy with anaesthesia of the region known to be supplied

362 DISEASES OF THE PERIPHERAL NERVES.

by its sensory fibres, is an important criterion of the peripheral origin
of the disease.

4. The absence of reflex and sympathetic movements in the region
of the palsied nerve is of similar import. If the continuance of the
normal sensibility informs us that the function of the sensory nerves
of a part is still preserved, and that its connection with the brain re-
mains intact ; and if, nevertheless, no reflex signs arise when the sen-
sory nerves are irritated, there can remain no doubt that an interrup-
tion exists in the motor nerves, and hence that the palsy is peripheral.
For instance, if a patient be unable to close his eye at will, and do
not even wink when the bulb is touched, although the sensibility of
the conjunctiva be normal, the palsy is certainly peripheral. The re-
verse of this condition is a still better proof of the central origin of a
palsy. If a patient be unable voluntarily to bring a certain nerve into
excitement, and, hence, unable to contract the muscles supplied by
that nerve (for instance, if he cannot close the eye when told to do so ;
and, on the other hand, if the nerve be excited, and all its muscles
made to contract if a sensory nerve be irritated, as when we touch the
conjunctiva with the finger), we have to do with a central palsy. In
such a case the irritability of the motor and sensory fibres is perfect,
as is also the path by which the impression is conveyed from the cen-
tripetal to the centrifugal nerves ; but the centre of volition in the
brain, or the channel through which the influence of the will is im-
parted to motor nerves, is destroyed.

5. Finally, the early extinction of electric contractility in a nerve —
that is, the absence of contractility of its muscles upon application
Df the induced current — is an important sign that the paralysis is of
oeripheral origin. The induction apparatus, the exaggerated and in-
liscriminate employment of which, for therapeutic purposes, should be
liscouraged, deserves a much greater employment as a means of diag-
nosis, especially in private practice, than it has obtained hitherto.

In recent cases of peripheral palsy, which come under our notice
tolerably often in private practice, and where, owing to the greater
prospect of successful treatment, it is of peculiar importance to knpw
whether the disease be of peripheral or central origin, examination
with the induced current will decide the matter almost with certainty.
In many cases of peripheral palsy, the electric contractility of the mus-
cles suiks to a minimum, even within a few days after the occurrence
of the palsy, and soon afterward ceases entirely. In cerebral paralysis
it is quite otherwise. There the electric contractility often continues
unimpaired for months. Hemiplegic patients, indeed, are apt to be
much impressed when the faradizer, by application of the electrodes,
readily causes contraction of muscles, which for months have been be-

PERIPHERAL PALSY. 363

yond the power of their will, and they spare neither time nor money
hi order to subject themselves to a treatment in which — ineffectual
though it be — they place the utmost confidence. The degeneration
of peripheral nerves, which soon follows upon their separation from
the central organs, and which we are able to demonstrate anatomically,
accounts, in some measure, for the early extinction of electric contrac-
tility in peripheral palsy. Nor, for the same reason, should we wonder
that it soon ceases in rheumatic palsy, and in cases of lead-poisoning.
No matter how slight the disease from which the nerve suffers in such
a case, it will always suffice to bring about in it such a change that
neither the will nor the application of the induced current is capable
of producing excitement in it. In cerebral palsy, also, a degeneration
of the peripheral nerve finally sets in, as well as an atrophy and fatty
degeneration of the unemployed muscles. Hence, in very old cases,
loss of electric contractility can no longer be made use of as a means
of distinction between central and peripheral palsy. In spinal palsy
the electric contractility is sometimes long retained, while at other
times it speedily ceases. Hence, it is of little worth in a diagnostic
point of view. I believe that these differences may be accounted for,
in some degree, from the results of the investigations of the structure
of the spinal marrow by Schroeder van der Kolk. "Where centrifugal
fibres exist in the spinal marrow, which, instead of passing to the pe-
ripheral nerves, first go to the ganglion-cells from which the peripheral
nerves spring, it would seem (arguing from analogy) that, upon de-
struction of this first set of fibres, a similar condition, as regards the
electric contractility, exists, as obtains in cerebral palsy, while, upon
destruction of the fibres proceeding from the ganglion-cells, the condi-
tion is analogous to that of a peripheral paralysis. It is remarkable
that, in many cases of peripheral palsy, the muscles can be made to
contract, by means of the constant current, while the induced current
will fail of effect, and, still more strange, that streams so feeble as to
excite no contraction upon the unaffected side will induce it upon the
paralyzed side. We have no satisfactory explanation of this circum-
stance, which I have met with in two cases of rheumatic palsy in the
course of a single semester. One thing, however, may be deduced
from our previous remarks : that the character of the irritation pro-
duced in a nerve by the constant current, with its catalytic action, is
essentially different from that caused by the induced current.

Separation of a motor nerve from the central organs and the ex-
tinction of its irritability induce the same derangements of circulation
and of nutrition which we have described while treating of the pe-
ripheral anaesthesias, and such derangements are particularly severe in
cases where ana?sthesia and acinesis exist together. Lowering of the

DISEASES OF THE PERIPHERAL NERVES.

temperature in paralyzed regions depends upon a retardation of the
circulation. The quicker new blood reaches the peripheral region,
which is constantly giving off heat, so much the less readily does it
become cooled. On the other hand, the slower new warm blood enters
the part, so much the sooner will its temperature assimilate itself to
that of the surrounding region. Retardation of the circulation seems
to me to be dependent upon a contraction of the arteries ; at all events,
the pulse is often smaller upon the palsied side than upon the sound
one. We are as yet unable to account for this narrowing of the artery
upon the paralyzed side. When a palsied part becomes inflamed, an
elevation of its temperature is observed in it, instead of a depression.

We do not attempt to decide whether the incomplete anaesthesia,
which usually develops by degrees in palsied parts (even where origi-
nally the disease has been a motor paralysis), depends upon retarda-
tion of the circulation, or whether it is to be ascribed to a transmission
of the passive condition, through the ganglion-cells, from the motor to
the sensory fibres.

The course of peripheral palsy exhibits great variety, according to
the cause which produces it. Where a nerve has been cut through,
the interrupted connection not unfrequently becomes restored, and the
palsy gradually and completely disappears. If, however, a large por-
tion of a nerve be destroyed, the palsy remains stationary throughout
life. The progress of rheumatic palsy usually is favorable, and it gen-
erally terminates in complete recovery. This is also the case with the
exhaustion of irritability resulting from convulsions, and from the in-
complete traumatic palsy caused by slight injuries. The paralysis
which sometimes remains after recovery from typhus also admits of
favorable prognosis, while that arising from lead-poisoning is exceed-
ingly intractable, and often proves incurable.

TREATMENT. — The fulfilment of the causal indication in peripheral
palsy is but rarely possible, and even then is seldom followed by bene-
ficial results. Thus the extirpation of a tumor, which has caused pa-
ralysis by pressure upon a nerve, scarcely ever restores normal motion
of the part.

Rheumatic paralysis forms an exception to this rule, when not of
too long standing, as a proper treatment of the primitive disease in
such cases often furnishes the best results. However, this is not to
be anticipated from the use of those very uncertain remedies, colchi-
cum, quina, and aconite, but rather from the methodical employment
of warm baths. Every year troops of paralytic patients, curable and
incurable, crowd to Teplitz, Wiesbaden, Wildbad, or Pfaffers. The
reputation which these watering-places enjoy, especially in the treat-
ment of palsy, is mainly due to their really surprising efficacy in rheu

PERIPHERAL PALSY.

365

matic paralysis. As corroborants of the bath-treatment, but only in
cases where, owing to unfavorable circumstances, bathing is impracti-
cable, we recommend the application of stimulants to the skin, applied
along the course of the affected nerve. The usual prescription of an
embrocation of aromatic tinctures, which irritate the nose more than
the skin, should be set aside in favor of rubefacients and issues.

Of the remedies called for by the indication from the disease itself,
the application of the constant electric current is that which deserves
our greatest reliance. We have already expressed our opinion that
cures effected by the constant current probably depended solely upon
its catalytic action, and that, by means of the galvanic treatment, it is
in our power greatly to modify the circulation, the process of endos-
mosis, and nutrition itself, even in tissues lying deep beneath the skin.
The induced current does not have this effect, and we have seen many
cases of peripheral palsy, which had been treated unsuccessfully by
the induced current, healed when the constant stream was applied.
This is especially the case with the rheumatic and traumatic palsies,
and those induced by lead and other poisons.

The symptomatic indication demands : 1. That we should preserve
what remains of irritability in a partially paralyzed nerve, and avert, if
possible, its complete extinction. 2. That we should prevent atrophy
and fatty degeneration of the palsied muscles, or check them where they
have already begun. Both complete extinction of the already reduced
irritability, and the atrophy and degeneration of the palsied muscles,
are mainly due to continued rest, and to lack of excitement, which thus
constitute a new factor, whereby a palsy, dependent upon other causes,
is rendered more severe and intractable. It may even furnish the sole
reason why a paralysis merely improves sometimes, without disappear-
ing entirely. For the prevention of such a mishap, localized faradiza-
tion is an invaluable remedy. It is an important rule, in its employ-
ment, not to protract the sittings too much, and not to employ too
strong a current. Since we know that the excitability of a nerve is
quite as liable to impairment or destruction from too much exertion as
from too much rest, this rule needs no comment. It is equally evident
that, in traumatic, rheumatic, and toxic palsy, the induced current is
not to be employed before the disturbance of continuity has been al
layed, and the excitability of the affected nerve has begun to return ;
or, in other words, that the current is not to be applied until we find
that the muscles begin to contract under its influence. It is very de-
sirable that every physician should make himself so familiar with fara-
dization localized that he need not leave its employment to some one
else. The labors of Ziemssen have rendered this task quite an easy
one. A few days of practice upon the healthy subject, under the in-

366 DISEASES OF THE PERIPHERAL NERVES.

structive guidance of this book, suffices to impart the degree of skill
requisite to impress the uninitiated.

The curative effect of strychnine upon peripheral palsy may be
placed by the side of that of the induced current. Nor does strych-
nine at all tend to promote the union of divided nerves, nor repair the
structural changes which have caused the palsy. On the other hand,
it is probable that this drug, by exciting reflex action in the spinal
column, and through the augmented reflex excitement thereby induced
in the motor nerves, may stimulate the irritability of the latter, where
it is not already completely extinguished. In order to obtain results
from strychnine, doses must be given of sufficient size, and must be
kept up long enough to produce visible effect upon the reflex action of
the spinal marrow — that is, until slight twitching is induced. We
prescribe either the alcoholic extract of nux vomica, one-third of a
grain, gradually increasing up to two grains, or the nitrate of strych-
nine, in dose from the twelfth to the fourth of a grain. Other medica-
ments, such as arnica and rhus toxicodendri, scarcely have any effect
upon peripheral palsy.

CHAPTEE XX.

ETIOLOGY. — In the coming chapter we leave unnoticed the variety
of facial palsy arising from suspended volition, which is almost always
accompanied by hemiplegia, and constitutes a common symptom of
apoplexy, and of other diseases of the brain.

The irritability of the facial, or of its attachment to the brain, may
be impaired : 1. By causes which act upon it prior to its entrance into
the internal auditory meatus. 2. By such as affect it during its course
through the petrous bone. 3. By agents which involve the peripheral
ramifications upon the face. Within the cranium the facial nerve is
most frequently compressed or destroyed by cerebral tumors springing
from the base of the skull, or which have advanced toward its base. More
rarely it proceeds from exudation, from thickening of the dura mater,
or from exostoses. In the canal of Fallopius the nerve is more fre-
quently destroyed by caries of the petrous bone, although one or two
cases have been observed in which fractures and gunshot wounds have
caused injury of the facial within the petrous bone. The peripheral
oranches are sometimes cut, either by accident or intentionally, during
surgical operations. Thus it was with the coachman who was so
thankful to Sell for the successful extirpation of a tumor about his
ear, but who complained that since the operation he could no longer
wliistle to his horses. The continuous pressure which the ramifications

BELL'S PALSY OF THE FACIAL NERVE. 367

sometimes are subjected to by enlarged lymphatic glands, or other
tumors, as well as contusions and concussions, resulting from blows
upon the ear, may give rise to facial palsy. It is not unfrequently ob-
served in newly-born children, when branches of the nerve have been
bruised by the forceps during labor. Sudden chilling of a warm face,
however, is a much more common source of facial palsy than any other
agent. Many patients acquire it by looking out of the window imme-
diately after rising in the morning. Holla attributes the increasing
frequence of facial paralysis to the railroads. People hurry to the
station, arrive there warm, enter the carriage, and expose their face to
the draught of the window. The result is a palsy of the face.

The affection is a somewhat common one, so that J. Frank has
seen twenty-two cases of it in the course of fifteen years. Statistics
as to its frequence at various ages, and in different sexes, and different
sides of the face, have not led to any important conclusions. If it be
true that the affection is more common upon the left side of the face,
it is not on account of any predisposition of the left facial nerve, but
because of the greater exposure of the left cheek to blows on the ear,
and to other injuries.

SYMPTOMS AND COUKSE. — The symptoms of facial palsy consist in
an immobility and relaxation of the facial muscles, which are supplied
by the affected nerve-fibres. Palsy of the frontal muscle, and of the
corrugator supercilii, makes it impossible to wrinkle the forehead.
Romberg says : " The old man's forehead becomes as smooth as that of a
child, and there is no better cosmetic for old women." Palsy of the
orbicularis palpebrarum prevents the patients from shutting the eye
completely. If told to do so, they lower the lid a little, by relaxing
the levator palpebrae superioris, over which they still have control, and
roll the bulb upward, so as to hide the cornea. The tears are no longer
conducted to the lachrymal puncta, but flow down over the cheek.
The eye, being imperfectly closed, and exposed to all manner of inju-
ries, readily inflames. The levator labii superioris, alseque nasi, the
levator anguli oris, and the zygomaticus, are unable to draw up the
upper lip, nose, or commissure of the mouth, and to dilate the nostril.
The buccinator being disabled, the cheek puffs out during expiration,
like a loose sail. Some of the purposes for which the facial muscles
are employed, the pronunciation of the labial letters, whistling, blow-
ing, and expectorating, now fail. Even in chewing, which process,
being independent of the facial, goes on undisturbed, the morsel, when
on the affected side of the mouth, often falls between the teeth and
the cheek, and has to be disengaged thence by the fingers. When
the paralysis involves the whole of one side, there is a remarkable dis-
tortion of the countenance with every play of expression. This arises

368 DISEASES OF THE PERIPHERAL NERVES.

partly from the fact that muscular contractions only occur on the sound
side, while the other remains motionless, and partly because the con-
tracting muscles upon the sound half of the face are not counterbal-
anced by the palsied half, so that the countenance is drawn to one side.
Even during rest the face remains more or less distorted and unsym-
metrical. The palsied angle of the mouth is lower than the healthy
one, the nostril is narrower, and all the pits and depressions are ef-
faced. The point of the nose and the mouth are drawn over toward
the sound half of the face. All this deformity is due to the want of
balance between the healthy muscles of one half the face and their
palsied antagonists. In the same way there is lagophthalmos of the
affected side, from a preponderance of the unpalsied levator palpebnw
superioris over its palsied antagonist, the orbicularis palpebrarum.
When paralysis of the facial is bilateral, the face becomes void of all
expression, and the patient laughs and weeps without exhibiting any
play of countenance. I have never seen such a case myself, but can
easily believe that the aspect of a person whose face remains motion-
less, even while he is laughing loudly, will present the hideous appear-
ance of a mask. The impairment of the sense of taste, the distortion
of the uvula, and deviation of the 'tongue, though less obvious symp-.
toms, are equally constant. It is uncertain whether the obtuseness of
the sense of taste depends upon diminution of the secretion of saliva,
and consequent dryness of the mouth, or whether the chorda tympani
nerve, by erecting the papilla of the tongue, aids the gustatory sense.
Displacement of the uvula to the sound side is accounted for by the
fact that the motor nerve-fibres, passing through the nervus petrosus
superficialis major to the sphenopalatine ganglion, from which the de-
scending palatine branches proceed, only contract the muscles of the
uvula upon the side which is not palsied. This explanation, however,
is not absolutely satisfactory.2

Regarding the deviation of the tongue, we refer to what we have
already said while treating of apoplexy, as this symptom is of more
common occurrence in cerebral than in peripheral paralysis. In a pre-
vious chapter we have given a detailed explanation of why the reflex
motion should be impossible in complete peripheral palsy of the facial,
and why the electric contractility of the muscles of the face soon be-
comes extinct. In recent and uncomplicated cases, the sensibility of
the paralyzed half of the face is normal. When of longer standing,
it generally becomes somewhat blunted, probably in consequence of
nutritive disorder of the region supplied by the affected nerve. This
shows itself chiefly through emaciation and flabbiness of the palsied
part of the face, by the disappearance of the fat, and by the shrivelled
condition of the skin.

BELL'S PALSY OF THE FACIAL NERVE. 369

According to Bomber g, the following are the signs whereby we
may recognize whether the source of the paralysis is to be sought
within the cranium, in the petrous bone, or upon the face itself: 1.
We may infer that the affection originates in disease at the base of
the skull, when there is participation of other cerebral nerves in the
palsy, as shown by squinting, deafness, anaesthesia, etc., as well as by
the simultaneous occurrence of palsy of the extremities of the other
side of the body. 2. Evidence that the palsy originates in a disease
or destruction of the facial nerve within the canal of Fallopius con-
sists in long-standing otorrhcea, hardness of hearing or complete deaf-
ness, obliquity of the uvula, dryness of the mouth, perversion of the
sense of taste, which depends upon implication of the nervus petrosus
superficialis minor and chorda tympani, which are never affected except
hi this form of the disease. 3. We know that the palsy proceeds from
the peripheral ramifications, when the disease is plainly dependent
upon exposure to cold, or upon some violence done to the face, or upon
the pressure of a tumor upon the facial nerve, especially in the region
of the stylo-mastoid foramen, the ear itself meantime being sound, the
taste normal, and the uvula straight.

The course of facial palsy varies greatly, according to the seat and
nature of its cause. Where the nerve has been destroyed by a tumor
at the base of the skull, or by caries of the petrous bone, the palsy is,
of course, incurable, as is also the case when a tumor has broken the
continuity of the nerve by continued pressure upon its peripheral
branches. When the affection proceeds from exposure to cold, or from
slight injuries, the prognosis is better. This is especially true of the
congenital palsy induced by pressure of the obstetric forceps. But,
even in adults, it by no means invariably happens that traumatic or
rheumatic paralysis disappears in the course of a few weeks or months.

TREATMENT. — From what has been stated regarding the prognosis
of facial palsy, the rheumatic and traumatic forms of the complaint
are the only ones susceptible of treatment. Although they usually
recover without interference, it is better, in recent cases of traumatic
origin, to employ local antiphlogistics. Whenever an adult has a
palsy of one side of the face, caused by a blow or shock, we should
prescribe leeches and cold compresses, and should rub the part with
mercurial ointment. Congenital paralysis, also, when of traumatic
origin, may be left alone. When the disease arises from cold, and is
recent, the affected side of the face is to be covered with well-wrung
cold compresses, covered with oil-silk or india-rubber cloth, which are
not to be changed until after the lapse of several hours. The face may
also be enveloped in cotton wool, and a vapor-bath may be taken. At
a later period stronger irritants may be used : lotions of essence of

370 DISEASES OF THE PERIPHERAL NERVES.

mustard, mustard-plasters, embrocations of croton-oil, blisters, etc. A
great number of cases are on record in which rheumatic facial palsy
has been cured by the application of the constant galvanic current.
In two cases, I myself have succeeded in effecting a cure, although but
a gradual one, by employment of galvanism. In each of these cases,
treatment by the induced current remained without effect. Where
the electric contractility can be reestablished by localized faradization,
the cure will be promoted and hastened by the methodical use of the
induced current.

CHAPTER XXI.

PALSY OF THE SERRATUS MUSCLE.

ETIOLOGY. — In rare instances, two of which have come under my
personal observation, palsy of the serratus has formed part of a myo-
pathic paralysis, involving many of the muscles, the result of the so-
called progressive muscular atrophy (see appropriate chapter). The
affection is much more commonly confined to the serratus alone. This
fact, and the circumstance that the long thoracic nerve is not distrib-
uted to any other muscle except to the serratus anticus magnus, would
imply that most cases of palsy of the serratus are neither of cerebral
nor of myopathic origin. We have laid it down as an important sign
of the peripheral nature of a palsy, that the affection involves the re-
gion supplied by some particular nerve, and while neighboring muscles
supplied by other nerves remain sound. Besides this is the well-known
fact that peripheral palsy and peripheral neuroses by preference affect
the region supplied by nerves which pass through long, narrow chan-
nels and holes, like the long thoracic, which runs through the scalenu?
medius. This very important point in the pathogeny of palsy of the
serratus, and the proof of the fact that, in most of such cases, we have
to deal with a peripheral neuropathic affection, have not hitherto ob-
tained the notice which they deserve.

The exciting causes of palsy of the serratus are usually obscure.
It is plain that the long thoracic nerve, in its passage through the
scalenus medius, may suffer injuries which escape our attention. In
some instances, over-exertion of the upper extremities, or cold, has
been the assigned cause. In one observation, reported by Neuschler,
the palsy of the serratus was preceded by a fall, and a tumor afterward
formed in the neck, which the physician in charge proposed to open by
mcision. In one very interesting case, which came under my own ob-
servation, a carpenter, who used to carry the heavy beams for build-
uigs upon his right shoulder, had to employ the left shoulder instead,

PALSY OF THE SERRATUS MUSCLE.

371

on account of the development of a palsy of the right serratus muscle.
Some time afterward, palsy of the left serratus also began to appear.

SYMPTOMS AND COURSE. — Palsy of the serratus muscle is easy of
recognition, as the absence of its function and the undue action of its
antagonistic muscles occasion characteristic deformities and disorders
of motion. The function of the serratus is to press the scapula against
the thoracic wall, and to draw its lower angle downward and outward.
The serratus is especially required in the act of elevating the arms
above a horizontal line, as it then draws the lower angle of the scapula
outward, and turns the glenoid cavity of the joint upward. It is by
this act alone, and not by the contraction of the deltoid, that we are
enabled to lift the arm above the shoulder. When the serratus is
paralyzed, the inner border of the scapula, and particularly its lower
angle, instead of lying against the chest, stands up like a wing, draw-
ing up a three-cornered fold of skin before it, and admitting of our
reaching deeply into the subscapular fossa. At the same time, the
lower edge of the scapula stands up too high, and too far inward.
The antagonistic muscles, the trapezius and the levator scapulae, have
drawn the superior angle upward, and the weight of the arm and the
pectoralis minor have depressed the external angle, and thrown it for-
ward. The patient is unable to lift his arm above a horizontal line,
and is thus rendered extremely awkward. Any one, who has often
watched a patient with this affection put on or take off his coat or
shirt, will be able to make a diagnosis in the next case he meets with,
from these acts alone. If we press the inferior angle of the scapula
against the chest, and, at the same time, push it in, the patient is once
more enabled to lift his arm above his shoulder without difficulty.
Palsy of the serratus is an obstinate complaint. In none of the cases
which I have seen was a complete cure effected. In many in-
stances, however, the patients so far improved as to be able to do
easy work.

TREATMENT. — The most commendable remedy, in recent palsy of
the serratus, is local blood-letting and derivation to the skin, applied
over the point where the long thoracic nerve passes through the sca-
lenus medius. In chronic cases, according to our present experience,
faradization does not promise much benefit. On the other hand, the
constant current is strongly to be recommended. Unfortunately, how-
ever, hitherto I have had but one opportunity of applying it. The
cures obtained by means of the constant current, in cases of peripheraJ
facial patay, which I consider to be quite analogous with palsy of the
serratus, urgentlv demand the treatment of the latter by galvanism.

372 DISEASES OF THE PERIPHERAL NERVES.

CHAPTEK XXII.

PROGRESSIVE PALSY OF THE CEREBRAL NERVES PROGRESSIVE PALSY

OF THE TONGUE, VELUM PALATI, AND LIPS — GLOSSOLARYNGEAL
PALSY.

A SERIES of observations have recently been made, particularly by
French writers, of a paralysis, which, commencing at the lips, extends
successively to the tongue, palate, pharynx, and sometimes to the
muscles of the glottis, more rarely to those of the eyes. In all cases
hitherto observed no coexistent derangement has been perceptible in
the sensory nerves, nor in those of special sense.

The pathogeny of this peculiar disease is obscure. The only lesion
constantly found post mortem is an intense fatty atrophy of the pal-
sied nerves, especially the hypoglossal nerve. In some cases a diffuse
sclerosis of the medulla oblongata has also been found. According to
an hypothesis which is as yet unproved, advanced by Wachsmuth, who
proposes to call the malady in question " bulbar palsy," the disease
consists in a " central affection of the medulla oblongata, having its
seat in the olivary bodies, and in the gray matter lying far back be-
tween the diverging lateral and posterior columns, and which forms
the floor of the fourth ventricle. According to Wachsmuth, the atro-
phy of the nerves is secondary, and a consequence of the degeneration
suffered by the nuclei at the points above named. In some cases the
palsy of the region supplied by the cerebral nerves was preceded by
the symptoms of an incipient, progressive muscular atrophy, and the
majority of French authorities regard the two diseases as closely
related, although, in the progressive palsy of the cerebral nerves, no
diminution in size is observable in the affected muscles. At the out-
set the patient makes but little complaint. He cannot pucker up his
mouth, and hence cannot blow, whistle, nor spit. The saliva which
collects in the mouth runs from it involuntarily. The expression of
the countenance becomes blank and strange, as the muscles of the lips
cannot take part in the play of expression. Pronunciation of the
labial letters is difficult, and gradually becomes impossible. If the
malady extend to the tongue, not only does articulation become still
more embarrassed, but the acts of chewing and swallowing become
impeded; and afterward, when the tongue has become still more help-
less— lying quite motionless in the mouth — these acts are no longer
practicable. Palsy of the palate shows itself from the nasal tone of
the voice, and, as long as the pharyngeal muscles remain sound, by the
regurgitation, through the nose and mouth, of food and liquids which
enter the pharynx. If the pharynx also become palsied, the patient,

INFANTILE PALSY. 373

when offered to drink, rejects a large portion of the liquid with violent
expiratory motions, so that at last it often becomes necessary to feed
him by means of the oesophagus tube. The choking-fits thus pro-
voked by attempting to drink, and the rejection of the liquid amid
spasmodic coughing, might awaken the suspicion that a communication
exists between the larynx and pharynx, or oesophagus. In one case
of this kind, my colleague JBrims demonstrated, by means of the la-
ryngoscope, that, " if the patient merely was fed with small spoonfuls
of milk or porridge, the swallowed portion only passed as far as the
pouch which lies behind the larynx. If, by further swallowing, the
level of the liquid rises so as to pass the bottom of the notch between
the arytenoid cartilages, the so-called rima glottidis posterior, the soft
liquid mass immediately flows forward through this opening into the
larynx, and instantly gives rise to a fit of coughing."

This disease is generally a tedious one. Death is the usual result,
either from impairment of the general nutrition of the patient, owing
to the difficulty with which he obtains nourishment, or else from vio-
lent bronchitis, or pneumonia, in consequence of the repeated intru-
sion of liquid into the air-passages. Hitherto no authentic case of im-
provement or cure has been reported. Benedikt is the only one who
claims that, by galvanization of the sympathetic, and at the mastoid
process, he has obtained important success and even a cure, and in
advanced cases has relieved dangerous symptoms, such as difficulty
in swallowing. For this purpose he applied the copper-pole to the
spinal column, and strokes with the zinc-pole upon the pomum adami
and neighboring parts, so that in each sitting he is able to induce some
twenty or thirty acts of deglutition. May there not have been some
confusion with hysterical dysphagia in these almost miraculous cures ?
T have cured a hysterical patient by a treatment almost purely psychi-
cal, who for months previously had been fed through a tube, and had
carried a canula in her trachea for an equally long period of time.

CHAPTER XXIII.

ESSENTIAL PALSY OF CHILDREN — SPINAL INFANTILE PALSY (Heine).

ETIOLOGY. — Whether the essential palsy of children be a disease
of the brain, of the spinal marrow, or of the peripheral nerves, or
whether it proceed from all or any of them in turn, as Vogt supposes,
..s a matter which, in our present ignorance of its post mortem lesions,
cannot be positively decided. The name " essential palsy " I hold to
oe a most appropriate one. Although the paralysis originally may
have been due to an inflammation or effusion in the spinal marrow,

374: DISEASES OF THE PERIPHERAL NERVES.

}Tet, at the time when the palsy is called an essential palsy, all such
processes have long since subsided, and it is not the primitive disease,
but the paralysis and its consequences, that we have to treat. Essen-
tial palsy as a rule is the permanent product of a very acute process ;
for all observers agree that the affection develops within a few hours,
and that it never extends from the limb first attacked to the other
limbs.

The causes of the disease are as obscure as is its pathogeny. It
occurs almost exclusively among children during the period of denti-
tion, and for a short time afterward ; that is, from the sixth month to
the third year of life. Girls and boys are equally liable, as are also
scrofulous and cachectic subjects, and those previously robust. The
assigned causes have been the acute exanthemata, and cold, especially
allowing children to sit upon cold stones. The latter idea is unworthy
of attention, as innumerable children sit daily upon the stones, while
essential palsy is not at all a common disease.

SYMPTOMS AND COURSE. — In many instances the attack commences
with febrile symptoms, and signs of cerebral hyperaemia or meningitis.
Mental excitement, convulsions, loss of consciousness, gnashing of the
teeth, are common to this, as well as to the other two maladies above
mentioned; and as in such cases it often happens that it is only by
the course of the disease that we can decide whether we have a me-
ningitis or a cerebral hyperaemia to deal with, so here, too, we have no
means of distinguishing the primary stage of an essential paralysis
from that of hyperaemia of the brain, save that, after subsidence of the
convulsions and return of consciousness, a total paralysis of one or
more extremities remains. Sometimes one foot, sometimes one hand
is affected, sometimes both lower extremities ; but it never happens
that both extremities of the same half of the body are paralyzed, a fact
which very plainly implies the independence of the disease from cere-
bral apoplexy or encephalitis. The bladder and rectum never take
part in the palsy. A mode of commencement of the malady, which is
scarcely less common than that by violent cerebral symptoms, consists
in an undefined attack of feverish symptoms, during which, without
precursory convulsions or stupor, an arm, or leg, or both legs, suddenly
hang useless, and are entirely incapable of voluntary motion.

The subsequent course of the disease may vary. Sometimes the
palsy disappears in a day or two, and the disease ends in complete
recovery. Seine, who indisputably has seen the largest number of
cases, doubts whether such examples (to which the name " temporary
infantile palsy " has been given) proceed from the same causes which
give rise to the stationary, permanent essential paralysis. Duchenne
noticed that, in recent cases of the temporary form, the electric con-

INFANTILE PALSY. 375

tractility of the muscles was retained ; whereas, in recent cases of tho
permanent form, a few only of the muscles of the paralyzed limb
maintained their electric contractility, while in the others it was lost.
These observations may be summed up as follows : that the prognosis
of an essential palsy is favorable, and that a cure is to be hoped for,
when the affected muscles preserve their contractility ; but that it is
unfavorable, and that degeneration and atrophy ensue, when the elec-
tric contractility is extinct.

When the disease passes into the so-called second stage, the re-
laxed flexible soft limbs, which may readily be placed in any required
position, gradually lose their original plumpness. They suffer an
atrophy which involves the skin, fat, muscles, and even the bones. In
the course of a year the circumference of the limb, and even its length,
is far smaller upon the crippled than upon the sound side. The pulse
is small, corresponding to the deficient nutritive condition and marked
depression of temperature of the paralyzed limb. It has a livid hue,
and is liable to bed-sores, chilblains, and ulceration. As the disease
progresses, deformity and contractions of the crippled limb are added
to the atrophy. The wasted deltoid muscle is often no longer able tc
hold the head of the arm-bone in its socket on the shoulder-blade ; sc
that the arm sinks, stretching the capsule of the joint by its Weight.
We then find a depression immediately beneath the acromion, the
head of the bone lying farther downward and backward. It is easy
to replace the bone ; but, as soon as the arm is permitted to hang
down, it is immediately redislocated by its own weight. When the
lower extremities are attacked, particularly if it be at the period when
children try to move themselves about by shuffling, permanent short-
ening takes place in the muscles which still retain some degree of con-
tractile power and encounter no resistance from their antagonists.
This is the mode of origin of a variety of forms of clubfoot, flexions of
the hip, and the deformities of the knee-joint known as genu valgus.
In advanced periods of the disease, the electrical contractility of the
degenerated and wasted muscles is extinct. No conclusion as to the
origin of the affection can be drawn from this condition, as it occurs in
all forms of paralysis (even in the cerebral form) after it has lasted
long enough for the nerves and muscles to degenerate.

The general health usually remains unimpaired in essential paraly-
sis. Many patients attain a great age, and, when they belong to the
lower classes of society, are often seen as mendicant cripples on the
high-roads.

TREATMENT. — It is only in very recent cases of essential palsy that
any benefit is to be expected from local blood-letting, or from deriva-
tives by the side of the spine. In old cases we have as little reason
74

376 DISEASES OF THE PERIPHERAL NERVES.

to expect the resolution of the remains of a process which has long
since subsided, as to restore the apoplectic cicatrix of the brain after
an attack of apoplexy, and thus to cure the hemiplegia. Indeed,
where the electric contractility is extinct, and the nerves and muscles
have degenerated, the restitution of the spinal marrow to a state of
health would be of no benefit to the palsy.

Although we scarcely ever are able to fulfil the causal indications,
or the indications from the disease, yet a treatment of the symptoms
of the disease has been followed by comparative success. As long as
any of the muscles maintain the slightest trace of their contractility,
the systematic and active application of the induced current is indicated
as being the best and surest means of preserving and increasing what
remains of the irritability, and of arresting the atrophy and degenera-
tion of the muscles. It is proved, moreover, by the results which
Seine has obtained at his institution, that, even in cases apparently of
the most desperate nature, the lot of the unfortunate patient may be
materially alleviated by means of tenotomy and other expedients of
rational orthopedic surgery.

ADDITIONS TO THE REVISED EDITION OF 1880.

SECTION III. — DISEASES OP THE PERIPHERAL NERVES.
1.— P. 331.

Neuralgia is occasionally so obstinate that, besides exhausting
the patient, it exhausts the physician's list of remedies ; and it may
not be out of place to record some of the numerous modes of treat-
ment recommended.

Apply ice to the seat of pain as long as the patient can bear it,
while he holds brandy in the mouth.

In periodic cases, where quinine fails, try salicylic acid in 30-
gr. doses repeated two or three times ; or hypodermic injections of
Fowler's solution — arsenic in, v-x, with the same quantity of dis-
tilled water.

Granules of T^ gr. of aconitia, repeated three times daily till
they cause tingling, are said to give relief ; not to be used in cases
of heart disease.

Inhalations of ether, of chloroform, or of nitrite of amyl (gtt. iij);
if the latter is not effectual, it may be repeated in fifteen minutes
and increased to six or eight drops ; it is more apt to give relief in
cases where the face is pale.

ADDITIONS TO THE REVISED EDITION OF 1880. 37?

Either the induced or constant currents of electricity may do
good, though the latter is most reliable in neuralgia. Change of
air ; where there are spasmodic contractions of the muscles of the
face, compression of the carotid on that side ; and where there is
paresis on the neuralgic side, compression of the opposite carotid,
are said to do good.

Phosphorus gr. ^j, in mucilage, may be given ten minutes after
something has been taken into the stomach, and repeated thus every
two hours for three doses, then every three or four hours.

2.— P. 368.

Implication of the chorda tympani causes change in the sense of
taste, especially for sour or salty things, on the anterior two-thirds
of that side of the tongue. If it be true that the gustatory fila-
ments of the facial only belong in the short portion between the
entrance of the chorda tympani and the departure of the petrosus
superficialis major, and pass with the latter to the second branch of
the trif acial, loss of taste in facial paralysis would show that the cause
must be at this part. Diminution of saliva has also been observed.
Deafness may occur from disease of the internal ear or auditory
nerve. There may be excessive sensitiveness of hearing (hyperaku-
sis). In rheumatic paralysis this is said to occur especially for the
deeper musical tones, and is probably due to paralysis of a small
twig going to the stapedius muscle, and a consequent preponderance
of the tensor tympani muscle.

Alihaus says that in rheumatic paralysis the farado-muscular
excitability is generally normal ; there may be slight anaesthesia of
the skin ; the supinators and flexors are equally affected. In trau-
matic paralysis the farado-muscular contractility is lost ; there is
anaesthesia of the skin ; the supinators and extensors are equally
affected. In lead palsy the farado-muscular excitability is lost ;
there is no anaesthesia of the skin ; the supinators are healthy. In
cerebral paralysis the electro-muscular contractility continues. These
diagnostic points are true in other paralyses as well as in that of the
facial nerve.

SECTION IV.

GENERAL NEUROSES, OF UNKNOWN ANATOM
ICAL ORIGIN.

CHAPTER I.

CHOREA — CHOREA ST. VITI — ST. VITTJS'S DANCE.

ETIOLOGY. — St. Vitus's dance may be called a purely motor neu-
rosis, all of its symptoms being attributable to a morbid irritability of
the motor nerves, while no derangement, or, at least, no constant de-
rangement of the sensory or intellectual function can be detected.

The pathogeny of chorea is obscure. None of the anatomical re-
searches hitherto made upon the subject, nor any study of its symp-
toms, give us any positive information as to the real point whence the
morbid irritation of the motor nerves proceeds. The results of the
somewhat rare autopsies which have been made upon subjects who
have died of chorea have been either negative, or else so discordant
that any lesion discovered in the central organs of the nervous system
cannot be referred to the chorea, but rather to some accidental com-
plication, or to the disease of which the patient died. The general
implication of nearly all the cerebro-spinal motor nerves altogether
contradicts the supposition that the origin of the disease lies in the
peripheral nerves. The complete integrity of the other cerebral
functions makes it improbable that the movements of chorea originate
in the brain. On the other hand, certain pauses in the muscular rest-
lessness which occur, particularly during sleep and during the action
of chloroform, would seem to imply that the motor influence is derived
from the brain rather than from the spinal marrow. There is no good
ground for the hypothesis that chorea is dependent upon a dispropor-
tion in size between the spinal canal and the spinal marrow, or upon
inflammation of the vertebrae, or upon spinal irritation, for we do not
even know that the seat of the malady really lies in the spinal
marrow.

CHOREA. 379

In considering its etiology, in the first place, we are struck by the
prevalence of the .disease at the time of the second dentition and at
the period of puberty. It often happens that an individual suffers
from the disease at both these periods, and remains free from it during
the interval. This accounts for the belief of the laity, that the com-
plaint returns every seven years. Before the sixth year of life the
disease is rare ; and it is equally uncommon after the age of fifteen.
Even the most advanced old age, however, is not entirely secure from
it, and in such cases the affection exhibits a peculiar intractability.
The predisposition to the disease is far greater in the female sex than
hi the male ; and in certain cases an almost unmistakable hereditary
tendency to St. Vitus's dance has been observed. Moreover, hydraemia,
anaemia, and rheumatism seem to augment the tendency to this affection.
It undoubtedly is going too far to regard the connection between
chorea and rheumatism as constant ; but it cannot be denied that a
remarkable number of chorea patients have already suffered from acute
or chronic rheumatism, or else, during the disease or after it has sub-
sided, a rheumatic attack sets in. In like manner, inasmuch as false
heart-murmurs are very often heard in the hearts of chorea patients
(and although many of them may be considered as blood-murmurs,
and due to anaemia and to nervous derangement), yet the number
which are certainly dependent upon valvular disease is large enough
to enable us to judge how many of the patients have already suffered
from rheumatic pericarditis and endocarditis. One of the most severe
cases of chorea which I have ever witnessed was in a girl fifteen years
of age, each one of whose joints successively became swollen ; and
another was in a girl, twenty years old, who had bad disease of the
heart. Besides the mimic instinct, various mental emotions, especially
fear, have been assigned as causes of chorea, as have also the irritation
of worms in the intestines, onanism, pregnancy, and other agents. In
particular instances it of course is very difficult to determine the
causal connection between chorea and such influences, which so often
exist without perceptible effect upon the health. The effect of exam-
ple, which plays the principal r61e in the chorea major as well as in
chorea minor, is instanced in the epidemic appearance of the disease
sometimes observed in boarding-schools. The influence of pregnancy
is inferred from the fact that, among adult patients, very many of them
are pregnant women. Chorea rarely appears before the end of the
second month of pregnancy, and its appearance is equally rare in the
later half of the term. Once established, it usually lasts until after
delivery.

SYMPTOMS AKD COURSE. — St. Vitus's dance is characterized by
movements of the voluntary muscles, which, however, are not excited

380 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

by volition, but take place against the will of the patient, his con-
sciousness meantime being perfectly unclouded. These movements go
on not only at times when the patient does not intend to move, but
also when he moves voluntarily. In the latter case, as the voluntary
motion is complicated by the involuntary, the proposed action of the
patient either is frustrated or carried out imperfectly or awkwardly.
The involuntary movements of chorea are distinguished from the more
simple and monotonous jerking muscular contractions of epileptic or
hysterical attacks, by a great degree of variety, and by a sort of com-
bination which imparts the aspect of design to the motions. A cursory
and superficial observer would be much more apt to overlook and mis-
take the former than the latter.

In most instances the disease begins very gradually, and is not
recognized for some time. It may be noticed, perhaps, that the sick
child drops and breaks things a good deal ; that it does not sit still ;
that it writes badly, or makes more mistakes than usual in playing on
the piano, and it is accordingly scolded or punished that it may be
more careful and correct its awkwardness. The poor child often
does not know what it has done, and, in consequence of the unjust re-
proaches, becomes either depressed and sad, or else grows irritated and
perverse. The restlessness of the muscles, meantime, becomes more
and more apparent. The acts of awkwardness become more frequent,
and are grosser than ever. The child misses in reaching for its tum-
bler, pricks itself with its fork, or makes extraordinary grimaces. The
morbid character of this condition often becomes apparent to the minds
of its relatives quite suddenly, and without the occurrence of any
special change in the symptoms. It is much more unusual for the dis-
ease to develop suddenly, and from the outset to present the remark-
able symptoms which characterize St. Vitus's dance in its later stages.

In pronounced chorea, the utmost variety of motions follow each
other, in a manner so manifold and grotesque that the term " insanity
of the muscles," which has been applied to it, seems quite appropriate.
In the face, the eyebrows are alternately contracted and separated,
the forehead wrinkled and smoothed, the eyelids rapidly winked, and
now and then are fast closed for a moment. The eyes roll hither and
thither, the mouth is successively pursed up, closed, then suddenly
opened and shut, now spreading into a smile, now drawn down as if
to weep, while the tongue is often and suddenly thrust forward. The
head itself is turned, now forward, now backward, now sideways ; the
shoulders are raised and sunken. The upper extremities are flourished
about. In the elbows, hands, and finger-joints, flexion and extension,
pronation and supination, abduction and adduction, alternate with
one another. Similar movements, which, however, usually are of less

CHOREA. 381

active character, are observed in the lower extremities. The muscles
of the trunk also take part in the general restlessness, so that the spi-
nal column is inclined either forward, backward, or sideways ; some-
times in one direction, sometimes in another. If the patient be lying
in bed, he often is tossed upward, or toward the foot of the bed, or is
even pitched out of it. In the worst forms of chorea, the patients are
quite unable to sit upon a chair, but immediately slide off from it to
the ground. This morbid restlessness grows all the more intense and
general, if the patients pay attention to it, especially if they know that
they are being watched. Sometimes it is stronger upon one side than
upon the other, or is chiefly confined to one or more limbs. The mus-
cles of the larynx and those of respiration but seldom take part in the
disease, and the sphincters and the muscles of the pharynx probably
never do so. Owing to the constant motion, it is difficult for the pa-
tients to go to sleep ; when once asleep, however, the muscular twitch-
ing ceases. Occasional exceptions to these rules are now universally
ascribed to dreams of movement, ever since Marshall Hall originally
suggested the idea.

Nearly all the motions of the body, with exception of those of
respiration and deglutition, are seriously embarrassed by this restless-
ness of the muscles. The articulation becomes indistinct, as the inten-
tional movements of the mouth and tongue are accompanied by others
which are unintentional. In eating, the fork misses the lips ; in drink-
ing, the beverage is spilt, so that a patient often has to be fed. Some
of them have great difficulty in offering their hand, others are unable
to dress and undress themselves. Even in slight cases all occupations
requiring delicacy of manipulation become impossible, as, even in
walking, the feet only touch the ground by a circuitous route, and, as
the entire body is constantly making superfluous and irregular move-
ments, there is something very remarkable and characteristic in the
gait of the patient.

The other functions and the general health suffer comparatively
little. It is easy to comprehend why the patient should be dispirited,
sensitive, and wilful, when we consider that for weeks he has not been
master of his motions, and that he has been constantly taunted about
the mistakes he makes. Not unfrequently the grimaces of the pa-
tient are so at variance with his actual humor, or so unsuitable to the
subject of conversation, as to give him a foolish, imbecile look, although
his mind is quite sound. When of long duration, however, the accu-
racy of judgment seems really to be impaired, and other intellectual
disorder arises. Sometimes, but not always, there is complaint made
of headache and pain in the back. Although, strange to say, there i?
ao especial fatigue of the muscles, the joints of the limbs are some-

382 GENERAL NEUROSES, 01 UNKNOWN ANATOMICAL ORIGIN.

times swollen and painful from the constant strain and motion. Un
less there be some complication, there is no fever, although the pulse
usually is accelerated. The appetite, digestion, secretion, and excre-
tion do not present any constant peculiarity. When the disease has
been of long duration, the nutrition of the patient suffers in conse-
quence of the loss of rest, and he becomes anaemic and thin.

The course of chorea is chronic. It rarely terminates before the
end of six or eight weeks, and it often continues for three or four
months. In rare instances it becomes habitual, and lasts throughout life.
Its course either is marked by remissions and exacerbations, or else the
malady increases constantly to its acme ; then remains stationary for
a while, after which it gradually abates. Recovery is the most usual
termination of the complaint. The cases are exceptional in which
chorea becomes habitual ; but it often happens that, in certain of the
patient's motions, a trace of the former disease remains for years, as
well as a tendency to relapse. Permanent mental derangement is
also rare. Death scarcely ever occurs, unless through complications.
There are, however, a few instances on record where it has been the
result of the disease itself. In these cases the muscular contractions
rapidly become extremely violent and general. This was followed by
collapse and coma, in which the patient perished.

TREATMENT. — Our scant knowledge as to the causes of chorea
puts a fulfilment of the causal indication almost out of the question.
When the disease has been preceded by symptoms of anaemia and
hydraemia, the ferruginous preparations are to be selected from the
long list of reputed remedies against chorea. We do not attempt to
say whether carbonates of iron (gr. v — gr. x pro dosi), or ferr. hydro-
cyanic (gr. ij — gr. iij pro dosi), which are the favorites, possess any
real advantage over the other preparations. When the patient has
suffered from rheumatism, the sulphur-baths (as recommended by
Baudeloque), an ounce of sulphuret of potassium to twelve gallons of
water, in which the patient is to spend an hour at a time, are as much
to be recommended as are the chalybeates, when there is anaemia.
Where worms are known to exist in the intestine, the treatment may
be commenced by a dose of santonin or other anthelmintic.

The number of remedies proposed for the cure of the disease itself
is very large. As, however, the disease usually subsides spontaneous-
ly, hi the course of six or eight weeks, and as it very rarely is possible
to cut the malady short in a less period of time, we are very apt, it
quite candid and circumspect in measuring our success in special in-
stances, to be in doubt as to whether the chorea abated in consequence
of a six weeks' administration of the medicine prescribed, or whether
it " got well of itself." Fortunately most of these remedies, if cau-

CHOREA. 383

liously given, can do no harm. This is especially true of the prepara-
tions of zinc, particularly of the oxide. The sulphate, the valerianate,
and the hydrocyanate of zinc, are less innocent, but not more to be
relied upon, nor are the ammonio-sulphate. of copper and nitrate of
silver. Romberg's valuable opinion is in favor of arsenic ; and, indeed,
where we have determined to employ the metallic nervines, Fowler's
solution (gtt. iij — gtt. v t. d.) is to be preferred to all others. The
narcotics may be dispensed with, as a rule, in treatment of chorea, and,
moreover, are apt to be so ill-borne that we often have regretted the
administration of an evening dose of Dover's powder or morphine to
insure the rest of the patient. My experience as to the action of
opiates is, however, in opposition to that of one of our great authori-
ties. Trousseau urgently recommends the administration of large
doses of morphine, and claims, too, that they are remarkably well
borne. Strychnine, another medicine for chorea, strongly recommended
by Trousseau, and which has been given, as directed by him, at first
in very small doses, afterward in larger ones, until slight signs of
poisoning set in, has met with little approval in Germany. Their in-
troducer's own experience, which by no means resulted in sudden or
even in rapid cures, offers no encouragement to make use of these
noxious remedies. This is also true of the proposed hypodermic in-
jection of curare. With this article the certainty of benefit is by no
means proportionate to the dangers incidental to an overdose. When-
ever the vertebrae are sensitive to pressure, a few leeches or cups may
be applied by the side of the spine, to be followed by counter-irritants
to the skin. Care should be taken, however, not unnecessarily to dis-
figure the necks of young girls by scars ; hence we should avoid the
use of tartar-emetic ointment. Cold affusion upon the back, which is
probably the best method of producing determination to the skin,
seems to be of decided benefit in some cases, especially in cases of
long standing, although it sometimes aggravates the disease. The in-
halation of chloroform is an excellent palliative for the severer forms
of the chorea ; but further experience only can determine whether the
repeated and long-continued exhibition of this article, pushed to the
point of complete narcotism, has the effect of abbreviating it. A more
careful trial will be requisite ere the general adoption can be sanctioned
of the practice of forcibly holding or tying patients, a practice which
has been proposed by several authorities. Benedikt declares that,
".out of more than twenty cases of chorea, treated by him by the con-
stant galvanic current, not one has failed to recover." The current
which he employs is just strong enough for the patient to feel it dis-
tinctly, and he applies it along the spine, the patient standing erect.
Painful currents aggravate the symptoms. During convalescence we

384 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

should endeavor to teach the patient, by a systematic and humane
system of discipline, to resist the involuntary motions by the force 01
his will.

CHAPTER II.

LOCKJAW — TRISMUS — TETANUS.

ETIOLOGY. — Like chorea, lockjaw is a derangement of the motor
function. The symptoms of this disease are ascribable to a morbid
excitement of the motor nerves, the participation of the sensory nerves
in the disease being but slight, and, for the most part, of a secondary
character. In this malady, however, we know, with much greater cer-
tainty than we do in chorea, that the morbid irritation of the motor
nerves proceeds from the spinal marrow. This hypothesis is supported
rather than contradicted by the fact that the results of post-mortem
examination of the spinal marrow usually are negative in cases of
tetanus, and that real tetanic spasms are seldom observed in cases of
grave organic disease of the spinal cord. It would be quite impossible
for motor impulses to originate from a spinal marrow reduced to a mass
of debris, or whose elements were otherwise degenerate or destroyed,
wnile experience teaches that the lesions from which abnormally-active
impulses proceed are insusceptible of anatomical demonstration. At
the outset of the disease, tetanic spasms are generally produced by
the action of trifling but still appreciable irritants, which, acting upon
the extremities of the peripheral nerves, throw the spinal marrow into
a state of excitement, so that, at this period, the spasms, although dis-
tinguishable from other reflex symptoms by their greater violence and
longer duration, may be called reflex spasms. As the malady advances,
however, such causes are not required in order to give rise to the
cramps. The spinal marrow then remains permanently in the condi-
tion of intense excitement into which it is thrown by the motor nerves.

With regard to the etiology of the disease, a number of noxious
agents may be enumerated, which can be proved capable of inducing
the morbid state of the spinal marrow to whicn tetanus is due. First
among these are wounds, especially lacerated, punctured, and gunshot
wounds, and wounds in which foreign bodies remain lodged. Injuries
of this kind are more dangerous upon the extremities than upon othei
parts of the body ; but they never give rise to tetanus except under
certain conditions, of which, sudden change of temperature (such as
hot days followed by cold nights) Ts known to be one, while others are
unknown. JZardeleben aptly sums up this condition as follows: that
the wound is the predisposing agent, and the chilling the exciting
cause. We do nit know, however, what the changes in the nerve-

TETANUS. 385

tissues are which induce tetanus, nor how they affect the, spinal marrow.
The injection and swelling in the course of the nerve, between the
wound anithe spinal marrow, which have sometimes been observed, are
by no means constant. In other cases, lockjaw occurs from the effect
of cold, without any previous wound, as when a man has slept upon
the moist earth, or been wet while his body is heated. This form of
rheumatic tetanus is much more rare than the traumatic form. Here,
too, we are completely in the dark as to the ways and means by which
the lesion, suffered by the cutaneous nerves in rheumatic tetanus, is
transmitted to the spinal marrow. The tetanus observed sometimes
in newly-born infants (tetanus neonatorum) is usually regarded as a
third form of the disease, although it should properly be reckoned as
belonging to the traumatic variety. Tetanus neonatorum never occurs
excepting between the first and the fifth day after the fall of the navel-
string. Hence it has always been immediately preceded by a wound
(ligation and binding of the cord). The objection that, in some cases,
there is inflammation of the umbilicus, while in others there is none,
is not valid ; for, even in the wounds of adults which have caused lock-
jaw, although, in most cases, they are violently inflamed, and other-
wise affected, yet there have been instances in which the wound was
doing perfectly well, and was healing, or even was completely cica-
trized. Besides, in infantile tetanus, the ligation and division of the
umbilical cord can only be considered as the remote cause, while the
chilling of the skin, or other unknown agent, which sometimes seems
to be of an epidemic nature, must be regarded as the immediate cause.
Finally, a morbid condition of the spinal cord is induced by poisoning
with strychnine, which exhibits precisely the same symptoms as those
of lockjaw, so that the toxic signs induced by strychnine and brucine
have been called tetanus toxicus.

Traumatic and rheumatic tetanus is of far more frequent occurrence
m men than in women. Vigorous constitutions are more liable to it
than feeble ones. In the tropics the disease is more common than
with us ; and certain races, especially negroes, seem to be more prone
to the disease than Europeans.

SYMPTOMS AND COURSE. — Tetanus is characterized by continuous
tonic spasms, which principally Evolve the muscles of the trunk and
those of mastication, and which are marked by paroxysmal period?
of aggravation of extreme intensity.

The malady is usually preceded by signs consisting of a febrile
condition of no great severity, and pain, and stiffness in the back of
the neck, which may readily be mistaken for a trifling fit of rheuma-
tism. If such symptoms make their appearance after receipt of a
wound of the character above given, and if at the same time the

386 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

aspect of the wound change, and should it become dry and pain-
ful, we may already fear great danger to the patient. When the
disease has fairly set in, the head at first is almost always fixed and
drawn backward, by rigid contractions of the muscles of the neck.
Tonic spasms of the muscles of mastication press the jaws firmly
together (lockjaw, trismus), and at the same time deglutition is im-
peded or prevented by spasm of the pharynx. From the nape of the
neck the disease extends over the muscles of the back. Thus the
entire body is bent backward in the shape of a bow. The abdominal
and thoracic muscles, however, are also involved in the spasm. Hence
the belly is tense, contracted, and hard as a board, and there is a sense
of constriction at the pit of the stomach, which is very painful to the
patient. More rarely the muscles of the extremities, particularly those
of the forearms, legs, hands, and feet, are attacked by cramps. The terms
opisthotonos, emprosthotonos, audpleurosthotonos, are severally applied
to the disease, according as the contractions preponderate in the poste-
rior muscles of the neck and back, in the anterior muscles of the neck
and trunk, or in those of the side, and according as the body is drawn
forward, backward, or sidewise. When there is no such preponderance,
so that the body lies rigid as a statue, the condition is called orthotch
nos. Opisthotonos is by far the most common form of the malady ;
the other varieties are rare. The contracted muscles remain upon the
stretch throughout the whole disease. From time to time, however,
paroxysms occur, in which the cramps are so severe that the muscles
sometimes are torn asunder. At such times the middle of the body iu
suddenly jerked into the air, so that no part of it touches the bed ex-
cept the head and heels. The muscles are hard as stone, and are the
seat of frightful pain, which can generally be compared to that of a
severe cramp of the leg. The contours of the temporal and masseter
muscles stand out in bold relief, imparting a peculiar expression of
countenance. This is still further increased by contractions of the
mimic muscles of the face. The forehead is wrinkled, the brows knit,
the eyes rigidly fixed, and sunken deep into their sockets. The angles
of the mouth are drawn outward, and the lips are drawn apart, expos-
ing the clinched teeth. The muscles of the extremities are affected
last ; this is an important point in diagnosis. At the outset of the
disease the paroxysms do not occur spontaneously, but are provoked
by the most trifling causes. Just as in a frog poisoned by strych-
nine, in which tetanic spasms may be induced by merely tapping upon
the table on which he lies, so the slightest touch upon the skin or
breath of air upon it, a faint jolt of the bed, the sound of shutting
a door, every movement which a patient desires to make, the acts
of chewing or swallowing, or even the suggestion of the idea, suf-

TETANUS.

tice to bring on a new attack. The inability to swallow, and the spas-
modic seizures induced by every effort to drink, create a certain resem-
blance between tetanus and hydrophobia. The paroxysms are of
variable duration. At first they are brief, but at the height of the
disease they may continue for a quarter of an hour, or even an hour,
ere the remission set it. Consciousness and the intellect generally
remain unimpaired until the last in this frightful malady, nor are many
of the other functions materially deranged. The unhappy patient
suffers from hunger and thirst, which he is unable to relieve. As in all
other violent muscular exertion, the skin is bedewed with sweat, and
the pulse is frequent and small. The enormous elevation of the tem-
perature, first pointed out by Wunderlich, is a matter of great interest.
Now and then it has been observed as high as 110° F., and immedi-
ately after death a further rise has been observed almost up to 112° F.
[This may be due to the muscular activity. Leyden and others
have shown that the same elevation of temperature occurs in tetanus
artificially induced in dogs. But similar rises are said to occur after
injury of the cervical medulla and other cerebral and spinal diseases
of the warmth-producing centres ; as in J. W. Teale's case, where
the temperature was 108°-122° for some weeks, as witnessed by
several physicians.] The bowels are usually somewhat constipated,
and sleep, though ardently longed for, is impossible. Another source
of anguish, as well as of the greatest danger, consists in the derange-
ment of the respiration. There is no obstacle to the entrance of the
air, but, as Watson aptly remarks, the chest is compressed as in a vice,
and respiration is made extremely difficult by reason of the rigidity
of the muscles. There are instances where the victim perishes only a
few hours after the outbreak of the disease. In such cases, the spas-
modic contraction of the diaphragm and other respiratory muscles so
increases as to completely arrest respiration and cause suffocation.
The majority of patients are not relieved from their sufferings so soon.
For three or four days, the cramps, and the frightful pain and dread of
suffocation which accompany them, continue to increase in duration
and frequence, the remissions becoming more and more imperfect ;
until the sufferer expires, either poisoned by carbonic acid resulting
from the imperfect manner in which respiration is carried on, and from
the augmentation in the consumption of the oxygen, or else dying
during some very severe paroxysm, through sudden and absolute inter-
ruption to the respiration. Sometimes the breathing is not so much
interfered with as to cause death from lack of oxygen. The disease
may then go on for weeks ere the patient, in a state of extreme emacia-
tion, and exhausted by privation of nourishment, succumbs to starvation.
Recovery is extremely rare. Transitory remissions, in which the

388 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

patient may even enjoy a brief refreshing slumber, should not be
allowed to deceive us. After such pauses the malady generally breaks
out with all its former severity, or even with increased violence. We
must not indulge in the hope of recovery unless the seizures continue
to diminish in length and frequence, distinct relaxation of the con-
tracted muscles occurring during the intervals, and unless the patient
become able to take food and nourishment. Even in the most fortu-
nate cases this takes place with extreme slowness ; and it is not until
after the lapse of weeks that the muscles entirely lose then- tension,
and the patient is completely well.

The symptoms of tetanus neonatorum are but little modified by the
peculiarities of the infantile organism. Here, too, the outbreak of the
disease usually is heralded by indistinct prodromata. The child cries
out frequently during sleep ; has blue rings around the eyes and lips ;
and lets go the breast which it has just seized with avidity. The
mother first becomes aware of the onset of the disease itself when she
finds that neither the nipple nor the finger can be inserted into the
mouth. The jaws stand several lines apart, but it is impossible to
separate them further. The malady increases rapidly. The muscles
of the face are also contracted spasmodically. The forehead is wrin-
kled, the eyelids firmly shut, and surrounded by converging wrinkles.
The alae nasi are dilated, the lips compressed and puckered, while the
tongue usually is fixed between the jaws. Besides this, there is opis-
thotonos, the head is drawn backward, and the spine arched like a
bow. A touch, or an attempt to move or swallow, provokes a violent
spasm ; but the remissions usually are more complete than they are
in the tetanus of adults. Respiration is impeded, during the seizures,
by the rigidity of the thorax and the tension of the abdominal mus-
cles. Attacks of suffocation arise, of which the child often dies in
from twelve to twenty-four hours. In other cases the breathing grad-
ually becomes insufficient, and the child succumbs to overcharge of the
blood with carbonic acid. Death then takes place more slowly, but
still within a few days, during which the child loses flesh rapidly.
Recovery from tetanus neonatorum' is likewise extremely rare.

TREATMENT. — For the fulfilment of the causal indication, a series
of surgical operations — even amputation of the wounded member —
have been proposed and practised. The success of these operations,
however, was by no means what had been anticipated of them, and
more recently they have been abandoned. From the prominent part
which is unmistakably played by exposure to cold, both in rheumatic
and in traumatic tetanus, warm and stimulating baths, as well as Russian
vapor-baths, would seem to be indicated. The objection, that the
manipulation necessary in giving such baths tends to aggravate the

TETANUS. 339

symptoms, only held good in two of JSasse's cases, and that only at
the very commencement, and not after the manipulation had been con-
tinued. This circumstance and the relief which the baths afford to the
patients imperatively demand their employment.

Upon the supposition that tetanus was an inflammatory affection
of the spinal marrow, the attempt was formerly made to fulfil the indi-
cation of the disease itself by blood-letting, local and general, and by
the exhibition of calomel to the point of salivation. Such procedures,
however, have been abandoned more and more in later times. Unfor-
tunately we do not possess any remedy capable of bringing back the
irritable state of the spinal cord to its normal condition. Even the
narcotics do not have this effect, although they are indispensable for
the purpose of alleviating the sufferings of the patient. To accomplish
this, large doses must be given ; so that, unless the approach of narco-
tism be vigilantly watched, there is danger of hastening the fatal
termination. If the patient cannot swallow, morphia should be given
hypodermically, or else clysters, containing twenty or thirty drops of
laudanum. Injections of tobacco are not of much greater service than
opium-clysters, and, unless the dose be regulated with extreme caution,
they are much more liable to give rise to a fatal collapse than the lat-
ter. The ansesthetics, if possible, are of still greater importance than
the narcotics ; but, unfortunately, their effects likewise are merely pal-
liative. Too free use of them must be avoided, and the patient must
not be kept in a state of permanent insensibility from chloroform.
The English recommend the stimulants, especially carbonate of ammo-
nia, brandy, and wine, to which they give much greater credit than to
blood-letting and the narcotics. Trustworthy observers have obtained
very great benefit from the hypodermic injection of a solution of curare
in tetanus. This treatment certainly deserves further trial. However,
owing to the very variable character of the curare, it will be necessary,
Drior to the exhibition of the preparation to be used, to ascertain, by
experiment upon animals or upon the healthy human being, how large
a dose may safely be administered. When this precaution has not
been taken, we must commence with very small doses (gr. -J to gr. £),
and gradually increase them to gr. % to gr. 1J. Demme advises that
a solution of one or two grains in one hundred drops of water be em-
ployed, ten drops of this to be injected as a dose. According to
Demme, the action of curare lasts four or five hours, and then begins
to abate ; and upon this fact the repetition of the dose may be reg-
ulated. It is most important that the patient should be kept in a
quiet chamber, with a uniform temperature, and that his eyes should
be screened from too bright a light.

For the tetanus neonatorum we may prescribe camomile-baths,

390 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

clysters containing a drop of laudanum, and, if the spasms be very
severe, chloroform may be administered, but with great caution.

CHAPTEE III.

EPILEPSY — FALLING SICKNESS — MORBUS SACER — HAUT-MAL.

ETIOLOGY. — Unlike chorea and tetanus, epilepsy cannot be called
a purely motor neurosis ; since the interruption which takes place, both
in consciousness and insensibility, is quite as essential an element of
an epileptic fit as the convulsions. The absence of one or other of
these symptoms renders the seizure imperfect.

We may assume that the excitement of the motor nerves, of which
the convulsions are the exponent, proceeds from the medulla oblongata
and the portion of the brain lying upon the base of the skull. This is
shown.

1. By the interruption of the functions of the hemispheres, which
accompanies the convulsions. It is not probable that motor impulses
proceed from the hemispheres at a time when the irritability of the
other ganglion-cells and nerve-fibres is extinguished.

2. Because convulsions, similar to epileptic convulsions, can be ex-
cited by continuous excitement of the basilar portion of the brain by
means of the induction apparatus, while no such result is obtained by
a like irritation of the various parts of the hemispheres.

3. Because l&issmaul and Tenner, in then* experiments upon ani-
mals, could still produce convulsions of a decidedly epileptiform char-
acter after extirpation of both hemispheres.

4. Schroeder van der IZolk has found that, in all bodies of epilep-
tics where the disease had been of long standing, besides numerous
inconstant lesions, there was alway a dilatation of the arterioles and
capillaries of the medulla, with thickening of their walls. The influences
which tend to produce this condition of the medulla oblongata, where-
by it throws the nerve-fibres passing through it or originating from
it into such intense excitement, and which, for brevity's sake, we call
a state of irritation, are probably of a manifold character. It is true
that the experiments of Eussmaul and Tenner have proved that
epileptiform convulsions may be induced by cutting off the supply of
arterial blood from the brain ; but they do not prove that arterial
anaemia of the brain is the sole cause of epileptic fits. Schroeder van
der Kolk believes that epileptic convulsions depend mainly upon an
increased afflux of arterial blood to the medulla oblongata. There is
no doubt, moreover, that the morbid irritability of the medulla which
occasions epilepsy may arise without any increase or diminution of its

EPILEPSY. 391

supply of blood, merely from the improper character of its nutriment
and from the admixture of certain materials in the blood. It must
also be admitted that the medulla may be thrown into an irritated
condition by the transmission of a morbid impression from remote re-
gions of the nervous system, whether central or peripheral. It is well
known that neuromata and cicatrices, or tumors pressing upon periph-
eral nerves, have sometimes occasioned epilepsy (although, indeed,
such instances are not common), and that the epilepsy has ceased
after section of the affected nerve or after removal of the cause. Per-
haps, also, cerebral tumors and other diseases of the brain and spinal
marrow may induce epilepsy in a similar manner by gradual transmis-
sion of a morbid irritability to the medulla oblongata. This supposi-
tion has received strong support from the result of recent experiments
by JBrown-Sequard, in which dogs, whose spinal marrows had been
injured, suffered from convulsions, although not immediately, but
some time after the receipt of the injury. It is difficult to say why
the morbid irritability of the motor nerves is not continuous, but mere-
ly occurs in paroxysms, with intervals which frequently are of very long
duration. Are we at liberty to suppose that it is only now and then
that the medulla oblongata falls into this morbid state? Is there
really ground for the hypothesis that the cause of epilepsy is a tran-
sitory spasm of the muscular fibres of the arteries, with consequent ar-
terial anaemia? Is it true that poisons, or the irritation of remote
tumors, or other agents which give rise to epilepsy, act by the occa-
sional provocation of the spasm of the muscles of the blood-vessels ?
May we, with Schroeder van der Kolk^ compare the ganglia of the
medulla oblongata to a Leyden jar, or to the electric organ of certain
fishes ? May an epileptic fit be likened to the spark from the Leyden
jar, or to the discharge of the electric organ of the electric fish ? and
do the ganglia reload themselves, as it were, for a fresh explosion
during the intervals ? Or, finally, is the morbid state of the medulla
constant, but requiring the additional stimulus of some new transitory
irritant transmitted to it from some remote point in the brain, the spi-
nal cord, the peripheral nerves, or the intestines, in order that the
fit may occur ? Of all these conditions we as yet have no accurate
knowledge, and it were idle to advance other hypotheses in explana-
tion of the foregoing ones.

Equally inexplicable is the constant coexistence of irritability of
the spinal marrow with palsy of the cerebral hemispheres. The arrest
of sensation and consciousness has sometimes been regarded as a sec-
ondary condition, resulting from the convulsions. It has been attrib-
uted in part to venous engorgement of the brain, arising from com-
pression of the cervical veins by the contraction of the cervical mus
75

392 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN

des, and in part to surcharge of the blood with carbonic acid, in con-
sequence of spasmodic closure of the glottis. The fact that the loss
of consciousness and sensation and the occurrence of the convulsions
are almost always simultaneous ; and that the former sometimes pre-
cedes the latter ; and that in many cases of incomplete epilepsy it is
the sole symptom of the seizure, is a sufficient refutation of both hypoth-
eses. In like manner it must be declared that there is no proof as
to the truth of the theory of Schroeder van der Kolk^ that, in an epi
leptic fit, the ganglion-cells of the medulla excite a spasm of the vaso-
motor nerves of the brain, simultaneously with that which they induce
in the cerebro-spinal nerves, and thus cause cerebral anaemia and
palsy. So, too, with HenUs theory, which supposes the existence
of a plethoric and an anaemic form of epilepsy. He suggests that, in
the former, besides the more intense hyperaemia of the hemispheres
which induces the palsy, a lesser degree of hyperaemia, capable of in-
ducing symptoms of mere irritation, arises in the medulla oblongata ;
while, in the anaemic form, he imagines that the lack of blood in the
cerebral vessels occasions an increased blood-pressure upon the me-
dulla oblongata, inducing in it a degree of engorgement sufficient to
cause signs of irritation. Here, too, we shall refrain from further
theorizing, preferring to admit that to us the antagonism existing in
epilepsy, between the condition of the hemispheres and that of the
basilar portion of the brain, is entirely inexplicable.

Owing to the scantiness of our knowledge as to the pathogeny of
epilepsy, the statistics regarding its predisposing and exciting causes
are of but secondary importance. We do not know of one single
agent of which we can certainly predict that it will produce epilepsy ;
yet, besides this, we must admit that all the assigned causes of this
disease by themselves are incapable of inducing it, and that the co-
operation of a second and unknown factor is always requisite. Statis-
tics show epilepsy to be a very common disease, about six epilep-
tics being found in every thousand individuals. Females suffer from
it somewhat more frequently than males. There is no age which is
completely exempt from it ; but the majority of cases occur between
the tenth and twentieth years of life ; next to this, between the sec-
ond and the tenth year, and between the twentieth and thirtieth year.
It seldom commences during old age, and its congenital occurrence,
as well as its appearance in the first months of life, is equally rare.
Hereditary predisposition plays an unmistakable part in its produc-
tion ; its existence is demonstrable in nearly a third of all cases. It
is especially apparent in persons descended from epileptic parents, par-
ticularly from epileptic mothers, as well as in individuals whose par-
ents or ancestors have been insane or intemperate. In some families

EPILEPSY. 393

epilepsy afflicts many of its members throughout several generations.
Sometimes the disease skips a generation, and the grandchildren are
attacked, but not the children. Cachectic subjects, drunkards, and
onanists, are more liable to it than healthy, vigorous persons, although
the latter are by no means exempt. The chief of its exciting causes
are violent mental emotions, sudden fear, terror, and the sight of an
epileptic fit. In more than a third of all cases the first attack has fol-
lowed upon some violent fright. The most common structural altera-
tions found in the skull and brain, which, however, like the mental
emotions, are not constant, and only give rise to epilepsy under cer-
tain unknown conditions, are asymetry, imperfect development of the
skull, diffuse thickening or exostosis of the skull, thickening, adhesion
and ossification of the dura mater, tumors and deposits in the brain,
chronic hydrocephalus, and cerebral hypertrophy. Alteration in the
appendages of the brain, which Wenzel mentions as a constant lesion
in epilepsy, is absent in the majority of cases. Changes of structure
hi the spinal marrow are not so frequently found in epilepsy as similar
changes in the brain; but perhaps this is because the former have
been less diligently examined than the latter. We have already
alluded to the neuromata, tumors, and scars, which sometimes give
rise to the disease by the pressure which they exert upon peripheral
nerves. In a similar manner, epilepsy may arise from an abnormal
irritability of the sensory nerves, induced by some severe irritation at
their peripheral extremities. Thence, according as the irritation in-
volves the nerve-tips of the thoracic organs, those of the organs of
digestion, or those of the urinary or sexual apparatus, the epilepsy is
classified into epilepsia cardiaca, pulmonalis, abdominalis, nephritica,
uterina, etc. It is manifest that we may easily err in attributing the
disease to irritability of one or other of these organs. Uterine epi-
lepsy is perhaps the least ambiguous of all, as a gradual transition
from hysteria to epilepsy may sometimes be observed, and as some
women become epileptic upon their first coitus. The presence of
worms in the intestines also is sometimes an unmistakable cause of
the disease.

SYMPTOMS AND COURSE. — Epilepsy is a chronic disease, character-
ized by convulsive attacks, accompanied by loss of consciousness, with
intervening periods of exemption of variable and sometimes of very
»ong duration. Loss of consciousness during an epileptic fit necessa-
rily involves loss of sensation and incapacity for voluntary motion. In
incomplete epilepsy, the "petit mal" of the French, there usually are
no convulsions during the seizure, or else merely a few twitchings.
Such rudimentary attacks, of course, are not to be called incomplete
epilepsy unless they alternate with well-pronounced seizures, or arise

394 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

from them, or unless, in the further course of the case, the rudimen-
tary fits gradually developed into perfect ones.

In some patients an epileptic fit is regularly, or at all events gen-
erally, ushered in by an aura. This aura receives its name from a
sensation as of a vapor which rises from the extremities toward the
head, and terminates in the fit. This prodromic feeling, however, is
only described by a few patients. Far more frequently there are other
sensations, such as a sense of creeping, of warmth, or numbness, or a
peculiar pain in some part of the body darting thence to the brain,
which herald the attack, and which are called the " aura epileptica."
Instead of this sensible signal, the fit is preceded in other instances by
twitching or palsy of some part of the body. This is called the motor
aura, in contradistinction to the sensory aura above described. In
other cases, again, the seizure is ushered in by abnormal phenomena in
the organs of sense, hallucinations, visions of sparks or of colors, buzz-
ing in the ears, the report of a loud crack or other sound, dizziness,
and sometimes by the regular recurrence of phantasmagoria of more
or less grotesque character. This latter form of sensorial or mental
aura by no means proves that the epilepsy is of central origin, in the
sense, at least, that the malady is the result of appreciable lesion of the
brain ; nor is the occurrence of an aura arising from the extremities to
be regarded as a proof of the peripheral origin of a case of epilepsy.
It is an extraordinary fact that an epileptic fit may sometimes be
averted by binding a ligature firmly above the starting-point of the
aura, and thus, as it were, isolating it. That even such a phenomena
as this is no proof of the peripheral origin of an epilepsy is in some
degree manifested by the experiments above mentioned of JBrown-
Sequard. Here it was demonstrated that, in the dogs made epileptic
artificially by wounding of the spinal marrow, a fit occurred wherever
the skin was irritated within the province of a particular branch of. the
trifacial nerve. We cannot tell whether the fit was preceded by an aura
in these dogs, but we may positively conclude from these experiments
that, even when the individual epileptic attacks are induced by periph-
eral irritation, the real cause of the disease may consist in palpable
structural disease of central organs.

Whether preceded by an aura or not, the outbreak of the paroxysm
is usually announced by a shrill cry, whereupon the patient loses all
sense and falls to the ground, usually backward or sideways. He
scarcely ever has time to seek a convenient place, but falls, regardless
of place, often in the most perilous situations, striking, perhaps, against
a hot stove, a sharp corner, or down the stairs. There are but few
epileptics, whose disease is of long standing, who do not carry with
them the marks of more or less severe injury. The fall is usually fol-

EPILEPSY. % 395

lowed at first by tonic contractions, in which the body and extremities
are extended, the head drawn backward or to one side, the mouth
firmly closed, the eyes wide open, and rolled upward or inward, the
thorax fixed, and the respiratory movements arrested. After a few
moments, during which the jugular veins become distended and the
face purple, the tonic spasms are converted into clonic ones, which soon
convulse the whole body. The. countenance, hitherto immovable, is
now thrown into active agitation ; the angles of the mouth are drawn
hither and thither, the forehead and eyebrows twitch, the eyes open
and shut, the jaws are forcibly pressed together, and are worked back-
ward and forward, so that the teeth grate audibly. The teeth are not
unfrequently broken off, the tongue bitten through, and even the lower
jaw may be luxated. Upon the lips there appears a saliva, rendered
frothy by the constant movements of the mouth, and which, too, is
often bloody from wounds of the tongue or cheeks. The head is jerked
forward and backward, and from side to side ; while the convulsive
twitchings of the muscle of the trunk pitch the body hither and thither.
In the extremities, and especially in the upper extremities, quick
kicking, striking, twisting, and twitching motions occur in turn, and
with such violence as sometimes to result in luxation or fracture. The
fingers usually are flexed, the thumb being pressed into the palm of
the hand, a sign which the laity erroneously believe to be pathog-
nomonic. Sometimes it seems as if the violence of the convulsions
were remitting, and as though the fit were about to abate ; but the
lull is soon followed by a fresh outbreak, and the convulsions become
more violent than ever. Sometimes the twitching is superseded, for a
few moments, by a tetanic condition like that by which the paroxysm
commenced. Throughout the whole fit the respiration is much em-
barrassed, owing to the impediment offered by the tonic or clonic
spasms of the respiratory muscles to the regular heave and fall of the
chest. Still more is this the case when the glottis is closed by spasm
of the laryngeal muscles. As on all other occasions of unusual mus-
cular exertion, the beat of the heart is accelerated, the pulse is small
and sometimes irregular, while the skin is bathed in sweat. The
bowels and bladder are often evacuated unconsciously ; more rarely
erections and seminal emissions occur. Throughout the entire seizure,
consciousness is so completely extinguished that the patient is not
aroused, nor does he betray any sign of pain, even though he may
strike against a red-hot stove, or fall into the fire so as to completely
char a limb. Opinions are divided as to the state of the reflex ac-
tion during the attack. I admit that I find it very difficult to take
note of it in the more violent class of fits. During seizures which aro
mild from the beginning, or during the period of subsidence of more

396 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

severe attacks, I have been able fully to confirm Rorribercfs observa-
tions, that tbe reflex action is not arrested. The patient closes his
eye if the conjunctiva be touched, and winces if his face be sprinkled
with cold water. One observation of Basse's is exceedingly strange
and difficult of explanation. In a patient of his he found the electric
contractility was extinguished in the muscles of the thorax and ex-
tremities. After the fit has lasted for ten minutes, or, at most, for a
quarter of an hour (although it may seem much longer to the by
standers), either it subsides, the twitching gradually growing weaker
and weaker, and finally ceasing, or else it may stop suddenly, the con-
vulsions being all at once followed by complete muscular relaxation.
The fit often terminates by a long, sighing expiration ; more rarely by
vomiting, by passage of gas upward or downward, or by a profuse
evacuation of the bowels.

It rarely happens that a severe epileptic seizure is immediately
followed by complete recovery ; after the attack is over, generally,
unless violently roused, the patient falls into a deep sleep, with pro-
longed stertorous respiration. If awakened from this, he usually looks
blankly or anxiously around him. He does not know what has hap-
pened, and can scarcely account for his being in a strange place, or in
bed, or wounded. His sole desire is to be allowed to sleep. Next
morning, though still somewhat unwell and low-spirited, and com-
plaining of confusion about the head, he has recovered his faculties,
and all traces of the attack vanish in course of the day.

Many epileptic fits differ considerably from the typical seizure
above described, varying in duration, violence, and in the extent of the
convulsions. The variation of the condition which immediately suc-
ceeds the paroxysm is of more importance. While, as a rule, the pa-
tient is able to attend to his business the day after his fit, there are
instances in which every attack, or else each severe one or rapidly
recurrent succession of them, is followed by mental derangement, and
other disorders of innervation. The former may consist of well-marked
fits of mania. It is often necessary to protect both patient and by-
standers from violence, to put on a strait-jacket, or even — horrible to
relate — there is no other resource but to confine the patient in the
mad-house, even during his lucid period, because it is known that his
madness will recur with his next paroxysm. In other instances the
fit is succeeded by a condition usually called partial insanity : for ex-
ample, the patient may have an irresistible inclination to run. In
other cases, the patient may be in an irritable mood, which is quite
foreign to him on ordinary occasions, breaking out into violent rage
upon the slightest provocation. Sometimes the memory and mental
acuteness are impaired for some days. We may also mention that, in

EPILEPSY. 397

stead of the latter condition, an opposite one has been reported by
certain observers, the intelligence of the patient becoming remarkably
acute. With regard to the other disturbances of innervation, we have
already alluded to the transient and permanent paralysis of the ex-
tremities, which perhaps is due to exhaustion of the irritability conse-
quent upon excessive nervous excitement. The fit may also be fol-
lowed by aphonia, by dysphagia, or by asthmatic attacks, etc.

Two forms of the incomplete epilepsy are recognized (especially in
France), slight convulsive movements accompanying the lapses of con-
sciousness in one, and being absent in the other. In the former, the
genuine " petit mal," the patient is seized with giddiness, often amid
business or conversation. He has time, however, to seat himself, or
staggers, and sinks slowly to the ground, without outcry. His face is
pale, his eyes fixed. A few convulsive twitches play over the face,
and the extremities, especially the upper ones, are slightly tremulous.
In a few minutes, however, the patient recovers ; looks wildly around
him, not knowing what has happened, sometimes making confused
utterances ; then, after the lapse of a few minutes, all perturbation sub-
sides ; there is no somnolent stage, and the patient is once more in
a condition to resume his vocation.

In the still milder and more rudimentary form, the vertige epilep-
tique, the patient does not fall. His consciousness alone is clouded ;
his eyes stare, and his countenance is pale. He does not twitch, but
lets fall whatever he may have in his hand, and halts in his speech.
The attack passes off in a few seconds, and the patient proceeds with
nis conversation or business, as if nothing had happened. There are
many intermediate stages between epileptic vertigo, the petit mal^
and complete epilepsy, a description of which we forego.

It would be quite difficult to furnish a concise account of the gen-
eral course of the disease, and of the condition of the patient between
the paroxysms. We have stated already that epilepsy is a chronic
affection. Hence cases in which one epileptic fit is not followed by a
second one ought not to be counted as epilepsy, but rather should be
regarded as belonging to the eclampsia, a form of disease only distin-
guishable from epilepsy by the acuteness of its course. The pauses
which intervene between the fits differ greatly in different individuals.
In some patients, a year or even several years elapse, and, in many,
months and weeks pass away, ere a new attack occurs, while in other
patients one or more fits occur daily. Very often, during a period of
four or six weeks, there is not a single attack ; this is followed by a
series of fits, recurring at short intervals. As a general rule, however
the pauses between the paroxysms in the same individual remain toler-
ably uniform ; although, as the malady progresses, especially in young

398 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

persons, the fits gradually come closer together. Perfect regularity
in their sequence is never seen, or but for a short time ; although in
women a periodical type .is sometimes approximated to when the seiz-
ures only occur at the periods of menstruation. In some persons the
attacks are more frequent during the day; in others they occur chiefly
at night. Nocturnal epilepsy is considered to be of an especially
malignant and obstinate character. Generally speaking, it is im-
possible to detect the exciting cause of the fit ; but, besides the fits
which occur spontaneously, there are always some which are unmis-
takably ascribable to psychical emotion, especially to fear; others
which may be traced to onanism, to coitus, and, as we have already
stated, to menstruation. Sometimes we can tell, from the altered mood
of the patient, and from his complaint of a sense of weight in the
limbs, headache, or dizziness, that an attack is coming on. In the out-
set of the disorder, the seizures are usually of the complete form ; as
it advances, and especially in inveterate cases, both complete and in
complete paroxysms occur. It more rarely happens, instead of this,
that the attacks are incomplete in the beginning of the disease, and
afterward develop into complete ones as it advances. As, in some
cases, each fit is followed by temporary mental aberration, so, too, in-
veterate epilepsy often results in permanent and incurable insanity —
either mania, confusion, or idiocy. But, besides the large number of
epileptics who close their lives in the insane asylum, the "morbus
sacer " (which the ancients ascribed to the wrath of the gods), in course
of time, nearly always completely changes the mental and physical
habit of the patient. Acuteness of judgment is lost; memory and
power of imagination diminish ; the gentler and nobler impulses recede
more and more ; while the excited and unbridled propensities, lascivi-
ousness and gluttony, often impel the patient to commit violent or
criminal actions. They often avoid society, are odd and capricious ;
are very troublesome to those around them, and are apt to burst into
violent fits of anger. The personal appearance of the patient also un-
dergoes a change in cases of long-standing epilepsy. Esquirol calls
attention to the coarseness of the features of an epileptic, to his swollen
eyelids, his thick lips, faltering look, and clumsy body, remarking that
this malady deforms the most beautiful countenance.

With regard to the termination of epilepsy, recovery must be re-
garded as rare, in spite of the opposite opinion of many observers,
especially Herpin. The more distinctly the malady is traceable to
hereditary tendency, and the more plainly it depends upon structural
disease of the brain ; the longer it has lasted, the more violent the fits,
the more frequent their recurrence, and the deeper the impression
which they leave behind them, so much the less is the chance of re-

EPILEPSY. 399

sovery. Such a termination appears to occur somewhat more fre-
quently among women than among men; and it is likewise more
common among children and old persons than among those in the
prime of life. We must beware of building our hopes too sanguinely
upon the long-continued intermission of the fits, as this disease very
rarely terminates with one violent paroxysm. A better sign is when
the fits not only grow rarer, but feebler, and when a distinct change is
taking place, both in the physical and mental condition of the patient.
In some women, but not in all, there is an intermission of the fits
during pregnancy. Such an intermission, however, is nearly always
observed during the course of acute febrile disease. Sometimes a per-
manent cure dates from the period of invasion of some acute intercur-
rent malady, from the appearance or cessation of the menses, or from
the occurrence of some violent mental emotion. It is said that the
exanthematous eruptions, and the breaking out of old ulcers, some-
times have a similar effect. But, although epileptics seldom recover
fully from their disease, and although they are not often long-lived, yet
they rarely die during an epileptic fit, in consequence of suspended
respiration, or of extravasation of blood into the brain, or of general
paralysis during the comatose state which follows the fit. Their death
is much more frequently due to the progress of cerebral disease, which
has given rise to the epilepsy, or to the effects of injuries which the
patient has received during his paroxysms, and, oftener still, he dies
of some acute or chronic affection, which is in nowise connected with
the epileptic disease.

We shall have more to say regarding the difference between epi-
leptic and hysterical convulsions when we come to treat of hysteria.
In my opinion no sharp distinction can be drawn between epilepsy
and eclampsia, although the convulsions occurring in protracted cases
of urasmic intoxication are considered to be eclamptic by some authors
and epileptic by others. It is tolerably easy to unmask simulated cases
of the disease. The anaesthesia is often enough cleverly imitated, and
we must not expect that all malingerers will wince when burnt,
pricked, or pinched, although such reaction hardly ever fails to occur
when a violent stimulus of this kind is applied to them unawares and
suddenly. Watson's suggestion, to direct the nurse, in the hearing
of the patient, to pour hot water upon his feet, the nurse being
previously instructed to pour cold water instead, is both practical and
original. Nearly all malingerers keep the fit up too long, and devote
too much attention to certain symptoms, which they believe to be
pathognomonic, such as turning in the thumbs, foaming at the mouth,
etc., which an attentive observer cannot fail to perceive. It is a sus-
picious sign, when a person who claims to have been epileptic for a

400 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

long time has no traces of injury upon the tongue or peripheral parts.
Very often the simulation is recognizable because the patient makes a
bad imitation of the aura. He usually includes this symptom in his
comedy, believing it to be an essential one, and in enacting it often
makes a most wonderful exhibition. The surest sign that the fit is
not feigned, is the dilatation of the pupil, even upon exposure of it to
Bright light. This is a token which no impostor can imitate.

TREATMENT. — As a prophylactic means against epilepsy, Momberg
recommends that the intermarriage of families, in whom the malady is
hereditary, should be avoided. An epileptic mother should never
suckle her own child, but should intrust it to a vigorous wet-nurse.

In fulfilment of the causal indication, the treatment 'of epilepsy is
extremely difficult. Apart from the cases whose history gives no clew
as to the cause of the malady, and even when our information is com-
paratively of a satisfactory nature, we can only ascertain a few of the
secondary causes ; and it is not at all common for the disease to sub-
side after they have been allayed. An epilepsy, whose first outbreak
was unmistakably provoked by the presence of worms in the intestine,
or by a neuroma, usually persists, although the worms have been ex-
pelled, and the neuroma extirpated. If the malady be consequent
upon fright, the fits nearly always recur, though the patient be screened
from further terrors. However, our poor prospect of success should
not deter us from taking account of all causes which may have contrib-
uted to produce the malady, trifling though their apparent effect may
be. Experience teaches that such practice sometimes, although rarely,
leads to the happiest results. In the present uncertain state of our
means of treatment of this disease, even such exceptional successes
are of importance, and may serve as a guide to our proceedings. It is
our duty, in assuming the charge of an epileptic, before resorting to
the so-called specifics, so to regulate the external relations of the pa-
tient, his habits, and his bodily health, that every suspicious condition,
to which the origin of the disease can in any way be ascribed, may be
corrected. Thus, as feeble, cachectic persons are more liable to the
disease than robust and vigorous ones, all excessive or exhausting
mental occupation should be forbidden to the patient, and in its stead
a moderate exercise both of body and mind should be advised. Epi-
leptic children must not sit six hours a day on the school-benches ;
but, if possible, should live in the country, should spend most of their
time in the open air, and should take cold baths under proper super-
vision. We should carefully ascertain whether the patient be addicted
to great sexual indulgence, to onanism, or to intemperance in drink •
and, where such vices are discovered, they must be opposed with inex-
orable sternness. When the patient shows signs of anaemia and hv

EPILEPSY. 401

ircemia, a nourishing diet, an abode in the open air, wine, and iron, are
the proper remedies. If the impoverishment of the blood and cachexia
depend upon scrofula, rachitis, or tertiary syphilis, appropriate treat
ment must be employed. Should there be suspicion of plethora, let
the diet be reduced, and made to consist more of vegetables, and cause
the patient to drink plenty of water and to exercise freely. On the
other hand, avoid general blood-letting ; for epileptics, though quite
tolerant of medicines (particularly the nauseants), do not bear bleed-
ing well. If a scar, foreign body, or tumor be found pressing upon a
peripheral nerve, or if a neuroma be discovered upon it, an operation is
indicated. This applies especially to cases in which an aura arises from
the affected spot. As positive benefit is sometimes obtained by such
operations, the knowledge that in many cases neuromata and tumors
are extirpated in vain, should not deter us from operating again. The
application of setons and moxas, and the use of pustulating ointment
to the nape of the neck, are measures which are much in vogue in the
form of epilepsy dependent upon structural disease of the brain and
skull. Inunction of pustulating salve upon the scalp, and even trepan-
ning, has also been advised in such cases. We refer to the principles
laid down in the second part of this section with regard to this subject.
Where a tumor, a spicula of bone, an exostosis, or other disease,
encroaches upon the cavity of the cranium, and compresses the cere-
bral vessels, we can comprehend why trepanning should be of benefit,
especially to the convulsions, upon the supposition that the operation
affords more room for the brain and its vessels. When there is reason
to suspect that the epilepsy is induced by the presence of intestinal
worms, anthelmintics are indicated. We must be cautious, however,
how we encourage the too sanguine hopes of recovery, in which a
patient is too apt to indulge who has discovered joints of tape-worm
in his stools.

For other forms of abdominal epilepsy a cure may perhaps be found
at the baths of Karlsbad, Marienbad, etc. (Bomber g). In uterine epi-
lepsy, chronic uterine infarction and excoriation of the os must be
treated according to rules already laid down. It is in this form of all
others that the causal treatment affords the best results.

In order to meet the indications from the disease itself, Schroeder
van der IZolk urgently recommends repeated application of cups and
leeches to the nape of the neck, followed by blisters, issues, and
setons. This author regards the above as the only rational treatment^
believing that it alone is capable of reducing the morbid irritability of
the medulla oblongata, and of relieving its congestion,, He considers
that all other remedies tend merely to promote the cure by their action
upon the remote cause of the disease, by benefiting any morbid condition

402 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

which may exist in the brain or intestines, etc. Whether the theory
be right or wrong, the success which Schroeder van der Koltfs mode
of treatment has attained imperatively demands its adoption. In two
very severe but still recent cases of epilepsy I have applied leeches to
the back of the neck (four at a time), repeating the application at in-
tervals of from a fortnight to four weeks. The after-bleeding was en-
couraged by means of elastic cups. The influence of this treatment
upon the number and violence of the fits was so brilliant that I could
not make up my mind to desist from the blood-letting, and to proceed
to the derivatives and medication. If the measures advised in discuss-
ing the causal indication, as well as the procedure above proposed,
remain without effect, nothing is left but to have recourse to the
remedies which are reputed to have a specific action against epilepsy.
It would savor too much of pessimism to deny that the commendation
awarded to these articles is based upon a certain amount of benefit
derived from them, but, unfortunately, it must be admitted that we
are quite ignorant as to the conditions under which one or other of
them is to be preferred. In this respect the most experienced physi-
cian stands upon a par with the tyro. He must try one or other of
these remedies, and, if it fail, must try another ; and, in this frightful
disease, he should never remain idle on account of mere theoretical
considerations. With respect to the use of the anaesthetics and nar-
cotics, excepting atropine, we agree with Schroeder van der Kolk in
condemning them, and for similar reasons. In epilepsy our task is not
to allay an exalted sensibility or pain, but to soothe the undue reflex
irritation which causes the convulsions. Now, narcotics actually tend
to increase reflex irritability, insomuch that in large doses they pro-
duce convulsions. Chloroform, too, although it interrupts sensation
generally, augments the reflex action. A person under its influence
is like a decapitated frog ; its reflex movements are more active than
ever, although it feels no pain. Atropine is an extremely energetic
article, but it seems nearly always to act favorably upon both the se-
verity and number of the fits, even in cases of very long standing.
True, I have not seen complete recovery of inveterate cases, and T
have never used atropine in recent ones. Moreover, even at a dose
not exceeding one-fiftieth of a grain, not only did some of my patients
complain of a disturbance of vision, so that they could not do the sim-
plest work, but they suffered for hours with a dryness in the throat
which actually prevented them from swallowing solid food. Trousseau,
who believes belladonna to be the most efficient remedy against epilepsy,
gives the following directions for its exhibition with his characteristic
thoroughness and precision : Extract of belladonna and the pulv. herb,
belladonna, aa 3j, are to be made into one hundred pills. Of these

EPILEPSY. 403

the patient must take one daily during the first month ; with every
succeeding month he is to raise the dose one pill up to five, ten, fif-
teen, and twenty pills or more. The entire dose is always to be taken
at once. When any improvement takes place, the last dose is to be
continued for a while, and then gradually reduced in quantity. The
prime condition of success is patience on the part both of physician
and patient. Instead of the pills, we may use a solution of atropine
(atropine gr. ij — in spirit vini. rectif. 3 ijss), a drop of which corre-
sponds to one of the pills. We, therefore, begin with one drop, and
gradually increase to twenty. Of the metallic preparations, those of
zinc have the greatest reputation. Latterly, instead of white oxide of
zinc, formerly given to the extent of two drachms daily, the salts
of zinc have corne into use, especially the valerianate and hydrocya-
nate, and, above all, the acetate. The dose of the latter is twelve grains
a day at firSt ; subsequently more. This remedjr is said to be most
efficacious in young subjects, and in so-called abdominal and uterine
epilepsies. Heim and Rorriberg recommend nitrate of silver in doses
of two to four grains, but it must not be continued long enough to
produce argyria • ammoniated sulphate of copper and arsenic are now
little employed. Of the vegetable nervines, artemisia vulgaris and
valerian have the best reputation. Five or ten grains of the former
are to be given in powder, or else an infusion of one or two drachms
in beer. Of the valerian we at first may give a drachm daily, in pow-
der or electuary, gradually increasing the dose to half an ounce.
Quite recently, bromide of potassium has been one of the most gener-
ally employed articles in the treatment of epilepsy ; many say they
have used it with remarkable success, while others report its absolute
failure.

My experience of the efficacy of bromide of potash in epilepsy has
been greatly increased of late, and I can now speak much more
decidedly on the subject than two years ago, when preparing the
seventh edition of this work. The following circumstance induced me
to use the remedy in as many cases as possible, and to watch the
results : I heard that two cases of inveterate epilepsy, that I had for
years treated without any benefit, had been completely cured by a
so-called specialist, whose advertisements were to be found in the
columns of almost every newspaper. I investigated the subject more
closely, and found that in one patient, whose governess had for years
kept an accurate journal, and whom I had not lost sight of, the
attacks had been absent for several months, and that the general
health, which had been much impaired, was decidedly better. This
" specialist " refused the petitions of numerous patients of limited
means to moderate the high price of his medicine or to give a pre-

404 GENERAL NEUROSES, OR UNKNOWN ANATOMICAL ORIGIN.

scription for it, so I had a bottle of it analyzed by my colleague
Hoppe-Seyler. The analysis showed that the blue mixture consisted
of a solution of bromide of potash ( 3 jss — § vj) colored with indigo.
Both patients had taken the remedy in considerable doses. At first
only two tablespoonfuls were given daily — but after ten days four,
after ten days more six spoonfuls ; after that the dose was increased
more slowly, being gradually raised to ten, fifteen, and twenty table-
spoonfuls. So it appeared that in this case, as in most others where
secret remedies prove useful, it was not the remedy but the mode of
using it that was the secret; and I thought it probable that the
contradictory assertions about the action of bromide of potash were
greatly due to the fact that different observers had not given it with
equal perseverance and in the same doses. I determined to imitate
the treatment of the " specialist " where practicable, and induced other
physicians to do the same — and I became convinced that, thus used,
in large doses for a long time, although it will not cure all cases of
epilepsy, it will in many cases relieve the attacks for a considerable
period, and in some will even remove advanced impairment of the
psychical functions. Neither in my own practice, nor in that of
others, have I, of late, seen a case where the intervals between the
attacks did not grow longer. Even patients who had previously
received no benefit from the bromide of potash began to improve, when
the dose was raised to eight or ten tablespoonfuls of the above solution
daily. On long-continued administration of the bromide of potash, I
have often observed a papulous exanthema, and in one case an exten-
sive furunculosis which disappeared on stopping the medicine, and
again recurred after it had been resumed. After taking large doses
of the bromide for a time, some patients complained of loss of appe-
tite, confusion in the head, and catarrh of the air-passages, just as
they do after protracted use of preparations of iodine. Lastly, in two
cases there was some psychical change, evinced by great restlessness,
and diminished mental activity. In most cases, there were none of
these unpleasant concomitants ; hence I feel justified in urgently recom-
mending further trials of the bromide of potash in epilepsy, especially
in long-continued and large doses.

To these specifics may be added a large number of medicaments
which have been recommended with more or less urgency. Among
these are assafostida, folia aurantiorum, radix paeonse, viscum album,
oleum terebinthina, and oleum animale Dippelii, indigo, and others.
It is a good rule, in administering specifics, to give them exactly
in the form and dose prescribed, and not to pass too soon from one
article to another; and, on the other hand, to bear in mind the

ECLAMPSIA INFAKTUM.

405

fact that there are a great number of medicines which, for a while,
seem to do good, but which afterward fail as though the system had
become used to them.

The indications from the disease itself require that the patients
should be protected from the injuries which they are apt to inflict
upon themselves during the fits. Whenever circumstances permit, an
epileptic should not be permitted to go unwatched. This is the best
and surest preventive. It is a good plan to let the patient sleep in a
bed made with high sides, like a child's crib, but such measures do
not dispense with the necessity of further watching, since, if the pa
tient were to happen to He upon his face in such a bed, he might read
ily be smothered. The patient must not be bound nor held fast dur-
ing the fit, nor should his thumbs be forcibly unclinched. Many people
believe that the attack will soon subside if this be done. After the
fit is over, those patients generally feel best who have been allowed to
struggle through it unmolested. The next symptomatic indication is
to take the measures already recommended for the purpose of averting
a coming paroxysm and of cutting it short. On the whole, compres-
sion of a limb, from which the aura seems to proceed, is not advisable,
even although we may avert the fit by so doing, since, in the first
place, the patient feels worse after thus repressing an attack than if
he had had one ; and, in the second, because his next seizure is apt to
be of unusual violence. This is also true as regards the use of strong
emetics at the commencement of the aura. Sometimes it is possible
to arrest the fit by compression of the carotids. Such a practice, how-
ever, is very difficult to carry out during the attack, and might do
harm if awkwardly performed ; hence we would hardly recommend it.1

CHAPTER IV.

ECLAMPSIA INFANTTTM.

THE eclampsia of parturient and of puerperal women is very often
dependent upon a morbid condition of the gravid uterus, upon the re-
tention of portions of placenta after delivery, or upon other and un-
known disorders of pregnancy or of child-bed. We therefore refer the
subjects of puerperal and parturient eclampsia to the text-books of
obstetrics, just as we have already referred those of other puerperal
conditions of the womb, ovaries, and vagina.

ETIOLOGY. — We have called eclampsia an acute epilepsy. Here,
too, there are convulsions with loss of consciousness ; but, unlike epi-
lepsy, the recurrence of the fit, instead of continuing for years, lasts

406 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

for a few days or hours only, at the end of which time the eclampsia
terminates either in recovery or death.

As regards the pathogeny of eclampsia, the same remarks apply
which we have already made concerning epilepsy. For reasons al-
ready given in detail, we may regard it as proved that the morbid
irritability of the motor nerves, of which the convulsions are an indica-
tion, originates from the medulla oblongata and base of the brain.
There also seems to be no doubt but that causes, similar to those
which result in an habitual irritative condition of the medulla ob-
longata, and epilepsy, may often (and especially during childhood)
induce an acute temporary state of irritability in the medulla with
eclampsia. Strictly speaking, the animals upon which Tenner and
EUssmaul experimented died of eclampsia, and not of epilepsy. It
is more than probable, also, that congestion may be capable of in-
ducing a state of acute irritability of the medulla, and may thus give
rise to eclamptic seizures. This sometimes happens, owing to the in-
troduction of foreign matter into the blood, as is shown in the rapidly
fatal convulsions which sometimes arise in uraemia and in cases of
narcotic poisoning. In this category, too, the convulsions belong,
which arise — especially in children — in consequence of infection from
miasmatic or contagious diseases, as also are those which usher in an
attack of scarlatina, measles, or small-pox; as well as those arising-
from the febrile crasis, and from fever-heat, and which often announce
the commencement of pneumonia and other inflammatory diseases of
childhood. The convulsions proceeding from the progress of acute
diseases of the brain and spinal marrow, and which are analogous to
the form of epilepsy arising from cerebral tumors and other chronic
disorders of the brain, are not counted as eclampsia, or, if so counted,
are distinguished as a separate and symptomatic form. Convulsions,
however, which proceed from excitement of the cerebral ganglia, trans-
mitted thence to the medulla oblongata, and which are the result of
terror and other emotions, are regarded as true eclampsia. Most fre-
quently, however, the medulla oblongata seems to derive the morbidly
irritative state, from which eclampsia proceeds, from an excitement
which is transmitted to it from the peripheral nerves. To this class
belong the convulsions from teething and from intestinal worms, and
those which occur from painful injury of the skin.

The antagonism between the hemispheres and the basilar portion
of the brain is as great in this disorder as it is in epilepsy ; and we are
quite unable to explain why the convulsions are accompanied by loss
of consciousness.

With regard to its etiology, it is to be remarked that, at the period
during which a state of habitual irritation of the medulla is most rare,

ECLAMPSIA INFASTUM. 407

its predisposition to acute irritation is greatest. Newly-born infantSj
and those who are but a few months old, are the most frequent suffer-
ers from eclampsia. The disease is rare after the first dentition, and
still more rare after the second. The tendency to eclampsia is often
congenital, all the children of a family sometimes being afflicted in
this way. We do not know what the diseases or constitutional defects
are, on the part of the parents, which determine this predisposition in
their children. It occurs in vigorous, full-blooded children, as well as
in the puny and anaemic, and in boys quite as often as in girls, perhaps
oftener. Besides the exciting cause of the disease already mentioned,
the practice of allowing the child to nurse immediately after the
mother has been extremely angry, is believed to be a frequent cause
of eclampsia. Inexplicable as such an idea may be, it would be
neither judicious nor ri ^h* to slight it, and to oppose the appropriate
precautionary measures, which consist in not letting the child have the
breast immediately after the mother has been angry, until after the
breast has been drawn.

SYMPTOMS AND COURSE. — The only form of the disease which is
apt to set in suddenly and without warning is that which, during child-
hood, often substitutes the chill of older persons as a precursory symp-
tom of the acute exanthemata in pneumonia, and in other inflammatory
disorders. For a day or two the child is restless during sleep, and
sleeps with its eyes partly open, contorting its face and grating its
teeth from time to time, and starting when touched. Even while
awake, a difference in its manner is observable. The child is cross,
does not seem to enjoy its play, cries a great deal, and often changes
color. The character of an eclamptic fit is precisely like that of an
epileptic one. Here, too, at first, there are usually tonic convulsions,
which last for some moments ; the head is thrown back, the extremi-
ties extended, the eyes turned up, and the respiratory movements
arrested. Then, clonic spasms begin, which extend over the muscles
of the face, head, trunk, and extremities, throwing the entire body (or,
what is more rare, one side of it alone) into convulsive motion. The
spasms equal the epileptic convulsions in violence. The face is red-
dened and slightly cyanotic ; frothy saliva appears upon the lips ; the
skin is bathed in sweat ; the belly is inflated from air which has been
swallowed; the respiration is much embarrassed, and the pulse is
small and frequent. At the same time, consciousness is entirely sus-
pended, and with it all sensation, even of the most powerful stimulus,
is extinguished. A fit of this kind, however, rarely passes off as soon
as an epileptic fit, but often lasts from a quarter to half an hour, or
even longer. In private practice, the physician far more frequently has
opportunity to see eclamptic fits than epileptic ones, as the former
76

408 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN. .

often last until he arrives, while the latter usually pass over while the
messenger is still seeking him. A year or two ago I saw a child in an
eclamptic fit, which lasted for twenty-four hours, without interruption,
although there were occasional remissions. The fit usually terminates
with a long-drawn deep expiration, often, too, by a profuse evacuation
from the bowels. This rarely occurs suddenly during the height of the
attack, but more usually after its violence has somewhat subsided.
The child then falls into a deep sleep, and if, next day, we do no*
make our visit too early, -we may find it playing busily, as if nothing
had occurred. But it frequently happens that there is more than one fit.
A series of them often succeed one another at short intervals. A
repetition of them may be anticipated, when the sleep is not sound
after the first one has subsided, and when the children throw them-
selves about, gnash their teeth, and when their limbs twitch from time
to time. The subsequent fits resemble the first one in all essential
points, differing only in their degree of violence and in their duration.
Many children never have more than one eclamptic attack. In others,
they recur from time to time. The more plainly it can be shown that
these recurrences are the result of fresh irritation, so much the less
doubt will there be that we have an eclampsia to treat, and not
epilepsy. And, on the other hand, the less distinctly demonstrable
the exciting cause of the repeated paroxysms is, so much the more
doubt will there be whether they are eclamptic or epileptic. This
point can never be determined at the first fit, since its exciting cause
often enough eludes detection. Death may occur, during the fit, from
arrest of the respiration, and acute carbonic-acid poisoning, from ex-
haustion, or during the subsequent period of coma. Eclampsia is a
very dangerous complaint among children during the first months of
life, and a large proportion of those attacked die. In older children
the prognosis is more favorable, and the disease usually terminates
hi recovery. It will be readily understood that both children and
older persons are apt to die where the convulsions, with loss of con-
sciousness, are an accompaniment of grave disease of the brain or
spinal marrow, although in such instances it can hardly be said that
they die of eclampsia. The same may be said of the so-called sequelae
of eclampsia. When seizures of this nature are followed by idiocy,
palsy, squinting, or other grave disorder, it certainly is more than
probable that they, as well as the fits, depend for their origin upon
autritive disorder of the central organ.

TREATMENT. — I believe that it is very difficult, and often quite im-
possible, to determine whether an attack of convulsions, accompanied by
loss of consciousness, depends upon anaemia or hypersemia of the brain.
or whether either of these conditions exists. If the previous health of

HYSTERIA.

409

the child have been good, and his appearance still be one of robust
ness and vigor during the fit, I would advise the administration of a
clyster of one part vinegar and three parts water, the application of
cold compresses to the head ; and, if the convulsions do not soon sub-
side, the application of leeches behind the ears, in numbers correspond-
ing to the age of the patient. We cannot give medicine during the
fit. After it is over, and should we fear a recurrence, we may give a
laxative of calomel and jalap, or one or two doses of calomel with the
oxide of zinc. On the other hand, if the child be puny and enfeebled by
long sickness, let him have an enema of valerian, or camomile tea, with
one or two drops of tincture of castor ; or, if this be ineffectual, a clys-
ter of emulsion of assafcetida (3ss — j to § iv). Sinapisms may also
be applied to his calves, and he may be put into a warm bath. Other
means are not to be had recourse to until after the fit has subsided.
Apart from the cases in which eclampsia is symptomatic of cerebral
disease, of uraemia, or the initiatory stage of some acute disorder, it is
of importance to determine from which province of the nervous sys-
tem the morbid irritation proceeds which is acting upon the medulla
oblongata, for it will depend upon such determination whether we
give a laxative, an emetic, an antacid, or an anthelmintic, or whether
we ought to resort to some other course of treatment. I consider it
unjustifiable to dose every child, who has had an eclamptic fit, with
calomel and oxide of zinc, " in order to prevent his having another."
If the stupor which follows the paroxysm be very profound, cold affu-
sion should be prescribed. On the other hand, if there be severe col-
lapse, we should order wine, camphor, and musk, and other stimulants.

CHAPTER V.

HYSTERIA.

ETIOLOGY. — Hysteria is even still less susceptible of classification
in any particular category of nervous diseases than are epilepsy and
eclampsia. In this protean malady, derangement of the sensory, mo-
tor, and psychical functions is nearly always combined with disorder
of the circulatory and nutritive systems. Sometimes one set of symp-
toms predominates, sometimes another ; and there often is an exalted
excitability in one part of the nervous system, expressed in the form of
hyperaesthesia or spasm, and which is complicated with interrupted irri-
tability of some other region, evinced by anaesthesia and paralysis. We
cannot as yet give a satisfactory answer to the question as to the exist-
ence of actual although impalpable material alteration in the nervous
elements, to which the various forms of nervous derangement characteris-

410 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

tic of hysteria are ascribable. For instance, although most patients are
extremely susceptible to external influences, yet this may be due quite
as well to exalted irritability of the peripheral nerves as to an over-
excitability of those portions of the brain whence consciousness of the
impression is derived. The former supposition is contradicted by the
wide-spread character of the hypersesthesia, as well as by the simul-
taneous derangement of the psychical function ; the latter by the in-
tensity of the reflex action by which the hyperaesthesia is accompanied.
The latter condition is only ascribable to increased irritability of the
peripheral nerves, or to coexistent increase of irritability in the spinal
ganglia. Hence the most plausible theory of the origin of hysteria
is that to which Hasse adheres, namely, that the affection springs from
a nutritive derangement of the general nervous system, both central
and peripheral.

The facts that hysteria is observed almost exclusively in females,
and principally in females between the age of puberty and that of the
extinction of the sexual function, and that in a great number of cases
hysteria is accompanied by a morbid condition of the sexual organs,
have given rise to the supposition that hysteria is a disorder of the
general nervous system originating in the nerves of the organs of gen-
eration. This theory, although somewhat too narrow, is true in a
iarge number of cases. We have come to the conclusion, from the
various phenomena described in previous chapters, that disease not
unfrequently is transmitted from the nerves which it immediately af-
fects to other nerves, and to central organs ; and by analogy we may
infer that a morbid state of the nerves of the sexual apparatus may ex-
lend to those of the rest of the body, as well as to the central organs.
The mild derangements of innervation, the hyperaesthesia, the aug-
mented reflex irritability, and the psychical disorder which shows itself
in some women during the period of menstruation, would seem to de-
pend upon a process of this nature, and, as it were, form a physiolo-
gical analogue to the pathological state of the sexual organs which
exists in hysteria. There cannot be any doubt that some cases of
hysteria arise in this manner. If a uterine infarction should develop
after an abortion or a severe labor in a woman who has previously
been healthy, and should this be accompanied by a well-marked hys-
teria ; should the hysteria continue as long as the uterine disease lasts,
and should it disappear as soon as we succeed in discussing the infarc-
tion, it would be manifest that to the uterus alone were due the mani-
fold nervous derangements which we call hysteria. All diseases of
the womb and ovaries do not exert an equal influence in producing
this disease. Besides the infarctions, it is more especially the ulcera-
tions of the os uteri and the flexions of the womb which induce hvs-

HYSTERIA.

terical symptoms, while, in cases of malignant growth and in destruc-
tive affections, hysteria is much less common. Of the ovarian diseases,
the dermoid cysts of moderate size cause hysteria much oftener than
do the very large sacs resulting from cystoid growth. In some cases
irritation of the genitals arising from excessive coitus, or imperfectly
effected coitus, from onanism, or from simple sexual excitement, has
an influence upon the nervous system, similar to that of the textural
lesions of the sexual apparatus above mentioned. But it would be
both narrow-minded and frivolous, and indicative of a most imperfect
comprehension of the nature of woman, to ascribe all cases of hysteria,
whose source could not be traced to structural change of the genitals,
to over-excited sexual appetite, or to its unnatural gratification. I
certainly am no optimist, and indeed rather incline in the other direc-
tion, but I cannot believe that all the hysterical widows and old maids
who are hysterical, without exhibiting any structural disease of their
genital apparatus, suffer from suppressed sexual passion, or gratify it
in an illegitimate manner.

Where there is much predisposition to hysteria, it may proceed
from any other organ of the body which may happen to be diseased
I have seen a strongly-pronounced case of it in a young girl with a
tedious affection of the stomach, but whose sexual function was per-
fectly normal.

We must entirely agree with JETasse, in his delicate and excellent
description of hysteria, that the frequence with which hysteria occurs
in childless women, in widows, and in old maids of the upper class of
society, is attributable rather to psychical than to physical influences.
The effect of strong psychical impressions upon the nervous system at
large is often quite evident even in perfectly-healthy subjects. Per-
sons under the influence of great terror stand as if thunderstruck, un-
able to move from the spot ; an angry man clinches his fists, bites his
lips, and moves restlessly to and fro without act of his will. More-
over, we not unfrequently find that the influence of extreme terror or
anguish of mind produces complete anaesthesia, and excessive intel-
lectual exertion often gives rise to hypergesthesia. Indeed, every day
we have the opportunity of observing that mental emotion has an in-
fluence upon the excitability of the vaso-motor and nutritive nerves ;
that it causes the cheeks to redden or to grow pale, the muscles or
the skin to contract or to relax, the tears or saliva to flow. If all
these various disturbances of innervation can arise from transitory
psychical impressions, it is easy to imagine that permanent nervous
derangement, with disease of texture of the nervous system, may de-
velop under the influence of the permanent mental emotions, which
beset a woman who finds all the expectations and hopes of her life dis-

4:12 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

appointed, who believes that she has failed in her vocation, and who,
under the depression consequent upon such feelings, is unable to divert
her thoughts into other channels. I admit that the manner in which
the continuous action of psychical impressions modifies the nutrition
of the general nervous system, and thus leads to hysteria, is obscure ;
but it cannot be maintained that our insight into the mode in which
disease of the genital nerves extends to other portions of the nervous
system is any more clear. The state of mind which leads to hysteria
depends not only upon external accidents, but much more upon the
mental impression made by the accident upon the individual. A fate
which may befall one person, without producing any apparent effect,
may be the source of the deepest and most lasting depression in an-
other. I heartily agree with JETasse, that, though hysteria is often
seen in women wedded to impotent men, yet it originates quite fre-
quently in the sombre feeling and miserable consciousness of a wasted
life, which result when social claims of married life are not duly re-
spected, or when the sentimental anticipations and fantastic ideals of a
foolish girl are not realized.

The nutritive derangement of the nervous system from which hys-
teria arises may also be induced by improper nourishment. "We have
sufficient proof of this fact in the frequent occurrence of this complaint
in cases of chlorosis and impoverishment of the blood, unaccompanied
by any disease of the sexual organs, by sensual excitement or onanism,
and where it cannot be traced in the remotest degree to the psychical
impressions above alluded to.

There is great variety as to the degree of predisposition to hy»
teria. All the women with uterine infarction, or uterine flexion, or
who have ulceration of the os uteri, are not necessarily hysterical, noi
are all the old maids who believe their lives to have been thrown
away, nor all the chlorotic girls. On the other hand, I have no hesi-
tation in asserting that a tendency, either congenital or acquired, plays
a much more important role in inducing this affection than all other
causes mentioned hitherto. The truth of this assertion is easy of
proof. If we examine large numbers of women, we find moderate de-
grees of uterine infarction, slight flexions of the uterus, and erosions
of the os, to be so very common that the number of hysterical women
would be equal to that of the non-hysterical ones, if affections like
these alone sufficed to occasion hysteria, without the coexistence of a
decided predisposition to such disease. It rarely begins to manifest
itself before the twelfth or fifteenth year of life, and very seldom ap-
pears in old age. It frequently outlasts the period of child-bearing,
and continues in a moderate degree during the climacteric years. The
tendency to it is often congenital ; but, although a patient may have

HYSTERIA.

413

descended from an hysterical mother, and she, too, be descended from
hysterical parents, this alone is no absolute proof of the existence of
such hereditary tendency, as it may have proceeded from injudicious
training, which has likewise propagated itself in the family for gen
erations.

Constitution and temperament have no distinct effect upon the
tendency to hysteria. On the other hand, the mode of life of a pa-
tient, and her education, have a most decided influence in this respect.
The less a child is taught to control itself, the more it is allowed to
indulge in immoderate grief over a broken toy ; the more the rod is
spared, when it gives way to outbursts of excessive anger or passion,
stamping its feet and throwing itself upon the floor, all on account of
some disappointed expectation, or the refusal of some request, so much
the more apt will it afterward be to become hysterical. If we teach a
child to be industrious, to be conscientious, and to control itself; if we
prevent growing girls from knitting or doing worsted work all day
long, or from occupying themselves in other ways, which permit of
their indulging in dreams and reveries ; if we keep improper books,
likely to give them stilted ideas, out of their hands, we shall have
done our best toward averting the danger of hysteria. Hysteria is a
very rare phenomenon among men. Here, too, it usually proceeds
from derangement of the sexual apparatus, although this is not al-
ways the case ; but in men, likewise, it is only in instances of decided
congenital or hereditary tendency to the disease that it can be excited
by venereal excess, onanism, spermatorrhoea, and the like.

SYMPTOMS AND COURSE. — Owing to the complicated nature of the
symptoms of hysteria, and to the varied character of its course, it is
impossible to give a brief and comprehensive description of this dis-
ease. Hence we depart from our usual practice in describing hys-
teria, and, instead of drawing a picture of the affection itself, shall
give a classified discussion of its symptoms.

Derangement of sensibility is a very common symptom, and is
scarcely ever absent in any case of hysteria. General hypercesthesia,
or " nervousness," as the laity call it, is the first symptom of this class
to which we shall refer. It often exists for years uncomplicated by
any other form of the disease. This hyperaesthesia is sometimes
evinced by an unusual acuteness of the senses. Some patients are
able, by touch alone, to perceive the most trifling differences of
weight and temperature, and thus to distinguish objects from each
other, with their eyes shut, which healthy persons could not have
distinguished. It is easy to understand that a faculty of this kind
seems wonderful to the masses, and that it often is used for purposes
of imposture. In a similar manner some patients have their sense

414 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

of smell developed to a degree usually found in brutes alone. They
are able to distinguish persons and things in the most remarkable
manner merely by their olfactory sense ; or they may be able to hear
and to recognize the step of a person who is still far off. Similar
acuteness of the sense of taste has also been reported. Fortunately,
however, hysterical hyperaesthesia very rarely takes the form of ab-
normal acuteness of the senses, or else the number of clairvoyants
would be still greater than it is. Far more frequently the hyper-
sesthesia of hysteria shows itself in the annoyance produced by a very
slight degree of stimulation of the nerves of special sense. While, in
a healthy person, it requires a very loud sound, a very strong smell, a
very bitter or acrid substance, or a very bright light, to produce an un-
pleasant effect upon the senses, hysterical persons complain if we
elevate our voice a little in speaking, and beg us to talk in a whisper.
They will often banish all flowers from their room because they can-
not endure their odor ; or will reject their food if it contain the slight-
est particle of spice. To some hysterical persons bright daylight is
quite intolerable, so that they constantly keep their eyes closed ; to
others a red color is unendurable, and no one must approach them with-
out first putting off any red ribbon or article of clothing they may be
wearing. This great sensitiveness to comparatively slight stimulus is
often associated with idiosyncrasies. Certain forms of irritation, which,
from their quality rather than from their intensity, are repulsive to
healthy subjects, afford a sense of gratification to hysterical persons,
and conversely stimulants, which are pleasant to a well person, often
offend the senses of one who is hysterical. It is notorious that many
hysterical people love the smell of burnt feathers, and take assafcetida
without repugnance, while the odor of hyacinths, violets, and other
most agreeable perfumes is insupportable, to them.

Besides these signs of morbid irritability, there are other states of
excitement of the sensory nerves which must be regarded as of a dif-
ferent character. In the first place, there are neuralgias, especially
prosopalgia, migraine, mastodynia, and ischias, all of which are of com-
mon occurrence in hysteria. Closely related to these there is a form
of pain which is also very common, and which is generally confined to
one small point in 'the head (usually to one side of the sagittal suture),
and which is known by the name of davits hystericus. Besides this,
there is the almost never-failing tenderness, on pressure, of the back,
and finally those very peculiar hysterical affections of the joints
(Arthropathia hysterica) which consist in pain in the articulation,
ofteu of such exquisite severity and so obstinate a duration as to be
liable to be mistaken for grave inflammation. Morbid excitement of
the nerves of special sense may also occur, which cannot be accounted

HYSTERIA. 415

for by the action of any corresponding irritant. Some patients are
never free from the sense of a certain taste or smell ; some complain
of roaring and buzzing in the ears, or of spots before their eyes. It
is very remarkable that, besides these phenomena, indicative of exalted
excitability, and of a morbid irritability of the sensory nerves, there
should also be an anaesthesia, involving a variable extent of the surface
of the body. It is doubtful whether this anaesthesia be attributable to
suspension of function of the peripheral nerves, or to an extinction of
irritability at the nerve centres. I consider it very hard to determine
whether an hysterical person really is suffering from anaesthesia, or
merely indulging the caprice .of not showing signs of pain when
pricked, pinched, or burnt in particular parts of the body. There is
not the least doubt that such notions are of daily occurrence among
hysterical patients. If they only knew what a puzzling and interest
ing subject this matter of anaesthesia is, the number of hysterical cases
of this kind, no doubt, would increase vastly. I have seen a patient
who did not move a muscle while two streaks were being burnt along
her back with a red-hot iron, and yet there was not the slightest
ground for believing that she had anaesthesia of the back.

All the derangements of sensation hitherto described have de-
pended upon morbid irritability of the cutaneous nerves, and of the
nerves of special sense. Connected with these there is a series of per-
verted sensations in internal organs. While, under ordinary circum-
stances, we have either no perception at all (or, at most, a very ob-
scure one) of the condition of the internal viscera, as long as they are
in good order, and while, without laying our hand upon the heart, we
are unaware of its pulsation ; and while respiration goes on without
our consciousness of the necessity for such an act ; and while we have
no perception whatever of the ordinary state of our stomachs and
bowels, yet hysterical individuals have the greatest variety of com-
plaints to make as to the condition of their internal organs, and claim
to suffer the most extraordinary sensations. They nearly all complain
of palpitation of the heart— many of them of pulsation of the vessels.
Upon examining the heart-beat and the pulse, we may easily satisfy
ourselves that such sensations are but subjective ones ; and that the
shock of the heart is not really increased, nor is the pulse full and
hard. It is the same with the shortness of breath. Sometimes the
patients breathe laboriously and quickly, complain of the utmost op-
pression ; but, after exclusion of the possible existence of any disease
of the air-passages or circulation, or of a morbid state of the blood or
nutrition, capable of accounting for such dyspnoea, we may assure our-
selves that it is purely a case of hyperaasthesia or of perverted sensa-
tion. Besides this, although their digestion may be excellent, nearly

416 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

all hysterical patients complain of a sense of pressure and fulness ic
the region of the stomach, or else of cardialgia, and, independently of
the colic which sometimes troubles them, give most extraordinary ac-
counts of the sensations which they feel in their abdomens. Under this
head also come the thirst, often observed in hysterical persons, and
the frequently-recurring desire to empty the bladder, although it
is not full. Perverted sensation in the sexual organs is much more
rare than might be supposed, more so, indeed, than has been rep-
resented by many authorities. Husbands of hysterical women often
declare that their wives evince a disinclination to sexual intercourse,
and do not often exhibit much excitability. They seldom give an ac-
count of an opposite condition. Even in hysterical prostitutes it is
exceptional to see symptoms of nymphomania. In other cases, again,
coitus is very painful to the patient, although there may be no palpable
lesion of the genital organs.

The derangements of the motor function observed in hysteria are
scarcely less numerous and varied than those of sensation. Their
most common form is that of hysterical convulsions. There is no
doubt but that the morbid excitement of the motor nerves, which gives
rise to hysterical spasms, proceeds from the spinal marrow and me-
dulla oblongata. One of their characteristic signs is, that they never
cause loss of consciousness. It is usually supposed that hysterical
convulsions are of reflex origin, so that the spinal cord can only trans-
mit the impressions conveyed to it from the sensory nerves to the
motor nerves. As the convulsions frequently spring from impressions
produced upon the sensory nerves, or the nerves of special sense, it
seems probable that this theory is the correct one ; hence, in cases
where the convulsions seem to occur spontaneously, we must suppose
that the cause has eluded our observation. In some cases, hysterical
fits consist in a mere twitching of one or more of the limbs, especially
of the arms; They often recur, at short intervals, for a while, when-
ever the temper of the patient is excited, and whenever stimuli, even
of moderate strength, act upon the nerves of sensation or those of
special sense. In other cases the spasms extend more or less over the
entire body. They occur in violent paroxysms, and may almost assume
the appearance of tetanic spasms, and still oftener of epileptic convul-
sions. Opisthotonos, pleurosthotonos, and orthotonos, are seen often
enough in hysteria, as are also clonic convulsions, which set the face,
trunk, and extremities into spasmodic motion. The patient often
foams at the mouth, his thumbs are clinched in the palms of thr.
hands — the only sign, by which the attack may be distinguished from
an epileptic one, being loss of consciousness. Very often spasm in-
volves the group of muscles which operate in producing some complex

HYSTERIA.

417

act, such as yawning, laughing, crying, although the mental emotion
by which they are generally induced is not present. In this way fits
of spasmodic yawning, laughing, and weeping arise. Thus, spasmodic
expiratory movements, combined with spasmodic contraction of the
rima glottidis, and tension of the vocal cords, give rise to that obsti-
nate cough known as hysteric cough, and to its modifications, consist-
ing of barking and howling sounds. Spasmodic contraction of the
oesophagus, extending from below upward, gives the patient a feeling
as if a ball were rising from the epigastrium into the throat, a symp-
tom commonly called globus hystericus. Yery often hysterical per-
sons are troubled for a quarter of an hour, or even for hours at a time,
with eructations, which recur at short intervals, and during which a
quantity of inodorous air is belched up, usually with a loud sound.
If we watch the patient carefully, we can see, by the movements of her
mouth and throat, that she has previously swallowed this air. As
however, the majority of healthy persons are unaware of it, when they
swallow air in the movements of chewing and deglutition which they
make under the influence of violent nausea, I do not suppose that hys-
terical persons do it consciously and intentionally ; hence I have classed
this symptom among the disorders of motion. Just as anaesthesia and
hyperaesthesia of the sensory nerves may coexist, so in the motor sys-
tem hysterical convulsions may be accompanied by hysterical palsy.
Sometimes a single extremity alone is involved ; sometimes there is
hemiplegia. The fact, that the electric contractility is preserved in the
muscles of the palsied part, argues strongly against the peripheral
origin of this form of paralysis. If the peripheral nerves were diseased,
if they had lost their functional excitability, then electricity would be
just as powerless to excite them as the will is. Now, in hysteric
palsy, as every muscle which the patient is unable to contract volun-
tarily may be made to contract by application of the electrode to its
nerves, the palsy must be of central origin. Moreover, the rapid
changes which occur in hysterical palsy, especially the sudden way in
which it sometimes subsides, proves that its source is some slight and
easily-adjusted derangement of nutrition, and that it does not consist
hi serious structural change at the centre of volition, but, in some cases,
an excessive indecision and incapacity on the part of the patient tc
make up her mind to move the limb seem to be the reasons for the
palsy. I have no doubt that any one, as long as he is firmly persuaded
that he is unable to perform a certain act, is indeed incapable of gen
crating the necessary motor impulse. As the palsy in this class of cases
is due to a perverted mental impression, it should, properly speaking,
take rank among the psychical disturbances. Some time ago I saw a
patient suffering from a hemiplegia, which had lasted for months. The

418 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

history of the case was, that, for years past, the patient had suffered
from a similar palsy, which had disappeared at times, and then had re-
turned again. This peculiar behavior, together with other hysterical
symptoms, left no doubt as to the hysterical nature of the case. The
patient had repeatedly been assured that she could be cured by tho
application of electricity, and, as her reception at the clinic was delayed,
her anticipations as to the success of the treatment were wrought up
to the utmost pitch. The opening of her firmly-clinched hands, upon
the first application of the electrodes, unmistakably made a great im-
pression upon the patient, and from that time forth the paralysis im-
proved, and disappeared altogether in the course of a few weeks. No
doubt, any other remedy, in which the patient had felt equal confidence,
would have been quite as successful.2

Among the derangements of the vaso-motor and nutritive nervous
systems, the most striking are the uneven and fluctuating state of the
circulation in peripheral regions. Most patients constantly have cold
hands and feet, while, without apparent cause, the natural color of the
face gives place to a glowing redness, often accompanied by a disa-
greeable burning sensation. It is uncertain whether the secretion of
saliva, and that of the juices of the stomach and intestines, are also
modified by spasmodic contraction or paralytic dilatation of the vessels
of these organs; on the other hand, it undoubtedly is through de-
rangement of innervation that the determination of blood to the kid-
neys arises, which causes the profuse secretion of urine so often seen in
hysteria. This urine, which is voided in large quantities, contains but
little of the solid constituents of urine, is of a li rapid appearance, and
is often described as hysterical urine — urina spastica.

It is very difficult to furnish a brief and comprehensive description
of the psychical derangements observed in hysteria. In the first place,
at the outset of the affection, we are struck by the rapid fluctuations
which take place in the spirits of the patient, and by the sudden tran-
sitions from the most unbounded gayety to the profoundest gloom.
These symptoms are in part ascribable to the physical hyperaesthesia
described above, and in part to psychical hyperassthesia, by which it
is accompanied. As mental impressions produce an unusual influence
upon the temper of the patients, so, too, suggestions which would pro-
duce no apparent effect upon the spirits of a healthy person produce a
sense of annoyance or of repugnance in an hysterical one, although
more rarely the sensation is one of gratification and pleasure. While
the affection is still recent, it is almost always possible, by adroitly
conducting the conversation, in the course of a few minutes, to make
the patient laugh and weep alternately. It would seem also that,
besides this psychical hyperaesthesia, there may also be a psychical

HYSTERIA. 419

idiosyncrasy in hysteria, and that the odd and often very extraordinary
state of mind into which the patient falls is to be ascribed to this. As,
however, the real and imaginary impressions which inspire the patient
with a sense of disgust or displeasure are the predominant ones, her
spirits gradually become more and more depressed. She is constantly
sad, unhappy, and in despair about her fate, even although she may be
in possession of every thing which can tend to make life enjoyable.
This constant and apparently unreasonable lamentation and weeping
gradually tire out the sympathy of the friends of the patient. Her
relatives become indifferent to her troubles, do not listen to her com-
plainings, or allow it to be perceived that they are becoming tired of
them. Unfortunately, hysterical persons often become objects of
ridicule to inexperienced physicians. It is to this absence of sympathy
and to this gradual diminution of interest that we may most reason-
ably ascribe the tendency which develops in nearly all hysterical pa-
tients to exaggerate their complaints and to feign diseases — a tendency
which, although really a symptom of the malady, does away with the
last vestige of sympathy for their condition. Cases are on record
where patients have undergone the most painful operations, in order
to regain the attention and sympathy which have been withheld from
them. Krukeriberg tells of an hysterical girl, at his clinic, who mal-
treated a wound upon her skin with irritating substances until ampu-
tation became necessary, and who, after the stump began to heal, re-
commenced the practice. The capacity of such a patient for inventing
conditions calculated to excite notice or sympathy is something in-
credible. It is often very difficult to separate the truth from false-
hood. Credulous persons are often duped, and we should make it a
rule to accept all unusual reports with the utmost distrust, such as,
that the patient never takes any food, that she never passes either
water or faeces, that she has vomited blood or maggots, or other odd
objects. It is a very common occurrence for a patient to declare that
she cannot make water, and for her to submit to the passage of a
catheter twice a day. It is equally common for her to remain in bed
for months or years, asserting that she cannot stand upright. It is
easy to see what a treasure animal magnetism must be to hysterical
persons, and with what alacrity they submit to the manipulations of
the " magnetizers," and that, having once " got into magnetic rapport "
with some other person, and thus become enabled to perform all man-
ner of new tricks, they leave off then* old ones, and thus are " cured
of the most wonderful diseases by animal magnetism." In my opinion,
it is only necessary for the right man to appear (like the magic tailor
in Tmmermann's " Mlinch-hausen "), in order to convert any decidedly
hysterical female into a " somnambulist " or clairvoyant. At the same

420 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

time it is to be admitted that fanatical enthusiasts, who devoutly be-
lieve in their own wonderful gifts, and who are sustained in such be-
lief by their experiments with hysterical persons, are capable of much
more than mere impostors, who speculate in animal magnetism. The
power of reason usually remains unimpaired in hysteria. Like other
people, they are able to connect one idea with another, and to form
correct conclusions, although they are so preoccupied with a sense of
their own sufferings as to be unwilling to think of other matters. A
very prominent peculiarity in hysteria consists in the loss of power of
the will to control the movements of the body. This peculiarity is also
attributable to the almost absolute control which the mental excite-
ment has obtained. Even persons in good health, when agitated in
mind, pay less attention to the motions of their limbs, and do not, by
any action of their will, restrain their reflex movements which arise
during the agitation. In spite of the authority of Momberg, I cannot
agree with those who believe the enfeeblement of will of the hyster-
ical to be the result of a reflex action of such intensity as to overcome
the action of volition. The real state of the case I believe to be ex-
actly the reverse. At my clinic, I have nearly always succeeded in
producing a fit of hysterics in suitable cases, or in exciting a slight
attack into one of great violence, by expressing great sympathy with
the patient, and by assuring her that the fit was going to be a bad
one, thereby so agitating her as to hinder her from bringing her will
to act upon her motions. On the other hand, by treating the patient
roughly during the paroxysm, by throwing glass after glass of water
in her face, and by threatening to keep it up to the end of the attack,
I have nearly always been able to stimulate the patient to a vigorous
exertion of her will, and thereby have put an end to the involuntary
movements. Uneducated bystanders, and superficial observers, when
they see how manifestly the fits depend upon psychical influences, are
very apt unjustly to suspect the patient of an imposture. Besides, the
•course of the attack, as described above, corresponds exactly with the
well-established facts of physiology regarding reflex action and the
effect of the will upon it.

There is much variety as to the course, duration, and results of
hysteria. In most instances the disease comes on gradually. At
first, the cnly symptoms are those of bodily and mental hyper-
aesthesia and their consequences ; and it is not until afterward that
the convulsions and other symptoms of greater or less violence show
themselves. Sometimes they never appear. In rare instances the
complaint begins with an attack of hysterics running an acute course,
the other symptoms not making their appearance until afterward. At
the menstrual period, and immediately prior to it, the disease is almost

HYSTERIA.

421

always aggravated; sometimes, indeed, there never are any fits, ex-
cepting at this period. There is no fixed rule as to the duration of
hysteria. It may continue for years, with varying intensity, although,
during the climacteric years, it nearly always becomes milder. Recov-
ery is not uncommon, the physician's art having many a triumph over
hysteria to celebrate. There are plenty of cases, it is true, which are
never cured, and, indeed, which do not even improve. Sometimes the
malady runs into epilepsy or insanity. Death from hysteria, however,
is rare. There are only a few scattered cases on record, in which
death has occurred during violent convulsions, probably owing to em-
barrassment of respiration.

TREATMENT. — After what has been said above regarding the effect
of education and of habit in inducing hysteria, the necessary prophy-
lactic measures so important to the patient will have become suf-
ficiently evident, and will not require any further specification.

Cases where there is no doubt that the nervous derangement pro-
ceeds from disease of the sexual organs, call for appropriate treatment
of the infarction, ulcer, flexion, or other disease of the womb which
may be present. For further remarks upon this subject we refer to
the second division of this volume. Where the hysteria is the result
of psychical influences, and nevertheless the patient is compelled to
submit to the extremely unpleasant procedures necessary for the appli-
cation of leeches or caustic to the os uteri, the malady is almost always
aggravated. In hospital practice, it generally is impossible to meet
the indication as to cause in cases of this kind ; but, in private prac-
tice, a physician, who is intrusted by his patients with a most intimate
knowledge of their private relations, is often able to exert the most
happy influence in this variety of hysteria. It is impossible to lay
down any general rules of procedure. When the disease depends
upon impoverishment of the blood and upon chlorosis, the indication as
to cause requires that we should endeavor to improve the state of the
blood by the exhibition of iron and an appropriate diet. By means
of such treatment our object is soon effected, and the hysteria disap-
pears as the red cheeks return, without it having been necessary for
us to have recourse to antihysteric remedies. Hysteria which is trace-
able to anaemia is perhaps the most satisfactory of all forms of the
disease to treat.

The indications as to the disease demand that we shall attempt to
allay the nutritive derangement of the nervous system upon which the
hysterical phenomena depend. We must not expect to effect a final
cure of an hysteria by the mere healing of an erosion upon the os uteri,
although this may have been the original cause of the malady. It may
happen, but is by no means the rule. The proper means for attaining

422 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

oiir object are, first, remedies which have an active influence upon tbe
general nutrition of the system. Secondly, those which seem to act
specifically upon the nervous system — the so-called nervines. The
success in the relief of hysteria, of which the hydropaths justly boast,
is due to the effect of the so-called hydropathic treatment. When the
cause has been removed without benefit to the patient, or if it be im-
practicable to allay the cause of the hysteria, the cold-water cure is, in
many cases, strongly to be recommended. We must warn the patient
from the very first, that the " cure " cannot have the desired effect in
a few weeks, and that their abode at the water-cure establishment
must be continued for several months at least. Nor is it advisable to
allow a patient to undertake the water-cure at her own house, as it is
of the utmost importance that the treatment should not be conducted
by halves. The use of sea-baths also is often of remarkable benefit in
hysteria. When the patient is vigorous and well-nourished, the
springs of Marienbad, Kissingen, and Franzenbad, are often of great
service. The action of these springs is to be ascribed to the modifica-
tion which they exert upon nutrition. The nervines which have the
greatest reputation as remedies against hysterics are castor, valerian,
hartshorn, assafcetida, and other evil-smelling and ill-tasting articles.
The greatest skeptic cannot deny that a cup of valerian tea, a few
drops of the tincture of valerian, or a tincture of castor, taken by the
mouth, or an injection of the infusion of valerian, or an emulsion of
assafcetida, often act admirably as palliatives, although no radical
relief can be effected by such articles. I have accidentally hit upon a
nervine of great efficacy in hysteria, and have made use of it with
signal effect in many cases where there was no indication for the local
treatment of uterine disease, or else, where the hysteric symptoms per-
sisted although the local uterine affection had been cured. I mean the
chloride of sodium and gold. I had read that Dr. Martini, of Bibe-
rach, regarded this article as an efficient remedy against the various
diseases of the womb and ovaries. As the diseases which this gentle-
man (a much-respected gynecologist in his district) claims to have
cured by this drug, for the most part, belong to that class of disorders
which are incapable of resolution, and which are incurable, in the
strictest sense of the word, and as I had no reason to doubt the
veracity of Dr. Martini, I could only infer that the cases had been
imperfectly observed. My suspicion that the chloride of gold and
sodium, like other metallic articles, was an active nervine, and that the
improvement effected upon Dr. Martin? s patients was probably due
to this property, was fully confirmed by what followed. After having
employed the medicine in question for several years, and in a great
number of cases, and. encouraged by my success, having recommended

HYSTERIA. 423

it to my pupils as one of the most effective of nervines, I ascertained that
the chloride of gold has been recognized as a special re-agent upon tho
nerve-tissues, and that it is much used for this purpose in microscopic
investigations. Such a discovery, probably, would never have induced
me to make use of it as a remedy, but now this piece of information is
of great importance to me, as a confirmation of the fact that the cura-
tive action of this remedy had been rightly interpreted. I prescribe
the chloride of gold and sodium in the form of a pill (]J auric, chlorat,.
natronat. gr. v; gummi tragacanth. 3 j ; sacc. alb. q. s. u. f. pil. No. 40).
Of these pills I at first order one to be taken an hour after dinner, and
another an hour after supper. Afterward I order two pills to be taken
at these hours, and gradually increase the dose up to eight pills daily.

In some cases of severe hysteria where fulfilling the causal indica-
tions does not answer the purpose, or where the origin of extensive hys-
terical disturbances of innervation cannot be discovered, either in the
sexual apparatus or other organs, I have experienced some excellent
results from the use of bromide of potash in increasing doses (fully
described in the treatment of epilepsy), while in other cases it failed
entirely. An esteemed colleague also, who has a large consultation
practice, informs me that, when he is unable to refer severe nervous
symptoms to structural changes in the central organs or the peripheral
nerves, he often resorts to this effective but empirical remedy.

Moral treatment is of the utmost importance in all cases of hys-
teria, whatever may be the source of the disease. Homberg very
properly observes : " Psychical treatment is of such importance that,
without it, all other remedies fail." Every thing depends upon our
exercising the patient to " oppose the impulse of the will to the reflex
impulse." It of course depends upon the peculiarities of the patient
as to what measures we shall resort to in special instances. When
they have shown themselves to be willing and obedient, and seemed
to place reliance upon my directions, I have ordered them to take
a cold shower-bath twice a day, and to keep under the shower as
long as the utmost exertion of their will would enable them to
do so.

[Electricity is serviceable not only against certain symptoms of
hysteria, such as paralysis, anaesthesia, neuralgia, etc., but it is as-
serted to be of positive benefit for the general disease. The best
application is the induced current in the form of " general electri-
zation," as recommended by jBeard and Rockwell, where currents
of moderate intensity are passed over the entire surface.]
77

424: GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.
CHAPTER VI.

CATALEPSY.

ETIOLOGY. — Catalepsy belongs to the neuroses of stability (Sta~
bilitats-neuroseri), according to the classification of Blazius. Dur-
ing a cataleptic fit, the limbs of a patient remain in the attitude in
which the patient voluntarily placed them prior to its commencement,
or in which they may be placed by a bystander during the seizure.
The limbs do not sink by reason of their weight, nor can the patient
of his own will bring them into any other position. The resistance to
gravitation opposed by the limbs proves that the muscles must be in
a state more or less of contraction. In all conditions in which the
muscles are fully relaxed, as in a swoon, or after death, the limbs fall
of their own weight as soon as support is withdrawn from them. It
would seem most natural to attribute the steady continuance of the
limbs in one attitude to a continued excitement of the nerves which
induce the muscular action requisite to produce such an attitude. This
explanation, however, is contradicted by the other phenomenon, for,
if we alter the position of the limbs of the patient, the new pos-
ture is retained, just as the former one was. It is contrary to all ex-
perience that a change of attitude in a limb, effected by foreign inter-
ference, should arrest the action of one nerve and induce action in
others. Cataleptic attacks are not sufficiently common to enable us
to decide these points positively ; but it is most likely that all the
motor nerves are in a state of medium excitement in this disease, and
hence that all the muscles of the body are in a state of contraction
sufficient to counteract the resistance afforded by the weight of the
limbs. The facility with which the posture of a limb may be changed
(flexibilitas cerea), and the fact that a limb remains bent, if we bend it,
or straight, if we straighten it, lead to the conclusion that the con-
traction of the antagonistic muscles fully preserves their equipoise.
The supposition that the medium state of irritability of the motor
nerves, which is the cause of this condition, proceeds from the spina]
marrow, is also the most satisfactory and general. The incapacity of
the patients to modify this excited condition of the motor nerves and
contractile state of the muscles by the force of their will indicates that
there is also a morbid state of the brain. In cases of catalepsy, where
consciousness is entirely suspended, no struggles occur; and, in cases
where consciousness is retained, the patients wish to move, but can-
not, because that particular part of the brain is thrown out of function,

CATALEPSY. 425

whose duty it is to conduct the impressions fi-om the central organs
of imagination and volition to the motor nerves.

Catalepsy is quite common among the insane, especially among
persons suffering from melancholia attonita. It also sometimes pre-
cedes the convulsive attacks of hysteria. Cataleptic fits may also ac-
company St. Vitus's dance, the chorea Germanorum^ tarantism, and
other epidemic and endemic forms of convulsion of psychical origin,
and which Eomberg aptly terms psychical convulsions. It is very
rarely met with as an independent affection in persons whose health
.s otherwise good. Children and young persons seem to be most
'.iable to its attacks. Mental emotion is said to be its principal exciting
cause ; indeed, in healthy individuals, slight indications of this morbid
condition are sometimes observable as a result of such impressions.
It is a very common thing to see persons, under the influence of sudden
tear or horror, standing motionless, with outstretched hands, until the
emotion subsides.

SYMPTOMS AND COURSE. — In my description of the symptoms and
course of catalepsy, as an independent disease, I must rely entirely
upon the representations of others, since all the cases which I have
had an opportunity of observing personally have inspired me with the
suspicion that they were simulated. The precursors of a cataleptic
fit are said to be headache, dizziness, buzzing in the ears, broken
sleep, extreme irritability, and other symptoms of nervous derange-
ment. The paroxysm itself sets in suddenly. The patient remains
motionless as a statue in the attitude in which he may happen to
be at the moment of the attack. At first, some force is required
to move the limbs ; afterward, they can be moved with ease,
and it is possible to adjust them in any desired posture, and they will
retain that posture much longer than a healthy person would be able
to retain it of his own will. During the fit, consciousness and sensi-
bility to external impressions are either entirely suspended, or else,
though the senses may be retained, and though external impressions
are perceived, the patient is unable, either by word or act, to give any
sign of consciousness. The respiratory movements and the beat of
the heart and pulse are usually so feeble as scarcely to be perceptible.
The urinary and alvine evacuations usually are arrested. Deglutition
proceeds undisturbed, if the bolus be thrust far enough back into the
pharynx. Generally speaking, such a fit only lasts a few minutes ;
more rarely it continues for several hours or several days. When it
is over, the patients yawn and sigh like persons who have waked out
of a profound sleep. If the seizure be a very transient one, and be
accompanied by loss of consciousness, the patient often is quite unawaro
that any thing unusual has happened to him, and, after the fit is over

4:26 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

goes on with his business quite undisturbed, taking it up where he
left it off. In other cases, the patient remains stunned and dizzy, for a
while complaining of a feeling of confusion in the head. There is
often but one attack ; more rarely there is a series of them, recurring
at varying intervals. Between the fits the health is good, unless
there be complications. Recovery is the most frequent termination
of simple catalepsy. The dread lest cataleptic patients should be buried
alive has become exploded in modern days. It is stated that, in some
cases of the disease, the length of the fits, and the frequence of their
recurrence, and the consequent diminution in the supply of nourish-
ment to the patient, have sometimes resulted in marasmus, and even
in death. In such cases, however, it is probable that there was a com-
plication of diseases.

TREATMENT. — In spite of the old caution, not to interfere too ac-
tively with a cataleptic fit, I should not hesitate to resort to affusion
of cold water, to apply a strong electric current, and, unless the respi-
ration and pulse should seem too feeble, to give an emetic. In a pro-
tracted seizure, it may become necessary to feed the patient through
an oesophagus tube. As the treatment of the case between the fits
must be addressed to their apparent cause, to any derangement in the
nutrition of the patient, or to any other symptom which may appear,
no fixed rules can be laid down for our guidance.

CHAPTER VII.

HYPOCHONDBIASIS.

ETIOLOGY. — Properly speaking, hypochondriasis is a disease of the
mind, and, in the books on psychiatria, is usually classed with melan-
choly, lypemania, and phrenalgia, that is, to that class of diseases in
which, as their names indicate, the mind of the individual is oppressed
by a painful impression. The hypochondriac is always plagued by
the idea that he is sick, or that he is going to be sick. Hence, in the
opinion of Guislaine, an appropriate name for the disease would be
pathophobia or monopathophobia. All persons who are possessed by
the idea that they are sick, however, are not to be regarded as hypo-
chondriacs, but only those in whom such an impression constitutes a
symptom of disease. A father of a family, who is informed by his
physician that he is suffering from some incurable malady, and from
that hour is insane upon that point, suffering constant apprehen-
sion, and watching his bodily condition with all the attention and anx-
iety of a hypochondriac, quite assumes the aspect of one laboring
under this disease. He is not a hypochondriac, however, for hie

HYPOCHONDRIASIS. 427

mental and bodily derangement correspond, and do not stand in con
tradiction to the psychical peculiarities of the patient prior to his
discovery.

Like all symptoms of mental disease, hypochondriasis proceeds
from nutritive derangement of the central organs of all psychical ac-
tion, but we are not able to trace back the morbid state of mind, char-
acteristic of this malady, to any particular lesion of the brain. We
can scarcely ever point out the nutritive disorders of the brain to
which the derangements of its functions are due in any other form of
insanity, and, in hypochondriasis, it is equally impracticable to trace
the causes of the morbid mental condition to cerebral lesion. Where
a tendency to the disease exists, it may arise either from psychical or
from physical influences. There is no objection to the application of
the terms hypochondria sine materia to that form of the affection
which proceeds from psychical causes, and hypochondria cum materia
to that which arises from physical influences, but the expressions are
not to be employed in any other sense.

The predisposition to hypochondriasis is very slight indeed during
childhood, and is far less in females than in males. It is greatest be-
tween the ages of twenty and forty. Not unfrequently it is of con-
genital origin. In other instances it seems to proceed from debili-
tating influences, such as sexual excess, onanism, digestive disorder,
or want of fresh air, as well as from an inactive mode of life, or im-
moderate self-indulgence, from disappointment, failure of speculations,
and an ill-selected career.

The exciting causes of hypochondriasis are, first, physical diseases.
Certain morbid conditions are more liable to cause hypochondriasis
than others are, or (to speak more precisely) to produce those mate-
rial lesions in the brain which are the cause of hypochondriasis. The
principal of these are the gastric affections, especially chronic gastric
or intestinal catarrh ; next come diseases of the genitals, and, finally,
gonorrhoea and syphilis. In the latter, however, the mental impres-
sion made by the disease ought to be taken into account quite as
much as its physical effect. If these diseases sufficed of themselves
to produce such disorders, the world would be full of hypochondriacs.
Regarding them as mere exciting causes, however, only capable of
bringing on the disease where a predisposition to it already exists,
the disproportion between the frequence of gastric catarrh, of syphilis,
or of clap, and that of hypochondriasis, will not appear at all remark-
able.

The operation of mental impressions has a very similar effect.
The most important of these consists in the reading of those pernicious
books of " popular medicine," innumerable copies of which are in cir«

428 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

dilation all over the world. Now, although there is no doubt that the
reading of this kind of literature has often resulted in an attack of hy-
pochondriasis, yet persons free from any morbid predisposition may
read these books with impunity. An effect very much like that pro-
duced by reading popular medical books may arise from the exclusive
occupation of the mind with stories of disease and death, such as are apt
to be current in any region where an epidemic disease is prevailing.
Such impressions do no harm to the majority of people, but there are
a few who become hypochondriacs. It will be readily understood,
moreover, that the companionship of a hypochondriac is dangerous to
an individual of a hypochondriacal predisposition.

SYMPTOMS AND COUESE. — Hypochondriasis usually develops grad-
ually. At first, there is an indefinite sense of illness, which troubles
and oppresses the patient, but which does not as yet disturb his judg
ment or possess him completely. Nor are this restlessness and distress
usually permanent in the beginning. They generally cease at times,
and then reappear with somewhat increased intensity. The more pro-
foundly the disease takes root, so much the more assiduously does the
patient endeavor to discover the cause of his indisposition. He scru-
tinizes his tongue, his stools, his urine ; he counts his pulse and han-
dles Ins abdomen. Every trifling irregularity which he perceives, the
slightest irritation, the faintest coating of his tongue, a transient colic,
an insignificant cough, are all of the utmost importance in his eyes ;
not because he suffers more than any one else from such symptoms,
but because they seem to him to afford a clew to the nature of the
grave and obscure imaginary disease. To-day he may dread an apo-
plexy, to-morrow he may think that he has an ulcer of the stomach ; at
other times he may imagine his heart diseased, or that he is consump-
tive, or afflicted with some other serious malady of a character corre-
sponding to his sensations of distress. He studies all the " medical
advisers " and other books of " domestic medicine," but, instead of de-
riving comfort and aid from them, merely finds out new diseases, by
which he immediately imagines himself afflicted. As the disease gains
mastery over the patient, his belief as to his condition becomes more
and more biassed and incorrect. Argument is useless, as it cannot re-
lieve him of his feelings. A few hours only may have elapsed since
we last saw the patient. We then may have spared neither time nor
trouble in explaining to him that his condition was perfectly free from
danger, when a messenger arrives from him, begging us to come in
haste, that some serious change has taken place, and that his con-
dition has become a most critical one. In other instances, especially
when the patient really has some insignificant disorder, the hypo-
chondriac is not so apt to change his opinion as to the nature of hia

UYPOCHONDRIASIS.

429

disease, but sticks to a belief in one, and cannot be dissuaded from it.
He is not like other patients, satisfied with simply complaining of pain,
oppression, or fever ; partly, because he really feels worse than other
people, and, in part, because he is convinced that the doctor " makes
light of his sufferings." Hence he exaggerates, and often exhibits the
utmost fluency in description of his infinite suffering. In spite of the
severity of these imaginary symptoms, however, they by no means
despair of recovery; hence hypochondriacs seldom attempt suicide,
and never weary of seeking fresh medical advice and of trying new
treatment. Sometimes their hopes are so much in the ascendant, and
are so productive of happiness to them, that, for a while, in spite of
their sense of illness, they are cheerful and in even high spirits. Such
intervals, however, are usually very brief, and occur most frequently
immediately after the engagement of a new medical man or the con>
mencement of a new " cure." The old mood very soon returns. The
false realizations of their sensations, and the erroneous ideas of the pa-
tients as to the condition of their own bodies, which we sometimes see
in hypochondriasis, are a genuine delirium. Like other insane ideas in
other forms of psychical disorder, this proceeds from morbid bias of
the mind, and is to be regarded as an attempt to clear it ( G-riesinger).
Hallucinations — " sensations originating inwardly " — also arise in hy-
pochondriasis, owing to this sense of illness, and to the attempts of
the patient to account for it. Thus the idea that the heart is stand-
ing still, or that a limb is withered, or that the body is putrefying,
although it is not the result of a genuine sensation incorrectly inter-
preted, yet it is so vivid that the patients cannot distinguish it from
an impression actually furnished by the senses ; and they really believe
they can feel that the heart does not beat, that the skin is dried up, or
that they can smell the putrid emanations from then* body. In spite
of their mental aberration and morbid fancies, most hypochondriacs are
able to transact their business, and to take care of their house and
family ; and this is the reason why hypochondriasis, usually, has not
been regarded as a disease of the mind, being looked upon rather as a
nervous disorder, a custom with which we have complied. In the
worst forms of the disease, the patient loses all interest lor matters
which do not bear upon the state of his health. He becomes ab-
stracted, forgetful, and negligent of his affairs, gives himself no further
concern about his family, and often remains idle in his bed for years.
It is often a long time before his nutritive condition begins to suffer.
Gradually, however, especially in bad cases, the patient grows thin,
and acquires a sickly appearance, and derangement of the secretory
and digestive functions arises. We are not at liberty to account for this
emaciation and the other nutritive disorders, by supposing that the

4:30 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

perversion of sensation in the patient's various organs has led to
perversion of their functions ; for the same emaciation and the same
disorder of nutrition may likewise be seen in persons who have fallen
into a state of permanent mental depression, as a result of objective
conditions, and who feel no morbid sensations in the organs which
ultimately become diseased. Moreover, the very improper way in
which hypochondriacs often live, and their immoderate use of medi-
cines, contribute a great deal toward the development of a cachectic
condition.

Hypochondriasis always runs a chronic course. The cases in
which peculiar causes, acting upon a constitutionally timid and im-
aginative person, induce a transitory belief that he is ill, or a fear
that he is about to be ill, are not to be regarded as genuine hypo-
chondriasis. Recovery is not uncommon. More frequently the dis-
ease persists throughout He, with varying intensity. It rarely termi-
nates fatally, although there have been instances where the patient
died of marasmus and exhaustion.

TREATMENT. — It is useless to dispute with a hypochondriac, and
to try to convince him of the error of his ideas. The only way to cure
the patient is to rid him of his morbid sensations. For this purpose it
is necessary, in the first place, to correct any existing derangement of
the system which, as we have said, is often the exciting cause of the
disease, and which would cause a feeling of illness in a sane person.
The necessary therapeutic measures vary according to the peculiarity
of the case. The benefit often derived from the springs of Karlsbad,
Marienbad, and Kissingen, in the treatment of this affection, are, no
doubt, mainly due to the beneficial effect exerted by these waters upon
diseases of the gastric organs, which so frequently prove a source of
hypochondriasis. In other instances, preparations of iron will be ap-
propriate, while the springs will do harm. In others, again, sea-bath-
ing and cold foot-baths are to be used. We must be cautious in the
employment of the drastic cathartics, although they can seldom be
dispensed with altogether, and although they usually afford the patient
a temporary relief; and, above all, we must distinctly warn the patient
against over-dosing himself, a practice to which hypochondriacs are
very prone. This likewise applies to the use of carminatives, fo*
which the patients nearly always earnestly beg. The object of tlu
psychical treatment, as Romberg aptly says, should be diversion of
the attention from the sensory to the motor and intellectual spheres.
This object will not be attained in educated patients by ordering them
to take long walks, to saw wood, to practise gymnastics, and to occupy
themselves in other mechanical pursuits, because the attention of the
patient is not diverted, by such actions, out of the sphere of sensation.

PARALYSIS AGITANS. 431

A hypochondriac merchant, while sawing wood, is always busy with
the thought that he is sawing wood because he is sick. Such ordi-
nances, however, especially active gymnastic exercise, are of great
service, because, like the cold baths, they induce a vigorous modifi-
cation in the process of transmutation of the tissues, and because
they tend to restore the patient to a sense of physical energy.
Diverting amusements, as the excitement which they produce soon
becomes extinct, are seldom productive of lasting benefit. Travel-
ling with some definite object in view, or the study of agreeable
objects, is much more commendable. Of course, no general rules
can be laid down for the fulfilment of the task in question, as our
directions must always be in accordance with the capacity, educa-
tion, and means of the patient.

[CHAPTER VIII.

PAEALYSIS AGITANS — SHAKING PALSY.

THE most apparent symptoms of this disease are involuntary
movements of parts of the body, either a simple trembling or a
regular shaking ; sooner or later these are accompanied by partial
paralysis of the muscles affected. The disease is uncommon ; it
affects chiefly aged men; exceptionally it occurs in middle age, and
very rarely in youth. In some cases it has followed severe fright
or great anxiety ; in others it has seemed due to unfavorable sur-
roundings, exhausting work, continued exposure to moisture and
cold, or to irritation of peripheral nerves from injury ; in other cases
no external cause has been found.

The trembling usually begins in the fingers, hands, or arms, and
may remain limited there, or may spread to the whole upper or
lower limbs ; exceptionally it affects the muscles of the face, larynx,
or neck. The tremor may be restricted to the limbs of one side of
the body, rarely to one arm and the opposite leg. The movements
may cease temporarily, especially in the horizontal position ; but
when fully developed it is apt to be continuous, though varying in
intensity from mental or physical excitement ; during sleep or an-
aesthesia the movements cease.

The paralysis may not come on for some time, the impaired use
of the limbs meantime being due to disturbance from the motion.
Late in the disease there may be a tenseness and rigidity of the
muscles, with preponderance for the flexors ; after the tenseness
has lasted some time it will cause deformity ; the head may be

432 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

drawn down, the arm raised from the thorax, the forearm flexed.
If the lower limbs are affected, the rigidity may resemble paraplegia
with contractions. There may be various anomalies of sensation,
such as numbness, prickling, neuralgia, anaesthesia, heat, etc., and
cerebral symptoms, such as headache, dizziness, sleeplessness, etc.

The disease may drag along for -years, death at last resulting
from age, debility, or some intercurrent disease. The autopsies
made have proved nothing about the seat of the disease or the an-
atomical changes causing it ; their results have been so varied that
it is not even certain whether the original seat of the disease be in
the brain or spine.

Senile tremor, or that of very excitable persons, is less marked
than that of paralysis agitans. That due to poisoning by alcohol,
lead, or mercury is accompanied by other symptoms of poisoning ;
but it may be mistaken for multiple sclerosis, although this comes
earlier in life, and paresis appears as one of its first symptoms, and
the tremor usually comes only when the patient tries to execute
some movement.

Although some recent cases have seemed to recover, this must
be considered as spontaneous rather than as a triumph of medicine;
in some of the cases there may have been an error of diagnosis.
Among the remedies said to have proved beneficial are hyoscyamus,
hypodermic injection of small doses of Fowler's solution, continued
use of carbonate of iron, cold douches while in a warm bath, gal-
vanism, etc.]

[CHAPTER IX.

DELIRIUM TREMENS MANIA A POTU.

THE name delirium tremens is used even by the laity, and un-
fortunately it is so common that the symptoms which characterize it
are very generally known. Frequent as is this affection, the opin-
ions as to its immediate cause are not unanimous. Some believe
that it is the direct result of the abuse of alcoholics, while others
say that it is due to their sudden withdrawal. It is not improb-
able that it may be caused either way ; perhaps the worst cases are
those that come on during the use of liquors; those that result from
the patient's inability to obtain liquor, from having a broken leg or
some acute disease, or from being locked up, have seemed to us to
run a much lighter course than the former. Possibly the long-con-
tinued use of alcohol may induce such a state in the gastric mucous
membrane that it will absorb neither liquor nor nourishment ; this

DELIRIUM TREMENS. 433

might make the cases due to direct poisoning worse than those
arising from sudden withdrawal of stimulants.

This disease may develop more or less suddenly. It may be
preceded by a stage of melancholy, but the actual commencement
of the trouble is characterized by marked hallucinations; the patient
sees numerous insects or small animals around him; has hairs in his
mouth, which he constantly removes with his fingers and spits out ;
he hears music, voices, etc. While subject to these hallucinations,
the patient may still control himself enough to answer questions
rationally; but while speaking coherently he will look past you and
around the room, and it is evidently by a great effort of will that he
keeps his attention fixed on the conversation.

As the disease progresses the harmless animals seen may be re-
placed by frightful forms, robbers, the devil, and other terrifying
personages, who pursue and threaten the poor patient till he is a
most pitiable object. At this time more than ever his nerves are
unstrung, his limbs in a perfect quiver from excitement and fear,
perspiration bedews his face, the tongue is dry, and he constantly
stares around as if following his persecutors with his eyes. He can-
not sleep or eat. A good nurse, or a courageous, vigorous friend,
may persuade him to drink milk, beef -tea, etc. ; but the power of
masticating and of supplying saliva for solid food seems to be
absent.

In the first attack very frequently, and in subsequent ones more
rarely, the above symptoms will only last a couple of days ; then
the patient will eat a good beef -steak, have a sound sleep, and sub-
sequently be well except for a slight gastric catarrh, which is very
apt to have been induced by his previous prolonged use of liquor.
In severe cases, after one or several days of the delirium, while the
patient does not seem to be dangerously ill, he may suddenly die
from paralysis of the heart ; or in trying to escape his imaginary
tormentors he may jump from a window or otherwise do himself
serious injury. If the disease lasts several days, with delirium and
inability to eat, the tongue becomes dry, the pulse frequent and
dicrotic, and the patient dies in a typhoid state. In these cases
there is usually chronic disease of the kidneys and liver ; evidences
of chronic inflammation of these organs, and perhaps of the cerebral
meninges, being the chief changes found on autopsy.

Delirium tremens rarely lasts a fortnight; in our own experience
those cases that last over six days end in recovery. It must be
regarded as a very treacherous disease, and our prognosis may
always be guarded till the patient has eaten and retained some safe
solid food, such as tender beef or mutton.

GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

In all cases of delirium tremens the condition of the kidneys and
of the thoracic organs should be carefully scrutinized ; for we should
bear in mind that pneumonia attacking a person of intemperate
habits presents all the symptoms of delirium tremens, and in many
such cases there is neither cough nor expectoration, nor does the
patient complain of pain, nor indeed of any symptom likely to
direct the attention of the physician to the real nature of the dis-
ease. It has not unfrequently happened that a man has died under
diagnosis of delirium tremens, and a pneumonia, which had not
been even thought of during the progress of the case, has been re-
vealed upon dissection.

The symptoms of Bright's disease also are not always so marked
as to attract immediate attention. A uraemic convulsion sometimes
admonishes the unwary practitioner that a grave condition of the
kidneys has been overlooked.

TREATMENT of delirium tremens, as of any disease, must depend
greatly on the symptoms ; but numerous special plans have had
their advocates, such as that by opium, alcohol, and digitalis ; each
of these has doubtless proved useful in the hands of its advocates,
but no one has proved universally acceptable. The remedy at pres-
ent most generally relied on is bromide of potassium. It may be
given in doses of thirty grains every hour till the patient sleeps ;
if a few doses do not accomplish the desired result, an equal quan-
tity of hydrate of chloral may be added to it. When a good sleep
has been secured, the hallucinations may not recur, and further
treatment may be unnecessary, except such as is required for the
general state of the patient.

Another remedy which is very quieting, and may be used sub-
cutaneously when there is difficulty in getting the patient to take
bromide of potassium, is hyoscyamin, which may be given in doses
of the twenty-fourth of a grain, and if necessary increased to the
twelfth or sixth of a grain.

When the patient comes under treatment with a stomach full of
alcohol and undigested food, " just off a spree," it is well to give a
mild emetic and a cathartic (perhaps calomel) ; then, unless there
are complications, to rely greatly on a good-natured, stout, resolute
nurse, and good diet. If the symptoms be not urgent, we may give
the mineral acids, Horsford's acid phosphates, and similar remedies.
If there is marked sleeplessness, we may try one of the above reme-
dies. An important question is whether the patient shall have any
alcoholic stimulant. If the stomach is quiet, and apparently in a
condition to digest food which the patient objects to taking, it may

MORPHINE HABIT.

435

be well to promise a drink if he will eat a piece of steak ; but as a
matter of treatment, or by way of " tapering off," we may gener-
ally reject alcoholics.

When a quiet sleep has been secured, and a meal of solid food
has been eaten and retained, the patient generally progresses favor-
ably.]

[CHAPTER X.

MORPHINE HABIT — OPIUM-EATING.

CLOSELY allied to chronic poisoning by alcohol, with its frequent
accompaniment delirium tremens, is the result of long-continued
use of opium or the salts of morphine. This habit is not uncom-
mon, and as it is generally begun under the physician's recommen-
dation, we may consider ourselves as responsible for its cure.

As a patient suffering from indigestion finds his pain relieved
by alcoholic stimulants, he resorts to them more and more frequent-
ly, and finally employs them to excess ; in the same way frequent
attacks of pain from neuralgia, rheumatism, or inflammation induce
repetition of the doses of narcotics that have once been found effi-
cacious. Hence it would seem imperative that, when prescribing
the various pain-quellers, we should warn the patient against too
frequently resorting to them, and explain to him that they all grad-
ually lose their effect, and after being used for a time cease to afford
relief, or must be given in gradually increasing doses. The prepara-
tions of opium being especially liable to abuse in this way, we may
picture to the patient the painful symptoms of chronic poisoning
that are likely to result from their continued use, and which may
finally prove more annoying than the original pains for which the
anodyne was given. It is also claimed that protracted use of opium
begets a special tendency to neuralgia, and demoralizes the entire
nervous system.

There is no doubt that many opium-eaters reach advanced age
under the influence of that drug ; many of those who drink intoxi-
cating liquors, even to excess, live to be quite old, and many aged
men have been smokers from their youth ; but, as a rule, free and
continued use of opium, alcohol, or tobacco will be followed by
their peculiar toxic effects. It seems that any of these articles may
be used with greater impunity on a full stomach ; and those who
habitually indulge in them only after a full meal are less liable to
suffer bad results.

436 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

The symptoms of opium-eating or morphine habit are not always
very marked, even where the patient's life is rendered a burden by
it ; they vary greatly in relation to the time which has elapsed since
the dose last taken. While the effect is recent, and the nerves are
" keyed up," the patient may be lively and unusually bright ; as the
effect begins to wear off, there comes a quiet, rather drowsy time,
and those who are entirely regardless of the results do not go be-
yond this stage while their digestion and nerves will stand repeti-
tion of the dose, for they at once resort to their stimulus. But if
limited means, a troublesome conscience, or other cause prevents
the use of more than a certain quantity daily, the second stage is
followed by a third, where we have what are usually given as the
symptoms of opium habit, viz. : sunken features (as if the skin were
drawn tightly over the cheek-bones), lack of healthy color, furred
tongue, constipation, loss of appetite, sleeplessness, shaky hands
covered with clammy moisture, and great mental depression or rest-
less longing for more of the drug. Cold hands and feet, tendency
to sweat, and complaints of most varied pains and discomforts are
common. An almost universal symptom is emaciation, which is
magnified by the sunken look above referred to. Mentally the pa-
tients are depressed, suffer from loss of memory and energy, and
are apt to be untrustworthy.

If the use of the drug be suddenly and completely stopped, a
state resembling delirium tremens may supervene and result in
death. In strong patients, however, this sudden arrest is one of the
modes of treatment recommended ; but if we have the earnest co-
operation of the patient, or have complete control of him, we may
pretty certainly break off the habit without this rude shock, by
gradually reducing the amount of the drug, substituting for it if
necessary a variety of other remedies, not relying on any one for a
length of time for fear of replacing the opium habit by some other
only a little less pernicious. During the period of withdrawal the
doses of opium given will have to be regulated to some extent by
the previous habits of the patient ; i. e., if he has taken his dose
only at night, we have simply to reduce this dose gradually (with-
out the patient's knowledge). If it has been taken more frequently,
it is well to give a dose of the opiate with a tonic shortly before the
midday meal ; this will enable the patient to eat well, and possibly
the effects may last till the evening meal. If we can get along with
two doses daily, the second dose should be given about bedtime.
Administering the two doses in this way gives the best chance for
plenty of nourishment and plenty of sleep, which will be found

ADDITIONS TO THE HE VISED EDITION OF 1880.

437

absolutely necessary to keep the patient's " courage to the sticking-
point " of resisting the craving which exists even when the dose is
not being reduced. During the treatment appetizing food should
be offered and mental and physical occupation provided. Addition
of atropin to the opiate, occasional hot baths for the extremities, and
frictions with alcohol, seem to check the pain and sweating in the
hands and feet.]

ADDITIONS TO THE REVISED EDITION OF 1880.

SECTION IV. GENERAL NEUROSES, OF UNKNOWN ANATOMICAL

ORIGIN.

1.— P. 405.

Occasionally the urine passed a few hours after an epileptic
seizure contains albumen. Sometimes there is temporary mental
perturbation instead of a regular epileptic fit. The seizures may
be followed by paresis or paralysis, in which case we may suspect
disease of the brain ; or there may be aphasia, aphonia, dysphagia,
asthenia, etc.

The investigations of Reynolds oppose the general view that the
disturbance of intelligence is in direct proportion to the number and
severity of the seizures. Nothnagel even thinks that the mental
disturbance in the majority of cases is not the result of changes
in the pons and medulla oblongata, but accompanies them ; i. e., the
epilepsy and psycopathia are both due to some neuropathic dispo-
sition.

It is always important to decide whether any given case is idio-
pathic or secondary to some other disease, and this must be de-
termined by a careful examination of the whole body and of the
surrounding circumstances. We may suspect organic disease of the
brain when there is a permanent partial spasm, or when it always
begins at the same part of the body.

Attention has been called to pain in the hypogastric region,
which was attributed to the ovary ; this pain may be spontaneous
or induced by pressure over one or both ovaries (oftenest the left).
It is said that an hysterical aura is often induced by this pressure
— a feeling of constriction about the stomach and neck, nausea,
palpitation, tinnitus, disturbance of vision on the side of the pain-

438 GENERAL NEUROSES, OF UNKNOWN ANATOMICAL ORIGIN.

f ul ovary ; and that further pressure upon the affected part may
induce a true hysterical attack.

The following is said to be a favorite prescription with Dr.
Brown- Sequard : Bromides of sodium, iodinium, and ammonium,
each 3 iij ; iodides of potassium and ammonium, each 3 iss. ; am-
mon. sesquicarb. 3 j ; tinct. calumbae f iss ; aquae dest. ad § viij.
S. teaspoonful and a half before each meal and three teaspoonf uls
at bedtime. If bromide of potassium fails, try conium, cannabis
indica, or oxide of zinc.

Chapman's ice-bags applied to the spine for two to eighteen
hours have proved useful in some cases. Electricity, even in the
constant current, has not fulfilled expectations ; when used as an
adjunct, we try to affect the pons and medulla oblongata by placing
the electrodes on each side of the neck ; or we may galvanize the
sympathetic or peripheral nerves from which there is any reflex ex-
citement.

Dr. S. W. Mitchell recommends inhalations of from two to five
drops of nitrite of amyl for averting attacks ; but they can only be
tried where there is a protracted aura, and in cases where the face
becomes pale at the onset, showing spasm of the vessels. Sometimes
this remedy seems not only to avert attacks, but to render them less
frequent and severe ; in other cases the escape was followed by
severe attacks.

2.— P. 418.

Hysterical spasms may resemble epilepsy, or the latter may oc-
cur in hysterical patients. There may be hysterical paralysis of
almost any muscles, but especially of those of the extremities. The
electro-muscular contractility remains normal ; in most cases there
is cutaneous anaesthesia. Rarely with paralysis of a limb there is
facial paralysis, anaesthesia of the skin of the face, ptosis, etc.
There may be paralysis of the pharynx or oesophagus, which may
be diagnosed from spastic dysphagia by the passage of a sound.
Sometimes enormous tympanites occurs, the accumulation of gas
seeming due to temporary arrest of the gastric and intestinal con-
tractions ; the same sluggishness of peristaltic action may cause
constipation. Aphonia, due to paralysis of the glottis muscles, is
seen quite often. In rare instances paralysis of the diaphragm has
been seen, when on respiration the movements were in the reverse
direction, viz., sinking in inspiration and protruding in expira-
tion. There may be paralysis of the bladder with hemi- or paraple-

ADDITIONS TO THE REVISED EDITION OF 1880.

439

gia. These paralyses may last for days or weeks, and then sud-
denly disappear.

There may be great variation in the heart's action — palpitation
with a feeling of fulness and pressure in the chest, of constriction
and anxiety ; or, on the contrary, a tendency to temporary lack of
action, and faintness with hysterical trance.

There are changes in the vessels, the skin changing from red to
pale, either on part of or the entire body. These changes of the
vessels may affect different organs, as brain, lungs, uterus, etc., or
cause bleeding from the nose, mouth, stomach, respiratory passages,
etc. But hysterical patients sometimes simulate such things, drink-
ing blood and vomiting it, causing bleeding from the skin, etc.
78

DISEASES OF THE SKIN.

No notice has been taken, in the following chapters, of the altera-
tions which the skin undergoes in the acute and chronic infectious
diseases. Lake other symptoms of measles, scarlatina, small-pox,
typhus, and syphilis, these cutaneous affections are to receive the
attention due them, when we come to discuss the subject of the infec-
tious diseases themselves, as they only form a single link in the chain
of nutritive disturbances to which these maladies give rise.

We classify diseases of the skin as we do diseases of other organs,
according to the anatomical nature of the lesion which the disease
produces. We shall, therefore, have to speak of hypertrophy, atrophy,
hyperaemia, anaemia, haemorrhages, inflammations, neoplastic growths
and parasites of the skin. Since, however, it is in our power to observe
the variety in extent, in intensity of the morbid process, more accu-
rately upon the skin than upon other organs, and as we are able directly
to watch certain anomalies of secretions which are not accompanied by
palpable change of structure, diseases of the skin admit of a much more
minute classification than is possible in diseases of other organs. We
must so far conform to the practice of applying names to the cuta-
neous affections other than those belonging to the analogous lesions
upon other parts of the body, as to associate their proper pathological
and anatomical title with their customary name. Of the unpractical
and useless classification of the various forms of skin-disease into innu-
merable subdivisions, we shall merely make cursory mention.

I.— HYPERTROPHY OF THE SKIN.

AN hypertrophy, involving all the component parts of the skin,
the connective tissue, the vessels, nerves, epidermis, hair, and glands,
only occurs in small isolated spots as a congenital anomaly. Most of
the prominent " mother's marks " belong to this class, as well as the

HYPERTROPHY OF THE SKI*.

soft cutaneous warts or moles. But, even here, the hypertrophy does
not involve all the tissues of the skin hi equal degree. In the majority
of the projecting " mother's marks " and moles, there is a predominant
development of pigment and hair ; their brown or blackish color and
the strong growth of hair with which they are covered being one of
their striking features.

Large accumulations of horny epidermic cells are often found upon
certain spots of the body ; the callosities, the corns (clavi), and the
cutaneous horns, originate in this way. Callosities consist of low
flat, horny elevations, of a rounded or irregular form ; the condition of
the cutis which they cover being either normal or slightly hyperaemic.
Callosities are most apt to form at points exposed to irregular pres-
sure. Hence they are found upon the heels and upon the soles of the
feet of most persons ; upon the hands of blacksmiths, locksmiths, and
other mechanics ; and upon the index-fingers of tailors and of seam-
stresses. Corns are small, but very hard and thick conical callosities,
induced by the pressure of the boots or shoes, and which cause a cir-
cumscribed atrophy of the skin. The so-called cutaneous horns con-
sist in an excessive hypertrophy of the epidermis over a circumscribed
spot of skin. Some horns do not spring from the papillae of the skin,
but develop from dilated hair-follicles, and may be regarded as mon-
strous hairs. There is also a diffuse hypertrophy of the epidermis,
which is accompanied by hypertrophic development of the papillas of
the skin. Of this affection, which, when of moderate intensity, is
called pityriasis, and when more severe is called ichthyosis^ we shall
treat more in detail hereafter.

The brunette complexion, congenital in some persons, is due to a
copious deposit of pigment in the cells of the rete Malpighii. Another
congenital anomaly, which is seen in many persons, consists in a heavy
deposit of pigment in circumscribed patches upon the rete Malpighii,
producing brown or black spots (chloasmata, melasmata). When the
patches are of wider circumference, they are called pigmentary naevi
(ncevus spilus). If only as large as a lentil, they are called ephelides
or lentigines (Leber-flecke). The pigmentary marks and spots, which
are unaccompanied by hypertrophy of the cutis, and which, therefore,
do not project above the surface of the skin, are likewise often covered
with hair. In the majority of persons the formation of pigment in the
rete Malpighii is increased under the influence of the sun's light and
heat, and under that of wind and dampness ; hence, among soldiers,
field-laborers, and particularly among seafaring persons, the exposed
portions of the skin assume a uniform brown color. *It is remarkable,
too, that in some persons irritation of this kind does not produce such
deposit of pigment, or, as people say, they do not become " sunburnt "

442 DISEASES OF THE SKIN.

or " tanned." There is another circumstance, too, which is very diffi
cult of explanation, namely, that in certain persons with very white
skins, especially in blondes and in red-haired individuals, the pigment
formed under the influences just mentioned is only deposited in small
circumscribed specks and spots upon the unprotected surface. In
summer, the hands, face, and arms of such persons, though screened
from the direct rays of the sun, become covered with rounded spots of
a more or less dark color, called " freckles " (ephelides). The bronzed
skin of a seaman gradually loses its deep color if he stays at home in
winter, and, under similar circumstances, freckles also fade or entirely
disappear. Freckles may be removed by means of applications capa-
ble of producing desquamation of the epidermis, together with its
deeper pigmentary layer ; but, if the exciting cause be continued, they
will return in course of a few weeks. The well-known Lilionese is
merely a palliative cosmetic, as is also the wash recommended by
Hebra (hydrarg. chlor. corrosiv. gr. v; aquae | j). The application
is only to be kept on for a few hours, and care must be taken that the
compress upon which the solution is applied is free from folds. If the
skin becomes much inflamed, it is to be covered by compresses dipped
in oiL In a few days, as the epidermis scales off, the freckles disap-
pear.

In pregnant women, and women suffering from disease of the sex
ual organs, brown spots often appear upon the face, especially upon
the forehead and upper lip (chloasmata uterina). In most women they
disappear some time after confinement, but in some they are very per-
sistent or even become permanent. This phenomenon is as inexplica-
ble as is the increase in the pigmentation of the rete Malpighii, and
of the areola of the nipples and skin of the linea alba during preg-
nancy.

Besides the diffuse hypertrophy of the papillary portion of the
Bkin, which occurs in ichthyosis, hypertrophy of a single papilla, with
hyperplasia of the epidermis which covers it, is of very common occur-
rence. It is in this manner that warts and condylomata are formed.
Warts arise by the elongation and combination of a few papillae, so a?
to form a cone. It is covered by a very thick and hard layer of epi
dermis. If the several papillae of which the wart consists be each
covered separately by its epidermic envelope, the wart has a cloven
fibrous appearance. The cause of these growths is unknown. Un-
cleanliness of habit certainly plays but a very subordinate role in their
production, for, even among the cleanest people, the skin, especially
that of the hands, often becomes covered by them in a short time.
The sudden manner in which this papillary hypertrophy often disap-
pears is equally puzzling. The laity are accustomed to ascribe the

HYPERTROPHY OF THE SKIN.

443

disappearance of warts to the action of the so-called sympathetic reme-
dies or charms. Condylomata differ from common warts, as their papilla)
not only grow longer, but they also throw out lateral offshoots, and
the epidermis which covers them is not so thick and tough. There
are two forms of them, the pointed and the broad. The former appear
upon the mucous membrane of the external genitals, the urethra
and vagina, as well as upon parts of the skin which have been moist-
ened by the vaginal or urethral blenorrhceal secretion. Their appear-
ance is that of a mulberry or cauliflower, or, if compressed laterally,
they look like a cock's comb. Pointed condylomata require local
treatment. The structure of the wide condylomata is very like that
of the pointed form. They are less prominent, however, and show a
tendency to superficial ulceration. The most common seat of the
broad condylomata is upon the labia, the scrotum, and between the
nates. More rarely they occur upon the lips and between the toes.
As they are the consequence of constitutional disease, they require gen-
eral antisyphilitic treatment for their cure, instead of local applications.

The so-called polypi of the skin, and the hard and sometimes
pedunculated tumor, known as molluscum simplex (fibroma mollus-
cum of Virchow), are results of a circumscribed hypertrophy of the
connective tissue of the skin. The so-called Jceloid is a peculiar form
of partial hypertrophy of the cutis, resulting in the formation of irregu-
lar tumors, which in structure resemble a scar. Pachydermy, or
elephantiasis Arabum, is due to a diffuse hypertrophy of the cutis and
subcutaneous connective tissue. Of this we shall speak more fully
hereafter.

The hypertrophic development of the capillaries of the cutis, which
sometimes is combined with an hypertrophy of its connective tissue,
gives rise to the formation of red or reddish-brown spots, or tumors in
the skin, called telangiectasis. They may be congenital (ncevi vascu-
lares) , or they may not form until some time after birth. Telangiectasis
must be regarded as of two kinds — a kind which, after attaining a
certain size, remains stationary ; and a kind which grows continually,
its capillaries finally becoming so much dilated as to give way and to
bleed profusely.

The majority of " mothers' marks " are nearly always complicated
with hypertrophic development of the hairs and cutaneous glands
upon small portions of the skin. Curious cases are also met with in
which there is an extraordinary premature development of the beard,
and of the hair upon the pubis, and sometimes a remarkable growth
of hair covering the whole body, or parts of it, no other irregularity
coexisting. Molluscum contagiosum (epithelioma molluscum of Vir~
chow) is the result of hypertrophy and dilatation of the hair-follicles,

444: DISEASES OF THE SKIN.

which become distended by a collection of epithelial scales and glol>
ules of a fatty lustre. The tumors, which at first are scarcely larger
than a pea, and are covered by the normal skin, gradually enlarge,
while the skin becomes tense, red, and depressed in the middle, like a
runnel. New nodules develop in the vicinity of the first one, so that
finally a large area of the skin is often covered by these molluscous
tumors. This continuous progress, and the communication of the dis-
ease to other persons, the actual occurrence of which has been well
authenticated in several instances, indicate that it is of a contagious
character. The bearer of the contagion seems to be the fatty globules
above mentioned.

CHAPTER I.

DIFFUSE HYPERTROPHY OF THE PAPILLARY LAYER AND OF THE
EPIDERMIS ICHTHYOSIS.

ETIOLOGY. — It has been stated already that the exuberant forma-
tion of epidermis, which takes place in ichthyosis, is due to an abnor-
mal development of the papillary layer of the matrix of the epidermis.
Barensprung, of whose excellent work upon cutaneous diseases we
have made free use whenever the publications of this profound inves-
tigator have been available, makes a distinction between congenital
ichthyosis in its narrowest sense, where the child comes into the world
clad in a thick horny corselet, and the true ichthyosis. In the former
affection the child is born dead, or dies soon after birth, and it would
appear that the horny case which covers it must have formed at an
early period of intra-uterine life, probably through melting together of
the caseous varnish composed of cells of epidermis and cutaneous se-
cretion. It is always evident that the rigid horny coat, which is all
cracked into fragments, has become too small to cover the fully-grown
fcetus, and has crippled the development of its nose, lips, ears, fingers,
and toes.

The papillary hypertrophy, which is the cause of the true ichthy-
osis, likewise appears to be an hereditary and congenital disease. The
fact that the malady nearly always remains undetected during the first
year of the child's life, is to be ascribed to the manner in which the
skin is cared for during that time. The family history of a patient
with ichthyosis often shows that other members of the family, brothers,
parents, or grandparents, or other relatives, have suffered from the
same disease.

Besides the congenital true ichthyosis, which usually extends
over the entire surface of the body, there is a milder and acquired fora;

ICHTHYOSIS.

445

of the disease, which remains confined to portions only of the skin,
and which complicates pachydermy.

SYMPTOMS AND COURSE. — Instead of presenting the smooth ap-
pearance usually seen upon the skin of a healthy person, the skin in
the milder grades of ichthyosis is roughened and covered with delicate
white scales. It is this milder form of the disease which is usually
called pityriasis. The term pityriasis, in this sense, signifies a des-
quamation of the cuticle depending upon a mere exuberant growth of
epidermis, and not upon other disease. We know such to be the case,
from the habitual presence of the conditions above described, and by
the absence of any symptoms of congestion or of inflammation, or of
any derangement in the secretion of the glands and sebaceous follicles.
Most cases of desquamation of the epidermis upon the head, in which
the fine white scales adhere to the hair, and cover the collar of the coat,
do not depend upon exuberant formation of epidermis, but upon a
superficial dermatitis. The scaling off of the skin of the palms of the
hands and soles of the feet, too, is generally due to superficial inflam-
mation of the skin, and will be discussed more in detail in the chapter
upon eczema. In genuine ichthyosis, the epidermis is detached in the
form of larger and thicker scales, usually stained of a dark color by
pigment and dirt. In the worst forms of the disease the epidermis is
in horny plates, and even forms warty or spinous projections. Hence a
great number of subordinate varieties of ichthyosis have been recog-
nized, ichthyosis simplex, cornea, hystrix, etc., which, however, are not
varieties in kind, but merely in the degree of the disease. Certain
parts of the body, the face, the palms of the hands, the soles of the
feet, the armpits, and the bends of the knees and elbows, are not at-
tacked by the affection, while its favorite seat is upon the dorsal sur-
face of the extremities, especially upon that of the knees and elbows.
Hebra accounts for the fact that we cannot, at first, detect the ex-
istence of ichthyosis in newly-born children, upon the ground that a
child in the womb of its mother is in a continual warm bath, which
keeps the epidermis in a state of maceration. Moreover, owing to the
continual necessity for washing little children in their first year, the
scales of epidermis are not allowed to collect, and hence the disease
usually remains undetected.

TREATMENT. — This disease is incurable, as we know of no remedy
capable of producing involution of the hypertrophy of the papillary
layer of the skin. Our experience as to the uselessness of arsenic, anti-
mony, tar, and other external and internal medicines, is too ample to
warrant our making further trial of them. It is well to advise the
patient to take a warm bath daily, with or without the addition of an
alkali, and diligently to anoint his skin with some unctuous substance,

446 DISEASES OF THE SKIN.

as by these means the extensive accumulation of detached epiderm
may be prevented.

CHAPTER II.

DIFFUSE HYPERTROPHY OF THE SKIN AND SUBCUTANEOUS CONNEC
TTVE TISSUE — PACHYDERMIA — ELEPHANTIASIS ARABUM.

ETIOLOGY. — Repeated inflammation of the skin, and especially re
peated and permanent obstruction of the veins or lymphatics of a part,
sometimes lead to enormous growth of the connective tissue of the
skin, subcutaneous and intermuscular substance, and even of the perios-
teum of the bones of the affected part. This condition is called/>acAy-
dermia,) or, from the clumsy, deformed appearance of the limb attacked,
it is also called elephantiasis arabum. This disease has nothing in
common with the elephantiasis grcecorum, or leprosy (lepra, Spedalr
skhed). We do not know the reason why it is that a case of repeated
dermatitis, or phlebitis and primary thrombosis, or of obliteration of a
vein or lymphatic, only now and then terminates in pachydermia, and
why it does not always occur. It is also quite strange that this dis-
ease should be much more common in certain countries, especially in
the torrid zone (Barbadoes leg), than it is with us.

ANATOMICAL APPEARANCES. — The most usual seat of the disease
is upon the leg, which undergoes more or less irregular enlargement,
and attains more than two or three times its normal size. The skin
is immovable, and, when the papillary layer also takes part in the hy-
pertrophy, it is covered with scaly crusts. The tissue of the skin, and
of the adipose layer below it, is converted into a dense firm mass, re-
sembling bacon, whose microscopic elements consist of connective-tis-
sue cells of different stages of development. The muscles are atro-
phied and in a state of fatty degeneration, owing to a want of exercise,
and to the pressure to which they are subjected by their surrounding
connective tissue, which is likewise involved in the thickening. The
veins and lymphatics are often obliterated, and there is frequently a
varicose enlargement of them below the point of obstruction. The
anatomical appearances are quite similar when the disease attacks the
upper extremity, the scrotum, the penis, or the labia majora.

SYMPTOMS AND COURSE. — The first symptom of the disease is
either an erysipelatous inflammation of the skin, or else a lymphangitis
or a phlebitis. Some authorities state that the local disease is often
preceded by violent fever. This cannot be regarded as at all singular,
as in other inflammations the febrile disturbance is generally most
severe at the commencement of the attack, and attracts attention be

ELEPHANTIASIS ARABUM.

447

fore the functional disease becomes apparent. The portion of the
body which swells during the inflammation does not return to its nor-
mal size after the fever subsides, but remains moderately enlarged,,
and assumes a soft, boggy consistence. Soon, usually within a few
months, another attack occurs, which runs the same course as the first
one, and results in a further enlargement of the affected part. As the
attacks are repeated, and as the intervals between them diminish, the
deformity and weight of the limb increase, and the doughiness, which
is a result of cedematous infiltration, gives place to a board-like hard-
ness, due to the formation of dense connective tissue. If, as the in-
flammation recurs, the pachydermy spread beyond the point originally
attacked, all the different grades of the disease are often exhibited
simultaneously in the same extremity. Excepting during the periods
of inflammation, there is no pain in the swollen part. It is often the
seat of a superficial (eczematous) inflammation of the skin, accompanied
by a liquid exudation beneath the epidermis and upon the free surface.
The mobility of the afflicted member is, of course, seriously impaired.

TREATMENT. — A suitable treatment will often afford great relief
in cases of pachydermia which have not advanced too far, and may
even effect a complete cure. During the initiatory stage of inflam-
mation the limb must be elevated, and this posture must be retained
for some time after the inflammation has subsided. Cold applications
are then to be made. The inunction of mercurial ointment is also
urgently recommended in this stage. After the inflammation has sub-
sided, we must proceed to methodical compression of the part. Hebra
recommends that the limb be enveloped in a cotton bandage previous-
ly soaked in water. This is to be applied from the toes upward, so
that each turn of the bandage shall almost cover the preceding one.
It may be drawn very tightly, as the patient can bear a very firm
pressure without inconvenience, and as even a very tight bandage
usually becomes loose in a few hours. This simple treatment, if kept
up methodically, often produces a most beneficial effect.

In elephantiasis scroti, in which the scrotum sometimes reaches
down as low as the knees, and weighs over a hundred weight, and in
elephantiasis of the labia majora, the tumor must be removed by the
knife.

II.— ATROPHY OF THE SKIN.

ATROPHY of the skin may appear as one of the symptoms of a gen-
eral marasmus, and not only in the senile marasmus, but also in that
premature general atrophy induced by exhausting illness. Upon
pinching up the skin of a marantic individual into a fold, or, upon cut-

448 DISEASES OP THE SKIN.

ting it in post-mortem examination, a striking diminution of its thick
ness will be observed. A coating of detached scales of epidermis is
usually found upon the skin of such subjects. This is not a product
of any coexisting hypertrophy of the epidermic layer, but has formed
simply because the cutaneous secretion is diminished, which keeps the
skin pliable during health, and which causes the epidermis of healthy
persons to fall imperceptibly. In other words, in the so-called pityriasis
tabescentium the epidermic cells are not generated in undue quantity,
but they are shed in a more conspicuous manner than is natural to a
person in good health. Atrophy of the skin may also proceed from
continued pressure either from within or from without. We have al-
ready said that a corn induces partial atrophy of the corium. Favus
crusts and scabs, which have adhered to the skin for a long time, have
a similar effect. As pressure from without sometimes injures the pap-
illary layer of the skin, the product of the latter, the epidermic cells,
is formed in diminished quantity, and hence the cuticle over the com-
pressed point is remarkably thin. The effect is different when the
pressure upon the skin proceeds from within, as, for instance, in the
great distention of the belly which occurs in pregnancy or during
dropsical effusion, and in cases of excessive swelling of other parts of
the body covered by skin. In such cases it is the deeper layers of the
corium and the glandular structure of the skin which suffer, the pro-
duction of epidermis not undergoing any derangement. I have no
doubt that the pityriasis of the abdomen and extremities consequent
upon repeated pregnancy and extensive dropsy, as well as pityriasis
tabescentium, is attributable to atrophy of the deeper layers of the
corium and cutaneous glands, with abnormal dryness of the epidermis.

A congenital absence of pigment throughout the rete Malpighii of
the whole body occurs in albinos. Sometimes from unknown causes
the pigment disappears from circumscribed patches of skin. These
spots are of a milky whiteness, and, as they most frequently occur in
individuals of a strongly-marked brunette complexion, they create a
striking contrast with the surrounding surface (vitiligo, achroma).

The hair-follicles often undergo atrophy, particularly the follicles
of the scalp, and, in consequence of this, the hair falls off. If the
atrophy does not cause complete destruction of the hair-bulb, the pro-
duction of hair does not cease entirely, but the wasted follicles can only
produce a fine woolly down, instead of vigorous normal hair. Bald-
headed persons, finding this downy growth upon their heads, are often
inspired with fallacious hopes, especially if just before they have been
using the " eau de lob " or " lion-pomade," and have faith in the tales
told of these articles. Baldness arising from atrophy of the hair-bulbs is
called calvities, or calvities senilis, from its liability to occur in old per

ATROPHY OF THE SKIN. 449

sons. Not unfrequently, however, this calvities occurs in younger per-
sons ; hereditary predisposition apparently being one of the most com-
mon of its causes. No reliance is to be placed upon the statement of
Daldness's having arisen from over-exertion of the brain, over-anxiety,
or from sexual excess. There is a very large number of profoundly-
learned persons, as well as careworn and dissipated people, whose hair
grows luxuriantly ; while many others, who think but little, and live con-
tinently and unoppressed by care, lose then* hair early in life. Of course,
there is no means of producing a development of new hair-bulbs;
hence, in spite of the pretensions of charlatans, this form of baldness
is incurable. This is not the case with the deflumum capillorum, or
falling out of the hair, which occurs during and after certain acute and
chronic diseases, during which the hair-follicles suffer temporary de-
rangement of nutrition. Here the follicle is not destroyed, nor is it
even permanently injured. When the disease causing the loss of the hair
has subsided, and when its effects upon the general constitution have
disappeared, the hair-follicles are restored to health, and reproduce
new hairs in place of the fallen ones. Among the acute diseases,
typhus, and of the chronic ones, syphilis, are the most frequent causes
of defluvium capillorum, as this latter form of falling of the hair is
called. Severe pneumonia, however, and nearly every other exhaust-
iug disease, and in a slighter degree the puerperal state, almost al-
ways occasion more or less loss of the hair. Alopecia circumscripta
seu area Celsi also seems to depend upon temporary derangement of
the nutrition of the hair-follicles. In this -complaint, which is not un-
common, round spots of variable size appear upon the head, or, as is less
usual, upon the beard, or upon other regions, in which the hairs break
off close above the roots, split into brushes, and fall out, so as event-
ually to form a bald spot closely surrounded by a dense growth of
hair. The skin of the bald spot appears perfectly healthy, and this
will readily enable us to distinguish alopecia circumscripta from herpes
tonsurans, which may also produce round bald spots upon the skin.
The cause of alopecia circumscripta is unknown. It is not due to the
presence of a vegetable parasite. After a while the bald spot is once
more covered with healthy hair. Loss of the hair induced by inflam-
mation of the scalp, and by parasites (favus, herpes tondens), is to be
treated of by-and-by in its appropriate chapter.

In very old persons the hair almost always loses its color,
and, according to the observations of jSeitz, the discoloration begins
at the tip, and extends rapidly — i. e., in a few days — over the
whole hair. Now and then the hair loses color throughout its whole
extent from the first. The hair of young persons also loses its color
sometimes, and it then often takes place more rapidly than is usually

450 DISEASES OF TUB SKIN.

the case among older persons. As in premature baldness, hereditary
tendency seems to be the main cause of premature grayness of the
hair, although, perhaps, care and sorrow may also play some part in
producing the change. It is a curious fact that a hair, which is only
gray at its tip, if pulled out, does not become gray throughout, but re-
mains permanently in the same condition. From this circumstance it
would seem that the matrix exerts some vital influence in rendering
the hair gray. This fact, moreover, renders those stories, which have
been handed down to us, far less incredible, although their truth has
been much doubted, of the hairs becoming gray in a few days from
the effect of intense mental emotion ; all the more so, since, according
to Pfaff) the grayness does not depend upon a disappearance of the
pigment from the hair, but upon a thickening of its cortical layer. In
a case reported by Landois, sudden grayness of the hair took place in
consequence of an increased development of air in the hair. The pig-
ment does not disappear from the medullary substance of the hair un-
til in advanced old age.

III.—HYPERJEMIA AND ANAEMIA OF THE SKIK

THE quantity of blood contained by the skin varies more than that
contained by any other organ, because the skin is far more exposed
than other parts of the body to influences capable of modifying the
circulation. In our first volume we have already given a detailed ac-
count of those abnormities of the cutaneous circulation which arise
from disease of the heart, including both the overloading of the ar-
teries and arterial capillaries from increased cardiac action, and the
engorgement of the veins and venous capillaries (cyanosis), which re-
sults from lack of power in the heart.

Active hyperaemia of the skin (fluxion) occurs upon exposure of
the skin to great heat, especially to heat and moisture combined. It
also may result from the application upon it of irritating substances,
such as cantharides, mustard, or spurge-laurel, or from mechanical in-
jury. In all such cases, as has repeatedly been mentioned, the first
effect of the irritant seems to be a relaxation of the cutaneous tissue ;
and a dilatation of the capillaries seems to be consequent upon the re-
duced power of resistance of the ti&sues which surround them. If the
hyperaemia be intense enough to produce a redness of the skin, visible
through the epidermis which covers it, it is called erythema, and is fur-
ther distinguished as erythema caloricum, solar e, venenale, according
as the redness proceeds from heat, the sun's rays, or the action of mus-
-ard, cantharides, or spurge, and the like. With equal reas m, redness

HYPER^MIA AND ANAEMIA OF THE SKIN.

451

of the surface, caused by a blow, might be called erythema traumati-
cum. Such a variety of names for hyperaemia of the skin is quite use-
less, and, as some of the inflammatory cutaneous affections, when ac-
companied by redness, are also called erythema, it only creates mis-
understanding and confusion. Partial hypersemia of the skin, more-
over, is the first symptom of most of the acute and chronic exanthe-
mata, in whose subsequent course exudation is thrown out either
within the skin or upon its surface. Finally, partial cutaneous hyper-
semia is very often observed in certain febrile diseases, without our
being able to account for its occurrence. In such cases the hyper-
aemia usually is limited to a very small circumscribed area, forming
rounded or irregular red spots, varying in size from that of a lentil to
that of a farthing, and is thus called roseola. This name, however, is
not applied exclusively to the red spots of simple hyperaemia (macula),
but also to the small red nodules arising from an infiltration of the
skin combined with hyperaemia (papula). Typhoid fever, the typhoid
stage of cholera, and other infectious disorders, are accompanied by
roseola, but it also is by no means rare in the febrile, gastric, and intes-
tinal catarrhs of children, as well as in inflammatory diseases of the
brain and lungs. When we can discover a cause for the fever, we call
the roseola a symptomatic roseola / when no cause for the fever can
be found, the eruption is said to be idiopathic. To the latter class
belong the so-called roseola sestiva, ros. autumnalis, ros. infantilis,
and some of the affections entitled measles ("Rfltheln"). r

The only symptoms of erythema are reddening of the skin and an
augmented sense of heat. The hyperaemic surface becomes blanched
if the blood be expelled from the skin by pressure, while the redness
arising from haemorrhage into the cutis is not effaced by pressure.
When the reddened spot is likewise much swollen and painful ; when
the pressure leaves a white spot instead of a yellow one behind ; when,
after the redness subsides, the epidermis scales off, the disease is not
simple hyperaemia, but inflammation with infiltration.

Anaemia of the skin is an important symptom of poverty of the
blood. It also arises from exposure of the skin to a very low temper
ature, both owing to the physical action of cold and to the contraction
of the cutaneous muscles to which cold gives rise. Both of these ef-
fects render the skin denser and more resisting, and thereby impede
the influx of blood into the capillaries. This effect is increased by the
contraction of the smaller arteries which takes place at the same time.
Finally, a partial anaemia or ischcemia of the skin may arise independ-
ently of the influence of cold, from spasmodic (?) contraction of the
cutaneous muscles and muscles of the arterial walls. This phenome-
non is most frequently observed during the rigor which ushers in a

4.52 DISEASES OF THE SKIN.

fever. Sometimes, however, it occurs spontaneously, and without as-
signable cause, as is seen in the so-called " deadness " of the fingers
and toes.

Hyperaemia and anaemia of the skin seldom require active treat-
ment. The application of cold is indicated in the former, and, in the
latter, warmth, combined with moisture, as well as the application of
cutaneous stimulants and stimulating friction, is the proper remedv.

IV._ INFLAMMATION OF THE SKIN.

UNDER this heading we treat of all the nutritive disturbances of
the skin in which an exudation is thrown out within its substance or
upon its free surface. However, it is questionable whether, strictly
speaking, all these forms of disease ought to be regarded as inflam-
matory, as, in my opinion, an interstitial exudation is neither a neces-
sary condition nor a sure criterion of inflammation. We shall not,
however, indulge in further discussion of the question, and, after the
example of Simon, in the following chapters, shall employ the term
dermatitis to signify a process attended by exudation.

Infiltration of a somewhat extensive portion of skin results in the
so-called erythematous and erysipelatous inflammations. When the
infiltration is limited to small discrete spots of the capillary layer, -we
have the papular exanthemata. The variety of dermatitis, character-
ized by the formation of wheals or wales, proceeds from a more super-
ficial and extended infiltration. In the erysipelatous form of inflam-
mation, a simultaneous exudation upon the free surface of the cutis
often lifts the epidermis, forming vesicles and blebs of variable size.
An exudation upon the surface of the cutis, which elevates the epider-
mis into blisters, also occurs in other kinds of inflammation, both acute
and chronic, which are not attended by infiltration of the skin itself.

The vesicular exanthemata consist in superficial inflammation
which, like catarrh, is characterized by exudation upon the free surface
of the skin, unaccompanied by serious organic lesion, while in the
pustular form the exudation contains an abundant admixture of young
cells. There are also forms of cutaneous inflammation where the dis-
ease of the cutis is accompanied by a morbidly profuse growth of epi-
dermis, the so-called psoriasis. Besides these varieties, which diffei
chiefly in the intensity of the inflammation and the seat of the exu-
dation, there are others distinguished by the peculiar character of the
course of the disease, and by the causes which produce it, and which
compel us to treat of them in separate chapters, in order to avoid the
classification under one head of dissimilar diseases.

ACUTE INFLAMMATION OF THE SKIN. 453

CHAPTER III.

FIIE SLIGHTER FORM OP ACUTE INFLAMMATION OF THE SKIN WITH-
OUT VESICATION EEYTHEMATOUS DERMATITIS ERYTHEMA.

ETIOLOGY. — In this form of dermatitis, the papillary layer of the
skin, and, in most cases, the tissue of the cutis, becomes the seat of
hyperaemia and of serous infiltration. Since the epidermis usually
scales off after the erythema has subsided, it is to be presumed that
the attachment of the cuticle to the papillary layer has been loosened
by a simultaneous effusion upon the surface of the cutis. This effu-
sion, however, is insufficient in quantity to raise the epidermis into
blisters. Heat, the direct rays of the sun, mechanical and chemical
irritation, and other exciting causes to which we already have alluded
in speaking of hyperaemia of the skin, when allowed to act with great-
er intensity and for a longer time, give rise to erythematous inflam-
mation. Special names have been given to some forms of erythema
from mechanical irritation. Where it arises from the friction of two
opposing surfaces, it is called erythema intertrigo. This is very com-
mon among infants, especially among feeble ones, appearing in the
folds of the skin, upon the genitals, behind the ears, and in the neck.
It also occurs underneath the pendulous breasts of very corpulent fe-
males. When it arises between the nates, from their continuous fric-
tion upon one another during a long march, it is popularly called " a
wolf" ("Wolf"). The erythema which appears in cases of protract-
ed illness, caused by the pressure of the bed upon the sacrum, tro-
chanters, and other prominent parts of the body, is called decubilus.
That which is induced by tension of the skin in cases of severe dropsy,
or by trifling wounds, takes the name of 'erythema Iceve. Where there
long has been a discharge from the nose, and in blenorrhcea of the
conjunctiva, the acrid secretion which constantly bathes the skin often
gives rise to a superficial erythema of the upper lip and nose. Ery-
thema of the prepuce, scrotum, and inner surfaces of the thighs also
results from the continual moisture of the skin in cases of incontinence
of urine.

Besides these forms of erythema, which are the result of local irri-
tation, there is another variety, the symptoms and course of which are
peculiar, and the cause of which is unknown. In this country it some-
times appears sporadically, but not often, but shows a great tendency
to periodic relapses. In other places (Constantinople, Paris), it has
been observed to extend epidemically.

SYMPTOMS AND COURSE. — Erythema, arising from local irritation, is
characterized by red, slightly-prominent patches, the color of which grad-

454: DISEASES OF THE SKIN

ually becomes fainter at the edges. They become pale when pressed
upon, assuming a yellowish tinge ; and, when the pressure is removed,
the redness returns. The spots are the seat of a more or less severe pain.
If the irritant which has caused the erythema be speedily removed,
the redness and swelling disappear hi a day or two, and a slight des-
quamation of the epidermis finishes the process, which is always an
insignificant one. If the irritant be not removed ; if it be allowed to
operate continuously and vigorously, the erythema assumes a more
serious character, and new lesions form. Erythema solare becomes
an eczema solare ; blisters form upon burns ; in intertrigo, the epider-
mis is lost ; while erythema laeve may terminate in gangrene of the
skin.

Spontaneous erythema, that is to say, the erythema which appears
without assignable cause, always attacks the dorsal surface of the
hands and feet, much more rarely the body or face, the backs of the
hands and feet always suffering at the same time. Hebra lays stress
upon the constancy in the situation of the disease as an important di-
agnostic point. The attack commences with a moderate reddening
and tumefaction of the regions just mentioned as its first symptom.
Soon nodules and lumps of a deeper red hue, and sometimes even of
a bluish red, appear upon the reddened and swollen basis. Hence
the name erythema papulatum seu tuberculosum. In some persons
this eruption is attended by a disagreeable sense of burning at the
jx>int affected ; in others there is fever. In a day or two the redness
and swelling about the nodules begin to subside ; a day or two later
the lumps themselves grow smaller and paler, and finally disappear
altogether. The epidermis scales off, and the entire duration of the
disease is from one to two weeks. Both the bluish color of the no-
dules, and the yellowish tinge of the skin where the nodules were sit-
uated, which remains for some time after the nodules have disap-
peared, show that, besides the exudation, erythema papulatum is also
attended by slight extravasations of blood into the tissue of the cutis.
Sometimes erythema papulatum becomes chronic, and lasts for weeks
and months ; it then spreads from the point first attacked to other re-
gions. When new nodules form upon the periphery of the first erup-
tion, the disease meantime having abated in its centre, it is called ery-
thema annulare or circinatum. If there be a red spot remaining in the
middle of the ring, it is called erythema iris, or mamillatum. If, as the
circles extend, they become confluent and broken at the point of con-
tact, and thus form arched lines, they constitute the so-called erythema
gyratum. These names recur in other eruptions, in which the disease
extends upon the periphery of the original seat of the eruption, having
subsided at the centre, that is, at the point first attacked. The various

ACUTE INFLAMMATION OF THE SKIN. 455

lines or marks which are thus made upon the skin are not indicative
of different forms of disease, but merely of different stages of develop-
ment of the same morbid process.

Erythema papulatum or tuberculosum, however, differs from ery-
thema nodosum. This affection is most liable to attack young per-
sons, and is far more common in females than in males. Its seat is
almost without exception upon the lower extremities, especially upon
the legs. It consists in small circumscribed infiltrations in the deeper
layers of the skin, accompanied by extravasation of blood. We at
first perceive rounded knots of the size of a hazel-nut or of a walnut,
covered by slightly-reddened skin, and somewhat painful to the touch,
so that they strongly resemble bruises (dermatitis contusiformis). The
rose-red color of the skin gradually grows darker, and then changes
successively to a violet, to blue, green, and finally to yellow, the se-
ries of changes being entirely similar to that which occurs in traumatic
extravasations beneath the skin. Erythema nodosum is always accom-
panied by febrile disturbance, which debilitates the patient and con-
fines him to bed. The disease usually lasts one or two weeks, and its
termination is also followed by desquamation of the epidermis. As
a great rarity, erythema nodosum also becomes chronic, the first nodes
subsiding with desquamation of the epidermis, and new ones succeed-
ing them.1

TREATMENT. — Erythema resulting from local irritation soon sub-
sides when the exciting cause is removed. When the burning pain is
severe, we may make applications of cold water or of lead water. In
erythema intertrigo, in order to prevent the friction of the opposing
surfaces, we must sprinkle them with fine powder, lycopodium seeds
mixed with oxide of zinc being the one most in use (sem. lycopod. § ss,
zinci oxid. 3 ss), or else a pledget of charpie, smeared with zinc oint-
ment, may be inserted between the surfaces. Erythema arising from
the pressure against the bed (decubitus) may be relieved by the use
of circular india-rubber pads filled with air. When it results from
contact of acrid secretion, the skin should be protected from it by a
coating of lip-salve or other grease. Erythema papulatum requires no
particular treatment, although, if it be attended by much burning, we
may make use of cold compresses. In erythema nodosum proper at
tention must be paid to the fever and to the strength of the patient
Compresses wet with cold water, or with lead-water, should be applied
*o the nodules if they are painful.
79

456 DISEASES OF THE SKIN.

CHAPTER IV.

ERYSIPELATOUS DERMATITIS — ERYSIPELAS.

ETIOLOGY. — Erysipelatous dermatitis is distinguished by an intense
hyperaemia of the cutis, and by a profuse serous transudation, not only
into the skin itself, but into the subcutaneous areolar tissue, and some-
times between the cutis and the epidermis. It is also marked by the
slightness of its tendency to form abscesses, and by the invariable im-
plication of the lymphatic vessels and glands in the inflammation.
Erysipelas not unfrequently results in rupture of small vessels and of
haemorrhages into the skin and upon its free surface. The disease is
sometimes so violent as to end in gangrene.

I believe that it is an error to suppose that any cutaneous irritant,
if of sufficient intensity, may produce erysipelas. Comparison of ery-
sipelatous inflammation with that caused by a blistering plaster, in
spite of the blisters which may form in either case, seems to me de-
cidedly to contradict the identity of the two processes. Besides, the
inflammatory derangements of nutrition produced by burns and by me-
chanical injuries, and similar sources of local irritation, do not present
the characteristics of erysipelas, as they either produce simple blisters
without any other exudation either in the skin or under it, or else,
when of greater intensity, cause destructive disease of the part. We
may regard it as proved that most forms of erysipelatous dermatitis
proceed from the extension of an inflammation from the wall of an
inflamed lymphatic vessel into the surrounding tissue of the cutis.
First among these forms is that resulting from inoculation with some
acrid or venomous material. In such cases it can often be demon-
strated by direct observation that the poison was first taken up by the
lymphatics, and thus gave rise to inflammation of their walls, and
that the inflammation of the skin is a secondary occurrence. Here a
reddened cord, with nodular enlargements, is first observed, and
it is not until afterward that a diffuse and uniform redness and
swelling make their appearance upon the skin. Next to this form
comes the erysipelas, arising from the absorption of the ichorous se-
cretion of a wound, or of the putrid contents of an abscess by the lym-
phatics, and their consequent inflammation. Not to encroach too far
upon the province of surgery, I will merely call to mind the so-called
" tooth-rose." This consists in a dermatitis with all the peculiarities
of erysipelas ; and there can hardly be any doubt that it proceeds
from the extension of a lymphangitis to the skin, and that it is caused
by the absorption of the liquid from the fcetid contents of a gumboil.
The simplest explanation, for the fact that, in hospitals, erysipelas now

ERYSIPELATOUS DERMATITIS— ERYSIPELAS. 457

and then attacks the most trifling wounds, even leech-bites, is, that the
material which excites inflammation in the lymphatics, when absorbed
by them, needs not absolutely to be inoculated, nor to have been
generated by the decomposition of the secretion of a wound, but that
it may be contained in the surrounding air or in the dressings which
cover the wound. Although, however, I regard it as almost certain
that many forms of erysipelas proceed from the extension of an inflam-
mation from the walls of the lymphatics to the skin, yet I do not be-
lieve that all forms of the disease arise in this way ; and, in the so-
called erysipelas verum sen exanthematicum in particular, I believe
this mode of origin to be improbable. This primary idiopathic form
of dermatitis, which attacks persons previously in good health, and
which appears most commonly upon the face and scalp, bears some
analogy to pneumonia, pleurisy, laryngitis, bronchitis, angina, etc.,
which also occur primarily and idiopathically, and which likewise ap-
pears in previously healthy subjects. We have no reason for looking
upon true erysipelas as one of the acute exanthemata, or of regarding it
as infectious ; indeed, the great tendency which the complaint shows
to recur again and again, in the same individual, may be advanced as
an argument against its analogy with scarlatina, small-pox, measles,
etc., and against the supposition of its infectious origin. The causes
of exanthematic erysipelas are as obscure as are those of pneumonia
and the other inflammations above alluded to. In both forms of dis-
ease it cannot generally be ascribed to local irritation, nor to cold, to
errors of diet, nor to other pernicious agents. Violent mental emo-
tion, however, seems to have an influence in producing the disease,
especially in persons who already have suffered from it. Like pneu-
monia, angina, and the other inflammations, erysipelas sometimes pre-
vails without assignable cause, under the influence of a so-called
genius epidemicus stationarius. We are unable to determine whether
these inflammatory disorders are secondary local manifestations of
some primary general disease, or whether the affection is of a local
character from the outset. Erysipelas also resembles pneumonia and
the other inflammations, by its tendency to attack persons who have
already suffered from the disease in preference to those who never
have had it. It occurs most often during middle age, and is seen
somewhat more frequently in women than in men. The disease is
more common in warm weather than in cold.

SYMPTOMS AND COTTKSE. — Erysipelas proceeding from external
causes belongs to the province of surgery. In this work we shall
only consider the symptoms and course of the erysipelas verum seu
exanthematicum.

In many cases of true erysipelas, the local symptoms are preceded

458 DISEASES OF THE SKIN.

by some hours, and still more often by some days, of general disturb-
ance of the health, accompanied by more or less fever. As the pro-
dromic stage is not constant, and as sometimes the general derange-
ment of health and the fever do not appear until after the local symp-
toms, the precursory signs of erysipelas are not to be compared with
the fever of the acute exanthemata, but are rather to be regarded as
analogous to that which often, for several hours or days, precedes a
severe coryza, or the stitch and cough of a pneumonia. The first local
symptom of the disease which is developing, is a sense of heat, ten-
sion, and pain in the skin, which is not as yet reddened or swollen
The neighboring lymphatic glands are already enlarged and sensitive
to the touch. Soon the skin, begins to redden and to swell. At first
the redness is speckled and clear, but it soon becomes diffuse and
dark. The swelling increases and soon becomes extreme, especially
where the skin is attached to the parts beneath by loose connective
tissue (as in the eyelids), where it renders the skin smooth and
shining from the tension. With the swelling, the sense of burning
and fulness also increases. At this period there is almost always a
violent fever, which grows worse toward evening. The pulse is usu-
ally full, beating from a hundred to a hundred and twenty times a
minute, and the temperature rises to 105° F., or even higher. The
thirst is increased, the appetite lost. As in facial erysipelas, the mu-
cous membranes of the mouth and tongue sympathize with the inflam-
mation of the skin ; there are also signs of violent oral catarrh. The
tongue is heavily coated and dry from the effects of fever, while a
fetid odor proceeds from the putrefying epithelium which covers it.
There is a slimy or bitter taste in the mouth.

Although facial erysipelas may also be accompanied by symptoms
of dyspepsia, yet, from this, we are not justified in assuming that the
disease proceeds from a saburral condition, or from " biliousness," as
nearly all fevers are accompanied by more or less gastric derangement,
the patient sleeps badly, and his rest is troubled by dreams. Some-
times there is delirium, which, however, but rarely depends upon
implication of the meninges, and is due to the fever alone. At this
stage of facial erysipelas the patient is much disfigured and scarcely
recognizable. The epidermis is usually elevated here and there 151
small vesicles, or even in large blisters, while elsewhere the blisters
have burst, and their contents, with the debris of the epidermis, are
dried into yellow scabs. It is quite useless to give special names to
the unimportant variations observed in different cases of erysipelas,
caused by the degree of the swelling, the presence or absence of vesi-
cation, the size of the blisters, the nature of their contents, such as
erysipelas Icevigatum s. erythematosum, — miliare, vesiculosum, bullo

ERYSIPELAS. 4.59

*um, crustosum, ind the like. The redness usually begins to fade
about the third or fourth day, the swelling subsides, the pain abates,
and the tension of the blisters, which still remain, diminishes, part of
their contents undergoing absorption, another portion drying up into
a crust. It nearly always happens, in facial erysipelas, that the disease
spreads beyond the region first attacked, and that while the inflamma-
tion is subsiding at one point it is still at its height elsewhere. Hence,
patients often suffer more after the tumefaction of the face has sub-
sided, and they have again become able to open their eyes, because the
disease has invaded the scalp, which, being firmly attached and but
slightly distensible, is much more sensitive when in a state of inflam-
matory tension.

Excepting the " wandering erysipelas," to be described presently,
the disease does not generally spread over more than a moderate area
of skin. Facial erysipelas almost always involves the eyes, ears, hairy
scalp, and a portion of the throat, but scarcely ever attacks the back
of the neck or the trunk. Hence, as it also has to run its course upon
the region last attacked, its whole duration is usually about a week, or
somewhat longer. The process terminates in the peeling off of the
cuticle in large pieces, even where there were no blisters. If the scalp
has been inflamed, the hair always falls out soon afterward, for the
hair follicles have also been the seat of an exudation which loosens
the hair and detaches it from its matrix. Erysipelas, however, does
not cause any permanent injury of the hair follicles, hence the baldness
which it occasions soon disappears completely. In the somewhat rare
instances in which erysipelatous dermatitis passes into suppuration,
fluctuation appears at one or more points of no great magnitude (and
most frequently in the eyelids). Generally speaking, this is not ob-
served until the redness and swelling of the surrounding parts have
begun to subside. Puncture of the abscess or its spontaneous open-
ing, which is apt to be somwhat delayed, is usually followed by a dis-
charge of yellow laudable pus, and by speedy recovery. Reddening
of the contents of the vesicles by effusion of blood is not always an
unfavorable sign, although it is sometimes due to a gangrenous stasis
of the capillary circulation in the inflamed skin. Upon the appearance
of gangrene of the skin (which is not rare in the malignant forms of
symptomatic erysipelas, but which is of quite exceptional occurrence in
the true, or exanthematic form of the disease), the contents of the ves-
icles assume a dark color, and the skin beneath is converted into a
grayish discolored slough. The general condition of the patient
changes. The fever becomes asthenic ; the temperature is very high :
the pulse very small and frequent, and there is an intense prostration
which may be fatal to life. Even the most favorable cases of gan

460 DISEASES OF THE SKIN.

grenous erysipelas are very tedious in their course, as the loss of sub-
stance resulting from the separation of the sloughs is repaired very
slowly.

Erysipelas is sometimes complicated with bronchial or with intes-
tinal catarrh, sometimes with intense hyperasmia of the kidneys, and
with catarrhal or croupous inflammation of the uriniferous tubules.
A far more serious but less common complication is the extension of
the inflammation from the scalp to the meninges. There is no me-
tastasis in such cases, however. The so-called " striking-in " of
the erysipelas is a consequence of the malignant character of the
disease, and of incipient collapse, and is not to be regarded as the
cause.

Wandering erysipelas (erysipelas ambulans s. migrans) generally
attacks the extremities, and spreads toward the trunk and head. It
usually advances steadily, so that the disease, while subsiding in one
place, is commencing in the immediately adjoining one. Much more
rarely it advances by skips, so that there are intervening regions of
sound skin between the inflamed surfaces. The hyperaemia and swell-
ing are not generally so severe in the wandering erysipelas as in the
stationary ; and while in the latter the redness and tumefaction are
most intense at the centre and gradually fade toward the edges, in
the former the seat of the greatest swelling and reddening is close to
the healthy skin. This form of erysipelas is usually accompanied by a
more moderate fever. However, as the disease often continues for
weeks and even for months, during which time the inflammation some-
times reverses the direction of its progress, and even goes back to its
original point of departure, even this lesser degree of fever is capable
of so exhausting the patient as to endanger life.

TREATMENT. — A large number of so-called "sympathetic reme-
dies " against " the rose " are in popular «use ; even intelligent and
educated people often carry amulets to protect them from its attacks,
and submit to conjuration of the disease if the amulet fail. Owing to
the short, cyclical, and almost invariably favorable course of the dis-
ease, therefore, every new attack of erysipelas is a fresh proof, in the
eyes of superstitious people, of the efficacy of their sympathetic cures.
Hence, as one seldom receives any thanks for attempting to combat
such superstition, and as it usually is labor lost ; moreover, as the " in-
vocation of the rose " has this advantage, that the patients, confident
in the efficacy of the procedure, accommodate themselves to their dis-
tressing position with patience, and without longing for superfluous
medication, I deem it advisable to allow patients, who believe in such
remedies, to do as they like. At all events, they do much better thus
than when (as often happens) the physician commences the treatment of

ERYSIPELAS.

461

every erysipelas with an emetic, because the tongue is coated and the
breath is foul, and when he attacks the inflammation with all the exter-
nal and internal antiphlogistics, and applies irritants to the already in-
^amed skin, in order to prevent the " striking-in " of the disease. How-
ever, although in most cases we cannot cut the disease short, and as it
almost always terminates favorably, even without treatment, it is bet-
ter to let it alone, or, at most, to envelop the inflamed part in cotton ;
still accidents may arise, which call for active interference. When the
skin is very tense and painful, Skoda strongly recommends the appli-
cation of cold in the form of wet or iced compresses. But existing
prejudices will oppose insuperable obstacles to applications of this kind,
and, as any accident which may occur under such treatment will cer-
tainly be attributed by the laity to repression of the disease, I prefer,
not so much on my own account, but to save the patient and his rela-
tives from useless and erroneous qualms of conscience, to resort to
slight compression and to mild scarification instead of cold. The result
is the same. The painful tension usually soon subsides under the
compression induced by painting the inflamed surface with collodion,
similar relief is obtained by making minute superficial punctures with
the point of a lancet. One or two pencillings of the inflamed surface
and the surrounding parts with lunar-caustic in substance, or painting
't with a somewhat strong solution of nitrate of silver (argent, nitr.
3iv, acid, nitric, gtt. viij ; aquae dest. ^ ss), seems to have a similar
action, although I cannot speak from my own experience. The prac-
tice, formerly much in vogue, of drawing a line with lunar-caustic
around the area of inflammation, in order to prevent its spreading, has
proved useless, and is now generally abandoned. Especial attention
should be paid to the fever in treating erysipelas, particularly to that
slow form of moderate but very persistent fever which accompanies
erysipelas ambulans. Quinia and its preparations are particularly
appropriate to such cases, as are also a nutritious diet, wine and
strong-beer.

Wlllarfs indorsement of William's treatment of erysipelas with
from four to eight ounces of port-wine daily, and his assertion that
the worst case of erysipelas of the head and scalp that he ever saw
was cured by Burton ale, should be accepted as meaning merely,
that when the fever threatens to consume the patient, alcoholic stimu-
lants must be given freely. The complications of the disease, espe-
cially the meningitis, are to be treated upon principles already laid
down. When the inflammation disappears, it is not advisable to at-
tempt to reestablish it upon the surface again by means of vesicants
and other cutaneous irritants. Abscesses and gangrene of the skin are
to be treated upon surgical principles.

462 DISEASES OF THE SKIN.

The treatment of phlegmonous erysipelas, and of boils and carbun
des, we refer to the handbooks of surgery.

CHAPTER V.

HERPES — ACUTE SUPERFICIAL DERMATITIS, ATTENDED BY FORMATION
OF GROUPS OF VESICLES UPON THE SKIN.

ETIOLOGY. — Herpes closely resembles erysipelas, in being an acute
dermatitis arising from unknown causes. It differs from it, however,
both in the abruptness of the limits of the inflammation and in its seat,
which is confined exclusively to the most superficial layers of the skin.
Hebra defines the various forms of herpes as " a series of acute cuta-
neous diseases of cyclical course, marked by an exudation which col-
lects in drops under the epidermis and elevates it ; forming vesicles
which are never solitary but always appear in groups." These vesi-
cles are all of about the same size and shape. The various groups do
not appear simultaneously, but follow one another at intervals of sev-
eral days, so that crops of recent vesicles and of older declining ones
are usually to be found at the same time. Eruptions of herpetic vesi-
cles (called hydroa febriles) often appear upon the face, and especially
upon the lips of patients suffering from pneumonia, intermittent fever,
ephemera, and epidemic cerebro-spinal meningitis. This eruption is
hardly ever seen in other diseases, particularly in typhoid fever (typhus
abdominalis). The appearance of herpes upon the face in acute febrile
disease has long been regarded as a favorable prognostic sign ; perhaps
merely because the diseases, to which it is almost peculiar, recover
more frequently than those in which it is rarely or never seen. Her-
petic eruptions, however, occur also in individuals previously healthy,
as well as during the course of other diseases.

It may be regarded as established that herpes zoster depends upon
disease of the trophical fibres of the motor and sensory nerves, which
supply the part affected. Further confirmation is required of the sup-
position that all forms of herpes are of similar origin ; for instance,
that herpes labialis proceeds from disease of small nervous branches
in the lips.

SYMPTOMS AND COURSE. — According to the region attacked, herpes
is classified into, first, herpes labialis, which is situated upon the lips,
and which often extends to the mucous membrane of the mouth. When
the groups of vesicles appear upon some other part of the face, such as
the cheeks or eyelids, it is called herpes phlyctenodes. Hebra pro-
poses the name of herpes facialis for all forms of herpes appearing
upon the face. There is also a herpes preputialis, which, as it likewise

HERPES.

463

arises upon other parts of the external genitals, might more properly
be called herpes pudendalis. Finally, there is herpes zoster or zona
(shingles), which extends, in a very peculiar manner, along the course
of the cutaneous nerves. When herpes zoster appears upon the
thorax, the groups of vesicles form a somewhat broad, interrupted belt,
which begins at one of the vertebrae, and, following the line of one of
the intercostal spaces, reaches to the sternum, but scarcely ever occurs
upon both sides of the body. When the eruption is upon the belly,
the groups of vesicles are arranged much as they are in zoster of the
chest, and extend from the lumbar vertebrae to the linea alba and
mons veneris. Upon the neck the vesicles sometimes form a half-collar,
sometimes they extend downward toward the second rib. Upon the
face, the eruption spreads along the course of the facial nerve, espe-
cially along the cheek, to the dorsum of the nose. Upon the scalp it
runs over the forehead and skull along the course of the supraorbital
nerve, or else spreads over the occiput along the course of the occipital
nerve. Finally, in zoster of the arm and thigh, the eruption of vesicles
follows the courses of the nerves which spring from the brachial and
crural plexus. All forms of herpes begin with a sense of burning pain,
usually not of a very severe character, in the affected region. Numerous
red points soon become visible, which coalesce, forming red specks of
irregular shape, which, on the next day, usually are covered with small
transparent vesicles. The contents of the vesicles, which rarely exceed
the size of a lentil or a split pea, become turbid in two or three days,
or else reddened from admixture of blood. About the third or fourth
day the vesicles commence to shrivel, and they and their contents sub-
sequently dry up into a brownish scab. The scabs fall off in from ten
days to a fortnight after the first appearance of the eruption, and for
some time afterward there remains a reddish spot, covered with thin
epidermis. The pain, which is of a burning character, though not very
severe t usually abates when the vesicles begin to shrivel. Herpes
zoster is sometimes accompanied by fever, and in rare instances the
eruption of vesicles is preceded by febrile disturbance, like the inflam-
matory cutaneous exudation of erysipelas. There is no fever in the
other varieties of herpes, or the fever, if present, does not depend upon
the herpes, but upon the disease with which the herpes is associated.

Besides the forms of herpes above enumerated, there is also a
herpes circinatus and a herpes iris. These species are not classified
according to their locality, like the other forms, but according to the
arrangement of the vesicles. This is quite analogous to that of the
nodules in erythema circinatum and erythema iris. In herpes circina-
tus, a circle of vesicles encloses a tract of healthy skin. Moreover, the
vesicles themselves are usually smaller than those of other kinds of

DISEASES OF THE SKIN.

herpes, and they do not always form a scab as they subside, but termi-
nate in reabsorption of their contents, with desquamation. In herpes
iris a few solitary vesicles stand in the centre of a circle of vesicles, or
of several concentric circles of them, whose vesicles exhibit different
stages of development and decline. Most cases both of herpes circina-
tus and herpes iris, if not all of them, owe their origin to the presence
of vegetable parasites.

TREATMENT. — As the various forms of herpes run a cyclical course,
and as they soon subside, and are not followed by any serious conse-
quences, their treatment should be simply expectant. It is sufficient
to protect the vesicles, and the scabs after they have formed, from
friction or other violence. In herpes zoster, which is the most exposed
to friction, the eruption should be enveloped in cotton, which should
be allowed to remain just as in the treatment of slight burns. The
expectant treatment is especially advisable in herpes preputialis. The
spontaneous healing of an excoriation, which remains after the burst-
ing of a vesicle, affords the best confirmation of the diagnosis that we
have to deal with a herpes and not with a chancre. True, the diagnosis
is easy enough at first, as the grouping of the vesicles in herpes is
quite characteristic, and, in the excoriation which remains immediately
after they have burst, it is easy to perceive from its shape that it has
been formed by a cluster of several vesicles. Somewhat later, how-
ever (especially if the patient, in his anxiety, have cauterized them
with lunar-caustic), the diagnosis is more difficult, and frequently our
only sure criterion is in observation of their subsequent progress. If
the excoriation heal in a few days, under the application, twice a day,
of a bit of lint moistened in water, between the prepuce and glans, or
if the recovery is not delayed beyond a week, we may be sure that it
is not a chancre.

CHAPTER VI.

URTICARIA — NETTLE-RASH ACUTE SUPERFICIAL DERMATfllS, WITH

FORMATION OF WEALS.

ETIOLOGY. — In urticaria a serous infiltration of the papillae of the
skin, and, probably, too, a swelling and infiltration of the cells of the
rete Malpighii cause the formation of circumscribed flattened eleva-
tions, whose width is greater than their height, and which are called
weals. Owing to the rapidity with which the infiltration that pro-
duces the weals appears and disappears, we should not have reckoned
urticaria among the inflammatory affections, but should rather have
described it as a local oedema characterized by great peculiarities in its

URTICARIA.

465

distribution and limits, were it not that in a previous section we have
applied the title dermatitis to all the exudative diseases of the skin
without considering whether or not they are accompanied by genuine
inflammatory symptoms. We have also placed urticaria among the
acute inflammations, although there are cases in which patients have
Buffered for years from it. However, the disease has not been a
chronic one in such cases, but rather a series of acute relapses occur-
ring at very short intervals. The causes of nettle-rash are very varied.
Some of them we know, the rest are quite unknown. Urticaria has
been classified according to the different exciting agents which pro-
duce it

1. Urticaria from External Irritation. — Under this head come
all forms of nettle-rash arising from local irritation of the skin from
contact with stinging nettles, with the leaves of the rhus toxicoden-
dron, with the hairs of certain caterpillars, and with some of the mol-
lusca. It also includes the rash induced by the bites of fleas and
midges, and that caused in the skin of some people by scratching with
the finger-nails.

2. Urticaria from Ingesta. — This variety breaks out upon some
persons immediately after they have eaten strawberries, crabs, mus-
cles, mushrooms, or other unaccustomed food. It is quite hypothetical
to assume that in these cases an acrid material enters the blood and
upon reaching the skin occasions the irritation. It is very strange
that such food should only have this effect upon a few people, and that
in these it never fails to produce urticaria. The rash which we not un-
frequently see after the exhibition of large doses of balsam copaiba is
also included among the urticaria db ingestis.

3. Urticaria febrilis oifebris urticata. — The causes of this form
of the disease, which is accompanied by severe fever and gastric de-
rangement, and which greatly resembles the acute exanthemata in its
course, are unknown.

4. Chronic Urticaria. — The cause of this somewhat rare disease
is also obscure. It occasionally seems to depend upon hereditary pre-
disposition.

5. There is a form of urticaria mentioned by Hebra, which is evi-
dently dependent upon uterine irritation, and which appears in some
women during pregnancy ; in others, during menstruation ; while in
others, again, it accompanies diseases of the womb, or follows the in-
troduction of pessaries.

SYMPTOMS AND COURSE. — The weals always rise from a base red-
dened by hyperaemia. They themselves, however, are often white
(urticaria alba s. porcellana), probably owing to compression of the
vessels of the papillae by the infiltration. Sometimes they are dis

466 DISEASES OF THE

srete ; at others, they stand so closely together as to coalesce (urti-
caria conferta). Sometimes the duration of the individual weals is
very brief (u. evanida), then again it may be very persistent (u. per-
stans). When the weals are large and hard, the urticaria is called
tuberous ; when small, it is said to be papulous (lichen urticariw) ;
and, if the epidermis upon them be elevated into the vesicles here and
there, it is called urticaria vesiculosa. The rash is always accompa-
nied by a most tormenting itching of the part, so that the patient can-
not refrain from scratching it. With exception of the febrile urticaria,
the itching and the objective signs upon the skin are the only symp-
toms of all forms of the disease. It seldom lasts over a few days ;
although, in chronic urticaria, the rash recurs at short intervals for
weeks, months, and years, one eruption following another, but none
of them ever lasting very long. The fever which accompanies and
sometimes precedes the febrile urticaria may be so intense as to cause
dryness of the tongue, disturbed sleep, and even delirium. If the
fever be attended by violent vomiting (and, as often happens, by diar-
rhoea, due, no doubt, to an affection of the intestinal mucous mem-
brane similar to that upon the skin), the disease may present an as-
pect of great gravity. However, the eruption, fever, and gastric dis-
turbance subside in a few days, and a rapid convalescence ensues.

TREATMENT. — It would be a great gain, could we only relieve pa-
tients from the itching of that form of urticaria which sets in rapidly
and subsides spontaneously, and which so torments them as to deprive
them of all comfort and sleep. The palliatives recommended for this
purpose, however, the chief of which are bathing the skin in very di-
lute acids, and rubbing it with slices of lemon, are often ineffectual.
Neither do we know of any efficient remedy for chronic urticaria. We
must, therefore, confine our treatment to the endeavor to restore the
general health of the patient by suitable diet and medicines, to correct
digestive derangement, and to forbidding the use of such articles of
food as we know to be liable to cause the disease.

CHAPTEK VII.

ECZEMA DIFFUSE SUPERFICIAL DERMATITIS, WITH SEROUS EXUDA-
TION UPON THE FREE SURFACE, AND WITHOUT TYPICAL COURSE.

ETIOLOGY. — By far the most common form of dermatitis is eczema.
As in herpes, the inflammation is limited to the superficial layers of
the skin, and is accompanied by a serous exudation upon its free sur-
face. But it differs from herpes, on the one hand, in its tendency to
spread over the surface — a tendency which is quite unmistakable even

ECZEMA.

46T

in eczemas of very small extent ; and, on the other hand, it differs in
the irregularity of its course, which, unlike that of herpes, is not con-
fined to any fixed period of time. Eczema may be regarded as the
analogue of catarrh. It is the most common of all diseases of the
skin, just as catarrh is the most common affection of the mucous mem-
branes. Like catarrh, too, it is a disease of the surface rather than of
the parenchyma, and it is accompanied by a profuse superficial serous
transudation. It also usually involves wide tracts of the skin, or, if
its area be small, it shows a tendency to spread.

Eczema being a diffuse dermatitis, with superficial serous exuda-
tion, it is plain that the formation of vesicles must be a frequent oc-
currence in this disease ; but it is equally certain that the presence of
vesicles is by no means one of its constant or essential symptoms. If
the superficial exudation be profuse enough to form small drops, and
if the epidermis possess sufficient resisting power, not to give way im-
mediately before it, vesicles form, producing the variety of eczema
known as eczema simplex, seu vesiculosum. When there is a profuse
admixture of young cells with the contents of the vesicles (which
always contain a few such cells), so that the serum is turbid, yellow,
and purulent, the vesicles become pustules, and the disease is, called
eczema impetiyinosum. When the transudation is not so copious
as to elevate or to break through the epidermis, it usually soon dries
up ; and then, instead of vesicles or pustules, nothing is to be seen
except dry scales rising from the reddened skin. This has been
called pityriasis rubra, and is now known as eczema squamosum.

From its anatomical and pathological point of view, I cannot
regard the form of pityriasis rubra, which Helra considers as dis-
tinct from eczema squamosum, as any thing more than a squamous
eczema capable of endangering life from its superficial extent. Ac-
cording to Hebrtfs description, this affection is also a superficial
dermatitis, whose scanty superficial exudation, mingled with epi-
dermic cells, dries into scales, and which, like all exanthemata in-
volving the whole surface, is a dangerous disease.

Finally, when the exudation detaches the epidermis so as to deprive
the red, moist corium of its covering, and expose it to view, it is called
eczema rubrum (" salt rheum "). After the epidermis has disappeared,
the exudation upon the surface often dries up into scabs and crusts,
whence many other names formerly applied to moist eczema were
derived, such as tinece or crustce lactece, granulatce, mucosce, etc., etc.
Hebra also counts that form of eruption as an eczema which is usually
called lichen, and which appears as a rash of solid papules. He thus
adds a fifth species, eczema papulosum, to the series. Since a serous
exudation is also thrown out upon the surface in the papular erup-

468 DISEASES OF THE SKIN.

tions, which swells up the cells of the rete Malpighii, but is not co-
pious enough to overflow its free surface and to elevate the horny
layer of the epidermis into vesicles, we accept the classification of
lichen as a form of eczema ; but we deem it improper to make excep-
tion of certain of its varieties, and to distinguish them from eczema as
a separate affection.

The causes of eczema are : first, direct irritation of the skin. The
action of an atmosphere hotter than the normal temperature of the
body is the cause of eczema caloricum, which, no doubt, is identical
with the calori of the Italians, and with the lichen tropicus. Eczema
solare is produced by the rays of the sun. The effect of warm baths
of simple or medicated water is to produce a kind of eczema known
as " bath itch," while abuse of the skin, by means of cold compresses
and cold douches, gives rise to the " critical " eruptions of the hydro-
paths, and the inunction of blue ointment will cause a mercurial ec-
zema. If we were to give a name to the eczemas which proceed from
other causes, such as the action of the vegetable and mineral irritants,
parasites, pressure, and the like, the number of species of eczema
might be much increased. The itch, a dermatitis usually of an eczem-
atous character, and excited by the presence of the acarus scdbiei
shall be treated of in a separate chapter. Miliaria rubm, induced by
excessive sweating, is also an eczematous affection. The contents of
its vesicles is an inflammatory exudation of an alkaline reaction, and
is not acid like the sweat of the miliaria alba.

Secondly : Eczema may arise from obstruction of the venous circu-
lation. As such derangements of circulation usually arise in the lower
extremities, it is upon these that the eczematous inflammation usually
appears and forms an analogue with the catarrh of the stomach, which
arises in cases of compression of the portal vein, and with catarrh of
the rectum when the hgemorrhoidal vein is obstructed.

Thirdly : Eczema is often of constitutional origin. A tendency to
eczema and to other diseases of the skin is often called a herpetic dia-
thesis, or a herpetic dyscrasia. The term herpetic dyscrasia is based
upon the idea that the blood and humors of a patient with constitu
tional eczema have undergone some qualitative or quantitative change.
The soundness of such an hypothesis is not only unproved but quite
unlikely. Eczema of an indubitably constitutional origin is seen as
often in plethoric subjects as in anaemic ones, and in cachectic persons
quite as frequently as in those who are robust and whose humors cer-
tainly have not deteriorated. No objection can be made to the term
herpetic diathesis, because it leaves the question undecided whether
the predisposition to eczema and to other cutaneous diseases is depen
dent upon a perversion of nutrition or upon other conditions. The her

ECZEMA.

469

petic diathesis is frequently congenital, and, as Veil in Cans tat t has
demonstrated, is hereditary in many instances. One would naturally
suspect congenital predisposition to eczema in a family in which all the
brothers and sisters were afflicted by it, and that it was hereditary
if the parents and grandparents also have had it. We need hardly
state that a herpetic diathesis is not always transmitted from parent
to child, any more than any other hereditary disease. Scrofulous and
rachitic children always exhibit a most pronounced tendency to ec-
zema, especially to eczema impetiginosum. Sometimes there is a
connection between eczema and chronic dyspepsia or derangement of
menstruation. In such cases, although we may succeed in healing the
eczema by local treatment, yet there will always be relapses of the
eruption so long as the other complaint remains uncured. Much more
frequently, although there may be a most decided herpetic diathesis, it
is not accompanied by general nutritive derangement, nor by disease
of any particular organ. The appearance of eczema, unprovoked by
any appreciable irritation of the skin, and its frequent recurrence, in
spite of the most careful avoidance of all sources of irritation, is often
the sole sign of constitutional derangement.

SYMPTOMS AND COURSE. — The subjective signs of eczema consist
in itching, accompanied by an irresistible inclination to scratch, symp-
toms which are common to all cutaneous diseases, where the papillary
layer is affected. The objective signs have already been given above.
We have already seen that the cutaneous surface, which is the seat of
that atypical, diffuse, superficial dermatitis called eczema, sometimes is
studded with vesicles ; at others, with vesicles and pustules intermin-
gled, and sometimes again with scales ; that, in other instances, it
presents a red, moist surface, denuded of its epidermis, and that, in
still others, it is covered with crusts and scabs.

Besides the four forms of eczema (e. simplex, e. sqamosum, e. ru-
brum, e. impetiginosum), it is also customary to recognize a chronic
form of the disease. But not only is it illogical to associate one spe-
cies, distinguished by the nature of its course, with four others, classi-
fied upon an entirely different basis, but in practice this arrangement
is found to be attended by many inconveniences. Chronic eczema can
only be contrasted with acute eczema ; like the latter, it sometimes
assumes the simple form, sometimes the squamous or the impetiginous
form, and sometimes again that of eczema rubrum. In cases of very
_ong standing, which usually assume the type of eczema rubrum, the
disease upon the surface is occasionally accompanied by changes in the
structure of the cutis. This generally consists in an inflammatory hy-
pertrophy, quite analogous to that which occurs in the mucous mem-
branes in chronic, bronchial, and gastric catarrh. Less frequently there

470 DISEASES OF THE SKIN.

is an atrophy of the cutis caused by pressure of the crusts and scabs
adhering to it.

Classification of eczema, according to the extent and locality of the
surface which it involves, is of much greater importance than that
based upon its form and duration. Upon this basis, in the first place,
it may be divided into universal and partial eczema. The term uni-
versal, however, is not to be accepted literally, because, although the
eruption often involves a very large portion of the surface, it seldom
covers the whole of it. Universal eczema is a much less common
affection than partial eczema. It is either acute, when it usually
assumes the simple or squamous character less frequently than
that of eczema rubrum; or else it is a chronic disease, and then
takes on different aspects upon different parts of the body, showing
preference, however, to the type of eczema rubrum, so that the surface
is generally either moist and raw, or else covered with large crusts.
Chronic universal eczema is always a very distressing and very ob-
stinate disease, although it does not imperil life, and indeed often
does not seem materially to prejudice the health of the patient.

Partial eczema is often situated upon the scalp. Even when the
disease commences as a vesicular eruption, the vesicles are apt to be
overlooked, and to be destroyed by combing or scratching. If eczema
impetiginodes, or E. rubrum, appear on the scalp, the eruption dis-
charges very freely, the hairs are glued together and crusts form, which
are sometimes soft and flat, sometimes thick and hard, and to this
the name of tinea favosa, granulata, etc., was formerly applied. Such
a scalp, covered with scabs, is a very favorite and favorable abode for
lice. The cervical glands often become enlarged in moist eczema of
the head, and sometimes even suppurate. The disease presents a very
different appearance when the transudation is too scanty to form ves-
icles or to burst through the skin. In such cases it assumes the squa-
mous type, and a great quantity of small white detached scales of epi-
dermis are found, not merely upon the reddened skin, but among the
hairs and upon the collar of the coat. This was formerly called tinea
furfuracea ; or tinea amiantacea, when the epidermic scales, mixed
with exudation, formed thick, shining layers, like asbestos. All forms
of eczema frequently appear upon the face, although the impetiginou?
and rubrous types are the more prevalent ones during childhood.
Although it does not spare other regions, its favorite seat is upon the
cheeks and chin, which become reddened and shiny, and after a fe\v
vesicles have formed upon them, and burst, they are covered by a clear
yellow liquid. This soon dries up, forming yellow crusts. If we re-
move these before the disease has subsided, we come immediately upon
the bare, moist corium, and can find no intervening epidermis. Ecze

ECZEMA.

471

ma rubrum, et impetiginosum, of the face used formerly to be called
pomgo larvalis, tinea faciei, crusta Zactea, crusta serpiginosa, etc.
It often extends into the external auditory meatus, and still more fre-
quently is complicated with coryza, with ophthalmia, and with enlarge-
ment of the submaxillary and cervical glands. In many cases facial
eczema is confined to the ears, the eyebrows, the eyelids (especially
the commissures), and, above all, to the lips. These points are some-
times studded with vesicles ; sometimes stripped of their epidermis
and bathed in liquid secretion, or covered by scabs, and sometimes
again they are attacked by the squamous forms of the eruption. A
very obstinate species of eczema rubrum is also observed about the
nipples of nursing women, although it may also attack the nipples of
women who are not nursing, and even those of children. The vicinity
of the navel is also the seat of a partial eczema which is most common
in corpulent persons. A very important variety of the disease is
eczema pudendorum. In men, it usually attacks the penis and scro-
tum ; in women, the labia majora. Sometimes it is acute, assuming
the simple form ; sometimes chronic, when it presents a very moist
eczema rubrum. The intolerable itching which accompanies it almost
drives the patient to desperation. A similar eruption appears about
the anus and upon the perineum, only its secretion is not so profuse
as in eczema pudendorum. Under the name of eczema marginatum,
Hebra describes an eruption which is most common among shoemakers
and cavalry soldiers. It commences at the point where the scrotum
comes into contact with the thigh, but usually extends ; and after a
while a similar spot appears symmetrically upon the inner surface of
the other thigh. Eczema of the lower extremities is most common
upon the legs, where it forms large red patches, which either secrete
profusely or else are covered by scabs. This is generally called " salt
rheum." When the eruption attacks the flexures of the joints, they
become covered by a layer of rough crisp epidermis, mingled with dried
exudation, which is apt to crack when the joint is extended, and to
form painful fissures. Sometimes a moist eruption also appears on the
flexures of the joints. It is remarkable that eczema always attacks
the hands and feet simultaneously. When its chief seat is upon the
dorsum of the extremity, the eruption takes the simple vesicular form,
and may easily be mistaken for scabies. Vesicles are not so apt to
form upon the volar surface. More usually there is a hard and some-
what thick crust of dried exudation, mixed with epidermis, upon the
reddened cutis, and as this coating of the palms and soles is con-
stantly scaling off in the form of white scales, eczema at these points
is often and erroneously called psoriasis, for pityriasis, palmaris, 01
plantaris.

80

472 DISEASES OF THE SKIN.

TREATMENT. — Errors in the treatment of cutaneous diseases in
general, and in that of eczema in particular, are liable to assume one
of two directions. One class of physicians are possessed by the preju-
dice that all local treatment is wrong, because they can never be sure
that the suppression of an eruption will not be attended by dangerous
consequences. Hence, from the apprehension (which certainly is nearly
always groundless) that they may, perhaps, do harm to their patients
by treating eruptions locally, they resort to an internal medication,
which is injurious beyond all doubt. Another party, blindly following
the authority of Hebra, look upon all internal medication as super-
fluous, and treat all cutaneous diseases locally, without the exception
even of cases where an eruption has been followed by the abatement
of serious disease of internal organs. HebrcCs success leaves no doubt
that the direct treatment of disease of the skin is the best for many
patients. Not only is the disorder itself relieved and cured more
surely and quickly by such means, but it often does much less harm to
the patient than the old-fashioned practice of giving laxatives, metal-
lic preparations, and other noxious medicines. Moreover, with few
exceptions, it is a groundless prejudice to suppose that other diseases
proceed from the suppression of cutaneous eruptions by means of local
applications. On the other hand, it must not be denied that exanthe-
mata, when' treated by local means alone, are very apt to relapse ; and
that cases really do occur now and then, in which there is reason to
fear that their repression, under direct applications, may give rise to
disease of internal organs.

The forms of eczema in which I consider it inadmissible, or at all
events hazardous, to employ vigorous local treatment are —

1. The moist form which appears upon the scalp and face of children.
It is an unmistakable fact that the sudden disappearance of such erup-
tions is often quickly followed by bronchial catarrh, croup, or hydroceph-
alus ; and it is equally certain that a tedious catarrh or other affection
will often subside as soon as an eruption of this kind makes its appear-
ance. However, it does not by any means follow that the internal
maladies have arisen in consequence of the cessation of the cutaneous
disease, nor, on the other hand, have we any proof that it is because
of the outbreak of the eruption that they subside. But we are equally
uncertain of the contrary propositions, and even the possibility of the
existence of such a cause should contraindicate local treatment of
moist eczema upon the heads and faces of children. It is true that a
similar belief formerly prevailed regarding the supposed injurious
effects of the treatment of itch by local means. Such views are now
recognized as prejudices, and exploded ; and I readily admit that here-
after my fear of treating facial eczema locally may prove equally

ECZEMA 473

groundless ; but, according to our present knowledge, such apprehen-
sion seems well founded, and the fact, that it is safe to cure other
exanthemata by external applications, does not prove any thing re-
garding the disease in question ; since, in spite of the great external
similarity of the exanthemata, they differ essentially in their influence
upon nutrition, and in their effect upon the general health of the
body.

%. Local treatment is contraindicated in all forms of eczema
of adults that seem to appear vicariously for other diseases, which
have subsided upon the outbreak of the eruption. It is true that
Hebra expressly affirms that he has suppressed such eczemas without
injury to the patient, solely by the employment of local applications ;
but, in spite of his authority, I should not dare to resort to an external
treatment of a case of eczema, the establishment of which had been
followed by the recovery of an ophthalmia of long standing, or of a
chronic derangement of digestion, or other serious disease.

3. Local treatment, or, at all events, an exclusively local treat-
ment, is unadvisable in an eczema, the cause of which is evidently
constitutional. The number of cases suitable for external treatment
would then be a very small one, however, in the eyes of the class of
physicians who ascribe all exanthemata, whose origin they do not
know, to a dyscrasia. One of the important steps recently made in
the therapeutics of cutaneous disorders, however, consists in our no
longer ascribing an eczema to a constitutional origin, and subjecting
it to " anti-dyscratic " treatment, unless we have better evidence of
the genuineness of such origin than is afforded by the mere existence
of an eruption. The impropriety of treating the syphilitic exanthemata
locally is universally admitted, but even in the eczema which afflicts
scrofulous and rachitic subjects, as well as in that which attacks chlo-
rotic females, and in that which accompanies disorders of the sexual or-
gans, an exclusively local system of treatment is unwise ; not that direct
remedies are hurtful in themselves, but they should only be employed
as corroborants to general treatment, directed against the fundamental
disease. At the same time, we should mention that eruptions which
are undoubtedly of constitutional origin often continue, as it were,
independently, after the original disease has subsided, and require a
vigorous local treatment for their eradication. This is sometimes the
case even in syphilitic exanthemata. I knew a merchant in Magde-
burg, who, in addition to other signs of syphilis, had a very unsightly
eruption upon his face and head, which had lasted for years after all
the other syphilitic symptoms had disappeared. This man, after con-
sulting the most eminent physicians, and after undergoing all sorts of
anti-syphilitic treatment without benefit, was completely and per-

4-74 DISEASES OF THE SKtt.

manently relieved of his disease by means of an ointment of white
precipitate and carbonate of lead, prescribed by a second-rate sur-
geon.

The moist eruptions upon the heads of children, vicarious eczemas, and
eczemas of constitutional origin, after all, form but a small class compared
with the number of eczemas against whose local treatment no objections
can be made, and in the cure of which the most brilliant success may be
attained. The topical remedies which I would recommend before all
others is the white precipitate in the form of an ointment (hydrarg.
ammoniat. 3 j, adipis. f j), and corrosive sublimate in weak solution
(hydrarg. bichlor. gr. j — ij, aquae destillat. f j), as these articles are
much less disagreeable to the patient than tar ointment, soft soap, and
the like, and since in a great majority of cases they amply suffice to
effect a rapid and complete cure even of the most obstinate forms of
eczema. I am quite unable to account for the beneficial action of
these articles upon eczematous dermatitis; but I will suggest that
both white and red precipitate have long been considered as among
the most effective remedies in conjunctivitis. The forms of eczema
in which I prefer to use the white precipitate ointment are eczema of
the face and scalp, when not too extensive, and particularly when it
has not already produced too much thickening of the corium. In such
cases the treatment has hardly ever failed me, either in the clinic or
in private practice ; and under its use I have seen eczemas disappear
in a few weeks which had lasted not merely for a year or two, but for
eighteen or twenty years. Although I have hesitated to employ it
where the eruption was very extensive, from fear of causing mercurial
poisoning, yet I have had especial opportunity of satisfying myself
that in such cases it likewise does excellent service and does no harm.
By means of white precipitate ointment I once cured the wife of an
official, in the neighborhood of Greifswald, in a few weeks, of an ecze-
ma about the ears and scalp, which had existed for years. Some time
afterward, this lady, who was very philanthropic to the poor in her
husband's district, and who used to prescribe " homceopathically " for
the sick, informed me that she could not thank me sufficiently for my
recipe ; for she had made a quick and radical cure of a large number
of very extensive and obstinate cases of " salt rheum." The patients
did not suffer in the least from the rapidity of the cure, and none of
them were salivated. The application of white precipitate, however,
by no means secures the patient against a relapse, and it is well to
warn him of the probability of a fresh outbreak, and to recommence
the treatment as soon as he perceives any new signs of the disease.
Moreover, as the eczema is all the more easily and quickly cured by
the ointment, when the eruption is recent and slight, it is very impor-

ECZEMA.

4T5

taut to enjoin upon the patient to keep a sharp lookout for the first
traces of it, as I can illustrate by a most striking example. I cured
the wife of an officer, in Magdeburg, in less than a fortnight, of a
chronic eczema, for which she had in vain gone through a succession of
courses of Zittman's decoction, arsenic, iodide of potassium, mercurials,
baths, and mineral waters. This eczema had a great tendency to re-
turn. When the patient's husband was at home, in Magdeburg, ho
used every day to examine her face with a lens, and to anoint every
suspicious-looking spot with the salve, thus protecting her from any
unsightly extension of the disease. When her husband was on duty,
and absent from Magdeburg for any length of time, during the autum-
nal manoeuvres of the army, the eczema sometimes spread consider-
ably, and did not afterward yield so readily to the white precipitate,
and has sometimes even compelled me to resort to the corrosive sub-
limate instead. Two or three inunctions daily of this ointment, or an
equal number of pencillings with the solution of corrosive sublimate,
are usually sufficient. Of course, any adherent scabs must be softened
and removed, and the surface must be carefully dried before applying
either the ointment or the solution. I have often found that my for-
mer pupils, as they came home from their travels, fresh from a course
of lectures upon cutaneous diseases, and full of new ideas, at first treat
all the eczemas which come to them with soft soap, oil of cade, cod-liver
oil, and the like. In a year or two, however, they abandon such treat-
ment, or, at all events, before resorting to it, they try whether the old,
simpler, and far more convenient treatment by white precipitate will
not answer the purpose. The preparations of lead and zinc stand next
in virtue to the white precipitate salve, and the solution of corrosive
sublimate, as they are both best adapted for the treatment of spots of
eczema of no great magnitude, and where there is no hypertrophic
thickening of the subjacent corium. We generally prescribe a solu-
tion of sulphate of zinc (zinci sulp. 3 ss — aquae | vj), or an ointment
of the oxide of zinc, or of the carbonate of lead, in the proportion of a
drachm to the ounce of lard; or else, when the patient does not bear
salves well, we may order a paste of oxide of zinc with glycerine, or
dust the surface with a powder composed of oxide of zinc and lycopo-
dium seeds, or starch (zinci oxid. 3 j, amyl § j)- In the very moist
eczema, which arises behind the ears, and in the hollows of the joints,
and between the fingers and toes, Hebrews diachylon ointment does
excellent service. It is to be prepared as follows : Melt the simple
diachylon plaster over a slow fire, and add to it equal parts of linseed-
oil, and stir the mixture well when cool; or else the following: (1$.
olei olivarum optimi | v, lithargyri 3 x, coque 1. a. in molle, dein adde
ol. lavenduloe 3ij, f. ung. S. Rub the ointment upon the affected spot

476 DISEASES OP THE SKIN.

two or three times a day, or, what is preferable, apply it upon linen
compresses). In very extensive eczema accompanied by great itching,
especially in eczema universale, the shower-bath is strongly to be rec-
ommended. Some patients are quite unable to tolerate the irritating
remedies to be mentioned presently. Hebra directs the shower-bath
to be used two or three times a day for ten or fifteen minutes at a
time in a warm room. By this means the most obstinate eczemas,
which have defied all previous treatment, are often made to heal, but
only after a somewhat persistent employment of the shower. A suit-
able apparatus may be made at little cost. In partial eczema, which
does not tolerate irritating remedies well, cold compresses may be
substituted for the cold douche, especially in recent cases. When the
eczema is of very long standing, and particularly when the disease has
extended from the surface into the substance of the true skin, and the
more difficult it is to pinch up the skin in a fold, so much the more
often shall we be compelled to resort to that class of remedies which, from
the vigorous alterative action which they exert upon the skin, play
an important part in the therapeutics of nearly all inveterate cutaneous
affections. Experience teaches that of this class the preparations of
sulphur are the least adapted to the treatment of eczema, that it is
only in exceptional instances that they do good (as in eczema mar-
ginatum, according to Hebra), and that in most cases they actually do
harm. On the other hand, " green soap," tar, and caustic potash, are
of the utmost benefit in old cases of eczema accompanied by infiltra-
tion of the corium ; hence we shall briefly relate Hebrcfs directions for
their employment. The green soap must either be rubbed once or
twice daily into the affected surface, or else a piece of flannel is to be
smeared with the soap and laid upon the sore spot. This application
is also to be renewed once or twice daily, and the procedure should be
continued for from three to six days. It must then be discontinued ;
but the soap which has been rubbed in ought not to be removed. Af-
ter three days more the patient is to take a bath, when there must
be a pause in the treatment. This course is to be repeated until
all the infiltration has disappeared, and until the transudation has
ceased. At this stage, when a previously moist eruption has changed
into a dry scaly one, Hebra directs applications of tar to be substi-
tuted for the soft soap. Of the various kinds of tar Hebra prefers the
birch-tar (oleum rusci) and the oil of cade, prepared from the wood of
the Juniperus oxycedrus, as having a less offensive smell than the com-
mon pine-tar, or oleum empyreumaticum coniferum (pix liquida). In-
stead of pure tar, or tar-ointment, I for years have used a solution of
tar in alcohol (picis liquid., alcohol, aa, or else picis liq., sapon. virid., aa
3 ss, alcohol f j) ; for it answers every purpose, is much more con

ECZEMA.

4T7

venient to apply than pure tar, or than tar-ointment, and is much
easier to remove from the skin. The solution is to be rubbed in once
a day until the brown coat which forms, instead of being quickly de-
tached, adheres for several days, and until the skin ceases to look red
after the brown coat has been shed. As long as the tar-crusts con-
tinue to shed rapidly, leaving a reddened surface beneath them, the
disease is not extinct. Although the external application of tar is
generally borne without inconvenience, yet in some patients the first
inunction occasions such an intense irritation of the skin as to render
further prosecution of the treatment impracticable. It is still more
common for the continued use of tar over a large extent of surface to
be followed by violent irritation of the intestine and kidneys, accom-
panied by vomiting, diarrhoea, the discharge of a blackish-looking
urine having a distinct odor of tar, which becomes still plainer upon
the addition of one or two drops of sulphuric acid ; these symptoms
being accompanied by fever and distress in the head, thus necessitat-
ing an immediate suspension of the treatment. Not only is the appli-
cation of soft soap or of tar inadmissible in some cases of eczema, but
there are also examples in which, although the remedies are well
borne, they do not produce the desired effect. It is in these instances
that the cauterization of the part, with a concentrated solution of
caustic potash, is indicated (potassae caustic. 3 j, aquse 3 ij). The
cauterization is not to be repeated oftener than once a week. A swab
of charpie dipped in the solution is rapidly to be passed over the dis-
eased surface, which is immediately to be covered with cold com-
presses, in order to allay the intense pain which the application al-
ways occasions. Even the most inveterate cases of eczema usually
recover after five or six repetitions of the cautery.

Since local applications will merely rid the patient of his eruption,
but will not insure him against its return, the question finally arises,
whether we should limit ourselves to an exclusively local treatment, or
whether the topical applications should be combined with a general
internal medication, even when there is no evidence of scrofula or of ra-
chitis, and when the disease is not a consequence of chronic dyspepsia or
menstrual derangement, ffebra pronounces decidedly against such
practice. Veiel, on the other hand, who attaches quite as much im-
portance to local treatment as Jlebra does, combines it with laxative
tisans and with iodide of potassium in increasing doses, even when
there is no perceptible constitutional taint. The success obtained at
VeieVs institution is very brilliant ; and moreover, it being a private es-
tablishment, to which most of the inmates return if they have a relapse,
its superintendent has the opportunity of taking note of the ultimate
fate of his patients.

478 DISEASES OF THE SKIN.

For my part, I consider it to be not only advisable, but impera-
tively necessary, that local and general treatment should be combined
whenever the disease tends to repeated relapses, in spite of careful
protection of the skin from noxious influences. It is of but little ad-
vantage to a patient to be discharged from a hospital cured, if his dis-
ease is going to be as bad as ever again in a few weeks. We need not
search far to find innumerable examples, in which, in spite of the skill
of practitioners familiar with the most approved and newest modes of
treating diseases of the skin, persons have remained afflicted with eczema
for years, now suffering from the eruption, now resorting to treatment,
but seldom remaining free from it for any length of time. No general
rules can be laid down for the constitutional treatment of those ecze-
mas which depend upon a herpetic diathesis ; but in special instances
it is not very difficult to ascertain the suitable remedy, since the indi-
viduality of the patient, his physical habit, and his mode of life, furnish
a clew to the means by which his constitution may be modified effec-
tively and at the same time without injury. It would be unfortunate
if the conviction, that the effect of Hebrcfs treatment is often merely
palliative, were to lead physicians back again to the old routine of
systematically purging all forms of this disease ; but I do not hesitate
to declare that I regard Hebrdts assertion, that, " in chronic eczema, the
mere use of purgatives never does good, and often does harm," as quite
inaccurate. When chronic eczema attacks a corpulent patient who
eats and drinks more than enough for the requirements of his system,
and who is fond of fat food, and of food rich in fat-producing elements,
he will recover more quickly, and the cure will last longer, if placed
upon a methodical course of laxatives combined with suitable regula-
tion of his food, than if his treatment be merely local and no attention
be paid to diet. In such cases, where the eruption is very extensive, I
often prescribe Zittmarfs decoction — in spite of its absurd composi-
tion— simply because patients follow out the directions for its use with
such punctilious and almost superstitious exactness. But there is an-
other class of habitual sufferers from eczema, whose idiosyncrasies are
exactly the opposite of those described above, and who, without being
really sick, are poorly nourished and much emaciated. To purge such
patients as these, and to reduce their diet, would be to make the evil
worse. On the contrary, they require a treatment calculated to aug-
ment the supply of nutriment, and to diminish the wear and tear of
the system, such as the exhibition of cod-liver oil and similar medi-
cines. These suggestions must suffice. It would take too long were
we to attempt to detail all the indications for internal treatment which
may accompany the topical applications, and which are deducible from
the constitutional peculiarities of the patient.

IMPETIGO. 479

CHAPTER VIII.

IMPETIGO — DIFFUSE STJPEEFICIAL DERMATITIS, WITH FORMATION OF
SMALL PUSTULES.

ETIOLOGY. — In impetigo, as in eczema, a serous exudation is se-
creted upon the surface of the corium, but at the same time young cells
form in great abundance and are mingled with the serum. Hence, the
contents of the vesicles which arise in impetiginous dermatitis are not
limpid and transparent, like those of eczema, but turbid and yellowish,
and, upon rupture of their epidermis, a purulent liquid runs out from
them, which afterward dries up into yellowish or greenish crusts.

As the serum in the vesicles of eczema also contains a few young
cells, and since in eczema impetiginosum the contents of some of the
vesicles are yellow and puruloid, owing to the copious admixture of
young cells, it is plain that no distinct boundary line can be drawn be-
tween eczema and impetigo ; and that there are intermediate forms to
which either name might be applied with equal propriety. This is
especially the case in the moist eruption upon the scalp of children
which sometimes bears the title of eczema capitis or faciei, and some-
times that of impetigo or porrigo faciei or capitis.

The first cause of impetigo which we shall mention is the direct ac-
tion of irritants upon the skin. The more delicate the skin, so much
the more easily do even slight irritants cause exudation, and prolifera-
tion of cells upon its surface. In some persons, the application of a pitch-
plaster or of a poultice is sufficient to provoke an eruption of impeti-
ginous pustules. This " vulnerability " of the skin is most common
among people with a thin epidermis and clear complexion ; but, above
all, among scrofulous individuals. Among the latter, indeed, impetigo
often appears without any appreciable irritation of the skin, and, to-
gether with chronic catarrh, and enlargement of the lymphatic glands,
is one of the most decided symptoms of scrofula. Finally, impetigo at-
tacks children without perceptible irritation of the skin, scrofulous
diathesis, or other assignable cause. In such cases, which are not at
all rare, it is generally assumed that the food is too nutritious, that the
mother's milk is too rich, or that the eruption has been caused by the
presence of an " acrid " material in the blood. No sound reasons can
be advanced in support of such an idea.

SYMPTOMS AND COURSE. — The inflammation of the papilla, from
which the exudation proceeds, is accompanied by a sense of itching,
and by a desire to scratch. These subjective phenomena, and the
objective ones, of small acuminated pustules (psydracia) upon a red-
uened base, and of yellow scabs, are about the only symptoms pre-

480 DISEASES OF THE SKIN.

seated by impetigo. It is very rarely, and then only when the disease
is very violent and acute, that impetiginous dermatitis is attended by
fever and by general constitutional disturbance. According as the
eruption is limited to a small part of the surface, or extends widely
over a large area, it is called impetigo figurata, and impetigo sparsa.
The former variety is most often seen upon the face, especially upon
the cheeks, lips, nose, and scalp ; but its appearance upon the trunk
and extremities is also not uncommon. At first red specks, which
may be either discrete or confluent, are observed upon rounded, oval,
or irregularly-shaped spots of varying size. Extreme redness of the
skin, with tension and glistening, accompanied by fever, constitutes a
variety of impetigo, to which "Willan has applied the name of impetigo
erysipelatodes. Upon the reddened base, minute yellow points imme-
diately develop, which soon grow to the size of small lentils, and rise
a little above the level of the surrounding parts. After a day or two,
perhaps sooner, the pustules burst and discharge their contents, which
dry up into yellow crusts. Beneath these, the formation of pus con-
tinues, causing a gradual thickening of the crusts, while new pustules
continue to spring up at then* edges. At first, upon removing these
crusts, which sometimes attain considerable thickness (impetigo sea-
bida), we find beneath them the naked corium bathed in puruloid
liquid ; but, toward the end of the disease, a new, delicate covering of
epidermis appears, through which the redness of the cutis is visible,
and in which slight cracks form when the part is moved. The course
of impetigo figurata usually is subacute, so that the process termi-
nates in two or three weeks by detachment of the crusts. However, it
sometimes lasts for several months, and even for several years, al-
though this is not very common. In such instances, the substance of
the corium takes part in the process, and becomes thickened and indu-
rated just as it does in chronic eczema. The favorite seat of impetigo
sparsa is upon the extremities ; and it often covers an entire limb,
sometimes, indeed, extending over the whole surface of the body.
The reddening and itching of the skin, the appearance and bursting
of the pustules, the formation and thickening of the crusts, and the
continued development of new pustules around them, and, finally, the
shedding of the crusts, all occur just as in the form previously described ;
only impetigo sparsa more freqently assumes a chronic character, and,
since the cell-formation is not confined exclusively to the surface of
the corium, but is also going on within it, it is more apt to result in
superficial ulceration.

TREATMENT. — Many cases of impetigo require no treatment at all,
and heal ot themselves in a few weeks. Hence, in recent cases, we
may confine our interference to softening the crusts with fresh butter

ECTHYMA. 481

or oiner grease, when they grow too thick and hard, and to removing
them with a poultice. But, if the disease already have lasted for
weeks or months, expectant treatment is no longer appropriate, and
we must consider whether to treat the disease locally or generally,
according to the principles laid down in the previous chapter. The
latter is more frequently indicated in impetigo than in eczema, as this
form of dermatitis often constitutes one of the symptoms of a consti-
tutional disease. In the treatment of impetigo, as a rule, the same
local remedies may be employed which have already been proposed
for the treatment of eczema. The disease, however, is not so tolerant
of strongly irritating applications as eczema is, on account of its more
inflammatory character, as is shown by the suppuration which charac-
terizes it. White precipitate, the oxide and the sulphate of zinc, and
slight cauterization, with nitrate of silver, are usually to be preferred to
the preparations of sulphur, the soft soap, and tar.

CHAPTER IX.

ECTHYMA — DERMATITIS, WITH FORMATION OF LAEGE, ISOLATED, PER-
MANENT PUSTULES.

ETIOLOGY. — Although the pustules of ecthyma always arise from a
brightly-reddened, swollen, and infiltrated base, yet, in spite of the in-
tensity of the inflammation, the suppuration is usually confined to the
surface of the cutis, and is not apt to involve its parenchyma. In the
latter case only does ecthyma cause ulceration of the skin, and produce
scars, owing to contraction of the young connective-tissue cells by which
the loss of substance is supplied.

Ecthyma often proceeds from direct irritation of the skin. The
pustules caused by tartar-emetic ointment (ecthyma antimoniale), and
those which appear upon the hands and arms of smiths and masons,
from the contact of lime, or of detached particles of red-hot iron, are
of this class, as well as the large pustules which arise from the violent
scratching provoked by the presence of parasites, or by the itching of
other eruptions. In other instances, ecthyma arises without any ap-
preciable previous irritation during the course of febrile diseases, assum-
ing a form somewhat analogous to what is generally called hydroa
febrilis. Finally, ecthyma is also seen in persons broken down by
privation, or other cause of exhaustion, or who have become cachectic
by a physical drain upon the system, by severe or tedious illness, and
by an abode in prisons, or in other unwholesome dwellings ; as well
as among drunkards and in scorbutic individuals. We shall treat of
syphilitic ecthyma hereafter.

482 DISEASES OF THE SKIN.

SYMPTOMS AND COURSE. — The inflammation and infiltration of the
skin, which precedes and accompanies the development of ecthyma
pustules, are usually attended by lancinating pain, and in irritable per-
sons by fever. The pustules are scarcely ever very numerous. They
are isolated, surrounded by a broad, red areola, and are most fre-
quently situated upon the extremities, the seat, the bosom, the throat,
and, far more rarely, upon the face. These pustules are hemispherical,
project distinctly above the level of the surrounding skin, and are
usually somewhat larger than a pea (phlyzacium). Their contents
consist of a yellow, purulent liquid, often mingled with blood. After
a few days, the contents of the pustules dry up, forming round, brown-
ish scabs, which either remain flat, and soon fall off, or else, where the
suppuration continues beneath them, they gradually grow thicker, and
adhere for a longer time. In the first instance the scabs, after falling,
leave behind them red spots, covered with new epidermis, and in the
latter they leave ulcers, which, although usually shallow ones, some-
times eat deep into the skin. The course of ecthyma is sometimes
acute, sometimes chronic. In the acute form, induced by external
causes, or in that which arises symptomatically in febrile disease, there
is generally but a single eruption of pustules. Each pustule lasts but
for a short time, and the scab soon falls, leaving no excoriation, or at
most a very slight one. In the chronic form, which is peculiar to
cachectic ecthyma, successive eruptions of pustules take place at vary-
ing intervals ; the redness of the surrounding areola of inflammation
is often livid, and the contents of the pustules are bloody, or discolored
(ecthyma luridum). Moreover, beneath the thick scab, which is long
in forming, and late in falling, very obstinate ulcers develop, which
often penetrate deeply into the cutis.

TREATMENT. — The only species of ecthyma which requires active
treatment is the chronic variety, with tendency to ulceration of the
skin. First of all, the cachectic condition must be corrected, if pos-
sible, by means of proper ventilation, generous food, the use of wine,
good beer, and the preparations of iron and quinine. Externally,
while the inflammation continues, warm poultices must be applied ;
afterward, when the ulcers are indolent, they require stimulation,
especially by touching then* surface with nitrate of silver.

CHAPTER X.

PEMPHIGUS POMPHOLIX SUPERFICIAL DERMATITIS, WITH THE

FORMATION OF LARGE ISOLATED BLEBS.

ETIOLOGY. — In pemphigus, large blebs (bullas), filled tensely with
clear liquid, form upon a base which is slightly reddened but not infil-

PEMPHIGUS.

483

tratccL They resemble the blisters produced by vesicating plasters,
or by chafing of the skin. "We have no satisfactory explanation of
the cause of this curious disease. In new-born children, pemphigus
is nearly always, if not absolutely always, of syphilitic origin. Chil-
dren are more frequently attacked than adults. Some persons ex-
hibit signs of a general cachexia prior to the outbreak of the pem-
phigus ; while others retain their blooming appearance, and feel per-
fectly well throughout the disease, unless exhausted by its repeated
recurrence and by loss of sleep. Pemphigus sometimes assumes an
epidemic form.

SYMPTOMS AND COURSE. — The first change noticed in the skin
consists in the appearance, upon the back, belly, and extremities, of
red circular spots, which itch and burn. In a few hours, at the middle
of the spots, small transparent vesicles arise, which quickly enlarge
and soon cover the whole of it, or else merely leave a narrow margin
unoccupied. The vesicles are round or oval in shape, and of the size
of a pea, a cherry, or perhaps of a walnut. At first their contents
are transparent, afterward they become turbid and curdy. In two or
three days the blebs burst, leaving an excoriation. For some days
this continues to discharge, and then becomes covered by a scab,
under which a new epidermis forms. A stain of pigment remains to
mark the spot where the bulla was situated. Before the first blebs
heal, new ones form ; these are succeeded by others, and thus succes-
sive crops continue to spring up ; so that we are often able to study
all the stages of pemphigus simultaneously upon one patient. In
some cases this only continues for a few weeks, and then ceases. But
even then there is usually another attack, the whole process repeating
itself after a lapse of weeks or months. These relapses, which are often
three, four, or even more in number, resemble the first attack in their
course and duration. In other instances, the formation of new blebs
does not cease at the end of a few weeks, but continues for months,
and even for years. Although at the beginning of the disease the
general health of the patient is entirely undisturbed, yet as it pro-
gresses he grows pale, thin, and debilitated, either because the dis-
charge exhausts him, or because the unknown cause of pemphigus
exerts a noxious influence upon the entire economy. The emaciation,
and pallid, cachectic look make all the more rapid progress, if rest at
night be disturbed by the itching which attends the eruption of the
blebs. Nearly all patients with chronic pemphigus finally die of

marasmus.

The question has been actively debated, whether pemphigus be
always chronic, or whether there be not also an acute pemphigus.
This seems to me to be a mere dispute about words. When the enip-

484 DISEASES OF THE SKIN.

tion does not last ovei two or three weeks, we certainly are warranted
in calling it acute ; but, if we choose, we may regard the interval
when no blebs form, which often lasts for months, and during which
the patient feels as well as before his first attack, as a period of
" latence," and call the series of relapses chronic pemphigus.

Hebra and Cazenave describe a truly horrible malady called
pemphigus foliaceus. In this affection a very few, or perhaps only
a single bleb forms. They are not as tensely filled as those of other
forms of pemphigus, but have a tendency to spread. In pemphigus
foliaceus the liquid constantly pushes further and further beneath the
epidermis, until finally the entire skin looks as if it were flayed, or
else is covered with a brownish-yellow rind. It generally takes a
year for the disease to arrive at this pitch of progress. Meantime
portions of the skin heal, but only to be attacked anew. The malady
always terminates in death.

TREATMENT. — We can only treat the symptoms of pemphigus,
since, in spite of the meritorious labors of Bamberger, who has de-
tected ammonia hi the recently-passed urine of pemphigus patients, as
well as in then* blood and in the contents of the blebs, the cause of
the malady, and the nature of the cachexia, or dyscrasia, giving rise
to the eruption, are quite unknown. We can merely support the
strength of the patient until the disease subsides spontaneously, and
can endeavor to postpone his exhaustion and ultimate death as long
as possible. As in all similar cases, whatever tends to increase the
waste of the organism must be avoided, and every thing must be fur-
nished in abundance which can replace what is consumed, or which
can retard the consumption of tissue. With regard to external treat-
ment, Hebra prohibits the use of baths and ointments as expressly as
he does the internal administration of specifics. However, he recom-
mends sprinkling of the moist spots with dry vegetable powder, es-
pecially lycopodium-seeds.

OHAPTEK XI.

flUTIA — DERMATITIS, WITH FORMATION OP ISOLATED FLAT VESICLES,
FROM WHICH SCABS OF A PECULIAR SHAPE ARE FORMED.

ETIOLOGY. — Rupia, like pemphigus, forms isolated blebs. Those
of pemphigus, however, soon burst, while the rupia blebs last longer.
Their contents become purulent, and often are bloody, and, after a
while, dry up into a scab. Having once formed, the scab is gradually
thickened by the addition of fresh exudation, which generally proceeds
from ulceration of the deeper parts of the skin, and which also dries

PSORIASIS.

485

into a crust, while upon its edges a border of bullse forms, the contents
of which dry up like those of the first one. Thus, the peripheral part
of the scab is flatter than the older portion ; the scabs of rupia are
thick in the middle and flat at the edges, bearing some resemblance
to oyster-shells. In most cases, but not in all, rupia is a symptom of
constitutional syphilis. The causes of non-syphilitic rupia are un-
known. Like ecthyma, it occurs most commonly in broken-down and
cachectic subjects,

SYMPTOMS AND COURSE. — The usual seat of non-syphilitic rupia is
upon the extremities. The blebs are isolated, and have a reddened
base. They are not tightly filled, and their contents at first are limpid,
afterward yellow or reddish. The scabs which form are of a dark
color, and, after lasting some time, assume the shape described above.
According as the thickness of the scabs is slight or considerable, they
are distinguished into rupia simplex and rupia prominens. Removal
of the scab exposes either an excoriation, or else a deep ulcer, over
which a new scab soon forms. Sometimes the base of the bleb not
only ulcerates, but becomes gangrenous (rupia escharotica s. gan-
grenosd). In such case the contents of the blebs are discolored or
blackish. Beneath them, or beneath the scab, we find the corium de-
stroyed and converted into a foul ulcer, covered with debris of the
tissue, and indisposed to heal. Rupia simplex and prominens usually
recover, leaving behind them a shallow scar, which is often stained
with pigment ; while rupia gangrenosa may cause death from exhaus-
tion, or may accelerate the end of the already exhausted patient.

TREATMENT. — Our principal task in the treatment of rupia consists
in combating the constitutional vice upon which it depends. If we
succeed in this, young epidermis soon forms beneath the scabs, and
the ulcers heal. But if we do not succeed in improving the constitu-
tion, local treatment will generally be found useless also. Besides
the constitutional remedies, the scabs may be softened by poulticing.
The ulcers which remain require stimulating applications, such as re-
peated touching with lunar caustic.

CHAPTER XII.

PSORIASIS CHRONIC DERMATITIS WITH INFILTRATION OF THE CORIUM,

AND ABNORMAL GROWTH OF EPIDERMIS.

ETIOLOGY. — In psoriasis, the effusion which forms upon the sur-
face of the corium is insufficient to elevate the epidermis into vesicles.
On the contrary, this form of dermatitis, which is always chronic, con-
sists merely of a hyperaemia and infiltration of the skin, capable of

486 DISEASES OF THE SKIN.

causing the papillae to produce an unhealthy epidermis, which, mingled
with the exudation, scales off in large flakes. The cause of psoriasis
is quite unknown. This disease, which is of very frequent occurrence
among all classes of society, cannot be regarded as the exponent of a
dyscrasia, for it attacks perfectly healthy subjects, and, in fact, seems
to prefer them, while invalids and decrepit persons often remain ex-
empt. In some families psoriasis is hereditary. Men and women seem
to be about equally liable to it, while it rarely attacks either children
in their first year or very aged persons.

SYMPTOMS AND COTJESE. — The disease always commences in small
round spots upon the skin. These are reddened; project slightly
above the surrounding level, and immediately after their appearance
are smooth, looking as if the covering of epidermis had been raised by
a serous effusion, and had sunk back again after the liquid had been
reabsorbed. This small, round, red, infiltrated spot soon becomes cov-
ered with dry, white scales. According to Hebrews apt and simple
description, it is from this form of psoriasis — psoriasis guttata — that
all the other varieties of psoriasis arise, developing sometimes through
extension of the morbid process, sometimes through retrocession of the
disease at the point first attacked. An enlargement of the affected
spot converts a psoriasis guttata into a p. nurmdaris ; this latter,
when the process begins to decline in the central and older portion of
the area of disease, so that the scales grow thinner and commence to
fall off, becomes a p. scutellata, and this again becomes a p. annulata,
when the redness disappears from the centre, and the skin at that
point resumes its healthy appearance (lepra vulgaris, Willari). When
the circles thus formed touch one another, interruptions occur at the
points of contact, so that at last there merely remain segments of cir-
cles, producing a new form of the disease, called p. gyrata. Finally,
p. conferta s. diffusa is the result of the confluence of numerous spots
of the eruption. The favorite seat of psoriasis is upon the dorsal or
extensor surfaces of the extremities, and, above all, upon the knees
and elbows. The disease often remains confined to these regions, no
trace of it being discoverable elsewhere upon the body. In cases of
this kind, and indeed in cases where the eruption is quite extensive, it
is often arranged upon each half of the body with remarkable sym-
metry. This, however, occurs in other cutaneous diseases also ; for
instance, in eczema. In very rare instances, psoriasis is confined to the
eyelids, or to the lips, the prepuce, the scrotum, or to the labia majora r
and there is no reason why these varieties should not be called p. pal
pebrarum, labiarum,prceputii, scroti, or pudendorum, etc. But neither
the diffuse nor the circumscribed form of psoriasis palmaris and plan-
taris is included in this series of varieties. In the diffuse form, the

PSORIASIS. 487

palm of the hands and soles of the feet are reddened and covered with
dry scales. We have ascertained that this is really a species of eczema.
The circumscribed variety is always of syphilitic origin, and is to be
spoken of hereafter. The circumstance that the morbid process from
which psoriasis arises does not act continuously upon one spot for any
great length of time, is not only the reason for the peculiar figuration
of the eruption, but also accounts for the rarity with which degenera-
tion of the deeper layers of the skin occurs in this disease. The excep-
tional cases in which the eruption does not soon subside, and in which
the skin is thickened, rigid, and fissured, are called psoriasis inveterata.
The diffuse or irregularly extended variety of the disease is the one
most apt to assume this form.

TREATMENT. — Although it seldom is possible to effect a radical
cure of a psoriasis, yet the treatment which merely aims at a tem-
porary abatement of the eruption is very satisfactory. The objections
which exist against the local treatment of certain forms of eczema and
impetigo are not valid in case of the disease in question ; psoriasis is
never of constitutional origin, and never appears vicariously for other
diseases. Moreover, vigorous local treatment is tolerated much better
in psoriasis than in any other cutaneous affection hitherto described.
Psoriasis must always be treated locally and with the most energetic
remedies. Instead of the white-precipitate ointment, and the prepara-
tions of zinc and of lead, which often suffice to effect a cure of an
eczema or an impetigo, and which, indeed, are often the only remedies
applicable to the case, the articles best adapted to its treatment are
green soap, tar, and the preparations of sulphur. It is best to com-
mence the cure with one or two vapor-baths, in which, by means of
soap and a moderately hard brush, the skin is to be cleansed as much
as possible from the scales which adhere to it. If these vapor-baths
cannot be had, the same object may be obtained by means of long-
'continued warm- water baths. After removal of the scales, the green
soap is to be rubbed in twice daily, for a period of from three to six
days, or else it must be applied upon a compress, which is to be re-
newed twice in the day. While this is going on, it is best that the
patient should be enveloped in a woollen blanket, and that he should
remain in bed, and in a well-warmed chamber. The treatment should
then be suspended for about three days, during which the inunctions
should cease, and the compresses may be laid aside. At the end of the
interval, the patient must take another vapor-bath, or long-continued
warm-water bath. If the infiltration of the cutis has not yet disappeared,
the process is to be repeated. If, however, all the diseased spots seem
soft and pliant, we may proceed to the application of tar or of tar-oint-
ment (see page 476). We have already said that we prefer a solution
81

488 DISEASES OF THE SKIN.

of tar and green soap (aa f j), in alcohol ( f ij), to the pure tar or the
tar-ointment. If, from the first, there has only been a moderate degree
of infiltration of the cutis, we may begin with two or three daily applica-
tions of the above solution immediately after the bathing and removal of
the scales ; and we shall nearly always effect our object in two or three
weeks by this means. Similar results, of which, however, I have no
personal experience, may be obtained by the use of ointment of iodide
of mercury or of sulphur and iodide of sulphur. For a time, Hebra
used to recommend the application of a concentrated solution of sul-
phuret of lime, in psoriasis (Vleminckx's solution). (IjL sulphur,
oitrini Bbij, calcis vivae fi>j, to be boiled in three gallons of water down
to a gallon and a half; the liquid to be filtered when cool.) Hebra
orders the solution to be rubbed vigorously into each diseased spot,
upon a bit of flannel, until all the scales have come off and the papillae
are exposed. He then puts the patient in a warm bath, where he is
to remain for an hour. After the bath, the diseased spots are to be
rubbed with any unctuous substance (such as cod-liver oil) or else with
tar-ointment or ointment of chrysophanic acid.

The above plan of treatment is adapted for psoriasis in its more
severe and extensive forms. Pencilling the affected spot with a solu-
tion of corrosive sublimate (hyd. chlor. corrosiv. 3 j ; alcohol f j) is
an excellent way of treating slighter efflorescences of the disease. Such
pencillings have the advantage of being much simpler, but they cause
such severe pain that they cannot well be used where the eruption is
at all extensive.

Although the quickest and surest way of treating psoriasis is by
making topical applications, yet it cannot be denied that the same
object will be attained by the internal exhibition of arsenic. In view
of this, as well as of the fact that the treatment just described is quite
unable to prevent relapses, and bearing in mind the well-known harm-
lessness of treatment by arsenic, if carefully conducted, I hold it to be
ioctrinary and incompatible with the interests of the patient to adopt
one or other method of cure exclusively, and not to combine the two.
Arsenic is usually given in the form of Fowler's solution. At first, six
drops are to be taken daily ; and the dose is to be increased one drop
every fifth day, until it amounts to about thirty drops. Veiel uses the
" Asiatic pills " almost exclusively, because he can regulate the dose
much better when the arsenic is in this form than when it is in the
form of drops. He dissolves white arsenic in boiling water, mixes it
with bread and pepper, and makes it into pills, each of which contains
the thirtieth of a grain of arsenic. Of these, at first, he gives three
daily, gradually raising the dose to eight or nine pills daily (that is, to
a quarter of a grain of arsenic per diem). As soon as any sense of

LICHEN. 489

oppression occurs in the region of the stomach, or when tears begin to
flow from the eyes, the treatment is to be suspended for a few days.
Cantharides, the antimonials, anthracokali, tar-pills, and other articles,
formerly in vogue, having proved themselves worthless in treatment
of psoriasis, have very justly been abandoned of late years. However,
hi plethoric, vigorous subjects, the cure may be accelerated by restrict-
ing the diet, and by combining the use of laxative tisanes with the
specific treatment; for we know that such measures alone, when
pushed vigorously, will cause a psoriasis to disappear.

CHAPTER XIII.

LICHEN — DERMATITIS FORMING GROUPS OF PERSISTENT CONICAL

NODULES.

ETIOLOGY. — In lichen, instead of the appearance of vesicles, filled
with serum, upon the skin, there is an eruption of solid nodules (papu-
lae). The exudation which forms in this disease infiltrates the cutis,
and produces a circumscribed swelling of its parenchyma, but the por-
tion of it effused upon the free surface of the cutis is only sufficient lo
swell the cells of the rete Malpighii, and to loosen the layer of epider-
mis above it. This is why lichen terminates by desquamation. It
is only in a few cases that the source of lichen can be traced to the
action of slight external irritants ; for instance, to the bites of parasites,
to chafing of the skin by roughness of the clothing, to the effect of
dirt, or to the influence of high temperature. In most cases we can-
not tell why the numerous small circumscribed portions of the cutis,
of which the lichen-knots consist, should be thus affected, while the
rest of the skin about them appears sound. Lichen is especially com-
mon among scrofulous persons.

SYMPTOMS AND COURSE. — Lichen is characterized by nodules of
about the size of a millet-seed. They are of normal color, or else of a
pale, yellowish red ; sometimes they are even paler than the surround
ing skin. In the latter case, the blood-vessels, from which the exuda
tion originally proceeded, have afterward been compressed by the exu •
dation. The nodules usually form groups ; sometimes they only ap
pear upon particular regions of the body ; at others, they spread ove
a wider extent of surface. In the milder forms of lichen (lichen sim
plex), the papules itch but slightly, or give no annoyance whatever,
and only last for a short time. They disappear in a week or two, and,
after desquamation of the epidermis covering the papules, the disease
usually terminates. More rarely, lichen simplex assumes a chronic
form, fresh eruptions of the nodules following one another in rapid

490 DISEASES OF THE SKIN.

succession. In the severer form (lichen agrius) , the outbreak is some-
times accompanied by fever, and by general disturbance. The nodules
are often crowded closely together, and stand upon a reddened base.
They are likewise red themselves, and itch and burn intensely. The
Inflammation readily becomes aggravated, so that in a few days the
lichen changes into an eczema rubrum. The course of this variety may
also be acute, and terminate in recovery at the end of a week or fort-
night ; more usually, however, it becomes chronic.

Hebra — who never applies the term lichen to a papular eruption
unless the papules retain their solid form from beginning to end of
their course, and do not transform into vesicles or pustules — describes
lichen ruler as a disease which, in its later stages, bears some resem-
blance to psoriasis. Here there are red nodules of the size of a millet-
seed, which are covered with thin scales, and which at first are separate,
and do not itch nor extend at the periphery. With every succeeding
outbreak of the eruption, the part becomes more thickly studded with
nodules, and the intervening surface grows smaller, until at last the
edges of the papules touch one another, and form large, infiltrated, red
patches. Finally, the entire cutaneous surface may become the seat
of such a papular eruption, and of the diffuse infiltration arising from
it. Like all other universal exanthemata, this has a prejudicial effect
upon the general health of the patients, the majority of whom die in a
state of marasmus.

TREATMENT. — The slighter forms of acute lichen require no treat-
ment. In especially obstinate cases we may have recourse to the
exhibition of arsenic. Veiel believes this to be of most service in all
those cutaneous diseases in which the cutis is infiltrated, while in other
forms it is much less efficient. Cold applications and the exhibition
of laxatives are the suitable remedies for lichen agrius ; but blood-let-
ting, which likewise has been recommended, should never be practised.
Chronic lichen agrius often defies the most active treatment. Baths,
soft soap, tar, and the preparations of sulphur, but especially the inter-
nal administration of arsenic, are the remedies most to be advised.

CHAPTER XIV.

PRURIGO — DERMATITIS WITH SMALL, SCATTERED, ITCHING NODULES.

ETIOLOGY. — The flat nodules which are peculiar to prurigo have
the color of the surrounding skin. If punctured, they usually dis-
charge a drop of clear liquid, while the puncture of a papule of lichen
is followed by the flow of a drop of blood. Upon squeezing a prurigc
nodule laterally, we observe that the epidermis becomes stretched

PRURIGO. 491

and transparent, and that a watery liquid appears. From these pecu-
liarities of the nodule, and from the results of the treatment of prurigo,
Hebra concludes that in this disease we have to deal with a liquid
effusion in the deeper layers of the epidermis, which, however, is not
profuse enough to form vesicles, but merely produces flat nodules, at
first perceptible to the touch, and afterward to the eye. The subjec-
tive symptoms and course of the disease, especially the intolerable
itching which accompanies it, seem fully to substantiate the correct-
ness of this hypothesis, which, indeed, cannot be demonstrated directly
upon the dissecting-table, as the lesions described above always disap-
pear after death. In spite of the identity of their symptoms, it is
usual to discriminate between the form of prurigo provoked by lice,
ticks, irritating dust, and other external influences, and that very ob-
stinate disease known as true prurigo, which, arising without known
cause, often continues throughout life. "Want of proper care of the
skin and scanty food seem to play an important role in the etiology
of true prurigo, which is much more common among the poorer classes
than among the well-to-do. The disease appears at every age, except-
ing only the first years of childhood. Men are more liable to it than
women.

SYMPTOMS AND COURSE. — The most prominent objective signs of
prurigo consist in those resulting from the violent scratching, and not
in the nodules themselves, which are scattered and flat, and, indeed,
are often hard to find, although, from the irritation which they produce
upon the skin, they create an itching as intolerable as that produced
by the bites of insects, or by gently tickling the surface of the skin
with the tips of the fingers, or with a foreign body. Scratching with
the nails tears off the epidermis from the nodules ; a slight bleeding is
the result, and the blood effused dries into a crust. It is these innu-
merable little crusts which remain after the papule has disappeared
that form the most conspicuous object upon the skin of a patient with
prurigo. As scratches and papules are also induced by the bites of
vermin, we must always ascertain in such cases whether we have to
deal with lice and itch-insects, or with genuine prurigo in its stricter
sense. Gross errors, especially the mistaking of the itch for prurigo,
in persons whom one would not be apt to suspect of having the itch,
are of daily occurrence. One of the most important distinctive points
consists in the locality upon which the papules and scratches lie thick-
est. In prurigo the principal seat of the papules and scratched places
is upon the extensor side of the limbs, especially upon the legs — which
is never the case in the itch — and they are quite as numerous upon
the back as upon the belly. Body lice, on the other hand, lodge
chiolly where the shirt is thrown into folds, as about the neck and

492 DISEASES OF THE SKIN.

waist-band, while the favorite harbor of the itch-insect is upon the
flexor sides of the limbs, between the fingers, and upon the belly, where
the prurigo-papules do not often come. However, the positive dis-
covery of the tracks of the itch-insect, or the detection of the insect
itself, or the presence of lice, or their nits, furnishes a criterion for dis-
tinguishing between scabies, prurigo pedicularis, and true prurigo, bet-
ter even than that afforded by the seat of the papules and excoria-
tions. But even in the face of such testimony as this, when the itching
is of very long standing, and involves an unusually large extent of sur-
face, we should bear in mind the possibility of a complication of these
diseases, the more so since persons of the class most liable to prurigo
are equally likely to be infested by lice and the itch-insect. The dark
stain, seen upon the skin of patients who have long suffered from pru-
rigo, is a consequence of the scratching, and is of no service as a diag-
nostic mark, since it is nearly always seen upon the skin of people
who have long been infested by vermin. Slighter grades of prurigo
are called prurigo mitis / the severer grades are called prurigo formi-
cans, from the resemblance of the sensations to the intolerable itching
and burning produced by the contact of a multitude of ants. Prurigo
ani, which is limited to the region of the anus, and that form which
appears upon the labia majora in women, and upon the penis and
scrotum in men — or prurigo pudendorum — is intermediate between
prurigo and eczema. As has already been stated, this is a most ob-
stinate affection, and may last with undiminished intensity for months,
and even for years. Generally, however, it grows worse during the
autumn and winter, and makes a remission during the spring and sum-
mer. The itching is usually most distressing in the evening, and at
night. So constant are the disquiet and torment of the patients, who
are often deprived of their sleep night after night, that, driven to des-
peration, they sometimes commit suicide, while others become insane.
On the other hand, the general state of the nutrition does not often
suffer ; at all events, not until very late in the disease. Any prema-
ture marasmus which may exist is much more frequently dependent
upon complications, or upon the needy circumstances of the patient
(cachexia pauperum^, tnan upon the prurigo itself.

TREATMENT. — The radical cure of prurigo is a task so difficult
that it is rarely accomplished. On the other hand, it is nearly always
possible to produce a temporary abatement of the symptoms, and
sometimes, indeed, to effect a complete although transient relief, by
stimulating the process of desquamation of the cuticle by means of
cutaneous irritants, thus accelerating the process of its regeneration.
Hence, baths or lotions containing a solution of common salt, potash,
3orrosive sublimate, lime-water, or dilute acid, inunctions of tar-oint-

ACNE.

493

ment and of soft soap, and vapor baths, are preferable to the tepid
baths of bran-water, milk, or mucilage. A very sure remedy for pru-
rigo — although merely a palliative one — consists in friction of the skin
for half an hour at a time with a piece of flannel dipped in the solu-
tion of sulphuret of lime mentioned above (see p. 488), and known as
Vlemincky?s solution. After being rubbed down, the patient is to be
put in a bath, in which he must spend at least an hour. It is a good
plan to follow the bath by a shower-bath, and then to rub the body
with oil. Even the first bath always affords great relief, and the itch-
ing generally subsides completely after continuing the bathing for a
week. Unfortunately there is always a relapse, rendering a repetition
of the treatment necessary. Any complication which may exist must
be combated by internal medication and by suitable diet ; and, when
the nutritive state of the body is deranged, that also must be regu-
lated, if possible. Veiel regards arsenic as a real specific in prurigo,
and claims never to have used it without effect.

CHAPTER XV.

ACNE, ACNE VULGARIS, ACNE DISSEMINATA — INFLAMMATION AND SUP-
PURATION OF OBSTRUCTED SEBACEOUS FOLLICLES.

ETIOLOGY. — Bareneprung very properly classes inflammation and
suppuration of the sebaceous follicles with similar derangement of the
mucous follicles ; and in truth the acne pustule of the skin and the
follicular ulcer of the mucous membrane both originate by the same
process — obstruction of the outlet of a follicle, inflammation of its walls,
and bursting of its covering externally. By and by we shall consider
the effects of obstruction of the follicles by inspissated sebaceous matter
upon which the development of the so-called comedones (Mitesser)
depends. A comedo is not an acne at first, and does not become one
until the obstructed follicle inflames. In most cases such inflammation
terminates in suppuration, producing acne pustules. But it sometimes
happens that the inflammation is resolved, and then only leads to
chronic infiltration and thickening of the wall of the follicle, or, in other
words, to the formation of acne nodules or tubercles. Very few per-
sons ever remain perfectly exempt from acne vulgaris. The majority,
however, merely suffer from it during the period of puberty, and the
form of the disease is mild, and, even in individuals wTho have been
afflicted by acne vulgaris in its worst form for years, the affection has
never commenced in childhood, but only appears at the time of ado-
lescence, although it may considerably outlast that period. It is, how-
ever, extremely rare for acne to last until the age of advanced man-

DISEASES OF THE SKIN.

hood. Although the male sex is more predisposed to acne than the
female, yet, to the dismay of vain mothers, " a bad complexion " — the
usual euphemism for acne — often disfigures their daughters, at the
very time when they are about to be introduced into society. Hence,
it can hardly be denied that some connection does really exist between
the development of acne and the process which is going on in the
sexual system. The laity go further ; and, according as they are
inclined to regard mankind from a gloomy or a favorable point of view,
they ascribe acne to masturbation or to sexual excess, or else attribute
it to excessive chastity and over-continence.

SYMPTOMS AND COURSE. — The most frequent seat of acne is upon
the face ; next in frequence it appears upon the back, bosom, buttocks,
and upper arms. The disease commences by the reddening and swell-
ing of the skin at a circumscribed spot, in the middle of which there is
a black point — the comedo — (acne punctata). If resolution of the
inflammation takes place, the swelling subsides in the nodule, the epi-
dermis, loosened by the inflammation, scales off, leaving a reddened
and somewhat hardened spot which remains upon the skin for some
time. After a while, however, this likewise disappears. If the inflam-
mation passes on into suppuration, a small pustule forms at the apex
of the nodule, and after a while bursts, leaving a yellow scab. In
rare instances, the nodule upon which the pustule is situated disap-
pears soon after the pustule forms, or else after it bursts ; generally,
however, it subsides slowly and gradually. It not unfrequently hap-
pens that the cutis surrounding the inflamed follicle is more extensively
involved in the inflammation, and, becoming infiltrated, swells, hardens,
and acquires a deep-red hue. Inflammation of the skin arising from
this cause closely resembles furunculous dermatitis. This may end in
resolution, the rounded, flat, broad, elevation of the skin into which the
acne nodule has converted itself gradually subsiding, casting off its
cuticle, and slowly losing its color; but it frequently terminates in sup-
puration. The follicle which in such cases has become loosened from
its attachments is discharged just as the dead " core " of a boil is dis-
charged, and a scar remains.

TREATMENT. — Acne is quite independent of "impurity of thi
blood ; " and the " decoctions of woods " and the laxatives — even if
they had any real title to their supposed properties as " blood puri
fiers " — would not be suitable remedies hi this affection. But it is not
enough that the physician should merely refrain from prescribing these
articles ; he must also warn his patients — who usually take them behind
his back — of the impropriety of so doing. Other internal medication
should also be abstained from, as it is useless, and since the treatment by
external application is always effective. Great benefit is often obtained

SYCOSIS.

495

by washing the acne nodules in solutions of caustic potash or of corrosive
sublimate, or with tincture of benzoin. VeieFs treatment also, which
is exceedingly efficacious, consists ii\ vigorously brushing the nodules
with soft soap and a tooth-brush. The preparations of sulphur are
still more preferable ; they are very generally used, and IZummerf eld's
lotion enjoys a great reputation among the laity. (I£. sulphur, precip.
3 ij, camphor, gr.x, gum. mimosas 3j, aquas calcis, aquae rosar. aa § ij.)
The directions for the use of KummerfeWs lotion are : after shaking
it well, to apply it at bed-time to all that portion of skin affected by
acne, and the next morning to rub off all the sulphur which adheres to
the skin, without wetting it. JSebra directs precipitated sulphur to be
mixed with equal parts of alcohol, carbonate of soda, laurel-water, and
glycerine, so as to form a paste, and this is to be rubbed into the
nodules which are previously to be energetically scrubbed with soap
and water. This treatment is also to be practised in the evening, and
then the paste may remain upon the tubercles through the night. In
persons who can afford the time, the paste may be applied night and
morning, and left continuously in contact with the acne nodules.
Where matter has formed, it is to be evacuated by cautious punctures.
If the inflammation be very intense, the best application is a warm
poultice.

OHAPTEK XVI.

MENTAGRA — SYCOSIS — INFLAMMATION AND SUPPURATION OF
SEBACEOUS GLANDS AND HAIR-FOLLICLES OF THE BEARD.

THE

ETIOLOGY. — Sycosis is an inflammation of the sebaceous glands
and of the deeply-rooted hair-follicles of the beard, but the tissues of
the cutis about these glands and follicles likewise take part in the in
flammation and become the seat of intense hyperaemia, swelling, infil-
tration, and suppuration. The disease scarcely ever occurs in women
and children, who never shave ; but only affects adult males, particu-
larly at a time when the beard has acquired a tolerably thick growth,
Dull razors, awkward shaving, the effect of irritating soap, of snuff, 01
of dirt, seem to cause the disease, or, at all events, to predispose tow-
ard it. In the majority of cases, it has no assignable cause. I can
confirm the statement often made, that mentagra sometimes proceeds
from the penetration of the parasitical growth of herpes tondens and
herpes circinatus into the large and deeply-seated follicles of the beard.
I have seen a case in which a man, who had contracted herpes tondens
from a sick cow, had mentagra a few weeks afterward. What was
very characteristic in this case was, that the eruption, half of which

496 DISEASES OF THE SKIN.

was in the beard, the other half without it, presented the features of
herpes circinatus in the latter situation and that of mentagra in the
former.

SYMPTOMS AND COURSE. — The disease commences with a sense of
heat and tension, accompanied by the development of red infiltrated
nodules, of the size of a pea or lentil, between the hairs of the beard
upon the lips, chin, cheeks, and, in rare instances, between the hairs
of the eyebrows and armpits. After a while, pustules, which are al-
ways perforated by a hair, appear upon the tips of the nodules. The
pustules burst in a day or two, and pour out their contents, which im-
mediately dry into brownish crusts. The nodules still continue beneath
the crusts, and, even after the latter have fallen, they diminish very
slowly or not at all. Although at first the eruption is scanty and
scattered, yet, under the influence of successive attacks, the tubercles
multiply gradually, until, from the close crowding of the nodules,
together with the infiltration of the intervening skin, the appearance
of the surface becomes suggestive of a fig — whence its name, " syco-
sis" Sometimes sycosis is confined to single spots of no great mag-
nitude ; in other cases, every part of the face where the hah* grows is
covered with dusky-red nodules, pustules, and scabs. The disease is
of indefinite duration, and often lasts for years and even tens of years
without subsiding, but also without leading to other lesions. When
it heals, the hair-follicles having been destroyed, the hair does not
grow again upon the affected spot, which presents the appearance of
a scar.

TREATMENT. — I used formerly to regard sycosis as one of the most
intractable of diseases, as it generally resisted all treatment, notwith-
standing the numerous remedies which have been proposed for its cure.
In the last few years, however, during which I have adhered strictly
to the treatment proposed by Hebra, in Virchoufs hand-book, I have
altered my opinion, and recommend the following procedure. In the
first place, all the scabs are to be softened and removed by rubbing
them with oil, or by the application to them of a rag saturated with
oil. We must then insist upon the patient's shaving daily, in spite
both of his opposition and his barber's. The pustules which appear
after the shaving are all to be opened with a delicate scalpel ; and
where they are confluent, long incisions must be made through the
clusters. Like the shaving, this scarification is far less painful than
might be supposed, and it likewise must be repeated daily. In ex-
traordinarily obstinate cases the opened pustules must be touched with
concentrated acetic acid, or with a solution of corrosive sublimate,
consisting of one part of the sublimate to two of alcohol. During the
night it is generally sufficient to cover the affected part with a rag,

ACNE ROSACEA. 497

thickly smeared with white-precipitate ointment, or with a paste made
of equal parts of sulphur, glycerine, and alcohol.

CHAPTER XVII.

ACNE ROSACEA — GUTTA ROSACEA — CHRONIC INFLAMMATION OF THE
SEBACEOUS GLANDS OF THE FACE, WITH DILATATION OF THE BLOOD-
VESSELS AND GROWTH OF THE CONNECTIVE TISSUE ABOUT THEM,

ETIOLOGY. — In acne rosacea the sebaceous glands of the face,
especially those of the nose, become the seat of a chronic inflamma-
tion. The tendency to suppuration in this affection is much less than
in acne vulgaris and sycosis ; but, on the other hand, it is always ac-
companied by an inflammatory hypertrophy of the surrounding connec-
tive tissue, as well as by considerable dilatation of the blood-vessels
about the diseased glands. Acne rosacea is particularly common
among tipplers, especially among wine and brandy drinkers ; although
it is by no means so exclusively confined to such individuals as to war-
rant the inference that a person is intemperate because he has acne
rosacea on his face. Women at the climacteric epoch, even though they
never touch wine, beer, or spirituous liquor, are often afflicted by this
disorder, which is all the more distressing to them because of the pre-
vailing prejudices regarding its cause. Young women, also, with de-
ranged menses, sometimes are attacked by acne rosacea.

SYMPTOMS AND COURSE. — The disease commences by the appear-
ance upon the face of discrete coppery-red spots, whose color depends
upon the varicose dilatation of small blood-vessels. Acne nodules
then develop upon these bluish-red spots ; but, even when pustules
mature, the nodules do not decrease in size, but continue gradually to
grow larger. The effect of this constant formation of new tubercles,
and of the excessive hypertrophy of the adjacent connective tissue of
the skin, is to give rise to most unsightly deformity. The nose, which
is the usual seat of acne rosacea, becomes enlarged and misshaped, and
in bad cases it is studded with knobs and humps of various size, and
assumes a purple color. The forehead and cheeks are often similarly
affected, and sometimes the disease involves the whole face.

TREATMENT. — As soon as acne rosacea begins to appear, the use
of spirituous liquors is to be strictly prohibited. If there be any de-
rangement of menstruation, it is to be treated according to directions
already given. It is also advisable to endeavor to compress the ves-
sels of the reddened spots by painting them with collodion. When
this treatment is not well borne, Veiel obtains benefit from concen-
trated lead- water, with the addition of terra sigellata and a little cam

498 DISEASES OF THE SKIN.

phor. When the acne nodules appear, the preparations of sulphur may
be employed ; but, instead of the paste recommended for the cure of
acne vulgaris and sycosis, it is better to use IZummerf eld's lotion, or a
turbid mixture of sulphur and water, or alcohol. In old cases, almost
every treatment will prove ineffectual.

V.— HAEMORRHAGES OF THE SKIN—PURPURA.

ETIOLOGY. — All haemorrhages of the skin proceed from a solution
of continuity of the walls of the cutaneous vessels ; blood never trana
udes through the wall of a blood-vessel, unless it be ruptured. Pur-
pura are reddish, bluish, or blackish spots, the result of extravasation
of blood into the parenchyma of the cutis, the blood filling up the in-
terstices between the elements of the cutaneous tissues, but causing
no swelling of the skin. When the purpura are small and round, they
are generally called petechice / when elongated into stripes, they receive
the name of vibices; and when diffuse and of irregular shape, they are
called ecchymomata. If the effusion of a somewhat large quantity of
blood causes the skin to swell in the form of small nodules, we have
the lichen lividus ( Willan), or the purpura papulosa (Hebra). The
broader flat tumefaction of the skin caused by a more diffuse extrava-
sation, and which resembles the wheals of nettle-rash, is called pur-
pura urticans. Sometimes a haemorrhage separates the epidermis
from the papillary layer, forming blebs, purpura bullosa ; hi other
cases the blood perforates the epidermis and appears upon its exterior.
In the so-called " bloody sweat," blood really exudes through the pores
of the skin. It is not mingled with sweat, however ; and since, more-
over, this bleeding has nothing to do with the secretion of sweat, the
above term is inappropriate.

The causes of haemorrhage into the skin are :

1. External injury. The traumatic haemorrhages caused by the
bites of fleas deserve some attention, since inexperienced physicians
are occasionally misled by them, and are induced to diagnosticate
some serious disease of the blood. Immediately after the bite of a
flea, a roseola spot or wheal makes its appearance, in the middle of
which the small, dark-red wound — the stigma — is perceptible.

Besides this, however, in persons whose blood is deficient in fibrin,
a haemorrhage takes place into the cutaneous substance, about the
puncture, similar to that much more considerable extravasation which
occurs around a leech-bite in persons of a similar constitution. These
little haemorrhages from flea-bites continue visible after the puncture
has disappeared ; so that, although the stigma may afford a distinctive

PURPURA.

499

mark between a roseola or urticaria pulicosa, and other forms of roseola
and urticaria, it cannot be used to distinguish between purpura puli-
cosa and other forms of purpura. Besides the discovery of fleas and
of fresh flea-bites, the mere consideration of the region upon which the
purpuric spots are situated will often enable us to estimate their origin
correctly. Fleas generally lodge in positions from which they can
crawl between the folds of the shirt. Hence, when we find petechise
upon the neck and shoulders, and about the waist in women, while
few or none are visible upon other regions, especially upon surfaces
which are usually exposed, we may conclude that the haemorrhagic
spots are the vestiges of old flea-bites.

2. Haemorrhage into the skin may proceed from over-distention and
rupture of its blood-vessels. Thus, after severe coughing, or after vio-
lent vomiting, we often see the face speckled with purpuric spots ; and,
when the venous circulation of the lower extremities is obstructed, we
often find purpura upon them, accompanied by varicosities of the veins.
Even intense fluxionary hyperaemia seems sometimes to cause rupture
of blood-vessels in the skin. At all events, the English physicians
describe an affection called purpura simplex, which appears in healthy
and robust subjects, particularly in those who indulge freely in spirit-
uous liquors.

3. The most frequent source of haemorrhage into the skin is a nu-
tritive derangement of the walls of the blood-vessels. Under this
head comes the purpura senilis, one of the symptoms of senile maras-
mus, as well as the purpura which appear in severe constitutional dis-
ease, such as typhus, small-pox, measles, and scurvy, and that which
is the chief symptom of the morbus maculosus of Werlhoff. The pe-
liosis rheumatica, a form of purpura accompanied by rheumatic pains,
and which is only met with upon the lower extremities, is probably of
this class likewise.

SYMPTOMS AND COURSE. — Red spots resulting from haemorrhage
may be distinguished from similar spots caused by mere vascular dis-
tention, by the fact that the latter disappear under pressure of the
finger, while the former remain unchanged. They vary considerably
in size, situation, and duration ; but these variations, as well as the
subjective symptoms which accompany them, depend principally upon
the character of the original disease, or its complications. Hence, we
must refer to the chapters upon typhus, small-pox, measles, scurvy,
and morbus maculosus Werlhofii for a further account of these haemor-
rhages, and shall now merely add a few words about peliosis rheumat-
ica. This affection, first observed and recognized as a distinct disease by
Schonlein, usually attacks young subjects with delicate skin, who have
already suffered from rheumatism. It is generally accompanied bj

500 DISEASES OF THE 6KIN.

fever. The patient first becomes aware of a pain in the lower extrem-
ities, particularly in the legs. Upon examination, the painful part is
found slightly swollen, oedematous, and studded with red spots of the
size of a millet-seed or lentil. At first the spots are bright red, and
disappear under pressure of the finger, which shows that at this period
they depend upon hyperaemia. They afterward assume a dirty-brown
color, and then no longer are effaced by the finger, proving that blood
has escaped from its vessels into the substance of the skin. This erup-
tion of spots generally recurs by fits several times in succession, so
that the disease usually lasts for several weeks, although, if the pa-
tient maintain a recumbent attitude, the first crop of spots usually
fades out again in from four to eight days. In some cases the disease
drags on for months, with repeated relapses.

TBEATMENT. — In treatment of haemorrhage into the skin, special
attention must be paid to whatsoever constitutional disorder may exist.
Besides this, it is customary in these cases, as in almost all other
haemorrhages, to give the mineral and vegetable acids internally, and
to bathe the purpuric spots with dilute acids — especially with vinegar
and water. The efficacy of these prescriptions is very problematical.
In the treatment of peliosis rheumatica it is an important rule that
the patient should be kept in bed, and in an uninterruptedly horizontal
attitude, until the eruption disappears, and for some little time after-
ward.

VL— GROWTHS IN THE SKIN.

WE shall leave the description of a majority of the cutaneous
growths to text-books of surgery, especially the account of^carcinoma,
sarcoma, and epithelioma, and shall confine ourselves here to a brief
sketch of the disease known as lupus, a neoplastic formation peculiar
to the skin, and to the mucous membrane of the nose, mouth, and
fauces.

CHAPTER XVIII.

LUPUS — LUPUS EXEDENS.

ETIOLOGY. — The neoplasm, upon whose development in the skin
lupus depends, is classed among the " granulation growths " (Granula-
tionsgeschwulste), by Virchow. It arises in the form of nodules,
which either remain distinct (lupus tuber osus), or else coalesce, caus-
ing a diffuse thickening of the skin (lupus hypertrophicus). The ele-
ments which form a nodule of lupus consist of small cells which greatly

LUPUS.

501

resemble the cells of the rete Malpighii. The epidermoid elements
also suffer " accidentally." The epidermis over the diseased region is
very thin, and is usually covered with fine scales. Small white gran-
ules, like millet-seeds, are produced from the sebaceous glands ; the
hairs become deformed and humped from irregular deposit of the horn-
cells, and perish as the disease advances. The neoplasm penetrates
deeper and deeper below the surface ; it advances from the skin to
the subcutaneous tissues, and thence often attacks the cartilages and
bones. As the malady goes on, ulceration generally sets in. Crusts
form, under which the tissues break down into " devouring ulcers "
{lupus exedens). But it sometimes happens that the lupus-nodules
subside, then- cellular elements undergoing fatty degeneration, fol-
lowed by absorption. The site of the disease then becomes depressed,
and is marked by a deep scar, although it has never been hi a state of
ulceration (lupus non exedens).

The etiology of lupus is quite unknown. It is true that the disease
often attacks scrofulous persons ; but there are many well-marked cases
of scrofula who remain free from lupus, while quite as many, who never
have been scrofulous, and who previously had seemed quite sound in
other respects, are attacked by it. Its relations with congenital syphi-
lis are very similar. It cannot be denied that lupus is tolerably com-
mon among persons whom we suspect, or whom we know, to suffer
from hereditary syphilis ; but, on the other hand, it is well estab-
lished that the majority of persons so affected never suffer from lupus.
Hence we are not warranted in distinguishing lupus into lupus scrof-
ulosus, syphiliticus, idiopathicus, etc. Statistics as to the frequence of
lupus at different ages, and in the two sexes, and in the various ranks
of society, show that the malady is rare before the tenth year of age,
and still more rare after the fortieth, and most common between the
ages of ten and twenty ; that both sexes are afflicted by it with about
equal frequence, although perhaps women suffer a little more often
than men ; and, finally, that lupus is less frequently seen among the
rich than among the poorer classes.

SYMPTOMS AND COURSE. — The most frequent seat of lupus is
upon the face, especially upon the nose. Nevertheless, the disease
may attack other regions, such as the neck, shoulders, chest, and ex-
tremities, especially over the joints. The first symptoms are often
overlooked, or at least too little importance is attached to them.
They consist in the formation of small, painless, brownish-red specks or
nodules (L maculosus, s. tuber culosus), which, although quite hard, are
so remarkably vulnerable and tender, that they bleed readily ; and with
very slight force the point of a pencil of nitrate of silver may be made
to penetrate them deeply. The disease may remain at this stage, with

502 DISEASES OF THE SKIN.

out advancing for a long time, even for several years. It is only in
rare instances that lupus takes on a subacute course, so as to produce
extensive destruction in a few weeks. As the malady advances, its
appearance changes. In some instances the nodules multiply and
grow larger ; their surface becomes tense and shining, and is covered
with detached scales of epidermis (lupus exfoliativus). As the disease
goes on, the hardness of the spots and nodules is resolved, and the
affected portion of the skin, which formerly rose above the surround-
ing level, or which at least was even with it, now sinks gradually, and
attaches itself firmly to the part beneath it ; and, as the recovery pro-
gresses, shrinks and is converted into a white, hard, shining cicatrix.
When the course of a lupus is as above described, large portions of
the skin becoming transformed into a tissue resembling that of a scar,
without any ulcerations having occurred, it is called lupus non exedens.
Apart from the unsightliness of the scars themselves, the face may
suffer great deformity, in this form of lupus, from contraction or dilata-
tion of the nostrils, and from ectropion caused by retraction of the
cicatrices. In other instances the outset of the disease is quite similar
to the above ; brownish-red spots and nodules form, which continually
shed scales of dry epithelium. This condition, however, having con-
tinued for a variable period of time, the nodules begin to grow, the
maculae become papules ; new nodules form, and while the surround-
ing skin becomes more hypersemic, red, and shining ; a superficial ero-
sion occurs upon the summit of one of the nodules, the product from
which rapidly dries into a scab. These scabs gradually grow thicker
and broader by accretion of fresh matter at their base. If forcibly
detached, a slight bleeding ensues, and we can perceive that there is a
loss of substance of the skin, in which the middle of the scab is embed-
ded more or less profoundly. This is the characteristic course of that
form of the malady known as lupus exedens or exulcerans, and also as
1. rodens, as well as herpes rodens s. exedens, s. esthiomenos. Some-
times the disease begins from a pustule, without the previous develop-
ment of a reddish-brown spot or nodule. In such instances, lupus at
its outset might easily be mistaken for a simple impetigo, and the
error would only become apparent upon the discovery that there is a
loss of substance in the cutis, beneath the scab. According to Itiett, it
is convenient to distinguish two forms of ulcerative lupus, a superfi-
cially destructive and a profoundly destructive form. The former often
involves a large extent of surface, and occurs not only upon the fact
but upon the shoulders, and other parts of the body enumerated above.
Sometimes the process subsides at the point first attacked, leaving a
scar, which, by its ribbed and reticulate aspect, closely resembles the
scar of a burn ; meanwhile it continues to extend at the edges of the

LUPUS. 503

Beatrix; the disease is then called lupus serpiginosus. The more
deeply destructive form of lupus exedens begins almost exclusively
upon the alae nasi and the tip of the nose. It is accompanied by de-
cided swelling and hyperaemia of the anterior part of the nose. The
scab which forms upon these deeply-seated nodules is of great thickness,
proportionate to the depth to which the destructive process has pene-
trated. Beneath this scab, which is continually renewed, the skin,
subcutaneous tissue, cartilage, and even the bones of the nose, are
destroyed, sometimes in the space of a few weeks' time, but mom
frequently in course of several months or years. Sometimes the dis-*
ease, instead of commencing in the integument of the nose, first at-
tacks the mucous membrane, causing great devastation of the interior
of the nasal cavity, and even destroying the septum narium before the
ulceration involves the skin.

It now remains for us to describe lupus hypertrophicus. The most
frequent seat of this form of lupus is also upon the face, although it
not unfrequently appears upon other parts of the body. I have known
it to attack the face and extremities simultaneously. Here, too, numer-
ous nodules of variable size are first observed ; they are covered with
desquamating epithelium, and do not usually ulcerate except upon
the nose. In consequence of the generation and confluence of new
nodules, the skin becomes diffusely, and often quite uniformly, thick-
ened. The surface is red, shining, and tense ; here and there upon it
there are a few spots of a darker red, covered with denser scales of
epidermis.

Lupus hypertrophicus also shows a tendency to subside at its
point of origin, and to extend into the surrounding skin. In con-
sequence of the retraction of the new connective tissue which forms
during cicatrization, the swollen and reddened integument becomes
traversed by interlacing, hard, white cords. In the case of lupus hy-
pertrophicus mentioned above, the whole face had become a rigid, cal-
lous cicatrix, traversed by varicose vessels, and presented a frightful
deformity. The eyelids were everted, the nostrils dilated ; while upon
the ears the process was only just commencing. It must not be sup-
posed that, in a given case of lupus, one only of these varieties appears,
to the exclusion of the others. On the contrary, they usually exist to-
gether, one form generally predominating, although traces of the others
are nearly always to be found.

TREATMENT. — In the treatment of lupus our task is a double one.
In the first place, we have to remove the neoplasm which is embedded
between the fibres of the cutis, or else, by its gradual growth and sub-
sequent retrocession, it will cause great destruction of the skin ; and,
in the second place, we must endeavor to prevent the formation of
82

DISEASES OF THE SKIN.

further and similar deposits in the substance of the cutis. With regard
to the first point, all surgeons and dermatologists entirely agree that
the lupus nodules must be removed or destroyed ; but opinions differ
greatly as to the surest and most advantageous means and method of
effecting this object. It is not for me to go into the merits of purely
surgical questions, nor to express a preference for the use of the knife,
the actual or the potential cautery, nor to declare in favor of nitrate
of silver, or caustic potash, rather than for nitric acid, arsenic, iodide
of mercury, or chloride of zinc. In my opinion it matters much less
what particular caustic is employed, than that the operator should be
well versed in the management of the caustic, and should be familiar
with its action. Very obscure and ill-educated surgeons often acquire
a reputation from their wonderful success in the treatment of cancer,
and of " eating-sores," by means of a secret remedy. It would be
wrong to assume that all such reputations are without foundation.
Individuals of this class, the so-called " cancer-doctors," by dint of
operating daily, and in numerous cases, with one particular kind of
caustic, finally become more skilled in its use, and know better how
to adapt it to especial instances, than the most distinguished surgeons.
Patients, in whom the application of caustic is indicated, may be in-
trusted to their hands with perfect reliance. But if the state were to
buy the secret, science would be but little benefited by the purchase,
even though the seller were to act with perfect honesty ; for other
surgeons operating with the same caustic will not be nearly so suc-
cessful as the original possessor of the nostrum.

The second indication in the treatment of lupus is far more difficult
of fulfilment than the first. Unfortunately, we know of no sure means
of preventing the recurrence of lupus nodules in the vicinity of the old
site of the disease, nor in the scar of an old lupus, whether healed
spontaneously or by artificial means. We are not agreed even as to
the necessity of an internal medication for lupus, in addition to the
local treatment ; or whether we should rely upon external application
to produce an alterative effect upon the nutrition of the endangered
region. The internal medicines most in vogue are the iodide of potas-
sium, with or without an addition of iodine, and cod-liver oil, which
has been given in the enormous dose of twenty-five tablespoonfuls a
day. In badly-nourished subjects, and even in those who are not
scrofulous, experience warrants the trial of these articles, especially
the oil, in very large doses, although not such excessive ones as the
above — say six tablespoonfuls a day. In recent cases, and in robust
and plethoric subjects, in whom the lupus was making rapid progress,
I have seen remarkable benefit obtained from Zittmanri's decoction.
If the disease should come to a stand-still during this treatment, and

LUPUS 505

for some time after it, and should it break out again several weeks 01
months after the treatment has been suspended, the same procedure
must be repeated.

Among the external applications which have been employed for
the purpose of modifying the nutritive state of the skin, and to pre-
vent the recurrence of the eruption, are the ointments of the iodides of
mercury, sulphur, and potassium.2

VII.— PARASITES IN THE SKIN.

THE development of microscopic fungi is a constant accompani-
ment of certain diseases of the skin ; in others, again, they are some-
times present, while as a general rule they are absent. Favus^ pity-
riasis versicolor, and herpes tondens belong to the former class. The
constant presence of fungi in these diseases, and their contagiousness
by transfer of the fungi from one individual to another, is our sole proof
that the generation of such fungi is the primary and essential lesion
of the diseases. As the fungi are always found, and as transmission
of the disease by transfer of the fungi always succeeds, no doubt can
be entertained of the parasitic nature of these affections. To our
description of favus, herpes tondens, and herpes versicolor, we shall
add an account of the itch, as the cause of the cutaneous lesions in this
disorder is the presence of a parasitic animal.

The acarus folliculorum is also a very common parasite. It exists
in most persons, and may easily be obtained by scraping the nose with
the back of a knife. As this animal does not give rise to any disease
of the skin or its follicles, of which it seems to be a perfectly harmless
inhabitant, it possesses no pathological interest, and we may forego
further description of it, and omit the account of the various hypotheses
which have been advanced as to its importance as a matter of natural
history.

CHAPTER XIX.

FAVTTS — PORRIGO FAVOSA, LTJPINOSA.

ETIOLOGY. — Schonlein was the first to demonstrate that certain
dry, straw-colored crusts, found chiefly upon the hairy scalp, and for-
merly called porrigo favosa, or tinea lupinosa, and which were re-
garded as the product of a dyscratic pustulous inflammation of the
skin, really consisted of a mass of fungous spores and germinal fila-
ments (the oidium, or achorion Schonleinii). The spores of favus

506 DISEASES OF THE SKIN.

do not take root very readily ; hence the transfer of a mass of such
spores from one person to another by no means invariably results in a
transplantation of the disease. However, the cases in which a healthy
person has been thus infected artificially are numerous enough to place
the fact beyond a doubt that the growth of the fungi is no mere accident,
but that it is an essential condition of the disorder. Whence the seeds
of favus have come, cannot, in many instances, be determined ; but I
believe that the enormous multitude of sporules of different kinds
constantly floating in the atmosphere will always afford opportunity
for the implantation of favus, and that such implantation will always
take place whenever conditions favorable to the growth of the germ
present themselves. Opinions differ as to whether or not the favus-
plant is a peculiar species of fungus which only appears upon the scalp
and which always develops in the same manner. Hebra inclines to
the view that the various shapes presented by the skin-diseases due to
the presence of vegetable organisms, depend rather upon the stage
of development of the plant, upon whether the spores preponderate over
the filaments, and upon whether the parasite take root upon the epi-
dermis or upon the hairs, and that it does not depend upon any spe-
cific difference of species in the spores themselves. I have this objec-
tion to make against this opinion : that, to the best of my belief, com-
plications of these diseases, and transitions of pityriasis versicolor,
with favus or herpes tondens, never occur, and that complications of
favus and herpes tondens are rare. These facts make it improbable
that the differences between these parasitic diseases are mostly due
to differences in the situation and stage of development of the
same fungus. The most simple explanation of the exceptional cases
is, that sometimes the favus and herpes fungi are transplanted simul-
taneously to the same individual. According to the researches of
Hofmann of Giessen, who has cultivated the fungus, it is identical with
the mucor racemosus, and is sometimes accompanied by the penicil-
Hum glaucum, but only as an accidental occurrence. Dirt seems to be
the condition most favorable to the implantation and growth of the
germs of favus ; at all events, the disease is far more common among
the lower classes, whose members often neglect to wash and comb
themselves, than among the well to do, among whom the appearance
of favus is exceptional.

SYMPTOMS AND COURSE. — The seat of favus is aimost exclusively
upon the hairy portions of the scalp, and it is rarely found in other
situations. At the commencement of the disease we find the affected
skin studded with small yellow oodies, scarcely of the size of a pin's
head, which lie somewhat embedded in the skin, and each of which is
perforated by a hair. These bodies consist of masses of spores, which

FAVUS. 507

nave developed in the funnel-shaped mouth of the hair-follicle, and
have elevated the epidermis around the hair. When the masses of
favus are numerous, and as they increase in size, they come into con-
tact, coalesce, and finally form a continuous rind of fungi, covering the
entire scalp (favits conferlus s. confluent). If, however, the favus-
spots are separate and do not encroach upon their neighbors, a very
characteristic formation takes place, consisting of round, concave scabs,
like crabs'-eyes, the lower convex surface of which lies embedded in a
depression in the atrophied cutis, while their upper surface has ele-
vated edges with a depressed centre (favus scutiformis). This
thick, dry, sulphur-yellow scab consists of a structureless capsule,
which adheres very firmly to the thin layer of epidermis beneath it,
and of innumerable filaments and spores. As the hair-follicle and hair it-
self become overgrown by the fungi, the growth of the hair is impeded ;
it loses color, and becomes dry, thin, brittle, and falls out. When
favus is situated upon a part of the skin destitute of hair, the mass
of spores generally becomes loose after a few weeks and falls off,
thus putting an end to the disease. Its course is different upon
the hairy scalp. Here, too, the duration of the individual masses of
favus is limited, but the scabs adhere longer, and the fungi which they
contain infect the parts about them. When finally the scab detaches
itself, the pressure which it has exerted upon the skin leaves the latter
in a state of atrophy which is never repaired. The hair does not
usually grow again upon the former site of the disease, and the pa-
pillae which have more especially suffered from the atrophy can only
reproduce a thin layer of epidermis ; hence, for the rest of the patient's
life, there remain upon his head bald smooth depressed spots, whose
edges are often surrounded by more recent crusts of favus. The
growth of the fungus, the scratching provoked by it, and the lice by
which it is often accompanied, frequently cause eczematous and impe-
tiginous inflammation of the scalp. When this complication occurs,
besides the favus-crusts, there are other scabs, the desiccated product
of the eczematous exudation. These scabs are easily distinguishable
from those of favus. Under the latter, the skin, though depressed, 13
always covered by a thin layer of epidermis ; under the former, we
always find an excoriation.3

TREATMENT. — Difficult as it is artificially to induce the favus-spores
to grow, it is equally difficult to destroy them when once established
upon the hairy scalp, and to arrest then* further ravages. We have
said that the fungi form within the hair-follicles and upon the hairs
themselves ; hence, not only must all the crusts be removed, but all
hairs upon the diseased surface must likewise be extracted. The for-
mer object is best attained by saturating the crusts with grease, until

508 DISEASES OF THE SKIN.

they are completely softened. The head is then to be enveloped in a
poultice for some time, after which it is to be carefully washed several
times a day, with soap and water applied on a soft brush. For the
removal of the diseased hairs, the method formerly in vogue, of cover-
ing the head in a so-called " pitch-cap," and, when the hairs had become
firmly adherent, of forcibly tearing it off again, is both cruel and un-
certain. It is far better to draw them out one by one with a pair of
cilia-forceps. After the first few days, this process ceases to seem
tedious and troublesome, and, after a few sessions, a quarter of an hour
daily devoted to the purpose will be all that is required. Besides the
criterion afforded by then* dryness, their lack of lustre and faded color,
the diseased hairs may be distinguished from the sound ones by the
fact that they may be extracted with greater ease and with less pain
than the latter. This daily brushing and depilation must be steadily
continued for several months, if we expect to cure the favus radically.
Tedious and troublesome as this treatment is, yet it is the only one
from which we can anticipate any benefit. Other remedies are useless,
unless applied in combination with the above procedure ; and if so
combined, it always is questionable which of the two has really been
of service. Even the famous cures of favus, of the brothers Mahon in
Paris, which consisted in the inunction of a salve of carbonate of soda
with lime, and in afterward powdering the head with charcoal, seem
to have been effected mainly by careful depilation. The pariciticide
remedies most to be depended upon, during and after depilation, are
weak solutions of corrosive sublimate (gr. ij-iv to a pint of water or
of alcohol), the oil of turpentine, and very dilute creasote.

CHAPTER XX.

HERPES TONDENS.

ETIOLOGY. — Not only herpes tondens, but most cases of herpes cir~
cinatus, as well as many of lichen circumscriptus, impetigo figurata,
pityriasis rubra circumscripta, and porrigo asbestina^ depend upon
the development of a fungus, the trychophyton tonsurans, which
breeds between the epidermic cells, converting them into a white dust,
and penetrates into the hairs and hair-bulbs, the latter becoming more
or less inflamed thereby. In most cases it may be determined posi-
tively, by careful search, that this parasitic disease is transmitted by
contagion, and that this transmission takes place less often between
man and man, than between man and beast, especially the transfer of
the parasite from horses and cows, which are quite often afflicted by it,
to men who are brought into contact with them.

HERPES TONDENS. 509

SYMPTOMS AND COURSE. — All the above-named diseases exhibit
great uniformity of appearance ; the differences between them are un-
important, and are based solely upon the difference of intensity in the
inflammation to which the growth of the fungi in the hair-follicles gives
rise. In mild kinds of the disease, papules form, and an exanthema
appears, having the character of lichen. In cases of greater intensity,
vesicles or pustules arise, accompanied by a herpetic or impetiginous
eruption. When there is no real inflammation of the hair-follicles, we
have pityriasis rubra, or porrigo asbestina. "When the disease is situ-
ated upon the scalp, round spots become observable as large as a six-
pence and sometimes as large as a dollar, which, unlike alopecia cir-
cumscripta, are not quite bald, but are covered with short, broken
hairs, and which so much resemble tonsures, that the affection is well
entitled to its name, herpes tondens seu tonsurans. Between the
short hairs, the scalp is covered with scales. Upon microscopic exam-
ination, the roots of the hair are found to be split up like a broom, and
between the twigs so formed there is an innumerable quantity of
spores and filaments, which spread into the shaft of the hair in wreaths.
The same elements are also found in the scales of the epidermis.
When the disease is situated upon a portion of skin which is merely
covered with a fine down, this is not so apparent, but it is still charac-
teristic enough to place the diagnosis beyond a doubt, without the
assistance of the microscope. If a herpes circinatus, a lichen circum-
scriptus, or an impetigo figurata, be of a well-marked circular form,
abruptly distinguishable from the parts about it, when its edge is of a
bright red, and studded with nodules, vesicles, and pustules, its centre
being paler, smoother, and covered with mealy dust ; when each point
of eruption is perforated by a hair ; and, finally, when it can be ascer-
tained that the patient has been in contact with a man or beast simi-
larly affected, the diagnosis is sufficiently insured. Herpes tondens
may recover without medical aid, the growth of the fungi finally ex-
hausting itself, the broken hairs falling out, and the diseased epidermis
becoming detached. Upon the hairy regions of the head, however, the
disease will exist for a long time before terminating in this way, while
upon surfaces void of hair it is usually of but short duration.4

TREATMENT. — Depilation is indicated in the treatment of herpes
tonsurans, but, owing to the brittleness of the hairs, the process is by
no means easy of accomplishment ; moreover, it is often possible to
cure the disease with comparative ease without it, by dint of daily and
vigorous washing with soft soap, which is always to be followed by
an inunction of white-precipitate ointment.

510 DISEASES OF THE SKIN.

CHAPTER XXI.

PITYRIASIS VERSICOLOR.

ETIOLOGY. — Eichstedt^ of Greifswald, was the first to demonstrate
that pityriasis versicolor, which used to be ascribed to a derangement
of the hepatic function, is really dependent upon the growth of fungi
in the epidermis. In this affection, the filaments are more numerous
than the spores. Its very common occurrence among patients with
pulmonary disease shows that the skin of such individuals often presents
favorable conditions for the implantation and growth of the parasite.
Pityriasis versicolor is a very common affection, and often appears upon
perfectly healthy persons.

SYMPTOMS AND COURSE. — The most common seat of pityriasis
versicolor is upon the neck, back, chest, and arms ; but I have never
seen it spread from the neck to the face. In recent cases, small, round,
yellow spots, which readily peel off, are found upon the affected skin ;
in cases of longer standing, the spots are larger or have coalesced,
forming irregular patches, which often extend over a large portion of
the skin. The yellow spots can easily be scratched off by the finger-
nail, and by this means, as well as by their ordinary situation, and,
still better, by the discovery of the parasite in them, they may be dis-
tinguished from chloasma uterinum and from freckles. Pityriasis versi-
color often occasions a slight itching. During summer it generally
improves somewhat, probably because the perspiration is freer ; but it
scarcely ever disappears unless judiciously treated.

TREATMENT. — I used formerly to treat pityriasis versicolor with
a mixture of carbonate of potash 3 vj, liquor hydrarg. nitric, oxydul.
3 iij, and aquae rosarum | vj, which must be well shaken, that the sub-
oxide of mercury may not remain at the bottom of the bottle. Under
this application, made morning and evening, pityriasis versicolor has
nearly always disappeared in a week or ten days. Recently I have
found that the same object may be attained with equal facility, by in-
unction of green soap twice a day.

CHAPTER XX11.

SCABIES ITCH.

ETIOLOGY. — The itch is an inflammation of the skin characterized
by the formation of nodules, vesicles, and pustules, and caused by the
presence of an animal parasite, the itch-mite, acarus scdbiei, or sar-
coptes hominis. The parasite is about J'" in length, and has a breadth

SCABIES.

511

Df about •$•'", and is recognizable as a round white body to the naked
eye. Under a sufficient magnifying power, it is seen somewhat to re-
semble a tortoise in shape ; its convex back is marked with curved
parallel transverse stripes, and is armed with spines of varying length.
The young insect has six, the adult eight, articulated feet, the anterior
pair of which are provided with suckers. In the female, two pah* of
the hindmost of the feet terminate in long bristles ; in the male, only
the first of them has bristles, while the posterior pair are also provided
with suckers. The head of the mite, which is armed with two horny
jaws, separated by a cleft, projects from between the anterior pair of
legs. The male insect is smaller than the female, and much less nu-
merous ; it is provided with a penis shaped like a horse-shoe ; the fe-
male, when pregnant, embeds itself between the lamellae of the epi-
dermis, and forms a burrow which is often several lines in length, and
sometimes an inch or more. These passages contain empty shells of
the mites, together with then* blackish faeces, and then* eggs in every
stage of development. The burrows dug by the males are shorter,
and therefore more difficult to find. The eggs seem to mature in
about eight days. The young mites, after escaping from their shells,
abandon the gallery of their mother, and burrow for themselves in the
vicinity. After casting their skin repeatedly (twice at least), and ac-
quiring an additional pair of legs with the first moulting, they come
out of their holes and pair — generally during the night, when the skin
is warm, in the bed. Sometimes the male insect visits the female in
her burrow. If a fecundated female be transferred from the skin of
one individual to another, the latter also becomes infected by itch.
As there is no opening in the galleries, and as those in which the
pregnant females lodge are stopped up by the eggs and fecal masses,
it may be assumed that the female only comes to the surface when
her burrow is scratched open. Sleeping with a person afflicted with
itch is, therefore, an especially dangerous procedure, although a very
brief pressure of the hand will suffice to transfer a mite scratched out
of her abode. It is not known how long the insect is capable of liv-
ing after it has been removed from its natural habitation and feeding-
ground ; but it seems that those which get into the clothing and linen
soon die. One of Hebrews discoveries proves the truth of this most
strikingly, and indeed better than the most minute observation of a
few captured mites. In Vienna, where fifteen hundred itch-patients
are treated annually, the number of relapses does not amount to one
per cent., although their linen, and other clothing, is not steamed nor
baked in the louse-oven, nor subjected to any other particular process,
in order to kill the itch-mite and its eggs. We are indebted to Mch-
stedt, Fftrsteriberg, Gudden, and others, for our more intimate acquaint-

512 DISEASES OF THE SKIN.

ance with the habits of the acarus scabiei, a knowledge which nas
completely overthrown the ancient errors regarding the origin of
the itch.

SYMPTOMS AND COURSE. — Generally speaking, a patient is first
made aware of his having scabies by an intense itching, which is worse
when he is warm in bed, and which is by no means limited to the re-
gions most frequented by the acarus, namely, between the fingers, ir.
the bends of the joints, upon the genitals, and between the nates ; for
it is also very severe upon the legs, abdomen, and chest. The most
conspicuous objective symptoms are nodules, pustules, and vesicles in
variable number, occupying the regions mentioned. In very little
children, whose head is often kept buried in bedclothes, they are
sometimes, although rarely, found upon the face. These nodules, vesi-
cles, and pustules do not denote different kinds of itch, but rather are
indicative of the stage of dermatitis excited in the skin by the presence
of the parasite, and still more by the scratching. In children, and in
other persons with tender skin, the inflammation is most apt to be so
severe as to form pustules, and even to suppurate. These nodules,
vesicles, and pustules are often excoriated by the nails, and converted
into bloody scabs. A much more characteristic sign of the disease is
afforded by the burrows of the itch-mite, which, with a little care and
practice, are not hard to find. They consist of dotted, sinuous, or zig-
zag seams, which look like the scars of needle-scratches. At their be-
ginning— that is, at the place at which the insect embedded itself —
there is often a vesicle, more rarely a papule or pustule ; at its termi-
nation there is a somewhat larger blackish or whitish point, corre-
sponding to the actual position of the insect. The burrows are most
numerous between the fingers, and upon the inner surfaces of the
wrist and elbow-joints, and upon the penis. In order to catch the
acarus, a needle must be thrust into the beginning of the burrow, and
carefully pushed toward its end, at the same time ripping open the
covering. A minute white point, which, upon attentive examination,
will be seen to change its position slowly, and which, after this pro-
cedure, is generally found on the point of the needle, is the acarus.
Not unfrequently an egg may be seen within her, which may be
squeezed out of her body by gently pressing upon the fine glass
cover. The itch-tracks found upon the penis are always accompanied
by infiltration of the skin beneath them. When the insects are ex-
cessively numerous, instead of the discrete efflorescences, there is a
diffuse eczematous dermatitis, whose scabs are inhabited by legions
of mites. This form, which is rare with us, but which used to be of
frequent occurrence in Norway, is "Norwegian itch," or Borkcn-
kratze.

SCABIES.

513

Scabies never gets well spontaneously, but is very amenable to
treatment ; hence it is an innocent disease. No educated physician
now believes in " metastasis of the itch " as a result of " incautious
suppression " of the malady. Even the homoeopaths — in spite of the
anathemas hurled by Hahnemann against suppression of the " psora "
by local applications — now prescribe green soap and sulphur, regard-
less of consequences. However, notwithstanding the ease with which
it is cured, the itch is an affection greatly feared by the so-called edu-
cated classes, by whom it is regarded as a plebeian and disgraceful dis-
ease. This prejudice is so great, that their horror over the discovery
that they have the itch is by no means diminished by the information
that it is more harmless and easier to cure than almost any other cu-
taneous disorder.

TREATMENT. — To cure the itch, it is only necessary to kill the in-
sects and their eggs, or to remove them from the skin. This done,
the eruption induced by the parasites, and by the scratching which
their presence provoked, soon subsides. There are many methods of
curing the itch with certainty ; of one, however, it is claimed, that it
affords the most rapid possible relief ; that it is less irksome to the
patient, and that it costs less, at all events in hospitals. The reme-
dies most commonly employed are green soap and sulphur. When
green soap alone is used, every suspected part of the skin must be
rubbed with it twice daily, until a decided eczematous dermatitis sets
in. With the exfoliation of the epidermis consequent upon this ecze-
ma, the itch-mites and their eggs are also got rid of, as the burrows
never extend down to the cutis. This cure is a certain one, but it re-
quires from six to eight days for its accomplishment. Meantime, the
patient must not wash himself nor change his clothing, and must re-
main in a room heated to a temperature of 75° to 80° Fahr. He must
not bathe until the sixth or eighth day, when the cure is complete.
This treatment is not adapted for private practice, being too irksome
and unpleasant. The object may be effected somewhat more quickly
by using a mixture of two parts of green soap to one of powdered sul-
phur, which is to be rubbed in as directed above. The English method
also consists in an application of green soap and sulphur, with certain
additions. The treatment is commenced by a warm bath, after which,
for two or three periods of twenty-four hours, the patient is to remain
packed in woollen blankets at a temperature of 90° or 96° Fahr. After
the first twelve hours, one-third of the ointment (consisting of sulphur
| j, white hellebore 3 ij, nitre gr. x, soft-soap | j, lard § iij) is to be
rubbed into all suspected regions ; after the second twelve, a second
portion is to be applied ; and in twelve hours more the remaining
third. Twelve hours after the last inunction, the treatment terminates

514 DISEASES OF THE SKIN.

by a bath. This method, also, though sure and rapid, is unfit for pri-
vate practice, being inconvenient and disagreeable, and because pa-
tients do not like to sacrifice a pair of woollen blankets to the itch.
Wilkinson's ointment, which contains tar and chalk in addition to the
softrsoap and sulphur, is still less adapted for treatment of private pa-
tients. For this purpose the simple ointments of lard ( 3 j), and sul-
phur ( 5 ss), are more suitable, as is also Helmerictts ointment, con-
sisting of carbonate of potash 3 ij, sulphur § ss, and lard § ij. After
one or two initiatory warm baths, the ointment is to be rubbed twice
or thrice daily over the entire body, excepting the face, or, at all
events, over every spot where any eruption or traces of itch can be
found. By this means the disease can be cured with certainty in from
eight to fourteen days. When the patient cannot conveniently absent
himself from his business, let him take a warm soap-bath at night, then
rub the suspected spots, or, better, the entire body, excepting the face,
with Helmericfts ointment, and in the morning let him take another
bath. This procedure also cures the itch in a few days. HelmericKs
ointment is likewise employed in Hardy's " speedy cure." This con-
sists in half an hour's rubbing with green soap, an hour's bathing,
during which the rubbing is to be continued, followed by half an
hour's inunction with the ointment. The cure is perfected in a few
hours, but, though often successful, is not quite sure. The Vle-
minclcx's solution, already described, would be a remedy preferable to
any .of the above-mentioned, being both simpler, more cleanly, and
cheaper, were it not that it often produces severe and obstinate eczema
in persons with delicate skins. The directions for the use of Vie-
mincktfs solution, as practised in the Belgian army, are as follows :
Half an hour's bathing, half an hour's rubbing with green soap ; then,
half an hour's rubbing with the solution of lime and sulphur ; then,
another bath for half an hour, when the treatment is ended.

Under the impression that it is sufficient to kill the mites and their
eggs, and, that if this be done, it is unnecessary to open the burrows,
and to effect the removal of both insects and eggs, by the production
of an artificial eczema, it has been proposed to rub the skin with para-
siticide substances, capable of easily penetrating the epidermis, and
especially to use petroleum and balsam of Peru. Nothing can be said
against the correctness of the theory ; and a series of experiments, by
rubbing in these articles, has succeeded. Nevertheless, according to
experimenters who have tested the treatment fairly, its effects are un
certain ; and it has not superseded the old treatment in many of the
hospitals where it has been tried. It would only be advisable to have
recourse to Peruvian balsam, or (when that is beyond the patient's
means) to try the efficacy of petroleum, when the use of sulphur and

DERANGEMENTS OF SECRETION IN THE SKIN. 515

soft soap is contraindicated. It used formerly to be thought neces-
sary to expose the clothing to a temperature at which albumen will
coagulate, in order to kill the insects and eggs lodged in them. The
linen was boiled ; and the cloth garments were baked in the so-called
" itch-oven," or sent to the " kettles " at the establishments for clean-
ing feather beds, which exist in all large cities. We have already
mentioned that Hebra declares this to be superfluous. According to
the undisputed testimony of this authority, the treatment of the itch
in private houses is much less difficult, and promises far more success
than was formerly supposed ; and the danger of catching the disease
anew from clothing, bedding, furniture, or other utensils that have not
been disinfected, is purely imaginary.6

VIII.— DERANGEMENTS OF SECRETION IN THE SKIN.

WE are aware that gaseous, watery, and oleaginous secretions are
given off from the surface of the skin. There is no doubt that, under
certain conditions, the quantity and quality of these secretions vary
from the normal ; but we are imperfectly acquainted with the nature
of these variations, and with the sources whence they arise.

The secretion of gases, especially of hydrogen gas, is increased in
febrile disease — apparently from causes purely physical — whenever
there is much elevation of the temperature of the skin. If we weigh
a patient who has had a fever, we shall find him much lighter than he
was prior to his illness. If we take account of every thing eaten and
drunk by him, and if we deduct from this the loss of weight, and the
weight of the fasces, sputa, urine, etc., which have been evacuated
during the sickness, it will be found that the excretion through
the skin (and lungs) greatly exceeds the normal amount. It is
well known that an increase of the insensible perspiration is not
always accompanied by an augmentation of the secretion of sweat ;
and indeed, that the skin usually is dry while the former is going on
most rapidly. A copious supply of watery liquid greatly increases the
amount of gaseous perspiration. An athletic medical student, for the
sake of experiment, dieted himself for a long period of time upon ex-
actly the same quantities of food and drink as were given to two patients
with diabetes mellitus. The quantity of urine which he secreted was
much increased, but upon calculating the daily amount supplied to the
system, and upon deducting the weight of the daily excretions of urine
and faeces, as well as the gain hi weight of the body, from the weight
of the food and drink which he consumed, it was found that the insen-
sible evaporation from the skin and lungs had been very considerably

516 DISEASES OF THE SKIN.

augmented. There had been no profuse sweating; and it is veiy
probable that, besides the conditions mentioned above, there are others
which likewise serve to increase the imperceptible perspiration.

A diminution of the insensible perspiration is probably of common
occurrence, for instance, in a very cold or very moist atmosphere ; but
hitherto, this fact has only been demonstrated directly by weighing, in
cases of diabetes mellitus.

We know nothing positive about the qualitative changes in the
cutaneous evaporation, and can merely suppose that in febrile dis-
orders this excretion not only increases in quantity, but is altered in
its composition. That such a change does take place seems to be indi-
cated by the peculiar odor emitted by the gaseous perspiration of pa-
tients suffering from the acute exanthemata.

The secretion of sweat is much increased in most people when they
ire exposed to certain influences. Both healthy persons, and persons
suffering from chronic diseases free from fever, if weighed before and
ifter a course of profuse artificially-induced sweating, are found some-
times to have lost four or five pounds' weight in a few hours. We
have no precise knowledge of the conditions which regulate the pro-
duction of sweat. Healthy persons sweat profusely when covered by
blankets and made to drink copiously ; but in most febrile diseases
they do not perspire at all, though treated in the same manner ; while
there are other disorders attended by fever (not merely the inexpli-
cable sudor angelicus of the middle ages, but many cases of pneumonia
and rheumatism), in which the sweating is profuse throughout the
whole attack. That the secretion of sweat, like that of the saliva, is
dependent upon nervous influence, is evident from the effect which the
mental emotions exert upon its production. Some persons perspire
more readily and profusely than others. An excessive tendency to
perspiration is called hyperidrosis. It generally depends upon un-
known causes ; but in some instances it unmistakably is a consequence
of repeated artificially-induced diaphoresis. Barensprung mentions
many examples of hyperidrosis proceeding from the above cause. I
myself have never noticed any great increase in the secretions of the
skin at the commencement of a course of diaphoretics, and have only
observed it in persons who had been under treatment for some time,
and hence can confirm the assertion that profuse sweating augments
the tendency to diaphoresis. When the secretion of the sudoriferous
glands cannot escape, owing to obstruction of the gland-ducts, or be-
cause the latter are incapable of transmitting all the secretion formed,
it emerges around the sweat-duct under the epidermis, and, lifting the
latter, forms small, clear vesicles containing an acid liquid, which are
sailed sudamina. Obstruction of the efferent ducts of the sudoriferous

DERANGEMENTS 0* SECRETION IN THE SKIN 517

glands occurs most frequently when the secretion of sweat has been
arrested for some time ; for instance, in the first weeks of typhus.
Sudamina, also called miliaria alba, have nothing in common with the
miliaria rubra, excepting that the source of both affections is in the
sudoriferous glands. Miliaria rubra has nothing to do with retention
of perspiration, but consists in an inflammation and exudation, induced
by excessive diaphoresis ; and for this reason we have classed miliaria
rubra under the eczematous affections. An eruption of sudamina has
no influence upon the course of the disease which it accompanies, and
is seen as often in critical sweats as in the profuse perspirations which
break out in unfavorable phases of a disease, and even in that stage
which immediately precedes dissolution. The profuse sweats of the
miliary fevers of the middle ages could hardly have been of a critical
character, as they appeared when the disease assumed a malignant
form; hence the miliary eruption was considered an unfavorable
sign.

A partial hyperidrosis, confined to the palms of the hands, the soles
of the feet, to the armpits, and to the region of the genitals, is of far
more common occurrence than general hyperidrosis. The "sweaty
hands and feet," by which many people are troubled, are unnaturally
cool. The disgusting odor emitted by the perspiration of the feet and
armpits is not dependent upon the presence of ill-smelling ingredients
in the secretion, but upon putrefactive decomposition of the perspira-
tion, sebaceous matter and macerated epidermis of the skin. Hebra,
undoubtedly, goes too far in asserting that this offensive decomposition
only takes place in old shoes saturated with sweat, and that people
usually accused of having stinking feet really have stinking boots.
This offensive perspiration was formerly regarded as a wholesome ex-
cretion, to be encouraged and cherished ; and many complaints were
ascribed to its repression. Such views nowadays have been declared
altogether unfounded, upon the high authority of Hebra and others ;
and indeed, to say nothing of the fact that it is by no means easy to
check sweating of the feet, its arrest immediately before the outbreak
of a fit of illness is, in most cases, the result of the illness and not its
cause. But I think that it is saying too much to deny absolutely that
such suppression of perspiration may possibly now and then be the
caube of disease. There is no doubt that people are often made ill by
exposure to a degree of cold while perspiring, which would have done
them no harm had the skin not been moist with perspiration ; and it is
equally certain that diaphoresis artificially induced, often is of the ut-
most benefit in diseases caused by exposure to cold. Admitting the
correctness of these facts, it is not absurd to suppose that sometimes
the chilling of perspiring feet may induce disease, nor that the reestab-

518 DISEASES OF THE SKIN.

lishment of the perspiration may act beneficially upon disease so in-
duced. The utmost objection that can be made against the statement,
that " suppression of the perspiration has caused illness," is, that it is
too indefinite ; since we are quite ignorant as to why it is that the
chilling of a perspiring body so often gives rise to disease. Hence, I
consider it to be entirely warrantable, when it has been proved, or
even when it is* very probable, that the cessation of an habitual hyperi-
drosis of the feet has been followed by sickness, that we should attempt,
by means of hot stimulating foot-baths and by warmly clothing the
feet, and by sprinkling the stockings with flour of mustard, to reestab-
lish copious diaphoresis of the extremities. I do not mean by this,
that persons suffering from offensively-perspiring feet and armpits are
to be forbidden to wash and bathe, or to use cold water for the pur-
pose. On the contrary, the judicious use of cold baths and of cold
washing, so far from being hurtful, is of the utmost benefit to persons
who perspire too freely, and who are liable to take cold. In fact, I
think it probable and by no means inconsistent with the opinions ex-
pressed above, that the cautious checking both of local and general
hyperidrosis is the best means of obviating the danger of catching cold
by which it is accompanied. At all events, people with sweating feet
should frequently change their shoes and stockings. When the epi-
dermis becomes soft and pasty from maceration, and when it inclines
to peel off, exposing the rete Malpighii, making it painful and difficult
for the patient to walk, Hebra recommends, as an excellent remedy,
that the soles and toes should be smeared for some days with the un-
guentum diachyli, and then be wrapped in linen rags. He claims
that, by this treatment, not only does a new and firmer layer of epi-
dermis take the place of the old and softened one, but it causes a dim-
inution of the hyperidrosis for some time afterward. I have no ex-
perience of my own testifying to the efficacy and harmlessness of this
procedure.

We have already mentioned that a diminution of the cutaneous
secretions may form one of the symptoms of senile marasmus. In
other instances, as has already been mentioned, it depends upon de-
rangement of innervation ; in others, again, it is due to disease of the
skin, to psoriasis or to ichthyosis, while, finally, cases exist of anidrosis
and now and then even anidrosis of half the body, the causes of which
are quite unknown.

With regard to the qualitative alterations of the perspiration, the
presence of biliary pigment in the sweat of persons with icterus, upon
which the yellow stain of their clothing depends, is perhaps the best
known. JBarensprung, however, believes that the vehicle of the pig-
ment is not the liquid of the perspiration, but the epithelial cells which

DERANGEMENTS OF SECRETION IN THE SKIN. 519

it contains. The composition and source of other substances, which
sometimes appear in the sweat and which likewise stain the linen, are
unknown. In a few instances of suppression of urine, trustworthy
observers have discovered crystals of urea upon the skin.

In some persons, the sebaceous secretion of the skin is so much
increased that the hair and cutaneous surface, especially that of their
face, always shines as if it had been freshly anointed with pomade or
grease. In others it is so deficient that, unless replaced by an un-
guent, the skin and hair are always dry, dingy, and disposed to crack.
The former condition is most likely to exist in persons with an exube-
rance of fat throughout the entire body ; the latter in individuals with
little fat, or in those who are suffering from wasting disease.

Qualitative changes in the sebaceous secretion are often observed,
in which the unctuous matter of the skin does not remain liquid, but as-
sumes a more solid consistence. Barensprung believes that the in-
creased solidity of the cutaneous secretion is due in part to a prepon-
derance of solid fat, and in part to an admixture of a larger amount of
cast-off glandular epithelium. The increased solidity of the sebaceous
matter of the skin is usually accompanied by exuberance in its quantity,
thus in some measure justifying the name seborrhoea, applied to a con-
dition of the skin in which it is covered with crusts of dry sebaceous
matter. Seborrhcea is most frequently observed upon the scalps of
infants, where the inspissated secretion, rendered brown by admixture
of dust, often forms scaly crusts of nearly a line in thickness, of which
superstition forbids the removal ; and it is not until the second year,
when the scabs are lifted from the scalp by a freer growth of the hair,
that they break up into separate scales, and are removed as such with
a comb. Many a case of the so-called pityriasis capitis, in which there
are many white scales, some of which adhere to the skin, some stick-
ing to the hairs, while still others are sprinkled upon the clothing, are
the result of seborrhcea. Microscopic examination, by which it is found
that the scales contain numerous oil-globules, affords the best means
of distinguishing this form of seborrhcea from a dry eczema capillitii.
Finally, thick crusts of sebaceous matter, browned by admixture with
dust, and whose surface is generally broken up into numerous blocks,
appears upon the cheeks, nose, eyelids, ears, and nipples, as well as
upon other parts of the skin where a copious lanugo prevents the fall
of the crusts. Abnormal secretion of sebaceous matter may go on so
rapidly, that the cast-off scabs are speedily replaced by new ones,
which greatly disfigure the patient, who is usually a female suffering
from menstrual derangement (ichthyosis sebacea, Rayer). Thick, hard
crusts of sebaceous matter are to be softened with liquid fat, and then
removed with caution, since the epithelial coat beneath them is ex-
83

520 DISEASES OF THE SKIN.

tremelj tender. Systematic washing with soap and water, or alcohol,
is the best preventive of the formation of new crusts, although it does
not alter the abnormal character of the cutaneous secretion. For
Beborrhoea capillitii the hair-dressers use an evening lotion of " honey
water," and a morning inunction of the head with macassar-oiL This
is a most rational procedure ; for the honey-water, which contains al-
cohol, loosens the scales, and the admixture of liquid of Macassar-oil to
the solidifying sebaceous matter prevents it from drying up into new
scales. Instead of the honey-water, however, any other liquid contain-
ing alcohol, such as French brandy, or eau de cologne, may be em-
ployed, and any other oil will do instead of Macassar-oil. In treating
Bayer's ichthyosis sebacea, especial attention must be paid to the
state of the sexual organs, since experience teaches that, upon relief
of any existing derangement of the latter, the tendency to excessive
production of sebaceous matter also subsides. Local applications
alone merely prevent accumulation of the secretion, but not its super-
abundant generation. When, instead of flowing from the follicle, the
secretion solidifies within it, creating hard masses like the shell which
forms on the scalp in seborrhoea (as above described), we have the
comedo, the milium, or atheroma. In a comedo, the outlet of the fol-
licle is obstructed by a plug of black, hardened sebaceous matter,
mingled with dust. Upon compressing the follicle, its contents are
squeezed out of the contracted orifice, and, like any other pasty sub-
stance, forced through a sieve, it assumes a fusiform shape. A milium
means a follicle distended by hardened secretion to the size of a mil-
let-seed, and covered by epidermis, so that there is no visible black
speck in its middle. Atheromata are sebaceous glands distended by
their inspissated contents to the size of a hazel-nut, walnut, or pigeon's-
egg. It is easy to understand that an excessively distended sebaceous
gland blends with the hair-follicles, into whose outlet it opens. In
treatment of the comedo we can merely remove the accumulated mat-
ter, it being out of our power to prevent its production. For persons
who are vain enough to submit to a somewhat unpleasant process, in
order to rid themselves from time to time of their comedones, I em-
ploy the following prescription (originally proposed by JRichter), and
have always obtained very good results from it, if not very speedy
ones : A mixture is to* be made of rye-meal, honey, and yeast ; after
waiting until it ferments, the fermenting paste is to be applied at bed-
time upon the part of the face upon which the comedones are situ
ated. Next morning, those comedones which evidently are somewhat
loosened and elevated — but only those — are to be pressed out, not
oetween the nails, or under a watch-key, but under a gentle pressure
of the fingers. This process must be kept up for several weeks. We

APPENDIX TO DISEASES OF THE SKIN. 521

have already mentioned the beneficial effect of the preparations of
sulphur, when treating of acne. For the treatment of milium,
Hebra recommends removal of the epidermic covering by bathing
it with a moderately strong solution of caustic potash (one drachm
to a pint of water), or by the application of soft soap upon a flan-
nel rag. Treatment of atheroma consists in division and extirpation
of the degenerated follicle.

[APPENDIX TO DISEASES OF THE SKIK

SCLEEODEEMA.

SCLEBODEBMA occurs at any age, but especially in middle-aged
women from unknown causes, and is due to a gradual increase and
atrophy of the cutaneous connective tissue especially of the face,
arms, etc., which becomes hardened, pale, red, or pigmented, and
adherent to the parts beneath, so that the lineaments of the face may
be stiffened, the lips and nostrils shortened, the fingers stiff, etc. The
disease goes on for years, and when arrived at the stage of atrophy
is incurable ; but earlier it may subside. This favorable result does
not appear due to rubbing, bathing, mercurial salve, or the internal
use of iodide of potash ; but tonic treatment and good nourishment
may do good. The nature of this disease is not fully understood ;
while some attribute the changes in the skin to stasis of lymph, either
from thickening or from disease of the lymphatics (and regard it as
related to elephantiasis), other observers, who have seen the joints
and some bones implicated, refer the disease to trophic neurosis
originating in the ganglionary system. A different form of the dis-
ease is sclerema neonatorum, or cellular-tissue hardening, which
attacks feeble, premature children under fourteen days old. There
is decided disturbance of circulation in the outer portions of the
body and great depression of the temperature ; the skin begins to
harden on the legs, and this hardening extends to the trunk, arms,
and even face. The portions of skin affected are sometimes rede-
matous, and subsequently hard as boards, cold and cyanotic ; the
stiffness greatly hinders all motion, the face is wrinkled, sucking and
drinking are impaired, the bodily temperature falls markedly, and
death usually occurs within a week. On autopsy, besides oedema of
the skin and perhaps of the deeper parts, the fatty tissues are found
unusually firm ; some regard this as due to the sinking of the bodily

522 DISEASES OF THE SKIN.

temperature. But generally there are remains of other morbid af-
fections, which have existed with or before the skin trouble, and
must have impaired the circulation, as pulmonary atelectasis, pneu-
monia, heart-disease, intestinal catarrh, and ulcers.

TREATMENT is to be directed against these causal diseases, to
securing good nourishment by a wet nurse, Nestle's food, nutrient
enemata, wine, ether, musk, etc., and improving the circulation by
wrapping the child in flannel, hot baths, etc.

LEPROSY ELEPHANTIASIS GR^ECORUM.

Leprosy, which was formerly so dreaded, and which is still en-
demic in some countries, and was so even in Europe previous to the
fifteenth century, still occurs sporadically. Although our knowl-
edge of this disease has of late been greatly enriched, its origin is
still uncertain ; but it has been ascertained that a minority of cases
were hereditary, and that the disease is not contagious. Although
the symptoms of leprosy are not always the same, still the cases
show that they are of the same general character. Among the
forms that have been described are lepra maculosa, I. tuberculosa,
and I. ancesthetica. The disease rarely begins before the seventh
to the tenth year ; it is more common in youth and middle age.
The local symptoms are usually preceded for a long time by
general symptoms, such as heaviness, chills, loss of appetite, vague
pains, evening fever, etc. In the maculous variety, spots come on
the skin ; these may disappear on pressure, and they may be dark
or white ; the disease may run its course with these appearances, or
combine with the other two forms. In the tuberculous form, sen-
sitive nodules as large as a nut form on the maculas or on healthy
skin. These nodules may be scattered or congregated ; they come
especially about the face and limbs. After it has lasted a long
time, the mucous membrane of the mouth, larynx, nose, and eye
may be aifected. Leprous nodules may last for years and then pass
away, leaving a dark pigmentation or spot of white atrophy in the
skin ; more rarely they soften and form abscesses, or ulcerate, even
going deep enough to expose the bones and open the joints, espe-
cially of the hand and foot.

Although cutaneous anaesthesia accompanies spotted and nodular
leprosy, in the form called anaesthetic loss of sensation exists in the
skin without spots or nodules. Later the anaesthetic spots become
flabby, yellow, and atrophied ; the muscles of the face and hands
participate in the atrophy ; the skin breaks through, leaving a tor-
pid, lifeless opening, which slowly enlarges, and finally exposes or
even detaches phalanges or portions of limbs. The anaesthesia of

ADDITIONS TO THE REVISED EDITION OF 1880. 523

the skin and the trophical changes have long directed attention to
the nerVous system, and large nerve-trunks have been found nodu-
lated. But in the central nervous system also changes have been
found, and perhaps more perfect methods of examination will there
find the causal changes. In one case Langhans found great soften-
ing of the gray commissures and posterior horns, showing the spinal
cord to be the seat of disease in that case at least. The neurotic
nature of leprosy is rendered more probable by the frequent coin-
cidence of pemphigus (which is regarded as a neurosis), and by its
tendency to occur symmetrically on the two sides.

The prognosis is bad. Though perhaps not for years, it usually
causes death, preceded by loss of the limbs, face, etc. Sometimes
the course is milder, and after many years ends in recovery.

TREATMENT is of little avail. None of the vaunted specifics
have held their own. So far as at present known, the best treat-
ment is change of residence, good hygienic surroundings, cleanli-
ness, nourishment, fresh air, iron and cod-liver oil, and attention to
special symptoms. At a leper asylum in British Guiana gurjun oil
is said to have proved beneficial, as has also chaulmoogra oil, in
doses of five to twenty drops three times daily, while it was applied
externally combined with psoralea corylifolia.]

ADDITIONS TO THE REVISED EDITION OF 1880.

DISEASES OF THE SKIN.

l._p. 455.

Besides ordinary erythema nodosum, which occurs in children
and youth otherwise healthy, Uffelmann describes a modified form
with certain constitutional peculiarities, where the patients have
an hereditary tendency to tuberculosis, feeble health, and delicate
frames.

Bohn regards erythema nodosum (as well as peliosis rheumatica)
as an inflammatory infarction from embolism of the cutaneous
arteries, while other observers make a decided distinction between
cutaneous embolism as seen in endocarditis and exudative erythema
proper.

Lewin defines exudative erythema as a vasomotor neurosis, and
calls attention to its symmetrical occurrence on the two sides of the
body. It is not unfrequently so modified as to resemble other dis-
eases. Pustules forming on the erythematous spots may induce the

524 DISEASES OF THE SKIN.

appearance of variola ; or it may be accompanied or followed by
articular inflammations, giving a resemblance to articular rheuma-
tism ; it is even possible that some of those cases of valvular dis-
ease of the heart of obscure origin may have been related to a pre-
cedent erythema exsudativum. Finally, Lewin believes that in
women the erythema may be due to inflammation of the urethra ;
that is, it is the manifestation of an irritation starting from the
urethral mucous membrane and reflected to the vasomotor nerves
of the skin, as gonorrhoeal rheumatism is in males.

Another form has been observed as an epidemic in Paris, the
Crimea, Mexico (acrodynia), as well as that called pellagra in Italy
and the South of France.

2.— P. 505.

The use of even nitrate of silver requires some practice. Each
lupus nodule should be bored into with a sharpened point, and
loosened up from the sound skin ; which is not difficult, as the for-
mer is readily broken up, while the latter is resistant. The pain in-
duced ceases after a few hours. The operation may be repeated once
or twice a week ; it would be too painful to destroy all the nodules
at once, where the nodules are numerous and disseminated. Hebra
and Kaposi recommend a sort of weak Cosine's paste (arsenic, alb.
gr. x, cinnabar. 3 ss, ung. aquae ros. f ss), which is spread on muslin
and applied for three days, being renewed every day. The second
day there is mild, the third day tolerably severe pain, and oedema-
tous swelling of the face and eyelids ; but the lupus nodules have
become dark-brown sloughs, which are detached by suppuration
after a few days, leaving cavities which soon granulate. If the
nodules have already ulcerated, it may suffice to apply the plaster
for one or two days. Arsenical poisoning rarely if ever occurs from
the above treatment. Another plan is to scarify the nodules at
intervals of some weeks. Volkmann recommends scraping out the
nodules with a sharp scoop, and if necessary subsequently scarify-
ing or cauterizing the raw surface ; this operation is painful, and
requires anaesthesia ; the same is true of treatment by the galvano-
cautery.

But destructive treatment is not always required. Where in-
stead of nodules there is merely infiltration of the skin, resolution
may take place without ulceration ; so we may try to aid resolution
by irritating the part with concentrated solution of nitrate of sil-
ver or tincture of iodine with intervals of rest. Mercurial oint-
ment may be applied daily.

ADDITIONS TO THE REVISED EDITION OF 1880.
3.— P. 507.

525

The microscope shows that the favus bodies consist of an epider-
mis coating, containing fungi and fine granular cement. From the
surface of the capsule numerous fungous filaments project into the
favus body. At first these filaments are simple, but deeper they
become branched and finally form chains. The same fungous ele-
ments are found in the roots of the hairs and in the hairs themselves.

4.— P. 509.

We should not confound herpes ton dens capillitii with the dis-
ease known as alopecia areata. In the latter, which occurs both in
children and adults, the hair falls from a circumscribed spot in the
midst of a luxuriant growth, leaving circular bald spots, which may
unite with other similar spots. But alopecia areata is not due to
fungi ; it is a trophic nervous affection. The bald spot is not red
or covered with scales, and after some months the hair grows again
without treatment.

Herpes tondens might be mistaken for roseola syphilitica or pso-
riasis ; but in the syphilitic affection there is no scaly deposit ; in
psoriasis, on the contrary, the red spots are covered with thick regu-
lar scales.

5.— P. 515.

A treatment for scabies, recently again resorted to and highly
spoken of, is with balsam of Peru, which when brought in direct
contact is said to kill the insect in 20 to 40 minutes. The patient is
to have a warm bath, then to rub the whole body except the head,
but more especially the parts most affected, viz., the hands, feet,
large joints, penis, scrotum, breasts, and nates. The treatment
requires about one ounce of balsam, which may be used in four to
six applications, made within two days and without changing the
underclothes ; then wash the body well. This treatment has the ad-
vantage of not inflaming the skin or being so disagreeable as most
others. A similar but somewhat less expensive treatment is by
using petroleum 30 parts, olive oil 8 parts, in the same manner.

DISEASES OF THE ORGANS OF LOCOMOTION.

IN the present section we would briefly call attention to all the
diseases of the joints, bones, or muscles coming within the reach of in-
ternal remedies, whether they be idiopathic affections of these organs,
or the prominent symptoms of constitutional disease, of a cachexia or
dyscrasia.

RHEUMATISM.

The series of morbid processes which were formerly grouped to-
gether as rheumatism has grown smaller, it is true ; all those dis-
eases of the mucous membrane, and in the parenchymatous organs,
which were formerly called rheumatism, have been excluded; and
we have also ceased to designate as rheumatic those cases of in-
flammation of the pleura, pericardium, and peritonaeum, referrible to
cold, or for which we can find no cause ; but still the number and
variety of morbid processes classed under the head of rheumatism are
sufficient to render a precise definition of the term impossible.

We may mention the following points as characteristic of the forms
of disease at present considered as rheumatic : 1. The seat of the dis-
ease in the fibrous tissues, the joints, aponeuroses, sheaths of the ten-
dons, neurilemma, periosteum, or in the muscles and tendons ; 2. The
painfulness of the affection, which is due in many, probably hi all cases,
to stretching of and pressure on the elements of the tissue by the di-
lated capillaries and an inflammatory oedema ; 3. The absence of trau-
matic causes and a kind of independent occurrence of the disease, that
is, its independence of other acute and chronic diseases. I think that
the negative description given in 3 is more distinctive than a posi-
tive one would be in its place, which would perhaps refer the origin
of the affection to catching cold and to atmospheric influences. Fre-
quently as catching cold and atmospheric influence lead to rheuma-
tism, it is not at all proved that they are its sole cause. In practice,
all painful inflammatory affections of the above-named tissues that oo

ACUTE ARTICULAR RHEUMATISM. 527

cur primarily and idiopathically, and are not of traumatic origin, are
termed rheumatic, no matter whether the disease can be referred to
catching cold or not. Another characteristic of rheumatic affections
is the frequent disproportion between the severe subjective symptoms
and the insignificant anatomical changes, as well as the tendency of
the disease to pass from the part first affected to others of analogous
structure and function. But the proportionately severe pain in rheu-
matism is less due to the variety than to the location of the disease ;
at least traumatic, gouty, and other inflammations of moderate degree,
are very painful, when they attack fibrous tissues. Nor is the fugacity
of rheumatic affections, their tendency to shift position, entirely char-
acteristic, for no one would object to terming rheumatic an idiopathic,
painful affection of a joint, which did not show this fugacity, but *e-
mained limited to the same joint for years.

CHAPTER I.

ACUTE ARTICULAR RHEUMATISM RHEUMATISMUS ARTICULORUM

ACUTA RHEUMARTHRITIS ACUTA FLYING GOUT.1

IN acute articular rheumatism the synovial capsule of a greater or
less number of joints is the seat of an inflammatory disturbance of nu-
trition. The simple name of polyarthritis acuta would be enough for
this disease, if there were not a secondary polyarthritis acuta occurring
in the course of infectious diseases from which acute articular rheuma-
tism is to be distinguished as polyarthritis acuta rheumatica seu idio-
pathica. In most cases of acute articular rheumatism, the inflamma-
tion of the synovial capsule does not attain a very high grade. The
exudation into the joint is usually neither copious nor fibrinous, nor
does it contain many pus-cells. The swelling visible about the affected
part depends mostly on inflammatory oedema of the connective tissue
around the joint. But this slight degree of inflammation and the
quality of the exudation are by no means constant peculiarities of the
disease ; on the contrary, there are some cases where the inflammation
has attained a far higher grade, and where a fibrinous or purulent ex-
udation is deposited.

The predisposition to acute articular rheumatism is very unequal in
different persons, without our knowing the reasons for this dissimilarity.
Some persons seem to inherit a predisposition to the disease. Those
who have had one or more attacks are very liable to it. The disease
is rare in early childhood and in old age ; it occurs most frequently be-
tween the ages of fifteen and forty years. Men are attacked as often
as women, or perhaps more frequently. The predisposition appears to

528 DISEASES OF THE ORGANS OF LOCOMOTION.

be somewhat stronger in robust, full-blooded persons than in those
who are weak and anaemic.

Among the inducing causes of acute articular rheumatism the more
important are temporary exposure to cold, either by suddenly wet-
ting the heated body, or by being subjected to a draught, and con-
tinued residence hi damp dwellings and working in damp places. The
working-classes, who are chiefly exposed to these bad influences, are
consequently more subject to the disease than the well-to-do classes.
In most cases the exciting cause cannot be recognized. The disease
occurs all over the world, but is more frequent in the temperate zones
than in the polar regions or the tropics. At some times, particularly
during the winter and spring, the disease is so common that the num-
ber of cases reminds us of an epidemic. In summer and autumn the
cases are usually solitary.

ANATOMICAL APPEARANCES. — We do not often have the oppor-
tunity of examining the bodies of persons who have died during an
attack of acute articular rheumatism. When we do, the changes
found in the joints are often unimportant, being limited to a moder-
ate hypersemia of the synovial capsule and a slight increase and tur-
bidity of the synovia. In some cases even these do not remain to tell
of the inflammation that has undoubtedly existed during life, and the
result of the autopsy is almost as negative as in most cases of erysipe-
latous dermatitis. On the other hand, on post-mortem examination,
we occasionally find the synovial capsule of some joints of a dark-red
color, from hyperaemia and ecchymosis, relaxed and puffed up, the joint
dilated and filled with purulent fluid ; the ends of the neighboring bones
even may be injected and contain extravasations of blood. In all recent
cases the blood contained in the heart and large blood-vessels shows
very plentiful deposits of fibrin. There are also the frequent anatom-
ical changes due to the complications of articular rheumatism, par-
ticularly of pericarditis, endocarditis, and myocarditis.

SYMPTOMS AND COURSE. — In some cases the outbreak of the dis-
ease is preceded for a few days by general uneasiness and a feeling of
weariness in the limbs. In others, the premonitory symptoms are
wanting, and the attack begins suddenly and unexpectedly. The
onset of the disease is not frequently marked by a chill, as we have
learned is the case in pneumonia and some other inflammatory dis-
eases. Usually there is only a slight rigor, which is often repeated
during the first few days ; in the other cases even this is absent, and
there is from the first the hot feeling, which otherwise does not occur
till after the chill. Just as the symptoms of fever begin, or soon after-
ward, the patients complain of pain in one or usually in several joints ;
this is moderate at first, but quickly and steadily becomes more severe

ACUTE ARTICULAR RHEUMATISM.

529

and soon grows very decided. As long as the patient makes no
attempt to move the affected joint, and it is not touched, the pain is
endurable ; but every attempt to move the joint or the slightest pres-
sure on it, in severe cases even the weight of the bedclothes, increases
the pain so that the patients often moan and cry till they have re-
mained quietly for a time in a comfortable position protected from
any injury. If we examine the affected joint, we sometimes find it
moderately, sometimes very much swollen. As we have already
said, the swelling only partly depends on the effusion into the joint ;
being partly due to oedema of the skin and subcutaneous tissue, it
usually extends to the neighboring parts of the limb, and on careful
examination it looks as if the ends of the bone were enlarged. The skin
over the affected joint is either of normal color or else light, or excep-
tionally dark red. The degree of the swelling and the severity of
the pain are not always in exact proportion; the pain is often very se-
vere, while the swelling is scarcely observable. The large joints, par-
ticularly the knee, foot, hand, elbow, and shoulder, are most frequently
affected ; but the small joints, especially the finger, sterno-clavicular
and intervertebral articulations, are be no means exempt. The toe-
joints are only exceptionally implicated. Occasionally also the sym-
phisis pubis is attacked. Not very unfrequently the inflammation
extends to the muscles and fascia about the affected joint. The num-
ber of joints involved varies. Even at the commencement of the dis-
ease it is rare for a single joint to be attacked ; far more frequently,
two, three, or even more, are simultaneously diseased. It is customary,
as the disease progresses, for joints, that have previously remained free,
to become involved, and for the symptoms to reach their height in
these, while it is subsiding or has even disappeared in those first
inflamed. If the pain and swelling disappear slowly in the joints first
seized, while they develop in others, the number of joints implicated
at one time may be very large, and the patient's state be very help-
less and pitiable. Occasionally such patients cannot make any move-
ments ; they are unable to stir from any position in which they have
been placed ; they fear even the most careful passive motion rendered
necessary for urination, defecation, eating, or drinking. Even slight-
ly shaking the bed increases their pain, and induces groans and com-
plaints. But this extent and severity of the symptoms are not frequent.
In most cases two or three, or at least only a moderate number of
joints, are simultaneously affected with severe pain, while the others
remain free, or are somewhat stiff and only pain when freely moved ;
sometimes also they crepitate.

Fever usually accompanies the commencement of the disease;
occasionally it precedes the local symptoms, and only exceptional] v

530 DISEASES OF THE ORGANS OF LOCOMOTION.

comes on late ; it usually corresponds to the severity and extent of the
local symptoms, and has all the characters of a sthenic inflammatory
lever. The bodily temperature does not usually attain the high grade
observed in infectious diseases ; in most cases it does not rise more
than two or three degrees above normal, but exceptionally it becomes
104° — 105.5°, or even higher. The pulse is more frequent, usually
from 90 — 100 beats in the minute, and is generally full and soft. Only
in those cases where the temperature becomes very high does the
pulse reach 120 — 130 beats in the minute. In many cases, even where
there is no complication with endocarditis, we hear blowing murmurs,
so-called blood-murmurs. The respiration is hastened, the skin is al-
most always covered with very profuse perspiration of acid odor, which
has no critical significance, but is usually just as abundant during the
advancing stage, and at the height of the disease, as in the declining
stage. The skin is often covered with an eruption of miliaria rubra.
We have previously shown that this exanthema belongs to the eczemas,
and results from irritation of the skin at the orifices of the perspiratory
glands from excessive sweating. Besides vesicles filled with a milky
fluid, we often see efflorescences in the shape of red papules, where
there has not been sufficient exudation to raise the epidermis into a
vesicle. More rarely sudamina, or miliaria alba, occur. The great
loss of water, due partly to increased evaporation caused by the high
temperature, partly to the profuse sweating, is shown not only by the
thirst, but by the scantiness of the urine. Frequently only twelve to
fourteen ounces of urine are evacuated in twenty-four hours. As the
amount of urea is increased on account of the accelerated change of
tissue, the concentrated urine has a very high specific gravity ; and, as
the amount of water it contains is insufficient to retain the urates in
solution at low temperature, copious sediments of these salts form as
soon as the urine cools. These appear darker red than common, on
account of the quantity of coloring matter which is deposited with the
salts. A very copious sediment of urates does not always allow us to
conclude that the amount of urea excreted in twenty-four hours is in-
creased ; at least, in two cases of acute articular rheumatism, treated
at the Greifswalder clinic, where Hoppe-Seyler had the kindness to
examine the very thick urine which deposited a large sediment, the
amount of uric acid was only normal. It is, to some extent, justifiable
to term such urine almost pathognomonic of acute articular rheuma-
tism ; for in scarcely any disease is the loss of water so great from
profuse sweating as well as from increased evaporation, caused by the
high temperature.

Among the complications of acute articular rheumatism, pericar-
ditis, endocarditis, and myocarditis, deserve especial mention. When

ACUTE ARTICULAR RHEUMATISM.

531

speaking of heart-diseases, we fully showed that the frequency of these
complications has been greatly exaggerated, particularly by JEtouillaud.
Apparently, Bouillaud considered inflammation as the cause of the
above-mentioned " blood-murmurs," which are probably due to an abnor-
mal tension and consequent irregular vibration of the valves and walls
of the vessels. We have mentioned that, according to Bamberger>&
statistics, the complication with endocarditis occurs in about twenty
per cent., with pericarditis in about fourteen per cent., of the cases of
acute articular rheumatism, while myocarditis is much rarer. Accord-
ing to Bamberger's observation, the tendency to complicating inflam-
mation of the heart and pericardium is greater in proportion to the
number of joints affected. In these cases the heart-affection is a com-
plication and not a metastasis, as is shown by the fact that, when any
form of carditis develops, the affection of the joint continues as it was
previously. For the symptoms and course of the heart-affection, we
will also refer to what has been said, and shall only again call atten-
tion to the fact that, in many cases, there are no subjective symptoms,
and the complication is only recognized by physical examination
Pleurisy and pneumonia are far rarer complications than the different
forms of carditis, and still rarer ones are cerebral and spinal menin-
gitis. In protracted cases, suppuration of the joints may lead to pyae-
mia ; but, as this termination of idiopathic arthritis is rare, such cases
are very uncommon.

The disease has no cyclical course, and lasts, with varying inten-
sity, in mild cases, one or two weeks ; in severe ones, for many weeks.
The pain and fever usually remit in the morning, and exacerbate in
the evening ; but these variations are not regular. Frequently, cases,
which at first appeared mild and favorable, subsequently become very
obstinate and malignant ; and, in the midst of an apparent improve-
ment, which has given hopes of a speedy recovery, the fever and local
symptoms suddenly become worse again, and advance to a height not
previously attained,

In regard to the results of acuto articular rheumatism, we must
especially bear in mind that not only the mild cases, where few joints
are affected and the fever is slight, may recover completely, but that
recovery is also the usual termination for severe cases, where numerous
joints are inflamed, very painful, and much swollen, and where the
severe local symptoms are accompanied by corresponding fever. But,
even in favorable cases, recovery does not take place with sudden sub-
sidence of the symptoms, but with then* gradual and not always regular
diminution. Notwithstanding its treacherous course and its frequent
complication with inflammation of the most important organs, this
malady rarely terminates fatally. Death seldom occurs, except when

532 DISEASES OF THE ORGANS OF LOCOMOTION.

the cardiac complications are unusually severe and are accompanied by
inflammation of the lungs and pleura ; even in such cases, recovery often
takes place, contrary to all expectation. Occasionally, also, death oc-
curs with the symptoms of sudden collapse, when there is no complica-
tion, being preceded for a short time by delirium, coma, or other symp-
toms of great nervous disturbance. On autopsy, in such cases, no
changes can generally be found in the central organs of the nervous
system ; hence it has been supposed that they depend on an unex-
plained blood-poisoning. But it seems to me that this hypothesis is
unjustifiable, till careful observations of the bodily temperature have
shown that, in these cases, the fatal result is not due to the fever and
the increase of the temperature to a point fatal to life ; particularly
since it has been shown that, in this disease, the temperature, which is
usually moderate, may rise quite high. In a few instances, moreover,
the severe brain-symptoms depend on inflammation of the meninges,
that is, on changes analogous to those in the joints. I myself have only
seen one case where the moderate increase of bodily temperature, the
delirium in the first stage, and the subsequent coma, together with ex-
cessive retardation of the pulse and repeated vomiting, left no doubt
as to the nature of the disease. This case ended in recovery, so that
the diagnosis was not confirmed by autopsy ; but in a dissertation
written by Dr. Flamm, under the direction of my colleague Kbhler,
on " Meningeal Symptoms in Acute Rheumatism," cases are reported
where post-mortem, examination showed the presence of inflammatory
disease of the meninges. It has not yet been decided whether the
chronic cerebral disturbances, occasionally left after acute articular
rheumatism are due to perceptible anatomical changes. G-riesinget
speaks of them as follows : " The severe cerebral disturbance, lasting
for months or more, caused by articular rheumatism, appears as insan-
ity without fever, characterized by depression, or as pronounced melan-
choly with stupor. It may be followed, or may alternate, with states
of excitement ; sometimes this disturbance is accompanied by convul-
sive choreic movements ; the prognosis is, on the whole, favorable ;
recovery seems to result most rapidly and certainly where, after a time,
during the cerebral disturbance, the joints are again attacked with
acute rheumatism." Acute articular rheumatism very often ends in
incomplete cure. In many cases the fever, severe pain, and the swell-
ing of most of the joints disappear, but a chronic rheumatism remains
in certain joints, proves very obstinate, and often never entirely disap-
pears. Still more frequently the patients live through the acute artic-
ular rheumatism and its complications, but acquire valvular disease of
the heart, which is never cured, and of which they soon die. After
the disease has lasted a long time, particularlv if the fever was severe,

ACUTE ARTICULAR RHEUMATISM.

533

the convalescents are usually very anaemic, and we may hear false
murmurs in the heart and great vessels, which, on careless examination
and insufficient attention to the general state of the patient, may be
confounded with valvular aifections.

TREATMENT. — For acute articular rheumatism all kinds of antiphlo-
gistic remedies have been used, particularly general and local bleed-
ing, nitrates of potash and soda, tartrate of antimony in small doses,
and many have thought it possible to shorten the course of the disease,
and to prevent the complications, by energetic antiphlogistic treatment.
From what we have said of the varying course and duration of the dis-
ease, it is evident that it would be very difficult to prove any such
suppositions. On the other hand, if energetic antiphlogosis did have
a beneficial effect in some cases, the fact that the disease has often
persisted for weeks and that heart-affections have often developed in
spite of it, speaks against its infallibility. Hence, in recent times, the
treatment by repeated bleeding, by large, and even dangerous doses
of saltpetre, as well as the systematic use of tartar emetic, has been
abandoned, and we now employ other remedies which may, perhaps,
be as uncertain, but are, at all events, less dangerous. Nitrate of
soda, in moderate doses ( 3 i j to § vi of water, a tablespoonful every
two hours), has alone maintained its position in the treatment of acute
articular rheumatism, and is prescribed by most physicians, without
any great expectations from it, just as it is given in pneumonia and
other febrile diseases. Since this remedy can hardly prove injurious
in small doses, and since its antiphlogistic action has not been dis-
proved, and is not at all improbable, and, finally, as we know no other
remedy that will certainly arrest or shorten the course of acute articu-
lar rheumatism, we have nothing to say against its employment. Per-
haps it has been wrong to follow JRademacher's advice, and prescribe
nitrate of soda instead of nitrate of potash, which is probably more
active. Recently, great authorities recommend a return from cubic
nitre to common nitre (Kohler). The next most popular remedies are
colchicum (tinct. or vin. sem. colchici f ss, tinct. opii 3 ss, 15 — 20
drops every three hours), lemon-juice ( f ss three times daily), iodide
of potassium ( 3 ss — 3 j dissolved in 3 — 4 oz. water, during the day), qui-
nine and the narcotics, especially opium and morphine We cannot,
with our present experience, give any special indications for the em*
ployment of colchicum, lemon-juice, and iodide of potassium, which
seem to have proved serviceable in some cases, but most generally
have no effect on the course of the disease. In very obstinate cases,
with frequent relapses, we will employ these remedies, slight as is the
hope of benefit from them. Quinine is no more a specific in acute
articular rheumatism than in pneumonia, typhus, and many other dis

534 DISEASES OF THE ORGANS OF LOCOMOTION.

3ases in which it is, nevertheless, an important remedy. But it is one
of the most powerful antipyretics, and it should be used when the
fever is high. It is customary to give a scruple or half a drachm during
the day, and it is best to give such large doses, for, according to my
experience, it is only from large doses that we can expect any decided
effect on the bodily temperature and frequency of the pulse. After
the experiments of Weber and Billroth, there can scarcely be any
doubt that the quality of the blood in fever patients decidedly favors
inflammatory disturbances of nutrition. If this be so, an antipyretio
treatment has also an antiphlogistic action, and quinine as well as
other antipyretic remedies would answer not only the symptomatic
indications, but also the indications from the disease, particularly in
acute articular rheumatism, where, while the fever continues, new
joints are continually becoming affected. At all events, quinine de-
serves a full trial in acute rheumatism, when there is any great in-
crease of bodily temperature. Most of the narcotics can be dispensed
with ; but opium and morphine are not only invaluable remedies for
moderating the sufferings of the patient, but it also seems as if their
exhibition prevented the inflammation in the joint reaching so high a
point. I shall not attempt to say whether they shorten the course of
the disease, as some observers claim they do ; but I can affirm that,
even where there is great fever, large doses of opium or morphine are
well borne. Where the pain disturbs the night's rest, it is advisable
to give the patient a grain of opium, or one-quarter of a grain of mor-
phia, in the evening ; and, when the pain is uncommonly severe, we
may order this dose every two hours, till relief is obtained. In the
treatment of most cases of articular rheumatism, I limit myself to the
exhibition of quinine and opium. Among the external remedies, warm
and cold compresses, leeches, blisters, as well as numerous narcotic and
irritant lotions and liniments are recommended. As might be sup-
posed from their number, these remedies have, on repeated trials, been
of less service than was claimed by the person proposing them ; we
must acknowledge that external remedies also usually have no effect
on the course of the disease, and are at most only palliatives. Any
physician in good practice will not deny that cases of acute articular
rheumatism, coming under treatment at the commencement of the
disease, often resist all external or internal treatment for three to
six weeks or more.

In cases of moderate intensity, it is well to envelop the affected
joint in wadding ; where the pain is severe, cool evaporating lotions
are best, parli'jularly as ice and cold-water compresses are popularly
considered as bad antirheumatics and are consequently used irregularly,
^hlorttre ( 3 ss — 3 j, lightly rubbed in), as recommended by Wun

CHRONIC ARTICULAR RHEUMATISM. 535

derlich, is an excellent palliative ; but frictions with, ether, which 1
used on economical grounds as a substitute for elaylchloriire, answered
the same purpose. Local abstractions of blood should be limited to
those cases where a single joint has been considerably swollen and
painful for a long while. If, after repeated leeching, the pain and
swelling do not subside, if they remain fixed in one joint after disap-
pearing from the rest, we may cover it with blisters, or paint the skin
with tincture of iodine. When ordering the diet of the patient, we
must bear in mind the exhaustion threatened by the fever. Hot
drinks should be forbidden, as they uselessly increase the perspiration.
The room should not be kept too warm, but its temperature should be
regular. The complications are to be treated as advised elsewhere.
If, during the disease, severe cerebral symptoms come on, we must
decide whether they depend on excessive increase of the bodily tem-
perature, or on inflammation of the meninges. In the former case it
will be well to reduce the temperature by wrapping the body in wet
sheets, or by cool baths. Both should be repeated as often as the
temperature threatens to increase to a great height. If, when the
brain symptoms occur, the temperature be not greatly increased, we
should apply leeches to the head, and then cover it with frozen com-
presses.*

CHAPTER II.

CHRONIC ARTICULAR RHEUMATISM — RHEUMATISMUS ARTICULORUM
CHRONICUS — RHEUMARTHRITIS CHRONICA.

ETIOLOGY. — Chronic articular rheumatism is the name applied to a
chronic idiopathic inflammation of the joints, which usually attacks
only one or a very few joints, which passes from one joint to another
far more rarely than acute articular rheumatism does, and which, in
spite of its long duration, induces comparatively little anatomical
change. When chronic articular rheumatism leads to suppuration of
the joint and caries of the ends of the bones, it is generally customary
not to consider it any more as chronic articular rheumatism, but as
chronic inflammation of the joint, and to transfer it to surgery just as
we do arthrocace and tumor albus. Chronic deforming rheumatism we
shall treat of in the next chapter. Chronic articular rheumatism often
develops from the acute thus : after the disease has run its course in
the other joints, one or more of them do not return to the normal state,
out remain the seat of permanent disturbances. In other cases it ap-
pears as a chronic disease from the start. Very frequently there is a
decided congenital predisposition to chronic articular rheumatism ; on
84

536 DISEASES OF THE ORGANS OF LOCOMOTION.

the other hand there are numerous cases where such a predisposition
is acquired. First among the predisposing causes are previous attacks
of acute articular rheumatism, for after these there often remains a
peculiar tendency to the chronic form which did not previously exist.
The same is true of one or more attacks of chronic articular rheuma-
tism, as this also usually leaves behind a so-called rheumatic predispo-
sition. The most frequent exciting cause is catching cold, but espe-
cially a protracted sojourn in cold, damp, and windy places. Thus
almost all old wash-women suffer from chronic articular rheumatism.
In many cases the exciting cause cannot be determined.

ANATOMICAL APPEARANCES. — In the comparatively rare cases
where we have an opportunity to examine joints that have been the
seat of chronic articular rheumatism, we generally find the synovial
capsule and the ligaments of the joints thickened, the fringe-like pro
cesses of the membrane hypertrophied, and not unfrequently degener-
ated, the cartilages relaxed and shaggy, the synovia is cloudy.

SYMPTOMS AND COUKSE. — Chronic articular rheumatism appears
under two different forms. In the first form, single joints are often for
months or years the seat of constant pain. This is increased by press-
ure, but particularly by active or passive motion, and there are also
severe paroxysms of pain which apparently come on spontaneously,
especially at night. If we place the hand on the joint in motion, we
often perceive a distinct crackling or crepitation. Occasionally the
joints are decidedly swollen ; but the swelling does not depend on in-
flammatory oedema of the subcutaneous tissue, as is the case in acute
articular rheumatism, but entirely on an increase of the synovia in the
joints, and on thickening of the capsule and ligaments. In other
3ases there is no swelling, as there is no considerable effusion in the
joint, or else the swelling is only apparent ; the joint becomes more
prominent, because the muscles are atrophied on the affected limb,
which is always less used. Where this form lasts a long time, in-
2omplete, false anchyloses are readily developed ; but it rarely leads
to tumor albus, or arthrocace. The second form of chronic articu-
lar rheumatism consists mainly of a series of attacks of acute artic-
ular rheumatism, occurring at short intervals, in which certain joints
are always affected. Persons suffering from this form often become
" rheumatic " at every change of the weather, every time they are ex-
posed to a draught, and just as often without any perceptible cause.
Sometimes one joint is affected, sometimes another; it is slightly
swollen, very sensitive to pressure, but particularly painful when
moved. The fever, which is almost always present, is evinced by con-
tinued frequence of pulse, constant perspiration, by thick sedimentary
urme, as well as by the gradually increasing apathy and emaciation

CHRONIC ARTICULAR RHEUMATISM. 537

of the patient. This form also of chronic articular rheumatism is very
obstinate, and, once rooted, often lasts for life. It is frequently com-
plicated with muscular rheumatism, and not unfrequently with those
forms of neuralgia and paralysis which are usually termed rheumatic.
TREATMENT. — The form of chronic articular rheumatism, limited to
certain joints, requires chiefly a local treatment ; while vague chronic
articular rheumatism, on the other hand, requires to be treated gen-
erally. In recent cases, the best local treatment is by leeches or wet
cups. To attain satisfactory results, these should be frequently re-
peated at moderate intervals ; they then do excellent service, and
cannot be replaced by any other remedy. Even in obstinate cases it
is well to begin the treatment with leeches or wet cups, unless con-
traindicated by the general state of the patient. The result of the
first abstraction of blood must decide us whether to repeat it in such
cases also, or to use derivatives instead. Among the latter, such as
redden the skin, or cause superficial inflammation of it, are to be pre-
ferred to those which, from their volatility, irritate the nasal mucous
membrane, but cause no perceptible change in the skin. Heretical as
it may sound, we still believe, that when the disagreeable opodeldoc,
volatile liniment, spirits of camphor, as well as the fragrant mixtura
oleoso-balsamica, prove beneficial, their efficacy is chiefly due to the
manipulation of the parts. For support of this assertion, we may re-
fer to the fact that of late even the laity, who formerly used the above
remedies as a matter of course in all rheumatic affections, use them
less frequently, and employ frictions with French brandy and salt in-
stead. The application of sinapisms and frictions with spirits of mus-
tard, by which the skin is temporarily reddened, are sometimes of un-
doubted benefit, and, when continued regularly, may cause permanent
improvement. Frictions with veratrine and chloroform liniment induce
peculiar sensations in the skin, which, to some extent, speak for their
derivative action. In mild cases I have employed a solution of veratria
(gr. vj — x), in chloroform ( f ss), and mixt. oleoso-balsamica ( § ij),
with apparently favorable effect. Vesicants are far more efficacious
than rubefacients ; among these may be classed painting the skin
with tincture of iodine, as it causes the epidermis to be thrown off;
and, if the undiluted tincture be used, it often induces blisters. In
very obstinate cases, in order to secure a good result, the portions of
surface denuded of cuticle must be kept suppurating for a time. I
consider a powerful douche over the affected joint as the most efficient
derivative, and even place it before the hot iron and moxae, which art
also advised in localized articular rheumatism. We may readily sat-
isfy ourselves that an energetic douche will leave a hyperaamia of the
skin lasting for several hours I have no personal experience of the

538 DISEASES OF THE ORGANS OF LOCOMOTION.

action of the steam douche. Besides the above-named local remedies,
and the popular resin and narcotic plasters, the application of " gout-
paper" (gicht papier), skins of animals, wadding, raw wool, cotton, etc.,
which partly favor derivation to the skin, partly maintain an equable
temperature, other remedies are also used locally, which are expected
to be absorbed, and consequently act favorably on the course of rheu-
matism. Chief among these remedies are iodine and mercury. Little
as I recommend frictions with mercurial ointment in these affections
generally, I must still decidedly advise continued frictions of ointment
of iodide of potassium, or of mercurial ointment, with iodide of potas-
sium (3j — ^ ss), in old cases of fixed arterial rheumatism, where ab
straction of blood and derivatives have proved inefficacious. The see
ond of these salves causes slight derivation to the skin at once, and,
after a few days, there is an eczematous eruption of the part. Paint-
ing the part once or twice daily with a lAigoVs solution (iodine 3 ss,
potass, iod. 3 ss, aq. dest. | j — ij) does excellent service. Among
the most efficient methods of treating chronic articular rheumatism is
the constant current of electricity. My experience with it is not very
great, it is true ; but it fully confirms the reports of Remdk and Er #,
that even obstinate cases of chronic articular rheumatism are usually
cured after a few sittings. I pass quite strong currents through the
affected joint, by applying thin metallic plates to the skin over the
joint, instead of using the common olive-shaped electrodes. When
the pain becomes too severe at the point where the negative pole is
applied, I change the electrodes. The very favorable results of the
constant current in chronic articular rheumatism confirm me in the be-
lief that its results in neuralgias and paralysis also depend on its cata-
lytic action. In the constitutional treatment, which must take a promi-
nent part in the vague form of chronic rheumatism, and must be used
in connection with local treatment in the fixed form, the systematic
employment of warm baths deserves most confidence. As no physi-
cian of experience will deny, many persons are perfectly cured by one
or more courses of treatment at Wildbad, Gastein, Pfaffers, Ragaz,
Teplitz, Wiesbaden, Rehme, etc., who had previously resisted all kinds
of treatment for years. The fact that warm springs of very varied
chemical composition, as well as those whose waters contain very little
mineral matter, have equal reputation in chronic rheumatism, indicates
very decidedly that the effect is much more dependent on the bathing
in warm water than on the different qualities of the water. In well-
constructed hospitals, provided with suitable baths, just as good re-
sults are attained in the treatment of chronic rheumatism as at Aix-la-
Chapelle, Teplitz, and Wildbad, as I can show by some very striking
although not very numerous cases from the Greifswalder clinic. In

CHRONIC ARTICULAR RHEUMATISM.

539

private practice it is difficult to conduct the bath-treatment with the
necessary care and prudence ; hence it is generally better to send
patients, whose means permit, to one of the above-mentioned warm
springs. Baths of 95° — 100° are sufficiently warm, and are probably
to be preferred to those of higher temperature ; at least, according to
my experience, Russian vapor-baths do less good in chronic rheuma-
tism than warm-water baths. The same observation has been made
elsewhere. The erection of a Russian vapor-bath, at a place where
there has formerly been none, usually pays very well the first and
second year, for most persons with chronic rheumatism crowd to it, ex-
pecting to be cured ; but the third and fourth years the number of
customers is usually much less, and this is certainly not because the
persons with rheumatism have all been cured, but because their hopes
have been disappointed. From the experience at Wildbad, Leuk,
and elsewhere, it seems advisable to gradually extend the duration of
the bath, and, toward the end of the treatment, to let the patient
pass an hour or more in it. It is very important for them to avoid
taking cold after bathing, and it would be well to give them a blanket-
sweat. It is customary to give about thirty warm baths in succession,
and if this number proves insufficient, it seems better to stop their use,
and take up the treatment again a few months later. In " cold-water
cures," patients with chronic rheumatism, especially old cases, are not
usually cured. I know not a few cases of this class who left the cold-
water cure establishment, after a sojourn of several months, sicker
than when they entered. In recent cases, on the contrary, hydropathy
appears to have a favorable effect. Among the "anti-rheumatic"
medicaments, tine, colchici sem. ( | ss), with extract, aconit. ( 3 ss),
and tine, opii ( 3 ss), in doses of 15 — 20 drops four times daily, has a
great reputation, and is probably the most common prescription in.
chronic articular rheumatism. Unfortunately, we do not yet know in
which cases colchicum (which is certainly not altogether inactive) is
indicated, nor when we cannot expect any thing from it. Ammo-
niated tincture of guaiac. and the antimonials, which formerly had the
reputation of being active anti-rheumatics, are little used of late. In
some cases of chronic articular rheumatism, and, as it seems, chiefly in
those cases where the ligaments are mostly affected, iodide of potash
in large doses (3j — 3 j daily) appears to be very serviceable. Im-
provement ordinarily begins with the appearance of slight iodism, and
it is advisable to increase the dose until the effect of the medicine is
observed on the skin, or the mucous membrane of the nose. In recent
cases, and in young persons, the regimen of the patient must differ from
that in old cases, or patients of advanced age. While, in the former,
especially after improvement has begun, we should advise a careful

540 DISEASES OF THE ORGANS OF LOCOMOTION.

hardening process by washing in cold water, cold bathing in rivei or
sea, regular walks in all kinds of weather, etc., in the latter, all op-
portunities of catching cold should be avoided, the sea and river baths
forbidden, and the patient should be advised to wear flannel next
the skin. If the sleeping-room be dark and damp, we cannot too
strongly urge its exchange for a healthier and drier one.

C HAPTER III.

DEFORMING ARTICULAR INFLAMMATION, ARTHRITIS DEFORMANS, AR-
THRITIS NODOSA, ARTHRITIS PAUPERUM, ARTHRITE CHRONIQUE
SECHE.

ETIOLOGY. — By arthritis deformans, we mean those forms of artic-
ular inflammation where not only the synovial capsule and ligaments
of the joint exhibit the signs of a chronic inflammation having no ten-
dency to suppuration, but where, at the same time, the cartilages and
surfaces of bone in the joint show peculiar changes characteristic of
this form of arthrophlogosis. The latter consist chiefly of a loss of
the articular cartilage and surface of the bones, and in a central indu-
ration of the epiphyses, accompanied by a proliferation of bone-sub-
stance at the periphery. Arthritis deformans is by some authors re-
garded as a peculiar form of chronic articular rheumatism, while others
consider it as essentially different from the rheumatic affections. From
the great elasticity of the term rheumatism, one view is as correct as
the other. Arthritis deformans has at least this in common with the
rheumatic inflammation of the joints described in the last chapter ; it
cannot always be traced to catching cold from living in damp places
exposed to draughts. Arthritis deformans never occurs during child-
hood. Solitary cases are seen about the age of puberty ; it is most
frequent between the twentieth and fortieth years ; but it also occurs
later in life, and even in advanced age. It attacks women more fre-
quently than men. It is so much more common among poor people
than among the wealthy, that it has been termed arthritis pauperum.
We do not know whether this depends on the bad, damp dwellings, on
the want of good nourishment, or on some other causes to which the
poor are more exposed than are the well-to-do classes.

ANATOMICAL APPEARANCES. — On anatomical examination of the
swollen, misshapen joints, we find the articular capsule decidedly
thickened and covered with ragged proliferations. The joint contains
a very small amount of synovia (hence the name arthrite chronique
sbche). The articular cartilages are broken down into filaments, occa-
sionally ossified, and in advanced cases they have entirely disappeared

DEFORMING ARTICULAR RHEUMATISM.

541

by wasting away, so that the ends of the bones come in contact, and
have smooth, articular surfaces. As a result of inflammatory atrophy
the central parts of the epiphyses appear porous, while their size is
decidedly increased, either regularly or in warty protuberances, by the
formation of osteophytes.

SYMPTOMS AND COURSE. — Arthritis deformans results from acute
articular rheumatism much less frequently than the above-described
chronic inflammation does ; in most cases it develops slowly, and grad-
ually reaches its height. A halt sometimes occurs in its progress, but
never a retrogression or a disappearance of the existing deformity.
At the commencement of the disease the patients complain of pain in
the affected joints ; this is usually slight, but is sometimes so severe as
to rob them of sleep. The pain is increased by pressure, and still
more by movement of thev joint ; if the hand be laid on it, we may al-
most always perceive a crackling or crepitation. The affected joints
seem decidedly thicker ; the skin covering them is of normal color, or
slightly reddened. The above changes most frequently affect the joints
of the hand and feet, especially those of the fingers, toes, and the
metacarpal and metatarsal articulations, but they may also attack any
of the other joints of the body and even the spinal column. Cases
where the patient is confined to his bed for years, or sits up during the
day in an arm-chair and at night is carried to bed, may be found in al-
most any large poor-house. The laity usually call this state being
" drawn up by the gout." The symmetrical appearance and progress
of the disease on the two sides of the body are often very remarkable.
It is rare for one hand to be affected first, and the other one subse-
quently ; the process is apt to begin simultaneously in both hands, and
to pass to the two feet at the same time. Characteristic subluxations
almost always occur in the affected joints, especially in the fingers ;
these are hardly explained by the widening of the epiphyses over
which the tendons pass, by the destruction of the articular cartilages,
and the smoothing off of the bony surfaces of the articulation. The
phalanges are almost always flexed on the metacarpal bones, and are
at the same time deviated toward the ulnar sides, so that the fingers
lie over each other like the shingles in a roof. In the phalanges them
selves the subluxations are sometimes in the flexed, sometimes in the
extended position, in the different joints. Patients with this tedious
disease may attain very old age. It is remarkable that, in spite of the
long duration, there is rarely complete anchylosis. The above process
sometimes occurs exclusively in the hip-joint, and then either induces a
wearing off of the head of the bone, or the formation of large stalac-
tite-like osteophytes, about its periphery. This disease, called malum
soxce senile, belongs to surgery.

542 DISEASES OF THE ORGANS OF LOCOMOTION.

TREATMENT. — Little hope as we have of removing by treatment
the deformity that has once developed, I cannot agree with those
authors who say that treatment is entirely useless in arthritis defor
mans. The impairment of motion does not usually depend solely on
the deformity, but to a considerable extent also on the still existing
inflammation. The remedies which we placed in the first rank against
chronic articular rheumatism, particularly the warm baths and the
painting with tincture of iodine, have in many cases at least a favor-
able effect on the inflammation. Every season at Toplitz, as I actu-
ally know, and probably also hi the other watering-places mentioned
in the preceding chapter, some patients with arthritis deformans have
improved so much that they were able to leave the chair with rollers,
a,nd after the termination of their treatment could roll other patients
to the baths.

CHAPTER IV.

MUSCULAR RHEUMATISM — RHEUMATISMUS MUSCULARIS.

ETIOLOGY. — Under the term muscular rheumatism it is customary
to class not only rheumatic affections of the muscles, but also those of
the fascia, periosteum, and other fibrous tissues, except those about
the joints. The changes induced in these tissues by rheumatic affec-
tions are not exactly known. The negative results of most autopsies
seem to render it very probable that the anatomical changes are of
that class that leave little trace in the cadaver, that is, that they consist
chiefly in hypenemia and scanty serous exudations. In rare cases, how-
ever, the rheumatic process appears not to be arrested at this point,
but to lead to inflammatory proliferations of connective tissue. Fro-
riep and Virchow found places in the muscles where the muscular
tissue was replaced by callous connective tissue (rheumatic callosities),
and Vogel observed thickenings and adhesions of the neurilemma of
the corresponding nerves in several cases of chronic rheumatism.
These cases are so rare compared with those where no changes can be
discovered, that it is hazardous to base a definition of rheumatic affec-
tions on them. Even supposing that hyperaemia and serous exuda
tions, and in severe cases an inflammatory proliferation of connective
tissue, be the basis of the rheumatic affection, it still remains undeter-
mined whether the sensory nerves traversing the muscles are morbidly
excited by changes in the muscles and sarcolemma, or by simultaneous
changes in their neurilemma. In the latter case, muscular rheumatism
would be a so-called rheumatic neuralgia of the small nerves supply-
ing the muscles. Regarding the etiology of muscular rheumatism, we

MUSCULAR RHEUMATISM. 543

may refer to what we have said of the etiology of acute and chronic
articular rheumatism, and the more so as muscular rheumatism is very
often complicated with the articular form of the disease. Catching
cold is certainly the most frequent cause ; but the sudden occurrence
of some forms, as lumbago, renders it very probable that, besides catch-
ing cold, there are other causes, especially straining or fatigue of the
muscles, etc.

SYMPTOMS AND COURSE. — The most important, and usually the
only symptom of muscular rheumatism, is the pain which is generally
designated as stretching or tearing. Moving or rubbing the affected
tissues increases this pain, while regular pressure generally diminishes
it. Occasionally the pain is accompanied by inability to shorten the
affected muscle, and to make active movements with it. The skin
covering the part does not appear red and swollen, or warmer than
the surrounding parts. The pain usually exacerbates toward evening,
and remits in the morning. It is generally made worse by cold and
dampness, and improved by dry warmth. But sometimes the warmth
of the bed increases rheumatic pains. Occasionally muscular rheuma-
tism is " wandering," that is, the pain leaves one place and appears in
another. Sometimes it remains " fixed " in certain muscles, fascias,
etc. In most cases muscular rheumatism is an acute disease, which
entirely disappears after a short duration ; rarely it is a chronic affec-
tion, and either the wandering or fixed form may become chronic, just
as wandering or fixed articular rheumatism does. According to its
location, muscular rheumatism has received various and sometimes pe-
culiar names. If the frontal, occipital, or temporal muscles, the galea
aponeurotica, or the periosteum of the skull be affected, we term it a
cephalalgia rheumatica. We should make it a rule not to misuse this
name, and in each case, before making a diagnosis of cephalalgia rheu-
matica, to determine carefully if the above tissues be really the seat of
the pain, whether movement of their fibres or contraction of the muscles
increases the pain, and, finally, whether the affection be primary and
idiopathic. Rheumatism of the head is most readily mistaken for neu-
ralgia, or syphilitic periostitis. It is a very common, bad habit, to
ascribe to rheumatism the numerous cases of severe and obstinate
headache whose true cause we cannot discover. The laity, who do
not make any great distinction between rheumatism and gout, gener-
ally call all obstinate headaches gout in the head. If the muscles of
the neck be affected with rheumatism, the movements of the head be-
come painful ; the patients fear and shun them. There is " stiff neck,"
an affection which complicates many cases of angina faucium. If the
muscles of only one side of the neck be affected, the head is held con-
stantly lo one side ("wry neck," torticollis rheumaticus). This affec-

544: DISEASES OF THE ORGANS OF LOCOMOTION.

tion, which is generally mild, and subsides in a few days, becomes
chronic, and may induce permanent shortening of the muscles in some
cases, which, however can hardly be distinguished from the previously
described spastic form of torticollis. Rheumatismus pectoris, or pleu-
rodynia rheumatica, occurs chiefly in the pectoralis major and inter-
costal muscles. In the former case, the movement of the arm forward
and motion of the affected muscular filaments are painful ; in the sec-
ond case, the respiratory movements, and especially coughing and
sneezing, as well as bending the thorax laterally, are so. From the
hinderance to the respiration, these patients look as if the pain were
deeper seated — as if the lung or pleura were diseased ; and as mov-
ing the skin, fascia superficialis and pectoralis, does not increase the
pain, the physician also might be deceived, if moving the intercostal
muscles from before backward with the point of the finger did not ren-
der the pain unbearable, while laying the hand on the part and making
even pressure usually moderates it ; and if the absence of cough, and
especially the physical examination of the breast, did not confirm the
diagnosis. Rheumatism of the back, particularly of the shoulders,
omodynia rheumatica, is among the most1 frequent forms of muscular
rheumatism ; it is easily recognized by the impaired motion of the
shoulder-blade and arm, as well as by the severe pain induced by mov-
ing the filaments of the trapezius, latissimus dorsi, and deltoid, or if the
deeper layer of muscles be affected by the stiff position of the patient,
and the severe pain induced by stooping. Painful affections of the
abdominal muscles occur chiefly after severe straining in coughing, and,
from their severity, may excite the suspicion of severe disease. Noting
the state of the pain on regular pressure over the abdomen, and on
movement of the muscular filaments, is the best means of avoiding
error. Rheumatism of the lumbar muscles and lumbo-dorsal fascia,
lumbago rheumatica, is remarkable for its severity and its frequently
very rapid occurrence. Not unfrequently, patients who, a few minutes
previously could move with perfect ease, cannot rise from their seat,
or at least suffer severely while doing so. When they go to bed, or
get up also, or even when they wish to sit up in bed, or on any at-
tempt to move the lower part of the spinal column, they make wry
faces, cry out, and place themselves in the most peculiar attitudes to
favor the painful parts, and attain their end without motion of these
parts. Hence, patients suffering this " witch's spell " (" Hexenschuss ")
excite laughter as well as pity. Lastly, all the muscles of the extrem-
ities may be attacked with rheumatism either individually or in groups,
so that sometimes one and sometimes another set of motions becomes
painful or impossible.

TREATMENT. — The same principles answer for the treatment of

MUSCULAR RHEUMATISM. 545

muscular rheumatism that we laid down for that of chronic articular
rheumatism ; that is, in the fixed form the treatment must be rather
local ; in the wandering form, more general. But, as the former is
usually a milder and less obstinate disease than the latter, less ener-
getic treatment is necessary in most cases. The most successful local
treatment is abstraction of blood, by wet cups, if possible. The life-
invigorator (Lebenswecker) has, of course, just the same effect as cup-
ping ; formerly its effect in rheumatism was regarded, even by physi-
cians, as miraculous. The success of irritating liniments, blisters, sina-
pisms, plasters, gout-paper, or skins of animals, in muscular rheuma-
tism, is about the same as in articular rheumatism. Perhaps one of
the most effective, but at the same time most painful, rubefacients, is
the application of the induced current by means of the electrical brush.
The same is true of the use of the constant current in this affection as
in chronic articular rheumatism. I can fully confirm the brilliant re-
sults reported by Erb. Stroking and kneading the painful muscles,
which forms the regular business of some persons called " rubbers," is
one of the most efficient means of local treatment. Diaphoresis is the
most reliable constitutional remedy. Treatment by baths is rarely
necessary, and is so only in obstinate cases which are usually compli-
cated with chronic articular rheumatism. A few cups of elder-blow
tea, or some warm drink, and plenty of blankets over the patient to
excite profuse perspiration once or twice, usually improve or remove
muscular rheumatism. In recent cases a vapor-bath often gives in-
stant relief ; and although I have spoken against the continued use of
vapor-baths in chronic articular rheumatism, I can recommend the trial
of one or two in recent cases of muscular rheumatism.

CHAPTER V.

GOUT — POD AGE A — ARTHRITIS.

ETIOLOGY. — There is scarcely any disease that shows so great a
similarity of symptoms at the commencement of all cases, and which
consequently is so markedly a peculiar disease, as gout. It is true,
old cases may resemble other diseases, particularly rheumatism ; but,
in such cases, it is only necessary to inquire about the commencement
of the affection, in order to prevent its being mistaken for rheumatism.
But although it is certain that gout is a peculiar form of disease, and
although constant chemical changes have been observed in the blood
of gouty patients (Garrod], and uric acid, the substance which is in
excess in the blood, has been found in the products of gouty inflam-
mation, still we have no exact knowledge of the pathogeny of this

5i6 DISEASES OF THE ORGANS OF LOCOMOTION.

disease. We neither know whether the " uric-acid diathesis " be the
primary and chief anomaly in gout, and whether it be not accompa-
nied by other and more important changes in the composition of the
blood ; nor do we know the disturbances of nutrition by which one
of the constant products of normal nutrition, uric acid, is formed
in excess. The remote causes of gout are somewhat better knowa
It is proved by statistics that hereditary tendency is the most impor-
tant factor in the etiology of gout. It can be traced in about half the
cases. If there be an hereditary predisposition, a slight amount of the
following exciting causes will induce the disease, while persons with-
out this hereditary tendency are rarely affected by gout, even when
they are greatly exposed to the same injurious influences. Gout does
not oecur during childhood ; it is ' rarer among women than men ; in
the latter it usually occurs after the thirtieth year of life. Among
poor folks it is so rare, that the disease is hardly ever seen in hospital ;
among the well-to-do classes, it chiefly affects persons given to the
pleasures of the table, who drink wine or beer regularly, and take
little exercise. All these points render it probable that, next to he-
reditary predisposition, the supply of more nourishment than is used is
to be regarded as the most important etiological factor of gout.
Among children, women, mechanics, and poor people, this dispropor-
tion is rare ; but even during manhood, where it is common among
the better classes, those persons escape the gout who do not eat and
drink more than is necessary to replace what has been used up in the
body. The assertion that in the above mode of life a larger amount
of uric acid is formed, because so much of the nitrogenous constituents
of the body are broken up, that there is not sufficient oxygen intro-
duced by respiration to transform them into urea by further oxidation,
and that this increased formation of uric acid and its collection in the
blood appears under the form of gout, is a pure hypothesis which is
not supported by facts, although it seems very plausible. If the case
were so simple, the world would swarm with gouty patients, while, as it
is, only a small proportion of topers and gourmands are affected by gout.
The experiments of Hoppe-Seyler and Zalesky^ who, in order to
find out something about the origin of uraemia, tied the ureters in geese
and chickens, and, a few days after the operation, found almost all the
viscera covered with crystals of the urates and the joints incrusted
with them in a manner that very strongly reminded of gout, render
the following hypothesis of the relation of the gouty diathesis to thf
attack of gout the most probable. The gouty diathesis depends on an
anomaly of nutrition, in which far more uric acid is produced than in
healthy persons, although not to the same extent as in birds and ser-
pents. As long as the excess of uric acid is regularly excreted by the

GOUT.

547

tddneys, the affected persons get along tolerably well, or have no
trouble at all. But the case is different when the uriniferous tubules
are plugged up by deposits of the urates, and the excretion of urine is
impeded ; for then, just as in the animals above mentioned, there is a
collection of urates in the blood, and they are deposited in the joints
and other organs, and we have an attack of gout. If the deposit of
urates in the uriniferous tubules be soon washed away, and the red
sandy sediment form in the urine, which we sometimes find even on
the diapers of young children, the attack of gout passes over ; if this
do not take place, and the kidneys atrophy, the acute attack becomes
chronic gout. This hypothesis is strongly supported by the fact that
Garrod and other trustworthy observers have always found the kid-
neys diseased, they being irregularly* atrophied and the seat of uric-
acid infarctions, I am far from considering this theory, to which
Traube also is inclined, as proved ; but I think that it agrees with the
physiological and pathological facts better than any other theory. If it
should finally be proved that the blood of gouty patients always con-
tains more uric acid than normal, while the urine constantly contains
less than usual during the attack, our theory would receive a still fur-
ther support.

ANATOMICAL APPEAKANCES. — On autopsy of gouty patients, which
is of rare occurrence in hospital, in the affected joints we find the re-
mains of a more or less intense inflammation, and genuine gout is
characterized by incrustation of the surfaces of the joint by chalk-like
masses, consisting of urates. In mild grades of the disease, only a few
joints are changed in this way. Frequently only the first joint of the
great toe is in this state. In severe and old cases, we usually find
numerous joints diseased ; then* articular surfaces are covered with thick
layers of urates, the cartilages are rough, the ligaments, periosteum,
and the mucous bursae near the diseased joints, are covered with thick
deposits of these salts. In such cases the joints are often much de-
formed, and through the dark, bluish-red skin we may often see white
chalky masses. We may also find these deposits at other points,
especially in the knuckles, eyelids, and cartilages of the ears. In the
auricle, where they are only covered by thin skin, they form white
pearls surrounded by varicose vessels (a certain sign of arthritis). I
know nothing from personal observation of the above-mentioned
changes in the kidney. According to Grarrod, who has very carefully
described and pictured them, gouty kidneys very much resemble those
in the third stage of Blight's disease, except that, in the pyramids,
there are always white striae, consisting of urates running in the direc-
tion of the tubuli recti, and on the apex of each papilla a white point
of the same substance.

548 DISEASES OF THE ORGANS OF LOCOMOTION.

SYMPTOMS AND COURSE. — Most gouty patients have shown, by
their appearance or sensations, some other results of high living before
the first attack of gout. They have usually become fat ; the face,
particularly the nose, is reddened, from the development of varicose
vessels ; they have haemorrhoids j we cannot, however, say that these,
and other signs which occur in various modifications, are premonitory
tokens of this disease.

But, besides the above symptoms, the first attack, as well as the
subsequent ones, is usually preceded by true premonitory constitu-
tional symptoms, arthritis imperfecta, or status arthriticus. The
patients feel languid, their sleep is restless ; the appetite is impaired,
and they have indigestion ; they complain of palpitation of the heart
and constriction of the chest ; they sweat profusely, and frequently
pass small amounts of concentrated urine. Careless patients do not
generally pay much attention to these premonitions, say nothing about
them to their physician, and continue their previous mode of life.

Hence the attack of gout almost always comes unexpectedly, in
spite of the premonitions, and surprises the patient like a thief in
the night. After he has gone to bed, without dreaming of the com-
ing evil, and has gone quietly to sleep, he is awakened, generally soon
after midnight, by a severe burning piercing pain in the metatarso-
phalangeal articulation of the great toe. The pain rapidly becomes
unbearable. The patient feels as if the affected joint were in a vice ; he
sighs, moans, throws himself around in bed ; the leg or even the entire
body trembles with pain. Soon after the commencement of the attack,
the skin covering the affected joint begins to swell and redden, and
there is fever, with a full, bounding pulse, dry skin, intense thirst, con-
centrated urine, and great mental excitement. Toward morning there
is a remission, and in the course of the following day the state of the
patient generally becomes endurable, although the pains have not
entirely disappeared, and the ball of the affected toe is more swollen,
shining, and very red, and the whole leg is slightly swollen by cedema.
The next night the scene of the past one is repeated with equal or some-
what less severity ; the following day brings another remission, and so
passable days alternate with bad nights for about a week, rarely
onger, at least in the first attack ; then the patient is temporarily free
from his trouble. After the redness and swelling have gradually sub-
sided from the ball of the great toe, there is a desquamation of the
cuticle, and the parts return to their normal state. The first attack of
gout hardly ever leaves any deformity. It does not often affect any
joint but the first one of the great toe; in other words, it is rare for
the first attack, instead of being a podagra, to be a chiragra, gonagra,
or omagra. After the patient has recovered from his pain and sleep

GOUT.

549

less nights, he usually feels better than before the attack ; hence the
gouty attack has often been considered as critical, and it has been as-
serted that during or through it a materies peccans has been removed
from the body. There is no reason for assuming this hypothesis in
explanation of the improved condition. The attack of gout places the
patient under circumstances directly opposite to those which have in-
duced his illness. The transmutation of the constituents of the body
is greatly increased by the fever, while there is a very insufficient sup-
ply of replacing material ; the sleeplessness and pain also increase the
consumption, or hinder the change of tissue ; the disproportion between
supply and demand, which we have indicated as the most important
etiological factor in gout, and which also lies at the root of its compli-
cations, such as corpulence, piles, etc., is thus more than equalized by
ishe gouty attack and the accompanying fever ; and this is the simple
explanation of the improved condition of the patient after the fit. If
pain and suffering that have left no mark were not so soon forgotten, the
first attack of gout would often be the last. But, after following their
good resolutions and the advice of the physician for a few months, gouty
patients generally return to their previous habits ; the first attack is
followed by a second, this by a third, and so on by a series of parox-
ysms whose course corresponds with that of the first. At first, the
interval between the attacks lasts a year or more ; later, several at-
tacks occur in one year. As the intervals become shorter, the attacks
usually deviate more and more from the first type ; the free intervals
are then generally less perfect ; the gout, instead of being regular, be-
comes irregular, chronic instead of acute, atonic instead of tonic.

We give the name of chronic gout to those irregular forms where
the attack is preceded for some time by premonitory symptoms, espe-
cially dyspepsia, where the seizures are accompanied by less pain and
fever, but last for weeks or months, and several joints are affected at
the same time, or in succession ; and the previously-described chalky
deposits of the urates in and about the joints occur chiefly in chronic
gout. The swelling and redness, which in acute attacks attain their
height the second day, develop more slowly in chronic gout ; the red-
ness is generally less intense, the swelling more diffuse and oedematous.
After the termination of the paroxysm, the swelling does not disap-
pear with desquamation of the cuticle, as it does in acute gout, but it
continues, feels soft and doughy at first, and later it contains firm bodies
of variable size, and at last a hard tophus is left. This is small in pro-
portion to the tumor whose remains it represents, but after repeated
attacks it grows by new deposits, and may attain a considerable size.
The deposits within the joints, the calcareous masses as well as the
inflammatory changes in the capsule and ligaments of the joint, induced

550 DISEASES OF THE ORGANS OF LOCOMOTION.

by the continued irritation of the deposits, after a time cause pain, dif-
ficulty of motion, and deformity of the affected joints during the inter-
val between the attacks. The patients often have difficulty in getting
about with the aid of a cane, and the usefulness of the hands and arms
is impaired if these be affected. In some cases, irritation of the sur-
rounding parts, by the concrements, induces phlegmonous inflamma-
tion. Abscesses form about the joint, and mortar-like masses, or firm
concrements, are not unfrequently mingled with the pus evacuated
from them. In proportion as the function of the limbs is gradually
impaired in chronic gout, the patient becomes infirm. The fulness of
body and strength are lost, and the digestion is impaired; the patient
suffers from acid stomach, flatulence and irregular bowels ; often, also,
there is disturbance of the circulation, and generally great irritability
and uneasiness. It is customary to refer the numerous disturbances
of function and nutrition that occur in the course of chronic gout to
the anomalous condition of the blood, or the gouty dyscrasia ; still it
is possible that an insidious fever, only to be recognized by the ther-
mometer, accompanies chronic gout, and induces the general cachexia.
As a rule, chronic gout results from the acute form, as we said above,
after the patient's constitution has suffered from repeated attacks of
the latter, or from debilitating treatment ; but cases also occur where
the disease is primary.

Atonic or anomalous gout is the designation generally applied to
those forms where there is no actual attack of gout ; or, as the name
" atonic " indicates, where the debilitated organism is not in condition
to develop a normal attack of gout. Formerly the diagnosis of atonic
or anomalous gout was carried to excess ; but, on the other hand, it is
certainly going too far to class many of the symptoms, some of them
very peculiar, as accidental complications of the disease, and not
directly dependent on it. In persons who have previously suffered
from attacks of regular acute gout, we not unfrequently meet a con-
dition which we are perfectly justified in calling atonic gout. In such
patients there is a permanent constitutional affection, which shows
itself chiefly by excessive general hyperaesthesia, muscular weakness,
and dyspepsia, and usually also by an increased amount of perspira-
tion, and thick, cloudy urine. The most insignificant causes, such as
slight errors of diet, excitement, exposure to cold, changes of weather,
and often without perceptible cause, these constitutional symptoms
are accompanied by pains in one or more joints, which are very severe,
and resemble commencing attacks of gout. But there is only a mod-
erate redness and slight swelling, which disappear after a few hours ;
in other cases there is no redness or swelling, and the severe pain ia
the only indication of the gouty attack. If there have already beec

GOUT.

551

ordinary attacks of the disease, this not unfrequent condition is readily
recognized, and intercurrent acute attacks place the diagnosis of atonic
gout beyond doubt.

The correct appreciation of the symptoms, and the diagnosis of the
disease from chronic wandering rheumatism, is far more difficult, if
there have been no precedent or intercurrent attacks of gout. It
seems to me there is no doubt that this atonic form of the disease is
also occasionally primary, and even when there have been no attacks
of gout I think it must be diagnosed, where there is an hereditary pre-
disposition, and where the disease has been preceded by luxurious liv-
ing, and where it is chiefly the smaller joints of the foot and hand that
become painful, red, and swollen. I have seen such cases where the
diagnosis was strongly supported by the experience of the patient.
The patients themselves have not only remarked that they could ex-
pose themselves to catching cold with impunity, while the return to
careless diet, and the use of beer and wine, always made them worse ;
but they have also observed that antirheumatic treatment did not im-
prove their case, while there was actual and permanent improvement
both of the local symptoms and general cachexia, by a course of treat-
ment hastening the transformation of tissue.

I have no doubt that in gouty patients there is sometimes a de-
posit of urates, accompanied by hyperaemia and inflammation, in other
organs instead of in the joints ; or, in other words, that an anomalous
internal gout, the arthritis metastatica retrograda of the old authors,
actually occurs. For the support of this view, I lay less weight on
the observations of Zalesky, who, after ligating the ureters of chickens
and geese, found deposits of urates not only in the joints, but in al-
most all the organs, among others in the stomach, heart, and lungs,
than on a series of clinical observations, which admit of no other
interpretation. For instance, some time ago, in an old gentleman,
who had suffered for years from gout, I saw an angina begin simul-
taneously with a typical attack of gouty inflammation of the joints ; it
was characterized by a peculiar blue color of the fauces, by a very dif-
ferent course from ordinary forms of angina, and lasted as long as the
inflammation of the joints did. I have not the slightest doubt that
this was a case of gouty angina. In two other patients, who also suf-
fered from gout, I have seen cerebral troubles, which I must regard as
circumscribed gouty inflammation of the meninges. All other diseases
of the brain or membranes could be excluded with certainty, especially
when the symptoms, which appeared very dangerous, and had excited
great anxiety, disappeared in the one case with a copious excretion of
urates in the urine ; in the other, with an attack of gouty inflammation
of the joints. It is true, autopsy has not proved the occurrence of in-
85

552 DISEASES OF THE ORGANS OF LOCOMOTION.

ternal gout. But we must remember how rarely we have the oppor-
tunity of making autopsies on gouty patients, and how carefully an
examination would have to be made to discover deposits of urates in
the gastric mucous membrane, lungs, or heart ; also, that it is not at
all improbable that these deposits disappear after the attack is over.
The organs most frequently attacked by gout appear to be the stom-
ach, brain, and heart. 1. Gout in the stomach appears with the
symptoms of severe cardialgia, which is occasionally accompanied by
violent vomiting, and sometimes with hsematemesis. 2. Gout in tfie
brain may sometimes present the appearance of apoplexie foudroyante,
while in other cases it manifests itself by severe circumscribed head-
ache, dizziness, and vomiting. 3. Gout in the heart induces irregular
and enfeebled action of that organ, and, as a consequence of the dis-
turbed circulation, dyspnoea, or fainting. Lastly, cases are reported
where there was metastasis to the spinal marrow, inducing sudden
paraplegia, and to the lungs, causing asthmatic attacks. We must
take care not to refer every intercurrent disease, affecting a patient of
gouty diathesis, to an attack of anomalous gout. We are only justified
in so doing when the disease runs its course with unusual symptoms ;
also when the patient is affected with gouty inflammation of the joints
at the same time ; when disease, running a peculiar course, occurs
suddenly in an internal organ while a gouty affection of the joints is
subsiding or developing ; and lastly, when the termination of the dis-
ease is accompanied by a copious excretion of urates through the kid-
neys.

The course of the disease is tedious and insidious. The termina-
tion in permanent cure is rare, but would be more common if the
patient would entirely change his mode of life before the disease be-
comes firmly rooted. Death, also, is a rare termination, and results
almost exclusively from severe attacks of anomalous internal gout.
Most patients die of complications, or of intercurrent diseases.

TREATMENT. — Since, next to hereditary predisposition, the dispro-
portion between supply and demand is the most important cause of
gout, the causal indications require the removal of this disproportion
by limiting the supply and increasing the consumption. During the
course of gout, particularly when the disease has become irregular
instead of regular, there is a time when the state of the patient does
not permit a restriction of the supply, and where the increase of con-
sumption must be made very carefully ; but in all recent cases of regu-
lar gout, and in all patients whose general health and nutritive condi-
tion indicate a continuance of this disproportion, the fulfilment of this
indication is the only means from which we can expect a cure. Hence
we see that in treating gout we should write few prescriptions, but

GOUT. 553

should regulate the habits of the patient. First, it is necessary to
prescribe precisely the form, quantity, and quality of his food. A
gouty patient should be carefully taught what and how much he may
eat, because, although he breaks the rules often enough, he gives way
to excess less readily than he would if he could excuse his errors by
the plea of ignorance. How many patients there are who fear the
evil results of breaking the rules laid down for them far less than they
do the reproaches of their physician ! Gouty patients must be abso-
lutely forbidden to go to dinners, etc., even if they promise to be very
moderate. It is best for them to eat only vegetables, soups, etc., and
to have meat only once a day. The use of beer and wine retards the
transformation of tissue, and hence is injurious for gouty patients.
Any one may observe on himself that he requires less to eat when he
drinks wine or beer with his meals, and also that when using these
articles moderately he bears fatigue better than he does without. Per-
sons but little inclined to the production of fat, under the regular and
free use of wine and beer, become very obese, and from this mode of
life most persons have a red face and distended veins, until their diges-
tion is impaired or there is some other injurious consequence. This
consideration, as well as the fact that in persons who drink neither
wine nor beer the occurrence of gout is very exceptional, should in-
duce us to forbid these drinks altogether, or else to give directions to
have them stopped off gradually. The same is true of the use of tea
and coffee. Although there is but little nutritive material in these
drinks, and consequently the actual supply of nutriment to the body
is but little increased by their use, still there is no doubt that tea and
coffee have the same influence on the transformation of tissue that
wine and beer have ; they preserve the strength, diminish the need of
iiutriment, limit the consumption, and hence are injurious to gouty
patients. Drinking large quantities of water has just the opposite
effect on the transformation of tissue from what is induced by the use
of tea and coffee, or of beer and wine. After drinking freely of water,
110 one feels less need of food, fatigue is not better borne, it does not
induce corpulence and a red face; on the other hand, it has been
shown that, when plenty of water is taken, the amount of water passed
is greater than it would be under like circumstances, without this in-
creased supply; and as the amount of urea excreted after drinking
plenty of water is increased permanently, not temporarily, we are led
to the conclusion that much water hastens the transformation of tissue,
and hence is as beneficial for the gouty patient as drinking coffee and
tea or wine and beer is injurious. Lastly, since muscular action also
nastens the transformation of tissue and the consumption of the con-
stituents of the body, it may be readily seen that a lazy, easy life is

554 DISEASES OF THE ORGANS OF LOCOMOTION.

bad for gouty patients, and that active exercise is important in the
treatment. We should not have entered into this discussion of theo-
ries, if theory and practice did not fully agree in the treatment. The
rules that we might lay down for the treatment of gout, from the
known action of certain substances on the transformation of tissue,
have long since been proved correct at the bedside of the patient.
The treatment by mineral waters forms a kind of connecting link be-
tween dietetic and medical treatment ; it is perhaps more highly es-
teemed in gout than in any other disease. The springs celebrated as
being antiarthritic are those of Vichy, Karlsbad, Marienbad, Kissin-
gen, Homburg, etc. The favorable effect of these mineral waters
appears to depend on their reducing the plethora, due to a mispropor-
tion between supply and demand in the body, whether the plethora
depend solely on hypertrophy of the blood, i. e., an increase of its
cellular elements and a certain density of the intercellular substance
(the serum of the blood), or on an accompanying absolute increase of
the amount of blood contained in the body. It is very interesting to
note that the beneficial influence of these natural mineral waters on
plethora, which has been long known, and which far exceeds that of
ordinary water, agrees with the observations of C. Schmidt and Vbgel,
according to which the amount of albumen in the serum of the blood
is inversely proportional to the amount of salt. I am undecided as to
which of the above springs deserves the preference in the treatment
of gout, whether the solution of salt, of which the Kissingen and
Homburg waters consist, removes the plethora more rapidly and com-
pletely than Karlsbad and Marienbad water, or the reverse. Nor
shall I attempt to say whether the supply of those solutions of salt
act beneficially not only on the plethora but also on that anomaly of
the change of tissue which shows itself as the gouty (uric acid) dia-
thesis in some plethoric persons. Nor can we, with our present knowl-
edge, say whether in any particular case the preference should be
given to Kissingen, Karlsbad, Wiesbaden, Homburg, or Vichy, and
what would constitute the peculiarity of the case which indicates one
rather than the others. It cannot be denied that in recent times the
regular therapeutic employment of the so-called BullricJi's salt, a mix-
ture of bicarbonate and sulphuret of soda, rivals the world-renowned
success of these springs — a fact which is at least opposed to the
asserted latent peculiarities and advantages of the natural solutions
of salt. Advantageous as the above treatment proves in recent cases
of regular gout, if carefully and judiciously instituted, there is often
great harm done by excessive limitation of the supply of nourishment,
by the sudden complete abstraction of spirituous liquors that had
been used for years, as well as by all other debilitating courses of

GOUT.

555

treatment which are employed carelessly or hastily. The patient is
often freed from attacks of acute gout by this too zealous or too hasty
treatment, but becomes affected instead with irregular, chronic, or
atonic gout, an exchange by which he certainly gains notliing. As
soon as gouty patients begin to show the signs of general cachexia,
their disease is rendered worse by a continuation of this debilitating
treatment ; we should then prescribe nutritive diet for them, and even
allow them to drink wine. But we must warn against excess even in
the strengthening treatment then indicated. Although in this stage
of the disease it is not admissible to limit the supply of nutriment, we
should nevertheless carefully try to increase the change of tissue.
Under no circumstances should we allow the patient to give himself up
to sluggish ease, but should see that he exercises as much as his
strength permits ; we should not allow more wine than is sufficient
for a slightly tonic and refreshing effect, and it is always better to let
the patient use the ferruginous, alkaline-saline and alkaline-muriatic
mineral waters, such as Eger, Kissingen, or Homburg, than to pre-
scribe simple chalybeate waters or preparations of iron. If there be
at the time no indication for prescribing solutions of salts, we should
at least see that the patient drinks plenty of water. In order that this
prescription may be regularly obeyed, we should direct how much
water is to be drunk daily. The probability that a retention of urates
from obstruction of the uriniferous tubules induces the attack of gout,
makes it appear practical to maintain the secretory pressure in the
kidneys at a certain height, and to dilute the urine, as the urates re-
quire a great deal of water for their dilution. In the later stages of
the disease the akratothermal springs, Wildbad, Gastein, Pfaffers, etc.,
are very serviceable. We may have the patient drink of these waters
and bathe in them ; perhaps the infarctions obstructing the tubules
may be carried away by the former, and the kidneys washed out, as it
were, while the latter has the most beneficial effect on the inflamma-
tion of the joints.

We cannot give any rules for fulfilling the indicatio morbi, as the
gout is a peculiar and obscure disease, which we can neither cure by
so-called rational treatment, nor have we any specific for it. It is true
some physicians consider colchicum as a specific in gout ; but its action
appears to be only palliative. The practice of giving colchicum for a
long time is being gradually discontinued, and it is administered only
iuring the acute attacks. Most physicians of the last century, who
generally had a high opinion of the efficacy of medicines, considered
gout as a noli me tangere, and even at present we cannot sufficiently
warn against the uncalled-for and injurious administration of medica-
ments in this disease.

556 DISEASES OF THE ORGANS OF LOCOMOTION.

The symptomatic indications require us, first of all, to shorten the
attack and to render it as bearable as possible ; for the idea that the
trouty attacK must be guarded and cared for, because it has a beneficial
depurative effect on the organism, has been very justly abandoned.
Experience has shown that, in gouty inflammation, antiphlogistics
neither alleviate the pain nor shorten the attack; and it has also
shown that the untimely use of antiphlogistics, especially general and
local bleeding and active saline purges, favors the passage of regular
acute gout into irregular chronic and atonic gout. We should also
advise against the application of cold or of warm and narcotic com-
presses over the painful joints ; on the other hand, in attacks of acute
or chronic gout, the narcotics, and, above all, colchicum, should be
freely given. It has not yet been decided to what peculiarity colchi-
cum owes its efficacy. Garrod has shown that it is not chiefly due to
its diuretic power and the removal of the collected urates from the
body. It is customary to give twenty to thirty drops of the tincture,
or vinum seminum colchici, four times daily. These doses do as much
good as larger ones, which cause pain in the abdomen, and diarrhoea.
Besides the colchicum, it is well to give the patient plenty of acid drink
during the attack; perhaps the favorable effect of this treatment
depends, as I above indicated, on the dilution of the urine and the
increased lateral pressure in the kidneys. Our theory would also
agree with the treatment of the attack after the method of Cadet de
VauXy according to which the patient is to drink six ounces of simple
water, as hot as possible, every fifteen minutes. It really seems as if
this were of some benefit, although it is not altogether free from dan-
ger. During the attack the affected limb should be elevated and cov-
ered with cotton or wool, and the patient placed on low diet. If the
motions be impaired after the attack, treatment by baths in Wildbad,
Teplitz, or Wiesbaden, is indicated. If abscesses form near the joints
attacked by gout, we should use cataplasms ; if the abscesses lead to
ulcers, the applications should if possible be continued till the ulcers
have healed. No general rules can be given for the treatment of
attacks of anomalous internal gout. Abstraction of blood readily
induces dangerous collapse, and, on account of the threatening paraly
sis, stimulant treatment is usually more appropriate. If the disap-
pearance of a peripheral affection be followed by an attack upon the
brain, stomach, or heart, we may cover the part previously affected
with irritating and vesicating plasters, although this rarely does mucb
good.

RACHITIS. 557

CHAPTER VI.

RACHITIS — RICKETS.

ETIOLOGY. — The actual changes in the bones in rachitis consist,
I . In proliferation of the cartilage of the epiphysis and of the periosteum,
which are the sources of the normal growth in length and thickness
of the bones. 2. The cartilaginous and fibrous tissues, resulting from
this proliferation, ossify more incompletely and later than in the nor-
mal growth of bone. Hence, in rachitis, there is not, as was formerly
supposed, a morbid softening of tissues previously hard ; but tissues
which normally become hard, from deposits of chalky salts, remain ab-
normally soft. This view is not in opposition to the fact that rachitic
bones bend more readily than they did before the disease. The me-
dullary cavity increases in rachitic just as it does in healthy bones ;
but, while in the latter the new formation of firm, bony substance
at the periphery preponderates over its loss from within, so that, ic
spite of the latter, the strength of the bone increases ; in rachitic
bones, the loss of firm, bony substance from within is not replaced
by a corresponding new formation at the periphery, and conse-
quently their resisting power is decreased. The excessive prolifera
tion of the cartilages of the epiphysis and of the periosteum, with
which rachitis begins, is by some regarded as inflammatory. The
great vascularity and infiltration of the affected parts, the pains which
accompany the disease from the first, as well as the many analogies
of the proliferation, with other undoubtedly inflammatory affections,
support this view ; but, on the other hand, it is opposed by the etiol-
ogy, course, and constant results of the disease. Many attempt to ex-
plain the retarded ossification of the newly-formed cartilage elements,
and the fibrous proliferation of the periosteum, by saying that, in ra-
chitic children, the calcareous salts taken up with the food cannot be
deposited in the terminal and peripheral layers of bone, because they
are held in solution by the lactic acid in the blood of the patient,
and are excreted through the kidneys. Part of the analyses of urine
made favor this explanation, as they showed that the urine of rachitic
children was not unfrequently very rich in lactic acid, and that it con-
tained four or six times as much phosphate of lime as is contained in
normal urine. Another point in favor of this view is, that children
who suffer from dyspepsia are especially apt to be attacked with ra-
chitis. The active decomposition going on in the stomachs of these
children forms quantities of acid, particularly lactic acid, and it is pos-
sible that their reabsorption and their presence in the blood hold the
phosphate of lime in solution, and that by their excretion with the

558 DISEASES OF THE ORGANS OF LOCOMOTION.

urine, the material for the formation of bone-substance is withdrawn
from the blood. But this hypothesis is not tenable ; the increase of
lactic acid and phosphate of lime in the urine of rachitic children is
not constant. Rachitis not unfrequently develops without precedent
disturbance of the digestion or formation of acid, and the proliferation
of the epiphyseal cartilages and of the periosteum, which are just as im-
portant factors of rachitis as the retarded deposit of calcareous salts is,
cannot be explained by the excretion of phosphate of lime through the
urine. Virchow, to whom we owe the most important explanations
of the histology of rachitic bones, and the pathogeny of rachitis,
says that the cause of the retarded ossification is more probably a
diminished supply of chalky salts than their increased excretion
through the urine. He reminds us of the recommendations of the car-
bonates and phosphates of lime as remedies in rachitis, and calls par-
ticular attention to the fact that, in the dyspepsia of children, which
usually precedes rachitis, as there is less albuminate taken into the
system, the amount of earthy salts required for the normal growth of
the bone absorbed is also diminished, as they are, for the most part,
introduced into the body as albuminate. Virchow does not pretend
that this view also is not problematical. It does not explain why the
disturbance of the supply of nutritive material should affect the bones
more than the other parts ; it is also opposed by the fact that rachitis
occurs not only in dyspeptic children, but also in those who are other-
wise well nourished ; lastly, it is evident that the diminished supply
of nutritive material does not suffice to explain also the proliferation of
the epiphyseal cartilages and of the periosteum. From these considera-
tions, it seems to me that the most probable hypothesis regarding the
cause of rachitis is that which refers it to inflammation of the epi-
physeal cartilages and periosteum. In other tissues, also, as in the skin,
mucous membrane, etc., we often see diffuse inflammations (exanthe-
mata, catarrhs, etc.), whose immediate cause we cannot discover. Like
rachitis, these occur chiefly, but not exclusively, in badly-nourished,
cachectic persons, and are also often accompanied by rachitis. From
what we know of periostitis, it is not surprising, as Virchow aptly
says, that the disturbance of circulation at the height of the disease
should hinder the deposit of calcareous salts in the morbidly-proliferating
tissue. Lastly, the excessive excretion of phosphate of lime through
the urine may just as well be the result as the cause of the lime-salts
not being deposited in the bones. Rachitis is a disease of childhood,
and it is doubtful whether the rare cases, where the disease is said to
have occurred in adults, or during foetal life, were actually rachitis.
The disease is most frequently seen from the second half of the first
year till the time of the second dentition ; before the seventh month,

RACHITIS. 559

and after the seventh yjar, it is far more rare. In some families, the
tendency to it appears to be hereditary. Improper nutrition of chil-
dren is undoubtedly the most frequent cause of the disease. I also
believe that the gastric and intestinal catarrh, due to the improper nu-
trition, greatly favor the occurrence of the disease, although I do not
consider it as proved that this results from reabsorption of the lactic
acid. The occurrence of rachitis in well-nourished children, with un-
impaired digestion, shows that, besides the above, there are some
other unknown causes of the disease.

ANATOMICAL APPEAKANCES. — For the histological details of the
examination of rachitic bones, I refer to the works of Virchow, Kolli-
Jeer, and JZ Mayer. Virchow enumerates the changes observed in
the epiphyseal cartilages during rachitis as follows : 1. Arrest of the
line of ossification while the preparatory line of proliferation of the
cartilage relatively increases. 2. Encroachment of the medullary space
into, or even beyond, the line of ossification, while the proliferation of
cartilage continues. 3. Formation of fibrous medullary spaces, osteoid
transformation of the parts around them, as well as of distant parts,
with calcareous deposits. The processes observed in the diaphyses are
grouped as follows, by Virchow : 1. Greater density of the periosteal
proliferation, with progressive rarefaction of the substance in the
areolae and cancellated tissue. 2. Deficient ossification of the cancel-
lated tissue, and continuance of the deep layers of compact exterioi
substance. 3. Partial formation of cartilage in the areolas.

The clumsy appearance of rachitic bones and the swelling of the
epiphyses are sufficiently explained by the proliferation of the perios-
teum and epiphyseal cartilages. The epiphyses are thickened and not
elongated, according to Virchow / not because the proliferation is
chiefly lateral, but because the soft proliferating layers are compressed,
and deflected laterally by the weight of the parts pressing on them,
and by muscular action. The distortions of rachitic bones depend
partly on curvatures, partly on angular deformity. The curvatures
occur chiefly at the epiphyses and at the points of cartilaginous union
of bones which have no epiphyses, while the angular deformities occur
chiefly at the diaphyses. In the long bones of the extremities it often
looks as if the epiphysis had slipped past the diaphysis. Curvature of
the posterior ends of the ribs of one side of the thorax not unfre-
quently induces asymmetry or obliquity of the thorax. In many
cases the points of union between the anterior ends of the ribs and the
costal cartilages are bent inward, while the sternum, with the sternal
end of cartilages, is pressed forward. This deformity, pectus carina-
tum seu gallinaceum, is due to the softness of the parts mentioned,
they having lost the power of resisting the pressure of the atmosphere

560 DISEASES OF THE ORGANS OF LOCOMOTION.

by inspiratoiy dilatation of the thorax. Any point of the ribs where
an elastic ligament replaces the bone would become depressed on in-
spiration. Curvatures of the upper and lower ends of the individual
vertebrae cause distortion of the spinal column ; curvatures of the pel
vie bones at their points of union cause pelvic deformities ; the most
frequent form is the so-called rachitic pelvis, where the antero-posterior
diameter is shortened, but occasionally, also, when the curvature does
not occur at the point of union of the sacrum with the ilion, but at
that of the pubis with the ischium, we have a heart-shaped deformity.
In the angular deformities the bone is only curved on the convex side,
but on the concave side it is actually broken. The medullary cavity
of a sharply-bent bone is, like the cavity of a sharply-bent quill,
greatly contracted at the bent portion, and is subsequently entirely
closed by callus. Total fractures, also, are not rare in rachitic bones,
but they differ from fractures of healthy bones, in never being accom-
panied by injury of the periosteum, which is separated from the com-
pact bone-substance by a soft, incompletely-ossified layer. The sutures
of the skull, which correspond to the epiphyses of the long bones, ossify
very late ; hence, in rachitic children even two or three years old, we
not unfrequently find the fontanelles still open, and so large as to in-
duce the suspicion of chronic hydrocephalus. The bones of the head
and face, which correspond to the diaphyses of the long bones, undergo
the same changes as the latter do ; imperfect ossific proliferations of
the periosteum occur on the bones, especially near their edges, and de-
form the head and face. Besides this thickening, a partial thinning of
the cranial bones is also observed in rachitis (Elsasser*s soft occiput,
craniotabes). This thinning, which may finally let the dura mater
and pericranium come in contact, results from gradual disappearance
of the cranium under the pressure of the gradually-increasing brain,
which is not accompanied by coincident formation of new bone-sub-
stance on the surface of the skull. These membranous spaces are
most frequently observed in the occiput, more rarely in the parietal or
frontal bones; they occur chiefly at places where the impressiones
digitatae, corresponding to the convolutions of the brain, are normally
found. A symptom analogous to craniotabes is also seen in the
lower jaw, the anterior wall of the alveolus being often perforated by
the milk-teeth. If the rachitis goes on to recovery, the swelling of the
articular ends of the bones subsides ; the bones become firm, while
only a small amount of the curvature of the limbs is corrected ; after
the disease has run its course, the cartilaginous proliferations of the
epiphyses often ossify sooner and more completely than is desirable
for the longitudinal growth of the bones, for which it is necessary that
the epiphyses should remain cartilaginous. It is, probably on this ao

RACHITIS. 561

count that persons who have suffered from extensive rachitis usually
remain very small, or even dwarf-like. If certain bones only have been
rachitic, while others have escaped, a marked disproportion remains
after the disease has subsided, from the irregular growth of the bones.
The shortness of the extremities has much less effect on the general
health than the distortion of the thorax or the rachitic pelvis, which
are also due to the slow growth of the thoracic and pelvic bones after
rachitis. Since the sutures and fontanelles of the skull remain open
for a long time, and since, until the sutures are closed, the growing
brain does not permit any distortion of the skull, the growth of the
skull is not arrested, and we often find persons, formerly rachitic, very
much deformed, having a small face surmounted by a large head, out
of all proportion to the misshapen body.

SYMPTOMS AND COURSE. — Rachitis occurring during the first
months of life is so often preceded by chronic intestinal catarrh, with
stools at first green and mucous, subsequently copious and watery,
that it appears almost justifiable to regard this form of chronic intes-
tinal catarrh, the " diarrhoea ablactatorum," " yeasty diarrhoea of chil-
dren," among the prodromata of rachitis. But the fact, that numerous
cases of this chronic intestinal catarrh do not pass on to rachitis, but
sometimes remain uncomplicated, sometimes induce other disturbances
of nutrition, renders this view doubtful, as well as that of Stiebel, ac-
cording to which, " cacotrophia " is the first, muscular atrophy the
second, and disease of the bones the third stage of rachitis. If, after
the above state has lasted for a time, we cannot find any changes in
the bones during life or on autopsy, there is hardly any proof that the
disease is rachitis. The first symptom, showing that rachitis has suc-
ceeded the diarrhoea and consequent marasmus, is the pain that the
children unmistakably suffer when they attempt to move their limbs,
or when they are moved by any one. Stiebel very truthfully describes
how children, whose greatest pleasure had been to kick out their legs
and put their toes in the mouth, then lie quiet, with their thin legs held
straight out, as if afraid to move ; how they cry at every motion, and even
begin to whimper for fear of being taken out of the bed when persons,
that they had formerly loved, approach them. These symptoms are
succeeded by enlargement of the epiphyses — which is most noticeable
at joints not thickly covered by soft parts, or normally very prominent —
as the knee and elbow are, and in the lower epiphyses of the radius and
ulna, as well as at the point of union of the ribs with their cartilages.

If rachitis begin in the manner above described, from diarrhoea ab-
lactatorum, that is, if it begin when the child has not yet attempted to
walk, it often escapes any distortion of the extremities, even if the dis-
ease last for years. This shows clearly that the curvatures and partial

562 DISEASES OF THE ORGANS OF LOCOMOTION.

fractures of rachitic bones are chiefly due to the weight of the body
resting on them, and to the action of the muscles. We have given a
different explanation for the occurrence of pectus carinatum ; and the
fact, that children who have become rachitic during their first year, and
still have straight legs, usually have chicken-breast, perfectly agrees
with this explanation. Children attacked by rachitis during the first
year are the ones who are affected with craniotabes, from lying so
long on their backs, probably from the pressure of the brain on the
inner surface of the skull, while the bed presses on the outer surface.
It is of little importance whether the rolling the head, thinness of the
hair over the occiput, disturbed sleep, attacks of spasmus glottidis,
eclampsia, and other symptoms of anomalous cerebral functions, which
are often seen in such children, are to be regarded as the results of
craniotabes, or as concomitant symptoms. Careful pressure on the
soft parts of the head is well borne by many children, while in others
it induces convulsions. We must further mention that chronic bron*
chial catarrh is the most frequent complication of rachitis early in life ;
its absence is exceptional. In this disease, the teeth are generally cut
very late, and often irregularly ; it frequently happens that the child
is a year old before he has a tooth in his mouth. Finally, there is no
question that rachitic children, who have acquired their disease during
the first months of life, usually differ from other children of equal age,
by their bright answers, and their attentive, sensible manners ; but, in
spite of the large head, we cannot agree to refer this precocious men-
tal development of rachitic children to hypertrophy of the brain, be-
cause we also see it in other children who are confined to the bed by
any disease, and so kept away from other children, and constantly sur-
rounded by sedate, grown persons ; and because in so-called hyper-
trophy of the brain there is not an increase of the nerve-elements, but
of the neuroglia. Moreover, the contrast between the physical help-
lessness and the mental development causes the latter to appear
greater than it really is ; and children three years of age, who cannot
yet walk, are usually considered younger than they really are. If the
disease end in recovery, the first sign of improvement is generally a
decrease of the emaciation. The loose skin is again filled by the
limbs, the wrinkled and old face grows smooth, while the protuberant
belly becomes smaller. After a while the children begin to sit up in
bed, and play. At this time there is great danger of curvature of the
upper and lower ends of the vertebrae, and permanent distortions of
the spinal column. At the commencement of convalescence, curva-
tures and partial fractures of the extremities also are most likely to
occur when the children attempt to get out of bed, and walk around,
holding «i to the chairs. The symptoms of rachitis differ in some

RACHITIS. 5(53

points from the above description, when the disease occurs in older
children. In them the symptoms of chronic intestinal catarrh, and
general emaciation, do not usually precede the symptoms of rachitis ;
the children often have, apparently, normal digestion, and are well
nourished when the disease develops. Nor do they usually suffej
the pain that is induced in smaller children by all active and passive
movements. They only complain of pain when they make a misstep,
and easily become fatigued. Finally, when the children attacked by
rachitis are two or three years old, or older, the ribs and vertebrae
escape in the commencement, and the extremities first become de-
formed. They are affected with curvatures, and partial fractures,
whose direction is not always the same. Sometimes they form an
increase of the normal curvature of the bones ; sometimes they are in
the opposite direction, variations whose cause is unknown. Not un-
frequently the thighs are bent outward, the legs inward ; the children
acquire a clumsy, waddling gait. It is generally a long time, often
many years, before the disease extends to the whole skeleton. Then
we notice frequently, but not always, as Gruerin asserts, that the dis-
ease extends with a certain regularity ; first, the bones of the legs,
then of the thighs, later those of the forearms, of the arm, and lastly
those of the trunk, are attacked. Even when we succeed in arresting
the disease at an early stage, the small size, the misshapen limbs, as
well as slight curvatures remaining in the lower extremities, remind us
through life of the rachitis that occurred during childhood ; in severe
cases very unsightly curvatures and shortenings of the bones remain,
which not unfrequently impair the functions of the body.

TREATMENT. — In cases where the rachitis develops from chronic
intestinal catarrh and marasmus, the causal indications require the
treatment described in Vol. I. We there remarked that it was diffi-
cult to arrest the active process of decomposition going on in the intes-
tinal canal of children, which induces the diarrhoea, and we must con-
sider the want of success in the treatment of this diarrhoea as the chief
cause of the tardy and imperfect results of treatment in rachitis. If
we succeed in curing the intestinal catarrh speedily and completely,
and in improving the nutrition of the child, the rachitic symptoms, in-
duced by these disturbances, also generally disappear in a short time ;
and, if the disease be recognized early, the children escape any per-
manent results of the rachitis. In the treatment of irritative diarrhoea,
if it be accompanied by rachitis, in view of the diminished deposit of
chalky salts in the tissues, it is customary to prefer carbonate of lime,
in the form of prepared chalk, to the carbonates of potash and soda,
which are generally used. In other cases, where the disease occurs
without our being able to discover chronic intestinal catarrh, or other

564: DISEASES OF THE ORGANS OF LOCOMOTION.

disturbance of nutrition as its cause, we cannot fulfil the causal indi-
cations.

The indications from the disease are not answered by giving car-
bonate and phosphate of lime, for the absence of the bony earths from
the bones is not the chief anomaly in rachitis. As soon as the disturb-
ance of nutrition in the epiphyseal cartilages and in the periosteum has
ceased, the ossification of the proliferation begins, and, indeed, often
becomes excessive, even if no material for aiding ossification be sup-
plied, except the calcareous salts taken in the ordinary articles of food.
Bitter and tonic remedies also, as well as rubia tinctorium, have not
fulfilled the hopes entertained of them on theoretical grounds, and
have been almost superseded by cod-liver oil, which is very efficacious
in most cases where it can be taken, as it generally can be. We do
not know to what peculiarity cod-liver oil owes its apparently specific
effect in rachitis. Brine baths are also of unmistakable benefit, and
should be used, particularly where the children are in a fair condition
as regards nutrition, or are even moderately fat. The diet suitable
for scrofulous patients, consisting of a small supply of vegetables, with
plenty of animal food, is also very important for the successful treat-
ment of rachitis. We would particularly recommend the administra-
tion of a moderate amount of finely-shaved raw beef twice a day, fol-
lowed by a small spoonful of Tokay or Malaga wine. Finally, we
should take care that rachitic children be not kept in damp, dark
rooms, but sent out of doors as much as possible.

The symptomatic indications are, to guard against curvatures of the
bones, and to rectify any existing curvatures. The former indication
is more readily fulfilled than the latter; the means for fulfilling it con-
sist, as may be inferred from what we have already said, of the mode
of origin of the curvatures and partial fractures, in carefully protecting
the soft, pliable bones from the weight of the body, the action of the
muscles, and external force. Rachitic children should sleep on mat-
tresses, not on feather beds. It does not make so much difference about
the material in the mattress as about the care with which it is made,
for on this depend its regular fulness and the evenness of its surface.
High pillows should be forbidden. The nurse should carry small chil-
dren out in a basket ; larger ones should be drawn about in the open
air, in a carriage provided with a mattress. Until the bones are con-
solidated, sitting up in bed for a length of time should be prohibited,
and still more should we forbid the children running about on their
flexible, fragile legs. But if the curvature has already occurred, we
should send the child to a reliable orthopaedic institute, that is, to one
where the actual results after the treatment correspond to some extent
with the promises made before its commencement, and the accounts

OSTEOMALACIA. 5^5

given while it is being carried out. Of course, institutions where
some particular plan of treatment is not followed exclusively, or with
partiality, but where all the aids of orthopaedia are employed, and es-
pecially where the general health of the patient is attended to, should
be preferred to others.8

OHAPTEE VII.

OSTEOMALACIA.

ETIOLOGY. — In osteomalacia, bones which have been hard become
soft from reabsorption of the salts of lime, to which they owed their
hardness. This explanation of the disease at once shows its difference
from rachitis, where the lime-salts do not disappear from the bones,
but have never been deposited there. The immediate causes of the
solution and reabsorption of the salts of the bones in osteomalacia are
obscure. The hypothesis, that the appearance of an acid in the tissue
of the bones lies at the root of the processes by which the phosphate
of lime is dissolved, is refuted by Virchow, who found the gelatin es-
caping from fresh osteomalacic bones was of alkaline reaction. There
is a great deal in support of Virchovfs theory that osteomalacia is, per-
haps, to be classed among the parenchymatous inflammations where
no interstitial exudation is deposited, but where the inflammatory dis-
turbances of nutrition affect the tissue-elements of the affected organ.
The rarefaction, the porous, spongy, or areolar condition of these bones,
which are perfectly analogous to the changes in osteitis proper, the
frequent occurrence of the disease in the puerperal state, its customary
origin from the pelvis, which has been injured during parturition, and
lastly, the severe pain accompanying it, render it very probable that
osteomalacia is of an inflammatory nature. This is a rare disease ; up
to the present time it has been observed almost exclusively in women.
The exciting causes are unknown ; we only know that the first signs
of it, in most cases, appeared some time after confinement, so that
pregnancy, parturition, or the puerperal state, undoubtedly have much
to do with its etiology.

ANATOMICAL APPEAKANCES. — In osteomalacia, the bones become
very porous ; in the spongy substance, the trabeculae decrease in num-
ber, and disappear ; hence the medullary cavities coalesce, and in the
long bones induce enlargement of the medullary spaces ; in the com
pact cortical substance, also, the vascular channels increase, and fonc
areolse, which unite and change the cortical substance also into a coarse,
meshed, spongy tissue. Finally, in the highest stage of the disease,
the soft, flexible bone, which may be readily cut, consists only of

566 DISEASES OF THE ORGANS OF LOCOMOTION.

periosteum and medulla, with a few delicate, bony trabeculse. In
recent cases the medulla is dark, brownish-red ; later, it is yellow, and
very fatty. There are cases of osteomalacia, where the disease is con-
fined to certain bones, especially the pelvis and spine ; in other cases
it affects almost the whole skeleton ; but, even then, the bones of the
skull almost always escape. Distortions of the body and limbs result
from the softness and flexibility of the bones ; these are often very
great, and actually frightful. The weight of the head occasionally
induces angular curvature of the cervical portion of the spinal column ;
the distortion of the dorsal vertebrae, and the ribs, may not only cause
deformity of the thorax, but may also greatly encroach on its capacity.
The pelvis is almost always compressed laterally by the thigh-bones,
often to such a degree that the horizontal branches of the pubis come
in contact, and project like a beak. The sacrum is also generally
curved into the pelvis. Sometimes the curvatures of the extremities
attain such a grade, that the feet are at last directed outwardly. In
some cases the shortening of the body is so decided, that women of
stately size become quite dwarf-like during the disease.

SYMPTOMS AND COTJKSE. — The first symptoms of osteomalacia are
boring, tearing pain, which the patients often locate in the bones.
This pain is usually relieved by perfect quiet, while it is increased by
motion. In some, but not in all cases, the pain, which at first is usu-
ally considered rheumatic, is accompanied by a remittent or intermit-
tent fever. According to many observers, copious sediments of phos-
phate of lime form in the urine of the patient ; where they do not
occur, renal calculi, consisting of phosphate of lime, are found after
death. It is also said that lime-salts are excreted through the sali-
vary glands and skin. Gradually, the gait becomes uncertain and
tottering, and, after a time, any motion becomes so painful, that most
patients fear leaving their bed. The pain is followed by distortion
and deformity of the body and limbs, which vary from accidental cir-
cumstances. Occasionally, the well-nourished state of the patient con-
trasts for a long time with the pain and deformity ; while in other
cases the general health is affected early, and the patients appear mis-
erable, and badly nourished. Osteomalacia has not ended in recoverj-
in any of the cases so far reported ; but in most of them it was not till
after several years of severe suffering that death occurred, from ex-
haustion, or from disturbances of the circulation and respiration.

TREATMENT. — The remedies theoretically recommended for osteo-
malacia, such as calomel and opium, phosphoric acid, lime-water, cod-
liver oil, and iron, have not answered in practice, and we are, unfortu
uately, obliged to confine ourselves to the prevention of distortions.

PROGRESSIVE MUSCULAR ATROPHY. 567

CHAPTER VIII.

PEOGEESSIVE MUSCULAR ATROPHY — ATROPHIE MUSCULAIRE GRAIS-
SEUSE PROGRESSIVE — PARALYSIE MUSCULAIRE PROGRESSIVE ATRO-
PHIQUE.

[FriedreicJi ascribes progressive muscular atrophy to chronic in-
flammation of the perimysium, inducing hyperplasia of the inter-
stitial connective tissue and destruction of the muscular filaments.
But of late the more perfect means for examining the spinal cord
show changes in its gray anterior horns, such as atrophy, increased
pigmentation, or even disappearance of its ganglion-cells. Appar-
ently the anterior ganglion-cell columns of the spinal cord are the
centre of nutrition for the muscles of the trunk and limbs ; hence
disease in this region would cause muscular atrophy ; this disease
may be primary, or may be secondary to other spinal diseases, such
as locomotor ataxy, sclerosis of the lateral cords, central myelitis,
etc. The anterior nerve-roots, which are traversed by the muscular
nerve-filaments, and even the peripheral nerves, participate more or
less in the atrophy of the trophic spinal centre. The affected mus-
cles atrophy and become pale-red or yellowish ; in cases not far
advanced we may find normal, fatty, and atrophied filaments in the
same muscle. Sometimes, instead of fatty degeneration in the
primitive filaments, it occurs in the interfibrillar connective tissue ;
so that a division has been made into parenchymatous and inter-
stitial. Allied to the latter form is pseudo-muscular hypertrophy ;
this occurs chiefly in young males, and is due to proliferation of the
interfibrillar connective tissue, with deposit of numerous fat-cells
and atrophy of the muscular filaments ; the deposit of fat enlarges
the muscle and gives the appearance of hypertrophy. This affec-
tion comes chiefly in the lower limbs, and then in the erector spinae
muscles.

Progressive muscular atrophy is most common in males between
thirty and fifty years. It is often hereditary, but is most frequently
due to continued strain of certain muscles ; sometimes also to cold,
excesses, certain diseases, such as typhoid, diphtheria, etc., and to
injuries.

Progressive muscular atrophy and bulbar paralysis differ in the
location of the original disease ; the former being due to changes
in the motor ganglion-cells of the anterior horns, the latter to
changes on the floor of the fourth ventricle.]

SYMPTOMS AND COURSE. — The first symptom of progressive mus-
86

568 DISEASES OF THE ORGANS OF LOCOMOTION.

cular atrophy is a gradually increasing feeling of weakness in certain
muscles or groups of muscles, with their very evident and steadily
increasing emaciation, but without pain or other trouble. The dis-
ease does not originate with equal frequency in the different mus-
cles ; but, in most cases, the muscles of one hand or one shoulder
are first affected, occasionally those of the neck, rarely those of the
face. The power of conduction and the size of the muscle, which
diminish about equally in the course of the disease, are finally so
much reduced, that the movements depending on the affected mus-
cles are entirely lost or very imperfectly made, and, where the belly
of the muscle was formerly prominent, we find a flatness or even a
depression. The effect induced is most apparent in the disappear-
ance of the ball of the thumb, depressions between the metacarpal
bones, flattening of the shoulder, and prominence of the spinous
processes of the vertebrae, when the muscles of the neck have atro-
phied. In the weak and atrophied muscles we may always see a
peculiar fibrillar twitching that has no effect on the point of inser-
tion of the muscles, and hence induces no movement of the corre-
sponding joint ; this twitching becomes more evident when we blow
on the skin covering the muscle, or irritate it in any other way by
exposure to cold. It is usually said that the excitability of the sen-
sory cutaneous nerves remains normal, and only that of the sensory
muscular nerves is lost (the "electro-muscular sensibility" of the
electricians) ; but I have seen many cases where the excitability of
the cutaneous nerves was much diminished, while all the other
symptoms were those of progressive muscular atrophy. A very im-
portant and even pathognomonic symptom is the above-mentioned
condition of the affected muscles and their motor-nerves in regard
to the induced current ; this current does not fail to induce con-
traction until the muscle is entirely atrophied ; up to that time the
contractions correspond to the strength of the current and the
amount of muscular substance that still remains. In some cases
progressive muscular atrophy is limited to certain parts of the
body ; in others it gradually extends to the greater part of the
muscles supplied by the cerebro-spinal nerves, while it never affects
the muscles of the heart, intestines, or bladder. The latter form is
a terrible disease ; patients affected with it preserve a good appetite
and good digestion, their intellect is clear, and the mental functions
are so unclouded that they can fully comprehend their lamentable
loss, while they lose the use of one limb after another. In advanced
cases the patients cannot walk or change their position ; they must
be fed too, as their arms hang useless by their sides ; the changes
of expression cease, the saliva runs out of the mouth, the speech is

PROGRESSIVE MUSCULAR ATROPHY.

indistinct, and the tongue cannot pass food into the pharynx, even
after it has been placed in the mouth. Finally, after years of suf-
fering, the patients die, because at last the muscles of deglutition
and respiration also become atrophied, and fail to perform their
functions. Some intercurrent disease of the respiratory organs, in-
significant in itself perhaps, proves dangerous to the patient and
hastens his end, because, owing to the paralysis of the abdominal
muscles, he is unable to cough up the secretion collecting in the
bronchi.

[In the last stages of some cases there is local anaesthesia ; and
sometimes there is contraction or faulty reaction of the pupil from
paralysis of the radial fibres of the iris. Besides the atrophy of the
muscles, there may be other trophic disturbances, such as atrophy of
the skin, herpes in the region of the affected nerves, and affections
of the joints and bones of the phalanges, carpus, etc. There may
be profuse sweating, and changes in the urine, especially diminution
of creatin (the product of muscular changes). Sometimes the tem-
perature of the affected limbs is at first higher ; later, it may be
several degrees below normal.

Progressive muscular atrophy may be mistaken for what Char-
cot has recently described as sclerosis of the lateral cords (scl'e-
rose laterals amyotrophique) ; this sclerosis is most extensive in the
cervical medulla, but may extend up into the pyramids and pons or
down into the dorsal and lumbar regions. As the anterior horns
of the gray substance are implicated in the disease, and undergo the
same changes as in progressive muscular atrophy, the symptoms of
the two diseases are mingled. But there are other symptoms which
do not occur in progressive muscular atrophy ; there is a true para-
lysis and a subsequent atrophy of all the muscles of the limb af-
fected ; these are followed by spastic contractions, which it is said
do not occur from progressive muscular atrophy.]

TREATMENT. — In those forms of progressive muscular atrophy
resulting from overwork and limited to certain parts of the body,
the methodical use of the induced or constant current of electricity
and massage sometimes arrests the progress of the disease, and even
improves the nutrition of the emaciated muscles. But great pa-
tience and perseverance are requisite for the attainment of this end.
All remedies, even the methodical employment of electricity, have
proved inefficacious in the form of the disease which spreads from
muscle to muscle.

570 DISEASES OF THE ORGANS OF LOCOMOTION.

CHAPTER IX.

PROGRESSIVE MUSCULAR PARALYSIS AS A RESULT OF HYPERTROPHY
OF THE INTERSTITIAL FATTY TISSUE.

IN 1869-'70 a series of very peculiar cases of progressive mus-
cular paralysis were published, in which the volume of the paralyzed
muscles was decidedly increased instead of being lessened, as it was
in the myopathic paralysis described in the last chapter.

On examining the affected muscles, as was done in several cases
during life by excising small pieces, they showed a changed appear-
ance even to the naked eye. They did not have the red hue of
healthy muscles, but were pale and yellowish, resembling lipoma
more than muscle. Microscopic examination showed a decided pre-
ponderance of the interstitial fatty tissue over the muscular ; in
some places the latter was entirely displaced by the former ; the
muscular filaments still remaining were atrophied, pale and small,
but not affected with fatty metamorphosis. Hence, in this disease
there is proliferation of the interstitial fatty tissue, which probably
induces simple atrophy of the muscular fibrillse by pressure on them.

The disease has been repeatedly observed in children of the same
family, and, curiously enough, only in boys. Occasionally the pa-
tients appeared to bring the predisposition to the disease into the
world with them. At least, in one case observed in my clinic, whose
history was published by my former assistant, Dr. Siegmund, in his
inaugural dissertation, and in the first volume of the " Archives fur
klinische Medicin," and in a case described by Griesinger, it ap-
peared that the patient did not learn to walk till late, and had al-
ways remained somewhat helpless.

Of course the symptoms of the disease vary with the group of
muscles affected. In my patient, the disease started from the gluteal
muscles. As long as these were exclusively or chiefly affected, the
patient could only walk when, by aid of his arms, he had given his
head and shoulders a position where their point of equilibrium fell
behind the pelvis ; if this position was changed, he doubled forward
at the hip-joint. Now the disease affects all the muscles of his
lower extremities ; the patient cannot leave his bed, and can only
change his position by great exertion of his arms.

I know of no cases of improvement or recovery except those of
Benedikt, who claims to have attained positive good results in three
cases by electricity. In my patients, who were treated for a long
time as advised by Benedict (by placing the copper pole on the
lower cervical ganglion, and applying the zinc pole along the side

ADDITIONS TO THE REVISED EDITION OF 1880. 571

of the lumbar vertebrae by means of a broad metal plate), neither
this treatment nor long-continued faradization of the diseased muscle
had any decided effect.

ADDITIONS TO THE REVISED EDITION OF 1880.

DISEASES OF THE ORGANS OF LOCOMOTION.

1.— P. 527.

Without doubt the articular inflammations in acute rheumatism
are not due to purely local causes, but evince a general morbid pro-
cess. This is shown by the inflammation of numerous joints distant
from each other, its disappearance from one on attacking another
which was previously unaffected, the frequent implication of the
heart and other internal organs, the remarkable sweating, etc. The
nature of this apparently constitutional disease has not yet been
solved, but there have long been two theories about it : 1. A hu-
moral theory, according to which there is a change in the blood
and fluids of the body, where from imperfect assimilation there is
an excess of lactic acid ; 2. A neuropathologic theory, which refers
the disease to a morbid excitement of the vasomotor trophic nerve-
centres ; this view finds some support in the tendency to symmet-
rical occurrence, and in the well-known dependence of certain other
joint-affections on spinal diseases.

From its frequence and severe consequences, acute articular rheu-
matism is one of the most important of diseases, and ranks along
with consumption, pneumonia, bronchitis, typhoid fever, etc. It
is rare in childhood, more frequent from the fifth to the fifteenth
year, and most so between fifteen and thirty-five ; after that its oc-
currence as -a first attack is more rare. Both sexes are about equally
liable. A considerable percentage shows a hereditary predisposi-
tion, especially among the younger cases. There seems to be a
greater tendency to its development after certain diseases, such as
scarlatina, dysentery, and in the puerperal state, after abortions, etc.

2.— P. 535.

In those cases with high fever and cerebral symptoms, we may
resort to cold baths, as spoken of in the treatment of typhoid fever.
In place of wrapping the joints in wadding or applying narcotic
liniments, firm bandages may sometimes be applied with benefit ;
for this purpose we may use pasteboard moistened and moulded, or
gutta-percha, placing plenty of wadding under them ; after the ap-
plication of such firm dressings the pain sometimes subsides very

572 DISEASES OF THE ORGANS OF LOCOMOTION.

quickly. Among remedies said to be specifics for rheumatism are
propylamin, trimethalin, and more especially salicylic acid or sali-
cylate of soda. The latter may be given in doses of 15 to 20 grs.
every hour or two hours, till the pain is relieved, unless tinnitus,
cerebral symptoms, or signs of collapse should require discontinu-
ance of the medicine. The possibility of such symptoms being in-
duced demands that the patient should be watched. Under the
influence of the salicylate, the fever and local symptoms usually
subside within twenty-four to forty-eight hours, the tongue cleans
off, and the appetite improves ; when the change has taken place,
the remedy is to be carefully and gradually discontinued by decreas-
ing the dose or lengthening the interval. The patient should be
watched for at least a week. Under this remedy heart complica-
tions are said to be much less frequent. Should the joints remain
swollen, we may try iodide of potash and warm baths, especially
alkaline baths.

3.— P. 565.

Observers agree that the most important point in the treatment
of rachitis, as well for preventing curvatures as for curing the exist-
ing disease, is proper diet. Infants should be nursed till the erup-
tion of the first teeth, say the seventh month ; then we may give in
addition meat broths, egg, rare or raw shaved meat, etc. They
should not be nursed over nine months or a year. When the mother
cannot nurse, and a good wet nurse is not to be found, something
must be substituted. About this substitute opinions are not unani-
mous. Some recommend cow's milk diluted and neutralized with
magnesia, others Nestle* a food, others again Liebig's food or con-
densed milk. Probably none of these is to be chosen under all cir-
cumstances ; but if the child does not thrive on one, try another.
Biedert discovered that the casein of human milk is chemically dif-
ferent from that of cow's milk, and claims that this is the cause of
their difference, and that cow's milk cannot be made to resemble
human milk simply by diluting with water and adding sugar. He
recommends a mixture of one-eighth of a pint of sweet cream and
three-eighths of a pint of boiled water, with the addition of 15 grs.
of sugar of milk. This mixture contains the proper amounts of fat,
salts, and sugar, and only one per cent, of casein, which is just
about what a child's stomach will digest, according to Biedert.
This is the proportion to begin with, but as the child grows older
more cream is to be added. The yolk of egg may be mixed with
water, sugar of milk, and a very little salt. Finely-ground linseed
meal is said to be the chief constituent of revalenta arabica, which
has some reputation as an article of nutriment.

CONSTITUTIONAL DISEASES.

THE diseases to be discussed in the following sections I have termed
constitutional diseases, in contradistinction to the diseases of the or-
gans, which have been thus far described ; because, from its greater
comprehensiveness, this term appears to me preferable to the names
djscrasias and cachexias, or diseases of the blood, as I originally in-
tended to call them. I shall first discuss the acute infectious diseases,
then chronic infectious diseases, and, lastly, the general disturbances
of nutrition, which do not depend on infection, but, at the same time,
shall confine myself to those complaints which occur in Germany. In
regard to exotic diseases, with which I am not personally acquainted,
and for whose description I should have to rely entirely on other
authors, I refer to the excellent works of Griesinger and Hirsch,
where the descriptions of these diseases are as concise as they are
complete.

SECTION I.
ACUTE INFECTIOUS DISEASES.

CHAPTER I.

MEASLES MOKBILLI KTJBEOLA KO UGEOLE.

. ETIOLOGY. — Measles is a purely contagious disease. There is no
doubt that a person is never affected with measles without having
been infected by a person with measles. This assertion has been ob-
jected to, on the ground that the first case of measles could not have
been induced by infection, because at that time there was no measles
for the patient to be infected from ; and it is asserted that, if the dis-
ease developed spontaneously once, there is no reason for denying the

574 ACUTE INFECTIOUS DISEASES.

possibiity of its doing so again. Such reasoning is idle. We know
nothing about the first development of measles, arid the fact, observed
wherever it is possible to watch carefully the commencement and
spread of the disease, that measles never occurs without a case having
been brought in from somewhere else, justifies us in concluding that
the same thing occurs where it is not possible to detect infection direct-
ly. It is just the same with syphilis ; we know that at the present
day it is only propagated by transfer ; the question how the first case
of syphilis originated lies outside of the circle of physical investiga-
tion. The infecting material which induces measles has not been dis-
covered, either chemically or microscopically. We do not even know
certainly whether it be organized or inorganic, and the hypothesis, that
the infection is due to the transfer of small, imperceptible, vegetable
organisms, is only to be preferred to other hypotheses, because it
agrees better with the facts. I shall only mention a few of the rea-
sons for this hypothesis. The period of incubation, that is, the day
or week intervening between the infection and the outbreak of the
malady, speaks against the infection being caused by substances which,
from their chemical or physical peculiarities, are injurious to the organ-
ism. If such a substance were transferred, its injurious effects would
appear at once, or in a very short time, and the infected person could
not remain free from all signs of disturbance for from eight to fourteen
days, and then have these suddenly break out with great severity.
But if healthy persons be infected by measles patients, through micro-
scopic organisms, the period of incubation is much more readily under-
stood ; for it is easy to suppose that these organisms are transferred
in too small numbers to do harm, but that they multiply in the in-
fected person, and immediately after this process, which is completed
in a certain time (the period of incubation), their injurious influence is
made manifest. A further reason for supposing that measles-poison
is organized, is its reproduction in the bodies of the infected patients.
For instance, in an epidemic in the Faroes observed by JPanum, one
case that was introduced infected the attendants of the patient ; these
infected other inhabitants of the island, and, finally, in the course of
seven months, 6,000 persons, out of a population of 7,782, were at-
tacked. If the observations of Hallier should prove correct, the con-
tagious principle of measles has been recently discovered by the micro
scope. In the blood and sputa of measles patients, Hallier found
microscopic cells of a fungus which grew on various substrata, but was
always the same fungus, the mucor muado (verus) of Fres. It is cer-
tain that the blood, tears, and secretion of the air-passages, are vehicles
for the contagion ; for inoculations made with these fluids have induced
measles hi previously healthy persons. But, as the disease most fre

MEASLES. 575

quently occurs in persons who have not come in direct contact with
either the blood or secretions of measles patients, but have only been
near those affected with the disease, we cannot doubt that the conta-
gion is also contained in the emanations from the skin and lungs.
From some very striking observations of Panum, it has been proved
that this contagion in the atmosphere can, without losing its activity,
be carried for miles by the body and clothes of healthy persons who
have been near a patient, and who are not themselves attacked by the
disease. The period of incubation lasts from ten to fourteen days.
In one epidemic of measles that I carefully observed, of which Dr.
Pfeilsticker has given some very interesting accounts in his disserts
tion, written under my superintendence, school-children only were at
first affected, and exactly ten days later, after the latter remained
home from school, a. large number of smaller children, who had been
infected by their brothers and sisters, were attacked. In some cases,
particularly where the infected person is already suffering from some
other disease, the period of incubation appears to be somewhat longer.
To the question, When is measles infectious ? with our present
knowledge, we should say that it is most infectious while the eruption
is out ; that it is probably not infectious in the stage of desquamation,
while numerous cases speak for its being so in the prodromal stage
The popular opinion, that measles is most catching in the desquamative
stage, arises from inattention to the period of incubation. A child in-
fected by its brother or sister breaks out with the disease while the
latter is desquamating, it is true, but was infected while the exan-
thema was at its height, or, perhaps, even before the eruption. The
probability of infection during the prodromal stage is supported by
the wonderful spread of measles through schools. Great care is
usually taken to keep out of the school any children who have not
gotten through the desquamative stage, as well as those having any
suspicious exanthema ; but children with catarrh and cough are al-
lowed to sit on the seat with well children. If the disease were only
transferred by the former class, it would be quite impossible to under-
stand why, during an epidemic of measles, a school is often entirely
emptied, while the children attending another school are not affectec?
oy the disease. The predisposition to measles is very extended. Al-
most every one has the disease once during life ; but one attack al-
most invariably exhausts the susceptibility to new attacks. Since
measles occurs quite frequently in populated countries, most persons
are attacked during childhood, and have lost the predisposition when
they are grown up. It is only in this sense that measles can be called
a disease of childhood. Of 196 children, under fourteen years of age,
that had not had the measles, who lived in a small town near Ttibin-

576

ACUTE INFECTIOUS DISEASES.

gen during the epidemic described by Dr. Pfeikticker, 185 were takec
sick ; or, only eleven out of the entire number escaped. Hence, it ap-
pears that in isolated places, which are rarely visited by measles, chil-
dren are not more liable to the disease than grown persons are. The
above-mentioned epidemic in the Faroes, described by Panum, was
the first that had occurred for sixty-five years in that isolated island ;
hence almost all the inhabitants under sixty-five years of age, who had
not had the measles somewhere else, were attacked by the disease,
whether they were young or old. Children under six months often
escape during an epidemic of this disease. In the above-mentioned
epidemic, not a child under five months was attacked ; while, above
six months, almost all were. Very old persons also rarely have the
disease. Acute and chronic maladies, pregnancy, and the puerperal
state, do not protect from measles ; but, as was above said, the dis-
order not unfrequently makes its appearance at the end of an acute
disease, during which the infection has occurred. Measles occurs in
more or less extensive epidemics ; the extent of the epidemic depends
chiefly on the length of the interval that has elapsed since the last one,
and consequently on the number of persons who have not yet been at-
tacked. The epidemic at the Faroes furnishes an excellent example
of this also. But the state of the weather appears to have a great in-
fluence on the extent of epidemics, for the greatest number and the
largest epidemics occur in the winter and autumn, or in cold, damp
summers. Great extent of the disease generally corresponds with
great severity of the individual cases, and the most malignant cases
usually occur at the height of the epidemic.

ANATOMICAL APPEARANCES. — The normal exanthema of measles
disappears after death, and only the haemorrhages in the tissue of the
cutis, which sometimes occur, are discoverable in the dead body. The
anatomical changes observed during life on the skin of a measles pa-
tient consist in an eruption of numerous roundish red spots about the
size of a millet-seed, somewhat elevated, and generally having a small
papule at the middle. In some places several spots unite, forming
irregular semilunar patches ; at other places the spots are isolated.
Between the spots the skin retains its normal color ; in the face, it is
usually somewhat cedematous. According to 6r. Simon, the papules
on the measles eruption, although chiefly located at the point where
the hairs escape from the skin, are not swellings of the hair-follicles or
sebaceous glands, but consist of small collections of inflammatory exu-
dation at circumscribed points in the skin. Occasionally the eruption
shows an unusual tendency to confluence (morbilli confluentes) ; even
in such cases, however, the diffuse redness is not regular, but main-
tains an irregularly spotted appearance. In most of the spots which

MEASLES. 577

have existed for any time, a very slight escape of blood into the cutis
appears to complicate the hypersemia, because these spots only lose
their color slowly and incompletely under the pressure of the finger,
and, after disappearing, they generally leave, for a time, a dirty-brown
stain. In some cases the spots acquire a dark, blood-red color, from
greater extravasation of blood in the cutis, and in these cases we also
occasionally notice petechiae between the spots (morbilli petechiales,
rubeolce nigrce).

Since a large number of the deaths occurring during measles result
from complications with croupous laryngitis, bronchitis, or pneumonia,
we often find anatomical changes due to these diseases. Where death
is caused by laryngitis, it is by the croupous form. But in this second-
ary croup we do not find coherent pseudomembranes so often ,as we do
in common idiopathic croup. On the contrary, the exudation usually
infiltrates the upper layer of the mucous membrane, so that the inflam-
mation approaches the diphtheritic form of inflammation of the mucous
membrane. The lesion most frequently found in the bodies of children
who have died of measles, is capillary bronchitis, which has sometimes
induced permanent inspiratory distention of the alveoli (called acute
vesicular emphysema, by most authors; see Vol. I., p. 71), sometimes
collapse of the lung, and catarrhal pneumonia (Vol. I., p. 194). The
blood shows no characteristic change, but, as in other infectious dis-
eases, is poor in fibrin, fluid, and dark-colored.

SYMPTOMS AND COURSE. — During the period of incubation, there
is no sign of the disease. This is followed by the first stage, stadium
prodromorum, which rarely begins with a single chill ; more fre-
quently with repeated rigors, and is accompanied by all the symptoms
of a severe catarrh of the conjunctiva and air-passages, and the actual
disease can only be rightly interpreted from the existing epidemic.
Unless it be known that there is measles in the neighborhood, the
most experienced physician can hardly recognize in the existing severe
catarrh the prodromal stage of measles. Increased frequence of pulse,
heightened temperature, constitutional disturbance, pain in the head
and limbs, dyspepsia, nausea, vomiting, disturbed sleep, and, in exci-
table children, delirium, occur also during simple catarrh, from catching
cold. The local symptoms are generally very decided ; the burning,
reddened eyes shun the light, and are filled with tears, there is pain
in the forehead, the nose is stopped, and discharges a copious, limpid,
salty secretion ; attacks of sneezing occur at short intervals, and often
continue for hours; there is, sometimes, epistaxis, the voice is husky,
the painful cough is hoarse and barking ; at night, the attendants are
often frightened by the symptoms of pseudo-croup, previously described
(Vol. I., p. 6). The catarrhal affection appears generally to begin iu

57$ ACUTE INFECTIOUS DISEASES.

the nose, and to extend upward to the mucous membrane of the frontal
sinus and conjunctiva, and downward to that of the larynx and trachea.
The stadium prodromorum usually lasts about three days, while the
above symptoms are of variable intensity ; but in some cases it lasts a
week or longer, and in others the symptoms are very slight, and
readily overlooked. Even in malignant epidemics, the fever preceding
the eruption is rarely severe enough to threaten life, as it is in scarlet
fever. Nor are the local symptoms, severe as they often are, and ter-
rifying as they seem to the friends (especially the croupy cough and
nocturnal dyspnoea), usually dangerous. True croup rarely occurs at
this time. Pfeilsticker's observations of the course of the fever during
the prodromal stage showed that the temperature was highest the
first day, and subsequently sank till the day of the eruption. Ziems-
sen and Hehn also mention cases where, after the bodily temperature
had attained a considerable height the first day, it became perfectly
normal the following days, and remained so till the eruption appeared,
when it rapidly increased. During the prodromal stage, Rehn ob-
served an eruption of pale-red, rather undefined spots on the mucous
membrane of the cheeks, gums, lips, and fauces ; and he explains the
increase of temperature at the commencement as being the eruptive
fever of this exanthema.

The second stage of measles, the stadium eruptionis, commences
with an exacerbation of the fever ; the pulse becomes more frequent,
the bodily temperature rises to the highest point ; in some cases there
are convulsions. The above-described eruption appears first in the
face, especially about the mouth and eyes ; it soon spreads to the neck
and breast ; even in twenty-four hours it usually reaches the feet, so
that the whole body is covered. At this time the perspiration of the
patient has a peculiar odor, which strongly reminds me of a freshly-
picked goose. In rare cases, which generally show some other anom-
aly also, the eruption does not spread from the face to the extremi
ties, but makes its first appearance on the arms or legs, and afterward
elsewhere. Still more rarely, the exanthema is limited to certain
regions of the body, or, at least, on the rest of the body it is very in-
distinct. These cases resemble the morbilli sine exanthemate, which
unmistakably results from infection with measles poison, but from first
to last runs the course of a very severe catarrh, without the appear-
ance of any eruption. Lastly, cases occur where the eruption comes
out so slowly, that the stadium eruptionis is not completed in twenty-
four or thirty-six hours, but continues to the third or fourth day. In
these cases, the last spots frequently do not appear till the first ones
are fading away. During the eruptive stage, the constitutional dis
turbance and catarrhal symptoms usuallv increase, and attain theii

MEASLES. 579

height as the exanthema reaches its full extent. The stadium flores-
centice cannot be distinctly distinguished from the eruptive stage, for
hi most cases the exanthema is just at its height as the eruption is
completed, and it generally begins to disappear in twenty- four hours.
The fever, also, which usually attains its height at the completion of
the eruption, rapidly moderates, and sometimes disappears in the sta-
dium florescentiae, so that the parents have great difficulty to keep in
bed the little patients, who are often still covered with red spots, but
are already full of spirits. The catarrhal symptoms continue, it is true,
but they are much milder ; the photophobia is less, the secretion from
the nose is more scanty and thick, sneezing is rarer, the voice less
rough, the cough looser, and older children, who do not swallow the
sputa, cough up more or less muco-purulent masses (sputa cocta). On
the third or fourth day after their occurrence, the spots, especially those
of the first crop, are ordinarily much paler, or have entirely disappeared,
commonly leaving a bright-yellow discoloration on the skin for a time.

In favorable cases, the fourth stage, stadium desquamationis, usu-
ally succeeds the stadium florescentia the eighth or ninth day of the
disease. At this time the spots have entirely disappeared, and their
former seat is covered by a bran-like desquamation of the epidermis.
If the detached epidermic scales be softened, and macerated by con-
stant perspiration, the desquamation is not so evident as if the skin be
dry ; hence, it is less perceptible on the parts covered by the bed-
clothes than on the face, neck, and hands. In the desquamative stage,
the fever has almost always disappeared. The catarrh also passes off
gradually, and about the fourteenth day of the disease, or somewhat
later, as the desquamation ends, the measles terminates.

In many cases the disease runs its course without much deviation
from the description above given. These cases, where there is no
material deviation from the " normal " course, and where the different
stages are not accompanied by any peculiar symptoms, are usually
called morbilli vulgares, simpttces, or erethici.

In other cases, usually called inflammatory or synochal measles,
the exanthema appears with very violent symptoms ; the spots, which
are usually close together, and often confluent, do not begin to lose
color in twenty-four hours, but at this time grow darker, and remain
visible on the skin for five or six days. Occasionally the exanthema
assumes a violet or bluish color, and does not disappear under the
pressure of the finger ; this depends on partial rupture of the over-
filled capillaries, and may be regarded as analogous to the haemor-
rhages occurring in the inflammatory disturbances of nutrition. The
correctness of this view is supported by the fact that this form of
hacmorrhagic measles usually runs a favorable course, and is not at aP

580 ACUTE INFECTIOUS DISEASES.

complicated with the signs of dissolution of the blood. The fever
symptoms accompanying so-called inflammatory or synochal measles
resemble those observed in the course of acute inflammations. The
action of the heart is increased, the carotids pulsate strongly, the pulse
is strong, full, and more frequent, but not excessively so ; the bodily
temperature does not much exceed 104°. Just as in the case of the
exanthema, the affection of the mucous membranes is characterized by
longer duration, greater intensity and extent, in synochal measles.
As long as the exanthema is at its height, the photophobia, nasal
catarrh, and cough remain the same. It is this form of measles also
which is chiefly accompanied by croupous instead of catarrhal laryn-
gitis, in which the inflammation of the air-passages often extends to
the alveoli of the lungs, in which also the gastric and intestinal mu-
cous membrane is often affected with catarrh (gastric measles). If a
hoarse, barking cough and the dyspnoea characteristic of croupous
laryngitis occur in the stage of efflorescence, the state of the patient
is by no means so free from danger as if these symptoms accompany
the prodromal stage ; but in such cases the disease readily takes a bad
turn, the dyspnoea increases, the breathing is impeded, and, as the
skin becomes congested, the exanthema subsides, or, if it has been ac-
companied by haemorrhage in the cutis, blue spots remain, which do
not disappear on pressure. In regard to the modification of the symp-
toms induced by an extension of the catarrh to the finer bronchial
tubes, we must refer to the first volume, where we have fully de-
scribed the symptoms of capillary bronchitis and the dangers accom-
panying it, particularly during childhood. The description of collapse
of the lung and catarrhal pneumonia in the first volume also gives the
symptoms from which we may determine that these complications ex-
ist. Indeed, it is to the numerous observations of collapse of the lung
and catarrhal pneumonia, afforded by extensive epidemics of measles,
that we owe our accurate knowledge of the pathological anatomy and
symptomatology of these diseases. Far more rarely than catarrhal
pneumonia we have croupous pneumonia during synochal measles ; it
is almost always limited to one side, while catarrhal pneumonia usually
affects both sides ; the fever accompanying the latter is ordinarily in-
sidious, and disappears gradually, while that with the former runs a cyc-
lical course and defervesces suddenly. The course of the fever due to
the measles is decidedly modified by the above complications. This
is especially true in the case of the pneumonia. While, in uncom-
plicated measles, the fever, which has reached its acme at the height
of the eruption, subsides steadily, and often rapidly, it may attain
its acme much later when there is a complication with catarrhal or
croupous pneumonia. If measles be accompanied bv severe disease of

MEASLES. 581

the respiratory organs, and the consequent difficulty of breathing or
fever induce collapse, the eruption becomes pale, and may entirely
disappear in a short time. This symptom is often falsely interpreted,
as the disappearance of the eruption is regarded as the cause, not the
result, of the distress and of the bad symptoms in the respiratory ap
paratus.

A third class of measles described is the asthenic, typhous, or sep-
tic. In this very malignant form of the disease, the danger lies, not in
the extension of the catarrh to the bronchi, or in severe complications,
but in the pernicious influence of the measles poison on the entire or-
ganism. Measles resembles most acute infectious diseases in regard to
the great difference in the constitutional disturbance induced by the
infection during different epidemics. A physician who has only ob-
served epidemics of erethitic or synochal measles, such as have exclu-
sively occurred in Germany during the past ten years, may readily
suppose that measles poison has little constitutional effect. But this
view will soon be altered the first time he sees a case of asthenic sep-
tic measles. Even in the prodromal stage, the pulse, which is at first
full and strong, may become small, weak, and very frequent ; the pa-
tient very much depressed, the intellect cloudy, the tongue dry and
crusted, and patients may die of the increasing prostration, which is
occasionally interrupted by eclamptic spasms, even before the appear-
ance of the eruption. In other cases, these typhoid symptoms, which
are often accompanied by abundant epistaxis, do not begin, or do not
become dangerous, till the outbreak of the eruption. The exanthema,
which is usually irregular, is sometimes pale red ; sometimes bluish-
violet, as a result of coincident haemorrhage into the skin ; occasionally
there are petechiae between the spots, or bluish spots remain after the
exanthema has quickly disappeared. When the pulse has become
very small, and cannot be counted — the extremities cool, while the
body is hot — most patients die in a soporose state, with or without
general convulsions. It has not yet been accurately ascertained
whether the adynamia and paralysis occurring during measles, in-
ducing the so-called asthenic, typhous, or septic form of the disease,
be a direct result of the blood-poisoning, or if they be due to the ex-
cessive increase of bodily temperature induced by the infection. The
latter view is apparently supported by the fact, that in diseases not in-
duced by infection, as soon as the bodily temperature rises above a
certain point, the pulse becomes small and weak, and the same ner-
vous or typhoid symptoms appear ; as well as the second fact, that
remedies which lower the bodily temperature have a decidedly favor-
able effect on these symptoms.

The cough continuing during the desquamative stage forms a con-

ACUTE INFECTIOUS DISEASES.

necting link with the sequelae of measles; for it often remains for
weeks or months after tne desquamation is over, and grows worse
from the most trifling causes. In many cases this cough appears to
depend on simple bronchial catarrh, and its obstinacy and occasional
exacerbations seem due to increased vulnerability of the bronchial
mucous membrane, or to a sensitiveness of the skin remaining after
measles ; but, hi other cases, the cough is more serious, and depends
on severe disease of the lungs. It is well proved that measles often
induces pulmonary consumption, and, consequently, that after an ex-
tensive epidemic of measles, the rate of mortality among children is
usually increased for a few years. But it appears to me very doubtful
whether the chronic pulmonary tuberculosis, often induced by measles,
is always or chiefly due to a deposit of tubercles in the lungs during
measles, or to softening of tubercles already existing there. Most
cases of phthisis pulmonum in children are not due to deposit and
softening of miliary tubercles, but to caseous transformation and disin
tegration of the products of lobular pneumonia, which is generally also
accompanied by caseous degeneration of the bronchial glands. But
as lobular pneumonia is one of the most common complications of
measles, it appears very probable that the frequent occurrence of pul-
monary consumption, as a sequel of measles, is due to further meta-
morphosis of the products of inflammation, which have not yet been
resolved. But this does not mean that true tuberculosis of the lungs
never occurs as a sequel of measles (for I have several times seen acute
miliary tuberculosis directly follow measles), but only that most cases
of pulmonary consumption after measles depend on chronic destructive
pneumonia. Besides chronic bronchial catarrh and chronic pulmonary
consumption, the whole series of scrofulous diseases, especially ophthal-
mia, otorrhcea, chronic rhinitis, swelling of the lymphatic glands, chronic
inflammation of the periosteum and joints, may be mentioned as se-
quelae of measles. At least, we very frequently see children, who
had never before suffered from scrofula, troubled for years with various
forms of these chronic inflammations after recovering from an attack of
measles. Among the sequelae of measles, which, fortunately, are rare,
we may mention the mortification of the cheeks or vulva, noma, and
the diphtheritis of the oral mucous membrane, stomacace, which occur
even during desquamation.

TREATMENT. — The only efficient prophylaxis is a strict isolation
of healthy persons, who have not yet had the measles, from those in
whom the disease has broken out, as well as from those that are sus-
pected of being in the prodromal stage. To protect children from the
affection, it is necessary to keep them out of school ; and it is still
better, if possible, to send them away from the place where an eoi

MEASLES. 583

demic is raging. This plan will probably only be adopted in those
rare epidemics that are characterized by their malignancy and fatality ;
in mild epidemics this will not be done, because we know that sooner
or later almost every person has the measles. As inoculated measles
is not milder than other cases, and as malignant epidemics are rare,
inoculation during mild epidemics has not proved popular.

If measles has once broken out in a person, we must remember
that we have no remedy for cutting short the attack ; also that the
medicines usually given for the different symptoms are not only uncer-
tain, but often act injuriously on the course of the disease ; lastly, that
the great majority of cases end in recovery without any medical treat-
ment. If we remain convinced on this point, we shall abstain from
superfluous and dangerous medication. To most of the patients we
ehall probably give no medicine, but only order proper regimen, and
shall only act energetically when actual danger threatens. All mea-
sles patients should be kept in an even and moderate temperature. The
physician should insist that the temperature of the room be regulated
by the thermometer, not by the feelings of the nurse, and kept at
about 60° to 65°. And the chamber must be aired every day, while a
thin cloth is thrown over the head and face of the patient, and his bed
is protected from draughts by a screen. The old custom of leaving a
measles patient at least fourteen days without washing him, or chang-
ing his linen, has very justly been given up, since it has been proved
that, notwithstanding the dirt, the exanthema sometimes disappears,
but in most cases does not do so, in spite of careful daily ablutions.
But this excess of care is no worse than neglect of attention when
washing or changing the linen of the patient. Both of these opera-
tions must be done quickly, and without unnecessary exposure. Luke-
warm water is preferable to either cold or hot. The body and bed-
linen should not be taken from the clothes-press and placed directly on
the patient, but should be first warmed, and aired, or, still better, worn
for a night by some well person. The chamber should be darkened in
proportion to the degree of conjunctivitis and photophobia. If we
make the room too dark, by thick, green curtains, we render the eye-
trouble worse, for the patients are dazzled every time the door is
opened, and light enters the room. In the prodromal as well as in
the eruptive stage, we should order absolute diet, water-soup, bread,
and, if there be constipation, stewed fruit. If the fever subsides dur-
ing the stage of efflorescence, we may give meat broth and milk, and,
in the desquamative stage, let the patient return gradually to his cus-
tomary diet. Simple cold water, that has stood in the room for a
while, should be freely given, as it is never injurious, and does not
even render any of the symptoms worse temporarily. On the other
87

584

ACUTE INFECTIOUS DISEASES.

hand, it is cruel and injurious to withhold from the patient the only
thing that will quench his thirst, as long as he is feverish and thirsty,
and in place of it to make him drink warm tea or water. Sweet
drinks, which generally soon become distasteful to the patient, and do
not alleviate the cough, as they are expected to, are superfluous. The
time that the patients are to pass in bed, and in their chamber, should
aot be measured in the customary way by days and weeks, but we
should insist on his remaining in bed as long as there is any indication
of fever, while the desquamation is going on, and the cough is severe,
and he should keep his chamber as long as there is any trace left of
the measles-catarrh, whether the customary fourteen or forty-two days
have elapsed or not. Even after the patient has fully recovered, the
physician should keep a watchful eye on him for months, and should
particularly attend to any cough, no matter how slight and insignifi-
cant it may appear. Among the accidents that demand active treat-
ment, during measles, most authors place the " striking in of the erup-
tion " in the first rank, and consider its " restoration " as the most
important point in treatment. We do not hesitate to say that it is
just as unscientific as it is dangerous to carry out this indication; it is
dangerous because it readily induces rules which may have an injurious
effect on the course of the disease. As above shown, the so-called dis-
appearance of the eruption is not to be regarded as the cause, but
as the result of a bad turn of the disease, and is due to the general
collapse of the patient, in which the skin participates ; but, as we have
also shown above, this bad turn of the disease usually depends on the
appearance of some complication, especially pneumonia ; if this fact be
not borne in mind, if the patient be rubbed with irritating tinctures
and liniments, placed in a hot bath containing mustard or caustic pot-
ish, or wrapped up in blankets wet with decoction of mustard, " to
bring the eruption out again," we shall often do much harm, even if
we succeed in our object, because these procedures do not generally
ict advantageously on the pneumonia and other complications, while
they increase the fever. Among the symptoms of the prodromal stage,
the attacks of hoarseness, aphonia, and severe dyspnoea, which occur,
particularly during sleep, require the same treatment as when they
occur in the course of genuine laryngeal catarrh, such as emetics, hot
applications to the throat, and plenty of warm drinks. If the cough be
uncommonly severe and persistent, we may give adults five or ten
grams of Dover's powder at night, and for children, where opium is
dangerous, especially during fever, we may prescribe small doses of
lactucarium, or a weak infusion of ipecac, (gr. vj to f iv water, with
syrup | ss). If, during the stage of eruption and efflorescence, the fever
show a synochal character, there is no reason why we should not give

SCARLATINA. 585

nitrate of soda, although it will very rarely prevent any inflammatory
complications. Great care must be exercised in the employment of
tartar emetic, for violent vomiting and purging are injurious to measles
patients, and readily induce sudden collapse, even during so-called in-
flammatory measles. Laryngitis and pneumonia complicating measles
are to be treated in the same way as when they occur primarily, al-
though the prognosis is not so good ; the same is true of other com-
plications. In asthenic, typhous, and septic measles, quinine, mineral
acids, and stimulants, are most frequently given. I have not seen any
malignant measles recently ; but should it prove that they induce a
very high bodily temperature, from my experience in analogous forms
of other infectious diseases, I should not hesitate in such cases also to
wrap the patients up in cold, wet cloths, at short intervals, and to give
thorn large doses of quinine.

CHAPTER II.

SCARLET FEVER — SCARLATINA.

ETIOLOGY. — Scarlatina is an infectious disease, as is shown by a
few cases of successful inoculation, and by many well-known instances
where the disease was carried from one place to another by scarlatina
patients. It is less clearly proved that contagion is the only mode of
propagating the disease, and that scarlatina never develops sponta-
neously. At least, epidemics have occurred in places where its exten-
sion could be readily observed without its being detected, or even being
probable that the disease had been imported. We know no more about
scarlatina poison than we do about that of measles. The infection of
persons who have been near scarlatina cases, without being immedi-
ately in contact with them, appears to show that the poison is con
tained in the exhalations of the patient, and is mingled with the atmos-
phere about them. Well-proved facts also render it probable that the
contagion may be carried by persons who are not themselves affected
by the disease. Past experience has not yet taught us whether the
blood and secretions are also means of conveyance. The period of in-
cubation appears to be shorter than in measles, and to last only eight
or nine days. But, from the difficulty of deciding the time when the
infection terminates, this point is not exactly determined ; and, for the
same reason, we cannot accurately answer the question, In what stage
is scarlatina infectious ? The predisposition to scarlatina is far less
common than that to measles ; there are not a few persons who never
nave it. One attack almost unexceptionally removes the liability to
another. Nursing children often escape during an epidemic; while

ACUTE INFECTIOUS DISEASES.

those over two years old are most susceptible to the disease ; but even
adults, who have not had scarlatina during childhood, are often at-
tacked by it, and cases occur even in old age. In very large cities it
seems never to disappear entirely ; we do not know why the disease
occasionally spreads, and why, after occurring sporadically for a year,
it should suddenly break out into an epidemic. Nor do we know the
causes of the differences between epidemics in regard to the mildness
or malignancy of the attacks. Epidemics of scarlatina occur chiefly>
but not exclusively, in autumn and spring ; they succeed each other at
longer or shorter intervals, and are of very variable duration.1

ANATOMICAL APPEARANCES. — The anatomical changes in the skin
during life are those of a very extensive erythematous inflammation,
consisting of a very intense hyperaemia and an inflammatory cedema
of the superficial layers of the cuticle. The redness of the skin caused
by the hyperaemia begins as numerous small points, close together,
which soon unite and form an even redness (scarlatina Icevigata). Far
more rarely the redness is limited to a few spots of variable size and
irregular shape, or the surface is pale red, with some darker red spots
over it (scarlatina variegata). More rarely than in measles, collections
of inflammatory exudations at circumscribed spots form small papules
(scarlatina papulosd) ; on the other hand, exudation effused on the
surface frequently elevates the epidermis to numerous small vesicles
(scarlatina miliaris seu vesicularis), or to larger vesicles filled wit>
limpid or cloudy-yellow liquid (scarlatina pemphigoidea seu pustulosd)
In malignant cases, the hyperaemia of the skin is occasionally accom-
panied by more or less extensive haemorrhages, causing petechiae and
extensive ecchymoses. If death occurs at the height of the scarlatina,
the skin of the cadaver often appears thickened and hardened by infil-
tration, and we frequently find dried vesicles and dark-colored petechiae
on it, that have not disappeared after death as the hyperaemia has done.

Inflammation of the pharyngeal mucous membrane is induced by
scarlatina poison just as often as inflammation of the cutis is. The
most frequent form of this pharyngitis is the catarrhal, in which the
mucous membrane of the palate, tonsils, and pharynx, is dark red,
swollen, at first dry, but subsequently covered with quantities of mu-
cus. In malignant epidemics, scarlatina is not unfrequently localized
;n the pharyngeal mucous membrane as a diphtheritic inflammation ;
in such cases, the fauces and pharynx are at first covered with gray
plaques, which cannot be wiped off from the mucous membrane, be-
cause they are due to infiltration of its tissue with fibrinous exudation.
After lasting for a short time, this infiltration causes necrosis of the
patches of membrane, which are thrown off as discolored, badly-smell
ing sloughs ; and irregular losses of substance, covered with disinto

SCARLATINA.

587

grated tissue and dirty sanies, are left. In many cases this process
advances through the fauces to the nares, inducing the notoriously
malignant scarlatina coryza. The diphtheritic inflammation also occa-
sionally extends to the mouth and lips, and particularly to the angle
of the mouth, while it rarely attacks the larynx. Lastly, in some
cases, scarlatinous pharyngitis runs its course as a parenchymatous
angina, inducing great swelling, and, after a time, suppuration of the
tonsils.

Combined with the malignant pharyngitis, or even independent of
it, we often have inflammations of the parotids and lymphatic glands
and of the connective tissue of the neck ; these rarely end in resolu-
tion, but generally after a hard swelling of the inflamed parts has
lasted for a variable period, they terminate in suppuration or diffuse

necrosis.

Scarlatina is localized in the kidneys just as often as it is in the
skin or mucous membrane of the pharynx. The usual form of this
localization is an intense hypersemia and catarrh (throwing off of the
epithelium) by the uriniferous tubules ; but, in many cases, and in
some epidemics in almost all the cases, the scarlatina infection induces
orottpous inflammation of the uriniferous tubules instead of simple
nypersemia. "We should not consider either diphtheritic angina or mor-
bus Brightii among the complications of scarlatina ; or else we shall
have to regard the inflammation of the skin, catarrhal pharyngitis and
hyperaemia of the kidneys as complications and not symptoms of
scarlatina.

Perhaps the same thing is true of inflammation of the joints, pleura,
pericardium, and also with that of the ear, cornea, and other rarer dis-
turbances of nutrition observed during the course of this disease ; at
all events, there is no proof that, in cases where these inflammations
have occurred in scarlatina patients, there has been any second cause,
besides the scarlatina infection, acting on the patient to excite these
diseases as complications. It is, at least, fully as probable that the
infection, which generally only induces palpable changes in the skin,
throat, and kidneys, decidedly modifies the nutrition of the entire body,
and, under some unknown circumstances, excites severe, and conse-
quently perceptible, changes in the organs above mentioned.

Lastly, we may mention that, in the bodies of those who have died
ol scarlatina, the blood is generally poor in fibrin, thin and dark, and
occasionally the spleen and intestinal glands are tumefied.

SYMPTOMS AND COURSE. — It is customary to give the name sim-
ple, normal, or benign scarlet fever to those cases where the fever
maintains a synochal character, and where the perceptible localizations
of the disease are limited to the exanthema, severe catarrhal angina,

ACUTE INFECTIOUS DISEASES.

and simple hypersemia of the kidneys. We shall first describe the
symptoms and course of this simple form (which is, however, quite a
serious disease), and subsequently shall speak briefly of the modifica-
tions caused partly by the asthenic character of the fever, probably
from the great increase of bodily temperature, partly by the extent
and variety of the local affections.

During the stage of incubation, some patients complain of weari-
ness and depression, and an undefined feeling of sickness ; but most
of them feel quite well.

The prodromal stage begins with repeated rigors, more rarely with
a single chill. This is followed by a feeling of burning heat, nausea,
or actual vomiting, severe headache, feeling of great relaxation, pain
in the limbs, and the series of symptoms that accompanies almost any
severe fever. Even at this time the pulse is often 120 to 130 beats a
minute, and the bodily temperature occasionally rises to 104° to 105°, or
higher. Such an increase of the pulse and rise of temperature are not
often observed at the commencement of other diseases, even in inflam
mation of important organs, hence these symptoms alone should excite
the suspicion that we are dealing with the first stage of an infectious
disease. And, since, along with the fever, the subjective and objective
symptoms of pharyngitis usually occur, we may generally decide with
great probability, even at this time, that the case is one of commen-
cing scarlatina, and not of commencing measles, small-pox, or other in-
fectious disease. The patients complain of a feeling of dryness and
heat in the throat, and of pain, which is increased by swallowing. On
examining the throat, we find the mucous membrane of the tonsils and
soft palate dark rod and swollen. And in some cases the tongue is
already very red at the edges. Occasionally, the prodromal stage only
lasts a few hours, or the eruption may occur almost at the same time
with the fever, so that there is no real prodromal stage ; but in most
cases this stage lasts one or two days, and rarely longer. The inten-
sity as well as the duration of the prodromal stage varies in different
cases ; this is partly due to the individuality of the patient, partly to
unknown causes. Some patients are very much excited or delirious;
others lie benumbed and apathetic ; children not unfrequently have
convulsions, just as they do in other febrile diseases. Other patients
are less severely affected by the prodromal stage of scarlatina, and
have no serious symptoms.

The stadium eruptionis almost always begins with an exacerbation
of the fever. The symptoms accompanying the fever, also the head-
ache, weakness, excitement, or apathy, increase, and it is at this time
that convulsions most frequently occur in children. The eruption does
not come first on the face, as that of measles does, but begins on the

SCARLATINA. 589

neck, and thence extends over the body. Even in twenty-four cir thirty-
six hours the whole surface is usually covered with a scarlet color. In
the face, the cheeks only are generally red ; hence the exanthema is
less readily recognized here than elsewhere. The deepest redness is
usually on the neck, outside of the limbs, joints, hands, and feet. The
exhalations of the patient are said to smell like mouldy cheese, or
caged wild beasts in menageries. When the eruption appears, the
throat troubles increase, the fauces become more intensely red, the
tongue is of a dark raspberry redness, not only at the edges, but also
on its dorsum, from which the previous coating is thrown off; the
swollen and erect papillae give the surface of the tongue a rough ap-
pearance (cat's tongue). During the stage of eruption there are varia-
tions from the above symptoms, which have no material effect on the
course of the disease. For instance, in some cases the exanthema
spreads over the surface with uncommon rapidity ; sometimes the red-
ness is brighter, at others much darker ; in other cases the exanthema
presents the characters of scarlatina miliaris. In the same way che
throat troubles are sometimes very severe, again very slight ; they are
rarely accompanied by catarrh of the larynx, trachea, and bronchi.

In the stadium florescentice, which usually lasts four or five da^s,
the fever at first increases, reaching its height about the second day.
At the same time the eruption is in its bloom, and the threat trouble
has reached its height. The urine contains quantities of detached
epithelium, and often, traces of albumen ; the general health of the
patient is also most affected at this time. Then all the symptoms
usually begin to decrease, the frequency of the pulse and the tempera-
ture go down, the exanthema fades, the difficulty of swallowing grows
less, the general health improves. In this stage also, besides the mate-
rial deviations due to increase of the fever, or extensive and unusual
local affections, different cases do not agree in all respects ; occasion-
ally, the exanthema remains out longer, or it fades and disappears
earlier; the same is true of the changes in the pharyngeal mucous
membrane, and of the fever symptoms.

The stadium desquamationis usually begins on the fifth day after
the appearance of the eruption. While the eruption continues to some
extent in the extremities, especially about the joints, it disappears
about the neck, and here we first notice that the skin is rough and
dry, the epidermis is raised, and falls off in small shreds. A few days
later the redness usually disappears from the extremities also, and
desquamation begins. This does not occur in the extremities as it
does in the neck, with a detachment of small scales, but large flakes
come off, particularly from the hands, and they are not unfrequentl}
peeled off by the patient. During the stage of desquamation, which

590 ACUTE INFECTIOUS DISEASES.

lasts from eight to fourteen days, the last traces of fever and angina
disappear, and, when the disease runs a favorable course, it ends in
perfect recovery during the third or fourth week.

Scarlatina sine exanthemata and scarlatina sine angina belong to
the simple, or, at all events, to the benign cases. The former is only
to be distinguished from simple angina by its occurrence during an
epidemic of scarlatina, by the high fever, by the great constitutional
disturbance, and by a marked prodromal stage. In scarlatina sine
angina, the fever symptoms and the exanthema are characteristic ; but
localization of the scarlatina process on the pharyngeal mucous mem-
brane either cannot be found, or is limited to slight pain in swallow-
ing, or to faint redness of the fauces We should be very careful
about diagnosing scarlatina sine angina, particularly if it cannot be
proved that the patient has been near scarlet-fever patients ; from the
great similarity of the eruption, scarlatina sine angina can occasionally
only be diagnosed from some forms of roseola, especially roseola ab
ingestis, by considering the causes. Like measles, scarlatina may
prove very injurious, without any dangerous local symptoms ; the pa-
tients may even die of the disease before the customary local symp-
toms have appeared on the skin or pharyngeal mucous membrane. In
such cases the patients die of paralysis of the heart, which is preceded
by the symptoms of excessive adynamia. Here, as in the case of malig-
nant measles, we shall not attempt to say whether the alteration of
the blood has a directly paralyzing effect on the nervous system, and
especially on the nerves of the heart, or whether the injurious effect be
due to the high grade of the fever, that is, to the excessive increase of
bodily temperature. But since, even in simple benign scarlatina,
the temperature is usually very high, and since, as we have before
shown, a still further increase destroys life, as is proved by physiologi-
cal and pathological experiments, we regard it as very probable that
the excessive increase of bodily temperature in malignant, asthenic, or
typhoid scarlatina, induces the paralysis. The symptoms of asthenic
or typhous scarlatina closely resemble those of asthenic or typhous
measles and the same forms of other diseases, especially infectious dis-
eases. Even in the prodromal stage, the patients are very much de-
pressed ; they lie in a state of apathy, cannot collect their thoughts,
scarcely answer any questions, and finally become perfectly comatose
The pupils are usually dilated Slight twitchings of the muscles, and.
in children, general convulsions, not unfrequently occur ; the tongue
becomes dry, the pulse small, and scarcely to be counted ; the body is
often burning hot, while the extremities are cool. Even before the
eruption appears, the patient may die with the symptoms of excessive
collapse, and oedema of the lungs. The scarlatinous sore throat, which

SCARLATINA. 591

from the severe constitutional disturbance, is often overlooked in such
cases, is frequently of diphtheritic nature. If the patient do not die
during the prodromal stage, the eruption usually appears slowly and
irregularly, is pale or livid, only remains on the skin for a short time,
and is often accompanied by petechise, which remain after the disap-
pearance of the exanthema. The appearance of the eruption does not
generally induce any amelioration of the patient's symptoms ; on the
contrary, the high fever continues, the pulse becomes weaker, the pros-
tration greater. Diarrhoea and meteorism often occur, and the tongue
and gums are covered with dry sordes. Most of the patients die in
this stage of the disease, and of the few who reach the stage of des-
quamation the greater part die of the sequelae.

Cases, where angina maligna, infiltration, and suppuration of the
lymphatic glands, or other disturbances of nutrition, of themselves dan-
gerous, occur, may run just as malignant a course as those where gen-
eral paralysis is induced, directly or indirectly, by the excessive fever ;
we can only point out the various forms of the disease due to malignant
local affections, because any exhaustive description of them would be
impossible within the limits proposed for this work. Angina maligna
not unfrequently occurs during an apparently benign, or so-called nor-
mal scarlatina, and in its first stages is not by any means universally
accompanied by dangerous symptoms ; the difficulty of swallowing
only attains a high grade when, as happens in many cases, there is at
the same time a parenchymatous inflammation of the tonsils, which
often renders swallowing impossible. The participation of the nasal
cavities in the diphtheritic inflammation of the fauces is so constant
that the occurrence of a coryza, with a discharge of secretion which is
apparently bland and has no peculiar odor, is a very suspicious and
usually threatening symptom. This coryza rarely accompanies the
catarrhal form of scarlatinous angina ; hence we should dispel the illu-
sions of the parents, who consider this discharge from the nose as
favorable, and, when they see it, expect their children to escape any
cerebral trouble. The only certain point for the diagnosis of diphthe-
ritic angina, in its first stage, is the examination of the fauces, which
shows the above-described dirty-white, firmly-adherent plaques on the
dark-red mucous membrane. But, even in a few days, the symptoms
change, and the disease appears very dangerous ; it is true the exan-
thema offers no peculiar symptoms, but in the vicinity of the patient
we may perceive a fetid odor, which comes from his mouth and nose.
The sloughs, changed to dirty tags, adhere to the fauces, or, after they
have been detached, unhealthy-looking ulcers form. A yellowish,
badly-smelling secretion flows from the nostrils over the cheeks, and
corrodes the skin with which it comes in contact ; the cervical glands,

592 ACUTE INFECTIOUS DISEASES.

also, are much swollen, and form unsightly hard lumps at the sides of
the neck. The patient usually lies with the head thrown back, in a
half comatose or perfectly unconscious state ; the pulse, which was
previously full, becomes small and beats 140 to 160 times a minute ; the
bodily temperature rises to 104° or even higher. In such cases, just
as in measles complicated with lobular pneumonia, the fever induced
by the scarlatina infection becomes excessive from the accompanying
pharyngeal inflammation, and the bodily temperature is elevated to a
point where adynamia and paralysis always occur. Laryngitis, com-
plicating this form of angina, occasionally hastens the fatal result ; it
is characterized by hoarseness and dyspnoea rather than by croupy
cough. If the patient lives through the stage of efflorescence, des-
quamation often takes place normally ; but, in the most favorable
cases it lasts a long time, till the ulcers in the neck have healed, and
till the discharge from the nose has ceased. Quite often the inflam-
mation extends through the Eustachian tubes to the tympanum, result-
ing in otitis interna, which leads to perforation of the drum, and often
also to caries of the petrous bone. Hence, after scarlatina, many pa-
tients have otorrhcea for years, and suffer from deafness for the remain-
der of life. If the diphtheritic process has extended to the mouth and
lips, the resulting ulcers, especially those at the angles of the mouth,
heal very slowly. During the stage of desquamation and convales-
cence, the patients are liable to great danger from inflammatory infil-
tration of the lymphatic glands and subcutaneous connective tissue of
the neck. These rarely end in resolution ; and even suppuration re-
sults slowly, and is accompanied by fever, which wears out the patient.
I have seen patients die from suppuration of these enlarged glands,
even six or eight weeks after recovery from the scarlatina. Inflam-
matory infiltration of the cervical glands may also develop without
angina maligna, and in such cases also it induces increase of the fever
and consequent " typhoid symptoms." It is more probable that the
brain symptoms, are due to the high fever accompanying this infiltra-
tion of the glands than that they are caused by pressure on the vessels
supplying blood to the brain. Parotitis, which sometimes occurs dur-
ing the stage of desquamation, just as it does in the course of typhus
and cholera, must not be confounded with the above inflammations
and suppuration of the lymphatic glands. It is chiefly in this stage,
too, that we see inflammations of the synovial membranes, pleura, and
pericardium.

We have mentioned croupous nephritis as a frequent and im-
portant localization of the blood-poisoning in scarlatina. The fact that
scarlatina dropsy, which generally depends on this localization, usually
makes its appearance during this stage, has given rise to the still preva-

SCARLATINA. 593

lent belief that the dropsy and renal disease are due to cold, tc
which the patient has been exposed during the height of the exan-
thema or during the desquamative stage. The fact that albuminuria
and dropsy are very rarely seen in some epidemics, while they occur in
almost every case in others, sufficiently proves the error of this hypoth-
esis, although we cannot explain the causes of the difference in fre-
quency of nephritis, angina maligna, and other local affections in dif-
ferent epidemics. We have already (Vol. II., p. 12) fully described the
symptoms and course of croupous nephritis, and we can now refer to
that description the more readily, because most of the cases of croup-
ous nephritis, which formed the basis of that description, occurred in
children in the desquamative stage of scarlatina. While part of the
patients affected with hydrops scarlatinosum, which is a symptom of
acute inflammation of the kidney, recover and another part die with
the symptoms of ursemic intoxication, and still more of pneumonia,
pleurisy, pericarditis, etc., the second form of scarlatinous dropsy, not
accompanied with albuminuria, is a sequel of scarlatina as free from
danger as it is inexplicable. It generally develops gradually, may be-
come very extensive, is not limited to the subcutaneous connective
tissue, and rarely extends to the serous cavities. In some cases of very
extensive scarlatinous dropsy without albuminuria, recovery takes place
in a remarkably short time, as I know from my own observation.

TREATMENT. — Prophylaxis requires the isolation of healthy persons
from those affected with the disease and from those who have inter-
course with such patients. This is the only rule that promises any
good results ; hence it should be urgently recommended during malig-
nant epidemics. Belladonna (extract belladonnas gr. iij, aq. dest. f j ;
give daily twice as many drops are there are years in the patient's
age) is regarded as a prophylactic by some physicians as well as by
the homoeopaths ; but experience has shown that, even when continued
for weeks, this remedy affords no protection against scarlatina. The
same is true of all other medicines, either internal or external, that
have been recommended as prophylactics. The same rules apply to
the treatment of scarlatina as we gave for that of measles. Before
asking ourselves what we shall prescribe, we should decide whether
it is necessary or even admissible to interfere actively with the regular
course of the disease. We should keep the sick-chamber at an even
temperature, not exceeding 55° to 65°, not allow the patient to be cov-
ered with heavy bedclothes, freshen the air of the room occasionally
by opening the window, and have the patient carefully washed daily.
The best drink is pure cold water or lemonade ; as nourishment, we
may at first give water-soup, bread, stewed fruit, etc. ; later, we may
give meat-broths, milk, etc. If there be constipation, we may order

594: ACUTE INFECTIOUS DISEASES.

an enema of tepid water, avoiding active purges, except in case of
necessity. It is an old custom to keep scarlatina patients in bed till
the stage of desquamation is over, and it is well to keep up this cus-
tom, undeterred by the fact that patients neglecting this rule do not,
by any means, always suffer for so doing. Even after desquamation is
completed, the patient should be protected from cold, and in winter
should be kept in his room for at least a fortnight. During this time
he should take several baths in lukewarm water. In simple, mild
cases of scarlatina this expectant plan is sufficient, and should be pre-
ferred to any medicinal, hydropathic, or other treatment.

But, during scarlatina, changes often arise which urgently demand
therapeutic interference, and which are sometimes successfully com-
bated by energetic treatment. Chief among these changes are exces-
sive increase of the bodily temperature and consequent occurrence of
symptoms of adynamia and threatening paralysis. Formerly, in such
cases, general stimulants were employed, occasionally with the effect
of arresting the impending paralysis, as it seemed ; but most of the
patients died, in spite of the carbonate of ammonia, which was given
as a specific in scarlatina maligna. Recently, the knowledge that the
hydropaths treat scarlatina very successfully by wrapping the patient
in wet sheets, and by cold douches, has greatly increased the popular-
ity of this treatment, which had already been extensively used by
Currie, and other physicians, in the treatment of asthenic or typhoid
cases. And this is the most important therapeutic remedy in malig-
nant scarlatina ; and, in cases where there is no dangerous local disease,
it often has a surprising effect. The employment of wet sheets and
cold douches cannot be replaced by Schneemanrts treatment of smear-
ing the whole body with grease twice daily during the first three
weeks, once daily during the fourth week, although this operation
renders the patient more comfortable. I shall not attempt to say
whether placing the patient in an empty tub and pouring cold water
over him, or wrapping the naked body in wet sheets, deserves the
preference ; but we should abstract heat by one method or the other
every time the temperature of the body becomes excessive, and the
symptoms of adynamia reappear. The wet sheets should be reapplied
from three to six times, at intervals of ten or fifteen minutes ; the pa-
tient should then be placed in bed, and left quiet till it is necessary to
repeat the process. As even the laity are tolerably familiar with the
success of the hydropaths, we rarely meet any great objection to the
above treatment, even in private practice. If we should find this ob-
jection, large doses of quinine should be given, although I cannot
speak of its benefits from personal experience, as I can of those from
the energetic abstraction of heat. In desperate cases, where the

ROSE-RASH. 595

above plan fails, we may try to prevent the impending paralysis by
powerful stimulants, such as carbonate of ammonia, camphor, musk,
etc. The development of angina maligna is not arrested by abstrac-
tion of blood, or the local application of cold ; but pieces of ice taken
into the mouth, and allowed to melt there, have a favorable palliative
effect in this as in other severe forms of scarlatinous pharyngitis. As
soon as the sloughs have been detached, and foul ulcers are left in the
throat, we should proceed to energetic local treatment. We may
touch the ulcers daily with a solution of nitrate of silver ( 3 j to | ij
water), applied by means of a probang, and for the coryza, which al-
most always coexists, we may inject a weak solution of nitrate of sil-
ver (gr. v — x to § ij water) into the nostrils. I have not only seen
unmistakable benefit from this treatment in some cases, but I have
found that older children submit to the annoying operation without
much opposition, because they find that it relieves them. Croup com-
plicating angina maligna indicates the administration of an emetic, and
the application of a solution of nitrate of silver to the glottis. We
cannot do much against inflammatory infiltration of the lymphatic
glands and connective tissue of the neck. According to my experience,
abstraction of blood, cold, irritant, and resorbent remedies, cataplasms,
etc., have no effect on these hard, indolent tumors, which are covered
by normal skin. When they show a tendency to suppurate, and the
skin over them grows red, we may apply cataplasms. As soon as
there is fluctuation, the pus should be evacuated, to prevent extensive
mortification of the tissues, which the pressure of the pus threatens to
induce. We sufficiently explained the treatment of croupous nephritis
when treating of renal affections, and may also refer to what has been
already said for the treatment of scarlatinous dropsy, accompanied with
albuminuria. According to my experience, a mild diaphoretic treat-
ment suffices for simple cases of dropsy without albuminuria.

CHAPTER III.

ROSE-BASH — ROSEOLA FEBRILIS.

Cannstatt aptly defines rose-rash as an eruption witn red spots,
concerning which, from its general symptoms and the affections of the
mucous membranes, we are in doubt whether it should be classed with
scarlatina, measles, urticaria, or erythema, as it resembles one or other
of these diseases in some points, while differing in others. Epidemic
roseola arising from infection, which alone we shall discuss here, from
unknown causes consists in modifications of scarlet fever or measles.
By rubeola scarlatinosa, we mean a scarlet fever where the exanthema

ACUTE INFECTIOUS DISEASES.

resembles measles, while the high fever, the throat affection, and the
dropsy, which often follows, resemble the course of scarlatina. By
rubeola morbillosa is meant a form of measles where the exanthema
is confluent, and resembles that of scarlatina, while the affection of
the respiratory mucous membrane and the escape of the pharyngeal
mucous membrane leave no doubt of the morbillous nature of the
disease.

CHAPTER IV.

SMALL-POX — VARIOLA — PETITE VEROLE.

ETIOLOGY.— Small-pox spreads solely by contagion ; at least, any
other cause of its extension and a spontaneous development of variola
poison is very improbable, as we can always trace the contagion where
there is no peculiar obstacle in the way of our seeking it. Small-pox
poison, which we only know from its effects, is contained in the con-
tents of the pustules, and in the perspiration of patients having the
disease. This is proved on the one hand by successful vaccination
with the contents of the pustules, and on the other by the contagion,
which, in most cases, results without immediate contact with small-
pox patients. The poison is most active at the period when the
clear contents of the pocks begin to turn cloudy. The negative
results of attempts at vaccination with the blood and secretions of
small-pox patients, seem to prove that the poison is not contained in
these fluids. Variola poison is very tenacious of vitality ; it is not de-
stroyed by drying ; it clings for a long time to objects that have been
near a patient with the disease, and, when protected from the air, it
remains active for years. The same poison induces the severe forms
of variola as well as the mild ones of varioloid. If a healthy person
be infected by a patient with varioloid, he may have a severe variola,
and the reverse. The different effect of the poison, that is, the un-
equal intensity of the symptoms, appears chiefly due to the greater or
less susceptibility of the patient exposed to the poison. This indi-
vidual predisposition has always been very unequal ; for, in former
centuries also, there were some persons who were perfectly insuscep-
tible to variola poison, so that they could expose themselves to it with
impunity ; there were others in whom the susceptibility was so slight
that they were only attacked by the milder forms (varioloid) ; wliile,
in most persons, it was so decided that, on exposure, they were affected
with the severe form of the disease (variola). The liability to small-
pox, which, with the above exceptions, is common to all mankind, well
and sick, young and old (even the foetus), men and women, expires al-

SMALL-POX. 597

most entirely for the rest of life, after one attack. The disease arti-
ficially induced by vaccinating with the cow-pock has a similar effect
on the predisposition. In some persons it seems to remove the ten-
dency to the disease for life, in others only for a number of years ; but
the latter class are rarely affected with severe forms of small-pox when
exposed to infection. Since, in our day, almost every one has been
vaccinated during childhood, it may be readily understood why the
number of cases of small-pox is far smaller now than before the intro-
duction of vaccination ; and since, after vaccination, any returning dis-
position to small-pox rarely reaches a high grade, we may also under-
stand why, in the epidemics of the present day, the milder forms of
the disease (varioloid) preponderate over the severer forms, which
were formerly the most common. At certain times, in more or less
extensive localities, from some unknown cause, the intensity of small-
pox poison, or the susceptibility to it, is greatly increased ; epidemics
result. These are more apt to occur in summer, but are not limited
to any season. They have a variable duration, and the cases are
sometimes malignant, at others very mild, although we cannot dis-
cover any cause for this difference.

ANATOMICAL APPEARANCES. — The anatomical changes in the skin,
after infection with small-pox, are those of a superficial dermatitis, with
a tendency to suppuration. In the milder forms of the disease, the
suppuration starts from the cells of the rete Malpighii only ; in the
severer forms, on the other hand, it attacks the tissue of the cutis,
destroys it, and leaves a loss of substance, which is replaced by cicatri-
cial tissue. It is only in the latter cases that evident traces of the
disease (pock-marks) remain for life. In the somewhat malignant
epidemic that raged in Germany last year, these extensive and
deep destructions of the skin, such as used to occur frequently, were
rarely seen.

Variolous dermatitis commences with circumscribed hypersemia of
the skin, which, according to Barenspntng, extends through the cutis
into the subcutaneous tissue. Very soon, elongation of the papillae in
the efflorescence, and, more particularly, swelling of the cells of the
rete Malpighii, change the hyperaemic spot of skin into a sharply-
bounded nodule, flattened on top, which is not as yet excavated, and
contains no fluid, but is perfectly solid. If the process advances
(which is not always the case), the outer layer of the epidermis is ele-
vated to a vesicle by a fluid exudation. The contents of this vesicle,
at first clear, are soon clouded by the formation of pus-cells, which form
from the young cells of the rete Malpighii, and the vesicles are thua
changed to pustules. Besides the fluid exudation, the pus-corpuscles
mixed with it, and the swollen cells of the rete Malpighii (which ofter

598 ACUTE INFECTIOUS DISEASES.

form a ring-shaped swelling at the edge of the pock), we find a mesh-
work in the pock pustule, which results from old cells of the rete Mal-
pighii, compressed by the exudation, particularly of the central cells
of the epithelium dipping down between the papillae. This mesh-
work traverses the middle of the pock more particularly, and causes
the fan-like formation which has been so much discussed. If the vari-
olous inflammation has not extended to the papillae, they are com-
pressed and flattened by the pressure of the pock ; in such cases the
pock-pustules dry up early. New epidermis forms under the resulting
scabs ; when it is fully formed, the scabs fall off. A shallow excava-
tion is occasionally left at the point where they have been, as the flat-
tening of the papilla is not removed. The case is different when the
papilla becomes infiltrated with pus, and breaks down. In such cases
the contents of the pustules are changed into a more purulent fluid by
the greater admixture of pus-cells, and by the detritus resulting from
the breaking down of the papillae. The pustules become more dis-
tended, and thus the umbilications (or shallow depressions in the cen-
tre) of some pustules are obliterated. Some pocks burst, and allow
their contents to trickle out, others dry up ; in the latter case, as the
middle part dries first, the umbilication is sometimes renewed. The
resulting scabs do not fall off for some time, and they leave depressed,
radiated cicatrices, on whose base we may see the dilated openings of
the hair-follicles.

The variety in extent and form of the pocks has induced the divi-
sion into different classes. According as the pustules remain separated
by intervals of healthy skin, or touch each other, or, lastly, unite to-
gether into vesicles, the cases are divided into variolce discretce, cohce-
rentes, and confluentes. Where the pocks do not pass beyond the
first stage, so that no vesicles form on the sharply-bounded flattened
nodules, it is called variola verrucosa. Variola lymphatica or serosa
is where the contents of the pock do not become yellow and purulent,
but remain a clear or slightly-clouded fluid ; variola cruenta is where
I he pocks are colored red or blackish, by the admixture of blood
(" black pox "). A form where the contents of the pock are absorbed,
and the empty covering alone remains, is called variola siliquosa seu
emphysematica ; where the pock is filled with a discolored, ichorous
matter, and accompanied by gangrene of the skin, the disease is termed
variola gangrenosa.

We do not find pocks on the serous membranes in autopsy of
small-pox patients, but we not unfrequently find the remains of inflam-
mation, with haemorrhagic exudation. Sick found fatty, extensive
degeneration in the liver, kidneys, heart, and muscles of patients who
had died of variola.

SMALL-POX. 599

SYMPTOMS AND COURSE. — During the period of incubation there
are usually no symptoms either in mild or severe cases. After the in-
oculation of variola, changes occur at the point of inoculation, even on
the third day ; but the general health of the patient remains undis-
turbed, and no other symptom shows the infection till about the ninth
day ; as the pustule completes its development, the period of incuba-
tion terminates. Then there is an eruptive fever, followed by an out-
break of pocks on the other parts of the body, and by other signs of
general infection. According to the observations of Barensprung and
Ziemssen, the period of incubation of non-inoculated pocks lasts twelve
or thirteen days.

We shall first describe the symptoms and course of the severe
forms, true variola, and close with a description of the milder forms,
varioloid.

The first stage of variola, the stadium prodromorum sen invasionis,
commences with a chill, or with several rigors, which soon give place to
a feeling of permanent heat. The pulse is full, and frequent, the tem-
perature increased sometimes to 104° or 106°, the face is reddened,
the carotids pulsate strongly ; the patients have great thirst, loss of
appetite, a bruised feeling in the limbs, and a sensation of pressure
and fulness in the epigastrium ; the tongue is coated, the taste slimy ;
nausea and vomiting are frequent, sometimes there is severe epistaxis.
Sleep is restless, and broken by dreams. Some patients become de-
lirious ; in children we not unfrequently see twitchings, and gnashing
of the teeth, or a somnolent condition, which is occasionally interrupted
by general convulsions. The high fever and severe constitutional dis-
turbance are not accompanied by such characteristic affections of the
mucous membranes as would enable us to decide the nature of the ex-
isting infectious disease before us, as we can do in the prodromal stage
of measles and scarlatina ; but the symptoms above mentioned are al-
most always accompanied by such severe pain in the sacral and lumbar
regions, that we may very strongly suspect the existence of small-pox,
when this disease is prevalent. It is not known whether the sacral
and lumbar pains, so characteristic of the prodromal stage of variola,
depend on hyperaemia of the spinal medulla, on pressure on the spinal
nerves, where they escape from the vertebral canal, by the distended
venous plexus, or on the excessive hypersemia of the kidney, concern-
ing which J3eer has made some important suggestions in his valuable
examinations into the connective tissue of the kidneys. After imper-
fect remissions during the second and third day, the fever and accom-
panying disturbances usually increase, and attain their height on the
evening of the third day. Generally, the intensity of the symptoms in
the prodromal stage is in direct proportion to the subsequent eruption,
88

600 ACUTE INFECTIOUS DISEASES.

and the highest fever and most severe disturbances usually precede
confluent small-pox. But this is not always the case; sometimes a
Bevere prodromal stage is followed by a scanty eruption; in other
cases, a very mild prodromal stage precedes a confluent eruption.
Deviations in the duration of the prodromal stage are rarely observed,
and still more rarely it is entirely absent, and the eruption is the first
symptom.

The second stage, stadium eruptionis, almost always begins with
the appearance of the first papules in the third exacerbation of the
fever. If the eruption be very copious, the red points lie close to-
gether, and unite at some places, as they do in measles, or by a general
confluence they cause a regular redness, and granular swelling of the
face ; if the eruption be scanty, the different nodules remain isolated,
and are separated by more or less extensive patches of normal skin.
The next day the eruption usually spreads from the face to the neck,
breast, and back, and on the third day to the extremities. The num-
ber of papules on the body and extremities is proportionately far less
than on the face ; so that, even when the disease is confluent on the
face, the pustules on the body and extremities usually remain discrete,
or at most would be called variolae cohaerentes. The points gradually
become large, blunt conical nodules ; the second or third day these
change to vesicles, and the third or fourth to pustules, the contents
becoming cloudy and purulent. The pocks appear late on the extrem-
ities ; they also develop late ; on the face, the papules have become
larger, and changed into vesicles, or their contents have become
cloudy when the first nodules appear on the extremities. The erup-
tion on the mucous membrane begins at the same time it does on the
skin ; but we do not generally notice it till later, as it at first causes
little trouble. The pocks in the mouth induce increased flow of saliva ;
those in the pharynx, difficulty of swallowing ; those in the air-passages,
hoarseness and cough ; those on the conjunctiva, lachrymation and pho-
tophobia. The fever, the severe pains in the sacral and lumbar re-
gions, and the constitutional disturbance, which attain their height
toward the end of the prodromal stage, always remit when the erup-
tion icomes out, decrease still more as it extends to the body and
limbs, and toward the end of the eruptive stage the patient usually
feels quite well. He is then encouraged because he thinks he has
passed through the worst. A few years since, a patient with conflu-
ent small-pox presented himself at my clinic, who, after lying in bed
lor three days at Esslingen, with severe fever, had walked the five
miles from Esslingen to Tubingen without difficulty. In confluent
small-pox the eruptive stage is usually shorter, the exanthema spreads
:>ver the l>ody more rapidly, the contents of the pocks become purulent

SMALL-POX. 601

earlier, and from the confluence of the pustules the face often looks as
if it were covered with one large bladder of matter. The affections of
the mucous membrane also, which in variola discreta do not usually cause
much trouble at this time, are also accompanied by very painful symp-
toms, severe salivation, dysphagia, croupy cough, great photophobia,
and by ischuria and burning pains in the external genitals. The high
fever and severe constitutional disturbance of the prodromal stage re-
mit during the eruptive stage of confluent small-pox also, but only to
a moderate extent ; the fever never disappears entirely, as it does in
discrete variola, nor does the patient feel well toward the end of the
eruptive stage, as he does in the latter form.

The third stage, stadium suppurationis seu maturationis, begins
about the sixth day after the first appearance of the eruption, and about
the ninth day after the first symptoms of fever. The pocks become
larger ; the bluntness of their summit gives place to a hemispherical
shape. If they be punctured, their thick purulent contents escape all
at once, because of the atrophy of the partitions, which previously let
only part of the contents escape on puncture. The skin around the
pocks swells decidedly, and becomes dark red ; even in discrete variola
the red areola surrounding one pock unites with that around the next.
The redness and swelling thus become diffuse. The patients are
greatly disfigured, and complain of severe, tense, pulsating pain in the
reddened skin, which is covered with large pustules. More or less of
these pustules rupture, and their contents flow over the surface, where
they dry into crusts, which are at first yellow, subsequently brown.
In these changes, also, the pocks on the body and extremities are one
or two days behind those on the face. The pain and distress induced
by the intense dermatitis are increased, during the suppurative stage?
by the annoying symptoms due to the eruption on the mucous mem-
brane. The saliva trickles constantly from the mouth of the patient,
swallowing becomes almost impossible, the nose is stopped, the voice
inaudible, the cough distressing and hoarse, the eyes, dark red and
filled with muco-pus, burn and are very sensitive to the weakest light.
The eruption in the vulva, vagina, and urethra, comes later than that in
the mouth, pharynx, and larynx ; hence the tense, burning pain in the
external sexual organs and the ischuria are most severe after the sali-
vation, dysphagia, and laryngeal symptoms have subsided. The fever,
which had moderated or even disappeared during the eruptive stage,
exacerbates during the suppurative stage, or begins anew with re-
peated chills. This fever is generally called the secondary or suppu-
rative fever, and it really seems as if the secondary fever did not
directly depend on the variolous infection, but were chiefly or solely
due to the dermatitis. The more severe and malignant the inflamma

ACUTE INFECTIOUS DISEASES.

tion of the skin, the mere intense is the fever; the dermatitis and the
fever attain their height together, and the decrease and disappearance
of the eruption go hand in hand with the decrease and subsidence of
the suppurative fever. In many cases the suppurative fever becomes
dangerous, because the bodily temperature rises so high as to induce
the symptoms of adynamia and fatal paralysis (asthenic, nervous,
typhous small-pox). In such cases, just as in asthenic measles and
scarlatina, the symptoms of adynamia are not unfrequently accom-
panied by those of an acute haemorrhagic diathesis ; the contents of
the pock become bloody, and petechiae appear between the pocks.
Occasional!}^ also, there is profuse epistaxis, more rarely haematem-
esis, bronchorrhagia, or metrorrhagia (haemorrhagic or septic small-
pox). In some rare cases, during the excessive adynamia of the sup-
purative stage, the inflammation of the skin increases to partial morti-
fication of the inflamed tissue ; gangrene of the skin results, and the
pocks fill with a discolored ichor. Such patients almost always die
early with the symptoms of excessive prostration (gangrenous small-
pox). Besides the adynamia induced by the high fever, and besides the
occurrence of a haemorrhagic diathesis or of cutaneous gangrene, which
favor the threatening paralysis, the suppurative stage is especially
dangerous on account of the localization of the variolous process on
the serous membranes and in the parenchymatous organs, which occurs
most frequently during this stage, and from the frequent increase of
the affection of the mucous membrane to croupous and diphtheritic in-
flammations. Thus, in many cases, increased dyspnoea, sharp pain in
the side, tormenting cough, bloody expectoration, as well as the phys-
ical signs of condensation of the lung, show the occurrence of pneu-
monia. In other cases the subjective and objective signs of pleurisy
accompany the above symptoms of the stage of maturation. The
symptoms of the disease are also variously modified by the occurrence
of suppuration of the joints, suppurative periostitis, subcutaneous, and
intermuscular abscesses, inflammation and suppuration of the lym-
phatic glands, panophthalmitis which begins as a hypopion and may
be readily overlooked, as well as by the symptoms of pericarditis,
meningitis, or of pyaemia from absorption of ichor. It is chiefly in
confluent small-pox that the fever assumes an asthenic character during
the suppurative stage, and that unusually dangerous local diseases of
the internal organs occur. Moreover, in confluent small-pox, during
the stage of maturation, the eruption on the mucous membrane of the
pharynx and larynx readily becomes complicated with croupous exuda-
tion and oedema of the glottis. Hence, this form of the disease is
correctly considered very malignant ; and confluent small-pox is often
regarded as identical with malignant.

SMALL-POX 603

The fourth stage, the stadium exsiccationis, usually begins on the
eleventh or twelfth day. Part of the pustules, which have remained
unruptured up to that time, burst, and their contents, which are thrown
out, dry to soft, yellow crusts, which subsequently become hard and
brownish. The other pocks lose their tension, become brown in the
middle, dry, and sink in ; gradually the contents and wall of the pock
dry into a round scab. In proportion as the formation of the crusts
progresses, the parts around lose their redness and swelling ; the pa-
tients again become recognizable ; the tense, pulsating pain subsides,
and gives place to a very annoying itching, so that the patient finds it
very difficult to avoid scratching. In the stadium exsiccationis it is
usually most evident that the pocks on the extremities are of more
recent origin than those on the face ; for just at the time the painful
tension and the disfigurement of the face are disappearing or are al-
ready gone, the patients complain of unbearable pain in the swollen
fingers and toes. The scabs are detached very irregularly; at the
points where there has been no ulceration of the skin (and these are
more or less frequent, even in the most malignant cases) the crusts do
not generally remain attached more than three or four days ; on the
other hand, at points where the ulceration has entered deeply into the
cutis, the crusts remain attached longer; as the suppuration contin-
ues, they become thicker and horny. The crusts that fall off early
leave red spots, which are somewhat elevated as long as the skin re-
mains swollen, and which, after a time, disappear without leaving a
trace, or else change to slight depressions. On the other hand, when
the crusts that have remained adherent for a long time at last fall off,
round deep cicatrices are left, these have inverted edges and a punc-
tate, seamed base. They are at first red, then become very white, and
last during life. The symptoms induced by the eruption on the mu-
cous membrane disappear when the redness and swelling of the skin
subside. The salivation, dysphagia, hoarseness, cough, photophobia,
and ischuria, all cease gradually. At the commencement of the stadi-
um exsiccationis the fever continues, but is moderated (exsiccation
fever) ; but the more the formation of the crusts progresses the more
the fever decreases ; the pulse becomes quiet, the skin is covered with
perspiration, the urine deposits a sediment, the general health becomes
normal. In confluent small-pox, which usually extends more in depth,
as well as superficially, than other varieties, during the drying stage
thick, dark crusts form, which cover the face like a mask. The irreg-
ular crusts constantly increase on account of the continued suppuration,
and cracks form in them, from which the pus trickles out. Finally, the
trusts fall off in large pieces, and extensive irregular losses of sub-
stance are left, instead of small round cicatrices, as after variola dis*

ACUTE INFECTIOUS DISEASES.

jrcta. In such cases, just as after deep burns, the retractions of the
cicatricial tissue readily induce tense cicatrices, or bridge-like strings,
ectropion, distortion of the mouth, etc., which cause the most hideous
deformities. Not unfrequently, a previously beautiful countenance is
rendered disgustingly ugly by confluent small-pox. Salivation, hoarse-
ness, cough, and the other symptoms of variolous affections of the mu-
cous membranes, disappear far more slowly after confluent small-pox
than after the discrete form. And the affections of important organs
that have been caused by the infection during the eruptive stage have
not usually terminated in the suppurative stage. At this time the
patient often has subcutaneous and intermuscular abscesses, boils, and
other localizations of the variolous process, but especially pyasmia.
Hence, too, the secondary fever is usually more severe and continued
in confluent small-pox than in the discrete, and even in the most favor-
able cases a long convalescence follows the severe disease.

We may describe varioloid very briefly, because its symptoms dif-
fer from those of variola only in degree. The prodromal stage is the
same as that of small-pox, except that it is shorter and less intense.
But there are numerous exceptions to this, a severe and protracted
prodromal stage being sometimes followed by varioloid instead of by.
variola. The appearance of an erythematous rash, forming large red
spots, or of a diffuse scarlatinous redness over a large part of the body,
particularly the lower part, is somewhat characteristic of varioloid, be-
cause it occurs more rarely in variola. This exanthema precedes the
varioloid eruption from twelve to twenty-four hours. In the eruptive
stage, which usually begins with the third exacerbation of the fever,
the eruption does not spread from the face to the body and extremities
quite so regularly as it does in variola. The eruption usually ends in
twenty-four or thirty-six hours. The pocks are generally less numer-
ous than in variola ; they rarely become confluent, and then only at
certain spots. The papules become vesicles, and the vesicles pustules,
much sooner than in variola ; the form of the efflorescence offers no
peculiarities. In varioloid also, the mucous membranes are affected,
and we have salivation, difficulty of swallowing, hoarseness, cough, etc.
As the eruption terminates, the fever usually disappears entirely, and
the patient almost always feels quite well, except suffering some incon-
venience from the affection of the mucous membrane. The most im-
portant differences between varioloid and variola occur in the stage of
maturation ; for it is then most evident that in the milder form the
dermatitis is more superficial, while in variola it affects the parenchyma
of the cutis deeply. During the suppurative stage the pocks are filled
with thick fluid pus, they become larger, and hemispherical ; some of
them burst, and let out their contents ; but the areola around them is

SMALL-POX.

605

smaller, and less swollen, consequently the tension of the skin, the
pain, and deformity, are always less than in variola. As the dermatitis
is not so severe, the secondary fever is less, and, when the eruption is
very scanty, the stage of maturation may run its course almost with-
out fever. During the suppurative stage variola and varioloid differ
less in regard to the affections of the mucous membranes ; for the pho-
tophobia, dysphagia, cough, and hoarseness in varioloid often trouble the
patient as much as they do in variola ; on the other hand, croupous and
diphtheritic inflammations of the mucous membranes, and malignant af-
fections of the internal organs, are very rare. The suppurative stage
usually passes into the stage of desiccation by the fifth or sixth day of
the eruption. But few pustules rupture ; most of them dry up with
their contents ; a brown, dry spot forms in the centre, gradually be-
comes larger, and as it reaches the periphery, the pock changes into a
brown scab ; most of the scabs fall off in three or four days, and leave
red, somewhat prominent spots. The contents of some of the pocks
are not thickened, but are reabsorbed, and, instead of a slough, the
wrinkled, dry envelope is thrown off; this course is seen quite often,
especially in the pocks on the extremities. But, as, in the severest
cases of variola, some pocks always spare the tissue of the cutis, and
do not leave a scar, so, in the mildest cases of varioloid, single pocks,
which exactly resemble those of variola, often cause a loss of substance,
and leave cicatrices. If we group the peculiarities that distinguish
varioloid from variola, we should mention especially: 1. The short
duration of the different stages, and of the entire disease. 2. The
mildness or total absence of the secondary fever. 3. The escape of
the cutaneous tissue, and the recovery without cicatrices. 4. The
slighter mortality. In the times when, during small-pox epidemics,
variola prevailed, or occurred exclusively, a third, or in some epidemics
even a half, of the patients died. Of late, as the disease almost exclu-
sively affects persons who have been vaccinated, and consequently
varioloid is in excess, the mortality is very low ; scarcely four or five
per cent, of the patients die.

TKEATMEITT. — Prophylaxis demands vaccination or revaccination.
All objections to vaccination, even if well founded, would have to give
way to the facts, proved by statistics, that in the last century one-
tenth of the population died of small-pox (about 400,000 people dying
of the disease every year in Europe), another tenth were disfigured by
the disease ; and that, since the introduction of vaccination, the general
mortality is less, and that of small-pox is reduced to a minimum. Dur-
ing an epidemic, persons who have been vaccinated, but in whom the
vaccination has not yet taken, are attacked by small-pox, and the two
diseases run their course at the same time without modifying eacb

ACUTE INFECTIOUS DISEASES.

other. These cases show that vaccination during the period of incuba-
tion of small-pox cannot cut short the disease, and also that the sus-
ceptibility to vaccination is not lost during the period of incubation.
To avoid vaccinating persons who are already in the inclibation stage
of variola, it is well for a physician to vaccinate without delay all of
his patients, where he considers the operation necessary, as soon as he
knows of the appearance of small-pox in the vicinity. Inoculated
small-pox generally runs a milder course than that due to infection, it
is true ; but the exceptional cases where the inoculated variola runs
a malignant course, and ends fatally, are still so numerous that at pres-
ent we should not think of inoculation, as we have vaccination to rely
on. Besides vaccination and revaccination, we should not be deterred
by any personal considerations from exercising the most stringent rules
for the isolation of small-pox patients, even if they should be very an-
noying for the patient and his friends.

The treatment of small-pox can only be symptomatic, as we know
of no remedy for cutting short the disease, and averting dangerous
accidents. In the prodromal stage the patient should be kept mod-
erately cool, the temperature of his room should be about 60°, the bed-
covers should not be too heavy ; we should not dose him with warm
tea, but let him have cold water or lemonade, absolute diet, and, where
there is constipation, we may order enemata of three parts of water to
one of vinegar. If the prejudices of the patient render it necessary to
give some medicine, we may order a solution of nitre. Even in severe
congestion of the head, with a full pulse, we should avoid bleeding,
which was formerly so popular in inflammatory small-pox, and limit
ourselves to the application of cold to the head, and repeated ablutions
of the body with cold water. The administration of camphor and other
remedies, for causing derivation to the skin and hastening the eruption,
formerly so much in vogue, is very objectionable. During the eruptive
stage we should especially attempt to prevent the development of a
severe eruption on the conjunctiva. This may be done by the assidu-
ous employment of cold water compresses, or, still better, by com-
presses moistened with a weak solution of corrosive sublimate (gr. j to
water § vj). Cold and the mercurials are also much used for the pre-
vention of deep destruction of the skin, and disfiguring cicatrices. For
this purpose it is best to cover the face (which is the only part usually
protected) with a mercurial plaster, emplastrum de vigo, and to leave
it on for several days. Skoda prefers compresses moistened with solu-
tion of corrosive sublimate (gr. ij — iv to water f vj) to mercurial plas-
ter, which induces an injurious elevation of temperature. Hebra re-
jects both mercurial plaster and solution of corrosive sublimate, as
well as collodion, and touching the individual pocks with nitrate of

SMALL-POX.

607

silver, which have also been recommended. He has come to this deci-
sion from the observation in his wards that the pocks do not leave
cicatrices any oftener since he has stopped employing these remedies,
than when he used them. Hebra applies only cold-water compresses ;
while the skill is tense, these relieve the patient, although they cannot
protect the skin from destruction. During the eruptive stage, the
chief attention should be directed to the fever, for the patient may be
much endangered if it become severe. Unless the temperature rise
very high, we may abstain from treatment; if it do rise high, we
should give large doses of quinine. In the stage of desiccation, we
should let the patient have an easily-digestible but nutritious diet,
and a little wine ; for the exhausted strength requires building up, and
the frequent pulse subsides more readily under the careful supply than
under the continued withholding of the nutritive material necessary
for the restitution of the body. The patient should be warned against
scratching off the crusts, and we should take measures to prevent his
doing so involuntarily, while asleep. If the crusts be firmly adherent,
and especially if suppuration under them continue, we should employ
cataplasms. Among the other symptoms requiring especial attention
during variola, are the troubles from the affections of the mucous mem-
branes. We cannot hope for an abortive treatment of the pocks on the
mucous membrane, except in those in the mouth ; and, even there, as-
tringent mouth-washes, and touching the individual efflorescences, are
of no material service. If dangerous dyspnoea, and other symptoms of
croupous laryngitis occur, we may give an emetic of sulphate of cop-
per, and attempt to apply a solution of nitrate of silver through the
entrance of the glottis, by means of a probang. In oedema glottidis,
if we cannot relieve the patient by scarification, we should perform
laryngotomy. Inflammation of the serous membranes, and of the
parenchymatous organs during small-pox, may require venesection,
especially when, during pneumonia or pleurisy, collateral oedema in-
duces difficulty of respiration ; but it should only be employed in cases
of absolute necessity, for experience shows that abstraction of blood
is badly borne in all infectious diseases. In other respects pneumonia,
pleurisy, and other local affections induced by variola, are to be treated
according to the rules given when speaking of the primary forms of
these diseases. Abscesses of the cellular tissue and suppurating lym-
phatic glands should be opened early.2

ACUTE INFECTIOUS DISEASES.
CHAPTER V.

COW-POCK — VACCINA.

ETIOLOGY. — Vaccina is an excessively infectious disease. The re-
markable fact, that, even at the present day, extensive epidemics of
small-pox occur in spite of most persons being vaccinated, or even in
many cases revaccinated once or oftener, has induced me to make
some very careful observations regarding the duration of the protec-
tive power of vaccination. I have not yet completed this work, but
have gone far enough to satisfy myself that the protection against
variola afforded by vaccination is for a far shorter period than is gen-
erally believed.

On the presumption (which is certainly correct) that a person who
takes vaccina after vaccination would have taken variola or varioloid if he
had been exposed to infection, I have made a large number of observa-
tions on revaccination. Through the politeness of Surgeon-General
Von Klein and Dr. Von Kottreutter, in Stuttgart, among other cases,
I have had the opportunity of following, day by day, the effect of re-
vaccination in five hundred recruits. In these cases, where I had per-
fect control, I satisfied myself that the number of the recruits in whom
normal cow-pocks developed was proportionally small, and corresponded
very nearly with the number given by other observers. But it also
showed that the number where there was no result was also slight.
In most cases, a few days after the vaccination, there were redness and
infiltration of the skin, papules, vesicles, etc. Among the latter class,
in many cases, eight days after the operation, the inflammation has
run its course, and, if the case has not been watched during the inter-
val, it would be classed among those where the vaccination had no
effect. These inflammations at the point of vaccination may have been
the result of the wound from the lancet, and of the foreign body intro-
duced under the epidermis through it, or a result of scratching ; but
there was also a possibility that it was due to incomplete vaccina run
ning a rapid course, and holding the same relation to ordinary vaccina
that varioloid does to variola, and which consequently has been called
vaccinoid or varioloid-vaccina, in opposition to variola-vaccina. To
settle this question, I first vaccinated a number of persons with the
contents of blisters and of pustular eruptions. In none of these per-
sons was the like result produced. I also revaccinated a number of my
pupils and house-patients, in whom, at the first attempt, this modified
result had occurred, and in them also the effect failed. These facts
make it appear to me very probable that, at the time of a small-pox
epidemic, in spite of the common vaccination and revaccination, the

VACCINA. 609

number of persons liable to variola or varioloid is quite large ; and, al-
though I have arrived at no conclusion as to the duration of the pro-
tective power of vaccina, I think I may still advise physicians to revac-
cinate all their patients at the outbreak of an epidemic, no matter what
the length of time since their last vaccination. The contents of the
vaccina pustule are the only known vehicle of the contagion ; the ema-
nations from the skin and lungs, which convey the variola poison, do
not carry vaccina poison ; at least, a well person is never infected by
entering the atmosphere of a person or beast with vaccina. A second
important difference between variola and vaccina poison is, that the
latter only induces an eruption at the point where it was introduced,
never at remote parts, as the former does. It is not necessary to de-
cide the question whether this difference depends on the fact that
vaccina poison is of a different nature from variola poison, or whether
the latter is weakened by being transferred to another species of ani-
mal, being more imperfect and less active when reproduced in the cow.
The predisposition to vaccina is very general, and it is rare for a per-
son vaccinated for the first time to escape the disease. A single at-
tack sometimes removes the liability to the disease for the rest of life ;
but, in the majority of cases, this immunity only lasts a number of
years, and then ceases. The important discovery, that having had
vaccina removes the susceptibility to small-pox just as it does to a
second attack of vaccina, is still more important, since it has been
shown that even this protection is only temporary, and that vaccina-
tion must be repeated from time to time, if we would prevent a return
of the liability to small-pox. Leaving out of consideration certain
foolish objections, that have been advanced against vaccination, it can-
not be denied that it sometimes endangers life, and in other cases
leaves permanent impairment of health, especially cutaneous erup-
tions, and other scrofulous affections. The hypothesis that scrofula
was transferred, by the vaccination, from one child to the other, is
false, as may be proved. Sometimes children become scrofulous after
vaccination, although the lymph have been taken from the arm of a
perfectly healthy child ; and sometimes children remain perfectly
healthy after being vaccinated with lymph from a decidedly scrofulous
child. The occurrence of scrofula after vaccination seems to be due
to the debilitating influence of the fever accompanying the vaccina,
and the prominence of the exanthema among these scrofulous affec-
tions appears to depend on the disease of the skin, artificially induced
at the point of vaccination. At least other febrile diseases, as well as
all debilitating affections, occurring in young children with a tendency
to scrofula, have the same influence in developing this disease that
vaccina has. And we know that blisters, and other irritants to the

610 ACUTE INFECTIOUS DISEASES.

skin, not only induce inflammation at the point of application, but alsc
increase the predisposition to other cutaneous affections. Many chil-
dren, who have never previously suffered from any exanthema, are
affected for months with moist eczema of the face, after having their
ears pierced, as well as after vaccination. But it is only in rare cases
that the occurrence of scrofulous affections is due solely to vaccination,
and is not influenced by other causes, such as weaning and teething,
which usually take place about the time that vaccination is done, and
it is still rarer for life to be endangered by the operation. Complete
ignorance of statistics of mortality, which show a decided decrease of
mortality since the introduction of vaccination, must be the only ex-
cuse for urging these exceptional cases as grounds against vaccination.
It may be readily seen why more children die of measles, scarlatina,
croup, and hydrocephalus, since small-pox leaves a larger number for
these diseases to attack, as it were. But the slight increase of mor-
tality in the above diseases does not, by any means, equal the diminu-
tion of mortality in variola. Unless the occurrence of a small-pox
epidemic throws all other considerations into the shade, I do not vac-
cinate weakly children, inclined to scrofula, during their first year, but
wait till the second or third, after the teeth have developed, because I
am satisfied that, in such children, very much depends on protecting
their first development from injurious influences.

ANATOMICAL APPEAEANCES. — The anatomical changes in the skin
after the first vaccination exactly resemble those in variola, except
that they are confined to one point. The third day after the vaccina-
tion there is a small red nodule at the point of operation ; the fifth or
sixth day this changes to a vesicle ; by the eighth day the vesicle at-
tains the size of a lentil, and has a central depression, the umbilica-
tion, and a cellular formation. The ninth day the contents of the
pock become cloudy and whey-like, while a broad, dark-red halo de-
velops around then- periphery ; on the tenth day they become puru-
lent; from this time the pock begins to dry up, rarely rupturing.
Toward the end of the third week, or even later, the crust falls off.
and leaves a somewhat excavated, round, white cicatrix, whose base is
stippled and ridgy. The umbilication of the vesicle, according to
Simon, depends on the puncture made during the vaccination ; as a
result of the inflammation caused by the puncture, there is an adhesion
of the epidermis to the cutis, hence, when a serous liquid is subse-
quently effused between the two membranes, the epidermis does not
become loosened at the point where it is most firmly attached ; this
hypothesis is supported, among other points, by the fact that the form
of the umbilication corresponds to that of the wound : if we have
vaccinated through a puncture, the depression is small and round ; if

VACCINA. 611

through an incision, there is an elongated depression along the middle
of the oval pock. The changes that occur at the point of vaccination,
in persons whose susceptibility to vaccina is diminished, are very varied.
They always take place sooner, and run then* course more rapidly, than
in normal vaccina. In some cases we see nodules, or wart-like swell-
ings, surrounded by a dark-red and infiltrated areola, which either do
not develop further, or else change to vesicles, whose contents quickly
dry up. In other cases, on the reddened and infiltrated spots we see
no efflorescence ; in still other cases, there is a furuncular inflammation
of the skin, resulting in superficial ulceration. To determine, in
any case, whether this inflammation be modified vaccina, we would
have to vaccinate a child, who has not yet been vaccinated, with the
products.

SYMPTOMS AND COUESE. — Regarding the symptoms and course of
normal vaccina, a short description may suffice. There is no premoni-
tory stage. In the eruptive stage, the anatomical changes in the skin,
above described, are the only symptoms of the disease. In the stage
of maturation the inflammation causes severe tense pains, and hinders
motion of the affected arm. The lymphatic glands in the axilla often
swell. Sometimes an eruption, resembling lichen, or eczema, instead
of the pock eruption, appears in the vicinity of the vaccina pustule and
at other parts of the body. While fever never occurs at the com-
mencement of vaccina, the stage of maturation is always accompanied
by a secondary fever. In incomplete, modified vaccina, the inflamma-
tion of the skin sometimes causes insupportable itching, sometimes
tense or burning pain. From numerous measurements of temperature,
I have satisfied myself that the patients have a fever which is not at
all in proportion to the intensity and extent of the dermatitis. Where
the local symptoms were very slight, I have noticed a temperature of
104°. But, from the less extent of the dermatitis, the fever never be-
comes so high as in variola ; it can only prove dangerous to very weakly
children, and even then only in rare ca»es. It is rare also for danger-
ous erysipelatous or pseudo-erysipelatous inflammation of the arm to
occur during the stage of maturation.

TREATMENT. — In the following paragraphs we have to treat not so
much of a cure of vaccina, as of conducting the disease to a proper
termination. The most important rules to follow, in vaccinating, are :
1. To take the lymph from a healthy child, who has not previously
been vaccinated. Little as we believe in the transfer of dyscrasias by
vaccination, we still consider it foolhardy and improper to make use-
aess experiments- as to whether this view is correct. Experience shows
that the lymph taken from the vesicles of revaccinated persons ia
much less certain to produce normal pocks than that taken from pe^-

ACUTE INFECTIOUS DISEASES.

sons vaccinated for the first time. 2. We should take this lymph, the
seventh or eighth day after vaccinating, from pocks which are perfectly
normal as regards size, form, and areola. The lymph from older or
younger pocks, or from those in any way abnormal, is less certain.
3. When possible, we should vaccinate from arm to arm. If obliged
to use old lymph, that which has been preserved in glass tubes, with
the ends sealed, is the best. 4. We should vaccinate through punc-
tures made with the lancet or vaccinating needle, and should choose a
part of the arm which would be covered even when short sleeves are
worn. About five punctures should be made in each arm ; sufficient
space should be left between the punctures to prevent the confluence
of the pocks or their areolae. 5. Except during the prevalence of a
small-pox epidemic, we should only vaccinate healthy persons. If the
vaccination do not succeed, we should repeat it after a few months.
6. When an epidemic of the disease breaks out, it is well to revaccinate
persons who have not been vaccinated for seven years or more. 7. We
should protect the pocks from pressure and friction, and should espe-
cially guard against children scratching their arms ; and we should
keep the patient in his room during the maturating fever. If there be
much inflammation around the point, we may apply compresses wet
with lead-water ; if ulcers remain, use cataplasms.

CHAPTER VI.

WIND-POX, WATER-POX, SHEEP-POX, VARICELLA, CHICKEN-POX.

ETIOLOGY. — Many dermatologists consider varicella as identical
with variola and varioloid, and as being the mildest form of small-pox.
From this view, the almost exclusive occurrence of this disease in
children is explained by saying that in them, from the short time which
has elapsed since vaccination, although the liability to small-pox is not
entirety gone, it is reduced to a minimum ; while in older persons tho
liability to small-pox is usually so much reestablished by the long pe-
riod that has elapsed since vaccination, that, when exposed to the con-
tagion, they are affected with varioloid. The falseness of this view
may be shown by striking examples. In the first place, the frequent
occurrence of varicella in children that have never been vaccinated,
speaks against the identity of varicella and variola poison. Why
should persons who might be supposed to have the greatest predispo-
sition to small-pox be so often attacked by the mildest form of the
disease ? But experience also shows that varicella offers no immunity
to vaccina or variola ; on the contrary, many children who have jusl
recovered from varicella are successfully vaccinated, or, during an eni

VARICELLA. 613

demic of small-pox, may take variola or varioloid ; this is in direct
opposition to the almost absolute protection afforded by an attack of
either of the latter diseases to another attack. Lastly, cases also occur
where children who have been vaccinated or had variola a few weeks
previously, are attacked by varicella. The above facts render it certain
that varicella is not the mildest form of small-pox, but is a disease sui
generis. The cases where persons with varicella are said to have in-
fected others with variola or varioloid, and vice versa, appear due to
mistaking mild cases of varioloid for varicella. The infectious origin
of varicella may almost always be traced; but all those infected,
whether vaccinated or not, are attacked by varicella, not by variola or
varioloid. Varicella usually occurs in more or less extensive epidemics,
which occasionally accompany, precede, or follow small-pox epidemics,
but in other instances coexist with epidemics of measles or scarlatina ;
varicella not unfrequently occurs sporadically also.

ANATOMICAL APPEAKANCES. — The exanthema begins as small, red,
distinct spots, which, after a few hours, are changed to limpid vesicles
of the size of a pea or lentil, by a copious serous effusion between the
cutis and epidermis. These vesicles have neither a central depression
nor a cellular formation. After a time their contents become whey-like,
but never purulent. Thin crusts form from the dried vesicles, which
fall off after a few days, without leaving a cicatrix. From the form of
the vesicles, the different varieties, varicellae globulosse, ovales, lenti-
culares, coniformes, and acuminatse, are distinguished. We often see,
especially when the eruption is very extensive, that, besides numerous
varicella vesicles running the usual course, a few filled with pus (vari-
cellae pustulosae) acquire the appearance of variola pustules, and even
leave cicatrices. Since the form of variola pustules is not specific, but
exactly resembles that of some erythema pustules, we should not at-
tach too much importance to the external resemblance of some of the
efflorescences in varicella to those in variola, and consequently consider
the two diseases as identical.

SYMPTOMS AND COURSE. — In some cases the appearance of the
eruption is the first symptom of the disease. Even the most careful
and anxious mothers often notice no prodromal stage, and assure ua
that, the day before the eruption appeared, the child was perfectly
well. More rarely the exanthema is preceded for a day or two by
slight fever and general discomfort, derangement, loss of appetite,
headache, etc. The varicella spreads over the body without any regu-
larity. The eruption is usually thickest on the back and breast. The
face occasionally remains perfectly free. Individual vesicles develop
in from six to twelve hours ; their contents become cloudy the second
.iav, and dry up the fourth. It is rare to have only a single crop of

ACUTE INFECTIOUS DISEASES.

vesicles; new crops usually appear for several days, so that the disease
is often protracted for a fortnight, or longer; and in the later stages
we find dried vesicles and fresh ones alongside of each other. Rarely
vesicles form on the mucous membrane of the mouth and fauces, and
they soon change to small, round ulcers. There is no constitutional
disturbance.

TREATMENT. — Treatment is scarcely necessary in varicella, as the
disease is not dangerous, or very inconvenient, and always terminates
in recovery, after lasting a week or two. Nevertheless, it is advisable
to protect the patients from all injurious influences while the affection
lasts, to keep them in their chamber, and to regulate the diet.

CHAPTER VII.

TYPHUS FEVER — EXANTHEMATIC TYPHUS — PETECHIAL TYPHUS,
SPOTTED FEVER.

ETIOLOGY. — Exanthematic typhus (morbus acutus, febrilis, conta-
giosus, exanthemate proprio ac eminenti systematis nervosi passione
stipatus, Hildebrand) is very closely related to the previously de-
scribed infectious diseases, measles, scarlatina, and small-pox, by its
contagiousness, and by the local affection of the skin in the shape of
an extensive exanthema ; while, on the other hand, its symptoms cor-
respond so closely with those of abdominal typhus, that many authors
consider it a variety of the latter. The contagiousness of exanthe-
matic typhus can only be doubted by those who have had the opportu-
nity of observing the disease in large epidemics solely. When an
epidemic disease first affects a large city, or still larger district, it is
almost impossible to decide whether the disease be transferred from
one person to another, or if different individuals be affected inde-
pendently from having been exposed to the same causes of injury.
The case is quite different when the disease attacks smaller places,
where it may readily be watched and its extension observed. In such
cases there is a more favorable opportunity of observing the contagious
or non-contagious nature of the malady. All observers who have had
such an opportunity in exanthematic typhus agree that the power of
contagion is just as evident, in this disease, as in any other. Among
the numerous observations tending to prove the contagiousness of ex
anthematic typhus, I may mention two of my own, which are particular-
ly striking. In the year 1854 two typhus patients were received into
the Magdeburg hospital from the prison, which was much crowded. Foi
months previous there had been only a few cases of abdominal typhus,
and not a single case of exanthematic typhus in my wards. Eighi

TYPHUS FEVER. 615

days after the reception of these patients, two patients that had lain
alongside of them were attacked by the same disease (one of them
had been received into the hospital for intermittent fever, the other for
epilepsy) ; in a short time the attendants who had taken care of the
patients were similarly attacked. After the isolation of these patients,
all the other persons in the hospital escaped the disease ; nor were
there any other cases in the city at this time. In March, 1855, a
tradesman from Heiligenstadt was attacked with exanthematic typhus
while away from home ; he was received into my ward ; a year had
almost elapsed since the appearance of the last case there. Eight days
after the reception of this patient, a blacksmith's apprentice and a me-
chanic, lying next to him, were attacked by the disease. After these pa-
tients were isolated, my assistant, a washer-woman, and every one who
had been chosen to attend the patients, were also attacked. It was not
till a convalescent from exanthematic typhus was placed as the sole at-
tendant for the typhus patients, that new cases ceased to appear. (These
patients were nursed with great conscientiousness and self-sacrifice by
the convalescent, who, for twenty years previously, had been in chains
for the murder of a clergyman, and had only obtained his liberty a short
time before.) The contagion is contained in the atmosphere about the
patient, in his clothes, bed linen, and other property. Hence the treat-
ment and nursing of patients with exanthematic typhus is much more
dangerous than is the case with patients having cholera or abdominal
typhus. Like measles, the disease may be carried by persons who do
not themselves become affected. The more patients are crowded to-
gether, the more intense the contagion becomes ; this fact agrees per-
fectly with the recently-adopted view of a contagium vivum (see page
673). A place of a certain size, where many patients produce the
germs of the disease, is more thoroughly filled with the poison than
one where the germs are only produced in the body of a single patient.
I do not agree with most recent authors in considering the ques-
tion settled in regard to whether exanthematic typhus be exclusively
propagated by contagion, or if it be also due to miasm. There is no
solid ground for such assertions as this, " that a disease is either only
miasmatic, or only contagious," and even the persons making them do
not always strictly adhere to them. When one acknowledges that
the germs of cholera probably develop from diseased rice, and are thence
brought to us by cholera patients and their dejections, he cannot deny
the possibility, and even probability, that the germs of contagious dis-
eases native among us may, under favorable circumstances, develop
and increase outside of the human body. The hypothesis of a " spon-
taneous generation" of infectious diseases, in the sense that their
cause is a new agent induced by injurious influences, is, of course, to
89

Q1Q ACUTE INFECTIOUS DISEASES.

be rejected, for, in that case, we should be inferring a generatio aequir
voca, which has been disproved ; but it has not by any means been
proved that, besides purely miasmatic affections, whose germs develop
outside of the organism and are not reproduced in the bodies of pa-
tients suffering from them, there are no miasmatic-contagious dis-
eases, whose germs develop outside of the body, but are also repro-
duced in the bodies or dejections of patients suffering from them. I
know of no absolute objections to this theory, and a series of facts
agrees better with it than with the unproved assertion that there is no
miasmatic-contagious disease. We not unfrequently see the disease
in question appear under circumstances which render origin from con-
tagion very doubtful ; for instance, in ships at sea (ship-fever), in care-
fully-guarded prisons (jail-fever). On the other hand, under certain
circumstances, which appear favorable to low organisms and to their
reception into the body, as in years of famine, where bad, spoiled food
is eaten (famine typhus) and in over-filled lazarettos, where the air is
loaded with exhalations from the patients (lazaret-fever), exanthematic
typhus occurs so frequently, that, where these circumstances prevail,
its appearance may almost be predicted. Of course, this does not prove
that the body of a patient diseased by the introduction of these germs
may not be a more favorable soil for its development and reproduction
than decomposing flesh, or the air of a lazaretto overloaded with ex-
cretions, and that the disease may not only continue to exist, but to
extend and even spread greatly, long after the disappearance of the
circumstances which favored the development of the germs of the dis-
ease outside of the body. If the above-mentioned assertion, that the
cholera-germ is developed on dried rice, should be confirmed, it would
be still more probable that the germ of exanthematic typhus developed
outside of the human body in decomposing animal matter, and when
circumstances were peculiarly favorable, increased so as to become
dangerous to man. The susceptibility to the miasm or contagion of
exanthematic typhus is very general. Males and females, strong,
healthy persons and weak, sickly ones, are about equally liable to the
disease. Only early childhood and extreme age are usually exempt.
Excessive exertion and other debilitating influences appear to in-
crease the predisposition. One attack seems to destroy the suscepti-
bility to the affection.

Griesinger and Hirsch speak of the geographical extension of ex-
anthematic typhus in Europe thus : from the beginning of the sixteenth
to the end of the eighteenth century, this disease extended over all
Europe as the common form of typhus ; during the war, at the. com-
mencement of this century, it attained its height. After that time
it was so rare on the continent, that there was a current belief thai

TYPHUS FEVER 617

typhus never occurred without ulcers in the intestines. It is only in
the last ten years that the epidemics in Upper Silesia, the fatal epi-
demics during the Crimean War, and recently the epidemics in East
Prussia, etc., have dispelled this error. In the British Islands, and in
certain places in middle Europe, exanthematic typhus is the endemic
form of the disease. In Southern Europe, Lower Italy, the Oriental
countries, Hungary, etc., exanthematic typhus occurs, sometimes alone
and sometimes combined with other forms. Small epidemics of exan-
thematic typhus are occasionally seen almost everywhere, and may
usually, but not always, be traced to contagion.

ANATOMICAL APPEARANCES. — The characteristic exanthema of ty-
phus, typhus roseola, cannot be recognized on the dead body any moro
than the exanthema of measles and scarlatina can, for the circumscribed
hypersemia, on which the roseola depends, disappears in the general
paleness of the surface. Occasionally, indeed, this circumscribed cuta-
neous hypersemia causes rupture of the vessels and small haemorrhages
in the cutis, and we then find the skin of the cadaver covered with more
or less numerous and extensive petechiae ; but this is by no means con-
stant, and we must not consider petechiae as pathognomonic of " pete-
chial typhus." The roseola-spots, observed on the skin of the patient
during life (which we shall describe under the anatomical appearances, as
we did measles, scarlatina, and small-pox), resemble those of measles,
are about the same size, shape, and color ; like these they unite to irreg-
ular figures, but, unlike the spots in measles, they are not capped by
small papules. Sometimes they are on a level with the surrounding
skin, sometimes they project slightly above it, while in abdominal ty-
phus the eruption of roseola on the chest and abdomen is usually
scanty and does not always exist ; in exanthematic typhus it is not
always confined to those parts, but usually covers the trunk and ex-
tremities in great numbers, and is so apparent that, even on superficial
examination, it is not readily overlooked. The roseola rarelv occurs
on the face, and this one fact is sufficient to prevent a mistake in diag-
nosis between the exanthema of measles and typhus.

The other anatomical appearances also usually resemble those
found after other exanthemata. If death takes place early, the bodies
are but little emaciated, the rigor mortis is marked, and there is ex
tensive hypostatic congestion in the dependent parts of the body.
The muscles are dark-colored, the heart and great vessels contain
cherry-colored blood. The bronchial mucous membrane is always
strongly injected, and covered with tough mucus. In the lungs we
find more or less extensive hepatization and atelectatic spots. The
bronchial glands are swollen, but not infiltrated. There are no con-
stant, marked changes in the intestinal canal and mesenteric glands.

ACUTE INFECTIOUS DISEASES.

The spleen is enlarged and soft. If death do not occur till late in the
disease, the rigor mortis is less marked, and soon passes off; the bodies
are more emaciated ; the alae nasi seem smoked, the teeth and gums are
covered with sordes ; the blood rarely contains any fibrinous clots ; it
is smeary, dark, or inclined to cherry-color, and the walls of the vessels
are infiltrated. There is usually extensive hypostatic congestion in
the lungs ; the spleen is decidedly enlarged ; it is sometimes the seat
of hsemorrhagic infarction, or of small abscesses. There are no con-
stant anomalies in the stomach or intestinal canal ; at most, there is
swelling of the solitary and Peyer's glands, such as is also seen in the
acute exanthema. Nor do the other organs show any constant char-
acteristic deviations from their normal state. In the rare cases, where
death occurs still later from the sequelae, on autopsy we find the most
varied anomalies, suppurating parotid glands, the remains of croup
and diphtheria, extensive necrosis of connective tissue, bed-sores, gan-
grene of the extremities, etc.

SYMPTOMS AND COURSE. — There are few diseases whose symp-
toms correspond so exactly in different cases, and which run such a
similar course in different persons, as exanthematic typhus.

The period of incubation, which appears to last eight or nine days,
rarely longer, is not usually free from symptoms of the disease ; but
these consist of slight chills, headache, disturbed sleep, loss of appe-
tite, a feeling of dulness, depression, and discomfort ; in short, of symp-
toms such as precede the outbreak of other diseases, and give no clew
to the disease which is commencing. It is only during the prevalence
of exanthematic typhus that we should suspect from these symptoms
that the patient was infected with typhus poison ; the suspicion would
increase in certainty if there were, at the same time, catarrhal troubles,
cough, coryza, burning feelings in the eyes, etc. The first two cases
of exanthematic typhus that I saw in the Magdeburg hospital during
the stage of incubation, I at first supposed to be cases of simple catar-
rhal fever. The intensity of these prodromatae varies, so that, while
they last, some patients go about their business, while others are con-
fined to bed even at this stage of the disease.

The stadium invasionis begins with a single protracted chill of
great violence, or with repeated slight rigors, followed by a continued
feeling of great heat. After the first chill, the patients are rarely able
to leave their bed ; they feel excessively fatigued and weak, complain
of heaviness and numbness in the head, occasionally also of headache,
which is not unfrequently temporarily relieved by nose-bleed. These
symptoms are followed by dizziness, flashes of light, tinnitus, deafness,
pain in the muscles, trembling of the extremities on motion ; the pa-
tients usually lie in a state of apathy, talk in their sleep, and even

TYPHUS FEVER.

wiiile awake have a muttering delirium. Ot tiers are excited and rest-
less, have anxious, wild fantasies, and can scarcely be kept in bed.
At my first visit I found one of the patients, sent to me from jail with
exanthematic typhus, in a strait-jacket. Besides these symptoms
of disturbed innervation, there are almost always signs of intense
catarrh during the invading stage ; the eyes shun the light, and are
red ; there is an increased flow of tears ; the nose is dry and stopped
up, or its secretion is at first fluid, afterward more tenacious, and dries
to crusts ; the act of swallowing also is often difficult and painful, the
tongue has a white coating, the taste is slimy ; occasionally there are
nausea and vomiting, and not unfrequently some diarrhoea. These
symptoms are absent, or only slight, in some cases ; a more constant
one is a painful, hoarse cough, which brings up a tough mucus, occa-
sionally mixed with blood. On auscultation we hear numerous ronchi.
We have but few exact observations as to the grade and course of the
fever ; these are especially due to Wunderlich. According to these,
even at first the temperature rises to 104° to 106° ; the pulse is usually
large, full, soft, rarely double, and beats about 100 in a minute. From
the great loss of water from the body of the patient, induced by the
increased perspiration due to the high temperature, the thirst is great,
the urine scanty and of high specific gravity. Even in this stage, en-
largement of the spleen may usually be discovered by percussion.

With the first appearance of the roseola spots, which occurs in the
second half of the first week, usually between the third and fifth, rarely
on the seventh day of the disease, the stadium eruptionis et florescetir
tice begins (if we keep up the analogy between exanthematic typhus
and the acute exanthemata, which, however, only exists at first, and is
subsequently lost). At first the spots are few in number and only
appear on the trunk, but they soon multiply and spread toward the
neck and extremities, till finally the entire body, except the face, is
covered with them ; at some places they are more numerous than at
others ; the eruption is only exceptionally scanty ; but even in these
cases it is more extensive than the roseola eruption in abdominal
typhus. The exanthema lasts longer than it does in measles or scar-
latina ; the roseola spots do not disappear till toward the end of the
second week, when the fever defervesces and the other symptoms sub-
side. The longer the roseola spots last, the more their bright-red color
changes to a livid hue ; they then disappear imperfectly under the
oressure of the finger ; part of them often change to petechias. The
general symptoms do not improve with the outbreak of the eruption.
It is true the patients complain less of pain in the head and limbs,
but this is only because their mind is more affected ; they can no
longer think clearly, give slow and incomplete answers to questions,

ACUTE INFECTIOUS DISEASES.

and after their recovery they scarcely remember this period, during
which they are in a quiet or noisy, violent delirium, and sometimes
make constant attempts to jump out of bed and run away. They
often become very hard of hearing. The tongue is dry and covered
with a brownish crust; the cough has usually subsided, but the res-
piration is superficial and rapid ; ronchi are more numerous, and at the-
dependent parts of the chest the percussion-sound is often dull. In
some cases there is constipation, in others there is more or less diar-
rhoea, and the urine is often passed involuntarily. According to Wun-
derlich, in mild cases the fever retains till the end of the first week
the height that it had attained the third or fouth day of the disease,
or in the second half of the first week there is a slight decrease of the
temperature, and on the seventh or eighth day a decided remission.
In severe cases, on the contrary, the temperature increases during the
second half of the first week, and there is no remission the seventh
day. At this time the pulse is often very small and soft, and its fre-
quence corresponds to some extent with the height of the temperature,
so that in mild cases the pulse is about 100, in severe ones 120 or more, a
minute. Toward the end of the first week even, the spleen is usually
enlarged. In the second week, while the exanthema becomes more
livid, all the symptoms increase, and about the middle of this week
they attain their height. Then the patients lie almost constantly on
their back, the eyes half closed, the knees rolling outward, the hands
between the thighs, they are in a deep stupor from which they can
scarcely be awakened. From time to time they mumble unintelligi-
bly, make grimaces, gesticulate, pick the bedclothes, attempt to rise,
and to thrust the feet out of bed, and it is evident that while all sense
of shame and propriety is gone, and the real world is lost to the
patients, they still live in an imaginary world, and their minds are
more or less active. They do not appear thirsty, although the tongue
is dry, and often covered with a blackish hard crust ; but, if a glass of
water be placed to their lips, they show great avidity for drink ; at-
tempts to satisfy their thirst often fail, because the tongue trembles
or is stiff and immovable, and the act of swallowing is more difficult.
The nostrils are usually filled with a sooty crust, the teeth and gums
are covered with a smeary coating, whose decomposition causes a dis-
agreeable fetor ex ore. In many patients the skin is at this time
covered with petechiae and miliary vesicles ; in some there are symp-
toms of pneumonia and extensive atelectasis, in others those of par-
otitis. Not unfrequently the urine contains albumen. The abov^
symptoms of severe constitutional disease and great disturbance ol
innervation, as well as those of pneumonia, collapse of the lung, paro
titis, etc., occur even m those cases of exanthematic typhus that run s

TYPHUS FEVER. 621

favorable course, a fact that we should know, to avoid exaggerating
the danger. Whether a remission occur on the seventh day or not,
the fever always increases in the beginning of the second week. In
mild cases, tliis increase only lasts a few days, and is not excessive ;
but in severe cases the increase lasts till the end of the second week,
or even till the sixteenth or seventeenth day, and the temperature may
become very high (108° or more). At this time the heart's action is
not only much increased, but it is weakened ; hence the heart-sounds
are very imperfectly heard, the pulse is small and indistinct, the cir-
culation is so much retarded that, in the extremities, the temperature
of the skin approaches that of surrounding objects, and the hands and
feet appear cool while the trunk is burning hot.

The third stage of exanthematic typhus, which authors very cor-
rectly call the stadium criticum, almost always begins in the latter part
of the second week, or, exceptionally, in very severe cases, at the begin-
ning of the third week. Before actually seeing such cases, it is almost
impossible to imagine the wonderful change in the symptoms, during a
single night, in the stadium criticum. In no other disease is there so
rapid a change from an apparently hopeless to a very comfortable
state. After a peculiarly marked exacerbation of all the symptoms,
the patients fall into a quiet deep sleep for several hours, from which
they awake with unclouded mind, but usually without any recollection
of what they have passed through for the previous days or weeks.
During this critical sleep the temperature often falls four degrees, the
pulse twenty or thirty beats ; the calor mordax disappears from the
skin, and there is a gentle perspiration ; the roseola spots become
pale. In favorable cases defervescence is immediately succeeded by
convalescence, which, however, is always slow. The patients sleep a
great deal ; on waking, their intellect gradually becomes less clouded,
although they retain an idiotic, stupid expression for weeks. The
dirty coating is thrown off from the teeth and gums, the tongue again
becomes moist, and the appetite returns. Sputa cocta are raised by a
loose cough ; the skin, from which the roseola spots have disappeared,
begins to peel off, any remaining petechiae fade out, the temperature and
pulse fall to the normal standard or below it, and the spleen decreases
in size. But, even in the best cases, weeks pass before the patient can
leave his bed and move about his room. In most of my cases the
mental vigor returned even more slowly than the bodily strength.

The stadium criticum does not always pass immediately into con-
valescence ; the typhus proper is often followed by sequelae, which
are apparently caused by the high fever, disturbance of respiration,
continued abstinence, absorption of exudation, and other unknown
causes. This view of the sequelae of typhus is supported by the fact

£22 ACUTE INFECTIOUS DISEASES.

that the same sequelae also occur after abdominal typhus, puerperal
fever, cholera, and some other severe diseases. Some patients, with
out our being able to find inflammations of any important organ or
other material cause for it, are attacked by a new fever, of which they
die, with the symptoms of great prostration, the already exhausted
powers being rapidly consumed. In other patients, after the typhus
has run its course, there are inflammation and suppuration of the paro-
tids ; in others, there are pneumonia, pleurisy, diptheritic and follicular
inflammation of the intestine ; in still others there are numerous furun-
cles, ecthyma pustules, or large abscesses in the subcutaneous and in-
termuscular connective tissue. In many cases, the slowly-healing bed-
sores prove dangerous, partly from the drain on the system, partly
from reabsorption of ichor. Lastly, there is frequently thrombosis of
the femoral veins, with its results. Recovery is by far the most fre-
quent termination of exanthematic typhus in most epidemics, especially
in those which are not very extensive. The circumstance that a fatal
termination is less frequent than persons unacquainted with the disease
would expect from the severity of the symptoms, is probably because
the disease, which runs a cyclical course, is of comparatively short
duration. The organism could not long stand such a fever as ac-
companies typhus. The hypothesis which we have frequently ad-
vanced, that the chief danger in infectious diseases is from the eleva-
tion of the temperature to a point where general paralysis is induced
and the continuation of life impossible, is well supported by the obser-
vations made in WunderlicJi's clinic during a small epidemic of typhus.
In the fatal cases, death almost always resulted at the height of the
tever ; moreover, all patients in whom the temperature reached 108°
died ; and of fourteen patients that died, five, or more than one-third,
had this high temperature. Of the patients whose temperature never
rose above 105.5°, not one died. Besides the high temperature, capil-
lary bronchitis, pneumonia, and atelectasis, are dangerous to the pa-
tient ; other patients die of the sequelae. Exhausting haemorrhages,
gangrene of the tip of the nose, fingers, toes, and lungs, and other
complications, which formerly proved so destructive in the malignant
form of exanthematic typhus, called putrid fever, are rarely observed
in the present day ; but, in the severe epidemics, such as occurred dur-
ing the Crimean War, which cannot be compared in danger to those
above mentioned, half the persons attacked died.

Lastly, I shall speak of a rarely-mentioned abortive form of typhus,
of which I observed some cases in the Magdeburg hospital ; a large
number of observations made in the Prague epidemics of 1843 and
1848 exactly correspond with mine. The patients, who, in my cases,
bad always been exposed to typhus poison (among others, the nurse

TYPHOID FEVER. 623

of my assistant), complained of rigors, great depression, tightness of
the head, frontal headache, weakness of the limbs, loss of appetite, and
other symptoms common to the incubation stage of typhus. After a
time there were stronger chills, with subsequent continued feeling of
heat, increase of pulse, great apathy, and disturbed sleep. Some pa-
tients were slightly delirious. There were also catarrhal symptoms;
the injected eyes were very sensitive to light, the nasal mucous mem-
brane was swollen and dry, the nose stopped up ; but, more especially,
there was troublesome cough, by which a scanty tough secretion was
brought up. We daily expected the eruption and the enlargement of
the spleen, not doubting that the cases were commencing typhus ; but
these two characteristic symptoms did not occur ; toward the end of
the first week, the constitutional disturbance, fever, and catarrhal
symptoms disappeared, and the patients began to convalesce ; they re-
covered very slowly, and were not generally able to leave their bed
before the end of the second week.

TREATMENT. — "We have no remedy for arresting exanthematic ty-
phus ; hence we are limited to a symptomatic treatment. As this is to
be directed chiefly against those symptoms that threaten the life of the
patient, particularly against the fever, and since in treating abdominal
typhus also combating the fever is the most important indication, we
shall defer our remarks on this subject to the next chapter. We may
also refer to the next chapter for the treatment of dangerous increase
of respiratory difficulty, for great collapse, bed-sores, and other danger-
ous symptoms, for just the same points arise in abdominal typhus, and
require the same remedies.

CHAPTER VIII.

ABDOMINAL TYPHUS — ILEOTYPHUS (TYPHOID FEVER).

ETIOLOGY. — The belief that exanthematic typhus is a simple, and
abdominal typhus a complicated form of the same disease ; that, in ab-
dominal typhus, besides the changes that the blood undergoes in exan-
thematic typhus, there are changes in other organs directly concerned
in the formation of the blood, in the intestinal and mesenteric glands,
lacks all foundation. We shall not deny that there is a certain resem-
blance between the symptoms of the two diseases; but the resem-
blance is not perfect, and is not much greater than that between exan-
thematic typhus and typhous measles ; hence, we do not consider it
justifiable to regard the changes of the blood in the two diseases as
being the same, or that the poison producing the one is the same as
that causing the other. It is perfectly inadmissible to represent at>

ACUTE INFECTIOUS DISEASES.

domiiial typhus as a higher grade, exanthematic typhus as a lower
grade of the infection with typhus poison, for there have been epidem-
ics of the latter that were more malignant than those of abdominal ty-
phus ; and even in the milder epidemics of exanthematic typhus, the
intensity of the symptoms, especially of the fever, was almost always
greater in the individual cases than in most cases of abdominal typhus.
While the fact that patients with varioloid often infect others with
variola, and vice versa, shows us that variola poison and varioloid poi-
son are identical ; the fact that persons infected by patients with ex-
authematic typhus always have that disease, never abdominal typhus,
shows us that the poison inducing the former is not identical with that
of the latter, and that, in spite of some similarity of symptoms, the twc
diseases are of different nature. If the resemblance between measles
and scarlatina were even greater than it actually is, the single fact, that
infection with measles poison never induces scarlatina, would suffice to
prove the non-identity of these diseases, and that the difference be-
tween them is not only one of degree ; but we shall not deny the
possibility that the two typhus poisons resemble each other more
closely than do those of scarlatina and measles ; nor shall we compare
the prevalence of one or other form of typhus, at certain times and
places, with the repeated epidemics of measles at certain times and
places, or with the almost exclusive occurrence of scarlatina epidemics
at other times and places. The belief in the relationship, or, to speak
more generally, in the resemblance of the poisons which induce exanthe-
matic and abdominal typhus, is supported by the similarity of the
causes favoring their development, as well as by the similarity of their
effects, that is, of the symptoms of the disease, as will appear from what
follows.

I consider the extension by contagion, as well as by miasm, as even
more probable in abdominal than in exanthematic typhus, or (to speak
in a way that shall better show my position in regard to the views on
contagion and miasm), that the germs which cause abdominal, typhus
may develop and multiply as well in the organism of a typhus patient
as they would under favorable circumstances outside of it. It is true,
I cannot prove the correctness of this hypothesis, but I must also deny
that the recent assertions, that abdominal typhus spreads solely by
contagion, have been proved, or even rendered very probable, by the
facts adduced.

The contagion of abdominal typhus is not so intense as that of ex-
anthematic typhus. There is no doubt that it clings particularly to
the dejections of the patient, and that persons exposed to the emana-
tions from typhus stools are most apt to be infected. On the other
hand, I consider it doubtful if the contagion be transferred by the ex

TYPHOID FEVER. 625

nalations from the skin and lungs (which, in exanthematic typhus, are
certainly vehicles for the contagion, while in cholera they just as cer-
tainly are not so). Infection of the nurses and physician is rarely seen
in abdominal typhus, and, when it occurs, it is always questionable
whether it be due to the emanations from the patient, or from his de-
jections. At all events, using the bed-pans, night-stools, and privies,
where the dejections of the patients have been emptied, appears more
dangerous than being brought in contact with the patient himself.

The miasmatic origin of abdominal typhus is rendered probable by
cases occurring in places removed from travel, where no cases of this
disease have occurred for years, and where there is not the slightest sus-
picion of a contagious origin. If it be not considered an axiom that mi-
asmatic diseases are never contagious, no wild hypotheses are necessary
for the explanation of such cases. The most simple and probable ex-
planation of them is, that the low organisms, which we suppose con-
stitute the germs of abdominal typhus, may originate and increase not
only in the bodies of patients and their dejections, but outside of them
also. We at least partially know the circumstances that favor the
origin and development of this poison, since we know that abdominal
typhus occurs sporadically, and in so-called house-epidemics, especially
in places where quantities of animal matter are decomposing. The
absorption of the germs appears to take place chiefly through the
lungs ; but there are some instances where several persons, drinking
water from a well that communicated with the privy, were attacked
with abdominal typhus. I consider it doubtful whether the germs of
this disease can also be swallowed with decomposing meat. The cele-
brated Andelfinger epidemic is often quoted as such an instance, but
Liebermeister, in opposition to Griesinger, has shown that this was
not abdominal typhus ; while the latter, in opposition to the former,
nas shown that it was not a trichina epidemic.

In large, overcrowded cities, it can rarely be determined whether
the cases of abdominal typhus be of miasmatic or contagious origin.
At all events, the requirements for the development and increase either
of spontaneous germs, or those from the dejections of typhus patients,
are excessively favorable in such places, as the soil of large cities
always contains quantities of decomposed and putrid animal sub-
stances. Pettenkofer reckoned that the excrement of Munich amounted
to one hundred and fifty loads daily, and that on an average scarcely
ten were removed, so that over seven-eighths of the excrement of the
city remained and were absorbed by the soil. We shall hereafter show
that the number of cases of intermittent fever in malarious regions
varies with the rise and fall of the water in the marshes, because this
induces the decay of vegetable matter, on which the production of the

ACUTE INFECTIOUS DISEASES.

morbific germ of intermittent depends. In the same way, experience
shows that the number of typhus cases, in any place where the disease
prevails, varies with the greater or less moisture of the soil ; this is
simply because certain degrees of moisture of the ground are favorable
or unfavorable to the decomposition of animal substances on which
the production of the typhus poison depends. It has often been ob-
served that the sudden drying of previously moist soil, or, as is usually
said with doubtful propriety, the sudden fall of the sub-soil water, cor-
responded with an increase of the typhus cases. The explanation of
this is simple, according to what we have already said. But even the
exceptions, where a moist state of the previously dry soil, sudden rise
of the sub-soil water, coincided with an increase of the disease, are not
surprising, nor are those where, while the height of the water remains
the same, the number of cases varies. Of course other causes besides
the moisture of the soil influence the decomposition of animal sub-
stances, and consequently affect the production of typhus germs.

The susceptibility to typhus poison varies greatly with the individ-
ual. There is one very interesting point, which is also seen in other
infectious diseases, that persons who have lived for some tune in a
place peculiarly liable to the disease (as Munich), without being at-
tacked, are in less danger when epidemics occur than those who have
recently come to the place. It can scarcely be supposed that this is
because the former were originally less disposed to the disease than the
latter, but because, after a long absence from their native place, on
their return to it, they are just as liable to the disease as new-comers
who have only been there a short time. This fact probably depends
on some unexplained accommodation to typhus poison. Statistics
concerning the influence of age, sex, condition of life, and constitution,
on the susceptibility for typhus, have shown that infants and old people
are rarely attacked by abdominal typhus ; persons of middle age are
most liable to it ; males are attacked oftener than females ; strong,
well-nourished persons, oftener than weak, badly-nourished ones ; and
that the disease is proportionately more frequent among the poor than
among the well-to-do classes. Formerly, it was generally believed
that tuberculous patients were never attacked by abdominal typhus ;
this is not absolutely true, although it rarely occurs. The same is
true of patients with heart-disease, carcinoma, and other chronic or
acute diseases, and of pregnant or nursing women. Pregnancy gives
almost absolute immunity to the disease. Except in rare cases, one
attack removes the susceptibility. Since 1820-1830, during which
time exanthematic typhus has become more rare, abdominal typhus
has become more frequent. With the exceptions mentioned in the pre-
ceding chapter, it is the common form of typhus throughout Europe.

TYPHOID FEVER. 627

It occuis far north in Russia and Denmark ; in middle Europe, espe-
cially in Germany, France, and the Netherlands ; and even in the
south — in Italy, Syria, and Turkey — it is not rare. In Great Britain,
exanthematic typhus is the common form, but abdominal typhus also
occurs, especially in the countiy towns, and the parts of England not
visited by Irish emigrants (Hirsch^ Griesinger).

ANATOMICAL APPEAKANCES. — It will be most convenient to
speak first (as Hamernik does) of the post-mortem appearances when
death has occurred early in the disease, before the typhus process
proper has set in, and then to give a description of the lesions that
are found when death has occurred later, during the repair of the
changes induced by the typhus.

The bodies of persons who have died early in the disease do not
appear greatly emaciated ; rigor mortis is very marked ; we find ex-
tensive hypostatic congestion in the dependent parts of the body, and
occasional bed-sores commencing over the sacrum. The nostrils oftei*
appear smoky, and the teeth and gums are covered with a black coat-
ing. There are often numerous sudamina on the skin. On opening the
body, the muscles appear very dark red, hard, and dry. The blood in
the heart and large vessels is thick, dark colored, and contains little,
loose, blackish-red coagula, rarely a small amount of discolored fibrin.
Chemical and microscopical examinations of typhus blood have so far
given negative results as regards the actual anomalies, that is, as to
those which depend directly on the infection with typhus poison. The
decrease of fibrin occurs in other infectious diseases also ; the increase
of blood-corpuscles, on which the dark color chiefly depends, seems to
be only relative, and to result from the thickening of the blood, caused
by great perspiration, and loss of water by diarrhoea. After the typhus
nas continued some time, the blood is consumed, and becomes poor in
albumen and blood-corpuscles. The brain and spinal medulla show no
constant changes corresponding to the severe functional disturbances
of these organs during life. They sometimes contain more, sometimes
less blood, and vary in consistence. We find changes in the respira-
tory organs in all cases ; the typhous laryngeal ulcer already described
(Vol. L) is not unfrequently found, especially in certain epidemics.
There are always signs of an extensive catarrh, even in the smallest
bronchi, marked by dark redness of the mucous membrane, and scanty,
tough secretion. At the dependent parts of the lungs there is more
or less hypostatic congestion, sometimes only great hypostatic hyper-
aemia and condensation of the pulmonary tissue from swelling of the
alveolar walls (splenization) ; sometimes hypostatic cedema ; sometimes
the so-called hypostatic pneumonia (Vol. L). Besides the above, more
or less extensive portions of lung are not unfrequently collapsed, or in

ACUTE INFECTIOUS DISEASES.

a state of atelectasis, from collections of secretion or swelling of the
mucous membrane of the bronchi leading to them having rendered the
passage impervious. In some cases also we find lobular and lobar
pneumonia, not affecting the dependent part of the lung, and not de-
pending on hypostasis, even at the height of the disease, although it
is more common after it has run its course. The bronchial glands are
swollen, vascular, and occasionally have a medullary appearance, such
as we shall describe for the mesenteric glands. The heart is usually
relaxed, its muscles pale, sometimes of a dirty-red color ; the endocar-
dium and lining membrane of the vessels are infiltrated, red, and dis-
colored. The spleen is greatly enlarged, occasionally twice, or even
six times its normal size ; its capsule is tense, its parenchyma pulpy,
and of a dark-violet or blackish-red color. In rare cases we find the
capsule of the spleen ruptured, and blood poured through the rupture
into the peritoneal sac. In the great curvature of the stomach, some-
times only the large vessels are distended, sometimes the mucous mem-
brane appears dark red, from injection of the finer vessels, and relaxed
from infiltration after death. The most important changes occur in
the small intestine ; to these ileotyphus owes its name. Rokitansky,
on whose unsurpassed description of the "typhous affection of the
mucous membrane of the ileum" we base our description, divides it into
four stages. In the first or congestive stage, the mucous membrane
of the small intestine is the seat of great hypersemia. It appears
swollen, relaxed, cloudy, covered with mucous and epithelial masses.
This condition extends over all the membrane of the intestine, it is
true, but it is most marked in the lower part, near the valvula Bauhini.
The mesenteric glands are moderately swollen, soft, vascular, and dark
colored. In the second stage, or that of typhous infiltration, the gen-
eral redness and swelling of the mucous membrane increase, and con-
centrate on the parts around the solitary and Peyer's glands in the
lower part of the ileum. In these tissues there are very peculiar
changes, which are pathognomonic of typhus. More or less of the
glands, and parts around them, swell so as to rise half a line or a line
above the surrounding mucous membrane. These prominences are
rather hard, and show through the mucous membrane with a gray or
yellowish-red color; they have flat or steep edges; they are seated
firmly on the muscular coat, and are intimately connected with the
mucous membrane covering them. The size of the swollen solitary
glands varies from that of a millet-seed to that of a pea. Peter's
patches, on the contrary, form patches from the size of a silver gros-
chen to that of a dollar ; they are generally oval in shape, and in the
vicinity of the valve they usually coalesce, so that at this point they
often cover a strip of intestine several inches long. On the cut surface

TYPHOID FEVER. 029

it looks as if the diseased intestinal glands were infiltrated with a soft,
grayish- white, or pale-reddish encephaloid mass ; and although it has
of late been found that in typhus disease the intestinal glands are not
infiltrated with amorphous exudation, but that there is an increase of
their cellular elements which, even under normal circumstances, are
peculiar ; still the expression " medullary infiltration " has almost uni-
versally been preserved. Occasionally the degeneration extends be-
yond the follicles, and there is a " medullary infiltration " of the con-
nective tissue of the mucous membrane in their vicinity, a cellular
neoplasm, originating from the connective-tissue corpuscles ( Virchow).
In this stage the mesenteric glands are swollen to the size of a bean,
or a hazel-nut, are of a grayish-red color, and quite hard. In the third
stage, which Rokitansky calls the stage of relaxation, softening, and
breaking down, the changes in the affected glands vary greatly in dif-
ferent cases. Not unfrequently the process becomes retrogressive,
without the occurrence of destruction of the wall of the follicle or of
the mucous membrane covering it ; the swelling of the glands subsides,
while their contents are reabsorbed after the cellular elements have
been destroyed by fatty metamorphosis. These cases appear chiefly
to correspond to the so-called abortive typhus. In other cases, the
covering of the follicles is changed to a dry, friable slough, colored yel-
low by the faeces ; this slough sometimes extends over the whole of
the gland, so that its form and size correspond to those of the plaque ;
sometimes it is limited to part of the covering, and the slough has an
irregular, angular, or roundish form. In still other cases, the individual
glands composing Peyer's patches rupture, and empty their contents
outwardly, without the covering sloughing. As a result of this, the
surface of the plaque looks as if full of holes, or has a net-like appear-
ance (plaques d surface reticulee). The mesenteric glands are most
swollen in this stage ; some of them attain the size of a pigeon's or
even of a hen's egg. Their covering is usually bluish or brownish red,
while their substance has a grayish-red, medullary appearance. In the
fourth stage, or that of ulceration, the sloughs formed on the plaques
or solitary glands are either thrown off in mass, or, after precedent dis-
integration, and a loss of substance, a typhous ulcer remains. Roki-
tansky gives the following as the most important characters of the
typhus ulcer : According as it has resulted from a solitary follicle or
from a Peyer's patch, it is round or oval, and, if there has only been a
partial slough on the Peyer*s patch, it is irregular ; it varies in size
from that of a hemp-seed or a pea to that of a dollar ; its seat is in the
lower part of the small intestine, and the ulcers proceeding from Peyer'a
patches are of course opposite to the insertion of the mesentery. The
long diameter of the elliptical ulcer corresponds to the long axis of the

630

ACUTE INFECTIOUS DISEASES.

intestine ; the margin of the ulcer is formed by a bluish-red, later slate-
gray border of mucous membrane, about a line broad, which is movable
over the surface of the ulcer. The floor of the ulcer is a delicate layer
of submucous connective tissue, which covers the muscular coat. As
soon as the slough is detached, the swelling of the mesenteric glands
begins to subside, but they long remain larger and more vascular than
normal. There are many deviations from this customary course of the
disease on the mucous membrane ; we shall briefly mention the more
important of them : Occasionally, in the second and third stage, the
hypereemia of the mucous membrane over the swollen glands, and in
then* vicinity, becomes excessive. The mucous membrane is dark red,
covered with ecchymoses; the patches resemble spongy, vascular,
polypous proliferations, and the contents of the intestines are often
mixed with a quantity of blood. A very serious event in the third, 01
sloughing stage, is the perforation of the intestine, which results from
gangrene, not only of the mucous covering, but also of the correspond-
ing part of the serous and muscular coats. The perforation is followed
by severe peritonitis. Milder peritonitis also occurs without perfora-
tion. The deviations of the intestinal affection in typhus, as regards
extent, are very marked ; sometimes only a few Peyer>s and solitary
glands are affected ; sometimes the ileum is almost covered with them.
In the latter case we usually find the process further advanced in the
vicinity of the valve than in the upper part of the intestine, and oc-
casionally the difference of the stages in the different points is so
marked as to lead us to suspect a succession of attacks. Not unfre-
quently the colon participates in the disease (colotyphus), then the
solitary glands of the colon undergo the same changes as those of the
small intestines. Far more rarely the process extends to the jejunum,
and even to the pyloric portion of the stomach (gastrotyphus), the
solitary glands, and certain portions of the mucous membrane, which
usually correspond to the folds, undergoing the changes characteristic
of typhus.

Where death occurs during the recovery of the ulcer and the other
results of the disease, after the proper typhus process has run its course,
the post-mortem appearances differ from those above described, and we
must not limit ourselves to describing the processes which precede the
healing of the ulcer, but must give a short glance at the state of the
other organs, particularly as they show certain anatomical changes
which never or very rarely occur during the first weeks of the disease.
Ihe bodies of patients who have died during the third or fourth week
of the disease, or later, are more or less emaciated ; the skin is pale,
rigor mortis moderate, and, if there be decided anaemia, there is but
little hypostatic congestion. In many cases the teeth and gums are

TYPHOID FEVER. 631

etill covered with a blackish coating. Over the sacrum, trochanters,
and elbows, we usually find bed-sores ; there may be destruction of
the skin only, or of the other soft parts also, extending to the bones.
In many bodies there is slight oedema of the lower extremities, and, if
one or other femoral vein be obstructed by a thrombus, there is very
marked oedema of the corresponding limb. Lastly, on the skin we
often find petechise, miliary vesicles, ecthyma pustules, and, in some
cases, abscesses in the subcutaneous and intermuscular connective
tissue, and suppuration of the parotid glands. On opening the body,
the muscles no longer appear red and dry, but are pale and infiltrated.
The blood in the heart and great vessels has lost its , dark color, is
fluid, and not unfrequently contains fibrinous clots, particularly when
there has been inflammation of any organs. The brain is usually pale,
moist, and the blood-points appearing on its cut surface are lighter,
and contrast less with the white brain-substance than they did earlier
in the disease. In the lungs, besides extensive hypostasis, we often
find lobar or lobular pneumonia, and occasionally there are inflamma-
tory exudations in the pleural sac ; any laryngeal ulcers extend deeply
and reach or destroy the perichondrium. In rare cases we find peri-
chondritis laryngea without ulceration of the mucous membrane (Vol.
I.). The heart is very relaxed and flabby, the endocardium and tunica
intima of the vessels are greatly infiltrated. The swelling of the spleen
has subsided, its capsule is often wrinkled, its tissue relaxed and pale ;
occasionally it contains haemorrhagic infarctions. The distention of the
vessels and capillary hyperaemia of the stomach have disappeared at the
same time as the swelling of the spleen. The ulcers of the intestine are
on the road to recovery, or are already cicatrized, especially in those cases
where death was due to other causes. Rokitansky describes the healing
and cicatrization of typhus ulcers as follows : The loose border of mu-
jous membrane, forming the edge of the ulcer, becomes attached to the
floor of the ulcer gradually from the periphery toward the centre, at the
same time it becomes more pale and less thick ; the delicate connective-
tissue layer, which covers the muscular coat in the floor of the ulcer, be-
comes whitish, thickened, and is finally transformed into a serous plate,
into which the adherent border passes imperceptibly, thinning as it ap-
proaches the centre. The mucous membrane gradually extends over
this plate toward the centre of the ulcer, but, at the same time, be-
comes thinner, from the tension to which it is subjected. When the
edges of the mucous membrane come together and adhere, the healing
is complete. From the thinning of the mucous membrane, the cicatrix
forms a slight depression ; it is often somewhat pigmented, it is
smoother than the parts around, and studded with a few tufts. Cica-
trization of typhus ulcers never causes stricture of the intestines. As
90

ACUTE INFECTIOUS DISEASES.

the ulcers heal, the mesenteric glands return to their normal size, and
often shrink to small, firm, slate-gray bodies. Some, also, become case-
ous and subsequently calcareous. Typhus ulcers do not always heal
up, as above described. Occasionally the healing is delayed, but does
finally occur. In other cases there is ulceration at the edges and base
of the ulcer, which may cause erosion of vessels and abundant intes-
tinal haemorrhage or perforation of the intestine. It is difficult to de-
termine whether rupture of the serous coat in these slow ulcers finally
results from suppuration of its tissue, from extensive gangrene, or, after
destruction of the muscular coat, from simple rupture of the thin wall.
The fact, that, not unfrequently, errors of diet and mechanical causes,
such as compression of the abdominal contents by vomiting, precede
the perforation, seems to show that the perforation of the serous coat
is often induced mechanically. When death occurs late in the disease,
besides the remains of the typhus processes, we occasionally find the
evidences of croupous and diphtheritic inflammation of the mucous
membrane of the intestinal canal, especially of the large intestine, and
very rarely in the gall-bladder also. Lastly, we must add that more
or less extensive nephritis, as well as thrombi in the veins, is among
the changes not unfrequently found after the typhus proper has run
its course.

SYMPTOMS AND COURSE. — In many cases, the evident commence-
ment of the disease is preceded for days or weeks by indefinite pre-
monitory symptoms, which do not at the time enable us to determine
the nature of the malady, but are of diagnostic importance after the
disease has developed, as in doubtful cases they aid us in distinguish-
ing typhoid fever from other affections that begin suddenly, without
premonitory symptoms. These prodromata are feelings of general
illness, mental disquiet, great dulness and relaxation, loss of appetite,
indigestion, restless sleep disturbed by dreams, headache, dizziness,
wandering pains in the limbs, which are usually considered rheumatic,
and repeated epistaxis. These symptoms may last from a few days to
several weeks.

We generally consider that the disease proper begins when
the first chill occurs during the premonitory symptoms, or, if there
has been no prodromal stage, when a chill notifies the patient of his
illness. This chill is rarely so severe and continued as in intermittent
fever or pneumonia ; there is usually no shivering or chattering of the
teeth. Frequently there is not a single chill, but several, and cases do
9ccur without any chill. Hence, especially in inattentive patients, we
?annot always tell whether the disease is at the seventh or eighth, or
at the tliirteenth or fourteenth day.

The pathologico-anatomical changes in the intestines during ty

TYPHuID FEVER. (333

phoid fever do not correspond to any marked clinical stages, so as to
enable us accurately to distinguish the symptoms corresponding to the
stages of congestion, typhus infiltration, sloughing, and ulceration, and
to give the symptoms of these different phases of the intestinal dis-
ease. Nor does the time that has elapsed since the first chill give any
definite clew to the pathologico-anatomical stage of the bowel affec-
tion ; but, on the other hand, we may suppose that, at the end of the
third, or, at latest, at the end of the fourth week, the true typhus pro-
cess has terminated, and that any existing morbid symptoms are only
its remains, and belong to the secondary diseases of the blood and of
different organs, induced by the typhus infection. Therefore Hamer-
nik makes " a first and second period of the typhus blood-crasis ; " in
his communications from the Pfeufer's clinic, Vogel speaks of two
groups of symptoms, the " intoxication " and the " reaction " symp-
toms ; Griesinger makes a " first and second period of the disease."
We also shall divide the symptoms into two classes, and shall speak
first of the symptoms of the disease itself, afterward of the symptoms
of the sequelae. As we mentioned above, the former occur in the first
three or four weeks of the disease, the latter later in its subsequent
course.

Even during the first week the patient becomes very weak and
much prostrated ; but few can leave their beds during the first days ;
at the same time they complain of headache, which is chiefly in the
forehead ; of vague pains in the extremities, of buzzing in the ears,
flashes before the eyes ; of dizziness, which is particularly severe when
they rise in bed, or attempt to walk. The sleep is restless and broken
by dreams, in which the patients often speak single words, or whole
sentences, in a loud voice. During the first week, while awake, the
patient is usually perfectly conscious, but shows little interest in
things around, and answers slowly and unwillingly to questions.
There is great thirst, no appetite ; there is a slimy or bitter taste in
the mouth ; many patients ask for an emetic, because their stomach
is out of order. Occasionally there is diarrhoea, but at first the
bowels are usually constipated, and it is not till the end of the week
that the patient has several pulpy or even fluid stools daily ; in still
other cases, the bowels remain constipated throughout the week, and
induce imprudent physicians to prescribe laxatives. If these or an
emetic be given at the commencement of the disease, they almost al-
ways induce severe diarrhoea, which it is difficult to arrest. The pas-
sages are rarely accompanied by much pain. During the first week
of typhoid, there is often repeated epistaxis, which is not apt to be
abundant, and which relieves the headache. In most, but not in all
sases, cough and mucous expectoration betray the bronchial catarrh,

634 ACUTE INFECTIOUS DISEASES.

jrhich may be discovered by physical examination even during tbo
first week. Among the objective symptoms comes next the changed
appearance of the patient. While in bed, the face, especially the
the cheeks, appears red ; but, if he has been sitting up for some time,
he looks pale and meagre. At first the tongue is rarely thickly coated,
moist and broad, showing impressions of the teeth along its sides ; it
usually has a thin, whitish, epithelial coating, through which some
papillae project as red points ; it is covered with a tough, slimy mucus,
and appears narrow and pointed. The thin, epithelial coating usually
falls off, gradually leaving, as Vogel aptly describes it, " a moist, red,
smooth tongue, that looks as if covered with gold-beater's skin, or else
is already inclined to dryness. If there be at first a thick, adherent
coating on the tongue, it is usually detached from the point posterior-
ly, and from the sides toward the middle, so that the whitish yellow
coating appears enclosed in a very red border, which constantly in-
creases in width ; but in some cases the detachment begins centrally,
so that in the middle of the tongue there is a red stripe, that has a pe-
culiar tendency to become dry, and at the sides two whitish-yellow,
moist, slimy stripes. The central stripe is often broad anteriorly, and
disappears posteriorly, so that on the point of the tongue we see a red
triangle, with the apex posteriorly." In spite of this peculiar disturb-
ance of nutrition on the surface of the tongue, and of the diminution
of secretion in the mouth, on microscopical examination of the coating
of the tongue, Vogel could find nothing characteristic. Palpation and
percussion do not show any anomaly of the heart or lungs, but on
auscultation even at first, and always by the end of the first week, we
find a more or less extensive whistling sound (rhonchus sibilans), due
to catarrh of the smaller bronchi. Even during the first days the ab-
domen is usually somewhat puffed up and tense ; deep pressure over it
is generally painful, and this sensitiveness to pressure exists not only in
the ileo-ccecal region, but also about the navel and in the epigastrium.
On pressure in the right iliac region, particularly if there has already
been severe diarrhoea, we notice a gurgling sound, the so-called ileo-
coecal gurgling, whose diagnostic importance was formerly much over-
estimated. Toward the end of the first week, the enlargement of the
spleen is ordinarily marked. The enlarged organ usually has a horizon-
tal position ; it rarely projects beyond the ribs, and is pressed upward
and backward against the spinal column by the distended intestines.
Hence, the typhus spleen is rarely to be reached on palpation, and,
even when it can be touched, it is so soft that we are unable to define
its outlines. But, if we lay the patient on his right side, with his left
hand on his head, on percussing the lower ribs of the left side, we find
a dull space, which may be six niches long by four wide, and which.

TYPHOID FEVER. 635

jorrespondins: to the eighth, ninth, and tenth ribs, nearly reaches the
spinal column posteriorly, and the margin of the ribs anteriorly. An
increase or decrease of the spleen-dulness, to the extent of a centime-
tre or so, cannot be made out with certainty, in spite of what enthusi-
asts in physical diagnosis assert. Even when the dulness has undoubt-
edly increased or decreased slightly, we must bear in mind that this
may depend not only on diminution or enlargement of the organ, but
also on changes of its position. A greatly enlarged spleen may in-
duce but little dulness when it is pressed into the hollow of the dia-
phragm by the distended intestines, and only a small part of it lies in
contact with the thoracic wall. Toward the end of the first week, on
careful examination, we often find a few pale-red, roseola spots, about
the size of a lentil, on the epigastrium and neighboring portions of the
abdomen and breast. Finally, the most important objective symptom
is the fever. The temperature rises very regularly, in a manner al-
most pathognomonic of abdominal typhus. During the first week,
the evening temperature is nearly two degrees higher than that of
the morning ; the morning temperature of the next day is about one
degree lower than that of the preceding afternoon. For instance, a
patient who has a temperature of 104°. 6 this evening, will, as a rule,
have a temperature of 103°. 7 to-morrow morning, and to-morrow even-
ing a temperature of 105°.5. Toward the end of the first week, oc-
casionally there is no increase of evening temperature ; but even then
the morning temperature is almost always about one degree lower
than that of the evening ( Wunderlich). During the first week, the
pulse usually increases to ninety or a hundred, or even higher. Its fre-
quence does not by any means always correspond to the temperature
of the body, for, besides this, there are other causes, not always evident,
that influence the heart's action. Among other things, the pulse is ac-
celerated from twenty to thirty beats in the minute, if the patient sits
up in bed awhile, strains himself, or becomes excited in any way.
Regarding the quality of the pulse, the blood-wave is usually quite
large, but the artery remains soft during its diastole, and we often no-
tice that the first pulsation is followed by a second, weaker one, that
the pulse beats double. The double pulse, which does not occur exclu-
sively in abdominal typhus, but is more frequent here than in any
other disease, and consequently is not without diagnostic importance,
is probably due to deficient activity of the contractile elements of
the arterial walls, which are in a sub-paralytic state, as it is called.
At least it may be shown that, if the arterial walls possessed no
?on tractile filaments, but only elastic elements, the first pulsation,
caused by the blood-wave, would be followed by a second evident
pulsation (" Nachscliwingung"). During the first week, in accord

636

ACUTE INFECTIOUS DISEASES.

ance with the severity of the fever, the urine is concentrated, high-
colored, and of increased specific gravity (1020 or more). If the pa
tients replace the water they lose in perspiration and diarrhoea by
drinking freely, the absolute amount of urine is not diminished ( Vogel)
The production of urea, which is increased in proportion to the supply
of nourishment, as shown by Vogel, corresponds to the elevation of
temperature, which depends on the increased transformation of tissue.
Later in the disease, when the fever disappears, the increased produo
tion of urea also ceases, and, like the temperature, falls below the nor-
mal amount. The chlorides are diminished in the urine of typhus pa-
tients. The explanation of this is less simple than that of the increase
of urea. It partly depends on less salt being eaten with the food,
partly on increased excretion of the chlorides by the bowels, partly
perhaps because, while the blood is deficient in albumen, it retains
more salts. However, neither the increase of urea, nor the decrease
of chlorides, nor, finally, the slight albuminuria, is characteristic of
typhus, as it also occurs in other diseases accompanied by severe
fever and copious exudations.

In the second week of the disease the complaints of pain in the
head and limbs cease, but the dizziness becomes worse and the noises
in the ears are accompanied by deafness, which, however, does not
depend on disturbance of innervation, but, on a propagation of the
typhous oral and pharyngeal catarrh to the Eustachian tube and cavity
of the tympanum. The expression becomes more stupid, the inatten-
tion greater; the intellect, which was usually clear during the first
week, becomes cloudy, and the patient gradually falls into a somnolent,
stupid state, from which he can only be aroused with difficulty, and for
a short time. In spite of the dry mouth, he manifests no desire for
water, but drinks with avidity when a glass of water is placed to his
lips. It is often necessary to urge the patient repeatedly, to make him
show his tongue, and when he has at length, after several unsuccessful
attempts, succeeded in protruding the trembling organ, he occasionally
forgets to draw it back, and must be reminded and urged to do this
act also. Toward the end of the second week particularly, the stools
and urine are often passed in bed, because the patient does not per-
ceive the necessity of evacuating the distended rectum or bladder, 01
because he neglects to contract the sphincters energetically by an ac
tion of his will. Many patients lie unconsciously on their backs ; if
placed on the side, the body and limbs follow their own weight, with-
out the patient making any attempt to change his position, even if it
be uncomfortable. The occasional trembling movements of the lips, or
a few incomprehensible words that the patients mumble, alone show
that the mental activity is not all lost (febris nervosa stupida) Othci

TYPHOID FEVER. (537-

patients, who are just as insensitive to the external world, who denude
themselves without any modesty, do not answer questions, and scarcely
react to the strongest irritants, show by their whole manner that they
are living in an excited dream ; they are constantly agitated, throw
off the bed-covers as fast as they are replaced ; thrust first one foot,
then the other, out of bed, attempt to stand up or run away, talk loud
or disjointed words, gesticulate, speak unknown tongues, and become
morose and angry when they are held or in any way restrained
(febris nervosa versatilis). It is astonishing what energy and persist-
ence such patients often show in attempting to carry out their morbid
impulses. Occasionally, during the entire disease, a certain circle of
hallucinations recurs ; the patients pursue any object that they can-
not attain, are grieved by any sorrow that they are constantly combat-
ing, etc. ; in other cases the phantasms alternate confusedly with
others having apparently no connection with them. Occasionally this
alternation is so great that during the day the case appears to be a
febris nervosa stupida, while during the night it seems to be a febris
nervosa versatilis. In some cases the patients are constipated, even
during the second week of typhoid fever ; but, as a rule at this time,
there are several watery evacuations daily. They vary in number
from three to six, or even to twenty or more in twenty-four hours, but
we cannot, from their frequence, decide the number and extent of the
typhus ulcers, as the diarrhoea does not depend on them, but on the
catarrh accompanying them ; it is exceptional for the stools to be ex-
cessively frequent, and it is most common to have only three or foui
passages daily. The dejections have the color and appearance of
badly-cooked pea-soup, in which the meal is not thoroughly mixed,
but has sunk to the bottom. They have an alkaline reaction, contain
uniy traces of albumen, and have no microscopic elements or chemical
constituents peculiar to typhus. The upper watery layer contains
chiefly salts, and owes its alkaline reaction to the large amount of car-
bonate of ammonia in it. The lower stratum consists of remains of
food, detritus, epithelium, mucous corpuscles, numerous crystals of triple
phosphates, and small yellow flocculi and globules, of whose origin and
character we know nothing definite. Respiration is hastened and
superficial. In some cases, in spite of the extensive catarrh, there is
neither cough nor expectoration ; in other cases the patients cough a
good deal, and expectorate quantities of tough mucus. The objective
symptoms also have changed to some extent in the second week. The
cheeks are now more brownish red or bluish, the eyelids are half-
closed, there is dried mucus at their corners, the conjunctiva is injected,
the nostrils smoky-looking. A brown, tough mucous, fuliginous coating
clings to the teeth and gums, and the tongue is covered with a browr

ACUTE INFECTIOUS DISEASES.

crust, which gradually becomes blackish by admixture with blood
from small fissures in its mucous membrane. Decomposition of the
coating of the tongue and teeth causes a very disagreeable, penetrating
odor ; movement of the tongue is much impaired, so that speech be-
comes indistinct, chewing of hard substances often impossible, and
even drinking difficult. Physical examination of the thorax almost
always shows more or less extensive condensation of the dependent
portions of the lungs ; on both sides of the spine the percussion-sound
is less intense ; on ausculting over the back, we find a weak vesicular
or undecided breathing and fine mucous rale, rarely bronchial respira-
tion, and at other parts of the chest there are numerous loud rhonchi
The belly is usually puffed up by the excessive meteorism of the intes-
tines, which has never been explained. Its sensitiveness to pressure
continues, as does the ileo-caecal gurgling in many cases. The en-
largement of the spleen has increased ; and that organ is pressed still
farther backward and upward by the inflated intestines. In some
cases the roseola spots have become quite numerous, and have spread
from the epigastrium and lower half of the thorax to the back ; suda-
mina frequently occur. Among the objective symptoms of fever, the
bodily temperature in the evening is usually 104° to 106° ; in the
morning there is only a slight remission. The pulse, which is less
full, soft, almost always double, is often as high as 110 to 120, or
more. In many cases the urine contains traces of albumen.

In the third week of typhoid fever, the patient becomes excessively
weak ; he cannot sit up ; and, if the bed be inclined, he slides down
coward the foot of it, as often as he is lifted up. In the relaxed mus-
cles we may often see and feel contractions of single fasciculi, the so-
called subsultus tendinum. The somnolence and stupor reach the
highest grade ; the noisy delirium ceases, and the restlessness gives
place to increasing stupor; some patients make automatic motions
with the hands, or pick at the bedclothes, and almost always pass
their faeces and urine in bed. Occasionally the detrusor urinae is also
paralyzed, and the bladder excessively distended. The coating on the
tongue and teeth becomes thicker, crusty, and fetid ; the stammering
speech grows unintelligible ; drinking is very difficult. The chest and
abdominal symptoms, also the frequency of respiration, rhonchi and
mucous rales, dulness along the back, diarrhoea, and meteorism, become
very decided. The spleen does not enlarge any more, but its swell-
ing begins to subside. In the third week the roseola spots also
Ixjgin to grow pale, while the sudamina increase, and petechiae some-
times appear. In most patients there, is erythema about the sacrum
and detachment of the epidermis, and the exposed cutis sloughs. At
the commencement of the thi~i week there is also apt to be an ir>

TYPHOID FEVER. 639

crease of the temperature and of the pulse. The morning remissions are
indistinct. Fatal termination is most common in the third week , if not
induced by some peculiar accident, death results from cedema of the
lungs, after the prostration, weakness, temperature, and pulse have
reached the highest grade. The more the respiration is affected, the
sooner and more readily paralysis of the heart occurs. In favorable
cases there is a subsidence of the symptoms about the middle of the
third week. The state of deep sopor, during which the patient lives
a dream-life, gives place to natural sleep. While awake, the expres-
sion of the patient shows that he pays some attention to the things
about him, which, at the height of the disease, had no existence for
him ; he also recognizes his attendants. The first glance in which
affection and gratitude again appear may be regarded as an advance,
although the danger is not yet over, and although the hopes awakened
by this and other signs are often blasted. The more quiet and con-
tinued the sleep, the clearer the intellect usually is during the waking
state. The patients begin to complain of the bed-sores, and to lie on
the side, so as to avoid pressure on the sore parts. They no longer
pass their urine and faeces in bed, but call for the bed-pan when they
wish to have a stool, or empty the bladder. The number of respirations
decreases, the patients cough oftener, and more strongly, and easily
expectorate the mucus collecting in the bronchi, which has become
less tough, and is usually yellowish. The passages are less frequent,
and contain some consistent matter. The blue, sodden appearance of
the patient disappears, the face becomes paler. The tongue grows
moist at the edges and tip, its coating is gradually thrown off; speech
becomes more intelligible ; there is less difficulty in drinking. We
hear moist rales in the chest, the dulness along the spine disappears ;
even at these points the respiratory murmur becomes distinct, mete-
orism decreases, the spleen dulness grows less, the roseola spots dis-
appear. With the abatement of the other symptoms, the difference
between the morning and evening temperatures becomes remarkable ;
while the thermometer placed in the axilla still rises to 104° to 106° in
the evening, in the morning it is often only 101° to 103°, or even less.
These lower degrees are not observed in the evening for some time
yet. As the temperature decreases, the pulse also falls, although the
two do not keep pace. At the same time the pulse becomes fuller,
and loses its rebounding character. This general improvement, which
often does not occur till the fourth week, while the symptoms have
maintained their intensity, or even increased till the end of the third
week, often passes directly into convalescence, and the slow recovery
alone shows that remains of the typhus process, especially intestinal
ulcers, still exist ; in other cases, the improvement is only temporary ;

640 ACUTE INFECTIOUS DISEASES.

the symptoms grow worse, and the patients die of paralysis of the
heart and suffocation. In some cases, finally, the above symptoms are
followed by those of retarded repair of the typhous local affections
and sequelae. The appetite, which often becomes wolfish during con-
valescence, may prove fatal, if the physician be careless, or the patient
intractable. We shall again refer to the danger accompanying this
symptom. Almost all convalescents lose their hair. But, as the hair-
follicles have undergone no permanent disturbance of nutrition, a new
growth of hair sprouts up soon after the old has fallen out.

We have attempted to give as comprehensive a view as possible,
and, at the same time, a tolerably complete one, of a severe " normal "
case of typhus.* But it would lead us too far to describe with equal
fulness the numerous and varied deviations that it presents in differ
ent cases, and-we must satisfy ourselves with noting the most impor-

* Wunderlich, who has made a very large number of measurements of tempera-
ture in typhoid fever, gives the most important results of his observations about as
follows : The course of the fever is typical and perfectly characteristic ; it distin-
guishes abdominal typhus from any other disease. Besides the cases which exactly
follow the regular type, there are others which deviate from it — irregular cases. The
causes of the irregularities cannot be recognized in every instance. The course of the
disease shows two sharply-bounded, distinct periods, which correspond to the deposir
tion and reabsorption of the infiltrations and exudations. These periods agree with
certain portions of time, and in regular or nearly regular cases they respectively
correspond to the first and last half of the disease. In mild forms, the first period
lasts only a week, or a week and a half; the entire disease lasts three or four weeks.
In severe cases, tlie first period lasts two, three, or three and a half weeks ; the en-
tire disease lasts five, six, or occasionally from eight to ten weeks.

In the first week, it is such an absolute rule for the temperature to rise two de-
grees toward evening, and to fall one degree before the next morning, that, if the
temperature on the second or third day be 104° or over, we may exclude typhoid ;
the same is true, if between the fourth and sixth days the evening temperature do
not rise to 103°, and, lastly, if the evening temperature begins to decrease again
as early as in the second half of the first week. A decided increase of temperature
during the first week is generally an unfavorable sign, while u slight increase ia
favorable.

In the second week we may exclude typhoid, if the temperature be below 104° on one
or more evenings between the eighth and eleventh day, and, conversely, on the evenings
of the second week, scarcely any other acute disease shows repeated rise of the even-
ing temperature to 104°. A favorable course of the disease during the second week
renders it probable that the third week will be still milder, while, on the contrary, a
severe and unfavorable second week may lead us to expect that the subsequent course
of the disease will be unfavorable. Among the favorable indications during the sec-
ond week are : an evening temperature between 104° and 105° ; a morning tempera-
ture one or two degrees lower; late occurrence of the exacerbation (not before 10
A. v.) ; early occurrence of the remission (before midnight) ; regular and daily moder-
ate decrease of temperature, as compared with that of the preceding day. Among the
unfavorable indications are : continued elevation of the morning temperature ; in
crease of the evening temperature to 105°. 5, or more; early occurrence of the daily

TYPHOID FEVER. 641

*:ant modifications of its course, and the severest and most dangerous
accidents that present themselves.

First, there are many cases which are not characterized by any re-
markable lack of intensity of the symptoms, or by any other peculiari
ties during the first week ; but in the second week the symptoms do
not grow worse and prove dangerous, as in " normal " typhus, but
they decrease, and toward the end of the second or third week have
all disappeared. Lebert has proposed the name abortive typhus for
these cases, and it seems to me preferable to other names, such as
" febricula," " febris typhoides," etc., because it better expresses the
fact that these cases are only modified, benign, brief forms of typhoid,
and not a peculiar variety of disease. After what we have said, it
would be a useless repetition to give a description of the course of
abortive typhoid during the first week ; so we shall only remark, that
many of the cases which former writers call " gastric fever " or " mu-
cous fever " are to be regarded as abortive typhus. The old customary
precaution, of waiting till the ninth day of the disease before saying
whether the case was " one of gastric or nervous fever," was and still
is very justifiable. The designations " gastric fever " and " nervous
fever," in common use, exactly correspond to what modern physicians
mean by " abortive typhus " and " normal typhoid," and since the laity
do not understand precise scientific terms, it would be well to keep up
this old custom. As in the first week the thermometer is the most
certain means of distinguishing typhoid from a genuine febrile gastric
and intestinal catarrh (Yol. I.), so in the second week it is the most
certain means of deciding whether the disease will be an abortive ty-
phus or not ; the other symptoms are far more deceptive. If we find
thv-t on the eighth or ninth day of the disease the temperature ceases
to rise, but gradually falls, and especially if we find decided morning
remissions at this time, we may be almost certain that the case is
one of abortive typhus. Cases where the temperature rises again

exacerbations ; late occurrence of the daily remissions ; and very high temperature at
any time.

In the third week, in mild cases, there are great morning remissions, so that the
morning temperature may be three to three and a half degrees lower than the even-
!ng temperature, and may become normal toward the end of the week. And from
the middle of the week the evening temperature also decreases. In severe cases, on
the other hand, the temperature sinks but little during the third week, or else it
maintains the same height, or even rises. In the latter case, we may almost posi-
tively expect a severe fourth week, and not look for a decided decrease of the fever
before the fifth week.

"We. may look for the approach of death, if the temperature remain for some timo
at 107 J ; if it suddenly rise to 107°.5 or 108°, or when it suddenly falls very low, say
to 94°. We must not expect perfect convalescence till the temperature is normal in
the evening also.

64-2 ACUTE INFECTIOUS DISEASES.

toward the end of the second week, and the subsequent course of the
disease is as above described, are rare. Even in abortive typhus,
the sleep is restless and disturbed by dreams, and patients talk in
their sleep during the second week ; but when awake their mind is
clear, and only a more or less marked apathy reminds us of the coma
vigil of severe cases. The bronchitic symptoms are moderate; the
daily evacuations are few in number, or there is no diarrhoea. The
patient looks pale and worried rather than blue and sodden. The
tongue is inclined to dryness, but is not covered with a firm crust.
There is either no deafness, or else it is only slight, like the oral and
pharyngeal catarrh. The abdomen is soft and only moderately promi-
nent. Frequently there is no ileo-caecal gurgling or sensitiveness of
the abdomen to pressure. The spleen-dulness is but little increased.
Only exceptionally a few roseola spots occur on the epigastrium.
During the morning, and while the patient remains in bed, the pulse
is only moderately hastened. In the third week, or toward the end
of the second, the temperature is usually normal, and is only elevated
moderately toward evening ; the tongue remains moist, and the patient
begins to have some appetite. The morbid symptoms of the thoracic
and abdominal organs have disappeared, particularly the diarrhoea.
Many patients are anxious to get up ; but, on attempting to rise or
move about the room, are usually surprised at their feebleness, of
which they were not aware while in bed. The strength returns slowly,
and this tardy convalescence shows the severity of the disease that
the patient has had. The conjecture above advanced, that in abortive
typhus there is no sloughing of the diseased intestinal glands, is not
founded on post-mortem examination, for which the favorable course
Df the disease gives no opportunity, but on the early cessation of the
diarrhoea, and the absence of the sequelae, so common in severe and
tedious cases of typhus, especially of those depending on retarded cica-
trization of the intestinal ulcers, and on the ulceration occurring in
their place.

There is a second modification of typhus which differs materially
from that above described ; it is usually termed typhus ambulatorius.
It is not very rare for persons who have only suffered from a slight
amount of weariness and depression, loss of appetite and slight diar-
rhoea, but have still been able to attend to business, or go on a jour-
ney, to die suddenly of perforation of the bowel or intestinal haemor-
rhage. On autopsy of such cases, we may find numerous intestinal
ulcers along with sloughing patches and medullary infiltration of the
mesenteric glands ; in short, the anatomical changes of advanced ty-
phous disease of the intestines. It is difficult to explain this peculiar
form of disease, except on the supposition that, under some circum-

TYPHOID FEVER. (54.3

stances, the infection with typhous poison may give rise to local
changes in the intestines, but induce so little alteration in the blood
and nutrition as to cause no noticeable functional disturbance.

While in typhus ambulatorius the constitutional disturbance and
fever are so slight as to be scarcely observable, some other cases of
typhoid are characterized by unusual intensity of the constitutional
disturbance, and especially by the height of the fever. In these cases
the disease usually runs a " tumultuous " course. Even in the first
week the temperature rises to 106° or more, and the pulse beats 120
to 130 per minute. During the day, the patients lie in a state of
deep somnolence, and look stupid ; at night they have high delirium,
and can scarcely be kept in bed. Subsultus tendinum, picking at the
bedclothes, and occasionally convulsive movements, begin early. The
ntensity of the local symptoms usually corresponds to that of the gen-
eral disease. The tongue becomes dry and crusted early ; even during
the first week the bronchitic symptoms, the signs of condensation of
the lungs, the meteorism, diarrhoea, and the enlargement of the spleen,
attain as high a grade as they usually do by the end of the second
week. Toward the end of the first or the beginning of the second
week the patient is greatly prostrated, slips down in bed, has a small,
irregular pulse, and very rapid superficial respiration. Such patients
often die early of paralysis of the heart and oedema of the lungs. In
other patients, after a tumultuous course during the first week, the
symptoms moderate and show no marked peculiarities during the
second or third week. Between typhus of great intensity and tu-
multuous course, and typhus of moderate intensity, and between this
and typhus ambulatorius, there are numerous intermediate forms,
which we shall not fully describe. Many cases, treated for weeks as
" gastric " or " mucous " fever, and finally recovering without any affec-
tion of the intellect or dryness of the tongue, are mild cases of ty-
phoid ; but it is certainly going too far to scratch gastric and mucous
fevers entirely out of the list of diseases. As we have shown above,
the height of the bodily temperature is more important than the roseola
or the enlargement of the spleen in diagnosing between typhoid, that
is, an infectious disease, and a genuine intestinal catarrh.

The appearances are also modified when the typhous intestinal
disease is very slight, or, to use the customary expression, when the
typhus localizes itself very slightly, if at all, in the intestines, and
" runs almost exclusively in the blood." Since, in the first weeks espe-
cially, the distinction between abdominal typhus and other acute in-
fectious diseases is based chiefly on the intestinal symptoms, an exact
diagnosis is entirely impossible in such cases, and we must occasionally
content ourselves with a probable diagnosis, by the exclusion of other

ACUTE INFECTIOUS DISEASES.

infectious diseases. If the intestinal symptoms fail entirely, or if there
are only slight indications of them, while the bronchitis is severe and
is early complicated with collapse and hypostasis of the lung or with
decided pneumonia, we have the disease which, especially in those
fatal cases where autopsy has shown medullary infiltration of the
bronchial glands, has been called pneumo-typhus or broncho-typhus. It
is evident that these cases, where the patients have a very cyanotic
look and hastened and painful respiration, belong to the malignant
forms. While the severe fever increases the production of carbonic
acid, the disease of the bronchi and lungs impedes the excretion of the
extensively formed deleterious gases. The formation of typhous ulcers
in the larynx is not usually accompanied by any characteristic symp-
toms, and modifies the appearance of the disease so little that we are less
justified in making " laryngotyphus " a separate class than we should
be in so considering broncho- and pneumo-typhus. But while, during
the first weeks of the disease, laryngeal ulcer is not usually recognized,
and is accidentally found on autopsy, it plays a very important part
hi the sequelae of typhus.

Among the accidents that interrupt the normal course of the dis-
ease during the first weeks, the most important are perforation of the
bowel, intestinal haemorrhage, and the abundant epistaxis which
occasionally occurs during the second or third week.

The perforations of the intestine, which occur during the first
weeks of the disease from the formation of a slough not only in the
mucous coat covering the patches, but also in the muscular and serous
coats at the affected parts, induce intense peritonitis ; but since, pre-
vious to the perforation, there has occasionally been adhesion between
different loops of intestine, from inflammation of the peritonaeum, this
inflammation is sometimes partial, not total, at first. The first signs of
perforation are a severe pain in the abdomen, which usually arouses
the patient even from deep stupor, and which becomes excessive on
the lightest pressure over the abdomen; the patient collapses sud-
denly, the face becomes distorted, the pulse small, the extremities cool,
and death usually occurs in from twenty-four to thirty-six hours, with
the symptoms that we have described (Vol. I.) as indicative of peri-
tonitis from perforation of the bowel. The most certain point in the
diagnosis of perforation of the intestine is the escape of air into the
peritoneal cavity, which is shown by the liver being pressed away from
the abdominal wall and a consequent disappearance of the liver-dul-
ness. If this symptom be absent, there is at least a possibility thai
the peritonitis is not due to perforation of the intestine.

Intestinal haemorrhages, occurring in the first weeks of typhus, from
erosion of the vessels on the detachment of the slough, or from rupture

1YPHOID FEVER. 645

of the overfilled capillaries in the spongy elevations of the mucous
membrane over the plaques above described, if abundant, often betray
themselves before the appearance of blood in the dejections, by the
collapse of the patient, which is accompanied by a sudden fall of his
temperature, and occasionally by a clearing of the intellect. The loss
of blood is often very considerable, but patients rarely die as a direct
result of the haemorrhage; the bleeding usually ceases, the typhus
pursues its course, but the strength of the patient does not carry him
through, and most patients die, sooner or later, after the haemorrhage,
from the exhaustion that is completed by the fever and diarrhoea.

The abundant haemorrhages from the nose during the second and
third weeks are far less dangerous than the intestinal haemorrhages ;
they are due to an acute hsemorrhagic diathesis, which frequently
occurs from excessive debility. They may be so severe as to require
the tampon, they exhaust the patient, and at least retard convalescence.
In women there is often haemorrhage from the genitals also, which does
not always occur at the menstrual period. Although the loss of blood
is not great, those haemorrhages which are greeted by the laity as
favorable signs are usually mail ominis.

If we bear in mind that most typhus patients recover very slowly
even when the intestinal ulcers heal, the fever disappears, and the ap-
petite returns immediately after the disease has run its course, and do
not fully regain their strength for five or six weeks, it is not difficult
to understand that retarded healing of the intestinal ulcers, and the
continuance of even a moderate fever by the bowel-disease, should in-
crease the danger to the patient. In these cases we find the typhus
proper followed for weeks by symptoms of an asthenic fever, or of a
fever in debilitated and anaemic persons. The intellect remains cloud-
ed, although the violent delirium usually disappears ; the patient be-
comes weaker, and slips down in bed more frequently than before.
The tongue does not again become moist, or else becomes dry again,
the bronchitic symptoms disappear, but the hypostases extend; en-
largement of the spleen and roseola spots can no longer be found, but
the meteorism and diarrhoea continue more or less marked. The bed-
sore over the sacrum spreads, increases in depth, and may cause fright-
ful destruction. Bed-sores also develop over the trochanters, elbows,
and on the knees also, if the patients be laid on the belly. Petechiae
and ecchymoses form at different parts of the body, especially where
there has been any temporary pressure. Emaciation becomes exces-
sive ; the pallid skin is constantly bathed in perspiration. The visible
mucous membranes also become pale and bloodless. There is often
slight oedema of the lower extremities, or excessive oedema of one leg
from thrombosis of the femoral vein. Many patients die in the sixth

646 ACUTE INFECTIOUS DISEASES.

DF seventh week, or even later, of this slow form of typhoid. Ju other
cases the diarrhoea ceases, the intestinal ulcers heal ; but the bed-sores
nduce fatal exhaustion ; at least, we not unfrequently find deep de-
struction of the soft parts and exposure of the bones, and recently-
healed intestinal ulcers, as the only post-mortem appearances in cases
that have proved fatal late in the disease. The pneumonias, pleurisies,
suppurations of the parotid, diphtheritic inflammations of the intestines,
nephritis, and other sequelae of typhoid above mentioned, show them-
selves, just as in other debilitated persons, by objective rather than by
subjective symptoms. Chills, and renewed increase of the bodily tem-
perature, should excite the suspicion of one of these consecutive diseases
and induce a more careful examination. Repeated chills, very high
temperature, quick collapse, generally depend on pyaemia, induced by
absorption of ichor from the bed-sores. The occurrence of severe pain
in the larynx, hoarseness, aphonia, and the signs of acute laryngeal
obstruction, indicate perichondritis laryngea, which is caused by ty-
phous laryngeal ulcers penetrating deeply, but also occurs indepen-
dently of this as a sequel of typhus.

Lastly, we must mention that in some cases perforation of the in-
testine occurs in the fifth or sixth week, not only while the patient is
debilitated by the fever, induced by sluggish ulcers, but even while
convalescence is going on perfectly well. Far more rarely haemor-
rhages occur at this time, from slowly-healing ulcers.

Recovery is the most frequent termination of typhoid fever ; it
takes place in about three-fourths of all cases ; but some epidemics are
far more malignant, while in others the mortality is much less. In
most fatal cases death occurs in the second or third week of the dis-
ease, that is, at its height ; but we have already stated that, where
the course is very rapid, the disease may prove fatal in the first week,
and, in protracted cases, not till the fifth or sixth week, or even later.
The different causes of death have been sufficiently described when
speaking of the symptoms and course.

Sometimes typhoid ends in incomplete recovery ; sequelae, such as
disturbances of innervation, neuralgias, partial paralyses, partial anaes-
thesias, or mental disturbances, remain ; occasionally typhus leaves a
tabes and a lasting anaemia and hydraemia, which are not thoroughly
understood. The material changes on which these disturbances of in
nervation depend have not been discovered on post-mortem examina-
tion. The supposition, that the remaining sickness and the deficient
formation of blood depend on destruction of the intestinal glands and
impermeability of the mesenteric glands, is incorrect. Pulmonary con-
sumption not unfrequently develops during convalescence from severe
typhoid fever.

TYPHOID FEVER. 647

TREATMENT. — Prophylaxis requires that, in large cities, where
typhoid fever is endemic, there should be sanitary police rules to pre-
vent the soil from becoming soaked with putrid decomposing materials.
Of late, many attempts have been made, by drainage in cities, to re-
move the moisture of the soil, which greatly favors the decomposition
of animal substances, and, consequently, the occurrence of typhus and
cholera germs. Should the drainage succeed, and should it decrease
the number of typhus and cholera cases, as the • drying up of swamps
sometimes does that of intermittent fever, the still youthful science of
hygiene would boast of a brilliant triumph. Some physicians still
doubt the contagiousness of abdominal typhus, or, at least, consider it
as not proved. But such views must not be brought to the bedside
of the patient ; here the fact, that the non-contagiousness has not
been proved, must make us act as if its contagiousness had been de-
monstrated. The sick should be isolated from the well, and only
those attendants required in caring for the patients should be allowed
in his vicinity. It is just as important that all healthy persons, who
can be spared, should be removed from the locality where the infection
of one or more persons has occurred. I have learned of one very sor-
rowful instance in Rheinland during the past few years, where, ap-
parently, from the neglect of this precaution, almost all the members
of one family, one after another, died of abdominal typhus. Lastly
we must take care that the dejections of patients be not thrown into
privies used by other persons. We know no prophylactic remedies
that protect from infection by typhoid.

When abdominal typhus has once begun, we may, under some cir-
cumstances, attempt to cut short its course. It is now generally recog-
nized that this cannot be done by emetics or venesection, which, for a
time, were recommended for this purpose ; in fact, these measures al-
most always have an injurious influence on the course of the disease.
Only when there is undigested food in the stomach, should we give a
dose of ipecac. ; in all other cases we mi^st remain immovable to the
senseless and often annoying requests of the laity for the administra-
tion of an emetic. The case is very different with a few large doses
of calomel. After the accurate observations of Wunderlich, we can
scarcely doubt that by this remedy we may, in some few cases, cut
short the disease (according to Wunderlich, one or two five-grain
doses are enough), and that in the great majority of cases where this
remedy is given during the first week, and before the occurrence of
much diarrhoea, the course of the disease is rendered milder and shorter.
The experience of Pfeufer's clinic, as well as my own, perfectly agrees
with W'Mnderlicli's. We shall not attempt to say whether the calo-
mel has a favorable influence on the typhous intestinal disease, by op-
91

ACUTE INFECTIOUS DISEASES.

posing the sloughing and ulceration, and whether, consequently, we
can only expect benefit from it in the first weeks of the disease, when
these changes have not yet taken place. Willebrand has lately rec-
ommended iodine as a specific in typhoid, and the results published
by him, Liebermeister, and others, urge us to make more trials with
the preparations of iodine in this disease, although the treatment is
not a new one. Wittebrand dissolves six grains of iodine and twelve
of iodide of potassium in one drachm of water, and gives three or four
drops of this solution in a wineglassful of water every two hours. It
is said that, even after one, two, or three days of this treatment, there
is a decided remission of the temperature ; sordes do not come on the
gums, or they disappear early ; the fever ceases in an unusually short
time.

In most cases of typhus, the indications are to protect the patients
from all injurious influences, to combat dangerous symptoms, and to
maintain the strength of the patient by dietetic rules. In the first
place, wherever circumstances permit, we should see that the sick-
room be not too small, and be very careful to have it well ventilated.
Fresh, pure air is very necessary for all typhus patients, and they do
not catch cold nearly so readily as the laity imagine. The tempera-
ture of the room should be regulated by the thermometer, and should
be kept as nearly as possible at 60° to 65°. In North Germany there
is a belief that a vessel of water under the bed prevents bed-sores. If
it do not fulfil the expected end, this practice is probably useful in
maintaining a certain degree of moisture in the room. We should also
attend carefully to the patient's bed. The coverings should not be too
heavy, and the sheet should have no creases in it. The bed and body
linen should be changed as often as soiled. We should not neglect to
see that the body of the patient is kept scrupulously clean through-
out the attack. Even among the neatest persons this is not super-
fluous, for they are often prejudiced, or else fear to injure the patient
by exposure, or do not carefully inspect the parts about the anus and
sexual organs, so as to cleanse them from any excretions. Neglect
of this precaution frequently cannot be subsequently made good.
The most insignificant erythema on the nates, which might have
been avoided, may prove very dangerous late in the disease, by
forming the commencement of an extensive bed-sore. If the pa-
tient be too weak to clean his own mouth, we should have it washed
out regularly with a linen rag wet with cold water, or, still better,
with cold soda-water. Particular care should be paid to washing
ff the sticky mucus clinging to the teeth and gums, before it dries
and decomposes. Even when the patient is in a state of stupor, he
usually shows some signs of pleasure and gratitude after this proceed

TYPHOID FEVER.

jig. The best article of drink is pure spring-water or soda-water ; if
there be severe diarrhoea, we may give oat or barley water. All addi-
tions of fruit-juices, vegetable acids, toasted bread, etc., to the drinks,
soon become objectionable to the patient. The patient must drink
freely, in order to replace the loss of water induced by the copious
perspiration. If, during the advanced stages of typhoid, they do not
ask for drink, because they do not perceive the want of it, it should be
offered to them. Badly-instructed or thoughtless nurses sin a great
deal against this rule. Shall we give the patient nourishment, or
place him on absolute diet ? Views vary greatly on this point. Most
German and French physicians consider the administration of meat-
broths, eggs, and other nutritious substances in fevers generally, as so
decidedly injurious, that they regard " fever-diet " and water-soup as
identical. From England, there is an accusation against the German
physicians particularly, that their dietetic rules cut off from the patients
the supply of material by which the consumed portions of the body
might be replaced, and that, consequently, the mortality is greater in
Germany than in England, because the patients are starved, as it
were. There is some truth in this assertion. I have no hesitation in
saying, that the aggravation of a fever by giving the patient milk,
eggs, and meat, has not been proved by actual observation, and I be-
lieve that much injury may be done by blind faith in the correctness
of this hypothesis. There is no doubt that in every fever the con-
sumption of the constituents of the body is greatly increased, and that
no sort of exercise will use up the body so rapidly as a fever does.
While continued bodily exertion is usually borne with impunity, be-
cause the increased consumption is hidden by increased supply, most
fatal cases of fever are due to insufficient material being furnished for
the replacement of that used up. Regarding typhoid fever, particu-
larly, we find that in this disease the bodily temperature is above the
normal for several weeks, and the consumption of tissue, by which this
calorification is induced, is greatly increased. We see that in the
most favorable cases, during convalescence, the greatly debilitated pa-
tients, who have often lost ten to twenty pounds in weight, recover
very slowly; and we must agree, that these facts urge us to give
meat, milk, eggs, etc., rather than water-soup, until it shall be proven
that such diet increases the fever. But, on the other hand, it cannot
apparently benefit the patient if we give him this nourishment, and he
is not able to assimilate it ; on the contrary, it would hurt him to fill
his stomach with food that will not be digested, but will decompose
and cause irritation of the gastric and intestinal mucous membrane.
We have before seen that dyspepsia is a constant accompaniment of
all fevers. If we do not attend to this fact in regulating the diet of

ACUTE INFECTIOUS DISEASES.

typhoid cases, but expect that their stomachs will supply plenty of gas
trie juice to digest large quantities of protein substances, we shall not
increase their strength, but shall add a complication which will aug-
ment the danger. From this we have the rule, supported by ex-
perience, that at first we should give typhoid patients small quantities
of milk and strong broth several times daily, whenever they desire it.
The longer the disease continues, and the greater the exhaustion of the
patient, the more untiringly we must attempt to supply nourishing food,
but always in small quantities and in fluid form. In addition to these di-
etetic rules, we should have typhoid patients washed all over with pure
cold water, or with a mixture of three parts of water to one of vinegar.
This should be repeated several times daily, and should be done very
carefully, so that its beneficial and soothing effects may not be an-
nulled by the fatigue induced by the act itself. In a mild, regular
course of typhoid, we need give no medicine ; but probably the old
prescription of dilute chlorine- water (aqua oxymuriat. § ij, aqua des-
till. § vj, det. ad vitr. nig., tablespoonful every two hours), or of mu-
riatic acid in mucilage (acid, muriat. cone. 3 ss, mucil. salep | vj, syr»
simp. | j, tablespoonful every two hours) is at least of palliative ser-
vice ; and, as there are few patients that can be treated entirely with-
out medicine, we should prescribe the above mixture, and it deserves
the preference over other more active prescriptions. We may also
follow the old custom of giving the muriatic acid in a weak infusion
uf ipecac, (gr. viij to § vj), instead of in simple mucilage, during the
second week, if the diarrhoea and bronchitic symptoms increase, and
hi a weak decoction of Peruvian bark during the third week.

The above treatment answers for most cases ; but there are many
others which require a different procedure, and in which threatening
danger can only be averted by energetic treatment. In abdominal
as in exanthematic typhus and other infectious diseases, the greatest
danger is from the severity of the fever. But against this we have a
most efficient remedy. The danger from the fever is a double one.
On the one hand, the increase of bodily warmth above a certain point
induces paralysis of the heart and renders life impossible ; on the other
hand, continued increase of the production of heat, or, what is the
same thing, protracted increased transformation of tissue, on which the
feverish over-heating depends, induces consumption of the body of the
patient. In fevers of proportionately short duration, as in the acute
exanthemata, exanthematic and abdominal typhus, the danger from
increase of the bodily temperature is, of course, more to be feared than
that accompanying the increased production of heat. But, in combat-
ting the former, we should not lose sight of the latter, or else we may
injure the patient instead of benefiting him. Without fear of being

TYPHOID FEVER. 651

misunderstood, I may give this warning before urgently advising the
abstraction of heat in treating either exanthematic or abdominal ty-
phus ; because, so far as I know, the hydrotherapeutic treatment of
typhoid fever was first introduced and carefully observed in my clinic.
Until within a few years, when the bodily temperature had risen to a
dangerous height, and there was occasion to lower it, I have had the
patients wrapped in cold, wet sheets, and the proceeding repeated at
intervals of ten to twenty minutes, until the desired end was attained.
After satisfying myself that the patients were unnecessarily annoyed
by the repeated transportation from one bed to another, which was
unavoidable in this operation, I have used cold baths in its place, and
they are much more convenient. I found that they had the same effect,
and were better borne by the patient than was the repeated envelop-
ment of the body in wet sheets. But I could not hide from myself
that, immediately after the bath even, there was occasional exhaustion
along with the retardation of the pulse, sinking of the temperature,
and clearing of the intellect. This exhaustion usually passed off
quickly, and the disease finally terminated in recovery ; but, along with
such cases, others occurred where the exhaustion continued longer after
the baths, and where early death made me doubt if I had actually
benefited the patient, or if, while removing one danger, I had not in-
duced another. Perhaps this anxiety was overstrained, but, after the
careful observations made at my clinic by Liebermeister and Tmmer-
mann as to the amount of heat passing from the patient into the
water, the possibility of this danger cannot be denied. It is true we
reduce the temperature of the body by cold sheets and cold baths, but
we at the same time increase the production of heat. If this were
not so, the patient would be cooled much more. I think it would be
proper to compare the action of an energetic abstraction of heat to
that of excessive exercise ; then it will be asked if it be advisable to
subject an already exhausted patient to this action. The question, is
it not possible, by hydrotherapeutic means, to reduce the temperature
of the body without exhausting the patients by an excessive increase
of the production of heat ? which I consider a very important one, has
been solved by Obernier and especially by Ziemssen. I consider the dis-
covery, that a far less energetic and less sudden abstraction of heat than
was accomplished by the methods formerly employed by myself and
others will reduce the temperature of a typhoid patient two degrees
or more, is a very important advance in the therapeusis of the disease
I have not observed the above-mentioned state of exhaustion, which
formerly alarmed me, since I have ceased to wrap patients in cold, wet
sheets, or place them in cold baths, but have employed the following
plan, recommended and tried by Ziemssen : As often as his tempera-

652 ACUTE INFECriOUS DISEASES.

ture rises above 104°, the patient is placed in a bath, whose tempera-
ture is about 10° below that of his body, or about 94°. While the
body and limbs are gently rubbed, we add cold water gradually till the
temperature of the bath is reduced to about 68°. The patient is to
remain about twenty or thirty minutes in the bath, till he is slightly
chilled, and then to be placed quickly in a warm bed. At first, four or
five baths daily are necessary, subsequently two or three. The method
of Ziemssen has one great advantage, that in private practice there is
no great objection made to it. The laity consider it much less objec-
tionable to place a patient in a lukewarm bath than to wrap him up in
wet sheets, or to pour cold water over him, etc. For moderating the
fever in exanthematic as well as in abdominal typhus, next to the ab-
straction of heat, the administration of quinine deserves most confidence.
This remedy has been repeatedly recommended in abdominal typhus,
and almost as often it has been given up, because it did not equal the
expectations of the employers. The only effect of quinine on the
disease is to moderate the fever. If the temperature of a typhoid pa-
tient rise above 102°, I give quinine, but of late do not give such large
doses as formerly, when I prescribed ten-grain doses and during the
day gave as much as thirty grains. Now I usually prescribe one or
two grains at a dose, in solution with dilute sulphuric acid. If we use
quinine at the same time with the abstraction of heat, we are not
obliged to repeat the latter so often, which is a decided advantage.
Wunderlich has recommended digitalis as an antipyretic in abdominal
typhus, and the results claimed by this trustworthy observer, in cases
with frequent pulse and continued high temperature, urge us to
further trials of this remedy, of whose antipyretic action, in the treat-
ment of pneumonia and other inflammatory diseases, we have already
spoken.

Next to the fever, the most dangerous symptoms, when extensive,
are the disturbances of the respiratory organs, the bronchial catarrh,
hypostasis, and collapse of the lung ; but, unfortunately, we are far
more powerless in regard to these dangers than in regard to that in-
duced by the fever. The advice of most authors to give lukewarm,
instead of cool drinks, when there is severe bronchitis, is based rather
on theory than practice ; when feeling the burning skin of a typhoid
patient, no one would think seriously of combating the bronchitis b}
warm infusions. In severe typhous bronchitis, the most customary
prescriptions are wet or dry cups, warm compresses, sinapisms, and
blisters to the chest, and the internal administration of an infusion
of ipecac, (gr. vij to f vj), or of an infusion of senega ( 3 ss to § vj), to
which may subsequently be added liquor ammoniae anisat. ( 3 ss — 3 j).
None of these prescriptions do much good, though the occasional ap-

TYPHOID FEVER. 653

plication of wet and dry cups most frequently causes temporary allevia-
tion, and in most cases the cutaneous irritants are even injurious. If
we hear extensive moist rales in the chest, while the expectoration is
arrested, we may give a few doses of flores benzoes (gr. ij — iv), and,
if they fail, give a certain emetic, which will be of service here, and,
avert the threatening danger, if any remedy can. To prevent the ex-
tension of hypostasis, we may attempt to preserve the patient from
constantly lying on the back, by changing him from one side to the
other ; but, unfortunately, this good advice cannot always be carried
out continuously. The treatment of collapse of the lung and of pneu-
monia is the same as that of the bronchitis. In profuse epistaxis, we
should not try mineral acids and cold applications too long, but apply
a tampon early.

Among the intestinal symptoms, moderate diarrhoea requires no
especial treatment. If the evacuations become very profuse, we may
give astringents, especially solutions of alum ( 3 j to | vj), or of
tannin (3j — 3 ss to § vj), with an addition of tinctura opii (3j —
3 ss). For the tenesmus, which is occasionally very annoying, starch
injections containing ten to twelve drops of laudanum are almost al-
ways beneficial. Where there is much meteorism, we may attempt to
evacuate the gas by passing a stomach-tube up the anus. Constipa-
tion is to be overcome by injections, or by castor-oil. In intestinal
haemorrhage, we should apply cold or ice compresses to the abdomen,
and renew them frequently, at the same time giving alum internally
in the form of serum lactis aluminatum. In perforation of the intes-
tines, we should also employ cold compresses to the abdomen, but
especially should give opium in quickly-repeated large doses (a grain
every hour or two). At the same time, the patient may take small
quantities of ice-water, or small portions of ice, to quench his thirst,
but should have no food at all for several days. If peritonitis occur,
independently of perforation of the bowel, cold compresses over the
abdomen still deserve the preference to leeches. If there be paralysis
of the detrusor vesicae, which, to the great injury of the patient, is
often overlooked by inexperienced and careless physicians, the bladder
should be evacuated at least twice daily by the catheter.

It has already been stated that scrupulous cleanliness greatly aids
in preventing bed-sores. On the first appearance of erythema, we
should protect the reddened spot from further pressure by an air-cushion,
and wash it several times daily with lead- water, dilute brandy, or with
red wine. Eroded spots should be covered with lead or zinc salve,
or with ungt. tannicum (ungt. contra decubitum Autenreithii), and
aghtly touched with nitrate of silver. If there be a deep loss of sub-
stance, with unhealthy base, it should be treated, according to the

654 ACUTE INFECTIOUS DISEASES.

rules of surgery, with cataplasms, stimulating salves, red precipitate,
or nitrate of silver.

Ifj in spite of all our care, the strength of the patient sink more
and more, if the pulse become small, the collapse and prostration
dangerous, we should boldly give strong wines, such as madeira, port,
etc., or strong beer (Pfeufer). No analeptic or roborant medicine in
the pharmacopoeia has an effect equal to that of a strong wine. The
fear of increasing the fever by administering alcoholic liquors is un-
grounded ; and it is best not to wait for great exhaustion before giv-
ing wine, but, in all cases where the patients begin to grow weak
toward the end of the second or commencement of the third week, tc
give them half a pint of light wine daily.

Lastly, during convalescence, the diet of the patient should be
most carefully watched. The number who die during convalescence
from typhoid fever, from the fault of the physician, because he has
neglected to say exactly what and how much they may eat, or from
their own, because they have not followed the rules laid down for
them, is proportionately large. It is best to let the patient eat fre-
quently, but only a little food at a time, so that the slight amount of
gastric juice secreted by the convalescents may suffice for its com-
plete digestion. All indigestible food, which forms large amounts of
faeces, should be strictly forbidden. An apparently insignificant indi-
gestion, a moderate diarrhoea, or slight vomiting, should be regarded
as a very dangerous occurrence, because it may induce perforation of
an ulcer that has not yet cicatrized.3

CHAPTER IX.

FEBBIS RECURRENT RELAPSING FEVER.

ETIOLOGY. — Relapsing fever is among the acute infections about
whose propagation by contagion there is no doubt ; but we hesitate to
proclaim this as a purely contagious disease, such as the acute exan-
themata, measles, scarlatina, and small-pox, which never occur in a
person who had not been infected by a measles, scarlatina, or small-
pox patient. There are certain points in favor of the view that the
infecting substance, which induces relapsing fever, is not only pro-
duced in the body of the patient, but that it may be produced outside
of the human body. The mere fact, that certain regions, whose telluric
conditions give rise to a pure miasm, malaria, are also subject to epi-
demics of relapsing fever, can hardly be made to agree with the ex-

RELAPSING FEVER. 655

tension of the disease by contagion alone ; this is still more true of
the fact taught by experience, that, in places where relapsing fever
has not been seen for years, if a famine occur, and, from lack of proper
food, people are obliged to eat bad or spoiled provisions, the disease
will not unfrequently break out. On the other hand, there are grave
objections to this double mode of origin and extension. The same
reasons that satisfied us that the contagion in other infectious dis-
eases consists in low organisms, are just as valid in relapsing fever ;
and, although we cannot say it is impossible, we are still very averse
to supposing that organisms which reproduce themselves in the human
body may also develop and increase outside of it under such different
conditions.

The great resemblance in the mode of extension of relapsing fever
and in its symptoms to the forms of typhus already treated of, cannot
escape notice. On the other hand, there are some points indicating a
difference between relapsing and typhus fevers, and a certain relation-
ship to intermittent fevers. This circumstance, as well as the fact
that there is no case known where a patient with typhoid or typhus
fever has communicated relapsing fever to another person, and vice
versa, has decided the best authorities to rank febris recurrens as
a third form of typhus after abdominal [typhoid] and exanthematic
[typhus] typhus fever. Now, if, after typhoid and typhus fevers had
long reigned, relapsing fever occurred with them or in their place,
this might probably be simply due to a modification of the low organ-
isms forming the contagion of typhoid or typhus fever, induced by the
vicinity of a marsh or the effect of bad food ; in other words, to the
development of a new species allied to but differing from the former
ones.

I believe generally that the history of epidemics strongly supports
the correctness of JJarwirfs theory of the origin of new species. For
my part, I have no doubt that, in the course of centuries, new infec-
tious diseases have developed and taken the place of others that for-
merly prevailed. In the writings of the ancients we find wonderfully-
accurate descriptions, even of forms of disease, whose recognition and
distinction offered the greatest difficulties. There can be no doubt
that the regular and easily-recognized combination of symptoms char-
acterizing measles, scarlatina, typhoid fever, etc., would not have es-
caped the sharp observation of Sippocrates, if it had existed then as
it does now about the native place of the great Asklepiad.*

If the correctness of this hypothesis be accepted, and the depen-

* But in the writings of Hippocrates there is one place which seems to indicate
that febris recurrens occurred even in his day.

ACUTE INFECTIOUS DISEASES.

dence of contagious diseases on an infection of the body from low or-
ganisms be regarded as certain, the appearance of new infectious dis-
eases must seem a proof of the development of new species of organic
beings. Should not the varied malignity shown by epidemics of the
same disease at different times, and certain peculiarities of the indi-
vidual epidemics, be most simply referred to slight modifications, and
the gradual passage of certain phases of infectious disease in other
forms as extensive modifications of the low organisms ?

The susceptibility to relapsing fever seems very general, and it
has often been noticed that almost every dweller in even large houses
exposed to the contagion was attacked by the disease. No age es-
capes the affection ; but most cases are among the young and middle-
aged. The predisposing influence of bad dwellings and insufficient
food is not to be mistaken. Poor people furnish so large a contin-
gent of the cases of relapsing fever that this cannot be explained solely
by their numerical preponderance over the well-to-do classes. Peo-
ple in good circumstances' have no immunity from this disease, and
nurses and physicians attending patients with it are not unfrequently
infected. One occurrence of relapsing fever does not seem to remove
the liability to it, as it does in other forms of typhus.

ANATOMICAL APPEARANCES. — The result of autopsies made in epi-
demics of febris recurrens of different intensity and malignity, together
with symptoms observed during life, justifies the following conclusions :
The infection of the organism by contagion not only induces high
fever running a peculiar course, but also pathological changes in vari-
ous organs, especially in the spleen, liver, and kidneys. Usually these
pathological changes consist only of disturbances of the circulation
and in such changes of structure as may be readily removed. But in
malignant epidemics more extensive structural changes develop in the
above organs, bearing partly the character of parenchymatous, partly
of suppurative inflammation. The disturbances of nutrition due to
relapsing fever have not a specific character, and do not differ from
those induced by other injurious influences.

The corpses long retain a rigor mortis which occasionally begins
very early. The skin is usually light yellow, sometimes typically
jaundiced. At the dependent parts of the body there is extensive
postmortem hypostatic congestion.

The muscles are not so dark as in other forms of typhus. On mi-
croscopical examination a more or less extensive degeneration of the
muscular fibrillae will be found ; they appear cloudy, indistinctly trans-
versely striated, filled with molecular fine granules, which disappear
on the addition of acetic acid, while the filaments become pale, and
show neither transverse nor longitudinal striae (l&Mtner). This degen

REiAPSlNG FEVER. 657

eration is not confined to, or even chiefly locaieu in muscles, which,
during life, were the seat of severe pain, but, when found at all, usu
ally extends to all the muscles of the body.

In recent cases the blood is dark cherry-red, and contains but few
fibrinous clots. In protracted cases the blood is watery and without a
trace of coagulation.

When death occurs at the height of the disease, the brain and
meninges are vascular and dry, the ventricles empty. If death does
not result till the later stages of the disease, the meninges are slightly
injected, the brain itself bloodless and pale, the subarachnoid spaces
and lateral ventricles containing quantities of serous fluid.

Some observers (Kremiansky) found hsemorrhagic pachymeningi-
tis very often, partly in its commencing stage, partly as an extensive
haematoma of the dura mater.

The bronchial mucous membrane presents no constant changes ;
the lungs are more or less congested, especially at the dependent
parts; in protracted cases they sometimes contain haemorrhagic in-
farctions or extensive pneumonic infiltrations.

The heart is flabby, pale, and friable. On microscopical examina-
tion, Ktittner found it infiltrated with an albuminous or fibrous mass.
If the disease has lasted long, the walls of the heart are occasionally
much thinned.

As a rule, the gastric and intestinal mucous membrane is reddened
by injection and ecchymosis. The intestinal glands are sometimes
enlarged, but never sloughing. The ductus choledochus is occasion-
ally closed, by swelling of its mucous membrane, and obstructing
masses of mucus. In such cases the contents of the intestine are but
little colored, while the gall-bladder is distended.

The liver is considerably enlarged, apparently from the increased
amount of blood in it. According to Ifiittner, it sometimes has a mar-
bled appearance, distinct, yellowish- white, wax-like spots appearing in
the normal parenchyma ; when far advanced, these resemble nodules
of medullary cancer. At such points the individual acini are not rec-
ognizable. The liver-cells have lost their polygonal form ; the nuclei
are perceived with difficulty, and filled with homogeneous contents.
In cases beginning with icterus, and proving fatal in the first attack
(bilious typhoid), the same author found the liver smaller, the paren-
chyma jaundiced, much relaxed, and broken down. There were the
same microscopical appearances as in acute yellow atrophy of the
liver.

The spleen also is enlarged ; it may attain five or six times its
normal size and weigh four pounds or more ; its parenchyma is only
exceptionally as soft and fluid as in the first stages of the other forms

ACUTE INFECTIOUS DISEASES.

of typhus; usually it is hard and friable, and on section the Mal«
pighian bodies project as grayish-white or jaundiced points the size of
a pin's head. Occasionally in the spleen we find yellowish-white foci,
roundish or irregular in shape, from the size of a hemp-seed to that
of a hazel-nut, at first quite firm, but later breaking down into pus.
Kattner considers these as ruptures in the cavernous venous meshes
of the spleen, which subsequently, as in phlebitis after venous throm-
bosis, induce inflammation, suppuration, and putrefaction of the parts
around.

The kidneys also are enlarged, sometimes to double their normal
size ; this is due solely to swelling of the cortical structure. It is
difficult to detach the capsule, and, when this is done forcibly, small
portions of the renal tissue remain adherent to it. On microscopical
examination we find the epithelium of the uriniferous tubules swollen
and filled with fine molecules ; in the later stages the epithelial cells
have been destroyed, and the tubules are filled with fine granular de-
tritus. Rarely there are numerous small abscesses scattered through
the kidneys.

SYMPTOMS AND COURSE. — The length of the period of incubation
is not yet accurately determined. Many patients feel perfectly well
from the inception of contagion till the outbreak of the disease, while
others complain, a few days before the actual commencement of the
malady, of ill-defined and uncharacteristic disturbances of their
general health, of great weariness, pain and heaviness in the head,
increased thirst, and occasionally of migratory pain in the extrem-
ities.

Whether the above prodromata have occurred or not, the disease
itself almost unexceptionally begins with a chill of variable duration
and intensity, followed by a persistent feeling of great heat.

With the commencement of the fever the patients become very
weak, complain of pain in the head, especially in the forehead, often
also of dizziness and tinnitus, and of severe muscular pains almost
characteristic of the disease, which affect chiefly the neck and limbs,
and are among the most annoying symptoms of the disease. A slight
amount of psychical excitement, usually present at first, generally
passes off. The feeling of illness is unmistakable, the patients show-
ing no interest in their surroundings. Delirium and deep sopor are
exceptional, even where the fever is very high, which is a strong argu-
ment against the exclusive dependence of psychical disturbances, in
acute infectious diseases, on the height of the bodily temperature.
At first, the face is slightly flushed, the skin hot and dry, rarely is it
severed with slight perspiration. We must beware of regarding this
moisture of the skin at the height of the disease as a favorable sign.

RELAPSING FEVER. 659

(I have already stated that, of two patients with equal bodily temper-
ature, the one whose skin is moist is the more feverish.) There is
great thirst, but no appetite, although the patients do not obstinately
refuse food. The tongue is broad, rounded anteriorly, and bears the
imprint of the teeth along its sides ; it has a thick, white coating, the
edges and point are red. Even where the fever is high the tongue
usually remains moist, and is scarcely ever covered by the dry, black
coating visible on the small pointed tongue, and on the teeth, and
gums, in typhoid fever.

The pharynx also is affected by catarrh, usually mild, but some-
times very intense, characterized by more or less injection of the mu-
cous membrane and secretion of a tough mucus. In some cases bil-
ious vomiting occurs at the commencement. As a rule, there is con-
stipation ; far more rarely, diarrhoea, perhaps from excessive drinking.
The respirations are increased in proportion to the fever, and, without
any complication of the lungs or bronchial tubes, may attain to thirty
or forty, or even more, in a minute. There may be symptoms of bron-
chial catarrh or not. The abdomen is neither distended nor depressed ;
the regions of the liver and spleen are sensitive to pressure, and some-
times spontaneously painful. Physical examination early shows con-
siderable enlargement of the liver and spleen. Not unfrequently the
former extends almost to the navel and far into the left hypochon-
drium. The latter is also perceptible to the touch when it extends
beyond the angles of the ribs.

According to the careful researches of Obermejer, in most cases
the urine shows the peculiarities of parenchymatous nephritis. Be-
sides more or less albumen, blood-corpuscles and dark epithelial cyl-
inders were found in about two-thirds of his patients ; later in the
course of the disease the cylinders were covered with granular epi-
thelial detritus, and finally perfectly pale*cylinders were passed. As
a rule, during the fever the amount of urine passed is diminished ; its
specific gravity is 1012 to 1020.

A slight degree of icterus, sometimes accompanying the above
symptoms and depending on catarrh of the ductus choledochus, is
readily recognized to be hepatogenous by the diminished color of the
fasces and the discovery of bile-acids in the urine, and is to be distin-
guished from the icterus hereafter described, which is probably haema-
togenous and renders the disease malignant.

From the above description it is evident that, apart from the se-
vere muscular pains, the patient's symptoms resemble those accompa-
nying intense fever ; and iri fact we may regard the fever as the most
prominent and characteristic symptom of this disease. This fever shows
not only the peculiarities to which the disease owes its name, but it

660 ACUTE INFECTIOUS DISEASES.

has others which enable a certain diagnosis, even in the first at-
tack.

From the observations of Obermejer, who has taken accurate meas-
urements of temperature during the chill, with which the later at-
tacks also usually begin, we may assume that the bodily tempera-
ture is elevated even during the initial chill, and that this is even
preceded by a slight elevation of temperature. The bodily tempera-
ture attained is very unusual ; it is not at all rare for it to reach
107.3°, and in some cases 109°, or an elevation that never occurs in
other diseases, and at which many regard the continuance of life as
impossible. This, like typhoid fever, has a remittent type. The daily
variation is usually about one degree, the greatest differences being in
the morning and evening. The pulse also is more frequent in relapsing
fever than in almost any other disease. In nearly every case it rises
to 110 or 120, not unfrequently to 120 or 130 and even to 150 beats
per minute, without being in itself of very evil import. The frequency
of the pulse corresponds far less than in other diseases to the bodily
temperature. As a rule, the pulse is at first hard and tense, later, from
paresis of the muscular coats of the vessels, it becomes soft, undulat-
ing, and not unfrequently dicrotic. With slight modifications the dis-
ease goes on thus for from five to seven, rarely longer than eleven or
twelve days ; then there is a sudden change. After a transient increase
of all the symptoms, in which the bodily temperature reaches its
highest point, the peripheral arteries pulsate strongly, and abundant
epistaxis often occurs ; the previously-dry skin breaks into a copious
perspiration, and there is an alleviation of all the symptoms. Accord-
ding to Obermejer, the duration of defervescence is usually eight or
nine hours, during which time the body cools off about 9°, so that, if
before the crisis the temperature was 106.4°, afterward it will be
96.8°, or less than normal. I have no doubt that the excessive loss
of warmth, caused by the evaporation of the perspiration, contributes
materially to this rapid fall of temperature. During a critical sweat,
the active flow of blood from the interior of the body to the surface
will almost equalize over the body the loss of warmth that is induced
by evaporation of the perspiration. Such a sweating must induce
cooling, such as could not be attained in the same length of time by
any hydropathic procedure. It does not lessen the loss of heat by
conduction and radiation ; and to this is added the great loss due to
evaporation of the perspiration. I would call attention to the im-
mense amount of heat withdrawn by evaporation of the abundant
perspiration during a Turkish bath ; for there, in spite of the sur-
rounding air being 40° or more warmer than the body, and the con-
tinued heating from within, there is no considerable elevation of its

RELAPSING FEVER. 661

temperature. I should like to know if such a rapid defervescence of
the fever is seen in cases where, instead of sweating, there is critical
diarrhoea.

In the days following the crisis, the bodily temperature, which had
almost always fallen below the normal, rises one to two degrees.
The pulse varies from 48 to 50 beats a minute, the appetite returns,
the tongue cleans off, the muscular pains subside, the patients feel
stronger, and many of them wish to leave their beds.

But only in rare cases, where the disease is incorrectly termed re-
lapsing, does this very agreeable condition (which, to the uninitiated,
must seem a commencing convalescence) actually form the beginning
of recovery. In most cases, in from six to eight days, rarely less, or
from twelve to fourteen, there is a new attack, closely resembling the
first. This second attack also usually begins with a chill of variable
duration and intensity ; the subsequent feeling of heat, debility, de-
pression, and thirst, attains about the same degree as in the first stage
of the disease. The muscular pains also recur, but are less severe ;
the tongue, which had cleared off, is again coated, the appetite is
lessened. The spleen and liver, which during the interval had some-
what decreased in size, again swell, and occasionally become even
larger than in the first attack. During this second paroxysm, the
bodily temperature rises just as high as, in many cases higher than,
in the first, but the pulse is usually less frequent.

The second attack is commonly shorter than the first, lasting only
three or four days. The crisis terminating it has about the same symp-
toms as that closing the first attack. The disease generally ends with
the second attack. Far more rarely it is followed by a third, fourth,
or even fifth, which have essentially the same symptoms.

By far the most common termination is in recovery; the very
slight mortality, which in most epidemics is only two or three per
cent., and rarely higher than six or eight per cent., is in great con-
trast to the severity of the symptoms, especially to the temperature.
If the disease prove fatal, death results either during the attack, from
collapse and general paralysis, or more rarely during the interval, from
exhaustion, or lastly as a result of secondary diseases and complications,
among which pneumonia is the most important.

Pastau, as well as Obermejer, has given us valuable investigations
as to the weight of the body in relapsing fever. These show that
during the disease the body loses from a tenth to a fifth of its weight,
and that this cannot be solely referred to the diminished supply of
nutriment. Exact investigations prove again the correctness of the
doctrine that increased transformation of the constituents of the body
plays the most important part in the elevation of temperature during

(562 ACUTE INFECTIOUS DISEASES.

fever. It is very interesting to me to find that Obermejer has proved
that there is a steady decrease of the weight of the body during the
attack, but that it is far greater and more rapid on the critical days.
These observations agree perfectly with those which were made in
my clinic by Dr. Steiner even before the Leyden investigations, and
which led to the following conclusions : Where the bodily tempera-
ture is only moderately increased, the loss of weight may be less than
that observed during the same length of time in healthy persons. This
is because during fever the function of the perspiratory glands, as
well as of other secretory organs, is suspended, and the loss of bodily
weight from evaporation depends chiefly on evaporation of the per-
spiration. But, if the bodily temperature rise to 102° or 104°, the loss
of weight is always greater than in healthy persons under circum-
stances as nearly as possible the same. When the temperature of the
body is so high, even if the secretion from the sweat-glands be entirely
arrested, more fluid is evaporated from the mucous membrane of the
respiratory passages than is usually evaporated from the surface of the
body and the air-passages together of persons with normally-acting
sweat-glands. The most rapid decrease of bodily weight occurs at the
defervescence of the fever, for then the sweat-glands again act, while
the still-elevated temperature is accompanied by accelerated evapora-
tion. I believe in the correctness of the idea that, at the height of the
fever, there is only a relative retention of water in the body, but do
not think it necessary to refer this retention to diminished action of
the sweat-glands.

Under certain influences still unknown, possibly merely as a re-
sult of the action of a particularly intense contagion, relapsing fever
assumes a very malignant character. The appearance of the disease
is especially modified by excessive participation of the biliary appara-
tus, and in most cases death appears with severe symptoms. Grie-
sinfjer describes this malignant form of relapsing fever, from his obser-
vations made in the East, and terms it bilious typhoid. The St. Peters-
burg epidemic of 1864 to 1866, where, besides simple recurrent fever,
there were numerous cases of bilious typhoid, especially at its com-
mencement, fully confirmed Griesinger's description of the disease,
as well as his opinion that it was a severe form of recurrent fever.

At first the symptoms vary little from those of simple recurrent
fever, except that there are more depression and headache, and greater
mental sluggishness, bilious vomiting is more frequent, and the
tongue shows a tendency to dryness, while in simple recurrent fever
it is apt to remain moist during the whole course of the disease.
Usually, after a few days there is diarrhoea, with evacuation of bilious
looking masses; or else the passages have a dysenteric appearance.

RELAPSING FEVER.

Often also there is bronchial catarrh of variable intensity; and gen-
erally from the fourth to the sixth day of the disease, after the liver
and spleen have swollen considerably, and become painful, there is
severe icterus without discoloration of the faeces. About this time the
prostration of the patients is very great ; they are perfectly apathetic
and somnolent or delirious. The tongue is dry and crusted, pulse
slow, the hot skin loses its turgescence ; and, in this state, many die
with the symptoms of sudden collapse.

In others, at about the same time as in simple recurrent fever,
there is a more or less complete crisis, followed by a rapid improve-
ment of all the symptoms. The patients seem to be convalescing,
tiL a relapse occurs with the former symptoms, and they generally
soon succumb.

Finally, in other cases there is no crisis, and in the second week,
except for the intense icterus, we are reminded of severe and protracted
cases of other forms of typhus. According to Griesinger*s description,
this period of the disease is characterized by more or less profound
sopor, delirium, great sensitiveness of the abdomen, involuntary pas-
sages of dark, thin faeces, or markedly dysenteric dejections, or occa-
sional large evacuations of clotted blood, difficulty of swallowing,
croupous coating on the pharynx, bronchitis, extensive lobular pneu-
monia, occasional pericarditis, petechia and miliaria of the skin, and
irregular chills. It almost always terminates with slight convulsions,
sometimes by sudden collapse, internal haemorrhages (rupture of the
spleen), or secondary disease of the thoracic organs. Barely, the
patient recovers either with a rapid change, or slowly and irregularly
— the latter is especially the case if there has been extensive disease
of the thoracic or abdominal organs, such as pneumonic infiltration or
dysentery.

TREATMENT. — The prophylactic rules for preventing the spread
of or protecting one's self against relapsing fever appear at once from
what we have said of its etiology. Improvement of the condition of
poor people, care for healthy nourishment, and roomy dwellings, ne-
cessary as they are for prophylaxis, will probably never be fully car-
ried out, as it is so much easier to separate the healthy from the sick,
as is required by the contagiousness of the malady.

The slight mortality contraindicates an energetic treatment of the
disease. Thus far attempts to cut short the process and prevent
relapses by quinine have failed. In the same way digitalis did no
especial good in the Berlin epidemic.

By cold baths, in recurrent fever also, we may almost always lower
the temperature from one to five degrees ; but this usually continues
only a short time, the bodily temperature soon rising again to its
92

ACUTE INFECTIOUS DISEASES.

previous height or even higher ( Obermejer). I have repeatedly said
that I consider energetic abstraction of heat by cold baths quite a he-
roic remedy. If the high temperature in recurrens were accompanied
by great danger to life, of course we should have no hesitation in com-
bating the exhaustion of the body, from the increased production of
heat, by the energetic and continued use of cold baths ; but, since, in
spite of the high temperature, relapsing fever has a low mortality,
scacely three per cent, of the patients dying, I do not consider cold
baths indicated in this disease. It will be well to limit ourselves to
sponging the body with cold lotions, and, if the cerebral symptoms be
severe, to the application of ice to the head. At the same time we
should attend most carefully to the patient's cleanliness and supply of
fresh air, and internally give dilute mineral acids. Obermejer recom-
mends the administration of lemon-juice when the kidneys are much
affected. We should carefully give the patients nourishment early,
and, if there be much debility, prescribe some wine. From the ten-
dency to diarrhoea, they should not drink much water. During con-
valescence, iron and quinine may be given.

Ghriesinger recommends large doses of quinine (gr. x-xxx daily)
in bilious typhoid. He says it is just as useful here as in intermittent
fever ; but it is well not to begin the quinine treatment till after the
administration of a mild purgative of salts, oil, or cream of tartar, at
the commencement of the disease.

CHAPTER X.
«

EPIDEMIC DIPHTHERITIS — MALIGNANT PHARYNGITIS — ANGINA
MALIGNA DIPHTHERIA.

ETIOLOGY. — Epidemic diphtheritis belongs among the infectious
.Useases, and even among those that are most typically contagious.
The miasmatic origin of the disease is doubtful, at least in our coun-
try, where it has only occurred during the past ten years, and has ap-
peared almost exclusively as more or less extensive epidemics which
occasionally spread around from one place to another. The contagion
is contained in the false membrane and shreds of tissue detached from
the fauces, and in the air breathed out by the patient. Physicians are
in great danger of being infected by the morbid products coughed out
by the patient when they are painting or cauterizing his throat, or per-
forming a tracheotomy. Science has to mourn the loss of a series of
excellent physicians and observers who fell victims to diphtheria while

DIPHTHERIA. 665

m the line of their duty. The numerous cases of infection of persons
who have been in the same room with diphtheritic patients, without
coming in their immediate vicinity, prove that the air exhaled by the
patient, which does not contain shreds of exudation or tissue, is a ve-
hicle for the contagion. Further observation must decide, if, besides
the above vehicles for the poison, there be still others ; how tenacious
the infection is ; whether persons who do not themselves take the dis-
ease may carry it to third parties, etc. The predisposition to diphthe-
ria is unmistakably very extensive. The greater frequency of the dis-
ease among children than adults does not seem to me due to greater
predisposition of the former, but to their being more exposed to infec-
tion than adults are.

ANATOMICAL APPEAKANCES. — Just as in other infectious diseases,
in diphtheritis also certain organs are chiefly subjected to the disturb-
ances of nutrition, and (to employ our former mode of expression)
diphtheritis is constantly localized in the fauces, less constantly in the
upper portion of the air-passages, in the kidneys, spleen, and in some
very obscure manner in the nervous system. The disturbances of nu-
trition in the above organs do not anatomically correspond. In the
pharynx we find the form of diphtheritic inflammation to which the
disease owes its name, and which we have often described. The
fauces, and especially the tonsils and soft palate, are covered with
grayish-white pseudomembrane, which is not easily removed, and
which leaves an ulcerated loss of substance, when it finally breaks
down into a discolored fetid mass, and falls off. The diphtheritic
pseudomembranes, or, to speak more precisely, the diphtheritic sloughs,
result from superficial gangrene of the mucous membrane, which again
depends on compression of its nutrient vessels by an interstitial fibrin-
ous exudation, or from swelling of the tissue-elements, which are filled
with a cloudy substance. If the larynx and trachea participate in the
disease, the croupous, not the diphtheritic, form of inflammation of the
mucous membrane occurs ; that is, the surface of the mucous membrane
is covered with a more or less tough and consistent false membrane,
which may readily be removed, and leaves no loss of substance after
its removal. This circumstance has induced some physicians to iden-
tify primary genuine croup, which is due to catching cold, etc., with
croupous laryngitis caused by infection with diphtheritic contagion.
I consider this a false view. The division of diseases, according to the
pathologico-anatomical changes they induce, is only a make-shift. In
all «ases where, as in genuine and diphtheritic croup, we find that two
anatomically similar disturbances of nutrition depend on very different
causes, we should consider them as distinct. A small-pox pustule
may very much resemble one induced by rubbing antimonial ointment

ACUTE INFECTIOUS DISEASES.

into the skin ; a pemphigus bleb may resemble a blister induced by
a circumscribed burn, but no one would assert that these scarcely-dis-
tinguishable disturbances of nutrition were due to the same disease.
The previously-described parenchymatous degeneration of the kidneys
is found in about half of the cases. The spleen is usually enlarged
and soft. The anatomical changes of the nerve centres, or peripheral
nerves, on which diphtheritic paralyses depend, have not yet been dis-
covered. We know as little about the anomalies of the blood in diph-
theritis as in other infectious diseases.

SYMPTOMS AND COURSE. — The disease almost always begins with
apparently insignificant and harmless symptoms. In some cases the
general health is disturbed a few days before the disease breaks out ;
the appetite is less ; the patients complain of dulness, depression, and
chilliness. More rarely the disease begins with a severe chill, ac-
companied by nausea and vomiting. At the same time the patient
complains of difficulty of swallowing; but in most cases this is no
greater than it usually is, in simple catarrhal angina. If the fauces be
not yet covered with false membrane, but only somewhat reddened
and swollen, at this stage we can only suspect or recognize the disease,
when we know that diphtheritis is epidemic, or that persons about the
patient have or have had the disease. A very suspicious, and usually
a very early, symptom is a hard swelling of the lymphatic glands lying
at the bifurcation of the carotid artery, which, as I/uschka especially
insists on, are directly connected with the lymphatic vessels of the soft
palate. Not un frequently the persons about the patient have their
attention first called to the disease by swelling of these glands, the
complaints of slight difficulty of swallowing having passed unnoticed.
It is far more common for us to find more or less extensive grayish-
white patches in the fauces at our first examination, than to have the
opportunity of examining the throat at the commencement of diphthe-
ritis, before the formation of false membranes has begun. And then
we can have no doubt about the dangerous and malicious foe with which
we have to deal. Even in cases where the disease has begun without a
chill, where the fever is slight, or entirely absent, where the general
health is excellent, so that the patient can hardly be kept in bed, even
where the difficulty of swallowing is very insignificant, and where the
deposits are very slight, are thrown off without putrescence, and leave
a scarcely-perceptible loss of substance, we are not at all sure that
the disease will run a favorable course, that the dangerous accidents,
of which we shall hereafter speak, will not occur, and that there will
be no paralysis during convalescence. The fact, which I have fre-
quently observed, that albuminuria occurs during the above cases,
which run their course without fever, shows that the parenchvmatous

DIPHTHERIA.

degeneration of the kidneys in diphtheritis is not due to excessive in
crease of the bodily temperature, but is a direct result of the infection
with diphtheritic poison.

If the disease has begun violently, if a chill and repeated vomit-
ing have been the first symptoms, the subsequent course of the dis-
ease also is usually more severe. It is true, the difficulty of swallow r-
ing generally remains moderate, and the fever does not become very
high, but the patient grows pale, the eyes become dull, the pulse
small, and usually frequent, rarely retarded; the patients are very
sluggish and apathetic. In many cases the putrefaction of the false
membrane causes a penetrating, foul breath. If the nasal mucous
membrane participate in the disease, a discolored, fetid fluid flows
from the reddened and eroded nostrils. The swelling of the cervical
glands becomes more marked ; the enlarged glands are very hard and
resistant, but have no tendency to suppurate. In about half the cases,
examination of the urine shows the presence of a considerable amount
of albumen. Even, after a few days, death may occur from general
paralysis, while the intellect remains clear. Some patients, whose
state had not excited any anxiety, and whose general condition was
previously very satisfactory even, die unexpectedly with the symptoms
of general collapse, without our being able to find any explanation for
the occurrence. Sometimes also attacks of deep syncope occur, and
pass over, till finally a new attack ends in death. Even the last-
mentioned severe cases may terminate favorably. Then the false
membranes are detached, and no new ones are formed ; the remaining
ulcers clean up and cicatrize. At the same time the difficulty of
swallowing disappears, the glandular enlargement subsides, the de-
pression of the patient disappears, and, if there be no sequelae, perfect
convalescence follows in two or three weeks ; but it is usually a long
time before the patients recover entirely.

The disease, as above described, is greatly modified when the
diphtheritic inflammation of the fauces is accompanied by croupous in-
flammation of the larynx and trachea ; for then the above symptoms
are complicated with hoarseness, aphonia, excessive dyspnoea, and
other symptoms described when speaking of genuine croupous laryn-
gitis. This complication occurs in the mild, as well as in the severe
eases. Frequently, examination of the fauces and the epidemic occur-
rence of diphtheria alone enable us to decide to which form of croup-
ous laryngitis the case belongs. Even such cases may end in re-
covery; but most of the patients die, some with the symptoms of col-
lapse, some with those of insufficient respiration, and poisoning of the
olood with carbonic acid.

Even when the disease apparently ends in recovery, it is often fol

ACUTE INFECTIOUS DISEASES.

lowed by paralysis. The not unfrequent occurrence of diphtheritic
paralyses after very mild cases, as well as the curious fact that they
never follow the disease immediately, but come on from two to four
weeks after its disappearance, sufficiently explains why the connection
between the paralyses and the diphtheritis so long escaped recogni-
tion. Paralysis of the soft palate and pharynx is the most frequent
form of diphtheritic paralysis, and generally precedes the other forms ;
when the soft palate is paralyzed, the patients have a nasal voice ; on at-
tempting to swallow fluids, they enter the nose. If the pharynx also be
palsied, the act of swallowing is greatly impaired, and we are some-
times obliged to nourish the patient through a stomach-tube. This
paralysis of the muscles near the seat of diphtheritic inflammation is
most frequently accompanied by that of the muscles of the eye, by
which the power of accommodation is lost, and the patients begin to
squint. The extremities also, especially the feet, are occasionally at-
tacked by more or less complete paralysis. In a very small epidemic
I saw two cases of total paralysis of all the extremities. The progno-
sis of diphtheritic paralysis is generally favorable ; almost all cases re-
cover sooner or later. The various attempted explanations of these
cases are unsatisfactory. We do not even certainly know whether
they are of peripheral or central origin. It has been suggested that
the paralyses after diphtheria are analogous to those occasionally ob-
served after other severe diseases, especially after severe typhus. But
this suggestion is opposed by the great frequency of diphtheritic paral-
ysis compared to that after other diseases, as well as by the marked
disproportion between the intensity of the malady and the consequent
paralyses, distinguishing diphtheritic paralyses from those remaining
after other diseases.

TREATMENT. — Prophylaxis requires that the physician should pro-
tect himself from contact with the false membrane and shreds of tissue
that are coughed up, and that he should warn the attendants on the
patient of the danger of this contact. When circumstances permit,
those who have nothing to do with the care of the patient should keep
out of the sick-room.

The recommendations of the varied internal and external remedies
that are said to have proved efficacious against diphtheritis, have usu-
ally originated in the last stages of epidemics, at which time the cases
are usually milder, and recoveries more frequent, even without treal
ment. Almost all physicians, experienced in the treatment of diph
theria, agree that, in severe attacks, the most prized remedies are per-
fectly useless. In recent cases I deem it advisable to remove the false
membrane carefully, and touch the dried bases with nitrate of silver,
concentrated muriatic acid, or liquor ferri sesquichlorat., but not to re-

DIPHTHERIA. 669

peat this operation more than once or twice daily, and not to continue
't too long. Besides this, as long as the mucous membrane is still
very red and swollen, I let the patient swallow small pieces of ice
slowly, and prescribe a solution of chlorate of potash ( 3 i to § vi),
with directions to take a tablespoonful in the mouth every two hours,
and to keep it in contact with the pharyngeal tissues for some time
before swallowing it. I have no personal experience about the local
application of chlorine-water, or the solutions of sulphite of soda
( 3 i to the | j), or of permanganate of potash, which are said not
only to remove the fetid odor, but also to arrest the putrefaction. On
account of the threatening collapse, we must avoid all debilitating
treatment, especially abstraction of blood ; on the contrary, we should,
from the first, attend to keeping up the strength of the patient by
tonics, quinine, and iron, and by wine and nutritious diet. If collapse
occur, we should give analeptics, camphor, musk, and particularly
plenty of strong wine. Croupous laryngitis coming on during the
disease requires about the same treatment that we advised in the first
volume for idiopathic croupous laryngitis ; only I do not employ ab-
straction of blood or calomel even in recent cases. Tracheotomy
should not be deferred too long, if we hope to have it succeed, which
it rarely does.

Short, cold ablutions, cold douches, and sea-bathing, have obtained
the most confidence in diphtheritic paralysis. The induced and con-
stant currents have also been advised. I have subjected many cases
to long-continued treatment by electricity without benefit. In one
case, where the patient was paralyzed in all her extremities, and was
treated at my clinic by electricity, without benefit, for four weeks, she
completely recovered, without any treatment, a short time after be-
ing dismissed from the hospital.4

[Diphtheria so often occurs without our being able to detect the
source of contagion, that we may very strongly suspect its occa-
sional spontaneous origin.

Some authors regard general blood-infection as the first step,
and say the throat-affection is only a local expression of this, as
the bronchitis is of measles or pharyngitis of scarlatina ; while
others say the affection is at first local, and may remain so or may
become a general disease. Numerous vegetable organisms (micro-
cocci) have been found in the diphtheritic membranes and even in
the blood of the patients. The transmissibility of diphtheria to
the lower animals by inoculating in the muscles, trachea, cornea,
etc., has been proved, and the excessive multiplication of bacteria
at these points has indicated them as the bearers of the contagion.
In favor of the first view is the fact that at the commencement of

ACUTE INFECTIOUS DISEASES.

the disease there may be high fever, but no change perceptible at
the point where the diphtheritis subsequently appears ; also that in
scarlatina, which is a primary blood-disease, diphtheria often occurs.
The claims for the local origin of the disease are supported by the
results of inoculation, which tend to show that the disease starts
from the point of inoculation and spreads through the body. It
has been asserted that these experiments prove nothing certainly,
and that inoculation of other decomposing substances may induce
the same changes as the diphtheritic membrane causes. If the diph-
theritic poison entered the lungs and was thence transferred to the
blood in some cases, and located and was propagated in the pharynx
in others, it would perhaps explain both classes of cases. Some
English observers consider it as established that milk is frequently
an infectious agent ; whether the poison is generated in the cow
itself, or whether the milk is merely a carrier of germs taken in
the cow's food, is not decided.

Persons in the vicinity of a diphtheria patient may have a catar-
rhal angina due to the poison. A second form is croupous diph-
theritis, with a membrane which may be readily detached from the
subjacent mucous membrane. The third and severest form is where
the fibrinous deposit is both on and in the membrane ; between the
fibres are pus- and blood-cells, micrococci, etc. ; the mucous mem-
brane is quickly destroyed, leaving gray or brown sloughs, which
render the breath very foul ; this slough may extend to the sub-
jacent cartilage or bone.

Deeper in the air-passages, diphtheria is croupous in nature ;
the ulceration of the mucous membrane does not usually extend
below the larynx, that is, where pavement changes to cylindrical
epithelium. In persons who have died of diphtheria, the blood is
generally imperfectly coagulated, dark, and tar-like. Changes in
the kidneys are very common.

The latent stage of diphtheria is usually short, though cases
occur where it is possibly of some weeks' duration. The catarrhal
form has the same symptoms as ordinary angina, and it may be only
the surrounding circumstances that would lead us to suspect diph-
theria ; it may run its course in this way, or become a severe dis-
ease. Croupous diphtheria is usually accompanied by high fever ;
there may be burning in the throat or pain on swallowing ; if these
symptoms be absent, the disease may for some time escape recogni-
tion. Inspection shows the mucous membrane to be dark red and
swollen, with deposits of false membrane, which develop rapidly,
and may even cover the whole pharynx and extend into the nares
or middle ear, but especially into the larynx, or else may remain
confined to the pharynx. The latter cases are apt to terminate

INTERMITTENT FEVER. 671

favorably, the false membranes being detached and the fever sub-
siding in a few days. Such cases are common in youths and adults,
but advance of the disease to the larynx is more to be dreaded in
infants. As the first deposits clear off, others may take their place.

In septic or putrid diphtheria there is infiltration and mortifica-
tion of the mucous membrane itself, with consequent ulcers and
gangrenous loss of tissue. The detached fragments putrefy and
give a foul odor to the breath ; the submaxillary and lymphatic
glands are swollen ; there is fever characteristic of septicaemia ; and
usually the patient dies in a few days. But a line of demarcation
may form around the necrosed parts, and recovery take place. If the
disease attacks the nose, it causes a running, which may be mistaken
for cold in the head till the discharge becomes bloody or sanious.

Diphtheritic paralysis may not occur till four or five weeks after
the disease ; it is peripheral in character, as is shown by the diminu-
tion of electro-muscular excitability ; it lasts several weeks or even
months ; it most frequently affects the muscles of the pharynx and
eye ; the prognosis is usually favorable.

In the treatment, various disinfectants, such as chlorine one part
to six of water, weak solutions of carbolic acid, salicylic acid, per-
manganate of potash, also alcohol, etc., may be employed locally in
conjunction with hot vapors, which hasten suppuration, and possibly
the pus may wash off the micrococci ; these hot vapors may be tried
every half hour or so. We should avoid rough or frequent cauter-
izations, for fear of increasing the inflammation. In diphtheria of
the larynx we may use sprays of lime-water and salicylic acid.
Tracheotomy has rarely proved a successful operation in this dis-
ease. Internal administration of chlorate of potash and tincture of
muriate of iron, properly diluted, and in doses suited to the age,
every half hour to two hours, is perhaps one of the most favorite
methods of treatment.]

MALARIAL FEVERS.
CHAPTER XI.

INTERMITTENT FEVEK.

ETIOLOGY. — Intermittent fever results from infection of the body
with a poisonous substance called marsh miasm, or malaria. Malaria
is not a product of decomposition (see below), but the decomposition
of vegetable substance has an unmistakable influence on the devel-
opment or excessive increase of this poison. I shall only adduce the
following circumstances in support of this fact : Malarial fevers are

672

ACUTE INFECTIOUS DISEASES.

chiefly in marshy regions, and in such places the number of
persons affected increases or decreases according as circumstances favor
or do not favor the decomposition of dead vegetable matter in the
marshes. If it grow very cold, so that the marshes freeze up, the in-
termittent fever ceases. The same thing occurs when, in dry seasons,
the marshes entirely dry up, or if, in very wet seasons, a thick layer
of water protects the mouldering bottom of the marsh from the action
of the sun and air. On the other hand, in marshy regions, hot seasons,
if not too dry, so that the sun's rays can act freely on the exposed but
still moist bottom of the marsh, are characterized by the great preva-
lence of intermittent fever. It is uncertain whether the decomposi-
tion of certain vegetables, or a peculiar quality of the water, favors the
development of malaria more than other causes. A mixture of sea-
water with spring and rain water — which occurs in marshes near the
ocean, from high tides or heavy winds forcing the sea-water into the
marshes — so-called brackish water, appears to be peculiarly injurious,
because many fresh-water plants, as well as many marine plants, con-
tained in the mixture, cannot thrive in it, and consequently die and
decompose. Malarial fever is endemic in low lands near rivers, which
are flooded yearly, just as in marshy regions. No especial explanation is
necessary to show that this flooding also causes the death of quantities
of vegetable matter, which subsequently decomposes when exposed to
great heat. Intermittent fever occurs where land has lain for a long time
uncultivated, and is then broken and tilled again, from the same causes
as it does in marshy regions ; for here, too, quantities of dead vege-
table matter are brought up and undergo decomposition. Lastly, in
some cases where intermittent fever occurs under apparently opposite
circumstances, that is, when it is very dry, it has been shown that
the soil was rich in subsoil water, and that, under a dry, porous sur-
face, parched by the summer heat, there were subterraneous swamps.
These common peculiarities, which appear in most of the regions where
malarial fever prevails, do not, however, as was before said, justify us
in concluding that malaria is a chemical body, an organic or inorganic,
a solid or gaseous product, formed by the decomposition of vegetable
substances. On the contrary, the non-occurrence of intermittent fever,
in some typically swampy places, and its appearance in some places
where extensive or specific putrefaction would be most unlikely to
take place, seem to indicate that while the conditions peculiar to
swamps, marshes, etc., favor the development of malaria, they are not
a sine qua non, nor do they alone suffice to induce the disease. This
view is even more strikingly supported by the observations that all
the persons drinking water from a certain swamp were taken sick with
intermittent fever, as these observations contrast with a large number

INTERMITTENT FEVER. 673

of others, where the water of other marshes was drunk without this
effect. If the morbific power were simply the product of chemical de-
composition, this exclusiveness would be entirely inexplicable. I have
no hesitation in saying decidedly that marsh miasm — malaria — must
consist of low vegetable organisms, whose development is chiefly due
to the putrefaction of vegetable substances. It is true these low
organisms have not actually been observed. No one has seen " mala-
ria spores," but the facts above mentioned, as well as many other
causes, urge us to believe that the poison exhaled by marshes, as well
as that given off by a patient with measles, is an organic living sub-
stance. There is, however, an important difference between the mias-
ma vivum, which is the specific cause of intermittent fever, and the
jontagium vivum by which the acute exanthemata, exanthematic ty-
phus, and other infectious diseases, spread. The latter reproduces
itself in organisms infected with it ; malaria, on the other hand, is not
reproduced in the body of a patient with intermittent fever. There is
no soil in the human body favorable to its development or increase.
Intermittent fever is never introduced into other places by patients
who have caught it in a swampy region. While a short residence in a
malarious district is often enough to give intermittent fever, one may
share the same ward with a large number of intermittent patients in a
hospital, at some distance from such a place, without danger. Hence,
in distinction to the " contagious " diseases, malarial fever is termed
" miasmatic contagious " or " purely miasmatic."

There 'are extensive sections of country where the circumstances
for the formation of malaria exist everywhere, in all parts of which in-
termittent fever occurs ; but there are also small circumscribed mala-
rial foci, where numerous cases of intermittent are seen every spring
and summer, while the whole surrounding country remains free. In
these last-mentioned circumscribed malarial foci, in towns lying near
marshes, in certain sections or streets of cities, where intermittent fever
is endemic, some very interesting observations have been made about
the extension of malaria : among other things, it has been shown that,
from its point of origin, miasm spreads more readily in a horizontal
than in a vertical direction, it is often arrested by insignificant obsta
cles, such as groves, stone walls, etc., and rarely passes the boundaries
thus formed, unless the wind be in a particular direction.

The extensive epidemics of intermittent fever which occasionally
appear are very remarkable. During such epidemics, while the cases
are unusually frequent in places where the disease is endemic, they
also occur in places where either no cases or only sporadic ones had
been seen for years. These epidemics do not always come in very
hot, moist seasons, so that they might be referred to the circumstances

(J74 ACUTE INFECTIOUS DISEASES.

being very favorable to decomposition of vegetable substances, and
hence uncommonly favorable for the development of malaria, and for
its spread from places where it always exists to others that are gen-
erally free from it; but they appear to be due to other unknown
causes, which also favor the development of malaria, or to an extension
of the disease from its point of origin to distant places by currents of
air. We do not know why, but great epidemics of intermittent have
often preceded epidemics of Asiatic cholera. In hot countries, cholera
and intermittent, and, still oftener, dysentery and intermittent (see
next chapter) frequently prevail at the same time.

The sporadic occurrence of intermittent is most curious. Those
cases where persons affected with malaria move from places where ma-
laria is prevalent, and continue to present the symptoms of infection
for a time after settling in their new home, are not to be counted as
sporadic. But, both in city and country, cases occur where the persons
could not have been infected elsewhere. There is no explanation for
these cases, except the supposition of very limited foci, which are
harmless for persons outside of them, or of a very diluted miasm, which
only affects a few persons who are peculiarly disposed. There is not
the least ground for the supposition that, under some circumstances,
intermittent may result from other causes than from infection with
malaria.

Every age, both sexes, and all constitutions, have a predisposition
to intermittent fever, and the greater or less tendency to the disease,
in various persons, does not depend on the constitutional differences to
which it has been referred, but to other only partially understood in-
dividual peculiarities. Exhausting exercises, and other debilitating
influences, errors of diet, and particularly catching cold, increase the
predisposition so much, that persons, who have long been exposed to
malaria with impunity, are not affected by it till one of these causes
has acted on them. The same explanation must answer for those
cases where persons who have escaped the disease in malarious places
are attacked by it after leaving them. Then the infection has evi
dently taken place earlier, but has not shown its effects in the person
who was little disposed to the disease, and has not caused injurious
results till the necessary predisposition was induced by other noxious
agents. Among the influences that increase the predisposition to
intermittent, the most evident is one or more previous attacks of the
disease, which is just the opposite of the case in the acute exanthe-
mata and typhus. There is .only an accommodation of the organism
to the poison to the extent that persons who have been exposed tc
it for some time have a chronic disease with enlargement of the
spleen, without fever, instead of having intermittent fever. The

INTERMITTENT FEVER. 675

geographical extension of intermittent fever is immense ; in the torrid
zones the disease is especially frequent, and it prevails in most places
that are not very dry : in the temperate zones it chiefly affects certain
more or less extensive districts ; in the frigid zones it does not occur.
For further information, we refer to G-riesinger*s work and to the very
exhaustive treatise of Hirsch on the geography of intermittent fever.

ANATOMICAL APPEARANCES. — Autopsies of persons who have died
of simple intermittent fever are rare. They show no characteristic
changes beyond those that we have already described (Vol. I., Dis-
eases of the Spleen). If simple intermittent fever depends on infection
with malaria, the anomalies of the blood dependent on the infection
have so far escaped chemical and microscopical examination. The im-
poverishment of the blood in red corpuscles and albumen, which always
results from long-continued intermittent, depends on consumption from
high fever, and perhaps also on degeneration of the spleen. On
autopsy of persons who have died of pernicious intermittent, we often
find signs of melansemia and occasionally remains of inflammation,
effusions of blood, or excessive hyperaemia in different organs.

SYMPTOMS AND COTJKSE. — I. Simple Intermittent Fever. — The pe-
riod of incubation of the malarial infection is not exactly known. It
is probable that, at most, two weeks may pass from exposure to the
miasm till the first symptoms appear ; in some cases the latter seem
to follow the former immediately.

Before the intermittent character of the disease, to which it owes
its name, becomes very evident, before attacks of fever (paroxysms)
and intervals of exemption from fever (apyrexias) alternate, the infec-
tion with malarial poison not unfrequently evinces itself by a con-
tinued, only more or less remitting and exacerbating, disturbance of
the general health and various functions. This constitutional disturb-
ance, which is called the prodromal stage of intermittent, has no char-
acteristic peculiarities, and can only be rightly interpreted and distin-
guished from the prodromal stage of other infectious diseases by bear-
ing in mind the endemic and epidemic circumstances. After the pro-
dromal symptoms have lasted several days, or in other cases without
their appearance, the first fever paroxysm occurs.

A paroxysm of intermittent fever consists of three stages : chill,
fever, and sweating. The chill begins with a fit of weakness, and
great faintness; the patients gape, and stretch then* limbs. These
symptoms are soon accompanied by a subjective sensation of cold, at
first consisting of cold shiverings over the skin ; afterward, of continued
chilliness, so that the patient wants to wrap up as warmly as possible.
When the chill increases, the limbs tremble involuntarily, the lips
quiver, the teeth chatter, and the whole body is often shaken around

ACUTE INFECTIOUS DISEASES.

in bed. When the chill begins, there is also more or less headachy
oppression of the chest, and hurried respiration ; the latter, and the
quivering of the lips, render speech indistinct and interrupted ; there
is often vomiting also, especially if the chill comes soon' after eating.
Objective examination first shows the altered appearance of the pa-
tient ; he looks like a person exposed to severe cold, without sufficient
clothing, and who is consequently thoroughly chilled. The size of the
body appears diminished ; the face is sunken ; the nose pointed, the
rings are too large for the fingers. As the flow of arterial blood to
the skin is impeded, the latter appears pale, and, as the blood collects
in the veins and capillaries, the lips, ends of the fingers and toes, look
blue. The flow of blood to the fingers is often entirely arrested ; they
look waxy, have no feeling, and do not bleed if wounded. The skin
of the extremities and body has the appearance known as goose-flesh
(cutis anserina). The pulse is very frequent, small, and hard ; the se-
cretion of urine is usually increased ; the urine passed is limpid, and
of low specific gravity. Physical examination generally shows en-
largement of the spleen. While the diminished supply of warm blood
during the chill causes the periphery of the body to assume more and
more the temperature of the surrounding atmosphere, and to actually
sink several degrees, the temperature of the blood and internal organs
rises rapidly. This rise, which begins even before the chill, reaches
two or three degrees, and, in severe cases, still more. The above
symptoms are mostly to be ascribed to spasmodic contraction of the
muscles of the skin and peripheral arteries during the cold stage.
The immediate results of this spasm are the goose-flesh, the small,
hard pulse, and the deadness of the fingers. The contraction of the
muscles of the skin and peripheral blood-vessels secondarily in-
duces the apparent diminution in size, the dryness and pallid ap-
pearance of the skin, the collection of blood in the veins, and the
fall of temperature on the surface of the body. The chilly feeling
of the patient is too decided to be referred exclusively to the fall
of temperature of the periphery ; on the other hand, the contin-
ued coolness of the surface, even under thick feather-beds (which is
peculiarly remarkable, because the body gives off but little heat
to the parts around), is certainly due to the fact that, during the
chill, there is less warmth supplied to the surface, on account of the
diminished supply of blood. Lastly, the disturbance of the peripheral
circulation increases the lateral pressure in the vessels of the internal
organs. But, as we do not know whether the spasm of the muscles of
the vessels is limited to the peripheral arteries, and does not extend to
the internal ones, it is doubtful whether the headache, oppression, ac-
celerated respiration, vomiting, increased secretion of urine, swelling of

INTERMITTENT FEVER. 677

the spleen, etc., can be referred to collateral fluxion to the organs impli-
cated in these symptoms. At all events, as we have before said, col-
lateral fluxion to the spleen is not the sole cause of enlargement of
that organ. The cold stage lasts from half an hour to three hours ; in
the first paroxysms, it is usually shorter and less severe than subse-
quently ; and its intensity and duration generally decrease again if the
disease last a long time. The hot stage does not begin suddenly, but
gradually ; at first the chill is only interrupted by temporary flashes
of heat, and a permanent feeling of warmth only comes on by de-
grees. The headache becomes more severe ; the patients grow rest-
less, and not unfrequently slightly delirious or somewhat stupid ; the
feeling of oppression on the chest increases, while the breathing almost
always becomes deeper, freer, and slower. Thirst is greatly increased.
The appearance of the patient changes. The size of the body ap-
parently increases, the color returns to the skin, the pale, livid look,
the goose-flesh, the cyanotic hue of the lips and ends of the fingers
disappear ; the face becomes flushed, and herpetic vesicles often come
out on the lips ; the previously small pulse grows full and strong, the
carotids throb, the urine becomes more saturated, and the enlarge-
ment of the spleen increases. In the hot stage, the bodily temperature
is increased at the periphery also ; at the commencement of this stage,
the temperature of the blood reaches its highest point, and remains
there till toward its termination, when it gradually begins to fall. All
these symptoms show that the spasm in the muscles of the skin and
vessels has disappeared and given place to a subparalytic state. The
relaxation of the cutaneous tissue and of the walls of the vessels suf-
ficiently explains the increased entrance of blood into the previously
bloodless tissues, and their consequently increased color and warmth.
The severe headache, the oppression of the chest, which are often
accompanied by catarrhal symptoms, and finally the continued enlarge-
ment of the spleen, render it very probable that the arteries of the
brain, bronchi, and spleen, are in the same condition as those of the
periphery. The duration of the hot stage varies ; sometimes it is only
a few hours, in severe cases the dry heat continues six, eight, or even
twelve hours before a pleasant perspiration breaks out on the skin.
The sweating stage begins with moisture in the armpits and on the fore-
head ; but soon the perspiration, at first moderate, but later very copi-
ous, extends all over the body. The patients feel greatly relieved, the
headache remits and gradually disappears, the mind becomes clear, the
oppression passes off, the depth and frequence of the respiration be-
come normal, the thirst is less annoying, the pulse is full, soft, and
less frequent. The dark urine generally deposits rich sediments of
urates ; this depends on the great concentration resulting from the loss

(578 ACUTE INFECTIOUS DISEASES.

of water by evaporation and sweating ; it does not occur it the patients
replace the loss of water by drinking freely. During the sweating
stage, the bodily temperature gradually falls, and toward its end be-
comes nearly normal. When the paroxysm is over, and the apyrexia
begins, most patients fall into a deep sleep, from which they awake
much fatigued and dull, it is true, but feeling relatively well. Wher
all the stages of the paroxysm are well marked, the disease is called
an intermittens completa ; if one or other stage fails or is indistinct, it
is called incompleta. In rare cases, the stages of the fever are said
not to follow the regular order ; for instance, the cold stage closes the
paroxysm instead of opening it (typus in versus).

After the first paroxysms of intermittent, the apyrexia is rarely
" pure." *' The patients have no fever, it is true ; in some cases the
temperature is even low and the pulse slow; but the appetite is
often poor ; the tongue coated, digestion disturbed ; the patients are
sensitive to changes of temperature, and complain of an indefinite feel-
ing of illness. After a few paroxysms the disturbances usually sub-
side, and during the apyrexia the only symptoms we notice are
steadily-increasing debility and more evident impoverishment of the
blood. If intermittent fever is very protracted, the apyrexias often
become impure again, and the intermittent type approaches the remit-
tent (febris intermittens subcontinua).

According to the rhythm in which the paroxysms follow each other,
we distinguish intermittens quotidiana, tertiana, and quartana. In the
quotidian, the paroxysms recur in nearly or exactly twenty-four hours ;
in the tertian, in twice twenty-four hours ; in the quartan, in three
times twenty-four hours after the commencement of the last one. It
is less certain if there be also a five, six, or seven day rhythm, or if
the intervals be even longer. The most frequent varieties are the
tertian and quotidian. If the paroxysms recur at an earlier hour than
it did the last fever-day, the disease is called anticipating, in the oppo-
site case it is called retarding. By continued anticipation or retarda-
tion, the rhythm of the fever may change, and a tertian may become a
quotidian, or the reverse. If a paroxysm last almost till the com-
mencement of the next one, we have a febris intermittens subintrans.
When the apyrexia of a quotidian, tertian, or quartan intermittent is
interrupted by a weak, short paroxysm, which often occurs at a differ-
ent time of day, it is called febris intermittens duplicata. In quo
tidiana duplicata there are two attacks each day, one severe, the
other mild ; in tertiana duplicata there is one attack each day, but
one day it is mild, the next weak, etc. ; in quartan duplicata, parox-
ysms occur on two successive days, while the third day remains free.
Intermittent fever never begins double ; this rhythm usuallv develops

INTERMITTENT FEVER. 679

after the disease has lasted a long time, or particularly after numerous
relapses.

The course of intermittent is so often modified by the administra-
tion of medicines, especially of quinine, that few physicians have
actually observed a case left to itself, or, as is generally said, the nor-
mal course of an intermittent. On this point also we are indebted to
the homoeopaths for some important information. In the first place,
there is no doubt that the peculiar fever paroxysms and apyrexias,
which characterize infection with malaria, almost always continue for
a time, even if the patient be removed from further action of the
poison. Among other cases, I know of a young sailor who suffered
from intermittent fever in Greifswald, and who had a relapse while at
sea, four weeks after his last attack. It is also certain that, when a
long time has passed since the action of the poison, the symptoms of
malarial poisoning almost always disappear without medical aid. To
avoid illusion, we must bear in mind that it is not only those who fly
from the malarious region after acquiring intermittent fever, but also
those who remain in the place till the malaria has disappeared, that
finally escape the action of the poison. At a time when no new cases
are observed in a place which has been visited by intermittent, it
would be foolish to regard the final cure of a case, which had previous-
ly been treated ineffectually, as a proof of the peculiar efficacy of the
remedy last used. As the prevalence of the malaria among us only
lasts a few months, the number of spontaneous cures is certainly much
greater than is usually supposed.

Another question is, whether, from continued action of the poison,
the organism becomes so blunted to its injurious influence, that the
symptoms of intoxication cease. At all events, such cases are rare,
and it is more frequent to find those where continued action of the
malaria has only modified the symptoms of intoxication, so as to
change a pure intermittent into an intermittens subcontinua, or
clironic malarial illness without fever. As was stated, when speak-
ing of the individual paroxysms and apyrexias, after a prodromal
stage but little characteristic, most cases of intermittent begin as
tertian or quartan fevers, the apyrexias being at first imperfect,
but becoming pure after a while. When the disease has lasted even
a very short time, the patient appears very pale and cachectic, and
this symptom is the earlier and the more marked, the greater the en-
largement of the spleen. If the spleen remain small, from rigidity of
its capsule, or from other unknown causes, the patient does not have
this peculiar pale and sickly appearance until later. From this fact,
which may be observed in most cases, as well as from the second fact,
that the healthy color quickly returns when we can rapidly reduce the
93

030 ACUTE INFECTIOUS DISEASES.

size of the spleen, we have concluded that the great pallor of the
patients after the first attacks of intermittent does not solely, and, at all
events, does not exclusively, depend on general impoverishment of the
blood, but mostly on the lack of blood in the skin, which must be induced
by its collection in the spleen. While Junod's boot is applied to one
extremity, there is great hyperaemia of that limb, and consequent
anaemia of the rest of the body ; if the boot be removed, the normal
distribution of blood is soon reestablished. We do not, however,
mean to say that the fever of intermittent differs from other fevers in
regard to the consumption of the body ; on the contrary, intermittent
fever would be one of the most dangerous of diseases, if those inex-
plicable pauses did not occur between the paroxysms, during which
the consumption is interrupted, and the tissues of the body restored
by plentiful supply of nourishment, more than in any other feverish
disease. From the high temperature (106° Fahr. or more), reached in
intermittent fever, the consumption of the body is very marked. This
is evident, not only from the increased production of urea, but also
from the emaciation and hydraemia that occur in protracted cases.
There is no doubt that the production of urea is only increased during
the paroxysm, and not during the apyrexia ; on the other hand, in two
cases of quartan intermittent, I found that the excretion of urea was
increased during the apyrexia also, or, in other words, that the in-
creased amount of urea produced during the paroxysm was not all ex-
creted till some time during the following apyrexia. If the paroxysms
be not temporarily or permanently arrested by the administration of
quinine, or if they do not soon cease spontaneously, the hydrsemia at
length becomes so excessive, that in many cases more or less dropsy oc-
curs, without the urine being diminished in quantity, or containing albu-
men. This dropsy is analogous to those occurring during other exhaust-
ing diseases, although it is probable that the organic and functional
disturbances of the spleen accompanying protracted intermittent fever
add to the degree of hydrsemia, and to the frequency of the dropsy. The
longer the affection lasts, the more reason there is to fear the devel-
opment of permanent organic change in the spleen, liver, or kidneys •
this usually assumes the form of lardaceous degeneration, with coinci
dent deposit of pigment, and leads to incurable disease. Continued
intermittent fever often induces chronic parenchymatous nephritis also,
and, in other cases, a haemorrhagic diathesis. These severe sequelae
of simple intermittent fever are generally prevented by proper treat-
ment ; and, even where intense malaria is endemic, under careful man-
agement, excessive dropsy, fatty degeneration of the abdominal or-
gans, and cachexia, rarely occur. It is true, neither quinine, nor any
other known remedy is so certain an antidote for malarial poison ag

INTERMITTENT FEVER. (581

to cut short the entire disease ; but, for the most important and dan-
gerous symptom, the fever, quinine is almost infallible. After giving
proper doses of quinine, the patient almost always escapes a series of
paroxysms ; and, as the cachexia and impoverishment of the blood,
and, to some extent, the spleen-affection also, probably depend on the
fever, the patients not only do not grow worse during the administra-
tion of the quinine, but they improve and pick up even if the disease
be not entirely extinct. Although, for the sake of brevity, we may
designate as relapses the many cases where paroxysms recur shortly
after stopping the quinine, strictly speaking, it is incorrect ; for the
cases where these so-called relapses occur, even after moving into a
region free of malaria, prove that the disease was not cured, but only
one of its symptoms removed. The homoeopaths assert that under
their treatment there are no relapses : there is some truth in this as-
sertion ; for, when the paroxysms have ceased under homoeopathic
treatment, the disease is certainly all gone. The fact, that, after the
administration of quinine in sufficient doses, relapse does not occur in
jiany cases, rather favors the view that, besides its palliative action
on the paroxysms, this medicine has also a favorable influence on the
entire disease caused by the malarial infection ; but it is also possible
that in such cases the palliative action continues till the disease passes
off spontaneously. When the action of quinine is only palliative (as
it is in the majority of cases), usually about seven, fourteen, or twenty -
one paroxysms are missed, and the next one occurs in about two, three,
or four weeks, rarely sooner. According to my own observation, the
assertion, that the relapses almost regularly take place the fourteenth,
twenty-first, or twenty-eighth day, is exaggerated ; I have far more
frequently seen relapses a few days before or after these dates. It is
not at all rare for relapses to occur three or four times, or oftener, and
for the disease to run on interruptedly for months, before actually
ceasing. I deem it proper to speak of the modification of the course
of intermittent fever by quinine under symptomatology, because, ae
we have already said, most physicians have no opportunity of ob-
serving intermittent fever without this modification of its course.
Much that is said in the text-books on medicine, about the course of
intermittent fever, certainly does not refer to the disease when left to
itsel£

1L Pernicious Intermittent Fever. — Intermittent fever may prove
dangerous to children, to the aged, and to very debilitated or sickly
persons, without being of unusual intensity or duration, or having any
complications. Children inclined to convulsions not unfrequently have
an epileptiform attack during the cold stage, as they also have in the
initiative chill of inflammatory diseases. This is not usually danger-

ACUTE INFECTIOUS DISEASES.

ous, but occasionally it passes into general paralysis, ending in death
In very old or broken-down persons, the danger from a simple par-
oxysm lies chiefly in the threatened exhaustion of the still remaining
strength. Such cases, which only take on an acute course from indi-
vidual peculiarities of the patient, are not usually called pernicious.

Some cases of intermittent acquire a pernicious character, from the
usual symptoms becoming very intense, or being protracted a long
time. In this class belong the cases where the hyperaemic swelling
of the spleen is so great that its capsule is ruptured, or where the
cliill is so severe as to cause dangerous obstruction of the circulation,
as well as those cases where the paroxysms do not cease in from six
to ten hours, but continue for twenty-four hours, or longer, and leave
the patient very much exhausted, or where only certain stages con-
tinue beyond the usual time. It seems to me very probable that some
forms of the so-called pernicious fever also should come under this
head, as it is probable that they are not complicated, only that the
customary symptoms are greatly increased. Even in simple normal
intermittent there is an increase of the temperature, such as is ob-
served in scarcely any other disease ; and the short time that this
increase lasts is the only reason that it does not prove dangerous to
the patient. In all diseases where the bodily temperature becomes
excessive, or remains high for a long while, we have the symptoms of
great adynamia, and finally of paralysis of the heart, and these are the
most prominent symptoms of pernicious fever. The deep stupor of
patients with febris intermittent comatosa, as well as the delirium
preceding the coma, reminds us strongly of the symptoms in severe
typhus, malignant measles, and other infectious diseases accompanied
by high fever. When these cases terminate fatally, we do not gen-
erally find any anatomical changes in the brain. In febris dlgida the
heart's action grows feebler, the pulse smaller ; the blood collects in
the veins ; there is cyanosis ; the temperature of the periphery closely
approaches that of the surrounding air, because the loss of warmth
due to the obstructed circulation is not replaced by a supply of warm
blood ; the patients grow cool ; in short, we have the symptoms of
acute paralysis of the heart, which may even result from the intensity
of the fever without complications. There is no doubt that, in these
severe forms of intermittent fever, there is often pigment in the blood ;
but the coincidence of melanaemia with severity of intermittent fever
does not justify us in regarding the latter as a result of the former.
On autopsy of several cases of intermittent fever that died with severe
brain-symptoms, JFrerichs found melanaemia, it is true, but he found
no pigment in the capillaries of the brain ; and I have observed si mi
lar cases.

INTERMITTENT FEVER. 683

Under the head of congestive, pernicious intermittent, in the strict
sense, we must class those cases where the malignant course of the
disease is caused by hyperaemia, effusions of blood, inflammations, and,
perhaps, also by obstructions of the circulation in different organs, in-
duced by stoppage of the capillaries with pigment. Probably these
disturbances of nutrition and circulation in the central organs of the
nervous system are the origin of the maniacal, apoplectic, epileptiform,
and tetanic convulsions, which occasionally complicate the paroxysms,
and have led to the designations febris intermittens perniciosa, mani-
acalis, apoplectica, epileptica, tetanica. A rather frequent but rarely
dangerous complication of intermittent fever is a severe bronchitis,
which exacerbates with every paroxysm and remits with each apyrexia.
Febres intermittentes comitatae pneumoniacse and pleuriticae, or cases
of intermittent haemoptysis, are rare. In many cases of congestive in-
termittent, there is jaundice. Copious watery transudations from the
intestinal canal, violent vomiting, and profuse diarrhoea, may cause
thickening of the blood, and give the paroxysm a great resemblance to
the algid stage of cholera. In some cases there are also profuse inter-
mittent intestinal haemorrhages. (Among fifty-one cases of pernicious
intermittent, observed by Frerichs, there was profuse diarrhoea seven-
teen times, profuse intestinal haemorrhage three times.) The serous
transudations and haemorrhages into the intestinal canal may depend
on acute congestion due to obstruction of the hepatic capillaries by
pigment, but this has not been proved in all cases. Lastly, we have to
mention the complications of intermittent with diseases of the kidneys.
They evince themselves by albuminuria, haematuria, and in severer cases
by the suppression of urine. (In the fifty-one cases of Frerichs, albu-
minuria was seen twenty times, suppression of urine five times.)

Pernicious intermittent fever occurs chiefly in tropical-fever regions,
it is true, but even with us, in places where intense malaria prevails,
it is not rare, and individual cases are seen in every large epidemic of
intermittent fever. The malignant character either appears at the
start, or does not manifest itself till the second or third paroxysm, or
even later. After malignant congestive symptoms have appeared, the
apyrexias are often so imperfect that the diagnosis is very difficult or
even impossible. In the epidemics observed by Frerichs, most patients
were sent into the hospital with the diagnosis of a typhus.

III. Concealed Intermittent Fever. — While, as a rule, intermittent
fever results from infection with malaria, we not unfrequently see ex-
ceptional cases where, instead of fever-paroxysms, there is neuralgia,
the attacks of neuralgia being separated by regular intermissions, cor-
responding to the apyrexias of a simple intermittent. These deviations
from the rule are inexplicable, it is true, but this is also true of regular

ACUTE INFECTIOUS DISEASES.

simple intermittent fever, which we do not in the least understand.
The intermittent neuralgiae resulting from malaria, which chiefly bear
the name of intermittentes larvatae, most frequently affect the supra-
orbital, more rarely other branches of the trigeminus or other nerves.
We may omit a description of the attacks, as they are about the same
as those of neuralgic attacks from other causes. They are accompa-
nied by a slight elevation of temperature, perceptible by the thermom-
eter. In rare cases, other anomalies of excitement of the cerebro-
spinal and vaso-motor nerves appear to result from malaria. Among
these are intermittent anaesthesia, paralysis, spasms, psychical dis-
turbances, and hyperaemia or cedema of different organs.

TREATMENT. — Prophylaxis requires that the State should attempt
to remove by sanitary laws (which do not come in our province) the
injurious influences which notoriously favor the development of mala-
ria ; that it should drain the marshes in whose vicinity intermittent
fever is endemic, and should protect by dikes those lands that are
overflowed yearly. Moreover, persons obliged to reside temporarily or
permanently in malarial regions should observe certain rules, which
afford more protection than any prophylactic medicines. Hauschka,
who has apparently had great experience, gives very precise and prac-
tical rules for life in malarial regions. In his special pathology and
therapeutics, he advises : 1, on going to a dangerous place, to assume at
once the peculiar mode of life of the inhabitants ; on the Weichsel to
drink schnaps, in Banate slivovitz, in Hungary only to eat melons and
pickles with plenty of pepper, in Italy to drink plenty of lemonade
and black coffee, and avoid eating at night, also to drink water pre-
pared as is customary at different places ; 2, to suit the clothing to the
temperature of the time of day, especially to protect the person by
warmer clothes against the cool evening air, and to keep the windows
closed at night ; 3, to seek a dwelling high and dry above the marshes,
etc. ; 4, to avoid getting wet through, errors of diet and other excesses,
so as not to bring on any other disease by which the tendency to ma-
laria will be increased ; 5, to avoid certain things, such as the use of
vegetables, milk, and bathing in rivers or the sea, especially after sun-
down. Sleeping in the open air seems to be most dangerous.

Treatment of the paroxysm may almost always be dispensed with,
except as regards directing the regimen. As soon as the first symp-
toms of chill are observed, the patient should go to bed; but we
should warn the attendants against piling on too many bed-clothes, as
they do not warm the skin, and only interfere still more with the cir-
culation in the peripheral parts, and with the impeded respiration. If
the chill be very severe, the skin may be rubbed with warm woollen
cloths, and warm bottles placed in the bed. Hot drinks neither re-

INTERMITTENT FEVER.

aeve tne feeling of chilliness nor increase the temperature in the pe-
ripheral parts, which is diminished in spite of the increased temperature
of the blood ; but we may yield to the generally urgent entreaties of
the patient for warm drink, so far as to allow him a few cups of tea, if
we are certain that he will be moderate. If there be severe vomiting
during the cold stage, we may give effervescing powder, and, if this
fail, a few drops of laudanum. If the patient become so collapsed as
to alarm us, we may give analeptics, strong coffee, wine, camphor,
ether, and opium, have the patient rubbed, and apply sinapisms. In
the hot stage we may try cooling treatment, light covering, plenty of
cold drink in small quantities ; where there is severe congestion of the
brain, use cold water or ice-compresses to the head, and sometimes
local blood-letting. Venesection is only to be practised in the most
urgent cases, as it rarely does good, and may cause dangerous collapse ;
in its place, in attacks of pernicious fever, besides local blood-letting
and derivatives, the use of opium has proved the most efficient treat-
ment. The sweating stage must be awaited in bed. Especial treat-
ment to increase the sweating is unnecessary, as there is no advantage
Irom its being very profuse. The patients should not change their
underclothes till this stage has terminated. The treatment during the
apyrexia aims at preventing the return of paroxysms by the adminis-
tration of quinine, unless there be some peculiar objection to giving
that medicine. The formerly common idea, that it was advantageous
for the patient to have a certain number of paroxysms, and that the
fever should not be arrested till after the third, fifth, or even seventh
attack, was based on false premises. The sooner he is freed of his
paroxysms the better for him. A morbid state of the gastric mucous
membrane, however, which occasionally occurs after the first paroxysm
of intermittent, contraindicates the administration of sulphate of
quinine, and, in mild cases at least, this morbid state should be re*
moved before ordering the irritating salt. In treating intermittent
fever, the diagnosis of gastric catarrh, or foul stomach, is not made
very exactly, and emetics are used too freely ; some physicians begin
the treatment with an emetic, as a matter of course ; others prescribe
muriate of ammonia till the tongue is thickly coated, and then give an
emetic to prepare the patient for quinine. Unless certain indications,
that we have given for the administration of emetics in gastric catarrh,
be present, we consider it improper, or at least superfluous, to open
the treatment of intermittent with one. But if, at the commencement
of the fever, the patient has made great errors of diet, especially if,
just before the paroxysm, he has filled his stomach with food which
has remained undigested, and by decomposing has irritated the gastric
mucous membrane, there is just cause for giving an emetic. We have

686 ACUTE INFECTIOUS DISEASES

already described the difference between gastric catarrh due to inJi
gestion and the slignt dyspepsia accompanying most fevers which re-
quires no emetic, and does not prevent our giving quinine. Pfeufeft
recommendation, to give quinine in one large dose instead of in several
smaller one sduring the apyrexia, has very rightly become popular.
Usually, in adults, one dose of ten grains of sulphate of quinine suffices
to arrest the chills ; in children, five grains suffice, in still smaller chil-
dren, two or three grains answer. Another slight chill often occurs,
and the attacks then cease. It is best to give this dose of quinine
some hours before the expected chill, so that we may be sure of its
acting during the apyrexia. Small doses should only be preferred
when large ones are vomited by the patient ; in such cases we may
give two grains every two hours, till twelve or fifteen grains have been
taken during the apyrexia. Quinine is most frequently given in pow-
der or pill (quiniae sulphat. gr. x, ext. gentian, q. s. ut f. pill. no. iv).
Solution of bisulphate of quinine (quinise sulph. gr. x, aquae meliss.
% iij, acid, sulphur, dilut. 3 ss, syrup. § ss) is said to be particularly
effective, but it is unpleasant to take, especially in large doses. If
quinine is not borne by the stomach, it may be given by injection, as
it acts just as well by the rectum (or by hypodermic injection). Other
salts of quinine have no advantage over the sulphate ; quinoidine and
tincture of quinoidine are cheaper, and hence may be preferably used
in poor practice ; of the latter remedy we may give twelve or fifteen
drops every two hours, or give a teaspoonful a short time before
the expected chill. According to Wunderlich, this is quite as effica-
cious as quinine. If the patient has escaped one chill under the above
treatment, he almost always escapes a second and third, or even a
number ; but it is advisable to continue small doses of quinine for a
few days longer, unless the spleen has distinctly and steadily de-
creased in size. The more perfectly the spleen returns to its normal
bulk, the greater is the probability that there will be no relapse. I
have already given my ideas about the custom of repeating the qui-
nine on the seventh, fourteenth, twenty-first, and twenty-eighth days.
When this is being done, the chill often occurs on the day just pre-
ceding the one when the medicine was to be given. I think it much
safer to tell the patient that he will probably have a relapse toward
the end of the second, third, or fourth week, and that at these times he
must watch carefully for any premonitory symptoms, and on the
slightest suspicion of a chill he must take a full dose of quinine. By
careful attention to the rudimentary attacks which almost always pre-
cede perfect relapses, most patients of moderate intelligence may pro-
tect themselves from the latter. The belief, that, in cases of relapse,
the patient must daily take an ounce of tincture of Peruvian bark ir

REMITTENT AND CONTINUED MALARIAL FEVER. 687

stead of quinine, is antiquated. Besides the administration of quinine
or its repetition, we should urge the patient to adopt all the rules
spoken of under prophylaxis. When the circumstances of the patients
permit, we should have them leave the affected place for six or eight
weeks. We have already explained that this does not render the ad-
ministration of quinine superfluous.

If chronic malarial dyscrasia develop, besides a nutritious and
strengthening diet, the patient should twice a day take half a glass of
bark and wine (tine, cinchonse § i, tine, cinnamom. 3 i, acid, sulph.
aromat. 3 ij to a bottle of Rhine wine), or three or four teaspoonfuls
daily of tine, cinchonas comp., combined with large doses of iron. In
most cases the benefit of this treatment is very evident : even advanced
dropsy usually disappears in a short time without any diuretic reme-
dies ; should it unexpectedly fail, we ought to absolutely insist on a
temporary change of residence, even if it be very inconvenient.

The above treatment is almost always successful in simple inter-
mittent. Experiments with substitutes for quinine, such as salacin,
piperin, salt, etc., have led to negative or doubtful results. The only
febrifuge, except Peruvian bark and its preparations, that deserves con-
fidence, is arsenic, in the form of Fowler's solution (four to six drops
three times daily during the apyrexia). In view of the far more cer-
tain and safe action of quinine, I consider the use of arsenic as only
justifiable in those rare cases where quinine fails, even in large doses.

In pernicious intermittent, our first object is to prevent the occur-
rence of the next attack. While carrying out the treatment required
by the congestive symptoms during the attack, we should not wait
for a complete intermission before giving quinine ; but, as soon as there
is the slightest abatement of the symptoms, we should give large doses
of quinine (3j to 3 ss. or more), and, if the patients cannot swallow,
give it by enema [or, better, by hypodermic injection, giving about
one-third the dose by the mouth, perfectly dissolved].

In the concealed form of intermittent, quinine is almost as effica-
cious as in the simple form ; but even here its action appears only pal-
liative and symptomatic, as it does not prevent relapses.

CHAPTER XII.

REMITTENT AND CONTINUED MALARIAL FEVER.

ETIOLOGY. — Remittent malarial fevers occur chiefly in the tropics,
it is true, but they are occasionally observed among us also, in places
where malarial diseases are endemic, and at other places also when
epidemics of intermittent are prevailing. Hence I cannot class remit-

683 ACUTE INFECTIOUS DISEASES

tent malarial fever among the exotic diseases and pass it by, but I
shall follow the excellent description of Griesinger in my short ac-
count of it, as I have but little knowledge of the affection from per-
sonal observation.

The dependence of remittent fever on malarial infection is shown,
first, by its exclusive occurrence in places where we know, from the
quality of the soil and climate, and from the occurrence of numerous
cases of intermittent, that there is an intense malaria ; secondly, from
the many cases where remittent fever becomes intermittent. "We do
not know whether the change of symptoms be due to a modification
of the poison, and, if so, in what this modification consists. The more
severe the cases of intermittent, the more frequent are the remittent
cases.

ANATOMICAL APPEARANCES. — As regards the melanaemia, the post-
mortem appearances of remittent fever correspond with those of per-
nicious intermittent. At least, in almost all places where remittent
fever is endemic, in the rare cases of autopsy it has been noticed that
the cortical substance of the brain is of a dark, ashy hue, and the
spleen and liver are blackish. Besides these changes, which are not
constant, traces of more or less severe icterus are often found, some-
times with, again without, obstruction of the gall-ducts ; as well as the
remains of catarrhal and diphtheritic inflammation of the intestines,
and, more rarely, haemorrhages into the stomach, haemorrhagic infarc-
tions in the lungs, or lobular pneumonia.

SYMPTOMS AND COURSE. — Griesinger distinguishes three forms of
remittent fever. According to him, the first and mildest form begins
with a sudden feeling of severe illness, high fever, and foul stomach.
These are soon accompanied by enlargement of the spleen, mild jaun-
dice, irregularity of the bowels, discoloration of the faeces, and herpes
labialis. The depression of the patient, the pain in the head and
limbs, the dizziness, noise in the ears, and not unfrequent bronchitis,
remind us of a commencing typhus ; but from the first the fever shows
a decided remittent character. Irregular exacerbations, which subse-
quently become regular, and usually have a quotidian type, are fol-
lowed by distinct remissions. These gradually pass into perfect inter-
missions, the patient sweats freely, and feels well; the remittent
becomes a simple intermittent. In other cases, even without this
change, the disease terminates in recovery, by a gradual decrease of
the symptoms ; it lasts from a few days to three weeks.

In the severer form the fever is very high, the remissions are well
marked only at first ; the disease reminds us of a severe typhus ; the
patients become stupid and delirious ; the tongue grows dry, and the
spleen is enlarged. Generally, also, but not always, there is icterus ;

REMITTENT AND CONTINUED FEVER. 689

other cases are complicated with pneumonia, dysentery, etc., and still
others have indications of the so-called pernicious attacks. The dis-
ease usually lasts from eight to fourteen days. If it ends in recovery,
it usually first becomes intermittent. Death may occur suddenly with
the symptoms of a pernicious intermittent.

The severest forms run their course with the symptoms of an indis-
tinct and irregular exacerbating and remitting fever of very adynamic
character. The patients collapse quickly, and soon fall into deep
apathy. There are also various but not constant disturbances of func-
tion and nutrition in almost all the organs, so that the symptoms of
the disease vary greatly. Many patients become jaundiced. There is
often epistaxis, vomiting of blood, and haematuria ; in other cases
there is albuminuria, or suppression of urine ; in others, symptoms of
cholera or dysentery ; the spleen and liver enlarge considerably, and
often become the seats of inflammation and suppuration. Inflamma-
tory exudations not unfrequently form in the serous membranes and
lungs also, and in the skin there are petechiae, bed-sores, and gangrene.
Death usually occurs in this stage, with coma or convulsions, or with
the symptoms of febris algida.

TEEATMENT. — According to G-riesinger, in the milder forms of re-
mittent fever, the acute affection of the gastro-intestinal mucous mem-
brane should be combated by absolute diet, acids, and, if requisite, by
emetics and laxative medicines. We should give quinine as soon as
the remissions and exacerbations become decided, and the latter begin
with a chill. Any complications should be treated separately, as
quinine alone does not answer for them. In the severer and severest
forms, the most important indication is the early and continued use of
quinine in large doses, till improvement begins. At the same time,
the congestive symptoms are to be treated symptomatically, just as in
pernicious intermittent fever.

[At present malarial poison is by many supposed to consist of
microscopic vegetable parasites, in algae cells and spores, from the
decomposition of vegetable substances. Harkness asserts that the
algae cells, which Salisbury found in the sputa of patients and re-
garded as the active principle of malaria, are found not only in
malarial regions, but on the highest Alps, and occur in the sputa
and other secretions of healthy persons.

Intermittent fever is a wide-spread disease. It is especially
frequent in the tropics at places which are not particularly dry ;
in the temperate zones it occurs at certain places ; but the frigid
zones escape. It is very common in Western Africa, the West
Indies, Mexico, and our Southern States, but occurs to some extent
in all the States.

(590 ACUTE INFECTIOUS DISEASES.

The period of incubation for malaria is uncertain. Patients sub-
jected to the poison for a long time, or suffering from the disease,
look pale and cachectic, probably from changes in the blood, per-
haps partly due to fever, partly to affection of the blood-forming
organs. The red blood-corpuscles are less numerous ; the remains
of those destroyed appear as pigment in the blood and some of the
organs. This diminution in number is greatest at first, but goes on
till recovery begins ; but at the same time it is said they increase
in size. Kelsch says the white corpuscles decrease in number faster
than the red do, but in the interval increase gradually, and that at
the time they are least numerous the spleen is largest.

If after the intermittent paroxysms have ceased the spleen or
liver remain enlarged, the patient cannot be regarded as cured.
Chronic enlargements of the spleen may attain an enormous size ;
or there may be amyloid degeneration of the spleen, the liver, or
the kidneys.

Where in the treatment of malarial diseases the preparations of
cinchona prove ineffectual, we may try eucalyptus globulus, of
which we may give 3ss-3ij of the tincture, or 10-20 drops of
fluid extract, several times daily. Another substitute for quinine
is arsenic, either as pills of arsenious acid or as Fowler's solution.
In cases of malarial neuralgia, or where there is gastric disturbance,
the Fowler's solution may be used hypodermically. Faradization
of the splenic region is said often to diminish the size of the spleen,
as also the use of cold douches over that organ while the patient is
in a tepid bath.]

[CHAPTER XIII.

YELLOW FEVER.

WITHOUT discussing the question as to when and where yellow
fever originated, we may say that in the United States its different
epidemics seem to come from the West Indies, and to start among
us from New Orleans ; thence its course of travel is along rivers or
by the seaports.

The cause of the disease is not certainly known, but it is sup-
posed to be in the nature of germs. The affection is not conta-
gious ; i. e., a patient having it, if stripped of his clothing and dis-
infected, may be placed among other patients without spreading
the disease. So, the germs do not develop and multiply in the

YELLOW FEVER. 691

patient, but they do so in articles about him (fomites) ; germs may
be carried in clothes and other articles, or in ships, especially in
the bilge- water. These germs are deprived of activity by a freez-
ing temperature, but may be awakened by a heat of 90° Fahr. ;
they are destroyed at 250° Fahr.

It has been maintained that yellow fever is only a variety of
malarial fever, but the evidence seems to be very strongly against
this view.

The National Board of Health (United States, 1879) reaches
conclusions about as follows :

The essential cause of yellow fever is a " germ " which is capa-
ble of growth and propagation outside of the human body, and
which flourishes especially in decaying organic matter. Disinfec-
tion must attack the germ and that on which it grows. Disinfec-
tion is a poor substitute for cleanliness ; it is best done by sulphate
of iron, carbolic acid, fresh quicklime, fresh charcoal-powder, chlo-
rides of zinc and aluminium, and permanganate of potash. The
disinfectant must be brought into actual contact with the germ ;
when the germ is dry, it must be moistened or else subjected to a
dry heat of 250° Fahr. While the infected articles are dry, move
them as little as possible ; moisten them with boiling water or
some disinfectant solution. The Board advises moist cleansing,
followed by fumes of sulphur, using about 18 ounces of sulphur
to 1,000 cubic feet of the space to be disinfected. The removal of
an unpleasant odor is no proof of disinfection. Textile fabrics
which have been exposed to yellow-fever infection should be placed
in boiling water or in an oven ; rooms and houses which have been
occupied by yellow-fever patients should be disinfected as soon as
possible. Lastly, they suggest that " every suspicious case of sick-
ness should be at once isolated, and every possible precaution taken
to prevent infection, by providing attendants who have had the
disease, and thorough disinfection of all discharges from the sick.
If the disease proves to be yellow fever, all articles of clothing and
bedding used about the sick should be burned, the house should be
vacated, and every room tightly closed and fumigated with burning
sulphur."

Yellow fever only occurs when the temperature is high ; in the
northern part of the United States most of the epidemics have be-
gun in July and August. A frost suddenly checks the spread of
the disease.

Susceptibility to this affection is greatly influenced by race and
acclimation ; in many epidemics negroes escape ; acclimation may

692 ACUTE INFECTIOUS DISEASES.

cause some change in the tissues that impedes absorption of the
germs. It is said that acclimated persons are not troubled by
mosquitoes, which are usually very plentiful in yellow-fever re-
gions.

ANATOMICAL APPEARANCES. — Rigor mortis is early and decided.
The skin is more or less jaundiced. The heart is often pale and
relaxed ; its muscles may have undergone fatty degeneration. The
greatest changes are seen in the abdomen ; there is acute catarrh
of the mucous membrane of the alimentary canal ; rarely there
may be ulcers in the stomach, and there is usually more or less
dark blood (black vomit is blood mixed with the fluids of the
stomach). The liver is but little changed in size, but is of uneven
yellow color (more marked in the left lobe), and its cells are filled
with fat ; it looks like the fatty liver of drunkards. The spleen
is not especially changed. The cortical substance of the kidneys
is often swollen, and there are signs of inflammation in all parts
of them.

SYMPTOMS AND COURSE. — The period of incubation is not set-
tled, but probably is from a few hours to three days. The first
symptoms are chilliness alternating with fever, or perhaps a severe
chill, great restlessness, red face and eyes, headache (" the most
characteristic symptom of the disease is the peculiar pain in the
forehead and eyeballs, with the drunken appearance of the eye "),
pain in the joints, fever (102° Fahr. or more), frequent respira-
tion, and frequent pulse. Severe cases sometimes have a cadav-
eric odor early in the disease. The tongue is coated and swol-
len, the pharynx reddened ; the gums swell and bleed readily.
The epigastrium is very sensitive, and there is usually vomiting.
The kidneys are affected, and albuminuria is common ; it is said
that if the albumen disappears gradually, it is a favorable sign,
while its continuance or increase is ominous. The symptoms in-
crease till the second or third day, the temperature rising to
about 105°. Then there may be jaundice of the skin and conjunc-
tiva ; the urine contains bile ; the faeces retain their color, show-
ing that the jaundice is haematogenous. There is frequent haemor-
rhage from the nose, or more rarely from the stomach ; the latter
is of evil import.

After increasing in severity for about two or three days, the
symptoms subside ; the temperature may fall to normal in twelve
hours, but does not usually go below 100° ; the patient may feel so
much better as to think he is well ; but the nausea and sensitiveness
of the epigastrium remain. This stage of remission may last one or

YELLOW FEVER. 693

two days, or it may be the commencement of convalescence. In
the third stage the symptoms again grow worse, the temperature
rising to 104° ; the patient is usually apathetic, though he may
completely retain consciousness. Now come the jaundice and haem-
orrhages from the alimentary canal ; that from the stomach con-
stitutes the " black vomit " which has given one name to the dis-
ease. While this " vomit is thick and pasty, being raised in small
quantities, and thrown up mixed with natural mucus, the physician
does not despair of his patient. The thin black fluid with the coffee-
ground sediment is always, in Mobile, a fatal symptom." If the
disease continues, the kidney trouble may grow worse, and entire
suppression of urine occur. If this third stage is severe, it mostly
terminates in death (" from syncope, uraemia, apoplexy, or asphyx-
ia") ; but sometimes the temperature falls suddenly, the patient
sweats freely, and the severe symptoms all subside. Convalescence
is slow, and for a long time the stomach remains weak. In severe
cases the strength of the patient may not be " reestablished sooner
than from ten to ticenty days after the cessation of the febrile symp-
toms" " The average duration of fatal cases is less than a week."
THE TREATMENT of yellow fever, as of other epidemic diseases,
has varied greatly with different epidemics. Bleeding, salivation,
purging, sweating, etc., have each had their advocates ; but at pres-
ent the most favored plans may be considered — first, that of ad-
ministering at the start a large dose (gr. xx each) of calomel and
quinine, followed after a few hours by a purge, and subsequently
to treat symptoms ; and, secondly, the treatment by laxatives, such
as cream-of-tartar and tamarind-water, followed by tonics, and,
if the disease goes on, by active stimulants. It is considered very
desirable to keep the patients well covered in bed, and in moder-
ate perspiration ; the latter may be aided by hot foot-baths under
the bed-clothes and by warm aromatic teas. Possibly frequent
small doses of jaborandi or its active principle, pilocarpin, might
prove beneficial.]

ACUTE INFECTIOUS DISEASES.

CHAPTER XIV.

8UDOE ANGLICUS. — STJETTE MTLIAIRE. — SWEATING-SICKNESS. —
FRIESEL FIEBER.

A LARGE number of authorities, especially the Germans, deny the
existence of sudor anglicus as a peculiar disease. Thus Hebra ignores
the well-known fact that the prevalence of this malady is restricted
within extremely narrow geographical limits, and that, between the
various epidemics of it which have arisen long intervals have elapsed ;
so, having never met with a case of it himself, he concludes that there
is no such disorder. His remarks that there is no febrile affection in
which fever-vesicles may not appear, and that the invasion and course
of malaria are never accompanied by symptoms which accord with those
of sudor anglicus, prove nothing, save that the exanthema is not patho-
gnomonic of this disease, and by no means disprove the fact attested
to by many trustworthy authorities, that, besides typhus, acute ar-
ticular rheumatism, puerperal fever, and many other febrile com-
plaints, there also exists a peculiar sickness characterized by sweating
and a miliary eruption more profuse than is often observed in any
other disease.

That suette miliaire, or the sweating-sickness^ should be named
after one of its prominent symptoms, is quite consistent with the ordi-
nary practice in the case of a disorder not referable to some simple
pathological state of a special organ.

ETIOLOGY. — Sudor anglicus, beyond a doubt, is an infectious dis-
ease. Its exclusively epidemic appearance, its independence of the
action of the weather, and other assignable antihygienic influences,
as well as the results of the few autopsies which have been made,
sufficiently warrant our classing it with typhus, the acute exanthe-
mata, and other disorders which we believe to proceed from infection
of the organism by a specific and probably organic poison, and which
diseases are certainly more numerous and varied than they are said to
be in the schools. Whether the specific poison of the sweating sick-
ness be reproduced in the person of the patient, and thence be trans-
mitted to others ; or, in other words, whether it be a contagious dis-
ease, is doubtful. All inoculations with the contents of the miliary
vesicles, hitherto made, seem to have afforded negative results. This
fact, as well as its narrow territorial confines, make it seem more prob-
able that sudor anglicus is not contagious, but that it proceeds from a

SWEATING SICKNESS. 695

miasma, that is, a poison which originates without the body, and
which is not reproduced within it.

Regarding the geographical range of sudor anglicus, and the influ-
ence of the seasons, and other causative agents upon its epidemic oc-
currence, Sirsch, who has made it the subject of a most thorough
historical, geographical, as well as pathological study, speaks as fol-
lows : " But few diseases have so limited a geographical range. Its
home is in France, southwest Germany, and Italy, while in the Neth-
erlands, middle and northern Germany, and latterly in Spain, it has
only been met with in occasional epidemics. In other parts of Europe,
and the continents of either hemisphere, it is quite unknown." Of the
recorded epidemics, five-sixths broke out in the spring or summer.
In autumn they were rare, in winter somewhat more frequent, but
never very extensive. The appearance of sudor anglicus does not
seem to depend upon any particular atmospheric conditions, and arises
as often in mild spring weather as during hot summer. Most fre-
quently epidemics broke out during weather characterized by a
moderate temperature and remarkably moist atmosphere. Swampy
ground seemed less favorable to its development than a dry, sterile
soil. In contrast with many other infectious disorders, sudor anglicus
is less frequently seen in large, densely-populated cities, than in small
rural communities, country market-towns, and other similar localities.
Of the older physicians, Lancisi, and more recently Schorilein, accuse
the water in which hemp has been steeped, of favoring the develop-
ment of the sweating-sickness.

With regard to the conditions in life which, during an epidemic of
this disorder, have been found to predispose to it, it has everywhere
been observed that vigorous persons of middle age are peculiarly
liable to be attacked, and that women, especially those who are preg-
nant, or in child-bed, or suckling their children, are more prone to it
than men are. In other respects the mode of life seems to have no
effect upon the predisposition to the sweating fever. The poor, who
usually afford the greatest number of victims to epidemics, do not
suffer from sudor anglicus more than the rich.

ANATOMICAL APPEABANCES. — Nearly all authorities speak of the
early appearance and rapid progress of putrefaction of the corpse.
There are no fibrinous clots in the blood, which is thin and dark of
color. The cerebral veins and sinuses are full of blood, and the serum
in the ventricles is sometimes increased in quantity. The mucous
membrane of the air-passages appears reddened. Somewhat rarely
pneumonic infiltration is found in the lungs. The assertion that vesi-
cles similar to those of the skin are found upon the mucous membrane
of the intestine as yet lacks confirmation. The rpleen is swollen and
94

696 ACUTE INFECTIOUS DISEASES.

soft ; the liver filled with blood ; the general appearance corresponds
with that usually revealed upon the autopsy of an exanthematoua
patient.

SYMPTOMS AND COUBSE. — In a few instances the disease is pre-
ceded by languor, headache, soreness of the limbs, loss of appetite,
indigestion, and other premonitory but non-characteristic symptoms.

Much more commonly the disorder breaks out suddenly, without
any precursory signs whatever. The patient goes to bed feeling per-
fectly well, and awakes in the night bathed in sweat, the flow of which
in a few cases is preceded by a slight chill. He complains of a painful
sense of constriction about the precordium, and of an indescribable ter-
ror and restlessness. The countenance is reddened, the skin hot, pulse
frequent, and urine scanty and concentrated ; strange to say, thirst is
not always much augmented. Most patients further complain of head-
ache, of a feeling of stiffness and tension about the nucha ; many also
suffer from mental confusion, dizziness, roaring in the ears, palpita-
tion of the heart, and painful spasms of the extremities, like those of
cholera. These are accompanied by a more characteristic symptom, a
sense of numbness and pricking of the skin, particularly in the fingers
and over the regions where the eruption afterward breaks out most
profusely. The sweating is so copious as to saturate the clothing and
bedding, and sometimes even the mattress. A peculiar odor has been
ascribed to this perspiration by some, who compare it to the smell of
rotten straw or musty vinegar ; but more probably the odor proceeds
from decomposition of the sweat which soaks the bedding.

At the end of about three or four days, the eruption appears, pre-
ceded by an aggravation of all the above symptoms, but particularly
by an increase of the perspiration, and the prickling of the skin.
Scattered here and there among the spots of the eruption, solitary
sudamina appear — limpid vesicles filled with sweat, beneath which
the skin seems so normal that one might mistake them for drops of
water.* The greater part of the eruption, however, is of the miliary
form and should rank with the eczemas, since the elevation of the
cuticle is not the result of mere perspiration, but of an inflammatory
effusion. The vesicles at first are tolerably transparent, but soon be-
come pearly and turbid ; and according as they are or are not surround-
ed by an intensely reddened areola they are described as miliaria
rubra or miliaria alba. Sometimes the effusion accompanying the
hyperaemia of the sudoriparous glands in miliaria rubra is so slight
that there are apparently no distinct vesicles, but merely solid nodules

* To guard against misunderstanding, the term miliaria crystallina should be
disused.

SWEATING SICKNESS. 697

(eczema papulatum). The eruption then bears a great resemblance
to measles. WLen the effusion is very profuse beneath the cuticle
the vesicles become so large as to suggest a varicella. — The first ap-
pearance of the exanthema is upon the sides of the neck and the upper
part and front of the chest. Thence it spreads to the belly, back,
arms, and legs ; it rarely attacks the face or hairy scalp. The erup-
tion breaks out either all at once, the whole body becoming cov-
ered with vesicles within a few hours ; or else it comes out in crops,
one part of the body after another being assailed. The latter is a very
common form of the eruption. The fresh outcroppings of the rash
are always preceded by an aggravation of the other symptoms, espe-
cially of the sweating and pricking of the skin.

Sometimes there is no eruption at all. Such instances are not
to be regarded as analogous to the rare cases of scarlatina with-
out exanthema and of abdominal typhus without intestinal lesion.
Here the rash seems to depend upon mere sweating; and the
latter is the real pathognomonic sign of sudor anglicus. Whether
or not there be also a miliary eruption depends a good deal upon
the degree of susceptibility of the skin of the individual, just as in
cases of sun-burn or of mercurial inunction, it depends in part
upon the activity of the irritant and in part upon the sensitiveness
of the skin whether or not an eczema solare or eczema mercuriale
shall ensue.

When the disease takes a favorable type, the fever and other
symptoms assume a remittent and sometimes even an intermittent
form, and about the sixth to the tenth day the sweating begins to
abate, and no more fresh crops of the vesicles arise. The restlessness
also ceases, as well as the headache, prickling, and loss of appetite ;
the fever subsides, sleep is tranquil, urine copious, the vesicles dry up,
and convalescence is established; during which the macerated and
loosened cuticle exfoliates, sometimes in large sheets, sometimes in
bran-like scales.

Occasionally a relapse interrupts convalescence, and runs a course
like that of the original seizure. The malady may thus drag on for
weeks, and greatly exhaust the patient, rendering his recovery very
slow.

While in many epidemics the favorable type is so much the rule,
that the majority or even all patients recover, yet there are others in
which the sudor anglicus, without especial complication, makes many
victims. It may terminate fatally at any period, death taking place
suddenly and without warning, either with symptoms of excessive
dyspnoea, or else of cerebral and cardiac palsy. Sometimes the end
is preceded by a cessation of the sweating and a fading of the exan-

6QS ACUTE INFECTIOUS DISEASES.

thema. This has been accounted for upon the obscure hypothesis of
a metastasis of the disease to internal organs.

The most common complications of sweating-sickness observed
in the more accurately described epidemics are angina and a diphthe-
ritic stomatitis, generally termed aphthae. More rarely it is compli-
cated with bronchitis and pneumonia. In a few of the epidemics
dysentery was observed instead of the usually obstinate constipation.
When of very protracted duration, or unusual intensity, then, like
other tedious and very severe infectious disorders, it develops a
hsemorrhagic diathesis with abundant epistaxis and the appearance
of petechia, and in women by abnormal bleedings from the genitals.

Unfortunately, no accurate measurements of the bodily tempera-
ture during sudor anglicus have as yet been taken. This circumstance
greatly embarrasses our estimate of the physiological value of the
symptoms. How, for instance, is the peculiar restlessness to be ac-
counted for ? Is it due to inspissation of the blood through enormous
sweating, and upon consequent impediment to its circulation through
the capillaries of the lungs, as in cholera, with which sudor anglicus
has been compared ? — Or, is the calorification so much heightened
during the fever as to occasion a surcharge of carbonic acid which
cannot be neutralized by respiration ? Indeed, we are forced to the
inference (owing to the considerable cooling which the skin must
suffer through evaporation of the profuse perspiration) that the pro-
duction of heat is much more active in sudor anglicus than in infec-
tious diseases in which the skin remains dry, always supposing the
temperature of the diseases to be equal. Cooling of the body by
evaporation of the sweat may protect the patient from the perils aris-
ing from too high a temperature of the blood, but not from its over-
charge with carbonic acid — one of the necessary results of excessive
calorification ; at all events, this would account for the apnoea of
sweating-sickness. Again, does the supposed danger of checking the
sweating depend upon the fact that, without the cooling effect of
rapid evaporation of the sweat, the temperature will reach a point at
which the brain and heart are palsied ? Such questions must be de-
ferred until our knowledge of the temperature in sudor anglicus shall
be made as exact as that of typhus and other disorders.

TREATMENT. — Until we shall have more thoroughly investigated
the conditions upon which the sweating-sickness depends, prophy-
lactic measures against its invasion and extension are out of the
question.

At the outset of the attack an emetic is urgently recommended by
many. From all reports, however, it is by no means clear that the
disease has ever been cut short by this means; and we shall

CHOLERA ASIATICA. 099

therefore do well to confine its exhibition to cases which commence
with well-marked gastric disturbance. Its administration, however,
at the beginning of a sudor anglicus, during which the bowels are
generally confined throughout, is not so hazardous a step as it would
be at the commencement of a typhoid fever, when an emetic might
seriously aggravate the diarrhoea which always sets in.

The various drugs which have been deemed specifics in certain
epidemics have invariably failed in others, and quinine alone seems to
have maintained its reputation as an antipyretic. It may be given in
doses of twelve or fifteen grains daily, not only when the type of the
malady is decidedly remittent or intermittent, but even when the type
is continued and the temperature exceeds a certain height. The fact
that the danger of the sweating-fever is greatly dependent upon the
height of the temperature has already forced itself upon the attention
of the best observers, even without the use of the thermometer.
When there is no occasion to use quinine, it is best to prescribe acids,
especially muriatic or phosphoric acids properly diluted.

An important step in the treatment of sudor anglicus dates from
the time when the practice ceased of keeping the patients immod-
erately warm, for fear that the sickness should " strike in." If my
opinion be correct, namely, that the production of heat is intensely
active, but that the danger of an overheating of the body is averted
by evaporation of the sweat, then it is plain that it would be danger-
ous to envelop the patient in thick blankets, beneath which the air is
so saturated with moisture as to impede further evaporation. Light
clothing and free ventilation are imperatively indicated. At the same
time the patient must not be set in a draught, lest he take cold, the
danger from which is greater in sudor anglicus than in kindred affec-
tions, owing to the profuseness of the perspiration.

CHAPTER XV.

CHOLERA ASIATICA.

ETIOLOGY. — It is possible, and even probable that, where cholera
is endemic, it results from miasm. Whether this miasm, the cholera
germ, develop in India, on diseased rice or not, and whether or not
the disease rage in India, more especially in years when circum-
stances particularly favor the increase of these vegetable germs, among
us, it is not indigenous ; but all the cholera epidemics occurring among
us are due to the exotic parasite being brought to us by cholera pa-
tients, and finding for a time a suitable soil and favorable circum-

700

ACUTE INFECTIOUS DISEASES.

stances for increasing ; with us cholera is never miasmatic. (I shall
not dwell on the question whether Hallier and Kloll, who have found
numerous fungi in the dejections of cholera patients, have actually
discovered the cholera germ, for I do not feel competent to decide it.)
Cholera is not contagious in the strict sense of the word, for a healthy
person never takes cholera from contact with a patient having that
disease. (My experience in the first cholera epidemic that I saw,
where I wrapped many naked patients hi blankets, and often held
them in my arms for some tune, made me a decided anti-contagionist,
and I took this ground in my first publication, some twenty years
since.) But, as the word contagion is universally used in the sense,
that diseases which are transferred from sick to healthy persons are
contagious, and as this is very decidedly the case in cholera, we must
class cholera among the contagious diseases. The vehicle of conta-
gion is not, as in the acute exanthemata and exanthematic typhus, the
exhalation from the skin and lungs, but the dejections of cholera pa-
tients. It has been certainly proved that fatal cholera epidemics have
broken out in places previously free from it, because some traveller,
having cholera germs in his intestines, has used a privy, or that the
dejections of a cholera patient have been emptied into a privy, fre-
quented by other persons. In 1848, a transport of recruits from Stet-
tin, where cholera was raging, came to Magdeburg ; two of these re-
cruits sickened of cholera the night of their arrival. They were imme-
diately taken from their quarters to the military hospital, which was
some distance off, without coming in contact with the inhabitants. A
few days after, the cholera broke out in the house, and in the street
where they had passed the night. The fatal epidemic did not spread
to the rest of the city for some weeks. In large, thickly-populated
cities, where there are numerous cases of the disease, the extension of
an epidemic is more difficult to follow than it is in small, thinly-settled
towns where the number of cases is limited. A small epidemic in Greifs-
wald gave me an excellent opportunity for observing the spread of
cholera. In almost every case I could find that the patient had used
the privy of some house containing cholera patients, or one whose cess-
pool communicated with that of the privy of affected houses, or that
they had used a privy in common with persons from these houses who
had diarrhoea. Since it has been known that cholera is only trans-
ferred to healthy persons through the dejections of cholera patients, a
series of previously enigmatical and apparently contradictory observa-
tions, concerning the spread of the disease, have been satisfactorily ex
plained. We may readily understand that cholera should spread from
place to place more rapidly than it formerly did, since in these days of
railroads and steamboats people travel more quicklv than thev used to

CHOLERA ASIATICA.

do. It is no longer surprising that cholera should follow the routes of
travel, that it should spread sometimes with the wind, sometimes
against it; sometimes from west to east, again from east to west.
The long leaps that cholera epidemics often make are simply due to
the fact that travelling cholera patients only infect those places where
they leave their dejections, while all intervening places escape. If
the cholera germ were contained in the dejections of those patients
only who suffered from the severest form of the disease (cholera as-
phyxia), as they cannot travel, long springs of cholera epidemics could
only occur when persons infected with cholera poison travelled during
the period of incubation, and the disease did not fully develop in them
till they had reached some place distant from their previous residence.
But besides such cases, among which are the cases in Magdeburg
above mentioned, numerous examples show that a person suffering
from simple choleraic diarrhoea, and who does not feel very sick at the
time, nor even become so later, contains the germs of cholera, so that
he may infect a privy, and thus start an epidemic.

Against the view that cholera was spread by the evacuations of
the patients, it has been urged among other things that in some cases
persons who had swallowed the dejections of cholera patients escaped
the disease, and that attempts to give animals cholera, by introducing
into their bodies the contents of the intestines of patients who had
died of cholera, or the evacuations of cholera patients, had generally
failed. These facts cannot be denied. To make them agree with
those above mentioned, it has been suggested that the recent dejec-
tions of cholera patients do not contain the cholera germ in the stage
of development necessary to infection, nor in the necessary amount, but
that the dejections only become dangerous when the germs of the dis-
ease are placed under circumstances favorable to their development
and increase, by admixture with decomposing animal substances. This
hypothesis is very plausible, and has been generally accepted, as it is
supported by numerous facts ; for, while, according to the observations
of Thiersch, recent cholera dejections were not dangerous for animals,
feeding them with old dejections of the same sort induced cholera.
Experience has taught that persons who wash the clothes of cholera
patients, after they have lain for some time, and persons who change
the bed-clothes a few days after the death of the patient, are more apt
to be infected than those who place the bed-pan under the patient, 01
replace the wet sheets by dry ones. It is most dangerous for the per-
sons in a house, if the evacuations of a cholera patient are emptied
into a privy filled with excrement, into a cess-pool, or thrown on a
dung-hill. At such places the cholera germ seems to find circum-
stances most favorable to its development and increase.

702

ACUTE INFECTIOUS DISEASES.

When cholera has been introduced into a place, it sometimes hap-
pens that only those persons are attacked who live in the same house,
or use the same privy. It has even been observed that, in certain
cities where cholera has been repeatedly introduced, it has always
been limited to these house epidemics. But, in other cases, the dis-
ease spreads from the house where it was introduced, to neighboring
streets, large portions of the city, or even over the whole vicinity.
This may either happen every time the cholera visits the place, or only
in certain epidemics, while in others this extension does not occur.
We are indebted to Pettenkofer for the discovery that porosity of the
soil, enabling the contents of the privies and cess-pools containing the
cholera germs to freely permeate and soak the ground for some dis-
tance around with this dangerous mixture, favors the rapid extension
of the disease, while the opposite quality to some extent protects from
such an extension. We are also indebted to Pettenkofer for the dis-
covery that the occasional predisposition of a place to an extension of
cholera depends on the excrements containing the germs, and per-
meating the soil, being exposed to circumstances favorable to decom-
position. As we have already shown, when speaking of the etiology
of typhus, moisture of the soil plays a very important part among
these circumstances, but it is not the only one. There is no doubt
that the conditions for decomposition may be peculiarly favorable
when a very moist soil suddenly dries to a certain extent ; and it can-
not be denied that the sudden fall of the water of the soil may prove
very dangerous for the spread of cholera. The opposing facts, which
have also been proved, show that the number of cholera cases may in-
crease independently of the sudden fall of the water in the soil, and
that it is one-sided to regard the fall of the water as the sole cause for
favoring decomposition of the excretory matters, mingled with cholera
germs, which have soaked through the soil.

The cholera poison is rarely taken into the system by drinking
water containing it. As a rule, it undoubtedly enters the nose and
mouth with the air, and is swallowed with the saliva. Using infected
privies is so dangerous, because they are the favorite lurking-places
for cholera germs, and the gases arising always contain dust-like par-
ticles. The poison passes from the privy into the atmosphere of the
house, and we must agree with Jliermer in considering the dwellings
as more liable than the inhabitants to infect. Next to the soaking of
tne infecting substance through the soil, the disease appears to spread
from one house to another, chiefly through the gutters and drains.

The susceptibility to cholera pcison is very extensive. No age,
Bex, or constitution, escapes it. When the cholera poison spreads over
the whole city, almost every one suffers from it ; even those not af

CHOLERA ASIATICA. 703

fected with the severer forms have some troubles, apparently depend-
ing on the weaker action of the poison. Certain influences appear to
increase the predisposition to the severer forms of the disease, or to
diminish the resisting power of the organism to the action of the poi-
son. Chief among these are errors of diet, emetics, and laxatives,
catching cold, and other debilitating influences. It is true, foolish
people seek to excuse their excesses at the time of cholera epidemics
by saying that the mode of living can have no effect in inducing cholera,
because persons who lead the most proper lives are attacked by and
die of the severest forms of the disease. Even if this reasoning was
meant in earnest, it does not require refutation. Whoever is exposed
to a poison, whose action kills many persons, while others recover
from it, is foolish to subject himself to injurious influences which lessen
his chances of recovery, even if the avoidance of these injurious influ-
ences gives no guaranty for a favorable termination. The number of
cholera patients taken into the Paris hospitals is said to be one-eighth
greater on Monday than any other day. In the Magdeburg epidemics,
the commencement of a fair, which gave opportunity for excesses of all
sorts, has repeatedly been observed to have a very unfavorable influence
on the number of cases and deaths.

For the numerous important historical and geographical data that
have been collected concerning cholera, since 1830, when it first ap-
peared in Europe, I must refer to special works where the principal
epidemics are fully described ; for imperfect extracts from them would
be unsatisfactory.

ANATOMICAL APPEARANCES. — Bodies of patients who have died
of cholera remain warm a long time ; a post-mortem increase of the
bodily temperature has sometimes been observed. A second pecu-
liarity of these bodies is the occasional contraction of certain muscles
after death, by which the extremities, especially the fingers, are moved,
and change the position they had just after death. The movements
of the fingers that I have actually seen, and the changed position in
which I have found the bodies a few hours after leaving them, have
always made a very disagreeable impression on me.

If death has occurred at the height of the disease, the appearance
of the body is characteristic. We usually find it in a position to which
the clinched hands, variously bent limbs, and swollen muscles, give a
peculiarly threatening appearance (" fighting attitude "). The rigor
mortis is hard to overcome. The face is often so distorted as to be
hardly recognizable. The eyes are deep in the orbit, and are sur-
rounded by wide, blue rings ; the eyelids are half closed ; the uncov-
ered portions of the eyeballs are dry as parchment, the nose is pointed
and projects far beyond the sunken cheeks. The lips are bluish,

704: ACUTE INFECTIOUS DISEASES.

sometimes deep blue. The other parts of the body also have a more
or less marked cyanotic appearance. This is most apparent in the ter-
minal phalanges of the fingers and toes. The skin of the fingers is
often shrunken, and wrinkled like that on the fingers of a washer-
woman who has had her hands in the suds all day. On opening the
bodies we remark the hardness and dryness of the subcutaneous con-
nective tissue, and the dark-red color of the muscles. The blood is
thick, of the color of huckleberry-juice, and contains a small amount
of soft, black clots ; it is collected in the right heart and veins, while
the arteries and left heart are often perfectly empty. The cerebral
sinuses and veins of the meninges are distended with dark blood, while
the cerebral substance is dry and hard. The pericardium does not con-
tain a trace of serum, its inner surface feels pasty, and is often covered
with ecchymoses ; the muscular substance of the heart is contracted,
hard, and of a dirty-red color. The surfaces of the pleura, like those
of the pericardium and other serous membranes, are covered with an
adhesive layer. They also often contain small ecchymoses. On open-
ing the thorax, the lungs collapse very quickly and completely, appar-
ently because the empty, dry bronchi offer no opposition to the escape
of air from the alveoli. On cutting into the lungs, we find them re-
markably dry, and free from hypostasis and cedema. The relaxed,
baggy small intestine has a peculiar rosy appearance, even before it is
opened, while the large intestine preserves its natural color. On open-
ing the intestines, quantities of a colorless or faintly-colored fluid, con-
taining white flocculi, often escape ; this liquid exactly resembles the
"rice-water discharges" of cholera patients, which we shall more
minutely describe. I have found the greatest amounts of transuda-
tion in the intestines, in cases of so-called cholera sicca. The mucous
membrane of the small intestine is finely injected, especially near the
valve, and growing less so as we pass upward. The vascularity is
occasionally accompanied by greater or less escape of blood into the
tissue, and on the free surface of the mucous membrane. Then the
mucous coat shows numerous, often extensive, ecchymoses, and the con-
tents of the intestines appear reddened from the admixture of blood.
Sometimes the small intestine is pale, and neither vascularity nor ecchy-
moses can be found ; but since we find the intestines filled with watery
transudations even in such cases, and as these transudations come from
distended, not from empty vessels, it follows that the pale hue of the
mucous membrane is to be regarded as a post-mortem appearance. It
is a matter of daily experience for visible mucous membranes that have
been very hypereemic, and secreted abundantly during life, to become
pale after death. The mucous membrane and whole intestinal wall are
swollen and relaxed from opdematous infiltration. As a rule, also, the

CHOLERA ASIATICA. 705

solitary and Peyer's glands are swollen and distended* The individual
follicles may attain the size of a hemp-seed. In consequence of this
swelling of the intestinal glands, the inner surface of the bowel looks
as if sprinkled with isolated and conglomerated granulations. Occa-
sionally certain follicles of the patches burst, and then the surface has
a sieve or net like appearance (plaques d surface reticulee). The most
important appearance in the intestine is the great loss of epithelium
The intestinal villi are stripped of their protecting envelope ; occa
sionally, at certain spots, the epithelial covering is only elevated by a
serous effusion, and is still loosely adherent to the villi ; but in most
places it is already detached, and lies on the intestinal wall as shreds
of mucus, or forms the whitish flocculi already spoken of as floating in
the transudation. The comparison of the intestine in cholera to a por-
tion of the skin from which the epidermis has been removed by a blis-
ter, or by boiling water, is very correct; and, if it be remembered thai
the denuded portion of intestine is quite extensive, it will be difficuli
to understand why some observers speak of a " disproportion " be-
tween the anatomical changes in the intestinal canal and the severe
symptoms observed during life. The large intestine does not show
any constant changes, and there is but little alteration in the jejunum,
The gastric mucous membrane is more or less reddened by hyperaemia
and ecchymosis ; its tissue is swollen and relaxed from serous infiltra-
tion. The liver is of normal consistence and pale ; on being incised,
only a small amount of thick, huckleberry-colored blood flows out
slowly from the large vessels. The gall-bladder is almost always dis-
tended with thin, brownish or greenish bile. The spleen has no con-
stant change. In the first stages of cholera the kidneys are appar-
ently normal, except an excessive venous hyperaemia ; in other cases,
even at this time, certain places, especially in the pyramids, are whit-
ish ; and at these points, on microscopical examination, we find the
uriniferous tubules filled with cloudy, swollen epithelium and fibrous
exudation. The mucous membrane of the urinary passages is covered
with mucous and epithelial masses, the bladder is contracted, and
almost always entirely empty. Hence we see, when death occurs at
the height of the disease, the characteristic changes consist chiefly in
extensive catarrh of the intestines, accompanied by detachment of the
epithelium and copious transudation, in decided thickening of the
blood and excessive venous hyperwmiq of the Jcidney.

When death occurs during the stage of reaction, or so-called cholera
typhoid, the anatomical appearances differ in some respects from the
above. Then the limbs are less constantly contracted, rigor mortis is
less marked ; the teeth and gums are often covered with a dirty coat-
ing, the cyanosis has disappeared or is slight. The subcutaneous con-

700 ACUTE INFECTIOUS DISEASES.

nective tissue and muscles are moister ; the blood is more fluid and
less dark. The cerebral membranes are usually injected ; not unfre-
quently there is a considerable amount of fluid in the meshes of
the pia mater and in the lateral ventricles ; the cerebral substance
itself is moister ; the right heart is usually overfilled, the endo-
cardium and lining membrane of the large vessels is greatly infil-
trated In this stage the lungs are no longer dry, but are vascular,
and are often the seat of extensive oedema and hypostasis, and not
unfrequently also of lobular or lobar pneumonia, or of hsemorrhagic
infarctions. The outer surface of the small intestine has lost its rosy
tint ; the contents are colored with bile. In some cases the epithelium
is replaced, and no disturbances of nutrition are discoverable in the
mucous membrane ; but it is often the seat of a typical diphtheritic
inflammation, which changes more or less extensive patches of the
mucous membrane into brown, dry sloughs. This secondary diphthe-
ritis occurs not only in the small intestine, but often extends to the
large intestine ; it may also attack the gall-bladder, vulva, and vagina.
The liver and spleen are not always changed, but are usually very
hyperaemic. Not unfrequently rupture of the spleen has been found.
The kidneys also are vascular, and often show the signs of acute
croupous inflammation. The bladder contains more or less urine,
which is usually albuminous.

SYMPTOMS AND COURSE. — Almost every one exposed to cholera
poison complains of light oppression in the praecordium, rumbling in
the bowels, and a feeling of impending diarrhoea. These symptoms of
slight indigestion, which unmistakably result from the action of the
poison, apparently only increase where the infection is rather intense,
or the organism inclined to a more or less severe disease. It has also
been attempted to refer the feelings of terror, the fainting-fits, cramps
in the legs, and other disturbances of innervation occurring during a
nholera epidemic, to the action of cholera poison ; and among the laity
the idea has become so firmly implanted, that the fear of cholera is
very dangerous, or is even the commencement of the disease, that
during a cholera season there are plenty of persons who dread having a
fear of the cholera (!). I regard this belief as groundless, and think that
the above symptoms are solely the result of the psychical impressions
induced in excitable persons, by the terrible disease, the accounts of
sickness, the numerous and unexpected cases of death. The same, or
very similar symptoms are experienced by the inhabitants of a bom-
barded town ; and, although timid persons show no immunity to chol-
era, they are not more frequently attacked than unterrified persons
are. According to my observation, cholera attacks never begin with
a feeling of terror, fainting, cramps in the legs, etc., although it often

CHOLERA ASIATICA, 707

happens that these symptoms urge the patient to seek medical aid.
If we examine such cases carefully, we always find that they have
been preceded by diarrhoea, to which the patient paid no attention.

Some observers estimate the period of incubation at from one to
three days ; others say from eight to fourteen. We rarely have the
opportunity of exactly determining the time between the action of
the poison and the outbreak of the disease. In a few cases that I
observed in Greifswald, in 1859, as well as in a number observed by
Dr. GrUttner^ then assistant physician in the Medical Polyclinic, in a
small town on the Mecklenburg boundary, where the limits of the in-
fection could be pretty accurately determined, the period of incubation
was certainly not less than thirty-six hours, and not more than three
days.

The mildest form of cholera is a simple diarrhoea, which is not ac-
companied by colicky pains or tenesmus, and causes no constitutional
or other disturbance, except a moderate degree of depression and re-
laxation. The evacuations follow each other more or less closely;
they are very copious and watery, but have neither lost their odor nor
color. These cases do not appear on the official lists as cholera ; but,
although the police do not consider them as such, science should do so.
This is shown : 1. By the large number of cases of diarrhoea occurring
in cholera times, although almost all sensible people carefully avoid
errors of diet, catching cold, and other sources of injury. 2. The great
obstinacy of these diarrhoeas, and the slight efficacy of opium against
them. 3. The well-known transportation of cholera by persons suffer-
ing from these diarrhoeas. 4. But especially the numerous transfor-
mations of simple " cholera-diarrhoea " into the severest forms of the
disease. Many patients, especially of the poorer classes, worried by
a diarrhoea that would not give way to domestic remedies, go to the
doctor's house for a prescription at noon, and in the evening lie cold,
pulseless, and cyanotic, in an almost hopeless state. The investiga-
tions concerning cholera, made during the late epidemic, especially in
the hospitals, which are otherwise very serviceable and valuable, have
made some believers in the false views concerning the significance of
the intestinal affection in cholera, which I combated twenty years ago
It has again been forgotten that very many cholera patients, who do
not seek admission into hospital, have no symptoms but the profuse
diarrhoea. I consider it much more important to determine the fre-
quent occurrence of a gradual transformation from simple cholera diar-
rhoea to cholerine, and to malignant cholera, and to prove the iden-
tity of these three forms, than to seek for pathognomonic signs of epi-
lemic cholera.

The transformation from the mildest forms of cholera to the severest

ACUTE INFECTIOUS DISEASES.

is formed by those cases where violent vomiting accompanies the diar-
rhoea, where the discharges acquire the well-known "rice-water" ap-
pearance, but without the occurrence of the paresis of the heart and
thickening of the blood, which constitute the terrible symptoms of
cholera asphyxia. This still mild form, or, rather, these comparatively
low grades of the disease, which, however, often increase to the highest
grades, have been distinguished from cholera diarrhoea on the one hand,
and from cholera asphyxia on the other, by the names " erethitic chol-
era," or "cholerine." The discoloration of the dejections depends
chiefly, or entirely, on their excessive dilution by the quantities of
fluid transuded into the intestine ; hence the more copious the pas-
sages, and the more rapidly they succeed each other, the more com-
pletely and speedily they lose their brown color and fecal odor. Oc-
casionally all the contents of the intestine are passed at the first evac-
uation. In such cases, even after the second movement, the dejections
consist of an almost colorless and odorless fluid, holding in suspension
more or less white flocculi. We must not conclude, from the lack
of color in the passages, that the formation or excretion of bile has
ceased ; for even if the bile be produced in normal amount, and poured
into the intestines, it can have no great effect on the color of the large
quantity of liquid. Chemical and microscopical examinations of chol-
era stools have shown that the serum, transuded from the intestinal
capillaries, contains little albumen, but plenty of salts, especially of
chloride of sodium, and that the white flocculi floating in the serum
rarely consist of perfect cylindrical epithelium, but generally of its re-
mains, in the shape of fine, loose nuclei, with coarse and fine granular
masses embedded in a mucous basement substance, and of round, nu-
cleated, coarse, or finely-granulated cells (Uruberger). Cholera-stools
occasionally contain crystals of triple phosphate, remains of food, para-
sites, vibriones, and fungi. Lastly, the dejections sometimes contain
blood-corpuscles ; then the fluid is somewhat richer in albumen, which
has escaped from the capillaries along with the blood. These charac-
teristics of cholera-stools, which all authors consider pathognomonic,
fully explain the symptoms of cholera. We are justified in comparing
the effects induced in the bowels by cholera poison, with those pro-
duced on the skin by a blister. In both cases the protective covering
is removed, and there is an excessive transudation from the capillaries.
It only depends on the intensity, and particularly on the extent, of the
process, whether symptoms of paralysis of the heart develop, and
whether the loss of water from the blood shall prove dangerous. Cases
where the heart's action is but little weakened, and where the loss oi
water from the blood is to some extent replaced, correspond to chole-
rine. When the characteristic cholera stools begin, the thirst alreadv

CHOLERA ASIATICA. 709

caused by the simple cholera diarrhoea is decidedly increased. This
torturing symptom hardly requires explanation, as it always follows
loss of water from the blood, whether induced in fevers by the increase
of insensible perspiration, by sweating, or by increased excretion of
urine. In cholerine the loss of water from the blood is greater, and
consequently the thirst is more intense than in cholera diarrhoea. The
characteristic evacuations, severe thirst, weariness, and depression, are
usually accompanied by a very annoying symptom, which it is difficult
to explain ; there are occasional spasmodic contractions of certain mus-
cles, especially of the calves of the legs, which last from half a minute
to a minute, and are very painful. These cramps are not pathognomo-
nic of Asiatic cholera, however, for they also occur in severe attacks
of cholera morbus. In favorable cases, the discharges gradually be-
come less frequent and copious ; the bile poured into the intestines
again suffices to color the passages. Finally, the diarrhoea ceases, and
the patient begins to recover ; but convalescence is always slow. In
other cases the disease relapses after it appeared to be doing well, and
then becomes dangerous. Lastly, in still other cases there is no im-
provement, the cholerine changes to cholera asphyxia.

Cholera asphyxia depends on the highest development of the intes-
tinal affection. At least all its characteristic symptoms may be directly
referred to the severe and extensive disease of the intestinal mucous
membrane and to the copious exudations from the intestinal capil-
laries. The accounts of persons dying during cholera epidemics with
the symptoms of pulselessness, cold skin, cyanosis, etc., who had had
neither diarrhoea nor vomiting, and in whose intestines no characteristic
changes were found, have become more rare in late epidemics ; so that
at present almost all experienced physicians deny the occurrence of
" cholera sicca," which was generally considered as proved in the firs4
cholera epidemics. But the case is different in regard to the views
about the dependence of the other symptoms of asphyctic cholera on
the intestinal disease. Many physicians, who consider the latter as
constant, do not refer the other symptoms of cholera to it, but think
that the intestinal disease in Asiatic cholera has no more effect on the
general appearance of the disease than the bowel lesion in abdominal
typhus has on the symptoms of that affection. We shall again refer
to the erroneousness of this view. In many cases asphyctic cholera
develops from a cholera diarrhoea or a cholerine that has existed for
several days ; but, fully as often, the symptoms to which this form owes
its name come on a few hours after the first cholera passage. By this
all the contents of the intestines seem to be evacuated ; the patients
are astonished that the vessel which they used is nearly filled, but do
not suspect that they are in great danger and neglect to seek aid for

710 ACUTE INFECTIOUS DISEASES.

the simple and painless diarrhoea, while previously they have perhaps
worried the physician about every insignificant colicky pain. The first
passage is soon followed by a second, this by a third, and so on till a
great number have occurred at short intervals. The evacuations are
very copious and fluid, and, as they lose their fecal odor and become
colorless, they soon acquire the rice-water appearance. Even after the
second or third passage, many patients feel very weak and depressed,
or they may be so faint as to be unable to move from the close-stool to
the bed without assistance ; at this time, also, painful contractions of
the muscles of the leg usually begin, and a longing for drink, which
increases with every passage. The more the patients drink, the sooner
the diarrhoea is accompanied by vomiting, by which at first merely the
contents of the stomach, but, after a time, large quantities of a pale,
yellow liquid, are evacuated. The patient rapidly grows weak, the
voice loses its power (vox cholerica), the evacuations are passed in-
voluntarily, the secretion of urine ceases, the painful muscular cramps
increase and return more frequently ; the torturing thirst cannot be
allayed, and these symptoms are accompanied by a feeling of great
anxiety and oppression, which, together with the cramps in the legs,
forms the most painful symptom of cholera. Meantime the appearance
of the patient has become frightful ; the eyes are sunken, the nose
pointed, the cheeks hollow (facies cholerica) ; the skin of the hands is
wrinkled like that of a washerwoman who has washed all day ; if it be
picked up in a fold, the fold remains for a time and disappears slowly.
The lips, extremities, and genitals, grow blue ; the whole surface some-
times assumes a bluish or grayish look. The radial pulse, which be-
comes smaller after the first passages, frequently cannot be felt an hour
after the commencement of the cholera attack. Finally the pulse dis-
appears from the carotids also, the impulse and sounds of the heart
become indistinct, and, while the circulation grows more imperfect,
while less warm blood reaches the periphery, the temperature becomes
corpse-like, particularly at the uncovered parts (stadium algidum).
Rarely the patients complain of headache, more frequently of black
spots before the eyes, noises in the ears, or dizziness. The mind is
not cloudy, but most patients are apathetic ; while they complain of
pain and oppression they are indifferent to the danger, and answer in-
attentively and slowly. Reflex excitability is diminished ; in severe
cases even irritating vapors induce neither coughing nor sneezing ; the
patients do not wink if the finger be approached to the conjunctiva,
and do not wince if we dash water on them. It cannot be wondered
at, that in the first cholera epidemics even those physicians who re-
garded rice-water passages as pathognomonic of cholera, who ordered
careful anti-diarrhceic regimen for their patients, and treated every diar-

CHOLERA ASIATICA.

rhoea energetically, should not have gone a step further, and recognized
the intestinal lesion as the starting-point of the other symptoms and
as the true source of danger. The rapidity with which the patients
changed, the great disturbance of all the functions, the pulselessness,
coldness, suppression of urine, vox cholerica, facies cholerica, lack of
contractility in the skin, and the fact that many patients were received
into the hospital in this state, who had no diarrhoea or vomiting after
their reception, and who did not always tell that they had previously
had violent evacuations, led to untenable hypotheses. It is true it was
acknowledged that cholera poison led to an affection of the intestinal
canal ; but at the same time it was accused of having a directly per-
nicious effect on the blood, nervous system, and more or less on all the
organs and tissues, the intestinal canal escaping altogether sometimes.
Cases where the algid stage develops in a few hours are certainly less
suited to explain the dependence of all the symptoms on the intestinal
affection than are those where it develops in the course of several days.
From the identity of the symptoms that finally result, however, we
cannot doubt that the rapid cases are to be explained in the same
way as the others. The immediate result of acute intestinal catarrh,
of the excessive transudation from the intestinal capillaries, and of the
diminished absorption of the fluid drank, is a thickening of the blood,
its sudden impoverishment in water and salts. As long as the disease
is moderate, it has no particular effect on the circulation and distribu-
tion of blood through the body ; only the thirst is increased and the
secretion of urine diminished. But, as a burn of the second order is
free from danger as long as it affects only a limited portion of the sur-
face, while it becomes very dangerous if widely extended, and as we
dare not deprive the entire surface of its epidermis by blisters, so an
extensive and intense choleraic affection of the intestines induces the
severe and threatening symptoms that characterize the algid stage.
The heart's action is palsied, the blood, deprived of its water, eagerly
takes the fluid from the interstices of all the tissues. Hence the tis-
sues all become dry and diminished in size ; the nose becomes pointed,
the cheeks hollow, the eyes sink into the orbit, the skin of the fingers
shrivels, and, when pinched up, stands in folds. Even pathological
collections of fluid, which had previously resisted all treatment, effu-
sions in the pleura, joints, etc., are absorbed. Moist eruptions and
ulcers acquire a parchment-like surface. In spite of the patient's
drinking constantly, the loss of fluid so far exceeds the supply that
he may lose one-fifth of his weight in a few hours. The thicken-
ing of the blood explains the drying up of all the secretions of the
saliva, tears, sweat and urine, just as well as it does the absorption of
the interstitial fluids ; the blcod actually does not contain the material
95

710 ACUTE INFECTIOUS DISEASES.

for these secretions. In the suppression of urine, however, the stag-
nation of the circulation also plays an important part. The feebleness
of the heart's action, which causes the weakness and indistinctness of
the impulse and tones of the heart, the diminution and disappearance
3f the pulse in the radial arteries, and even in the carotids, appear to
depend chiefly on the depressing influence that severe acute disease,
especially of the abdominal organs, has on the organic nervous system,
and particularly on the nerves of the heart. Immediately after the
perforation of an ulcer of the stomach I have often seen loss of pulsej
cyanosis and coldness of the extremities, and in one case, already men-
tioned, perforation of the duodenum, was diagnosed as cholera sicca.
Such cases, where there could not be the slightest suspicion of an in-
fection, show that the hypothesis that the cholera-poison poisons the
sympathetic, is untenable. On the other hand, it is not improbable
that the stagnation of blood in the capillaries of the heart's substance
has something to do with the paralysis of that organ. We know that
blood can only pass freely through the capillaries when the blood-cor-
puscles are separated from each other by a sufficient amount of inter-
cellular fluid. Hence a loss of water from the blood, such as occurs in
cholera, must hinder or even arrest the circulation in the capillaries ;
and, if the blood in the capillaries of the heart stagnate, according to
all physiological and pathological experience, paresis of the heart is
the inevitable result. The cyanosis that occurs in the algid stage of
cholera depends on the same cause as that occurring in other diseases,
on an abnormal distribution of the blood — the arteries, which receive
no blood from the heart, contract and press their contents into the
capillaries and veins ; but the collection of the blood in these vessels
causes very great cyanosis in cholera, because the blood is so concen-
trated, and hence is relatively rich in colored corpuscles, and because,
from the retardation of the circulation, it has become so venous in
character, and consequently very dark. If an attempt be made to
bleed in the algid stage, as was often done in the first epidemics, a
thick, dark stream springs from the swollen vein, but no more blood
follows the first spirt, the stream soon ceases, and then it is difficult to
bring out even a few drops by pressure and rubbing. As the circula-
tion is reestablished, the cyanosis rapidly disappears, although the
blood still remains of a dark, huckleberry color. As early as 1848, in
my pamphlet, "Die Symptomatische Behandlung der Cholera," I
showed that the cyanosis and asphyxia did not depend exclusively on
the thickening of the blood, but was mostly due to the paralyzing
influence of the extensive intestinal disease on the sympathetic nerve.
The correctness of this view is supported by the frequently rapid dis-
appearance of the cyanosis, etc., by its ceasing before the thickening

CHOLERA ASIATICA.

of the blood could possibly be remedied by the absorption of liquid.
The stagnation of blood in the capillaries of the lungs, induced by the
paralysis of the heart and thickening of the blood, explains one symp-
tom, for which I could give no explanation in 1848, that is, the feeling
of anxiety and oppression, which is rarely absent in the algid stage.
The change of the blood in the pulmonary capillaries is just as neces-
sary for the respiratory act as the change of air in the air-cells ; and
stagnation of the circulation induces the feeling of want of air and
oppression, just as is done by obstructions in the bronchi and alveoli,
which impede the entrance and exit of air. The very slight amount
of carbonic acid in the air expired by cholera patients shows that, in
spite of the extensive movements of the chest and the unimpeded en-
trance of air to the air-cells, respiration is imperfectly performed.
Lastly, the complete arrest of the secretion of urine in the algid stage,
and its diminution even in cholerine and cholera diarrhoea, are easily
explained. We know that the amount of urine secreted depends chiefly
on the amount of lateral pressure in the glomeruli of the Malpighian
capsule ; we have already explained, that in heart and lung diseases,
which induce imperfect filling of the heart and arteries, the secretion
of urine is diminished ; hence it is not strange that the urine should
be suppressed in the algid stage of cholera, where the heart's action is
reduced to a minimum, and the pulse cannot be felt even in the large
arteries. The low temperature of the periphery of the body appears
partly due to the diminished production of warmth, partly to the
diminished supply of warm blood to the skin (from the weakened ac-
tion of the heart).

Cholera asphyxia runs a very acute course. Many patients die in
six, twelve, or twenty-four hours. The algid stage rarely lasts longer
than two days. The evacuations often cease some time before death,
and we must be careful about regarding this as a favorable sign, as it
is not due to cessation of the transudation, but to paralysis of the in-
testinal muscles. On the contrary, patients in whom the evacuations
continue for a long time recover more frequently than those in whom
they cease suddenly. It would be wrong to decide from this fact that
an excessive and long-continued transudation into the intestine had a
favorable influence on the course of the disease, or was at least unim-
portant. It would be much more correct to interpret the fact thus :
In cholera, the occurrence of paralysis of the intestines is one of the
most unfavorable symptoms, and the continuance of the evacuations
shows that the intestines are not yet paralyzed, and so justifies a more
favorable prognosis. The death of the patient is a gradual " going
out ; " the rattling in the throat especially, which takes place shortly
before death in most diseases, is absent. In favorable cases the pas-

ACUTE INFECTIOUS DISEASES.

gages become fewer and less copious, and the liquids taken into the
stomach are no longer vomited. The first signs of improvement, which
always introduce the change in the disease, are soon followed by symp-
toms which show that part of the liquid taken is absorbed, and that
the blood is consequently thinned. The capillary circulation is re-
stored, the pulse returns to the carotids, then to the radial arteries ;
the cyanosis disappears ; the skin resumes its color, and the face loses
its distorted appearance ; the disease passes from the algid stage to
that of reaction. Occasionally, this stage offers no peculiarities, and
forms the beginning of convalescence ; then, when the asphyctic symp-
toms have ceased, there are a few more copious passages, with dis-
tinctly fecal odor. Even on the second or third day there are pulpy
or formed stools, or else constipation. Every thing indicates that the
lost epithelium has been regenerated. We may compare these cases
to those where a superficial dermatitis from a blister has been entirely
removed in a few days by regeneration of the epidermis. When the
stage of reaction forms the commencement of convalescence, even the
stagnation in the capillaries during the algid stage has not led to any
considerable disturbance of nutrition in any organ ; only there is ex-
ceptionally albumen in the first urine evacuated, on account of the
stagnation in the veins that precedes the ree*stablishment of the nor-
mal circulation. In other cases, where the damage to the intestine is
less quickly and completely repaired, the violent evacuations cease dur-
ing the stage of reaction, but a moderate diarrhoea, with fluid, badly-
smelling greenish stools, continues ; the pulse remains small ; the tem-
perature of the extremities low, and the patients are in great danger
of dying from exhaustion on an exacerbation of the intestinal disease.
But there is not generally a return of the algid stage with disappear-
ance of the pulse, cyanosis and coldness of the body ; the incomplete
reaction is more apt to pass into the so-called typhoid stage of cholera,
but not unfrequently it ends in protracted convalescence, after the
diarrhoea has ceased. Sometimes after the algid stage the pulse not
only returns, but becomes unusually full and strong, the previously
sunken temperature rises above the normal height, the cheeks turn
dark red, the eyes are injected, and the signs of fluxionary hypersenw
to the brain and other organs appear. These violent reactive symp
toms are difficult to interpret. They most probably depend, at least
partly, on the abnormal quality of the blood, and the consequent im-
pediment to the capillary circulation. The symptoms of violent reac-
tion also pass imperceptibly into those of the typhoid stage, or into
convalescence. The opinion, which I advanced from my observations
of the first cholera epidemics, that the temperature was only dimin-
ished at the periphery while it was elevated within the body, has been

CHOLERA ASIATICA. 715

proved to be correct on the whole. From numerous careful observa-
tions of the temperature in cholera patients, Jilterbogk arrived at the
following results : 1. In the algid stage, the head, extremities, etc., are
colder than in almost any other disease. 2. In the algid stage, the
temperature of the cavities of the body, such as the vagina and rectum,
is the highest (that can be measured) in the body, and it should always
be taken for measurements. 3. In the algid stage, whether the case
be favorable or fatal, the temperature within the body is usually in-
creased, more rarely normal, most rarely diminished, although no cause
for this has ever been found in the pathological symptoms during life,
or on autopsy. 4. In the algid stage, the temperature of the whole
body usually rises with the approach of death, but does not appear to
increase afterward. But there are cases where this rise does not take
place without our being able to find any reason for this deviation. 5.
The commencement of reaction is not accompanied by any elevation of
temperature, but the interior of the body usually cools off, while the
outer parts warm up. 6. In cases of protracted reaction, the tempera-
ture of the whole body generally sinks below the normal. 7. The in-
flammatory sequelae generally, if not always, cause a decided eleva-
tion of temperature. 8. During perfect convalescence, an abnormal
elevation of temperature is often seen, without any pathological cause
for it being discoverable.

The general name of "cholera typhoid" has been given to the
secondary symptoms that often follow the proper cholera attack.
From the fact that these sequelae follow cholera asphyxia almost
exclusively, never simple cholera diarrhoea, rarely cholerine, and do not
constantly follow the first form of the disease, we may conclude that
they do not directly depend on infection with cholera poison, but are
based on the pathological processes during an attack of cholera, par-
ticularly of the severest form. As we have already seen, the same
state of affairs occurs in typhus, where also the proper symptoms of
poisoning are often, but not always, followed by secondary affections
due to the typhus. It may be readily seen that the stagnation of the
thickened blood in the capillaries, and the consequent interruption of
nutrition, if they last for several hours, a day, or more, may have a
very injurious effect on the nutritive condition and functions of the
organs; and we have already mentioned a series of inflammatory
symptoms whose remains were found in the bodies of persons who
died after the termination of the actual cholera attack. This view of
the origin of the secondary diseases (the cholera typhoid) also agrees
with the fact that they most frequently occur when the algid stage
has been very marked and protracted. The fact that the secondary
inflammations remain more or less latent, and often betray them-

ACUTE INFECTIOUS DISEASES.

selves only by symptoms of excessive adynamia ("typhous symp-
toms"), is a peculiarity shown also by other inflammations when they
attack debilitated persons. We shall only call attention to the fact
that in old, decrepit persons, if physical examination be neglected, the
outward resemblance and the subjective symptoms often cause pneu-
monia to be diagnosed as catarrhal fever, nervous influenza, typhus,
etc. According to my experience, acute croupous nephritis, with the
retention of urine that it causes, by plugging up the uriniferous tubules,
is the most frequent sequel of cholera asphyxia, but is by no means
the constant cause of cholera typhoid, as is often asserted. If the se-
cretion of urine remain suppressed after the disappearance of the symp-
toms of collapse, or if the scanty urine contain quantities of albumen
and fibrinous casts for days, if vomiting recommence, and the patients
complain of severe headache, and become comatose, or have epilepti-
form convulsions, we may make a diagnosis of acute croupous nephri-
tis and so-called ursemic intoxication. In such cases the skin has oc-
casionally been found incrusted with crystallized urea. The first or
second day after the cessation of the asphyctic symptoms many pa-
tients pass a normal or even very large amount of urine ; and the albu-
men, which is at first constant in it, usually disappears after a few days,
nevertheless they fall into a state of great apathy and stupor, or mut-
tering delirium, the tongue becomes dry and crusted, the pulse fre-
quent, and often double ; the temperature is elevated ; the patients
slip down toward the foot of the bed, and the disease so exactly re-
sembles a severe typhoid, that there is no doubt the name cholera
typhoid was intended for these cases. Besides the above symptoms,
there is usually diarrhoea, with fetid evacuations mingled with shreds
of epithelium ; and, while the patients can scarcely be aroused from
their comatose state by loud cries or other irritants, they twitch the
face or recover consciousness, and complain of pain, if strong pressure
be made on the abdomen. In these cases there is diphtheritic inflam-
mation of the intestines, which often succeeds the catarrhal or proper
choleraic enteritis, and which is perhaps induced by the irritation of the
denuded intestines by their contents ; most patients who fall into this
state die of exhaustion. If, instead of diphtheritic inflammation of the
intestine, there be a similar affection of the genitals, a pneumonia,
pleurisy, or some other inflammatory sequel of cholera, the appearance
of the patient does not materially differ from the above description.
The typhoid symptoms due to the fever prevail, and the subjective
symptoms of the local disease fall into the background, or disappear
entirely. Lastly, in some cases, neither during life nor on autopsy can
we find any local disease to which to refer the exhausting fever, of
which many patients die after the cholera proper has run its course

CHOLERA ASIATICA. 717

Peculiar importance has been attached to the fact that, during the so-
called cholera typhoid, a maculated, papular, or erythematous exanthe-
ma has been observed ; and the " cholera-exanthema " has even been
compared to the " typhus-exanthema," and its occurrence regarded as
a proof of the similarity or relationship of cholera typhoid and typhus.
The exanthema is not, however, so constant a symptom of cholera ty-
phoid as to be pathognomonic, and according to my observation it oc-
curs chiefly in those cases where sinapisms have been applied repeat-
edly or continuously to the extremities during the algid stage, or where
the extremities have been rubbed energetically. The exanthema, which
chiefly affects the limbs, often extends to the trunk, hence its occur-
rence seems to me to be due to continued stagnation of the circulation,
and consequent interruption of the nutrition of the skin, and to be
favored by precedent irritation of the skin. Moreover, attention has
recently been called to the fact that the diagnostic importance of the
exanthema of typhoid fever has been overvalued, and that roseola
spots and erythema also occur in many other feverish diseases.

TREATMENT. — We shall not discuss the sanitary police regulations
by which we may hope to arrest the progress of cholera epidemics ;
and shall only call attention to the fact that, in the Mecklenburg epi-
demic of 1859, it was shown that the quarantining and locking up,
which, from the experience of previous epidemics, were declared to be
utterly useless, were found to afford full protection when energetically
and perseveringly followed out. Since a person, suffering from an ap-
parently simple and harmless diarrhoea, may carry the cholera-poison
to a previously healthy place and there induce a fatal epidemic, places
that would be protected must cut themselves off from all communica-
tion with the rest of the world. It would be very satisfactory if the
attempts to dry the soil of cities by drainage, and by improving the
erection of privies, should have the desired result of lessening the pre-
disposition of the affected places for extensive cholera epidemics. It
would also lead us too far, were we to treat fully of the police regula-
tions that physicians, in places where the cholera has appeared, must
require of the proper authorities, and here we can only make certain
suggestions. Since the privies, cess-pools, dirty gutters, etc., favor the
development of the cholera-poison, they should be energetically
cleaned and disinfected. Stools of cholera patients should never be
thrown into the common privy. One of my pupils, Dr. JKeich, while
btill a student at Greifswald, was cholera physician at Tribsees, a
small town on the Mecklenburg border, where he succeeded in urging
the police to empty all the privies and have a certain quantity of solu-
tion of sulphate of iron poured into them. Large tanks, filled with
this fluid, were placed before each house to facilitate this procedure,

ACUTE INFECTIOUS DISEASES.

which was strictly enforced on the inhabitants. But it has not been
proved, on the contrary, it is much doubted by competent authority,
whether sulphate of iron, which so well removes the unpleasant smell
from privies, also interferes with the development and increase of the
cholera germs. The epidemological section of the Berlin Academy
of Medicine recommend the disinfection of body and bed linen by
boiling in water ; for the disinfection of privies, chloride of lime (ten
parts, in solution, to one hundred of faeces) ; for bed-pans, night-stools,
etc., they recommend a mixture of two parts of permanganate of soda,
forty-five parts of sulphate of iron, and fifty-three parts of water (ten
parts to one hundred of faeces, or a wineglassful for each person) ; for the
disinfection of dwellings where cholera patients have been sick, chlo-
rine gas. Physicians should also persuade the proper authorities to
have prepared sufficiently large and properly-constructed lazarettos,
well supplied with nurses, where patients with suspicious diarrhoea may
be separated from those with well-marked cholera ; they should urge
the supply of healthy nourishment to the poor by soup and eating
houses, and that the people may be informed, by temperate and simple
publications, of the danger they run by neglecting an ordinary, pain-
less diarrhoea. Lastly, where it is possible, places should be arranged
where the inhabitants of houses that have been attacked may find
shelter.

The prophylactic rules for physicians to recommend to their own
patients, on the outbreak of a cholera epidemic, are as follows : since
there is far more danger in a city where cholera is prevalent, and still
more in a house where it has broken out, than in other places, it is
sensible for persons, who can make a long journey without great incon-
venience, to fly from the disease. Such persons should be sure — 1, to
start on their journey soon enough ; 2, to go off as far as possible ;
3, not to return till the last trace of the disease has disappeared. We
should strictly forbid those who must remain from using a strange
privy. It is remarkable that this important and certainly not super-
fluous advice is not given in the cholera regulations published by
Griesinger, Pettenkofer, and Wunderlich. If I were writing regula-
tions for the cholera, before treating of disinfection of privies, I should
urge not to rely on it, and not to visit even a carefully-disinfected
privy that is used by strangers. There are many heads of families
who would not object to buying a night-stool for themselves and
family during a cholera epidemic. We should also let our patients be
careful about their diet; i e., avoid all food that is difficult of diges-
tion, and all articles of diet and drink that tend to produce diarrhoea.
Complete and sudden change of the mode of life is not advisable, and
we should allow the moderate use of good red wine and strong beer

CHOLERA ASUTICA. 719

that is Dot too new and has not become sour. On the other hand,
all excess should be carefully shunned. The foolish assertion, that
these rules are useless, as many persons who are careful of their diet
are taken sick, while others who live carelessly escape, should be an-
swered with rational arguments, and persons who are susceptible to
reason should be shown that no one knows that he is not already in-
fected with cholera, and that the impending attack will certainly have
a very severe course, if some other injurious influence besides the
cholera-poison be acting on the intestinal canal. Lastly, the patients
should be advised to send for a physician as soon as they are attacked
by a diarrhoea, and to remain in bed till the physician comes, to drink
a few cups of hot coffee or peppermint-tea, and to take some " cholera
drops " which they should have on hand. It cannot be denied that
energetic diaphoresis occasionally averts an attack of cholera. At
least, in every cholera epidemic, we see persons that have been at-
tacked by copious diarrhoea, great debility, cramps in the legs, and
even vomiting, and who, on account of these symptoms have drunk
large quantities of hot liquids (usually coffee with rum), buried in the
bed-clothes and reeking with perspiration, while the passages, which
were often discolored and beginning to resemble rice-water discharges,
and the vomiting also, have ceased. Experience also teaches that in
such cases, if the sweating be arrested too soon, a true cholera attack
not unfrequently comes on, and that it is well not to let a cholera
patient leave his bed till he has had a formed stool. The cholera
drops, usually named after some well-known physician, that are sold
by the apothecaries during cholera epidemics, consist of laudanum,
generall/ with the addition of some ethereal tincture, which is super-
fluous and often detracts from the efficacy. Their use without medical
advice should be recommended, because opium is one of the most
efficient remedies against cholera diarrhoea, and because its success is
the more certain the more recent the case. The so-called Russian
cholera drops are particularly celebrated: IjL tinct. valer. aeth. 3ij;
vin. ipecac, 3i; tinct. opii 3j; ol. menth. pip. gtt. v. fll. S. twenty
to twenty-five drops every hour or two.

While the most careful prophylactic treatment often fails, we are
still less able to fulfil the indications from the cause or from the dis-
ease, after cholera has once broken out. In almost every epidemic,
especially toward its close, when the malignancy of the disease has
abated, arid the number of recoveries is greater than that of the deaths,
certain specifics are recommended both by physicians and quacks.
But their reputation has never lasted through the first weeks of a sub-
sequent epidemic. Radix sumbul, carbo trichloratus, and other rem-
edies recommended as panaceas in cholera, have very justly been

A.CUTE INFECTIOUS DISEASES.

thrown aside. Hence we must content ourselves with striving to nil
fil the symptomatic indications, and we shall do this the more success-
fully, the more closely we attend to and combat those symptoms on
which the others depend. The symptomatic treatment which, in the
first epidemics, consisted in attempts to elevate the fallen temperature
by vapor-baths, and by having the patient drink hot teas during the
algid stage, but not allowing them a drop of cold water, and in at-
tempting to draw blood from all cases of cholera asphyxia, was cer-
tainly incorrect. Depression of the temperature of the body is a late
occurrence in the series of symptoms induced by the cholera infection ;
warm tea, which is more readily vomited than any other drink, is not
nearly so well borne as small quantities of cold water; venesection
cannot raise the depressed action of the heart, on which the venous
congestion depends. The symptomatic treatment of cholera requires,
first of all, attention to the intestinal disease, the arrest of the acute
catarrh and extensive transudation of serum from the intestinal capil-
laries, the source of all the other symptoms and of the danger. The
second symptomatic indication is, to replace the water lost from the
blood. If we succeeded in making a cholera patient sweat while the
transudation into the intestines continued, we should injure him by
the increased abstraction of water. Lastly, the third indication, which
we must bear in mind from the first, is to combat the threatening
paralysis of the heart. We shall not discuss whether opium (the most
frequent prescription in genuine intestinal catarrh, and the last refuge
in all other diarrhoeas), besides retarding the movement of the intes-
tines, also lessens the secretion of the intestinal mucous membrane,
and the increased transudation from the intestinal capillaries ; at all
events, it owes its frequent use in cholera to its antidiarrhceic action.
Even after satisfying themselves that, in many cases, opium has had no
effect on cholera diarrhoea, most physicians seek its aid in new cases,
because they have sometimes found it of undoubted benefit even in
this affection. I fully agree with this treatment, and, before trying
other methods, I give opium for cholera diarrhoea, although not in the
form of cholera drops but in the shape of Dover's powder, or as tinc-
ture in mucilage, without the addition of any ethereal substance. If
the patient has taken a number of doses of opium (half a grain to a
grain) in the course of a few hours, and the diarrhoea has improved, it
is well to continue it hi smaller doses till a formed stool shows that the
excessive transudation into the intestines has ceased. If, on the other
hand, in spite of the repeated doses of opium, the diarrhoea continues or
grows worse, if the patient collapses visibly, if his skin grows cool, and
the dejections lose their color, I regard the continuation of opium as
aontraindicated ; while, in such cases, I have had the best results from

CHOLERA ASIATICA. 721

cold compresses frequently applied to the abdomen, and from the ad-
ministration of calomel (a grain every hour). In regard to the speedy
favorable effect of this treatment, especially of the application of cold
compresses to the abdomen, on most patients, in regard to its favor-
able influence on the entire disease, and the principles which induced
me to employ it, I refer to my brochure already mentioned, "Die
Symptomatische Behandlung der Cholera," Magdeburg, 1848, and would
only mention that, in 1854, when Pfeufer was commissioned to instruct
the Bavarian physicians in the treatment of cholera, he recommended
my method as being the most successful, according to his experi-
ence. Nitrate of silver, which has been recommended by many per-
sons, especially by Levy of Breslau, and which I have frequently em-
ployed, because, a priori, it seemed the most efficient, did not succeed
with me. The second indication, to replace the loss of water from the
blood by supplying water, is best attained by giving the patient small
portions of ice-water, or small pieces of ice to swallow at short inter-
vals. Large quantities of liquid, especially of warm drink, are usually
vomited at once. At all events, since cholera patients have been
almost universally allowed to drink cold water, they suffer less than
when, in spite of the torturing thirst, they were allowed no drink, or,
at most, warm tea. As the paralysis of the heart disappears, as the
transudation from the capillaries ceases, and the normal functions of the
stomach and intestines are restored, the circulation usually becomes
normal at once, and, without the use of any stimulant, the action of
the heart, even where reduced to a minimum, may become greater
than normal within a few hours. But this does not prove that stimu
lants are useless or unnecessary in the treatment of cholera ; in the
earlier epidemics, they were almost exclusively employed. As soon
as the pulse grows small and the patients are evidently in collapse,
stimulants should be given from time to time, to try and prevent com-
plete paralysis of the heart, until the termination of the acute disease
in the intestines. Among the stimulants, champagne that has stood
on ice is preferable to most others, especially to the ethereal oils, car-
bonate of ammonia, etc., because, along with its stimulant action on
the nervous system, it has no irritant effect on the gastric and intes-
tinal mucous membrane. In poor practice, rum or arrack, diluted with
water, is best. In some cases it is well to alternate the administra-
tion of ice and ice-water with a few cups of hot strong coffee. It is
often vomited again, but frequently not till the pulse has become fuller,
and the temperature somewhat elevated. If the evacuations upward
and downward have ceased, while the continuance of the symptoms
of collapse shows that paralysis of the intestinal muscles, and not arrest
of the transudation, has induced this change in the disease, stimulation

722

ACUTE INFECTIOUS DISEASES.

is the proper treatment, and the return of the evacuations is the best
evidence of its success. Frictions of the skin with tincture of mustard
often relieve the painful cramps in the muscles ; but I would warn
against the very common application of mustard-plasters. For, even
if they be left on a long while, the patients rarely complain of their
burning, and the attendants are so excited by the fearful appearance
of the patient that they lose their presence of mind, and forget the
sinapisms, and I have seen them left on half a day, and during conva-
lescence the patient has been troubled by obstinate and painful inflam-
mations of the skin induced by the mustard. Of course, nourishment
cannot be given to cholera patients during the actual attack ; but, even
after the attack is over and reaction has begun, we should be very
careful about the food, and in order to protect the diseased intestine
from injury, we should give nothing more irritating than diluted milk,
meat-broth, and biscuit. Nutritious and solid food should not be
allowed till pulpy and consistent stools appear. Infringement of this
rule is generally severely punished.

No general rules can be given for the treatment of the stage of re-
action, and still less for the sequelae of cholera comprised under the
name of cholera typhoid, for the treatment must be based on a careful
analysis of the symptoms in each case. The former custom of bleed-
ing for violent reaction should be discontinued. If there be evidences
of great fluxion to the brain, we should apply ice compresses to the
head and leeches behind the ears. But we must take care not to mis-
take the hydrocephaloid that often occurs in children after an attack
of cholera with hyperaemia and cedema of the brain. If the severe
symptoms of cholera typhoid depend on uraemic intoxication, we may
employ the treatment already laid down, little as is the prospect of
success. If the attack be followed by an asthenic fever with typhoid
symptoms, and the belly be puffed up and painful, and thin but colored
and badly-smelling evacuations are passed from time to time, we maj>
cover the abdomen with cataplasms, and order small doses of calomel
and opium. In the same way, when treating inflammations of the
different organs occurring after cholera, we must bear in mind the ex-
haustion of the patient.

CHAPTER XVI.

BLOODY FLUX — DYSENTERY.

ETIOLOGY. — Dysentery is an infectious disease (when treating of
diseases of the intestinal canal, in the first volume, we spoke of " ca-
tarrhal dysentery," which does not depend on infection) ; but it differs
from typhus, and other infectious diseases, in that the infection with
dysenteric poison induces perceptible pathological changes in the in-

DYSENTERY.

tcstinal canal only. The anomalies observed in other organs, and in
the blood, during dysentery, as well as the more or less severe fever
accompanying the disease, are secondary symptoms, induced by the
intestinal affection. Dysentery is thus closely allied to cholera, where
the infection also causes, first, a severe disease of the intestinal mucous
membrane, and, secondarily, as a result of this primary disease, changes
in the composition of the blood, in the circulation, and in the nutrition
of the various organs. Of course, the intestinal affection is not the
same in dysentery as in cholera, and consequently its influence on the
blood differs from that of cholera.

Dysentery poison cannot be directly observed, as an organic, living
substance, any more than the poisons inducing other infectious diseases
can, but the reasons so often repeated, especially when speaking of
typhus, induce us to refer dysentery also to an infection of the body
by a certain species of low vegetable organism, and to speak of a
"dysentery germ," as we have already spoken of a "typhus germ"
and a " cholera germ." From this point of view, we may, to some
extent, understand the facts which have been determined by thorough
observation concerning the spread of the disease. .

Dysentery results, although not exclusively, from a miasm ; or, in
other words, the dysentery germ grows, flourishes, and increases, out-
side of the human body, and persons staying near its locality are in
danger of being attacked by it. The circumstances favorable to the
increase and propagation of dysentery poison, among which a high
temperature and a certain amount of moisture are prominent, exist in
the tropical regions ; there the disease is endemic through large por-
tions of country. According to the classical work of Hirsch, in Europe
only the peninsulas, as the south of the continent, and the islands
about them, constantly offer such favorable conditions for the increase
of the dysentery germ as to cause the disease to be endemic there.
But, through almost all Europe, the conditions for the increase and
propagation of dysentery, which is endemic with us also, are occasion-
ally so favorable, especially late in the summer, that the disease be-
comes epidemic. The circumstance that dysentery is not endemic or
epidemic in all regions where high temperature and moisture con-
stantly exist, justifies the conclusion that these are not the only things
necessary for the growth of the germ, or else that it is not so widely
spread as to be found everywhere that conditions favorable to its de
velopment exist. The coincident epidemic or endemic occurrence ol
dysentery and intermittent is frequent, but not at all constant, accord-
ing to the recent observations of Hirsch. Dysentery exists where the
requirements for malaria, marshes, etc., are not present. It attacks
the open country oftener than the city.

^01 ACUTE INFECTIOUS DISEASES.

I J T

The dysentery germ appears to reproduce itself always, or un-
der favorable circumstances, in the body of the infected person, and it
would seem that the dejections of the patient contain the contagion
thus formed, or its components ; for, while it has not been proved that
one person catches dysentery from another, it is more than probable
that the disease may be communicated to healthy persons through the
dejections of dysentery patients, or by the night-stools, bed-pans, or
enema syringes that have been used by them. This causes dysentery
to resemble cholera, while it speaks against the asserted connection
between it and malaria. Why should not the same or similar influ-
ences, such as high temperature and moisture, favor the development
of various specific low organisms, just as it does the increase of differ-
ent varieties of higher plants and animals ?

Catching cold, getting wet, great fatigue, the use of unripe vege-
tables, and other injurious influences, have been advanced as causes of
dysentery, and it cannot be denied that persons exposed to these influ-
ences are more readily affected than others. Nevertheless, infection
with a specific poison is the sole cause of this disease, and the part that
the above influences play in the etiology is only to render the organ-
ism more sensitive to the action of the poison ; in other words, they
increase the predisposition to dysentery.

ANATOMICAL APPEARANCES. — The anatomical changes found in
the intestines of dysentery patients, on autopsy, are a type of diph-
theritic inflammation. The diseased portions of mucous membrane are
infiltrated with a fibrinous exudation, and, as a result of their compres-
sion by the exudation, are necrosed and changed to a slough. If the
slough be cast off, a loss of substance in the mucous membrane re-
mains. According as this loss of substance is superficial and of slight
extent, or deep and extensive, the destruction of the mucous mem-
brane is, or is not, capable of complete repair. In the former case only
can the intestine become perfectly well, while in the latter, in place
of the membrane destroyed, there is a callous cicatricial tissue, which
not unfrequently constricts the intestine.

In the mildest grades of dysentery we find the mucous membrane
of the large intestine, especially the summits of the folds projecting
inward, deeply reddened by ecchymosis and injection, and to some
extent infiltrated by a grayish-white, soft exudation, covering the epi
thelial coating. In these cases, it looks as if the diseased part were
covered by a bran-like coating ; but if we scrape off this coating with
the handle of a scalpel, there remains a superficial loss of substance,
which shows that the exudation did not lie on the mucous membrane,
but entered into it. The submucous connective tissue is infiltrated
with serum, and swollen. The serous coat appears cloudy and dull

DYSENTERY. 725

from oedema. This change occurs chiefly, and generally exo.usive,ly,
in the large intestine, and it is rare for the dysenteric affection to ex-
tend to the lower portion of the small intestine. In higher grades of
the disease, more glutinous, or more hard, membranous gray-white
layers cover large portions of the interior surface of the intestine ; they
are removed with difficulty, and only along with the mucous mem-
brane. If they are already detached, the submucous tissue lies exposed.
The whole intestinal wall appears thickened by the excessive oedema
of the submucous tissue, and of the muscular and serous coats, but cer-
tain parts, corresponding to the spots formed by the exudation, are
especially swollen, so that they form nodular prominences on the inner
surface of the intestine. When dysentery is of this high grade, the
serous coat of the intestine usually participates in the inflammation,
and is covered with a thin layer of fibrin, which unites it to the sur-
rounding parts. The diseased intestine is evidently dilated, and is
filled with epithelial masses, shreds of exudation, and with an albumi-
nous fluid mixed with more or less blood ; it usually contains no faeces.
In the highest grades of dysentery, according to Rokitansky^ " large
portions of the mucous membrane are changed to a black, rotten,
friable, charred mass, which subsequently is not unfrequently thrown
off and passed as tubular pieces ; the submucous tissue either appears
infiltrated by charred-looking blood and by a bloody serous fluid, or
else pale, and the blood in its vessels is consumed to a black, stiff,
powdery mass ; but later, as a result of the throwing off of the dead
parts by a reactive inflammation in the deeper layers, it appears infil-
trated with pus. Besides a dirty-grayish discoloration and loss of
lustre, the peritoneal coat is in some places injected by dilated capil-
laries, and covered by a brownish, discolored, ichorous exudation.
The foul-smelling intestine, containing a blackish-brown fluid, like
coffee-grounds, is either in a state of passive dilatation, or it is collapsed,
and, when the process, has lasted a long time, the muscular coat is
shrunken, pale, faded, and readily torn."

The glands of the mesocolon belonging to the diseased portion of
intestine are more or less vascular, swollen, and relaxed. The liver is
hypersemic, and in the malignant dysentery of the tropics it is not un-
frequently the seat of abscesses, which are doubtless due to the intes-
tinal veins carrying ichor or emboli from the diseased intestine to the
liver.

If death do not occur at the height of the disease, the dysenteric
process either subsides, or a slow inflammation (" chronic dysentery " )
remains, which subsequently carries off not a few of the patients. In
the former case, the edges of the loss of substance are approximated,
by the contraction of the connective tissue which forms their base, till

726

ACUTE INFECTIOUS DISEASES.

they finally come in contact, if the loss has not been too great. Then,
as in cicatrizing ulcers of the stomach, there is sometimes stiicture,
sometimes not. If, on the other hand, the opening be very large, its
edges do not come together, and we find more or less extensive patches
of the inner surface covered, not by mucous membrane, but by callous
connective tissue. According to Rokitanskifs apt description, this
tissue not unfrequently forms " fibrous bands and striae, which project
in the shape of seams into the intestine, cross each other in various
directions, and often form valvular or ring-shaped duplicatures in the
intestine, thus inducing a very peculiar stricture of the colon." If, on
the other hand, the intestinal disease takes a chronic course or tends
to recovery, the losses of substance become chronic ulcers, and those
changes occur in the intestine which we described as follicular ulcera-
tion. In the thickened, strongly pigmented, mucous membrane, the
inflamed follicles become ulcers, at first round, afterward irregular;
occasionally, also, in the thickened submucous tissue, abscesses and
fistulous passages form, and subsequently perforate the muscular coat
and induce peritonitis or abscesses about the rectum.

SYMPTOMS AND COURSE, — Occasionally, premonitory symptoms
precede the actual outbreak of the disease for several days; these
consist in an undefined constitutional disturbance and irregularity of
digestion, especially loss of appetite, thirst, slight colicky pains, and
inclination to diarrhoea. The commencement of the disease is rarely
characterized by a chill, and not often by rigors even, or other symp-
toms of fever. But in most cases dysentery begins with an apparently
innocent diarrhoea, during which the faeces passed are not suspicious-
looking, which is preceded by very moderate colicky pain, and is ac-
companied by very little, if any, of the tenesmus which afterward be-
comes so painful. But the more frequently the passages succeed each
other, the more severe and continued become the colicky pains (tor-
mina ventris) which begin some time before each evacuation, and
shortly before its occurrence attain great severity. The evacuations
are accompanied by a very torturing and painful bearing down of the
rectum, to which is often added strangury. In spite of the severe and
long-continued straining, proportionately slight, non-feculent, mucous,
gray-colored masses (dysenteria alba) or muco-bloody masses (dysen-
teria rubra), and occasionally pure blood, are evacuated. In some
cases a few hard scybala are from time to time passed with the mucous
or muco-bloody masses. Immediately after an evacuation the patient
feels relieved, and usually has pain only on hard pressure against the
abdomen, especially in the region of the colon ; but soon, often even
in a few minutes, the tormina begin again ; the patient writhes and
groans, and, when the pains have attained the highest grade, tenesmus

DYSENTERY. 72 f

recommences, and again a small quantity of dysenteric dejections of a
sickening odor is passed. Sometimes this scene is repeated twenty 01
thirty times in twenty-four hours. If at first absent, febrile symptoms
always come on in the course of the disease. Where the intestinal le-
sion is moderately intense, the fever has an erethetic or synochal char-
acter ; the pulse is moderately frequent, full, and hard. But in the high-
est grades of the disease the fever acquires an asthenic character very
early ; the pulse becomes small, and very frequent. According to the
character of the fever, dysentery has been divided into inflammatory,
adynamic, and putrid, or typhous. This classification corresponds very
nearly with the different grades that we described above. Even in
the mildest grades, and when the fever is moderate, the patients are
greatly run down by the loss of albumen, the pain, and the loss of
sleep ; they become pale ; the pulse, at first full, grows small ; there
is great mental depression ; the dulness and want of spirits are very
marked. If we filter the dejections, and add nitric acid to the filtrate,
we shall find that the albumen in it is sufficient to stiffen almost the
whole contents of the reagent-glass, even where the dejections scarcely
have a reddish tinge, and only solitary blood-corpuscles are found un-
der the microscope. This great loss of albumen also explains why, in
favorable cases — where, after four to eight days, the tormina and tenes-
mus grow less and gradually disappear, and where, often by the end
of the first, or the beginning of the second week, the masses passed
again become feculent — the convalescence is almost always slow. The
character of the blood of a convalescent from dysentery is, as Schmidt
aptly remarks, very similar to that of a person with Brightfs disease ;
and I can confirm, from my own experience, the observation that gen-
eral dropsy follows slight cases of dysentery far more frequently than
it does other diseases of equally short duration.

In the higher grades of dysentery, the evacuations succeed each
other at very short intervals, the colicky pains scarcely cease, and oc-
casionally become unbearable ; the abdomen is sensitive to even a
light pressure. The tenesmus also is more continued and severe than
in the milder forms. The dejections contain a great deal of blood, nu-
merous flocculi and shreds, and occasionally large membranous masses.
In many cases large quantities of pure blood are evacuated. At first
the pulse is more frequent and full ; later it becomes very frequent,
while its fulness usually diminishes rapidly. There are also great con-
stitutional disturbance, loss of appetite, dry tongue, deep physical and
mental depression, and frequently dulness of the mind and slight delir-
ium. If the disease runs a favorable course, the symptoms gradually
subside, the intervals between the evacuations become longer, the
dejections again grow brownish and feculent ; the epithelial and exu-
96

728 ACUTE INFECTIOUS DISEASES.

dation masses, as well as the blood, which long continues to be mixed
with them, diminish ; the pulse rises, the tongue grows moist, the mind
clearer ; but convalescence is always slow, and, in the most favorable
cases, weeks elapse before the patient can leave his bed. If the dis-
ease is to prove fatal, the pulse becomes smaller, the apathy increases,
consciousness is lost, the complaints of pain and tenesmus cease, the
evacuations are involuntary, and the patient dies, as in other rapidly-
exhausting diseases, of general paralysis. If the disease pass from the
acute to the chronic form, as is very often the case in the higher grades,
the fever disappears, and we have the symptoms of follicular ulcera-
tion of the intestines. Diarrhoea generally alternates with constipa-
tion ; occasionally normal faeces, with muco-bloody masses clinging to
them, at other times only a puriform fluid from the ulcerating mucous
membranfc, is evacuated ; the patients become very much emaciated,
and, after languishing for months, usually die of marasmus and dropsy.
If the losses of intestinal mucous membrane heal, leaving a cicatricial
stricture, the symptoms of protracted dysentery of high grade are fol-
lowed by those of stricture of the intestine. For the rest of his life
the patient suffers from habitual constipation, and the various incon-
veniences accompanying this state. On carefully inquiring into the
causes of chronic abdominal diseases, we can frequently trace them to
a dysentery that existed several years previously.

In the highest forms of dysentery, the putrid or septic forms of
authors, after the disease begins as above described, the passages as-
sume a discolored, brownish-red or blackish color, and a carrion-like
odor ; and large, black, sloughy shreds of mucous membrane are not
unfrequently mixed with them. The pulse soon becomes small and
very frequent, the extremities cool, and the body burning ; the patients
are collapsed, the countenance distorted, the tongue and gums are cov-
ered with dry sordes, and the mind is very dull. Tormina and tenes-
mus cease very early in the disease ; the discolored, thin, fetid passages
are passed involuntarily, owing to the relaxation of the sphincter, and
they excoriate the parts with which they come in contact. In such
cases, to the symptoms of adynamia are often added those of an acute
haemorrhagic diathesis, bleeding from the nose, petechia, etc. During
the first days even, the patient may die of septic dysentery ; and re-
covery is very rare in this form of the malady, which occurs chiefly in
camps, besieged towns, or under other unfavorable conditions. Dysen-
tery patients with the higher and highest forms of the affection do not
often die of peritonitis or pyaemia ; in the tropics not a few probably
die later from the hepatic abscesses which develop during the disease.

TREATMEOT. — Prophylaxis demands that the circumstances which
experience shows to favor the development and propagation of dyson-

DYSENTERY.

teiy poison be removed as much as possible ; the rules for obtaining
this end are, according to what was said above, partly the same as
those treated of in the prophylaxis of intermittent fever, partly those
of typhus and cholera. Since the dejections of dysentery patients are
very probably the bearers of the poison reproduced in the infected or-
ganism, prophylaxis further requires that the bed-pans, enema syringes,
etc., of dysentery patients should never be used for other persons, and
that the dejections should not be thrown into the common privy, but
into a separate pit, and disinfected with a solution of sulphate of iron.
Lastly, prophylaxis requires the avoidance of all those causes which
increase the tendency to dysentery by rendering the body more sus-
septible to the action of the poison. Little probability as there is of
a person acquiring dysentery by eating unripe fruit, sleeping on the
wet ground, etc., if he be not at the same time exposed to the dysen-
tery poison, it is still certain that, during an epidemic, these causes
favor the outbreak of the disease.

We cannot fulfil the causal indications, or those from the disease
in dysentery, as we know no antidote that counteracts the poison.
The attempt to arrest the disease by active treatment with bleeding,
emetics, purgatives, large doses of opium, etc., has very properly been
abandoned, and, at present, the treatment is limited to combating the
symptoms. But the symptomatic treatment of dysentery only prom-
ises good results, if we bear in mind the dependence of the diarrhoea,
tormina, tenesmus, and other symptoms, on a diphtheritic inflammation
of the intestinal mucous membrane. If we do not attend to this fact,
but give opium to arrest the diarrhoea even in cases where hard masses
of faeces are collected above the inflamed portion of intestine, we shall
render the disease worse, for impacted and decomposed faeces alone
are enough to excite a diphtheritic inflammation. In the milder grades
of dysentery it is well to begin the treatment with ' a mild laxative,
such as castor-oil or decoction of tamarinds, and to return to this rem-
edy every time that the dejections contain no faecal matter for a day or
two. The reason for this treatment has just been explained. It is
only advisable to give an emetic, of ipecac, or tartrate of antimony, in
cases where the stomach is filled with undigested substances. Even
in the mildest grades of dysentery, the patient should carefully keep
in bed, and eat nothing solid, tut live on soup diet. If he be strong
and full-blooded, mucilaginous water-soup is sufficient ; but, if he be
weak and anaemic, it is well to attend to keeping up the strength from
the first and to advise concentrated meat-broths. Most patients are
relieved by the application of warm poultices to the abdomen. If the
tormina be very severe, and be not relieved by the cataplasms, or if
the abdomen be unusually sensitive to pressure, we shall find great

730

ACUTE INFECTIOUS DISEASES.

benefit from the application of leeches to the abdomen (in adults ten
to twenty), and allowing the bites to bleed for a time under the poul-
tices. Internally we may give an emulsion, and at evening a moderate
dose of opium. This treatment is enough for many cases of mild dys-
entery ; but in others, in spite of it, the passages increase in number,
the tormina and tenesmus are more severe, and the fever augments
greatly. In such cases, as well as in the higher grades of dysentery
where local abstraction of blood is almost always indicated, the ad-
ministration of calomel with opium is the most trustworthy treatment.
It is customary to give one grain of calomel with a quarter of a grain
of opium every two hours ; and I think this treatment, especially when
combined with five to ten grains of Dover's powder at bed-time, de-
serves the preference over large doses (gr. x) of calomel, which have
also been recommended. If salivation result from the continued use
of calomel, we must stop it, and continue the opium alone, then it is
best to give the tincture in mucilage, or in a weak infusion of ipecac.
In just such cases a combination of opium and acetate of lead is highly
spoken of. But I always consider it best, besides the small doses of
opium given during the day, to give a full dose at night. If this treat-
ment also fail, we have still less to expect from the internal adminis-
tration of nitrate of silver and the vegetable astringents, especially
tannin. According to my experience, the employment of the latter
remedy in the form of enema, which is praised by many authors, is
objectionable on account of the difficulty of giving a clyster when the
tenesmus is so great, and on account of the increase of the tenesmus
caused by the most careful injection as well as by the medicament
itself. Moreover, if the remedy is to come in contact with the whole
of the diseased surface, the enema must be very large ; the contents
of a simple enema syringe do not pass much above the rectum. In
the highest grades of dysentery, treatment is almost always with-
out benefit. The great prostration of the patient, the threatening
paralysis forbid the abstraction of blood as well as the administration
of calomel and opium, and we must limit ourselves to maintaining the
strength of the patient as well as possible, and preventing general
paralysis, by the administration of tonics and stimulants. In chronic
dysentery, especially when the tenesmus has abated, enemata of solu-
tions of nitrate of silver or sulphate of zinc deserve most confidence.
If there be no collection of faeces above the seat of disease, or if the
muco-purulent and bloody masses are accompanied by the passage of
thin faecal matter, we may give astringents internally also, and in such
cases I prefer catechu ( 3 ij to § v j water and § ss gum-arabic, a table-
spoonful every two hours) to tannin and nitrate of silver, as it is
doubtful if the latter reach the intestines in a very efficient form. If

TRICHINOSIS.

stricture of the intestine remain after dysentery, it is to be treated as
previously described.

CHAPTER XVII.

TRICHINA DISEASE — TRICHINOSIS.

THERE may be some doubt in what division of special pathology
trichina disease should be considered ; whether it should be treated
of among the diseases of the stomach, as the first seat of the disease
is there, or among the diseases of the organs of motion, as the trichinae
pass from the intestinal canal into the muscles ; or among the infec-
tious diseases. In the present edition I have decided to treat of tri-
chinosis among the infectious diseases, as I here uphold the depend-
ence of the infectious diseases on the presence of a lower organism,
more strongly than I did in former editions. The origin of trichinosis
from a contagium vivum is proved. The symptoms have the greatest
resemblance to those of the infectious diseases. Even the period of
incubation is common to both. We may go still further and say that
there is far less doubt about trichinosis being an infectious disease
than about any other disease belonging to this class.

ETIOLOGY. — For more than twenty years numerous punctate, white
bodies had occasionally been seen in the muscles, on autopsy, which
the microscope showed were small cysts containing a thread-like worm,
wound up spirally. This worm, the trichina spiralis, showed no sexual
organs, and it was altogether obscure whence it came, how it reached
the muscles, and whether it was capable of further development. We
have already shown that the supposition, according to which the muscu-
lar trichina was the undeveloped state of the tricocephalus dispar, was
soon found to be erroneous. From experiments, by Virchow, Leuck-
art, and others, of feeding animals with flesh containing trichinae, it
was shown that the muscular trichinae become free in the stomach and
intestines of the animals fed, during the digestion of the meat ; in a
f 3w days they attain the length of three or four millimeters, and form
male and female perfect animals, intestinal trichinae. In the female,
which is far more numerous and about two-thirds larger than the male,
innumerable eggs develop, and from these young ones escape, living,
from the body of the mother, even in from five to eight days, atod move
freely in the intestines. The young brood of the intestinal trichinae
now soon perforate the wall of the intestine, part of them passing into
the abdominal cavity, part between the folds of the mesentery to the
spinal column, thence to the diaphragm, abdominal muscles, and fol-
lowing the intermuscular connective tissue to the other muscles of the
body. The number of these wandering trichinae is innumerable. They

ACUTE INFECTIOUS DISEASES.

are particularly numerous about the ends of the muscle, where it be-
comes tendinous, probably because their further progress is obstructed
at these points. Trichinae have a particular preference for the muscles
of the loins, diaphragm, the intercostal and cervical muscles, and foi
those of the eye and larynx. In the extremities, as a rule, " the fur-
ther from the trunk, the fewer trichinae in the muscles" (Reny). In
the human being, at least, they seem never to enter the muscles of the
heart. The wandering of trichinae induces parenchymatous and inter-
stitial myositis. The free, emigrating trichinae, which gradually attain
the length of one-third of a line, are not visible to the naked eye. At
the point where they finally become attached, the irritation they induce
leads to a development of the sarcolemma, and thus to the formation
of a capsule, which is egg or lemon-shaped. This capsule grows
thicker; calcareous salts are deposited in it, and it is the trichinae
enclosed by such calcified capsules that are visible to the naked eye.
At least two months are required for the formation of a perfect
capsule.

The etiology of the trichina disease in animals is still obscure. Of
course the solution of the question, whence come the trichinae in pork ?
is very interesting, and of great practical importance. It is probable
that they acquire them chiefly or solely by eating trichinous rats. It
is well known that pigs not unfrequently eat live and dead rats, and it
is also known that rats not only frequently have trichinae, but that they
often die of them.

In the human being the trichina disease results solely from eating
trichinous pork. The raw flesh is the most dangerous, hence the dis-
ease is proportionately more frequent and more severe in those who
have the bad habit of eating raw meat than in others. More fre-
quently than in the raw form, pork is eaten prepared in a manner that
does not kill the trichinae. Even large pieces of well-boiled or baked
pork, which do not show any red spots on being cut, and into which
we may easily pass a fork without a feeling of grating, never contain
trichinae. But they may exist in roast pork, whose external portion
only has been exposed to a temperature of 55° R. [156° F.], while
the inner part has not been heated so much, looks bloody, and
is somewhat hard and coherent. And even in small pieces of meat,
and in the various forms of sausages, if they be cooked for only a
short time, the trichinae remain alive in the parts distant from the
surface. Trichinae are found especially often after the use of so-
called fresh blood and meat sausages, of meat-balls, and similar
preparations. Long-continued salting (pickling) of pork, without the
addition of water, kills the trichinae even in large pieces ; on the othei
hand, numerous trichinae may survive in pickled meat that has oul\

TRICHINOSIS 733

remained a short time in a weak solution of salt. Smoking the meat
only kills those trichinae that are near the surface. The so-called quick
smoking, where the ham is painted with pyroligneous, acetic acid, or
creasote, and left in the smoke only a short time, or not at all, affords
the least protection. Poisoning by raw hams, chitterlings, brain pud-
ding, chopped sausage, and other slightly-smoked varieties of sausage,
is often seen. The fact that smoked trichinous flesh is repeatedly
eaten without injury, is partly because it has been carefully pickled
for a long time before smoking, and partly because the meat in ques-
tion had been kept for a long time, and completely dried, which also
kills the trichinae. Very few cases of encapsulated trichinae, and not
a single one of acute trichina poisoning, have been observed in southern
Germany ; this is because the people there dislike raw flesh, even when
pickled and smoked.

Since all persons who eat living trichinae are not equally affected,
and as the severity of the disease is not by any means always in pro-
portion to the number of trichinae probably introduced into the stom-
ach, we may speak of a greater or less predisposition to trichinosis.
But the causes on which this predisposition depends are not yet
known. We can only assert that it is connected with the condition
of the gastric and intestinal mucous membrane, or with the character
of the contents of the stomach and intestines, and that, after the use
of trichinous meat, severe diarrhoea, by which the still undigested por-
tions of flesh, with the trichinae contained in them, are evacuated, is
to be regarded as favorable. Children have a certain immunity to
trichinosis; at least children recover from trichina poisoning, from
which they certainly are not exempt, more readily than adults, per-
haps because they do not digest a part of the meat.

ANATOMICAL APPEARANCE. — On autopsy of the lower animals that
have been poisoned with trichinae, if they have died or been killed dur-
ing the first weeks, besides the numerous intestinal trichinae and young
ones that have already entered the muscles, we find in many cases the
remains of enteritis and peritonitis. On the other hand, on autopsy of
human beings who have died in the first week or two after accidental
poisoning by trichinae, we never find exudation in the intestine or peri-
tonaeum, but only the signs of a more or less intense intestinal catarrh,
and often a decided swelling of the mesenteric glands. This is doubt-
less because, on intentionally poisoning, a much larger number of
trichinae is given them than is swallowed by a person accidentally so
poisoned, consequently a much larger number of the trichinae pass
through the intestinal walls, and the lesion caused by them is far
more intense. After the fifth week, distinct signs of interstitial and
parenchymatous inflammation appear in the muscles as fine, grayish-

734: ACUTE INFECTIOUS DISEASES.

red striae. The microscopic examination of such spots shows that in
them the muscular fibrillae have broken down to a granular detritus
mass, while the interstitial connective tissue is increased by fresh pro-
liferation. The number of trichinae in the muscles is the greater, and
the parts affected more extensive, the longer the disease has lasted.
In protracted cases we find even the muscles of the extremities con-
taining quantities of trichinae. This circumstance, and the experience
that even in the seventh and eighth week we find living intestinal
trichinae, filled with eggs and embryos, render it not improbable that
the intestinal trichinae bear young not only once but repeatedly, and
that they pass into the muscles at different times. The other changes
found in the bodies of trichina patients are not pathognomonic, and cor-
respond with those found in the bodies of persons who have died of
other diseases, accompanied by high fever and rapid exhaustion. Ac-
cording to Cohnheim, even the muscles have no constant and charac-
teristic appearances, except the above-mentioned anomalies, and a cer-
tain density and toughness, but in regard to their color and moisture
vary greatly, just as they do in typhus. In many cases there are signs
of extensive bronchitis, and of hypostasis in the lungs, or pneumonic
infiltration, and sometimes thromboses in the veins. Lastly, when the
disease has lasted a long while, and the fever has been very severe, in
some bodies we find the parenchymatous degenerations of the liver,
kidneys, and heart, which we have already mentioned.

SYMPTOMS AND COURSE. — Since Zenker, in 1860, made the impor-
tant discovery that the entrance of trichinae into the human body
caused a severe and even fatal disease, a number of violent epidemics
of trichinosis have been so carefully observed and described, that the
symptomatology of the newly-discovered disease is now as well de-
termined as that of most other maladies that have been known a long
time.

Before the trichinae which have entered the stomach are set free
by the digestion of the flesh in which they are embedded, the patients
have no trouble. In some cases, which Renz calls insidious trichino-
sis, even when the trichinae have become free, when they have mated
and are rearing their young, and when the young brood perforate the
intestinal canal, there are no signs of an intestinal disease. Such pa-
tients have a good appetite, regular bowels ; they feel fatigued and
depressed, and complain of travelling pains, and a certain stiffness in
bhe limbs, it is true, but they can go out and attend to their business.
Gradually the vague pains are localized in certain muscles : these swell,
become hard and rigid ; oedema, fever, and other symptoms characteris-
tic of trichinous myositis are developed. It is most probable that, when
the disease runs this course, onlv a few trichinae have reached the stonv

TRICHINOSIS. 735

ach, or remained there, and that consequently the development of the
intestinal trichinae and their passage through the walls have only slightly
interfered with the functions of the stomach and intestines, while suc-
cessive broods and repeated emigrations of young trichinae have filled
the muscles with the parasites. It is difficult to explain the occasional
sudden change of insidious trichinosis into dangerous forms, unless it
be due to an extensive emigration of a new generation of trichinae into
the respiratory muscles.

This insidious commencement of the disease, with its total absence
of gastric disturbance, is in striking contrast with the very trouble-
some intestinal symptoms observed at the commencement of some
cases. The first cases in the famous Hederleben epidemic were re-
garded as cholera, because the patients were attacked with severe
vomiting and purging, which could not be checked. Three of them
died on the sixth day of the disease, with the symptoms of paralysis
and thickening of the blood. For the diagnosis between " trichinous
cholera " and Asiatic cholera, and cholera morbus, Kratz and Ruprecht
lay particular stress on the peculiar stretching, muscular pain, which is
located chiefly in the flexors of the extremities, and is increased both
by movement and pressure. The commencement of trichinosis with
cholera symptoms, which is not frequent, shows that an unusually
large number of living trichinae have reached the stomach, and that
consequently the gastric and intestinal walls have suffered more than
usually. This idea is supported by the fact that cholera symptoms
have hitherto been observed only in cases of poisoning with raw meat.

The absence of all intestinal symptoms, as well as severe attacks
of vomiting and purging, is only exceptionally observed after the use
of trichinous flesh. Far the greater number of patients complain in a
few hours, or not till a few days after the poisoning, when the young
brood has been hatched, of severe pressure in the stomach, of eructa-
tion and nausea, combined with a feeling of great heaviness and de-
pression. There is almost always diarrhoea, the passages being at first
brownish, subsequently yellow, thin, and accompanied by more or less
severe colicky pain. These gastric symptoms are soon accompanied by
those of the entrance of the trichinae into the muscles, vague pains, and
a feeling of stiffness, as well as a peculiar oedema of the face affecting
chiefly the eyelids, in which the conjunctiva also participates occasion-
ally, so that there is chemosis. The movements of the patient are
now sometimes very much impaired, partly because their muscles be-
come more rigid and less supple, partly because every attempt to
stretch them is very painful. The different muscles swell considerably,
become tense and as hard as caoutchouc, just as in the rigor mortis.
According to Cohnheirrfs description, in severe cases the constant and

736 ACUTE INFECTIOUS DISEASES.

characteristic position of the patient is as follows : " He lies on the
back with the shoulder and elbow-joints sharply bent, and the hands
slightly flexed ; on the other hand, the knee and hip joints are but
slightly bent, or nearly straight ; so that the patient is unable to lift
the arm, extend the forearm, sit up, or bend the knees." Cohnheim
explains this position correctly, by ascribing it to the patient's attempt
to assume a position where the different groups of muscles are the lease
extended ; with the swelling of the muscles there is cederna extending
from the arms toward the hands, from the thighs toward the feet, but
not affecting the scrotum or labia. Besides the above symptoms, from
the third to the fifth week of the disease, there are frequently attacks
of severe dyspnoea, which subside again in the sixth week ; they doubt-
less depend on trichinous disease of the respiratory muscles. Where
the disease attacks the muscles of the glottis, the voice is sometimes
lost ; sometimes affection of the masticatory muscles causes trismus ;
participation of the glossal and pharyngeal muscles induces impaired
movement of the tongue and dysphagia. Trichinosis is accompanied
by high fever, with slight morning remissions. Although this fever is
unmistakably not of zymotic origin, but depends on the extensive dis-
ease of the muscles, and is to be regarded as a symptomatic inflamma-
tory fever, it very closely resembles the fever observed in the course
of typhus and other infectious diseases, and occasionally the tempera-
ture curves can scarcely be distinguished from those of typhus. The
evening temperature sometimes reaches 106°, that of the morning re-
mains somewhat lower. The bodily temperature does not become
normal for a long time, often not till the sixth or seventh week. The
frequency of the pulse corresponds with the temperature, and in severe
cases reaches 120 to 140 beats a minute. Copious perspiration, with
a miliary eruption, is somewhat characteristic of the fever accompany-
ing trichinosis. The constitutional influence of trichinous fever, the
effect that it has on the sensorium and other functions, is just the same
as that from great elevation of the bodily temperature in other dis-
eases. The pulse becomes small and weak, the thirst painful, the
tongue dry, the patients sink into apathy, or become delirious ; occa-
sionally there are twitching and trembling of small groups of muscles,
bed-sores over the sacrum, and with these symptoms the patients may
die of exhaustion. The usual symptoms of trichinosis are more or less
modified by the occurrence of extensive bronchitis, hypostasis, or
pneumonic infiltration; but the pneumonic infiltrations alone (which
are frequent) betray their presence by subjective as well as objective
symptoms, by piercing pain in the side, cough, dyspnoea, etc. If the
disease takes a favorable course, as not unfrequently happens in severe
cases, the muscles gradually become less rigid and painful, the bodih

TRICHINOSIS. 737

temperature and the pulse lower, the perspiration less copious, the
thirst abates, appetite returns, but the exhausted patients are confined
to bed for a long time, and regain strength very slowly. Just as after
other severe diseases, oedema often occurs during convalescence, affect-
ing even the scrotum and labia.

TREATMENT. — Prophylaxis. — When the flesh of a slaughtered hog
is carefully examined microscopically, and no trichinae can be found, it
may be used, even raw, without danger. There is no doubt that, if
competent microscopists examined the flesh of all the pigs killed, new
epidemics of trichinosis might be avoided with certainty. I do not
think it would be at all difficult, either in the city or country, to find
competent persons, who could be so instructed, by microscopical courses
and popular theoretical teaching, that they could tell certainly whether
specimens of meat referred to them contained trichinae or not. My
brother, by his trichina catechism, and by practical courses, has fully
qualified a large number of the laity for the microscopical examination
of pork for trichinae. Nevertheless, in opposition to celebrated author-
ities, I must say that I regard the introduction of an obligatory micro-
scopical examination of meat as no guaranty against new epidemics
of trichinosis. I have not sufficient trust in the conscientiousness of the
persons to whom this would be intrusted, especially in the rural dis-
tricts, to believe that, after they had examined for trichinae in vain for
years, they would continue their examinations with the necessary ex-
actness. It is evident that a microscopical examination, if not carefully
conducted, might prove dangerous, because persons relying on it might
carelessly eat uncooked meat. The only certain protection against
trichina-poisoning is, to eat no pork that has not been prepared in a
way that would kill any trichinae present. Whoever wishes to eat
uncooked pork, smoked ham, sausage, etc., should previously inform
himself that the pig from which they came contained no trichinae. I
advise my students to warn their patients (even those living in places
where the flesh is examined) against the use of all dishes prepared from
pork, which we mentioned under Etiology as being dangerous.

Treatment of the Disease. — From what we have said of the tenacity
of life of muscular trichinae, there is little hope of finding a remedy by
which they may be killed without injury to the patient in whom they
exist. Friedreictts proposal, to use the very bitter nitropicrate of pot-
ash in trichinosis, has not proved serviceable ; it certainly permeates all
the tissues of the body, but the views regarding its anthelmintic action
differ. It is also doubtful whether benzine, as recommended by Mosler,
has any effect. There is far more hope that, some time, we shall find
a remedy to kill intestinal trichinae, or remove them from the bowels.
This indication exists, not only in recent cases, but must be remem-

738

ACUTE INFECTIOUS DISEASES.

bered later in the disease, since it is proved that, after weeks, liv-
ing intestinal trichinae, filled with embryos, may exist in the bowels,
and consequently it is not improbable that there may be new emi-
grations of trichinae into the muscles. The presence of diarrhoea
should not deter us from beginning the treatment with a few doses
of calomel or castor-oil, and, if necessary, repeating this treatment
occasionally, as advised by Ruprecht. It does not seem to me to
be proved that benzine, of which Hosier gives 3 j to 3 i j in gela-
tin capsules, is inefficacious against intestinal trichinae, so that we
should cease using it. The rest of the treatment is symptomatic.
For the fever, quinine is advised ; for progressive prostration, stim-
ulants ; for the subsequent anaemia, the preparations of iron. Mos-
ler proposes, as the most efficacious remedy for the painful swelling
of the muscles, the use of long-continued warm baths.

[The origin of the trichinae in swine is an interesting question.
The assertion that the disease originates in the rat is doubted, for it
is said that trichinous rats come from slaughter-houses, where they
may have fed on hogs' flesh. It is at least as probable that trichinae
are original with swine as that they are so with rats ; and they
may be propagated by pigs which eat offal of other pigs containing
intestinal trichinae and embryos, or by their eating the flesh itself,
as sometimes happens.]

ADDITIONS TO THE REVISED EDITION OF 1880.

SECTION I. ACUTE INFECTIOUS DISEASES.

1.— P. 586.

Bacteria have been found in the blood of scarlatina patients, as
in that of measles and small-pox patients ; when rabbits were inoc-
ulated with this blood, the bacteria were found in their blood. Dr.
Carpenter thinks that scarlatina is sometimes caused by decompos-
ing blood from slaughter-houses. It has been variously stated that
cases occur from defective sewerage. The sources of contagion are
so varied and often so obscure that in a large city at least it is dif-
ficult to exclude this mode of origin from any case.

Among the complications of scarlatina, acute nephritis is proba-
bly the most common. Its symptoms usually begin in the desqua-
mative stage during the third week. In this stage also comes a
rarer complication, viz., acute articular rheumatism ; this has the
same symptoms and endocardial complications as simple rheuma-

ADDITIONS TO THE REVISED EDITION OF 1880. 739

tism, but it is more apt to be accompanied by severe joint-disease
and suppuration. Besides these, there may be inflammations of
serous membranes, pleuritis, pericarditis, or meningitis, also pneu-
monia, etc.

The prognosis is less favorable than in measles ; mild epidemics
are less frequent, and even mild cases often become complicated ;
this is justly called a treacherous disease. In not a few epidemics
the mortality will reach one-third. Cases in children under five
years or in old persons, those with high fever, intense and long-con-
tinued eruption, or with any of the severe complications, are unfa-
vorable.

2.— P. 607.

Some persons are so susceptible to the poison that it acts even
when very dilute, as coming through the windows from the next
house, or by letters, paper money, etc. The nature of the poison ia
not understood. Minute spherical bodies (bacteria) have been found
in the contents of the pustule, in the skin around it, and in the in-
ternal organs ; . but it is not certain that these bacteria are the vehi-
cles of the contagion. The results of the experiments of Chauveau,
Jlur 'don- /Sanderson, and others, in removing the bacteria from vac-
cine lymph, do not agree with those of M. Wolff and Hillier.

Weigert believes that the first changes, which occur in the cells of
the rete Malpighii, are not of inflammatory nature, but are analogous
to changes caused by diphtheritis in the epithelium. The cells of
the rete are transformed into translucent flakes of irregular shape
and size, and without nuclei ; they cause an irritation, which induces
an effusion of lymph that separates the affected cells, forming small
interspaces in a sort of mesh-work made by the remains of the epi-
dermis. About these interspaces there is active cell-proliferation,
and numerous pus-corpuscles escape from the vascular loops lying
under the swollen papillae of the skin, which gradually fill the meshes
as the efflorescence ripens. In regard to the central excavation in
many pocks, it is not a constant appearance, and is said by Rind-
fleisch to occur where the pustules develop around a hair-follicle or
sweat-gland, and to be caused by the covering of the pustule being
held down by the epidermis projecting into these depressions.

On the mucous membranes variola is often accompanied by
catarrhal redness and swelling ; but where these membranes are
exposed to the air, there is a pustular eruption like that on the skin.
When patients die in the eruptive stage, the spleen is usually much
enlarged.

When delirium occurs in small-pox, it may be due to the fever,

ACUTE INFECTIOUS DISEASES.

and partly perhaps to the inflammation of the scalp causing hyper-
semia of the brain. Delirium is more apt to occur in those who
have previously been drinkers. A stage of great excitement is often
followed by one of weakness with feeble heart-action, which may
end fatally.

As the pocks dry up the parts around become pale and less swol-
len, and the patients are again recognizable ; the inflammatory pain
gives place to excessive itching, and probably many of the resulting
cicatrices may be due to scratching.

Small-pox has numerous complications, such as bronchitis, pneu-
monia, pleurisy (often with purulent effusion), diseases of the larynx,
meningitis, uterine haemorrhages, abortions, and affections of the eye
and ear.

Some observations seem to show that the protection from vacci-
nation does not begin till twelve or thirteen days after the opera-
tion ; but it should be resorted to even after exposure, in hopes it
may at least render the course of the disease milder. Inoculation,
which was formerly in vogue, usually induced very light cases, but
deaths sometimes occurred.

It is a question how long a patient convalescent from small-pox
continues to produce contagion, and how long he should be isolated.
He should be isolated till the stage of desquamation is entirely
past — say fourteen days after the disease is over.

Dr. Waters, in the London " Lancet," says if sun-light be ex-
cluded from the room, the disease is arrested at the papular or
vesicular stage, and the pain, itching, and smell are less annoying.
Constant applications of emulsion of bitter almonds seem to have
the same effect.

3.— P. 654.

If the fresh dejections of a typhoid patient spread the contagion,
persons immediately about him would be most apt to contract the
disease, but this does not seem to be the case ; so the stools proba-
bly undergo some change which render the germs in them more
active. Some authors believe that typhoid may develop spontane-
ously, others that it is always due to contagion ; the poison from
the patient reaching some place favorable to its development, and
thence again entering the human body.

Most epidemics of typhoid begin after the heat of summer, when
the soil is dried to the greatest depth ; but others occur indepen-
dently of the time of year or of the dryness. Their extent is usually
limited, perhaps to a town or one part of a city, or perhaps to a single
house, in which case it must be referred to infected drinking-water

ADDITIONS TO THE REVISED EDITION OF 1880. 74-1

or defective drainage. Typhoid is relatively rare during pregnancy,
but doubts are rising against the old view that it hardly ever occurs
in the puerperal state.

The period of incubation probably varies, but seems to average
about fourteen days.

The parenchymatous degeneration of the muscles of the heart
may result in passive dilatation ; the feeble action following the de-
generation may induce disturbances of the circulation, especially
emboli, particularly if the weakened contractions favor coagulations
in the heart, and particles from these coagula pass from the right
heart into the lungs or from the left into the aorta, and reach the
spleen, kidneys, etc., causing haemorrhagic infarctions and possibly
abscesses. Venous thrombosis, especially of the crural vein, not
unfrequently follows the impairment of circulation.

Among the nervous symptoms, besides the febrile delirium or
stupor, there may be others referrible to cerebral redema or haemor-
rhage, meningitis or embolism ; mental disturbances, which usually
recover ; paralyses of the facial, ocular, or vocal muscles, or para-
plegia. If these paralyses cannot be attributed to severe changes
in the nervous centres, they usually recover.

Besides the albuminuria, which disappears with the disease,
there are sometimes haemorrhagic infarctions or even diffuse ne-
phritis.

In severe cases of typhoid, bed-sores are not uncommon in spite
of the greatest care, and as a sequel of the disease there may be
numerous furuncles.

According to Liebermeister, from 7 P. M. to 8 A. M. is the best
time for baths ; this being the natural period for remission, if the
patient can be kept for several hours at a temperature approach-
ing normal, he may better stand a brief increase of temperature.
Another good time for the bath is about noon, at which time also
most patients show a tendency to remission.

Menstruation, which usually comes in typhoid at its regular time,
is customarily regarded as a centra-indication to baths ; but in severe
cases they may be continued, as they may with almost any of the
complications, such as diarrhoaa, meteorism, etc. Even in threaten-
ing paralysis of the heart, some stimulant may be given, and fol-
lowed by short tepid baths.

SECTION IL
CHRONIC INFECTIOUS DISEASES.

CHAPTER I.

SYPHILIS.

OP late years the study of syphilis has undergone a complete
revolution, and the new doctrines have been adopted with remarkable
readiness by almost all prominent writers upon the subject, even by
those who a few years ago were then* most zealous opponents. In
previous editions of this work I have expressed a disbelief in the an-
cient views, according to which inoculation by one and the same poison
at one time acts locally, and at another induces infection and disorder
of the entire system ; and I there declared my preference for the modern
theory, according to which there are two poisons, one of which merely
induces local disease, namely, an ulcer at the point of inoculation, ac-
companied in some instances by inflammation and suppuration of the
neighboring lymphatic glands ; while the other always gives rise to
constitutional disorder, with extensive derangement of nutrition. At
that time, however, I did not declare myself so unreservedly in favor
of the doctrine of the duplicity of the virus (or duality, to use another
common expression) as I now do.

I think that it will be to the advantage of my readers if I devote a
few lines to a brief analysis of the belief which a short time ago was
universally current, regarding the relation of the chancre, or primary
syphilitic ulcer, to constitutional syphilis, or lues venerea. It was sup-
posed that the secretion of the ulcer possessed virulent properties,
whereby, when brought in contact with an excoriated surface, or upon
penetrating through a thin coating of epidermis, it induced a specific
dermatitis, and a primary syphilitic ulcer. At this stage, it was be-
»ieved that the noxious power of the virus often became exhausted ;
and that, if we could succeed in destroying or in healing the ulcer be-
fore the infection from it could involve the constitution, the disease

THE CHANCRE. 743

would remain local ; if the attempt failed, then a series of affections of
remote parts of the body, resulting from constitutional implication, fol-
lowed the local ulcer, the secondary and tertiary syphilitic diseases.
The formation of an induration upon the base or edges of the primary
sore was considered an ominous sign, proving the almost certain infec-
tion of the system. Hence the attempt was usually made to destroy
recent non-indurated ulcers with strong caustics, while older and in-
durated sores were nearly always treated constitutionally, especially
with mercury, which was almost universally regarded as the antidote
for syphilis. Finally, the majority of syphilologists, following the teach-
ing of Ricord, supposed that syphilis could only be propagated by the
primary sore, or chancre, or, in other words, that the secretion of the
chancre was the only vehicle of contagion ; and that it was not con-
tained in the discharge of secondary affections, nor in the blood, or
secretions of syphilitic persons, a theory which was never fully credited
by practising physicians. It would take too long to relate in detail
how each of these propositions in turn first was doubted, then was re-
futed, until at last the whole theory was abandoned as false, or, at all
events, as based upon erroneous observation. We shall touch upon
some of these errors in laying down the tenets of the modern doctrine.
In the present chapter we shall treat first of the chancre, and of
the glandular chancre or acute bubo; after which we shall describe
constitutional syphilis, the first manifestation of which consists in
syphilitic induration and the primary syphilitic ulcer. To the latter
we shall not apply the term chancre, according to the usage of most
modern authors.

A.— THE CHANCEE.

As the chancre is not a constitutional disease, it might, perhaps,
have been entirely separated from the subject of syphilis, and classified
with gonorrhoea, and other affections of the genitals ; but, although
such an arrangement would be more systematic, yet, considering the
extremely frequent coexistence of the chancre with syphilitic indura-
tion, it does not seem so practical.

The chancre often is called the " soft chancre," in contradistinction
to the sore of primary syphilis, the " hard chancre." Other authors
call it the " chancroid," reserving the term chancre for the primary
syphilitic ulcer. Other syphilologues apply the epithet " virulent " to
the chancre, and call the ulcer of primary syphilis the " infectious '
ulcer. It is very desirable that authors should agree as to the names
of the two diseases, in order to allay the confusion arising from a diver-
sity of nomenclature.

ETIOLOGY. — We shall not discuss the question as to the origin of
97

CHRONIC INFECTIOUS DISEASES.

the chancrous virus, since we have no means of deciding it ; but there
is no doubt that at the present time it never develops spontaneously,
and that no one nowadays contracts a chancre who has not been in-
fected with its virus. The chancre, then, belongs to the class of purely
contagious diseases; and we are fully entitled to employ the term
chancre-contagion instead of chancre-virus.

Unlike the contagion of measles, scarlatina, and small-pox, the con-
tagion of the chancre is not volatile, nor capable of poisoning the at-
mosphere about the patient, and of infecting individuals within its
reach. It is of a fixed nature, and is only found in the secretion of the
sore, and in the contents of a chancrous bubo. The poison itself can-
not be detected in either of these vehicles, either under the microscope
or by means of chemical examination. The matter which covers the
sore, and the contents of a glandular chancre, do not differ perceptibly,
either morphologically or chemically, from the discharge of an ulcer of
any other kind, or from the pus of other suppurating glands.

The predisposing conditions for the chancre are usually more gen-
eral perhaps than those of any other disease. Neither age, sex, nor
constitution, seems capable of modifying the susceptibility to its infec-
tion. It is true that individuals in the prime of life are more often af-
fected than children or old persons ; that men suffer oftener than wo-
men, the vigorous and healthy more frequently than the feeble and
sickly; but this is simply because the former expose themselves to
contagion more than the latter, and not because they are more sus-
ceptible to its influence. Hence persons with a thin epidermis are
more liable to infection, because slighter injuries suffice to produce
solution of continuity of their skin, thereby enabling the poison to act
upor the corium. The results of syphilization, that is, the artificial
production of chancres by inoculation, seem to show that such inocula-
tions, when repeated a great many times, have the effect of extinguish-
ing the susceptibility to contagion.

By far the most common mode of transmission of the chancre is by
coitus with a person who is already diseased. Infection also some-
times results from lewd embraces, from kisses, and from the use of
water-closets, tobacco-pipes, tumblers, and similar articles, impregnated
with the chancre-virus. Physicians and midwives are sometimes in-
fected in making vaginal examinations, and conversely, women are
now and then inoculated by nurse or doctor ; but these and all other
modes of origin of the chancre, often as they are assigned by patients,
are extremely rare in comparison with that of impure intercourse.
Excoriation of the cuticle or epithelium, at the point where the poison
comes in contact with the genitals, favors transmission of the disease,
but it has not been proved that an abrasion of the surface is essential

THE CHANCRE.

to infection. On the contrary, chancres are often observed to develop
upon parts of the genitals where the most careful search immediately
after coitus had failed to detect any breach of continuity of the epider-
mis. Upon other parts of the body, too, where the epidermis is thin,
such as the lips or the nipples, infection may occur without wound of
the cuticle, while upon the hand or other region thickly covered with
cuticle, as long as there is no breach of continuity, the contact of the
poison produces no effect. The seat of the chancre, therefore, is most
generally upon the genitals, far more rarely upon the anus, between
the breasts, in the mouth, or upon the hands.

SYMPTOMS AND COURSE. — According to the concurrent belief of
all trustworthy observers, the period of incubation of the chancre-virus
is a very brief one. Hicord goes so far as to declare that it has no
incubative period, but that changes arise at the point of contact of the
poison immediately upon its implantation, although they are not com-
monly noticed at first, owing to their apparent insignificance.

Course of an Inoculated Chancre. — Upon introducing some of the
secretion of a chancre beneath the epidermis, through a puncture from a
lancet-point, no change takes place at the point of inoculation during the
first twenty-four hours. At about the thirty-sixth hour a slight redness
appears, and in forty-eight hours there is a distinct, bright-red macula.
In the course of the third day the macula rises into a flattish papule,
and upon the fourth day the epidermis is raised, forming a vesicle, sur-
rounded by a reddened areola. In the next day or two its contents
become more yellow and purulent, the vesicle transforming into a pus-
tule, which bursts between the fifth and eighth day ; or else, together
with its contents, dries up into a scab. After rupture of the pustule,
or after removal of the scab, we see an ulcer of the size of a pin's
head, or perhaps as large as a pea ; it is almost circular, and penetrates
into the corium in a manner disproportionate to its size. Its edge,
which is cedematous from inflammation, has a puckered appearance.
In the next few days, the base and edges of the sore are attacked, by
a diphtheritic process, and it begins to enlarge. As the elements of
the tissues are necrosed, and broken down into detritus, the base of
the sore assumes a grayish, dirty, lardaceous appearance. As the diph-
theritic destruction goes on irregularly at its periphery, the borders of
the ulcer acquire a gnawed, ragged form. If the point of inoculation
be destroyed by caustic within the first four days, the destructive pro-
cess may generally be cut short. After the fourth day this is scarcely
ever possible.

A chancre of accidental origin begins either by a macule or papule,
upon which, after repeated exfoliation of the cuticle, an excoriation
and loss of substance takes place, or else a vesicle or pustule forma

CHRONIC INFECTIOUS DISEASES.

first and bursts ; or, what is more common still, the chancre proceeds
from infection of a laceration, which, instead of healing immediately,
becomes covered with a dirty-looking exudation. The characteristics
of a sore arising in this way are not always so well marked as to admit
of its ready distinction from other forms of ulceration. In doubtful
cases, therefore, it is very advisable to inoculate the thigh of the patient
with some of the secretion of the sore ; two or three such punctures
should be made, and should be covered with a watch-glass attached by
adhesive plaster. As we shall hereafter learn, the inoculation of a
patient having a syphilitic ulcer with some of his own matter results
negatively. When the inoculation takes place, and the changes de-
scribed above occur, there can be no further doubt of the chancrous
nature of the ulceration. For the present, we shall merely describe
the more common forms of simple uncomplicated chancre ; then, after
giving an account of the primary syphilitic ulcers, we propose to treat
of the modifications of the chancre which arise from its complication
with syphilitic induration.

The common diphtheritic chancre is characterized by ragged and
detached edges. The loss of substance looks as if it were made by a
punch. Its most common seat in men is upon the inner surface of the
prepuce, the surface of the glans and sulcus between the prepuce and
glans, and, above all, the fraenulum ; less frequently, it is upon the outer
surface of the prepuce, or the integument of the penis. Ulcers of the
fraenulum are nearly always deep and excavated, and the fraenulum
itself is perforated. When the sore is situated in the sulcus, between
the prepuce and glans, the ulceration is apt to extend, by spontaneous
inoculation, over a large portion of the corona glandis. If it penetrate
deeply at this point, the loose subcutaneous tissue becomes infected
by the secretion, and gives rise to a virulent abscess. When seated
upon the glans, it usually penetrates more profoundly than when
upon the prepuce, although perforation down to the urethra, with the
formation of a urethral fistula, is rare. The urethral chancre is not
common. It usually begins at the mouth of the urethra, and a small
loss of substance which extends inward is visible upon its swollen and
deeply-reddened lips. At other times the urethral chancre is more
deeply situated, and only betrays its existence by the purulent flow
from the meatus and by pain in the urethra, situated at some particu-
lar point, and which is increased by pressure or by making water. If
a concealed urethral chancre be not complicated with gonorrhoea, it is
easy to recognize it, as the scantiness of the purulent flow will attract
attention, and prevent its being mistaken for a clap. Successful inocu-
lation, however, is the only means of making the diagnosis sure. It
is hardly ever detected, though, when accompanied by a gonorrhoea,

THE CHANCRE. 747

as, owing to the copiousness of the discharge, and to the absence of
other conspicuous symptoms, inoculation is almost always neglected
In women, the most frequent seat of the common chancre is the vulva
upon the posterior commissure, and at the entrance to the vagina. In
very rare instances it appears in the vagina, and even upon the vaginal
portion of the neck of the womb. When the common chancre begins
to heal, the destruction ceases, and the lardaceous appearance of the
base of the ulcer disappears ("the chancre cleans up"), granulations
appear upon the base and edges of the ulcer, which gradually fill up
the loss of substance. After the chancre has healed, there remains a
cicatrix, more or less distinctly stellated, according to the depth of the
ulcer. The period at which the process of repair commences is very
variable. Some chancres become covered with granulations, and trans-
form into simple sores, which do not secrete inoculable pus in a week
or two, while others go on extending for months, and retain all their
characteristics; that is, ragged edges, lardaceous base, and virulent
discharge.

The superficial chancre occurs most frequently upon the glans and
prepuce in men ; and between the labia and nymphae, and at the en-
trance to the vagina, and on the neck of the womb, in women ; and it
appears in both sexes with equal frequence on the skin. When situ-
ated upon the glans, an exact counterpart of the ulcer is usually found
upon the corresponding inner surface of the prepuce. The form of the
ulcer is irregular, and its surface looks as if the cuticle had been scald-
ed off. At its edge there is a white border. The destructive process
never extends deeply. When situated at the orifice of the prepuce,
cracks occur in its folds, which render retraction of the prepuce very
painful. The superficial chancre often results in phimosis and para-
phimosis. In the former instance it is almost indistinguishable from
balanitis, excepting by means of inoculation. When a superficial
chancre is situated upon the external integument, the scanty secretion
soon dries up into a thin crust, and it is not until after it has been
treated with a wet dressing that its raw, reddish-yellow surface, spar-
ingly covered with secretion, becomes visible.

The follicular chancre develops from a sebaceous gland. Its sur-
face is very small, disproportionately deep, and long retains its regular
round form.

The phagedenic chancre usually originates from the common
chancre. Its secretion is thin, ichorous, and very offensive ; its form
is irregular, its base is of a grayish-white or greenish color, consisting
of necrosed tissue and of infiltration ; its edges are livid, and sur-
rounded by coppery-red areola. It spreads rapidly, and in men it
sometimes destroys a large portion of the prepuce, glans, skin of the

CHRONIC INFECTIOUS DISEASES.

penis, and scrotum ; and in women, eats away the labia, perinaeum,
and parts about the anus. The phagedenic ulcer only appears in
broken-down, cachectic subjects, and loses its malignant character as
the constitution improves. Then the devastation ceases ; the diphthe-
ritic coating upon the base of the ulcer is cast off; healthy granulations
form, and the malignant, eating sore changes into a simple ulcer, with
a tendency to cicatrize. If the constitution of the patient does not
improve, or if it becomes still more depraved by the further exposure
to noxious influences, especially by the use of mercury, the destructive
process, which continues without stopping, finally becomes complicated
by a slow fever which consumes the patient.

The gangrenous chancre is sometimes a modification of the phage-
denic chancre, while at other times it develops from the ordinary form
of the disease ; in either case, the base of the ulcer and the parts about
it become bluish, and are afterward converted into a black, insensi-
ble moist slough. There is a dusky redness immediately around the
3schar, which is encircled by a somewhat extensive and severe oedema.
The disease may advance until it has destroyed a large portion of the
penis, or labia and perinasum, and life itself may be imperilled by the
constitutional disturbance which accompanies the gangrene. At other
times the destructive process ceases sooner; a line of demarcation
forms, the sloughs separate, and the disease recovers, leaving a more or
less extensive loss of substance behind it. We do not always know
why chancres become gangrenous. Now and then, owing to the action
of unknown causes, gangrenous chancres become of very frequent
occurrence, or, at least, are more common than usual. In many in-
stances, however, mechanical action, such as straining or tension of the
inflamed part (as, when the chancre is complicated with phimosis or
paraphimosis), chemical agents, or irritation of the sore by the putre-
faction of retained secretion, may be regarded as causes of the malady.

TREATMENT. — In proportion as the opinion has gained ground that
the chancre never leads to constitutional syphilis, the old and erroneous
practice of treating chancres by mercury has died out. The progress
of knowledge has speedily borne fruit in this instance, the importance
of which cannot be sufficiently prized. We have only to consider that,
but a few years ago, at least one-half of the physicians used to subject
all patients with chancres to a course of mercury, and thus often enough
ruined their health by means of this pernicious poison, under the mis-
taken impression that they thereby averted induration of the ulcer, and
prevented constitutional contamination. Nowadays, a physician who
treats a simple chancre with mercury makes a gross blunder. On the
other hand, I do not think it judicious to make the treatment of a sim-
ple chancre a purely local one. It will heal much more rapidly if the

THE CHANCRE. 749

patient be brought under favorable hygienic influences, and if he be de-
fended from all noxious agencies throughout the course of the disease.
If the circumstances permit, it is well to confine him to his chamber, or,
at all events, to forbid all unnecessary walking. Moreover, since the
majority of this class of patients are young and vigorous, living more
or less freely, and drinking spirituous liquors, it is generally advisable
to place them upon a rigid diet (gruel morning and evening, with broth
and a little meat at mid-day), to forbid coffee^ beer, wine, or spirits, and
now and then to give small doses of some saline cathartic (one or two
glasses of Friedrichshaller, or Pullnaer bitter water), which may be
taken in the morning, fasting. Although a chancre usually heals much
more quickly under this treatment than when a strict regulation of the
diet is neglected, it is merely because of the luxurious mode of life led
by most patients who have exposed themselves to the infection of the
chancre. The above directions are not applicable, and indeed might
do great mischief, and retard the healing of the sore, if applied hi the
case of a badly-nourished, cachectic patient. In such a case, the diet
must be nutritious and rich ; the use of wine and beer is indicated,
and often exerts a favorable effect upon the healing of the ulcer.

The local treatment of a chancre must be similar to that of any
other atonic ulcer, of which the chancre may be regarded as the proto-
type. Until after the fourth or . seventh day, it is advisable to de-
stroy the ulcer by caustics. For this purpose, it is best to make use
of the potassa fusa, the Vienna paste (quicklime, five parts ; caustic
potash, six parts), or the chloride of zinc, which makes a dry eschar
(rj& zinci chlor., butyr. antim., aa 3ij, f. c. pulv. alth. past, mollis).
After the seventh day it is not advisable to cauterize, as then the pro-
cess of healing is retarded rather than promoted thereby. As a rule,
ointments should not be used, and the sore should be dressed with
warm camomile-tea, or other mild, stimulating liquid. The most
common applications are the aromatic wine, the black-wash (calomel
3 ss ; aquae calcis § ij), the yellow-wash (hyd. chlor. corrosiv. gr. j ;
aquae calcis § ij). The blue-wash (cupri sulp. gr. j ; aquae § j), which
is almost exclusively used by Von JZarensprungr, is also highly to be
recommended. When the chancre is very painful, and when its dis-
charge is very profuse, compresses, wet with lead-water and cold sitz-
baths, are of benefit. It is generally sufficient to dress the wound
twice a day, after previously washing it or bathing the part in camo-
mile-tea. Too frequent dressing does harm. If, in spite of this treat-
ment, the floor of the ulcer retains its lardaceous aspect, it is advisable
to sprinkle the surface now and then with a thin layer of red precipi-
tate. After the sore has lost its specific character, and nevertheless is
slow in healing, it may be touched lightly with lunar caustic, or dressed

CHRONIC INFECTIOUS DISEASES.

with a wash of zinc or lead. When the fraenulum has been perforated
it is best to divide the remaining bridge of mucous membrane at once.
Where a phimosis prevents the proper treatment of the chancre, injec-
tions beneath the prepuce must be practised methodically, in order
to remove the accumulated secretion. It is sometimes necessary to
operate for phimosis ; but this is never to be done excepting in urgent
cases, as the entire wound generally becomes converted into a chancre.

In the treatment of the phagedenic chancre, the general health of
the patient must receive our first attention. His strength is to be
husbanded rather than reduced ; and a nourishing diet, and sometimes
wine, bark, and iron, are indicated. The utmost cleanliness is to be
observed. As a topical application we recommend dressings of dilute so-
lution of acetate of lead, or of chloride of lime ( § ss — f j to water § vj).

Treatment of the gangrenous chancre is to be conducted upon simi-
lar principles, paying due attention to the surgical rules for the treat-
ment of mortification.

APPENDIX.

THE GLANDULAR CHANOBE. — THE VIBULENT, ACUTE BUBO.

ETIOLOGY. — We have seen that the virus which the chancrous mat-
ter undoubtedly contains (although we are unable to isolate it or to de-
monstrate it to view) may be transferred to other parts of the body, and
that it will cause inflammation and ulceration at its point of implanta-
tion. In a similar manner the virus is very often taken up by the lym-
phatic vessels, and conducted to the neighboring lymphatic glands, in
which it also gives rise to specific inflammation and suppuration. A
lymphatic gland thus inflamed and suppurating from absorption of
the chancre-poison is called an acute, virulent bubo, or, what is better,
a glandular chancre. All chancres do not cause virulent adenitis with
equal frequency. It is most apt to accompany an ulcer of the fraenu-
lum. Neglect of cleanliness and a too irritating mode of treatment
seem to favor absorption of the virus, and the production of the viru-
lent bubo. Cases seem to occur now and then, in which the virus
reaches the corium through the epidermis without producing any lesion
at its point of entry, but is there taken up by the lymphatics, carried
by them to their glands, where it gives rise to specific inflammation and
suppuration. Such a bubo, which has not been preceded by a chancre,
is called a " bubon d'emblee."

SYMPTOMS AND COURSE. — A virulent bubo generally makes Us ap-
pearance in the second, third, or fourth week, more rarely in the fifth
ar sixth week, and it sometimes develops immediately after the forma-

THE GLANDULAR CHANCRE. 751

tion of the chancre. The first symptom of this troublesome complica-
tion consists in a feeling of pain at a circumscribed point in the groin,
not far from the genitals. Upon examination, we find a small lump,
which, already even, is sensitive to the slightest pressure, and which
corresponds to a moderately enlarged inguinal gland. The dispropor
tion between the severity of the pain and the smallness of the swell-
ing, the proximity of the latter to the genitals, the fact that one or two
only of the glands are enlarged and never a large number of them,
make us aware, even thus early, that we have to deal with an acute
virulent bubo, and not with the so-called sympathetic bubo, or with
the syphilitic glandular enlargements hereafter to be described. The
further course of the virulent bubo varies. In very rare instances the
inflammation is resolved, and the pain and swelling of the affected
gland gradually subside. In such cases it is not improbable that it is
merely the inflammation which has spread along the lymphatic vessels
to the gland, but that the chancrous virus has not been absorbed with
it, or, in other words, that the bubo is a sympathetic one. . The process
above alluded to, namely, the extension of an inflammation along the
lymphatics to the lymphatic glands is a very common occurrence also
among non-specific ulcers. Far more frequently, and probably always,
in the case of a virulent bubo, the inflamed gland suppurates. In
favorable cases the pus soon perforates the capsule of the gland and
the adherent skin which covers it. In other instances, the connective
tissue about* the gland becomes the seat of an extensive inflammatory
exudation, the tumor becomes much enlarged, and is no longer mova-
ble. It becomes very difficult for the patient to walk, and, in spite of
the efforts which he usually makes to conceal it, we can perceive that
he favors the affected side as he steps. In persons with a tendency to
fever, there is also an elevation of temperature, acceleration of the
pulse, general malaise, and other febrile symptoms. Considerable time
elapses thus, ere the skin begins to redden, and ere the circumscribed
point of fluctuation makes its appearance. If a puncture then be made
at this point, or if the skin assume a dark-red hue and grow thinner
and thinner, until the matter is discharged spontaneously, a small
portion only of the swelling subsides, and it is often as large as a
man's fist, and of an irregular, knobby form. By-and-by fluctuation,
followed by escape of matter, occurs at other points ; but, in spite of
the numerous abscesses, weeks and months often pass by without any
diminution in the size of the tumor in which they form. The course
of a virulent bubo is equally tedious and intractable, if the matter
which has escaped from the inflamed gland into the surrounding
areolar tissue have formed sinuses and fistulous tracts, as well as
when the accumulation of matter within the gland is slow to point and

752 CHRONIC INFECTIOUS DISEASES.

Joes not discharge itself until the inflammation of the surrounding tis-
sues has also resulted in numerous abscesses. After breaking of the
abscess and discharge of the matter, the resulting ulcer shows the
' properties of a chancre and discharges inoculable pus. Its edges are
ragged, bluish red, and generally somewhat undermined ; its floor is
covered with false membrane, and it is very slow to heal. A chancre
thus produced from a virulent bubo may become phagedenic or gan-
grenous, and may give rise to wide-spread destruction, which some-
times terminates in erosion 6f the femoral vessels, or in peritonitis.

TREATMENT. — It matters little whether a virulent adenitis be ac-
companied by a chancre or not ; in either case, the probability that the
inflammation of the gland will not end in suppuration is so small, that
we may spare the patient the applications usually recommended to
discuss a bubo, such as leeching, inunction of blue ointment, method-
ical bandaging, and the like. I usually cover a bubo with a simple
plaster, generally the emplastrum fuscum (emplas. galbani. co.), and
make it fast with a spica bandage. Under such treatment the bubo
now and then subsides; in other instances, it suppurates without
causing the patient much' annoyance. Should fluctuation appear at a
point which unmistakably corresponds to the gland, I immediately let
out the matter through one or more punctures ; but if the surrounding
areolar tissue be already in a state of phlegmonous inflammation, and
if fluctuation appear, which does not seem to be in a gland, but to
pioceed from a phlegmonous abscess, I am not so hasty in opening it,
but prefer to wait until the parts about the softened spot are also in
a state of suppuration, and until the hardness has disappeared under
the pressure of the pus. As soon as this occurs, and after the skin
over the point of fluctuation has become well thinned, I convert the
entire top of the abscess into an eschar, by persistent rubbing with
caustic potash. During this process (which I learned at the Hamburg
hospital) the adjacent parts must be protected from contact with the
liquefying potash. This treatment is, no doubt, painful, but has this
great advantage, that no fistulous track nor sinuses ever form, and that,
the day after the separation of the eschar, the bottom of the abscess
presents the aspect of a healthy ulcer. According to my experience,
also, this cure is much more rapid than when we have to make punc-
ture after puncture, as fresh points of fluctuation show themselves, to
lay open fistulas as they form, and to remove the undermined edges of
the ulcer.

Latterly, I have often had recourse to another mode of treating
virulent buboes, and with striking effect. I put a vesicatory upon the
tumor, cautiously open the resulting blister, and then allow a new
cuticle to form under a simole dressing. I then immediately blistei

CONSTITUTIONAL SYPHILIS. 753

again, and repeat the procedure until the infiltration about the gland,
which usually begins to resolve after the first vesication, disappears
entirely. Then, if a fluctuating point appear, I puncture it, or destroy
its covering with caustic paste. In none of the cases thus treated by
me have any sinuses or fistulae formed

£.— CONSTITUTIONAL SYPHILIS.

The question as to the origin of the syphilitic poison is quite as
obscure as is that of the origin of the chancre-virus. At the present
day, syphilis is a purely contagious disorder. Its venom reproduces
itself in the organism which it infects, and the transplantation to an-
other person, of the virus thus reproduced, is the only manner in which
syphilis can be propagated.

The exact nature of the syphilitic virus, or, as we may say with
equal propriety, the syphilitic contagion, is unknown, since we are un-
able to obtain it in an isolated form, and to test its chemical and phys-
ical properties. Like the chancre-virus, however, it is of a fixed char-
acter, and does not pervade the atmosphere around the patient ; but
its habitat is by no means confined to the secretion from the syphilitic
ulcer, and to the contents of syphilitic tumors, for it is also contained
in the blood. It does' not seem to exist in the natural secretions of
the body, such as the saliva or urine, nor in pathological exudations
produced by intercurrent disease. Thus, if we inoculate a healthy
child with pure vaccine lymph, obtained from a syphilitic subject, the
child thus vaccinated does not become * syphilitic ; but, if the lymph
contain a little blood, which is a vehicle for the syphilitic poison, the
latter will also be implanted upon the patient. It has not yet been
determined whether the virus exists in the milk of a syphilitic woman.
The frequence with which the disease is transmitted to infants, from
wet-nurses, may be due to the existence of bleeding excoriations upon
the nipples of the nurse. In the following chapter we shall treat of
its propagation during the act of generation.

Liability to syphilis is so general, that an immunity to its virus, if
it exist at all, is certainly very rare. The fact that healthy persons,
adults, and men, are more frequently infected than invalids, women, or
children, is simply because the former are more apt to be exposed to
the disease "than the latter. Like the chancre-virus, the syphilitic poi-
son is more difficult of inoculation when the cuticle is thick and resist-
ing than when it is the reverse, a circumstance which argues in favor
of the practice of circumcision. Infection is also more likely to occur
when the genitals are strongly developed than when they are small.
Eczema of the glans and prepuce, likewise, greatly increases the dan-
ger. Notwithstanding this very general susceptibility to the syphilitic

754 CHRONIC INFECTIOUS DISEASES.

virus, however, the system once contaminated by it obtains an immu-
nity almost absolute against subsequent infection. This very interest-
ing fact is analogous to the freedom from further attacks of scarlatina,
measles, and small-pox, enjoyed by persons who have once suffered
from those diseases. If we inoculate the discharge of a syphilitic sore,
or any other vehicle of syphilitic contagion, upon a person who has a
primary syphilitic induration or syphilitic ulcer, at the moment of in-
oculation, or who has already had one, we shall obtain negative results.
It is this fact which has given rise to such gross errors. For a long
time experimental inoculation was only practised upon individuals who
were already syphilitic, and, from the negative results which followed,
when blood or the secretion of secondary sores was employed, it was
inferred that blood and secondary secretions were not contagious. It
was not until it was determined to inoculate healthy, or, at least, non-
syphilitic persons with these vehicles that it was ascertained that the
want of result of the former experiment was simply due to the immunity
of syphilitic persons to further infection, and that their blood, and the
discharge from secondary syphilitic ulcers, were quite as infectious as
the secretion of a primary sore. Exceptions to this rule seemed to oc-
cur ; inoculation of the secretion of a primary sore upon the person
having the sore resulting sometimes in another sore. It is now deter-
mined that in such cases the syphilitic ulcer is complicated by the
chancre. The ulcer which follows the inoculation is a chancre, and
not a syphilitic ulcer. Contamination of the system with syphilitic
virus affords no protection against infection by the chancre, any more
than does the preexistence of one or several chancres secure the pa-
tient from further action of the chancrous virus.

Since even a person having a primary syphilitic ulcer or induration,
but who has no secondary symptoms, is already secure from further
syphilitic infection, we may regard the primary induration and ulcer as
a sign of contamination of the system, and as the first symptom of con-
stitutional syphilis. Since, however, the above-named affections stand
first in the series of disorders which occur, and as the first sign of con-
stitutional infection always appears in the form of an ulcer or indura-
tion at the point of entry of the virus, the terms " primary induration ''
and "primary sore" may be regarded as perfectly appropriate. The
immunity against fresh infection, which contamination with syphilitic
poison affords, accounts for the interesting and formerly very perplex
ing fact that infants are infected by syphilitic nurses more frequently
than by syphilitic mothers. Generally, a child sucking at the breast
of its nurse is not at first syphilitic, and, therefore, is liable to infec-
tion, while the child which sucks the breast of a syphilitic mother is
nearly always syphilitic itself, and hence can not be inoculated.

CONSTITUTIONAL SYPHILIS. 755

By far the most frequent exciting cause of syphilis is coitus with
an infected individual ; but there are many well-authenticated cases
where infection has been conveyed by the hand of a physician or mid-
wife, by using a pipe, or tumbler, or privy, polluted by the venereal
virus. There is no doubt, moreover, that the disease has often been
propagated by vaccination, and another series of cases is known to
have sprung from the use of dirty lancets, and in bleeding and cupping,
by careless surgeons.

SYMPTOMS AND COTTKSE. — L The Primary Syphilitic Indura*
tion^ and Primary Syphilitic Ulcer. — The period of incubation of the
syphilitic virus is from three to four weeks. A correct knowledge of
this fact is of recent date. Prior to this discovery, which was made
by inoculating healthy subjects with syphilitic virus, we were unable
to account for the phenomenon that, in a large number of cases, a chan-
cre (chancroid), after lasting for some weeks, would become indurated
at its base and edges ; and this it was which caused the false impres-
sion that a soft chancre could assume a pernicious character, and
change into a hard one. Experience has taught that the indurated
chancre is almost always tjbe precursor of secondary symptoms. The
following is the correct, interpretation of these facts: Both poisons,
the chancrous, as well as the syphilitic, act simultaneously upon one
and the same point ; in a few days the chancre forms ; the period of
incubation of its virus being a very short one. Three or four weeks
afterward, the time of incubation of the syphilitic contagion having ex-
pired, the syphilitic induration develops at the base and edges of the
ulcer. It 'may happen that the chancre has healed before the incuba-
tive stage of the syphilis has terminated. In such a case an indura-
tion forms in the scar of the chancre. The conversion of a syphilitic
induration into a chancre, by the implantation of chancrous virus, may
also take place.

[Some observations seem to indicate that the poison of chancre
and chancroid may be present on the same sore, giving a " mixed
ulcer ; " so that an apparently soft chancre may become indurated
and be followed by constitutional symptoms, and, on the other hand,
inoculation from an apparently hard chancre on the bearer of it may
induce a chancroid. It has, however, been asserted that inoculation
of pus of any kind in a syphilitic patient may induce an ulcer re-
sembling a chancre. Even on this point, where so many observa-
tions have been made, opinions are not undisputed ; and we may
consider that the relation of chancre and chancroid to each other,
and to syphilis, is not absolutely determined in all details.

After exposure to the disease, some time elapses before the de-
velopment of the indurated sore, then some weeks longer before the

CHRONIC INFECTIOUS DISEASES.

appearance of the other symptoms of constitutional syphilis. There
is considerable regularity in the succession of these symptoms, re-
minding us of the course of the acute exanthemata. There may
even be premonitory fever and enlargement of the spleen. The
so-called " secondary " symptoms affect the skin and mucous mem-
branes ; in the " tertiary " stage there are changes in the subcu-
taneous and submucous connective tissue, the bones, fibrous and
serous membranes, and internal organs. This division into stages is
not always accurate, as they may extend into each other ; but usu-
ally they are separated by an interval of latency more or less long.

Chancroid sometimes occurs in the anus and rectum from un-
natural coitus, or from the pus of a neighboring chancre. A care-
less physician may mistake syphilitic ulcerations of the anus for
haemorrhoids ; they may cause stricture of the rectum. If syphilitic
iritis be accompanied by much dimness of vision, this may be due
to cloudiness of the vitreous or to retinitis.

When the periosteum and bones are diseased, the joints may
become affected from the same cause ; but other joint-affections
may occur incidentally, and be called syphilitic rheumatism. Even
in these cases, iodide of potassium is very useful.

All authors do not agree that treatment of the primary sore is
useless ; but some claim that where it is recent and favorably situ-
ated (on the prepuce, etc.), it may be excised and sequelae be thus
prevented. Fournier says, in treating syphilis, he gives one or two
grains of iodide of mercury daily for two months, then discontinues
for one month ; a second treatment for two months is followed by
an interval of three months, and a third treatment for one or two
months. This treatment with increasing intervals is continued for
two years. The second year iodide of potash is combined with the
mercurial.]

After inoculation of a suitable subject with syphilitic virus, whether
accidental or intentional, that is to say, of a subject who is not syphi-
litic, and who has never been so, and after expiration of the term of in-
cubation, there arises, not a vesicle nor pustule which breaks, leaving
a sore — as occurs after infection from the chancre — but a hard papule,
or nodule of variable size and thickness. The smaller syphilitic indu-
rations are of the size of a lentil or pea, the larger attain the size of a
bean, or of a small hazel-nut. Microscopic research shows the indura-
tion to be the product of profuse proliferation of cells and nuclei, which
have no characteristic peculiarities, and which lie embedded between
the normal elements of the parts, in the scanty connective tissue. The
epidermis, or epithelium, over this hard infiltration, at first does not ex-
hibit any lesion ; but soon the epithelial covering begins to exfoliate,

CONSTITUTIONAL SYPHILIS. 757

the new coating becomes thinner, the surface shows a peculiar glitter-
ing, dirty redness, and, after repeated exfoliations, the epithelial coat
is not renewed, but the surface remains raw, and gives off a scanty
secretion. In other instances the surface forms a scab, which, after
separation, leaves an ulcer with a hard base. The primary syphilitic
ulcer may be called the ulcerative induration of syphilis. Its most
common situation is upon the genitals ; in men, upon the inner surface
of the prepuce, and in the coronary fossa ; in women, between the
nymphse, at the posterior commissure, and at the entrance to the
vagina. Sometimes, however, it appears upon the nipples, at the
angles of the mouth, upon the tongue, and not unfrequently upon the
fingers. No part of the body is exempt, and a syphilitic induration
will arise wherever the virus touches a spot where the cuticle is thin,
or where it has been abraded. The localities above mentioned, how-
ever, are the ones most favorable to the occurrence of infection. When
but a single follicle is implicated, the induration assumes the form of an
upright cylinder, and, if a series of them lying close together be in-
volved, the confluence of these indurations forms a hard elevation.
When the induration is situated upon the lips of the meatus urinarius,
that orifice forms a somewhat gaping, rigid funnel, which feels carti-
laginous to the touch. Not unfrequently, when the mouth of the pre-
puce is somewhat narrow, its anterior border becomes fissured during
coitus. If this point becomes indurated in consequence of syphilitic
infection, the prepuce can no longer be drawn back, its outlet having
been converted into a hard ring. A phimosis of this kind will subside
after the induration has been resolved.

The bottom of a syphilitic ulcer is not lardaceous, its edges are not
eroded, nor does it show any tendency to spread. All these charac-
teristics are peculiar to the chancre (chancroid), nor is a syphilitic sore
painful, like a chancre, being usually very indolent. It is also soli-
tary, as a rule ; and it is only as an exception, when several points are
infected simultaneously, that several syphilitic sores are ever seen to-
gether. Until the induration ulcerates, it is often overlooked ; and it
is not until the sore is established, that the attention of the patient or
physician is drawn to it. Sometimes, the induration is so slight, that
the sore may be mistaken for a chancre. In such cases all doubt may
be dispelled by inoculation.

The following are the more important forms recognized among
syphilitic ulcers :

The superficial ulcer (Eicord^s chancre parchemin<§). In this
variety the induration forms a thin cake. An attempt to pinch up a
spot of this kind between the fingers imparts a feeling as though a bit
of parchment had been slipped beneath the ulcer. Its surface secretes

758 CHRONIC INFECTIOUS DISEASES.

a scanty thin liquid, in which no pus-cells can be found under the micro-
scope, but only a granular detritus. It often heals quickly, but the
secondary symptoms follow this form of sore quite as surely and
promptly as any other variety.

The elevated sore (ulcus elevatum) presents an excoriation which
is almost void of discharge, seated upon an indurated base of varying
thickness and consistence, by which it is elevated above the surround-
ing level. From time to time it is coated by a thin layer of epithelium,
which generally soon exfoliates in fine scales, leaving a new excoriation.

The Hunterian chancre (ulcus vallatum) not only has a hard base,
but is surrounded by an elevated, hard, callous border, so that it is
deeper in the middle than at the periphery. It rarely heals in less
than five or six weeks.

All the different forms of syphilitic sore may become phagedenic,
that is, they may be attacked by a rapidly-extending diphtheritic pro-
cess. The destruction then often spreads beyond the limit of the in-
duration, largely involving the skin or mucous membrane. When the
syphilitic induration is associated with the chancre, the operation of
both poisons upon the same point results in a modification of the ulcus
vallatum, that is, the border of the chancre becomes hard and callous,
and surrounds it like a wall. At a later period the induration likewise
appears in the bottom of the ulcer.

The duration of a syphilitic induration or a syphilitic sore varies.
Three months, at least, nearly always elapse ere the hardened spoi
recovers its normal consistence. The induration often lasts half a year,
and even longer. It is remarkable that, as the secondary symptoms
begin to appear, the induration begins to dissolve, and then soon sub-
sides, leaving behind it a brown pigmented spot. The pigment marks
the former site of the disease for a tolerably long time. When it
finally disappears, the spot remains whiter than the adjacent parts,
like the cicatrix of a neoplastic growth. Unless the indurated spot
has also been the seat of a chancre, there is no depression.

II. The Indolent JBubo and Extended Syphilitic Disease of the
Lymphatics. — An acute enlargement of the lymphatic glands occurs
in many of the acute infectious diseases and in syphilis, the prototype
of the chronic infectious maladies, the lymphatic glands always parti
cipate in the disorder induced by infection of the system by this per-
nicious poison. The changes which take place in the glands consist ic
a cellular hyperplasia, and they are but seldom the seat of actual in
flammation or suppuration. More frequently, especially when the dis-
ease has been of long standing, caseous metamorphosis occurs here and
there in them, and this is afterward followed by a calcification. In a
few days after its development, the primary syphilitic induration

CONSTITUTIONAL SYPHILIS. 759

almost always gives rise to a painless or else to a very slightly pain-
fid enlargement of the inguinal glands — to indolent buboes. The
number of the glands implicated is always somewhat large, and they
are seldom very greatly swollen. Each gland usually attains the size
of a bean or almond ; and it is exceptional, and only in scrofulous sub-
jects, that it becomes as large as a walnut. The surrounding con-
nective tissue is not affected ; the glands remain isolated, and, even
when then* number and the degree of tumefaction are such as to pro-
duce a large lump, it is always of an irregular nodulated shape, and it
can readily be perceived that it consists of a conglomeration of iso-
lated glands. Sometimes a thickened and indurated chain of lymphat-
ic vessels can be detected between the primary sore and the indolent
bubo. In the rare instances in which indolent buboes suppurate, the
skin becomes adherent to the glands beneath it, and gradually reddens,
and the tumor becomes painful ; some time elapses, however, before
fluctuation appears. If, finally, the purulent contents escape, or if they
be evacuated artificially, they leave sinuous and tedious fistulous ulcers
Behind them. Involution of an indolent bubo proceeds very slowly.
Several months always elapse ere the swelling of the glands dimin-
ishes, and often the last trace of the enlargement does not disappear
for years. Whenever cheesy metamorphosis with calcification has oc-
curred, small hard elevations remain for life. The usual seat of pri-
mary induration being upon the genitals, indolent buboes are generally
found upon the inguinal region ; and it is almost without exception
the glands which lie above the fascia lata, on the side corresponding to
the seat of the primary sore, which are affected. In primary affections
of the mouth and fingers, it is respectively the submaxillary and axil-
lary glands which are involved.

About five or six weeks after the formation of the indolent buboes,
upon careful investigation, we shall find numerous enlarged lymphatic
glands, lying far away from the point of infection and from the indolent
bubo, and situated in various regions of the body. This enlargement
is most frequent and conspicuous in the cervical and axillary glands,
the inguinal glands of the opposite side, and the cubital and submaxil-
lary glands. The size attained by these enlargements varies from that
of a pea to that of a bean or hazel-nut. They are quite painless ; and,
even when pressed upon, are not more sensitive than other parts of
the skin. These diffuse glandular swellings often last for years ; and,
as long as they continue to exist, the syphilis is not extinct, even
though no other manifestation of lues be discoverable. Inflammation
and suppuration of such glandular swellings are quite exceptional, and
are then always the consequence of a complication.

m. Condylomata. — The only condylomata which are of syphilitic
98

CHRONIC INFECTIOUS DISEASES.

origin are the broad ones covered by a thin coat of epidermis, ^m
which, if seated upon the skin, are usually in a state of superficial
ulceration, and bathed in a slimy, ill-savored secretion. The dry,
pointed condylomata, which are covered by a thick layer of epidermis,
are the result of local irritation, and most commonly appear at points
moistened by gonorrhceal discharge. The syphilitic condyloma is one
of the most frequent symptoms of general infection of the system,
and it rarely fails to appear in the series of morbid processes which
gradually develop under the influence of the venereal poison. As a
rule, too, the condyloma is the first symptom which succeeds the pri-
mary affection and the enlargement of the lymphatics. Its external
aspect and histological character have already been described. Upon
the skin, the most frequent seat of the soft condylomata is between the
nates ; in women, between the labia ; and in men, upon the scrotum
and outer surface of the penis. Sometimes they spread over the inner
surface of the thighs. Their appearance at the angles of the mouth is
quite common ; they are more rare at the commissure of the eyelids,
between the toes, and under pendulous breasts. They often become
fissured, especially when they have coalesced so as to form extensive
growths, and in this way painful and obstinate ulcers often form.
Fissures and cracks (rhagades) frequently appear in the skin about
the condylomata. They are attended by severe pain and heal slowly.
We have already treated of the condylomata of the mucous membrane,
of the mouth and fauces (plaques muqueuses), and of the condyloma-
tous growths which accompany syphilitic laryngeal ulceration.

IV. Syphilitic Disease of the Skin — Syphilides — Syphilitic Ex-
anthemata,— Syphilitic affections of the skin depend partly upon hy-
peraemia and exudation, and partly upon the development and meta-
morphoses of the " gummy tumor " (tubercular syphiloma) of the skin.
In the former class the exudation is sometimes thrown out upon the
surface of the skin, sometimes within the tissues, and sometimes in
both together. A classification of the syphilides into many species
has been based upon the modifications thus induced, and upon the
variety in extent and magnitude of the eruption. Since, however,
the classification of all other non-specific hyperaemic and inflammatory
cutaneous affections is also founded upon similar data, we may be
brief in our discussion of the syphilides, and confine ourselves to a
description of the differences by which the syphilitic exanthemata may
be distinguished from the non-syphilitic ones.

The general peculiarity of syphilitic eruptions, upon which most
weight has always been laid, is their color ; and, indeed, all syphilitic
exanthemata, when of somewhat long standing, are of a peculiar
coppery-red hue ; and chronic eruptions which do not present this color,

CONSTITUTIONAL SYPHILIS.

even though the}" appear upon notoriously syphilitic subjects, ought not
to be regarded as of syphilitic origin. This proposition, however, does
not admit of inversion. A rash need not be syphilitic because it has a
coppery color, as is sufficiently proved in cases of psoriasis and of acne
rosacea (commonly known as " copper nose," on account of its appear-
ance). The origin of this color is to be attributed to the addition to
the redness, caused by the capillary hyperaemia, of yellow, blue, and
brown pigment, the result of minute extravasations of blood, and the
metamorphoses of the haematin thus set free. In very recent cases the
coppery hue is not observable, no extravasations having as yet oc-
curred, or because the effused blood has not yet undergone change of
color.

Another characteristic of the syphilitic exanthemata (which is
closely related to the foregoing one, as it also depends upon gradual
transformation of the coloring matter of extravasated blood into pig-
ment) is, that, after they have recovered, stains of pigment are almost
always left in the skin.

Syphilitic eruptions may be further distinguished from non-syphilitic
ones, from their type being still less distinctly marked than that of the
latter. In the same subject we almost always find patches which be-
long in part to one and in part to another species, and here and there
a spot about which we shall be in doubt what category to assign it to
For instance, there are often red spots which we hesitate to call roseola/
because they are covered with scales of epidermis ; but, on the other
hand, we cannot regard them as psoriasis, because their coat of epi-
dermic scales is so much thinner than in the non-syphilitic psoriasis.

The situation of the efflorescence is also of great importance in dis-
tinguishing between the simple and the specific eruptions. The spe-
cific exanthemata are most apt to appear upon parts of the skin which
are exposed to the air, and upon such as lie immediately above the
periosteum. It is a very suspicious circumstance, when a rash which
has a peculiar predilection for certain localities — as psoriasis has for
the knees and elbows — appears elsewhere, upon some unusual region
instead of upon its favorite seat — as when psoriasis affects the palms
of the hands. Another peculiarity of a syphilitic eruption is, that the
various efflorescences generally take the form of circles, or of segments
of circles. It is to be borne in mind, however, that it is only when
this circular arrangement is the result of grouping, and not when it
proceeds from healing of a disease in the middle while it continues to
spread at its edges, that it is characteristic of syphilis. Finally, it
may be added, that syphilitic eruptions scarcely ever itch. In order to
determine the question of the syphilitic origin of a doubtful case, it is
of importance to ascertain whether it has been preceded by a primary

CHRONIC INFECTIOUS DISEASES.

ulcer, and whether there be any other concomitant syphilitic disease.
The crusts and scabs which form in syphilis are distinguishable by being
much thicker, as a rule, than those of non-syphilitic origin. This is
generally because, beneath the dried, purulent contents of a syphilitic
pustule, there is usually an ulcer, the product of which also thickens
and dries into a scab. The kidney-shape or horse-shoe shape of specific
ulcers of the skin is also somewhat characteristic. This is due to the
healing of the sore at one edge while it spreads at another.

The most common form of syphilitic cutaneous disease is the macu-
lous exanthema, the roseola syphilitica. This is an eruption of small,
irregular round spots of roseola, which here and there are often con-
fluent ; and its appearance is often preceded by a febrile disturbance.
The favorite seat of the rash is upon the belly, on the sides of the chest,
and upon the flanks. The face is hardly ever affected beyond where
the forehead and scalp join. At first the spots are bright red, but
afterward become livid and coppery. Some of them are level with the
skin, while others rise slightly above it. In the latter case they re-
semble the wales of urticaria, although, unlike the latter, they do not
itch. After lasting a long time, the roseola spots assume a dirty
brownish-red appearance, and, when they finally fade, they leave a
grayish-brown stain behind them. Sometimes the eruptions extend to
the glans penis. In the latter situation, the epidermis over the efflo-
rescence soon separates, leaving a bright-red, moist erosion, which
bleeds readily, and which is not to be confounded with the superficial
chancre. The roseola is one of the earliest symptoms of constitutional
infection. It is never seen m inveterate cases. When treated by
mercury, it usually subsides within four weeks. When neglected, it
passes over into the papulous, squamous, and pustulous forms of syphi-
lide. The papulous syphilide (lichen syphiliticus) is characterized by
its coppery-red, and frequently, in old cases, by its brownish-red color.
The papules are sometimes no larger than a millet-seed (miliary pap-
ules) ; sometimes they attain the size of a lentil (lenticular papules) ;
sometimes they are solitary ; sometimes they form groups, which latter
usually assume the form of circles, or the segment of a circle. Their
most common seat is the junction of the forehead with the hairy scalp,
although they also appear upon the trunk and extremities. When of
long standing, they are usually covered with scales of detached epider
mis. If, instead, small pustules form upon the apices of the papules,
the eruption is generally called acne syphilitica. Like the maculous
syphilide, the papulous exanthema appears early in the disease, although
it is sometimes observed in its later stages. In such cases, the points
of efflorescence are less numerous, and evince a still more marked ten-
dency to form circles or arcs of circles. The papulous syphilide is

CONSTITUTIONAL SYIHILIS. 763

more intractable than the maculous, and several weeks usually elapse
before it yields even to an energetic treatment.

The scaly syphilitic eruption (psoriasis syphilitica) often com-
mences as a syphilitic roseola or lichen. The spots are discrete, and
rarely become large, although they may be very numerous. The color
of a specific psoriasis is generally darker than non-specific, and the
scaly layer is usually thin. Not unfrequently cracks form in the infil-
trated skin, which lead to ulceration. As we have already remarked,
the knees and elbows are hardly ever affected in syphilitic psoriasis.
Palmar and plantar psoriasis, which always is of syphilitic origin,
begins with the formation of small, round; or oval callous spots of a
pale-red or yellowish color. After the thickened cuticle has become
detached from these spots, or has been scratched off by the patient,
the copper-colored, infiltrated cutis is exposed to view, surrounded by
concentric circles of dried desquamating epidermis. This circle en-
larges, while sometimes the centre begins to heal, or covers itself
afresh with a coat of horny cuticle. Now and then the efflorescences,
which at first were separate, afterward coalesce, causing great thick-
ening of the epidermis, which cracks readily, forming extremely painful
fissures or rhagades.

The pustulous syphilide is called impetigo, or ecthyma, according
as it produces small and pointed or large and flat pustules. They are
sometimes solitary, sometimes formed in groups, and appear upon the
face and scalp as well as upon the body and extremities. They are
surrounded by a coppery areola, and dry up into scabs, which, when
situated upon the scalp, are very annoying, owing to their liability to
be torn off by the comb. Beneath the scabs of the ecthyma pustules,
and more rarely under those of impetigo, there are ulcers, which eat
more or less deeply into the cutis. The color of the scars, which
always remain after the healing of ecthyma, is at first a coppery-red,
and afterward remarkably white. Syphilitic impetigo and ecthyma
are more serious affections, and appear at a later stage of the disease
than any of the exanthemata hitherto described. In spite of the most
careful treatment, many months often elapse ere they begin to heal.
The pustulous syphilides are quite intractable, and sometimes outlast
all the other symptoms of the disease.

There is an eruption known as varicella syphilitica, and which, in-
deed, bears a great resemblance to varicella. It is almost always pre-
ceded by febrile disturbance. The vesicles, which are numerous, and
scattered more or less over the whole body, spring from red maculae.
The liquid contained in them is at first slightly turbid, afterward
purulent, and finally dries up into round, blackish crusts, which, when
they fall, leave brownish stains behind. This, also, is an obstinate

CHRONIC INFECTIOUS DISEASES.

variety, and often drags on with repeated relapses for weeks and
months.

Rupia syphilitica, like ecthyma, originates in a destructive derma-
titis. Its mode of development is as follows : Upon a livid, red spot,
of the size of a pea or bean, there rises a flabby bleb, containing a
dirty, turbid, and sometimes bloody liquid. The contents of the bleb
dry up into a scab, which gradually is built higher and higher by the
product of the ulceration, which is constantly eating deeper into the
skin beneath it, while a ring of new vesicles forms around its border,
the drying of whose contents makes the scab wider. If we detach
one of these oyster-shell-like crusts, we find beneath it a foul, ulcerated
surface, secreting a thin ichor. Sometimes large portions of the body
are studded with numerous rupia scabs, which here and there are con-
fluent. In other instances, there are only a few, which then are very
large. Like ecthyma, rupia belongs to the graver affections, and only
appears at an advanced stage of the disease. They heal very slowly.
Not unfrequently, only one side of the ulcer beneath the scab heals,
while on the other it continues to spread. In this way, horseshoe-
shaped, or kidney-shaped ulcers form. The scars, which always result
from rupia, are like those of ecthyma, only larger.

While the syphilitic cutaneous affections hitherto described are the
result of irritative and inflammatory processes, syphilitic lupus depends
upon the development and degeneration of a neoplasm peculiar to this
disease, which arises in the form of nodules (" tubercula syphilitica ")
not merely in the skin, but in a variety of other organs. These syphi-
litic tubercles (called " gummata," or " gummy tumors," by Virchow,
even when they are of a hard consistence, and remain *so while they
exist, and which are called " nodular syphiloma " by Wagner) have
nothing in common with tubercle in the common sense of the word.
Virchow counts them in the class of " granulation tumors," that is,
humors which even at then* fullest stage of development contain no
mature connective tissue, nor any analogue of it, but consist mainly of
elements of a transitory nature, and in which degeneration, death,
softening, and ulceration is the regular and necessary consequence of
existence. Wherever the syphilitic tubercle appears, it consists of
nests of very numerous small cells, with large nuclei, which are lodged
in the interstices of the affected tissue, and from which they have sprung
through profuse multiplication of its cellular elements. The recent
uodules are soft, of a grayish-red color, and infiltrated with a scanty
juice. After lasting for some time, they either soften and ulcerate, or
else undergo an incomplete cheesy metamorphosis. The most frequent
seat of the syphilitic cutaneous tubercle is upon the face, especially
upon the forehead (corona veneris), and, next in frequence, upon the

CONSTITUTIONAL SYPHILIS. 765

region of the shouider-blades, and the dorsal surface of the extremities.
Some of the nodules are superficial, while others are deeply seated.
The more superficial ones are smaller, while the deeper seated ones
are larger. At first a small, movable tumor, somewhat sensitive to
pressure, appears in the skin, which gradually reddens above it, and
rises into a dark-red hemispherical nodule, which rather resembles a
boil. Sometimes the covering of the tubercle remains unbroken, and,
its contents becoming absorbed, its surface gradually grows paler,
sinks in, and a scar forms without there ever having been any ulcera-
tion. If the tubercle breaks, a turbid, serous liquid escapes under the
cuticle, and, thickening, forms with it a scab. Beneath this scab the
ulcer continues to penetrate more and more profoundly. Not unfre-
quently one common, broad crust covers a cluster of nodules. The
ulcer may retain the circular shape of the tubercle, but it more com-
monly happens that the sore extends at one edge, while it granulates
and cicatrizes at the other. Thus, like the rupia, the tubercle produces
horse-shoe and kidney-shaped ulcers. The scars, which remain after
healing of a syphilitic lupus, long retain a brownish-red stain, and, after
the disease has subsided, become remarkably white.

The hair often falls out, in syphilis ; but, as a rule, this is merely a
defluvium capillorum, unless the scalp be the seat of an eruption. The
hair-bulbs do not perish, and, after the disease has abated, the growth
of the hair is as luxuriant as ever. The syphilitic exanthemata, on the
other hand, usually destroy the hair-follicles, and cause permanent
baldness or alopecia.

The nails, also, undergo changes from implication of their matrix
in the cutaneous disorder. In the simple infiltration of the matrix of
the nail, which often accompanies psoriasis syphilitica, the nails de-
generate, becoming misshapen, fissured, and horny. In the more rare
ulceration of their matrix, they often become detached.

V. Syphilitic Disease of the Mucous Membranes. — Next to the
external integument, the mucous membranes are the most common
seat of syphilitic disease, although all of them are not affected by con-
stitutional syphilis with equal frequence. The lining of the mouth,
fauces, nose, and larynx, and, next to these, the mucous surface of the
rectum, are the regions upon which the malady is most prone to local-
ize itself.

The mildest form of syphilitic disease of the mucous membrane,
and at the same time the one which appears soonest after the primary
infection, is syphilitic catarrh. In special instances, it is not always
easy to distinguish between a catarrh depending upon syphilis, and
one arising from other causes. A remarkably deep, bluish redness, an
abruot line of demarcation between the affected spot and the sound

766 CHRONIC INFECTIOUS DISEASES.

parts, and a milky, turbid appearance of its epithelial coating, are sus-
picious, but not pathognomonic signs. In most cases the diagnosis
depends mainly upon the history of the case, and upon the coexistence
of other syphilitic symptoms, particularly enlargement of the lymphatic
glands, and maculous or papulous exanthemata, and above all upon
the refractoriness of the catarrh to simple treatment, and its speedy
disappearance when treated by mercury.

The appearance of mucous papules, with their transformation into
condylomata, erosions, and ulcers, is one of the earlier symptoms of
syphilitic infection. Their mode of development is as follows : A spot
of mucous membrane of about the size of a pea rises above the sur-
rounding level, and seems firmer, and somewhat reddened. If it does
not heal after reaching this stage, the epithelium covering the flattened
nodule becomes opaque, and assumes a milky, or pearly appearance.
After separation of the thickened epithelium, a bright-red erosion re-
mains, which bleeds easily. This is followed by a sore, with an un-
even, whitish-gray bottom, the product of molecular disintegration, or
else plaques muqueuse and mucous condylomata form, from augmented
vegetation and development of connective-tissue fibres. We have al-
ready treated of the syphilitic mucous papule, and of the ulcers and
condylomata of the mouth, fauces, and larynx, to which they give rise.
We rarely obtain an opportunity of observing the earlier stages of
syphilitic disease of the rectum. The ulcers which arise from mucous
papules of the rectum, and the scars which they leave after healing,
bear a close resemblance to dysenteric scars. A distinction may be
based in some measure upon the seat of the sore, and resulting cicatri-
cial stricture, the syphilitic ulcers being situated in the cloaca of the
gut, or else close to the anus, while the dysenteric ones are found in
the sigmoid flexure.

The gummata and tubercular syphilomata of the mucous membranes
have the same character and mode of development as those of the
skin. A nodule of the size of a shot forms in the mucous membrane,
and gradually grows until it projects above the surrounding level.
If not made to resolve itself by judicious treatment, it softens, bursts
its epithelial cover, and turns into a sore. Wide-spread destruction of
the nose, palate, fauces, and larynx, may thus occur. • Not unfrequently
the disease spreads to the submucous tissue, and the cartilage, perios-
teum, and bones. The ulcers often produce contractions in healing.

VL Syphilitic Iritis. — The syphilitic contagion not unfrequently
gives rise to inflammation of the iris and the choroid coat of the eye.
This is a very common complication of the syphilitic exanthemata.
Modern ophthalmologists deny the existence of any specific mark of
distinction between the syphilitic and non-syphilitic inflammations of

CONSTITUTIONAL SYPHILIS. 767

these membranes — such as distortion of the pupil inward and up-
ward. Besides the simple syphilitic iritis, there is another form,
known as " gummous " iritis. For a description of the very character-
istic symptoms and course of this affection, we must refer to the text-
books upon ophthalmology.

VII. Syphilitic Disease of the Periosteum and jBones. — One of
the common symptoms of syphilis consists in a pain along the bones,
unaccompanied by any appreciable objective manifestations. At first
these pains are vague and ill-defined. Afterward they are fixed at
certain points, particularly in the bones lying close beneath the skin,
such as the tibise and the cranial bones. They are increased by pres-
sure, and usually remit during the day and recur at night. These
osteocopic pains are probably dependent upon a slight disease of the
periosteum, capable of complete and speedy recovery, and which prob-
ably consists in moderate hyperaemia with an inflammatory oedema.
The severe strain which the naturally-unyielding periosteum suffers,
even when but slightly infiltrated by serum, fully accounts for the vio-
lence of the pain.

In bad cases of inveterate syphilis, swellings form here and there
upon the bones, accompanied by great suffering, which becomes excru-
ciating at night. Such swellings, when of a boggy consistence, are
called " gummata ; " if their consistence be somewhat hard, they are
colled " tophi " (nodes). Like all other syphilitic affections of the
periosteum and bones, they are most apt to appear upon the skull, the
shins, the sternum, and other bones lying close beneath the skin.
Gummata receive their name from the viscid-looking liquid which
flows from them when punctured. They consist of cells and nuclei,
with very little connective tissue, and a great deal of liquid intercel-
lular substance, their elements corresponding closely to those of the
recent succulent syphiloma. These tumors may decrease and disap-
pear entirely, the liquid and cells both being absorbed, the latter first
undergoing fatty degeneration. In other instances pus forms in them,
and they turn into abscesses, which, when opened, either naturally or
artificially, discharge their contents.

Tophi, although their consistence is very hard from the outset, so
that they are apt to be mistaken by ignorant persons for excrescences
from the bone, are circumscribed neoplastic thickenings and elevations
of the periosteum by inflammatory exudation. The periosteum whence
they spring has but little tendency to suppuration, and by means of
an early and appropriate treatment we can often bring about their
resolution. When of longer standing, bone forms in the thickened tis-
sue ; the tophi are thus converted into exostoses, and are then no longer
capable of reabsorption. Besides the form of exostosis just mentioned,

768 CHRONIC INFECTIOUS DISEASES.

which proceeds from ossification of the periosteum, there is another,
dependent upon inflammation and proliferation of the bone itself
Tophi and exostoses by pressure upon neighboring nerves may cause
neuralgia, anaesthesia, or palsy, and when situated upon the inner sur-
face of the skull may occasion serious disorder of the brain.

Syphilitic caries and necrosis are sometimes the consequence of
purulent periostitis, where the pus effused between the bone and peri-
osteum has cut off the portion of bone affected from its nutrient blood-
vessels. At other times it proceeds from an ulceration, originating in
the soft parts, and which has destroyed the periosteum, and laid bare
the bone ; while, in still another series of instances, the periosteum, at
first, is healthy, and the caries and necrosis are the result of a simple
or gummy syphilitic inflammation. The question why the denuding
of the bone of its periosteum and the ostitis sometimes cause an ul-
ceration of the bone, or caries, while, at others, it induces the death
and separation of large pieces of bone, or necrosis, we shall leave un-
discussed, as being a question belonging to general surgery. When
bone exfoliates from syphilitic necrosis, the loss of substance is seldom
filled up by new bone. A depressed spot almost always remains, or,
if the bone has been perforated, there will always be a hole in it with
smooth edges. Syphilitic caries and necrosis occur more frequently
upon the bones of the face and skull than upon those of the trunk
and extremities, although the latter, especially the sternum, tibiae, and
clavicles, do not always escape. The most dreadful devastation occurs
in the bones of the nose and hard palate. The vomer and the vertical
plate of the ethmoid usually go first, so that the two nostrils commu-
nicate by an orifice of variable size. Afterward the entire bony sep
turn perishes, and the turbinated bones, the walls of the ethmoid cells
and frontal sinus, the nasal and lachrymal bones, are also destroyed.
The nose thus loses its support, and sinks in behind its apex, which
then points upward. If the disease attack the floor of the nostrils,
after perforation of the hard palate, a communication is established be-
tween the cavities of the mouth and nose ; so that food and drink can
enter the latter. More rarely, destruction of the hard palate com-
mences in the mouth, although I have seen a piece of bone as large as
a florin exfoliate from the lower surface of the hard palate, without
any syphilitic ozaena. When caries and necrosis of the nasal bones
arise from ulceration of the mucous membrane which has penetrated
and destroyed the periosteum, the patients suffer long from an ill-smell-
ing ichorous and often bloody discharge from the nose, which, at a later
period, also contains bits of blackened bone. The septum of the nose is
often perforated in such cases without its external covering exhibiting
any particular change ; but, if the destruction of the nasal bones be

CONSTITUTIONAL SYPHILIS. 769

preceded by syphilitic periostitis, the skin soon becomes reddened, and
the face grows oedematous upon the affected side. Sometimes the
integuments are perforated by the pus and fragments of bone, and
thus a fistulous opening is established in the back of the nose. Syph-
ilitic ozaena, often causing a more or less extensive destruction of the
bones of the nose, may recover completely. Some time ago, at the
autopsy of a syphilitic person, besides an extensive recent anostosis
excentrica (see below), I found a complete absence of the bony sep-
tum, the turbinated bones of the nose and the inner walls of the antra
of the upper jaws. But there was no bare bone to be found, the huge
cavity which represented the nose being every where lined by a smooth
cicatricial membrane.

Besides caries and necrosis, a third destructive disease of the bones
occurs in syphilis, which was first accurately described by JBruns,
although Virchow first pointed out how frequently it originated from a
syphilitic taint. Bruns describes this peculiar form of consumption of
bone, to which he gives the name anostosis excentrica, as a dissolution
and liquefaction of the bone, beginning excentrically, proceeding from
the medullary canals and medullary cells, and marked by swelling and
redness of the tissues contained in these spaces, but never accompa-
nied by suppuration. The calibre of the canals is first enlarged at the
expense of their walls, the progressive absorption of which ultimately
causes the canals to blend into irregular cavities. The effect of this
process is to render the diseased bone porous, and spongy, like carious
bone, and in a macerated specimen it is impossible to tell whether the
destruction is the result of caries or of anostosis excentrica. When
the disease commences upon the exterior of the skull, its surface first
assumes the worm-eaten, rough appearance of superficial caries ; but
afterward the loss of substance extends more deeply, and here and there
may even perforate the cranial wall. The inner surface of the pericra-
nium is said to be reddened, swollen, and granulated over the whole
diseased region, and the medullary tissue within the diseased bone is
converted into a red vascular mass, intimately connected with the peri-
cranium. Not a trace of pus is anywhere to be found. The adjacent
bone is either unaltered, or else a reproduction of bony matter takes
place on the edges of the seat of disease, which is thus surrounded as
by a wall. When the process attacks the outer surface of the cranial
wall, an extensive growth of new bone may also occur on the interior
of the vault of the skull. This description of anostosis excentrica,
which has been taken almost word for word from the text-book of
Bruns, agrees so closely with Virchoufs account of " caries sicca,"
or the inflammatory atrophy of the bones of syphilitic persons, that it
can hardly be doubted that both observers have described one and the

770 CHRONIC INFECTIOUS DISEASES.

same disease. From microscopic examination of the soft tissue and
of the more solid and resisting masses, the points of which contain a
yellowish-white and very dry substance, Virchow has satisfied himself
that the conical or spindle-shaped contents of the cavities, resulting
from the loss of bone, consist of the specific neoplastic product of
syphilis, to which he gives the name of gummata even when it is not
soft, and which Wagner calls the syphiloma.

VIIL Syphilitic Sarcocele. — Syphilitic contagion sometimes gives
rise to an inflammation of the testicle, distinguishable from other
forms of orchitis by certain peculiarities, particularly by its seat,
and the tediousness of its course. The disease begins in the tunica
albuginea and its continuations, and induces a proliferation of young
cells and new connective tissue upon the interior of the tunic, and be-
tween the seminal tubules. Under the pressure caused by this tumor,
which afterward contracts and indurates, the proper substance of the
gland disappears. Besides this simple syphilitic orchitis, there is a
second form, distinguished by the formation of dry, whitish-yellow,
homogeneous nodules in the affected organ, in addition to the prolif-
eration of the albuginea. Virchow calls the former disease simple
syphilitic orchitis, and the latter, gummy orchitis. Wagner believes
that there is no essential difference between the nodular syphiloma, or
gummy tumor, and the diffuse syphiloma. According to his views,
the form first mentioned is the diffuse syphiloma, while the latter con-
stitutes the nodular syphiloma of the testicle. The symptoms of syphi-
litic sarcocele consist in a slowly-progressing enlargement of one or
both testicles, which develops either without any pain at all, or else is
accompanied by occasional lancinating twinges. The testicle becomes
very hard, loses its regular shape, and may grow to the size of a fist.
Sarcocele is often accompanied by a serous effusion in the tunica vagi-
nalis propria. Sometimes the disease, after making some progress in
one testicle, attacks the other.

Virchow describes a syphilitic periorchitis : This may commence as a
hydrocele, but soon occasions thickening of the albuginea and tunica vag-
inalis propria, causing adhesions, or even complete synechia of the latter.

IX. Syphilitic Disease of the Connective Tissue, Muscles, and
Viscera. — In cases of inveterate syphilis, tumors presenting the char-
acteristics of the gummy tumor, or syphilitic tubercle, are also found in
the subcutaneous and submucous connective tissue, and in the inter-
stices of the muscles (Virchow). When properly treated, they
sometimes disappear, while at other times they suppurate, producing
abscesses and intractable ulcers.

The muscles also, especially those of the upper extremity, the
throat and neck, are sometimes the seat of syphilitic disease. Virchow

CONSTITUTIONAL SYPHILIS. 771

aescriber 4 simple and a gummy myositis. The former depends upon
proliferation of the interstitial connective tissue, producing an indura-
tion of the latter, while the primitive muscular fasciculi suffer atrophy,
and perish. In the latter form, tumors, often of considerable size, arise
in the muscles, and upon section show reddish-white or yellowish-
white, slightly striped deposits, which are usually not absolutely dry.
Microscopic examination reveals a finely-cellular, dense granulation of
the intramuscular substance, with premature fatty degeneration, in
which the cells perish, leaving a granular, fatty, and apparently struc-
tureless mass. Similar masses are sometimes found in the substance
of the heart. Perhaps some cases of induration of portions of the car-
diac muscles depend upon simple syphilitic myocarditis.

Among the syphilitic diseases of internal organs, syphilitic hepatitis
has been described in detail. Wagner and other authorities have ob-
served syphilitic lesions in other organs, the spleen, the kidney, arid
even the pancreas, which closely corresponded with those found in the
liver, sometimes inducing thickening in the envelope of the viscus, some-
times diffuse induration of its substance, and sometimes producing cir-
cumscribed nodules in it. Dittrich has already recognized the occur-
rence of syphilitic disease of the lung, in the form of nodular, firmly-re-
sisting indurations, either of a white color, or else stained black, by
deposit of pigment, and which enclosed dry, cheesy accumulations. It
would also seem that, besides this gummous pneumonia, an interstitial
syphilitic pneumonia also occurs. It may sometimes be very difficult,
or even quite impossible, to decide whether a disease of the lung de-
pends upon syphilis or not.

Syphilitic affections of the encephalon consist in part of chronic in-
flammation of the meninges, which may involve the pia mater, the
arachnoid, or the dura mater, in the form of a pachymeningitis externa
(endocranitis) or interaa; and, among other symptoms, sometimes give
rise to palsy of one of the cerebral nerves. Sometimes, syphilitic de-
posits occur, which formerly were often mistaken for inspissated ab-
scesses, or for caseous tubercles. (See " Diseases of the Brain.")

It follows, from this brief enumeration of the various syphilitic dis-
eases of the tissues and organs, that the points on which the disease
localizes itself are far more numerous than was formerly supposed ;
and that Wagner's statement, that syphilis attacks all the tissues which
contain vessels, is fully warranted.

The General Course of Syphilis. — It is a remarkable fact that,
while the syphilitic taint at times gives rise to palpable symptoms, at
others no sign of the persistence of the infection can be detected, ex-
cepting the enlargement of the lymphatic glands, After the healing
of the primary ulcer, a period of several weeks usually elapses before

772

CHRONIC INFECTIOUS DISEASES

sondylomata, exanthemata, or other consequences of the infection, ap
pear ; and, after the latter have subsided, another interval of exemption
usually ensues, ere a second series of disorders disturbs the apparent
good health of the patient. For these alternations, which usually re-
cur again and again during the course of the disease, no satisfactory
explanation has as yet been furnished. The time which intervenes
between the healing of the primary ulcer and the appearance of the
secondary symptoms, as well as that between the various outbreaks
of the secondary manifestations themselves, varies greatly in different
cases. The causes of this difference, and the influences which shorten
or prolong the period of latency, are likewise in a great measure un-
known. It seems, however, that in vigorous constitutions, and in per-
sons who live luxuriously, the secondary symptoms set in sooner, and
recur at shorter intervals, and that the length of the period of latency
is somewhat dependent upon the treatment adopted.

Barensprung^ relying upon a large experience, affirms that, when
mercury is not employed, a period of latency of several months, or even
years, never occurs, and that the secondary symptoms and their re-
lapses appear within six weeks at latest, after the healing of the in-
durated ulcer, or after the subsiding of the outbreak last treated.
He does not hesitate to declare a patient treated without mercury to
be safe and permanently cured, who continues free from constitutional
symptoms three months after treatment has been discontinued. If
this assertion could be substantiated, the well-authenticated cases of
latency of syphilis, during a period of ten or twenty years, would be
attributable entirely to mercurial treatment. Such protracted periods
of latency, however, if they really do occur, are at all events extremely
rare, be the treatment non-mercurial or mercurial. It is equally rare,
also, for secondary symptoms to arise prior to the healing of a recent
primary sore. As a rule, they do not make their appearance until
from eight weeks to three months after infection, and the relapses
usually follow one another at similar intervals.

A certain degree of regularity can be recognized in the manner in
which the various manifestations of the disease succeed one another
After the healing of an indurated ulcer, there is a great probability
that in a few weeks or months it will be followed by condylomata, a
maculous exanthema, or by a syphilitic angina ; but, at this stage, the
patient is quite secure against rupia, syphilitic lupus, or disease of the
bones. Conversely, an individual, who for years has suffered repeated
relapses of syphilis, is in danger of destructive disease of the skin and
subcutaneous areolar tissue, of caries and necrosis of the bones, but not
of broad condylomata, or of sypmlitic roseola. The disorders and
complications of disorders which stand first in order in the series of

CONSTITUTIONAL SYPHILIS. 773

syphilitic affections are called secondary affections ; others, which are
akewise frequently combined one with another, but which appear later,
are called tertiary affections. The former are usually considered to
include indolent buboes, the condylomata, the exanthemata with the
exception of rupia and lupus, the superficial ulcers of the mucous mem-
brane, and iritis ; while lupus, rupia, disease of the bones, and the
gummy tumors of the submucous and subcutaneous areolar tissue, and
the disorders of the muscles and viscera, belong to the tertiary class.
Upon comparing the two classes, it will be found that the secondary
diseases are less malignant, that is, are less destructive than the ter-
tiary; and that they usually are limited to the superficial tissues, to
the skin and mucous membrane ; while the tertiary affections attack
the deeper-seated, " more noble " organs. This mode of classification,
however, makes it impossible to draw a sharp boundary between the
two forms, and it is idle and unprofitable to dispute as to whether the
intermediate varieties rank as secondary or tertiary, such as sarcocele,
which, though not one of the earlier consequences of infection, still
usually precedes lupus and disease of the bone, and which, in respect
to its malignity and to its locality, occupies an intermediate position.
In rare and exceptional instances, disease of the bones forms one of the
early symptoms of general syphilis. The opponents of the treatment
by mercury attribute this early appearance of the so-called tertiary
accidents to the mercury, and even go so far as to assert that the em-
ployment of mercurials, by aggravating the pernicious influence of
syphilis upon the organism, actually is the cause of the tertiary mani-
festations ; and that, under non-mercurial treatment, syphilis does not
affect the bones. Although both statements, in their fullest accepta-
tion, are decidedly untrue, yet neither of them is quite without foun-
dation ; for, if the disease be not subdued, while the constitution has
been ruined by immoderate and reckless dosing with mercury, perni-
cious forms of syphilis, such as lupus and disease of the bones, are more
liable to arise than when it still lurks in the system of a robust indi-
vidual. It would almost seem, indeed, that the constant increase in
malignancy which shows itself in each succeeding attack, in cases of
syphilis where mercury has not been employed, is the result of deterio-
ration of the constitution induced by the previous attacks. At all
events, the contrary effect is seen in robust constitutions, in whom,
when the disease is not completely extinguished at first, each relapse
is less severe than the preceding one.

While, with the exception of a slight fever, which usually precedes
and accompanies the secondary symptoms, the disease is borne for a con-
siderable length of time without constitutional disturbance, yet, when
the attacks recur constantly, when the patient's rest is continually dis-

774 CHRONIC INFECTIOUS DISEASES.

turbed by nocturnal pain, when protracted suppuration consumes his
strength, and, above all, if an active mercurial treatment be superadded,
a general marasmus, the so-called syphilitic cachexia, sets in. This term
is not exactly appropriate, since it does not proceed directly from syphi-
litic infection, but indirectly from the nutritive disturbance to which it
leads, or from the method of treatment adopted. Accordingly, the
syphilitic cachexia has no peculiar features by which it may be distin-
guished from other non-specific forms of cachexia. Even amyloid de-
generation of the liver, spleen, kidneys, and other organs, which often
accompanies the syphilitic cachexia, is not peculiar to this disease, but
also develops in the course of other non-syphilitic diseases of bone as
well as in malarious affections, scrofula, and rickets.

TREATMENT. — The treatment of the primary syphilitic induration
and primary syphilitic ulcer must be directed mainly against the con-
stitutional disease, the first manifestation of which we have found it to
be. Abortive treatment is out of the question, save when we have to
treat an excoriation produced during a suspicious coitus ; but in such a
case, after destroying the affected part, we cannot tell whether the
absence of induration and of subsequent symptoms is the result of
the treatment or not, as we have no criterion for distinguishing an in-
fected excoriation from a non-infected one. The extirpation of an in-
duration, or its destruction by means of caustics, is altogether useless.
As a general rule, a new induration forms upon the edges of the wound
thus produced. Besides the use of constitutional remedies, the primary
syphilitic sore should be treated according to the principles already
laid down for treatment of the chancre. First of all, the utmost clean-
liness must be maintained. Washes, mild or strong, according to cir-
cumstances, should be used, together with gentle applications of lunar
caustic, or sprinklings with red precipitate, and the like. Internally,
unless contraindicated by special circumstances, I treat the primary
ulcer and primary sore with mercurials. I am well aware that the in-
duration is capable of disappearing without their use, and that this
treatment affords no guaranty against the appearance of consecutive
symptoms ; but the indisputable fact, that the secondary symptoms are
fewer and later in appearing when treated by mercury than when
treated without it, induces me to prefer the former treatment to the
latter. Besides, a cautious employment of this drug is far less liable
to be followed by mischievous results than is asserted by its opponents.
In the first year of my practice I did not employ mercury in syphilis,
but in my second I commenced to use it upon almost every indurated
sore, and hi all cases of secondary disease. The number of patients
which I have treated in this manner cannot of course be compared with
that treated in the course of a year or two in the syphilitic ward of one

CONSTITUTIONAL SYPHILIS. 775

of the great hospitals, but it is large enough to prove that the mis-
chief produced by mercurial treatment has been greatly overestimated.
As I have kept most of the patients, whom I have treated for syphilis,
under observation for some time afterward, and since, after the marriage
of many of them, I have become their family physician, it would have
been more difficult for the pernicious effects of a course of mercury to
escape my notice, than that of many a chief of a large syphilitic ward,
who loses sight of his patients as soon as they are discharged A se-
ries of observations, many of them very close ones, and now continued
for over eleven years, of a by no means inconsiderable number of per-
sons who have undergone a careful mercurial treatment, has converted
me from an opponent into a decided advocate of mercury.

It lies out of the plan of this work to recount all the celebrated
modes of treatment by mercury, or to detail the minute directions en-
joined in the different methods, the number of pills to be taken daily,
the manner of raising and reducing the dose, etc. I admit that I re-
gard all sharply-defined routines not only as useless, but as absolutely
dangerous, as it induces inexperienced or careless physicians to treat
all varieties of constitution by the same formula. Experience has
taught that the efficacy of mercury, as a remedy against syphilis, does
not depend upon the form in which it is administered, whether as a
suboxide, an oxide, a basic salt, a chloride, or an iodide. It is equally
immaterial, as regards its efficiency as a remedy, how the mineral enters
the blood, whether it be by the intestinal mucous membrane or through
the skin. Hence our choice of a preparation of the drug should fall
upon one which, while an effective remedy, does the least possible
harm to the constitution. Since, however, the pernicious influence
which this mineral exerts upon animal life is susceptible only of a par-
tial explanation, we can merely diminish or avert the more subordinate
mischief to the intestinal mucous membranes, to which the use of mer-
curials gives rise, by choosing preparations which are the least irritat-
ing to them, or by not introducing the drug through the intestines at
all, but through the skin. If we deemed the action of calomel and
iodide of mercury upon the intestine, when cautiously administered, to
be very great or very pernicious, we should regard the reintroduction
of the " inunction-cure " as a most important step in the therapeutics
of syphilis; but, believing as we do, that these disadvantages are
trifling, and nearly always temporary, we cannot concur in the ecsta*
sies of those who see the beginning of a new era in the reestablish-
ment of the treatment of syphilis by mercurial inunction. I do not
mean by this that I look upon mercurial inunction as an improper
method of treating syphilis ; indeed, I very often make use of it myself,
especially in clinical practice, for it does all that mercurial treatment is
99

CHRONIC INFECTIOUS DISEASES.

capable of doing; and I know of no objection to it, excepting that
salivation sometimes occurs more suddenly and with greater severity
in this than in other cures. As a rule, I follow the directions laid
down by Sigmund for this mode of treatment (which, compared with
the notorious and dangerous "grand inunction-cure" of Louvrier,
scarcely deserves the name of inunction), but I do not pedantically
hold myself strictly to Sigmuntfs precepts. The patient having taken
several daily warm baths, I cause a half drachm of blue ointment to be
rubbed into the skin, and, where there seems to be danger from delay,
I rub in a whole drachm. Upon the first day I apply it to the legs,
the second to the thighs, the third to the arms, the fourth to the back,
the fifth to the legs again, and so on. The precise order in which the
rubbings succeed one another is of course unimportant. At points
within the patient's reach he can rub the ointment in for himself; at
others, an attendant must do it. Each inunction should continue from
ten minutes to a quarter of an hour, and, before rubbing again, the
surface previously rubbed is to be washed with soap and water. The
temperature of the room should not be above sixty-five or seventy de-
grees Fahrenheit, and must be ventilated daily. There is no objec-
tion to the patient's changing his linen. It is useless to combine the
hunger-cure with the inunction-cure ; and it may even do harm. As
soon as the least trace of salivation shows itself, the treatment must
be suspended ; and any of the ointment still adherent to the skin
should be carefully removed by a bath, or by a thorough washing.
Should the healing of the ulcer or resolution of the induration come to
a stand-still after cessation of the salivation, or, in cases of secondary
disease, should the improvement not continue after the salivation
abates, I recommence the mercurial frictions, one or two of which then
almost always perfect the cure. I observe the rule of always suspend-
ing the treatment upon the occurrence of salivation, not only when the
mercury is employed in the form of ointment, but in all other forms of
mercurial treatment, and simply because I regard salivation as a sign
that a sufficient quantity of the mineral has been absorbed. It mat-
ters not whether the mercury be applied upon the skin, or to the in-
testines ; in either case a part only of what is administered is absorbed,
and the rest either remains upon the skin or else is expelled in the
stools. Hence, even if we could tell how large an amount of it must
be introduced into the system in order to effect a cure of a syphilitic
affection, we should still be ignorant of the number of inunctions of
ointment, or of internal doses of calomel, corrosive sublimate, or iodide
of mercury, requisite to produce the desired result. Salivation, of
course, affords no criterion of the amount of mercury absorbed, but it
certainly indicates that enough of the drug has been taken up to pro-

CONSTITUTIONAL SYPHILIS. 777

duce a decided impression upon the system. That the one effect,
namely, the salivation, is almost always accompanied by another, the
improvement of the syphilitic lesion, follows even from the erroneous
belief entertained by many old physicians, that salivation is a beneficial
crisis. Notwithstanding that I regard salivation as a valuable guide in
the treatment of syphilis by mercury, just as I regard dilatation of the
pupil as valuable in treatment of epilepsy by atropin, showing that
the dose administered is sufficient, and although I do not regard the
appearance of slight traces of salivation as an objection to such method
of cure, yet I consider it extremely unsafe when we have not the op-
portunity to suspend the treatment before the salivation has made any
considerable progress. Salivation has no curative effect whatever, and
I always seek to allay it by administration of chlorate of potash, either
in solution ( 3 j to water § ij), a tablespoonful of it to be taken every
two hours, or else in the form of pastilles. If, when in doubt whether
to continue the cure or to discontinue it, we decide to give one or two
more doses of calomel, corrosive sublimate, or iodide of mercury, we
run far less risk, by so doing, of producing a severe sore mouth, than
if we rub in another half drachm of mercurial ointment.

The great objection to the inunction treatment, that in it we
cannot say how much of the mercury enters the body, does not
exist in using subcutaneous injections of corrosive sublimate. In
this treatment, which of late has run a strong opposition to the
inunction treatment, and has to some extent supplanted it, we may
even more certainly control the dose than we can in internal adminis-
tration, and we save the gastric and intestinal mucous membrane just
as completely as we do by the inunction treatment.

I acknowledge that I began the employment of subcutaneous
Injections of corrosive sublimate with a certain distrust, and that I did
not resort to it till it had been urgently recommended to me by
various persons. I feared that the pain and inflammations, with
partial necrosis of the skin that it must cause, would be out of
proportion to any possible benefits arising from its use ; indeed, it
seemed doubtful to me if this inflammation and necrosis of the skin
would not interfere with or entirely prevent the absorption of the
remedy. Experience soon taught me better. If sufficiently dilute
solutions are employed, the pains are perfectly bearable and of short
duration ; by the same precaution, severe inflammations and necrosis
of the skin may be avoided. The absorption of corrosive sublimate
appears to follow subcutaneous injection just as quickly as that of
morphine does ; in short, the advantages seem to outweigh the objec-
tions so much, that any practitioner, who has treated his syphilitic
patients for a short time with subcutaneous injections of corrosive

CHRONIC INFECTIOUS DISEASES.

sublimate, will acknowledge that we are much indebted to Lewin
for its introduction. In my clinic, we at first used Letter's syringe,
which holds twelve grains of fluid, and with this injected twelve drops
of a solution of corrosive sublimate (gr. j to 3 j). Later, with the
best results, we injected a solution (gr. j to § ss) with one of Paikrtfa
syringes, holding half a drachm (that is, the eighth of a grain of cor-
rosive sublimate in a solution one fourth the strength of the former)
once or twice daily. We obtained this syringe also from Leiter in
Vienna, but, as the canula was rather thick, and consequently the
puncture pained and bled, we had a canula made like that on the
ordinary hypodermic syringe.

Nevertheless, the conviction, that the internal administration of mer-
curials, cautiously conducted, does not produce any lasting injury to the
mucous membranes, has caused me, in spite of the general commenda-
tion of injections and the inunction-cure, to adhere to the internal ex
hibition of mercury in private practice. The article I generally employ
in cases of primary induration and primary sore, is calomel. Of all
mercurials, this one is the least open to the charge of causing serious
or permanent detriment to the mucous membranes when given in mod-
crate doses. If it really were injurious, considering how universally
it is employed, especially in diseases of children, the number of persons
suffering from its effects would be very large. I will only call to mind
that the Plummets powders, used in ophthalmia and other scrofulous
complaints, the minute doses of calomel used in infantile diarrhoeas,
the larger ones, pushed almost to salivation in croup, pleurisy, and
other inflammations, still are among the most common of prescriptions,
and that ten or twenty years ago they were even more generally ad-
ministered than now. An exceedingly rich experience has taught us,
that the innumerable multitude of persons who have used calomel
more or less, for other purposes than antisyphilitic treatment, have not
suffered any permanent injury to their digestion or their general
health, but are now as healthy as they were before. Calomel, how-
ever, has no great reputation as an antisyphilitic (at least, in Ger-
many), and the corrosive sublimate is preferred to it by most prac
titioners, as a means of treating primary and secondary symptoms
The reasons for this are twofold: firstly, it often causes diarrhoea;
secondly, it soon produces salivation. I do not regard either of these
objections as valid. I have never found that the diarrhoea which
nearly always sets in at the beginning of a course of calomel (but which
usually subsides in a few days) interferes materially with the cure, and,
as salivation soon occurs in spite of it, we may confidently infer that
the medicine is not all evacuated, but that a sufficient amount of it is
absorbed and taken into the blood. With regard to the second objec*

CONSTITUTIONAL SYPHILIS. 779

tion, for reasons given above, I rather look upon the early appearance
of salivation as an advantage, insomuch that, in cases where, owing to
idiosyncrasy of the patient, salivation occurs later than I had expected,
01 where it fails to appear at all, I have been anxious lest I might ad-
minister too large a quantity of mercury, not having this valuable guide
to inform me when to discontinue the remedy. To adult patients I
usually give a grain of calomel twice daily, or half a grain three times
a day. When given in the form of powder, I have it wrapped in
a wafer, in order to screen the mucous membrane of the mouth from
contact with the drug. Generally, however, I have it made up with
liquorice into pills, each of which contains half a grain. Next to calo-
mel, I have most frequently made use of the protiodide of mercury. I
am not aware that this article possesses any advantage over calomel,
and I have generally noticed that its exhibition occasions severe pain in
the bowels, which scarcely ever occurs in the diarrhoea induced by calo-
mel. On account of these annoying symptoms, Ricord (to whose au-
thority the protiodide of mercury mainly owes its reputation and exten-
sive adoption) combines it with narcotics ; but, even with Ricord's pills
(hydrarg. protiodid., lactucar. gall., aa 3 iss, ext. opii aquaeos. gr. ix, ext.
guaiac. aquaeos. 3 j, f. pil. no. xxxvj), I have often been obliged to give
opium, on account of severe pain in the bowels, so that I have now been
induced to abandon the use of the protiodide. I shall now merely add
a few words about corrosive sublimate, for, although I am by no means
one of its admirers, and consider it as far inferior to other preparations
of mercury, yet it probably is more generally employed in syphilis
than any other. The corrosive properties of the drug forbid its ad-
ministration in large doses, and I believe a gradual increase of the
dose to be improper. Can one expect the stomach to accustom itself
to the action of the medicine so as to tolerate large quantities without
becoming corroded ? and why should we increase the dose when it is of
importance to be able to suspend the treatment at precisely the right
moment, in order to avoid introducing too much mercury into the sys-
tem ? Corrosive sublimate is valued principally because, hi the first
place, it is slow to produce salivation, and because, under its use, less
mercury is taken into the system than under other mercurial treat>
ment. I cannot regard it as an advantage that the chemical proper-
ties of corrosive sublimate should compel us to administer it in such
doses that the object aimed at, the introduction of a certain amount
of mercury into the system, is only very slowly attained ; and I can-
not admit that much more mercury is taken up in a treatment by cal-
omel, if discontinued when salivation commences, than in a treatment
by corrosive sublimate when pushed to the same point. It cannot be
denied, however, that many people are cured of their syphilis by cor

780 CHRONIC INFECTIOUS DISEASES.

rosive sublimate, and especially by the very injudicious method of
Dzondi. If we employ this article, it must not be given on an empty
stomach, and is best administered in the form of pills ; but they should
not be made up with bread-crumbs and sugar, according to DzondVs
formula, but with powdered extract of liquorice ; and the dose should
not be raised, as is done in DzondPs treatment, from the fifth of a
grain to a grain and a half, but from half to three-quarters of a grain
should be given daily, in divided doses. In order to protect the gas-
tric mucous membrane from the corrosive action of the sublimate, it
has been proposed to give the albuminate of mercury, and thus at
once to furnish the combination which, when the pure bichloride is
used, eventually forms in the stomach, at the expense of the gastric
mucous membrane, and experience shows that double doses of this
preparation can be tolerated without detriment. If it were not that
[ am already perfectly satisfied with the medicines already spoken of,
[ should have recourse to the albuminate. Barensprung proposes
the following formula: 5 Hydrarg. bichlor. corrosiv. gr. ij, ovum
unum, aqua destillat. § vj, ammon. muriat. 3 j, misce exactissime.
Filtra. D. S., a tablespoonful every two hours. The dietetic rules Lo
be observed during internal mercurial treatment must be regulated
according to the condition of the patient. As a general rule, it is ad-
visable to restrict his diet, without going so far as to let him suffer
from hunger ; but now and then it may become desirable to feed the
patient upon the most nutritious food, under conditions already de-
scribed in treating of the chancre. The common practice of administer-
ing large quantities of " decoction of woods " is superfluous. Finally,
while we subject the patient to an active treatment, in order not to
expose him to other prejudicial influences, we must regulate his habits
and carefully watch over his general health. For this reason it is ur-
gently advised that syphilitic patients, who are undergoing a course
of mercury, should keep then* room, particularly in winter, and that
they should be visited daily.

We have said above that the primary ulcer and primary sore would
heal without the use of mercury ; but that under such treatment the
recovery was slower, and the secondary attacks came on more fre-
quently and earlier. This is equally true of the privation-cure (En-
tziehungs-cur), and the hunger-cure, the methodical use of cathartic
salts, and of Zittmanri's decoction, and other compound decoctions, the
object of which is to throw the skin, kidneys, and intestine, into a state
of increased activity, the supply of nourishment, meantime, being re-
duced to a minimum. If this kind of treatment be very energetically
conducted, and if the state of nutrition be depressed by a severe course
of simple or double Zittmanrfa decoction, we may, no doubt, succeed

CONSTITUTIONAL SYPHILIS. 781

in accelerating the heaxing of the primary affection. But, frequently,
just as the patient is beginning to recover from his eleven or twenty-
two days of fasting, purging, and sweating, the first crop of secondary
symptoms begins to develop.

The preparations of iodine are altogether useless against the pri-
mary affections ; although certain physicians, who only practise in the
country, or in the smaller towns, and who, rarely having occasion to
treat syphilis, have an exaggerated dread of the effects of mercury,
place great confidence in iodine. During my practice hi Magdeburg,
I remember many cases, where travellers visiting the small towns, and
consulting the physician of the place for indurated chancres, afterward
came under my hands, suffering from the worst iodine eruptions that I
have ever seen. From the recipes which they brought with them, it
was often quite evident that the iodic exanthema had been mistaken
for a syphilide, and the worse it grew, the larger were the doses of
iodine prescribed.

The secondary and tertiary symptoms of syphilis must always be
treated with the utmost circumspection and care, since there is no dis-
ease in which therapeutic errors can do such serious harm as in consti-
tutional syphilis. Mercurial treatment is nearly always of signal bene-
fit in the secondary and tertiary forms of the disease, and frequently
not only relieves and allays the symptoms as they arise, but some-
times brings about a complete and permanent cure. If, however, it be
administered again and again in unsuitable cases, instead of mitigating
the malady, it renders it still more pernicious, causing destruction of
the bones, degeneration of internal organs, and even endangering life
itself. The fact that horrible forms of syphilis are more rare than
they used to be, probably is partially because the " grand inunction-
cure " and other methods of over-treatment are being banished more
and more from the therapeusis of the malady, and that our employ-
ment of mercury is now more cautious and restricted. The indications
for mercurial treatment of constitutional syphilis have generally been
gummed up as follows : The secondary affections alone call for mer-
cury, while the tertiary accidents demand the exhibition of iodine.
Although this formula is somewhat inexact, yet, upon the whole, it 18
perfectly true. Mercurials are indicated in nearly all cases where the
affection belongs to the secondary group, while, in cases of a manifestly
tertiary character, they are generally contraindicated. To this rule an-
other is very properly added, that even in secondary affections mer-
cury is contraindicated, when it has already been used repeatedly with-
out success. The principles upon which the mercurial treatment of
syphilis is based may be deduced from what I have said above, re-
garding the course of the disease, and from the same remarks it wilJ

782 CHRONIC INFECTIOUS DISEASES.

also become apparent why I have spoken of the customary formulary
of indications as inexact, although right on the whole. When an in-
dividual, sooner or later after his recovery from an indurated chancre,
begins to suffer from condylomata or from eruptions, I do not hesitate
to prescribe mercury, either by inunction with blue ointment, or in the
form of calomel, to be taken internally, without regard to whether the
indurated ulcer has already been treated by mercury or not, for at this
period it very seldom happens that, owing to the state of the patient's
general health, or to the form of the syphilitic outbreak (then usually
a lupus or an affection of the bones), or from both the causes combined,
the constitution of the patient has suffered much either from the effects
of mercury or from the disease itself. It is only in these very excep-
tional instances that I consider a mercurial treatment contraindicated
at the period when signs of constitutional infection first appear, for we
may be almost certain that, if the syphilis cannot be successfully eradi-
cated by means of mercury, its next attack will be of a most pernicious
character. On the other hand, where the constitution is still unim-
paired, the good effect of mercury in allaying secondary symptoms is
most striking. The condylomata, exanthemata, and sore throat, dis-
appear much more rapidly than an indurated ulcer does, when treated
by mercury, and it often happens that not only are the immediate
symptoms allayed, but a permanent cure is effected. There are other
cases, however, in which the disease only becomes latent and not ex-
tinct ; and where it reappears some time after the subsidence of the
first set of symptoms, or relapses, to use the common expression. The
management of these relapses varies greatly, according to their character.
When the disorder is slight, as when plaques muqueuses appear upon
the tongue, or when a few scattered pustules form upon the scalp, the
attack is manifestly of a less serious character than the previous mani-
festations have been, and it is not advisable to renew the mercurials.
Syphilis never subsides suddenly, but usually dies out slowly and
gradually, and we may always hope for this favorable termination
when the new symptoms are of a less serious nature than their prede-
cessors. Although I do not advise a repetition of the mercurials in
such cases, yet the patient should be most carefully watched, kept
upon a reduced diet, and preserved as far as possible from all other
noxious influences, until the last traces of the disease have disappeared.
The "privation-cure" (" Entziehungs-cur"), and even the Zittmanrts
decoction, are suitable remedies for such cases. At the height of the
disease, the action of these methods of treatment is merely palliative,
but when it is beginning to decline, they really seem to accelerate its
complete disappearance. On the other hand, when the relapse shows
that the disease has not assumed a milder character, if the new mani-

CONSTITUTIONAL SYPHILIS. 783

festations are as severe as the former ones, or even more severe, but
still retain the nature of the secondary disorders, and if, as is generally
the case, the patient's constitution still seems to be unimpaired, I re-
commence the mercurial treatment, and, indeed, under certain circum-
stances (for instance, in case of rapidly-spreading ulceration of the
fauces, liable to become complicated with syphilitic laryngitis), I even
make the treatment more energetic than before. I order daily inunc-
tions of a drachm of blue ointment, or else give daily, or every other
day, two doses of calomel, of ten grains each, after the method of
Weinhold. It has often been objected, regarding WeinholcFs treat-
ment, that its only action is a laxative one ; that it does not salivate,
and that it exerts no important influence upon syphilitic affections.
These a priori views stand in direct opposition to the results of my
own experience in many cases where I have given half-scruple doses
of calomel.

If the relapse be unmistakably of a tertiary character, or if it be
merely of an intermediate nature between the secondary and tertiary
forms ; or, if the constitution of the patient have begun to suffer, wheth-
er from the disease or the treatment, then mercury is not only contra-
indicated, but even dangerous. Never use a grain of it under such cir-
cumstances, and I am certain that by such precautions the evil effects
of mercurial treatment may be averted.

I may be brief in stating the indications for the use of iodine in the
treatment of syphilis. In all cases where the spontaneous and speedy
extinction of the malady is not to be calculated on, and in which the
employment of mercurials is contraindicated, the exhibition of iodine
is urgently indicated, and then affords the utmost benefit. If we limit
the administration of the medicine to the above class of cases, and are
as methodical in its employment as we have been with mercury, we
shall find that its value in the treatment of syphilis is by no means in-
ferior to it. The preparation of iodine most generally employed is the
iodide of potassium, from ten to thirty grains of which are usually given
daily, in the form of a watery solution. Some physicians give larger
doses, or strengthen the solution, by adding one or two grains of iodine
to it, but apparently do not thereby augment its effect. According to
my experience, Barensprung to the contrary notwithstanding, I have
found the iodide of iron to be a very efficient preparation, especially
where there is advanced anaemia. I usually employ it in the form of
syrup of the iodide of iron (fy syr. ferri iodid. 3 ij, syr. simpl. § ij. nj,. S.
3j every two hours), and by its means have often produced iodic
eruption and catarrh. The appearance of this symptom, like that of
mercurial salivation, requires a suspension of the remedy. If the sus-
pension be followed by an arrest of improvement in the symptoms, tho

784: CHRONIC INFECTIOUS DISEASES.

iodine must be resumed after the catarrh or eruption has subsided
The diet should not be reduced ; not on account of the remedy, how-
ever, but because of the condition of the patient's general health. On
the contrary, his food should be nourishing, and he should be allowed
a little wine or beer. For persons of broken-down constitution I not
tmfrequently prescribe iron, quinine, and cod-liver oil, besides the iodine.

The local treatment of the secondary and tertiary symptoms should
be restricted to the extirpation of old condylomata (which, though they
always dry up under mercurial treatment, do not always disappear en-
tirely), to the application of atropine in iritis, to local blood-letting,
and to occasional surgical procedures, which may be demanded on ac-
count of destructive inflammation of the skin, caries, or necrosis. The
majority of the secondary and tertiary affections do not require local
treatment.

Syphilization, which, during the last ten years has been much
lauded as a certain means of eradicating syphilis, and of protecting
the system against further infection, has again fallen into disrepute,
or at all events is now merely practised by its introducers, and by the
enthusiastic disciples of their new doctrines. The process of syphiliza-
tion consists in the production of chancre pustules upon the skin of a
person afflicted with constitutional syphilis, which process is continu-
ally to be repeated, until the inoculation ceases to act. Apart from
the fact that some persons do not become proof against the chancre-
virus, after suffering several hundred and even as many as two thou-
sand inoculations, it has not by any means always followed that, the
immunity once attained, the syphilitic affection has healed ; and, where
recovery has taken place, it remains more than doubtful whether it has
been in consequence of the syphilization.

CHAPTER II.

CONGENITAL AND HEREDITARY SYPHILIS,,

ETIOLOGY. — We shall pay no attention to the forms of infantile
syphilis, arising from the infection of a child during birth by syphilitic
ulcers upon the genitals of its mother, or upon the nipples, lips, or
other parts of the body, of its nurse, for these forms of syphilis do nol
differ, either hi point of origin, or of course, from the syphilis of adults.

By the term congenital hereditary syphilis, of which alone we now
propose to treat, we mean a form of that malady occurring in newly-
born children, and originating in the embryo, from constitutional dis-
ease existing in the father at the time of begetting the child, or in the

CONGENITAL AND HEREDITARY SYPHILIS. 785

mother during the period of pregnancy. The manner in which the
contagion is transmitted to the embryo from the father or mother is
altogether unknown, and we shall, therefore, confine ourselves to a
statement of a few known and authentic facts, without attempting any
explanation of them.

If a woman who has secondary syphilis becomes pregnant, the
foetus nearly always dies prematurely, and is expelled by an abortion
or miscarriage. In such cases, the foetus is generally so much putre-
fied that it cannot be determined whether it bears traces of syphilis
upon it or not. In like manner, a woman who is healthy at the time
of conception, but who subsequently contracts syphilis, usually aborts
or miscarries, giving birth to a decomposing foetus. In other cases, the
child is carried to term, but dies either at the time of its birth or shortly
before. It then either bears distinct evidence of syphilis upon its
wasted body, or else there is no anomaly beyond its extreme emacia-
tion. In rare instances the child is bora alive, and lives for a longer
or shorter period of time. In such cases, the syphilis may appear im-
mediately after birth, or else may remain latent, and develop weeks or
months afterward. Inasmuch, then, as constitutional syphilis of the
mother exerts so pernicious an influence upon her offspring, that it
usually perishes either long before or else during birth, it will be
readily understood that the majority of cases of congenital syphilis,
which become the object of clinical investigation and medical treat-
ment, are the progeny of syphilitic fathers. It is an extraordinary but
well-established fact that syphilis may be thus transmitted from father
to child, without infecting the mother who bears the infected offspring
in her womb. Hereditary syphilis, derived from a syphilitic father,
sometimes manifests itself immediately after birth, while at other
times the characteristic symptoms do not appear until later.

SYMPTOMS AND COTJESE. — The symptoms of congenital syphilis
consist principally of affections of the skin and mucous membranes ;
and it is only in rare instances, when the disease drags on incurable,
out without killing the child, that it causes disease of the bones.
When children are born with evidence of the disease upon them, or
when it makes its appearance a few days after birth, it usually proves
to be of a more malignant nature than when it remains latent for
some weeks.

The former class, in which the malady assumes the character of a
bullous or pustulous syphilide, occasionally accompanied by a coryza
(see below), was for a long time misunderstood, and used to bear the
name of pemphigus neonatorum. When the child does not come into
the world with the disease already upon him, it usually commences
upon the palms of the hands and soles of the feet, and afterward

CHROXIC INFECTIOUS DISEASES

spreads to the arms, legs, and body, and sometimes to the face.
Roundish spots, as large as a pea or bean, and of a dirty-red color, are
first observable. In a short time the cuticle which covers them is
elevated into a bleb by the effusion of a turbid liquid. These blebs
burst, leaving excoriated, moist spots upon the skin, which show no
tendency to heal, and new blebs form upon the toes and fingers. Not
unfrequently some of the nails fall off. The later crops of blebs be-
have like their predecessors, and, as, day after day, new ones arise, the
unhappy child becomes excoriated at innumerable points. I have even
seen the blebs form in the mouth and nose. The malady may last
from a week to a fortnight ; more rarely three or four weeks, and al-
ways terminates fatally. Some of the cases occurring in my private
practice, in which the mother, with touching patience, daily cleansed
and bound up the fingers and toes of her babe, never suspecting that
its dreadful disease was the consequence of the excesses of its father,
have made an indelible impression upon my mind.

When syphilis remains latent for a few weeks, it presents another
aspect. (The bullous syphilide never commences latei than the first
week of infancy.) The child is often born in apparently good condi-
tion, and does not seem to differ in any respect from a healthy child.
About a fortnight after birth, and in some instances as late as a month,
or even two months after birth, it grows restless and thin, and its sur-
face assumes a remarkable dirty color. The skin also becomes ex-
tremely dry, rough, and shrivelled ; and, in particular, the hands and feet
look as if covered by a delicate husk, like that of an onion. It soon be-
comes difficult for the child to nurse, the nasal mucous membrane being
swollen, and the nostrils always filled by a thin secretion. This swell-
ing of the mucous membrane, and the profusion of the discharge, give
rise to a peculiar snorting and snuffling, which is almost pathognomonic
of congenital syphilis ; so that, in the absence of other signs, we can
hardly err in diagnosticating the disease from this symptom, together
with the peculiar condition of the skin. In most cases, the coryza is
accompanied by an eruption, which, beginning in the region of the
anus, spreads to the genitals, thighs, and loins, as well as to other
parts of the body, particularly to the face. This eruption is generally
of a character intermediate between that of the maculous, papulous,
and squamous forms. The separate maculae are rounded, of the size
of a pea or bean. Their color is a coppery or yellowish red, which be-
comes actually yellow when pressed upon by the finger. They may
be either distinct or confluent. At first they are level with the skin,
afterward they project somewhat above it ; then then- surface is not
rounded, but flattened, as if the top had been shaved off. As the
affection advances, the maculae are often covered with scales of epider-

CONGENITAL AND HEREDITARY SYPHILIS. Y8Y

aris, or with a continuous coating of thin desquamating layers of
cuticle, and, where the surface is habitually soiled by urine or the ex-
crements, it becomes excoriated. Another constant symptom of con-
genital syphilis consists in the formation of rhagades at points where
the skin changes into mucous membrane, especially upon the mouth
and anus. It can often distinctly be perceived that the lips of the
child are incurved and bleed readily upon the slightest movement, and
that it dreads to use them either in suckling, laughing, or crying. The
act of defecation cannot be accomplished without great suffering, so
that the child cries and moans whenever the bowels are moved. The
rhagades are often accompanied by condylomata, and in neglected
cases large ulcers, of a peculiar irregular, angular figure, form between
the nates, and sometimes in the flexures of the thighs, and in other
regions where intertrigo is apt to arise in healthy children. The dis-
charge from these sores is scanty, and readily dries up into a scab,
which is of a blackish color, owing to its containing an admixture of
blood. We have already stated that it is rare for congenital syphilis
to attack the bones. Cases are reported now and then, however, in
which the usually slight ulceration of the nasal mucous membranes
causes destruction of the bones of the nose, and depression of that
feature in the first year of childhood. In other equally rare instances,
congenital syphilis of early infancy either is overlooked or becomes
latent in consequence of treatment, and breaks out again at the period
of puberty in the pernicious form of syphilitic lupus, or disease of the
bones.

In the autopsies of children who have died of congenital syphilis,
or who have been born dead by syphilitic mothers, the characteristic
lesions of the disease are sometimes found in the internal organs,
especially the liver and lungs, more rarely in the brain. In the former
it consists merely of a diffuse, uniform induration, the sequel of a simple
non-gummous hepatitis. In the lungs, nodules, with cheesy centres of
the size of a pea or walnut, are formed, as well as a form of diffuse
condensation, first described by Virchoio, who calls it " white hepatiza-
tion," and which consists of a filling up of the air-vesicles with epithelial
cells in a state of partial fatty degeneration. In the brain, Schott, in
one case, has found gelatinous tumors of the size of a hazel-nut situ-
ated beneath the lower surface of the two anterior lobes of the cere-
brum. Finally, the thymus gland is sometimes considerably enlarged,
and contains abscesses.

TREATMENT. — Hitherto, the treatment of the bullous syphilide has
always been in vain. On the other hand, in the second form of con-
genital syphilis just described, comparatively good results may be ob-
tained by means of appropriate medication. The most common and best
method of cure consists in the exhibition of small doses of calomal (gr. J)

788 CHRONIC INFECTIOUS DISEASES.

morning and evening, and the inunction of five or ten grains of mercurial
ointment daily, or every other day. The treatment must not be pushed
to salivation, but should be suspended as soon as a decided improve-
ment in the symptoms begins to manifest itself, and renewed again
whenever the improvement seems to flag. It is very important that
the strength of the child should be supported by the most nutritious
diet possible. It would be wrong, however, to intrust it to a wet-
nurse, since this would expose the latter to the danger of infection.
That a syphilitic child, although it rarely infects its mother, often does
BO to its nurse, is simply because the mother is generally syphilitic
already, and hence is proof against further contagion.

APPENDIX.

INFECTIOUS DISEASES TRANSMISSIBLE FKOM BBTTTE8 TO HtTMAN UEINGS.

WE shall merely discuss the subjects of glanders and hydrophobia
in the following chapters. Regarding the malignant pustule, though
this is likewise an infectious malady, communicable from the lower
animals to man, yet, as it is more especially a matter of surgical inter-
est, I refer to the text-books of surgery.

(JHAPTEK I.

HUMAN GLANDERS. — MALLEUS HUMIDUS ET FABCINOSUS.

ETIOLOGY. — There is an infectious disease which attacks animals
possessing an undivided hoof, especially horses, asses, and mules, and
which is called glanders or farcy, according to the locality in which the
lesions induced by the virus develop themselves.

The virus of glanders, which is identical with that of farcy, repro-
duces itself within any organism which it has infected, and the trans-
mission of the virus thus reproduced in one individual to another is the
most frequent, and indeed probably the only manner in which the
malady is propagated. In other words, glanders is a contagious dis-
ease, and probably is a purely contagious one. Its virus, like other
contagions, is insusceptible of demonstration under the microscope, or
by means of chemical analysis, and we only recognize its presence by
its effects. It is contained in the discharge of the farcy-buttons pres-
ently to be described, in the flow from the nostrils, the blood, and
( Viborg) in the excretions, the saliva, urine, and sweat. Whether it
is volatile, and capable of pervading the insensible perspiration of the
.nfected oerson, is doubtful. The fact that the disease may be trans-

GLANDERS. 789

mitted at a distance of ten or twelve paces, might be dependent upon
the circumstance that particles of nasal secretion might be thrown that
distance by a horse, or because the snorting of the animals produces
small bubbles of the secretion capable of floating for some time, and
of being propelled by the faintest current of air. The glanders may
be communicated from the horse, ass, or mule, to various other mam-
malia. Man is likewise susceptible to it, so that coachmen, grooms,
cavalry-soldiers, horse-doctors, and other persons having business
among diseased animals, are not unfrequently infected by it. In rare
instances, and probably during post-mortem sections only, the disease
has been transmitted from man to man. The virus of glanders seems
to be capable of penetrating the epidermic and epithelial coats, since
most cases of infection by it have not been preceded by any wound
of the skin.

ANATOMICAL APPEARANCES. — The lesions induced by infection
with the poison of glanders consist in peculiar nodules in the mucous
membrane of the nose, the lymphatic glands, the skin, the muscles,
the lungs, and other organs. At first they are hard, but afterward
soften, disintegrate, and form abscesses and ulcers. According to
Virchow, whose description of glanders we follow, these nodules are
the product of a proliferation of cells. In the more recent nodules the
cells are young, small, and delicate, and there are many free nuclei ;
in the older ones the cells are large, distinctly nucleated, lie closely
together, and make up almost the entire mass of the tumor. As they
progress, the older cells degenerate, and become partially filled with
fat globules ; they then lose their sharply-defined contour, and break
down, so that the nodule finally contains only a mass of detritus, with
a few isolated elements. Virchow calls attention to the similarity in
the progress of development of the farcy and glander nodules, and
that of tubercle ; but remarks, pointedly, that no inference ought to be
drawn from the coincidence of these processes, as the transformation
of cells into caseous material is not peculiar to tubercle, and occurs not
only in that disease, but also in pus, cancer, and sarcoma.

The nodules which develop upon the nasal mucous membrane of
horses, asses, and similar brutes, and which constitute glanders par
excellence, are of the size of a hemp-seed or pea. The ulcers which re-
sult from their bursting are at first solitary, or grouped, but gradually
coalesce, imparting to the mucous membrane a peculiar worm-eaten
look. The destruction then extends by the development and burst
ing of new nodules upon the edges of the ulcer, as well as upon its
floor, and upon the surrounding parts, and by gangrenous disintegra-
tion of large portions of its surface. The ulceration also strikes
deeply laying bare the cartilages and bones, which die and are dis-

790 CHRONIC INFECTIOUS DISEASES.

charged The eruption of nodules is attended by a nasal catarrh,
which is very intense around the ulcers, and is at first accompanied by
a thin transparent secretion. The discharge subsequently becomes
thick, tenacious, and purulent; and when the ulceration is far ad-
vanced, it is discolored by the admixture of blood, and becomes acrid
and fetid, and contains the debris of the necrosed tissues.

In farcy, a disease which develops in the skin and lymphatics of
horses and similar animals, the tumors are larger than the genuine
tubercles of glanders. They contain a greater quantity of caseous mat-
ter, are discrete, or else congregate in clusters, or chains and wreaths.
After bursting, they form rounded ulcers, with elevated or everted
edges, with a foul, irregular bottom, furnishing a profuse ichorous dis-
charge, which often glues the surrounding hairs together, drying up
with them into hard crusts.

Both glanders and farcy appear in man. The latter form, however,
is the more common, and usually attacks the skin, upon which it gen-
erally produces an eruption of tubercles, which are larger and more
numerous than those occurring in brutes. The lesions of the nasal
mucous membrane are exactly like those found in the horse. Those
of the skin, subcutaneous areolar tissue, muscles, and lungs, are puru-
'lent rather than caseous; so that in the skin they look like pustules,
and in the connective tissue, muscles, and lungs, they bear a great
similarity to metastatic abscesses. The lymphatics and their glands
are likewise often implicated in the disease in man, and, as in horses,
they sometimes produce a chain of farcy-buttons. An inflammation
not unfrequently extends from the lymphatics to the neighboring skin,
which thus becomes the seat of a malignant erysipelas, with a ten-
dency to gangrene.

SYMPTOMS AND COURSE. — The period of incubation of glanders or
farcy is of very variable duration. Where the virus has been im-
planted upon a wound, the first symptoms generally appear within
three or four days ; but, when infection occurs where there has been
no breach of surface (as when the virus is inhaled), the malady often
does not break out for months. The course and magnitude of glan-
ders also differ in the two cases. When the poison acts upon an
abrasion, the first symptoms which appear are usually local ; the
wound inflames ; the lymphatics of the part form knotted chains, and
their glands swell painfully. The inflammation assumes an erysipela
tous character, and is attended by an intense oedema. Blebs form,
and pustules, having discolored ichorous contents, and sometimes real
gangrenous bullae, arise upon the skin, and abscesses often develop, or
diffuse phlegmonous destruction takes place in parts about the in-
flamed lymphatics. Sometimes the disease seems to go no further

GLANDERS. 791

than this, its effects remaining confined to the lesions about the wound
just described, and to a fever of an intensity corresponding to the
severity of the case. Signs of a general implication of the system
often accompany the above symptoms, however; and indeed they
usher in the disease whenever it has not been preceded by a wound.

The term prodromal stage, or stage of invasion, is usually applied
to the period during which, although none of the lesions characteristic
of glanders or farcy have as yet appeared, still the fever, constitutional
disturbance, and certain subjective symptoms, announce a general in-
fection of the system.

Sometimes a single rigor occurs at the beginning of the attack, in
others the rigor is repeated several times. The skin grows hot, the
thirst augments, the pulse is accelerated, the patient feels depressed
and languid, complains of pain in the head, sleeps badly, has no appe-
tite ; in brief, exhibits a series of symptoms such as accompany other
infectious diseases or local disorders which are accompanied by fever.
These manifestations, however, are accompanied by another constant,
and somewhat characteristic phenomenon, namely, a violent pain in
the joints and muscles. The seat of this pain is usually in the vicinity
of the greater articulations. It is generally augmented by motion or
pressure, and is sometimes, although not always, attended by moderate
swelling of the painful part. Although these articular and muscular
pains often cause the disease to be mistaken for rheumatism, yet, when
they occur in an individual whose history is suspicious, they may aid
us in an early and correct interpretation of the symptoms.

The first stage of the disease lasts for a longer or shorter period
(and it may continue for three or four weeks, or more) ; the symptoms
either increase steadily all the time, or else gradually grow milder, so
as to subside almost completely when the second or eruptive stage,
the stage of localization of the malady, sets in. The aspect of the dis-
ease at this period presents many varieties, according as the malady
selects one or other tissue as its seat. If it attack the nasal mucous
membrane as glanders in the stricter sense of the term, an erysipela-
tous inflammation makes its appearance upon the exterior of the nose
and its vicinity. The nose, the eyelids, and the forehead swell, as-
suming a dusky redness, and are covered by blebs, the precursors of
gangrene. The patient cannot breathe through his nostrils, from
which there flows a liquid, at first scanty, thia, and mingled with
streaks of blood ; afterward foul, bloody, and sanious. If the patienl
lie upon his back, the discharge flows through the posterior nares into
the pharynx, and provokes him to hawk and cough.* The discharge
sauses erosion of the lining of the mouth, soft palate, and tonsils,
winch are of a deep-red hue, and are covered with ulcers and sloughs
100

792 CHRONIC INFECTIOUS DISEASES.

In addition to these manifestations of glanders, or independently of
them, when the nose is not attacked, characteristic lesions usually are
found upon the skin, which were formerly regarded as a pustulous
eruption, until Virchow demonstrated that in glanders there was no
elevation of the epidermis by an exudation thrown out from the sur-
face of the cutis, but that the skin suffered a circumscribed disintegra-
tion, above which the cuticle for some time remained intact. Accord-
ing to Virchow, the affected portions of skin at first are intensely red-
dened, and very small, almost like flea-bites ; they then change into
papules, and the little elevations afterward assume the aspect of pus-
tules. Beneath their epidermis we find a tolerably thick, yellow
liquid, filling up a hole in the corium. The contents of the glanders-
pustules, enormous numbers of which often appear upon the body,
sometimes grow bloody, and dry up into small blackish or brownish
crusts. Besides this scattered eruption, Virchow describes clusters
of larger " farcy-buttons," which lie deeper in the skin, in the form of
large, flat, hard, red tumors, from which the cuticle is finally separated
by an effusion of blood, so as to form bluish bullae. The upper por-
tion of the cutis, which covers these clusters, is also infiltrated by a
haemorrhagic exudation, and afterward breaks down into a pulpy
detritus.

The " farcy-buttons " of the subcutaneous areolar tissue and mus-
cles arise either with diffuse inflammatory infiltration of the adjacent
parts and all the symptoms of a severe phlegmon, or else small cir-
cumscribed, hard, or boggy tumors form, which are quite painless, and
then may develop unobserved. Sometimes the contents of the nodules
are absorbed ; more commonly the skin either ulcerates or sloughs, and
great destruction, occasionally extending even to the bones, is the con-
sequence.

Participation of the lungs and bronchial mucous membrane in the
disease is announced by shortness of breath, cough, and rales. The
deposits are too minute to admit of detection by physical examination.

The larger the number of these symptoms simultaneously pre-
sented by the case, and the more rapidly they progress, so much the
sooner will the patient succumb with all the signs of the most intense
adynamy, and of the so-called typhous or putrid fever, the malady
always ending fatally. Death may occur as early as the first day or
two, while other cases drag on until the third week.

In chronic glanders and chronic farcy the characteristic lesions of
the nasal mucous membrane, muscles, and areolar tissue, are more
sparing and less speedy of development than in the acute form, which
is of far more frequent occurrence. The skin usually remains intact,
while the lungs and bronchial lining are soon affected. Pauses not

HYDROPHOBIA. 793

anfrequently occur in the eruption, so that the disease seems to have
subsided until another cold abscess begins to form or a new eruption
breaks out. In chronic glanders and farcy also, the majority of pa-
tients finally perish of marasmus, and there are very few instances in
which the disease is reported to have ended in recovery.

TREATMENT. — One of the important tasks of a sanitary police
should be to diminish the opportunity for the propagation of the virus
as much as possible, by the enforcement of strict regulations. Such
precautions alone can be productive of certain results, while the
utmost vigilance and care will not furnish security, when, either from
carelessness or selfishness, the regulations are neglected.

Prevention of constitutional infection, by vigorous destruction of
the point of inoculation of the glanders, can only be hoped for imme-
diately after contact of the virus with the wound. The remedies
proposed for the cure of pronounced glanders, calomel in large doses,
iodine, Fowler's solution, injections of a strong solution of creosote into
the nostrils, and the cold-water cure, are all productive of but little
benefit, according to our present experience. A treatment of the
symptoms, in which local disturbance, fever, and the strength of the
patient, are taken into account, is the one most to be commended.

CHAPTER II.

HYDROPHOBIA — LYSSA K ABIES.

ETIOLOGY. — The difficult question about the nature of rabies and
its proper position in the nosological system remains unsettled. The
fact that the poison, the absorption of which induces the disease, is
reproduced in the body of the patient, goes far toward proving that it
is infectious. This view is also favored by the symptoms occurring
among certain classes of animals. The two chief forms of rabies in
dogs, the quiet and raging, remind us of the febris nervosa stupida anc?
febris nervosa versatilis of old authors. On the other hand, there are
certain objections to classing lyssa among typhus fevers, the acute
exanthemata, and other acute infectious diseases. I would especially
call attention to the variable duration of the period of incubation in
different persons. We do not certainly know the length of time
between the action of the contagion and the outbreak of the malady in
all infectious diseases, but we suppose that the difference of this
interval is only slight in different persons. In lyssa the period of
incubation varies weeks and months, even if we do not consider

794 CHRONIC INFECTIOUS DISEASES.

extreme casss. Moreover, there is an essential difference between the
character of the fever in this and other acute infectious diseases.

In lyssa, among the symptoms are some nervous ones, slightly analo-
gous to the neuralgias which occasionally occur, instead of the fever
in malarial infection. Lyssa humana most resembles tetanus, although
I cannot understand how it is possible to deny the occurrence of lyssa
as an independent disease, and to identify it with tetanus. In the
well-observed cases, neither continued tension of the spinal muscles
nor pain in the contracted muscles has been mentioned, while neither
is ever wanting in true tetanus. The difference between lyssa and
tetanus is, that the spasms, which may be termed tetanic, only occur
in some paroxysms, and are limited to certain nerves, and more par-
ticularly to those which are by no means chiefly affected in traumatic
or rheumatic tetanus. When Homberg terms lyssa a toxoneurosis, he
says all that we actually know of the nature of the disease.

Without the experience that the poison is reproduced in the body
of the patient, we might most reasonably suppose that a toxic neuritis,
or a toxic neuropathia, spread from a peripheral nerve, on which the
poison had worked, to the medulla oblongata and cerebrum; and,
since in many cases changes in the wound or in the cicatrices precede
the outbreak of the malady, and the time between these changes and
the outbreak is very short, it would be most probable that the poison
had remained latent at the seat of injury, but afterward had rapidly
spread in a centripetal direction. This latency would most remind
us of that of syphilis between the different outbreaks of the disease.
However, all this reasoning lacks a solid foundation.

Lyssa, or rabies, in its stricter sense, is a disease which origi-
nates in pnimals of the dog kind, and which indisputably is propa-
gated, in most instances, by infection of one animal by another.
We shall not discuss the question whether this be its only mode of
propagation, or whether, under certain circumstances, it may develop
spontaneously. The rabies of other races of animals and the hydro-
phobia of human beings are purely contagious maladies. This
poison, which exists in the saliva, blood, and perhaps in other
fluids of the body, is not volatile, but fixed in character ; it cannot pass
through the epidermis, and hence does no mischief, unless brought ir
contact with an ulcerated or excoriated surface.

The most common cause of human rabies is the bite of a mad dog.
More rarely the disease originates in the bite of some other rabid
animal, such as the wolf, the fox, the cat, or the ox. The possibility
of infecting a healthy man by the bite of a man suffering from hydro-
phobia has not yet been proved positively ; but the inoculation of the
disease from human beings to brutes has reoeatedlv been successful

HYDROPHOBIA. 795

Bites of rabid animals upon bare portions of the body are far more
dangerous than if the part bitten be covered by the clothing ; as, in
the latter case, the poisonous saliva is not so readily conveyed to the
wound, being wiped off from the teeth by the clothing. For the same
reasons, there is no danger from the licking, or otherwise moistening,
of the sound skin by the saliva, blood, or other fluids of a rabid animal,
unless there should happen to be an abrasion or fissure upon its surface.

The virus, when implanted upon an excoriation of the skin, does
not lead to hydrophobia unless there be a certain degree of predispo-
sition to the disease. Inoculations of the saliva of rabid animals, as
practised by Hertwig, succeeded only in twenty-three per cent, of the
animals operated upon, seventy-seven escaping ; and, according to Fa-
ber's statistics, out of one hundred and forty-five persons bitten by
rabid animals, in WUrtemberg, only twenty-eight had hydrophobia.

ANATOMICAL APPEARANCES. — No lesions characteristic of the dis-
ease are found in the bodies of those who have died of hydrophobia.
The most common conditions consist in intense rigor mortis, extensive
post-mortem hypostasis, early putrefaction (so that, soon after death,
blebs full of gas begin to arise), intense staining of the endocardium and
walls of the vessels, hypersemia and serous exudation in the brain and
its membranes, in the spinal marrow, in some of the sympathetic gan-
glia and nerves ; hypersemia and swelling of the mouth and fauces,
both of which contain a collection of tenacious mucus ; hypostasis and
oedema of the posterior parts of the lungs ; engorgement of the walls
of the stomach, and great abdominal glands. All these lesions, espe-
cially the injection of the nervous centres and nerves, upon which, at
times, great stress has been laid as explanatory of the nature of the
disease, are not constant, and, for the most part, seem to arise just
prior to dissolution, in consequence of the disturbance suffered by the
functions of respiration and circulation during the attacks presently to
be described. In the cases which I have seen, autopsy showed a
decided swelling of the tonsils and follicular glands at the root of the
tongue and the posterior wall of the pharynx, exactly corresponding
with Virchovfs observations.

SYMPTOMS AND COURSE. — Most cases of lyssa that have been
well observed and described closely resemble each other. One that
I have seen corresponds closely to the dreadful picture which
Romberg drew from his own and other cases. As it is universally
assumed that morbid processes due to the action of a specific poison
run their course with symptoms which only vary through personal idio-
syncrasy and the variable intensity with which the poison has acted,
those reports of lyssa humana differing from our description, in which
the characteristic symptoms and their peculiar sequence are not

796 CHRONIC INFECTIOUS DISEASES.

mentioned or really did not occur, must arouse the suspicion that they
were badly observed, or that there was an error of diagnosis.

Opinions differ as to the length of its period of incubation. The
statements that hydrophobia has made its appearance twenty or thirty
years after the bite of a rabid animal, as well as those according to
which the disease has broken out as early as the second or third day,
are probably dependent upon imperfect observation. The shortest
term of incubation appears to be about eight or ten days ; the longest,
twelve or thirteen months. In the majority of instances, the malady
breaks out in about forty days after the reception of the bite. The
reasons for this inequality of the period of incubation are obscure. The
assertions of Marochetti, who claims that, during the incubative stage,
vesicles form beneath the tongue, and that, by destroying these vesi-
cles, the outbreak of the disease can be averted, have not been substan-
tiated. But there are numerous instances in which, toward the end
of the stage of incubation, and a day or two before the onset of the
malady, peculiar alterations have been observed in the wound or its
scar, for the wound has generally healed by this time. The bite as-
sumes a livid color, grows painful, and discharges a yellow ichor.
The scar, which has generally soon formed without remarkable symp-
toms, grows bluish red, swells, and sometimes breaks out afresh.
The patient also complains of painful sensations, shooting centripetally
from the wound or scar, or of a sense of numbness in the bitten mem-
ber. These disturbances at the point of entry of the virus are very
often wanting.

The first or prodromic stage of the disease is marked by a peculiar
depression of the patient's spirits, amounting to an acute melancholy,
and which has caused the term stadium melancholicum to be applied
to this period of the disorder. The patient seeks solitude, is timid
and apprehensive, and either sits motionless and plunged in deep ab-
straction, or else is unable to rest at all. Some complain of an indefi-
nite feeling of dread and oppression, and sigh repeatedly without
any reason for so doing. Some are preoccupied with sad forebodings,
or, if aware of their perilous condition, are incessantly tormented by
dread of the onset of the malady. Sleep is restless and broken by
frightful dreams. The precursory signs of the spasmodic disturbance
of respiration, afterward to attain so terrible an intensity, soon super-
vene. The patient complains of pressure in the prsecordium, draws
profound, sighing inspirations, the diaphragm is depressed, the epi-
gastrium bulges, and the shoulders are drawn upward. This spas-
modic breathing is the first token of the tonic spasm of the muscles
of inspiration which causes such frightful torments in the second stage
of the disease.

HYDROPHOBIA. 797

The prodromic term having lasted two or three days, the second
or furious stage begins. Its onset is marked by a fit of choking, sud-
denly induced by an attempt to drink, which renders the patient in-
capable of swallowing a drop.

The moment the fluid enters the mouth and the motion of swallowing
is made, spasmodic inspiratory motions begin ; the thorax rises inter-
ruptedly, and remains in the position of deepest inspiration for ten or
twenty seconds. During this time the features betray anxiety and
terror, the eyes protrude, head and shoulders are thrown back, then
comes an expiration, with which the attack passes off. I have satisfied
myself that the inspiratory muscles, as well as those of the pharynx,
are implicated in these seizures. This combination of spasmodic con-
tractions in both of these sets of muscles is a frequent symptom ; it
always appears in the straining preceding vomiting, as well as in the
retching following irritation of the pharynx by the finger, etc. Retch-
ing is always accompanied by a feeling of suffocation, from the contrac-
tion of the inspiratory muscles complicating the spasm of the pharynx ;
and we are justified in giving the name of retching-fits to these spasms,
which form the pathognomonic symptom of lyssa, and are given in
every well-recorded case.

The dread of water is entirely due to the dreadful experience of
the patient on trying to drink. This was so, not only in my case, where
the patient, an energetic and courageous man, voluntarily made
repeated attempts to drink, before he rejected with terror any sugges-
tion of the kind, but it is the same in all cases of undoubted lyssa
that have been well observed and accurately described. Reports of
cases where hydrophobia is given as a primary symptom are worthy of
no credence. It is a curious fact that, at first, the act of swallowing
solid food is not followed by spasms. Even a draught of air on the
skin, or touching any thing cold, sudden irritation of the eye by dazzling
light, even sudden mental excitement or surprises, may induce attacks.
According to my observation, the pharyngeal muscles do not partici-
pate in the reflex spasms induced by irritating other parts, as the
mouth or palate. On suddenly arousing my patient, he opened his
mouth widely, threw the head back, the thorax was raised as in full
inspiration, the epigastrium became prominent, but there was no
actual retching. At the height of the disease, it looked as if attacks
occurred from time to time, even without cause ; but I think that even
these apparently spontaneous attacks must be regarded as reflex
epasms, and be referred to collections of tough mucus in the pharynx
or to the trickling into it of saliva. This supposition is based on the
haste and abandon with which the patients eject saliva and mucus,

798 CHRONIC INFECTIOUS DISEASES.

and their attempts to introduce the finger far into the throat, for the
purpose of removing mucus and sputa.

Various authors name tetanic or epileptiform spasms among the
symptoms of lyssa ; but, on careful examination, I have not been able
to discover a case where the detailed description of the spasms fully
convinced me that they were tetanic or eclamptic. It is nowhere
stated that the muscles of the back were tense, except during the
attacks, or that consciousness was lost during the general convulsions.
In my patient, there was also opisthotonos — he threw his hands and
feet about, and pitched around, so that he frequently fell on the floor.
But these symptoms reminded one far more of hysterical spasms, or of
the actions of a tortured, despairing man.

The above symptoms are soon accompanied by attacks of
boundless rage, in which the patients are hard to manage, destroy all
tfiat comes in their way, strike, kick, scratch, and bite, if held fast —
and, not unfrequently, kill themselves, if they are carelessly watched.

The biting, inarticulate howling, and barking sounds, are not made
more frequently by a hydrophobic patient than by another madman
in the maniacal stage of chronic cerebral disease.* The patient often
warns his attendants between the fits, which seldom last longer than
a quarter or half an hour, and begs pardon for his misbehavior toward
them, and sets his worldly affairs in order, in perfect consciousness of
the near approach of his end. The paroxysms of madness and convul-
sions, having steadily grown more frequent for two or three days, now
begin to diminish in violence as the patient loses strength. Rarely,
it happens that death occurs at the height of the malady, during a
severe and long-continued choking-fit. The exhaustion and collapse
usually augment from hour to hour; the voice grows hoarse-and feeble,
the respiration shallow, the pulse small, irregular, and very frequent,
and death ensues with the signs of a general paralysis, which is some-
times preceded by a deceptive amelioration of the symptoms.

It might be supposed that the attacks of madness occurring in
lyssa were simply a result of the despair that would affect even a
person not having this disease, if he suffered from retching at short
intervals for a day or two. I once attended a patient suffering from
severe pharyngitis, who, when I asked him to try to drink, hurled the
glass from him, and acted like a madman.

We find something like this, too, in patients with croup or oedema
glottidis. The fact, also, that sometimes patients of very temperate

* Romlerg says that a great inclination to bite, along with the absence of charac*
teristic reflex spasms, is one of the diagnostic points between true lyssa and those
hypochondriacal and maniacal conditions that fear of the disease not unfrequently
develops in persons that have been bitten. This state might be termed lyssophobia.

HYDROPHOBIA. 799

and resigned natures do not become maniacal would also favor this
view. But there are some objections to it, especially the fact that,
even in persons the most resigned, the absence of mania is one of the
rarest exceptions, as well as the excessive height that the madness
usually reaches in lyssa patients. It is certainly more probable that
the madness in lyssa is not due to moral grounds, but is caused by a
propagation of the excessively increased morbid excitability of the
motor-central apparatus of the pharyngeal and respiratory nerves
to the central organs of the psychical functions. The symptoms of
the mania have many analogies to reflex spasms. Trifling mental
excitement causes severe outbreaks, violent motions, and excited
actions in manaical patients, just as slight irritation of the skin causes
severe reflex spasms in patients with tetanus.

TREATMENT. — We shall only make the following brief remarks
about the sanitary measures by which the state should try to protect
its subjects. The only prophylaxis is by confinement of dogs. No
attention should be paid to the lovers of dogs. Any one who
expends sympathy on the "poor dog," and petitions against his
being tied up, or wearing a muzzle, should be made to watch a patient
with hydrophobia for half an hour, and he would soon be cured.
Most muzzles that dogs wear do not prevent their biting, and they are
only protective when they do so. It is very important not to kill
dogs suspected of madness, but to shut them up and observe them
closely. Death, which soon takes place spontaneously, and the
symptoms under which it occurs, are far more important in deter-
mining that the dog was mad, than are the results of autopsy ; for,
from the latter, especially if the dog was killed by violence, it cannot
be said with certainty whether the dog was mad or not, and harm
has been done by such unreliable, demonstrative assertions. The
most we can say is that negative results of an autopsy, where no
changes have been found in any organ of a dog suspected of rabies,
to explain the symptoms and death, go to prove the probability of
the diagnosis — especially if we find hair, straw, rubbish, etc., in the
stomach ; for, while a healthy dog would not be apt to swallow
them, a mad one would.

If a man has been bitten by a dog suspected of rabies, prophy
laxis requires a destruction of the spot with which the poison may
have come in contact ; and every dog that has bitten without pro-
vocation, or without previous inclination to bite, should be sus-
pected.

The object of prophylactic treatment should be to destroy the por
tions of skin which have come in contact with the virus. It consists
in excision of the wound, and in the vigorous cauterization of the part

CHRONIC INFECTIOUS DISEASES.

with the hot iron, or with a deliquescent caustic, such as caustic potash,
butter of antimony, and the like. It is also advisable not to permit
the sore, resulting from detachment of the eschar thus made, to heal
too rapidly, but, if practicable, to keep it suppurating for months.
These measures are all the more likely to be successful, the earlier
they are applied, but they should never be neglected, even though
weeks have elapsed since the infliction of the bite.

As a further precautionary treatment, the exhibition of mercury to
the point of salivation, large doses of belladonna, and a series of other
so-called antilyssa, are employed ; but it is very questionable whether
the disease has ever been averted by the use of any of these articles,
and whether the cases in which hydrophobia has not followed upon the
bite after the use of anagallis arvensis, gentiana cruciata, rosa canina,
genista luteo-tinctoria, cantharides, or may-worm, did not belong to the
seventy-seven per cent, of subjects in whom the predisposition to rabies
did not exist, and without which hydrophobia never occurs. Inasmuch
as, after the establishment of the disease, these measures do not pro-
duce even the slightest palliative effect, their prophylactic virtue is
more than doubtful ; hence, I by no means regard it necessary to
subject a man, who has been bitten by a mad dog, to the baneful in-
fluence of mercury, although I should not hesitate to resort to any
procedure, be it never so severe or dangerous to the life of the
patient, if, according to actual experience, any benefit were to be
expected from it.

If the disease has broken out, there is little hope of curing it, or
even of alleviating the sufferings of the patient, for hitherto there
has been no accurately observed case of lyssa having any other termi-
nation than a painful death. Even the waiting and nursing are very
difficult, and should only be trusted to persons who are humane as well
as fearless and energetic. Every thing that can induce return of the
spasms, and, later, of the paroxysms of madness, should be carefully
avoided. To relieve the thirst, small enemata of cold water may be
given from time to time. In the case I saw, these were well borne
and quickly absorbed. In recent cases, where the patient is young
and vigorous, we may bleed, as in some cases this has proved of
undoubted benefit. If the patient will bear it, we may also let him
inhale chloroform from time to time, and give subcutaneous injections
of a strong solution of morphine. The favorable results said to have
been attained in some cases of tetanus, by the use of curare, decided
me to try it in a case of lyssa under my care. At first -j^th, later
^th of a grain of carefully- tested curare was subcutaueously injected
at intervals of three to four hours. Distrustful as we were about the
result, this treatment still seemed of palliative benefit, and seemed

HYDROPHOBIA. 801

to afford greater relief than the morphine injections. The patient
repeatedly prayed for the continuance of the curare injections, as he
was firmly persuaded that they relieved him. This experience is
enough to make me urge injections of curare in any case of lyssa
humana ; and, as nothing can be lost by it, to give it even more boldly
than we did.

SECTION in.

GENERAL DISORDERS OF NUTRITION WHICH DO
NOT DEPEND UPON INFECTION.

CHAPTER I.

CHLOROSIS.

ETIOLOGY. — The subjects of anaemia and hydraemia belong rather to
the province of general pathology, since such anomalies of the quan-
tity and quality of the blood never arise as independent affections, but
always appear as an accompaniment or consequence of other diseases.
The state of the blood which gives rise to the condition known as
chlorosis differs from that which induces hydraemia. In chlorosis, only
the cellular elements of the blood are diminished in number, while its
quantum of serum, albumen, and saline constituents, is generally nor-
mal. In hydraemia, on the other hand, not only is the blood poor in
cellular elements, but its serum is deficient in albumen, and it probably
is overcharged with salts. A chlorotic state of the blood (oligocythae-
mia, VogeT) often develops with a certain degree of independence ; or,
to speak more accurately, it frequently arises without our being able
to perceive any morbid condition which, by augmenting the consump-
tion of the blood, or by diminishing its production, might induce chlo-
rosis, and which generally can be discovered in anaemia and hydraemia.
In the present chapter it is the former class of cases alone with which
we have to do, and we shall not notice those rare instances in which
oligocythaemia develops as a symptom in certain diseases.

In females between the ages of fourteen and twenty-four, chlorosis
is one of the most common of disorders. It is very natural, then, to
ascribe the disease to the effects of those processes which are going
on in the bodies of young girls at the period of puberty; but we
are still ignorant as to what physiological connection exists be-
tween the two conditions. We know equally little of the causes

CHLOROSIS. 803

favor the occurrence of chlorosis at the time of puberty ; for, al-
though it is not improbable that the development of this affection is
often encouraged by a want of fresh air and exercise, by improper
nourishment, mental excitement, improper reading, masturbation, or
by a generally unhealthy mode of life, yet the disease arises often
enough under conditions precisely the opposite of these, in girls who
work all day in the open air, who are well fed, do not read novels, and
are not addicted to any secret vice. I may add that, according to my
observation, obstinate chlorosis attacks all young girls without excep-
tion, in whom the menses have appeared in the twelfth or thirteenth
year, and before the development of the breasts and pubes.

Far more rarely chlorosis — oligaemia without assignable cause —
appears in children and in pregnant women, and sometimes even in
males. The number of instances of chlorosis in this class is very
limited.

ANATOMICAL APPEARANCES. — The lesions characteristic of chloro-
sis lie mainly in the blood, which, with Virchow, we may regard as a
tissue consisting of cells with a liquid intercellular substance. As has
been said already, this intercellular substance, the serum, does not
present any constant anomaly. Its composition generally is normal ;
more rarely there is a diminution of its albumen. In other cases, again,
the amount of albumen of the blood-serum seems to be increased, so
that, besides the oligocythaemia, there is hyperalbuminosis. In the first
two instances, the whole volume of the blood is probably reduced,
while in the latter the possibility cannot be denied that, in spite of
the diminished number of the blood-corpuscles, the absolute bulk of
the blood is augmented, adding a serous plethora to the oligocythsemia.

In pronounced chlorosis, the disease in the red-blood corpuscles
may be so great that a thousand parts of blood may contain but sixty
or forty parts of dried blood-cells, instead of the normal average of one
hundred and thirty parts. Upon the autopsy of a chlorotic person,
who has died of intercurrent disease, the viscera are all found to be
remarkably pale. In some cases, the signs of simple fatty degenera-
tion are found in the tunica intima of the great vessels.1

SYMPTOMS AND COURSE. — The most striking symptom of chlorosis
consists in the pallor of the skin and visible mucous membranes. When
the skin contains but little pigment, as is the case in blondes, the sur-
face of the body is of a pure white ; while, when the pigmentation is
intense, as in black-haired persons, it is more of a dirty-gray or yel-
lowish hue. The pallor is often most distinctly pronounced upon the
ears, while in the mucous membranes the loss of color is most remark-
able in the conjunctiva and the gums. The reason for this blanching
of the complexion is manifest. The number of red-blood corpuscles

GENERAL DISORDERS OF NUTRITION.

upon which the blood itself depends for its redness, and the tissues
through which it circulates for their tints, is reduced one-half, or one-
third, or even lower. The exceptions to this rule, namely, the occa-
sional instances of chlorosis in which the cheeks retain their redness,
are easy of explanation, when we come to know that the color of the
blood is but one of the causes upon which the tint of the cheek de-
pends ; another consisting in the filling and distention of the capil-
laries. Just as there are persons whose cheeks are pale, in spite of
the deep hue of their blood, because their capillaries are inadequately
filled, so there are other chlorotic persons who, notwithstanding that
their blood is pale, always have red cheeks, because their capillaries
are filled to bursting, and are varicose. The transient flush observed
in almost all chlorotic persons when excited or heated, and to which
we shall refer hereafter, is also to be ascribed to a momentary disten-
tion of the capillaries with blood.

The fat in the subcutaneous areolar tissue of chlorotic persons is
often normal in amount, and is sometimes even in a state of exuberant
development. This condition furnishes an important distinctive mark
between chlorosis and the chronic anaemia which often manifests itself
hi latent consumption, and in other concealed disorders which affect
the quality of the blood. In a symptomatic ansemia or hydraemia of
this kind, which is frequently confounded with chlorosis, the subcutane-
ous fat soon vanishes as the color of the skin fades. CEdematous
effusion into the subcutaneous cellular tissue is rare in this disease.
Hence a moderate paleness of the surface, accompanied by oedema of
the feet, warrants the suspicion of hydraemia and not of chlorosis ; and
conversely, when the lips, cheeks, and ears are white as wax, and yet
there is no sign of oedema, it is probable that the serum of the blood
retains its normal composition, and that the case is a pure oligocythae-
mia and not a hydraemia.

Chlorosis is always accompanied by more or less shortness of
breath, owing to a diminution in the number, sometimes amounting
to one-half or more, of the bodies which take up oxygen, and give out
carbonic acid. The normal number of respiratory acts is insufficient to
supply oxygen to the lungs in quantity adequate to the wants of the
system. Every bodily effort, by increasing the consumption of tissue,
and augmenting the production of carbonic acid, aggravates the dysp-
noea, and multiplies the patient's breathings to a distressing degree.
Hence patients with pronounced chlorosis scarcely ever fail to com-
plain that they " get out of breath " when they walk fast, or mount
the stairs. The diminution in the interchange of gases, and especially
the impediment to oxygenation of the blood, also accounts for a second
series of symptoms peculiar to chlorosis. The strength of the muscles,

CHLOROSIS. 805

which, to be vigorous, calls for a supply of well-oxygenated blood, is
greatly reduced. The patient is easily fatigued, and complains of a
sense of weight in his limbs, and not unfrequently (pseudo-rheumatic)
muscular pains are induced by the slightest effort, such as only are felt
by healthy folk after unusual and excessive exertion. Important as it
is to the normal function of the muscles that a free supply of well-
oxygenated blood should circulate within them, this is equally essen-
tial to the proper action of the nerves. In treating of the neuroses,
in almost every instance, we have referred to the state cf the blood in
chlorosis as an important point in their etiology. Hence, neuralgia is
extremely common among chlorotic patients, that of the trigeminus
being especially frequent among the peripheral neuralgias, while in
the internal organs cardialgia is more common. Anaesthesia, convul-
sions, and palsy, are rarer, and are seldom observed excepting when (as
sometimes happens) hysteria develops during the disease. There are
nearly always signs of hysteria in chlorosis, which consist of general
bodily and mental hyperaesthesia, a troubled, irritable temper, a dis-
position to weep, perverted appetite (for instance, a craving for coffee-
beans, slate-pencils, etc.).

The organs of circulation present numerous deviations from the
normal. The patients nearly all complain of palpitation. I have
already declared that this symptom is not altogether due to an aug-
mented or accelerated action of the heart, being also in some degree
dependent upon a general hyperaesthesia, whereby the impulse of that
organ is rendered distressingly perceptible, whereas it is not felt at
all by most persons, even when its beat is enormously intensified by
hypertrophy (Vol. I.). Upon auscultation of the chest, over the heart
and great vessels, we hear the blowing sounds so often alluded to,
and which are known as " blood murmurs," to distinguish them from
the morbid murmurs depending upon alteration of the structure of the
heart. This name is inappropriate, however, as the sounds are not
caused directly by the altered condition of the blood. They most
probably arise from an abnormal tension of the valves and arterial
walls.

tfar more frequently, upon listening over the jugular vein, a pecu-
liar humming, singing murmur is heard, known as the "Nonnen-
gerausch," or " bruit de diable." The name is derived from the sound
of the humming-top, called " Brummkreisel " in North Germany, and
"Nonne" (nun) in other places; while in France it is called the
' diable." The sound is more intense upon the right side than upor,
the left, and subsides when the patient assumes a horizontal attitude
or draws a forced breath. The mode of origin of the " bruit de diable "
seems to be as follows : The lower part of the internal jugular veins

GENERAL DISORDERS OF NUTRITION.

lying behind the sternoclavicular articulation is attached upon all
sides, so that it cannot collapse, like other veins, when the stream of
blood is reduced in volume. When the jet of blood which enters
this large space is too small, it can only fill it by forming an eddy.
This whirling current throws the walls of the veins into sonorous
vibration. If the neck be turned to one side so as to compress the
jugular of the opposite side between the omohyoid muscle and the
cervical fascia, the bruit de diable becomes audible in the majority
even of full-blooded, healthy persons. When the sound is perceptible
without such a turning of the neck, it may always be inferred that the
patient's blood is impoverished and that his veins are scantily filled.
The excessive nervous irritability arising from inadequate oxygenation
of the blood also involves the vasomotor nerves ; whence the sudden
flushing and paling of chlorotic persons.

Besides the cardialgia already alluded to, other serious disorders
of the digestive system arise in chlorosis, which, unless watched with
patience and attention, might give rise to dangerous mistakes. The
appetite is nearly always diminished ; after eating, there is a sense of
pressure and fulness in the epigastrium, with acid eructations and otner
symptoms of dyspepsia, which, in most patients, depend on " atonic
weakness of digestion " (Vol. I.), and generally disappear as the state
of the blood improves. Affections such as these are not dangerous,
and nearly always get well under proper treatment ; unfortunately,
however, the chronic ulcer of the stomach is also a very common occur-
rence in chlorosis, and often develops undetected. In treatment of a
chlorotic patient, it must never be forgotten that the cardialgia and
dyspepsia may be dependent upon this grave lesion of the stomach,
and all suitable means must be invoked to aid us to a correct diagnosis.
Neglect of such precautions may terminate in an unexpected and tragic
denouement by haematemesis, or even by perforation.

The urine of a chlorotic patient, unless there be intercurrent fever,
is remarkably limpid and light. The lowness of its specific gravity is
probably owing to the small amount of urea which it contains, and its
light color to a deficience in coloring matter. Reduction in the supply of
oxygen sufficiently accounts for the decrease in the destructive assimi-
lation, and consequently for the diminution of the urea in the urine.
We know but little regarding the formation of its coloring matter, but
it can scarcely be doubted that it is derived from that of the blood ;
hence, when the number of the blood-corpuscles, which contain the
red matter, is diminished, it is not surprising, cfeteris paribus, that the
coloring of the urine should decrease.

The sexual function nearly always suffers derangement, generally
vn the form of amenorrhcea, more rarely in the form of excessive men-

CHLOROSIS. 807

struation or of dysmenorrhcea (Vol. II.). When amenorrhoea occurs, it
is almost always because the ovules do not mature ; for, generally, all
the other signs which attend ripening and expulsion of the ovum are
absent, besides the bleeding. By the laity, and even by some physicians,
amenorrhoea is supposed to be a constant symptom of chlorosis, an error
which may sometimes be productive of the utmost mischief, by inducing
the premature suspension of remedies still urgently required, on ac-
count of the presence or appearance of the menses. Indeed, owing to
this erroneous idea, that chlorosis is always attended by amenorrhoea, it
not unfrequently happens that chlorotic girls, suffering from dysmenor-
rhcea or menorrhagia, and complaining of headache and palpitation, are
supposed to be " too full-blooded," and are therefore purged and bled.
Finally, in many chlorotic patients, besides the irregular menstruation,
there is a catarrh of the uterus and vagina (Vol. II., pp. 123, 171).

The course of chlorosis, unless cut short by proper medication, is
almost always slow and tedious. This disease, if not detected, or if
treated homceopathically, often lasts for months, and sometimes for
many years. It generally terminates in recovery, although, in very
young persons, one or more relapses are apt to occur. More rarely,
chlorosis passes over into other disorders, such as tuberculosis. It
never endangers life, excepting through its complications, particularly
the very common one of chronic ulcer of the stomach. The stories
about acute febrile chlorosis terminating in death are the result of
erroneous diagnosis ; although it is true that unimportant febrile dis-
eases, when they attack chlorotic patients, are often accompanied by
typhoid symptoms and assume a malignant type.

TEEATMEJSTT. — Attempts to fulfil the causal indication in chlorosis
are very seldom followed by benefit, a proof that the causes to which
the disease is generally ascribed are not relevant ones. Chlorotic
girls are often restored to health in a few weeks, by the fulfilment of
the indications from the disease itself, although they had been long
and carefully, though fruitlessly, protected from pernicious agencies,
had passed months in the country, lived on the best of food, exercised
daily, and taken a course of German or Swedish gymnastics without
bringing color to their lips and cheeks, relief to their shortness of
breath, or improvement to their irritable and fretful temper. The
reputation which dietetic treatment enjoys, as a remedy for chlorosis, is
mainly attributable to the circumstance that not only does pure oligo-
cythaemia bear this name, but it also is given to a great variety of
anaemic conditions, in which such treatment is indispensable, while the
use of iron is but of secondary importance. Experience teaches daily
that brilliant cures of pure chlorosis may be made under the most un-
favorable external conditions.
101

GENERAL DISORDERS OF NUTRITION.

The indications from the disease itself demand the exhibition of
iron. If any medicine ever deserved the name of a specific, iron does,
as a remedy in this disease. The surer our diagnosis, so much the more
certain may we be of succeeding ; and when, contrary to our expecta-
tions, we fail of success, there will be reason for suspecting that the
case is not simple chlorosis, but an anaemia depending upon some
other unperceived or unrecognizable disorder. The progress of a chlo-
rosis, which, developing in a young girl at the period of puberty, has
defied all treatment, often proves it to have been but the initiatory
stage of a tuberculosis, or the anaemia consequent upon a chronic
gastric ulcer. We are ignorant of the manner in which the iron
improves the defective state of the blood. The existing red-blood
corpuscles are not wanting in iron, but there is a deficiency of the red
corpuscles themselves, into whose chemical composition iron enters
to a slight extent. Perhaps the iron stimulates the activity of the
region where the red corpuscles are formed, or perhaps it regulates
the digestion, and thus promotes the supply of material for the forma-
tion of blood-corpuscles. But there is no sound foundation for any of
these hypotheses, the number of which might be materially increased.

Opinions vary greatly as to the proper form and dose of iron. Iron-
filings are much prized by certain well-known and fortunate practition-
ers ; others, equally celebrated and successful, prescribe one or other
of its salts, to the exclusion of all the rest, claiming its effects to be
more certain, and better borne. Others, again, begin treatment with
the " mildest " of the ferruginous preparations, as the mallate or lac*
tate of iron, proceeding thence to the " stronger " ones, the chloride
and sulphate, winding up the treatment with the filings. Besides the
limatura ferri, which may be given in three to six grains as a dose,
generally with an addition of powdered cinnamon, the tinct. ferri pomat.
(gtt. XV-XXA), the lactate of iron (gr. ij-v), the ferri carb. saccharat.
(gr. iv-x), the tinct. ferri chlor. (gtt. x-xxx), ferri sulph. (gr. j-iv),
are the preparations of iron in most common use. From the estimate
hi which these various* preparations are held by different established
authorities, and from the fact that nearly every practitioner has his
"pet article," which he uses in the majority of cases, it may be in-
ferred : 1. That the efficacy of iron in chlorosis does not depend upon
the form in which it is administered. 2. That nearly all ferruginous
preparations are well borne in chlorosis. 3. That special indications
for the exhibition of one or other of them cannot be laid down. Foi
more than twenty years I have used Bland? s pills almost exclusive!}
in chlorosis, and have witnessed such brilliant results from them in a
large number of cases, that I have never found any opportunity to ex-
periment with other articles. Instead of the forty-eight huge boli,

CHLOROSIS. 809

according to Slaud^s original prescription (Ijt Ferri sulp. pi.lv., potass,
carb. purse, aa § ss, tragacanth. q. s. u. f. pil.), I have ninety-six
pills made. Nor am I so timid in increasing the dose according to
BlaucTs formula, but order three pills thrice daily, and sometimes four
or five if they are well borne, which they almost always are. Three
boxes of JBlaud's pills nearly always suffice to cure the most persistent
chlorosis. At Magdeburg and Greifswald I often had to send my re-
cipe for the pills to a great distance, my good fortune in the treatment
of chlorosis — to which, by-the-by, I owe the rapid growth of my prac-
tice— having given me a great reputation as the possessor of a sover-
eign remedy against that disease.

I do not suppose that BlaucPs pills excel all other ferruginous
preparations in virtue ; indeed, I have repeatedly satisfied myself that
colleagues who made use of other recipes obtained equal results, pro-
vided only that they gave doses of equal size ; but I also believe that
the efficacy of BlaucTs pills cannot be surpassed, simply because they
can be administered in very large doses without distressing the patient.
I had an opportunity to test the truth of this some ten years ago. I
was asked for my recipe by one of my colleagues, and at first referred
him to the Canstatt text-book, which contained the well-known formula
for Blautfs boli ; but, as he did not have that book, I told him the
formula, adding, that I began with three boli, raising the dose one
bolus every three days. Some time afterward my colleague took occa-
sion to thank me, extolling the excellent effect of the medicine, and
stating how well it had been borne by the patient. As it turned out,
however, he had misunderstood me, and, instead of raising the dose
every three days, had added one bolus at every dose.

It has been maintained that the treatment of chlorosis does not
require large quantities of iron, because the amount of it taken up by
the blood is very small, and since, even when small doses are given, a
large portion of the metal always passes off in the stools as superflu-
ous, and further, because the efficacy of the chalybeate springs in this
disease proves that a minimum of iron will suffice. Without going
into groundless theoretical discussions, I will admit that the disease
will also recover (although somewhat slowly) under the use of smaller
doses of iron, and may be cured by chalybeate waters ; but the numbej
of patients who have recovered in my practice through the employmeu^
of Blautfs pills, and under that of my colleagues under the use ol
carbonate of iron (pil. ferri carb.), or of lactate of iron in large doses,
after they had taken small doses of tincture of iron and wine of iron
for years without positive effect, and had repeatedly visited Pyrrnont
and Driburg, is large enough to warrant the assertion that we shall
cure chlorosis most speedily and surely by means of those ferruginous

GENERAL DISORDERS OF NUTRITION.

preparations which can be tolerated in the largest doses, and of these
Bland? s pills stand highest on the list.

A very common error in the treatment of this affection consists in
the attempt to relieve the erethism, digestive disturbance, and other
troubles due to the state of the blood, by means of mineral acids, bit-
ters, and other medicines ; while iron, from which alone, or at least
from which the greatest benefit is to be anticipated, is neglected.
Such preparatory treatment almost always retards the recovery un-
necessarily.

I will finally observe that, as long as my chlorotic patients continue
languid, indisposed to exertion, and void of appetite, I do not urge
them to walk or to eat, generally to their great satisfaction ; but I
make them promise that they will exercise assiduously as soon as they
feel the strength and inclination to walk, and that they will take food
freely whenever they gain an appetite to eat, the acquirement of which
is seldom long withheld. I have already said that relapses of chlorosis
cannot be averted, especially when it sets in at the commencement of
the period of evolution ; hence I always take the precaution of suggest-
ing the possibility or even the probability of a relapse, and have often
found that the patient and her relatives do not take the prospect much
to heart, when I assure them that the second attack will be as speedily
curable as the first.

Although, as I have said, I consider the chalybeate springs super-
fluous, and far less effective than iron given in large doses, yet, when
a convalescent from chlorosis fears a relapse, I would recommend the
springs of Pyrmont, Driburg, Cudowa, Altwasser, St. Moritz, in Swit-
zerland, and Imnau, in Swabia.

CHAPTER II.

SCOBBUTUS — SCUKVY.

ETIOLOGY. — The abnormal changes in the quality of the blood tt
which chlorosis is due can be detected by microscopic and chemical in
vestigation ; these aids fail us in our researches upon scurvy. It has
been stated, indeed, that, in scorbutic blood, the fibrin is diminished,
or has lost its coagulability ; or that the salts of soda are abnormally
increased, while those of potash are diminished ; but, after repeated in-
vestigation, the truth of none of these statements has been established.
Nevertheless, the commonly adopted opinion, that scurvy is a disease
dependent upon a derangement in the composition of the blood, is
probably correct. Independently of the fact that the disease arises
under conditions unfavorable to a normal composition of the blood, we

SCURVY.

shall see, while discussing its symptoms, that these depend upon a
disease of the capillary walls, extending throughout so large a portion
of the system that we must infer that the starting-point of the malady
is an imperfect state of nutrition of the capillary walls resulting from
improper nourishment.

With regard to the etiology of scurvy, we shall limit our remarks
to a statement of the conditions which are found to favor the develop-
ment of the disease, since, until we know in what the scorbutic state
of the blood consists, all theoretical reasoning upon its connection with
these pernicious conditions is idle. Scurvy is so common an occurrence
during long voyages at sea (sea-scurvy), where the crew live almost
entirely upon hard bread and salt meat, and are entirely deprived of
potatoes and fresh vegetables, that the disease has been attributed
sometimes to the over-supply of salt in the food, sometimes to want
of fresh meat and vegetables, and sometimes again to both causes com-
oined. The theory, that in scorbutic blood there is an undue prepon-
derance of the salts of soda over the salts of potash, seems to find
support from the frequence of this affection among seamen who are
deprived of vegetables, while profusely supplied with salt. Neverthe-
less, although it cannot be denied that the food of sea-faring people
during long voyages furnishes one of the conditions which favor the
occurrence of scurvy, yet this is by no means to be regarded as the
sole cause of the disease. Scurvy has been known to break out early,
and with great virulence, in ships where the crew have been greatly
exposed to cold, particularly to moist cold, as well as in ships which
have been detained by protracted calms at the equator. It has also
been observed that immoderate fatigue and a despondent, melancholy
state of mind favor the development of the disease, while a crew who
work moderately, and keep up their spirits and courage, retain their
health much longer, in spite of the badness of their food. That scurvy
does not depend exclusively upon the use of salt food, and want of
fresh provision, is proved still more forcibly, and moreover, the hypoth-
esis regarding the preponderance of the salts of soda over those of
potash in scorbutic blood is overthrown by the fact, that it also appears
among people whose diet is almost entirely vegetable, but who suffer
from destitution, and live in cold, moist cellars, as is the case in north-
ern countries, especially in Russia (land-scurvy).

The repeated outbreaks of scurvy among the inmates of garrisons
and prisons, and other humanely and conscientiously kept institutions,
is a remarkable fact, and one which cannot always be ascribed to the
influences above mentioned.

ANATOMICAL APPEARANCES. — The bodies of persons who have
died of scurvy, if the disease has been of long duration, exhibit ex«

GENERAL DISORDERS OF NUTRITION.

treme emaciation and a moderate oedema, particularly of the lower
extremities. The integuments are of a dirty, ashy hue, and are gen-
erally covered by dry detached epithelium. Here and there extrava-
sations of variable size are found in the tissue of the cutis as well as
in the subcutaneous and intermuscular connective tissue. Besides the
liq jid effusions of blood, hard coagulated infiltrations, stained red by
an admixture of blood, are almost always found beneath the skin, be-
tween the muscles ; more rarely within the muscles themselves. The
blood is remarkably liquid and dark in color. The walls of the vessels
and the tissues about them are deeply stained by it. In the cavities
of the pleura, pericardium, peritonaeum, and articular capsules, there is
almost always a serous or serofibrinous effusion, with an admixture of
blood. The lungs are more or less compressed by the pleural effusion,
while the uncompressed portion is the seat of a bloody cedema. The
liver, spleen, and kidneys, are studded with ecchymoses, and appear
relaxed and filled with blood, which also is extra vasated, and infiltrates
the tissues. Ecchymoses also exist between the serous and muscular
coats of the intestine. The mucous membrane of the intestine is red-
dened, swollen, and relaxed, and sometimes is in a state of follicular
ulceration.

SYMPTOMS AND COURSE. — The first signs of scurvy are usually
those of a general cachexia ; the patients complain of great debility
and lassitude, and particularly of a sense of excessive weight in their
lower limbs. Their spirits are deeply depressed, they can no longer
devote themselves to the slightest work, and are excessively sad and
despondent. At the same time the face of the patient loses its bright
hue and grows pale and muddy, the lips acquire a bluish, livid tinge,
the eyes sink into their sockets, and are surrounded by a blue ring.
These symptoms are usually accompanied by darting or piercing pains
in the limbs and joints, which might easily be mistaken for rheumatic
pains. It is not usual for the characteristic local manifestations of
scurvy to show themselves until the precursory symptoms have con-
tinued for some days or even for some weeks ; although CejJca has
often observed the disease to commence locally, the signs of cachexia
not appearing until the gums had grown very sore, and all the body
was covered with scurvy-spots.

In our first volume we have described the scorbutic sore mouth in
detail. It is the most common and generally is the first of the loca.
symptoms of the disease. There are exceptions, however, to this rule
also. Cejka mentions instances in which sugillations, tense cedema
of the feet, and hard, painful infiltration of the connective tissue, pre-
ceded the bloody cedematous relaxation of the gums. The effusions
of blood into the tissue of the skin, mentioned above, sometimes take

SCURVF. 813

the form of small round petechiae, sometimes of vibices, and sometimes
of extensive ecchymoses. They almost always appear first upon the
lower extremities, and afterward spread over the rest of the body.
Regions exposed to the action of trifling mechanical violence are espe-
cially liable to become the seat of the ecchymoses. In the epidemic in
the house of correction at Prague, described by Cejka, the influence of
mechanical action was strikingly apparent. In most patients the hol-
lows of the knees were most affected, but, in wood-cutters and in per-
sons who worked at the spinning-wheel, the right arms were attacked.
Wool-combers and laundresses suffered in their forearms ; women in the
place where their garters pressed. The spots which at first were violet,
and of almost a blackish brown, pass through the well-known changes
of color peculiar to extravasations, blue, green, yellow, etc. When
new spots appear, while the old ones are fading, dark-blue and green-
ish-yellow spots are found simultaneously upon the skin. Sometimes
circumscribed effusions beneath the epidermis give rise to blebs filled
with a bloody liquid (purpura bullosa, pemphigus scorbuticus), which,
if they burst and are treated carelessly, may result in obstinate ulcers.
Ulcers also form in some patients after the receipt of trifling injuries.
They are characterized by the flabby, spongy, bleeding granulations
which cover their surface. The hard infiltration of the subcutaneous
and intermuscular areolar tissue forms rounded tumors beneath the
skin, varying in size from that of a hazel-nut to that of a fist, situated
usually upon the lower, more rarely upon the upper extremities, and
upon the belly, throat, and cheeks ; they cause more or less pain, and
are covered by a skin which either retains its normal color or else is
suffused by blood. Sometimes the indurations are extensive and dif-
fuse, covering the hams, the calves of the legs, and the inner surface
of the thighs. They are hard as a board, and, owing to the pressure
which they exert upon the muscles, they render all movement of the
affected limb impossible. The cutis remains immovable above this
diffuse induration, and is either of normal appearance or is suffused
with blood. Besides the bleeding from the gums, which, though not
always very profuse, is seldom absent, haemorrhage from other mucous
membranes occurs in some patients, especially epistaxis, haemoptysis,
metrorrhagia, and bleeding from the bowels. Ecchymosis of the con-
junctiva and effusions into the chambers of the eye, with malignant
ophthalmia, have occasionally been noticed.

The inflammations of internal viscera, particularly scorbutic peri-
carditis and pleuritis, do not differ in any characteristic or peculiar man-
ner from primary inflammation. Voluminous effusions are often rap-
idly deposited, putting the patient in danger of suffocation ; but I have
also witnessed the rapid and unexpected reabsorption of large colleo

§14- GENERAL DISORDERS OF NUTRITION.

tions in the pleura and pericardium of scorbutic persons. Owing to
the variety and irregularity in the succession of the symptoms of this
disease, the few cases which have come under my observation have
presented very different aspects.

Its course is chronic, and, if the pernicious influences under which it
has arisen be not allayed, it is often extremely tedious. In these pro-
tracted cases the prostration of the patient becomes excessive ; some-
times he faints with every attempt to sit upright ; he complains of a
distressing palpitation and great dyspnoea; the action of the heart
grows very weak and rapid, extensive oedema arises in the subcuta-
neous connective tissue, while the soreness of the gums, the ecchy-
moses, the brawny infiltration of the areolar tissue, and the other local
affections, increase greatly in extent and intensity. A marked feature
of the disease consists in the rapidity of its abatement and the sudden
transformation from a condition of the utmost distress to one of rela-
tive convalescence, often terminating in full recovery, when the patient
is rescued from noxious influences, and placed in a condition favorable
to a cure. It is true that, under such circumstances, their recovery is
very slow, and they always retain a great tendency to relapse.

A fatal termination of scurvy occurs either late in the disease from
extreme exhaustion and general dropsy, or else it takes place earlier
and before the prostration has acquired much intensity from pleurisy,
pericarditis, profuse bloody diarrhoea, or other complications.

TREATMENT. — In modern days the sea-scurvy has become rare,
owing to the shortening of voyages, and to the better supplying of
ships, especially by the provision now made of lemon-juice, sauer-kraut,
and hermetically sealed vegetables. Land-scurvy also, which formerly
was of much more common occurrence, has become a rare disease in
this country, from the wholesomeness of the dwellings and the improved
diet which paupers now enjoy, thanks to the progress of modern cul-
ture, so that a prophylaxis against scurvy is no longer talked of. In-
deed, precautionary remedies are now superfluous, excepting when
several cases of scurvy break out in a barrack, or workhouse, or similar
institution, causing apprehension of an epidemic appearance of the dis-
ease. These precautions consist in the most scrupulous attention to
cleanliness, warmth of clothing, ventilation of apartments, exercise in
the open air, a sufficient allowance and proper choice of food, which
should consist of fresh meat, and, if possible, also of fresh vegetables,
and salad. Good beer should also be provided, and, where this is un-
obtainable, brandy-and-water should be administered. The cost of
Buch attentions is amply compensated for, if we succeed in putting a
check upon the disease.

In cases of pronounced scurvy, the freshly-expressed iuice of certain

PURPURA H.EMORRHAGICA. 815

plants, especially that of the order of crucifera, such as water-cresses,
cabbage, mustard, radishes, horse-radishes, spoon-wort (scurvy-grass),
and the like, is extremely beneficial, while the extracts of the same
plants are quite useless. The healing effect of a fresh vegetable diet
upon scurvy is much more positively ascertained than is the depend-
ence of the disease upon a want of such nourishment. Next in virtue
is the juice of certain acid fruits, especially that of lemons and
oranges, although that of cherries, currants, apples, and the like, is
also serviceable. The mineral acids are of no benefit whatever. The
bitters and aromatics, also, are of a questionable and certainly of a
very secondary value. The barm of beer, also, has a great reputation
as an anti-scorbutic, when given to the amount of six or eight ounces
daily. It is very important that the rules as to diet and regimen, laid
down above, in treating of the prophylaxis, should be carefully ob-
served. The local treatment of the sore mouth has been discussed
already. For the ecchymoses and infiltrations, lotions and compresses
wet with aromatic vinegar, spirits of camphor, and the like, may be
applied. The haemorrhages and internal inflammations are to be
treated upon general principles, due regard always being had to the
prostrate condition of the patient.

CHAPTER III.

PURPURA HJEMORRHAGICA THE " MORBUS MACULOSUS " OF

WERLHOF.

ETIOLOGY. — The symptoms of the spotted disease of Werlhof re-
semble those of scurvy, as far as regards the appearance of extravasa-
tions of blood from the capillaries of the skin and mucous membrane ;
but the haemorrhages are not accompanied by any affection of the
mouth, nor by the peculiar subcutaneous and intermuscular infiltra-
tions, nor the haemorrhagic inflammations of the serous membranes,
which we know to be symptoms of scurvy.

The reason for the tenderness of the capillaries in Werlhof *s dis-
ease is obscure. The extension of the haemorrhages over various parts
of the body, its frequent occurrence among feeble and debilitated per-
sons, and among convalescents from severe illness, and its appearance
in those who dwell in damp, unwholesome lodgings, or in other unfa-
vorable conditions, make it probable that the disease of the blood-
vessels depends upon an improper state of this nutrition, or upon
insufficient or bad nutriment. On the other hand, robust, powerful
jidividuals, living under the most advantageous circumstances, and

GENERAL DISORDERS OF NUTRITION.

who do not offer the slightest reason for a defective state of blood, aie
also sometimes attacked.

SYMPTOMS AIO> COUKSE. — Sometimes the first symptoms of Werlr
hops disease consist in the appearance of numerous purpuric spots
upon the skin ; in other instances the haemorrhages are preceded for
some days or weeks by digestive derangement, languor, debility, but
never by the signs of severe cachexia, such as generally precede the
onset of scurvy. The purpuric spots, though small, are generally nu-
merous. Their most common seat is upon the extremities and body,
although the face is often speckled by numerous petechiae. While the
first set of petechiae are passing through the blue and green stages,
new blood-red ones make their appearance. Now and then haemor-
rhages from the surface are observed ; but such phenomena cannot prop-
erly be called bloody sweat (p. 453). Minute, punctiform ecchymoses
are also found upon the mucous membranes, especially those of the
mouth and fauces. Epistaxis, haematemesis, haematuria, and bloody
evacuations from the bowels, are of far more common occurrence in this
disease than in scorbutus. When it attacks an otherwise healthy and
vigorous individual, and when the haemorrhages do not recur too fre-
quently, the undisturbed condition of the patient's general health often
forms a marked contrast with the objective symptoms. Very numer-
ous and oft-repeated haemorrhages may result in intense anaemia, a
tendency to syncope, dropsy, and even death. In previously healthy
persons, however, such a termination of the disease is rare. As a gen-
eral rule, the affection ends in recovery after a duration of between
two and four weeks.

TREATMENT. — The customary treatment of Werlhofs disease,
which originated with Werlhof himself, consists in the administration
of sulphuric acid and quinine. Although there is no proof that the use
of these articles exerts any decidedly beneficial influence upon the
course of the disease, yet, not to be too skeptical, and for want of more
certain remedies, it is advisable to give the dilute sulphuric acid or the
elixir of vitriol in doses of ten or twelve drops every two hours in the
beginning of the disorder, followed at a later period by a decoction
of bark with an addition of sulphuric acid. In cases of profuse epis-
taxis which do not readily subside under the application of cold, the
tampon must be employed promptly, since the longer the bleeding is
allowed to last, so much the more obstinate does it become. For the
haematemesis, bits of ice, alum-curds, and cold compresses to the abdo-
men, should be employed ; for haematuria, large doses of tannin. In ex-
treme anaemia it is of importance that the patient should preserve a
horizontal attitude as a precaution against swooning.

PROGRESSIVE PERNICIOUS ANEMIA. 817

[CHAPTER IV.

PROGRESSIVE PERNICIOUS ANAEMIA.

THE old names of " essential," " idiopathic," " fatal anaemia,"
etc., probably referred to the disease now called " progressive per-
nicious anaemia." Little is known of the causes of this gradually
progressing disease, which is nearly always fatal. It is most fre-
quent in middle age, but occurs later, as well as in childhood. It is
more frequent in females, especially after confinement or during
pregnancy, in which case it is apt to induce miscarriage, followed
quickly by death. Sometimes the disease can be ascribed to no
cause ; at others it may be referred to bad nourishment, repeated
losses of blood, diarrhoea, etc. The onset is usually insidious, with
great paleness of the skin and mucous membranes ; if there is no
fever, the nutritive condition of the patient may be little disturbed.
The patients are very feeble, with great tendency to faintness,
dyspnoea, palpitation, blood-murmurs, and gastric disturbances,
vomiting being very common. The spleen and lymphatic glands
are not swollen, wherein it differs from leuchaemia, nor does the
skin have the brownish color of Addison's disease. There is no
regular fever curve ; indeed, there is no fever till the disease is far
advanced ; autopsy has revealed no sufficient cause for the fever.

Often, especially late in the disease, there may be epistaxis, pe-
techiae, ecchymoses on the legs, and haemorrhages from the female
genitals, from the stomach, air-passages, etc., or into the tissue of
the heart, the pericardium, dura mater, brain, retina, etc. ; the lat-
ter are said to be quite frequently discoverable on ophthalmoscopic
examination of the region of the papilla as reddish spots or radiat-
ing striae ; it is said that these spots are characterized by peculiar
gray or white specks. These haemorrhages are not, however, lim-
ited to this disease ; they may occur in various other forms of anae-
mia ; they may be due to the retinal vessels being diseased and
being ruptured by vomiting.

As pernicious anaemia begins very gradually, and is not at first
detected, its duration cannot be determined ; it may prove fatal
within a few weeks from the time of its discovery, but usually runs
on for months or even years. All cases do not prove fatal.

The diagnosis is difficult in the commencement. It is said that
even in the early stages some of the blood-corpuscles are very small,
but this is a disputed point. The anaemic symptoms cause it to re-
semble leuchaemia, but in the latter there is marked increase of the

GENERAL DISORDERS OF NUTRITION.

white corpuscles, and in pseudo-leuchaemia there is swelling of the
spleen and lymphatic glands. Cases occur where it is impossible to
make an accurate diagnosis, especially when an enlargement of the
spleen accompanies the pernicions anaemia. There seem to be cases
of transition between this and other diseases. Litten says that
changes of the medulla of the bones are found in pernicious anae-
mia, just as in medullary leuchcemia ; and time must teach us how
far this is a constant process, and whether the real lesion in this
affection is a disease of the medulla of the bones, as that of the
spleen and lymphatic glands is in pseudo-leuchaemia.

Cases where cachectic states accompany undiscovered cancers
may be mistaken for pernicious anaemia.

TREATMENT has proved unsatisfactory ; even the cases ending
in recovery seem to have done so spontaneously. We can do little
more than remove injurious influences, and give good diet, air, and
tonics, especially iron.

It has been claimed that great benefit has followed the adminis-
tration of phosphorus, but other observers deny the efficacy of this
remedy. In some of these forms of anaemia the employment of
arsenic by the mouth and subcutaneously is reputed to be very
efficacious, but it has not yet been sufficiently tried to enable us to
say in which cases it will do good and in which it will fail. It
seems quite certain that some patients who are not benefited by
administration of iron, will improve if the iron is continued while
inhalations of oxygen gas are given in doses of two or three gallons
diluted with air several times daily.]

HEMOPHILIA. 819

CHAPTER V.
HAEMOPHILIA (HJEMOKBHAGIC DIATHESIS).

ETIOLOGY. — The names haemophilia, haemorrhaphilia, are applied
to a congenital haemorrhagic diathesis distinguished either by the un-
usual obstinacy of traumatic haemorrhage or a tendency to sponta-
neous bleedings. Hitherto no abnormity capable of accounting for the
symptoms has been detected either in the blood or the vascular walls
of the patient, although in a small number of cases the walls of the
blood-vessels have been found to be remarkably thin and delicate. In
most cases of haemophilia the disease is hereditary, that is, the patient
descends from a family one or more of whose members in preceding
generations have suffered from the same affection. There are instances
in which it has been transmitted through four generations ; others in
which a generation has been "skipped," the grandchildren having
haemophilia, but not the children. It is rare for every member of a
family to inherit this dangerous disorder, and the daughters seem to
remain free from it with especial frequence. There also are well-
authenticated observations which leave no doubt of the occurrence of
congenital haemophilia not dependent upon hereditary predisposition.

SYMPTOMS AND COUKSE. — Until the discovery is made that a tri-
fling wound will give rise to an irrepressible and dangerous loss of
blood, there is no symptom to warn the patient of his perilous con-
dition. Some observers, indeed, claim that this class of patients are
distinguishable by the remarkable delicacy of their complexion, their
superficially situated and conspicuous veins, blonde hair, and blue eyes,
and, in one family that I know of, this description is equally applicable
to the whole of them, including the female members, who are exempt
from the disorder. Other observers, again, state expressly that the
patient's appearance presents no perceptible characteristics.

The accidents which give rise to these alarming haemorrhages are.
generally extraction of a tooth, a puncture, a small cut or laceration,
and it would almost seem as if such injuries were more dangerous
than severe wounds. The blood oozes out as if from a sponge, al-
though no bleeding vessel is discoverable ; all attempts to stanch the
bleeding are in vain, and it persists for days. The blood, which at
first is normal, gradually grows thin and watery, forming small, loose
coagula. At last the complexion of the patient acquires a waxy pallor,
the lips lose their color ; syncope and other signs of exsanguinity oc-
cur, and the patient may perish in a few days. More commonly, how-
ever, the bleeding ceases, and the patient, in a state of utter exhaus-
tion, slowly recovers from the effects of his enormous loss of blood.

GENERAL DISORDERS OF NUTRITION.

which often amounts to many pounds. Besides these dangerous ex-
ternal haemorrhages, extensive extravasations occur beneath the skin,
in consequence of the slightest contusion. Wunderlich tells of a boy,
who, after receiving a flogging at school, came home black and blue,
and so covered with stripes and welts that a charge was preferred of
cruelty. It afterward appeared that he had the haemorrhagic dia-
thesis.

Spontaneous bleeding cr haemorrhages without assignable cause do
not generally take place until after the patient has suffered repeatedly
from traumatic haemorrhages. They generally proceed from the nose :
but likewise arise from the bronchi, stomach, intestines, and kidney, and
may also occur in the substance of the skin and subcutaneous areolar
tissue. They are generally preceded by molimina, such as palpitation
of the heart, stupor, signs of cerebral congestion, pain in the limbs,
and, in some cases, painful tumefaction of the joints, particularly those
of the knee and ankle. There have been instances in which the bleed-
ing from the navel-string could not be stanched, but more usually it
is not until the period of dentition, and sometimes after the sixth or
eighth year of life, or later, that the diathesis betrays itself by a dan-
gerous haemorrhage. Most patients die young — few surviving the
period of childhood. Cases are known, however, in which the patient
has lived to a good old age, the tendency to bleed diminishing, or
ceasing altogether, as life advanced.

TREATMENT. —No remedy is known likely to prove efficacious in
congenital haemorrhagic diathesis, and we must therefore confine our
efforts to a careful regulation of the habits, and the removal of all nox-
ious agencies ; so that, perhaps, by improving the general condition of
the constitution, this dangerous diathesis may subside. Of course, all
wounds must be scrupulously avoided. When the bleeding occurs in
spite of such precautions, besides the ordinary haemostatic articles,
among which steady pressure and the actual cautery are the best,
glauber salts in cathartic doses should be prescribed, and, when the
bleeding threatens life, two to five grains of secale cormitum every
half-hour. These two prescriptions have been of great benefit in somr
instances.

CHAPTER VI.

SCROFULA.

ETIOLOGY. — The term scrofula signifies a morbid (cachectic) con-
dition of the system, manifested by a remarkable liability to certain
forms of nutritive disorder of the skin, mucous membranes, joints,
bones, organs of special sense, and, above all, the lymphatic glands.

SCROFULA. 821

A. person having merely a tendency to such diseases may also be
called scrofulous, although not actually suffering from any one of the
above symptoms.

The hypothesis that scrofula depends upon a faulty composition of
the blood (dyscrasia), and that the lesions found in scrofulous persons
were due to the deposit in the tissues of a matter circulated by the
blood, and called a " scrofulous material," is almost universally aban-
doned. The alterations which take place in the skin, mucous mem-
brane, joints, bones, and organs of special sense, are of an inflamma-
tory nature, and cannot be distinguished from similar affections of a
non-scrofulous character, excepting by their intractability and the
tediousness of their course. It is impossible to point out any charac-
teristic features in a scrofulous eruption or arthritis, or to find any dif-
ference between them and similar non-scrofulous affections. Even the
caseous metamorphosis, to which the inflammatory products are so
prone, is by no means pathognomonic of scrofula, but is common to all
diseases of a chronic character which have a tendency to disintegra-
tion or destruction. Notwithstanding, however, that such inflamma-
tion presents no distinguishing mark whereby its scrofulous nature
may be recognized, yet there will rarely be any doubt as to whether
or not a case of this kind is entitled to the name. If its exciting cause
have been so slight as to be overlooked ; if we are informed that " the
disease came on of itself;" if this attack, or other similar ones, have
arisen repeatedly without assignable cause ; if it be accompanied by a
series of other disorders, especially chronic inflammation and persistent
enlargement of lymphatic glands, it is to be called scrofulous. If, on
the contrary, there be known external conditions, whose action upon
the system sufficiently accounts for the occurrence and the obstinacy
of the affection, without necessitating the supposition that there is any
special morbid tendency ; if it exist independently, and be uncompli-
cated with chronic enlargement of the lymphatics, then it is not to be
called scrofulous, notwithstanding the great similarity, nay, the abso-
lute resemblance, of its external symptoms to those of a scrofulous
disorder.

In its origin, scrofula, perhaps, is quite as often a congenital mal-
ady as an acquired one after birth.

Congenital scrofula is particularly common among offspring of
scrofulous parents. There are families, nearly or quite all the children
of which inherit the disease. This hereditary form of scrofula is close-
ly allied to that in which parents were tuberculous at the time of be-
getting the child, or in which the mother was so during pregnanc}', or
else suffered from cancer, tertiary syphilis, or some other malady, as
well as that form of scrofula occurring in children begotten of aged

822 GENERAL DISORDERS OF NUTRITION.

parents. As we know that many of the bodily and n ental traits of
parents are transmitted to their progeny, it will not seem extraordi-
nary that children of feeble, sickly fathers or mothers should have a
greater tendency to disease than those whose progenitors are vigorous
and healthy ; but we are totally unable to account for the fact that
scrofula is also very prevalent in the children of parents who are too
closely related to one another by blood. It must be added, moreover,
that it is not every child of scrofulous, sickly, feeble, or superannuated
parentage, and not all of the issue of the marriages of near relatives,
who suffer from congenital scrofula. Indeed, many children thus born
are healthy, and without any decided tendency to disease ; and, on
the other hand, this malady often attacks the offspring of parents
entirely exempt from the action of any of the above predisposing
agencies.

Acquired scrofula generally arises as a result of pernicious in-
fluences which have impeded the healthy development of the system
during the first years of life. First of all, among these, stands im-
proper nourishment ; a coarse diet, containing but little nutriment in
comparison with its bulk, being very properly held in especially evil
repute. The earlier this injudicious feeding of an infant commences,
so much the greater is the danger that it will become scrofulous;
hence, the children fed on pap furnish a very important contingent to
the army of scrofulous persons. Want of fresh air and exercise exerts
an influence as baneful as that of improper food. Hirscli has collected
a large number of facts, proving that, in foundling hospitals, orphan
asylums, boarding-schools, factories, and similar institutions, the con-
tinual abode in a badly-ventilated atmosphere, saturated with steam,
and poisoned by animal effluvia and the products of putrefaction, is in
the highest degree favorable to the development of scrofula ; and that,
according to the experience of these institutions where there is no
lack of cleanliness, good food, and warm clothing, the above pernicious
agents alone suffice to induce the disease.

It springs most frequently, however, from the combined effects of
all these different anti-hygienic influences. Although we have declared
the chief cause of scrofula to be the impairment of the normal develop-
ment of the system during childhood, through the action of the above-
mentioned noxious agencies, yet it must be added that, in prisons, poor-
houses, and workhouses, the disorder also breaks out among adults
subjected to the simultaneous effects of bad nourishment and want of
fresh air. The development or reestablishment of scrofula is, like-
wise, a not unfrequent sequel to certain acute and chronic diseases ;
and this is all the more likely to be the case, the younger and the
more undeveloped the subject of disease happens to be. Among

SCROFULA. 823

the diseases of childhood, measles is especially mischievous in this
way.

ANATOMICAL APPEARANCES. — Having already stated that scrofu-
lous inflammation has no peculiar characteristics, it would now be ab-
surd to attempt to describe the anatomical alterations of the skin and
mucous membranes, induced by scrofulous eruptions and catarrh. And,
indeed, we may refer altogether to the article upon cutaneous diseases
for a description of the anatomical alterations of the skin ; and to other
parts of this work, for an account of the lesions found in the various
mucous membranes, merely adding that in scrofula the inflammatory
products are generally richly provided with young cells, which accounts
for their tendency to caseous metamorphosis. A description of the
esions of the bones, joints, and organs of special sense, particularly
those of the eye, observed in scrofulous subjects, and which, likewise,
are not marked by any distinctive peculiarity, belongs to the province
of surgery and ophthalmology. The latter science has anticipated the
others by the discovery of the illusory nature of the oft-described
symptoms of scrofulous ophthalmia.

The alterations which take place in the lymphatics of scrofulous
subjects require further attention : first, because the disorders of these
organs as yet have received but cursory notice, no special section of
this work having been devoted to their consideration ; secondly, be-
cause, in persons thus afflicted, disease in the lymphatics is so common
that, among the laity, scrofula is commonly spoken of as having " en-
larged kernels," or simply " having kernels."

In the first place, it happens more frequently in scrofulous persons
than in non-scrofulous ones, that the lymphatic glands around an inflam-
mation of the skin or mucous membrane become the seat of an inflam-
matory process, which has extended along the lymphatic vessels from the
skin, and has involved the glands. The connective tissue around the
gland next participates in the inflammation of the glandular parenchy-
ma, and abscesses and ulceration ensue, which, like all abscesses and
ulceration of glandular substance, are very intractable, and often heal,
leaving an irregular, ragged, unsightly scar. Owing to the extreme
frequence of scrofulous eruptions upon the face and scalp, and of
scrofulous otorrhcea, the lymphatic glands of the neck are the most
common seat of this form of inflammation and ulceration.

Besides these, however, a chronic non-inflammatory enlargement of
the lymphatic glands is so often observed in scrofulous subjects, that
their presence may almost be regarded as pathognomonic. They may
attain a very considerable size, and, when several of them are clustered
together, they form huge, knotted cords, or shapeless lumps. The
individual tumors are regular in form, smooth of surface, and of a tol-
102

GENERAL DISORDERS OF NUTRITION

erably firm consistence. No foreign elements can be detected in them
under the microscope. They are the product of simple hypertrophy,
or, rather (since it is the cells that are multiplied, and not the tissue of
the stroma), of a " cellular hypcrplasia." But, as the number of cellu-
lar elements contained in a lymphatic gland, even during health, is a
very variable one, the complete subsidence of the enormously enlarged
glands of scrofulous subjects, which enlargement is entirely due to an
excessive accumulation of cells, will not seem extraordinary. Never-
theless, the gradual diminution of the tumor, with its final return to its
normal dimensions, is not the sole termination of this form of glandular
affection. Sometimes the tumors, which at first were the result of
mere hyperplasia, sooner or later become inflamed. The surrounding
areolar tissue takes part in the inflammation, after which, it is no
longer practicable to distinguish the individual glands in the general
mass. The skin becomes adherent to the tumor, and cannot be made
to glide over it. Suppuration and the formation of abscesses generally
follow slowly and gradually upon the inflammation, and the skin, hav-
ing become extremely attenuated, is perforated by the pus, leaving a
sinuous ulcer, with undermined edges. In other instances, inflamma-
tion and suppuration only take place at a solitary point in the tumor ;
and the matter formed at this spot does not burst through the capsule
of the gland, but thickens, and undergo escaseous metamorphosis. In
such a case, if the swelling subside, the caseous mass projects above
the surface of the gland, giving it an irregular shape. A partial or
complete caseous degeneration may also take place in the hyperplastic
mass, without any previous inflammation or suppuration, the over-
crowded cells drying up, and suffering " anaemic necrosis " (necro-
biosis). Such an occurrence at circumscribed points likewise renders
the contour of the gland irregular and angular. The caseous deposit
may subsequently become calcified, but, since it acts as an irritant upon
surrounding parts, like any other foreign body, it may subsequently
give rise to an obstinate inflammation and suppuration. When an
entire gland underwent caseous metamorphosis, the process used for-
merly to be called infiltrated glandular tuberculosis. If, on the other
hand, the deposit of caseous matter was limited, the gland was sup-
posed to be affected by miliary tuberculosis, although there were no
miliary tubercles to be found in it. The most frequent seat of scrof-
ulous hyperplasia of the lymphatic glands, like that of scrofulous in-
flammation, is in the neck, especially behind the ear, and under the
lower jaw, extending thence to the shoulder. The bronchial and me-
senteric glands are also very often the seat of scrofulous hyperplasia,
with all its consequences, as above described. The terms scrofulous
catarrh of the bronchi or intestines is perfectly appropriate to bronchial

SCROFULA. 825

and intestinal catarrhs, accompanied by enlargement or caseous de-
generation of the bronchial or mesenteric glands.

SYMPTOMS A:NT> COURSE. — In many instances the scrofulous ca-
chexia betrays itself by the patient's habit of body, which will often
arouse suspicion of his delicacy and of his feeble power of resistance
against disease, long before any actual morbid tendency (diathesis) is,
as it were, officially announced by the occurrence of frequent and ob-
stinate attacks of illness induced by causes so insignificant as to have
escaped observation.

The " scrofulous habit " is marked by a deficience of blood and by
a bad nutritive state of the more important and more highly-organized
tissues ; sometimes accompanied by an accumulation of fat in certain
regions, especially in the upper lip and nose. When the imperfect
nutrition is accompanied by an over-production of fat, there seems to
be an indolent state of the processes of constructive and destructive
assimilation ; but when not only the skin and the muscles, but also
the subcutaneous fat, is in a state of imperfect development, it is
probable that these processes are in a condition of unnatural activity.
Based upon these differences, in the patient's bodily habit, a classifica-
tion of scrofula into the torpid and erethitic forms has been made.
Canstatt very aptly describes the torpid scrofulous habit in the follow-
ing words : " An unusually large head, coarse features, a thick chin,
swollen abdomen, enlarged cervical glands, and flabby, spongy flesh ; "
and depicts the habit of erethitic scrofula as follows : " A skin of re-
markable whiteness, with a tendency to redden easily, and through
which the rose-pink or bluish subcutaneous veins are visible, a deep
redness of the cheeks and lips, blueness of the thin and transparent
sclerotica, which imparts a swimming and languishing look to the eyes.
The muscles of such persons are thin and soft, and their weight is light
in proportion to their stature, indicating a slightness of their bones. The
*eeth are handsome, and of a bluish lustre, though long and narrow ;
the hair is soft." There is no lack of examples of either of these forma
of disease, and though it may not be possible immediately to assign
every case to one or other category, yet in practice it will be well to
adhere to the classification into torpid and erethitic scrofula, since, as
we shall find by-and-by, we thereby obtain valuable data for the estab-
lishment of therapeutical indications.

Scrofula, although principally a disease of childhood, rarely declares
itself in the first year of infancy, excepting through a few faint tokens.
At the period of puberty scrofulous diseases usually subside, and with
them the scrofulous habit more or less completely disappears. More
rarely, exposure of the body to pernicious influences at this time excites
the subsiding scrofulous tendency to renewed activity, or even induces a

GENERAL DISORDERS OF NUTRITION.

relapse of disease which has been dormant for years. We have already
stated that, under such circumstances, persons, who during childhood
did not suffer from the disease, are attacked by it later in life.

It is impossible to describe scrofula briefly, and at the same time
comprehensively ; for its various manifestations combine in the most
diverse manner : in one case, this group of symptoms, in another, that
one assuming prominence ; and since many patients, notwithstanding
the tedious course of their malady, remain free from symptoms which
form the most important feature in other cases. And although it is
little to be doubted that the localization of scrofulosis (if we may use
the term) depends either upon the action of causes which are especially
hurtful to the organ attacked, or else upon the morbid susceptibility
of the organ to influences whose effect is universally injurious, never-
theless we can seldom tell why it should be marked in one case by a
scrofulous exanthema, in another by an ophthalmia ; why, in a third, a
disease of bone should prevail ; and it is equally inexplicable why the
inflammation and hyperplasia of the lymphatic glands should be more
extensive and obstinate in one case than in another. It has not been
determined even whether there be such a thing as primary hyperplasia
of the glands, or if this process, like the inflammation, be always of a
secondary character, proceeding from irritation transmitted to the
gland from some neighboring focus of inflammation. As the reality
of the latter fact is susceptible of proof in a great majority of instances,
it is not improbable, where it cannot be proved, that the irritation for-
merly existed at the point of origin of the lymphatic vessels involved,
but that it has already subsided ; for it is a rule that glandular enlarge-
ments long outlast the morbid process which has induced them.

The cutaneous eruptions which are the most common, and often the
earliest symptoms of the diathesis, are usually situated upon the face
and scalp. They generally belong to the form of dermatitis, in which
an exudation, more or less filled with cells, is effused upon the surface
of the cutis, and which nowadays are known as eczema and impetigo,
and used formerly to be called tinea and porrigo. The more destruc-
tive affections of the skin — such as lupus — do not usually appear until
a later period of life.

Scrofulous inflammation of the mucous membrane is most apt t<
appear in the vicinity of the natural orifices of the body, where it
readily implicates the neighboring skin, especially if it be moistened
by the superabundant secretions. Thus scrofulous coryza is usually
complicated with eczema of the upper lip ; inflammation of the exter-
nal auditory passage with eczema about the ear; catarrhal conjuncti-
vitis with eczema of the cheek ; conversely, the cutaneous eruptions
about an orifice often spread to its mucous membranes, thus inducing

SCROFULA. 827

coryza, otorrhoea, conjunctivitis, or ulceration of the cornea. Catarrhs
of the intestine and bronchi, and the rarer affections of the genito-
urinary apparatus by their obstinacy, may readily excite a suspicion of
a more malignant destructive process ; and indeed scrofulous catarrh
of the bronchi, by extending into the air-cells of the lung, and by in-
ducing caseous metamorphosis, with subsequent destruction of the
pneumonic deposits, not unfrequently terminates in pulmonary con-
sumption. Besides, it often happens that enlarged bronchial glands
soften and break down, forming vomicse, which discharge their con-
tents into the bronchi. Scrofulous ulceration of the bowels has already
been described in detail.

Scrofulous inflammation of a joint sometimes takes the form of a
simple hydrarthrosis, sometimes that of a so-called tumor albus, while
at others it assumes the nature of a malignant arthrocace, accompanied
by suppuration, caries of the articular surfaces, burrowing of pus, and
the establishment of fistulas. The disease of the bones sometimes
begins in the periosteum, sometimes in the bone itself, now presenting
the character of periostitis and ostitis, and now that of caries, necrosis,
or of the two combined.

As long as the existence of cheesy masses was regarded as char-
acteristic of the tuberculous nature of a disease, it was of course neces-
sary to ascribe many of the inflammations of the joints and bones of
scrofulous persons to a complication of scrofulosis with tuberculosis.

Among the organs of special sense, the eyes and more particularly
their superficial tissues, the Meibomian glands, the conjunctiva palpe-
brarum, the conjunctiva bulbi, and the cornea, are often afflicted by
obstinate inflammation. Indeed, in doubtful cases, the presence of
opacity or of scars upon the cornea, has been accepted as important
evidence that a patient has been scrofulous during childhood. In the
nose, excepting the rare instances in which that organ is destroyed by
lupus, scrofulous inflammation merely takes the form of an obstinate
coryza, which, however, is hardly ever absent. In the ears, besides
the inflammation of the external auditory canal, already alluded to,
caries of the petrous bone, with all its mischievous consequences, is
apt to ensue.

The objective symptoms of scrofulous disease of the lymphatic
glands have been described above. The adenitis and the phlegmonous
inflammation of the parts about them may be attended with great
pain and by more or less of fever, with evening exacerbations. In
consequence of this, not only does the patient's general health suffer,
but, if the inflammation and its attendant pain continue for weeks and
months, as they often do, his strength is consumed, and his nutritive
condition is greatly impaired. After the abscesses which form have

£28 GENERAL DISORDERS OF NUTRITION.

burst spontaneously, or have been lanced, and if no new centre of in
flammation have formed meantime, the fever gradually abates, the
patient's strength returns, the emaciation ceases, often long before the
ulcers have begun to heal, and while they still secrete large quantities
of pus.

Glandular tumors depending upon cellular hyperplasia are not
attended either by pain or fever ; but, when very voluminous, particu-
larly when seated upon the neck, they not only produce great deform-
ity but hinder the mobility of the head. Hitherto it has not been
ascertained whether scrofulous enlargement of the lymphatic glanda
exerts any detrimental influence upon the composition of the blood,
whether the cellular elements destined for the blood are retained in
the gland, or whether scrofulous glands affect the quality of the blood
as the glands of leucaemia do, but in a far slighter degree.

The progress of scrofula is tedious and treacherous, and nearly
always is marked by periodical alternations of improvement and aggra-
vation. Either the same series of symptoms recurs again and again
with renewed severity, or else, the former set having abated, or sub-
sided, new ones arise. Complete recovery from scrofula is a very com-
mon occurrence, especially if we include the cases in which no trace of
the disease remains excepting a peripheral speck upon the cornea, an
unsightly cicatrix, or other mark, which does not disturb the general
health and comfort. Death rarely results from the lesions to which
the epithet of scrofulous is usually given. Of these, tedious disease
of the bones and joints, and suppuration of the bronchial glands, are
the only ones which endanger life. On the other hand, a large num-
ber of scrofulous children die of croup, hydrocephalus, and other acute
maladies, for which such subjects have a predisposition quite as decided
as for the affections to which the term scrofulous usually is applied.
Finally, it should be mentioned that lardaceous disease of the liver
(Bud&s scrofulous tumor of the liver), spleen, and kidneys, often de-
velops during scrofulous disorders, particularly in tedious cases of
suppuration and disease of the bones.

Regarding the relationship of scrofula to tubercle, we have already
stated that no doubt many scrofulous children afterward become
tuberculous ; but also that a large number of them escape tuberculosis,
especially those in whom the constitutional delicacy, upon which the
former affection depends, subsides in after-life, and in whom no caseous
deposits remain as residua of scrofulous disease.

TREATMENT. — The prophylaxis against congenital scrofula lies
almost beyond the sphere of the physician. It is devoutly to be de-
sired that scrofulous, tuberculous, sickly, and superannuated persons
should not marry at all, *nd that healthy and vigorous individuals

SCROFULA. 829

should not wed their near relatives. But the representations of the
physician, that the issue of such alliances are likely to be scrofulous,
will rarely deter a man from marrying. On the other hand, it is not
only an imperative, but a grateful task to the physician, to endeavor to
provide, by proper precautionary measures, against the extension of
acquired scrofula. How to fulfil this duty becomes apparent from what
has already been said regarding the causes of acquired scrofula. Above
all, it should be borne in mind that the development of this disease is
promoted, not by one particular noxious influence merely, but by every
condition incompatible with health, to which the system, especially
during childhood, can be exposed. It often happens that, from the
moment when the first tokens of scrofula appear, or even as soon as
the parents begin to dread its attacks, the child is carefully deprived
of every particle of bread and butter, potato, and the like, and dosed
with huge prophylactic spoonfuls of cod-liver oil, while at the same time
he is suffered to sit all daylong in a close chamber, or upon the benches
of an overcrowded school-room. A sufficiency of fresh air and muscular
exercise are prophylactic measures of quite as much importance as
regulation of the diet is ; and we shall here call attention to an error
upon this subject, to which we have referred once before while discuss-
ing the prophylactic treatment of consumption : namely, the belief that
the use of bread and potatoes favors the development of scrofula and
tubercle, and the consequent complete privation of children of this kind
of food ; while in reality the mischief is due to an insufficient supply
of animal food — a diet of potatoes and other articles, containing little
nourishment in proportion to their bulk, not being injurious unless it
forms their sole or at least their principal subsistence. This error is
so prevalent, that the discovery that the child has surreptitiously eaten
a potato has cost many an anxious mother a sleepless night, and many
a child has uselessly been sent to bed hungry on this account.

The treatment of pronounced scrofula, where the prophylaxis has
been neglected or unsuccessful, requires, first of all, a careful regulation
of the regimen upon principles already laid down. Children with con-
genital scrofulosis must not be the subjects of experiment with artifi-
cial food ; but, if the mother have not milk enough, or if she be sickly
or feeble, so that, both in her own interest and in that of the babe, she
must be forbidden to suckle it, a good wet-nurse must be selected with
the utmost care. There is no substitute for the mother's or nurse's
milk, and the first year of infancy is perhaps the most important to the
constitution of the whole life. When the child is older, the directions
as to the diet and the mode of life must be given with the utmost pre-
cision. It is not advisable to order that "the patient shall eat but
little bread, and a good deal of meat, soup, milk, and the like;" and

830

GENERAL DISORDERS OF NUTRITION.

that " he must not work too long," and should take " plenty of out-
of-door exercise." To be successful in our object, the quantities of food
and drink must be prescribed definitely, as well as the number of hours
allotted to each form of occupation.

Cod-liver oil has a special and well-merited reputation as a remedy
ugainst scrofula, and there are plenty of instances where it has done
good service. On the other hand, perhaps no remedy has ever been
so much abused as this one. Whosoever supposes that the mere pres-
ence of a thick nose, a sore upper-lip, or a bunch of enlarged cervical
glands, affords sufficient ground for the prescription of this medicine,
will often fail to benefit his patient, and sometimes will do him harm.
Daily experience teaches, however, that such is the general belief, and
that he who seeks to combat it does not merely fight a windmill. Let
any one ask a patient whose scrofula has outlasted his childhood, and
who has passed again and again from one practitioner to another, how
often he has had cod-liver oil prescribed for him since the time of its
first failure during childhood ; how many months or years he has taken
it ; and how much the whole aggregate quantity would amount to ;
and he will be surprised at the answer. Nevertheless, in all proba-
bility, the next physician whom the patient consults will prescribe it
again. A most serviceable means of distinction, between the cases in
which cod-liver oil is indicated and those in which nothing is to be ex-
pected from it, is afforded by the symptoms of the torpid and erethitic
forms of scrofula. When the patient's slender frame, the lack of fat
beneath his skin, and his accelerated pulse, warrant the belief that his
nervous system is in a state of over-activity, cod-liver oil is generally
of the most signal benefit. Under its use the plumpness of the body
increases, while the general susceptibility of the system, and the dis-
eases consequent upon it subside. These are the cases to which this
article owes its name as an anti-scrofulous remedy. But if the patient
be clumsy and thick-set ; if the nose and upper-lip be enlarged, and
the adipose layer over the rest of the body strongly developed ; if the
action of the heart be retarded rather than accelerated ; if the irrita-
bility of the nervous system seem unusually obtuse ; in short, should
there be reason to suppose that the waste of the system is diminished
rather than increased, we cannot hope to relieve the disease by means
of the oil. Nevertheless, it is precisely this class of patients who in
vain have taken such enormous quantities of it in the course of their
lives. Besides the oil, and as a corroborant of its effects, so to speak,
articles containing a little tannin, such as parched acorns, " acorn-coffee,"
and home-made infusions of walnut-leaves, are very often prescribed.
Such a practice is greatly to be commended whenever there is a chronic
catarrh of the intestines embarrassing the digestion and the absorption

SCROFULA. 831

of chyle, and where apprehensions are entertained that the oil may
aggravate the intestinal disorder. When used in appropriate cases, we
prize the efficacy of cod-liver oil, with acorn-coffee, and walnut-tea, most
highly, although we strongly deprecate its indiscriminate employment
in every form of scrofula ; but, as it is requisite that its exhibition
should be long continued in order to produce favorable results, certain
rales for its administration must be laid down. The disgust for the
oil, which in adults is sometimes invincible, is soon overcome by chil-
dren, who generally speedily cease to fight against the customary dose
of two teaspoonfuls daily, and even ask for it themselves when the
period for its administration has expired. But, if the treatment be
kept up for months without occasional intermission, an unconquerable,
and then too generally a permanent aversion to the disgusting medi-
cine will arise, even among children, so that vomiting and retching
ensue after every attempt to force it down. This awkward occurrence,
which often renders further treatment futile, may nearly always be
avoided by interrupting the " cure " for a week or a fortnight after
continuing it for four or six weeks. In order to make children take
the acorn-coffee as willingly as real coffee, it is sufficient to add a few
coffee-beans to the acorns before roasting them.

It is far more difficult to furnish definite instructions for the use of
the brine-baths, whose anti-scrofulous virtues enjoy a reputation almost
as great as that of cod-liver oil. We know too little about the action
of these baths, and about the effect which they produce upon nutri-
tion, and the advantages derived from the salt, iodine, and bromine,
which they contain, to enable us to determine upon theoretical princi-
ples where they are indicated and where they are unlikely to do good.
A calm analysis of the positive and negative effects of brine-baths in
scrofula, which would be the best means of obtaining fixed indications
for their use, has not, as yet, been made ; and the doctors at the baths,
who certainly ought to be the best judges of the extent and limits of
their healing powers, rarely send away a scrofulous patient as unfit to
use the brine. Hence, there is no resource but to send persons, who
have in vain tried cod-liver oil and other anti-scrofulous remedies, to
Kreutznach, Ischl, Kosen, or Wittekind, or some similar watering-
place, in the hope that they may be among those to whom the baths
will exhibit their anti-scrofulous virtues, which are by no means illu-
sory ; and, if the circumstances of the patients do not admit of this,
they must use artificial brine-baths at home.

In recent times the cold-water cure has earned for itself a most
favorable reputation as a remedy for scrofula ; and, indeed, a series of
cases is on record in which complete and perfect cures have been ob-
tained by these means, after all other modes of treatment had been

GENERAL DISORDERS OF NUTRITION.

applied in vain. We certainly are justified in asserting that cod-liver
oil treatment cannot be substituted for the water-cure, nor vice versa;
but we may go still further, and declare that the oil is not only useless
in a case adapted for the water-cure treatment, but is absolutely per-
nicious ; and the same holds good regarding the hydropathic treatment
in a case where large doses of cod-liver oil are indicated. When we
consider that formerly the " decoctions of woods," laxative tisanes, an-
timonials, mercurials, and other drugs intended to stimulate the emunc-
tories into activity, were much employed in scrofula, and when, after
weeks of such treatment, a profuse flow of urine or of sweat was final-
ly induced, or, when the patient began to purge copiously, very good
results were sometimes obtained, it will be plain that this treatment
(the effect of which is to cause an intensely active destructive assimi-
lation and consumption of the tissues) can only benefit the class of
patients in whom these processes are in a state of indolence and inac-
tivity. The hydropathic treatment has a similar though far less per-
nicious influence, and is of signal benefit in the torpid form of scrofula,
that is, in that form where cod-liver oil is powerless, as I have repeat-
edly had opportunity of satisfying myself.

Iodine and the mercurials are also generally regarded as good anti-
scrofulous medicaments. It is impossible to hold such views while
believing scrofula to consist in a cachexia, marked by a peculiar prone-
ness to disease, and evinced by a series of nutritive disturbances ; for
one cannot well suppose that the use of iodine or mercury can aug
ment the power of the system to resist noxious influences. I therefore
consider it improper to prescribe these articles solely on account of the
scrofula, and without fixed indications arising from the peculiarities of
the case. At the same time I will not deny that the cases are pretty
numerous in which the preparations of iodine and of mercury are indi-
cated. For further details, I refer to the books of local pathology and
therapeutics, surgery and ophthalmology, merely alluding to the great
benefit derivable from the internal and external exhibition of iodine in
the chronic hyperplasia of the lymphatics. In particular, where chronic
indolent enlargements of the lymphatic glands form the sole remaining
vestige of a former disease, astonishing advantage is often gained by
the use of the Adelheid springs and the Krankenheil waters.8

CHAPTER VII.

DIABETES MELLITUS — MELLITUEIA.

ETIOLOGY. — The pathogeny of diabetes still remams obscure. The
discovery of the physiologists, that sugar appears in the urine of animals
after puncture of the floor of their fourth cerebral ventricle, has not as

DIABETES MELLITUS. 833

yet thrown light upon the mystery. We know that the presence of
sugar in the urine, whence diabetes mellitus derives its name, does not
depend upon functional abnormity of the kidneys ; that the sugar is
not formed in them, and that it is excreted from the blood ; but we
are altogether ignorant wherein the constitutional anomaly consists, in
consequence of which a diabetic patient's blood contains* sugar, and a
healthy person's none. As the various hypotheses offered to account
for diabetes are of little practical value, we shall mention a few merely
of those most generally entertained.

In the first place, diabetes has been ascribed to an insufficient de-
gree of transformation of the sugar in the blood. Indeed, if the sugar
into which the amylaceous substances that have been eaten are con-
verted, and that which is formed in the liver, were to circulate in the
blood without undergoing further alteration, and if this substance did
not disappear again from the blood during its passage through the
lungs, it would necessarily form one of the normal constituents of the
urine ; hence it cannot be denied that the. pathological presence of
sugar in the urine may possibly depend in some cases upon a failure
of the conditions under which the normal transformation of the sugar
takes place. However, as long as we are ignorant as to what these
conditions are, we obtain but little aid from the hypothesis that their
absence is the cause of diabetes. The assertion, that the non-assimila-
tion of sugar in the circulation of diabetic persons is due to a want of
alkalies in the blood, has been disproved. The theory of the existence
in the blood of healthy persons of a certain unknown ferment, which
induces the assimilation of sugar, but which is absent in the blood of
diabetic persons, is untenable.

Others have sought to trace the origin of diabetes to an abnormal-
ly accelerated conversion of amylaceous matter into sugar, this being
due to a diseased condition of the digestive juices. To this theory
there are still greater objections than to the preceding ones. It seems
that even in healthy persons the amylaceous ingesta are all changed
into sugar (Trommer has proved this to be the case even in geese
that have been "crammed"), and yet we know that healthy urine
never contains sugar even after the ingestion into the system of very-
large quantities of amylaceous matter, or of pure sugar. But the re-
sult of the treatment based upon these hypotheses has afforded the
best evidence of their unsoundness. Were the source of diabetes an
over-active and immoderate conversion of amylum into sugar, the dis-
ease should cease upon the stoppage of the supply of amylum. Ex-
perience, however, teaches us the contrary ; as, even where for weeks
and months the food of the patient has been exclusively animal food,
the sugar rarely disappears from the urine. Finally, since Claudt

GENERAL DISORDERS OF NUTRITION.

Bernard has shown that the liver produces glycogenous substances
and sugar, the hypothesis that diabetes depends upon a disease of the
liver has gained ground, although the theory is not supported either
by pathological or clinical observation. Claude Bernard himself
thinks that the diabetes induced experimentally in animals, by the
" diabetic puncture" depends upon the nervous derangement of the
liver to which the operation gives rise. As a consequence of abnormal
innervation, not only is the production of glycogenous matter aug-
mented, but its conversion into sugar is also hastened. He believes,
too, that in the human subject, diabetes mellitus likewise is due to an
over-activity of the nerves which stimulate the function of the liver,
and considers it probable that, " if it were in our power to galvanize
the sympathetic nerve," this would be the best possible mode of treat-
ing diabetes symptomatically ; the function of this nerve being weak-
ened by the undue activity of its antagonists. The possibility cannot
be denied that more glycogenous matter is formed in the liver of a
diabetic person than in that of a healthy one ; but it is neither proved
nor even probable that this anomaly constitutes the only or even the
essential lesion of the disease. It is not to be supposed that the pound
of sugar which some patients discharge in the course of every twenty-
four hours is only a small portion of the sugar which they produce
daily, and that a larger portion undergoes that transformation in the
blood which, normally as we know, is undergone by very large quan-
tities of sugar, while a smaller portion of it remains, as it were, super-
fluous, and passes away in the urine. In conclusion, I will present
another very specious hypothesis, which really accounts better than
any other for the origin of diabetes. According to Tscherinoff, the
liver-sugar is not made from the glycogen, but, on the contrary, the
glycogen is formed from the sugar which arrives in the liver. Hence,
instead of glycogen (sugar-former), it should be called glycophthin-
ium, or sugar-consumer. If the liver loses its capacity to convert the
sugar into glycophthinium, the sugar remains in the blood, and thus
causes diabetes.

Regarding the etiology of diabetes, our knowledge is equally
vague, for although we learn from the history of many cases that the
disease has arisen sooner or later after the exposure of the patient to
certain noxious influences, yet these influences are so general in their
character, and act so often upon the system without being followed
by diabetes, that it becomes questionable whether the disease be at-
tributable to their action at all.

Griesinger, after collecting a large number of foreign and domestic
cases, has come to the following conclusion : Diabetes occurs much
more frequently in males than in females, the proportion being about

DIABETES MELLITUS. 835

three to one. During childhood and old age it is rarer than dining
the prime of life, the period of greatest frequence being between the
ages of thirty and forty in males, and in females between ten and
thirty. The disease sometimes appears to depend upon hereditary
predisposition. The most commonly recognized exciting causes are :
exposure to cold and wet, external violence, concussions of the whole
body being a more fertile source of the disease than injuries to the
brain and spinal marrow ; also immoderate eating of sugar, new wine,
and " fruit-must," unfermented juice of fruit, indulgence in immoderate
mental exertion, mental depression, intoxication, etc.

ANATOMICAL APPEARANCES. — No constant lesion is found post-
mortem in the bodies of those who have died of diabetes mellitus.
The most common appearances are the following: extreme emacia-
tion, the integument often presenting remains of bed-sores, boils, car-
buncles, and sloughs. There is no remarkable lesion in the brain ; in
the lungs there are almost always tuberculous, or caseous deposits, of
variable age, and not unfrequently pneumonia, or gangrene. The heart
is flabby and atrophied ; the liver usually normal, though sometimes
hyperaemic. Hypertrophy of the pancreas occurs with remarkable fre-
quence, considering how seldom this organ is the seat of disease. The
walls of the stomach are moderately thickened, through muscular hy-
pertrophy, probably the result of distention. The kidneys are en-
larged by hyperaemia, and sometimes are in a state of chronic paren-
chymatous inflammation (Brightfs disease).

SYMPTOMS AND COURSE. — The most conspicuous and remarkable
symptom of diabetes mellitus consists in the evacuation of enormous
quantities of pale urine, whose high specific gravity, contrasted with
its limpid aspect and sweetish taste, often alone suffices to place the
diagnosis beyond a doubt. It is by no means rare for a diabetic pa-
tient, in the course of twenty-four hours, to pass from five to ten thou-
sand cubic centimetres of urine (from five to ten quarts), and, in some
instances, the daily discharge has been much larger. No credence
should be given to the stories of diabetic patients passing six or eight
times this amount, or even more. It is maintained by some that the
quantity of urine discharged exceeds the amount of liquid which has
been drunk during the meals. If this were true, and unless there were
a corresponding waste of the body, we should be compelled to assume
that, instead of exhaling liquid through the skin and lungs, the patient
actually imbibed moisture in this way from the surrounding atmos-
phere. Since, as long as the temperature of the body remains higher
than that of the air about it, such an occurrence would be incompatible
with physical laws, I think it most likely that the observations have
been erroneous in the instances where individuals have been reported,

836

GENERAL DISORDERS OF NUTRITION.

for long periods together, to evacuate a larger weight of urine and
faeces than they had taken in of food and drink, without losing in
weight. Every investigator and experimenter, who has given his at-
tention to the subject of diabetes, has to suffer from the strong in
clination on the part of the patient to deceive him, and to conceal a
portion of the liquid that he drinks. In the researches and experi-
ments of Reich and Liebermeister at the Greifswalder clinic, the re-
sults of which have been published by Dr. Reich, at first, the quantity
of urine and faeces, evacuated by both of the patients under observa-
tion, seemed to exceed the amount which they ate and drank. But
after they began to watch the patients so closely that they were never
left alone for a moment, nor withdrawn from immediate observation,
the quantity of ingesta began to exceed that of excreta of urine and
faeces.

With regard to the cause of the immense increase in the secretion
of urine in diabetes, Liebermeister and Reich have proved by their
experiments that the very large quantity of liquid which they imbibe
is not of itself sufficient to account for it. For a number of days, and
with great care, they measured out equal portions of food and drink to
two patients with diabetes, and a similar portion to a perfectly healthy
and trustworthy man (Mr. Hoffmann, student of medicine), and meas-
ured the flow of urine for every twenty-four hours, from each of them,
with the same accuracy. The result showed, that in Candidate Hoff
mann the secretion of urine was considerably augmented by the very
large quantity of liquid which he had swallowed in the cause of science,
but that it was far less than that passed in the same time by the sick
men. Hoffmann passed from five thousand to six thousand cubic
centimetres (five to six quarts), while the patients passed from
seven thousand to ten thousand. It is possible that the presence of
sugar in the blood may increase the power of filtration through the
glomeruli of the Malpighian capsules, thereby augmenting the amount
of urine secreted. However, this hypothetical explanation of the
polyuria of diabetes is superfluous, since it is fully accounted for by
Vbgel, in his classical work upon this disease, as follows : " What-
soever may be the source of the sugar contained in the blood in dia-
betes, the necessary consequence of its presence is, that the saccharine
serum of the blood greedily attracts to itself, by endosmosis, all the
liquids from the parenchyma, and all the water of the food and drink
which enters the alimentary canal. The more the blood attracts
water, so much the more does it increase in volume, and augment the
intravascular pressure. The increase of pressure in the glomeruli of
the Malpighian capsules of the kidneys then produces polyuria."

The high specific gravity of diabetic urine, which in mild cases

DIABETES MELLITUS. 837

ranges from 1020 to 1030, and in severe ones from 1030 to 1050, de-
pends almost exclusively upon the quantity of sugar in it ; for although
the common belief has not proved true, that the absolute amount of
urea and salts is reduced in diabetic urine, yet, owing to the enormous
quantity of water in which they are dissolved, their relative quantity
is very small indeed. Liebermeister and Reich found that the produc-
tion of urea of their patients not only was greater than that of healthy
persons moderately supplied with mixed food, but that it also exceeded
that of a healthy man, who ate as much food as the diabetic patients
did. The amount of urea fluctuated in the patients from thirty-two to
fifty-five grammes, and in a healthy subject from twenty-nine to thirty-
two grammes.

Although the profusion of the urine, its high specific gravity, and
its sweetish taste, are decidedly indicative of the presence in it of
sugar, yet its positive existence can be easily proved by means of one
of the many " sugar-tests." Although it is important to select the most
delicate and surest of these, when we wish to determine the presence
of very minute quantities of sugar, and although the supposed discov-
eries of traces of sugar in healthy urine, and in many other pathologi-
cal and physiological conditions, are in a measure due to our mistaking
other substances, having similar reaction, for sugar, yet, when it appears
in large quantities, as it does in diabetic urine, Trommels test is quite
sufficient to settle the diagnosis. An excess of liquor potassae is to be
mingled with a portion of the urine to be examined ; a dilute solution
of sulphate of copper is then to be added, drop by drop, as long as the
precipitate which first forms will redissolve when stirred. The liquid
(which, if sugar be present, will show a blue color) is then to be
filtered and warmed. The precipitation of red oxide of copper in the
liquid, while still below the boiling-point, furnishes absolute proof that
the solution contains sugar. If albumen also be present, it must pre-
viously be separated by boiling and filtration. Another more simple
test consists in warming the urine after adding a solution of potassa.
The presence of sugar is indicated by the liquid's assuming a yellow
color, which gradually deepens into a dark brown. If this color does
not appear, the non-existence of sugar is certain ; but, even when visi-
ble, it is always advisable to try Trommels test also. For the details
of the somewhat elaborate fermentation-test, and the other tests for
sugar, we refer to the text-books upon organic chemistry. Fehling's
" liquid " furnishes a very sure means of determining the percentage
of urea, and also of the sugar, if the quantity of urine passed in twenty-
four hours be measured. Liebermeister and Heich^ who, in their many
experiments, examined each portion of the urine separately, only
noting as reliable those observations which agreed, hardly ever had

g38 GENERAL DISORDERS OF NUTRITION.

occasion to repeat the process in the same portion of urine, after
they had conducted their researches for a few days. The polarizing
apparatus of Soleilr Ventzke is a more convenient and rapid method
of ascertaining the percentage of sugar in the urine. The cheaper
polarizing apparatus of Robiquet, though less accurate, is also appli-
cable to this purpose. In low grades of the malady, the quantity of
sugar is not more than from one to two per cent. ; in more intense
forms, it is as much as six or seven per cent., or more. In well-pro-
nounced instances, the entire amount excreted daily may exceed a
pound. The proportion of sugar, however, varies greatly during the
progress of the disease, sometimes even fluctuating perceptibly in the
course of a day. The causes of these fluctuations are in a great meas-
ure unknown, and we are acquainted with a few only of the agents
which are capable of increasing or diminishing the percentage of sugar
in the urine. Of the former, large draughts of liquid, heavy meals,
especially eating large quantities of sugar or of amylaceous matter ;
of the latter, the exclusion of sugar from the food and drink, particu-
larly the removal of amylaceous matter and similar glycogenous food.
The influence of a meal upon the percentage of sugar voided continues
for several hours, and then is replaced by a similar discharge of a much
more gradual character. Dr. Moritz Traube infers, from the great de-
crease in the elimination of sugar which takes place after several hours'
fasting, that, at a certain period during the night, there must be none
at all. Had Dr. Traube but tested the truth of his conclusion (and he
states expressly that he has not done so), had he merely examined a
little of this urine of the last few hours of the night, which he supposes
should not contain sugar, he would probably find himself to be in the
wrong. Among the cases under observation at my clinic, one of which
was of quite recent origin, affecting a young, vigorous man, still capa-
ble of work, and in the fourteen cases investigated by Seegen in
Karlsbad, the urine passed in the latter hours of the night and those
of early morning invariably contained sugar. Hence Dr. Traubds
proposed "law" is undeserving of credit until it shall have been
proved that cases do occur in which it is as he supposes.

The parching thirst which distresses the patient day and night is
easily accounted for, as it has been proved that the polyuria of diabetes
is not merely a consequence of much drinking, but rather that the
patients drink much because they suffer an excessive loss of water
through the kidneys. Claude Bernard ascribes the thirst of diabetic
patients to the elevated temperature of the liver, which undoubtedly
induces an increased absorption in the intestinal canal. This hypoth-
esis, like the others, is idle. A diabetic patient is thirsty on account
of the thickening of his blood, much of whose water has been dis-

DIABETES MELLITUS. 839

sharged from his kidneys, just as another one thirsts who sweats pro-
fusely, or who suffers a great evaporation from his skin from fever, or
ake a cholera patient who is discharging water through the capillaries
of his intestines. A second factor consists in the desiccation of all the
tissues as a result of intense endosmotic action from the parenchyma
into the vessels. Sugar may be employed as well as salt for the pur-
pose of drying meat in order to preserve it. It is by no means rare foi
a patient to drink from ten to fifteen quarts of water during the day.
The thirst is most intense an hour or two after meals, that is, while
the formation of sugar is most active and the production of urine the
most copious.

This immense waste of water through the kidneys likewise accounts
for the complete arrest of perspiration, and for the decrease in the in-
sensible evaporation from the skin, which have been observed at my
clinic. The antagonism between the secretions of the skin and kid-
neys is as well shown in the dryness of the surface of diabetic people
as in the reduction of diuresis, which usually accompanies profuse per-
spiration. Griesinger reports an interesting case, in which sugar was
present in the urine and sweat alternately, and in which, whenever the
sweat became strongly saccharine, the percentage of sugar in the urine
sank one-half. In the aforementioned researches of Liebermeister and
Reich, it was found that a diabetic patient scarcely perspired a third
of the quantity given off by a healthy person. Finally, according to
the experiments of IKunde and ITohnhom, who, by artificial abstraction
of water from frogs and mammalia, have induced opacity of the crys-
talline lenses of these animals, it seems not improbable that the cataract
which often accompanies diabetes is a consequence of the excessive
loss of water, although indeed the ophthalmologists have raised many
objections to this explanation.

An insatiable hunger is a symptom of diabetes, quite as constant
as is the unquenchable thirst. It is almost incredible how much food
such a patient will consume during a day, often quite regardless of its
quality. This voracious hunger, as well as the steadily increasing and
finally extreme emaciation, manifestly are due to the fact that a large
part of the food eaten is of no profit to the system, because, instead
of being devoted to the repair of used-up constituents of the body, it
is immediately excreted. Moreover, the consumption of the nitro-
genous components of the body is considerably increased in diabetes,
as is shown by the augmentation in the quantity of urea produced.
Of course there can be no elevation of the bodily temperature, a large
part of the heat-producing material passing off from the blood unused.

The impotence, which is nearly always observed in this disease, is
probably dependent upon a general decline in the patient's strength
103

340 GENERAL DISORDERS OF NUTRITION.

and nutritivt condition; nevertheless, the attempt has been made tc
ascribe diabetic impotence to the drying up of the sperm for want of
water, and to a saccharine condition of the semen, supposed to deprive
it of its power of inducing nervous excitement.

Finally, we have to mention a series of phenomena, which, al-
though less constant than those heretofore described, still often accom-
pany them and serve to complete the picture of the disease. Caries
of the teeth is a symptom which sets in early in the majority of cases.
Folk explains this phenomenon by supposing that the teeth are ex-
posed to the action of a free acid, formed by decomposition of saccha-
rine secretion within the mouth. Then, again, phymosis and excoria-
tions of the prepuce and glans in men, and of the parts about the
meatus urinarius in women, are very distressing occurrences, due prob-
ably to wetting of these parts with saccharine urine. Finally, there
is often a great tendency to inflammation, ending in necrosis and mor-
tification, exhibited in the very frequent occurrence of furuncles, car-
buncles, lobular pneumonia, and pulmonary abscesses and gangrene.

Consumption of the lungs develops as a terminal symptom in many
diabetic persons. According to Griesinger, nearly one-half of all pa-
tients die in this way. Now and then albuminuria is associated with
mellituria, thereby augmenting the exhaustion and accelerating the
demise of the sufferer. It is not improbable that the parenchymatous
nephritis, upon which the albuminuria depends, is a consequence of the
constant irritation of the kidney by the presence of sugar in the urine,
thus forming a sort of analogue with diabetic balanitis.

The course of diabetes is always chronic, lasting for months and
years. In but a very small number of the cases reported, the disease
has been acute, terminating fatally within a few weeks, or even sooner.
We have scarcely any trustworthy observations of the incipient stages
of the malady. Nearly all patients only come under treatment at a
period when the profuse urination, tormenting thirst, insatiable hun-
ger, and steadily advancing emaciation, have awakened the suspicion
of the existence of serious disease ; and they are scarcely ever able
accurately to state when the present symptoms first arose, or by what
others they had been preceded. Even in the few examples in which
the malady has developed quickly, an augmented hunger, thirst, and
an unnatural diuresis, were the first manifestations which attracted the
attention of the patients and their friends.

Diabetes usually lasts from one to three years. More than sixty
per cent, of the cases collected by Griesinger terminated fatally
within that period. It must, however, be recollected that statistics
usually refer to cases treated in hospital, while the majority of those
treated in private practice are never published. There is no doubt

DIABETES MELLITUS. 841

that patients in comfortable circumstances, and who possess the means
of taking good care of themselves, hold out against diabetes much
longer than those who are obliged to seek refuge in hospitals. A
complete and permanent recovery from diabetes (if it ever occur at all)
is extremely rare ; although plenty of cases have been recorded in
which a pause in the symptoms, of longer or shorter duration, has
been observed. Death, when not the result of some intercurrent com-
plication, usually takes place with the signs of extreme marasmus.
Sometimes nervous symptoms arise shortly before death, calling to
mind the characteristics of uraemic intoxication.

TREATMENT. — Numerous remedies and " cures " have been recom-
mended for diabetes ; unfortunately, most of them have been devised
upon principles based on purely hypothetical views as to the nature
of the disease, and very few of them rest upon facts established by ex-
perience. We shall not discuss procedures such as that whose object
is to hinder the conversion of amylum into sugar by exhibition of acids ;
or that in which nitrogen is to be supplied to the system by adminis-
tration of ammonia ; or in which it is sought to allay irritability of the
kidneys by means of opium ; or to act upon the liver by means of ox-
gall, or gallic acid, or any of the other purely theoretical suggestions.
We are indebted to Griesinger for a positive experimental demonstra-
tion of the inefficacy, and in some cases even the detrimental character,
of some of these modes of treatment, such as that by alcohol, rennet,
yeast, sugar — intended to supply the place of that lost from the blood.

Experience has also established the fact of the beneficial influence
of certain dietetic rules, the first hints of which, however, were derived
from theoretical reasoning. It is of the utmost importance that dia-
betic patients should live principally upon animal food, and that they
should eat but very little starchy or saccharine matter. The absolute
prohibition of food containing starch and sugar has been abandoned
of late ; experience having taught, in the first place, that although the
loss of sugar might undergo temporary diminution by this procedure,
yet it could not cure the diabetes ; and besides, it has been found that
there are very few patients who for years can endure a diet consisting
exclusively of meat, eggs, fish, oysters, crabs, salad, and Bouehardatfs
bran-bread. It relieves the patients greatly, in carrying out the rest
of the treatment, to allow them to eat a small portion of bread daily ;
and it does them no material harm. If we do not allow them this in-
dulgence, we run the risk of their soon becoming so impatient, at the
excessive restraint, as to refuse further obedience, and make up for lost
time by eating copiously of bread and fruit, for which they almost
always have a great desire. Besides the meats, the patient may be
allowed such vegetables as do not contai^ either sugar or starch, or

34:2 GENERAL DISORDERS OF NUTRITION.

but very little of them. Bouchardat has proved, by the comparison
of the articles of food which a diabetic may take without prejudice,
that it is quite possible to keep up a sufficient degree of variety in the
character of the meals. The list of articles which he permits is about
as follows : All sorts of meats roasted, stewed, and even dressed with
spices, but not with flour ; fresh water fish and marine fish, in eating
which the want of bread is less felt than in eating meat ; oysters, mus-
cles, crabs, lobsters, etc. ; eggs in all the forms known to the culinary
art ; rich, good cream, but no milk ; of the vegetables, spinach, arti-
chokes, asparagus, green beans, the different varieties of cabbage ; of
the salads, water-cresses, endives, lettuce ; of fruits, strawberries and
peaches. Although the loss of sugar is augmented by very free sup-
ply of liquid, and decreased by a privation of it, yet it is not advisable
to forbid the patient to quench his thirst. Griesinger, who has ex-
perimented upon this subject also, concludes that there is no rapid
or considerable decrease in the loss of sugar until the thirsting has
been pushed to the point of general disturbance of the system ; and, as
such a condition can only be endured for a very short time, he allows
the patient just enough liquid to slake his thirst. Besides spring-
water, acidulated water may be allowed as a beverage, as well as
coffee, well-fermented beer, and wine, if not too new, especially red
wine.

Inasmuch as diabetic persons are very liable to take cold, and
show a predisposition to pneumonia, and the like, directions regarding
their clothing must also be laid down, and especially must they be
urged to wear flannel next the skin.

Besides these dietetic rules, under the conscientious observation
of which diabetes, although incurable, is often tolerated for a great
length of time without appreciable decline (as can be proved by many
well-attested instances), there are certain medicinal remedies whose
effects in diabetes are very decided. In private practice, no credit
should be given to the claims of any drug based upon the bare asser-
tion that it has benefited or cured a case of diabetes, particularly when
it has been known to fail in other instances. But even those remedies
which only exert a slight influence upon the course of the disease
(proved, however, by accurate and continuous measurement of the
urine, sugar, weight of the body, etc.) should be urgently recom-
mended to private patients by then* physicians. At present, however,
the alkaline carbonates are the only medicines whose beneficial action
upon diabetes can be claimed with certainty. In Griesinger*s clinic,
the exhibition of doses of bicarbonate of soda effected a distinct al-
though slight improvement in the disease. The equally well-estab-
lished success of the springs of Carlsbad and Vichy have been much

DIABETES INSIPIDUS. 813

more marked. The old reputation of the Carlsbad waters, as a cure
for diabetes, has vindicated itself most brilliantly, according to the ob-
servations of Seegen. According to him, there can no longer be any
doubt that in many cases of diabetes mellitus, a course of several
weeks at these springs results in an abatement of the thirst, a decrease
in the urination, a gain in weight, and in a disappearance of the
sugar from the patients urine. Whether or not these results be per-
manent, or merely transitory, still, in our present state of knowledge,
a course of waters at Carlsbad is the measure which should deserve tho
chief reliance as a remedy for diabetes mellitus.8

CHAPTER VIII.

DIABETES INSIPIDT7S.

DIABETES rasiPiDUS and diabetes mellitus, in spite of the agree-
ment of their most conspicuous symptoms, polyuria and unquenchable
thirst, are altogether distinct diseases. In the former, the urine does
not contain any foreign ingredients, the presence of which might ac-
count for the symptoms.

It is true that not long since, in the urine of a patient with dia-
betes insipidus, Mosler discovered inosite, which is not among the
normal constituents of urine, and he advanced the hypothesis that
inosite played the same part in diabetes insipidus (inosuria) that
sugar does in diabetes mellitus (mellituria). But the very slight
amount of inosite excreted in the urine of Moslems patient would
render this idea improbable, and it is entirely refuted by one of my
pupils, Dr. Strauss, who wrote an excellent monograph on diabetes
insipidus.*

After finding inosite in the urine of two cases of diabetes insi-
pidus— in one case 0.1474 grm. in 6,700 ccm. of urine, in the other
1.508 grm. in 9,600 ccm. of urine — Strauss caused three healthy
persons, in 'whose urine there was no inosite, to drink large quan
tities of water (about ten quarts in twenty-four hours) ; after this^
inosite was found in the urine of all three patients, in about the same
proportion as in the patients with diabetes insipidus. These beautiful
experiments show that a body which normally exists in the kidneys,
liver, lungs, and muscles, but, as it undergoes changes in the body, is
not found in normal urine, may be excreted through the kidneys by
giving large quantities of water.

* Die einfache zuckerlose Harnruhr, von Dr. F. Strauss, Tubingen, 1870.
Veilag der Lauppschen Buchhandkrog.

GENERAL DISORDERS OF NUTRITION.

The most specious of the hypotheses, as to the pathogeny of
insipid diabetes, is that which ascribes the polyuria to derangement
of innervation of the blood-vessels of the kidney. If the afferent
vessels of the Malpighian capsules were to become dilated, in conse-
quence of paralysis of their walls, the pressure within the glome-
rali would increase, and with it the rate of filtration of the urine
would augment, thus giving rise to polyuria. This primary symptom
would be accompanied secondarily by polydipsia. When large quan-
tities of water are withdrawn from the blood, as a consequence of pro-
fuse urination, then (just as also occurs after profuse sweating, or
intense liquid diarrhoea) the fluids from the interstices of the tissues
are greedily absorbed by the now concentrated blood, thus giving rise
to an increased need for liquid, and to a sense of severe thirst. Al-
though I regard this as probably a true explanation, and although it
acquires further support from the discovery of Bernard, that polyuria
may be induced in animals by wounding their medulla oblongata at a
point somewhat farther up than that at which the so-called " diabetes
puncture " is performed, yet I am by no means inclined to regard it
as absolutely correct.

With regard to the somewhat obscure etiology of diabetes insipi-
dus, we must confine ourselves to the announcement of the following
facts : The disease is more common in males than in females, and in
youth than during middle age. I cannot confirm the assertion that
old age is exempt from it, as I have seen a case in a patient fifty years
old. Its exciting causes have so often been referred to mental affec-
tions, to the drinking of cold beverages while the body was over-
heated, to cold, to over-exertion, to abuse of spirituous liquors, and
other agencies, of a nature so- various, and of such common occurrence,
that the dependence of the malady upon their influence must be
regarded as questionable.

It is different with the observations of cases where diabetes
insipidus has occurred after injuries of the skull, and in the course
of acute and chronic diseases of the brain. These cases, in con-
nection with the above-mentioned experiments of Bernard, are
peculiarly interesting.

ANATOMICAL APPEARANCES. — The results of the small number of
autopsies held upon persons who have suffered from diabetes insi-
pidus agree so imperfectly, that nothing positive can be affirmed
regarding the anatomical lesions from which the malady originates.
Thus, in a case described by Neuffer, the kidneys, contrary to all expec-
tation, were found small and atrophied, while in another, mentioned by
Lebert, they were enlarged and hypertrophied.

SYMPTOMS AND COURSE. — The amount of urine discharged by a

DIABETES INSIPIDUS. 845

patient with diabetes insipidus is as great as, or even greater than,
that passed in diabetes mellitus. In twenty-four hours it often
amounts to from 10,000 to 15,000 ccm. (ten to fifteen quarts), and
sometimes even more.

A little girl, ten years old, with diabetes insipidus, who was
very undeveloped, and only weighed twenty-three pounds, during her
stay in the Tubingen clinic, passed daily an amount of urine that
weighed about one-third as much as her body. The urine is very
limpid, and, in contradistinction to diabetic urine, of low specific
gravity. It rarely rises above 1.005, and often sinks to 1.001 or
1.0005. The relative amount of urea and salts in the urine is low,
but the absolute amount of urea excreted in twenty-four hours is
usually normal or somewhat increased. In one case that I observed,
where the patient consumed a moderate quantity of nitrogenous
material, he passed 9,000 ccm. of urine, containing 38 grm. of urea,
in twenty-four hours. Barely the amount of urea passed in the twenty-
four hours is diminished. Thus, in one of the cases in my clinic,
published by Strauss, where the patient weighed about 114 pounds
and had good diet, he passed only 23.42 grm. of urea in the
twenty-four hours.*

The excretion through the skin and lungs seemed to be consider-
ably reduced, judging by the relative quantities of the liquid drank
and urine voided. Doctors Schmidtlein and Spaeth, who for some time
ate and drank exactly the» same quantities of food and drink taken
by a patient with diabetes insipidus at my clinic, in twenty-four hours
excreted from two thousand to twenty-six hundred grammes through
their lungs and skin, while the patient only lost from five hundred and
forty fa six hundred and forty grammes by the same way and in the
same time.

Straws^ observations^also led to the result that, taking the same
amount of fluid, the patients passed from five hundred to two
thousand centimetres more urine than healthy persons, while, in the
latter, the loss of weight by insensible perspiration was considerably
more than in the former.

* In some cases of diabetes insipidus the urine is said to have a very high specific
gravity, and to contain an abnormal amount of urea. In this form of disease,
about which the observations are very scanty, the original disease would consist
of an increased destruction of tissue ; the great thirst, as well- as the increased
secretion of urine, would be very insignificant as compared with the severe con-
stitutional disturbance, and would be explained as in diabetes mellitus. The serum
of the blood is abnormally concentrated, and, on endosmotic principles, draws water
from the tissues. We shall not further consider this obscure and problematical form
of diabetes insipidus.

846 GENERAL DISORDERS OF NUTRITION.

Strauss justly regards this as another proof that polydipsia is not
the cause oi polyuria, but the reverse. He writes as follows :

" What reasonable and satisfactory grounds are there for assuming
that the cutaneous and pulmonary exhalations of a polydiptic person
should differ from those of a healthy person who voluntarily drinks
copiously of water ? "

But if we suppose a polyuria with consequent concentration of the
blood, and decrease of water in the tissue, there would be nothing
strange in a diminished gaseous excretion of water by the skin and
lungs. In our cases, as in most others, among the symptoms referring
to the skin, we find mentioned dryness, harshness, and frequent itch-
ing, while profuse perspiration is not mentioned in a single case.

The quantity of liquid imbibed daily, including that contained in
the food, is said to have amounted sometimes to sixty or eighty pints.
Of course, such a quantity could never permanently be less than that
of the urine secreted, without the occurrence of a corresponding de-
crease of the weight of the body. All cases, wherein it is claimed
that the quantity of urine secreted exceeded that of the liquid imbibed,
must have been inaccurately observed.

In my case, the sense of hunger was considerably augmented.
Trousseau also tells of a patient who ate such enormous quantities
that, at a certain restaurant where bread was furnished d discrelio?i,
they paid him to stay away. In this disease (unlike diabetes mellitus,
in which a part of the food consumed, instead of going to repair the
used-up constituents of the body, is voided unused), this unnatural
hunger — which, moreover, is not a constant occurrence — can only be
accounted for by supposing that the exaggerated consumption and dis-
charge of water accelerate the waste of the nitrogenous elements of
the body. It may be accepted as a law that, during an accelerated
flow of the juices of the parenchyma through the organs, a larger
quantity of albuminous material is consumed.

In some patients the general health and vigor long remain undis-
turbed. A girl twenty years of age, with insipid diabetes, who
remained under observation at my clinic for a considerable time,
retained her blooming aspect, and could even do hard work without
special effort. In other patients, signs of digestive derangement,
cardialgia, vomiting, irregularity of the bowels, emaciation, and an un-
accountable sense of debility, set in early. In the instance reported by
Neuffer, the patient died with these symptoms, no appreciable cause
of death being discoverable upon autopsy. The course and duration
of the disease vary. In some cases it develops gradually, in others
it sets in suddenly. Not unfrequently a transient improvement in the
symptoms is observed. It may also happen that, during the attack

ADDITIONS TO THE REVISED EDITION OF 1880. 847

of some intercurrent disease, the daily flow of urine becomes normal,
and returns to its former profusion after the attack has terminated. As
a rule, the malady lasts for years without imperilling life. It is only
in rare instances, as in that of Neuffer^ already alluded to, that death
takes place without the intervention of some other disease. Complete
and permanent recovery from diabetes insipidus is likewise an ex-
tremely rare event.

TREATMENT. — It is always suspicious when numerous remedies are
recommended for a disease ; in such cases, usually, none of them have
any special effect on the course and termination of the affection. This
is also true of the recommendations of saltpetre, in the shape of sal
prunellse, of valerian, belladonna, opium, ergotine, creosote, and
other remedies in diabetes insipidus. They are not based on the
results of experience, but on theoretical grounds. I have not used
any of these remedies persistently and energetically, as my patients
bore their disease pretty well — so that there was no necessity for
energetic treatment. On the whole, I would advise you, in treating
simple diabetes, to limit yourselves to preventing the bad results
induced by the disease, or to combating them if they have already
appeared. Especial attention should be paid to the disturbances of
digestion and nutrition, which are not uncommon. Rational diet,
combined with cod-liver oil, malt extract, and iron, improved the con-
dition of the little girl above-mehtioned, without diminishing her thirst,
or the secretion of urine ; and, although her early death had been
expected, she was discharged from the clinic considerably increased in
weight and much improved in health.

ADDITIONS TO THE REVISED EDITION OF 1880.

SECTION III. GENERAL DISORDERS OF NUTRITION.

1.— P. 803.

According to Virchow, in obstinate cases of chlorosis there is
defective development and small size of the aorta and vessels gen-
erally. The aorta may be so small as not to admit the little finger,
while its walls may be uncommonly thin ; they, however, retain
their elasticity, unless there has been fatty degeneration of the
inner and middle coats. This failure of vascular development is
sometimes accompanied by stunted growth of the whole body.
The heart is sometimes small, but is usually normal, or slightly di-
lated ; exceptionally it is hypertrophied. There is an inclination

GENERAL DISORDERS OF NUTRITION.

to endocarditis of the left ventricle. In women with this trouble of
the heart and blood-vessels, child-bearing may induce ulcerous endo-
carditis. Feverish diseases are more dangerous in chlorotic persons
than in others. In giving iron in chlorosis, it is well to administer
it after eating. Mineral waters containing pyrophosphate of iron
may be drunk at meal-times. This drug may have to be discon-
tinued when there is gastric disturbance or fever. Iron is to be
aided by good, easily digestible diet, and residence in a healthy
locality. In chlorosis and anaemia generally, alcoholic beverages
may be useful by impeding transformation of tissue, but should
be avoided if they induce excitement, palpitation, rush of blood to
the head, etc. Trial must decide whether wine or beer answers the
best purpose.

2.— P. 832.

Of late it has been considered possible that the use of milk from
cows with murrain might have an injurious effect, because forma-
tions similar to those in tubercles in men have been found in the an-
thrax-nodules of cattle, and because experiments have shown that
feeding other animals on the milk of these cows will give them
tuberculosis and diseases of the lymphatic glands of the mesentery
and neck, similar to those in scrofula. Hence the use of such milk
may be suspected as a cause of the trouble, but has not yet been
proved to be so.

In the treatment of scrofula -considerable reputation is enjoyed
by the mud-baths of Nauheim, Kreuznach, etc., in Germany ; they
increase the transformation of tissue, and prove advantageous for
the glandular enlargements, as well as for the affections of the mu-
cous membrane and skin. When cod-liver oil is given} it is some-
times better borne when not taken on an empty stomach, but half
an hour or so after eating. Pale, anaemic children often require
some preparation of iron. When the patient is not anaemic or fee-
ble, at proper seasons it is often well to order a laxative mineral
water, such as a continued moderate use of Carlsbad water. The
waters containing iodine have so very small a percentage of it, that
it is doubtful if it has any special effect.

3.— P. 843.

There have been numerous disputes as to the glycogene builders ;
among them are grape, cane, milk, and fruit sugar, inulin, glycerin,
etc. Amylaceous food has the greatest effect on the formation of
sugar ; under its use the portal vein is always rich in dextrin. It

ADDITIONS TO THE REVISED EDITION OF 1880.

is not known just how sugar is made from the food ; it normally
exists in the blood in such slight quantity that it does not transude
into the urine ; in the blood of diabetic patients Cantani found it
as high as 8 parts in 1,000.

Artificial mellituria may be induced by dividing the inferior cer-
vical ganglia, or by irritating the floor of the fourth cerebral ven-
tricle (which at the same time induces polyuria) ; division of the
splanchnics has no effect. Schiff induced diabetes by destruction
of the spinal medulla before and behind the origin of the brachial
nerves, etc. Artificial diabetes may also be induced by injections
of curare, solutions of common salts, some of the salts of soda,
nitrite of amyl, morphine, etc. ; this effect is prevented by previous
division of the splanchnics.

Diabetes is a disease of the vasomotor nerve-system ; on au-
topsy the liver is found normal, but there are frequently changes
in the brain (tumors, etc.). Possibly the sugar formed during
digestion of amylaceous substances, being taken up by the lymphat-
ics and portal vessels, enters the blood directly. Cantani regards
sugar in the blood as necessary to life, and thinks it is one source
of strength ; it appears as grape-sugar, and is broken up by some
ferment ; if the organs furnishing this ferment (the pancreas ?) be
diseased, the sugar appears in the urine. In the first stages of
diabetes, by withdrawing amylaceous food, the collection of sugar
in the blood and its excretion by the urine may be prevented, and
by continuing this treatment for some time the disease may perhaps
be entirely cured ; even later in the disease, the excretion of sugar
may be arrested, but it is doubtful if the disease can be cured.
Although the above theories are not universally accepted, the treat-
ment advocated is probably the most successful of the many that
have been tried.

Possibly diabetes may depend on a variety of causes, having as
a common result the non-consumption of sugar and its excretion by
the urine. Senator divides it into neurogenous, gastro-enteroge-
nous, and hepatogenous forms. The first would include the cases
caused by injuries, tumors, etc., affecting the nervous system ; the
second, the Cantani cases ; and the third class, cases- where, as a
result of hyperajmia of the liver, hepatic sugar passes more rapidly
into the blood. There would seem to be either two forms of dia-
betes, or else two stages of the same disease, in one of which exclu-
sion of amylaceous substances from the diet prevents the appearance
of sugar in the urine.

Diabetic urine often has a peculiar odor, which is ascribed to
aceton. BoUcher tests for sugar by adding to urine in a test-tube

850 ADDITIONS TO THE REVISED EDITION OF 1880.

a small quantity of nitrate of bismuth ; then freely adding a con-
centrated solution of carbonate of soda, or some potash lye ; then
heating to the boiling-point. If sugar be present, the bismuth
turns gray, then black. This test may be used in addition to others,
but is less delicate than the copper test.

INDEX.

A.

Abscess of the Brain, ii., 255; of the
Heart, i., 355 ; of the Kidneys, ii., 36 ;
of the Liver, i., 669 ; of the Lungs,
i., 169 ; of the Ovaries,' ii., 110 ; of the
Spleen, i., 752 ; metastatic of the Liver,
i., 668 ; metastatic of the Lungs, i., 158.

Abscess, retropharyngeal, i., 476.

Acarus scabiei, ii., 510.

Acholia, i., 677.

Achroma, ii., 448.

Achromatopsia, ii., 310.

Acinesis, ii., 359.

Acne, ii., 493.

Acne rosacea, ii., 497 ; syphilitica, ii., 762.

Acorn Coffee, ii., 830.

Addison's Disease, ii., 49.

^Egophony, i., 186.

Agenesis, ii., 283.

Ageustia, ii., 349.

Agraphia, ii., 286.

Akinesis, L, 491.

Albino, ii., 448.

Albuminate of Mercury, ii., 780.

Albuminuria, Origin of, Test for, ii., 22 ;
after Scarlatina, ii., 592.

Alcoholic Poisoning, ii., 184.

Alopecia circumscripta, ii., 449 ; syphi-
litica, ii., 765 ; anata, ii., 525.

Amaurosis in Bright's Disease, ii., 30.

Amenorrhoea, ii., 160, 807.

Amylea, ii., 300.

Anaemia et Cachexia splenica, ii., 817.

Anaemia, progressive pernicious, ii., 817.

Anaesthesia dolorosa, ii., 345 ; of the cu-
taneous Nerves, ii., 342 ; of the Trige-
minus, ii., 348.

Analgesia, ii., 345.

Aneurism, true and false, i., 418; dis-
secting, i., 426 ; cylindrical fusiform,
i., 419 ; cardiac, i., 346 ; of the Aorta,
i., 417 ; of the cardiac Valves, i., 393.

Angina catarrhalis, i., 463 ; Ludovici, i.,
477; membranacca, i., 15; paren-
chymatous, i., 465; pectoris, i., 384;
syphilitica, i., 467 ; maligna, ii., 664.

Anidrosis, ii., 618.

Anostosis excentrica, ii., 769.

Anteflexion of Uterus, ii., 141.

Anteversion of Uterus, ii., 144.

Anthracosis, i., 201.

Antiperistaltic Motion of the Bowels, i.,
594.

Aorta, Aneurism of, i., 417 ; -Calcification
of, i.,415; Atheroma of, i., 415; fatty
Consumption of, i., 415 ; Rupture of,
i., 426 ; Inflammation of Coats of, i.,
413; Stricture and Obliteration of, i.,
427.

Aortic Valves, Constriction of, i., 359.

Aphasia, ii., 285.

Aphonia paralytica, i., 54 ; ii., 438.

Apneumatosis, i., 130.

Aphthae, i., 437.

Apomorphia, i., 563.

Apoplectic Stroke, ii., 215; Cicatrix, ii.,
218; Cyst, ii., 218.

Apoplexia meningea, ii., 230 ; sanguinea,
ii., 215 ; serosa, ii, 278.

Apoplexie foudroyante, ii., 227.

Apoplexy, cerebral, ii., 215, 320 ; pulmo-
nary, i., 139.

Appetite, perverted, ii., 805.

Area Celsi, ii., 449.

Argyria, ii., 403.

Arsenic, i., 339.

Arteriosclerosis, i., 430.

Arthritis, ii., 545 ; deformans, ii., 540.

Arthrogryposis, ii., 357.

Arthropathia, ii., 226, 414.

Artificial Anus, i., 589.

Ascaris lumbricoides, i., 623.

Ascites, i., 649.

Asthma acutum Millari, i., 51; convul-
sive, i., 88 ; humid, i., 74; laryngeal, i.,
51 ; thymic, i., 51 ; urinous, ii., 27.

Asymbolia, ii., 285.

Ataxie locomotrice progressive, ii., 302.

Atelectasis Pulmonum, i., 130.

Atheroma, i.,415, ii., 520; of the Ar-
teries, i., 359.

Aubrec's Specific, i., 94.

Aura epileptica, ii., 394.

852

INDEX.

B.

Bacteria, ii., 738.

Balanitis, ii., 91.

Baldness, ii., 448, 765.

Barbadoes Leg, ii., 446.

Bascdow's Disease, i., 388.

Basilar Meningitis, ii., 240.

Bath Itch, ii., 468.

Baths in Bronchitis, i., 82 ; Rheumatism,
ii., 535 ; Scarlatina, ii., 594 ; Typhoid
Fever, ii., 651.

Belladonna, ii., 402.

Bile Fever, i., 631 ; Test for, i., 708.

Black Vomit, ii., 692.

Bladder, Acinesis of, ii., 84 ; Anaesthe-
sia of, ii., 80 ; Cancer of, ii., 73 ; Ca-
tarrh of, ii., 66; distended, ii., 70;
Haemorrhage from, ii, 74 ; Hyperaes-
thesia of, ii., 80 ; Ilypercinesis of, ii.,
82 ; Neuroses of, ii., 79 ; Palsy of, ii.,
84 ; Spasm of, ii., 82 ; Stone of, ii., 75 ;
Tuberculosis of, ii., 73.

Bladder-worm, i., 624.

Blaud's Pills, ii., 808.

Bleeding at Nose, i., 305.

Blepharospasm, ii., 352.

Blindness from Tumors of Brain, ii., 269.

Blood-murmurs, ii., 531, 805.

Blood Test, ii., 8.

Bloody Flux, ii., 722.

Bloody Sweat, i., 160; ii., 498.

Bothriocephalus latus, i., 623.

Brain, Abscess of, ii., 255 ; Anaemia of,
ii., 195 ; partial Anaemia of, ii., 201 ;
Atrophy of, ii., 282 ; Aneurisms in, ii.,
262, 287 ; gummy Tumor of, ii., 264 ;
Hyperaemia of, ii., 175; partial Hy-
peraemia of, ii., 193 ; Haemorrhage
into, ii., 215 ; Hypertrophy of, ii., 280 ;
Inflammation of, ii., 254; Softening
of, ii., 201 ; yellow Softening of, ii.,
204; white Softening of, ii., 206;
Sclerosis of, ii., 260; syphilitic Disease
of, ii., 771 ; Tumors of, ii, 262.

Brayera anthelmintica, i., 628.

Breast, irritable, ii, 337.

Bright's Disease, acute, ii., 10; chronic,
ii., 14.

Brine Baths, i., 13; ii., 831.

Bromide of Potassium in Epilepsy, ii.,
403.

Bronchi, Diseases of, i. 61 ; Catarrh of,
i., 61 ; Catarrh of, in the newly-born,
i., 72 ; Croup of, i., 86 ; Dilatation of,
i., 65, 202 ; Haemorrhage from, i., 145 ;
Hyperaemia of, i., 61; Spasm of, }.,
88.

Bronchial Asthma, i., 88 ; Respiration,
i., 140, 185.

Bronchiectatic Cavities, i., 199.

Bronchitis, capillary, i., 70.

Bronchophony, i., 185.
Bronchopneumonia, i., 194.
Bronchorrhoea, chronic, i., 76.
Bronzed Skin, ii., 49.
Bruit de Diable, ii., 805.
Bubo, acute, ii, 750 ; indolent, ii., 758.
Bulbar Palsy, ii., 372.
Bullrich's Salt, ii., 554.
Buttermilk, i., 519, 564.

c.

Cacotrophia, ii., 661.

Calcareous Infarction, ii., 62.

Calculus, ii., 77 ; renal, ii., 60.

Callosities of Skin, ii, 441.

Calomel as an Anti-syphilitic, ii., 778.

Calori, ii., 468.

Calvities, ii., 448.

Cancrum Oris, i., 439, 462.

Capillary Bronchitis, i., 70.

Caput obstipum, ii., 354.

Carbonic-acid Poisoning, i., 23.

Cardialgia, i., 551.

Carlsbad Water in Diabetes, ii., 843.

Catalepsy, ii., 424.

Cataract in Diabetes, ii., 839.

Catarrh, i., 1 ; syphilitic, ii., 765.

Catarrhal Fever, i., 631.

Cerebral Arteries, Aneurisms of, ii., 262,
287 ; Thrombosis of, ii., 201 ; Sinus,
Inflammation of, ii., 233.

Cerebrospinal Meningitis, epidemic, ii.,
247.

Chancre, ii., 743; glandular, ii., 750;
parchemine, ii., 757 ; inoculated, ii.,
745 ; phagedenic, ii., 747 ; gangrenous,
ii., 748; diphtheritic, ii., 746; Hun-
tcrian, ii., 758.

Chancroid, ii., 743.

Chicken-pox, ii., 612.

Chloasma, ii., 441 ; uterina, ii., 442.

Chloride of Sodium and Gold, ii., 422.

Chlorosis, ii., 802, 847.

Cholsemia, i., 677, 720.

Cholelithiasis, i., 733.

Cholera Asiatica, ii., 699 ; infantum, i.,
504 ; morbus, i., 501 ; quarantine, ii.,
717; typhoid, ii., 715.

Cholerine, ii., 708.

Cholesteatoma, ii., 264.

Chorda Tympani, ii., 327.

Chordae tendineje, Adhesions and Rup-
ture of, i., 393.

Chordee, ii., 92.

Chorea, ii., 378.

Cirrhosis of Liver, i., 670.

Clairvoyants, ii., 419.

Clap, ii., 88.

Clavus hystericus, ii., 414.

Cliquetis m6tallique, i., 325.

Club-foot, ii., 375.

INDEX.

853

Cod-Liver Oil in Scrofula, ii., 830.

Cold Applications in Inflammation, i.,
28, 282.

Cold Beverages as Causes of Consump-
tion, i., 220.

Colic, i., 617; biliary, i., 734; Painters',
i., 619; of Prostitutes, ii., 110; renal,
ii., 63.

Comedones, ii., 493, 520.

Compressed Air, Respiration of, i., 92.

Conception, ii., 159.

Condyloma of Larynx, i., 37; syphilitic,
ii., 759.

Constipation, habitual, i., 571, 590.

Consumption, galloping, i., 253 ; pulmo-
nary, i., 212, 235.

Convulsions, ii., 189.

Coqueluche, i., 95.

Cor taurinum, i., 318.

Corns, ii., 441.

Corona veneris, ii., 764.

Coryza, i., 299.

Cosme's paste, ii., 524.

Cough, induced by irritation, i., 767.

Cow-pox, ii., 608.

Cracked-pot Sound, i., 238.

Cramp, ii., 350 ; idiopathic, of Extrem-
ities, ii., 357.

Craniotabes, ii., 560.

Crepitant Rale, i., 185.

Critical Eruption, ii., 468.

Croup, i., 15; Membrane, i., 17; false,
spasmodic, i., 7.

Crusta lactea, ii., 471.

Curare in Chorea, ii, 383; in Tetanus,
ii., 389.

Cyanosis, acute, i., 123, 133; in Croup,
i., 23 ; in Disease of the Heart, i., 205,
376, 382; of Hunchbacks, i., 133; of
Cholera, ii., 712; in congenital Mal-
formation of the Heart, i., 382.

Cysticercus cellulosus, i., 624 ; of Kid-
ney, ii., 47 ; of Brain, ii., 205.

Cystitis, catarrhal, ii., 66 ; croupous and
diphtheritic, ii., 72.

Cystoplegia, ii., 84.

Cystospasm, ii., 82.

D.

Darwin's Theory, ii., 655.

Deafness, from Tumors of Brain, ii, 269 ;

from Uraemia, ii., 31.
Death-rattle, i., 69.
Decubitus, ii., 453.
Defluvium Capillorum, ii., 449.
Deglutition, Disturbance of, ii., 514.
Delirium, ii., 186; tremens, ii., 432.
Derangement of Secretion in the Skin,

ii., 217.
Dermoid Cyst, ii., 114.

Dextro-cardia, i., 880.

Diabetes mellitus, ii., 832 ; insipidus, ii.,

843.

Diachylon Ointmemt, ii., 475.
Diapedesis, i., 160.
Diaphoresis, ii., 35.
Diaphragm, Movements of, i., 120.
Diarrhoea serosa stercovalis, i., 569 ;

lienterica, i., 572 ; ablactatorum, i.,

572, ii., 561.
Diet of Infants, i., 505.
Digestion, Diseases of Organs of, i., 431.
Digitalis in Heart Disease, i., 329, 371,

406.

Diphtheria, epidemic, ii., 664.
Diuretics in Heart Disease, i., 372.
Divertjculi of (Esophagus, i., 488.
Dizziness, ii., 187 ; from Tumors of Cere-
bellum, ii., 213, 273, 561.
Dropsy of Kidney, ii., 12, 24; malarial,

ii., 680.

Duodenal Ulcer, i., 583.
Dura Mater, Inflammation of, ii., 233.
Dysentery, epidemic, ii., 722 ; chronic, ii.,

725 ; catarrhal, i., 570.
Dysmenorrhoea, ii., 125, 164.
Dyspepsia, i., 502, 555.
Dysphagia, i., 480, 491.
Dysphagia inflammatoria, i., 480.
Dysphonia, i., 54.
Dyspnoea, i., 229, 283, 290.
Dysuria spastica, ii., 83.

E.

Ecchymomata, ii., 498.

Echinococci of Liver, i., 697 ; of Kidney,
ii., 47 ; of Brain, ii., -262.

Eclampsia Infantum, ii., 405 ; Puerpe-
rarum, ii., 44.

Ecthyma, ii., 481.

Ecti'opionof Os Uteri, ii., 124.

Eczema, ii., 466.

Eczema solare, mercuriale, ii., 468.

Electricity in Chorea, ii., 383 ; in Consti-
pation, i., 596 ; in Diagnosis of Paraly-
sis, ii., 312, 363, 377; in essential in-
fantile Palsy, ii., 376 ; in facial Neu-
ralgia, ii., 370; in facial Palsy, ii.,
370 ; in Neuralgia, ii., 322 ; in Impo-
tence, ii., 108; in Torticollis, ii., 354;
in Sciatica, ii., 341 ; in Scriveners'
Spasm, ii., 356.

Elephantiasis Arabum, ii., 443, 446 ;
Graecorum, ii., 522.

Embolism, renal, ii., 7, 37 ; cerebral, ii.,
292.

Emphysema of the Lung, i., 110.

Emphysematous Thorax, i., 125.

Emprosthotonos, ii., 386.

Empyema, i., 268, 272.

854

INDEX.

Encephalitis, ii., 254.

Endarteritis deformans, i., 314, 414.

Endocarditis, i., 342 ; ulcerative, i., 346,
392.

Enteralgia, i., 617.

Enteritis catarrhalis, i., 565.

Enuresis, ii., 306 ; spastica, ii., 83 ; noc-
turaa, ii., 81, 87.

Ephelides, ii., 441.

Epididymitis, ii., 93.

Epiglottis, tuberculous Ulcer of, i., 40.

Epilepsy, ii., 390 ; simulated, ii., 399.

Epileptiform Convulsions, ii., 259, 271.

Epistaxis, i., 305 ; ii., 816.

Erysipelas, ii., 455 ; ambulans, ii., 460.

Erythema, ii., 453; nodosum, ii., 323,
455.

Eucalyptus globulus, ii., 690.

Eustachian Tube, Closure of, i., 475.

Exanthemata, syphilitic, ii., 760.

Expectorants, i., 83.

Expectoration, Absence of, in Senile
Pneumonia, i., 179 ; in Abscess of
Lung, i., 182; in Bronchial Croup, i.,
87 ; in Bronchial Dilatation, i., 204 ; in
Bronchon-hoea, i., 76 ; cocta, i., 6 ; of
Croup, i., 21 ; cmda, i., 6 ; elastic Fi-
bres in, i., 233 ; of Empyema, i., 269 ;
gangrenous, i., 182; globosa fundum
petentia, i., 233 ; mucopurulent homo-
geneous, i., 67 ; in (Edema of the
Lungs, i., 140; of Pneumonia, i., 173;
of Pulmonary Abscess, i., 182 ; of Pul-
monary Consumption, i., 233.

F.

Facial Palsy, ii., 225, 366.

Facies Cholerica, ii., 710.

Faeces, i., 636.

Fallen Palate, i., 468.

Falling Sickness, ii., 390.

Farcy, ii., 788.

Fauces, chronic Catarrh of, i., 463.

Favus, ii., 505.

Fecal Fistula, i., 589.

Fever, bile, or catarrhal, i., 631 ; essen-
tial, i., 633; typhus, ii., 614; ship,
jail, camp, lazaretto, ii., 616 ; gastric,
mucous, nervous, ii., 641 ; hectic, i.,
234; spotted, ii., 614; typhoid, ii.,
623; intermitting, ii., 671; malarial,
ii., 671 ; remittent and continued, ii.,
687; relapsing, ii., 654; pernicious,
ii., 681 ; concealed malarious, ii., 683 ;
yellow, ii., 690.

Flea-bites, ii., 498.

Fluor albus, ii., 126, 173.

Formication, ii., 294.

Fothergill's Face-ache, ii., 327.

Freckles, ii., 442.

Fre'missement cataire, i., 424.

Friction Sounds, endocardial, extraperi-

cardial, pericardial, i., 404 ; pleuritic,

i., 278.
Friesel Fieber, ii., 694.

G.

Gall-bladder, Dropsy of, i., 731.
Gall-ducts, Catarrh of, i., 726 ; Croup and

Diphtheritis of, i., 729 ; Dilatation of,

i., 730.

Gall-stones, i., 733.
Galloping Consumption, i., 253.
Gangrene of Lung, i., 207.
Gangrenous Sore Mouth, i., 451.
Gastric mucous Membrane, acute Catarrh

of, i., 493 ; chronic Catarrh of, i., 511 ;

Croup and Diphtheria of, i., 524.
Gastric Influenza, i., 64.
Gastricismus, i., 499.
Gastritis phlegmonosa, i., 524.
Gastrodynia neuralgica, i., 645.
Gastromalacia, i., 497.
Genu valgus, ii., 375.
Gin Liver, i., 671.
Glanders, ii., 788.
Gleet, ii., 91.
Glioma, ii., 264.

Globus hystericup, i., 490; ii., 417.
Glossitis, i., 449.
Glossopharyngeal Palsy, ii., 372.
Glottic Muscles, Palsy of, i., 20, 54.
Glottis, (Edema of the, i., 45.
Gluge's Inflammation Globules, ii., 254.
Gonorrhoea, ii., 88 ; in the Female, ii.,

170.
Gonorrhoeal Abscess, ii., 92; Gout, Or-

chitis, Ophthalmia, Rheumatism, ii., 93.
Gout, ii., 645 ; flying, ii., 527 ; atonic or

anomalous, ii., 550; internal, ii., 551.
Goutte militaire, ii., 91.
Grape-cure, i., 142, 329.
Gravedo, i., 299.
Gravel, ii., 607.

Graves's Disease : sec Bascdow's Dis-
ease.

Grayness, ii., 450.
Green Soap, ii., 476.
Grippe, i., 64.
Gummata, or gummy Tumors, ii., 764.

H.

Haematocele, retro-uterine, ii., 165.
Haematoma of Dura Mater, ii., 230.
Haematuria toxica, ii., 74.
Haemometra, ii., 137.
Haemophilia, Haemorrhagic Diathesis, ii.,

8-19.
Haemoptysis, i., 150; from Inhalation of

Astringents, i., 13.

INDEX.

855

Haemorrhoids, i., 609 ; of Bladder, ii.,
75.

Hallucinations, ii., 186.

ITaut mal, ii., 390.

Headache, ii., 1S3.

Heart, Abscess of, i., C55 ; acute Aneu-
rism of, i., 316 ; chronic Aneurism of,
i., 350 ; Atrophy of, i., 339 ; Ausculta-
tion of, i., 380 ; congenital Anomalies
of, i., 351 ; Cancer, Tubercle, and Par-
asites of, i., 376 ; Degeneration and
Growths of, i., 375 ; Dilatation of, i.,
330; fatty Metamorphosis of, i., 375;
fibrinous Deposits in, i., 379 ; Hyper-
trophy of, i., 371, ii., 28 ; Neuroses of,
i., 384 ; Percussion of, i., 324 ; Palpita-
tion of, i., 384 ; Rupture of, i., 378 ;
valvular Disease of, i., 358 ; Immunity
of Persons with Heart Disease to
Phthisis, i., 222.

Heat-stroke, ii., 182.

Hectic, i., 204.

Heim's Pill's, i., 250.

Hclminthiasis, i., 622.

Hcllor's Test for Blood, ii., 8.

Helmerich's Ointment, ii., 514.

Hemicrania, ii., 331.

Hemiplegia, ii., 225, 286.

Hepar adiposum, i., 685.

Hepatitis, chronic, i., 670 ; metastatic, i.,
666 ; suppurative, i., 665 ; syphilitic, i.,
681.

" Herdsymptomc," ii., 194, 206.

Herpes, ii., 462 ; rodens, ii., 502 ; ton-
dens, toasurans, ii., 449, 508 ; circina-
tus, ii., 463 ; zoster, ii., 463.

Hip Gout, ii., 338.

Hoarseness, i., 5, 232.

Hodgkin's Disease, i., 767.

Hump-backed Persons, i., 133.

Hunger in Diabetes, ii., 839.

Hydatids, i., 697.

Hydroa febrilis, ii., 462.

Hydrocephalic Softening, ii., 276.

Hydrocephaloid, ii., 199.

Hydroccphalus acquisitus, ii., 275 ; acute,
ii., 242 ; chronic, ii., 277 ; congenitus,
. ii., 278 ; externus, ii., 275 ; ex vacuo,
ii., 276 ; senilis, ii., 276.

Hydrometra, ii., 137.

Ilydroncphrosis, ii., 54.

Hydropathy in Scrofula, ii., 831.

Hydropcricardium, i., 408.

Hydrophobia, ii., 793.

Ilydrops vesicse Fella?, i., 731 ; Ovarii, ii.,
115.

Hydrorachis acquisita, ii., 293 ; congen-
ita, ii., 300 ; rheumatica, ii., 294.

Hydrothorax, i., 281.

Hypcraesthcsia, ii., 413.

Hyperidrosis, ii., 516.
104

Hypcrinosis, i., 171.
Ilyperkinesis, i., 490; ii., 350.
Hypertrophy : sec various organs.
Hypochondria, i., 515.
Hypochondriasis, ii., 426.
llypostasis, i., 136.
Hysteria, ii., 126,409,438.

I.

Ichthyosis, ii., 444 ; sebacea, ii., 579.

Icterus, i., 705 ; catarrhal, i., 726 ; haema-
togenous, i., 714 ; in Relapsing Fever,
ii., 659 ; in Cirrhosis, i., 675 ; from Gall-
stones, i., 735 ; in Pneumonia, i., 175 ;
spasticus, i., 714.

Idiocy, ii., 283.

Idiosyncrasies, ii., 414.

Ileus, i., 574.

Illusions, ii., 186.

Impetigo, ii., 479 ; figurata, ii., 508.

Impotence, ii., 104.

Infantile Palsy, ii., 373.

Influenza, i., 64.

Inhalation of nebulized Liquid, i., 12.

Injections of hot Water, ii.. 129.

Inoculation of Tubercle, i., 39.

" Insanity of the Muscles," ii., 380

Insolation, ii., 181.

Intestine, Catarrh of, i., 565 ; Carcinoma
of, i., 604 ; Contraction and Closure of,
i., 586 ; Haemorrhage from, i., 609, ii.,
644 ; Imagination of, and Intussuscep-
tion of, i., 587; Perforation of, ii.,
644 ; Rotation of, upon axis, i., 587 ;
Scrofulosis of, i., 593 ; stony Concre-
tions in, i., 588 ; Strangulation of, i.,
587 ; Tuberculosis of, i., 598.

Iritis, syphilitic, ii., 766 ; gummous, ii.,
767.

Iron in Chlorosis, ii., 807.

Irritable Breast, ii., 337.

Ischias, ii., 338.

Ischias antica, ii., 342.

Ischuria spastica, ii., 83.

Itch, ii., 510.

J.

Jail Fever, ii., 616.
Jaundice, i., 705.
Joints, hysterical, ii., 414.
Jugulars, Pulsation of, i., 374.
Junod's Boot, i., 135.

K.

Keloid, ii., 443.

Kidney, Diseases of, ii., 1 ; Abscess of,
ii., 36 ; amyloid Degeneration of, ii.,
41 ; Bright's Disease of, acute, ii., 10;
chronic, ii., 14; contracted, ii., 17;

856

INDEX.

Carcinoma of, ii., 45 ; Carcinoma and
Tubercle of Pelvis of, ii., 64 ; Deform-
ities of, ii., 48 ; Dilatation of the Pel-
vis of, ii., 54 ; Diseases of the Pelvis
of, ii., f>4; granular, ii., 18; Haemor-
rhage fiom, ii., 7; Horse-shoe, ii., 48;
liypcreemiaof, ii., 7 ; Infarction of, ii.,
9 ; Inegularities of Position of, ii., 48 ;
nietastatic Deposits in, ii., 36 ; Mobil-
ity of, ii., 48 ; pain in, ii., 4 ; Para-
sites of, ii., 47 , parcnchymatous De-
generation of, ii., 43 ; stony Concre-
tions in Pelvis of, ii., 59; Tuberculosis
of, ii., 46.

Kummerfeld's Lotion, ii., 495.

KiissmauPs Treatment, i., 522.

Laryngismus stridulus, i., 51.

Laryngitis, croupous, i., 15 ; catarrhal,
i., 1.

Laryngo-stenosif", i., 8.

Larynx, acute Catarrh of, i., 1 ; chronic
Catarrh of, i., 7 ; Cancer of, i., 43 ;
Croup of, i., 15; Fistula of, i., 40;
Growths and Polypi of, i., 43 ; nervous
Affections of, i., 57; Ossification of,
i., 40 ; Perichondritis of, i., 49 ; Syphi-
litic Disease of, i., 35 ; typhous and
vaiiolous Ulcers of, i., 33 ; tuberculous
Disease of, i., 38 ; Ulcers of, i., 31.

Lead Colic, i., 617.

Lead Palsy, ii., 861.

Lebenswccker, ii., 545.

Lcntigjncs, ii., 441.

Lcpra maculosa, ii., 522.

Lepra vulgaris, ii., 486.

Leprosy, ii., 522.

Leuchsemia, i., 756.

Lcucocythaemin, i., 756.

Lcucorrhoea, ii., 173.

Lichen, ii., 489 ; circumscriptus, ii., 508 ;
lividus, ii., 498.

Lilionese, ii., 442.

Lipomata, ii., 264.

Liver, Abscess of, i., 668 ; acute yellow
Atrophy of, i., 717; Anatomy of, i.,
722 ; Budd's scrofulous Tumor of, ii.,
828 ; Cancer of, i., 692 ; Cirrhosis of,
i., 670 ; Degeneration of, amyloid, lar-
daccous, waxy, i., 090 ; fatty, 5., 685 ;
granular, i., 670; Ilydatids of, i., 697 ;
Hyperaemia of, i., 657 ; Inflammation
of, suppurative, parenchymatous, i.,
665 ; interstitial, i., 670 ; Metastasis of,
i., 666 ; nutmeg, i., 659 ; physical signs
of Enlargement of, i., 662; Syphilo-
ma of, i.,681 ; Tuberculosis of, i., 696.

Lockjaw, ii., 384.

Locomotor Ataxia, ii., 302.

Lumbago rhcumatica, ii., 543.

Lungs, Abscess of, i., 169 ; Apoplexy of,
i., 165: Atrophy ol', i., 109; Atelcctasis
of, i., 130; Cancer of, i., 257; catar-
rhal Inflammation of, i., 194 ; croupous
Inflammation of, i., 106 ; chronic inter-
stitial Inflammation of, i., 199; cheesy
Infiltration of, i., 170; Cirrhosis of,
1, 170; Collapse and Compression of,
i., 130; Consumption of, i., 212; Em-
bolism of, i., 158; Emphysema of, i.,
110 ; Gnnurcnc of, i., K9, 207 ; Ilami-
crrhagic Infarction of, i., 157; Ilam-
orrhpgc into, i., 157 ; Ilcpatization of,
i., 168; Hypcrarmia of, 5., 134; Hyper-
trophy of,i.,10S; Jnduraticnof,i.*K9;
Metastasis into, i., 157; rciliaiy Tuber-
culosis of, i., 253; (Kdema of, i., 134,
258; permanent inspiiatory Expan-
sion of, i., C9 : syphilitic Disease of, i.,
771 ; acute miliaiy Tuberculosis of, i.,
253; chronic Tuberculosis of, i., 210 ;
tubercular Initiation cf, i., 212.

Lupus, ii., 500 ; syphilitic, ii., 704.

Lyesa, ii., 793.

Lyssaphobia, ii., 798.

M.

Magnctizers, ii., 419.

Malarial Fever, ii., 671.

Malignant Pustule, ii., 788.

Malkus humidus ct farcinosus, ii., 788.

Malt Extract, i., 252, 536.

Malum Coxie senile, ii., 540.

Mania, ii., 190.

Mania a Potu, ii., 432.

Marasmus, i., 572.

Mastodynia, ii., 337.

Measles, ii., 573.

Meeglin's Pills, ii., 331.

Melanaemia, i., 761, ii., 682.

Mclasmata, ii., 441.

Mcllituiia, ii., 832.

Membranous Cioup, i., 15.

Meningite i'oudn yantr , ii., 251.

Meningitis simplex, ii-, 2E6 ; spinalis, it,
292 ; rheumatic, ii., 532.

Menorrhagia, ii., 163.

Mcntagro, it, 495.

Menstruation, Anomalies of, ii., 158;
Absence of, ii., 159; prtcccicus, ii.,
158; vicaiions, ii., 161; difficult, ii.,
163; excessive, ii., 163; irregular,
suppression of, ii., 161.

Mental Depression, i., 515.

Mercurial .Stomatitis, Sore Mouth, i., 431 ;
Eczema, ii., 468 ; mercurial Inunction,
ii., 776 ; mercurial hypodermic Injec-
tion, ii., 777.

Mercury in Syphilis, ii., 773.

INDEX.

857

Mesentevic Glands, scrofulous Disease of,
i., 598.

Metalbumen, ii., 113.

Metallic Click, i., 325.

Metritis, ii., 131 ; hsemorrhagica, ii., 132.

Metroi-rliagia, ii., 132.

Miasm, ii., 025, 671, 689.

Migraine, ii., 331.

Miliaria rubra ct alba, ii., 468, 51*7.

Miliary Tuberculosis, acute, i., 253.

Milium, ii., 520.

" Milk Cure," i., 435.

Mimic Spasm of Faco, ii., 351 ; facial
Palsy, ii., 366.

Miserere, i., 574.

Mistura solvens, i., 81.

Mitral Valve, Insufficiencc of, i., 365;
Constriction of, i., 370.

Mogigraphia, ii., 355.

Molluscum simplex contagiosum, ii., 443.

Monopathophobia, ii., 426.

Morbilli, ii., 573 ; confluentes, ii., 576.

Moi-bus maculosus of Werlhof, ii., 815.

Morbus sacer, ii., 390.

Morphine Poisoning, chronic, ii., 183;
hypodermic Injection of. ii., 326 ;
Habit, ii., 435.

Mother's Marks, ii., 443.

Mouth, Catarrh of, i., 431 ; Excoriations
and Ulcers of. i., 441 ; syphilitic Affec-
tions of, i , 444 ; scorbutic Affections
of, i., 445.

Mucor muado, ii., 574 ; raccmosus, ii.,
5o;>.

Muguct, i., 447.

Mulberry Calculi, ii., 60.

Mumps, i., 453.

Muscular Atrophy, progressive, ii., 570.

Muscular Rheumatism, ii., 542.

Myelitis, ii., 295.

Myocarditis, i., 354.

Myxoma of Brain, ii., 263.

N.

Naevus, ii., 441.

Nasal mucous Membrane, Catarrh of, i.,
299 ; Haemorrhage from, i., 305 ; Poly-
pus of, i., 301.

Nasal Tone of Voice, i., 466.

Nebulizer, i., 12.

Nephogenc, i., 12.

Nephritis, croupous, ii., 16 ; parenchyma-
tous, ii., 40 ; vcra, ii., 36 ; interstitial,
ii., 36.

Nerves, Inflammation of, ii., 313.

Nervous Cardialgia, i., 551.

Nervousness, ii., 413.

Nettle-rash, ii., 464.

Neuralgia, ii., 314, 317, 376; cardiac, i.,
385; coeliaca, i., 619; cervico-occipi-
tal, ii., 333; cervico-brachial, ii.,

334; crural, ii., 342; intercostal, ii.,
338 ; ischiadica, ii., 336 ; lumbo-abdo-
minal, ii., 338 ; of the Trigeminus, ii.,
327.

Neuritis, ii., 313.

Neuroma, ii., 315.

Ncuromantia, ii., 316.

Neurotoiny, ii., 330.

Nictitatio, ii , 352.

Night-sweats, i., 253.

Nodding Spasm, ii., 353.

Nodes, ii., 767.

Noma, i., 451.

Norwegian Itch, ii., 512.

Nosebleed, i., 305.

0.

(Edema of the Brain, ii., 191 ; in Bright's
Disease, ii., 25 ; of Lungs, i., 134 ; of
Glottis, i., 45; hypostatic, i., 137.

(Esophagitis, i , 480.

(Esophagus, Auscultation of, 5., 485 ; Di-
latation of, i., 486 ; morbid Growths
of, i., 488 ; nervous Affections of, i.,
490 ; Perforation of, i., 489 ; Rupture
of, 5., 489 ; Strictures of, i., 482 ; spas-
modic Stricture of, i., 490.

Oiditim albicans, i., 447 ; Schonleinii, i.,
505.

Oligocythsemia, ii., 802.

Omodynia rhcumatica, ii., 544.

Onanism, ii., 105.

Oophoritis, ii., 109.

Ophthalmoscope in Brain Lesions, ii., 270.

Opisthotonos, ii., 386.

Opium-eating, ii , 435.

Optic Nerve, Atrophy of, ii., 306.

Orchitis, ii., 93 ; syphilitic, ii., 770.

Orthotonos, ii., 386.

Ossification, deficient, in Rachitis, ii., 557.

Osteocopic Pain, ii., 767.

Osteomalacia, ii., 565.

Otorrhoea, a cause of Brain Disease, ii.,
255.

Ovaritis, ii., 109.

Ovary, Abscess of, ii., 110; Cysts in, ii.,
Ill; Dropsy of, i., 652; Inflamma-
tion of, ii., 109 ; Inflammation of, in
Parotitis, i., 456 ; Tumors of, ii., 120.

Ovula Nabothi, ii., 124.

Oxalic Diathesis, i., 559.

Oxaluria, i., 560.

Oxyuris vcrmicularis, i., 623.

Oztena, i., 303 ; syphilitica, ii., 758.

P.

Pacchionian Bodies, ii., 180.
Pachydermy, ii., 443.
Pachymeningitis, ii., 230; externa, ii.,
233.

858

INDEX.

Palpitation of Heart in Chlorosis, ii., 805.

Palsy cf Bladder, ii., 84; central, ii.,
268 ; of Deglutition, i., 491 ; dipth-
thcritic, ii., 60S; essential, of Chil-
dren, ii., 373 ; facial, ii., 366 ; hys-
teric, ii., 360; of Insane, ii., 239 ;
intermittintr, ii., 684; peripheral, ii.,
268, 359; of Pharynx, ii., 372; pho-
nic, of the Glottis Muscles, i., 54 ;
phonic, of the Glottis-closers, i., 56;
progressive, of the cerebral Nerves,
ii., 372 ; psychical, i., 55 ; spinal, ii.,
373 ; shading, ii., 431.

Papules, ii., 489.

Paracentesis Thoracis, i., 284, 298.

Paralbumcn, ii., 113.

Parametritis, ii., 135.

Paraplegia, ii., 298.

Parasites in the Skin, ii., 505.

Parenchymatous Nephritis, with amyloid
Degeneration, ii., 35.

Paresis, ii., 360.

Parotitis, i., 453.

Pars vagum, Section of the, i., 20.

Pathophobia, ii., 426.

Pectoral Fremitus, i., 183.

Pectoiiloquy, i., 186.

Pcliosis rheumatica, ii., 499.

Pelvis of Kidney, Cancer of, ii., 64 ; Dila-
tation of, ii., 14 ; Inflammation of, ii.,
56; stony Concretions in, ii., 59 ; Tu-
berculosis oi', ii., 64.

Pemphigus, ii., 482 ; foliaccus, ii., 484.

Pcnicillum glaucum, ii., 506.

Pericarditis, i., 394 ; scorbutic, ii., 753.

Pericardium, Adhesion of, to Ilcait, i.,
406; Cancer of, i., 412; Tuberculosis
of, i., 412.

Perichondritis laryngca, i., 49.

Pericystiti?, ii., 72.

Pericnccphalitis, ii., 239.

Pcrimctritis, ii., 135.

Pcrincphritis, ii., 40.

Pcriostiti?, syphilitic, ii., 767.

Pcriproctitis,' i., 607.

Peritonaeum, Air in, ii., 644 ; Cancer of,
i., 654 ; Dropsy of, i., 649 ; Tubercu-
losis of, i., 654.

Peritonitis, i., 638.

Pcrityphlitis, i., 568, 574, 607.

Pertiis is, i , 92.

Petcchiae, ii., 498.

Petit mal, ii., 397.

Pharyngitis, catarrhal, i., 463 ; croupous,
i., 462 ; diphtheritic, i, 479 ; follicu-
lari«, granulosa, 5., 465 ; phlcgmonous,
i., 471 ; syphilitic, i., 474.

Pharynx, Catarrh of, i., 463 ; gummy Tu-
mor of, i., 475.

Phlegma?ia alba dolens, i., 430.

Phonetic Paralysis, i., 54.

Phthisis pituitosa, i., 76 ; tuberculosa, i.,

212; renalis, ii., 39.
Pia Mater, simple Inflammation of, ii.,

236 ; tuberculous Inflammation of, ii.,

240.

Piles, bleeding, blind, i., 60P.
Pills, Asiatic, ii., 488 ; Blaud's, ii., 808;

Heim's, i., 250; Martini's, ii., 422;

Ricord's, ii., 779.
Pine-nccdle Bath, i., 80.
Piss-abed, ii., 81, 87.
Pityriasis of the Mouth, i., 448 ; rubra

circumscripta, ii., 508 ; tabescentium,'

i., 220, ii., 448 ; versicolor, ii., 510.
Plaques muqucuses of Larnyx, i., 36.
Pleura, Cancer of, i., 295 ; Inflammation

of, i., 264 ; Tuberculosis of, i., 294.
Pleurisy, Plcuiitis, acute, i., 264; fibrin-

ous, i., 266 ; purulent, i., 268 ; rheu-
matica, i., 265; scorbutic, ii., 813;

scro-fibrinous, i., 266 ; sicca, i., 269.
Pleuritic Effusion, i., 274.
Pleurodynia rheumatica, ii., 544.
Plcurosthotoncs, ii., 386.
Pneumogastric Nerve, Neuralgia of, i.,

551.
Pneumonia, i., 166; bilious,]., 175; ca-

tarrhal, i., 194; caseous, i., 212;

chronic,!., 199; croupous, i., 166; hy-

postatic, i., 137; interstitial, i., 199,

lobular, 5., 131; metastatic, i., 162;

migratory, i., 261 ; notha, i., 69.
Pneumoperieardium, i., 410.
Pncumorrhapja, i., 150.
Pncumothorax, i., 287.
Podagra, ii., 545.

Poisons, Effect of, on Stomach, i., 525.
Pollutions, diurnal and nocturnal, ii., 100.
Polypi of the Skin, ii., 443.
Polypus of Nose, i., 301 ; of the Womb,

ii'., 152.

Pompholyx, ii., 482.
Porrigo asbcstina, ii., 508 ; favosa, ii.,

505 ; larvalis, ii., 471 ; lupinosa, ii.,

505.

Portal Vein, Inflammation of, i., 683.
Progressive fatty muscular Paralysis, ii.,

570.

Progressive muscular Atrophy, ii , 567.
Progressive pernicious Anaemia, ii., 817.
Prosopalgia, ii., 327.
Prostate, Inflammation of, ii., 92.
Prune-juice Expectoration, i., 87.
Prurigo, ii., 490; Pudendorum, ii., 492.
Psammoma, ii , 263.
Pseudo-Croup, i., 60.
Pscudoleuchaemia, i., 767.
Psora, ii., 518.
Psoriasis, ii., 452, 485 ; annulata, con-

ferta, diffuse, grellata, gyrata, etc., ii.,

486 ; invctcrata, ii., 486 ; of the Mouth,

INDEX.

859

i., 449; Palmaris and Plantaris, ii.,

486, 763 ; syphilitica, ii., 763.
Ptyalism, i., 458.
Pulmonary Artery, Diseases of, i. 428 ;

Aneurism of, i., 429 ; Contraction of

Mouth of, i., 373.
Pulmonary Diseases : sec Lungs.
Pulsation, epigastric, i., 126 ; of the Ju-
gulars, i., 374.
Pulse, dichrotic, ii., 635 ; jerking, i., 364 ;

small, of Pneumonia, i., 191 ; slow, of

Icterus, i., 710.
Pulsus celerrimus, i., 364.
Punaisie, i., 303.

Pupil, Contraction and Dilatation, ii., 187.
Purpura, ii., 498 ; bullosa, ii., 813 ; haem-

orrhagica, ii., 815; papulosa, ii., 198;

pulicosa, ii., 499 ; rhcumatica, ii.,

499; scnilis simplex, ii., 499; urti-

cans, ii., 498.

Pustules, athcromatous, i., 415.
Pyelitis, ii., 56.
Pylephlebitis, i., 683, 723.
Pylorus, Stricture of, i., 513, 516.
Pyothorax, i., 268.
Pyuria, ii., 58.

Q.

Quinia as an Antiperiodic, ii.,686.

R.

Rabies, ii., 793.

Rachitic Pelvis, ii., 560.

Rachitis, ii., 557, 572.

Rales, crepitant, i., 785 ; moist, in Phthi-
sis, i., 238 ; subcrepitant, i., 69 ; tra-
chcal, i., 69.

Rectum, Cancer of, i., 604.

Relapsing Fever, ii., 654.

Renal Abscess, ii., 36.

Renal, Colic, ii., 69 ; Apoplexy, ii., 7 ;
granular Degeneration of Epithelium,
ii., 43.

Respirators, i., 248.

Respiratory Muscles, Spasm of, i., 94.

Retro-uterine Iloematoccle, ii., 165.

Retrovcrsion of Uterus, ii., 145.

Rcvelenta Arabica, ii., 572.

Rheumatic Callosities, ii., 542.

Rheumatism, ii., 526, 571 ; acute articu-
lar, ii., 527 ; chronic articular, ii., 535 ;
deforming articular, ii., 540 ; gonor-
rhofial, ii., 93 ; muscular, ii., 542.

Rhonchi, sibilant, i., 68; sonorous, i., 68.

Rickets, ii., 557.

Ricord's Pills, ii., 779.

Risus caninus, sardonicus, ii., 352.

" Rose," the, ii., 460.

Roseola aestiva, autumnalis, ii., 451 ; j
febrilis, ii., 595 ; idiopathica, infan- '

tilis, symptomatica, ii., 451 ; syphi-
litica, ii., 762 ; typhosa, ii., 638.

Rose Rash, ii., 595.

Kougcole, ii., 573.

Rubeola morbilosa, ii., 573.

Rupia, ii., 484 ; syphilitic, ii., 764.

Rush of Blood to the Head, i., 364 ; ii.,
175.

Russian Clap, ii., 92.

s.

Saint Yitus's Dance, ii., 378.

Salaam Convulsions, ii., 353.

Salivation, i., 458; in Syphilis, ii., 716.

Salt-rheum, ii., 467.

Sand-tumors of Brain, ii., 263.

Sarcina, i., 514, 542.

Sarcocclc, syphilitic, ii., 770.

Sarcoptes Ilominis, ii., 510.

Scabies, ii., 510.

Scarlatina, ii., 585.

Scarlet Fever, ii., 585, 738.

Schneemann's Treatment, ii , 594.

Schroth's Treatment, i., 522.

Sciatica, ii., 338.

Sclerodcrma, ii., 521.

Sclerosis, ii., 569.

Scarbutus, ii., 810.

Scriveners' Spasm, ii., 355.

Scrofula, i., 217; ii., 820, 848.

Scrofulous Habit, ii., 825.

Scurvy, ii., 810.

Scborrhoea, ii., 519.

Semilunar Valves, insufficiencc of, i., 359,
373.

Serous Effusions in the immature Skull,
ii., 278 ; in the mature Skull, ii., 275.

Serratus Muscle, Palsy of, ii., 370.

Sheep-pox, ii., 612.

Shingles, ii., 419.

Ship-fever, ii., 616.

Siderosis, i., 202.

Skin, Diseases of, ii., 440 ; Hypertrophy
of, ii., 440; Atrophy of, ii., 447 ; Hy-
peraemia of, ii., 450 ; Anemia of, ii.,
450 ; Inflammation of, ii., 452.

Small-pox, ii., 596.

Snuffles, i., 303.

Soor, i., 447.

Spasms, clonic and tonic, ii., 350 ; of the
facial Nerve, ii., 351 ; of the spinal
Accessory, ii., 353 ; hysterical, ii., 416 ;
idiopathic, ii., 357 ; intermitting, ii.,
684; psychical, ii., 422; nodding, ii.,
353.

Spasmus Glottidis, i., 51.

Spermatorrhoea, ii., 100.

Spina bifida, ii., 300.

Spinal Marrow, Apoplexy of, ii., 290;
Atrophy of, ii , 302 ; Carcinoma of, ii.,

860

INDEX.

300 ; Consumption of, ii., 302 ; Cysti-
ccrci and Echinococci in, ii., 299 ; gray
Degeneration of, ii., S02 ; Growths in,
ii., 291); Haemorrhage into, ii., 290;
Hypcracmia of, ii., 290 ; Inflammation
of', ii., 2P5 ; Inflammation of Mem-

• branes of, ii., 292 ; Irritation of, ii.,
200 ; Tubercle of, ii., 300.

Spleen, Diseases of, i., 739 ; Abscess of,
i., 752 ; amyloid Degeneration of, i.,
750 ; Carcinoma of, i., 754 ; acute
Enlargement of, i., 740; chronic En-
largement of, i., 745 ; haemorrhagic
Infarction of, i., 347, 751 ; Hydatids
of, i., 754 ; Hypcracmia of, i , 739 ; Hy-
pertrophy of, i., 745 ; Inflammation
of, i., 751 ; lardaccous, i., 750 ; Size of,
i., 743 ; Tuberculosis of, i., 754 ; En-
largement of, in Typhoid Fever, ii.,
628 ; wandering, i., 754.

Spotted Fever, ii., 614.

Sprue, i., 447.

Sputa : see Expectoration.

Status gastricus, i., 499.

Stenosis, i., 358.

Stickhusten, i., 95.

Stomacace, i., 439.

Stomach, Catarrh of, i., 493 : Cancer of,
i., 538; Cough, i., 123; Dilatation of,
i., 522 ; Haemorrhage from, i., 516,
545; Position of, i.. 542; Softening
of, i., 497 ; Spasm of, i., 551 ; Ulcer
of, i., 516, 528.

Stomatitis, i., 431 ; croupous, i., 437.

Stone in the Bladder, ii., 77.

Stricture, cardiac, i., 356.

Strychnine in Palsy, ii., 366.

Sudamina, ii., 576.

Sudor anglicus — sucttc miliairc, ii., 694.

Sugar, Test for, ii., 837, 849.

Sunstroke, ii., 181.

Supprcssio Mcnsium, ii., 161.

Supraclavicular Region in Croup, i., 19.

Suprarenal Capsules, Disease of, ii., 49.

Sweat, ii., 516.

Sweating of Hands and Feet, ii., 517;
Sweating in Phthisis, i., 253 ; Sweating
Sickness, ii., 694.

Sycosis, ii., 495.

Syphilidcs, ii., 760.

Syphilis, ii., 742; congenital, ii., 784;
constitutional, ii., 753 ; hereditary, ii.,
784.

Syphilitic Acne, ii., 762 ; Alopecia, ii.,
765; Catarrh, ii., 765; Disease of
Bone, ii., 767; Disease of Muscle and
Viscera, ii., 770; Disease of Perios-
teum, ii., 766 ; Disease of mucous
Membranes, ii., 765 ; Exanthemata, ii.,
760; Iritis, ii., 766; Lupus, ii., 764;
Roseola, ii., 762; Rupia, ii., 764;

Sarcocclc, ii., 770 ; primary Ulcer, ii.,

750 ; Varicella, ii., 762.
Syphilization, ii., 784.
Syphibmata, ii., 264.

* T.

Tabes dorsualis, ii., 302.

Tocnia mediocanellata, solium, i., 622.

Tape-worm, i., 622, 630.

Tarentism, ii., 425.

Tclangicctasis, ii., 443.

Temperature of Body, i., 637 ; in Cholera,
ii., 703 ; Danger from high, ii., 650 ;
in Typhoid Fever, ii., 640 ; in Sudor
arglicus, ii., 6£8; in Heat Fever, ii.,
182; in spinal Diseases, ii., 387.

Temporal Bones, Caries of, ii., 2^5.

Testicle, Inflammation of, in Parotitis, i.,
456.

Tetanus, ii., 384 ; Neonatorum, ii., 388.

Thrombosis, i., 430.

Thrush, i., 447.

Tic convulsive, ii., 351.

Tic douloureux, ii., 327

Tinea favosa, ii., 505 ; furfuracca, ii.,
470.

Tongue, parcnchymatous Inflammation
cf, i., 449; Deviation of, ii., 368.

Tonsils, Inflammation of, i., 474, 479.

Tooth-rose, ii., 455.

Tophi, ii., 767.

Torpid Indigestion, i., 558.

Torticollis, ii., 354 ; rheumatica, ii., 543.

Trachea, Diseases of, i., 61 ; Croup of,
i., 86.

Tracheotomy, i., 594.

Trembling, ii., 261.

Trichina Disease, Trichinosis, ii., 731.

Trichomonas vapinalis, ii., 172.

Tricocephalus dispar, i., 624.

Tricuspid Valves, Disease of, i., 374.

Trismus, ii., 384.

Trychophyton tonsurans, ii., 508. '

Tubercle, i., 214 ; syphilitic, ii., 764 ;
painful, ii., 316 ; Inoculation of, i., 262.

Tubercula dolorcsa, ii., 316.

Tuberculosis of the Bladder, ii., 73 ; in
Emphysema and Heart Disease, i., 222 ;
of the Intestines, 5., 598; of the Kid-
neys, ii., 46 ; of the Larnyx, i., 38 ; of
the Liver, i., 696; of the Lungs, i.,
212; of the Pleura, i., 294.

Typhlitis stercoralis, i., 581.

Typhoid Fever, ii., 623 ; Poison, ii., 740.

Typhus, abdominal, ii., 623; abortive,
ii., 641 ; ambulatorius, ii., 642 ; ex-
anthematic, ii., 614 ; ilcotyphus, ii.,
623 ; Sequela) of, ii., 646 ; Observation
of Temperature in, ii., 637.

INDEX.

861

U.

Ulcer of the Cervix Jfteri, ii., 157; of
the Duodenum, i., 553 ; of the Larynx,
i., 40 ; of the (Esophagus, i., 489 ; of
the Pharynx, i , 4(34 ; of the Stomach,
i., 523, ii., 806 ; of the Endocardium,
i., 316.

Umbilicition of Vaccine Vcsicre, ii., 610.

Uraemic Amblyopia, ii., 3 'j ; Intoxication,
ii., 28.

Ureters, Cancer of, ii., 02 ; Closure of,
ii., 54 ; Diseases of, ii., 54 ; Tubercu-
losis of, ii., 62.

Urethra, Abscess of, ii., 92 ; non-virulent
Catarrh of, ii., 98 ; virulent Catarrh
of, ii., 88.

Uric-acid Infarction, ii , 62.

Urina spastica, ii., 418.

Urinary Organs, Diseases of, ii., 1.

Urine, Amount of, ii., 4.

Urine in Bright's Disease, ii., 20.

Urticaria, ii., 464.

Uterine Colic, ii., 125, 133.

Uterus, Antcflexion of, ii., 141 ; Antevcr-
ston of, ii., 141; Cancer of, ii., 154;
Catarrh of, ii., 122 ; Curvature and
Flexions of, ii., 140 ; Descent and Pro-
lapse of, ii., 145; Displacements of,
ii., 145; fibrous Polypi of, ii., 147;
Infarction of, ii., 131 ; KotroScxion of,
ii., 140 ; Stricture of the Mouth of, ii.,
ir.7; Ulcers of, ii., 122, 124; Injec-
tions into, ii., 130; lacerated Cervix,
ii., 134 ; Tumors of, ii., 147.

V.

Vaccina, ii., 508.

Vaccination, ii., 605.

Vaccinoid, ii., 608.

Vagina, croupous and diphtheritic In-
flammation of, ii,, 173 ; non-virulent
Catarrh of, ii., 171 ; virulent Catarrh
of, ii., 170.

Valves of Heart, Aneurism of, i., 393 ;
Hypertrophy of, L, 358; Vegetations
upon, i., 345.

Valvular Disease of Heart, i., 358 ; com-
pensating Hypertrophy of the Ven-
tricles in, i., 360; Origin of, i., 351.

Varicella, ii., 612; syhilitiea, ii., 763.

Variola, ii., 595.

Varioloid, ii., 604.

Veins, Diseases of, i., 429.

Venesection in Apoplexy, ii., 228 ; in
acute (Edema of the Lungs, i., 149 ;

in cerebral Hypc-raem ia, ii., 192; in

acute Pneumonia, i., 188, 190; in En-

docavditif, i., 354.
Venous Trunks, Diseases of, i., 429.
Vcratria in Pneumonia, i., 192, 262.
Vermiform Appendix, Perforation of, i.,

575.
Vertigo epileptique, ii., 397 ; stomacale,

i.. 561.

Vertigo a Stomacho lacso, i., 561.
Vcsical Palsy, ii., 82; Catarrh, ii., 58;

Phthisis, ii., 70.
Vesic a Colonnc, ii., 59.
Vichy Water in Diabetes, ii., 842.
Virus, venereal, Duality of, ii., 748.
Vitiligo, ii., 448.
Vlcminckx's Solution, ii., 488.
Vocal Chords, Palsy of, i., 55.
Vomiting in gastric Catarrh,!., 501, 523;

in Disease of Crain, ii., 187 ; in Renal

Disease, ii.,,12.
Vomitus Matutinus, i., 514.
Vox cholerica, ii., 710.

w.

Warts, ii., 440, 442.

Water-brash, i., 514.

Water-canker, i., 451.

Water on the Chest, i., 284; on tho

Heart, i., 409.
Water-pox, ii., 612.
Wcrlhof's Disease, ii., 815.
Whey-cure, i., 11.
Whooping-cough, i., 95.
Wilkinson's Ointment, ii., 574.
Will in Motion, ii., 220.
Wind-pox, ii., 612.
Wolfish Appetite, i., 514.
Worms in the intestinal Canal, i., 622.
Writers' Cramp, ii., 355.
Wry-neck: see Torticollis.
Wunderlich on Typhus, ii., 640.

X.

Xanthopsia, i., 710.

Y.

Yeasty Diarrhoea, ii., 561.
Yellow Fever, ii., 689.
Yellow Vision, i., 710.

Zona, ii., 462.

z.

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